Rheumatoid Arthritis Part 1 (Kremer, 2/26/2020)

Dr. Lisa Kremer gave a wonderful Grand Rounds this week on Rheumatoid Arthritis. To be clear, RA is not a topic that normally gets me out of bed in the morning. But Dr. Kremer's presentation was so good that I found myself wishing for it not to end. Or for Part 2 to follow asap.  And even several hours later, in the chaos of a busy day in the hospital, I found myself considering this strange disease-- rarely seen before the 1600s, now quite common, terribly disabling, and brought about by a "perfect storm" of genetics, environment, and stress.


RA is characterized by symmetrical polyarticular swelling of the small and medium joints on more than one occasion, over more than six weeks, supported by lab and/or xray and absence of other diagnosis. Exact causes are unknown. Multiple triggers.

Dr. Kremer described RA as an autoimmune condition, with some genetic susceptibilities (e.g. HLA DR4), for which smoking doubles the risk. RA can be precipitated by infections, environmental toxins, social and physical stresses, and hormonal triggers.

• 1% of the the adult world has RA (1.5 million people in the US)-- the most common chronic inflammatory arthritis
• 4:1 female to male
• Peak age onset 40-60 years (but anytime after puberty is possible)
• All races and geographic areas are affected
• Specific populations with higher incidence (Native Americans, particularly: up to 10% of Sioux, Algonquian, Pima, Yakima, and Inuit peoples)

And while Dr. Kremer presented us with these data and more, she also presented the case of Pierre Aguste-Renoir (1841-1919), a French artist and a leading painter in the impressionist movement. She described him as a joyous and radical young man, struck by RA around age 50. His RA seems to have been precipitated by a fall from a bicycle and a resulting arm fracture. From which he never really recovered. And yet Renoir continued to paint long into his illness-- even designing his own wheelchair and equipment to be able to reach up to his large canvass painting surface. 

Dr. Kremer espouses that Renoir is a particularly excellent painter of hands. Perhaps he spent a lot of time thinking about hands. And looking at them. . .

Laboratory testing in RA is helpful but pretest probability determines the benefit of the test. 

• Rheumatoid factor (RF) is not specific
• Anti-CCP is more specific (can actually be positive a few years prior to onset of symptoms, but not always)
• ANA can be positive
• ESR and CRP really convey inflammatory cascade

RA vs. OA (from PPM here): 

Extra-articular complications of RA only occur only in seropositive patients (i.e. +RF ):

• fever and weight loss (can look like cancer)
• nodules (can be anywhere: eyes, heart, etc)
• interstitial lung disease
• pleuro-pericarditis
• CAD
• malignancy (specifically mymphoma)
• infections (like pneumonia)
• a variety of hematologic abnormalities (anemia, thrombocytopenia)
• osteoporosis

Prognosis:
Untreated RA shortens life by 5-10 years. Aggressive RA therapy decreases mortality risk due to CV disease, lung disease, and more (more on this next time). Treatment reduces need for joint replacement byup to 50%.

Disability:
Over 33% of RA patients working at the time of diagnosis will leave workforce within 5 years
Fatigue and unpredictable joint symptoms are frequently the most disabling issues

And finally, here are Dr. Kremer's pearls of wisdom:

• Deformity does not equal disability
• RA does not cause back pain
• Never order tests if you don't know what you are looking for
• Low SES is associated with onset and severity of RA
• Smoking DOUBLES the risk and worsens the progression
• RA is "soft and spongy" (not hard and bony like osteoarthritis)
• A positive RF is not diagnostic, it should prompt you to keep looking for a diagnosis
• DIP joints are almost always spared
• If after careful exam and lab testing, you suspect RA, refer early to rheum!

Stay tuned: Dr. Kremer will present Part 2 (Rheumatoid Arthritis: Treatment) in July or August of 2020. Keep your eyes out! And don't miss it.

2019 Practice Changing Papers: Ob, Peds & Medicine (2/19/2020)

Grand Rounds this week was a little bit like an average day in a primary care clinic: quite full, sometimes fun, and a little overwhelming. Definitely not boring! Three faculty members at the Santa Rosa Family Medicine Residency: Drs. Douglas Jimenez, Cherie Green, and myself presented a rapid medley of practice-changing papers from 2019 in obstetrics, pediatrics and adult medicine, respectively. Here are the the clinical questions, the papers, and a very abbreviated summary of each of our 2019 practice changers:

Obstetrics (Douglas Jimenez)

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The question: Does ursodiol improve adverse perinatal outcomes in cholestasis?

The paper: Ursodeoxycholic Acid: versus placebo in intrahepatic cholestasis of pregnancy: A Randomized Controlled Trial (PITCHES), Chappell et al, Lancet 2019

Bottom line: In this study of ~600 women with cholestasis, ursodiol was safe (we knew this) but did NOT improve maternal itching symptoms or lead to a decrease in bile acids. Ursodiol also did not reduce the incidence of stillbirth, spontaneous preterm birth, or NICU admission. Ursodiol might reduce total preterm birth (iatrogenic plus spontaneous). The authors’ conclusions: the only intervention to affect adverse perinatal outcomes is delivery.

The question: What can bile acid levels tell us about adverse perinatal outcomes?

The paper: Association of adverse perinatal outcomes of intrahepatic cholestasis of pregnancy with biochemical markers: results of aggregate and individual patient data meta-analyses, Ovadia et al, Lancet 2019

Bottom line: The risk of stillbirth with cholestasis (usually quoted at 1-3%) increases markedly when bile acids are >100milimol/L. Most women with bile acids <100 can be reassured and should be rechecked weekly until delivery. For women with bile acids>100, delivery should occur between 35 and 36 weeks EGA.

The question: Does hydroxyprogesterone prevent recurrent preterm birth in singleton pregnancies?

The paper: 17-OHPC to Prevent Recurrent Preterm Birth in Singleton Gestations (PROLONG), Blackwell et al, American Journal of Perinatology, January 2020

Bottom line: In this study of 1700 women with a history of preterm labor, progesterone did NOT decrease recurrent preterm birth. There was also NO difference in any of the individual components that were part of the composite neonatal morbidity and mortality. Despite these findings, American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal and Fetal Medicine (SMFM) have not changed their recommendations; they continue to recommend hydroxyprogesterone supplementation in all pregnant women with a singleton gestation and a history of a prior spontaneous preterm delivery.

Pediatrics (Cherie Green)

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The question: Is high dose oral dexamethasone our only option for croup?

The paper: Prednisolone versus Dexamethasone for Croup: A Randomized Control Trial, Parker et al, Pediatrics, September 2019

Bottom line: Oral steroids are an effective treatment of croup, and the type of steroid  (high dose dex (0.6mg/kg), low dose dex (0.15mg/kd), prednisolone (1mg/kg)) seems to have NO significant impact on efficacy either acutely or in the week after treatment. 

The question: How accurate is the M-CHAT/F as a screening tool for autism?

The paper: Accuracy of Autism Screening in a Large Pediatric Network, Guthrie et al, Pediatrics, October 2019

Bottom Line: In this “real world” use of the MCHAT in 26,000 children, sensitivity was quite low at 39% with a positive predictive value of 15%; this is much lower than previous studies. However children who screened positive and were ultimately diagnosed with autism, were caught 7 months earlier than those who screened negative. Children of color and those from low income homes were found to have lower rates of screening, screen positive more often, and have more false positives. Be aware of the low sensitivity, and be SURE to follow-up positive MCHAT screens in a sensitive manner.

The question: Which leads to speedier recovery in sport-related concussion: rest or a bit of exercise? 

The paper: Early Subthreshold Aerobic Exercise for Sport-related Concussion: a Randomized Clinical Trial, Leddy et al, JAMA Pediatrics February 2019

Bottom Line: Though the standard of care for sport-related concussion has been sustained rest until resolution of symptoms, this study of 100 teenage athletes shows that sub-symptom threshold aerobic exercise during the first week after injury safely speeds recovery in adolescents with concussion symptoms. 

Adult Medicine (Veronica Jordan)

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The question: Should we prescribe intermittent inhaled corticosteroids for mild asthma?

The paper: Budesonide-formoterol in adults with mild to moderate asthma, Hardy et al, Lancet September 2019 

Bottom line: Yes, probably. In this study of ~900 patients with mild asthma, the combination of inhaled corticosteroids (ICS) and beta agonist (SABA) (Symbicort Turbohaler) used PRN led to reduced incidence of both moderate and severe asthma exacerbations. Europe changed their guidelines in 2019 and now recommend ICS-SABA prn as first line in mild asthma. In the US, we don’t have access to the Turbohaler, and the ICS-SABA is much more expensive than albuterol MDI. For very low risk patients, you can probably continue albuterol only, but for anyone with any more risk, consider Symbicort MDI (budesonide-formoterol). 

The question: When should we stop and resume DOACs for patients with atrial fibrillation who are going for surgery?

The paper: Perioperative Management of Patients with Atrial Fibrillation Receiving a Direct Oral Anticoagulant, Douketis et al, JAMA Internal Medicine, August 2019

Bottom line: For patients who are on dabigatran, rivaroxaban, or apixaban for atrial fibrillation undergoing LOW bleeding risk surgeries/procedures (e.g. colonoscopy, dental extraction, pacemaker), stop DOAC 1 day before surgery, restart POD#1. For HIGH bleeding risk surgeries (most surgeries), stop DOAC 2 days before, restart 2-3 days after. Using this standardized perioperative management strategy, there are acceptable rates of bleeding and of arterial thromboembolism, but that number is not 0.

The question: What is new in the 2019 IDSA Pneumonia Guidelines?

The paper: Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America, American Journal of Respiratory and Critical Care Medicine,, October 2019

Bottom line: These guidelines, available here: (https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST) are 23 pages long. Please feel free to read the entire thing. Here are my personal favorite practice changers: 1) Health care associated pneumonia (HCAP) is gone! RIP. 2) You only need blood and respiratory cultures in patients with pneumonia for whom you are treating empirically for either MRSA or pseudomonas 3) No steroids for non-severe CAP 4) Only cover anaerobes in presumed aspiration pneumonia if confirmed empyema or lung abscess (no more flagyl!) 4) Amoxicillin is now FIRST line treatment for uncomplicated outpatient CAP. 5) No routine CXR after pneumonia.

Neonatal Dermatology (Sugarman, 2/12/2020)

Muchas Gracias to Dr. Jeff Sugarman for a solid tour through neonatal dermatology this week.

My biggest take home: IF/WHEN you see a hemangioma in a newborn on the face, refer them IMMEDIATELY to dermatology. That day, says Dr. Sugarman. Medical treatment is time sensitive, and you could be saving them future surgery.

Just for kicks, I am going to gift you with a photo quiz rather than a written summary.  Good luck (answers at the VERY bottom of this post):

Identify the following benign non-infectious lesions in neonates:

                                                                                                                                                                                                                                            

And now for infectious causes of newborn eruptions:

And finally, some really common markings and some zebras:

 

Don't cheat and look below until you have taken this quiz yourself!!! 

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ANSWERS:

First row: benign lesions

·         Erythema toxicum

·         Sebaceous hyperplasia

·         Milia

·         Neonatal cephalic pustulosis

·         Transient neonatal pustular melanosis

·         Acropustolisis of infancy

Second row: infectious  lesions

·         Impetigo Neonatorum

·         Scabies

·         Congenital candidiasis

·         Neonatal HSV
Third row  

·         Nevus simplex

·         Hemangioma

·         Scalp aplasia cutis

·         Nevus sebaceous

·         Neonatal lupus

Structural Violence and Mayan People in Guatemala (Schirmer, 2/5/2020)

Muchas gracias to Dr. Billy Schirmer who gave a compelling (and dense) Grand Rounds this week on Structural Violence and Mayan People in Guatemala—spanning from 1492 to the present. While some of us may be surprised to see such a topic at a hospital grand rounds, it was an excellent reminder that we are not caring for patients on an island in Santa Rosa—but rather in a complicated global, sociopolitical context. And that context matters.

Dr. Schirmer reminded us right up front that current immigration from Guatemala (and really all of Central America) are directly related to a long and sordid history of structural violence**—violence that has been perpetrated continuously by the United States toward indigenous people as long as there has been foreign policy. 


Dr. Schirmer challenged us to take the long view—Guatemalan people are not coming to the US simply because coffee prices have dropped or opium fields are being destroyed or gang violence is endemic. While all these individual things are true, the story is much more layered—full of centuries of war, classism, fear, racism and persecution.

**structural violence: the imposition of unequal risk for disease, injury, and death by social, political, institutional and economic configurations and policies on identifiable population groups . This violence is structural because it results from durable systemic inequality produced by large scale social forces, including racism, gender inequality, poverty and harmful public policies rather than from isolated individual actions or serendipity (-definition from Dr. Paul Farmer, physician and medical anthropologist)



Some stats:

• There are 21 unique Mayan languages in Guatemala
• 41% of Guatemalans identify as Mayan/indigenous
• 79% of indigenous Guatemalans live in poverty
• 40% live on less than $1.90/day
• 90% of poor kids never graduate from high school

• 33% of indigenous Guatemalans cannot read or write
• Average educational attainment for indigenous women is 2 years
• The number of Guatemalan people seeking asylum at the US-Mexico border continues to rise—surpassing Mexican nationals

• 33% of those that apply for asylum without medical evaluation are granted asylum; 88% are granted asylum with a medical evaluation

And some history (I cannot possibly cover it all here, check out the recording of his GR here if you want to hear in its entirety)

• 1500s Pedro de Alvarado leads the Mayan conquest
• After the Spanish conquest all of the land in Guatemala is divided amongst ruling class “encomienda system”--legal slavery of the indigenous people by the ruling class.
• 1821 Guatemalan independence from Spain (not for the indigenous, who continue to be oppressed)
• 1877 remaining land on which indigenous people are living is stolen and sold to private coffee growers, leaving most Mayans without land
• Early 1900s, the United Fruit Company (a US company) establishes the banana industry. United Fruit owns (and controls) much of Guatemalan infrastructure (roads, trains, ports, radio, land) in the name of the banana industry. All supported by dictatorships who were supported by the US.
• 1940s: Guatemalan spring: attempt at unionization of the United Fruit workers
• Early 1950s, democratically elected President Arbenz implements Agrarian reform to reacquire land for the people of Guatemala
• Soon thereafter (1954), President Eisenhower and other high level US officials (the Dulles brothers) create an uprising against Arbenz and force the democratically elected president out of office in the name of “anti-communism”
• Over the next 40 years—during the Cold War—fear of communism drives horrible human rights abuses. Land is burned and taken from indigenous people, people in power abused people without power, and thousands of indigenous people were systematically murdered
• The US supplied training and weapons to corrupt Guatemalan governments in the name of democracy. This training and weaponry has left footprints everywhere
• 1970s and 80s: era of La Violencia under President Rios Montt: “scorched earth campaign”, 70-90% of indigenous communities are burnt to the ground by the Guatemalan government. President Reagan continues to send money and weapons to support Pres. Rios Montt
• Rigoberta Menchu, Nobel Peace Prize 1992
• 1999 Historical clarification commission: investigation of human rights abuses, “Memoria de Silencio”, highlights endemic racism contributing to violence and war in Guatemala

And now fast forward to current reality:

• International commission against Impunity under former President Jimmy Morales: In 2013, Guatemalan president Rios Montt was convicted in Guatemala of genocide, a week later that ruling was overturned on a technicality. He was never retried, and ultimately died in 2018 without punishment.
• Ongoing rampant sexual violence in Guatemala: 50-80% have experienced intimate partner violence, a culture of silence
• President Trump’s 2019 “Safe Third Party Agreement” with Guatemala, Honduras and El Salvador requires that any asylum seekers passing through Guatemala on the way to the US (from Honduras, El Salvador, etc) MUST apply for asylum in Guatemala before applying in the US. Though international experts agree that Guatemala has neither the infrastructure nor the resources to support such people, Trump threatened tariffs if Guatemala didn’t cooperate

And SO what can we do as health care providers?

• Create safe spaces in clinics and hospitals (be aware of chronic institutional distrust)
• Know that trauma is ongoing; it doesn’t end when people arrive in the US. It has negative effects on people’s health and should be addressed sensitively
• Don’t make assumptions about patients’ history or language of choice. Ask, humbly.
• Don’t blame the victims.
• And last, but not least, get trained to do asylum evaluations