&nbsp; Summary: Dr. Robert Centor’s Knowledge Food, Part 2! &nbsp;On this episode of The Curbsiders, we continue our discussion with the legendary Dr. Centor, focusing on pharyngitis and the highly entertaining origin of the Centor Criteria. &nbsp;Not only do we learn how to dominate pharyngitis, but we also uncover one of Dr. Watto’s knowledge deficits - Lemierre’s Syndrome. &nbsp;(He owes us a two minute talk on Lemierre’s Syndrome in case you’re wondering. I know I am.) Clinical Pearls:  Admit your own limitations! &nbsp;Many overestimate their skills as a clinical educator.  Preadolescents get streptococcal pharyngitis (...or it’s nothing). Adolescents are much more complicated with streptococcus, EBV, CMV, acute HIV, fusobacterium, and multiple other causes.   Important: Separate the causes of pharyngitis in preadolescents and adolescents.  General rule: Sore throats should not cause rigors; if present then admit patient, obtain blood cultures, and start antibiotics.   Do NOT miss a peritonsillar abscess or Lemierre’s Syndrome in acute pharyngitis. Pharyngitis improves within three to five days. &nbsp;Failure to improve should prompt a more thorough investigation. Lemierre’s Syndrome (1 in 70,000 untreated pharyngitis patients) is septic thrombophlebitis of the internal jugular vein. &nbsp;The treatment is IV antibiotics and NOT anticoagulation. &nbsp; Dr. Centor and the IDSA recommends Amoxicillin once daily and, if penicillin allergic, Clindamycin. &nbsp;The most recent IDSA update recommends a 10-day course of Amoxicillin (50mg/kg up to 1000mg once daily).  Dr. Centor’s “Take-Home” Points:  Adolescents tend to have more complicated pharyngitis Pharyngitis and rigors? &nbsp;Admit, obtain cultures, and start antibiotics. Sore throats don’t get worse and, if they do, you need to rethink the case  Disclosures: Dr. Centor reports no relevant financial disclosures for this topic. Learning objectives: By the end of this podcast listeners will be able to:  Identify the limitations of the Centor Criteria in regards to (a) preadolescents and (b) adolescents, taking special precautions in the adolescent population Understand which acute pharyngitis patients require a more thorough investigation Be able to identify Amoxicillin as the treatment of choice for acute bacterial pharyngitis with Clindamycin as the second-line antibiotics choice.  Links from the show:  Check our Dr. Centor’s wonderful blog, at http://www.medrants.com or on twitter https://twitter.com/medrants Centor’s Criteria (MDCalc) --  http://www.mdcalc.com/modified-centor-score-for-strep-pharyngitis/ IDSA Guidelines on Diagnosis and Management of Group A Streptococcus Pharyngitis -  http://cid.oxfordjournals.org/content/early/2012/09/06/cid.cis629.full.pdf+html Original article using the Centor score for pharyngitis  https://www.ncbi.nlm.nih.gov/pubmed/6763125?dopt=abstract Dr. Centor’s article on fusobacterium Centor RM, et al. The clinical presentation of Fusobacterium-positive and streptococcal-positive pharyngitis in a university health clinic: a cross-sectional study. Ann Intern Med. 2015 Feb 17;162(4):241-7. doi: 10.7326/M14-1305.

Sore throat? Absent cough? Ask Doctor Centor.

Summary: In this episode our guest is Dr. Robert Dickson a Pulmonologist from the University of Michigan who studies the respiratory microbiome. We discuss how the lung microbiome differs in health, chronic illness and acute disease states like pneumonia, sepsis and ARDS. The lung microbiome has the ability to predict frequency of exacerbations and even severity and progression of certain lung diseases. We’ll explore all of this plus Dr. Dickson’s new paper published last month in Nature Microbiology, which had the surprise of finding gut bacteria in the lungs during critical illness. Please enjoy this wide ranging discussion &nbsp; Disclosures: Dr. Dickson did not report any disclosures. &nbsp; Clinical Pearls 1. The lungs are constantly bombarded by microbes and the largest host to microbe interface in the body where bacteria come within millimeters of the blood stream. 2. The lung microbiome is altered in both acute and chronic diseases 3. The lung microbiome is altered by antibiotics, corticosteroids, PPIs and probably lots of other things we are just beginning to discover. &nbsp; Links from the Show: Dr. Dickson’s latest article reporting gut bacteria in the lungs during critical illnesses. Dickson, R et al. Enrichment of the lung microbiome with gut bacteria in sepsis and the acute respiratory distress syndrome. Nature Microbiology 1, Article number: 16113 (2016). doi:10.1038/nmicrobiol.2016.113 &nbsp; A link to Dr. Dickson’s podcast discussing the role of microbiome and the care and treatment of critically ill patients.  The role of microbiome: The Lancet Respiratory Medicine: January 2016 &nbsp; Dr. Dickson’s recent publication in The Lancet.  Robert Dickson. The microbiome and critical illness. The Lancet. Published Online: 11 December 2015. DOI: http://dx.doi.org/10.1016/S2213-2600(15)00427-0 &nbsp; Five clinical pearls on the Pulmonary microbiome Robert P. Dickson and Gary B. Huffnagle. The Lung Microbiome: New Principles for Respiratory Bacteriology in Health and Disease. PLoS Pathog. 2015 Jul; 11(7): e1004923. Published online 2015 Jul 9. doi: &nbsp;10.1371/journal.ppat.1004923 PMCID: PMC4497592 &nbsp; A comprehensive review of the Pulmonary Microbiome field Dickson, RJ et al. The Microbiome and the Respiratory Tract. Annu Rev Physiol. 2016;78:481-504. doi: 10.1146/annurev-physiol-021115-105238. Epub 2015 Nov 2. &nbsp;

Wait! There’s a lung microbiome?!

Title: Don’t be afraid of the dark? Dominate insomnia. Summary: Are you afraid of the dark? Do complaints of insomnia stress you out? Well, never fear. In this episode our guest is Dr. Karl Doghramji, Professor of Psychiatry, Neurology and Medicine and the Medical Director of the Sleep Disorders Center at Thomas Jefferson University Hospital in Philadelphia. With his help we deconstruct the “dread pirate” insomnia (as I call it) so you can dominate it in your daily practice. Disclosures: Dr. Doghramji reports recent relationships with Merck (stock) and consulting work for Merck, Xenoport, Jazz, Inspire, Teva and Pfizer. He has a current research grant from Inspire. Clinical Pearls: *Pathophysiology: Likely biological, neurobehavioral and psychological hyperarousal. Possible genetic component. *Depression, anxiety or PTSD may be their primary disorder. Many insomniacs unaware of their depression. Need a high index of suspicion. *Sleep apnea is probably cause in 10-20% of patients who present with insomnia. *GERD can present with insomnia and night time awakenings as its primary symptom. *CBT works as well as pharmacotherapy and has lasting potential even 1-2 years after discontinuation of therapy. *High yield nonpharmacologic therapy: Get up at the same time every morning. Don’t sleep in, even if bedtime or sleep onset was delayed. *Melatonin: It’s effect depends on time administered (see below). It’s not as safe as you think (insulin resistance, low sperm count) 1. Administer very low dose (under 3 mg) four to five hours prior to bed for delayed sleep phase (usually occurs in teens). 2. Administer higher dose (3-5 mg) one hour before bed for sleep initiation (adults with fragmented sleep). *Agents for sleep initiation:&nbsp;zaleplon,&nbsp;zolpidem,&nbsp;ramelteon *Agents for sleep maintenance:&nbsp;zolpidem ER,&nbsp;eszopiclone,&nbsp;doxepin (low dose of 3mg or 6mg),&nbsp;gabapentin (off label) *Suvorexant (orexin antagonist)&nbsp;treats&nbsp;both sleep initiation and maintenance:&nbsp;Start 10 mg and go up 5 mg every few weeks to max 20 mg daily. Orexins are deficient in narcolepsy. Orexins seem to mediate a switch system between arousal and sleepiness. *Doxepin, gabapentin and ramelteon have very lose risk for abuse.&nbsp; *Off-label use of diphenhydramine for sleep is not recommended ("dirty drug"). Trazodone and mirtazapine also have uncertain benefit. *Mirtazapine 7.5 mg is the dose for insomnia (more sedating). Lower dose favors histamine receptor. Links from the Show: 1. This is one possible site for online CBT https://www.sleepio.com as referenced in this  study 2. Melatonin associated with impaired glucose tolerance http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173928/ 3.&nbsp;American Academy of Sleep Medicine 4. This site below has easy to understand information on sleep related disorders and links to videos explaining sleep hygiene. You can also download sleep logs, get info. SleepEducation.org Website 5. Review on use of mindfulness and meditation for insomnia. http://www.ncbi.nlm.nih.gov/pubmed/26390335

Don’t be afraid of the dark? Dominate insomnia.

Summary: Treating persistent pain in the elderly can be...painful. On this episode Matt and Paul interview Dr. Marissa Galicia-Castillo, a Professor of Geriatrics from Eastern Virginia Medical School board certified in Internal Medicine, Geriatrics, Hospice/Palliative Medicine. Are we being too stingy with opioid prescriptions? How do you assess and treat pain in patients with advanced dementia? We’ve got your answers. &nbsp; Clinical Pearls:  Persistent pain in the elderly is underrecognized and undertreated Nonpharmacologic therapy is still first line (get off the couch!) Scheduled acetaminophen is a valid first line Consider low dose oxycodone IR as a second line (assuming NSAIDS contraindicated) Diversion of medication by family members is a concern and may cause treatment failure Opiates can be a great tool. Don’t be afraid to use them with careful patient selection. Follow quality of life and functional status as your end points for pain control. Pain in cognitively impaired may present as behavior problems. Treat the pain and treat the behavior.  &nbsp; Disclosures: Dr. Galicia-Castillo reports no relevant financial disclosures. &nbsp; Learning objectives: By the end of this podcast listeners will be able to:  Recognize that pain in the elderly is often underrecognized and undertreated. Recognize the signs and symptoms of pain in patients with cognitive impairment. Utilize opiates safely and effectively for the management of noncancer pain in the elderly Formulate a basic therapeutic approach to noncancer pain utilizing nonpharmacologic and pharmacologic therapy  &nbsp; Links from the show:  Dr. Galicia-Castillo’s article on use of opioids for persistent noncancer pain in older adults   http://www.ccjm.org/current-issue/issue-single-view/opioids-for-persistent-pain-in-older-adults/a136ddc8a922abd74237073a1ab89d4f.html  CDC guidelines on prescribing opioids for chronic pain (#8 discusses criteria for naloxone prescribing)   https://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf  World Health Organization Pain Ladder   http://www.geriatricpain.org/Content/Management/Interventions/Documents/WHO%20ladder.pdf  Observational study of Naloxone administration along with opiate prescriptions (NEJM Journal Watch 2016).  http://www.jwatch.org/na41676/2016/07/19/should-naloxone-be-prescribed-patients-taking-opioids  Effect size seen with opiates and tramadol were small in this review, but adverse event rates were high. This is why a trial with monitoring of functional &nbsp;status is recommended.  http://www.ncbi.nlm.nih.gov/pubmed/21472151  A RCT looking at Tramadol for knee osteoarthritis with underwhelming results.  http://www.ncbi.nlm.nih.gov/pubmed/20215961  EULAR 2016 guidelines for treatment of fibromyalgia   http://ard.bmj.com/content/early/2016/07/04/annrheumdis-2016-209724.abstract  Dr. Clauw’s YouTube Video  Chronic Pain: Is it all in their head?  Dr. Clauw’s University of Michigan website for patient self education on fibromyalgia  Fibroguide.com

Use more opioids?! How to treat noncancer pain in the elderly.

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Wait! There’s a lung microbiome?!

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