北美华人医师联盟 (ANACP)， 华盛顿州华人医师协会(WACAP)和美国华裔心脏学会(CNAHA) 联合举办的2023年会，在9月9号下午分成四个分会场，着重不同的学科和话题进行了学习和讨论。
Clostridium difficile, a notorious spore-forming bacterium, contributes to up to 25% of cases of antibiotics-associated diarrhea and stands as the most prevalent hospital-acquired infection.
Dr. Mou delivered an engaging lecture encompassing the historical perspective, pathogenesis, laboratory diagnosis, and the evolving nature of this strain. He underscored crucial updates in current treatment approaches.
Key insights from the presentation include identifying clindamycin, cephalosporin, and fluoroquinolones as the antibiotics most frequently associated with C. difficile infection.
The preferred first-line treatment is oral fidaxomicin, with oral vancomycin serving as an effective alternative. For recurrent cases, fecal microbiota transplantation proves to be an efficacious preventive measure.
Importantly, proton pump inhibitors have not demonstrated an increased risk for C. difficile infection in intensive care units.
C. difficile produces two exotoxins, toxin A and toxin B, with toxin B appearing to be more pathogenic and responsible for CDI infection. These toxins disrupt cell structures and compromise tight junctions in intestinal cells, leading to fluid accumulation and damage in the large intestine.
The FDA-approved monoclonal antibody, bezlotoxumab, targets toxin B to prevent CDI. It’s worth noting that this treatment requires administration for 14 days, with a major side effect being potential exacerbation of congestive heart failure.
There’s some other medications are under development.
Dr. Alice Zhao discussed the most common hair loss, androgenic alopecia, its hair cycle, pathophysiology, and stages. She primarily focused on medical treatments, emphasizing minoxidil as the initial gold standard, available topically and orally in low doses for non-scarring alopecia. Oral minoxidil, with dosages ranging from 0.625 to 5 mg, is generally well-tolerated but may cause side effects such as palpitations and initial hair loss.
Dr. Zhao also introduced newer minoxidil formulations, including injections and sublingual options, offering similar hair growth benefits. However, weekly injections may not be practical for all patients.
The discussion extended to five alpha reductase inhibitors like finasteride and dutasteride. Topical finasteride, while not FDA-approved, matches the effectiveness of oral finasteride with fewer systemic side effects. Dutasteride displayed promise in investigational studies, featuring various formulations.
Pharmacological approaches to glycemic treatment were thoroughly discussed by Dr. Zhiyu Wang, providing a comprehensive update.
With a total of 17 classes of medications available for glycemic control, Dr. Wang stressed the importance of person-centered treatment. Evaluating factors such as the patient’s medical history, comorbidities, glycemic goals, weight objectives, tolerance, hypoglycemia risk, cost considerations, and individual preferences is crucial.
Following this patient-centric approach, for reducing cardio-renal risk, GLP-1 receptor agonists and SGLT2 inhibitors are the primary choices. SGLT2 inhibitors are recommended when estimated glomerular filtration rates (eGFR) are above 20. In heart failure patients, SGLT2 inhibitors are preferred over traditional anti-diabetic medications. Dr. Wang also highlighted medications with proven weight loss efficacy, with Ozempic and Mounjaro showing the best results, followed by Trulicity and Victoza. Metformin and DPP-4 inhibitors are weight-neutral options. It’s essential to avoid sulfonylureas, thiazolidinediones (TCD), and insulin due to their potential to lead to weight gain.
Nevertheless, insulin remains highly effective for individuals with advanced diabetes and insulin resistance. There are eight insulin formulations available, ranging from long-acting to ultra-rapid acting types, as well as concentrated and premixed varieties. Detailed information can be found in the provided table.
Dr. Wang cited a quality improvement study to address the preoperative evaluation. Frailty of a patient can predict the outcome of a surgical procedure. It is recommended to use a score system to evaluate frailty of a patient to optimize patient’s pre-op condition. As primary care physician, we can refer to expert consensus for preoperative medication management. The expert consensus is the evidence to support our decision, even without large meta-analysis data.
PUCCINI-TNFi trial published in July, 2022, recommends to continue TNFi in Crohn’s and UC for intra-abdominal surgery.
Regarding the best timing of performing noncardiac surgery after successful TAVI, Dr. Wang presented a JAMA Netw openarticle published last year, to conclude noncardiac surgery may be performed early after successful TAVI with relatively good outcomes.
The BASEL-PMI study, published in January 2023 on European Heart Journal, is a large prospective study involving almost 8000 patients, showed 1-year major adverse cardiovascular event (MACE) and death are unacceptably high rates for all etiologies of Perioperative Myocardial Infarction/Injury (PMI), emphasized how important it is to conduct active surveillance to detect PMI and prepare aggressive management postoperatively.
CRISTAl Randomized trial published last year and PREVENT CLOT Trial published early this year, give us a conclusion as “aspirin was not as effective as LMWH for VTE prophylaxis in total join arthroplasty patients” and “VTE prophylaxis with ASA is non-inferior to LMWH in patients with extremity fractures”
The insightful discussion by the four doctors, underscored the expertise and knowledge of esteemed doctors within our medical community.