Live long and Prosper: Longevity and Blue Zones (Perez, 2/21/2024)

 A recording of this presentation can be found HERE.

***

Many thanks to Dr. Jesse Perez for an excellent talk on longevity and "the blue zones". A full summary post will be available here soon.



Colorectal Cancer Screening (Toub, 2/14/2024)

 A recording of this presentation is available HERE

***

Many thanks to Dr. Danny Toub, who gave an excellent Grand Rounds presentation this week titled Colorectal Cancer Screening: What PCPs need to Know. A recording of the presentation is available above. 

My notes:

Colorectal cancer (CRC) is the #2 cause of US cancer deaths overall in men and women, the #1 cause of cancer death in men under 50. In 2024, we are predicted to have more CRC deaths than COVID deaths. In theory, CRC is an ideal disease to screen for because the slow development from polyp to cancer -- on average, 10 years -- means that early detection can actually lead to lives saved; if caught early, death can be prevented. 

Through many efforts, we have increased our CRC screening over the last two decades, and in doing so, we have  decreased CRC mortality. Unfortunately, it's not by a lot: a 2023 study published in JAMA, found that CRC screening only extends a person's life by an average of 110 days (see forest plot below). 

Despite what seems like a perfect set-up for screening success (a slow growing cancer with multiple tools for early detection), the reality is that CRC screening doesn't have great evidence for all-cause mortality benefit either. Sigh. Plus, the number needed to screen (NNS) to prevent one cancer death is not small -- 450 with q5 year flex sig and 900 with annual FOBT. Double sigh. 

It is important to note, however, that current quality measures do incentivize us to screen for CRC-- there are payments attached to our doing so, through both state and federal programs. So, to be clear, we screen to 1) decrease CRC mortality and 2) because our systems are set up to do so. 

How do we screen? 

Many of us are well aware that there are several CRC screening modalities, which are essentially considered equivalent in terms of CRC detection rates:

  1. q10 year colonoscopy (most invasive, most cumbersome, but benefit of being able to remove polyps during the procedure)
  2. Annual FIT test (has replaced the older FOBT test)
  3. stool DNA tests (frequency variable)
  4. q5 year flexible sigmoidoscopy (screens less of the colon but does not require anesthesia and can be done by primary care clinicians, if trained)
  5. Emerging serum tests (not yet FDA approved)

Current USPSTF Guidelines (2021) recommend shared decision-making to decide which modality to use; there are a number of studies showing many different screening tools decrease CRC mortality (with colonoscopy slightly better than the other modalities in detecting cases and averting death). More invasive screening tools have more serious potential harms, but all positive screening tests lead to colonoscopy, as the gold standard for diagnosis of CRC. Of note, there is a lack of screening colonoscopy access in our county, and most of the community health centers (and even Kaiser) default to non-invasive screening via FIT testing. As an aside, SRCH is moving to a pilot program screening with a more expensive DNA FIT testing q3 year (rather than q year) starting next month. 

Who to screen?

Current USPSTF Guidelines (2021) make a Grade A recommendation for all adults 50-75, with a Grade B recommendation for adults 45-49. They make a Grade C recommendation for people 76-85 with shared decision-making based on 10 year life expectancy (i.e. healthy 76+ year adults should  be selectively screened).

Whereas there is a statistical benefit to screening people 45-49, the AAFP actually disagrees with the USPSTF and recommends  screening starting age 50 with "insufficient evidence (I)" to recommend screening before then. The 2023 ACP guidelines are slightly less in terms of screening frequency, recommending a q2 year FIT test (vs 1 year per USPSTF).

What works?

Dr. Toub spent some time talking about how we get patients to get screened -- possible interventions include one on one conversations, client reminders, group education, provider prompts, navigation, EHR enhancements, but in the end, Dr. Toub advocates for all kinds of ways:

  • give nudges
  • use decision aids
  • give options (not too many)
  • tell stories
  • make personal recommendations
  • send serial text messages
There are lots of different ways to remove friction to opt-out defaults. This includes not requiring physician visits to be screened, giving people deadlines, and helping people to structure their choices. This also includes having PCP mention the importance during the visit -- once again, what we say matters.

For more ideas, see some of the images below. Also note that The Community Guide , supported by the same folks who sit on the USPSTF and gives evidence-based recommendations for what works to improve population health, recommends making sure that materials in given in the correct language, that transportation assistance be made available, and that dedicated patient navigation helps in low-resourced settings-- increaseing rates of colonoscopy and FIT by 13 and 12 percentage points respectively.



Dr. Toub ended his information-packed presentation with the suggestion that maybe we are thinking about CRC screening all wrong. In some well-resourced countries with national health plans, CRC screening is approached differently: rather than screening EVERYONE over a certain age, this BMJ guideline, published in 2019, suggests using a risk-based calculator to determine who should be screened. This suggests NOT screening anyone with <3% 15-year risk (based on this RISK CALCULATOR), which takes into account age, smoking and alcohol use, BMI, cancer hx among other things) to calculate that risk. IT also uses decision aids to help in determining screening decisons (see below):


What is the future of CRC screening?
It's AI, of course! Watch the last few minutes of Dr. Toub's talk for breaking news on AI in CRC screening. I think I'll leave it out of my summary today, as it is all still just starting and not really moved into standard practice.

For now,  remember these take home points: 1) CRC screening decreases deaths from CRC but does NOT improve all-cause mortality, 2) multiple screening modalities at multiple different intervals are considered equivalent, so use shared decision-making with your patients to meet their needs, and 3) use lots of different nudges to get your patients to follow-up with screening, but don't forget to mention the importance of CRC screening yourself!

Until next week. . .



Kink and BDSM for the Medical Provider (Grimley 2/7/2024)

A recording of this presentation can be found HERE.

***

Many thanks to Dr. Grimley, who gave their senior Grand Rounds presentation on a topic that most of us would be nervous to touch with a ten-foot pole -- alternative sexual lifestyles -- also known as "kink" and "BDSM." Dr. Grimley shared the prevalence and range of alternative sexual practices in our country and showed data about how people's sexual behavior influence health, illness, and experiences of the healthcare system (no surprise). Many healthcare providers don't know enough about alternative sexual practices to even begin a conversation, much less to be able to provide comprehensive care. Ultimately, they encouraged us to not shy away from learning about all the kinds of sex our patients are having so that we can better serve them. 

First, let's define "kink" --the practice of unconventional or unusual sexual preferences or behaviors, fantasy or desires. These are behaviors that are influenced by political leanings, cultural upbringings, and religious beliefs and vary widely among individuals. What about "BDSM"? The BDSM Triskelion, created in the 1990s defines the three pillars of BDSM: Bondage and Discipline, Domination and Submission, Sadism and Masochism. But there are many other "kinks" outside these tenets. And not all of them are sex-related

Dr. Grimley started by laying out the dominant "sex hierarchy" -- reading a passage from a 1984 piece by Gayle Rubin's "Thinking Sex: Notes for Radical Theory of the Politics of Sexuality.

"Good" sex according to this hierarchy is heteronormative, monogamous, home-based sex. "Bad" sex is trans-sex, fetish-sex, public sex. If we, as healthcare providers,  are acculturated to accept these norms, then we tend to disregard a decent subset of the population that engages in alternative behaviors, and in so doing, miss opportunity to improve people's health. From this perspective, there may be an uninformed assumption that kink is happening without consent and is potentially harmful to participants. These are biases we carry. 

In fact, Dr. Grimley said, every interaction in the kink community must be grounded affirmative consent (i.e. "opt in"-- we talked about what was going to happen before it happened and I agreed that I want to participate), rather than the more traditional, heteronormative "opt out" (i.e. person pushes forward with sexual advances without aforementioned conversation, participant is supposed to say "no" if they  don't want to mid-act).

Core principles of kink:

  • Consent: mutual, iterative, can be revoked at any time, enthusiastic yes!
  • Pre-negotiation: talk about everything
  • Community: strong cultural values (see above), historic roots, and social networks that guard against violence/abuse
  • Knowledge
  • Producing good experiences

Here are some important terms to learn in the kink community:

  • safe word: a word agreed on before the sexual act beings that, when spoken, stops any sexual act/scene immediately
  • scene: a kinky encounter or experience, often planned in advance, that can last for minutes, hours or days
  • aftercare: time and attention given to partners after a scene is complete
  • drop: a feeling of mental or physical exhaustion after a scene
  • hard limits: what someone will absolutely not do, does not want to do
  • soft limits: a behavior or action someone is hesitant to do but may try
  • munch: a public meet up of people in the kink community
  • roles: top/dominant/dom/domme/sadist + bottom/submissive/sub/masochist
  • dungeon: a room or venue specifically for BDSM activities
  • play: kinky activities or interactions
  • toys: implements or tools
  • edge play: greater risk, higher intensity, or considered more transgressive than common play
For providers who may be concerned about how to distinguish BDSM (which may involved marks on skin, restraining partners, etc.) from abuse/intimate partner violence, Dr. Grimley encouraged us to very simply "ask the patient". Any sexual act or harm done without consent is abuse.

After giving us a education on the vocabulary and core principles of kink, Dr. Grimely went on to share with us some of the statistics showing kinksters as an unrecognized sexual minority. But activities associated with kinking are perhaps less rare than you might suppose: 21% of participants in the 2015 Sexual Exploration in America Study had been "tied up", 15% had participated in "playful whipping", 31.9% reported "spanking" during sex, and 3.4% reported having gone to a BDSM party or dungeon. In another study, sponsored by Durex condoms, 10% of participants reported SM and 36% bondage in their sexual acts.

Kinks were surveyed in the 2016 Kink Health Survey, revealing some startling health disparities: 10x national average of HIV , 5x the national average (24%) had attempted suicide. Interestingly enough, 85% of kinky people said that their involvement in kink had But many people are not "out" with their healthcare providers -- there is a lot of anticipated stigma, only 38% were out as kinky, and in another study 58% had not disclosed to their provider (even lower for BIPOC patients). Perhaps unsurprisingly, many report previous disappointing experiences with the system.

How should providers talk to patients about kink? Invite your kink patients to "come out". First, know the language. Second, do not be afraid to ask the question: "Is there anything else you want me to know about your sexuality?

Also, ask about mark on people's bodies. "Where these marks consensual?" and "I noticed bruises on your buttocks. Can you tell me how you got them?" are two simple ways to enter into that conversation.

Dr. Grimley ended their presentation by running through some specific unintentional injuries that can happen in kink and BDSM play, and some suggestions on how to help mitigate risks. These include but are not limited to:
  • Risks in bondage: rope constriction, strangulation and circulatory issues. Risk mitigation includes bondage release methods, soft rope, breaks to allow for circulation (after 20-30 minutes), never leaving someone unattended when bound, stopping immediately in the case of loss of sensation, and even using a squeaky toy to stop/drop as a non-verbal communication
  • Risks in impact play of unintentional injuries. Risk mitigation includes hitting fleshy and fatty areas (buttocks, thighs, calves); avoiding and watching out for "wrapping", and cleaning and dressing any broken skin
  • Risks of wax play: skin issues, burns, and unintentional fire. Risk mitigation includes moisturizing skin and/or shaving hair prior to wax play; not wearing flammable perfumes or colognes, avoiding skin that is already problematic (eczema, psoriasis), choosing the correct materials (bees wax burns the skin, shea butter or soy is safer and lower heat)
  • Risks of electricity play: not suitable for those with heart disease or electronic device or implant, not suitable with water/fluids, avoid mucous membranes, care with metal piercings
  • Risks of breath play: very high risk and potentially deadly. Risk mitigation: avoid using anything other than a hand, never put pressure on the windpipe, never do breath play alone.
Resources:

Neonatal and Infant Eruptions (Sugarman, 1/31/2024)

 A recording of this presentation can be found HERE

***

Many thanks to Dr. Jeff Sugarman, local dermatologist, who gave an excellent Grand Rounds presentation this week on Neonatal and Infant Eruptions: when to worry and when to reassure. See above for the link to watch it.

My notes this week come in the form of a dermatologic photo quiz for your testing pleasure. Answers are below the final photo and question.

1. What is this neonatal rash categorized by fragile pustules that erode very quickly, leaving behind brown collarettes with post-inflammatory hyperpigmentation. It can be present at birth and last days to weeks. More common in neonates with more pigment. Benign.

Source: DermNetNZ.org
2. What is this benign newborn rash often caused by over-bundling newborns? Erythematous papules and pustules often occurring on covered portions of the skin. Totally benign.

Source: DermNetNZ.org

3. What is this benign rash of the neonatal period, often during the first 1-3 weeks of life, acneiform, often occurring on the face and upper chest and scalp. It has NO comedones and is the result of an inflammatory reaction. Treatment is either topical antifungal or  topical 1% hydrocortisone, though no treatment is also acceptable. Often mistaken for neonatal acne, which presents later AND always has comedones.

Source: DermNetNZ.org
4. What is this benign self-resolving rash that is notable for pustules on feet and hands that can last for months, come and go in crops, and look a lot like scabies (but when scraped show no mites). This will resolve on its own but can take months to do so?

Source: DermNetNZ.org
5. What is this papule on the scalp, often solitary with a unique yellow color? The papule is self-resolving but can last years (5-10) before it disappears. Can sometimes occur in multiples and have extra-cutaneous involvement, with particular issues in the eye. In rare cases, multiple of these are associated with leukemia. 

Source: DermNetNZ.org
6) What is this condition characterized by peau d'orange (texture). Often missed by primary care clinicians. Usually solitary but can be present in sheets. Featured by pockets of histamine -- Darier's sign when stimulated (scratched or rubbed), can be accentuated. Can last for years. Activated by cold/hot/rubbing. 

Source: DermNetNZ.org
7) There are four variants of #6: 1) solitary (most common) 2) urticaria pigmentosa with peak onset first year of life 3) diffuse cutaneous mastocytosis and 4) most rarely mast cell leukemia. This is one of those variants, which features flushing, hives, pruritis, blisters and sometimes diarrhea (due to mast cells in the GI system). Treatment involves: antihistamines, oral cromolyn for GI symptoms, consider epi pen. If a high burden of disease, consider monitoring serial serum triptase.

Source: DermNetNZ.org
Of note, activators of mast cells include: alcohol, aspirin, narcotics (including codeine), some contrast agents, and hot/cold/sunlight. Consider limiting these triggers in patients with mastocytosis.

8) What is this eyebrow bump, often seen on the lateral brow, caused by a sequestration of ectodermal tissue during embryogenesis? It is usually present at birth but not noticed. It is rubbery,  not compressible, not tender. It is also not a true cyst. 

Source: DermNetNZ.org
Of note, you need to worry when the location suggests a CNS connection, which is always in the midline (25% of midline dermoids have a CNS connection). If a dermoid cyst is leaking clear fluid, this is likely spinal fluid and is BAD. It is good to remember that the neural tube closes in a series of discontinuous zippers, and there is no CNS connection in any other place than the "hot spots" where the zippers close. 

9) Do you have to worried about a CNS connection in this infant with a dermoid cyst?

Source: https://webeye.ophth.uiowa.edu/eyeforum/cases/115-dermoid-cyst.htm

Of note, dermoid cysts on the lateral brow are generally removed after a child's second birthday. They should be referred to pediatric plastics for the excision for best cosmetic effect. 

10) What vitamin deficiency -- often due to inadequate intake and appearing around the time a baby is weaning -- leads to  this psoriaform rash (well demarcated) on the face and in the diaper area? Hint: the name of the rash is acrodermatitis enteropathica.

Source: MDEdge
11) What is this uniquely pediatric form of this autoimmune disorder, often characterized by raccoon eyes (periorbital accentuation of erythema) and diagnosed by maternal serologies? Hint: photosensitive, 50% of cases have congenital heart block. Rare (10%) have hepatobiliary disease and even rarer (1%) thrombocytopenia.

Source: DermNetNZ

Source: DermNetNZ
12) Cool pearl!! Alternate treatment for umbilical granuloma. Aside from silver nitrate, a study showed that a single application of THIS common household item, covered with bandage tape can resolve this problem. What is the common household item?

13) What is this scary looking fixed erythematous rash (lasting 24+ hours) that often appears on the face, arms and legs. Child tends to be non-toxic appearing, and the trunk is spared. It resolves on its own. It is in the HSP spectrum, but has no cutaneous findings.
Source: DermNetNZ
14) Last but not least, what is this rash in a 6 week old baby that did not respond to topical steroid, topical anti-fungal, systemic antihistamines, or antibiotics?


And the bonus final: how do you treat it? Treatment of infantile scabies, even in children under 2 months and <15kg is the same as for children >2 months and >15kg (though the drug labeling does not promote this). Per Dr. Sugarman, you can confidently treat with either oral ivermectin OR topical permethrin safely and effectively in neonates.


********************
No cheating!!! Don't look down here until you have really thought about each of the photo questions above!!

Answers:

1) Transient Neonatal Pustular Melanosis

2) Miliaria Rubra

3) Neonatal cephalic pustulosis

4) Acropustulosis of infancy

5) Juvenile Xanthogranuloma

6) Mastocytosis

7) Urticaria pigmentosa

8) Dermoid Cyst

9) YES! This baby needs imaging (CT or MRI) to rule out encephalocele or mucocele prior to excision).

10) Zinc Deficiency: Treatment is rx zinc 3mg/kg/day

11) Neonatal Lupus Erythematosus

12) Table Salt!! A study of 17 infants with umbilical hernia found 100% resolution  (17/17) with a single application of table salt, occluded with medical bandage x 24 hours.

13) Acute hemorrhagic edema of infancy

14) Infant scabies, characterized by vesicles and pustules on the palms and the soles

Integrative Medicine for the Skeptic (Meckler, 1/24/2024)

 A recording of this presentation is available HERE

***

Many thanks to Dr. Gabriela Meckler, senior resident for her excellent presentation titled Integrative Medicine for the Skeptic. She covered the evidence behind some important herbs and supplements for common primary care conditions.

Dr. Meckler wanted us to feel comfortable knowing the data for some specific integrative remedies for common medical problems:

  • Ginger for nausea and vomiting of pregnancy 
    • 500-1500 mg BID to TID
    • A metanalysis of 10 RCTs found that ginger at these doses is as effective as pyridoxine and metoclopramide, and dimenhydrinate
    • Most common side effect: heartburn
    • There is also some evidence for ginger in migraine, dysmenorrhea, metabolic syndrome, respiratory diseases, and milk volume in the early post partum period
    • Take home: consider recommending ginger either alone or as an adjunct to the traditional rx'd in pregnancy. Stop ginger when nausea starts (to prevent heartburn)
  • Daily Magnesium for migraine headache prophylaxis 
    • 400-600mg/daily
    • Safe in pregnancy
    • Most common side effect: diarrhea
    • PO magnesium alleviates frequency and intensity of migraine (statistically significant)
    • IV magnesium has the best evidence for treatment of acute migraine, but oral has good evidence as ppx
      • IV magnesium helped migraine within 15-45 minutes after initial infusion, and lasted up to 24 hours
    • Additional supplements that may be useful in migraine: 
      • Riboflavin 400mg/day reduces headache from 4 days/month to 2 days/month (must be taken for 3-6 months), 
      • Butterbur (but careful, must come from trusted source to remove pyrrolizidine alkaloids)
    • Ginger 400mg + ibuprofen, can also be used for dysmenorrhea (2 days prior to onset of menses)
  • Side note on Licorice safety in pregnancy (licorice is often found in combination in ginger tea products)
    • Licorice contains glycyrrhizin, which can act as a mineralocorticoid
    • Side effects: hypertension, hypernatremia, hypokalemia, renin suppression
    • Glycyrrhizin is often present in low doses in these teas, about 31mg/cup of tea. 
    • A longitudinal cohort study in Finland found licorice consumption in pregnancy to be associated with  lower intelligence and memory scores, higher HPA-axis activity, and higher incidence of ADHD in offspring. This high dose of glycyrrhizin was >= 500mg/week, So a pregnant person would have to drink upwards of two cups of tea containing licorice every day to get an adverse event

  • Turmeric for osteoarthritis pain
    • 100-2000mg daily for knee OA
    • In a study of turmeric vs. paracetamol 500 BID vs. 650 TID x 6 weeks for OA, both arms showed decrease in pain and stiffness, increase in function =equivalent to tylenol!
    • 1000mg should be paired with 6 mg piperine -- black pepper extract -- (just a tiny amount) for improved absorption 
    • Warming up turmeric increases absorption and likely efficacy
    • Most common side effect: GI upset, diarrhea

Recommended Resources for practitioners and patients 

Game Changers: Groundbreaking Studies in OB and Peds 2023 (Jimenez, Bernard-Pearl 1/17/2024)

 A recording of this presentation can be found HERE

***

There is almost nothing that gets me more professionally excited than an in-person gathering of teachers and learners reviewing the medical literature and discussing the evidence for how we should best be practicing family medicine. This week's Grand Rounds was all of that -- a fast-paced review of a few important 2023 studies in Obstetrics and Pediatrics -- studies that either reinforce a practice and/or change our practice.

The two faculty who spoke did a fantastic job! Dr. Douglas Jimenez focused his Ob portion on hypertensive disorders in pregnancy, including: ASA for Pre-E prevention, management of chronic hypertension in pregnancy, and intrapartum BP management. Dr. Deirdre Bernard-Pearl spent her peds time on cannabis intoxication and adolescent depression, with a particular emphasis on exercise and patient-centered counseling. 

All of it made me proud to be a family doctor. A link to a recording of their presentations is available above. If you want the take-homes, here they are:

OB (Douglas Jimenez):

1) Aspirin definitely works to reduce Pre-Eclampsia! For maximum effect, ASA should be dosed a minimum of 100 mg daily (in the US, that means 160mg = 2 baby aspirin), ideally started between 12-16 weeks (closer to 12 the better, but ACOG recommends starting as late as 28 weeks), and taken at night. ASA should ideally be stopped 1 week prior to delivery.

2) Good BP control in chronic hypertension in pregnancy is associated with better outcomes-- for the baby and the mom (NNT=14). Contrary to common practice, you should treat elevations in pressures with medication for BPs above 140/90. There is even some evidence that a lower goal (<130/80) is associated with even better outcomes. This BP management does not lead to SGA babies.

3) Intrapartum management of elevated BPs has historically been more based on practice comfort than science. There is evolving evidence that BP management should be considered using a physiological approach. Pre E should probably be considered as two distinct entities: early onset (vasoconstrictive) and late onset (hyperdynamic). As such, hydralazine  -- a potent vasodilator -- may be a better BP med choice intrapartum for vasoconstrictive hypertension, and labetalol a Beta blocker may be a better BP med choice for hyperdynamic hypertension. As an aside, oral nifedipine may actually be as good as (or even better) than IV BP meds intrapartum.

4) For volume overloaded patients with Pre-E who are post partum and continue to have elevated BPs, a 5 day course of furosemide may help both problems. Dosing is 20mgx 5 days.




Pediatrics (Deirdre Bernard-Pearl)

1) Edible MJ products have skyrocketed in the last decade, as have documented pediatric marijuana toxicity, which increased 13X (!!) from 2017-2021. Lethargy is the number one effect of accidental edible MJ consumption in children. Safe storage of edibles should be integrated into well-child care preventive care.

2) Adolescent depression rates remain high since COVID -- as 2X the rate prior to the pandemic. Exercise is a potent treatment for adolescent depression. A 2023 Meta-analysis of 13 studies found that exercise had SAME strength of effect as SSRIs for depression treatment. This review concluded that 20-60 minutes of exercise, 3x per week, for at least 12 weeks had the largest and most sustained effect. Group exercise is more effective than individual exercise, and mixed exercise (aerobic and non-aerobic) is superior as well.

3) We can definitely do better assessing and treating our teens with depression and anxiety! See the table below to see how poorly we are doing, and don't forget to use a screening tool, counsel about exercise and sleep, refer for CBT (we know, mental health is hard to access), and see teens with new diagnosis of depression and anxiety WEEKLY until they are stable.



Thanks again to these 2 excellent teachers for their 2023 Game Changers. Stay tuned in coming months for a medicine version of the same (Inpatient and Outpatient).

Healing through Strengths, Movement, and Culture (Fleg, 1/10/2024)

 A recording of this presentation is available HERE.

***

Deep gratitude for today's Grand Rounds, an impactful presentation by Dr. Anthony Fleg from  University of New Mexico in Albuquerque, about changing the way we assess and treat patients by assessing for their strengths, rather than their deficits. 

I would say this is a presentation better watched and absorbed than summarized, but here are my notes for those of you who prefer them.

Dr. Fleg encouraged us from the beginning of his presentation to consider how we are trained in medicine to assess and manage patients by understanding their "problems" or "deficits" rather than to understand their strengths. 

To begin, he asked us to consider one of the patients we may have struggled to serve effectively in recent weeks and to list out their problems. After about a minute, he then asked us to list out this same patient's strengths. Once we were done with the exercise, he made us do a self-assessment.

  • What was our ratio of problems to strengths for our patient? (on average, he said, physicians are able to list 6 problems to 1 strength)
  • Did we have trouble thinking of strengths? It wouldn't be surprising, we aren't trained to look for them.
  • How might we care for our patients differently if we ask "what is right with you?" instead of always "what is wrong with you"?          
  • How can we possibly ask patients to use those strengths if we do not know what they are? 
  • How can we change even very complex medical situations into achievable goals for patients -- particularly for historically marginalized patients, e.g. BIPOC patients, but really for everyone?    

Dr. Fleg spoke about how social workers are trained to do something called "asset mapping" with their clients, which is exactly what it sounds like -- looking for people's strengths, even under challenging conditions. The idea is that, by understanding assets, we  empower people in communities to build on what they do well in order to improve their health. 

Take, for example, Dr. Fleg's wife's 95 year old Navajo grandfather, a traditional medicine man, who died of COVID early in the pandemic. This person, Grandad Bahe Manybeads, looked at from a traditional medical model -- a deficit perspective -- had many things stacked against him: low English proficiency, low educational attainment, minimal eye contact, hard to communicate with, doesn't share, geriatric. But what happens if we flip his deficits into strengths: he is Navajo speaking, culturally competent and highly educated in Navajo culture, a recognized community healer, humble and modest, stoic and strong, wise elder, a physical strong healer who still performs all night healing ceremonies well-into his nineties. How does that lens change how we treat his medical illness?



By not focusing on strengths, Dr. Fleg argues, we perpetuate racism, lose key chances to empower patients to heal from within, dehumanize patients and ourselves, and feed into our own burnout. Deep breath. Take that for consideration. Consider how focusing on patient strengths may actually feed you and sustain your practice.

***



Dr. Fleg ended his thought-provoking presentation on leading with strength on a reminder of  the decimation of the Indigenous people in California (from the state of CA court's website):

  • From 1840-1870, the California indigenous population decreased from 200,000 people>> 12,000 due to disease, removal and death. This was not accidental.
  • Even still, CA has the largest Native American population in the country (12% of all Native Americans in the US live in California)
    • Over 1/2 of California's indigenous people are descendants of those displaced due to mass relocation to urban centers (SF and LA)
  • Systematic oppression, codified by law:
    • Any Indian declared vagrant could be thrown in jail 
    • Indian children were allowed to be sold as slaves
    • Laws explicitly prohibited Indians from testifying in court against a white person
  • While there are currently >100 tribes recognized in CA, there are also tribes that were erased by federal policy. Be careful with each individual's identity and passing value judgements without understanding
In summary, while we may be medically proficient, we may also be culturally and historically deficient in understanding people's contexts. Be sure to consider be peoples contexts and make an effort each day to care for people, rather than treat patients.

I'll end on a state from Dr. Fleg that was particularly poignant for me: "We decolonize ourselves when we are strength-based and that is good for ourselves and for every single person we care for."

An Integrative Approach to Substance Use Disorder (Adachi Serrano, 12/13/2023)

 A recording of this presentation is available HERE

***

Many many thanks to Dr. Katya Adachi Serrano, SRFMR Alumna class of 2014 and Integrative Medicine Fellow (2015) on An Integrative Approach to Substance Use Disorders. Dr. Adachi Serrano blends her family medicine background with training in herbal and integrative medicine, plus a board certification in addiction medicine. In so doing, she spoke thoughtfully on topics from buprenorphine  induction to  herbal supplements for SUD to spiritual support. This is definitely a presentation worth watching! The link is above.

For those of you who prefer the written word, my notes below:

Dr. Adachi Serrano took us through the case of a young man suffering from alcohol use disorder (AUD) and repeated episodes of alcohol withdrawal syndrome (AWS). She started by grounding us in the concept of the tribal MAT Echo Clinic Wellness Wheel (see below): consideration of the mind, body, spirit, and community, as a means to think about the care of patients with SUD. 

Tribal MAT Echo Clinic "Wellness Wheel"

The Body

Medication assisted treatment -- or medication for addiction treatment (MAT)-- is the gold standard for treatment of patients with many SUD. SUD is just like any other chronic disease, Dr. Adachi Serrano argues: SUD has a gradual onset, affects all races/ethnicities/SES, it relapses and remits, is partially relieved by lifestyle changes. And so, we should approach SUD like any other chronic disease.


AWS; Typical treatment for acute alcohol withdrawal involve either long-acting benzodiazepines (chlordiazepoxide or diazepam), or gaba-ergic meds (e.g. gabapentin) tapered by either dosing interval or amount daily. See these patients daily, says Dr. Adachi Serrano.

AUD: The best medication option we have for chronic management of AUD is naltrexone, which decreases cravings and suppresses the pleasure people get from drinking ETOH. This can be dosed 25-50mg qhs, Precaution with: acute hepatitis, liver enzymes 3-5x normal, decompensated cirrhosis, active opioid use. Common adverse events include headache, nausea, drowsiness. Some people also experience anhedonia. 

Another option is long-acting naltrexone (aka vivitrol), which is an IM injection 380mg given q4 weeks (after a 4 day PO trial of naltrexone oral). An alternative maintenance medication is acamprosate, which is dosed 666mg TID (2 tabs of 333 TID). Side effects include diarrhea and adherence. A third option is Gabapentin 100-300mg daily to TID.

OUD: Standard treatment or opiate withdrawal syndrome (OWS) is supportive measures (e.g. clonidine, hydroxyzine, trazodone, ondansetron). Maintenance for OUD is either suboxone or methadone, usually dosed 2-4mg q2-4 hours, max 8mg on D#1. Sublocade, a long-acting injectable buprenorphine, may be available to better-insured patients, dosed at 300mg SQ x 1-2 doses, then 100mg q28 days. Finally, naltrexone is a third maintenance option, but you must be opioid free for minimum of 5 days (ideally 7-10 days). This is idea for patients who do not use opioids. Clonidine is often used as an adjunct during the withdrawal phase 0.1-0.3mg q1 hour. 

Dr. Adachi went on to talk about the value of herbal supplements for SUD, as an adjunct to the standard allopathic medications. Three main categories of herbs: adaptogens, nervine, and nutritive. 

1) Adaptogens help the body to adapt to stress, "normalizing influence on physiology". They tend to be derived from the roots of plants that grow in hardy environments and rugged terrain, and their effect is thought to be due to the hormones the plants themselves have generated in these rugged environments.

  • Ashwagandha, dosed 400-500mg BID helps to normalize GABA activity in the body. This can be helpful in all forms of SUD. Precautions: nightshade allergy, hyperthyroid
  • Rhodiola, derived from arctic regions, is very stimulating. Dosed 100-200mg. Caution: can sometimes be too stimulating, especially in stimulant use, w/d and recovery. Thought to "get the fire burning again"
  • Eleutero aka Siberian Ginseng, increased dopamine, thereby increasing energy levels
  • Licorice also can be helpful, sweet and easy to take
2) Nervines: have a direct effect on the nervous system. The following nervines are considered "calming nervines" which can be helpful in recovery:
  • Skull cap, a GABA agonist, 850-1200mg daily in tincture (very concentrated)
  • Valerian, another GABA agonist
  • Lavender, 1-2 tsp in 8 oz of water
3) The last category are the Nutritives, which are nutrient rich and thought to support the body. One of Dr. Adachi's favorite is milky oats extract, which is nourishing to the nervous system and also increases dopamine. 

The Mind

Mental health treatment should be considered an essential part of MAT. All patients with SUD should be screened for underlying mood disorders (including anxiety, complex PTSD), learning disabilities, and ADHD. These underlying disorders should be treated with both medications and therapy.

Trauma: 90% of patients with OUD report a history of trauma, 80% have child sexual abuse, emotional abuse, or violent trauma. We should see SUD as a marker of trauma and work to normalize  in a therapeutic way. Here Dr. Adachi Serrano used the image of a record playing in our ear-- "our early experiences teach us messages, like a record playing in our mind" that we may not even know is playing. 


This is where mindfulness practice comes in, also CBT. Introduce the concept of brief CBT for a non-therapist (for those of working in primary care practices where mental health services can be hard to come by). Dr. Adachi Serrano took us through brief CBT (see image) and reminded us that the goal is to rewrite the core message, overwrite the music playing in our head: "I am valuable. I am loved. I matter. I am safe"


She encouraged us to teach residents to cultivate their own dopamine -- "give yourself a high five and do a little dance". But in order to prevent burnout in primary care, really important to use motivational interviewing techniques and meet patients where they are at-- know the stages of change and tailor your intervention to the patient's stage, not your desired outcome.

The Spirit

This leads us to spiritual and somatic treatments. Often in patients with SUD there is a temporal disconnect between what the body is experiencing and the present, i.e. the spirit is not living within themselves. This is categorized in different cultures with different words, including susto, soul wound, etc.

EMDR and somatic experiencing may be helpful treatment modalities.

In addition, there are many other spiritual treatments: sweat lodges, talking circles, spiritual counseling, limpiezas.

Meaning is important, and looking for ways to experience normal emotions  -- a safe space to feel both sadness and JOY. To look for one's core values, to recognize safety.

The Community

Healing community is necessary to support recovery. Patients need to ask if their community is supportive to recovery? Is their current community a barrier to recovery? Dr. Adachi Serrano described a person in recovery as being in a "bubble". When you are early in recovery, you are cleaning up your space, trying to keep your bubble strong. If your bubble doesn't have a thick shell, you don't want to be in an environment that is going to stress or test that bubble. You also need the community to provide support around that bubble, to protect the individual while they are vulnerable. This involves tending to the community, offering community -- in whatever healthy forms are available.

Group settings for SUD include: NA, AA, SMART Recovery groups, Talking circles, spiritual communities, etc. Creating connection to community, culture, family. Find space for new identity to grow. We may need to help patients guide them through a change of identity, friends/support circles to see the opportunities that are there.

Multidisciplinary Pain Management (Revelis 12/6/2023)

 A recording of this presentation is available HERE

***

Thank you to Dr. Yulia Revelis, SMGR Pain Management physician, for an excellent Grand Rounds presentation this week on Multidisciplinary Pain Management. Dr. Revelis, who is fellowship trained in pain management, is a relatively new addition to SMGR. Dr. Revelis took us systematically through how she assesses and treats pain complaints in her clinic. I was most impressed with her pragmatic approach to pain and her simple advice to believe patients when they complain of pain.

Here are the rest of my notes:

  • Acute pain: days to weeks (after acute injury, surgery, etc.)
  • Subacute pain: <3 months
  • Chronic pain: >3 months
Most common pain, no surprise, is low back pain, followed by neck pain, joint pain (knee, shoulder, hip), and TBD or "total body dolor", which is all-body pain.

Dr. Revelis encouraged us to always go back to the history and physical when assessing pain. Also consider imaging, medications/interventions/treatments, social components, and psychiatric components ("depression and anxiety go hand in hand with chronic pain, and it is a vicious cycle")

She covered a few key tools to help in your assessment of pain. These include the following (links are live when possible)

These are all tools to quantify pain, its impact on activities of daily living and quality of life, and can often be used to track benefit of interventions offered.

To evaluate pain, Dr. Revelis encouraged us to go back to the history: get detailed description of the pain, its location, associated factors, chronicity, family history and social history. Then do a focused exam including inspection, palpation and any indicated special testing. "You don't always have to get imaging," she cautioned, "only when it is clinically appropriate to do so." 

Pain management is multifactorial
  • Physical therapy
  • Medications 
  • Interventional options
  • Counseling/CBT
Physical therapy offers long-term solutions gives people autonomy and self-determination with regards to their pain. She is a big big fan.

Medication options are many:
  • topical meds (including lidocaine patches, Voltaren gel, and compounded creams including ones that have TCA or topical gabapentin)
  • NSAID (care with elders, contraindications)
  • Acetaminophen is an excellent pain med and is often under-dosed!
  • Anti-spasmodic (including cyclobenzaprine, baclofen, tizanidine) her first line is cyclobenzaprine (Flexeril) 5mg at bedtime x 2 weeks max, "start low, go slow". Only rx'd as needed and should almost always be rx'd in conjunction with PT
  • Gabapentinoids (gabapentin and pregabalin), particularly for neuropathic or radicular pain
  • TCA/SSRI/SNRI: duloxetine particularly helpful in fibromyalgia
  • Opioids should be A LAST RESORT, really only indicated for cancer-pain and acute pain, not adequately treated with all of the above
Dr. Revelis is able to over her patients injections, when appropriate, using either ultrasound or x-ray guidance. These include injections of neck, epidural injections, knees, hips, etc. 

It is important to screen for addiction/addictive behaviors in patients with chronic pain and remember that chronic pain specialists are not the same as addiction specialists. Pts with chronic pain exhibiting addictive behaviors should be evaluated by addiction specialists.

When to refer to pain specialist?
  • chronic non-cancer pain
  • cancer pain
  • acute on chronic pain
  • most importantly, patients who WANT to be helped

Care of Acute HIV in the Hospital (Fenning, 11/29/2023)

  A recording of this presentation is available HERE.

***

Many thanks to Dr. Reece Fenning for an excellent presentation this week on Acute HIV in the Hospital. A recording of his presentation is available above. 

My notes:

  • 75% of the HIV+ population in Sonoma County is >40 years old
  • HIV disproportionately affect African American and Latinx people, who make up 65% of the new diagnoses each year
  • Whereas in California 73% of people living with HIV are engaged in care and 64% are virally suppressed, in Sonoma County, 86% are engaged in care, and 82% are virally suppressed
  • Patients with HIV have 1.5x the hospitalization rate as their HIV- counterparts
The CDC recommends that ALL US adults receive a one time HIV screening. People who should be tested more frequently (annually) include: 1) people with partners who are known HIV+ or have a known exposure, 2) pregnant patients, 3) patients who use IV drugs, and 4) people who exchange money (or other goods) for sex. 

Luckily, our HIV testing sensitivity has improved in the last decade, and the so-called "window period" is now much shorter than the past -- it is only around 10 days (but up to 3 weeks) between viral acquisition and possibility of a false negative test. 

When seeing patients with HIV in the hospital and/or outpatient, you should check their CD4 count AND their viral load. Also, screen for common co-morbid infections: TB (the most common worldwide), acute viral hepatitis (A, B, C), and other STI testing (RPR, GC/CT), and lipids.

HIV is staged based on CD4 count and/or CD4 percentage:
  • Stage 1: CD4 count >500
  • Stage 2: CD4 count 200-500
  • Stage 3: CD4 count <200 and/or CD4 percent <14%
Newly diagnosed HIV should be treated immediately (rapid tx induction), except in rare cases of specific comorbidities. These exceptions include Cryptococcus meningitis and active TB. Both require initiation of treatment of these conditions prior to treating the HIV disease. (see chart below):

Standard anti-retroviral treatment for HIV includes 2NRTIs and 1 NSF. You ideally want to know the viral load and genotype prior to starting treatment, but this may not always be possible.
  • Biktarvy (bictegravir/emtricitabine/TAF) is a single pill containing all three meds
  • Alternate options includes a couple of different dolutegavir-containing regimens
    • Trivicay + Descovy (2 pills)
    • Trovicay + Truvada (2 pills)
    • Triumeq (only one pill, but requires HLA testing, so not great for rapid treatment)
What about empiric prophylaxis Opportunistic Infections (OIs)? 
You should be worried about OIs if CD4<200 and/or CD4 percentage<14%. The most common OIs for which to consider ppx are PCP pnuemonia (aka PJP) if CD4<200-- ppx is TMP-SMX daily,  and MAC (if CD4<50) -- ppx is azithromycin once weekly.

How should we think about OIs in the acute setting? There are a couple of different ways to think about OIs:

Time with HIV
  • newly acquired (<6 months)
  • previously on treatment but now stopped
  • on treatment, but its not working
Presenting symptoms:
  • AMS --> think CNS infection (Crypto
  • respiratory symptoms --> think PCP, MAC
  • dermatologic symptoms --> think HSV, VZV, MRSA, KS
Random acute HIV symptoms and pearls:
  • Acute HIV: The large majority of patients will have viral/flu-like symptoms with acute HIV that will self-resolve. Most are not sick enough to present to the ER during this acute illness.


  • Immune reconstitution inflammatory syndrome (IRIS) usually appears 2-4 weeks after starting tx, it is a diagnosis of exclusion. Greatest risk with high viral load and very low CD4 (<50). Treatment is NSAID (outpatient) or steroids (inpatient)
  • HIV wasting syndrome: acute weight loss (>10% of body weight), often with acute diarrhea. Looks like cancer. May need an EGD and/or colonoscopy for biopsy to diagnose. See testing algorithm below.



  • Odynophagia: pain with eating may be a sign of oral thrush and/or esophageal candidiasis
  • Dermatologic infections in HIV are very confusing and also often require a biopsy (see images)
  • (L>R clockwise: Kaposi's Sarcoma, HSV, MRSA Shingles)

  • Respiratory illness in HIV disease should be evaluated like non-HIV with CXR, blood work, but also add beta-D-glucan (for fungal infections). You likely will need tissue (bronchoscopy or induced sputum) to get a diagnosis. 
  • Neurologic symptoms in someone with HIV require a head CT, followed by CSF studies. Also don't forget a fundoscopic exam (CMV retinitis)

Additional resources:


Live long and Prosper: Longevity and Blue Zones (Perez, 2/21/2024)

 A recording of this presentation can be found HERE . *** Many thanks to Dr. Jesse Perez for an excellent talk on longevity and "the bl...