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

 A recording of this presentation is available HERE. 

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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 

• Institute for Functional Medicine (ifm.org)
• Nurtritionfacts.org (Dr. Michael Greger)
• IHerb.com
• Consumerlabs.org (requires subscription)

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

 A recording of this presentation can be found HERE

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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.

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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.

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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."