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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: January, 2017

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

Jan 30, 2017

Summary:

More tools, tips, and tricks so you can master obesity in clinic. On this first roundtable episode, The Curbsiders give their take on the management of obesity, and offer their own practice changing tips. Also, Paul announces his goal to watch 365 movies in 365 days, and the guys give more great book, movie, and TV recommendations.

Got feedback? Email thecurbsiders@gmail.com  

Picks of the week

  1. Matt’s pick - Never Eat Alone by Keith Ferrazzi
  2. Paul’s pick - Sing Street (film)
  3. Stuart’s pick - Lemony Snicket's: A series of unfortunate events

Clinical pearls (from Recap and response OR Brief topic review)

  1. Obesity is a DISEASE. Not a lifestyle choice.
  2. Percent weight loss by intervention
    • Diet and lifestyle 5-10%
    • Medications >10%
    • Bariatric surgery >30%
  3. Utilize specialist referral to gain resources e.g. dietician, and psychologist through bariatric surgery referral
  4. Put faith in your patients ability to change and they will hold themselves accountable

Coding tips

  1. If BMI >35 then code “morbid obesity” to increase medical decision making
  2. Code “BMI” in addition “Morbid obesity”
  3. Be sure to code comorbid conditions e.g. hypertension, diabetes, hyperlipidemia, OSA

Time Stamps

00:00 Intro

01:29 Picks of the week

06:07 Recap and responses to our obesity interview with Dr. Garvey

08:55 Mechanisms of obesity

10:15 Discussion of relapse rates, weight gain

11:23 Percent weight loss per therapy

14:35 Treating obesity on a budget

18:51 Coding tips

20:43 Diet, lifestyle counseling and how to leverage resources

26:38 Closing remarks

28:40 Outro

Disclosures:

The Curbsiders report no relevant financial disclosures, but as always hope to have lots of them in the future.

Links from the show:

  1. Tomlinson, S et al. Mechanisms, Pathophysiology, and Management of Obesity. NEJM 2016; 376(3) http://www.nejm.org/doi/full/10.1056/NEJMra1514009
  2. E&M University website http://emuniversity.com
  3. ICD10Data.com http://www.icd10data.com
  4. Matt’s pick - Never Eat Alone by Keith Ferrazzi
  5. Paul’s pick - Sing Street (film)
  6. Stuart’s pick - Lemony Snicket's: A series of unfortunate events

 

Tags: care, doctor, family, health, hospitalist, hospital, internal, internist, medicine, medical, obesity, primary, physician, student, resident

 



Jan 16, 2017

Obesity is of epidemic proportions in the United States and, unfortunately, many physicians are ill-equipped to tackle this disease.  In this episode, we talk with Dr. Timothy Garvey, MD, FACE, one of the world’s leading experts in obesity research.  We asked the American Association of Clinical Endocrinology to recommend an obesity expert and they gave us the best!

Got feedback? Email thecurbsiders@gmail.com 

Clinical Pearls:

  1. Obesity is a DISEASE. Not a lifestyle choice!
  2. Obesity is known to be associated with many of the most common preventable diseases and, thus, should be an important component of any treatment program.
  3. BMI goals differ between ethnic groups (for example, east Asians developing heart disease with a BMI greater than 23).
  4. Weight loss treatment should focus on the disease burden and not on body image.
  5. While diet and exercise are independently important, failure to address the underlying sedentary lifestyle will likely prove fruitless.  The American College of Sports Medicine recommends avoiding any sedentary activity greater than 90 minutes at a time and at least 150 minutes of moderate activity weekly.
  6. Always ask permission before talking about weight loss; otherwise, you might negatively impact the physician-patient relationship.
  7. In order to prevent weight-related complications, aim for approximately 10% weight loss.
  8. Weight regain is a REAL problem that should be anticipated (decreased BMR, hormonal implications, and many other issues); weight loss medications help to fight against these pathophysiological mechanisms.
  9. Weight loss medications (Orlistat [inhibits fat absorption], Lorcaserine [5HT2C agonist, blunts appetite], Liraglutide [GLP1-RA] at higher dosages [3mg/day], Phentermine/Topiramate [“...most effective…”], Naltrexone/Bupropion) are under-utilized across the board, but before using these medications, the physicians should understand how to use these medications and consider them as part of a weight loss treatment plan that includes lifestyle modifications (i.e. dietary assessment and exercise “prescription”).
  10. Liraglutide, Phentermine/Topiramate, and Naltrexone/Bupropion are the most effective medications.
  11. If the patient does not lose at least 5% of their weight by three months, stop that specific medication and consider trying another medication.
  12. Follow-up with your weight loss patients frequently over the telephone (2 weeks after starting a medication) and in the office (at least monthly).
  13. Minimal data supports using weight loss medications in the elderly (>70 years of age)

Dr. Garvey’s “Take-Home” Points:

  1. Obesity is a DISEASE not a lifestyle choice!
  2. Don’t be afraid to use weight loss medications!
  3. Weight loss should be a tool to improve HEALTH, not appearance.

Disclosures:

Dr. Garvey reports several financial disclosures for this talk:

  1. Scientific Advisory Board:  Novo Nordisk, Eisai, Janssen, Vivus, Liposcience, Takeda, Astra Zeneca, Alexion, Merck
  2. Research Funding (university administered):  Merck, Astra Zeneca, Weight Watchers, Eisai, Sanofi, Pfizer, Novo Nordisk, Lexicon, Elcelyx
  3. Stock Ownership (publicly traded):  Eli Lilly, Pfizer, Novartis, Merck, Isis, Bristol-Myers-Squibb, Affymetrix

Learning objectives:

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

  1. Understand the impact obesity has on overall health and disease burden.
  2. Identify the weight loss medications and which might be appropriate for your patient(s).
  3. Have a general understanding of the impact that each individual treatment modality (lifestyle modification, medications, and surgery) has on weight loss.

Links from the show:

  1. Dr. Timothy Garvey’s bio (UAB):  https://www.uab.edu/medicine/diabetes/faculty/faculty-bios/111-w-timothy-garvey
  2. Dr. Timothy Garvey’s app recommendation, “Lose It,” available from https://www.loseit.com/.
  3. Dr. Timothy Garvey’s book recommendation:  “House of God” available https://www.amazon.com/House-God-Samuel-Shem/dp/0425238091/ref=sr_1_1?ie=UTF8&qid=1484443555&sr=8-1&keywords=House+of+God.
  4. AACE 2016 Obesity Guidelines:  https://www.aace.com/files/final-appendix.pdf
  5. AACE Obesity Treatment Algorithm (highly recommended):  https://www.aace.com/files/guidelines/ObesityAlgorithm.pdf
  6. Naltrexone/Bupropion SR for Weight Loss:  Method-of-use study of naltrexone sustained release (SR)/bupropion SR on body weight in individuals with obesity.  Obesity (Silver Spring). 2016 Dec 27. doi: 10.1002/oby.21726.
  7. Phentermine/Topiramine for Weight Loss (Review Article):  Combination phentermine and topiramate extended release in the management of obesity.  Expert Opin Pharmacother. 2015 Jun;16(8):1263-74. doi: 10.1517/14656566.2015.1041505.
Jan 15, 2017

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.

Comments or questions? Email thecurbsiders@gmail.com

Jan 2, 2017

Summary:

Consolidate your knowledge and reinforce the learning you’ve done with us in 2016. Enjoy this holiday helping of knowledge food for your brain hole. The guys offer their best of recommendations for 2016 and recap key teaching points from the past year so you have the tools to dominate 2017.

Recommend a guest or topic and give feedback at thecurbsiders@gmail.com  

Clinical Pearls:

SPRINT trial debate

  1. Bias effects results seen in this trial. e.g. stopped early
  2. Blood pressure (BP) control may have been overestimated based on how BP was measured leading to increased CV events (Stuart’s view).
  3. BP measurements in trial likely reflected out of office BP so results are useful (Paul’s view).
  4. Lower BP is probably safe, even in the elderly so be reluctant to back off on meds.

HTN Urgency

  1. Verify BP reading and measurement technique
  2. Evaluate for pain, anxiety, volume overload, nonadherence, or noncompliance
  3. Treat high BP with long term goals in mind (i.e. go up on chronic/long-acting meds)

Anticoagulation

  1. Avoid warfarin in patients with gastric bypass or Crohn’s with ileitis.
  2. Use SPARC tool to visually demonstrate risks and benefits of anticoagulation in Afib.
  3. Physicians commonly underestimate benefit of anticoagulation in older sicker patients and overestimate risk of bleeding.

Fibromyalgia and chronic pain

  1. Recognize the constellation of fatigue, memory problems, sleep disturbance, and multifocal pain as fibromyalgia.
  2. Use the 2011 American College of Rheumatology criteria for diagnosis. No tender point exam required!
  3. Nonpharmacologic therapies and education are most effective (see video links below).
  4. Chronic painful conditions like rheumatoid arthritis, or lupus can lead to fibromyalgia.

Functional Medicine

  1. At least 80% of your food should be whole foods.
  2. Use the Dirty Dozen and Clean 15 to guide organic food choices.
  3. Knowledge of pathophysiology and biochemistry can be used to treat disease e.g. treating small intestinal bacterial overgrowth can fix iron deficiency and indirectly treat iron deficiency.

Lipids

  1. Lowering LDL is key. Some statin is better than none, so consider intermittent dosing (three times weekly) of atorvastatin or rosuvastatin.
  2. Statins have a 20 year safety record, are cheap, and will remain king for now.
  3. Check baseline LDL and monitor percent decrease on statin therapy to ensure desired effect (e.g. 50% drop in LDL for patient requiring high intensity).
  4. Withdrawal of statins at end of life is warranted and safe.

Insomnia

  1. Nonpharmacologic therapy is as good or better than pharmacologic therapy.
  2. Benefits of nonpharmacologic therapy persist 1-2 years after discontinuation.
  3. Identify problem with sleep initiation versus maintenance, or both, then choose agent.
  4. Use long taper of sleep agent (several months) along with CBT for nightly problems with sleep.
  5. Intermittent dosing of sleep agent okay if only intermittent sleep trouble.

Osteoporosis

  1. If secondary hyperparathyroidism present, then target normal PTH not just a Vit D level 30-50 ng/ml.
  2. After hip fracture, first normalize Vit D and/or PTH, then treat with bone conserving agent.
  3. Drug holiday stops when bone density falls, fracture occurs, or risk increases (e.g. steroid use).
  4. Patients may require multiple courses of bisphosphonates or other bone conserving drugs.

In-flight emergencies

  1. Know contents of standard medical kit include:
  2. Be prepared to improvise.

Lessons learned

  1. Failure is essential to learning and improving.
  2. Don’t fall victim to “fear of being left out”. Saying “No” protects you from being spread thin.
  3. Overcome the “curse of knowledge” by teaching the basics and gearing lesson to level of learner.

Disclosures:

The Curbsiders report no relevant financial disclosures, but hope to have a long list of them in the future.

Time Stamps

00:00 Intro

02:54 Best of 2016 Articles

07:45 Best of 2016 Book recommendations

12:44 Best of 2016 Apps

15:49 SPRINT trial

24:34 Hypertensive urgency

27:05 Anticoagulation

33:00 Fibromyalgia and chronic pain

38:38 Functional Medicine

42:05 Lipids

48:09 Insomnia

52:13 Osteoporosis

56:29 In-flight emergencies

59:09 Lessons learned in 2016

1:03:45 Outro

Links from the show:

Articles

  1. Blood pressure as a risk factor for headache and migraine: a prospective population-based study.  Eur J Neurol. 2015 Jan;22(1):156-62, e10-1. doi: 10.1111/ene.12547. Epub 2014 Aug 25.
  2. Imbalanced insulin action in chronic overnutrition: Clinical harm, molecular mechanisms, and a way forward. Atherosclerosis. 2016 Apr;247:225-82
  3. Sniffing out significant “Pee values”: genome wide association study of asparagus anosmia http://www.bmj.com/content/355/bmj.i6071

Books

  1. How Doctors Think by Jerome Groupman
  2. Multipliers: How the Best Leaders Make Everyone Smarter by Liz Wiseman:
  3. Spook Country by William Gibson
  4. Carter Beats the Devil by Glen David Gold
  5. Evidence Based Physical Diagnosis by Steven McGee

Apps

  1. Download Google Drive
  2. UptoDate
  3. My Fitness Pal
  4. Map My Run

Other links

  1. SPARC Tool for anticoagulation in atrial fibrillation
  2. Warfarin use in heart failure patients may have a mortality benefit
  3. Fibroguide.com
  4. Chronic Pain is it all in their head
  5. Five minute video on Chronic Pain from Australia (not the VA!)
  6. EWG.org (environmental work group) - gives the Dirty Dozen and the Clean 15
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