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The Curbsiders Internal Medicine Podcast | MedEd | FOAMed | Internist | Hospitalist | Primary Care | Family Medicine

Supercharge your learning and enhance your practice with this Internal Medicine Podcast featuring board certified Internists as they interview national and international experts to bring you clinical pearls and practice changing knowledge. Doctors Matthew Watto, Stuart Brigham, and Paul Williams deliver some knowledge food for your brain hole. No boring lectures here, just high value content and a healthy dose of humor. Fantastic podcast for Internal Medicine, Family Medicine, Primary Care, and Hospital Medicine. Topics include heart disease, obesity, diabetes, cardiac imaging, migraines, fibromyalgia, hypertension, cholesterol, osteoporosis, insomnia, testosterone, functional medicine, dementia, and more!
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Now displaying: October, 2016

Supercharge your learning and enhance your practice with this Internal Medicine Podcast featuring board certified Internists as they interview national and international experts to bring you clinical pearls and practice changing knowledge. Doctors Matthew Watto, Stuart Brigham, and Paul Williams deliver some knowledge food for your brain hole.

thecurbsiders@gmail.com

Oct 31, 2016

 

Summary:

Dr. Robert Centor’s Knowledge Food, Part 2!  On this episode of The Curbsiders, we continue our discussion with the legendary Dr. Centor, focusing on pharyngitis and the highly entertaining origin of the Centor Criteria.  Not only do we learn how to dominate pharyngitis, but we also uncover one of Dr. Watto’s knowledge deficits - Lemierre’s Syndrome.  (He owes us a two minute talk on Lemierre’s Syndrome in case you’re wondering. I know I am.)

Clinical Pearls:

  1. Admit your own limitations!  Many overestimate their skills as a clinical educator.
    1. Preadolescents get streptococcal pharyngitis (...or it’s nothing).
    2. Adolescents are much more complicated with streptococcus, EBV, CMV, acute HIV, fusobacterium, and multiple other causes.
  2. Important: Separate the causes of pharyngitis in preadolescents and adolescents.
    1. General rule: Sore throats should not cause rigors; if present then admit patient, obtain blood cultures, and start antibiotics.
  3. Do NOT miss a peritonsillar abscess or Lemierre’s Syndrome in acute pharyngitis.
  4. Pharyngitis improves within three to five days.  Failure to improve should prompt a more thorough investigation.
  5. Lemierre’s Syndrome (1 in 70,000 untreated pharyngitis patients) is septic thrombophlebitis of the internal jugular vein.  The treatment is IV antibiotics and NOT anticoagulation.  
  6. Dr. Centor and the IDSA recommends Amoxicillin once daily and, if penicillin allergic, Clindamycin.  The most recent IDSA update recommends a 10-day course of Amoxicillin (50mg/kg up to 1000mg once daily).

Dr. Centor’s “Take-Home” Points:

  1. Adolescents tend to have more complicated pharyngitis
  2. Pharyngitis and rigors?  Admit, obtain cultures, and start antibiotics.
  3. Sore throats don’t get worse and, if they do, you need to rethink the case

Disclosures:

Dr. Centor reports no relevant financial disclosures for this topic.

Learning objectives:

By the end of this podcast listeners will be able to:

  1. Identify the limitations of the Centor Criteria in regards to (a) preadolescents and (b) adolescents, taking special precautions in the adolescent population
  2. Understand which acute pharyngitis patients require a more thorough investigation
  3. Be able to identify Amoxicillin as the treatment of choice for acute bacterial pharyngitis with Clindamycin as the second-line antibiotics choice.

Links from the show:

  1. Check our Dr. Centor’s wonderful blog, at http://www.medrants.com or on twitter https://twitter.com/medrants
  2. Centor’s Criteria (MDCalc) -- http://www.mdcalc.com/modified-centor-score-for-strep-pharyngitis/
  3. IDSA Guidelines on Diagnosis and Management of Group A Streptococcus Pharyngitis - http://cid.oxfordjournals.org/content/early/2012/09/06/cid.cis629.full.pdf+html
  4. Original article using the Centor score for pharyngitis https://www.ncbi.nlm.nih.gov/pubmed/6763125?dopt=abstract
  5. Dr. Centor’s article on fusobacterium Centor RM, et al. The clinical presentation of Fusobacterium-positive and streptococcal-positive pharyngitis in a university health clinic: a cross-sectional study. Ann Intern Med. 2015 Feb 17;162(4):241-7. doi: 10.7326/M14-1305.
Oct 24, 2016

Summary:

Dr. Robert Centor’s Knowledge Food, Part 1.  This Halloween, the “Curse of Knowledge” is REAL!  So you think you can teach? This master clinician educator, known for “Centor’s Criteria,” schools us the most common errors made by medical educators and how to improve learner retention.  While we only scratch the surface, Season 1’s arguably penultimate episode should NOT be missed.  After all, how else are you going to learn about Pretty Pimpin’?  Stay tuned for Part Duex when we briefly review Pharyngitis and Dr. Watto finally learns about Lemierre’s Syndrome!  As always, you’re welcome.

Clinical Pearls:

  1. Don’t fall victim to the “Curse of Knowledge!”  Remember that your students/residents do not know what you know!
  2. Effective rounding should include a healthy mixture of both table-top and bedside rounds.
  3. Feedback should be specific, timely (even immediate!), and focused on improvement.  
  4. Allow the learner to self-evaluate before providing specific feedback and invite all members of the team to provide collaborative feedback.
  5. Always remember that feedback should be positive as well as constructive.
  6. There are multiple courses available to further your own skills as a medical educator
  7. The physician-educator should embody the “servant leader” and prioritize medical education (the “service” you are providing).
  8. Consider blogging to improve your own writing!

Dr. Centor’s “Take-Home” Points:

  1. The “Curse of Knowledge” is real -- never assume the basics are known.
  2. The attending physician should embody service before self.
  3. Dr. Centor’s playlist -- Matt Duncan, Lawrence, Saint Paul and the Broken Bones, Houndmouth, Kurt Vile

Disclosures:

Dr. Centor reports no relevant financial disclosures for this topic.

Learning objectives:

By the end of this podcast listeners will be able to:

  1. Understand the basics concepts that underscore effective feedback (specific, timely, and collaborative)
  2. Identify the tenants that underscore effective rounding
  3. Re-evaluate your own teaching style and consider training seminars to improve your skills as a medical educator

Links from the show:

  1. Dr. Centor’s Blog -- http://www.medrants.com/
  2. Dr. Bradley Sharpe’s profile -- http://profiles.ucsf.edu/bradley.sharpe
  3. Stanford Faculty Development Course -- http://sfdc.stanford.edu/
  4. UCSF Workshop - “Developing Skills in the Art of Effective Feedback” -- http://meded.ucsf.edu/radme/developing-skills-art-effective-feedback
  5. Ten Tips for Receiving Feedback -- http://med-ed-online.net/index.php/meo/article/view/25141
  6. Who should take statins? -- https://www.washingtonpost.com/news/to-your-health/wp/2016/10/04/who-should-take-statins-a-vicious-debate-over-cholesterol-drugs-side-effects/?postshare=1551475707596812&tid=ss_tw
  7. Kurt Vile - “Pretty Pimpin” -- https://www.youtube.com/watch?v=659pppwniXA
  8. 7 Habits of Highly Effective People by Stephen Covey
  9. Made to Stick: Why Some Ideas Survive and Others Die by Chip and Dan Heath
Oct 10, 2016

Summary:

Stop feeling helpless in the face of vague complaints like fatigue, digestive problems, mood swings, inability to lose weight, etc. Learn to treat any chronic disease without writing more prescriptions. Heal yourself and your patients with the power of food. Join us for the return of Functional Medicine physician, Dr. Yousef Elyaman, as he schools us on elimination diets, phytonutrients, liver detoxification, going “paleo” and more. This is a deluxe episode so we’ve included a time key below. You’re welcome.

Clinical Pearls:

  1. Use the 80:20 rule. Try to make 80% of your food paleolithic (unprocessed).
  2. Eliminate the chemicals when possible (processed foods, plastics, cleaning products, cosmetics, etc.)
  3. Workarounds for your budget: home garden and/or frozen foods.
  4. Preserve phytonutrients - Avoid microwaves. Lightly saute or eat veggies raw.
  5. Try an elimination diet for one month then reintroduce foods one at a time.
  6. Assess patient readiness and prescribe diet that fits their degree of commitment.
  7. Basic lab panel to consider: Check homocysteine, zinc, 25OH Vit D, B12, RBC folate, RBC magnesium (use diagnosis of fatigue).
  8. More specialized labs: 
    1. SpectraCell - Micronutrient panel.
    2. NutraEval Plasma by Genova Diagnostics.
    3. Check for MTHR mutation (if off then patient needs methylfolate).

Dr. E's Four steps to healing with food

  1. Ensure a nutritionally dense diet.
  2. Remove bothersome foods.
  3. Replace deficiencies.
  4. Rebalance the system.

Disclosures:

Dr. Elyaman reports no relevant financial disclosures for this topic.

Learning objectives:

By the end of this podcast listeners will be able to:

  1. Appraise the quality of a patient’s diet and identify potential sources of intolerance/food sensitivity
  2. Counsel patients on sustainable dietary changes to remove potentially bothersome foods and chemicals
  3. Perform a basic laboratory evaluation to identify deficiencies
  4. Identify resources for patients and providers to facilitate education and adherence

Show breakdown

0:00 Intro.

02:30 Welcome Dr. Elyaman.

03:15 Stuart bums everyone out with a current event.

04:30 Functional Medicine defined.

07:10 Logistics of educating patients on dietary changes.

11:15 Four steps to healing with food.

15:00 Use food to treat chronic disease.

16:45 Fats and a nutritionally dense diet.

20:00 Alzheimer’s and food.

23:45 Phytonutrients.

27:45 Eating on a budget.

33:40 Genetically modified foods, lectins and autoimmune disease.

40:30 Elimination diets.

46:00 Multiple sclerosis, Milk and casein.

50:00 Autism’s interplay with diet, genes, folate metabolism.

53:00 How to boost liver detoxification.

56:00 The Wahl’s protocol for multiple sclerosis.

58:30 Paleo diet.

1:00:00 Patient adherence.

1:07:35 Testing for and repleting vitamin deficiencies.

1:11:15 Fast food salad and inflammatory markers (Stuart derails the show again).

1:14:30 Dr. E’s Take home points.

 

Links from the show:

  1. The Institute of Functional Medicine's Elimination Diet Plan
  2. Stanford FODMAP Diet Handout
  3. Visit Dr. E's website for Absolute Health
  4. Institute of Functional Medicine website - https://www.functionalmedicine.org
  5. Learn the basics - Intro To Functional Medicine by Dr. David Jones and Sheila Quinn
  6. MSQ questionnaire from Dr. Hyman's website - assess medical symptoms and toxicity
  7. DASS 21 questionnaire - for anxiety, depression, stress
  8. A study of macronutrient type on ApoE levels in ApoE2, E3, E4 genotypes
  9. Video on the “10 Americans” study by the Environmental Working Group - chemicals in cord blood https://youtu.be/0-kc3AIM_LU
  10. EWG.org (environmental work group) - gives the Dirty Dozen and the Clean 15
  11. Gluten free diet removes anti islet cell Ab in a child https://www.ncbi.nlm.nih.gov/pubmed/12434905
  12. Dr. Terry Wahls TED Talk - Diet for Multiple Sclerosis (the Wahls protocol)
  13. The Paleo Diet book can be purchased here
  14. Handful of nuts per day lowers mortality in both of these studies https://www.ncbi.nlm.nih.gov/pubmed/25833976 and https://www.ncbi.nlm.nih.gov/pubmed/26548503
  15. 23 and Me genetic testing
  16. SpectraCell - Micronutrient panel
  17. NutraEval Plasma by Genova Diagnostics
  18. Stuart’s Omron blood pressure cuff




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