The Curbsiders (00:00.142) So Paul, I was looking for a good Christmas pun and because I'm such a cool guy, I'm wearing a Santa sweater, just like Beyonce, Paul, I slay, I slay. Does that make sense? Does she have a I got it, I got it. I'm hip, yeah. For the listeners, by the way, Matt took about 10 minutes to look that up and that was the one he landed on. So.

The Curbsiders (00:30.03) The Curbsiders podcast is for entertainment, education and information purposes only and the topics discussed should not be used solely to diagnose, treat, cure or prevent any diseases or conditions. For the more of the views and statements expressed on this podcast are solely those of those and should not be interpreted to reflect official policy or position of any entity aside from possibly cash like moral household and affiliate outreach programs. If indeed there are any, in fact, there are none. Pretty much we are responsible if you screw up. You should always do your own homework and let us know when we're wrong.

The Curbsiders (00:54.574) Welcome back to the Curbsiders. I'm Dr. Matthew Francois here with America's primary care physician, Dr. Paul Nelson Williams. Paul, how are you doing? I feel infested, Matt. How are you? I'm doing well, Paul. This episode is going to come out on Christmas Day. So it's the holiday season. That's why we're all wearing, except for you, Paul, we're all wearing holiday colors of some sort. And Paul, we have some great.

co -hosts with us. This is the Recap Extravaganza, which we have done for many, many years now. And Paul, can you tell people what is it that we do on the Curbsiders and what will we be doing on this show? Sure. So as a reminder to our listeners, we are the Internal Medicine Podcast. We use expert interviews from you, clinical pearls and practice changing knowledge. The format of our end of the year summary is a little bit different where we are the experts.

and we don't have anyone additional. We do have some special guests with us, but they are part of the Curbsiders team, which is not to say they're not experts, but this is a long -winded way of saying that we'll be going over the pearls and the highlights from the past year that we found especially meaningful or especially practice -changing or that made us think the most. We're going to round -robin style, go through our picks of the year, if you will, for some of our favorite episodes and recap and summarize for our listeners.

And we should mention that these are, I mean, we had so many episodes come out that we couldn't even pick one pearl from each episode. So what we did, there's four of us. We have with us the great Dr. Nora Taranto of the Digest. Nora, how are you? I'm doing great. How are you guys? We are very excited to have you on the show to share some of your favorite pearls from this past year, from Digest and from the Curbsiders episodes. And of course with us, Dr. Rahul Ganatra of our Hotcake series. Rahul, how are you?

I'm grand, just grand. I love the Christmas hat. It looks great. Thank you. You know what? You say wear holiday garb and I take that seriously, Matt, unlike some of us. Parenthetically, if you want to. You could have used a turtleneck. You could have used a turtleneck, but otherwise you look great. Should we do some picks of the year, Paul, since it's the last chance of the year for us to give our favorite, our top picks?

The Curbsiders (03:04.11) And Paul, I don't think anyone wants to follow you. So would you care to start? So everyone can follow me? Sure. I like that system. Yeah, so I'm going to this is like a Russian doll of a pick of the week. So I may mention this album before my pick of the year is actually going to be the album Murder the Mountains by Red Fang. They're the stoner metal group. This album came out in 2011. I mentioned this because I felt kind of dumb saying that music is my pick of the year. It just feels like too broad a topic. But I will say that music has always been

super important to me. It's always been something that's been restorative. And then I think over the past couple of years, like I'll just put my iPhone on shuffle and just kind of listen passively and have not been engaging with it actively. Like it's just been a thing that's been kind of in the background. And then with COVID, I couldn't do live shows. And I, with things starting to reopen up, I actually went to a couple of live shows this year. And one was, I saw Charlie Bliss in Philadelphia and almost cried there and felt like a fool. And then I saw Red Fang in a cornfield basically in Lancaster, Pennsylvania.

They're at this dive bar that was in Micastore of all places and they were awesome. They ruled. It was an incredible show. And then the other thing is I got into vinyl, so I've been just impugnating and awful about that. I think that this whole experience and sort of having this kind of intentionality about something I love just sort of taught me to not take things for granted in a way and not be sort of not to passively enjoy the things that bring you passion, but to be really deliberate and intentional about them. And so, you know, having vinyl and being able to go back to live shows has been a way to do that. And I've been really grateful for it. So.

Take that pick of the year however you want to take it, but the short version would be the album Murder the Mountains by Red Fang. All right. Great pick. Nora, you're up next. Yeah, so I feel like going on a theme here, my general pick of the year is Good Fiction, which I found a decent number of books that I really enjoyed this year. The Great Balloot.

Believers is one of them by Rebecca McKay and then Tomorrow and Tomorrow and Tomorrow is another by Gabrielle Zevin, both just really like enthralling. And then my highlight pick of the year is, of course, my brother's novel, which came out this year. He's a debut novelist. It's called How I Won a Nobel Prize. And it was described as very funny, very good by B .J. Novak. Very exciting.

The Curbsiders (05:24.686) Amazing. Yeah, you know, and I have to say I agree with that assessment of it. It's about cancel culture and doing science for science's sake and for kind of bigger, bigger reasons while ignoring, ignoring cultural and value based problems that are occurring kind of in order to do that. It's great. I really enjoyed it. I'm obviously biased.

big conflict of interest here, but it's really wonderful. That's awesome that your brother wrote a book. Yeah. Did it take several years to write the book? I hear it's like, it's not fun to write a book. So you only write one if you have to get it out of you. Yeah, he's actually, since college, he's been kind of writing part -time and he's a lawyer by training. And so he worked as a lawyer for... I know, I know, boo, boo, boo.

But he was able to go part -time kind of a few years ago and got more time to write. And then he's actually given up the law for now to do full -time writing. So yeah, it seems like he really does feel compelled to do it in some ways. That's very cool. That's great. Sounds like he fought the law and he won. Yes. Indeed, indeed. Ooh. Rahul, how about you?

Okay, so, you know, there's a lot to kind of be anxious about in the world and a lot to worry about. So my pick of the year was something that really helped me remember the natural beauty of the world. And, you know, I'm really lucky I can get outside, I can see beautiful things, but I had sort of forgotten how much joy you can get from just really well done nature documentaries.

And especially as my kids are getting kind of old enough to be interested, we're trying to figure out what nature documentaries we can watch with them. And this year I discovered something that was produced a couple of years ago now in 2021 called Secrets of the Whales. And this is a National Geographic documentary that actually only has four episodes. So it's not a big commitment, but it is truly mind blowing and a such a.

The Curbsiders (07:47.682) welcome reminder of like the mystery and the beauty that exists, you know, in the world, kind of outside of our little spheres. It just to give you an example, it turns out whales have what you could call culture in the sense that they have to pass down, you know, traditions and behaviors related to hunting and social rituals. It's amazing. I highly recommend it. And the drone footage is like incredibly beautiful. It sounds amazing.

Okay, so I'll give a quick pick of the week before we get on to our pearls. My pick is watching soccer, or just soccer in general. My kids have been obsessed with soccer since the World Cup in 2022, and it was a warm winter, so we played soccer all winter, all spring, and kind of led us into the summer season, and it's been a lot of fun. So we have all the apps, Peacock, Paramount Plus.

ESPN Plus and basically follow all the different European soccer leagues and not as much of the MLS for whatever reason. And then there's all sorts of daily or weekly soccer podcasts as well. So if anyone wants to on the Discord wants to talk soccer with me, I am down. OK, we're going to kind of go round robin here for the audience. We're going to spend a couple of minutes talking about some favorite episodes or favorite stories from the past year.

and we'll just kind of take turns. So Nora, you're up first. What would you like to talk about? So I thought I'd kick us off with a few pearls from episode 409, which was one of my favorites from the year. This was an episode on hormonal and non -hormonal therapy for the vasomotor symptoms of menopause. And we had an expert, Dr. Monica Christmas on the show. I found it honestly, like hugely useful.

for my own practice and then also just I think in primary care generally. There were a ton of pearls here about pharmacologic, non -pharmacologic pearls. And one of the kind of interesting pieces that I guess makes sense but that she spent more time on than I would have expected was the focus on...

The Curbsiders (10:04.234) kind of behavioral modification, which I think is so hugely important in and kind of expectation setting with yourself in terms of when you get a hot flash, like how you can modulate your own experience of that. And so kind of referred several times to the utility of cognitive behavioral therapy and kind of self -taught management style. So I thought that was really interesting. And then a bunch of facts.

throughout this episode, including the fact that these hot flashes in particular and vasomotor symptoms can occur for five to ten years, even longer. She referred at one point to the long flasher phenomenon, which I thought was really a very funny way to describe this, but a useful one to make us remember that this is happening for longer than just a few years, right around 50.

Nora, I think she said her mom was a chronic flasher, which taken out of context could be really, you know. I But it was perfect. I loved it. And then she got into both the non -hormonal therapies of which we talked about venlafaxine that would seem to be her preferred SNRI, SSRI of choice in terms of management of vasomotor symptoms and talked to her.

briefly about gabapentin and fezolinotan, which I didn't know actually, but she said could cause headaches as one of its kind of primary side effects, not necessarily significantly more than the placebo in the trials, but she said anecdotally, she's actually seen a lot of headaches with patients on that. Yeah, Paul and I, we talked about this recently for one of our Patreon episodes where we were recapping this menopause episode in...

We haven't really seen many patients on it yet. I do think because the direct to consumer ads are out there now, I think people are going to be asking about it. I mean, it was more effective in placebo than trials, but this is a condition where placebo has a really strong effect. So most things you try, you're going to get some sort of effect. And it's all about, you know, just kind of risk benefit, patient preference. And so I really, this is a condition where I just really work with people.

The Curbsiders (12:23.406) give them some options and see what they want. And you can try a bunch of different things. Right. And that includes that even the duration of the hormone therapy too. I thought that was one of the most compelling points where it's like, yes, theoretically 10 years after menopause, you should have a conversation about discontinuation, but there are some patients that really feel that it meaningfully changes their life. And if you're doing informed decision making and you're doing shared decision making, that kind of stuff that, you know, Dr. Christmas will talk about, you can continuing that as long as you're documenting assiduously and the patients understand the risks that they're possibly taking. So it doesn't necessarily have to be.

a hard stop after a certain period of time. And a shout out to the show notes for this because Dr. Christmas gave us a bunch of tables that list pretty much all the different hormone therapies that are available, the different formulations. And she just basically said she usually starts with like a medium dose of estrogen. So you can look at the dose, you can look at the agents and the dose range and ultimately you're just prescribing what's on a patient's formulary for this.

Nora, before we move on, any last things you wanted to say about hormone therapy? No, I mean, the only other thing that I thought was particularly interesting that I really didn't know before was her. She mentioned just very quickly at the end that for a number of the hormone gels and creams that you should actually be aware of the fact that they like take time to dry and you can actually transfer like estrogen.

to kids, to pets, if you don't actually wait for that. So that was kind of an interesting little tidbit that I really, I don't think I would have thought to advise patients about otherwise. Yeah, it can happen with testosterone gel as well. All right, Rahul, you're up next and I believe you were gonna talk about number 380, hemocroptomatosis with your friend, Dr. Elliot Tapper. Yes, this was one of my favorite episodes that we put out in the past year.

There are pearls of knowledge just deposited throughout this episode, not unlike iron in hemochromatosis. Praho, you're on fire tonight. I've been saving these up all year. So I learned a lot from this episode and filled in a lot of knowledge gaps that it turns out that I had about hemochromatosis. And one of the biggest knowledge gaps that this episode filled for me is that in elevated transfer and saturation,

The Curbsiders (14:47.766) Although that is sort of part of the pathophysiology of hemochromatosis, you shouldn't reflexively think, okay, that indicates that a patient has hemochromatosis, or even in patients who are homozygous for the gene mutation, that that is necessarily reflective of iron overload from hemochromatosis. So Elliot really put together a very nuanced approach to this, and I'll just share some of the pearls that stuck with me from that episode. So it turns out that,

Alcohol also leads to alterations in iron metabolism, leads to increases in hepcidin, increases in ferritin, and an increase in transfer and saturation. And so patients who, even in patients who are homozygous for the hemochromatosis gene mutations, alcohol can play a big role in kind of affecting their indices of iron and iron deposition.

And Elliot talked about a great teachable moment case in JAMA IM from 2017 that we can link in the show notes, which really illustrates the pitfalls of anchoring on hemochromatosis as the cause for an elevated TSAT in patients who also consume alcohol. So I thought that was really great. I've used TSAT myself as sort of a screening test for hemochromatosis, probably inappropriately in patients who are sick in the hospital with inflammation and other problems.

So that was a really important thing. Yeah. And he talked about this concept of, for us in primary care, this dysmetabolic iron overload, which is basically the patient with metabolic syndrome, like their ferritin levels can be elevated too. And it doesn't mean that they have hereditary hemochromatosis. So he actually said he creates maybe a little more extra work for himself where if someone sees him and they have elevated ferritin and T -SAT, he'll say, okay, let's stop alcohol.

let's get you metabolically healthy and then we'll kind of repeat labs in three to six months and see if it gets better. Cause if it does, you know, he's less suspicious of hemochromatosis. And yeah, I mean the pathophysiology of it, of why hemochromatosis is, you know, why it happens is a little bit confusing to me, but I do think that just remembering that even if someone has like,

The Curbsiders (17:07.374) both genes that the penetrance is not 100%. So that's why you don't want to over test people because they're going to only hear that they have these two abnormal genes. They're not going to really understand that what penetrance, incomplete penetrance is. So Paul, any comments as America's primary care? No, this was one I was going to pick if somebody else didn't.

Just because this is one of the show notes that I refer to all the time because it's so common to come back with an elevated fare. You're like, well, shoot, what do I do with that? How worried should I be? What other things should I be looking at? Especially with hospitalized patients, I think that the patients are already inflamed or if they're coming with an acute liver injury and you set off the usual sort of battery of tests and they come back wonky and you're like, well, I don't know what to do with any of this. I think Elliott's parsimony as usual is really much appreciated and I thought this was a particularly great episode.

So for the listeners, the cutoffs you can look for for transparent saturation are greater than 45 to 50%. And for ferritin are greater than 200 to 300. And with women being on the lower end of those ranges and men being on the higher end. And he made the point that women, probably because they're having blood loss throughout life, they might manifest symptoms later or just might seem to have less penetrance even if they have the genes.

So I thought that was interesting as well. Any other comments before we move on from this one? Elliot did say one thing in his typical piffy fashion during the episode that really stuck with me, talking about patients who report feeling better after phlebotomy, even if their ferritin and transferrin saturation are not that high. He said, I've learned the hard way never to take a placebo effect away from a patient. Yeah. I thought that was really wise. That's right. OK.

So let's move on to Paul. And Paul, what did you want to talk about next? Sure. I'll go lead with our episode 404, which was hematuria with Dr. Derek Fine. A long time fan of the shows may know that I have been threatening to do a hematuria episode for like six years before this one started to even come together. And it's hard for me to separate out. This was a live episode. So we actually, we were at Hopkins in front of an audience, which is always fun. They always do this very well. So it's...

The Curbsiders (19:23.886) This episode will always be a whole place in my heart, but was also full of clinical pearls. I thought Dr. Fine really helped clarify and kind of reinforcing things about hematuria in general. And I think probably, I feel like I see in residency clinic and maybe just in life that hematuria is probably underestimated and people don't do a great job of restratifying someone who is at high risk for malignancy versus low risk for malignancy. Especially, and I'll talk about this in a second, like if they're on anticoagulation, we almost kind of just be like, well, that we have a reason for them to be bleeding then. But it was just nice to have.

sort of concrete thing. So age, more than 30 pack years of smoking. If you have gross hematuria, all these things are almost immediately shift you into the high risk category and you should be more concerned and probably do a more facilitated workup. So I have now moved to CT Urogram personally in the office, just even in advance of gain from urology, just because I have a feeling that's where they're headed. So I'm just doing, I think a better job of facilitating follow -up for hematuria that raises concerns for malignancy. So, and I had mentioned the anticoagulation thing. This has come up in,

a couple of times recently for me where it was almost the hematuria was attributed to the patient's anticoagulation. They were on a DOAC for whatever reason. And I just, I'm going to make the point for the bazillionth time that DOACs don't make you bleed. They just keep you from stopping bleeding. So you still have to have a reason to have a hematuria. You still have to work up the etiology. And in fact, there've been a couple of neat papers that have looked at patients with gross hematuria are more likely to have their cancer declare itself earlier because of that hematuria and they end up with better outcomes. So they are diagnosed at earlier stages. They...

They just have better morbidity mortality associated with it. So in a weird way, the hematoma is kind of protective for people who are declaring themselves to have a malignancy. So don't blow off blood in the urine just because a patient's on a blood thinner because you still have to work it up and it still may be something bad. Yeah. And Paul, you made a really nice figure to go along with this one to summarize a lot of the pearls of the episode.

To recap, so the more red cells you have in your urine, the higher the risk. If you have gross hematuria, that's high risk. And the older your age, the higher risk, obviously history of smoking. And for lower risk patients, we talked a little bit about like you can get a renal ultrasound. It says that in the guidelines, but usually for me, if it's a high risk person, I'm usually getting a CT urogram and then sending to urology for the cystoscopy. That's kind of my move. I'm not sure.

The Curbsiders (21:42.55) Nora, as an oncologist in training, do you have any differing views on this? No, I mean, I think that that's the basic workup that they would do if it wasn't already done. So I think that's kind of the most helpful thing, tools to know, to employ. And I think it's a really interesting point, the reminder that anticoagulation does not beget bleeding from the bladder. And there's...

you should investigate causes if you're seeing it. Is the thought of the ultrasound just to diagnose a stone, if that's the cause? Yeah, it's like, is there hydronephrosis? Is there, are there stones? You know, just that's my thinking too. It's like, it feels like you could miss a lot with just an ultrasound. And that's why I think they do it because not everyone has the resources to get a CT Urogram and...

And you can catch cysts and you can see renal cell carcinomas with ultrasounds. I think that's also part of it. But you're missing stones with renal ultrasound. So I'm kind of with you, Matt, in terms of my practice. And it just doesn't make a whole lot of sense to me if the renal ultrasound would come back negative, and they're getting a CT or a gram, if it comes back positive, they're getting a CT anyway. So it just seems to me that probably you may as well just skip the step and go right to the CT or a gram. Yeah, I don't know whether it's just challenging from a national point of view.

perspective to get high quality CT Urograms that are timed appropriately. I don't know whether that's a piece of it. I could imagine maybe that's some of it. Yeah. I'm sure it's the cost. People are worried about giving dye, and it's just a bigger resource. It's radiation, all those kind of things too. So yeah. And we did, most bleeding is urologic, as Dr. Fine said, but he did also give us his sort of how he thinks about

Glamour, you're bleeding too and that that's in that figure as well that Paul Paul made Yeah, that's something I'm gonna have to look up always but I will say that if you see the creatinine is going up or the patient comes in something hypertensive like those things should raise immediate alarms for a Nephrologic source as opposed to something a urologic source so it's just don't forget that there are certain glomerular clauses of actual grossy material though if you see clots

The Curbsiders (24:02.926) that does almost certainly, like it's almost certainly to be like malignancy somewhere in the urinary tract and not something within the kidney itself. All right. So the next, next we're going to talk about, we did two diabetes episodes this year because it seems both Paul and I and the audience can't get enough of diabetes episodes. So the first was number 387 with Dr. Marie McDonald, who, just, just a fantastic guest. Some of the things she said that, that really stuck with me. She said, you know, insulin is,

is not the right medication for most patients with type 2 diabetes. And I do believe that's true. I think we know that now more so than probably in the past. We have so many more tools now that we can use before we get to insulin. And she did say the one time that she really—you can really convincingly say it as if like the patient has weight loss and they really have a lot of the poly symptoms, polyuria, polydipsia, polyphagia, you know, that probably—probably that's the type of person, especially if they have like double digit—

uh, a one C that you can, you could potentially start on insulin, but the GOP one agonists and now the G I P slash GOP one agonists, that would be terseptide. Those ones are as potent as insulin almost. Uh, I mean that you're talking to a one C lowering of 2%. So, uh, they, they work really well for people. And, um, I, you know, I am prescribing a lot of them now in addition to my base of like lifestyle changes and metformin. Paul, what are you?

anything to add to this here? No. I agree with you. We've talked about this a bazillion times, which is why I don't have a whole lot to add. The paradigm shifted where the goal is now to get patients off of insulin if possible, as opposed to just getting them onto it, trying to talk them into it, and keeping them on it for the rest of their lives. We just have so many good, powerful medications with better outcomes that are as effective in lowering blood sugars. So yeah, this is me agreeing with everything you said.

So let me ask you this then, Paul. She mentioned it's very expensive for both insulin and the newer medications. So is it ever acceptable to use like a sulfon or urea or like a DPP4 inhibitor? She said sometimes she'll do that as like sort of a temporizing measure, just knowing it's not really offering a lot of other benefits. I'm not sure if that's something that you incorporate in your practice or if you have another work around. I mean, that's, yeah, that's something I've done.

The Curbsiders (26:22.542) Like I'm not a, you know, we have patients who are very needle averse or perhaps you have an extremely old patient who's A1C is just not quite where you want it. Like, you know, it's, their blood sugars are sort of consistently a touch higher than we'd like. So maybe you just feel like they need a little bit of help, but you don't want to burden them with the, with the insulin injections. Then maybe I'll sort of talk myself into it, but even still, I know you have to be careful with the sulfonylureas in your older patients. So, but I, I'm not above using them for patients who are not in love with the other options. If you, if you still need a little bit of glycemic control. Okay. And then.

The next episode was number 397. This was an insulin focused episode with Dr. Jeff Colburn. And he taught us a lot about the different types of insulin. Some of the pearls that stuck out for me were that NPH insulin can be used as monotherapy, like instead of a basal insulin. And he usually doses it two thirds in the morning and one third in the evening. And Paul, I'm not sure if you see this too, Rahul, Nora, but.

A lot of patients I see just skip that step where they're on metformin and NPH as the basal insulin and they go right to 70 -30 insulin, which is basically a basal bolus regimen. That's commonly what I see. Rahul, probably in the hospital you might see patients being discharged with that. Yeah. I want to say that that was on the VA formulary for, if not, so I would occasionally see patients on that. Yeah. Yeah.

And so what Dr. Colburn was basically saying is, you know, for a lot of patients with type 2, if they do need an insulin, usually you start them first on just a plain basal insulin. So NPH can be given by itself and some of the big box stores, you can get it for a good price there. And then the other big thing was insulin Detemer, Paul, twice daily. Is that what you commonly see?

I had not been commonly seeing him. This one was practice changing. I think especially at the lower doses and having talked to my clinical pharmacist, that is now the adjustment that I'm making. And I even had patients figure that out for themselves before I even had the chance to make the change. They'll be like, yeah, it wasn't working for me. So I just split up the dose and do it twice a day now and it seemed to be much more consistent. I was like, well, congratulations, you figured out the science before I did. So yeah, it was a big point that was certainly practice changing for me. Yeah, if you look in the pharmacokinetics,

The Curbsiders (28:37.646) Section of lexy comp it basically says the lower the dose the the shorter the half -life and the less the more variable it is So on those people especially on the lower doses, make sure you're splitting it up. And then this the last thing I'll say on insulin is Over basal ization. Look out for that. So if they're on more than half a unit per kilogram body weight So if someone weighs a hundred kilograms if they're on more than 50 units of a basal insulin, glargine, detimer,

NPH, probably they need to be on pyrandial insulin as well. And so you could go ahead and switch them over and make sure you prescribe everybody something for hypoglycemia and tell them the 15 grams of carbs every 15 minutes and recheck their sugar until it's up. All right, so Nora, moving on to your next topic, what do you have for us?

I have episode 392, which was another live episode that you guys filmed in, I think, March. And this one covered opioid and xylazine withdrawal in the hospital. This was with Dr. Joseph D 'Orazio and was similarly filled with lots of pearls about a topic that I had kind of heard of very briefly prior to this, but really hadn't seen much of.

on the new and developing field of xylazine overdose and withdrawal, which we're seeing in particular on the East Coast and seems to be spreading west somewhat slowly. So xylazine is also known as Trink or tranquilizer. It's an animal sedative. It's similar to Clonidine. It's an alpha -2 agonist. And we

notably have been seeing it mixed into, in particular, the fentanyl supply over the last few years. There's no reversal agent for it in particular, and so it produces Narcan -resistant opioid overdoses. And so in patients who you know have ingested opioids, you may see that they're not responding to Narcan as you would expect. And so that's.

The Curbsiders (31:00.494) The main way that Dr. D 'Orazio said that we have been seeing these clinically suspicious cases of xylazine overdose. And Narcan being the treating infernal oxygen, right? Yes, sorry. Yeah. Yeah. So the patients have often been coming into the hospital or are being treated out in the field. Lots of this in Philadelphia in particular and on the East Coast, broadly speaking, and

Xylazine can be used via various modalities. So it can be injected, smoked, insufflated. And we don't have a good rapid test for it in the hospital yet. Sounds like there's some work to try to develop a urine drug screen for this as well. But I don't know of any systems that are using that yet. I don't know if, Paul, you have any.

I think there might be some regulatory barriers. I think there's some things in the work, but I'm not sure they're actually approved for use in formal system settings yet. So Rahul, I'm not sure if you're seeing a lot of opioid withdrawal in your practice as a hospitalist. Tell me if this speaks to you. Supposedly one of the ways to identify this is if you treat someone for opioid withdrawal and give them adequate amount of opioids so they shouldn't be in withdrawal anymore.

but they're still really anxious. That's one of the ways our guests told us to sort of recognize that this might be on board as well. So I'm not sure if this is a problem up there. Yeah, you're right. I'm really not, mainly because of my patient population is sort of older. So I have not seen so much of this. Also our inpatient mental health and substance use treatment facility is actually in a different hospital. So we only end up seeing the people who have medical

contraindications to going directly there. So I have not seen a lot of that yet. You're not seeing it. And Paul, one thing I wanted to ask you, because when we were on this episode, I think this was still sort of in flux and we weren't sure. Do the wounds appear only in the area they're injecting or can they appear like, you know, at distant sites? Because I feel like we've heard both things. Do we know this yet? We've heard both things. I don't know that it's been actually confirmed yet or not. Yeah. OK, so to be determined. But if you have the patient.

The Curbsiders (33:18.246) with opioid use disorder and necrotic skin wounds, you know, that is sometimes a clue that there's xylazine in their supply. So a couple of plugs while we're on it. So you mentioned Jodorazio. He actually just wrote a great narrative review on xylazine that's in the annals, like it came out this week. So we can link that in the show notes. And there's also...

an article that just came out, sorry, I'm fighting with my cat at the same time, about wound care for xylazine -associated wounds, lessons learned from a low -barrier wound clinic in Philadelphia. So a couple of colleagues also put that out. Actually, I think again this week, this week has been an incredible week for addiction medicine articles. Like there's been a lot of things published by like personal friends and people that we know from Twitter and stuff. But yeah, Joe's review on xylazine is certainly worth reviewing. Yeah, it was kind of interesting. It sounds like these wounds are significant, but they actually heal pretty well on the spectrum of wound healing.

Yeah, I was surprised. I was really surprised when he said that. Yeah. So it sounds like if you can get, if you can stop with injection, assuming that that's kind of the main trigger of this, that they actually heal pretty well and pretty quickly. And actually, Matt, the article about the wound care that I was referencing, they mention, at least according to these authors, that they see it in sites remote from injection. And in fact, even in patients who smoke, who get it through inhalation. So it seems like it is not.

necessarily a direct injury. Yeah, very, very strange. Yeah. Okay. Nora, any other addiction medicine pearls before we move on to Rahul? I mean, just generally to give a shout out to the addiction medicine series and the update in addiction medicine that we've had the chance to cover kind of throughout the years. I think there are a ton of pearls throughout those episodes and...

The topics are all evolving kind of by the week as Paul was saying. All right, Rahul, what's next? All right. So my next pick is episode number 386. This was a neph madness pod crawl with Dr. Matthew Booth. And this episode was all about primary aldosteron ism or primary hyper aldosteron ism. And most of my day in the hospital is spent, you know,

The Curbsiders (35:34.446) talking to patients and residents about why we do not need to worry about their elevated blood pressure right now, and trying to avoid escalation of treatment for hypertension when possible. So this episode similarly filled in a lot of knowledge gaps for me about management of hypertension in the office setting. And probably the single biggest pearl that I learned from this episode was that primary aldosteronism is thought to be the most common cause of resistant hypertension.

and I think we've all had patients with persistently difficult to control hypertension. Dr. Luther estimated that as many as 15 to 20 % of patients who are referred to specialty hypertension clinics will end up being diagnosed with primary aldosteronism. So it's worth evaluating patients for this. We talked about, used the case to talk through kind of the recommended testing and stuff. The thing that pearl from this is that the recommended initial diagnostic testing,

is a morning plasma renin activity or PRA, or you can do a plasma renin concentration, depending on what your lab has available, as well as a plasma aldosterone concentration. And another interesting pearl from the episode was Dr. Luther talked about whether or not, if you get these labs, whether or not renin is suppressed on a patient's current blood pressure medications can also be a diagnostic clue.

And in the case in the episode, we talked about a patient who is on hydrochlorothiazide, telmasartan, and amlodipine, yet this patient had a suppressed renin level, which Dr. Luther indicated would really not be explained by those medications. And it kind of makes mechanistic sense to me, because you might expect hydrochlorothiazide to lead to volume depletion, if anything, in which case the renin should go up, it shouldn't be suppressed. So I thought that was a cool way to use.

you know, interpretation of those labs on a patient's current meds. Yeah, we, Paul, we talked a lot about aldosterone and the adrenals this year in 2023. You know, my take home for it is we should in primary care be empowered to test for this, send a, you know, send an early morning renin, aldosterone in patients with hypertension or have a low threshold to do so. And,

The Curbsiders (37:48.542) Yeah, you can call for help from your friendly neighborhood endocrinologist or nephrologist or even cardiologist, whatever hypertensive expert you have if you need help interpreting it. But you can really do a lot of good for patients if you figure out if they have this or not. And if they're on the three standard initial meds, calcium channel block or diuretic and an ACE or an ARB and their blood pressure is not controlled, an MRA is usually a good choice as a fourth medication.

It's a little bit of a pain for them to test after you start the MRA, but, you know, if you need to get a person's blood pressure under control, just you can get them under control and then you can always work out the testing in the future. Yeah, there's a whole body of literature about how we under test for this. Like, even like there are people that actually advocate for anyone with even sort of essential hypertension we should be testing for. Even in patients with resistant hypertension, the primary care setting is like.

2 % of patients are actually, like appropriate patients are just green, like absurdly low. So we should be testing earlier and testing more often because I think it's far more prevalent than we give our credit for. And also because in some cases we can do definitive treatment for it. It's not just medications. Like if it's coming from your adrenals and not just medical disease, then we can actually, there are surgical interventions that may appreciately change their quality of life and their morbidity and mortality. So it really is worth chasing down.

Okay, so let's move on to the next one because we'll pick up the pace slightly. So we don't, this isn't a four hour long episode as Paul was joking earlier. Paul, so what's next for you? Yeah, a long line, still more hypertension because we love it. So this is episode 390, the resistant hypertension with Dr. Jordy Cohen, who's been back with us multiple times. Dr. Cohen is the best. She's, I was just doing a talk on resistant hypertension and all of my background literature.

When I found a great article, she was the lead author on it. It was almost kind of insurrecting after a certain point. And I used this episode to crib from Literally. So thanks for that. But she taught us that there are a couple of pearls that really stuck with me that I keep coming back to. One of the ones that is kind of neat that I've not used as much, but just I think it's interesting, is this use of sitalopram and a possible blood pressure lowering effect. So you would think someone who is anxious and has sort of extra adrenergic overdrive, you might opt for a beta blocker or maybe even

The Curbsiders (40:04.654) something like a Clonidine, but there's some evidence to support that some Talopram may actually help lower those patients' blood pressure. So I just think that's a neat sort of synergistic way that probably is going to come up more often than you might expect. And then the one point that I think raised all of our eyebrows and I was shocked by was this idea of not reaching for the beta blocker as like your sort of fourth medication. I think a lot of the times we talked about sort of reaching for the MRA, which makes sense.

But I think oftentimes I've seen folks reach for like a carbadolol when they feel like they're running out of options and sort of skipping over things like clonidine. And I think Dr. Cohen referenced a paper where patients who were prescribed beta blockers as first line therapy in the absence of other indications had worse cardiovascular outcomes. So it's, I'm now avoiding those blood pressures a little bit more assiduously unless I have a good reason to actually start them. And she, I think even said that she would opt for like a clonidine patcher before she would reach for a beta blocker in patients like Or guanfacine.

I think you asked her, you were like, am I getting this correct? Your fourth line agent might be guanfacine over. Yeah. Yeah, because I felt like I had to have misheard it, but it's... Yeah. But that was for the anxious person, right? Because like we just talked about with Rahul's pearl, MRAs for most people is going to be the fourth agent. But if it's that really anxious phenotype, they might have that sympathetic driven hypertension and something like a citalopram, quantidine, guanfacine, something like that to try to target the...

you know, the anxiety component of it could help. Have you guys tried that actually? Like, have you seen how it works? I'm just curious. MRAs for sure. I definitely have patients on MRAs and... But the Citalopram or the... Yeah, the Guantanine. I have not had the right patient for that since learning this, but I mean, I would certainly do it. I have never seen a guanifacene prescription out in the wild. Like, I know it exists, but I've never actually seen I've seen it for... I've...

I have some patients with ADHD and their psychiatrist has them on that in addition to a stimulant, but that's where I've seen it mostly. I had not seen it for this indication. And Paul, you wanted to mention about blood pressure cuff size, right? Because we talked about this on Spooky Cakes, number 414. It seemed disenergized because we also talked with Dr. Cohen about pseudo -resistance.

The Curbsiders (42:18.978) So there's this, you know, you're stacking on the medications and you just can't seem to get it. And one of the most common causes of pseudo resistance, and there's been studies of this, of patients referred to high blood pressure clinics, is just mismeasurement or improper measurement of blood pressure. So they actually looked at this and about, it was something like 20 % of patients, if they just measured the blood pressure correctly, they were controlled, which is kind of embarrassing. So there was this Cuff, was it Cuff S .D. trial? I'm embarrassed for not remembering the name, but by Ishigami et al. that looked at sort of the effect of blood pressure cuff size.

on blood pressure measurements. And if you have someone who has a larger arm and has the blood pressure cuff size that's too small, so say they require an extra large and they have like a small cuff, that can raise or that can give you a systolic blood pressure that's actually 20 millimeters mercury higher than reality. And that's like the mean. So like you have these really appreciable, significant differences in blood pressure measurement just based on cuff size alone. So just reminding everyone to repeat the blood pressure, do it on bare skin, have their legs supported, their back supported, make sure their bladder is empty, don't talk to them, make sure the cuff size is actually measured correctly.

And I consistently, over and over again, will get systolic blood pressures that are 20, 30 millimeters mercury lower than what was initially measured in triage. And we should not be making treatment decisions based on improper blood pressure measurements. So I just, while we're thinking about resistance, don't miss it or resistance things like medication non -adherence, but especially just inappropriately measured blood pressures. That article, I believe said something to the effect of more than half of patients or close to half the patients do not fit in the...

regular size cuff that comes with most machines. So most people are going to need a large or even an extra large cuff in the country. So think about that when you're measuring. Okay, next up, number 375, Delirium with Dr. Esther Oh. This is one of our first episodes in 2023. And the main thing that I wanted to just highlight for people is something that I didn't know is that...

Because they think that the pathogenesis of delirium involves inflammation and neurodegeneration in the brain, they've actually done studies where they like measure some of the sort of same kind of this neurofilament light, which is typically found in traumatic brain injury, and that can be elevated in delirium as well. And then there's this DECIDE study where they followed patients out who had delirium and they saw that their future risk of cognitive decline and dementia was way higher. So,

The Curbsiders (44:40.494) The idea is that the longer and the more severe delirium is, the more likely that person is to go on to develop dementia. And that's part of why delirium is like an emergency and you really have to try to figure out why someone has it, which, you know, Rahul, I'm sure you spend a lot of the time in the hospital trying to figure out why someone has delirium. And I don't know if you have a number or just what's your gestalt of like how often you actually find the exact cause of their delirium. Um, I don't know that I'm.

ever able to confidently say that this was one smoking gun, I will say that for most of my patients, and I'm on service right now, if I am thinking hard and really looking, I can identify two, three, four contributors to delirium for basically any hospitalized patient. So if you're looking hard and you're thinking carefully, you can identify a lot of intervenable causes for these patients for sure. Adam, who's also a hospitalist, who helped with this episode, one of his big questions for her was like, so,

the patient that is still delirious in the hospital, or they're having hypoactive delirium, and they're just not quite back at baseline, can we ever discharge that person? Because a lot of the times, you've sort of done your due diligence, you look for any big bad causes, you kind of try to mitigate all the little factors you think are contributing to it, and you still don't find anything. And she said, well,

It can be very nuanced, it can be case by case, and sometimes if they have a really safe and supportive home environment, maybe sending them out and they might be more likely to come out of the delirium there. Because it can last for days, weeks, months. I mean, it can be a really bad condition. So I thought this was a really great episode and a really likable guest. So check that out if you haven't heard it yet. Nora, what do you have next?

I have another spooky cake from episode 414. It's chock full of good stuff. And I feel like we kind of have to end the year talking about the Acorn trial, which we talked about in episode 414 by Quan et al. just published in JAMA in October. This trial looked at Ptasso versus Cephapeem in...

The Curbsiders (46:54.798) patients who were hospitalized with suspected infections and found that there was no difference from an acute kidney injury perspective between patients who were randomized to Peptazo and patients who were randomized to Cephapeem. And notably, a majority of the patients in both groups, I think upwards of 80%, got vancomycin. So this kind of lends credibility to the thought that there is no reduce.

there is no increased risk of AKI with VINC and Piptazo. So I'll pause there because I feel like we've been talking about this a little bit the last few weeks and on Spooky Cakes, but also just on Twitter. So I'm curious whether this is going to change your guys' practice, generally speaking. We got to hear from Rahul about this. Yeah. Yeah.

I can, I think this is going to change my practice for sure, because the question that I'm often or the decision I'm often trying to make in these situations is, is anti -pseudomonal coverage indicated? Yes or no. And, uh, you know, I have sort of genuine equipoise about whether. Cephaseme or Piptazo is safer from a, from a renal standpoint. So, so I found this persuasive that, uh, it didn't really seem like Piptazo either alone or in combo with Vank.

for a median of three days, granted that's not a huge duration, but at least for what was seen in the trial, there didn't seem to be any increased risk over cephapine. One criticism that was, the digest on this was really well done. I mean, the author pointed out one problem is that this was an open label trial. So investigators knew what drugs patients were getting and that could affect detection of adverse events, things like delirium neurotoxicity if,

people had a preconceived bias in one direction or another. So, nevertheless, it's kind of the best evidence we have to date. So, I yeah, for me, I consider this kind of exciting results and I'm definitely gonna not fear the Vank and Piptazo anymore. That was Alexander Chatov that wrote that, right? Yeah, kudos Alex, that was really good. Yeah, it was really good. Kudos. Yeah, it was also impressive. I think they managed to get...

The Curbsiders (49:10.762) complete enrollment in like under a year for this trial. It was pretty large. It was a single center trial, but just impressive from a kind of trial running perspective that they managed to get a important question answered, at least in this context. All right, Nora, what other favorite trials you wanted to quickly mention? I guess there were a couple of interesting HIV trials. Can't have to mention Reprieve.

which looked at pit of a statin in patients with HIV who are low to moderate risk from a cardiovascular disease perspective and found a benefit in that population. So I think this probably should be practice contemplating, you know, that we should probably be thinking about whether or not to start a statin in these, even these lower risk patients with HIV.

This feels kind of landmarky to me. Yeah. Like I think not just practice changing, but I think this is going to be one that is going to be referenced in the future as the reason that we have changed our practice entirely. So I think it's an exciting trial. I think that's going to go into guidelines, whatever guidelines are out there for HIV. I bet they'll put it in there as a, like they have it in for statins for, moderate intensity statin for diabetes. Yep. Yeah. And we covered that in the digest episode 418, I think. Yeah. Which would have been last. Yeah.

would have been at the time this is airing, it would have been just, you know, a month ago. Um, all right. So, uh, let's, let's move on. Rahul, you had some updates. This was number 393. These were clinical updates in hospital medicine at SHM. So Rahul, how did your updates hold up? Yeah. So I thought I would take the opportunity to hold myself accountable. Cause so often when you give these update talks, you know, you get to say whatever you want and then no one.

kind of you don't have to deal with the results of that whether or not the things you thought were going to be practice changing really held up or not. So. Medical education, baby. Exactly. So I thought I'd put myself on the chopping block here. So I had the opportunity to the privilege to review the literature in hospital medicine from the last year with Heather and I from the division of hospital medicine at the San Francisco VA. And so we did we recorded this episode at

The Curbsiders (51:32.526) the SHM national meeting in Austin in March of this year. So what sort of held up from then to now? Well, for one, one of the papers we talked about was the mPulse trial, and this was published in Nature Medicine in the past year. And the bottom line of this trial was, it was really persuasive to me that starting impagliflozin in patients hospitalized with acute decompensated heart failure improves clinical outcomes,

that persists out to 90 days, but the symptom improvement starts as early as 15 days after initiation. And patients who got impagliflozin were 36 % more likely to have this composite outcome of clinical benefit at day 90. And it seemed to me that this benefit was really driven by a greater improvement in symptoms and a greater diuretic response. So this result, how do I know this held up? Well, former guest on a...

The last episode and friend of the pod, Michelle Kittleson and colleagues authored an expert consensus statement for the American College of Cardiology that was published this year. We'll put the link in the show notes. And there's a figure in the consensus statement, figure nine, which really highlights the central role of SGLT -2s in patients, particularly with HEPF -PAP. We've kind of known about the benefits for patients with HEPF -REF for more than just the past year.

but they now recommend initiation of SGLT -2s before even loop diuretics in patients with HEPPF. And if additional diuresis is needed for those patients, you can add a loop diuretic and any other classes of medications. So that would definitely help out. Matt, I was gonna ask you, I think one of the things that I sometimes see is the decision to start an SGLT -2 just ends up in limbo. There's a lot of clinical inertia and is the primary care doctors, the cardiologist, specifically in the outpatient setting. So I think if it started,

while the patient's admitted, they're getting sort of their initial workup and they're discharged the SGLT -2, like it seems like, oh, thank God, like that decision's already been made and then you don't have to, there's not this sort of back and forth as to who's going to start it and should we wait for endocrinology? Like they have already gotten the evidence for medication. So I think from a system standpoint, like this is probably going to improve outcomes in a really meaningful way. Yeah. I just wonder, cause SGLT -2s are supposed to be held for something like two or three days before a surgical procedure. So starting it during the hospitalization,

The Curbsiders (53:55.086) I think that came out of concern maybe for, I don't know if it was dehydration or if it was concerned for euglycemic DKA while they're in the hospital. But I really feel like we're going to get comfortable using those agents in the hospital or continuing them if patients are going to be getting them routinely now for heart failure. So I'm curious to see how that's going to pan out. And yeah, my big barrier for SGLT2s right now is a lot of my patients who qualify for them.

or who have an indication are on Medicare and they're still pretty expensive for patients on Medicare. So that, but otherwise I have a really low threshold to prescribe them. Rahul, any other studies you wanted to highlight? Well, you know, so on the theme of GDMT for heart failure, it's becoming increasingly clear that getting patients on these medications as soon as possible is better. And I think, you know, I have been guilty of not,

initiating patients on all the classes before discharge. In the past year, we finally have evidence that it really makes a difference in terms of mortality and rehospitalization. The strong HF trial in the Lancet found that getting patients rapidly up -titrated on GDMT led to a 34 % reduction in all -cause death and heart failure admissions at 180 days. So really exciting stuff. Yeah, that's pretty cool. It's cool that because...

Most people aren't going to have the guts to just rapidly up -tie trade all those medications. But if it's been done in a trial in a protocolized or safe way, then that probably would make people feel more comfortable doing that. It could become the standard. Let's move on. Paul, you wanted to talk about kratom, which I believe you can get at a gas station near you. Literally, I can. Yeah, I mean, it's Billboard's tour. I could get it if I wanted to. And I...

I won't take too much time on this. I'm going to make the same point I made before. So, cradum is an interesting substance. It initially came from the leaves of a tree indigenous to Southeast Asia where it had been used for centuries and sensibly as kind of it was treating things like hypertension and cough and fever, but also just for aches and pains. If you're kind of tired, like it has pharmacologically, it's kind of a mess. Like it stimulates every receptor known to man. So like it's so it's there's mu receptors. So it's analgesic. There's some.

The Curbsiders (56:15.726) a tox -2 pathway inhibitor and there's some alpha agonism, like it just, it's kind of all over the place. But it had been used safely, again, in Asia. And then of course, in the States, we hyper -concentrated in solid gas stations and these incredibly potent forms. And now we're running into issues with it. But it's a medication, it has psychoactive properties. It has a partial affinity from u -opioid receptors, which is why it's thought to have analgesic effects. It does not cause the same sorts of respiratory depression that you see with other opioid agonists.

And it also has, like I said, it has some COX -2 pathway inhibition and alpha agonism, as well as serotonergic and dopaminergic antagonism. So it's all over the place pharmacologically. Why it's important is patients are using it recreationally. They are sometimes patients with opioid use disorder are using it to mitigate withdrawal symptoms. They're self -treating with kratom to kind of come off of opioids in a way that is less miserable for them. And more importantly, people are using it and then using increasing doses and are finding themselves with withdrawal symptoms from the kratom itself. And so there are

an increasing number of case areas about patients who are actually being treated with buprenorphine for, this is not a diagnosis code yet, but basically for creatine use disorders. They have tolerance, they have withdrawal symptoms, it is impacting their function. And as a result, these patients are being treated as if they have opioid use disorder. And in my personal practice, now that I'm starting to ask patients about it, many of them have heard of it and many of my colleagues and I certainly had not up until sort of this episode. So it's...

When you're taking your social history, I think it's probably worth at least asking about some of these more unusual substances because they have real clinical implications and we're going to have to contend with them in one point or another. We don't, I think, know enough to have a lot of evidence to manage them, but at least knowing about them is a good place to start until we actually build that evidence. And there's only, the only way to build the evidence is to have more clinical exposure. So just think about asking your patients about kratom. And that's really the only plug I'll make about it right now. So it's been around for a while.

But I'm hearing about it more and more and you're gonna be hearing about it as well. So just wanted to raise awareness of it. Yeah, and maybe, you know, it's the holiday season. Maybe put someone in, if you have a kid, maybe put someone in their stocking. Or another kid. Your brother, yeah, or your sister. Just chill them out a little bit. Do you eat it? Did you mention that? I think it's pills, right? It's ingested, that's correct. There's pills, there's powders, there are different formulations.

The Curbsiders (58:34.67) But yeah, it's always adjusted. I don't think it's used in other formats. All right. So, Paul, the last topic before we get to our reflections is RSV. So we talked about this on number 414, Spooky Cakes. And I beat up on the Pfizer study. There's a couple of vaccines. So Pfizer and GSK both have vaccines that are approved.

brand names are Rex V. That's the GSK one and a brisvot is the Pfizer one. They're both FDA approved for adults over 60, both to prevent acute RSV infection and or lower RSV lower respiratory tract infection. Neither of the trials, the phase three trials were able to target hard endpoints of hospitalization or death, but they did prove that they prevented.

acute RSV infection and lower respiratory tract infection, which they were confirming with PCR testing. So my critique of especially the Pfizer study was that they had a really younger, healthier cohort without comorbidities and they excluded immunocompromised people. The GSK study, which was by Poppy, they were both 2023 in New England Journal.

the GSK study had a larger proportion of older, sicker patients. I looked at that one before this, and they did see less RSV infections. I should mention that both the Pfizer and the GSK study had a really small number. You know, they had like 25 ,000 patients in the GSK and almost 40 ,000 in the Pfizer study, and they still only had like under 100 RSV infections total in both groups. You know, it was a small numbers that we're talking about, absolute. So they're...

They're giving you this 80 % relative risk reduction, but it's, you know, we're talking about very small numbers here. The absolute numbers are pretty small. So my questions, Paul, are, are these vaccines going to work for the older sicker patients or people that are truly immunocompromised chemotherapy on, you know, meds for rheumatologic disease, chronic steroids? How often do they need to get them? And...

The Curbsiders (01:00:50.958) Are they going to work to prevent hard endpoints like hospitalization and death? The trials are still ongoing because they want to see if they work over two different RSV seasons. So Paul, what is your, what do you think? Yeah, you had me sold on on poopooing them earlier, I think, just because you're a convincing guy. I will say that all the studies look kind of the same. And there's there's whether you're talking about the Janssen or the GSK or the Pfizer, like all the trials showed like this around 80 percent reduction. And I.

I don't know. The more I think about it, the more I do think that's significant. The heart and point thing I think is a valid point, but I also think it starts to feel a little bit like the not having randomized controlled trials for parachutes. If they're not getting the infections, then they're probably less likely to die from the infections. So they're having less symptoms. So I hear your concern. I think those outcomes will probably come. But I do think that the numbers that they have so far are reasonably impressive. RSV is reasonably prevalent. And the safety profiles, which I think is probably the larger concern, there is

The neurologic outcomes, I think, I don't think were statistically worrisome, but there was enough of them that kind of raised your eyebrows, you know what I mean? So I do think that that probably warrants watching, but I think overall, if you're having a decrease and a significant decrease in symptomatic infection, probably those hard outcomes are going to follow. Like it just doesn't make sense that they wouldn't. And it would be nice to see the hard data, but I just think it stands to reason that if you're not getting the infection that's symptomatic, then you're less likely to have an infection that's gonna land you in the hospital or kill you.

Okay, so it's hard to find how many people over 60 there are. So I'll just say over 65, there's 50 million people in the US, $200 a pop -pall, that's $10 billion a year. So this is a huge moneymaker. And there is a risk of like, you know, some of these, like there were some Guillain -Barre, Miller -Fisher syndrome scene. It's rare, but...

Not everyone over 60 looks the same. So, you know, I want to know if it works in my patient with COPD, with chronic heart or lung disease, kidney disease, liver disease, you know, those people, I think it makes sense to get it. But if you're like a 60 year old with hypertension and then you get a vaccine for what for you would probably be a cold and you get like Miller Fisher syndrome or, you know, that's that's where my calculus is sort of. And I'm just it's just a blanket recommendation to give to everybody. They pocket ten billion dollars a year. Everyone's.

The Curbsiders (01:03:08.142) fat and giggly, Paul. You know, that's my - Listen, you'll get no argument from me that big pharma is evil. And I do think from a public health standpoint, again, if you're decreasing symptomatic infection and the people who are not going to die from it, you're probably protecting the people who will. So I think in general, that's sort of how vaccines, that's the big sell. So it's, well, I always think big pharma is evil and always, I think it's good to be really critical of the outcomes. It does seem to me from a public health standpoint, if you're preventing symptomatic infection, you're going to still be indirectly preventing -

the more adverse patients from getting sick. So I do have hopes for the downstream effects from it, but I think your point is well made. It is often a mild infection. It usually doesn't have catastrophic outcomes and pharmacies are evil. Rahul? I agree. It does seem all about the population in which the results are applied. And I'll note that we mentioned, we covered briefly in that Spooky Cakes episode, the concomitantly published Matisse trial of the RSV vaccine in pregnant women. That did show a...

reduction in medically attended severe respiratory tract infections from RSV in neonates. So, you know, in all depends on the population, the sort of risk we're talking about. So this definitely been an exciting year for RSV. Yeah. And I guess you could say protecting kids and babies, you know, if the adults aren't getting infected, they won't either. So I'm not smart enough to figure this out, Rahul. I just I'm just always I'm just I'm going to be the skeptical one on the show from I'll play that role. So and I'm the stooge.

Yeah, I do have conversations with people and you know, some of my patients want to get it and some of my patients don't and I just tell them, you know, I'm still, something I'm still monitoring, essentially the trials aren't done yet, but I'd say about half my patients that are eligible are getting it and you know, when they have the conversation and the other half are like, no, I'll wait till next year.

It's not the one I'm prioritizing. Like I feel like the patients who are interested are the ones who have probably gotten it, whether or not I recommend it or not, like the ones who are sort of all in for all vaccines. But if I'm having conversations about which vaccines I think are important, this is not the one I'm gonna push for if there are other ones that I can make a stronger case for. All right, so that ends this portion of the show. We're now gonna move on, just, you know, it's the end of the year. I always like to, at this time, just, you know...

The Curbsiders (01:05:19.798) do a quick reflection, say something nice to the audience, maybe to the team. So let's go around the horn here. Nora, would you start us off? Sure. So I am very grateful to have gotten to work with you guys over the last many years. And especially for the kind of jokes and the laughs before the show, after the show, the sarcasm throughout the trial.

analysis, the trial name analysis in particular. And coming off of an afternoon of clinic, I'm really grateful to be able to apply the pearls that I'm learning by working with you guys to patients and just having that space to take care of patients and have them trust me and actually take my advice about Kiwis and about improving constipation, all of that.

So very grateful for that. And I really can't overstate how grateful I am for the chance to work with you three in particular on a regular basis and to learn from our guests, to work with my amazing team of Digest writers and to figure out how to disseminate knowledge as clearly and thoughtfully as possible. Yeah. So thanks to you guys for keeping my love of learning alive and creating a wonderful space.

that I get to learn alongside you guys and for doing it all with jokes and a good sense of humor. For the audience that didn't hear the last Digest episode, the way Paul rates trial names is, did they correctly apply the acronym? Which everyone, I thought it's just how cool of a word did they choose? That's what I do, Paul, but. Well, I mean, it's lazy is what that is. I mean, back when I was coming up, people said,

There's some thoughts on trial names these days. They're not even trying. Matisse, get out of here with that. Yeah, Paul, what was your favorite trial name of the year? I feel like that maybe is the That should be a new, I gotta put that down for next You gotta get it, Nora. They've all been kind of gorkily bad. There's not been one that is really - Figaro, I kind of like, what's that? Figaro? Fidelio's good. Fidelio. Yeah, those I didn't hate as much just because they were at least kind of cute. So yeah, I'll the opera ones. I know.

The Curbsiders (01:07:40.846) Those are my favorites personally. They should be ashamed of themselves. Whatever social media managers are leading the way with that, they should just. That's the best. All right, Rahul. Some of my favorite moments from the show this past year and just always have been listening to Matt and Paul describe real life patient experiences in primary care. And I am reminded that access to excellent primary care is not something to take for granted.

It's really the bedrock of a healthy and well -functioning healthcare system. And especially nowadays when it feels very difficult to do that job well, I just think about how grateful I am to my own PCP and to everyone out there who is involved in providing care to patients. And it is a real privilege to play a small role in making high quality learning easier and more accessible for everybody who is taking care of patients. So thank you to our listeners for all the hard work you do.

Thank you for listening to us. And I'll also say I'm so grateful to the three of you and to everybody involved in the show for making critical appraisal of the medical literature as much of a part of our educational mission as clinical reasoning. And I couldn't be more honored to do this work alongside you all. So thank you. Paul? Yeah, I feel like I say the same thing every year, but it's true every year. So I don't know what to tell you. But I...

This year reflecting more about community and just sort of as cornball as that sounds, like I just I was just thinking about like ACP coming up and the number of speakers that we personally know thanks to the show, like people that we've had on this episode, people that have come up with us. And so and almost that's true of almost any conference that you go to. And now almost like on Twitter, just that like the scope and reach of this show and the people that I have met. And I tend towards depressive and I tend towards not liking human beings in general, even though I chose a weird profession for that.

I just think about the number of incredible people that we've met, both the ones who are on this recording right now, the people, the Curbsiders team, the guests that we've had, the people, the learners and the residents and just everyone I've gotten to interact with in this role. It almost makes me optimistic, which is not an easy thing to do. I just think there are so many incredible people in medicine and to have this forum where I can actually engage with them and get to know them and sort of see their work and appreciate them as people and as educators and as caregivers and healers. It's just.

The Curbsiders (01:10:01.038) It really, it's remarkable and I'm just, I'm grateful for it every single day, even though I don't think I do a great job of expressing that all the time. So again, just reflecting on the chances that the show is going to meet to sort of meet so many incredible people, both as part of our media team and then sort of across the country that are doing sort of the same stuff that we're doing. So yeah, I think I'll stop there. So Paul, this has been eight years of going, February of the eight years of since we've been releasing podcasts, but you know, we've been working on this since September, 2015. So.

It's already been eight years for us that we've been working on this over 420 numbered episodes. And if you look on our channel, I mean, we have 450 probably that we've released because some of them are non -numbered and just overwhelmingly the audience has really been positive mostly in their comments. I mean, we get trolled a little bit, Paul, but not nearly as much as I thought I would at the start of all this. Most people are just - tell Paul to slow down.

A lot of telling Paul to slow down, that is true. But yeah, we're so grateful that the audience has, you know, stuck with us for all these episodes and has spread it to, you know, the main way the show has stayed around and grown is by word of mouth. We don't do any advertising. I mean, we have our social media, but we don't do any other type of advertising. So it's word of mouth.

This year in 2023, Paul, we changed our website. We overhauled that so we could showcase all the shows that we do. So there's the Cribsiders is on there with their team. Of course, the, the Curbsiders, our shows on there. We have Curbsiders Teach, Addiction Medicine. We have the Digest on there now and the back issues of the Digest are on there as well. And also the mini series, the Teach released it's like third season and Addiction Medicine releases second. The Digest has been.

Nora, we're close to 50 issues of the Digest now. And now we're doing monthly episodes of either Hot Cakes or Digest. Nora and Rahul are sort of shifting off each month because it's so much work to put those together. So we're making so much content. And I think all told, we probably have more than 70 people working between all the different shows and projects. And these are all just people remotely, largely working for very little. We have...

The Curbsiders (01:12:21.366) little bit of support for them, but these people are largely just doing this on top of their full -time jobs. So thank you to all the fans who have supported us, the patrons on Patreon. Discord has been a lot of fun to get to know some of the fans better on there. And we will hopefully we can keep doing this. Paul gets a little harder each year. I get a little tired, but we are trying to find ways to make it sustainable and we have a great team around us to help us do that. So...

Paul, let's get to an outro, because this is a long one, but it's been fun and thank you to all of you on this call for being so great to record with every month.

The Curbsiders (01:13:01.646) This has been another episode of the Curbsiders, bringing you a little knowledge food for your brain hole. Yummy. There's like three of you. Someone step up and give us a yummy. Oh, I did not like saying that out loud. That would help, man. All right, editor, please isolate that and drop into every episode. I literally gagged. I don't know if you heard that on my... Anyway.

Still hungry for more? Join our Patreon and get all of our episodes ad -free plus twice monthly bonus episodes at the patreon .com slash Curbsiders. You can find our show notes at thecurbsiders .com. While you're there, you can sign up for our mailing list to get our weekly show notes in your inbox. And that includes our outstanding Curbsiders Digest, which recaps the latest practice changing articles, guidelines, and news and control notes. And we're committed to high value practice changing knowledge. And to do that, we want your feedback. So you can email us at askcurbsiders .gmail .com.

And please subscribe right and review the show on YouTube, Spotify, Apple podcasts. It really does help people find the show. This episode will not be available for CME because we're taking a break for this one, but most episodes going forward are available for CME through vcuhealth at curbsiders .vcuhealth .org. A special thanks to Dr. Nora Toronto and Dr. Rahul Ganatra for helping to write and produce this episode and to our whole Curbsiders team.

Our technical production is done by PodPaste, Elizabeth Proto runs our social media, Jen Watto manages Patreon, and Stuart Brigham composed our theme music. And with all that, until next time, I've been Dr. Matthew Frank Watto. I've been Dr. Nora Toronto. I've been Dr. Rahul Ganatra. And as always, our main doctor, Paul Nelson Williams, thank you and goodbye.

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