, 60 tweets, 19 min read
#WAACP today and tomorrow and time for another string of #clinicalpearls! 1/
@WashACP @WashACP @HollonMD
First up: The Microbiome. The microbiome is all viruses, fungi, bacteria, and their products. No two microbiomes are the same. And for every 1 gene of ours, there are 250 bacteria genes. 2/
Dysbiosis is a maladaptive change in our microbiome. Even a few days of constant pressure (like poor sleep and diet) can change the microbiome. 3/
The microbiome has been linked to a whole host of illnesses, most famously obesity.
ncbi.nlm.nih.gov/pmc/articles/P… 4/
Fecal transplant from obese mice can promote obesity in thin mice. But the opposite had not been shown. 5/
Can you change your microbiome? Unprocessed diet compared to processed diet has been shown to lead to microbiome diversity and weight loss, even with the same calories. 6/
In NAFLD, mice fed low fat diet had complete reversal of disease, while mice on 'paleo' diet had significant improvement, and mice on highly processed Western diet had worsening of disease. 7/
Interestingly, a fecal transplant from mice receiving low fat diet to mice receiving high fat diet accelerated fibrosis. The conclusion is at this time, improved lifestyle can improve microbiome and disease process, but we are not able to shortcut this process with probiotics 8/
Kaiser has the most successful population control program for hypertension, by 1) creating a registry 2) giving providers an algorithm for mgmt and quality metrics feedback and 3) having MA visits for blood pressure checks to increase access. Control increased from 44 to 90% 9/
Implementing the Kaiser hypertension model in the Harborview population, control increased from 62 to 65% over 18 months. Wonder if the difference is insurance, access, inability to implement algorithms when cost is uncertain, or diversity of health literacy? 10/
31% of transgender patients report that none of their providers know that they are transgender. 11/
Comparing VTE risk in estrogen replacement, equine estrogen>estradiol>transdermal estrogen. @WashACP 12/
In estrogen replacement, the safest is probably transdermal estrogen +microionized progesterone, but studies are small and in postmenopausal women. 13/
In #transgender women s/p vaginoplasty, remember they still will retain prostate and attendant risks. 14/
Gender affirming surgery in #transgender men with phalloplasty commonly have stricturing of the urethra. 15/
Though transdermal patches are probably safest form of #estrogen, the dose is not high enough to promote transition of appearance in #transgender patients. But this is a good thing to push at age 50, when we start to have much higher VTE risk. 16/
Now for #vaping: we don't know the consequences of Vaping associated lung injuries, so patients should be advised to not vape anything. Interestingly, the public health consequences have long been known, in spite of FDA's unwillingness to evaluate them. 17
Presentation of #vaping associated lung injury can include respiratory and GI symptoms, and GI symptoms may proceed respiratory, so important to ask patients about vaping (time to update our intake forms??) /18
Clinicians should ask patients about #vaping in last 90 days including: brand used, content, and any modification. /19
CDC recommends chest xray on everyone with vaping exposure and respiratory symptoms and chest ct if xray doesn't correlate with symptoms. #clinicalpearls /20
We don't know the natural course of #vaping lung disease so reeval patients 1-2 weeks after illness and 1-2 months after. There may be longterm consequences due to scarring. /21
Fentanyl is increasing across Washington, associated with a 35% increase in overdose deaths over the past 10 years, which is accelerating in the last year, along with amphetamine overdose. /22
#Fentanyl is being sold widely across Washington state, sometimes disguised as #oxycodone and other #opioid pills. Standard UDS does not pick it up. /23
(So far this public health update has included #vaping, #opioids, #suboxone, #vaccines. I miss public health.)
PCV 13 has not really panned out in terms of preventing pneumonia. We may shortly be recommending PPSV23 only. 24/
HPV vaccine is recommended through age 26 for anyone not adequately vaccinated by ACIP, and through 45 with shared decision making. A nice update of ACIP recs here
cdc.gov/vaccines/acip/… 25/
The severity Australian flu season never correlates with the severity of our flu season. Last year was mild there, and 43 million illnesses here, appr. 50,000 here. Ignore inflammatory news articles. 26/
Back at #WaACP19 for iron deficiency talk. Remember low MCV can be due to
1) Low iron (chronic dz, iron deficiency)
2) Globin disorder (thalassemia)
3) Heme disorder (sideroblastic, lead poisoning) 27/
Diagnosis of iron deficiency should prompt looking for sources of bleeding. It is unlikely that diet, even vegetarian diet is adequate to explain. Consider LARCs for women. 28/
#clinicalpearls about iron
1) Taking iron on an empty stomach increases absorption slightly, but increases side effects
2) Vitamin C may help, but only small doses are needed.
3) Milk only minimally inhibits absorption
4) Taking iron every other day is better than daily 29/
Iron deficiency in heart failure is associated with increased mortality, but oral iron did not improve outcomes. Effect of IV iron is still up for debate. 30/

Now for headache! The classification of migraine is simple. Consider asking patients to keep a headache diary to facilitate diagnosis. 31/
To be a migraine, HA must include one of the following:
-Nausea  or vomiting
-Phonophobia 32/
In headache, don't forget red flags. 33/
How to explain medication overuse headache to patients:
"Medications like tylenol and ibuprofen can treat headaches but if used too often, medications can CAUSE headache. Avoid using medications more than 10 days per month. And opioids and barbiturates make headache worse." 34/
And we are back with #diabetes
The big shift is using GLP-1 and SGLT-2 after metformin, for CVD effects as well as weight loss
#WaACP2019 #Clinicalpearls

Image from diabetes care vol 42 s 1 2019
GLP1 inhibitors (-utide)
-stimulate insulin production
-reduce postprandial rise in glucagon after meals

As a result, lead to weight loss. Also have been found to reduce CVD events. 36/
Comparing GLP1 to DPP4 (iptins)
-promote weight loss
-improved CVD outcomes
-daily injection vs pill
-nausea and vomiting
-much more expensive

Bottom line: if tolerated and affordable, they are preferred 37/
Now for SGLT 2 inhibitors

Mechanism of action: promote excretion of glucose 38/
SGLT 2 inhibitors (-glifozin) also improves heart outcomes, including hospitalization for heart failure (probably because it acts as a powerful diuretic). But effect is probably not as powerful as GLP1. Renal outcomes greatly improved.39/
Important to balance benefits of SGLT2 with adverse events and side effects, especially dehydration, hypotension. Consider stopping other diuretics. 40/
Love these summary slides getting into the nitty gritty of different SGLT2 inhibitors and GLP1 agonists 41/
🚨🚨🚨Everything you need to know about diabetes updates in three bullet points. 42/
Time for an update in lipids. I am feeling some lipid whiplash because ldl goals are back, baby, and lower than ever. 43/
The groups that benefit from statins remain the same. But I think that group of projected risk is still up for debate right? @kennylinafp 44/
Consider nontraditional risk factors when deciding if starting a statin
-Inflammatory rheum dz
-South Asian ancestry
-Fasting triglycerides>175
-Coronary artery calcium score 45/
The primary reason to check coronary artery calcium is to decide if they will benefit from statin. -ASCVD risk<7.5% no statin needed
-Risk >20% start a statin
-Risk 7.5-20%: if CAC score>1-->start a statin. 46/
A random clinical pearl here from the jeopardy session because Cannabis Hyperemesis has been on the brain thanks to my NPR article on marijuana. Topical capsaicin may be a reasonable first line treatment

ncbi.nlm.nih.gov/pubmed/3110448… 47/
Appr 4.6 billion in costs a year related to burnout, and higher among younger physicians (<55)

46% of physicians are planning to change their careers
49% would not recommend their career to their children. 48/
The suicide rate for physicians is 28-40/100,000. The suicide rate for combat veterans is 28/100,000

@johnlimouze @MDaware @browofjustice 49/
While there are high economic burdens of burnout, estimates of increased errors are uncertain, driven by unsophisticated analysis and systematic publication bias. @laxswamy 50/

Read this 🔥essay by @sarahgcandler freshlook.annals.org/2019/10/were-n…
"It is counterproductive to ask physicians to “heal themselves” through superhuman levels of resilience even as the practice environment continues to deteriorate." @dyrbye 51/

The OVIVA study compares oral to IV antibiotics in patients with chronic bone or joint infections and found no difference in treatment failure, and shorter hospitalizations in oral antibiotics. Guidelines unlikely to change until it is replicated. 52/
IDSA guidelines are now to not use procalcitonin to guide antibiotic therapy @DavidAScales tell Genevieve I was wrong 😮 53/
AUGUSTUS trial in patients with afib and ACS found in patients on clopidogrel, apixaban improved outcomes, warfarin did not, and aspirin did not. 54/
AFIRE study found that rivaroxavan is better than rivaroxavan plus antiplatelet therapy 1 year after last CVD event. 55/
Discontinuation of DOACs without heparin bridge 1-2 days prior to procedure and resumption 1-2 after is likely safest course, but data is new. 56/
One hundred percent going to change my practice: prescribed lidocaine 5% patches cost $250, and 19 bucks for 4% at Walgreens 57/

In adolescents given opioids by their #dentist, 5.8% developed an opioid use disorder in the next 12 months, compared with 0.4% in controls (!!!) 58/58
That's it for me! Thanks @marcottl @HollonMD @WashACP @ACPinternists for a great conference! Use @threadreaderapp if you want an easy to read version of this thread 📜
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