The Curbsiders podcast

#420 Recap Extravaganza: 2023 Highlights and Top Stories

December 25, 2023 | By

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Transcripts available via YouTube

Join us as we recap various topics discussed throughout the year, including hormonal and non-hormonal therapy for menopause symptoms, hemochromatosis, evaluation and management of hematuria, updates in diabetes management (insulin, GLP1 agonists, SGLT2 inhibitors, hypoglycemia), xylazine overdose and withdrawal, primary aldosteronism, resistant hypertension, delirium, and its implications, the ACORN trial on AKI risk with pip-tazo vs. cefepime, the REPRIEVE trial on statin therapy in patients with HIV, inpatient heart failure management, the implications of kratom use, and the effectiveness of RSV vaccines. Plus, Paul Williams (@PaulNWilliamz), Rahul Ganatra (@rbganatra), Nora Taranto (@norataranto), and Matt Watto (@doctorwatto) share their picks of the year and take a moment to reflect on their gratitude for the fans and the opportunity to work on Curbsiders.

Our team needed a break so we did not make CME for this episode. 

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Show Segments

Time Stamps are for Patreon (Ad-Free) Version

  • 00:00 Introduction and Overview
  • 09:42 Hormonal and Non-Hormonal Therapy for Menopause Symptoms
  • 14:20 Understanding Hemochromatosis
  • 19:24 Evaluation and Management of Hematuria
  • 25:00 Updates in Diabetes Management
  • 29:35 Xylazine Overdose and Withdrawal
  • 35:35 Primary Aldosteronism
  • 39:36 Resistant Hypertension
  • 44:12 Delirium and its Implications
  • 46:29 The Acorn trial and AKI risk
  • 49:47 HIV trial: Reprieve
  • 51:11 Updates in hospital medicine
  • 56:00 Kratom and its implications
  • 59:11 RSV vaccines and their effectiveness
  • 01:05:38 Reflections and Gratitude

Recap Extravaganza Pearls

These are abbreviated show notes. Links to the original Show Notes are included at the end of each bullet.

  1. Hormonal and non-hormonal therapy can be effective in managing menopause symptoms, and behavioral modification techniques can also be helpful. (Show notes for ep. #409)
  2. Hemochromatosis has incomplete penetrance. Ferritin and tsat can be elevated for many reasons, including alcohol and inflammation (e.g. infections, sepsis, dysmetabolic iron overload). Dr. Tapper talked about a great Teachable Moment case in JAMA IM illustrating the pitfalls of anchoring on hemochromatosis as the cause for an elevated Tsat in a patient who also consumes alcohol. (Show notes for ep. #380)
  3. Anticoagulation unmasks bleeding but should not be considered the cause for bleeding. Hematuria should be evaluated carefully, considering the potential causes and risk factors for malignancy. (Original show notes ep. #404)
  4. Insulin is not the right medicine for most patients with type 2 diabetes absent weight loss/polyuria (catabolic symptoms), or those with longstanding burned-out type 2 diabetes. GLP1 agonists have similar potency to insulin, and the new GIP/GLP1 agonists seem even more potent (Frias, 2021). (Show notes for ep. #387
  5. NPH insulin 2/3 in AM and 1/3 PM can be used as monotherapy and may be more affordable through the big box stores. Detemir is a TWICE daily insulin. It has a dose-dependent duration of action that is shorter and more variable at lower doses (e.g. 0.1-0.2 units/kg) and longer and less variable at higher doses (e.g. >=0.87 units/kg) —per Lexicomp. Watch for OVERBASALIZATION! Look for patients on more than 0.5 units/kg/day basal insulin (e.g. >50 units/day for 100 kg person) with high differences in bedtime-morning glucose, hypoglycemia, and high variability (ADA Standards 2023, Chapter 9). Follow the rule of 15 for hypoglycemia. Give 15 grams of carbs and repeat the glucose every 15 minutes. (Show notes for ep. #397)
  6. Xylazine (nicknamed tranq), a drug increasingly lacing the fentanyl supply and sometimes used on its own, can be injected, smoked, or insufflated. There’s no reversal agent to this centrally acting alpha 2 agonist. Overdose with xylazine can present with respiratory depression and sedation. Anxiety is a prominent feature of withdrawal. Curiously, necrotic skin wounds can occur even in patients who do not inject xylazine. (Show notes for ep. #392
  7. Primary aldosteronism is THE MOST COMMON cause of resistant hypertension – as many as 15-20% of patients in specialty hypertension clinics (per Matt Luther), so it is worth evaluating patients with resistant hypertension for this. Look for suppressed morning plasma renin activity (PRA) or plasma renin concentration (PRC), as well as an elevated plasma aldosterone concentration (PAC). (Show notes for ep. #386
  8. Hypertension expert, Dr. Jordy Cohen, taught us that citalopram could be considered another second-line antihypertensive agent for patients with anxiety; she often reaches for citalopram before thinking about beta blockers. While there is mixed data about the effect of citalopram on blood pressure (Calvi et al 2021), Dr. Cohen finds that citalopram is useful in lowering blood pressure in patients with comorbid treatment-resistant hypertension and anxiety. Individual studies of citalopram have shown it to be effective at lowering blood pressure in patients with chronic posttraumatic stress disorder or patients already on amlodipine (Tucker et al 2003 and Fu et al 2015). Beta-blockers should not be used for hypertension unless otherwise indicated (atrial fibrillation, heart failure with reduced ejection fraction, or migraines), because they have been associated with an elevated cardiac risk in several patient populations (Rethy et al 2021). (Show notes for ep. #390)
  9. Proper blood pressure measurement, including using the correct cuff size, is crucial to avoid misdiagnosis and overtreatment. (Show notes for ep. #414)
  10. We need to recognize delirium ASAP and treat the underlying cause to prevent long term effects. Newer studies are finding that the pathogenesis of delirium is ongoing inflammation and neurodegeneration in the brain. For example, Dr. Oh notes that delirium is associated with elevated biomarkers of neuronal damage, such as neurofilament light (NfL), which is typically found in traumatic brain injury and dementia (Casey, 2020). The recent DECIDE study found that episodes of delirium increase the risk of future cognitive decline and dementia, and more severe delirium episodes were associated with worse outcomes (Richardson, 2021). (Show notes for ep. #375)
  11. The ACORN trial suggests that there is no increased risk of acute kidney injury (AKI) with the use of Pip-tazo and vancomycin compared with cefepime and vancomycin. Neurologic side effects were more common with cefepime, but keep in mind this was an open-label trial, so there is a potential for ascertainment bias. (Show notes for ep. #414)
  12. The REPRIEVE trial highlights the potential benefit of starting statin therapy in low to moderate-risk patients with HIV. (Digest #45, Show Notes #418)
  13. Updates in hospital medicine include the use of empagliflozin in patients with acute decompensated heart failure (EMPULSE trial), and the importance of rapid up-titration of guideline-directed medical therapy (STRONG-HF) in heart failure patients. 2023 JACC Consensus Guidelines on HFpEF. (Show Notes for ep. #393)
  14. Kratom, a psychoactive substance, is being used recreationally and for self-treatment of opioid withdrawal symptoms. It is available at the counter in convenience stores and gas stations. Healthcare providers need to be aware of its use and potential for misuse. (Show Notes for ep. #403)
  15. RSV vaccines: Arexvy (Papi, 2023 by GSK) and Abrysvo (Walsh, 2023 by Pfizer) are FDA-approved for adults over 60 to prevent acute RSV infection and RSV lower respiratory tract infection based on an interim analysis of ongoing trials. Some remaining questions include Whether these vaccines are immunogenic in older, sicker patients. Will they work in immunocompromised adults (excluded from trials)? Will they prevent hard outcomes like hospitalization and death? How frequently will they be administered? (Show notes for ep. #414)

Picks of the Year

  1. Nora’s pick – How I Won a Nobel Prize (book) by Julius Taranto
  2. Paul’s pick – Murder the Mountains (album) by Red Fang
  3. Rahul’s pick – Secrets of the Whales (docuseries) 
  4. Watto’s pick – Watch European soccer on the Peacock, Paramount Plus, and ESPN+ apps.

Goal

Listeners will recall top pearls from Curbsiders podcast 2023

Learning objectives

After listening to this episode, listeners will

  1. Recall that Paul Williams is #America’sPCP
  2. Be familiar with the hotcakes rating system
  3. DIGEST key pearls from the digest

Disclosures

The Curbsiders report no relevant financial disclosures. 

Citation

Taranto N, Ganatra R, Williams PN, Watto MF. “#420 Recap Extravaganza: 2023 Highlights and Top Stories”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast Final publishing date December 25, 2023.

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Episode Credits

Written, Produced, and Hosted by: Nora Taranto MD, Rahul Ganatra MD, MPH; Matthew Watto MD, FACP; Paul Williams MD, FACP
Cover Art: Matthew Watto MD, FACP
Showrunners: Matthew Watto MD, FACP; Paul Williams MD, FACP
Technical Production: PodPaste

CME Partner

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The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.

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