A few primary care pearls from our own Shilpa Shah!

These are some questions that came up from precepting with Shilpa! 
1. When should we get a sleep study in patients with obesity?
– Should be performed on patients with unexplained excessive daytime sleepiness
– In the absence of excessive daytime sleepiness, pursue diagnostic testing if the patient snores and either works in a mission-critical profession (pilot, bus or truck driver) or has 2 or more additional clinical features of OSA (restlessness, non-restorative sleep, snoring are a few)
– Screening questionnaires exist but are way more sensitive than specific (80-90%, 40-50%) so may be most useful in reducing concern about OSA if patients have low scores (you can find these online easily)
2. If “intestinal gastric metaplasia” is noted on an EGD, what should I do?
– This is essentially an intermediate precancerous lesion on the spectrum of chronic gastritis to adenocarcinoma
– The risk of gastric cancer with this finding is increased, but overall still low given the relativley low prevalence of gastric cancer in our population
– It does not cause symptoms itself, but may be associated with small intestinal bacterial overgrowth and symptoms of that
– Goals of management is to reduce risk of gastric cancer: 1) Eradication of H. pylori if present 2) Surveillance: repeat EGD in 2-3 years is recommended if metaplasia is extensive (multiple sites) or poorly differentiated. Can consider surveillance on individualized basis if particularly high risk (family history, particular non-Caucasian race/ethnicity) though not recommended for all patients with intestinal metaplasia
3. What affects the accuracy of a hemoglobin A1C?
– Glycation rate of hemoglobin influenced by several factors: length of glucose exposure, glucose concentration, hemoglobin level, pH, temperature, anemia
– Falsely HIGH values if red cell turnover is low (iron, vitamin B12, folate deficiency anemia)
– Falsely LOW values if red cell turnover is high (hemolysis or anemia and those treated iron, B12, folate, erythropoietin)
– A1C values may be falsely elevated or decreased in those with CKD (depending on assay, due to high urea concentrations, use of epo)
4. Remind me what a Gleason score is…
– When prostate cancer is present in the biopsy, the combined Gleason score, based upon architectural features of the prostate cancer cells, correlates closely with clinical behavior and has been incorporated into the TNM staging.
– Based upon the growth pattern and degree of differentiation, tumors are graded 1 to 5, with 1 being most and 5 being least differentiated
– The composite Gleason score is derived by adding together the numerical values for the two most prevalent differentiation pattern (a primary grade and a secondary grade) which looks something like 3+3 (which is the most common Gleason score of prostate cancer and typically correlates with localized disease).
– Gleason 6 (3+3) is the most common form of prostate cancer

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