Health Disparities of Pandemic Proportions: A Review of Health Disparities in the COVID-19 Pandemic (Sidhu, 5/27/2020)

Many thanks to Dr. Navee Sidhu, who gave a disturbing and thought-provoking presentation on Health Disparities in the COVID-19 Pandemic.

Dr. Sidhu described how health and social disparities permeate the COVID-19 Pandemic, examined the impact of racism on COVID-19, discussed how long-existing institutional and structural factors put communities of color at particular risk, and challenged us to consider how this impacts everyone.

Five questions from Dr. Sidhu for you to consider:
1) What will it take to create a more equitable society post COVID-19?
2) How do we center disenfranchised communities in the recovery process?
3) How does the health care system (at all levels) need to change to better support the health and well-being of its workers, patients and the society it serves?
4) What does it take to become healthy and maintain health?
5) What does quarantine look like for different people?

Part 1: Historical context for events in the present pandemic
"Any time we talk about historical context in the US, it is important to acknowledge where we have come from. . .a history of colonialism, genocide, slavery, oppression, exploitation, and capitalism."

• Social undesirability has long been associated with increased risk of "contagion" and "sickness"
• We have a history of protection of whiteness to ensure that power remains in white hands in our socialized system (xenophobic scapegoating)
• Immigrants have always been associated with disease: Irish immigrants=>Typhoid, Italian immigrants=>TB and smallpox, European Jews=>Cholera, 1900s Chinese immigrants=>Bubonic plaque
• 1980s AIDS=>gay men and Haitians, 2002 SARS=>Chinese, 2000s Ebola=>African
• This lens reinforces well-established misconceptions that individual biological differences are based in race, e.g: 
• non-truth that African Americans were "immune" to yellow fever (1890s)
• undertreatment of black patients  in ER for pain, different lab values for African Americans (NOW)
• Decreased COVID testing for black patients (NOW)

Part 2: COVID-19 Disparities in SoCo, SF, CA and USA

• In Sonoma County, Latinx currently comprise 67% of COVID cases while only making up 27% of total population. (see image) 
• This is a case rate of 104/100,000 in Latinx vs. 24/100,000 in whites
• In SF, 95% of COVID positive patients in the Mission District are Latinx (Latinx population comprises 44% of total population)
• only 10% of Latinx reported being able to work from home
• majority earn <$50K/year (poverty)
• majority household size >3 people
• In California, Latinx make up disproportionate number of cases and deaths from COVID-19 compared to proportion of the population-- across ALL age spectrums
• In the US, there is a paucity of data reported based on race, however  with the data we DO have, we know that 
• Black people account for 25% of US deaths (while only comprising 13% of US population), and are tested at lower proportional rates
• In Arizona, Native Americans comprise 20% of cases, and 21% of deaths (but only 4% of the state's population)
• In Illinois, African Americans account for 38% of COVID deaths and 24% of confirmed cases (while making up 15% of the state's population)
• In Kansas, Latinx comprise 51% of cases (and only 12% of the population)
• You can find more of this data on https://covidtracking.com/
• In summary, people of color experience lower testing rates, higher infection rates, and greater mortality rates. People who test positive more likely to live in poverty and live in multi-person households

Part 3: Impact of systemic racism and capitalism on the pandemic

• Black and brown communities are set up by our society to suffer greater health consequences during a national health emergency
• American capitalism is born from slavery
• Profit as motivation that reinforces oppressive conditions 
• Billionaires gaining wealth at expense of workers
• Large corporations getting bail-outs
• Recovery focused on GDP rather than health and well-being of human beings
• Racism (from Camara Phyllis Jones, MD, MPH, PhD)
• A system of structuring opportunity and assigning value based on the interpretation of how one looks, which we call 'race'
• Structural and institutionalized racism are "differential access to the goods, services and opportunities by race. . . [it is] normative, sometimes legalized, and often manifests as inherited disadvantage
• Predominant white bodies shelter in place, while black and brown bodies continue to work, sacrificing more to return to economic baseline
• Long-standing health and opportunity disparities in housing, finance, judicial system and healthcare correlate with increased covid-19 exposure, hospitalization. and death


• Housing: significant disparities between house ownership between races (home ownership is an important marker of social mobility in this country) (see image)
• Finance/accumulation of wealth is racially discordant (see image below)
• Justice system: disproportionate incarceration of black and brown bodies make people more susceptible to the pandemic (see image below)
• Healthcare: private entities value profit over people. Access to healthcare is paramount to a successful pandemic response, inevitably distributes the response along racial and class lines

• Historically disadvantaged communities have higher rates of comorbidities:
• African Americans have higher rates of hypertension, 2x rates of heart failure, 3x risk of dying from asthma, 3x rates of chronic kidney disease, and 2x prostate and colon cancer, also comprise 44% of HIV+ population
• Latinx are twice as likely to have and die from diabetes, and twice as likely to have chronic liver disease (than non hispanic whites)
• During a crisis, people of color present sicker at baseline, while also in crisis, hospitals are allocating resources in time of scarcity to those who are "less sick"
• Although disparities have improved slightly, 40% of quality measure still worse for blacks than whites (2017)

Part 4: Life in Quarantine

• The Essential Worker 
• "You (meatpacking worker) are giving a great service to the people of the US, and we need you to continue as a part of critical infrastructure, to show up and do your job" (VP Pence)
• With inadequate education, few resources for workers, people of color being asked to make a sacrifices at great risk to their own health
• Who are our essential workers?
• 64% women, 41% people of color, 34% over age 50, 16% live with someone >65, 36% have minor at home, 24% live in families with incomes <200% poverty level
• Ongoing outbreaks at meat processing, UPS, amazon distribution centers
• Essentially these bodies expendable, at great financial benefit to their employers
• Essential workers are being told to return to hazardous work environments, sites with very high exposure risk
• What does life for folks who can effectively work at home and remain safe look like compared to continuation of life for "essential workers"?
• Normalizes sacrifice of health and body
• Only 10% of white americans know someone who has died from COVID
• Pre-exiting stress from minority taxes
• The "myth of individual accountability"
• The US Surgeon general asked African American people to stop drinking, smoking or doing drugs to protect them during COVID-19 (blames black people without explaining larger forces at play, which all people of color more vulnerable to this pandemic)
• Only 18% of white adults are worried they will get covid, while 43% of Latinx and 31% of black adults say they are concerned
• Racialization of comorbid disease focuses on a group; while true health disparities exist, these are actually markers of racial inequality (not biological). In fact, systemic racism results in comorbidities and increased infection and death from COVID-19

Part 5: Ideas for individuals how to move forward, where do we go from here?
Will the system stretched to its limits snap back to its original state of inequity? OR Will the system stretch exacerbate states of oppression and make things worse? OR Will the system morph completely and focus on equity, reconciliation and appreciation of the sacrifices people have made historically and in the present?

What individuals can do now?
Here are a few concrete action items:

• Understand your implicit biases: Harvard Implicit Bias Test
• Also know your biases can be exacerbated by stress
• Watch these Right to Health Web-in: 
• https://www.youtube.com/channel/UCz6VafF5GzIuCmqdF9yFb4A
• https://www.youtube.com/watch?v=xoXA8QFlC7s
• Read this article: https://journals.sagepub.com/doi/full/10.1177/1090198120922942
• Connect with HPEACE, volunteer with IsoCare, Petaluma People Services
• Talk to local governments: write letters to SoCo Board of Supervisors, state and national representatives using your clout as healthcare provider (www.5calls.org)
• Donate to Undocufund (or ask your wealthy friends to)
• Talk to your employer to hold them accountable for workplace safety for everyone

Primary Care of Alcohol Use Disorder (Lund 5/20/2020)

Thanks to Dr. Erin Lund, who gave an excellent Grand Rounds presentation this week on the Primary Care of Patients with Alcohol Use Disorder. Dr. Lund encouraged primary care providers to be forward thinking and proactive about diagnosing and treating alcohol use disorder.

Here's the quick and dirty: 1) AUD is super common 2) Screen for AUD 3) Start with brief interventions, and 4) Offer medications when indicated. Keep reading, you'll feel much more comfortable once you have a few of Dr. Lund's tools in your toolbox.

Alcohol use disorder (AUD) is SUPER common in the US with a 12-month overall prevalence of almost 14% of adults (7% mild, 3% moderate and 3.4% severe).

• Lifetime prevalence of AUD is is 29% (13% lifetime prevalence of severe AUD)
• Men>>women, Young>old
• Alcohol is the 3rd leading cause of death from modifiable risk factors (behind smoking and obesity/poor diet)
• Genetics definitely play a role: 5-10% of women and 25% of men have a relative with AUD

A little reminder about what is considered "one drink" when you ask a patient how much they drink:

Remember, however  that different beers and wines have different alcohol contents, so it's not uncommon that people are drinking 'more' than they realize.

How much is too much?

• Binge Drinking: at least 1 day in the past 30 days with >4 drinks for a woman, >5 for man on one occasion
• Heavy Alcohol Use: binge drinking more than 5 days (in the past 30 days)
• Drinking limits (cut offs for low risk vs. high risk drinking) are based on both gender AND age. 

**Note: for people over 65, limits are the same for men and women: no more than 3 drinks/day or 7 drinks/week.

**Note also that many people you know and love meet criteria for at least a mild AUD; this may be particularly true in this land of wine country and craft beers.

DSM-5 criteria for Alcohol Use Disorder : a maladaptive pattern of substance use with 2 or more of the following 11 criteria within past 12 months (Mild 2-3 criteria, moderate 4-5, severe ≥ 6)

1. Drinking larger amounts/longer periods than intended
2. Effort/desire to cut down
3. Great deal of time spent obtaining, using, and recovering
4. Craving
5. Recurrent failure to fulfill role
6. Continued use despite social/interpersonal problems related to drinking.
7. Activities given up (social, occupational, recreational)
8. Recurrent physically hazardous behavior.
9. Continued use despite physical or psychological problems
10. Tolerance
11. Withdrawal

Why screen for risky drinking?

• It's a USPSTF Grade B recommendation 
• AUD is really common; harmful drinking is estimated at 30% in primary care practices 
• Patients with AUD have a higher risk of death by ALL causes
• Plus, they die years earlier, increased automobile crashes, accidental and intentional injury, social and legal problems
• AUD affects every organ and system in the body: from brain (sleep, mentation) to gut (gastritis, cancers) to heart (cardiomyopathy, CAD)

How to screen? Two options;
1) Single question alcohol screening test (NIAAA): How many times in the past year have you had more than  X or more drinks/day? (X=4 for a woman and X=5 for a man) (>1 is a positive screen, 82% sens, 79% specificity)
2) AUDIT-C

Addiction medicine specialists use a format called SBIRT when talking about how to intervene. (SBIRT stands for Screening, Brief Intervention, Referral to Treatment)Brief Intervention:

You can use the AUDIT C to screen, but also to guide treatment ad your intervention:

0-3: health promotion (great job, keep it up! you are drinking responsible)

4-5: moderate risk drinking, brief intervention

6-7: high risk drinking, brief intervention +/- meds +/- specialty care mgt

8-9: severe risk drinking: start meds, psychosocial intervention, specialty mgt

10-12: specialty management

Here is an example of a brief intervention called FRAMES: 

Treatment for AUD includes 1) acute treatment of AUD (intoxication and withdrawal) AND 2) chronic treatment (abstinence initiation, use reduction, and relapse prevention)

• Psychosocial: formal therapy, self/help 12-step (There are LOTS, including AA, SMART Recovery, Rescue Recovery, and more). Each have varying levels evidence and should be tailored to patient's preferences
• Local resources available HERE, click to explore what is available in Sonoma County
• Medications???

Okay, what about the meds, do they actually work? 

• Pharmacologic management of AUD is underutilized in primary care
• AUD is one of only 3 substances with THREE FDA-approved medications
• Disulfiram (aka Antabuse)
• Acamprosate
• Naltrexone (oral vs. extended release injectable)
• Only 8% of adults with AUD in the US are treated with medications!
• There are also LOTS of medications with varying degrees of evidence used (off label) for AUD, including topiramate, baclofen, gabapentin, ondansetron and sertraline (more below)

Acute Alcohol Withdrawal (AWS):

• Look for signs of sympathetic nervous system hyperactivity: HR, BP, pupils, diaphoresis, tremor
• Use the CIWA vs. Short Alcohol Withdrawal Scale (SAWS) to characterize severity of the AWS: patient scores symptoms, <12 mild AWS, >12 moderate to severe AWS
• CIWA takes 2 minutes, assess 10 (mostly subjective) symptoms
• SAWS is completed by patient, validated in the outpatient setting



SAWS, AAFP 2013

Inpatient vs. outpatient management of AWS?

• 90% of patients with AWS can be managed outpatient
• Must be able to take oral meds, return for frequent follow-up visits, have a friend/relative/caregiver to watch for red flags
• Contraindications to outpatient management: serious lab abnormalities (e.g. profound anemia), hx of withdrawal seizures or DTs, serious medical or psychiatric comorbidity, current polysubstance use
• FYI: Supervised detox (with meds rx'd by YOU for symptom management) is available at Orenda Center. Call: 707-565-7460
• There is evolving evidence for the use of both anticonvulsants (e.g. valproic acid, carbamazepine, and more, see table) and gabapentin to treat AWS

Oral medications to treat AWS (AAFP 2013)

 A little more on the FDA approved meds to treat AUD. While none have great evidence at abstinence, they all have varying evidence for reducing quantity, frequency, etc. They are worth offering in shared decision-making conversations:

• Disulfiram (Antabuse): not really recommended by Dr. Lund because it doesn't really work
• oldest med around for AUD (approved in 1949)
• makes you sick when you drink, inhibition can last for days (up to 14)
• Two blinded studies in 2014 showed no better than placebo in reducing overall ETOH consumption
• Acamprosate,  2 tabs TID (1998 mg/day), covered by PHP
• short half life: has to be dosed so frequently
• NNT 12 to return to "any drinking", can use in people who are still drinking
• may be more effective in women, particularly women with anxiety
• Naltrexone (oral vs. injectable), covered by PHP
• oral tabs 50mg daily, injectable 380 mg IM/month
• oral NNT 20 to prevent return to 'any drinking', NNT 12 to prevent return to 'heavy drinking'
• injectable: reduces number of drinking days
• cannot be combined with opiates, cannot use in cirrhosis

Other meds (non FDA approved) with emerging data for AUD

• Topiramate: A 2014 meta-analysis found it more effective than naltrexone and acamprosate, particularly for increasing abstinence and reducing heavy drinking. Dosing: start with 25mg/day titrate up slowly by 25-50mg per week. Goal: 100-300 mg/day, divided BID
• Gabapentin: 2014 RCT found reduced craving and increased abstinence. Effective dose for relapse prevention: 600 mg TID, small abuse potential (esp in opiate use disorder), can be combined with naltrexone to increase efficacy. Can be sedating.

Okay, don't you feel braver!? Go out and heal, and remember: screen, intervene, and offer meds (when appropriate).

Abnormal Uterine Bleeding (Bartlett, 5/6/2020)

Thanks to Dr. Bartlett for her Grand Rounds this week on The Surgical Management of Abnormal Uterine Bleeding (AUB).

Here are some summary points:

Typical presentations of AUB:

• irregular periods, heavy periods
• abdominal cramping or dysmenorrhea
• fatigue
• dizziness
• pelvic pain or pressure
• missing work or school

AUB is subjective-- normal uterine bleeding is a 28 to 30 day cycle but definitions of "normal blood flow" is really based on a woman's "normal" menstrual cycle is.

Women should be treated for AUB if/when they request treatment and/or if it is adversely affecting their life--i.e. missing work or school. Unless a woman has symptomatic anemia due to her AUB, surgery is an elective procedure.

Diagnostic work-up AUB:

• medical, surgical, and OB history
• pelvic exam
• pelvic ultrasound (BEST imaging for gyn organs)
• CBC, TSH, pregnancy test (+coagulopathy workup particularly if young/teenage)
• up to date pap smear
• Endometrial biopsy advised (if >45 and/or risk factors)

Ddx:

PALM (structural)-COIEN (non-structural)

polyp, adnenomyosis, leiomyoma, malignancy or hyperplasia

coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not-yet-classified

Treatment options for AUB:

• Combined oral contraceptives (birth control pills)
• Tranexemic acid (TXA), used only during menses (slight increase risk of VTE)
• Progesterone IUD (Mirena, skyla)
• Hysteroscopy D&C
• Uterine ablation
• Myomectomy
• Hysterectomy

Recovery from surgical intervention:

• Hysteroscopy: outpatient surgery, bleeding and cramping, nothing vaginally x2 weeks
• Uterine ablation: outpatient surgery, discolored vaginal discharge, nothing vaginally x 2 weeks
• Myomectomy: depends on location (hysteroscopy vs. mini-laparotomy)
• Hysterectomy: can be done outpatient (or overnight stay), most done laparascopically/robotically, pelvic organs removed through vagina IF cervix also removed

An Epidemic of Loneliness (Naderi, 4/29/2020)

Such an important topic this week from Dr. Tahereh Naderi: An Epidemic of Loneliness. While she focused her talk on loneliness in elders, her presentation certainly has me pondering a loneliness in my own life-- especially in pandemic times.

What is loneliness? It's subjective: it's your own perception of the lack of interaction
What is social isolation? An objective lack of meaningful and sustaining communication and/or interaction.

Risk factors for loneliness include: older age (esp >80), poor subjective health and self-reported functioning, large number of chronic illnesses, impaired hearing, functional disability, lack of mobility or motor decline, hopelessness, depressed mood, psychiatric morbidity (e.g. depression), quality and quantity of social interactions, living arrangements, low SES, and race.

2 in 5 Americans report they sometimes or always feel their social relationships are not meaningful.
1 in 5 Americans feel lonely or socially isolated
In the past decade, average household size has decreased leading to 10% increase in people living alone, 28% of older adults live alone
Over the past 2-3 decades, the average size of our social networks has declined

The impact of loneliness is real:

• greater risk of cognitive decline and dementia
• lower self esteem and limited use of coping mechanisms
• increase in personality disorders, schizophrenia
• increase in risk for depression
• predictive of suicidal ideation and behavior
• increased substance use (especially alcoholism)

And what about quarantining?

Data following the SARS health crisis in China in 2003, found that quarantining had particular impact on healthcare workers even after restrictions were lifting including:

• low social contact
• avoiding enclosed public spaces
• not returning to work
• long term behavioral changes such as excessive hand washing

Isolation can exacerbate feelings of anxiety, anger, and pre-existing symptoms, can increase one's risk of developing PTSD, and interrupt treatment for substance use disorders. 

Dr. Naderi reminded us (we need to keep hearing this) that social distancing DOES NOT equal social isolation.

Also, guess what? There is an antidote to loneliness: social connection. Social connection actually makes people healthier!

• A meta-analysis including >300K people concluded that greater social connection is associated with a 50% reduced risk of early death
• In studies of the "blue zones" (regions in the world with the greatest concentration of centenarians), social connection is a component of 4 of the 9 of the power principles. The power principles are the 9 lifestyle habits that seem to be associated with longer, healthier, happier lives. 

Believe it our note, we can work on increasing or firming up our social connections in several different ways-- through mindfulness and acceptance, increased use of technology (yep, it's true, even for seniors) and intentionally reaching out to others to form community.

• A randomized controlled trial using mindfulness-based techniques was able to reduce loneliness by 22% and increased social interactions in daily life by 2 more interactions per day and one additional person per day!
• The use of technology-- even in seniors-- can effectively decrease loneliness (multiple modalities including email, video conferencing and computer training). 
• Shared activities were effective: gardening, physical activity, visual arts discssion, even animal therapy!!

Dr. Naderi introduced us to the concept of  Moais (模合, Mo-ai):social support groups that form in order to provide varying support from social, financial, health, or spiritual interests. Moai means "meeting for a common purpose" in Japanese and originated from the social support groups in Okinawa, Japan. These have been studies as part of the blue zone studies.

While Okinawan Moais are inherently built in to society, we may have to be more proactive about reaching out and creating ours. If you don't have one, consider taking steps toward forming a Moias. Or identify and strengthen the one you have. 

Dr. Naderi concluded with an quote by Vivek Murthy, internal medicine physician, 19th Surgeon General of the US, who took a particular interest in loneliness as surgeon general:

"The irony is that the antidote to loneliness, human connection, is also a universal condition. In fact, we are hardwired for connection-- as we demonstrate every time we come together around a common purpose or crisis- and even now as we face the global COVID-19 pandemic and resort to physical distancing to reduce the spread of the virus, we are recognizing that we cannot make it through fear, dager, and uncertainty of the current moment without supporting one another. "

Go ahead, close this browser, call that person you've been meaning to call. You won't regret it.

Cardiovascular Benefit of New Diabetes Medications (Magnotti, 4/22/2020)

One of the reasons I love Grand Rounds is that each week I know-- whatever the topic, whomever the speaker-- I will walk away wiser. My curiosity will have been piqued. I will have learned something. I will have been challenged.  I will be a better family physician. And I will have often have new (more educated) questions.

And as expected, this week, Dr. Mike Magnotti (SMGR Endocrinology) did not disappoint. He gave an excellent presentation on the cardiovascular benefits of two classes of "new" diabetic medications: GLP-1 analogs and SGLT-2 inhibitors. Definite practice changer for me.

Here are a few questions to start you off:

• Do you manage your diabetic patients with cardiovascular disease  (CVD) differently than those without CVD?
• Are you aware of the evidence that both the GLP-1 and SGLT2-inhibitors reduce stroke, MI and possibly even CV death in diabetics with CVD?
• Are you using GLP-1 agonists for cardiovascular benefit?  What about SGLT-2 inhibitors?
• How do you (and your patients) assess whether or not they should be on one of these new meds?

I don't know about you, but I have a hard time keeping these medications in my head-- the names are complicated, the abbreviations don't make it simpler, the mechanisms of action are new, and nothing sticks. Plus, until recently they have been unavailable to most of my patients due to cost and/or insurance restrictions.

In case you are in the same boat as me, here's a brief summary of the two classes of meds Dr. Magnotti presented evidence for in CV risk reduction:

GLP-1 agonists: glucagon-like peptide 1 agonists (aka incretin mimetics) are almost all INJECTABLE medications (except for one new oral version of semaglutide). They act on the gut: improve glucose-dependent insulin release, suppress glucagon, suppress hepatic glucose output, decrease the rate of gastric emptying, and suppress appetite.  

• Benefits of GLP-1 agonists include HbA1c reduction of 1.2-1.7%, weight loss, no risk of hypoglycemia (unless combined with insulin or sulfonylurea), and CV risk reduction  (non fatal heart attack and stroke-- see below for details)
• Side effects: mostly GI (nausea, vomiting, constipation, diarrhea), headache, injection site reaction, possibly pancreatitis, and a black box warning MEN2 or medullary thyroid cancer
• Currently available forms: short and long acting exenatide, liraglutide, dulaglutide, semaglutide (oral and sq)

SGLT-2 inhibitors: sodium-glucose co-transporter-2 inhibitors (aka gliflozins) are ORAL medications that inhibit resorption of glucose into the kidneys, thereby lowering blood sugar

• Benefits of SGLT-2 inhibitors include: Hba1c reduction 0.8-1.2%, systolic BP reduction (~5mm Hg), weight loss (2-4% of body weight), heart failure risk reduction, slowed progression of CKD, CV risk reduction (non fatal heart attack and stroke-- see below for details), and even CVD death reduction (empagliflozin only)
• Side effects:  yeast infections (women>>men), UTI/pyelo, polyuria, transient decrease in GFR, orthostasis (esp in elderly), small increase in LDL, hypoglycemia (if combined with sulfonylurea, insulin), DKA with minimal glucose elevation, increase in fractures, possible increase in amputation, fournier's gangrene
• Currently available forms: canagliflozin, empagliflozin, dapagliflozin, ertugliflozin

Is HbA1c lowering the only outcome that matters?
Standard diabetes management has focused on reduction of HbA1c, which we know prevents progression of microvascular disease but has little effect on macrovascular outcomes. HbA1c goals are the metric by which we have considered a patient "controlled" or "uncontrolled". You all know, our  goal is HbA1c<7 in most adults, <8 in elderly and those with significant comorbidity.  Secondary goals have been to prevent/avoid hypoglycemia and prevent weight gain/promote weight loss.

It may be time to rework our paradigm; start thinking diabetes meds in CV Risk Reduction
Yes, we know lowering HbA1c is important to prevent retinopathy, diabetic nephropathy, peripheral neuropathy. However, we also know that cardiovascular disease (CVD) is an important cause of morbidity and mortality in diabetic patients. What if there were medications that reduce HbA1c and also reduce the risk of MI, stroke, and CV death?

Guess what? There are! Both the GLP-1 agonists and the SGLT-2 inhibitors seem to have a positive effect on CV outcomes (ie they reduce heart attack, stroke, and maybe even CV death). To be right up front, no one is exactly sure why.

Since 2008-- due to concern about thiazolidinidiones (TZD) actually showing increased CV risk in diabetic patients-- the FDA has required that any new blood sugar lowering med be evaluated for cardiovascular safety ("a cardiovascular outcome trial" or CVOT). Most of these studies use a composite endpoint called a 3 point MACE (time to a Major Adverse Cardiac Event, including non-fatal MI, CVA or cardiovascular death). Initial studies found most novel diabetes meds to be neutral, but  more recently, they started to show some benefit.

Here are the studies Dr. Magnotti reviewed during Grand Rounds:

• EMPA-REG: (empagliflozin), NEJM 2015
• DM2, a1c range 7-10%, BMI<45, established CVD--> primary outcome 3P MACE 
• Relative risk reduction of 38%, 2.2% Absolute risk reduction
• NNT 46 patients for 3.1 years to prevent on CV death (for comparison sake, NNT is 31 patients for simvastatin x5.4 years, 49 patients with ramipril x 5 years)
• There were also significant reductions in all-cause mortality and heart failure hospitalizations
• FDA indication for empagliflozin: to reduce risk of CV death in diabetic patients with known CVD
• CANVAS/CANVAS R (canagliflozin), Circulation 2018
• Primary outcome: 3P MACE
• Relative risk reduction 14%, NNT=224
• LEADER: (liraglutide), NEJM 2016
• Primary outcome: 3P MACE
• Relative risk reduction, 13%, 3P MACE
• Reduction in all cause mortality 15%, CV death 22%
• SUSTAIN 6 (semaglutide injection), NEJM 2016
• 26% relative risk reduction 3P MACE

Dr. Magnotti's summary of the literature: 

• To date, 5 new diabetes agents have been shown to lead to a significant reduction in 3 point MACE. 
• This effect is INDEPENDENT of A1c and other risk factors. 
• These were all measured in addition to other standard of care therapies (such as ASA and statin)

In light of these studies, both the American Diabetes Association (in 2018, again in 2020) and the American COllege of Cardiologists (ACC, 2020) have updated their guidelines with regards to using SGLT-2 and GLP1 medications in diabetes. 

For patients with known ASCVD, these medications should now considered first line after metformin (see diagrams below from ADA and ACC).

ADA guidelines HERE in FULL text (snippet of image).

ACC guidelines HERE in FULL text (snippet of image). 

In Type 2 patients with Diabetes AND CVD (ie. known CAD, hx MI, hx CVA, PVD), regardless of A1c or current diabetes therapy, patient should be started on EITHER GLP-1 (liraglutide daily injection, dulaglutide weekly injection, semaglutide weekly injection) OR SGTL-2 (empagiflozin oral, canagliflozin oral)

Dr. Magnotti's Considerations when choosing an SGLT2 vs. GLP-1

• SGTlL-2 in patients with Heart Failure, CKD (GFR>30), those who might need improved BP control (or who you aren't worried to be on a diuretic), someone with history of pancreatitis, gastroparesis, significant nausea, or MEN2/MTC
• GLP-1 in patients who need MORE Hba1c reduction, CKD with GFR<30, recurrent yeast infections or UTI, concern for risk of DKA or other potential side effects from SGLT-2

Some practicalities:

You don't need to adjust a patient's other diabetes meds UNLESS they are on insulin or sulfonylurea (for risk of hypoglycemia)

• IF they are on a sulfonylurea:
• A1C<7 to 7.5, stop the sulfonylurea
• A1C 7.5-8.5, cut sulfonylurea dose in half
• A1c >8, no change
• IF on basal insulin
• a1c<7, cut insulin dose in half
• a1c7-8, reduce insulin dose by 20%
• IF on prandial insulin, consider getting endocrinology input OR cut prandial insulin at least in HALF. 
• IF patient on antihypertensive, for SGLT2, consider reducing dose, if diuretic cut dose or stop

What about insurance coverage?

Coverage has substantially improved for these medications with CV indications. (Even with Partnership Health Plan). There are NO other medications that can be used for "step therapy" for CV risk reduction, so be sure to prescribe these under CVD (rather than DM). 

What about patients who don't want to take an injection?

If the patient meets criteria for a GLP-1 but doesn't want an injection, remind them: 1) this isn't insulin 2) they will likely LOSE weight and improve their blood sugar control and 3) they will reduce their risk of heart attack and stroke. Then get them nursing and diabetic educator assistance with getting over the injection!

If you work in the hospital, you might at least consider discharging every diabetic patient with established CVD (MI, CVA, TIA, PVD) on a GLP-1 or SGLT-2 agent. 

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Another reason I love Grand Rounds is that I love sitting in the same room with engaged, big-brained, big hearted colleagues. (This is the part I miss during our shelter in place-- Zoom works-- but it sure isn't the same). Join us next week on Zoom. We will be back in that conference room eventually.

Small Bowel Obstruction (Sawyer 4/15/2020)

Big thanks to Dr. Russ Sawyer for an excellent presentation this week on Small Bowel Obstruction (SBO) during Grand Rounds. We are all getting better and better at this Zoom platform!

Cliff notes version of what primary care providers should know about SBO:

1. Lactate is highly sensitive for SBO (but not that specific)
2. The money is in the CT scan (CT is BOTH sensitive and specific)
• with IV+oral contrast is are ideal, but IV contrast only is probably okay
3. Many SBO patients don't need surgery (you actually can let the sun set on an SBO)
• In fact, all patients NOT acutely ill (w/fever, leukocytosis, tachycardia) deserve a trial of non-operative management
• SBO patients with a BM in last 24 hours likely will not need surgery
4. Gastrograffin challenge is an effective way to differentiate patients who may need surgery vs. those who definitely don't. 
• 90cc PO or via NGT x 8 hours in early/minimal symptom SBO (see below for details)

And now for the more robust version of my notes for those of you more in depth readers. . .

SBO is super common, >$1.5 billion per year in the US go to management of SBO

Classification of SBO

• functional (i.e. adynamic ileus)
• mechanical (acute vs. chronic, partial vs. complete) 
• adhesions (account for 80% of SBO)
• hernia (internal, groin, ventral)
• malignancy
• inflammatory disorders (IBD, ischemic bowel)

Pathophysiology of SBO

obstruction prevents people from passing food and air --> interluminal fermentation causes gas to accumulate--> bowel edema--> diminished absorption and decreased motility--> can gt transudative losses into the abdominal cavity (free fluid in the peritoneum)

Stats reminder from Dr. Sawyer, which is always helpful to review

Sensitivity: "positivity in disease" (how much you trust a positive result to mean the patient actually has that condition)

Specificity: "negativity in health" (how much you trust a negative result to mean that the patient actually does NOT have that condition).

(We are talking a fair bit about sensitivity and specificity this day with COVID testing. This is an excellent reminder!)

Clinical History

• Acute abdominal pain (92%), usually precedes the onset of nausea/emesis
• Nausea 
• Emesis (82%-- more common than nausea)
• Abdominal distention

Risk factors

• Prior abdominal or pelvic surgery (even a simple appendicitis many years ago)
• Abdominal wall or groin hernia (even internal hernia)
• IBD
• Prior irradiation of the abdomen

Physical exam

• Dehydration (even if not apparent on labs), often notable on physical exam (dry mucous membrane, decreased skin turgor)
• Abdominal distention (most important finding on exam)
• Surgical scars
• Tympanic abdomen
• High pitched bowel sounds or more commonly a rush of bowel sounds

Labs

• Leukocytosis is common
• Electrolyte abnormalities (hyperNa, hypoK)
• Lactate is helpful. It's extremely SENSITIVE 90-100%, Specificity 40-80%. This means that a positive lactate gives high likelihood of surgical SBO, but a normal lactate does not rule out an SBO

Imaging: "Everything in SBO comes down to imaging"

• Plain film (KUB): not very specific or sensitive (equivocal 20-30% of the time, misleading in 10-20%), consider skipping it and going straight to the CT
• CT with IV contrast (+oral contrast if possible-- oral contrast commits patient to 4 hours in the ER, often get get enough info with just IV contrast), 
• >90% sensitive, 95% specific. So you can pretty much trust the CT. 
• If the radiologist sees it, it's there. If the radiologist doesn't see it, it's not there.
• CT can usually tell grade, severity and even etiology (adhesion vs. malignancy)
• However, intra-operative location is only correct 60-70% of the time
• MRI (if CT contraindicated, e.g. pregnancy)

Surgical vs. Non-surgical Management:

Patients with SBO should be evaluated for surgical intervention WHEN/IF they are acutely ill with fever, leukocytosis, tachycardia, metabolic acidosis, ongoing pain.

HOWEVER, without the above findings (or with only a few of them) MOST patients should undergo initial non-operative management (this includes both partial AND complete SBO). How so?

Management of early/minimal symptom SBO (with Gastrograffin)
For patients who meet these criteria, Dr. Sawyer and team are working on a protocol to be started soon

If patient meets the following criteria:

1) SBO on CT, 2) distention w/o emesis (x8 hours, or at least minimal emesis, only need NGT if emesis), 3) BM in the last 24 hours, 4) minimal leukocytosis (<14), lactate (<4), THEN you can give them a gastrograffin challenge

How do I do a gastrograffin challenge for minimal symptom SBO?

1. Give patient 90cc of full strength gastrograffin (via NGT or PO);  order from pharmacy (not radiology)
2. Wait 6-8 hours for BM (up to 24 hours). If they have plenty of BMs, they passed! You don't even need to do KUB
3. If no stool in 8 hours, get KUB to look for gastrograffin. 
4. If it has made it to the colon, can pull NGT, start clear liquids and probably let them go home. 
5. If no contrast in cecum, repeat KUB next day. If in the colon, start clear liquids. If not, call surgery.

How does gastrograffin work? For this purpose, it is actually being used therapeutically (rather than diagnostically). Gastrograffin pulls fluid into the lumen and "flushes things through", decreasing the bowel wall edema and improving the SBO.

Who NOT to give gastrograffin challenge to? 

• infection (e.g. appendicitis, diverticulitis)
• cancer
• incarcerated hernia
• pregnancy
• abdominal surgery in last 6 weeks

Prevention of SBO:

There is not great data on any intervention or product done intraoperatively to prevent adhesions and prevent SBO. However, if a patient has had a first episode of SBO or recurrent SBO, Dr. Sawyer recommends:

• low fat diet (maintains intestinal transit time)
• clear liquids are tolerated well (4-6 days): patients with SBO do not need to go home on a regular diet, once a patient feels true hunger, it's time to eat

Recurrence

• 20% recurrence after first episode
• after 3 episodes, their risk of recurrence is greater than 80%, need to consider surgery to lyse adhesions (depending on interval between the recurrences)

Reflections on Inequity and Solidarity in the Pandemic Present (Holmes, 4/8/2020)

Many thanks to Dr. Seth Holmes, who jumped in late to present a terrific and timely Grand Rounds this week on Inequity and Solidarity in the Pandemic Present.

As a great thinker and scholar, Dr. Holmes took us through history, sociology, anthropology, philosophy, and breaking news to challenge the lens we use to view our current state of the COVID-19 Pandemic. And to insist that while we comply with physical distancing, we should simultaneously be striving toward social solidarity.

Some questions to start us off:

• How does the novel Coronavirus pandemic follow the fault lines that already existed in our society-- particularly the inequalities and the discrimination?  How does this pandemic force us to look anew at these fault lines?
• Is this an historic opportunity to think about what kind of society we want to be-- to remedy those inequalities so that our health system and our social system can be more healthy, more safe, more truly democratic, and more inclusive for all people? 
• While we undoubtedly need to adhere to physical distancing recommendations, how can social solidarity help us survive this and any future pandemics?

In his presentation Dr. Holmes invoked several scholars' work on the notion of SOLIDARITY:

• French sociologist Emil Durkheim, who studied societies and asked the question: How do societies hold together despite social differences and increasing division of labor? His answer: Social solidarity: the sentiment and practice or feeling and action of interdependence between individuals and groups in a society

• Physician and scholar from Martinique, Frantz Fanon: Solidarity can and must transpire in the midst of social difference, including solidarity across national lines (against colonial powers) and between people within the countries against colonization, as well as solidarity across racial lines (against racist social systems)

• Educator and theorist Paolo Freire: Solidarity is a collective project. .  capable of changing not only the ways in which society is structured but also has to change everyone who is involved (people with less and more power) . . .Liberation brings about transformation of the exploited and the exploiter.

• Combahee River Collective (Robin D. G. Kelley, Angela Davis): Solidarity as coalition building recognizes connections between different forms of inequity, different forces of exploitation, and highlights the need to stand together for the good of everyone. . .this is difficult to achieve in the US in which individualistic models of health are most common.

And as we ponder our place in this pandemic and many of us work on the front lines in hospitals, clinics, and facilities across Sonoma County and beyond, Dr. Holmes challenged us to ask ourselves the following.

How might we use social solidarity during this pandemic to. . .

• protect our mental health? 
• avoid social constructs of stigmatization?
• build systems that benefit the health of all?
• protect the health of everyone, including (and especially) those who have been most marginalized our society?

As former US Secretary of Labor Robert Reich pointed out in a recent opinion piece,  "In many senses, our country doesn't have a fully functional public health system. Instead we work in a for profit health care system that is disjointed and ill-prepared for this crises and future crises. . .If we want to survive this and future pandemics we must understand how critical our public systems are for everyone in our society.

Let us not overlook the effect of this pandemic our most vulnerable, those who are

• incarcerated
• detained
• homeless
• poor
• people of color
• Recent Atlantic article by Ibram X. Kendi: inordinate numbers of people of color dying at roughly twice the rate of white people in the US (histories of institutional and structural racism) (Ref: What the Racial Data Show: the pandemic seems to be hitting people of color the hardest)

We are all in this together. We must stay connected. We must confront racism, xenophobia, and stigmatization. We must fund our public health and social systems. We must support those most marginalized, stop incarcerating and detaining those on whom our system relies.

With social solidarity, we can change our system.

Evidence-Based Management of the Second Stage of Labor (Guerrero 4/1/2020)

Muchas Gracias to Dr. Kiana Guerrero, who delivered our second shelter-in-place zoom Grand Rounds at SSRRH. She did so with great grace and great thought-- as she does most things. The topic was Evidence-Based Management of the Second Stage of Labor.

Some definitions:

• Second stage of labor: full cervical dilation (10cm) to delivery
• Spontaneous vaginal delivery: delivery that occurs without the use of forceps, vacuum, or cesarean delivery
• Delayed pushing: delay after full cervical dilation to allow for spontaneous decent. Patient starts pushing on average 60 mins – 180 mins after complete dilation
• Immediate pushing: patient would start pushing on average 15 mins after complete dilation
• Spontaneous pushing/physiological pushing: pushing after full dilation without instructions; may push with an open glottis and vocalization or use an intermittent
• Directed pushing/Valsalva pushing: pushing after full dilation against a closed glottis

Question 1: Should we encourage patients with an epidural to "labor down"?
Answer: Probably not.

In a 2018 Randomized Control Trial of  2414 nulliparous women, >37 weeks, all with an epidural, randomized to immediate pushing vs. delayed pushing

• There was NO difference in normal spontaneous spontaneous delivery and NO difference in rates of c-section in the two groups
• However, there were differences in postpartum hemorrhage (PPH), chorio, newborn outcomes, and other potentially important secondary outcomes
• The immediate pushing group  had shorter total duration of second stage, lower risk of  PPH and lower risk of chorioamnionitis, as well as  a lower likelihood of neonatal acidemia and suspected neonatal sepsis
• The delayed pushing group had shorter mean duration of active pushing (by about 9 minutes) and a lower likelihood of third degree laceration

(Reference: Cahill, Alison G., et al. Effect of Immediate vs Delayed Pushing on Rates of Spontaneous Vaginal Delivery Among Nulliparous Women Receiving Neuraxial Analgesia.)

After reviewing this study, Dr. Guerrero was left with more questions: 

• Would even more time for laboring down (i.e. >60 minutes) be better?
• Would the outcomes be different for multiparous women?

Dr. Guerrero used a 2012 Systematic Review  Tuuli, et al, to answer these questions. This review featured 12 RCTs (~1500 patients in each group: immediate vs. delayed), with primary outcome spontaneous vaginal delivery. There was variable quality and mixed results, but here are Dr. Guerrero's take home points:

Answer 1a: Longer isn't better. Largest study showed that maternal fever was nearly two-fold higher among women who delayed pushing. Risk of maternal fever increased in a dose–response fashion

• RR 1.14, 95% CI 0.54–2.38 for delayed less than 1 hour
• RR 1.73, 95% CI 1.10 –2.72, for delay of 1–2 hours
• RR 2.33, 95% CI 1.54 –3.51 for delay greater than 2 hours

Answer 1b: There isn't enough data specifically for multiparous women; the studies that have been done with multips are of poor quality.

(Reference: Tuuli, et al, Immediate Compared with Delayed Pushing in the Second Stage of Labor: A Systematic Review and Meta-Analysis, Obstetrics and Gynecology, September 2012, Voume 120, Issue 3, 660-668)

Question 2: Should we control how a woman pushes during the second stage?
Answer: Probably not.

Dr. Guerrero cited a Cochrane Review (see reference) of 8 trials, including 884 women. The largest study in the meta-analysis found the following:

• NO clear difference in spontaneous vaginal delivery comparing spontaneous pushing and directed pushing groups
• Spontaneous pushing may decrease the duration of pushing by about 10 minutes
• No difference in rates of perineal tears (3rd and 4th degree), risk of episiotomy, admission to NICU or 5 minute APGAR <7

(Reference: Lemos, Andrea, et al. Pushing/Bearing down Methods for the Second Stage of Labour. Cochrane Database of Systematic Reviews, 2017)

Question 3: Is there a "best" position for women to be in during second stage?
Answer: We don't know.

Dr. Guerrero gave us a quick peek at two recent studies asking whether a woman's position affects the birth outcomes: a 2017 Cochrane meta-analysis and a 2017 BUMPES RCT (comparing upright vs lying down)

• A 2017 Cochrane Review found that for nulliparous women without an epidural, the upright position showed a reduction in rates of episiotomy, assisted vaginal delivery and a very small reduction of duration of second stage 
• BUT upright position was associated with an increase risk of 2nd degree tears and blood loss >500mL
• The 2017 BUMPES RCT concluded that for nulliparous women with low-does epidural, the lying down position results in more spontaneous vaginal delivery
• Hmmm. . . .

(References:  Gupta et al, Position in the second Stage of Labor for Women without Epidural Anesthesia, Cochrane Systematic Review, 25 May 2017 and  

Brocklehurst et al, Upright versus lying down position in second stage of labour in nulliparous women with low dose epidural: BUMPES randomized controlled trial, BMJ 2017). 

Grand Rounds often one leaves with more questions than answers. See you next time!