0:00

Hey listeners, it's 2024 and we

0:02

are so excited for everything ahead

0:04

this year. If you haven't

0:06

done so already, make sure to check

0:09

out our Patreon at patreon.com/curbsiders where you

0:11

can get access to bonus episodes. We've

0:13

already released 18 of them

0:15

and they come out twice a month. Plus you

0:17

can get access to ad free episodes and our

0:19

private discord server to hang out with other

0:21

members of the cash slack community. That's

0:25

patreon.com/curbsiders. Paul

0:29

did you hear about the coffee beans that were having

0:31

a comedy show just between friends?

0:35

Is there a punch line or was that it? No,

0:38

Paul, it was a light roast. Oh,

0:40

gotcha. What do you got? We're because

0:42

we're in bean town. Oh, good stuff. I

0:45

should have done a baked beans pun. So I asked

0:47

chat GBT to write a pun about the American College

0:49

of Physicians. Matt, why did

0:51

the American College of Physicians choose a stethoscope as their

0:53

logo? I don't

0:55

know. You're gonna be thrilled about this. All right.

0:58

Because they wanted to make sure they were always in tune

1:01

with their members' heartbeats. They've got the pulse of the medical

1:03

community. By the way, you don't listen

1:05

to a pulse chat. This

1:07

is this is so much pan that's

1:09

such a pandering by chat. So

1:11

wholesome and gross. Yeah, I AI. The

1:16

curbsiders podcast is for entertainment, education and information purposes only and topics

1:18

discussed should not be used solely to diagnose, treat, cure or prevent

1:20

any diseases or conditions for the more that you use statements expressed

1:22

on this podcast or solely those of those and should not be

1:24

interpreted to reflect official policy or position of any entity aside from

1:26

possibly cash like more hospital and affiliate outreach programs. If indeed there

1:28

are any in fact, there are not pretty much we are responsible

1:30

if you serve up, you should always do your homework and let

1:32

us know. All

1:38

right. Well, welcome

1:40

back to the curbsiders. I'm Dr. Matthew Frank

1:42

Wado joined by a lot of friends here

1:45

who will introduce in due time. But

1:48

this is our our first of two

1:50

recap episodes from ACP 2024. We

1:53

are in Boston and Bean Town. I couldn't find a baked

1:55

beans pun. So get off my back audience

1:57

and Paul Paul. That was that was

2:00

pretty good. use of chat DPT. Paul,

2:02

can you remind people what is it that we

2:04

do on the curbsiders? Sure, usually we are the

2:06

internal medicine podcast uses expert opinion to bring you

2:09

clinical pearls and practice changing knowledge but this time

2:11

around we are the experts kind of we're reporting

2:13

on what the experts are talking about at

2:15

ACP a million sessions and we went to

2:17

all of them. So we'll be explaining

2:19

some of the highlights in the pearls from ACP 2024 this first day

2:21

and then a second one will recap

2:24

what we picked up at the end. Yeah

2:26

and that'll release well there'll be a little time

2:28

between the two episodes but this one is the

2:30

you know first part of the conference that we

2:32

attended and since we don't have a digest this

2:34

month because we're here at the conference we have

2:36

with us the great Dr. Nora Toronto who is

2:38

the editor-in-chief of the

2:40

digest is that your title I don't remember you gave

2:42

yourself the title. Yeah, I gave myself the title. I

2:45

mean like we want you to have that. It comes

2:47

with a crown I hope. I

2:50

haven't received it yet

2:52

but. You can do this next time you have medicine

2:55

by the way. This is a career tip. You can just name

2:57

yourself directors. Oh yeah okay great. I'll just

2:59

add things to my CV you know see

3:01

flip them in they'll be great. Okay

3:04

also with us from Curbsiders

3:07

Teach Dr. Molly Hoiblein. Hello.

3:09

Hi Molly. Great to be here. I'm

3:11

very happy to be here. And you

3:13

can keep the mic because we'll go

3:15

to you for your pearls first. Dr.

3:17

Chris D'Chumantu from Cribsiders and of course

3:19

curbsiders and Dr. Rahul Ghanatra from our

3:22

hotcakes episodes. So we will all be

3:24

going around talking about some pearls starting

3:26

with Molly. So Molly tell us a session

3:28

you attended and what did

3:31

you learn there? Yeah well I attended

3:33

a number of good sessions today but

3:35

I'm excited to recap two of them.

3:37

I'll start with one with clinical pearls

3:39

on cardiology and pulmonary medicine. The cardiology

3:41

part was done by Dr. Michael Cullen

3:44

and so I'm gonna use some of your techniques

3:46

here Matt. Okay. Alright so you've got somebody with

3:48

atypical chest pain and you're trying to differentiate is

3:51

this real score? No. It's not

3:53

cacti. Is this truly and

3:55

in us? If their chest pain gets

3:57

better with nitrile that means that it really was a

3:59

skill. Is that right? That's got to be true.

4:01

Yeah. Yeah. You're on

4:04

it. So apparently we're not

4:06

actually supposed to be saying atypical angina because

4:09

it's confusing. And so we should be

4:11

saying possible cardiac chest pain, cardiac

4:14

chest pain, if we truly find out or

4:16

think it's ischemic or non-cardiac chest pain. Because

4:19

atypical angina is a confusing term and,

4:22

you know, many times it's not actually heart-related, so

4:24

it's not truly angina. And

4:27

the speaker, Dr. Cullen, highlighted that nitric

4:29

ghost serum really is not helpful in

4:31

deciding, sorry, the response to nitric ghost serum, if

4:34

that helps relieve the chest pain, is not

4:36

helpful in determining if a patient really has

4:38

angina. And he cited a

4:40

study that showed that nitro relieved chest pain in

4:43

35% of patients who actually

4:46

had ACS and actually relieved the

4:48

chest pain in 41% of patients

4:50

who did not have ACS. Super

4:52

helpful. Yes. And then, maybe

4:54

on to pulmonology, that was Dr. Meghan Scrondon, Scroden,

4:56

actually, I think. She

5:07

talked about a few different cases, but one

5:09

that I thought was quite helpful was thinking

5:11

about if you have a patient

5:13

with COPD, thinking about if they

5:15

may also have asthma overlap and being careful

5:18

to treat the asthma, if that's the case.

5:20

So for example, if you have someone with

5:22

COPD alone, you might have them on a

5:24

laba llama, but if they maybe also have

5:26

asthma, you would want to make sure that

5:28

you optimize the inhaled corticosteroids as well. And

5:31

she recommended thinking about using an exhaled

5:34

nitric oxide testing, which is a

5:37

non-invasive measure of eosinophilic inflammation and

5:39

has a good positive predictive value

5:41

for diagnosing asthma. And we

5:43

were talking about this, Molly, Paul, you're both

5:45

primary care physicians. Is this a test

5:47

that you're ordering when you're ordering your

5:50

standard PFTs? It sounds like

5:52

not as often as I should be, because I feel like so many patients

5:54

– there's such an increase

5:56

in COPD, asthma overlap, which I just don't think

5:58

enough about, probably. I should probably

6:00

doing it more often. Yeah. And

6:02

then there's that non-asmatic ESNFL bronchitis, which I'm pretty

6:04

sure that test can be used for as well.

6:07

But this, I had not thought

6:09

about using it to help figure out if someone

6:11

has COPD asthma overlap. That's a good

6:13

pearl. That's something that I actually may try doing

6:15

for... I have never ordered it. So she

6:17

did have the caveat that it doesn't have a good

6:20

negative predictive value. So if it's low,

6:22

that doesn't rule out asthma. And

6:24

she highlighted that smoking and using

6:26

inhaled corticosteroids are associated with lower

6:29

fractional excretions of nitric oxide. So

6:31

just kind of being aware it's only helpful if it's

6:33

positive. And then I feel

6:36

like this is something I should have known,

6:38

but she also was talking about in patients

6:40

with advanced COPD who have exertional hypoxia but

6:42

not resting hypoxia. Using

6:44

home oxygen does not improve their quality of life

6:46

or their function. I think I knew

6:48

that it didn't improve mortality, but I was hopeful

6:50

that it would improve their six-minute walk

6:53

test or help them feel better.

6:55

But unfortunately, it does not do that. It

6:58

would look convincing patients that if they think

7:00

they need it. But it's one

7:02

of those things that I think we probably

7:04

have some people on oxygen that don't

7:06

really need it because of that because they're doing

7:08

the walk test. And that's how a lot of

7:11

patients qualify for oxygen. So I don't

7:13

quite know what to do with that, Paul. Yeah. No,

7:16

that's exactly... That has been my experience that they

7:18

actually... You're required to document the walk test specifically to

7:20

get the supplemental oxygen, which is the thing that is

7:22

not necessarily all that helpful with. So yeah. Yeah.

7:26

And then you've gotten caught up to the evidence in that area.

7:28

Did they talk about any practical tips for

7:30

that? Or are they just saying... They were just

7:32

saying, don't do it. Yeah, it's

7:34

not helpful for patients. And she

7:37

actually had felt like in her experience for some

7:39

patients, having the oxygen actually made their quality of

7:42

life worse because they're kind of tied to a

7:44

machine or they're nervous to go on longer trips

7:46

if they don't have a concentrator. And

7:49

yeah. So she was discouraging us from prescribing

7:51

that, which I actually just did two weeks

7:53

ago. Yeah. And

7:57

Dr. Leah Witt on our COPD

7:59

and older adults. That's one of

8:01

the points she made, that it can be

8:03

like isolating for people and also risk of

8:05

fall over the oxygen tubing and things like

8:07

that. So make sure people really need

8:10

it. But it's

8:12

a tricky one. Anything

8:14

else from that session? Nothing else from that session. And

8:16

then the other one that I wanted to highlight was

8:19

an update on current clinical guidelines

8:21

and colorectal cancer screening with Dr.

8:24

Amir Kaseem and Dr. Wanda Nicholson

8:26

and Dr. Timothy Wilt. And

8:29

they were highlighting the American College of Physicians'

8:31

2023 colorectal cancer screening guidelines,

8:34

which differ from the ones that we more typically

8:37

follow. I think most of us use the United

8:39

States Preventive Service Task Force guidelines

8:41

and are offering our patients 45

8:43

to 49 colorectal cancer screening now.

8:47

And they differ in that.

8:49

They say that clinicians should consider

8:51

not screening asymptomatic average risk people

8:55

from 45 to 49 and,

8:57

you know, shared decision making.

8:59

But they were saying that it's

9:02

really a minimal net benefit and

9:05

the risk in this population is small. And

9:08

I think the USPSPF recommended

9:10

lowering the screening age partially because

9:13

we're seeing this increase rate in

9:15

younger patients. But they highlighted

9:17

that the absolute rate increase was very

9:19

small. It was a 15% rate increase

9:21

for colorectal cancer screening in that age

9:23

range from 2016 to 2021. But

9:26

the numbers were tiny. It went from 29 per 100,000 to 33 per 100,000.

9:32

So only a four per 100,000

9:34

increase, which may not be

9:36

worth screening. Right. And we were

9:38

talking about this offline, Paul. I think it's because

9:40

it's hard to capture people at age 50. And

9:42

a lot of times they might not get it

9:44

until a couple years later. So this just gives

9:46

us more lead time to get people a colonoscopy

9:48

around the age of 50 but I don't know

9:50

what your thoughts are. No, I

9:52

agree with that. I also wish this should not go

9:55

now. We practice medicine but about the medical legal implications

9:57

of now having two conflicting guidelines and what happens if

9:59

you happen to miss an early colorectal cancer because you

10:01

followed one versus the other and what do you do

10:03

with that and which guideline carries more weight. So it's

10:06

just, it's, I don't quite know what

10:08

to do with it, I'll be honest. And they have some thoughts

10:10

about the screening modalities as well, right? And they

10:12

did, yeah. But I would agree with you. I don't think

10:14

this is necessarily practice changing for me. I

10:16

will still be offering my 45-year-old colorectal

10:18

cancer screening. But if you forget, you

10:20

can say you're following. Yes. I'm

10:23

following you. I won't feel as bad about

10:25

chasing them down to convince them. And

10:28

then they also specified that they do not

10:30

recommend using stool DNA, CT

10:32

colonography, or serum screening testing

10:34

for colorectal cancer screening. And

10:37

they specifically state that those have

10:39

increased cost and reduced specificity compared

10:42

to the other modalities like fecal

10:44

col blood testing and colonoscopy or

10:46

sigmoidoscopy. I still think

10:48

that, I mean, there's commercials for that test now,

10:50

the stool DNA test. So that one I've been

10:52

getting asked about a lot noticeably since those commercials

10:54

of that little box that comes up and knocks

10:56

on a guy's door and the

10:59

manager fills him in time. There's

11:02

that SNL skip people can look up. Okay.

11:05

That's so scary. I won't have to

11:07

check by that. Do

11:09

you feel like people are equally willing

11:12

to do the stool testing and

11:14

the colonoscopy? Or do you feel like

11:16

it's easier to convince and take? Because

11:18

I feel like in my experience, people

11:20

take some time to be willing to do

11:22

a colonoscopy, whereas kind of doing something where they

11:25

can do it at home, even if they do

11:27

have to like transport stool somewhere, which they do

11:29

have to do for some of these stool testing

11:32

kits, is a little bit easier to do.

11:35

Yeah. And their guidelines kind of covered this as

11:37

well, that it really should be a discussion about

11:39

what the patient's preferences are and that

11:42

patients could change their mind throughout. So if

11:44

they start with fecal col blood testing for

11:46

a few years, they could switch over

11:49

to colonoscopy. I would say in my

11:51

experience, it's really variable. Some

11:53

people want the best

11:55

test, even though we don't have clear evidence

11:57

that colonoscopy is clearly that much better than...

12:00

Which is shocking. That a fit? But

12:04

yeah, I think, you know, it's nice to be able to

12:06

have options to say, this is more involved but you only

12:08

have to do it every 10 years. This

12:11

one's like lazy, theoretically. Yeah,

12:14

the USPSTF authors made the point that the test that the

12:16

patient completes is the best test for colorectal cancer screening. And

12:18

I will say anecdotally, I've had the

12:20

home test then prompts patients to undergo

12:22

the colonoscopy. So you kind of get

12:24

there regardless and I've seen sort of

12:27

more enthusiasm regarding colorectal cancer screening

12:29

with increased options. I don't

12:31

know, I'm not quite sure how I feel about taking it off the

12:33

table. So we have a really good reason to. It

12:36

also takes so long to get scheduled

12:38

for colonoscopy in a lot of areas

12:40

that it just, yeah, that can be

12:42

hugely problematic from getting people to the test

12:44

they're going to do. Or

12:46

even the home. Yeah, yeah, yeah. You need

12:48

transportation back, you're not driving yourself, even that can be a barrier

12:51

in and of itself. Yeah, well, there's certainly not recommended taking the

12:53

fit off the table. It's just the DNA testing.

12:56

Let's go on. So you and Nora were

12:59

both at the multiple small feedings of the mind.

13:01

There were some oncology pearls about the checkpoint inhibitors.

13:03

We did an episode on that a couple of

13:05

years ago, but anything you wanted to bring

13:07

up from that one? So Nora,

13:09

you're well into oncology fellowship at

13:12

this point. So

13:14

what reactions should we think about early on and

13:16

sort of over the course of treatment? Yeah.

13:19

So Molly and I went to

13:22

the multiple small feedings of the

13:24

mind. One of the areas that

13:26

they covered was cancer survivorship topics.

13:29

And Dr. Nargis Flores presented on

13:31

this topic. And one of the

13:33

areas that she focused on was

13:35

toxicities from

13:38

medications that patients are increasingly

13:40

getting and are actually increasingly

13:42

surviving with. So

13:44

patients will have received checkpoint

13:46

inhibitors, for example, and many of

13:49

them will be surviving for long

13:51

periods of time after having received

13:53

checkpoint inhibitors. And so there's increasing

13:55

awareness of what the side effects

13:57

are and also... also

14:00

with the nuance and the understanding now more

14:02

than 10 years ago that many

14:04

of these drugs that are new, we understand

14:07

longer term side effects in a different way

14:09

than we did five or

14:11

10 years ago. And

14:13

so for the checkpoint inhibitors in particular,

14:15

she pointed out that kind of the

14:18

way we're understanding the side effects

14:20

is evolving, but skin rash

14:22

toxicity tends to occur

14:24

earlier than other

14:27

toxicities that are checkpoint toxicities. And

14:30

then colitis, so diarrhea,

14:32

and the diarrhea can

14:34

be very profound, lots of like

14:37

liquidy diarrhea cramping. And

14:39

then the endocrine opiates, so

14:41

the thyroid issues, which can

14:44

be hypo or hypercyroidism, and

14:47

all of the other adrenal and endocrine

14:50

problems can occur. And they're

14:52

temporary and reversible? Great

14:55

question. So no, some of

14:57

them can be treated and should be treated promptly.

14:59

And so that's one of the reasons I think

15:01

this is a great topic for this

15:04

conference, because these are

15:06

things that people may be coming to you as their

15:09

primary care doctor with saying, oh yeah,

15:11

I'm having these new symptoms. And

15:14

if you aren't thinking about the possibility that

15:16

like even six months out, a year out,

15:18

I've seen some of these happen

15:20

like two years out from checkpoint inhibitor

15:22

therapy that they need to be treated

15:25

promptly. And she was saying, I don't

15:27

know whether any of you have done

15:29

this, but she was saying, if

15:31

you're ever in doubt, just start them on

15:34

prednisone, one milligram per kilogram. Have you done

15:36

that in primary care or are you going back

15:38

to that? All the time. Almost

15:40

everything. Yeah, I

15:42

feel like even some oncologists,

15:45

like they want more work out before

15:47

they'll do that. But it

15:49

is true that like the longer you wait,

15:51

the more you have a risk of things

15:54

being permanent and not reversible. And a lot

15:56

of the endocrinopathies in particular are not reversible.

15:58

And so people need hormone. replacement

16:01

for them. Yeah, and

16:03

I think it was helpful as a PCP. You know,

16:05

hopefully these people are seeing their oncologist regularly, but sometimes

16:07

if it is months out and the patient might not

16:10

be aware that this is a potential

16:12

complication from their treatment, they're likely to come to

16:14

me and say, you know, I have this new

16:16

cough or I have this diarrhea, and

16:18

so just being aware of those potential later

16:20

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by passion. The

18:16

one thing about survivorship that she was talking

18:18

about that just kind of struck me where

18:20

she was talking about how patients like they

18:23

have a diagnosis of cancer so they're just like she's

18:26

like YOLO they're like they're smoking, they're drinking, they're

18:28

out partying and then they're like cured from their

18:30

cancer and then they're like suffering from the consequences

18:32

of some of these things. So she's just like

18:34

don't forget to like talk to them about smoking

18:36

cessation because then she's seen patients who had a

18:38

breast cancer and now come back with a lung

18:41

cancer and things like that. I just

18:44

thought it was interesting the lifestyle things you

18:46

know I'm a big lifestyle person Paul. So

18:48

I hear. And or like

18:50

other cancer screening which like in the

18:52

treatment for their one cancer they

18:55

will not have gotten the other cancer

18:57

surveillance that really they could

18:59

have been getting for five years while they

19:01

were undergoing cancer treatment. So that's something that

19:03

kind of falls between the oncologist and the

19:06

primary care doctor and often I think does

19:08

get forgotten. I was survivorship broadly. Right exactly.

19:10

Like the fall apart. Yeah. Okay

19:12

well let's move on to the chew man,

19:15

Chris the chew man chew with

19:17

some smoking cessation pearls and Chris who

19:19

was who was giving this session. Do

19:21

you have. Yeah it was has been

19:23

a cafeteria. It was the seven

19:25

o'clock session on the first day. So where

19:28

were you when you were. I

19:31

start off with brush my teeth. As well.

19:34

I watched in last week Chris. But

19:37

I made it there in person by the end. So

19:39

it was great. It was you definitely weren't in the

19:41

bathroom. We

19:46

went through a lot of things. I think one thing

19:48

that was brought up and I really feel

19:50

that you know I think we've talked about on episodes before

19:52

is the Eagles trial and

19:54

I think this is always reasonable to bring this up

19:56

again with so many of our patients

19:58

who are smoking and need. need help with that.

20:01

There is safety and efficacy in using medications

20:03

like Varenicline and Bropropran and patients with psychiatric

20:06

disorders. So I think the Eagles trial was

20:08

one of the trials that really showed this.

20:10

And I think it's just good to reiterate

20:12

that and for people to know that, hey,

20:14

just because they have a psychiatric disorder, don't

20:17

take this off the table for them. Yeah.

20:19

The other one that, and I think it

20:22

was that trial as well, people talk about

20:24

the vivid dreams. And actually, I think nicotine

20:26

replacement therapy can affect

20:28

dreams just like Varenicline can. But

20:30

people say, I don't want to take it. I heard it

20:32

messes with your dreams. But nicotine replacement therapy can do that

20:35

as well. So it's just one of

20:37

those things where somehow Varenicline got a ton

20:39

of bad press and so a lot of patients don't want

20:41

it. They're like, I heard I can't take that because I've

20:43

been depressed or my friend took

20:45

it and they had really vivid dreams, so I don't want to

20:48

take it. Sounds kind of fun, Paul.

20:50

I don't know. Yeah, like good dreams or bad dreams? No,

20:52

just a question. Yeah. Depends. If

20:54

it's like Freddy Krueger, you know, then maybe. People

20:57

up to the Varenicline in the past and just have yourself a

21:00

whole eight hour vacation at nighttime. Okay,

21:03

Chris, what about e-cigarettes? Anything on that in

21:05

the session? What I liked about talking

21:07

about e-cigarettes is we just haven't had a lot of studies

21:10

looking at e-cigarettes in terms of, well,

21:13

we now know, you know, some recent studies

21:15

showing that yes, e-cigarettes are good for smoking

21:17

cessation. But now we know that people then

21:19

just are now addicted to e-cigarettes and can't

21:21

get off them. So what

21:23

do we do with those patients? And we don't, we

21:26

previously didn't have a lot of studies showing what

21:28

is evidence-based that we can use to help people

21:31

with e-cigarette cessation. So

21:33

there were some studies that were

21:35

presented talking about Varenicline and counseling

21:37

for vaping cessation. So it looks like there are

21:39

some studies. We can put those in the show

21:41

notes that see, it was a

21:43

true randomized 12 weeks of Varenicline plus counseling

21:46

versus placebo plus counseling at

21:48

the end of 140. And basically there was high

21:50

continuous abstinence with Varenicline. So I think we have

21:53

good evidence for that. And also just

21:55

plain evidence of just using regular nicotine

21:57

replacement therapy and counseling for vaping cessation

21:59

as well. Yeah, we, when we

22:01

talked about this on Hotcakes recently, we were looking

22:03

this up and the, one of those pods that

22:05

comes with nicotine that goes in the e-cigarette devices

22:08

is, has as much nicotine as someone get from

22:10

like a pack of cigarettes. So it

22:12

does really replace one nicotine addiction with

22:14

another. We think this is still

22:17

harm reduction based on like the recent editorials, even

22:19

the experts are saying that now. I,

22:21

we should mention that the two studies we talked about, there

22:23

was one by Auer et al.

22:26

from 2024, that was in New England Journal. That

22:28

one, the e-cigarettes versus the counseling plus

22:30

vouchers, Paul, and that one held firm.

22:33

E-cigarettes, you know, did help. But

22:35

the, the one where we, it was by Lynn et al. from

22:37

2024 and I think it was in, it was

22:40

in one of the internal medicine journals. That

22:42

one was recalled. Rahul, do you remember it

22:44

was like data issue? Yeah, it was

22:46

a coding error and it was actually, the

22:48

retraction was kind of proposed in a letter

22:51

by the authors. So that's not quite as

22:53

bad as, you know, retraction for fraud and

22:55

we'll have to sort of stay tuned to

22:57

see if there's a reanalysis. And this doesn't

22:59

like topple the whole e-cigarettes being something that

23:01

could be beneficial thing. That was

23:03

my take home from, it's not like we, we

23:06

now had to take back everything that good that

23:08

was learned about e-cigarettes. This was just one study.

23:10

I think that's right. I mean, it is important

23:12

to sort of look out for retractions of studies

23:14

that you're basing your decisions on and to

23:16

sort of see what happens. Paul's

23:18

shaking his head in disagreement. Yeah,

23:21

but no, I don't think this topples everything.

23:23

Either e-cigarettes are going to be less harmful

23:25

than cigarettes with respect to specific outcomes and

23:28

cardiovascular disease, pulmonary medicine remains to be seen.

23:31

Yeah. Okay, Chris, what makes a certain intuitive sense to me,

23:33

by the way, because like there's still the behavioral elements. So

23:36

the e-cigarettes will take the place of that and then transitioning

23:38

to forensic thing. So the trial that would make, that would

23:40

be interesting to me would actually be having a period of

23:42

transitioning e-cigarettes and then following up with a running clean, like

23:44

actually doing that in a structured way. And I would bet

23:46

you see some success with that. Well, Paul,

23:48

watch this transition. So Chris, cigarettes are bad

23:51

for you, but I heard that walking

23:53

10,000 steps a day, I will

23:56

live forever. Is that true? Yeah,

23:58

that's true. Well, so that's true. That's

24:00

a great question. It's not actually. You

24:02

have to finish all of this. And did the

24:04

Consul guys talk about this? Yeah. So

24:07

I went to the apparently great

24:09

talk from the Consul guys. Do you

24:11

know Merle and Howard White? Sure.

24:14

Yes. Do you know Howard?

24:16

You know, there's some great guys from the Annals

24:19

of Internal Medicine. So a lot

24:21

of times they'll bring up a question and then

24:23

they say, do I need to bust a Smith

24:25

or not? And so one of

24:27

the questions that they brought up, or at least the Consul

24:30

they got was, the patient said, hey, do I really need

24:32

to make 10,000 steps? Everyone

24:34

keeps on recommending this. And what was

24:36

great was they sort of went through the history of the

24:38

10,000 steps where it came from. And

24:41

so the Tokyo Olympic Games were in 1964. And

24:44

basically Japan was in the middle

24:46

of this fitness craze at the time. And

24:48

this company called Yamasa decided that this term

24:50

they have is called, I'm

24:53

probably going to mess this up,

24:55

Manpo-K, which means 10,000 steps or

24:57

something like that. It just sounded right. So that's

24:59

how they landed on 10,000 steps. So

25:01

there was absolutely no evidence base for when they decided

25:03

on 10,000 steps. And so this is

25:05

from 1964. So that was what, 60

25:08

years ago. And since then they

25:10

haven't had a lot of really good studies to follow

25:12

that up to say, hey, this is what's going on.

25:14

So we haven't had a lot of good studies since that time that

25:16

they decided 10,000 steps was going to be what

25:19

we're going to do for, you know, recommend to our

25:22

patients. And so recently we've

25:24

actually had quite a few studies come out.

25:26

And the one that they brought up during our

25:28

discussion was this Steens et al. from the

25:30

Journal of American College of Cardiology. And

25:32

so basically, and that's how you found that as

25:34

few as 2,517 steps, so, you know, 2.5

25:38

thousand steps per day can be associated with an

25:41

8% reduction in all cause mortality. By 2,735 steps

25:43

per day can achieve 11% reduction in cardiovascular disease

25:45

risk. So

25:49

they found that the optimal daily step count for minimizing

25:51

health benefits to be about 8,763 steps for a 60%

25:53

reduction in all cause mortality at a 7,126. step

26:00

for 51% reduction in cardiovascular risk. So basically

26:02

they found that this sort of plateaus after

26:04

that point so you know if you round

26:06

things up you know shoot for 8,000 steps

26:08

a day you can do 10,000 steps

26:10

but probably you're not going to get much more benefit

26:13

after that. So Rahul what about

26:15

you? What session did

26:17

you attend? Yeah I went to Dr.

26:20

Jerry Smetana's update on new

26:22

medications and primary care. This

26:25

is a really useful session he

26:27

talked about four novel drugs that

26:30

have recently gained FDA approval for

26:32

a couple different indications that are common in

26:35

primary care. First medication he

26:37

talked about was voneprazine, veneprazine. I actually don't

26:39

know how to pronounce that yet probably gonna

26:41

butcher that. We'll go with veneprazine I think.

26:44

Yeah I like it yeah. Okay so we're

26:46

gonna sign it on this podcast right now.

26:48

Yeah this is a new class

26:50

of medication that's been approved for

26:52

refractory GERD. So

26:55

you all have a sense persistent symptoms

26:57

on PPIs are really common. This

26:59

medication is a novel class of

27:02

medications called a PCAB potassium competitive

27:04

acid blocker and these

27:06

drugs are more rapidly absorbed than PPIs.

27:09

They have a longer half-life and

27:11

somewhat more potent and the

27:13

bottom line on the data for voneprazine is

27:16

that they're more effective than PPIs for patients

27:18

with severe erosive esophagitis and

27:21

they have similar efficacy for people with

27:23

garden variety GERD. The important

27:25

things to keep in mind when using

27:27

this drug this will reduce absorption of

27:29

drugs that need an acidic environment for

27:31

absorption and there's also some CYP3A4

27:33

interactions and not surprisingly

27:36

this is expensive. It is only going

27:38

to be approved for six months of

27:40

use currently not for continuous use. So

27:42

it's an option for patients with refractory

27:45

symptoms of GERD or severe erosive esophagitis.

27:47

He also talked about a drug that

27:49

we have discussed on our show before,

27:51

pheasant. We discussed this in episode

27:54

403 which is a hot cakes

27:56

in episode 409 with Dr.

27:58

Monica Christmas. This is a non- hormonal

28:00

therapy for hot flashes, some of

28:02

the vasomotor symptoms of menopause. So

28:05

hormonal therapy is the most effective

28:07

treatment for vasomotor symptoms, but it

28:09

does carry risks that some patients

28:12

will fairly be uncomfortable with.

28:14

There are alternatives like gabapentin and

28:17

SSRIs, but those are not

28:19

really that effective. So Fecilinotant is

28:21

a new medication. It's a neurokinin

28:24

receptor blocker, and this works

28:26

fairly well to reduce the frequency and severity

28:28

of menopausal hot flashes. Headache and

28:31

transaminase elevations are kind of common with this

28:33

medication, so you gotta watch for those. But

28:36

it's good to have a new option in

28:38

our reminitarian for menopause. Yes, and

28:40

Molly was telling us, because

28:42

Molly deals with a lot of women

28:45

going through this, and they're not thrilled when

28:47

they find out they have to get this

28:49

three, six, and nine-month testing of their LFTs

28:51

for the first year that they're taking

28:54

the medication. I think that's probably gonna

28:56

go away, because the side effect wasn't

28:58

that common in the trials. And we'll

29:00

see as more people are on this. It's

29:02

still really expensive. They're advertising it on TV,

29:04

direct to consumers, so I'm sure people are

29:07

coming and asking about it. But

29:09

I have not yet prescribed it for anybody.

29:12

Yeah, you're absolutely right. Chris brought up

29:15

before we recorded that the concern about

29:17

transaminase elevation came from reports of related

29:19

molecules that showed this in preclinical testing.

29:22

And Dr. Smetana pointed out that very

29:24

few patients had severe elevations in transaminases

29:26

from this, so hopefully that will go

29:29

away. He also talked

29:31

about the RSV vaccines, and there's a

29:33

lot more that he said than we're

29:35

gonna go into here. But one thing

29:37

that I thought was kind of interesting

29:39

is that on the market currently, there's

29:41

a vaccine from GlaxoSmithKline and a vaccine

29:43

from Pfizer. Moderna is also

29:45

developing an mRNA vaccine for

29:47

RSV, so stay tuned for that. That's

29:50

expected to gain FDA approval in the

29:52

next year or so. There's

29:55

been some concern about neuroinflammatory side effects with

29:57

the RSV vaccine so far, so. It's

30:00

hopeful that the Moderna version might be safer,

30:02

so stay tuned for that. And

30:05

one of the pulmonologists, and I think

30:07

this was in the multiple small feedings

30:09

talk earlier today, was saying she thinks

30:12

it's going to be for

30:14

people under 60 in the next few months

30:16

with high risk, like lung disease, so really

30:18

bad asthma or COPD. It's

30:20

probably going to be approved for them as well because

30:22

you're really trying to target. The populations that get sick

30:24

from this are really young kids and

30:27

older folks who are sicker and so

30:30

they're expecting that. I'm curious, I guess

30:32

they're just going to extrapolate. To my

30:34

knowledge, it hasn't been studied in that

30:36

population, so that might

30:38

be coming down the pike as well. Yeah. Yeah,

30:40

we did discuss RSV vaccines on a prior hotcakes

30:43

and we discussed the trials,

30:45

Renoir and Matisse that studied

30:47

the RSV vaccines in older

30:49

patients. And

30:52

currently only the Pfizer vaccine has approval

30:54

for administration in pregnant women in the

30:56

third trimester. But yeah, I don't know

30:58

if there's data that I don't know

31:00

about which is always possible or if

31:02

that data will be an extrapolation. Yeah.

31:05

And the GSK vaccine is the one that's adjuvanted and

31:07

there was increased risk of

31:09

miscarriage so it's not approved in pregnancy. But

31:13

that's where we're at with that. So we will

31:15

continue to follow that on hotcakes and the digest,

31:17

I'm sure. Oh, you know we will. Okay.

31:21

What about, I think there's one last agent

31:23

to talk about. Yeah. The

31:26

first novel agent that got FDA approval in

31:28

the last year is a new option for

31:30

depression. And this is a

31:32

medication called Jeparone. And

31:35

this medication is a 5-HT1A partial agonist.

31:39

And this is more similar to Bucepirone

31:42

than the SSRIs. And

31:44

this drug has kind of a storied

31:46

past. This was previously rejected by the

31:48

FDA three times and apparently the fourth

31:50

time is a charm. This

31:53

is a major red flag. Yeah. So the

31:56

history of this is online. You can Google it

31:58

and it's a fascinating story. Dr.

32:00

Smetana pointed out that this medication might

32:02

have a role in treating

32:04

patients who can't tolerate SSRIs due to side

32:07

effects. Dizziness and nausea

32:09

were the most common side effects with

32:11

this medication. Importantly, there is no weight

32:13

gain, no fatigue, and no sexual side

32:15

effects. So, you know, stay

32:17

tuned for more information on how this medication is

32:20

going to end up being used. Dr. Smetana wondered

32:22

if this might be something that might end up

32:24

getting used oftenly before sexual dysfunction with or without

32:26

depression. And in our next batch

32:29

of episodes, we are going to

32:31

try to do a depression update and talk

32:33

about some of the newer therapies. That's something

32:35

on our list. So that should sometime in

32:37

2024, we should have another depression episode, which

32:39

is long overdue. What was next

32:41

on the agenda? I think cannabis, the harms of cannabis.

32:43

Is cannabis good for the heart, Rahul? I think we

32:45

should talk about cannabis. I can see Paul just like

32:48

turtling with glee. Yeah. Yeah,

32:50

it is. So there was another great

32:52

talk at this conference, What's New

32:54

in Addiction Medicine? And this is with

32:57

Dr. Charles Resnickoff. And he

32:59

gave an update on a bunch of different

33:01

pieces of addiction medicine. The

33:04

first thing that was discussed was

33:06

cannabis and just, you know,

33:08

an oyster farm of interesting pearls in

33:10

this section. So there

33:12

is increasingly convincing

33:15

observational data that cannabis

33:18

has sympathomimetic properties and

33:20

is a coronary vasoconstrictor

33:22

and a peripheral vasodilator.

33:25

So this is the basis

33:27

behind why it's concerning that

33:29

cannabis might have cardiovascular implications.

33:31

Paul, can I get your take on that? Sounds

33:34

bad. He's

33:36

always been skeptical of all the

33:38

health benefits of cannabis. And every

33:41

time there's cannabis articles, he's always sending them out

33:43

to us on our internal Slack channel. That's why

33:46

we knew Paul would always want us to talk about this. I

33:48

feel like you're trying to protect my career, which I appreciate. Dr.

33:52

Resnickoff did talk about some of the benefits of

33:54

cannabis use. And one of the things he mentioned

33:56

that I thought was just really actually important to

33:58

recognize is that many people. use it for

34:00

pleasure because it's fun. And

34:03

that's absolutely worth recognizing in

34:05

the balance of risks and

34:07

benefits of why people do

34:09

anything. And there's many

34:11

people who use it for sleep

34:13

regulation. There's some thought

34:15

that it might help with nightmares

34:17

and PTSD. He did

34:19

talk about the risks of rebound insomnia

34:21

with stopping cannabis. And then we all

34:24

had some familiarity with cannabis

34:26

hyperemesis syndrome at this point. A

34:28

lot of other interesting pearls on cannabis.

34:30

What about the pre-op? Wasn't

34:32

there a pre-op? I thought that was something that

34:34

I wasn't aware of and you had mentioned. Should

34:38

patients smoke cannabis right up to the time they're

34:40

getting rolled into the operating room? Why

34:43

no, Matt. They shouldn't. You know, I'm

34:45

not familiar with the data on this,

34:47

but he did cite a study showing

34:50

that pre-operative cannabis use is thought to

34:52

increase perioperative adverse cardiac outcomes like more

34:54

than fivefold. So this is, in

34:56

my mind, if true, this is an easy lever to

34:58

pull to the sort of counsel patients that, hey,

35:00

before an elective surgery, you know, it's worth

35:02

it to curb the cannabis use. So

35:05

that kind of fits in my mind with, you

35:07

know, cannabis having vasoactive properties. He

35:10

did mention that the increase in

35:12

MI, coronary disease and stroke are,

35:14

you know, on the order of 1.2 to 1.4 times the risk

35:16

of nonuse. But

35:19

he noted that that's about an

35:22

order of magnitude less than people who smoke

35:24

tobacco. So still clinically relevant, but you're

35:26

not as bad as smoking tobacco. Okay.

35:28

Paul, let's go to you. I guess we're just

35:30

going straight around the table here. I know the

35:33

cannabis thing I just want to say just because

35:35

even in states where it's used medically and not

35:38

just sort of legal in general, like I don't

35:40

think that the vetting process or the counseling process

35:42

around its safety is probably very thorough for the

35:44

patient. So we can be certified for medical use.

35:46

Like, I'll have my card. Oh, for what? For

35:49

anxiety? Like, okay, great. Good. This

35:51

seems legitimate. Perhaps the adverse

35:53

effects, the cardiovascular effects are really worth talking about.

35:56

So I think that's just compelling and important information.

35:58

And If someone discloses it to you, we should. Then

36:00

you get are much more comfortable doing these

36:02

days because it's so prevalence is a chance

36:04

that we seven have a conversation about the

36:06

safety. the yeah we didn't get on there

36:08

certified as we do with alcohol, tobacco and

36:10

any other substance people are using. He

36:12

and he also did point out that

36:14

that. Incidence. Of use in

36:16

the like elderly. And aging population is

36:18

going dramatically. apps or at least or

36:21

were capturing it. Much. More

36:23

than we assume and south's I think that that's

36:25

a big part of this. This. Increased

36:28

understanding of they the incidents and

36:30

risks from a cardiovascular perspective. to

36:32

set the Achilles in ascending probably

36:34

the. So. Far

36:36

so tell us a little bit about what did

36:38

you are about I'll D and who was who's

36:40

giving a talk yeah this was I was the

36:43

I'll Be for the interest this was given by

36:45

Kevin Wilson from Boston University School of Medicine and

36:47

to say a really nice over you in terms

36:49

of wonder suspected what to do about it would

36:51

prominence you're talking about So the broad strokes if

36:53

if you have a patient was unexplained call for

36:55

just me or or in assists of progressive passes

36:57

that he can explain. otherwise they might be time

36:59

to start thinking about I'll Dietz and gave sort

37:01

of them all the classes of the A queue

37:03

causes of I'll do it like hypersensitivity, Unitas and

37:05

Cgt really dial. D and drug induced and

37:07

a few decent if elected unisys pneumonia but

37:09

in any case so you have an acute

37:11

presentation what you think is I'll d the

37:14

debate the Pa announcer having is. How

37:17

soon and how aggressive should be about diagnostic testing

37:19

vs when she just miss a dream of these

37:21

patients. Now the minutes and it sounded come out

37:23

as soon. Agree is not a

37:25

whole on a consensus about their so the diagnostic

37:27

testing. yeah it's it's done to run cost to

37:30

be. For. The most part and there's

37:32

different things they can do. they can do.

37:34

Lovaas was the presenter. Like you can do

37:36

transcranial force of biopsy. You can do these

37:38

trends. Cranky? Okay oh Bob Sees was primatologist

37:40

flights. Are not widely available

37:42

necessarily. At. your really hellbent on

37:44

getting a diagnosis and you can you do a

37:46

surgical biopsy i'm but a patient and up with

37:48

a chest tube of their the hospital for a

37:50

little bit and if they have to to me

37:52

i'll the if make it much much worse so

37:54

a plus i disagree diagnostic yield the downside to

37:57

commit things worse and does it matter and that

37:59

matters is going to treatment for all the different

38:01

subcategories of ILD. It turns out it's like 40 milligrams

38:03

of prednisone for almost all of them. So the

38:06

one point that he made, which I think is just

38:08

important to consider, is if you think that it might

38:10

be scleroderma-related ILD, prednisone can actually precipitate

38:12

a renal crisis, recognizing that we as internists are probably

38:14

not going to be clearing out the prednisone for specti-ILD,

38:16

but just something to be mindful of. And

38:19

the treatment, of course, is usually at least a

38:21

couple of weeks. He talked

38:23

about antifibrotic treatments for ILD, too. And most

38:25

of these conditions don't progress the fibrotic lung

38:27

disease, so there's no urgency to start them

38:29

on these antifibrotic medications. And again, we're not

38:31

going to be doing this unless

38:33

you're talking about IPF, which by definition

38:35

is fibrotic, and then it's a different conversation. The

38:38

other thing that he talked about are these sort

38:40

of acute exacerbations of ILD, and these can be

38:43

due secondary to things like pneumonia, which is the

38:45

most common scenario, but also these patients often have

38:48

comorbid heart failures, they get heart failure exacerbations

38:50

on top. Or you can have ILD that

38:52

has its own exacerbations. The takeaway point here

38:55

is that prognostically that's an awful sign. And then the last

38:57

thing that I thought was super interesting in this talk is

38:59

this, as we're doing more

39:01

lung cancer screening and more CT scans, we're seeing

39:03

more findings that are consistent with ILD

39:05

in patients who don't have symptoms and are not presenting

39:07

for that specifically. And what do we do for this?

39:10

These are what they call interstitial lung abnormalities. And

39:12

so the point here is you should think about

39:14

the risk factors for progression, of which tobacco is

39:17

one, age greater than 60, and family

39:19

history are all really important prognostic indicators. And

39:21

these patients probably merit relatively close following. So

39:24

if you find this, even if they don't

39:26

have symptoms, you should probably do a follow

39:28

up scan like three months, then six months, then annually thereafter. This

39:30

is not something that you can just be like, well, they're not

39:32

symptomatic, so I'll just park it, forget about it, because they can

39:34

progress. And ILD, as we

39:36

know, can be dire. So it's good

39:38

to sort of get a sense of their tempo and

39:40

get pulmonology involved very early on if you think that

39:42

this might be what's going on. So good, good talk

39:44

over all nice consolidation of things that we've talked about

39:46

in prior episodes. This

39:52

podcast is brought to you by Freed. Freed

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41:08

of Curbsiders can use code CURB50 for $50 off their first

41:10

month. I

41:15

went to with Chris Chuman.

41:17

We were at the Nephrology

41:20

Updates talk. Our speaker was

41:22

Dr. Michael Ross, and he

41:24

talked about this Apo-L1-mediated kidney

41:26

disease, which actually is something

41:29

I hadn't heard of. Apparently,

41:31

it's very common in black

41:34

patients because it is

41:36

a genetic mutation that has some

41:38

association with protection against African sleeping sickness.

41:40

So sort of he made the analogy to something

41:42

like sickle cell disease. Chris, did you heard of

41:44

this before? I had never heard of it before,

41:47

and it seems like maybe we should have because

41:49

it seems much more common than we think. Yeah,

41:51

so the reason that he was presenting

41:53

this is because a lot of

41:56

patients who are classified as like hypertensive kidney disease, when they do,

41:58

they're not going to be able to do it. This able

42:00

L one testing the they might actually

42:02

find genetic markers saying that this might

42:04

have been the cause of their and

42:06

states kidney disease and there is a

42:08

drug now targeting this some the i

42:10

guess apparently causes and Fscs and a

42:12

drug was called and a plan and

42:14

they were looking at it. This is

42:16

still early stage but it in in

42:18

an early stage study at reduce protein

42:20

urea by almost fifty percent in April

42:23

L one high risk genotypes or at

42:25

thirteen weeks So this is something just

42:27

to think about you might be hearing

42:29

about it. Not yet practice changing, but

42:31

certainly something that I hadn't heard about. Now

42:33

there's a drug that might be coming to

42:35

market for it eventually, so something we should

42:38

know about. Gonna be expensive likely, but prompt

42:40

least from our primary care journalists prospective may

42:42

be coming up. We might be the ones

42:44

doing that. You're typing always before they go

42:46

to mythology. The other saying

42:49

that came up this year in the

42:51

talk was so sad and see or

42:53

says that and see and. It.

42:55

Has some advantages over the regular creatine

42:57

because it doesn't depend on muscle mass

42:59

and some of some of those other

43:01

non kidney factors that can make us

43:04

trip up with creating a little bit.

43:06

That's the big take on there is.

43:08

I think it's gonna become more available

43:10

and I think we're going to be

43:12

using it more. The equations that estimate

43:15

eg, fr the most accurate ones use

43:17

both create need and say that and

43:19

see to. To. Estimate the Eg

43:21

Fr so if you if you can

43:23

order in some patients that might be

43:26

helpful The patients he said it where

43:28

it might be most helpful. These adults

43:30

over sixty five who have like Ctv

43:32

Three a right to these are people

43:34

with Eg Fr Forty five to Sixty

43:36

Nine by your creatine equations. Those patients,

43:38

some of them are like. Worried

43:41

I have states three disease would that

43:43

sounds bad? But. He said a lot

43:45

of those patients, nothing bad going to happen to

43:47

them but you can use this is that and

43:50

see to help. Classify. Them are

43:52

they higher risk or look or lower risk so that

43:54

might be an area where you might use it. I

43:57

think so that the things that you we just have to

43:59

keep my mouth. at least for now is that

44:01

it's a little more expensive and that many places

44:03

may not have it in-house. So yeah, I think

44:05

you know some of our institutions if we have

44:07

to order it it's a sendout and comes back

44:09

in a couple days. Yeah, you know

44:11

the way that I was thinking of it Paul is

44:14

if I'm seeing an outpatient and you know it's someone

44:16

that's worried oh I have CKD3A and

44:19

I'm sending their six month or

44:21

twelve month creatinine I can just send this to 7C and

44:23

it doesn't matter to me if it comes back in a

44:25

day or seven days. So that's probably

44:27

how I would use it. The

44:29

other session that I wanted to highlight was the

44:32

testosterone replacement therapy session with

44:35

Dr. Bradley Anewalt who did

44:37

a great job and he

44:39

talked about this continuum of

44:42

testosterone saying that this

44:44

was his most important slide and it was

44:46

basically just like a continuum of severe hypogonadism

44:49

all the way up to eugonadism and

44:51

the severe people with severe hypogonadism

44:54

are most likely to benefit from

44:56

testosterone replacement therapy. People with

44:58

eugonadism are not going to benefit and in

45:00

between you benefit based on how

45:03

severe it is. So I think that

45:05

was a useful thing and

45:07

not a way I'd been taught. He didn't

45:09

give hard and fast cutoffs for you know

45:11

what makes severe or not severe but he

45:13

did say that and Colburn has told

45:15

us this before too Paul this we

45:17

need to have an orchidometer. Paul

45:20

as a physical exam guy do you have an

45:22

orchidometer? Not yet. I'm asking Nora to google it

45:24

for me. Nora

45:27

did you google orchidometer? Not yet but I

45:29

will. I guess it's not as

45:31

relevant to your yeah. We have

45:33

a needs clinic. You do okay.

45:36

So the one other thing

45:38

he said was that this that

45:40

Klein filters is which is X-F-Y

45:42

karyotype he said that it's present

45:44

about one in 500 to 600

45:48

men. So if you have a panel of

45:50

a couple thousand people you might have two

45:52

or three cases in your panel and these

45:54

men are typically tall. Gynaecomastia the testes volumes

45:57

if you have an orchidometer would be like

45:59

less than five. four cc's and

46:01

15 cc's or more

46:04

is a normal. So this is quite low size.

46:08

And he said, you know, the physical

46:10

exam and the history, sometimes they present

46:13

with fertility concerns or concerns about puberty.

46:16

And so think about that. But

46:19

the main part of the talk was more talking

46:21

about like our commentations that come in asking

46:24

us for testosterone replacement therapy. And

46:27

we'll have to revisit a full episode on this,

46:29

Paul. I think. But I did want

46:31

to just talk about the formulations that the IM

46:34

versions of testosterone, they cause this big

46:36

peak that can be like a super

46:38

physiologic spike. And

46:40

depending on the formulation, it can occur like

46:42

a week or so later. But

46:45

that is a formulation. And one of

46:47

the IM formulations is actually the cheapest

46:49

formulation, which I wasn't aware of because I'm mostly

46:51

prescribing gel. He said the gel

46:54

was marketed as if, oh, yeah, it's just

46:56

it gives you a more steady levels. But

46:58

actually the levels on the gel look like

47:00

a seismograph. They're like all over the place

47:02

when they actually studied it because he said

47:04

there's so many factors like how quickly the

47:06

person showers or goes swimming after they put

47:08

the gel on. And are they

47:11

exercising and getting more blood flow to the muscle

47:13

so it's absorbing differently. So there's just so many

47:15

factors. So the levels are

47:17

really variable. But we should

47:19

still check this morning testosterone 7

47:22

to 10 a.m., preferably fasting. And

47:25

that's how you can go. You

47:27

said something when we were prepping

47:29

for this about like young men when they're

47:31

asking about their early morning in the range.

47:34

Yes. So when you have these healthy young men

47:36

coming in and saying, oh, yeah, I looked online

47:39

and my testosterone of 300 something is low. I

47:43

have the testosterone of an 80 year old. You

47:45

can tell them actually the normal range of testosterone

47:47

that is reported in the lab is based on

47:49

healthy young men. So if you're in that range,

47:51

then you have the testosterone of a healthy young

47:54

man. So he's not being aggressive about

47:56

treating that. He did say that not every patient

47:58

loves that answer. He also

48:00

said that for you gonadal men who

48:02

start testosterone therapy, about 60% of them

48:05

seem like they stopped within the first year. So

48:08

even if they start it, I think

48:11

because it's not this miracle cure

48:13

that everyone thinks it is coming into the

48:15

office asking for it, a lot of people

48:17

maybe decide it's not worth it once they actually get on

48:19

it. So that's all I had to

48:21

say about that. Nora, I think you're our

48:24

final presenter. And what are you getting

48:26

into? I went

48:28

to a bunch of great sessions, some

48:31

overlap with my colleagues over here as

48:33

well. But I started the

48:35

day with how to treat the toughest

48:37

bugs in which Dr. Paul Pottinger

48:40

talked about antimicrobial resistance

48:42

and kind of best practices,

48:45

both inpatient and outpatient management for treatment

48:47

of some of these. The

48:49

one that he spent the most time on was MRSA,

48:52

which we see both in

48:54

the inpatient and in the outpatient setting. And

48:57

one pearl that he

48:59

brought up was differentiating

49:01

between community-associated and hospital-associated

49:04

MRSA. Community-associated,

49:06

we think of more as the kind of skin

49:08

and soft tissue infection, abscesses.

49:12

And then hospital-associated is the more

49:14

severe, really more resistant

49:16

generally. So much more

49:19

rarely, MRSA-associated pneumonias and

49:22

bloodstream infections. But he said

49:24

in this day and age, even though we may have thought

49:26

about hospital-associated MRSA infections as

49:29

being the majority of the

49:31

hospitalized MRSA infections, actually most of

49:34

the MRSA infections that we see,

49:36

even on the inpatient setting, are

49:38

going to be community-acquired. So I

49:40

think that was useful and a

49:42

good reminder for me. Also

49:45

advised and recommended using the nasal swab,

49:48

which many of us use in the

49:50

inpatient setting more often than the outpatient

49:52

setting. And as a good tool that

49:54

has a really high negative predictive value

49:56

to tell you whether

49:58

or not something is mergetic. and

50:01

peel off MRSA coverage in

50:03

particular, especially obviously with clinical

50:05

improvement. So he did say this

50:08

with the caveat that the

50:10

MRSA nasal swab should not supersede

50:12

your clinical judgment. And so if

50:14

you have a high pretest probability

50:17

of clinical suspicion

50:19

for MRSA pneumonia, then a negative

50:21

nasal swab should not prompt

50:24

you to take off. Right.

50:26

Which would be somebody, cavitary lesion or

50:28

like necrotic? Yeah. Pneumonia.

50:30

Okay. The

50:32

other two things that I found

50:34

really interesting in his talk, one

50:37

was about tetracycline testing, which

50:39

on antibiograms and the susceptibility

50:42

from cultures, you'll often see

50:44

tetracycline susceptibility, which obviously, I

50:46

don't know about you guys,

50:48

but we're not using tetracyclines

50:51

all that much. Yeah. I

50:53

always thought that that just meant it was susceptible to doxycycline.

50:56

So you can actually interpret it, but it's not a

50:59

perfect correlate. And so the pearl

51:01

that he mentioned in his talk

51:03

was that if something is tetracycline

51:06

susceptible, then you can trust that

51:08

that means that it is doxycycline

51:10

susceptible. But if

51:12

something is tetracycline resistant,

51:14

then you should ask

51:16

the lab for doxycycline

51:18

susceptibilities or minocycline susceptibilities,

51:20

because not all cultures

51:22

that are tetracycline resistant

51:25

will actually be doxycycline

51:27

resistant. And

51:29

so you may still be able to use doxycycline

51:31

or minocycline. That's useful. The

51:33

first time he told me that, I had it the

51:35

other way around. So that's actually, that's much easier to

51:38

deal with. Yeah, yeah. So basically, just

51:40

if something is listed as being tetracycline

51:42

resistant, ask for doxy susceptibilities, because you

51:44

may still be able to use it.

51:46

And it's a great antibiotic. And

51:50

then the last thing from this

51:52

talk was just a useful clinical

51:54

tool to try to understand penicillin

51:56

allergy. And it's called Palergi, and

51:58

we'll link to that. it in

52:00

the show notes, but it's a kind

52:02

of nice clinical decision-making tool like the

52:05

Penfast, but you can enter in the

52:07

history. It takes about a minute, he

52:09

said, to collect the information from patients.

52:11

It's just like what the antibiotic was

52:13

that they had a reaction to, what

52:16

the reaction was. If they don't remember

52:18

what the reaction was, that's fine. It'll

52:20

still give you recommendations about what you

52:22

can and can't use for patients. So

52:24

we'll link to that. I

52:27

also went to the allergy testing

52:29

and primary care session with Dr.

52:31

John Kelso, and he

52:33

also had a bunch of useful clinical

52:35

pearls. The first

52:37

set was relating to

52:40

serum-specific IgE testing to

52:43

look for food allergies and then allergies

52:45

to other things in the environment.

52:48

One of his recommendations was don't send these

52:50

panels because you'll get information you don't know

52:52

what to do with about

52:54

random allergens. I've

52:57

never ordered it. Patients should be like, yeah,

52:59

they tested this. Can you please interpret this?

53:01

I'd be like, it seems bad. I've

53:04

done it before and because they

53:06

test like 40 different things. Right, exactly. And

53:08

a lot of them are not. And they're

53:10

not actionable, a lot of them. Right. They're

53:12

allergic to the South American Yew tree. Like,

53:15

okay, I don't know. Is that your? Yeah.

53:17

It's like an incidental oma, basically. Right,

53:19

right, exactly. And so that was, that

53:21

kind of leads to his next recommendation,

53:23

which is think about what you're ordering

53:26

before you order it, which is kind of

53:28

common sense. Like dog hair or something like

53:30

that. Yeah, so like if someone comes in and

53:32

says, I am sneezing a lot around my

53:35

neighbor's dog, then test for

53:37

an allergy to a dog. And

53:41

then kind of on that note, don't test

53:43

for like food allergies that are either

53:46

not clinically correlated or

53:48

that you know the patient, they

53:50

won't want to follow the instruction to

53:53

stop eating something anyway. So

53:55

mostly common sense there. He

53:58

did say that you shouldn't be

54:00

doing total IgE testing

54:02

because the total IgE

54:04

level is not predictive

54:07

of atopy and allergic

54:09

reactions. So you should

54:11

really be doing like specific IgE as opposed

54:13

to the total level. And

54:16

he went through the different

54:18

types of hypersensitivities to medications

54:21

and talked at some length about how

54:24

to de-label patients and how to get

54:26

rid of that penicillin allergy and the

54:28

fact that not everyone needs to be

54:30

referred to allergy for that. And

54:33

specifically said, you know, if patients had

54:36

a non-serious reaction or if

54:38

they don't really remember it but

54:41

weren't hospitalized, didn't have any systemic

54:43

signs or symptoms, didn't have a

54:45

really bad skin rash like

54:48

SJS, TEN that required

54:50

them to be hospitalized, anything like that,

54:52

then it's probably safe. And the majority

54:54

of patients, it's actually safe to proceed

54:57

to an oral amoxicillin challenge in your

54:59

own office. And so that involves

55:02

giving it 250 milligrams, just

55:04

PO, oral

55:06

amoxicillin, having them

55:08

observed for an hour just sitting in the office.

55:10

Make sure you have an EpiPen. Yeah, yeah,

55:13

good point. And

55:15

then as long as they're okay, they can leave and they should

55:17

just tell you if they have developed any

55:20

symptoms or rash. They

55:22

can totally protocolize this with a

55:24

swart flow. My branch of CashTech

55:27

Children's Hospital, our allergists

55:29

had us do this because obviously we can't take

55:31

care of all these patients. But it was very

55:33

important for our pediatric allergists to really get de-label

55:35

these kids early on. Do you

55:37

know what you have over there? Like what

55:39

do you have to have safety-wise? Like do

55:41

you have to have just like Crash Cart

55:43

and that's it? No, just EpiPens. Just EpiPens,

55:46

okay. All right. All right.

55:48

We have to leave early because we're going to

55:51

hang out with some patrons from our Patreon. And

55:54

if you're not on there, then you're missing

55:56

out. Sorry. This could be

55:58

catastrophic. We'll see how it goes. This

56:03

has been another episode of The Curbsiders where you can get a

56:05

little knowledge food for your brain hole. Yummy. I

56:08

didn't even give her a assembled guess at chance of doing it. Still

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56:46

special thanks to our whole team,

56:48

Nora, Molly, Chris, Rahul, I guess

56:51

Paul as well, for

56:53

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Our technical production is done by Podpaste.

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57:01

moderates our Discord. Stuart Brigham composed

57:03

our theme music. And with all that, until next

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time, I've been Dr. Matthew Frank Watto. And

57:08

I've been Dr. Molly Hoytbling. I've

57:11

been Dr. Rahul Ganatra. This has

57:13

been Christa Chiu Manchu. I've been Dr.

57:15

Nora Toronto. And as always,

57:17

I ring Dr. Paul Nelson-Williams. Thank you and goodbye. The

57:33

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