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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: Category: internal medicine, primary care, science

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

Sep 12, 2016

Summary:

Fifty four percent of physicians report at least one symptom of burnout. On this episode Dr. Philip Kroth an Internist and Chief of Clinical Informatics from the University of New Mexico schools us on how electronic health records (EHR) relate to burnout and tips to promote physician wellness. Miss this episode and you might get burned...out. I refuse to apologize for that pun. Enjoy!

 

Clinical Pearls:

*Check out the article by Shanafelt below to view breakdown of burnout by specialty.

*24/7 access to EHRs is a double-edged sword. You have to protect your own time.

*Turn off email alerts.

*Limit your screen time when off the clock. Kids are only allowed 1 hour per day!

*Take the EHR training and become a MASTER.

*Keep in mind these four domains related to burnout and try to mitigate your risk.

  1. Health information technology and documentation burden
  2. Stress versus control and support. You need to balance the “seesaw”
  3. Health policy and regulation (e.g. ACOs, MACRA)
  4. Physician culture of endurance (e.g. giving yourself an IV when sick instead of going home)

Disclosures:

None reported.

Links from the Show:

1. Article by Shanafelt finding burnout in 54 percent of physicians.

Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014 Shanafelt, Tait D. et al. Mayo Clinic Proceedings , Volume 90 , Issue 12 , 1600 - 1613

2. Turnover of primary care doctors cost about $250,000 in 1991!

Buchbinder, SB et al. Estimates of Costs of Primary Care Physician Turnover. Am J Manag Care. 1999 Nov;5(11):1431-8.

3. Maslach Burnout Inventory

http://www.mindgarden.com/117-maslach-burnout-inventory

4. Volkswagen stops sending emails in the evening.

http://www.bbc.com/news/technology-16314901

Aug 29, 2016

Do complaints of insomnia stress you out? Well, never fear. In this episode our guest is Dr. Karl Doghramji, Professor of Psychiatry, Neurology and Medicine and the Medical Director of the Sleep Disorders Center at Thomas Jefferson University Hospital in Philadelphia. With his help we deconstruct the “dread pirate” insomnia (as I call it) so you can dominate it in your daily practice.

Disclosures:

Dr. Doghramji reports recent relationships with Merck (stock) and consulting work for Merck, Xenoport, Jazz, Inspire, Teva and Pfizer. He has a current research grant from Inspire.

Clinical Pearls:

*Pathophysiology: Likely biological, neurobehavioral and psychological hyperarousal. Possible genetic component.

*Depression, anxiety or PTSD may be their primary disorder. Many insomniacs unaware of their depression. Need a high index of suspicion.

*Sleep apnea is probably cause in 10-20% of patients who present with insomnia.

*GERD can present with insomnia and night time awakenings as its primary symptom.

*CBT works as well as pharmacotherapy and has lasting potential even 1-2 years after discontinuation of therapy.

*High yield nonpharmacologic therapy: Get up at the same time every morning. Don’t sleep in, even if bedtime or sleep onset was delayed.

*Melatonin: It’s effect depends on time administered (see below). It’s not as safe as you think (insulin resistance, low sperm count)

1. Administer very low dose (under 3 mg) four to five hours prior to bed for delayed sleep phase (usually occurs in teens).

2. Administer higher dose (3-5 mg) one hour before bed for sleep initiation (adults with fragmented sleep).

*Agents for sleep initiation: zaleplon, zolpidem, ramelteon

*Agents for sleep maintenance: zolpidem ER, eszopiclone, doxepin (low dose of 3mg or 6mg), gabapentin (off label)

*Suvorexant (orexin antagonist) treats both sleep initiation and maintenance: Start 10 mg and go up 5 mg every few weeks to max 20 mg daily. Orexins are deficient in narcolepsy. Orexins seem to mediate a switch system between arousal and sleepiness.

*Doxepin, gabapentin and ramelteon have very lose risk for abuse. 

*Off-label use of diphenhydramine for sleep is not recommended ("dirty drug"). Trazodone and mirtazapine also have uncertain benefit.

*Mirtazapine 7.5 mg is the dose for insomnia (more sedating). Lower dose favors histamine receptor.

Links from the Show:

1. This is one possible site for online CBT

https://www.sleepio.com as referenced in this study

2. Melatonin associated with impaired glucose tolerance

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173928/

3. American Academy of Sleep Medicine

4. This site below has easy to understand information on sleep related disorders and links to videos explaining sleep hygiene. You can also download sleep logs, get info.

SleepEducation.org Website

5. Review on use of mindfulness and meditation for insomnia.

http://www.ncbi.nlm.nih.gov/pubmed/26390335

Aug 15, 2016

Summary:

In this episode our guest is Dr. Robert Dickson a Pulmonologist from the University of Michigan who studies the respiratory microbiome. We discuss how the lung microbiome differs in health, chronic illness and acute disease states like pneumonia, sepsis and ARDS. The lung microbiome has the ability to predict frequency of exacerbations and even severity and progression of certain lung diseases. We’ll explore all of this plus Dr. Dickson’s new paper published last month in Nature Microbiology, which had the surprise of finding gut bacteria in the lungs during critical illness. Please enjoy this wide ranging discussion

 

Disclosures:

Dr. Dickson did not report any disclosures.

 

Clinical Pearls

1. The lungs are constantly bombarded by microbes and the largest host to microbe interface in the body where bacteria come within millimeters of the blood stream.

2. The lung microbiome is altered in both acute and chronic diseases

3. The lung microbiome is altered by antibiotics, corticosteroids, PPIs and probably lots of other things we are just beginning to discover.

 

Links from the Show:

Dr. Dickson’s latest article reporting gut bacteria in the lungs during critical illnesses.

Dickson, R et al. Enrichment of the lung microbiome with gut bacteria in sepsis and the acute respiratory distress syndrome. Nature Microbiology 1, Article number: 16113 (2016). doi:10.1038/nmicrobiol.2016.113

 

A link to Dr. Dickson’s podcast discussing the role of microbiome and the care and treatment of critically ill patients.

The role of microbiome: The Lancet Respiratory Medicine: January 2016

 

Dr. Dickson’s recent publication in The Lancet.

Robert Dickson. The microbiome and critical illness. The Lancet. Published Online: 11 December 2015. DOI: http://dx.doi.org/10.1016/S2213-2600(15)00427-0

 

Five clinical pearls on the Pulmonary microbiome

Robert P. Dickson and Gary B. Huffnagle. The Lung Microbiome: New Principles for Respiratory Bacteriology in Health and Disease. PLoS Pathog. 2015 Jul; 11(7): e1004923. Published online 2015 Jul 9. doi:  10.1371/journal.ppat.1004923 PMCID: PMC4497592

 

A comprehensive review of the Pulmonary Microbiome field

Dickson, RJ et al. The Microbiome and the Respiratory Tract. Annu Rev Physiol. 2016;78:481-504. doi: 10.1146/annurev-physiol-021115-105238. Epub 2015 Nov 2.

 

Jul 25, 2016

Summary:

In this episode our guest is Master Lipidologist, Dr. Peter Howard Jones from Baylor College of Medicine and the National Lipid Association. My guest host is Dr. Paul Williams, Clinician Educator extraordinaire from Philadelphia. We explore everything you’ll ever want to know about cholesterol and lipids. Are statins still king when it comes to cholesterol lowering? Should we be rushing to use PCSK9 inhibitors? Should we throw away older drugs like fibrates? Are nonpharmacologic therapies like niacin and fish oil worthwhile? Join us for this extensive conversation.

 

Disclosures:

Dr. Jones is the Chief Science Officer at the National Lipid Association. He has served as a scientific advisor to Merck, Amgen and Sanofi.

 

Learning objectives:

1. Identify each individual's risk for cardiovascular disease and counsel them on benefits of therapy.

2. Learn to lower atherogenic lipids by any means necessary and understand the effects of the common lipid lowering drugs

3. Effectively counsel patients on benefits of lipid lowering drugs to promote patient buy in and adherence.

 

Clinical Pearls

1. Omega 3 fatty acids at 1,000 mg daily or more is useful for prevention of sudden death in post ACS patients.

2. Omega 3 fatty acids at dose of 4,000 mg per day is needed to lower triglycerides. Indicated if TG remain above 500 on first line therapy.

3. Hypertriglyceridemia with level above 500 on optimal statin dose, then consider addition of fibrate and/or omega-3 fatty acids. Uncertain clinical benefit in patient with moderate elevation (200-300) of triglycerides.

4. Statin intolerance can be overcome in most patients using the following methods:

a. Same statin at lower dose

b. Different statin

c. Use of rosuvastatin or atorvastatin 3 times weekly

5. Statins are safe to take for at least 20 years and probably longer (this data is still being collected, but will be available in the future)

6. Withdrawal of statins at the end of life is not harmful and may be beneficial.

 

Links from the Show:

 

Studies that used fibrates for preventions of CV events:

Helsinki Heart Study for primary prevention NEJM 1987

VA HIT Study for secondary prevention NEJM 1999

 

Withdrawal of statins at the end of life

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4618294/

 

Expert Consensus on use of Non-Statin Drugs

http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2016/03/30/11/58/2016-acc-expert-consensus-decision-pathway-on-the-role-of-nonstatin

 

National Lipid Association recommendations for patient-centered management of dyslipidemia

https://www.lipid.org/sites/default/files/Recommendations-Part-1.pdf

 

Recommended websites

National Lipid Association

The Heart.org (Medscape)

Journal of Clinical Lipidology

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