These are clinical pearls based on the presentations from the ACP 2019 conference. Wherever possible, I have included a reference to fact-check. Like all things in medicine, these may eventually be proven wrong, or better data may become available. If you have a correction, please don’t hesitate to share in the comments!
The oral bioavailability of bumetinide and torsemide is 80-100% vs 10-100% for furosemide. If patients aren’t responding to furosemide orally, consider switching.
Valvular atrial fibrillation=mitral stenosis or mechanical valve. Vitamin K antagonists preferred over NOACs.
Rhythm control does not mean you can stop anticoagulation. Use the CHADSVASC score to determine if you should continue. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4321065/
Based on the Seattle heart failure model, the life expectancy on optimized therapy (ace, bb, aldo, ARB) can increase by years. “If you can talk, walk, and pee, it doesn’t matter what the blood pressure is.” https://depts.washington.edu/shfm/
Resting echo is not sensitive enough to rule out heart failure with preserved ejection fraction. This is a clinical diagnosis. https://www.slideshare.net/DukeHeartCenter/heart-failure-with-preserved-ejection-fraction-55864890
Restarting aspirin after surgery in patients with prior PCI has been found to reduce MI. https://www.jwatch.org/na45455/2017/11/13/aspirin-before-noncardiac-surgery-patients-with-previous
ECG is not predictive of perioperative complications. (But I’ll probably still be forced to do them for preop. Sigh.)
Aspirin is not effective for stroke prevention in nonvalvular atrial fibrillation. Patients should be on anticoagulation (women less likely to be in appropriate therapy even though they have higher stroke risk).
There is an increased risk of cardiac events but not in the prevalence of CAD in asymptomatic LBBB. It may not warrant work up (stress, cath) without symptoms.
Due to advances in anesthesia, it is reasonable to perform elective surgery in patients with severe, asymptomatic severe aortic stenosis and regurgitation with close hemodynamic monitoring.
Asymptomatic hypertensive “urgency” should probably not be treated as urgency. Consider rest, outpatient meds, and f/u. (In patients with SBP>220, only 0.2% had a major event 7 days after discharge from ED, and IV treatment associated with increased strokes.)
Murmurs that get louder with inspiration are right sided murmurs, but not all right sided murmurs increase with inspiration.
HOCM murmur increases with decreaesed left ventricular filling, so valsalva should make the murmur louder.
There are no proven tx for heart failure with preserved EF that improve morbidity or mortality. Guidelines advise: 1) Control BP (Ace/arb by expert opinion: nitrates likely harmful) 2) Screen for a fib, OSA, DM, HTN
Work up of sinus tachycardia includes: 1) Everyone: ECG, exclude noncardiax causes 2) Consider: exercise testing, tilt table/autonomic testing If idiopathic, tx is symptomatic only. Exercise may be more effective than meds.
24 hr ambulatory blood pressure measurements are stronger predictors of cardiovascular mortality than clinic measurements.
According to a meta analysis of 13 studies, DOACs are more effective and safer than LMWH in treatment of DVT.
Thrombosis 2018:March 2.
DOACs have shorter half-life than warfarin, so noncompliance with warfarin—>predictor of failure with DOACs.
Distal DVT (below the knee) likely do not need anticoagulation, unless high risk. (Risk factors: D-dimer over 500 ng/mL, unprovoked, malignancy, prior history, severe symptoms, inpatient status)
From the CACTUS trial
LAMA/LABA inhaler combos are superior to LABA/ICS for reducing exacerbations in COPD.
In patients with severe asthma not controlled on high dose corticosteroid, check if eosinophilia count>300, add IL5 antagonist to reduce exacerbations and hospitalizations.
Hoarseness is common in inhaled corticosterooids. Risk factors include: 1) Poor technique 2) Not using a spacer 3) Not rinsing the mouth after. Teach proper technique, consider switching to MDI, and don’t forget about scoping for candida.
The risk of cancer in 6mm solitary pulmonary nodule in high risk patient is less than 1%! https://www.cancertherapyadvisor.com/home/decision-support-in-medicine/hospital-medicine/solitary-lung-nodule/
Metered dose inhalers require a lot of coordination, while powder inhalers require deep inspiratory effort to use. Nebulized medications reduce admissions for patients with COPD who have reduced peak inspiratory flow. https://www.ncbi.nlm.nih.gov/m/pubmed/12022894/
PRN ICS/LABA (SYGMA-1 trial)
•>PRN SABA for asthma symptom control and prevention of exacerbations
•=maintenance ICS for prevention of exacerbations
•<maintenance ICS asthma control
•83% lower cumulative dose of ICS —>reasonable to use PRN ICS/LABA in mild asthma
For healthy adults, according to one study, metronidazole does not interact with alcohol. Otherwise, risk is theoretical. https://www.ncbi.nlm.nih.gov/m/pubmed/12022894/
For iron deficiency anemia, once daily dosing of iron supplement appears to be better absorbed and tolerated, with similar or better improvement in anemia. Every other day dosing is emerging.
Most expired medications in tablet and pill form are still potent well past their expiration date (with caution re: albuterol, aspirin, and suspensions). https://onlinelibrary.wiley.com/doi/abs/10.1002/jps.20636
The only expired medication ever reported to cause toxicity is tetracycline (Fanconi’s syndrome). The worst that happens with other meds is lack of efficacy.
Epinephrine is 90% potent and sterile up to 2.5 years after expiration. Ok to keep expired pens as back up.
About 1% of B12 is absorbed even if intrinsic factor is not active, so oral doses of B12 of 500-1000 mcg are as effective as IM B12
In a study of almost 3,000 patients with “sinus headache” (self or physician diagnosed), 88% actually had migraines.
In patients with migraine (HA lasting atl least 4 hrs, w/ either phono/photophobia or n/v), calcitonin gene related protein antagonists may be more effective than current therapies for migraine.
For every 200 patients who are prescribed beta blocker, 1 more developed depression compared to controls. Risk thus appears to be low, weigh benefits, and consider much more likely diagnosis of primary depression.
Patients with egg allergy can receive any flu vaccine.
Expert Rev Vaccines. 2014 Aug;13:1049-57
Colace is probably no more effective than placebo in the prevention or management of constipation.
Canadian Agency for Drugs and Technologies in Health; 2014 Jun 26.
Surgical evaluation of acute abdomen is as good and perhaps better if patients have gotten IV morphine. (Note the reference is from 1992 and I was taught this in 2012!!)
BMJ 1992; 305:554-6
According to IDSA guidelines, Vanco or fidoxamicin is frontline for C diff to. Due to resistance, metronidazole is no longer preferred.
Antibiotics do not reduce infection risk in patients with prosthetic joints undergoing dental procedures.
Infect Control Hosp Epidemiol. 2017;38:154–161
The only diabetes drugs that decrease CVD are metformin, SGLT2-I, and GLP1-a. In patients with CVD these should be chosen first (though they are very expensive). DPP4, sulfonylureas, and pioglitazone are CVD neutral.
Sulfonylureas suppress glucose production but not insulin—>hypoglycemia. They are not appropriate for patients who can’t eat regularly.
Drugs and Alcohol
Perhaps my favorite of the #clinicalpearls: beer before liquor does not make you sicker.
Am J Clin Nutr. 2019 Feb 1;109(2):345-352
Even 1 5-oz glass of wine a day is associated with a decrease in healthy life, and a big decrease is seen at 2 or more a day. (Global Burden of Disease Study 2016)
Nobody knows what a “drink” is. I like to say portion. Try pouring a 5 ounce glass of wine as a bartender and see what happens.
There are two main components of medical marijuana: CBD and THC. Cognitive effects primarily seen in THC, and many products have high doses of CBD. (Sativa and Indica, two distinct types of plants, have more cognitive effects and are not recommended for treatment.)
Evidence for the effectiveness of medical marijuana is weak: 1) neuropathic pain: small improvement, more AE (Cochran’s review) 2) OUD: primarily epidemiological data 3) Spasticity: improved in MS, otherwise mixed 4) Epilepsy: small improvement, but more adverse effects.
There is very limited evidence to suggest benefit of medical marijuana in: 1) HIV anorexia (some small studies) 2) Sleep disorders: some initial improvement, no longterm studies 3) Tourette’s: may help with severity 4) PTSD: insufficient data 5) Glaucoma: ineffective
Cannabis use disorder (continued use in spite of negative consequences) is seen in about 9% of adult users, 17% of adolescent users. Risk factors are similar for other addictions.
There is likely low risk of interaction with medication and marijuana based on in vitro studies, but it does interact with CYP450 and we have limited human data.
Direct to consumer genetic tests have poor 1) Validity: 40% of “positive” results are false positives 2) Utility: Do not increase screening behaviors And may put patients at legal risk: GINA law does not apply to small businesses, military, or disability insurance.
All stool-based tests have low sensitivity for precancerous lesions (25-45%). Colonoscopy remains standard of care.
The most active patients (90th percentile vs 10th percentile) had a >20% risk reduction in 7 kinds of cancer (but study did not control for alcohol or SES)
45-60 minutes per session of moderate physical activity improved cognitive function in a large meta-analysis (esp aerobics, circuit training, and tai chi) British Journal of Sports Medicine 2018 Feb;52(3):154-160
18 years of follow up data from the Women’s Health Initiative shows no difference in mortality between HRT and placebo, but increased risk of CVD, BCa, stroke. (Average time of use 5-7 yrs.) Conclusion: it is resonable to use HRT for symptoms if no contraindications, but not for prevention of other morbidities.
Treatments for dyspaerunia in women include: 1) Lubricant (safe, modestly effective) 2) Topical lidocaine (safe, possibly more effective) 3) Topical vaginal estrogen (safe with negligible systemic absorption, most effective)
<1 lifetime death from breast cancer prevented/1000 women with dense breasts screened with u/s in addition to mammography, compared to q2yr mammography Conclusion: U/S for dense breasts is not currently recommended by any major guideline Sprague, Annals of Internal Medicine
Basics of wound care: 1. Keep wounds moist so cells can grow 2. Compression to improve venous flow 3. Control underlying insult 4. Control infection (Bacterial inhibitors: silver, silvadene-but resistance develops over time) 5. Dead tissue has to be removed at some point
Things that inhibit wound healing 1. Wet to dry dressings (these rip off healthy skin, keep moist) 2. Full strength Betadine 3. Dakins solution
Medications that interfere with wound healing include steroids (may be ameliorated by vitamin A 20,000 units), methotrexate, anti-neoplastic drugs, anti-rejection drugs
Vitamin A, B, C, and E are needed for wound healing. But if intake is adequate, supplementation has not been shown to help.
When wounds don’t heal think about 1. inadequate wound care 2. ongoing injury or infection 3. malignancy in the wound (burns, radiation, and other injuries are risk factors)—>biopsy
If a wound is already infected, topical antibiotic cream may be helpful, and>oral antibiotics. But they are not helpful for infection prophylaxis.
In rotator cuff tear, passive ROM is usually preserved. In adhesive capsulitis, it is diminished. If you get MRI, you may see rotator cuff injury in patients whose pain is primarily from AC. Surgery can make them worse. So don’t jump to MRI!
1. Neurological (thoracic outlet, cervical radiculopathy, cubital tunnel syndrome, CTS, metabolic neuropathy) 2. MSK (tendinopathy, Arthritis, injury) 3. Vascular (cardiogenic, occlusive) 4. Mass (Tumors, cysts) 5. Other (CRPS, somatic)
I was also invigorated by the enthusiasm of the super nerds of various internal medicine podcasts, like CoreIM, the Curbsiders, Bedside Rounds, and The Clinical Problems Solvers. These are huge operations putting out amazing content for the world, and I’m grateful for their dedication. Check their websites for more pearls, and the Curbsiders website for an IMPod supergroup clinical pearl round up from the conference.