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June 10, 2019
#154 DVT and PE Master Class with Michael Streiff MD
What do Judas Priest, surfing, and clots have in common? They are the passionate interests of expert Dr. Michael Streiff who guides us through the diagnosis and management of DVT and PE aka venous thromboembolism (VTE). By the end of the episode you will know how to catch a clot very Wells! We dive deep into the treatment options, literature, and some unique cases. ACP members can claim CME-MOC credit at https://acponline.org/curbsiders (CME goes live at 0900 ET on the episode’s release date). Full show notes available at https://thecurbsiders.com/episode-list. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by (including CME questions): Justin Berk MD, MPH, MBA Cover art by: Kate Grant MBChB DipGUMed Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP; Stuart Brigham MD Edited by: Matthew Watto, MD, FACP Guest:  Michael Streiff MD Time Stamps 00:00 Intro, disclaimer and guest bio 04:40 Guest one-liner, book and music recommendations, advice about rejection, how to think about studies 11:15 A case of DVT and some basic terminology 15:37 Which DVT risk factors are most important? 18:40 Use of the Wells score and D-dimer testing; should we use an age adjusted D-dimer; What about the YEARS criteria 22:55 Classifying DVT; determining need and duration of anticoagulation [distal (calf vein) DVT, proximal DVT]; brief discussion of IVC filters & catheter directed therapies 27:56 IVC filters for trauma 29:30 Upper extremity DVT 33:12 Proximal vs whole leg ultrasound for diagnosis of DVT 36:25 A case of pulmonary embolism; how to diagnose pulmonary embolism and a bit on V/Q scans 40:35 PESI score and HESTIA criteria 42:05 Summary of how to diagnose DVT and PE 43:34 Choice of initial anticoagulation 45:29 DOACs for cancer 48:14 DOACs for patients with very high or very low BMI 49:33 Why apixaban is Dr Streiff’s favorite DOAC? 51:20 Duration of therapy for DVT and PE 53:33 Unprovoked DVT/PE: Risk scoring models 57:52 Is thrombophilia workup necessary? 58:28 Antiphospholipid antibody syndrome 59:58 An extensive cancer workup is unnecessary 60:33 Subsegmental pulmonary embolism: To treat or not to treat 61:49 Apixaban dosing in CKD and ESRD 63:51 AUGUSTUS trial for dual versus triple therapy 64:52 Plug for National Blood Clot Alliance “Stop the Clot”; Anticoagulation Forum website; new 2019 ASH guidelines 66:35 Outro 68:00 Post credit scene
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68 min
June 3, 2019
#153 Heart Disease in Women with Dr Bairey Merz
Expand your idea of ischemic heart disease to include non-obstructive patterns, which as our guest, Dr Noel Bairey Merz, a clinical investigative cardiologist whose multiple roles include Director of the Barbra Streisand Women’s Heart Center and the Preventive Cardiac Center at the Smidt Cedars-Sinai Heart Institute, shares with us, is incredibly common, especially in women.  Learn to recognize these women and treat according to guidelines, preventing unnecessary IHD mortality in our female (and some male) patients. We review a variety of non-obstructive pathologies and the best techniques to evaluate them. Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Shreya Trivedi MD, Molly Heublein MD Hosts: Paul Williams MD, FACP; Shreya Trivedi MD; Molly Heublein MD Edited by: Matthew Watto MD, FACP; Emi Okamoto MD Graphics by: Hannah Abrams Guest: Dr. C Noel Bairey Merz MD, FACC, FAHA Curbsiders' Schwag! We’ve got the perfect father’s day gift for every internal medicine nerd. The Curbsiders have opened our own online shop. Get your Curbsiders t-shirts, hoodies, stickers, and coffee mugs. Help support the show and gain instant bragging rights. Note: All purchases come with admitting privileges at Kashlak Memorial Hospital! Time Stamps 00:00 Intro, disclaimer and guest bio 04:36 Guest one-liner; Advice for success in research and clinical practice 07:07 A case of shortness of breath and chest tightness; Why the paradigm of obstructive coronary artery disease is flawed. 12:04 Why is there a sex difference in ischemic heart disease? 14:52 How to recognize ischemic heart disease in women; Are certain symptoms more likely in women; Categorizing angina 20:13 Who needs stress testing?; Screening for ischemic heart disease in women 24:52 How guidelines make good doctors great doctors 27:00 Diagnosis of NSTEMI in a woman without obstructive coronary disease 29:33 Medical therapy for non-obstructive ischemic heart disease 33:18 Additional testing: Cardiac MRI for myocarditis; perfusion reserve testing; CT coronary angiograms 35:48 How current non-invasive techniques fail to identify microvascular ischemic heart disease in women 39:10 Antianginal therapy 41:40 HFpEF in women 47:10 Weight loss for paroxysmal atrial fibrillation 48:45 New nomenclature for ischemic heart disease 50:18 Take home points 52:40 Outro
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54 min
May 29, 2019
#152 Dare to Lead: Becoming a PGY2
Dare to lead. Master the transition to PGY2 with tips from expert educator Abby Spencer MD, MS, FACP, IM Residency Program Director and Vice Chair for Education for the Medicine Institute at Cleveland Clinic and Shreya Trivedi MD, GIM Fellow at NYU School of Medicine. Topics include: how to run work rounds, preparing your team for attendings rounds, how to teach on the fly, finding your leadership style, and what to read during residency. This is the first of three episodes that we’re co-developing with the American College of Physicians for their Resident Transitions Series. Full show notes available at http://thecurbsiders.com/podcast. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Shreya Trivedi MD Graphics and Show Notes by: Hannah R Abrams Hosts: Paul Williams MD, FACP; Stuart Brigham MD; Matthew Watto MD, FACP; Shreya Trivedi MD Guest: Abby Spencer MD, MS, FACP Sponsor The Resident Transitions Series is brought to you by The American College of Physicians with support from its Council of Resident/Fellow Members. Visit acponline.org/resident to learn more about the benefits of Resident/Fellow Membership and join our proud internal medicine community today! Time Stamps 00:00 ACP’s Resident Transitions Series - Sponsor 01:50 Disclaimer, intro and guest bio 06:05 Guest one liner, book recommendations, favorite failure, advice for learners 14:10 Stuart’s tale of struggle from residency 18:05 New PGY2 resident thinks she has nothing to teach her learners 20:20 How to run work rounds and set expectations 31:55 How, when and where to teach as a resident 46:09 Leadership skills, understanding your learners, and giving difficult feedback 60:08 What to read during residency, how to find time, and some strategies to achieve your learning goals 71:30 Take home points 75:28 Outro 77:10 End credit sequence
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78 min
May 27, 2019
#151 Anaphylaxis with Dr Olajumoke Fadugba MD
Recognize common presentations of anaphylaxis and stop under-treating this deadly allergic reaction with tips from Dr. Olajumoke Fadugba, Assistant Professor of Medicine, University of Pennsylvania! We review the basic pathophysiology and the standard criteria for diagnosing anaphylaxis, treatment basics, the primary importance of epinephrine, and the utility of adjunctive therapies. Also included are great tips on counseling patients about auto-injectable epinephrine, and a reminder not to panic...even when you inject your own thumb?! ACP members can claim CME-MOC credit at https://acponline.org/curbsiders (CME goes live at 0900 ET on the episode’s release date). Full show notes available at https://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Writer (interview, show notes & CME questions) and cover art: Emi Okamoto MD Infographic by: Emi Okamoto MD Hosts: Matthew Watto MD, FACP; Stuart Brigham MD Editors: Matthew Watto MD, FACP Guest: Olajumoke Fadugba MD Special thanks to Sarah Phoebe Roberts MPH for booking! Time Stamps 00:00 Intro and disclaimer 03:00 Guest one-liner, book recommendation, advice to fellows and trainees 07:15 Case of anaphylaxis with mucocutaneous and GI symptoms 09:05 Anaphylaxis (IgE mediated mast cell action) vs anaphylactoid (non-IgE mediated mast cell activation; e.g. contrast allergy, vancomycin) 12:34 Vancomycin and non-IgE mediated reactions 14:40 Common presentations of anaphylaxis and the three diagnostic criteria 22:09 Biphasic reactions and predicting severity 26:42 Counseling patients on the use of epinephrine 28:35 Stuart’s thumb question 30:00 Adjuvant medications: antihistamines and corticosteroids 33:20 Are there any contraindications to epinephrine use? 34:25 Use of tryptase levels when the diagnosis of anaphylaxis is uncertain 37:10 Outro
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39 min
May 20, 2019
#150 HFpEF with Dr Clyde Yancy MD
HFpEF (heart failure with preserved ejection fraction) with master cardiologist, Dr Clyde Yancy MD, Chief of Cardiology and Professor of Medicine (Cardiology) and Medical Social Sciences, Northwestern, Feinberg School of Medicine. Topics include: pathophysiology, HFpEF phenotypes, how to interpret a borderline ejection fraction, evidence based therapies, diuretics, and future directions (pulmonary artery monitors, intra-atrial shunts, ARNI compounds), and more! Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Paul Williams MD, FACP; Sarah Phoebe Roberts MPH Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP; Stuart Brigham MD Show Notes: Justin Berk MD, MPH, MBA; and Beth Garbitelli MS1 Infographics: Beth Garbitelli MS1 Editor: Matthew Watto MD, FACP Guest: Clyde Yancy MD, MSc, MACC, FAHA, MACP, FHFSA Time Stamps 00:00 Thanks to our producers Sarah Phoebe Roberts, Beth Garbitelli and Justin Berk 00:50 Intro and guest bio 04:00 Guest one liner, career advice 08:20 Ms Diana Stolic has HFpEF. What’s the difference in HFpEF and diastolic dysfunction?   11:33 How should we think about borderline ejection fraction? 15:24 Pathophysiology and Phenotypes of HFpEF 18:57 More on the pathophysiology of HFpEF (nitric oxide, fibrosis, inflammatory signaling) 21:00 Are there morbidity and mortality differences for HFpEF versus HFrEF? 24:45 What historical factors are most important in HFpEF? 27:50 Pulmonary artery monitors for HFpEF 29:00 Does Diuretic therapy differ in HFpEF and HFrEF? 33:44 Ischemic workup for new HFpEF 35:33 Right heart cath for HFpEF 36:53 Future of HFpEF 41:04 Will ARNI compounds work for HFpEF? What are the current medications for HFpEF? 45:20 SGLT2 inhibitors for heart failure 46:30 Outro
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47 min
May 17, 2019
Recap SGIM19 Day 2
Recap of random pearls and highlights from SGIM19 Day 2 including: methadone and buprenorphine, perioperative buprenorphine, medical cannabis, HPV vaccination, young adult medicine, academic promotions, long term sequelae of childhood kidney disease, stage 1 hypertension, some great free resources in addiction medicine, and more! Special thanks to the Society for General Internal Medicine for their hospitality. Full show notes available at https://thecurbsiders.com/episode-list. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written, produced, and cohosted by: Paul Williams MD, Matthew Watto MD, Justin Berk MD, Carolyn Chan MD, Shreya Trivedi MD, Nora Taranto MS4 (soon to be MD!) Edited by: Matthew Watto MD Time Stamps and Links are included below 00:00 Intro and Disclaimer 02:30 Generalists receive the same number of grants, but publish fewer publications and are less likely to achieve professorship versus medical or surgical subspecialists (JGIM 2017) 05:30 GIM division directors differ in their emphasis on peer-reviewed publications for academic promotion (Acad Med 2015) 07:30 Only about 30% of patients are started on MAT after an overdose despite a known mortality benefit and a known mortality rate of 5% twelve month mortality in this population (Larochelle Annals Int Med 2018) 08:48 A representative in NYC has proposed a bill to get rid of the buprenorphine waiver program. 11:00 Stimulant use is not a contraindication to continuing buprenorphine (expert opinion from SGIM session on Addiction Medicine). 11:45 Perioperative buprenorphine: 1) Consider switching to full agonist therapy or 2) Dose buprenorphine 3-4 times daily and continue use during the perioperative period (Expert opinion from SGIM session titled “Buprenorphine 2.0”) 12:40 Options to transition from methadone to buprenorphine: Option 1) Taper methadone to 30-40 mg once daily. Then, hold methadone for 72 hours before starting buprenorphine. Option 2) “Microdosing” with buprenorphine patch while still on methadone and then start oral buprenorphine. Note: This is expert opinion so consult with your local expert before attempting this on your own! 13:46 UCSF has a “Warm Line” for free consultation about substance use https://nccc.ucsf.edu. Get a free buprenorphine waiver from https://pcss.org 15:10 New joint guidelines on transitions remind providers that young adults need help navigating the healthcare system. Many young adults have never accessed healthcare resources on their own (Pediatrics 2018) 18:50 Childhood kidney disease increases risk for end stage renal disease as an adult (NEJM 2018) 20:35 Two studies concluded that stage 1 hypertension in young adults confers an increased risk for morbidity and treating it confers a benefit (Yano AMA 2018; Son JAMA 2018) 23:35 HPV update: The 9 valent vaccine was approved for young adults age 27-45 years old, but this has not yet made it into the guidelines. The HPV vaccine is effective for preventing cervical cancer (Cochrane Review 2018) and provides some herd immunity (Clin Inf Dis 2018) 26:40 Dr Chan offers tips on how to handle resident mistreatment and phrases that you can use to defuse the situation. 31:30 Some broad comments on the use of medical cannabis for pain management (Expert opinion from SGIM session) 36:30 Newer data suggests that even one drink daily might have adverse health outcomes (Lancet 2019). 39:00 Outro Citation Paul Williams MD, Matthew Watto MD, Justin Berk MD, Carolyn Chan MD, Shreya Trivedi MD, Nora Taranto MS4. Recap SGIM19 Day 2”. The Curbsiders Internal Medicine Podcast https://thecurbsiders.com. May 17, 2019.
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41 min
May 13, 2019
Recap SGIM19 Day 1
Recap of random pearls and highlights from SGIM19 Day 1 including: Kidney stone treatment (roller coasters, sex and tamsulosin), aspirin, SGLT2 inhibitors to reduce kidney events, oral antibiotics for endocarditis, preferred physician attire, sexual harassment, writing letters of recommendation, triple therapy for COPD, DAPT for stroke, and more! Special thanks to the Society for General Internal Medicine for their hospitality. Full show notes available at https://thecurbsiders.com/episode-list. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written, produced, and cohosted by: Paul Williams MD, Matthew Watto MD, Justin Berk MD, Carolyn Chan MD, Shreya Trivedi MD, Abby Spencer MD, MS, Nora Taranto MS4 (soon to be MD!) Edited by: Matthew Watto MD Special Guest: Abby Spencer MD, MS  Time Stamps and Links are included below 00:00 Intro and Disclaimer 02:33 Abby explains what it means to attend SGIM 04:35 Tips for writing letters of recommendation 08:54 How to handle lapses of professionalism in a trainee 10:30 How to address sexual harassment 12:42 Oral antibiotics after 10 days of IV antibiotics are noninferior for left sided endocarditis in non-IVDU (NEJM 2019) 14:22 Patients prefer physicians to dress in more formal attire. (BMJ Open 2018) 16:29 Kidney stone passage occurs more frequently when sitting in the back car of a roller coaster (J Am Osteopath Assoc 2018) 18:00 Sexual intercourse three times weekly improves rate of kidney stone passage (Urology 2015) 18:58 Vancomycin coverage for hospital acquired pneumonia can safely be stopped after four days if cultures remain negative for MRSA (Chest 2019) 20:00 Notes that contain stigmatizing language are associated with negative provider feelings and less aggressive pain management (JGIM 2018) 21:10 Medication errors are less frequent if the medication reconciliation is performed at time of ICU discharge (Ann Intensive Care 2018) 21:56 Five of six pediatricians found Lego heads in their stool after intentional ingestion (J Paediatric Child Health 2018). 24:40 Canagliflozin (SGLT2 inhibitor) improved renal outcomes and cardiovascular events (Credence trial, NEJM 2019; Check out the Freely Filtered (NephJC podcast coverage)) Triple therapy for COPD with LAMA/LABA/ICS is superior to dual therapy (IMPACT trial NEJM 2018) 27:20 The ASCEND trial of aspirin for primary prevention in patients with diabetes contained 97 percent white patients and showed similar NNT to NNH for cardioprotection and bleeding respectively (ASCEND trial NEJM 2018) 28:45 Consider a short course of dual antiplatelet therapy for minor stroke or high risk TIA (BMJ 2018) 30:07 Omega-3 fatty acids decreased cardiovascular events in patients whose triglycerides remained elevated despite statin therapy (REDUCE-IT trial NEJM 2019) 30:24 Tamsulosin did not help pass stones under 5 mm, but might be effective for stones >5 mm (J Fam Pract 2018) 31:06 Trainees who are stressed during residency tend to stay stressed (I was unable to quickly locate this citation. Sorry. -Dr. Watto) 32:02 How does our team choose their pearls for the recap show 35:21 A needs assessment at University of Michigan found that female residents want to learn skills on leadership, negotiation and giving pitches to prepare them for careers in medicine (Poster by Dr Jennifer Lukela). 36:57 Abby Spencer received an AAIM Innovations grant: “Key steps to rise for women trainees in leadership development”. 38:42 Outro
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40 min
May 6, 2019
#149 Hip Pain for Primary Care
Identify and treat the most common causes of hip pain in the outpatient setting with returning guest, Dr Ted Parks. A large majority of hip pain in the office setting will be due to one of three conditions (hip osteoarthritis, greater trochanteric pain syndrome, and lumbo-sacral back pain). Learn to easily identify these conditions, how to initiate conservative treatment, and more about hip replacements. ACP members can visit https://acponline.org/curbsiders to claim free CME-MOC credit for this episode and show notes (goes live 0900 EST). Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Molly Heublein MD, Nora Taranto MS4 CME questions by:  Molly Heublein MD, Nora Taranto MS4 Hosts: Matthew Watto MD, Paul Williams MD, Stuart Brigham MD, Molly Heublein MD Edited by: Matthew Watto MD, Emi Okamoto MD Guest Presenter: Ted Parks MD Time Stamps 00:00 CME announcement, disclaimer, intro and guest bio 04:05 Guest one-liner; advice for teachers and learners 08:30 Case of hip pain, review of hip anatomy, and the three buckets of hip pain 15:35 Greater trochanteric pain syndrome 16:20 The zebras of hip pain 18:12 Physical exam for hip pain 21:33 Hip osteoarthritis: imaging and initial therapy 24:18 Hip injections: Do steroids work? What about hyaluronic acid? 29:00 Who needs hip replacement surgery? How long will it last? 32:30 Greater trochanteric pain syndrome 35:58 Lumbar spine versus hip pain from OA 38:58 Hip replacement technology: materials; etiology of component loosening and need for re-operation 42:03 Take home points and outro
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44 min
May 2, 2019
Telehealth with Ana María López MD
Electric cars, virtual reality, nanotechnology, and now… telemedicine? We chat with Dr. Ana María López MD, FACP about the future of telehealth, how to implement it in your practice, and the challenges you might face in doing so. Dr. López is immediate past president of the American College of Physicians (ACP) as well as Vice Chair of Medical Oncology and Chief of New Jersey Division Sidney Kimmel Cancer Center of Thomas Jefferson University. Her main areas of professional interest and expertise include cancer prevention and equity, integrative oncology, implementation of innovations in health care including telemedicine, and women’s health. We learned immensely from our talk with her and we hope you will, too! ACP members can claim free CME & MOC credit at https://acponline.org/curbsiders. Download Dr Brigham’s telehealth cheat sheet as a PDF at http://thecurbsiders.com/podcast. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Hannah Abrams, Stuart Brigham MD Cohosts: Matt Watto MD, Stuart Brigham MD, Paul Williams MD, Hannah Abrams Guest: Ana María López MD Time Stamps 00:00 Disclaimer, intro and guest bio 04:20 Guest one line, poetry recommendations, favorite failure 12:00 Defining telemedicine 14:12 What kind of services exist in telemedicine? How can the technology make your practice easier? 20:18 Is there good evidence for telehealth and telemedicine? 24:20 Concerns about telehealth and the loss of touch as part of the doctor-patient relationship; haptics and the remote physical exam 30:17 Providing telehealth across state lines 34:35 Consultation codes for telehealth and ECHO (remote consultations) 40:20 Basic steps and best practices to start implementing telehealth 44:30 Stuart’s shares some preliminary data on use of telehealth and workforce satisfaction 49:12 Adding access by using telehealth in primary care 51:40 Take home points 54:42 Stuart shares a pun  
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55 min
April 29, 2019
#148 Benign Prostatic Hyperplasia for the Internist
This week we narrow in on the enlarging prostate and decipher the common issue of benign prostatic hyperplasia with Adam C. Reese MD, Associate Professor of Urology at the Lewis Katz School of Medicine at Temple University and Chief of Urologic Oncology at Temple University Hospital. Learn how to interpret the symptom profile for patients presenting with common urinary issues, what to feel for in the digital rectal exam, how to treat BPH, and when to refer. ACP members can visit https://acponline.org/curbsiders to claim free CME-MOC credit for this episode and show notes (goes live 0900 EST). See you at SGIM 2019! Find us in our red Curbsider’s t-shirts handing out Curbsiders and Kashlak stickers/patches at SGIM 2019 in Washington DC! We’ll be recording full length shows and daily recaps! Credits Written and produced by: Paul Williams MD Hosts: Paul Williams MD, Matthew Watto MD Images and infographics: Elena Gibson, Beth Garbitelli Show Notes: Elena Gibson, Beth Garbitelli Edited by: Matthew Watto MD, Chris Chiu MD Guest: Adam Reese MD Time Stamps 00:00 SGIM announcement 00:30 Disclaimer, intro and guest bio 03:20 Guest one liner, book recommendation, favorite failure and surgical M&M 10:56 Case of benign prostatic hyperplasia, defining terms and obstructive/voiding versus storage/irritative symptoms 16:11 IPSS score and evaluating symptoms 22:10 Digital rectal exam. Will this give any useful information? 26:55 Taking a history about BPH and some lifestyle modifications 29:20 Lab studies for urinary tract symptoms and interpreting PSA and free PSA 36:20 Initial therapy for BPH and managing patient expectations, alpha blocker side effects 39:25 Choice of agent and monitoring symptoms on therapy 42:25 Nonpharmacologic management of bladder complaints 45:10 Who and when to refer to urology 47:33 Counseling about use of 5 alpha reductase inhibitors, their side effects and is there a risk for high grade cancer? 52:35 Phosphodiesterase inhibitors for BPH symptoms 53:50 Urethral milking. NOT prostate milking 54:55 Desmopressin for nocturia 56:20 Take home points 59:03 Prostate volume and PSA 61:10 Outro Full show notes available at http://thecurbsiders.com/episode-list. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.
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62 min
April 22, 2019
Random Pearls #IM2019 Day 3
Random pearls from ACP #IM2019 Day 3. The Curbsiders crew is joined by Dr Alan Dow of VCU to discuss highlights from ACP’s Internal Medicine Meeting in Philadelphia including: sleep deprivation, the glymphatics system, inflammatory back pain, heart failure, dermatology pearls, a new definition for pulmonary hypertension and more! "Sorry, no time stamps or full show notes for this one. We're too tired." -The Curbsiders Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. #IM2019 Curbsiders Crew Guest: Renee Dversdal MD, Alan Dow MD, Alia Chisty MD Cohosts: Paul Williams MD, Stuart Brigham MD, Shreya Trivedi MD, Molly Heublein MD, Emi Okamoto MD, Justin Berk MD, Cyrus Askin MD, Matthew Watto MD, Chris Chiu MD Director of operations: Chris Chiu MD Twitter: Cyrus Askin MD, Hannah Abrams MS3 Instagram: Beth Garbitelli MS1 Facebook: Chris Chiu MD Off-air producer: Sarah Phoebe Roberts MPH, Nora Taranto MS4 Marketing: Jen Watto
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35 min
April 19, 2019
Random Pearls #IM2019 Day 2
Random pearls from ACP #IM2019 Day 2. The Curbsiders crew is joined by Dr Alia Chisty (future PD at Penn State Hershey) at ACP’s Internal Medicine Meeting in Philadelphia to discuss highlights including: baloxavir a new drug for flu, stress testing and coronary CT angiography pearls, celiac disease, H. pylori pearls, and a bunch of random pearls from infectious diseases, palliative care and more! "Sorry, no time stamps or full show notes for this one. We're too tired." -The Curbsiders Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. #IM2019 Curbsiders Crew Guest: Renee Dversdal MD, Alan Dow MD, Alia Chisty MD Cohosts: Paul Williams MD, Stuart Brigham MD, Shreya Trivedi MD, Molly Heublein MD, Emi Okamoto MD, Justin Berk MD, Cyrus Askin MD, Matthew Watto MD, Chris Chiu MD Director of operations: Chris Chiu MD Twitter: Cyrus Askin MD, Hannah Abrams MS3 Instagram: Beth Garbitelli MS1 Facebook: Chris Chiu MD Off-air producer: Sarah Phoebe Roberts MPH, Nora Taranto MS4 Marketing: Jen Watto  
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44 min
April 15, 2019
Random Pearls #IM2019 Day 1
Random pearls from #IM2019 Day 1. The Curbsiders crew is joined by Kashlak’s POCUS Chief, Renee Dversdal MD at ACP’s Internal Medicine Meeting in Philadelphia to discuss day 1 highlights inlcuding: POCUS, lyme rash, back pain, syphilis, women’s health, patient handoffs, the flip-flop fungal sign a ton of cardiology pearls (ie diuretics, paracentesis for CHF, beta blockers, LBBB, when is it safe to have intercourse after an MI?) and more! "Sorry, no time stamps or full show notes for this one. We're too tired." -The Curbsiders Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. #IM2019 Curbsiders Crew Guest: Renee Dversdal MD, Alan Dow MD, Alia Chisty MD Cohosts: Paul Williams MD, Stuart Brigham MD, Shreya Trivedi MD, Molly Heublein MD, Emi Okamoto MD, Justin Berk MD, Cyrus Askin MD, Matthew Watto MD, Chris Chiu MD Director of operations: Chris Chiu MD Twitter: Cyrus Askin MD, Hannah Abrams MS3 Instagram: Beth Garbitelli MS1 Facebook: Chris Chiu MD Off-air producer: Sarah Phoebe Roberts MPH Marketing: Jen Watto
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47 min
April 8, 2019
#147 Rheumatoid Arthritis for the Internist
Join(t) us in learning about rheumatoid arthritis care for the internist with Robert McLean MD, rheumatologist, Associate Clinical Professor at Yale, and President Elect of the ACP! We discuss the complexity of rheumatoid arthritis, how to differentiate from other arthritic conditions, and how to have a patient-centered framework for the evaluation and treatment of affected patients. ACP members can claim CME-MOC credit at on ACP's site.. Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Writer (Interview & CME questions): Cyrus Askin MD Show Notes and Infographic by: Elena Gibson MS4 Hosts: Matthew Watto MD, Stuart Brigham MD Editors: Matthew Watto MD, Emi Okamoto MD Guest: Robert McLean MD Time Stamps 00:35 Disclaimer, intro and guest bio 03:38 Guest onliner; Nudge (book) on behavioral economics 08:30 Favorite failure; Stuart’s pick of the week 12:24 Key historical features of RA 15:30 Differential diagnosis 19:20 Physical findings in RA 20:58 Initial labs orders for suspected inflammatory arthritis; CRP vs high sensitivity (cardio) CRP assays 27:45 Epidemiology of RA; Is there a utility for scoring systems?; A bit more on inflammatory markers 32:30 Recap and test interpretation 36:22 High yield physical exam in RA 40:56 Initial counseling after RA diagnosis 46:00 Therapeutic trial with NSAIDS or steroids for inflammatory arthritis 50:29 When to reach for the DMARDS 52:40 Are steroids considered DMARDS? 54:50 Primary care considerations for patients starting steroids or DMARDS (TB, vaccinations) 60:34 When and how long to hold DMARDS for surgery or acute illness 62:10 Drug-drug interactions and monitoring with methotrexate, hydroxychloroquine, sulfasalazine 70:10 Anti-inflammatory diets 73:30 Take home points 76:00 Outro
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77 min
April 1, 2019
#146 NephMadness: Pain Meds in Chronic Kidney Disease
Pain management in patients with chronic kidney disease (CKD) often goes something like this: NSAIDs are evil, acetaminophen hardly works, opioids are dangerous, and all the rest (tramadol, gabapentinoids, antidepressants) are messy. But, we tackle the complexities of pain management in patients with chronic kidney disease in this special @NephMadness 2019 episode that, on a scale of 1-10, will leave you feeling very relieved in addressing pain. Full show notes available at https://thecurbsiders.com/episode-list. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Earn CME and read about each region in NephMadness 2019 at AJKD blog. Credits Written and produced by: Justin Berk MD, Samantha Gelfand MD NephMadness Pun Contest produced by: Hannah R Abrams MS3 Cover art by: Kate Grant MBChB, Dip GUMed Hosts: Matthew Watto MD, Paul Williams MD, Stuart Brigham MD Edited by: Matthew Watto MD, Emi Okamoto MD Guests:  Samantha Gelfand MD, Matthew Sparks MD, David Juurlink MD  Time Stamps 00:00 Kidney Pun 01:19 Disclaimer, intro and guest bios 06:30 Guest one-liners 10:42 Books recommendations, staff picks and a patient complaint 15:25 Clinical Case and Pain Management Disclaimer 16:33 Modalities in pain medicine 18:20 Opioids for pain and their metabolites 20:44 Dave Juurlink reframes the question, “what is our real goal with pain management?” 24:42 Matt Sparks reiterates the dangers of morphine and codeine in patients with advanced CKD 27:44 Communicating meds that are contraindicated or relatively contraindicated in CKD 30:40 Buprenorphine 32:40 What about the WHO Pain Ladder for CKD?; 33:32 Should we use more cannabinoids? Ketamine? 37:07 Dave Juurlink rants on Tramadol 44:20 How to pick winners in NephMadness 46:06 NSAIDS and CKD 57:07 Gabapentinoids (gabapentin and pregabalin) for neuropathic pain and driving?! 65:57 Estimating eGFR in CKD and AKI. Which equation is best? 70:38 How would each of our experts treat this patient with CKD and knee pain 75:20 NephMadness 2019 picks for the pain region 82:55 Outro
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84 min
March 25, 2019
#145 NephMadness: Hepatorenal Syndrome vs AKI
Does your sympathetic nervous system get activated when you notice acute kidney injury in patients with cirrhosis? Ever wonder how to really diagnose hepatorenal syndrome (HRS)? Think you have the bile-acid-stones to start diuretics on a patient requiring pressor support for kidney failure? You have come to the right place! Listen to @kidney_boy Joel Topf, HRS expert Juan Carlos Velez (@veleznephhepato), and self-proclaimed most-handsome-nephrologist Bill Whittier (@TWhittier_RUSH) tackle the complex pathophysiology and treatment of hepatorenal syndrome in this NephMadness 2019 special episode! Fill out your bracket for NephMadness 2019 today and sign up as part of The Curbsiders! Earn CME and read about each region at AJKD blog. Full show notes available at https://thecurbsiders.com/episode-list. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Justin Berk MD, Nora Taranto MS4 Infographic by: Alex M @nephroguy Hosts: Matthew Watto MD Edited by: Matthew Watto MD, Emi Okamoto MD Guests: Joel Topf MD, Juan Carlos Velez MD, Bill Whittier MD Sponsor Get your ACP membership today and use the code CURB100 to save $100 when you join by March 31, 2019. Time Stamps 00:00 NephMadness Kidney Pun Contest 01:04 Disclaimer 01:38 Sponsor - Become an ACP member today! 02:12 Intro, guest bio 04:38 Guest one-liners, some career advice and Joel’s pick of the week 13:14 Sponsor - Become an ACP member today! 14:48 Case of acute kidney injury in a patient with cirrhosis 16:37 Initial differential diagnosis and approach to newly elevated creatinine in cirrhosis (urinalysis, FeNa, urine sodium) 21:34 History and physical in cirrhosis and AKI 24:56 Hepatorenal physiology 26:45 Fluid choice 30:27 Diuretic therapy in cirrhosis and volume overload 34:38 Is a Renal Ultrasound useful in AKI? 40:05 Recap: the initial approach to AKI in cirrhosis 40:52 Therapeutic trials when volume status is uncertain 46:02 Hepatorenal physiology revisited 50:03 Vasoconstrictor therapy with octreotide, terlipressin, or norepinephrine 62:24 Type 1 versus type 2 hepatorenal syndrome 63:55 Large volume paracentesis (LVP) in cirrhosis with AKI; how much fluid to remove; use of diuretics or LVP in patient on norepinephrine?! 71:18 Diagnostic criteria or HRS 73:00 NephMadness matchups including bile cast nephropathy 78:40 Outro
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80 min
March 20, 2019
HCP: Primary Care Workforce with Fatima and Deep
Some precocious policy wonks take a deep dive into the evolving trends and future directions for our primary care workforce. Experts, Dr. Fatima Syed and Dr. Deep Shah return to school us on Physician Supply and Demand, the Access Gap, role of NPs and PAs, Retail Clinics, and Managed Care Clinics. ACP members can visit https://acponline.org/curbsiders to claim free CME-MOC credit for this episode and show notes (goes live 0900 EST). Catch up on our previous discussions with Dr. Syed and Dr. Shah: Episode #62: Pod Save Health Care: The Curbsiders Foray into health policy and Episode #120 Health Policy, Patients, Payments, Paperwork for more context. We also did an overview of health care policy essentials with Dr. Sue Bornstein in Episode #64: Stuff You Should Know About Health Policy Full show notes available at http://thecurbsiders.com/episode-list. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Fatima Syed MD, MSc; Deep Shah MD, MSc CME questions by: Chris Chiu MD, Beth Garbitelli MS1, Hosts: Stuart Brigham MD, Paul Williams MD, Matthew Watto MD, Images and infographics: Beth Garbitelli MS1 Edited by: Matthew Watto MD, Chris Chiu MD Guest: Fatima Syed MD, MSc, Deep Shah MD, MSc   Time Stamps 00:00 Disclaimer, intro, guest bios 04:40 Picks of the week 11:40 Defining physician supply and demand 21:30 Why are physicians less productive? 28:23 What does the supply demand mismatch mean for patients? 30:19 Discussion of various care delivery models (retails health clinics, minutes clinics, urgent care centers) 42:15 Physician compensation 53:50 Take home points from Fatima and Deep 59:39 Outro
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61 min
March 18, 2019
#144 NephMadness: Inpatient Hypertension
Inpatient hypertension is tricky. What’s the best way to answer those overnight nursing phone calls for elevated blood pressures? What’s the role of treating hypertensive urgency in the hospital? Plus, Our nephrology experts put a new issue on the generalist’s radar: are ACE-inhibitors dangerous to give (or hold) during an operation? This NephMadness 2019 episode, features special guests Dr. Pascale Khairallah (@Khairallah_P), Dr. Charlie Wray (@WrayCharles) and Dr. Joel Topf (@kidneyboy) to better understand the role of anti-hypertensives in the inpatient setting and keep your blood pressure down on those overnight calls. Fill out your bracket for NephMadness 2019 today and sign up as part of The Curbsiders! Full show notes available at https://thecurbsiders.com/episode-list. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Justin Berk MD, MPH, MBA; Pascale Khairallah MD Hosts: Matthew Watto MD, Paul Williams MD, Stuart Brigham MD Edited by: Matthew Watto, MD Guest:  Pascale Khairallah MD, Charlie Wray DO, Joel Topf MD Sponsor Get your ACP membership today and use the code CURB100 to save $100 when you join by March 31, 2019. Time Stamps 00:00 Kidney Pun Contest with Hannah Abrams 01:16 Disclaimer 01:45 Sponsor - Become an ACP Member today! 02:14 Intro and guest bios 03:50 Picks of the weeks 06:00 Sponsor - Become an ACP Member today! 07:20 Case of acute severe hypertension; Does hypertensive urgency exist? Should we treat it? 26:40 Case of perioperative medicine. Should we hold the ace inhibitor? Is there evidence to guide us? 35:02 Take home points 36:54 Everyone picks their NephMadness winners for the hospital medicine region 43:13 Outro
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45 min
March 15, 2019
#143 NephMadness: Fluid Wars
The battle over the superiority of resuscitation fluids is coming to a boil. Enter the Fluid Wars. Are Lactated Ringers superior to normal saline? Will LR increase a patient’s lactate? What about albumin? The Curbsiders quench the thirst for knowledge by turning to masters Dr. Pascale Khairallah (@Khairallah_P), Dr. Charlie Wray (@WrayCharles) and Dr. Joel Topf (@kidneyboy) for guidance in this special @NephMadness episode that will get your feet wet with the complicated world of fluid resuscitation. Fill out your bracket for NephMadness 2019 today and sign up as part of The Curbsiders! Full show notes available at https://thecurbsiders.com/episode-list. Join our mailing list and receive a PDF copy of our show notes every Monday. Credits Written and produced by: Justin Berk MD, Pascale Khairallah MD NephMadness Pun Contest produced by: Hannah R Abrams MS3 Hosts: Matthew Watto MD, Paul Williams MD, Stuart Brigham MD Edited by: Matthew Watto MD Guest:  Pascale Khairallah MD, Charlie Wray DO, Joel Topf MD Time Stamps 00:00 Nephmadness pun contest 02:18 Disclaimer 02:52 Intro to the show and NephMadness, guest bios 08:04 Guest one-liners, 10:58 Joel explains NephMadness 12:58  Guest book recommendations and career advice 17:30 Clinical case; goals of fluid resuscitation; choice of initial IV fluid Corporate (TV series) Comedy Central 19:41 Complications of normal saline 21:29 Colloids versus crystalloids LR versus normal saline is not an innocuous decision 26:32 Saline versus balance fluids. What’s the makeup? 28:19 Does lactated ringers elevate lactate? 31:03 Is hyperkalemia a contraindication for LR? 32:39 Lactated ringers versus plasma-lyte and cost of fluid 34:49 In vitro risks of normal saline 40:31 SMART and SALT-ED trial 46:08 Stuart finds the IV fluid price list 44:37 Each panelist weighs in on saline versus balanced fluids 46:45 Why do patients with metabolic alkalosis thrive on saline? 49:04 Outro
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51 min
March 11, 2019
#142 Cirrhosis TIPS: Acute Complications
Cirrhosis TIPS for the decompensated cirrhotic & acute on chronic liver failure from expert hepatologist and keto-practitioner Scott Matherly MD, @liverprof and chief hepatologist at @KashlakHospital. We walk through acute management of variceal bleeds, when to suspect SBP in decompensated cirrhosis (all the time, it turns out), how much fluid to remove in paracentesis, and some definitions about what decompensated cirrhosis and acute on chronic liver failure really mean. Take our pretest on cirrhosis! Full show notes available at http://thecurbsiders.com/episode-list. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Nora Taranto MS4, Matthew Watto MD Pretest by: Cyrus Askin MD Hosts: Matthew Watto MD, Paul Williams MD, Images and infographics: Hannah Abrams MS3 Edited by: Matthew Watto MD Guest: Scott Matherly MD Sponsor  Get your ACP membership today and use the code CURB100 to save $100 when you join by March 31, 2019. Time Stamps 00:00 NephMadness teaser 00:50 Sponsor - Become an ACP Member today! 01:25 Intro, guest bio 03:45 Guest one-liner, keto diet 07:40 Picks of the week from Paul, Matt and Scott 11:50 Sponsor - Become an ACP Member today! 13:26 Clinical case of bleeding and altered mental status in cirrhosis 16:10 Interpretation of our patient’s labs and physical exam 18:53 Defining terminology in cirrhosis (decompensated vs compensated vs acute on chronic liver failure) 24:48 Initial workup, resuscitation and stabilization in variceal bleeding 26:10 Why occult blood and ammonia levels are unhelpful in cirrhosis 29:00 Fluid choice for the cirrhotic patient with hypotension; octreotide (or terlipressin); antibiotics prophylaxis 33:10 Proton pump inhibitors and ulcers from variceal banding 34:00 Mechanism of action for octreotide and terlipressin 35:54 Prevention of recurrent bleeding with TIPS, or nonselective beta blockers 40:40 Scores for prognostication in the acute setting 44:00 Coagulopathy of cirrhosis and should DVT prophylaxis be used 48:38 Elevated INR and procedures 56:55 Paracentesis in the acute setting and interpretation of fluid studies:cell count, total protein, SAAG, blood culture vial; pathophysiology of ascites 67:30 Treatment of SBP: antibiotics, IV albumin; plus, Hepatorenal physiology explained 79:04 Hepatic encephalopathy is a shunt phenomen; how to evaluate for causes; treatment of HE 87:58 Rifaximin 89:10 Take home points 91:02 Outro
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92 min
March 4, 2019
Reboot - Diuretics, leg cramps, and resistant hypertension
Listen to our first ever discussion with @kidney_boy, Joel Topf MD. It’s a classic episode with a fresh intro as we prepare for @NephMadness 2019 with our friends from Twitter and @AJKDonline Dominate leg cramps, diuretic therapy, and resistant hypertension with tips from @kidney_boy, Joel Topf MD @kidney_boy, Chief of Nephrology Kashlak Memorial Hospital, co-creator @NephMadness. We start with basic renal physiology and build up to the treatment of resistant hypertension. Corrections: Dr Topf posted the following corrections on his blog PBfluids.com 3/22/2017 “I enjoyed the experience immensely, but in an hour of talking off the cuff I made some embarrassing mistakes: In describing water reabsorption I said it occured in the cortical collecting duct rather than the medullary collecting duct. In describing my cure for cramps I tell the story of Gitelman’s and say it is like congenital loop diuretics rather than congenital thiazide diuretics I mucked up the story about the MRFIT story and how it allowed a head to head comparison of HCTZ and chlorthalidone. I really oversold what happened.”   Full show notes at https://thecurbsiders.com/podcast. Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written by: Matthew Watto MD Produced by: Stuart Brigham MD and Matthew Watto MD Cohosts: Stuart Brigham MD and Matthew Watto MD Guest: Joel Topf MD Sponsor Get your ACP membership today and use the code CURB100 to save $100 when you join by March 31, 2019. Time Stamps 00:00 Sponsor - Become a member of the American College of Physicians 00:28 Disclaimer, Intro, Recap of upcoming shows, Corrections and Omissions 05:50 Guest one-liner, Discussion of social media in medical education, Joel’s book 12:45 Twitter for medical education including NephJC and NephMadness 19:50 Sponsor - Become a member of the American College of Physicians 21:30 Intro to diuretics, mechanism of action and a brief review of renal physiology 28:26 Use of thiazide diuretics 30:18 Chlorthalidone versus hydrochlorothiazide 34:47 Diuretics and hyponatremia, Monitoring electrolytes and renal function on diuretics 39:05 Leg (muscle) cramps and pickle juice 42:55 Thiazides, osteoporosis and fracture prevention 45:32 Resistant hypertension and  the workup for secondary hypertension 53:36 Loop diuretics: how to choose an agent, dosing 62:15 Take home points 67:00 Outro
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67 min
February 25, 2019
#141 Wound Care Pearls
Demystify chronic wound care management with high yield pearls from wound care expert Dr. Elizabeth (Foy) White-Chu. She takes us through a simple yet thorough approach to manage complex chronic wounds. We discuss everything from selecting a dressing, to pain management, and what kind of water should you really use when cleansing a wound. Answers to all of these burning questions and more await you, so don’t waste anymore time! Press play and let Dr. White-Chu take you on a journey through evidence based practices for the management of chronic wounds. ACP members can visit https://acponline.org/curbsiders to claim free CME-MOC credit for this episode and show notes (goes live 0900 EST). Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written by: Carolyn Chan MD CME questions by: Justin Berk MD Produced by: Matthew Watto MD Hosts: Matthew Watto MD, Paul Williams MD, Carolyn Chan MD Guest: Dr. Elizabeth (Foy) White-Chu Sponsor Check out the ACP's Medical Knowledge Self Assessment Program, MKSAP 18. Time Stamps 00:00 Sponsor - ACPs MKSAP 18 00:25 Disclaimer, intro, guest bio 03:58 Guest one-liner, movie recommendation, favorite failure, career advice 11:40 Picks of the week 15:58 Sponsor - ACPs Medical Knowledge Self Assessment 18 17:50 Clinical case of lower extremity ulcer; describing a wound 21:04 Taking a wound focused history 26:28 Differentiating wound types 29:04 Edema and compression therapy; Should diuretics be used? 36:43 Description of the multi-component wrap 38:10 Counseling a patient about wound care and setting expectations for healing 41:29 High value options for each wound type 44:35 Gardening and wound bed preparation 51:32 A bit on silver therapy 53:40 Back to the case; Red flags in wound care 55:40 Culturing a wound 58:17 Instructions on how to write wound care orders 62:00 Rundown of topical therapies for wound care 65:04 Negative pressure wound therapy aka “wound vac” 66:14 How often are dressing changes needed? 68:27 Take home points 70:20 Outro 71:30 Carolyn gives a wound care PUN!
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72 min
February 18, 2019
#140 Psychopharmacology 2.0 - Antidepressant Master Class
Dive deep into the psychopharmacology of depression with Dr Patrick Finley, PharmD at UCSF. Learn practical tips including how to switch from one antidepressant to another, what to expect with SSRI and SNRI withdrawal, and how to choose a second (or third) antidepressant for refractory depression. We also summarize the safety around antidepressants in the peripartum period. ACP members can visit https://acponline.org/curbsiders to claim free CME-MOC credit for this episode and show notes (goes live 0900 EST). Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Molly Heublein, MD CME questions by: Molly Heublein, MD Hosts: Matthew Watto MD, Paul Williams MD, Stuart Brigham MD, Molly Heublein, MD Edited by: Matthew Watto MD Guest Presenter: Patrick Finley, PharmD BCPP Sponsor Check out the ACP's Medical Knowledge Self Assessment Program, MKSAP 18. Time Stamps 00:00 Sponsor ACP’s MKSAP 18 00:25 Disclaimer, intro and guest bio 04:33 Guest one-liner, book recommendation, and first patient complaint 08:04 Picks of the week 12:10 Sponsor ACP’s MKSAP 18 14:03 Clinical case of depression; assessing target symtpoms to characterize depression; choice of initial SSRI 17:49 Discussion of iron, ferritin, folate and L methylfolate as they relate to treatment refractory depression 20:12 Postpartum depression, iron, genetics and environmental factors 22:35 How to switch from one SSRI to another; Cross-titration from SNRI to SSRI or from SSRI to SNRI 26:05 Withdrawal symptoms from SSRIs or SNRIs and a bit more on switching and cross titration 31:33 Is paroxetine ever a good idea? 33:03 Ultra-rapid metabolizers of SSRIs and pharmacogenomics 34:43 Postpartum depression and treatment with antidepressants during pregnancy and lactation 39:25 Monitoring response to therapy with antidepressants ie PHQ-9 40:53 Augmentation for partial response; bupropion for augmentation and sexual side effects; 43:58 Counseling patients about discontinuation of therapy 47:00 How to choose an agent for augmentation of antidepressant therapy 51:02 Mirtazapine 52:41 Vortioxetine 53:24 Atypical antipsychotics for augmentation 55:37 Pregabalin and gabapentin for augmentation 57:42 Dr Finley’s take home points 60:48 Outro
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61 min
February 11, 2019
#139 Genetic Testing in Primary Care
Join us at the forefront as we talk genetic testing in primary care with Dr Dallas Read, esteemed gynecologist and **the only** medical geneticist at Tufts Medical Center. Topics include: what internists should be comfortable testing for in the office, how and when to refer for screening, what tests to order, how to interpret test results, how to handle direct-to-consumer results or requests, and so much more! For years, the medical community has been talking about the immense potential for genetic testing to guide diagnosis and treatment. But has it realized its full potential? The answer to that seems to be a resounding no at the moment--but the days of ubiquitous genetic testing to identify disease and disease risk may not be so far off after all. ACP members can visit https://acponline.org/curbsiders to claim free CME-MOC credit for this episode and show notes (goes live 0900 EST). Coming to you from the Curbsiders, we hope you’ll enjoy this latest episode about the genes you wear, whether you want to put them on or not. Genes, Genes, they’re (maybe) good for your heart. But do patients want to know if they are, or if they aren’t? Full show notes available at http://thecurbsiders.com/episode-list. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Nora Taranto MS4 CME questions by: Nora Taranto MS4 Hosts: Stuart Brigham MD, Matthew Watto MD, Nora Taranto MS4 Images and infographics: Beth Garbitelli MS1 Edited by: Matthew Watto MD, Chris Chiu MD Guest: Dr. Dallas Reed MD Sponsor  Check out the ACP's Medical Knowledge Self Assessment Program, MKSAP 18. Time Stamps 00:00 Announcement 00:37 Sponsor: ACP’s MKSAP 18 01:04 Disclaimer, intro, guest bio 06:31 Guest one liner, book recommendations, career advice 12:23 Cohost picks of the week 16:22 Sponsor: ACP’s MKSAP 18 18:12 Dr Reed walks us through the genetic machinery from the top down (genome, chromosomes, exons, genes, SNPs, and epigenetics) 26:18 A clinical case of Jeanne Sequence; What are the indications for genetic testing? 29:54 What is actually being tested? 33:57 What is the turnaround time for testing? What resources are available for counseling? Why is this challenging in primary care? 38:58 Variant of Uncertain Significance 41:22 Direct to consumer genetic testing 44:54 Back to our case of Jeanne Sequence; How to take a history for patients with family history of breast cancer. 50:41 Guidelines on use of genetic testing; Deciding which family member to test 59:49 Laws about genetic testing and discrimination; How does this effect life insurance or disability insurance eligibility 63:47 Is routine whole genome testing practical? Will this be commonplace in the future? 68:22 What genetics resources are useful for primary care practitioners? 72:13 Cost of genetic testing 77:32 Take home points 82:57 Outro
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84 min
February 4, 2019
#138 Inflammatory Bowel Disease: Crohn’s and Ulcerative Colitis
Learn expert tips for the diagnosis and management of inflammatory bowel disease (IBD) from Dr. Adam Ehrlich, Assistant Professor of Medicine and co-director of the Inflammatory Bowel Disease Program at Temple University Hospital.  In this episode, we learn about the initial work-up, general principles of management, and important primary care considerations for Crohn’s disease and ulcerative colitis (ie endoscopic surveillance, immunizations, bone health/osteoporosis, and more!). Full show notes available at https://thecurbsiders.com/episode-list. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Paul Williams MD Edited by: Matthew Watto MD Hosts: Matthew Watto MD, Stuart Brigham MD, Paul Williams MD Guest: Adam Ehrlich MD Sponsor Check out the ACP's Medical Knowledge Self Assessment Program, MKSAP 18.   Time Stamps 00:00 Sponsor: MKSAP 18 00:32 Disclaimer, Intro, guest bio 04:05 Guest one-liner, Adam’s movie rec - RBG (documentary), career advice, Paul’s movie rec - Edge of Tomorrow 09:25 Sponsor: ACP’s MKSAP 18 11:25 Definitions and pathophysiology of inflammatory bowel disease (IBD) Ulcerative Colitis 13:40 A case of ulcerative colitis; Classic symptoms; Initial approach and basic differential diagnosis 19:10 Smoking and ulcerative colitis 21:17 Initial workup for suspected IBD; Fecal calprotectin 25:50 A bit more on CRP and IBD 26:55 When to refer for colonoscopy 27:58 Back to the case; a typical colonoscopy reports in ulcerative colitis (UC) 30:33 Extraintestinal manifestations of UC 34:50 Initial counseling for newly diagnosed IBD; natural history of IBD, prognosis 39:50 Treatment of ulcerative colitis 43:02 Some specifics on steroids, plus topical therapies Crohn’s disease 47:05 A case of Crohn’s disease; initial approach and differential diagnosis 50:25 Initial diagnostic testing; colonoscopy findings in Crohn’s; IBD trivia 53:58 Treatment of Crohn’s disease 58:26 Specifics about biologic therapy for IBD; Endpoints 62:25 Steroid sparing agents, immunomodulators like azathioprine, 6-mercaptopurine 64:48 Can drug therapy be stopped or tapered in IBD? 66:50 Prognosis in Crohn’s and initial patient counseling Primary Care considerations 68:35 Surveillance endoscopy, 71:47 Do diet and lifestyle changes for IBD work? What about pregnancy? 76:31 Immunizations 79:25 Bone health, osteoporosis and IBD, screening for iron and nutritional deficiencies 82:27 Take home points 86:28 Outro
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88 min
January 28, 2019
#137 Hyperkalemia Master Class with Joel Topf MD
Master the management of hyperkalemia with tools, tips and tactics from @kidney_boy, Joel Topf MD, Chief of Nephrology @KashlakHospital. We cover: common causes of hyperkalemia; the U-shaped curve of potassium levels and mortality; albuterol nebs; how to safely use insulin; potassium binding resins and colonic necrosis; Does it make sense to give loop diuretics and fluids?; Should we be using fludrocortisone?; Plus, answers to all your questions about a high potassium diet and oral potassium supplements! Join us for Dr Topf’s masterful insights on hyperkalemia and potassium homeostasis. Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Sponsor Join us at ACP's Internal Medicine Meeting 2019 April 11-13th in Philadelphia, PA . We'll see you there! Credits Written and produced by: Matthew Watto, MD Hosts: Matthew Watto MD, Paul Williams MD, Stuart Brigham MD Infographic: Matthew Watto MD Edited by: Matthew Watto MD Guest: Dr Joel Topf MD   Time Stamps 00:00 Ad disclaimer, intro and guest bio 05:11 Guest one-liner and picks of the week —Peloton indoor cycle, “your local library”, The Nice Guys (film) by Shane Black, and Forgotten Hand (PS4 game) 11:17 ACP Internal Medicine Meeting 2019 details 12:55 Clinical case of hyperkalemia; discussion of pseudohyperkalemia 19:55 Hyperkalemia and the EKG 23:38 Threshold for treatment of hyperkalemia 27:20 Use of telemetry and the U-shaped curve for potassium and mortality 30:11 Choice of therapy for acute hyperkalemia 33:13 Albuterol for hyperkalemia 34:24 First rule out urinary obstruction and hyperglycemia; Use of IV insulin and dextrose and frequency of monitoring 39:44 Loop diuretics plus fluid; Distal sodium delivery and potassium handling in the nephron 43:10 Fludrocortisone for hyperkalemia 45:05 Calcium for elevated potassium 48:43 SPS, potassium binding resin 52:43 Risks of SPS (sodium polystyrene sulfonate) and colonic necrosis 58:28 Sodium bicarbonate for acute and chronic hyperkalemia 61:00 Back to the case; TMP-SMX, ace inhibitors (or ARBs) and hyperkalemia 63:05 Threshold for admission; Diet and potassium 65:52 Treatment of chronic hyperkalemia and a bit more on high potassium foods 68:45 Patiromer and sodium zirconium 71:51 Loop diuretics and empiric potassium supplementation 74:12 Can diet alone be used to treat HYPOkalemia? 75:26 Take home points 77:40 NephMadness is coming! March 2019 79:53 Outro 81:00 More Kidney Boy!
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81 min
January 21, 2019
#136 Sickle Cell Disease, Management & Complications
Stuck on sickle cell disease? We hammer out the basics of diagnosis, common sickle cell variants and their manifestations, preventive medicine, acute and chronic pain management, opioid use, and how to recognize and treat common complications like anemia, fever and acute chest syndrome. Sickle cell expert, Sophie Lanzkron MD, Associate Professor of Medicine and Oncology and Director of the Sickle Cell Center for Adults at Johns Hopkins joins! Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Sponsor ACP's Internal Medicine Meeting 2019 April 11-13th in Philadelphia, PA. We'll see you there! Credits Written (including CME questions) and produced by: Justin Berk MD, Martha Brucato MD PhD, Beth Garbitelli MS1 Hosts: Paul Williams MD, Justin Berk MD, Matthew Watto MD Edited by: Matthew Watto MD Guest: Sophie Lanzkron MD MHS Time Stamps 00:00 Announcements, intro 02:30 A quick refresher on hemoglobinopathy 03:45 Guest bio 05:03 Guest one-liner, movie recommendation, career advice, picks of the week 10:53 ACP Internal Medicine Meeting 2019 (ad read) 12:33 Clinical case; defining sickle cell; pathophysiology 16:23 Different types of hemoglobinopathy genotypes and phenotypes 20:20 Preventive care for sickle cell disease 22:56 Taking a history at the initial visit in patient with sickle disease 26:40 Life expectancy in SCD 28:30 Hydroxyurea 30:40 Chronic red blood cell transfusion therapy; complications; monitoring 37:07 Silent cerebral infarcts and mild cognitive impairment in SCD  40:10 Chronic pain management; opioid use disorder in sickle cell disease 46:00 Acute pain crisis management; PCAs vs bolus therapy 54:08 Reticulocyte count in sickle cell disease 55:40 Itching, opioids and naloxone? 58:10 Red blood cell transfusion threshold in sickle cell disease (anemia) 60:03 Acute fever in SCD 61:48 Acute chest syndrome 66:45 Transition from pediatrics to adult medicine in sickle cell 68:00 Incentive spirometry to prevent acute chest syndrome 68:45 Take home points 70:00 Outro
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71 min
January 14, 2019
#135 Perioperative Medicine
Optimize perioperative risk and dominate perioperative medicine. Topics include surgical risk calculators, preoperative labs, stress testing, use of BNP and troponins, postoperative MI, cardiac and pulmonary risk stratification, and more! We’re joined by perioperative medicine expert, Avital O’Glasser MD, Associate Professor of Medicine at Oregon Health & Science University and Assistant Program Director for Scholarship and Social Media. ACP members can visit https://acponline.org/curbsiders to claim free CME-MOC credit for this episode and show notes (goes live 0900 EST). Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Matthew Watto MD CME questions by: Matthew Watto MD Hosts: Matthew Watto MD, Stuart Brigham MD Edited by: Matthew Watto MD Guest: Avital O’Glasser MD Time Stamps 00:00 Disclaimer, intro and guest bio 04:20 Guest one-liner, book and movie recommendations, career advice 11:20 ACP Internal Medicine Meeting 2019 details 14:02 Patient with coronary artery calcifications going for elective hip surgery and wants "clearance" 20:50 Functional capacity 25:00 Preoperative stress testing and coronary revascularization 31:55 Canadian guidelines, BNP and troponin testing 36:30 The METS trial and predicting perioperative cardiac events and mortality 40:44 Preoperative testing (labs, imaging, urine studies) 50:24 Choosing your perioperative cardiac and surgical risk calculator (RCRI, MICA, ACS-NSQIP) 59:50 Communicating risk to patient and their surgeon 61:30 Pulmonary risk assessment and complications 70:35 Perioperative use of opioids 75:30 Who needs an echocardiogram prior to surgery? 79:00 Canceling a patient's surgery 82:55 Take home points 83:45 Outro
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85 min
January 7, 2019
#134 Urinary Tract Infections Delirium and Voltaire
“Urinary tract infections” (UTIs) are overdiagnosed. Antibiotics are overprescribed. UTIs are inappropriately blamed for geriatric syndromes (eg delirium) despite little supporting evidence. Our guest, Tom Finucane MD, Emeritus Professor of Medicine at Johns Hopkins makes us question everything. Topics: How can we diagnose “UTI”? Who needs treatment? Do urinary tract symptoms matter? Does malodorous urine correlate with infection? Who’s at risk for pyelonephritis and sepsis? Don’t miss this paradigm changing episode. And stop using the term “urinary tract infection” unless it’s prefaced by air quotes! Sponsor: Join ACP's Internal Medicine Meeting 2019 April 11-13th in Philadelphia, PA . We'll see you there! Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Matthew Watto MD Hosts: Matthew Watto MD, Paul Williams MD Edited by: Matthew Watto MD Guest: Tom Finucane MD, MACP Time Stamps 00:00 Disclaimer, intro and guest bio 04:00 Guest one liner, book recommendation, career advice 08:22 The “medical ignorome” 13:40 ACP Internal Medicine Meeting 2019 details 16:20 Case of malodorous urine; Urine is NOT sterile; Defining terms 25:14 Stop saying UTI unless using air quotes 28:34 What symptoms or history matters in evaluation for “UTI”? And can we predict who will become systemically ill? 34:47 Voltaire and when treatment is warranted for “urinary tract infections” 37:15 Delirium in an older adult with possible UTI, how to work it up, and who warrants antibiotics 51:55 Take home points 53:38 Outro
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54 min
December 31, 2018
2018 Recap Extravaganza
Take a trip down memory lane with top clinical pearls and favorite moments from The Curbsiders in 2018. Welcome to our 2018 Recap Extravaganza! Since last year, the Curbsiders team has grown substantially and the podcast has undergone several exciting developments. These include our collaboration with ACP that allows us to provide CME and MOC credit for select episodes, our new partnership with Human Dx as featured in our Kashlak Morning Reports, and the launch of our Women in Medicine series. For our 2017 year-end show, we had listeners vote for their favorite episodes from the past year. This year, we're changing it up a bit and have invited our Curbsider colleagues to share their picks for pearliest pearls and most illuminating episodes of 2018. We hope you’ll enjoy hearing the team’s highlights, and we’ll be back in 2019 with fresh content. Note: No CME-MOC credit for this episode, but stay tuned in 2019 for eligible episodes. Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Chris Chiu MD and Sarah Phoebe Roberts, MPH Hosts: Matthew Watto MD, Paul Williams MD, Stuart Brigham MD, Chris Chiu MD Edited by: Chris Chiu MD Time Stamps 00:00 Disclaimer, Intro 06:39 Clinical Reasoning Pearls 12:35 Pulmonary Hypertension Pearls 15:52 Women In Medicine Pearls 20:40 Iron Deficiency Pearls 24:52 Tick-Borne Illness Pearls 28:00 STI Pearls 31:00 Physical Exam Pearls 32:51 “Things we do for no reason” Pearls 36:16 Host Picks 42:38 Paul Wraps-up the Year 43:38 Outro and Curbsider Team sign-offs
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52 min
December 24, 2018
#133 Herpes for Everyone
Master the diagnosis and management of Genital Herpes with tips from expert, Robert Bettiker MD . Topics include: the natural history, diagnosis & screening guidelines for genital herpes; cold sores; options for primary and recurrent episodes including prophylaxis; and consideration of specific populations including symptomatic and asymptomatic patients, pregnancy and MSM (men who have sex with men). We also discuss partner notification and treatment. Full show notes available at http://thecurbsiders.com/podcast. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Kate Grant MBChB DipGUMed, Matthew Watto MD Images by: Kate Grant MBChB DipGUMed Hosts: Stuart Brigham MD, Paul Williams MD, Matthew Watto MD Guest: Robert Bettiker MD Time Stamps 00:00 Disclaimer, guest bio, intro 01:50 Guest one liner, memorable teaching moment and a few failures 10:50 Intro to herpes 12:25 Case 1: Genital herpes in a married man 15:42 Overview of testing options 18:50 Marital counseling in Herpes 22:18 Prophylaxis in serodiscordant partners and asymptomatic shedding 25:08 Case 2: Severe outbreak of genital herpes in a young woman 31:50 Case 3: Young male with recent exposure to herpes 38:45 Herpes 1 (HSV1) versus Herpes 2 (HSV2) 44:12 Case 4: Herpes in pregnancy 50:45 Do topical agents work for herpes 55:05 Take home points 56:10 Outro 57:52 Stuart shares a PUN!
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58 min
December 19, 2018
#132 A Case of Abdominal Pain
Sharpen your diagnostic schema for abdominal pain and eosinophilia with this mystery case http://hdx.org/Rxg (click link to follow along). Reza Manesh MD, editor of Global Morning Report at The Human Diagnosis Project aka Human Dx attempts to solve this challenging case with the help of The Curbsiders. Use this link http://hdx.org/Rxg to follow along with the case on the Human Dx app and check out more Global Morning Report cases. Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Hannah R Abrams Hosts: Matthew Watto MD, Paul Williams MD, Stuart Brigham MD Edited by: Matthew Watto MD Guest: Reza Manesh MD Special thanks to: Steph Sherman, Zaven Sargsyan, Anand Jagannath, John Inou Hwang, and Rabih Geha for contributing and editing the cases; and to Tyler Brandon for helping to coordinate these wonderful episodes. Time Stamps 00:00 Announcement, disclaimer, intro, guest bio 01:20 Picks of the week 05:42 How Reza fell in love with clinical reasoning 08:58 Case of 50 yo male with abdominal pain 21:14 Some unexpected findings 43:00 Case conclusion/answer, cognitive autopsy and Reza’s take home points 48:35 Outro
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50 min
December 17, 2018
#131 A Case of Cough and Dyspnea
Hone your diagnostic skills with this mystery case of cough and dyspnea http://hdx.org/pdp (click link to follow along). The Curbsiders deconstruct the case and discuss their diagnostic schemas for these common problems with the help of returning guest, Reza Manesh MD, editor of Global Morning Report at The Human Diagnosis Project aka Human Dx. Use this link http://hdx.org/pdp to follow along with the case on the Human Dx app or website and check out more Global Morning Report cases. Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Hannah R Abrams Hosts: Matthew Watto MD, Paul Williams MD, Stuart Brigham MD Edited by: Matthew Watto MD Guest: Reza Manesh MD Special thanks to: Steph Sherman, Zaven Sargsyan, Anand Jagannath, John Inou Hwang, and Rabih Geha for contributing and editing the cases; and to Tyler Brandon for helping to coordinate these wonderful episodes. Time Stamps 00:00 Announcement, disclaimer, intro, guest bio 03:13 When and how to practice clinical reasoning 05:53 Creating diagnostic schemas and Clinical Problem Solvers Podcast 09:40 A bit on Human Dx and the show format 12:00 Case of a 40 yo male with a cough 23:22 Some insights from Reza on “signal versus noise” 37:10 Case conclusion/answer, cognitive autopsy and Reza’s take home points 45:36 Outro
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47 min
December 13, 2018
#130 Work-Life Fit: Women In Medicine
Create a successful partnership and career withs tips from Wonder Woman, Sue Hingle MD of ACP.  Work-Life Balance: is it a myth, or attainable if we could just find the right fit? In this episode, we chat with Dr. Susan Hingle about identifying our work-life priorities and re-evaluating these priorities throughout our lives. We strategize about achieving personal and professional goals (pro tip: stop worrying about what others think!). Dr. Hingle is Professor in the Department of Internal Medicine and Vice Chair of Education and Faculty Development and Associate Internal Medicine Residency Program Director at Southern Illinois University. She is also the Immediate Past Chair of the Board of Regents of the American College of Physicians (ACP). She has served at the ACP in a variety of ways, including as a member of the ACP Women’s Task Force. Her clinical expertise is in women’s health, health promotion, and disease prevention. Enjoy the episode! ACP members can visit https://acponline.org/curbsiders to claim free CME-MOC credit for this episode and show notes (goes live 0900 EST). Full show notes available at http://thecurbsiders.com/podcast. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Nora Taranto MS4, Shreya Trivedi MD, Leah Witt MD, Sarah P. Roberts MPH. CME Questions by: Shreya Trivedi MD Editors: Matthew Watto MD and Chris Chiu MD Hosts: Shreya Trivedi MD, Paul Williams MD, Leah Witt MD Guest: Susan Hingle MD Time Stamps 00:00 Disclaimer, intro and guest bio 02:52 Guest one liner, WIM Moment of awakening, advice for her younger self 07:45 Picks of the week 10:30 Physician with family and caregiver responsibility; How to plan for personal and professional goals 18:20 What to look for in a partner, how to work with them to achieve work life fit, and non-traditional roles 28:35 Advice on family planning 31:40 Residency programs and life events 32:55 Should you go part-time? 39:43 Work life balance? Or work life fit? And some examples/tips for success 49:54 Take home points 50:45 Outro 52:22 Bonus story
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53 min
December 10, 2018
#129 Depression and Suicide: Occupational Hazards of Practicing Medicine
Dr Elisabeth Poorman MD joins us to discuss the natural history of physician depression in residency and beyond. We share some of our own personal stories, and discuss how we can support one another and reach out for help, how to take care of our mental health in an emotionally demanding career, how to deal with licensing questions and worry about stigma, and what systemic changes may be coming (read: we think need to be coming) down the line. The problem of depression and suicide is a particularly real one in medicine, a profession that is, by its very nature traumatic and emotionally draining (both in terms of work demands and also the sick and dying patients we treat). N.b. This is a sensitive topic. If this is triggering for anyone listening, the national suicide hotline number 1-800-273-8255. Moreover, if anyone needs or wants guidance on available resources, Dr. Elisabeth Poorman has made herself available either via email, private msg on FB or twitter (@DrPoorman), or any of us on twitter. We are happy to talk and see that you get support you need. Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Nora Taranto MS4, Shreya Trivedi MD Hosts: Stuart Brigham MD, Shreya Trivedi MD, Matthew Watto MD Edited by: Matthew Watto MD Guest: Elisabeth Poorman, MD Time Stamps 00:00 Disclaimer, Intro, Guest Bio 3:25 Wellness Recommendations: Find a Therapist 6:12 How to find a therapist in training 6:39 Licensing and Mental Health 12:14 Disclaimer and Trigger Warning: Stories are Sensitive. National suicide hotline info Next, Dr Poorman and each of The Curbsiders share their personal experiences with mental health (see below). 12:05 Shreya story 21:40 Stuart’s story 31:19 Elisabeth’s story 36:17 Watto’s story 37:41 Passive suicidal ideaiton, a definition   41:10 Suicide and Depression: Do they always coexist? (No) 42:20 Life Cycle of Depression and Suicide in the Medical Profession 47:15 Depression and Suicide in Primary Care 47:59 Mini-Cases 54:00 Noticing signs in a colleague: how to help 58:00 Specific programs doing things well 1:03:08: Questions from Social Media 1:03:10: Burnout vs. Depression 1:04:27: Will getting treatment affect your board applications 1:06:14 Take home points 1:08:00 Outro
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69 min
December 3, 2018
#128 Aspirin Overhyped and Overused
Aspirin’ to figure out if ASA can help prevent a heart attack? Interpreting all the new trials doesn’t have to cause chest pain! Join Dr. Ambarish Pandey from UT Southwestern as he helps The Curbsiders ASCEND the mountains of the latest studies to ARRIVE at some well-informed conclusions on the role of aspirin in primary prevention for cardiac events. The team also discusses secondary prevention, aspirin and dual (or triple) antiplatelet therapy, and whether it’s okay to stop giving aspirin to older adults without known CAD (Spoiler alert: it’s okay). ACP members can visit https://acponline.org/curbsiders to claim free CME-MOC credit for this episode and show notes (goes live 0900 EST). Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Justin Berk MD, Matthew Watto MD CME questions by: Justin Berk MD Hosts: Matthew Watto MD, Paul Williams MD, Stuart Brigham MD Edited by: Matthew Watto MD and Chris Chiu MD Guest: Dr. Ambarish Pandey MD Time Stamps 00:00 Disclaimer, intro and guest bio 04:15 Guest one liner, book recommendation, career and research advice 11:07 Case of aspirin for primary prevention, aspirin’s public persona, and nocebo effects of statins 21:40 ARRIVE and ASCEND trials 28:14 Aspree trial 32:38 Coronary artery calcium; aspirin use for secondary prevention 37:42 Dual antiplatelet therapy and the DAPT score 41:25 Should we continue aspirin when a patient also needs a DOAC? 46:14 Should we continue DAPT in a patient who needs a DOAC (or warfarin)? 49:40 Deprescribing aspirin for primary prevention in older adults? 50:51 Closing remarks 52:33 Outro
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53 min
November 29, 2018
Hotcakes: Exercise, Aspirin, Fish Oil and Hypertension
Tony Breu MD joins us for some hotcakes, and “cold cakes” including: how aspirin and zodiac sign affect the treatment of acute MI, a recent study on how exercise is probably still good for you, the recently announced REDUCE-IT trial, and the evidence (or lack thereof) for the treatment of hypertensive urgency. Welcome to another edition of Hotcakes and Hot Takes, where we discuss the most interesting articles and news that we have been reading. Special guest is the prolific Dr. Tony Breu (@tony_breu) who is an Assistant Professor of Medicine at Harvard Medical School and a Hospitalist and Director of Internal Medicine Resident Education at the VA Boston Healthcare System. He is known for his series on "Things We Do For No Reason” as well as his thought-provoking “Tweetorials” online. ACP members can visit https://acponline.org/curbsiders to claim free CME-MOC credit for this episode and show notes (goes live 0900 EST on day of release). Full show notes available at http://thecurbsiders.com/podcast. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and Produced by: Sarah Phoebe Roberts MPH, Christopher Chiu MD CME Questions: Christopher Chiu MD Hosts: Matthew Watto MD, Stuart Brigham MD, Paul Williams MD, and Christopher Chiu MD Guest Presenter and Content Planning: Anthony Breu MD Editor: Christopher Chiu MD Cover-Art: Christopher Chiu MD Time stamps 00:00 Disclaimer, intro, guest bio 05:53 Discussion on Tweetorials 08:00 Cold Cake: ISIS-2 and the treatment of acute MI with aspirin 14:04 ISIS-2 and zodiac subgroup analysis 16:19 What is the relationship between cardiorespiratory fitness on mortality? 24:40 Discussion of the REDUCE-IT study 33:00 Cold Cake: VA Cooperative study and the evidence for treating essential hypertension 36:42 TWDFNR and the treatment of hypertensive urgency 46:36 Wrap-up and outro
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49 min
November 26, 2018
#127 STIs: Syphilis, Gonorrhea and Chlamydia
Master the diagnosis and management of common STIs (sexually transmitted infections) with tips from expert, Dana Dunne MD, Associate Professor of Medicine in Infectious Diseases at Yale. Topics include: the stages and many presentations of syphilis, syphilis treatment and counseling, the natural history, diagnosis, and screening guidelines for gonorrhea and chlamydia, treatment options in the age of growing resistance, and a discussion of partner notification and treatment. Full show notes available at http://thecurbsiders.com/podcast. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Bryan Brown MD Hosts: Bryan Brown MD, Paul Williams MD, Matthew Watto MD Guest: Dana Dunne MD Special thanks to Kate Grant MBChB, Dip GUMed for her contribution of knowledge and artwork. Time Stamps 00:00 Announcement, disclaimer, intro and guest bio 04:29 Guest onliner, book recommendation, advice for learners/teacher, and picks of the week 11:00 A case of syphilis, clinical manifestations and discussion of the stages 26:05 Testing for syphilis 39:05 Mandatory reporting and partner tracing 42:40 Counseling patients with syphilis 44:44 A case of gonorrhea and chlamydia, clinical manifestations, screening guidelines 52:30 How to counsel patients to obtain samples from urethra, rectum, vagina, oropharynx; Mycoplasma genitalium 59:40 CDC treatment guidelines, Super gonorrhea, test of cure, and treatment of partners 72:35 Take home points 74:30 Outro
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75 min
November 19, 2018
#126 Kashlak Morning Report with Human Dx
Practice solving diagnostic puzzles with The Curbsiders and Internist / Diagnostician, Reza Manesh MD, Assistant Program Director for Clinical Reasoning of the Osler Medical Training Program at Johns Hopkins! Solve along with us at these links: Case 1 http://hdx.org/I2B and Case 2 http://hdx.org/uM2. Topics include: clinical reasoning terminology, how to use cases to practice diagnostic reasoning, how to build a diagnostic schema, and how to conduct your own cognitive autopsy. Full show notes available at http://thecurbsiders.com/podcast. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and Produced by: Hannah Abrams Hosts: Hannah Abrams, Paul Williams MD, Stuart Brigham MD, Matthew Watto MD Guest: Reza Manesh MD Special thanks to: Doctors Steph Sherman, Zaven Sargsyan, Anand Jagannath, John Inou Hwang, and Rabih Geha for contributing cases Time Stamps 00:00 Disclaimer, intro and guest bio 04:02 Guest one liner, book recommendation, favorite failure, advice for learners 11:27 Human Dx Project and Global Morning Report 15:35 Diagnostic terminology 21:25 Case #1, Reza solves 33:40 Diagnostic autopsy and teaching points for case #1 38:00 Case #2, The Curbsiders solve 57:30 Diagnostic autopsy and teaching points for case #2 61:33 Take home points and a plug 64:30 Outro
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66 min
November 15, 2018
#125 Hidden Curriculum
Check out this audio treasure map to find the hidden curriculum and learn how it can change your practice. Learn how positive teaching spans not just the classroom or bedside but, how we simply talk about patients. Sanjay Desai MD, coauthor of ACP’s Position Paper on Hidden Curriculum and Internal Medicine program director at Johns Hopkins guides us through several cases that illustrate how our institutional norms can shape the practice of medicine...for better or worse. ACP members can visit https://acponline.org/curbsiders to claim free CME-MOC credit for this episode and show notes (goes live 0900 EST). Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Sanjay Desai MD; Justin Berk MD, MPH, MBA; Matthew Watto MD CME questions by: Justin Berk MD Editors: Chris Chiu MD & Matthew Watto MD Hosts: Justin Berk MD, MPH, MBA; Matthew Watto MD; Paul Williams MD Guest: Sanjay Desai MD Time Stamps 00:00 Disclaimer, Intro and guest bio 04:00 Guest one liner, book recommendations, career advice 10:50 Intro to the hidden curriculum and ACP’s three recommendations 22:00 Case #1: A patient with schizophrenia 32:10 Case #2: The iPatient 38:07 Case #3: Attending forgets to wash their hands 41:10 Case #4: A dying patient’s primary care doctor saves the day 46:26 Case #5: A case of violating duty hours 60:10 Take home points 62:00 Outro
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63 min
November 12, 2018
#124 The Shoulder - Simplify Your Approach
Shoulder pain made simple. Develop your confidence and skills with tips from sports medicine specialist Dr. Carlin Senter MD. We discuss her simplified approach to the basic shoulder exam, including when and how to do special tests, high yield exam maneuvers, when to refer shoulder pain patients to orthopedic surgery, and who can be managed conservatively. Full show notes available at http://thecurbsiders.com/podcast. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Molly Heublein MD and Nora Taranto MS4 Editor: Matthew Watto MD Hosts: Molly Heublein, MD, Paul Williams MD, Matthew Watto MD Guest: Carlin Senter, MD Time Stamps 00:00 Disclaimer, intro, and guest bio 03:15 Guest one liner, book recommendation, career advice, and some picks of the week 13:20 Clinical case of shoulder pain; helpful historical features 18:54 Differentiating referred pain from c-spine pathology from shoulder pathology 21:00 A framework for shoulder pain, HIP-ROT, and using ROM to generate a differential 27:40 Frozen shoulder aka adhesive capsulitis 31:57 Glenohumeral joint arthritis 33:52 Rotator cuff disease 40:53 Specific testing for rotator cuff tears 51:45 Impingement syndrome versus bursitis 56:25 Counseling patient with shoulder pain or injury 59:03 Steroid injections, topical therapy, and AC joint arthritis 65:18 When to refer to surgery and some take home points
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71 min
November 5, 2018
#123 Sleep Apnea Pearls and Pitfalls
The sleep apnea episode that won’t put you to sleep. Become a sleep apnea guru with incredible insights from Barbara Phillips MD, MSPH, FCCP an expert in pulmonary medicine, critical care and sleep medicine who is also a past president of CHEST! We discuss high-yield topics in the world of obstructive sleep apnea including: home sleep studies vs in-lab polysomnography, the importance of oxygen saturation (the T90 and ODI) when interpreting sleep study results, tricks to improve CPAP adherence, and alternatives therapies for obstructive sleep apnea. ACP members can visit https://acponline.org/curbsiders to claim free CME-MOC credit for this episode and show notes. Full show notes available at http://thecurbsiders.com/podcast. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Cyrus Askin MD CME questions by: Cyrus Askin MD Editor: Chris Chiu MD & Matthew Watto MD Hosts: Cyrus Askin MD & Matthew Watto MD Guest: Barbara Phillips, MD Cover-Art & Infographic - Beth Garbitelli, MS1 Time Stamps 00:00 Disclaimer, intro, guest bio 03:00 Guest one liner, book recommendation, advice for trainees 08:10 Clinical case of sleep apnea, some basic stats, and key predictors of sleep apnea 12:38 Barriers to diagnosis and treatment of OSA 15:23 Discussion of T90, hypoxemia and sleep fragmentation 17:05 How to read a sleep study report 21:55 Home sleep apnea testing 24:15 What are the consequences of sleep apnea 28:30 What is the efficacy of cpap for lowering blood pressure and mortality 31:45 Counseling a patient who is new to cpap 33:45 Choice of mask 40:10 Do alternatives to cpap work? e.g. surgery, mandibular advancement devices 44:17 Modafinil and z-drugs 47:15 Driver’s license issues in sleep apnea 48:35 Future of sleep medicine and take home points 51:15 Outro
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52 min
October 29, 2018
#122 Headaches Advanced Class
We delve into advanced management of headaches, including novel therapies, migraines with aura, migraines in complicated patients, and headaches of short duration with Dr. Rebecca Burch, a headache medicine specialist at the John R. Graham Headache Center at Brigham and Women’s Hospital. Full show notes available at http://thecurbsiders.com/podcast. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Paul Williams MD Edited by: Matthew Watto MD Hosts: Paul Williams MD, Stuart Brigham MD, Matthew Watto MD Guest: Rebecca Burch MD Time Stamps 00:00 Disclaimer, intro and guest bio 03:28 Guest one-liner, movie and podcast recommendations, favorite failure and picks of the week from The Curbsiders 10:38 Clinical case of migraines; diagnosis and classification 14:12 Does medication overuse headache exist? 16:16 Chronic daily headache; Conversion from episodic to chronic and vice versa 21:43 Approaches to medication overuse headache 25:54 Case 2: migraine with aura and other types of migraine (retinal, hemiplegic, etc.) 32:09 Pathophysiology of migraine; how triptans work; How should aura effect management? 38:44 Migraine cocktails 41:15 Comorbid mood disorders; Use of psych meds and triptans 45:08 Migraines and oral contraceptives 48:42 Botulinum toxin and new CGRP therapies 53:36 What does success look like in migraine therapy? 55:32 Nonpharmacologic management 60:45 Case 3: headaches of short duration 66:36 Headache red flags; Imaging for headaches; pathophysiology of high and low pressure headaches 72:00 Idiopathic intracranial hypertension 75:25 Take home points 77:00 Outro  
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78 min
October 22, 2018
#121 HIV Care for the Internist
HIV care for the internist with author and HIV expert, Michael Saag MD, Professor of Infectious Diseases at University of Alabama and founder of the 1917 Clinic. We discuss the specifics of screening & diagnostic testing in HIV, monitoring CD4 counts and viral loads, first line antiretroviral therapy, harm reduction, and how to provide excellent HIV care in your primary care clinic. Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written & Produced by: Elena Gibson MS4, Justin Berk MD MBA MPH Artwork by: Elena Gibson MS4 Hosts: Matthew Watto MD, Paul Williams MD, Justin Berk MD MBA MPH Editor: Matthew Watto MD Guest: Michael Saag MD Time Stamps 00:00 Disclaimer, intro, and guest bio 04:35 Getting to know our guest, a movie recommendation, and words of wisdom 08:48 Clinical case, HIV screening, in-depth discussion of HIV testing & diagnosis 15:56 New diagnosis of HIV, counseling after diagnosis, confirmation, follow-up testing, the second visit 24:20 Treatment - what to start and when; some basic comments on therapy 30:05 Primary care after diagnosis, vaccines, cancer screening, cardiovascular disease prevention 34:35 Monitoring CD4 counts and viral load; interpreting CD4 count; time course of response for CD4 and viral load 42:02 Harm reduction counseling; addressing medication non-adherence 47:40 PCP prophylaxis 49:43 The 1917 Clinic, Ryan White Clinics, and linking patients to care 53:10 Take home points 55:40 Plugs 57:45 Will a cure or vaccine for HIV emerge? 59:16 Outro
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60 min
October 19, 2018
#120 Policy, Patients, Payments, Paperwork
Join us in this roundtable discussion of patients before paperwork, administrative burden, the new CMS payment model proposal, and a bit on health insurance with cohost, Fatima Syed MD MSc and guest, Deep Shah MD MSc. Doctors Syed and Shah are both early career physicians with masters degrees in comparative social policy from Oxford University and are active members of the American College of Physicians. ACP members can visit https://acponline.org/curbsiders to claim free CME-MOC credit for this episode. Full show notes available at http://thecurbsiders.com/podcast. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Fatima Syed MD MSc and Matthew Watto MD CME questions by: Matthew Watto MD Hosts: Fatima Syed MD MSc, Matthew Watto MD Guest: Deep Shah MD MSc Time Stamps 00:00 Disclaimer, intro, and guest bios 02:18 Guest one liners, book recommendations, picks of the week 11:00 Administrative burden 16:00 Will the documentation problem get better? Suggestions for improvement 25:11 Why do CMS rules spread to the private insurance sector? 29:30 What innovations might reduce administrative burden? 32:40 The Affordable Care Act, health insurance, price transparency 40:20 Take home points 43:20 Outro
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44 min
October 15, 2018
#119 Nutrition Pearls, Heart Health and Bacon
Nutrition pearls from integrative cardiologist, Steven Devries MD, Associate Professor of Medicine, Northwestern Feinberg School of Medicine, Executive Director of The Gaples Institute. Clinicians receive little formal nutritional training in medical school and residency. It’s time to fill that gap! We discuss the strength of the literature supporting dietary interventions for cardiovascular health and review practical tips to help patients achieve healthy eating patterns. Patients need to hear from us that nutrition matters! Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written & Produced by: Molly Heublein MD Hosts: Matthew Watto MD, Paul Williams MD, Molly Heublein MD Guest: Stephen Devries MD Editor: Matthew Watto MD Special thanks to Elena Gibson MS4 for writing our show notes Time Stamps 00:00 Disclaimer 00:35 Intro and guest bio 02:40 Guest one-liner, book recommendation, favorite failure, nontraditional career path 10:10 Nutrition and medical education 12:45 Evidence for how nutrition can improve health outcomes 15:33 How to describe a heart healthy or Mediterranean diet to patients 25:16 Discussion of fats and oils 31:44 Food deserts, healthy snacking options 37:15 Calorie counting and use of healthy eating apps 40:55 How to frame the discussion about a healthful eating pattern with patients 47:18 Macronutrient content. Does it matter? 52:50 Intermittent fasting 54:24 A free resource for patients to learn about nutrition  
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57 min
October 8, 2018
#118 Female Sexual Problems with Stacy Lindau MD
Houston, we have a female sexual dysfunction problem. Female sexual problems, which can affect women of all ages, are underdiagnosed and undertreated--in part because clinicians are not the best at asking about sex in primary care visits. In the course of this episode, learn about how to have that sex talk you’ve (maybe) been avoiding, what to ask when working up sexual problems in women, and find the words to talk to patients about sex. Today, we’re lucky to have the female sexual health expert of experts, Dr. Stacy Lindau, MD, MA, Professor of Obstetrics and Gynecology and Medicine-Geriatrics at the University of Chicago Medicine, on the show to teach us the best “sex talk” language, the differential for female sexual problems, and explore therapies. Sadly, there’s no sildenafil-like magic bullet, but a multidisciplinary team can make real impact on female sexual problems. Don’t forget to check out http://womanlab.org Full show notes available at http://thecurbsiders.com/podcast. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by: Nora Taranto MS4 Hosts: Leah Witt MD and Matthew Watto MD Infographic: Leah Witt MD Editor: Matthew Watto MD Guest: Stacy Lindau MD Time Stamps 00:00 Disclaimer 00:35 Intro and guest bio 03:30 Guest one liner, book recommendations, favorite failure, career advice and picks of the week 12:57 Clinical Case of female sexual dysfunction and some definitions 15:08 Are sexual problems a normal part of aging?; How to take a sexual history; Etiology of sexual dysfunction; “Diagnostic sex”; Red flags 27:54 Medications that contribute to sexual dysfunction 31:00 Labs 34:45 Treatment: pelvic PT, medications, counseling, flibanserin, herbal supplements 49:05 Screening for female sexual problems 51:58 Take home points; WomanLab.org 55:19 Outro Tags sexual dysfunction, female, gynecologist, ob-gyn, female sexual disorder, libido, sex, hormones, care, doctor, education, family, FOAM, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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56 min
October 1, 2018
#117 Clostridium Difficile: IDSA Guidelines, Bad Puns, and Random Pearls
Summary Conquer Clostridium difficile (Clostridioides difficile) with this “spore-tacular” episode featuring infectious diseases expert, Dr. Curtis Donskey, Professor at Case Western Reserve University and clinician at the Louis Stokes VA Hospital. We discuss the updates in the 2017 IDSA C. difficile guidelines plus a bunch of random pearls. If you have ever laid awake at night wondering how many pills are needed for a fecal transplant, then this is the episode for you!  We discuss why metronidazole was dropped as the first line therapy for Clostridium difficile infection (CDI) along with other hot topics such as two-step testing, loperamide use, which antibiotics are the least likely to cause CDI, and more. Do not miss this episode! Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written by: Carolyn Chan MD Produced by: Matthew Watto MD Hosts: Carolyn Chan MD, Matthew Watto MD, Paul Williams MD Editor: Matthew Watto MD Guest: Curtis Donskey, MD Time Stamps 00:00 Intro, disclaimer, guest bio 02:19 Getting to know our guest, recommendations for reading, career advice 06:40 Clinical case and CDI testing 09:30 Testing for CDI: PCR and Two step testing 16:30 Testing after treatment 20:00 Treatment of initial CDI episodes, metronidazole pharmacokinetics 24:15 Classification of CDI severity 29:30 Fidaxomicin pearls: when to use, cost, and tapers 34:10 Vancomycin tapers 36:05 Fecal transplant pearls: freeze dried capsules, c-scopes, treating fulminant CDI 44:44 Infection control: counseling homegoing patients, hand washing, and baths 47:50 Social media questions: immodium and toxic megacolon, antibiotics less likely to promote CDI, probiotics, and more! 59:14 Best CDI joke in the history of time 60:00 Take home points 62:42 Outro Tags Clostridium, difficile, cdi, C.Diff, infectious, diseases, diarrhea, IDSA, guideline, antibiotics, vancomycin, fidaxomicin, fmt, transplant, fecal, stool, toxin, assistant, care, doctor, education, family, FOAM, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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63 min
September 27, 2018
#116 Geriatric Psychiatry: Sleep, Dementia, and Behavioral Disturbances
Geriatric psychiatry returns. We tackle sleep problems and behavioral disturbances in patients with dementia with returning guest, and Geriatric Psychiatrist Dennis Popeo MD, Clinical Associate Professor of Psychiatry at NYU Langone Medical Center. Topics include: pharmacologic and nonpharmacologic management of insomnia; treating agitation and irritability; medical management of psychotic symptoms and paranoia; ethical concerns about the treatment of challenging behaviors in dementia; and the shortage of geriatricians and geriatric psychiatrists. Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written & Produced by: Jordana Kozupsky NP, Matthew Watto MD Artwork by: Kate Grant MD Hosts: Jordana Kozupsky NP, Matthew Watto MD Editor: Matthew Watto MD Guest: Dennis Popeo, MD Time Stamps 00:00 Intro and guest bio 01:55 Case of sleep disturbance in a patient with dementia; medications for sleep disturbances; nonpharmacologic strategies for sleep 11:32 Irritability and agitation versus paranoia, or psychotic symptoms; benzodiazepines in older adults 15:40 Antipsychotic medications, the black box warning and ethical concerns 23:50 Geriatricians, geriatric psychiatrists in short supply; Behavioral interventions 28:16 Outro Tags psychiatry, psych, geri, geriatrics, dementia, paranoia, psychosis, sleep, insomnia, agitation, antipsychotics, atypical, black, box, warning, adverse, zolpidem, benzodiazepine, side, effects, therapy, mirtazapine, gabapentin, assistant, care, doctor, education, family, FOAM, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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29 min
September 24, 2018
#115 Geriatric Depression
Summary Geriatric depression got you down? Boost your spirits with tips and tactics from Geriatric Psychiatrist, Dennis Popeo MD, Clinical Associate Professor of Psychiatry at NYU Langone Medical Center. Topics include: suicide in the older adults; how to diagnosis depression in older adults; how to counsel patients about antidepressants, how to choose an antidepressant, how to monitor and titrate medications, and how long to continue therapy. Stay tuned for part two of our discussion with Dr Popeo on managing sleep and behavioral problems in older adult patients with dementia. Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written & Produced by: Jordana Kozupsky NP, Matthew Watto MD Artwork by: Kate Grant MD Hosts: Jordana Kozupsky NP, Matthew Watto MD Editor: Matthew Watto MD Guest: Dennis Popeo, MD Time Stamps 00:00 A question for you, the listeners 01:12 Disclaimer, intro and guest bio 05:00 Getting to know our guest, recommendations for reading, and career advice 14:13 Case of geriatric depression; effective history taking; recognizing associated symptoms; depression scales 19:03 Suicide in older adults; firearm safety 24:26 Choice of therapy; Pharmacologic agents; Counseling patients and managing expectations; Dose titration and tracking symptoms 34:41 Augmenting therapy versus cross-titration to another agent; When is it okay to stop an antidepressant 40:50 Take home points 44:40 Outro Tags: psychiatry, psych, geri, geriatrics, depression, mdd, sleep, insomnia, appetite, agitation, suicide, SSRIs, side, effects, therapy, diagnosis, serotonin, mirtazapine, bupropion, assistant, care, doctor, education, family, FOAM, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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45 min
September 17, 2018
#114 High Value Care: Assess Quality, Mitigate Diagnostic Uncertainty, Overcome Barriers
Kick up the quality of your care with tips and tactics from Caitlin Clancy MD, coauthor of ACP’s High Value Care Curriculum. We learn to define quality and value in healthcare; the most common barriers to high value care; use of probability and likelihood ratios to boost clinical reasoning and combat diagnostic uncertainty; some useful tools to estimate cost; sources of healthcare waste; and some general pearls on how the healthcare system works...or doesn’t. ACP members can claim free CME-MOC at acponline.com/curbsiders (goes live 0900 EST on podcast release date). Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits: Written & Produced by: Matthew Watto MD Hosts: Paul Williams MD, Stuart Brigham MD, Matthew Watto MD Guest: Caitlin Clancy MD Time Stamps 00:00 Disclaimer, intro and guest bio 03:50 Guest one-liner, some discussion on non traditional paths, and picks of the week 12:10 Case 1: Defining value, cost, quality; sources of healthcare waste; and how to avoid the waste of daily labs 23:00 Case 2: An uninsured patient who needs major surgery; costs for uninsured versus insured patients 28:35 Do insured patients have better outcomes? 31:15 How to determine cost and “fair market price” 36:29 Case 3: Clinical case of suspected heart failure 45:45 Case 4: Clinical case of patient requesting antibiotics; barriers to high value care and how to overcome them 57:05 Outro Tags: high, value, care, quality, cost, diagnostic, uncertainty, likelihood, ratio, testing, treatment, consumer, acp, college, american, insured, uninsured, bill, charge, reimbursement, assistant, care, doctor, education, family, FOAM, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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58 min
September 10, 2018
#113 Gout: Uric acid targets, urate lowering therapy, and random questions from social media
Master the management of gout with tips from expert, Tuhina Neogi MD, PhD, Professor of Medicine at Boston University School of Medicine. Topics include: how to initiate and titrate urate lowering therapy, guidelines controversy over uric acid targets, colchicine & NSAIDS for anti-inflammatory prophylaxis, uricosuric agents, febuxostat, HLA B5801, use of uric acid levels in the acute setting and more random gout facts. Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits: Written and produced by: Matthew Watto MD Hosts: Paul Williams MD, Stuart Brigham MD, Matthew Watto MD Guest: Tuhina Neogi MD, PhD Time Stamps 00:00 Intro and guest bio 01:30 Allopurinol initiation and titration 07:10 Uricosuric therapy 09:10 Controversy over uric acid targets for gout 17:40 Parachutes and randomized controlled trials 19:15 Colchicine or NSAIDS for prophylaxis 23:20 Who needs febuxostat? 26:20 When to refer for gout, HLA B5801, and checking uric acid levels in the acute setting   33:29 Take home points 36:15 Outro Tags: allopurinol, uric, urate, acid, level, therapy, management, gout, flare, crystal, arthritis, titration, probenecid, febuxostat, target, acr, acp, guidelines, nsaids, colchicine, hla b5801, septic, rheumatology, assistant, care, doctor, education, family, FOAM, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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38 min
September 3, 2018
#112 Gout Flares: Bathtubs and Firefighting
Crystalize your knowledge of gout and stop flares in their tracks with tips from expert, Tuhina Neogi MD, PhD, Professor of Medicine at Boston University School of Medicine. On this first of two gout episodes we learn to diagnose gout with or without arthrocentesis, how to treat flares, and how to counsel patients about gout, which apparently involves fire fighting and bathtubs. Don’t miss next week’s episode on urate lowering therapy, gout guidelines controversy, and answers to your gout questions from social media. Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits: Written and produced by: Matthew Watto MD Hosts: Paul Williams MD, Stuart Brigham MD, Matthew Watto MD Guest: Tuhina Neogi MD, PhD Time Stamps 00:00 Disclaimer, intro 01:40 Guest bio 03:20 Guest one liner, music recommendations, advice for researchers, and some comments on failure 09:15 Clinical diagnosis of gout 12:15 Is taking a diet history useful? 14:30 Classification criteria for gout 17:35 MSK ultrasound and Physical exam findings in gout 21:06 Arthrocentesis and MSU crystals 24:45 A recap of how to make the diagnosis of gout 26:50 The bathtub analogy and how to counsel a patient with a new diagnosis of gout 30:55 Pathophysiology of gout 34:55 Treatment for acute gout flares (steroids, colchicine, NSAIDS. And topical NSAIDS?)  45:30 Outro Tags: gout, crystal, colchicine, steroids, nsaids, joint, flare, acute, chronic, urate, uric, acid, arthritis, acr, exam, diagnosis, rheumatology, assistant, care, doctor, education, family, FOAM, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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47 min
August 31, 2018
#111: Hotcakes - Complementary Medicine in Cancer, Dosing Aspirin by Body Weight, Marijuana & Respiratory Symptoms, Penicillin Allergies and More!
Dr. Neda Frayha (@nedafrayha) of Primary Care RAP (Hippo Education) joins us this month for our thoughts and analysis of some recent (and not so recent) journal articles that interested us this month. Our articles spanned topics that include at cancer survival among patients pursuing treatment with complementary medicine, the effect of body weight on effectiveness of preventive aspirin dosing, strategies to promote physician leadership, respiratory symptoms in those with marijuana use and MRSA risk among patients with penicillin allergies. ACP members can claim free CME-MOC at acponline.com/curbsiders (goes live 0900 EST on podcast release date). Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list to receive a PDF copy of our show notes every Monday! And hey, while you’re here, consider rating us on iTunes and leaving a review. The Curbsiders thank you! Thoughts on the Journal Club series? Article or guest nominations? Compliments or complaints? You can reach us at thecurbsiders@gmail.com. We are also on Facebook, Instagram, and Twitter: @thecurbsiders.   Credits: Written by: Sarah Phoebe Roberts MPH, Neda Frayha MD, Christopher Chiu MD Producers: Sarah Phoebe Roberts MPH, Christopher Chiu MD Hosts: Matthew Watto MD, Stuart Brigham MD, Paul Williams MD, and Christopher Chiu MD Editor: Matthew Watto MD  Time stamps: 00:00 Disclaimer, intro, guest bio 05:05 Do patients using complementary medicine for cancer therapy have worse outcomes? 13:11 Does low dose aspirin work for primary prevention of major adverse cardiac events? 19:16 Do physicians make better leaders? 24:55 Does marijuana cause respiratory symptoms? 30:40 Does penicillin allergy confer increased risk for C Diff and MRSA infection? 38:40 Wrap-up and outro Tags:​ aspirin, cardiac risk, mortality, cancer, complementary, alternative, conventional, therapy, marijuana, cannabis, respiratory, symptoms, leader, leadership, assistant, care, doctor, education, family, FOAM, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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42 min
August 27, 2018
#110: Driver’s safety for Older Adults: When is it Time to Give Up the Keys?
Get schooled on driver’s safety for older adults by expert, Alice Pomidor MD, Professor of Geriatrics at Florida State University. Whether or not older adults can continue to drive is a huge problem faced by for primary care clinicians, and will remain one until driverless cars become ubiquitous. Topics covered include: how to take a driving history, red flags, physical exam, cognitive exam, and vision assessment for driver’s safety, resources, when to refer, alternate means of transportation, and the legal repercussions of reporting...or not reporting. Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits: Written and produced by: Matthew Watto MD and Elizabeth Garbitelli MD Candidate 2022 Editor: Matthew Watto MD Cover Image by: Kate Grant MD Hosts: Matthew Watto MD, Stuart Brigham MD, Paul Williams MD Guest: Alice Pomidor MD  Time Stamps 00:00 Disclaimer 00:35 Intro and guest bio 03:10 Guest onliner, book recommendations, and career advice 10:43 Clinical case, and the 5 Rs of clinicians responsibility 19:15 Taking a history from older adult drivers 26:28 The clinical exam for driver’s safety (cognition, vision, and MSK tests) 37:24 How can we avoid patient anger towards clinician and family members? 41:10 When and where to refer for driving evaluation 47:00 Alternative transportation 52:00 What to do if someone refuses or forgets to stop driving 59:45 Reporting requirements and legal ramifications 69:15 Take home points 72:00 Outro  Tags: driving, elderly, geriatrics, dementia, treatment, prevention, cognition, seniors, drivers, safety, crash, motor, vehicle, car, assistant, care, doctor, education, family, FOAM, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student  
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73 min
August 20, 2018
#109: Things We Do For No Reason: A High Value Episode
Things We Do For No Reason #TWDFNR highlights some widespread practices that are difficult to justify based on lack of proven health benefits, but significant cost (both financial and non-financial harms). Avoid these low value practices and inflated medical bills with tips from expert, Dr Lenny Feldman, MD, FACP, Associate Professor of Medicine Johns Hopkins. Topics include: renal ultrasound and urine electrolytes in acute kidney injury (AKI), folate deficiency and anemia work-up, prealbumin and malnutrition, blood transfusions, shellfish and contrast allergies, monitoring after switch from IV or oral antibiotics, and “against medical advice” discharges. Don't forget to check out Clinicwiki.org a free, online resource for teaching ambulatory medicine. Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.  Credits: Written and produced by: Justin Berk MD, MPH, MBA Editor: Matthew Watto, MD Hosts: Justin Berk MD, MPH, MBA; Matthew Watto MD; Paul Williams MD, FACP Guest: Lenny Feldman MD, FACP Goal: Listeners will recognize things we do for now reason aka low value practices with an unfavorable ratio of benefits to cost and/or harm. Learning objectives: After listening to this episode listeners will… Determine if renal ultrasound is indicated in acute kidney injury Recognize the limitations of urine electrolytes in AKI. Identify the shortcomings of folate testing. Explain the significance of low albumin and prealbumin. Identify patients at risk for serious allergic reactions from IV contrast administration Explain the futility in discharge Against Medical Advice (AMA) paperwork Counsel patients on harm reduction in “AMA” discharges Rationalize discharging patients immediately after switching from IV to  oral (PO) antibiotics. Time Stamps 00:00 Announcements 00:38 Disclaimer, intro, and guest bio 03:53 Guest one liner, some recommendations, and advice 08:35 Defining high value care and things we do for no reason (TWDFNR) 12:40 Why do clinicians order useless testing? 14:58 Urine electrolytes for acute kidney injury 20:30 Renal ultrasound for acute kidney injury 25:54 Stop ordering folate for anemia workup 31:47 How many units should I transfuse? 34:40 Prealbumin and albumin for malnourishment. 43:24 Iodine, shellfish and contrast allergy 50:28 Patient leaving against medical advice 56:45 Switching from IV to oral antibiotics 63:27 Dr Feldman’s plugs 65:36 Outro  Tags: high, value, choosing, wisely, acute, kidney, injury, renal, ultrasound, transfusion, AKI, malnutrition, folate, prealbumin, albumin contrast, allergy, antibiotics, AMA, TWDFNR, assistant, care, doctor, education, family, FOAM, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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67 min
August 13, 2018
#108: Point-of-care Ultrasound for the Internist
Point-of-care Ultrasound AKA POCUS ain’t no hocus. Dr. Renee Dversdal (@ReneeDversdal) Director of the Oregon Health & Science University Point of Care Ultrasound and General Medicine Ultrasound Fellowship Director, joins The Curbsiders to discuss her craft. Topics include: Defining POCUS, the value POCUS adds to the physical exam, training pathways and the appropriateness of billing. This episode is sponsored for CME-MOC credit by the American College of Physicians. ACP members can claim free credit at acponline.org/curbsiders (goes live at 9am on release date). Follow this link to read the ACP’s statement in support of POCUS in Internal Medicine. Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits: Written by: Christopher Chiu MD and Renee Dversdal MD Produced and CME questions by: Christopher Chiu MD Edited by: Matthew “Mike” Watto MD Hosts: Matthew Watto MD, Stuart Brigham MD, Christopher Chiu MD Guest Expert: Renee Dversdal MD Tags: point-of-care, acp, impocus, ultrasound, bedside, POCUS, CLUE, exam, training, lifestyle, management, assistant, care, doctor, education, family, FOAM, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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61 min
August 6, 2018
#107: Women in Medicine, Be Bold
“Women in medicine, be bold.” Medical World, powerful women are here to stay. Dr. Vineet (Vinny) Arora, Professor of Medicine at University of Chicago, an exemplary Woman in Medicine and Leadership, shares snippets of her own story, valuable career advice to folks at all levels of training, and fascinating data about the gender disparities that exist in training, promotion, and pay.  We hope you’ll learn from this episode, whether you have faced or anticipate facing these struggles as a Woman in Medicine or as a member of another marginalized group, or whether you’re an ally and want to learn more about the issue. Women are entering medical school now more than ever, and are learning to provide the best possible care to patients (didn’t you see that patients of female physicians have significantly lower mortality rates than patients of male physicians? (Tsugawa et al., 2016)).  The modern medical woman wants to teach, mentor, and lead--and be fairly evaluated, and promoted. That’s where We In Medicine (both women and men) have some work to do.  Because gender disparities (and other disparities hinging on identity) do exist. N.b. This episode is our inaugural in what we hope will be a Women in Medicine series for the Curbsiders.  We have many more topics with which we’d like to engage, from career trajectory to imposter syndrome to sexual harassment to balancing career and personal lives (as inequity is not only at work (Khullar. Being a Doctor is Hard. It’s Harder for Women. NYT 2017)), to conversations about race, gender, and LGBTQ identity in medicine.  We’re passionate, at The Curbsiders, about all these topics, and we want to dive deep into how to make Medicine a more welcoming and ceiling-less place for all.  We can’t wait to bring this series to you, not to mention to bring some more fabulous female experts on air. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits: Written and produced by: Leah Witt MD, Shreya P. Trivedi MD, Nora Taranto AB, Sarah Phoebe Roberts MPH, Molly Heublein MD, Beth Garbitelli, Hannah R Abrams, Images by: Beth Garbitelli and Hannah Abrams Editor: Matthew Watto MD Hosts: Leah Witt MD, Shreya P. Trivedi MD, Matthew Watto MD Guest: Vineet Arora MD Time Stamps 00:00 Disclaimer and intro 03:15 Guest bio, and one liner 05:55 Dr Arora’s Women in medicine moment of awakening 11:05 Advice to young women, “Be bold” 13:20 Picks of the week 16:45 Mistaken identity. Women not recognized as physicians due to appearance 22:05 Gender bias starts early in training and why it's important to shout-out accomplishments 31:24 Contracts, promotions and the leaky pipeline 38:32 Defining coaches, sponsors, and mentors 44:06 How to use your team and shout-out your accomplishments 52:04 How to write effective evaluations and letters that avoid gender bias 53:55 Take home points 57:00 Outro Tags: women, medicine, wim, LeanIn, leadership, mentorship, doctor, education, family, assistant, career, sponsorship, vineet, arora, care, doctor, education, family, FOAM, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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59 min
July 30, 2018
#106: Hotcakes: Cardiac risk, diabetes, pulmonary embolism, opioid use disorder, neck ties and nose picking?
Short on time but hungry for knowledge? Curbsiders’ Journal Club gives you the speedy article analysis you crave. We provide brief summaries of recent research and news items in the field of internal medicine, so you can save time and stay on top of the literature. On this episode, we were joined by Kashlak Memorial’s very own Chair of Medicine, Dr. Robert Centor AKA @medrants on Twitter or “Uncle Bob” to the Curbsider Crew. This month’s topics include: estimating atherosclerotic cardiovascular disease risk, whether CT pulmonary angiography (CTPA) effectively rules out pulmonary embolism, discharging low risk patients with pulmonary embolism from the ED, metformin and risk of acidosis in patients with CKD, treating opioid use disorder after a nonfatal overdose, Canagliflozin and renal protection in type 2 diabetes, screening for diabetes among patients below age 40, and the association between nose-picking and staphylococcus. ACP members can claim free CME-MOC at acponline.com/curbsiders (goes live 0900 EST on podcast release date). Join our mailing list to receive a PDF copy of our show notes every Monday! And hey, while you’re here, consider rating us on iTunes and leaving a review. The Curbsiders thank you! Thoughts on the Journal Club series? Article or guest nominations? Compliments or complaints? You can reach us at thecurbsiders@gmail.com. We are also on Facebook, Instagram, and Twitter: @thecurbsiders.   Credits: Written by: Christopher J Chiu MD, Sarah Phoebe Roberts MPH Producers: Christopher J Chiu MD, Sarah Phoebe Roberts MPH Editor: Matthew Watto MD Hosts: Christopher J Chiu MD, Stuart Brigham MD, Paul Williams MD, and Matthew Watto MD Guest: Robert Centor MD Time stamps: 00:00 Disclaimer and Intro to Curbsiders Journal Club 04:00 Dr. Centor's Pick of the Week 06:10 Clinical Implications of the Revised Pooled Cohort Equations 12:10 Negative Predictive Value in CTPA for VTE 18:34 Can low risk patients with PE be discharged from the ED? 23:03 Is Metformin associated with Lactic Acidosis in those with low eGFR? 28:45 How do medications for opioid use disorder affect mortality after non-fatal overdose? 36:44 Canagliflozin and Renal Protection 43:00 Performance of USPSTF screening criteria for diabetes 46:08 Stuart on Nose picking 50:00 Chiu Bites: Infectious ties and physical attire 53:50 Outro Tags: atherosclerotic, cardiovascular, disease, risk, CT, pulmonary, angiography, CTPA, embolism, ED, metformin, acidosis, CKD, treatment, opioid, use, disorder, oud, mat, overdose, canagliflozin, renal, diabetes, screening, nose-picking, staphylococcus, ACP, CME, MOC, assistant, care, doctor, education, family, FOAM, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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55 min
July 23, 2018
#105: Lyme Disease and Tick-Borne Illness with ID Expert Paul Sax: Why you should never go outside or to Boston in the summer
Lyme disease and tick-borne illness deconstructed by Infectious Diseases expert, Paul E. Sax MD, of episode 78 fame. Oh, Summer Nights. The time for romance between Danny Zuko and good girl Sandy, the time to sit in the backyard around the bonfire, the time for sunset hikes in the woods and mountains…..and don’t forget, it’s also the time for those pesky woodland ticks who’ll go for a ride on you and maybe suck your blood (gross!). Dr. Sax takes us through the essentials of tick-borne illness, with a focus on Lyme Disease: diagnosing it, treating it, identifying possible co-infections, and managing Post-Lyme residual symptoms.   Our (And Dr. Sax’s) Disclaimer about this episode, and the shownotes: Tick-borne illness is a very serious problem in public health in the US, but management is quite a controversial issue. We’ve done our best with this episode to stay as evidence-based as possible. Moreover, given the limited time we have on air, we have tried to focus on what we think is most clinically relevant. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits: Written by: Shreya P. Trivedi MD, Nora Taranto AB Produced by: Shreya P. Trivedi MD, Nora Taranto AB Editor: Matthew Watto MD Images by:  Hannah R. Abrams Hosts: Shreya P. Trivedi MD, Matthew Watto MD, Paul Williams MD Guest: Paul E. Sax MD Time Stamps 00:00 Intro 02:17 Disclaimer 03:19 Guest bio 05:17 Getting to know Guest 08:33 Favorite hiking experiences 12:20 Disclaimer of Tick-borne illness 12:28 Clinical case of recent hiking in endemic area with a rash 20:59 Lyme testing limitations 27:38 Patient education to doxycycline 30:16 Case of elderly outdoorsy healthy male with flu-like symptoms in the summer 32:39 Differentiating anaplasmosis and babesiosis 33:17 Workup for patient with possible tick co-infections 39:22  Post-lyme disease residual symptoms 48:02  Case of tick attached to patient 56:19  Outro Tags: lyme, disease, anaplasmosis, babesiosis, treatment, prevention, coinfection, doxycycline, paul, sax, infectious, diseases, nejm, harvard, pcr, antibody, tick, borne, illness, chronic, post, syndrome, removal, endemic, anatomical, assistant, care, doctor, education, family, FOAM, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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58 min
July 16, 2018
#104: Renal tubular acidosis with Kidney Boy, Joel Topf MD
Renal tubular acidosis aka RTA deconstructed by @Kidney_Boy, Joel Topf MD, Chief of Nephrology at Kashlak Memorial Hospital. We review the three buckets of non gap metabolic acidosis, normal renal physiology & acid base handling, points of failure in RTA, complications and treatment of RTA. Check out Dr Topf’s awesome slides on renal tubular acidosis at http://thecurbsiders.com/podcast . Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits: Written by: Matthew Watto MD and Joel Topf MD Produced by: Matthew Watto MD Hosts: Matthew Watto MD, Stuart Brigham MD, Paul Williams MD Guest: Joel Topf MD Time Stamps 00:00 Announcements 01:02 Disclaimer 01:40 Intro and guest bio 04:00 Joel’s one liner 06:05 Joel’s “favorite failure” 11:45 Paul shares a failure 13:20 Tweetorials 16:39 Clinical case of non gap metabolic acidosis 18:06 Three buckets of NAGMA and GI losses 21:02 Chloride intoxication and normal saline 25:14 Renal tubular acidosis and normal role of kidney in acid base 35:03 Proximal (type 2) RTA 40:33 Cases of proximal RTA 43:38 Distal (type 1) RTA 53:15 Bicarbonate dosing and titration 55:28 Type 4 RTA (hypoaldosteronism) 62:09 Urinary anion gap and ammonium 67:26 Replacing GI losses of bicarbonate 70:25 Joel reviews quick cases of RTA and NAGMA 74:49 Outro  Tags: renal, tubular, acidosis, non, gap, rta, nagma, metabolic, kidney, diarrhea, sodium, normal, saline, ringer's, lactate, tubule, bicarbonate, physiology, acid, base, ammonia, ammonium, nephrolithiasis, assistant, care, doctor, education, family, FOAM, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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75 min
July 9, 2018
#103: Train Your Brain: Mapping out your road to expertise
Expert diagnostician, Dr. Gurpreet Dhaliwal, again joins The Curbsiders to dive deeper into the topic of clinical expertise.  Topics include, and are mainly focused on, Dr. Dhaliwal’s “training regimen:” feedback, simulation, quizzing, learning from consultants, and how to read the medical literature as a clinician.  While we found this episode to be incredibly useful (and entertaining to record), don’t let our bias sway your opinion! In fact, just listen to the episode and listen for practical advise on how to improve your own clinical acumen.   Dr Brigham’s comment:  Be forewarned, much of what we talk about is seemingly common sense, but, upon listening to the episode many times, I realize that we have, over time, overly complicated the fundamentals of expertise.  I’m just as guilty as the next physician. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits Written and produced by:  Stuart Brigham MD Hosts: Stuart Brigham MD, Paul Williams MD, Matthew Watto MD Guest: Gurpreet Dhaliwal MD Images by: Beth Garbitelli Edited by:  Matthew Watto MD Time Stamps 00:00 Disclaimer, Intro 02:25 Guest Bio 03:57 Pun 04:25 Dr. Dhaliwal 05:57 Pick of the Week - Move, “Jiro Dreams of Sushi” 08:00 Pick of the Week - Podcast, “Unspooled” 09:06 Pick of the Week - Water Putty, “Durham’s Rock Hard Water Putty” 10:20 “Clinical Case” Introduction 12:00 Developing expertise, introduction 15:50 Developing a patient log 21:30 Asking the wrong question leads to the wrong answer 23:35 Telling a colleague they were wrong 26:00 Five to one ratio 28:58 Understanding the why 33:57 Simulation in practice 37:35 Quote on learning… Just listen. 41:00 Quizzing and consolidating memory 44:24 Reading the literature as a clinician 50:10 Bottom line 57:10 Outro Tags: clinical, reasoning, diagnosis, diagnostician, accuracy, Osler, misdiagnosis, train, brain, care, test, self, Dhaliwal, Gurpreet, Curbsiders, podcast, patients, cats, funny, educational, inspirational, educator, school, free, doctor, education, family, foam, foamed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, physician assistant, resident, student
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58 min
July 2, 2018
#102: Curbsiders Journal Club Hotcakes and Hot Takes June 2018
Curbsiders’ Journal Club features rapid summary and critical appraisal of recent articles and news stories in internal medicine by The Curbsiders. This month’s topics include: asthma, maintenance versus as needed inhaler use, procalcitonin, Pneumocystis pneumonia prophylaxis, colon cancer screening, smoking cessation, cannabis and cognitive impairment, LDL cholesterol and mortality, plus some medical podcast recommendations. Over the last month, we have developed a list of more than 40 interesting articles and news stories that we have been feeding our own brain holes. From this list we have plucked a select few that we really wanted to highlight and share with you. Join our mailing list to receive a PDF copy of our show notes every Monday! And hey, while you’re here, consider rating us on iTunes and leaving a review. The Curbsiders thank you! We are also on Facebook, Instagram, and Twitter: @thecurbsiders. Credits: Written by: Christopher J Chiu MD, Sarah Phoebe Roberts MPH Producers: Christopher J Chiu MD, Sarah Phoebe Roberts MPH Hosts: Christopher J Chiu MD, Stuart Brigham MD, Paul Williams MD, and Matthew Watto MD Editor: Matthew Watto MD Time Stamps: 00:00 Announcements 00:20 Disclaimer 01:00 Intro to Curbsiders Journal Club 03:07 Mild asthma and as needed versus maintenance inhaler use 09:50 Smoking cessation, e-cigarettes, and financial incentives 17:23 Pneumocystis pneumonia prophylaxis 22:18 Cannabis and cognitive impairment 26:15 Colorectal cancer screening update by American Cancer Society 30:37 Procalcitonin for lower respiratory tract infections in the ED 37:29 Cholesterol, baseline LDL-C, mortality and cardiovascular events 41:01 Incorrect symbology and some podcast recommendations 46:22 Outro Tags: asthma, maintenance, inhaler, procalcitonin, Pneumocystis, pcp, pneumonia, prophylaxis, colon, cancer, screening, crc, smoking, cessation, marijuana, cannabis, cognitive impairment, LDL, cholesterol, mortality, cardiovascular, podcast, assistant, care, doctor, education, family, FOAM, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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49 min
June 25, 2018
#101: Cirrhosis: Medications, decompensation, complications
Cirrhosis. Take control of cirrhosis and treat your patients like the pros! In this episode of The Curbsiders, Dr. Scott Matherly, assistant professor in the Dept of Medicine at Virginia Commonwealth University and board certified hepatologist, builds upon his introduction to cirrhosis. You already know what to look out for and how to diagnose these patients, now it’s time to build your knowledge and medical repertoire against this deadly condition! Topics include: high protein diet, ascites, diuretics, hepatic encephalopathy, lactulose vs rifaximin, portal hypertension, esophageal varices, beta blockers, spontaneous bacterial peritonitis prophylaxis and more pathophysiology! Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits: Written by: Cyrus Askin MD Infographics: Beth Garbitelli Produced by: Cyrus Askin MD and Matthew Watto MD Hosts: Cyrus Askin MD, Matthew Watto MD, Stuart Brigham MD, Paul Williams MD Guest: Scott Matherly MD Time Stamps 00:00 Announcements 00:54 Disclaimer 01:30 Guest bio 02:28 NASH, diet, vitamin E, pioglitazone and prevention of cirrhosis 06:56 Clinical case of decompensated cirrhosis 09:02 Pathophysiology of circulatory dysfunction in cirrhosis and use of diuretics 18:25 Hepatic encephalopathy, ammonia, lactulose and rifaximin 25:10 Timing of medical therapy 26:39 MAP of 82 mmHg, beta blockers and variceal bleeding 31:04 Use of midodrine for hypotension 33:45 Prophylaxis of SBP 36:05 Take home points 38:04 Outro Tags: cirrhosis, liver, high, protein, diet, sodium, restriction, ascites, diuretics, furosemide, spironolactone, hepatic, encephalopathy, lactulose, rifaximin, portal, hypertension, esophageal, varices, beta, blockers, spontaneous, bacterial, peritonitis, prophylaxis, pathophysiology, sbp, assistant, care, doctor, education, family, FOAM, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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39 min
June 18, 2018
#100: Cirrhosis: Initial Evaluation and Management
Cirrhosis. Finally. Take your liver game to the next level with tips from @liverprof, Scott Matherly MD, Assistant Professor of Medicine at Virginia Commonwealth University. Topics include: exam findings in cirrhosis, interpreting liver function tests, incidental cirrhosis on imaging, fatty liver disease, steatohepatitis, hep c, shear wave elastography, screening for varices and hepatocellular carcinoma, pathophysiology, and lifestyle measures for initial management. This episode is sponsored for CME-MOC credit by the American College of Physicians. ACP members can claim free credit at acponline.org/curbsiders (goes live at 9am on release date). Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits: Written by: Cyrus Askin MD CME questions by: Cyrus Askin MD Produced by: Cyrus Askin MD and Matthew Watto MD Hosts: Cyrus Askin MD, Matthew Watto MD, Stuart Brigham MD, Paul Williams MD Guest: Scott Matherly MD Time Stamps 00:00 Announcements 00:45 Disclaimer 01:19 Intro to the show and our guest 04:15 Guest one liner, books recommendations, and career advice 09:04 Cyrus’ pick of the week 10:14 Clinical case of abnormal liver functions tests 11:12 Seven hand findings of cirrhosis 13:28 Should we screen for NASH? 15:28 Incidental finding of cirrhosis on imaging 17:47 Next steps after diagnosis of cirrhosis 20:36 Non-invasive scoring systems to predict cirrhosis 23:55 Liver biopsy 25:33 Shear wave elastography 29:10 Recap of what we learned so far 31:58 Three ways cirrhosis can kill you 33:56 Counseling patients about cirrhosis 36:05 Management of NASH and early  cirrhosis 42:55 Screening for varices and hepatocellular carcinoma 46:28 Outro Tags: cirrhosis, liver, function, shear, wave, elastography, fibroscan, imaging, fatty, liver, disease, nash, nafld, steatohepatitis, hepatitis, hep c, hcv, screening, varices, hepatocellular, carcinoma, pathophysiology, lifestyle, management, assistant, care, doctor, education, family, FOAM, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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48 min
June 11, 2018
#99 Cancer Survivorship: What to do when the treatment is done
Step up your primary care of cancer survivors with tips from Dr Regina Jacob, Assistant Professor of Medicine at Temple University. Care of the cancer patient does not end when their cancer treatment is over, and there is more to a past diagnosis of cancer than surveillance. We discuss cancer survivorship care with Dr. Regina Jacob, including the changing demographics of survivorship, the importance of survivorship care plans, and how survivorship is largely just good primary care. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits: Written by: Paul Williams MD Hosts: Stuart Brigham MD, Matthew Watto MD, and Paul Williams MD Produced by: Paul Williams MD Edited by: Matthew Watto MD Guest: Regina Jacob MD  Time Stamps 00:00 Disclaimer 00:35 Intro to the topic and guest bio 02:15 Guest one liner, book and app recommendations 06:58 Paul’s pick of the week. 07:40 Clinical case, definitions, and phases survivorship 12:36 Survivorship statistics 15:04 Co-survivorship 17:41 Care models for survivorship 20:56 Assigning roles in care of cancer survivors 22:59 Sample survivorship care plan 27:39 Childhood, adolescent and young adult cancer survivorship 34:18 Sexual dysfunction in cancer survivorship Turn down Watto and Regina tracks 35:56 Stressors in young adult cancer survivors 37:33 Fatigue 43:28 Guidelines on survivorship 45:06 Late cardiac toxicity 46:23 Support groups and resources 49:04 Take home points 50:29 Outro  Tags: Survivorship, cancer, breast, ovarian, colon, radiation, chemotherapy, side, effect, fatigue, sexual, dysfunction, care, plan, surveillance, doctor, education, family, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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52 min
June 4, 2018
#98: Knee Pain: History, exam, bracing, x-rays, and injectables
Knee pain is easy with practical tips from Orthopedist, medical educator, car-builder, and inventor extraordinaire Dr. Ted Parks. He teaches us the four buckets of knee pain, how to perform a 30-second knee exam, choose a knee brace, order x-rays, and the red flags to look for in a history and physical that should have you shouting for your closest neighborhood orthopedic surgeon. This episode is brought to you in partnership with the American College of Physicians. ACP members can claim free CME-MOC credit at acponline.org/curbsiders. Check out our video of the Parks-Approved 30-second knee exam! Credits: Written by: Nora Taranto BA, Matthew Watto MD Produced by: Chris Chiu MD and Nora Taranto BA Edited by: Matthew Watto MD. Hosts: Matthew Watto MD, Stuart Brigham MD, Paul Williams MD. Guest: Ted Parks MD.   Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.  Time Stamps 00:00 Announcement 01:00 Disclaimer 01:35 Intro and guest bio 04:08 Dr Parks’ one-liner, book recommendation, inventions, and career advice 10:52 A case of knee pain, and recognizing emergencies 14:17 Four buckets of knee pain 17:40 Initial approach to treatment of knee pain 20:19 Corticosteroid injection controversy 22:47 Hyaluronic acid injections 24:50 Topical agents 27:03 Taking a history about knee pain 29:39 Knee locking or giving out Practical Office Orthopedics by Ted Parks 31:44 How to order knee X-rays 36:45 Knee braces 41:00 How to perform a 30 second knee exam Ms Anita Bones has left knee pain and recent fall. 53:00 PRP, stem-cell injections 61:00 Glucosamine chondroitin 63:09 Take home points 64:36 Outro Tags: orthopedics, knee, pain, ortho, joint, exam, osteoarthritis, arthritis, xray, physical, injection, corticosteroid, hyaluronic, hyaluronate, prp, stem, cell, bracing, nsaids, glucosamine, chondroitin, assistant, care, doctor, education, family, FOAM, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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65 min
May 28, 2018
#97: Curbside Journal Club: Hotcakes and Hot Takes May 2018
Keep current with this monthly journal club covering landmark articles through May 2018, plus rapid fire hot takes from the medical literature and health news. We rate each article according to a highly scientific ‘Hotcakes’ scale to highlight what practice-changing knowledge we’ll take to work this month. Topics: Hypertension, blood pressure monitoring, prostate cancer screening, Intimate Partner Violence screening, alcohol is killing you, new diabetes drugs and mortality, DPP-4 inhibitors and IBD risk, NT-proBNP-guided therapy vs usual care, effect of teaching status on mortality, and more! If you’re a listener and have something interesting for us to discuss, please send it our way. Join our mailing list to receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. We are also on Facebook, Instagram, and Twitter: @thecurbsiders. Credits: Written and produced by: Christopher J Chiu MD, Sarah Phoebe Roberts MPH Hosts: Christopher J Chiu MD, Stuart Brigham MD, Paul Williams MD, and Matthew Watto MD Editor: Matthew Watto MD Time Stamps:  00:00 The Curbsiders need a web master 00:50 Disclaimer 01:25 Intro to the format 03:25 Ambulatory BP monitoring and mortality 09:08 Blood pressure treatment strategies: CVD risk score vs systolic BP targets 14:14 Repeated BP measurements important at office visits and future directions of BP management 21:25 Hot takes in order of appearance: Prostate cancer screening, intimate partner violence, alcohol, DPP4 inhibitors mortality and IBD, teaching status and mortality in US hospitals, 5 lifestyle factors that may add to life expectancy, NT pro-BNP, BNP and mortality 38:12 Outro Tags: Hypertension, blood, pressure, monitoring, cuff, automatic, ambulatory, prostate, cancer, screening, Intimate, Partner, Violence, alcohol, mortality, DPP4, sglt2, glp1, IBD, risk, BNP, teaching, assistant, care, doctor, education, family, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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39 min
May 21, 2018
#96: Diabetes: A1C targets & ACP guidelines controversy
Get schooled on hemoglobin a1c targets in type 2 diabetes mellitus by American College of Physicians guidelines coauthor, Devan Kansagara MD MCR, Associate Professor of Medicine, Oregon Health Sciences University. We summarize outcomes from the landmark diabetes trials (ACCORD, ADVANCE, VADT, UKPDS 33 & 34), how a1c targets effect microvascular and macrovascular events, estimating life expectancy, and how to personalize diabetes control for your patients. We’re proud to announce our new partnership with the ACP to provide free CME credit and MOC points on select episodes of The Curbsiders. ACP members can visit acponline.org to redeem free CME/MOC credit. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list to receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits: Written, produced, and edited by: Matthew Watto MD. Hosts: Stuart Brigham MD, Paul Williams MD, Matthew Watto MD. Guest: Devan Kansagara MD, MCR Time Stamps 00:00 Announcement 00:48 Disclaimer and intro 03:11 Getting to know our guest: one liner, book recommendation, mentorship 06:50 How and why did ACP write their guidance statement on diabetes, A1C targets 09:18 Landmark trials in type 2 diabetes 11:36 Does tight control prevent micro or macrovascular complications 13:20 Trials of newer agents like SGLT2i, GLP-1 and DPP4i 14:33 How do ACP’s guidelines differ from other published guidelines 17:20 Quick recap of landmark trial findings 22:24 Personalizing glycemic control 24:30 Controversy over an A1C goal of 7-8% 28:05 Clinical inertia 30:26 Legacy effect and metabolic memory 34:00 Deintensifying therapy 38:29 Life expectancy and comorbid conditions 43:15 Performance measures in diabetes 44:42 Take-home points 46:30 The Curbsiders recap and give some closing remarks 49:13 Outro  Tags: diabetes, a1c, target, dm, hypoglycemia, glycemic, intensive, tight, glucose, control, cardiovascular, risk, outcome, mortality, death, metformin, insulin, acp, guideline, accord, advance, vadt, ukpds, microvascular, macrovascular, aace, ada, VA, DoD, assistant, care, doctor, education, family, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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50 min
May 14, 2018
#95: Food allergy, food intolerance and celiac disease
Separate the wheat from the chaff when it comes to food allergy, food intolerance, and celiac disease. Featuring renowned gastroenterologist and current president of the American Gastroenterological Association, Dr. Sheila Crowe MD FRCPC FACP FACG AGAF, we discuss how to differentiate a food allergy from an intolerance, what diagnostic testing is appropriate, and why fructans might be the real culprit in patients with ‘gluten sensitivity’. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Credits: Written by: Sarah P. Roberts, MPH Guest: Sheila Crowe, MD Hosts: Matthew Watto, MD; Stuart Brigham, MD; Paul Williams, MD Producers: Sarah P. Roberts, MPH and Chris Chiu, MD Editor: Matthew Watto, MD Time Stamps: 00:00 Disclaimer 03:35 Getting to know our guest, book recs, and career advice 10:35 Clinical case 11:40 Defining allergy, intolerance 14:05 Food intolerance and FODMAP 18:02 Taking a history in patient with potential food allergy vs intolerance 21:34 Dermatitis herpetiformis, gluten ataxia, and extraintestinal manifestations of celiac 26:12 Diagnosing celiac disease 30:53 Next steps if celiac testing is negative; lactose, fructose intolerance, IBS 33:48 Non-celiac gluten sensitivity (NCGS) 37:48 Study of NCGS 40:41 Olmesartan and drug-induced enteropathy 43:38 Dieticians, dietary recs, elimination diets 48:10 “Voodoo” testing 52:36 Counseling patients on diet 54:35 Take home points 55:50 Outro Tags: food, allergy, intolerance, sensitivity, celiac, disease, diarrhea, diet, fodmap, paleolithic, paleo, weight, loss, lactose, olmesartan, refractory, protein, gluten, fructan, wheat, anaphylaxis, tTG, genetic, gene, testing, assistant, care, doctor, education, family, FOAMim, FOAMed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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57 min
May 7, 2018
#94: Random Pearls: Microbiome, POTS, Gabapentin, and Leonardo Da Vinci
A random serving of knowledge food for your brain hole with returning guest, Dr. Alan Dow, Professor of Internal Medicine at Virginia Commonwealth University School of Medicine. Our final live recap show from ACP 2018 covering: human microbiome, copper deficiency, POTS syndrome, substances of abuse, drugs for delirium and how to be more like Leonardo Da Vinci. Please let us know what you liked, didn’t like and how we can make the show better. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. We are also on Facebook, Instagram, and Twitter: @thecurbsiders. Time stamps: 00:00 Disclaimer 01:30 Guest bio 03:19 Getting to know our guest, podcast, and book recommendations 08:55 Human microbiome 11:05 A case of anemia and neuropathy 13:30 Physiology and treatment of POTS syndrome 17:00 Novel substances of abuse 20:17 Benzodiazepines for delirium 24:00 Leonardo Da Vinci versus the modern physician 27:18 Outro Tags: microbiome, transplant, bupropion, gabapentin, pregabalin, copper, POTS, substance, use, disorder, leonardo, da, vinci, acp, journal, article, literature, news, media, doctor, education, family, foam, foamed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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28 min
April 30, 2018
#93: Clinical Pearls ACP 2018 with Nina Mingioni MD
A fast moving recap of hot topics and clinical pearls live from Internal Medicine’s largest national conference, ACP 2018 in New Orleans! Dr. Nina Mingioni, Clinical Associate Professor and director of Undergraduate Medical Education in Internal Medicine at Thomas Jefferson University Hospital serves up some knowledge food for our brain holes. Topics: the athlete as a patient, sports physicals, food as medicine, medical marijuana (cannabis), and more! Listeners, please let us know what you liked, didn’t like and how we could make this better. YouTube video of this episode available here: ACP 2018 Recap with Nina Mingioni.  You can join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. We are also on Facebook, Instagram, and Twitter: @thecurbsiders.    Time stamps: 00:00 Music and disclaimer 02:48 Getting to know our guest 06:07 The athlete as a patient 10:20 Relative energy deficiency in sports 12:00 Drug interactions 15:51 Food as medicine 21:56 Marijuana 30:24 Outro Credits:  Written by: Nina Mingioni MD, Hannah Abrams. Producer/videographer: Chris Chiu MD. Hosts: Matthew Watto MD, Stuart Brigham MD, Paul Williams MD. Editor: Matthew Watto MD Tags: food, microbiome, marijuana, athlete, ekg, ecg, physical, sports, training, energy, relative, deficiency, cannabinoid, entourage, effect, cannabidiol, thc, cannabis, acp, 2018, assistant, care, doctor, education, family, foam, foamed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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31 min
April 23, 2018
#92: Pulmonary Embolism for the Internist
Wow the crowd with your knowledge of pulmonary embolism! What are the red flags? What tools are available to guide you? How on Earth do you triage a patient with pulmonary embolism (PE)? What exactly is the RV spiral & how do PEs really cause morbidity and mortality?! Get schooled by pulmonary embolism expert, Dr. Oren Friedman, associate director of the Cardiac-Surgical Intensive care unit at the Cedars-Sinai Heart Institute. Doctors Cyrus Askin and Chris Chiu join as co-hosts. Test Yo’ Self Pulmonary embolism quiz Written by Cyrus Askin, MD, Justin Berk, MD, MBA, MPH. Figure by Cyrus Askin, MD. Edited by Matthew Watto, MD Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.  Time Stamps 5:10 - Start of Interview / Introduction 10:00 - Case Presentation - Introduction of DVT / PE Spectrum and Pathophysiology 16:18 - How to Triage and Work-Up Pulmonary Embolism (CT, Echo, troponins, “eyeball”) 23:30 - Other ways to risk-stratify (Other CT findings, clot burden) 28:45 - What does a low-risk patient look like? 30:35 - When to consider treatment modalities other than general anticoagulation 35:12 - Anticoagulation treatment options 36:38 - Next step intensive interventions after anticoagulation 42:00 - Evidence behind catheter-directed lysis 44:05 - IVC Filter discussion 47:22 - Discharge criteria for PE 50:00 - Incidental PEs 52:40 - Interdisciplinary PERT Team Tags: pulmonary, embolism, thrombolysis, heparin, anticoagulation, right, ventricle, RV, left ventricle, LV, circulation, hypotension, shock, IVC, vena, cava, filter, catheter, TPA, echocardiogram, CT, scan, computed, tomography, shock, bleed, clot, deep, vein, thrombosis, vte, venous, embolism, assistant, care, doctor, education, family, foam, foamed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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57 min
April 21, 2018
Random Clinical Pearls ACP 2018 Day 2
Random clinical pearls from day 2 of ACP 2018 live in New Orleans. Topics include: Perioperative medicine, DOACs, anticoagulation, reversal agents, ACP statements on hidden curriculum, physician well being and burnout, modeling behavior, dermatology pearls, rashes, venous stasis ulcers, pentoxifylline, biotin and Grave's disease, dermatology pearls, Stuart's tips on sports doping, and how chocolate milk improves recovery time. Doctors Chris Chiu and Chris Thrash join us to discuss their favorite teaching points from today's sessions. Cochrane Review on Venous Ulcers https://bit.ly/2JdQAMu Joinour mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.
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22 min
April 20, 2018
Random Clinical Pearls ACP 2018 Day 1
The Curbsiders share random clinical pearls from day 1 of ACP 2018 live in New Orleans. Topics covered include: breast density and cancer risk, patients before paperwork, diverticulitis, social determinants of health, migraine prevention, PrEP and thunderclap headaches. Doctors Chris Chiu and Chris Thrash join us on air to discuss their favorite teaching points from today's sessions. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.    
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18 min
April 16, 2018
#91: Curbside Journal Club: Hotcakes and Hot Takes April 2018
Keep up-to-date with this fast moving discussion of recent journal articles and thought-provoking headlines in medicine. Welcome to the first-ever Curbsiders journal club covering landmark articles from March to April 2018, plus rapid fire hot takes and the unveiling of our new hotcake based rating system. Please let us know what you liked, didn’t like and how we can make this better next month. Topics: Resident work hours, saline versus balanced IV fluids, barber shops and hypertension, coffee causes cancer, Twitter based medicine, clonidine versus spironolactone, opioids versus nonopioids and aromatherapy for nausea! Written by: Chris J Chiu, MD; Producer: Sarah Phoebe Roberts MPH; Edited by: Matthew Watto, MD Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. We are also on Facebook, Instagram, and Twitter: @thecurbsiders.  Time stamps: 00:00 Disclaimer 00:35 Host intros, featuring special guest and correspondent Chris Chiu, MD 01:30 Introducing a new Curbsiders segment! 03:20 First article: Duty-Hour Flexibility Trial 08:55 Second article: Trial of Blood-Pressure Reduction in Black Barbershops 14:27 Third article: SALT-ED Trial 20:00 Hot takes—intro 20:36 Hot take #1, Dr. Milton Packer and Twitter-based medicine 24:07 Hot take #2, Coffee and cancer risk 26:24 Hot take #3 Aromatherapy for nausea 28:10 Hot take #4 Opiates vs. non-opiates for chronic pain 29:00 Hot take #5, Surgeon general’s statement on naloxone 29:46 Hot take #6, Spironolactone vs clonidine for resistant HTN 31:54 Outro & announcements Tags: duty, hours, salt, balanced, ivf, saline, normal, barber, shop, hypertension, alcohol, nausea, spironolactone, clonidine, coffee, cancer, opioid, pain, naloxone, twitter, journal, article, literature, news, media, doctor, education, family, foam, foamed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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33 min
April 9, 2018
#90: Clinical Reasoning: Become an expert diagnostician
Become an expert diagnostician like Dr Gurpreet Dhaliwal, Professor of Medicine at UCSF. Join us for this deep dive into clinical reasoning and how doctors think! Topics include: how to improve your own clinical reasoning and diagnostic skills, how to teach these skills, and the initial steps to building your own expertise/mastery in clinical medicine! Dr. Osler once admonished his students to build experiential wisdom and follow-up with their clinical cases (clear cases, doubtful cases, and mistakes), but to do so, one must “...learn to play the game fair, no self-deception, no shrinking from the truth; mercy and consideration for the other man, but none for yourself, upon whom you have to keep an incessant watch.” Test yo’ self: Take our quiz here Written and produced by:  Stuart Brigham, MD; Images by Hannah Abrams; Edited by:  Matthew Watto, MD Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Goal: Listeners will gain an appreciation for the Clinical Reasoning process and the difficulties that underpin building expertise in medicine. Learning objectives: After listening to this episode listeners will… Develop an appreciation for clinical reasoning. Recall the importance that the educator plays in role modeling. Learn how to improve diagnostic accuracy by keeping a patient log. Identify the common nomenclature used in clinical reasoning and how teaching this common verbiage could serve to improve diagnostic accuracy Recognize that misdiagnosis is common in clinical practice and every clinician could benefit from deliberate practice. Explain the difference between experience and expertise. Time Stamps 00:00 Disclaimer, Intro 02:30 Guest Bio 04:50 Dr. Dhaliwal 06:45 Book recommendation 09:14 App recommendation 11:34 Advice for learners and teachers (Pearl #1) 12:40 Can a computer out-think a human? 15:49 Defining Clinical Reasoning 18:38 “Train the Brain” introduced 20:30 Knowledge is a precondition 21:46 A learner who lacks synthesis 24:23 How to provide learner feedback 27:04 Defining problem representation, illness scripts, etc. 29:20 How to start teaching clinical reasoning 31:00 Focus on the “why” and not the “what” 32:11 Teaching the nomenclature of clinical reasoning 36:07 “You can’t get the right answer if the brain is solving the wrong problem” 36:34 Osler and his “Incessant Watch” 40:40 Being wrong feels exactly the same as being right 42:00 Patient tracking (Dr. Dhaliwal’s recommendation) 45:30 Why keeping a patient log is so important 47:00 Are heuristics beneficial? 48:55 Can you debias yourself? 50:00 “Going slow just makes you slow.” 52:00 All evidence has flaws, but knowledge is still king. 55:13 Clinical reasoning on multi-disciplinary teams 59:27 Take-home points Tags: clinical, reasoning, diagnosis, diagnostician, accuracy, Osler, misdiagnosis, train, brain, care, test, self, Dhaliwal, Gurpreet, Curbsiders, podcast, patients, cats, funny, educational, inspirational, educator, school, free, doctor, education, family, foam, foamed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, physician assistant, resident, student
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64 min
April 2, 2018
#89: Conjunctivitis: Red Eye in Pr-eye-mary Care with Dr Glaucomflecken
Revolutionize your approach to the red eye in pr-eye-mary care! Dr. Glaucomflecken (of GomerBlog/Twitter--fame) teaches us to recognize and manage common eye complaints. You’ll develop an approach to diagnosing and treating your patient with the dreaded red eye. We answer: What presentations should have us running down the hallway for that prized ophtho consult? What on earth does glaucomflecken stand for? Which eye drops are best? What is an eye dentist? Plus, answers to your twitter questions, and so much more! By the end of this episode, you’ll be sure to say “Eye Understand!” Self Assessment Questions: Take the ophtho self-assessment! Donate at FirstDescents.org to support young cancer survivors like Dr. Glaucomflecken! Written and produced by: Nora Taranto AB, Carolyn Chan MD; Original art by: Bryan Brown, MD. Edited by: Matthew Watto, MD. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.  Times Stamps 00:00 Disclaimer 02:33 Guest bio 04:15 Dr Glaucomflecken 05:40 Best advice as a learner 06:05 Book recommendation 07:33 App recommendation 08:32 Clinical case 10:02 Corneal ulcers and contact lense hygiene 12:10 Indicators of urgent eye problems 13:39 The eye exam 18:00 Visual acuity exam without an eye chart 21:15 Approach to the red eye, blepharitis, allergic conjunctivitis 23:45 Approach to vision loss 25:52 Angle closure glaucoma, and other emergencies 27:37 Bacterial conjunctivitis 29:00 Viral conjunctivitis 31:26 Return to school or daycare after “pink eye” 34:00 Rundown of common eye medications 38:35 OTC redness relievers 40:30 Breast milk eye drops?! 42:07 How to correctly use an eye drop bottle 44:16 What does Glaucomflecken mean? 45:40 Questions from Twitter: Floaters, diabetic retinopathy treatments, blurry vision from high glucose 50:15 Eye dentists? 53:10 Take home points 54:28 Plug for First Descents charity 56:54 Outro Tags: eye, ophthalmology, eyedrop, GOMER, conjunctivitis, twitter, red, glaucoma, glaucomflecken, acute, angle, closure, glaucoma, bacterial, viral, blepharitis, assistant, care, doctor, education, family, foam, foamed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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58 min
March 26, 2018
#88: Acid base, boy bands, and grandfather clocks with Joel Topf MD
Dominate acid-base disturbances with the wisdom of @kidney_boy aka Joel Topf, MD, Chief of Nephrology at Kashlak Memorial Hospital.  Master his 5 key steps for interpreting acid-base disorders and decode any ABG, VBG, and BMP to find the primary disorder, and any other disorders tucked away in the ABG! Plus: Henderson-Hasselbach and pH simplified; the anion gap, should your correct it?; choice of IV fluid; osmolar gaps, methanol, ethylene glycol, isopropyl alcohol; and how metabolic disorders are like a boy band. Be sure to follow along the Dr. Topf’s brilliant acid-base powerpoint. Written and produced by Joel Topf MD, Shreya Trivedi MD, Xavi Jimenez MD; Images by Hannah Abrams; Edited by Matthew Watto MD Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.  Time Stamps 00:00 Announcement 01:00 Disclaimer 01:34 Intro 02:45 The setup and guest bio 03:15 How does Dr Topf compensate for difficulty 07:10 What has helped Dr Topf become successful as an educator 10:40 With which electrolyte do you most closely identify? 14:05 Picks of the week 16:05 Nephmadness explained 19:50 Joel’s big picture look at acid base 22:17 Acid base and logorhythmic scale 24:28 A caution about ABGs 27:23 Clinical case from Kashlak Memorial Hospital 28:05 Misinterpretation of low bicarb on a metabolic panel 29:20 Step 1 of acid base 32:00 Metabolic disorders and One Direction 35:15 Acidemia vs acidosis; alkalemia vs alkalosis 37:52 Compensation for acid base disorders 40:45 ABG apps and analyzers 42:40 Step 2 Is there a second primary disorder? Use equations for determining if compensation is appropriate. 51:31 How to determine if respiratory compensation is acute or chronic 54:26 Step 3 The anion gap 57:21 Correcting the anion gap 60:33 What causes a low anion gap? 63:58 Anion gap acidosis 66:05 GOLDMARK 69:15 Step 4 Is there an osmolar gap? 71:48 Toxic ingestions: Methanol, ethylene glycol, and isopropyl alcohol 76:15 Calculating the osmolar gap 79:08 Step 5 Gap-gap calculation aka “the bicarbonate before” 85:05 Choice of IV crystalloid fluid and when to use a bicarbonate drip 88:15 Bicarbonate in DKA 90:18 NephMadness plug 91:10 Outro Tags: acid, base, anion gap, metabolic, respiratory, toxic alcohol, goldmark, mudpiles, albumin, acidosis, alkalosis, compensation, nephrology,  Henderson-Hasselbalch, equation, ABG, VBG, bicarbonate, pCO2, assistant, care, doctor, education, family, foam, foamed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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93 min
March 19, 2018
#87: Toxicology 101: Talking Tox with The Dantastic Mr. Tox & Howard
Want to look cool like a toxicology consultant, sipping coffee on rounds? Ever check a patient for armpit sweat? Learn the secrets of tox from the titans of toxicology podcasting, The Dantastic Mr. Tox & Howard (AKA Dr. Dan Rusyniak and Dr. Howard Greller), as they loquaciously dish on all things tox. Topics include: how to approach the patient with an unknown overdose, are toxidromes clinically useful, clues on physical exam, is GI decontamination still recommended, and why they hate bupropion and tramadol. We recommend cautious ingestion of fluids while listening because this was a seriously funny episode. Try our Self Assessment Questions Toxicology 101 Quiz. Written and produced by: Christopher Chiu, MD; Graphics by: Beth Garbitelli; Edited by: Matthew Watto, MD Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.  Time Stamps 00:00 Disclosures 00:35 Intro 01:19 Guest bios both real and sarcastic 04:38 Getting to know our guests 06:33 Multiple choice toxicology 09:13 Book recommendations 11:30 Advice for learners and teachers 15:48 Clinical case from Kashlak Memorial Hospital 16:27 Initial approach and some thoughts on toxidromes 21:59 Physical exam, a toxicologist’s approach 27:09 Review of physiology: anticholinergic, cholinergic, sympathomimetic and how to recognize these findings on exam 34:18 Different speech patterns seen in toxicology 35:30 History taking and how much detective work is truly necessary 40:05 The approach to overdose on multiple substances or in setting of polypharmacy 45:52 Seinfeld, ipecac, and the controversy about gastrointestinal decontamination 63:10 Antidotes and when to give them 67:15 EKGs and overdose. Antidote for long QTc versus wide QRS 71:25 Tramadol and Egypt 73:45 Bupropion and bath salts 78:00 Outro Tags: antimuscarinic, anticholinergic, cholinergic, sympathomimetic, overdose, tramadol, bupropion, quetiapine, wellbutrin, seroquel, pupil, overdose, naloxone, narcar, toxicology, tox, toxidrome, poisoning, gi, decontamination, charcoal, ipecac, antidote, dantastic, howard, ekg, qrs, qtc, bicarbonate, assistant, care, doctor, education, family, foam, foamed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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79 min
March 12, 2018
#86: COPD: Diagnosis, treatment, PFTs, and nihilism
Take a deep breath and tune in to this week’s episode full of COPD diagnosis and management pearls, with expert Dr. Denitza Blagev, a pulmonologist, intensivist, and Medical Director for Quality, Speciality Care at Intermountain Healthcare in Utah with a particular interest in physician wellness and issues related to women in medicine. We cover: history taking, interpreting PFTs, patient counseling, inhalers and medications, exacerbations, antibiotics, steroids, and who needs BIPAP...so basically everything you ever wanted to know about chronic obstructive pulmonary disease. Take our self assessment here. Sponsored by @nephmadness. Registration opens March 15th at AJKDblog.org Written and produced by: Leah Witt, MD, Cyrus Askin, MD. Edited by Matthew Watto, MD Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 NephMadness announcement 01:10 Disclaimer 01:45 Intro 03:50 Guest bio 05:03 One liner; What advice would you give our younger self?; Should I do a fellowship?; Book recommendations 10:30 Picks of the week 15:50 Case of COPD from Kashlak Memorial 16:55 Initial approach to a potential case of COPD 18:34 Misdiagnosis of COPD 20:10 Classic spirometry in COPD and GOLD 0 21:30 Diagnosis of emphysema 23:18 Diagnosis of chronic bronchitis 24:54 Counseling the patient with a new diagnosis of COPD 27:00 Spirometry 28:45 How to read PFTs 33:29 How to order PFTs and get what you want 36:00 Why does pre- and post-bronchodilator response matter? 38:45 Asthma COPD overlap syndrome 40:13 Staging of COPD, does it matter? 42:50 Prognosis in COPD 45:00 Therapies with mortality benefit 48:29 Therapies to improve symptoms and prevent exacerbations 52:00 Azithromycin as chronic therapy 53:00 Counseling patients on therapy 55:00 Short acting inhalers in COPD 56:20 Treatment of COPD exacerbations 59:18 Antibiotics, who needs them in exacerbation 61:52 Nebulized inhaled steroids 63:18 Duration of antibiotics and steroids during an exacerbation 66:30 Who needs BIPAP chronically? 69:22 Who needs BIPAP during an exacerbation? 71:33 How often should PFTs be repeated? 73:00 When should we suspect PE in COPD exacerbation? 74:25 Which labs should be check in the initial COPD workup? 76:46 Take home points Tags: copd, chronic, pulmonary, disease, asthma, emphysema, bronchitis, inhaler, nebulizer, steroids, embolism, exacerbation, bipap, cpap, antibiotics, azithromycin, doxycycline, mortality, oxygen, spirometry, dlco, fev1, fvc, pfts, #nephmadness, assistant, care, doctor, education, family, foam, foamed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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80 min
March 5, 2018
#85: Contraceptives: Pills, mini pills, and tiny pills
Contraception simplified with clinical pearls from reproductive health and family planning experts, Dr Angeline Ti, and Dr Moira Rashid. We cover it all including: the menstrual cycle, mechanism of action for various methods of birth control, hormonal versus nonhormonal contraceptives (e.g. intrauterine devices, patches, pills, rings, implants), patient counseling, and lots of resources to make your job easier. Women’s health correspondent, Dr Molly Heublein returns as cohost. Take our self-assessment quiz! Written by: Molly Heublein, MD, Beth Garbitelli and Sarah Roberts, MPH. Edited by Matt Watto, MD Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Disclaimer 00:35 Intro 01:32 Guest bios 03:45 One liners, app recommendations, picks of the week 09:32 Picks of the week 12:45 Intro to contraception and a clinical case 13:33 Starting a conversation about contraception 16:55 Is having a period needed? And, which agents cause amenorrhea? 19:28 The menstrual cycle reviewed 23:29 Pros and Cons of long acting progesterone only agents 26:55 Choosing between IUDs 30:00 Who should get a copper IUD 30:53 Mechanism of hormonal IUDs 31:37 Risk with IUDs 34:05 Why are there so many OCPs? 36:05 Counseling patients on risks of OCPs 38:00 Risk of breast cancer with hormonal contraception 42:10 Benefits of hormonal contraception 43:38 Migraines and hormonal contraception 44:53 Mono- vs bi- vs triphasic pills. Does it matter? 46:15 Starting dose for OCPs 48:31 Is the mini pill effective? 49:37 Patches and rings 51:15 Take home points 52:40 Whoops, almost forgot emergency contraception! 56:32 How do copper IUDs work? 58:10 The Curbsiders recap the episode, plus some clinical pearls from Molly about birth 65:00 Outro Tags: contraception, birth control, IUDs, LARCs, mirena, skyla, lilletta, Paragard, OCPs, minipill, birth, control, pills, menstruation, follicular, phase, luteal, side, effects, emergency, contraceptives, ulipristal, ella, plan B, levonorgestrel, women’s, health, internal, medicine, internist, primary, care, family, practice, nexplanon, depo-provera, breast, cancer, family, planning, CDC, MEC, eligibility, criteria, bedsiders, pregnancy, ovulation, meded, foamed, nurse, student, physician, assistant, doctor
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66 min
February 26, 2018
#84: Anemia, Iron Deficiency, IV iron, and Tony Stark
Abolish anemia, and iron deficiency w/tips on IV iron therapy from real life iron man, Michael Auerbach, MD, FACP, Clinical Professor of Medicine Georgetown University School of Medicine. Topics include oral versus IV iron therapy, safety of IV iron, ferritin cutoffs, and how to diagnosis/ treat iron deficiency in patients with chronic inflammation, chronic kidney disease, pregnancy, heart failure, and more! Take our Self Assessment Test Here. Images by Beth Garbitelli; Written and produced by Justin Berk, MD and Matthew Watto, MD. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Disclaimer 00:35 Intro 01:27 Listener feedback 02:35 Guest bio 04:49 Basics of diagnosing iron deficiency, ferritin, soluble transferrin receptor, a new definition 07:09 Getting to know our guest 08:27 Book recommendations 09:33 Brief history of iron deficiency and IV iron 15:20 Iron deficiency from menorrhagia 19:55 IV iron cures symptoms of iron deficiency, pica immediately 20:40 Iron and neurologic symptoms, restless leg syndrome 23:30 Iron restricted erythropoiesis, anemia of chronic inflammation 26:02 Overview of iron absorption 28:35 Iron deficiency without anemia, treatment 33:52 Time to improvement with iron therapy 34:45 Indications for IV iron 38:09 Comparing the oral iron formulations 40:05 Iron deficiency and pregnancy 42:54 Diagnosis of iron deficiency 46:20 Should IV iron be given to patients getting blood transfusion 48:40 Is iron safe during active infection? 49:17 Iron in congestive heart failure 51:50 Questions from social media 53:35 Minor infusion reaction from IV iron 54:35 Comparison of different IV iron formulations 57:35 Take home points 60:35 Outro Tags: iv, iron, ferrous, sulfate, ferric, sucrose, dextran, anemia, deficiency, oral, dosing, fatigue, pregnancy, ckd, heart, failure, chf, bleed, blood, loss, ferritin, transferrin, erythropoiesis, esa, transfusion, reaction, infusion, assistant, care, doctor, education, family, foam, foamed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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62 min
February 19, 2018
#83: Valvular heart disease, anticoagulation, TAVR, and primary care
Get the latest on valvular heart disease: TAVR vs SAVR, choice of valve type, rheumatic heart disease, antibiotic prophylaxis for endocarditis, who needs an echocardiogram, and anticoagulation goals with tips from cardiologist, Dr Eli Gelfand, Section Chief of General Cardiology at Beth Israel Deaconess Medical Center in Boston and an Assistant Professor of Medicine at Harvard Medical School. Correspondent Dr Kate Grant joins us for this conversation w/Dr Gelfand about his common sense approach to the evaluation and management of valvular heart disease. Written by Kate Grate, MD and Matthew Watto, MD. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Disclaimer 00:35 Intro 02:55 Guest bio 04:15 Getting to know our guest 12:18 Picks of the week 17:07 Clinical case of aortic stenosis 18:00 Types of valve procedures available and initial workup for valvular disease 26:11 Counseling patients about a heart murmur 29:33 Symptoms in valvular heart disease 31:07 Who needs an echo? 32:36 Who needs a referral? 34:40 Frequency of echocardiogram 36:25 Medications for valvular heart disease 39:12 Diuretics and aortic stenosis 40:40 Medication for mitral stenosis and anticoagulants in valvular heart disease 43:31 INR goals and use of ASA by valve type and position 45:23 Endocarditis prophylaxis 48:50 Rheumatic heart disease 51:55 Valvulitis and a quick history lesson 53:50 Transaortic valve replacement 57:58 Multidisciplinary teams and how to determine if valve is causing symptoms 62:14 Take home points 63:47 Closing thoughts from The Curbsiders 66:15 Outro Tags: valve, heart, disease, valvular, cardiomyopathy, failure, systolic, murmur, aortic, mitral, tricuspid, surgery, tavr, diuretic, rheumatic, stenosis, regurgitation, echo, echocardiogram, repair, replacement, inr, anticoagulation, assistant, care, doctor, education, family, foam, foamed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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68 min
February 12, 2018
#82: Dementia Dos and Don’ts: The GeriSiders
Challenge your beliefs on the efficacy of pervasive treatments used in dementia with expert Eric Widera, MD, Professor and clinician-educator in the Division of Geriatrics at the University of California-San Francisco. We explore the use of cholinesterase inhibitors, antipsychotics for behavior disturbances, feeding tubes, medications and supplements used for weight gain (inspired by Choosing Wisely and the American Geriatric Society’s “Ten Things Clinicians and Patients Should Question”). Plus, we introduce our new correspondent, Dr. Leah Witt, Geriatrics Fellow at UCSF. Written and produced by: Jordana Kozupsky, NP, Nora Taranto, MS3, Leah Witt, MD; Edited by: Matthew Watto, MD Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Self Assessment Questions Take the quiz now!  Time Stamps 00:00 Disclaimer 00:37 Guys set up the show 02:00 Dr Widera’s bio 03:15 Getting to know our guests 13:10 Picks of the week 16:40 Clinical case: new diagnosis of dementia 17:40 Discussing dementia with patients and caregivers 23:42 Cholinesterase inhibitors 27:35 Stopping cholinesterase inhibitors 33:35 Follow up to therapy 36:05 Dealing with behavior disturbances 39:15 DICE approach 44:17 Risks of antipsychotic medications 48:00 Use of benzos or sedative hypnotics 49:45 Melatonin for delirium or sleep 52:00 Mirtazapine 53:54 Clinical case: patient with dementia not eating 54:40 Feeding tubes 59:40 Dysphagia and NPO orders 62:04 Misinformation on malnutrition and girth creep 65:10 Thickened liquid challenge 70:25 Appetite stimulants 72:38 Megestrol 73:54 Take home points from Dr Widera 79:17 Outro Tags: dementia, donepezil, cholinesterase, inhibitor, antipsychotic, behavior, disturbance, agitation, benzodiazepine, supplement, feeding, tube, restraints, thickened, liquids, geriatric, choosing, wisely, american, society, ags, assistant, care, doctor, education, family, foam, foamed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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81 min
February 5, 2018
#81: Placebos, nocebos, and the doctor as a placebo
Boost treatment efficacy and amplify the “doctor as a placebo” phenomenon with tips from placebo expert (and ex-cartoonist), Mark W. Green, MD, Director of Headache/Pain Medicine and Professor of Neurology, Anesthesiology, and Rehabilitation Medicine at the Icahn School of Medicine at Mount Sinai. Topics include: What’s that pesky sugar pill actually doing to us? Why do we get a boost from taking medicines that have no active compounds within them? How does placebo work? How can it be leveraged? What does it mean for study design/blinding? And what’s with its pesky dark twin--the nocebo effect? “Enjoy this, our only placebo-controlled episode”  (Thanks, Stuart!). Written and produced by: Molly Heublein, MD and Nora Taranto MS3; Edited by: Matthew Watto, MD Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.  Time Stamps 00:00 Disclaimer 00:37 Intro banter 01:30 Picks of the week 08:02 Getting to know our guest 14:00 Clinical case of pain 15:08 Placebo hierarchy 17:19 Non-inferiority studies 18:20 Clinical trials, placebo, eligibility creep and regression to the mean 22:04 Nocebo response 27:05 Physiologic response to placebo 29:13 Placebo amplification 30:18 Caffeine experient Dr Green reports no relevant financial disclosures 32:47 How to counsel patients interested in alternative or ineffective therapy 34:22 Surgery and placebo; sham surgery 37:15 Open-label placebo and genetic response to placebo 42:04 Blinding in placebo controlled trials may be ineffective 43:53 Script for counseling patients on alternative therapy 45:51 Take home points 47:56 The Curbsiders recap and lessons learned 52:52 Outro  Tags: placebo, nocebo, study design, dopamine, opioids, COMT, pain relief, therapeutic relationship, research protocol, randomized controlled study, non-inferiority, assistant, care, doctor, education, family, foam, foamed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student  
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52 min
January 29, 2018
#80: Pulmonary hypertension, freeways, and cows in heart failure
Pulmonary hypertension deconstructed with clinical pearls from cardiologist, John J. Ryan MD, FACC, FAHA, director of University of Utah Pulmonary Hypertension Center. We discuss classification, diagnosis/differentiation, initial workup, additional testing, echo findings, how to counsel patients with pulmonary hypertension, and why cows never get ankle edema! Written and produced by: Jordana Kozupsky, NP and Matthew Watto, MD Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps: 00:00 Disclaimer 01:30 Introducing our new Correspondent Jordy 03:05 Listener feedback 04:40 Guest bio 06:25 Getting to know Dr Ryan 09:33 Picks of the week 15:20 Clinical case 16:35 How to explain pulmonary hypertension to a patient 18:12 Groupings of pulmonary HTN 21:20 Taking a history. Ask these questions. 23:30 Physical exam 25:45 Initial testing 27:40 Overnight pulse oximetry 29:00 Echo findings in pulmonary HTN 31:30 Transpulmonary gradient 33:33 What is a normal pulmonary artery pressure 35:15 Accuracy of PA pressure estimate by echo 39:04 Mechanism of shortness of breath in PH 40:10 Should you hold PAH meds in a hypotensive patient? 41:55 Therapy for PH and follow up 46:28 Who to refer 47:40 PAH risk factors 52:09 Mortality in PH 58:22 Take Home Points 60:24 Outro Tags: pulmonary, arterial, hypertension, group, classification, prognosis, pressure, blood, diagnosis, treatment, pay, ph, echocardiogram, ekg, hypoxic, chronic, lung, disease, heart, left, right, failure, chf, pressure, mean, diuretic, HFpEF, cteph, embolism, assistant, care, doctor, education, family, foam, foamed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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62 min
January 22, 2018
#79: Dermatitis: Atopic to Remember w/The DermSiders
Differentiate, diagnose, and treat the various forms of dermatitis and stop the ‘itch that rashes’ with this in-depth, myth-busting episode of “The Dermsiders” with Dr. Kalman Watsky Clinical Professor of Dermatology at Yale Medical School. Topics include: how to differentiate between and diagnosis various forms of dermatitis, topical therapies, common pitfalls, patch testing, and more! Special thanks to Bryan Brown and Beth Garbitelli who wrote and produced this episode and the show notes! Written by: Bryan Brown, MD and Beth Garbitelli Edited by: Matthew Watto, MD Infographics by: Bryan Brown, MD Cover image by: Beth Garbitelli Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Hook 00:24 Disclaimer 02:32 Picks of the week 03:33 Guest bio and intro to the topic 05:01 Getting to know our guest 10:24 Clinical case of dermatitis 11:00 Atopic dermatitis and eczema: definition and background 16:21 Counseling patients w/atopic dermatitis on choice of soap 19:46 Mimics of atopic dermatitis 25:16 Seborrheic dermatitis 26:46 Dyshidrotic eczema 28:35 Behavior modification for atopic dermatitis 32:21 Wet pajamas 34:34 Bleach baths 36:52 Contact dermatitis 41:29 Patch testing 45:58 Back to our case, making the diagnosis 47:44 Topical steroids 51:43 Skin atrophy from steroids 55:45 Calcineurin inhibitors as steroid sparing agents 59:30 How to handle chronic need for topical steroids 65:24 Questions from Facebook 69:04 Take home points 72:21 Outro Tags: eczema, dermatology, dermatologist, skin lesion, atopic, contact, allergic, irritant, steroid, topical, therapy, atrophy, dermatitis, rash, skin, patch, testing, calcineurin, inhibitor, assistant, care, doctor, education, family, foam, foamed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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73 min
January 15, 2018
#78: ID Pearls with Paul Sax MD
It's a potpourri of Infectious Diseases with tips from expert, Dr Paul Sax, MD, Clinical Director of the Division of Infectious Diseases at Brigham and Women's Hospital, and Professor of Medicine at Harvard Medical School. We discuss the man flu, the flu vaccine, travel medicine, malaria, lyme disease, post lyme syndrome, chronic lyme, shingles, cellulitis, abscesses, antibiotics, c diff, antibiotic associated diarrhea, the dangers of fluoroquinolones, why doxycycline is awesome, and more! Told you it was a potpourri. Dr Shreya Trivedi joins Matt and Paul as guest host. Show Notes, MCQ by Shreya Trivedi, MD Edited by Matthew Watto, MD Infographics and cover image by Matthew Watto, MD Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps: 00:00 Announcement 01:38 Intro 03:46 Picks of the Week 06:47 Guest bio 08:47 Getting to know our guest 15:40 Flu vaccination 19:54 Barriers to the flu vaccine 23:34 Can you give the flu vaccine to an ill patient 24:14 Man flu 26:27 Travel Medicine 30:35 Tick bites 33:49 Lyme serologies 35:38 Lyme prophylaxis 37:37 Chronic lyme disease and post lyme syndrome 38:55 Penicillin and antibiotic allergies 41:48 Fluoroquinolones and adverse reactions 45:24 Should antibiotics be given after an I&D of an abscess  49:34 Antibiotic associated diarrhea, C diff 52:10 Probiotics, stool transplantation, and C diff 54:50 Shingles, recurrent zoster, complications, and the new subunit vaccine 61:45 Using salad tongs at a buffet 63:04 Take home points 64:26 Outro Tags:  ID, infectious, diseases, disease, flu, influenza, lyme, doxycycline, cdiff, antibiotics, infection, cellulitis, abscess, vaccine, zoster, shingles, malaria, travel, assistant, care, doctor, education, family, foam, foamed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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66 min
January 8, 2018
#77: Hypertension Guidelines Showdown
Ease the tension around blood pressure goals in older adults and get inside the hypertension guidelines released by the ACP and ACC/AHA in 2017 with the sagacity of Dr. Mary Ann Forciea, MD, MACP, Professor of Medicine at University of Pennsylvania. We cover: how to properly measure blood pressure, how to diagnose hypertension, blood pressure targets, why BP goals differ by society, how to guidelines are written and how to interpret them with a critical eye, plus a hot take on the 2017 ACC/AHA guidelines. Dr. Shreya Trivedi joins as cohost. Special thanks to Hannah Abrams for her wonderful infographics and to Dr Trivedi for compiling our show notes. Time Stamps 00:00 The setup 02:15 Disclaimer 03:32 Picks of the Week 08:13 Getting to know Dr Forciea 13:35 Broad overview and a clinical case of geriatric hypertension 14:45 Brief history on BP targets 18:05 How do you measure a blood pressure? What type of monitors are available? 22:13 How to standardize BP in the office? 23:55  Ambulatory BP monitoring 24:55 Home blood pressure monitoring 26:11 Standing blood pressure readings and orthostatic hypotension 27:53 How guidelines are written 30:51 Evaluating evidence quality and strength of recommendation 32:35 Timeline and process for guideline generation 34:27 How to read guidelines with a “critical eye” 36:15 Return to our case of uncontrolled hypertension 38:25 Blood pressure targets from ACP guidelines and BP management in frail older adults 40:33 Counsel patients on BP targets    42:25 Low diastolic blood pressure 45:35 SPRINT and the ACP BP guidelines 48:58 Take home points from Dr Forciea 50:07 HTN targets and pay for performance in clinical practice 51:45 Curbsiders recap the ACP guidelines 53:45 Matt and Paul recap the AHA guidelines 54:47 AHA definitions of hypertension 56:15 Diagnosing hypertension and how to measure a blood pressure 60:35 Choosing a blood pressure monitor and HBPM 62:29 Blood pressure goals in ACC guidelines 66:08 Non-pharmacologic measures 69:15 Will we follow these new strict targets? 72:45 Outro Tags:hypertension, blood, pressure, monitor, cuff, heart, aha, acc, act, stroke, cardiac, cardiovascular, event, guidelines, assistant, care, doctor, education, family, foam, foamed, health, hospitalist, hospital, internal, internist, meded, medical, medicine, nurse, practitioner, professional, primary, physician, resident, student
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75 min
January 1, 2018
#76: Pneumonia Pearls with Dr Robert Centor
Conquer community acquired pneumonia and avoid misdiagnosis with tips from Dr. Robert Centor, Professor Emeritus University of Alabama and newly appointed Chair of Medicine at Kashlak Memorial Hospital. We discuss diagnosis, misdiagnosis, procalcitonin, steroids for severe pneumonia, pneumonia severity index versus CURB-65, and how to determine antibiotic choice and duration. Special thanks to Correspondents Neela Bhajandas (cohost), Justin Berk and Bryan Brown who all contributed several articles, resources, and questions to prep for this show. Cover image by Dr Kate Grant paintscientific.com. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Intro 02:38 Brief bio for Dr Centor 04:22 Picks of the week with Dr Centor 11:27 Clinical case of suspected pneumonia 12:30 Brief history of community acquired pneumonia 14:40 Misdiagnosis rates are high 16:18 Defining diagnostic criteria for pneumonia 18:50 Chest x rays and pneumonia 22:18 Illness scripts teaching about pneumonia 23:41 Ubiquitous misunderstanding of pneumonia definition 25:26 History and physical exam tips from Dr Centor 27:19 Further testing for pneumonia, PSI, CURB-65 32:50 Procalcitonin discussed 38:10 Antibiotic choice discussed with Dr Bhajandas 41:15 Safety considerations for various antibiotics 43:38 Use of high dose amoxicillin 44:45 Dr Centor’s antibiotic preferences, and some thoughts on blood and sputum cultures 46:55 Dangers of fluoroquinolones 48:25 Antibiotic duration 51:40 HCAP is no longer a thing and how to assess risk for drug resistant organisms 55:42 Corticosteroids for pneumonia 60:25 Inpatient antibiotic choices 62:00 Dr Centor’s take home points 62:45 Dr Centor becomes Chair of Kashlak Memorial 65:38 Outro Tags: pneumonia, community, acquired, cap, antibiotic, duration, diagnosis, misdiagnosis, strep, cough, procalcitonin, steroids, fluoroquinolones, azithromycin, drug, resistant, mdro, illness, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, meded, medical, medicine, practitioner, professional, primary, physician, resident, student
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67 min
December 25, 2017
#75: Recap, highlights, and clinical pearls extravaganza for The Curbsiders 2017
Join us for this recap of the key clinical pearls and favorite fan voted episodes from 2017 including: lipids, asthma, diuretics, hyponatremia, CKD, vertigo, and dizziness. Plus, Picks of the Year, exciting announcements for 2018, and Paul reveals that he has a wife! Matt, and Paul are joined by Curbsiders Correspondent, Dr. Chris Chiu, who wrote and produced this episode. Stuart was out with the Man Flu. My apologies to Dr. Bryan Brown whose name I forgot to shout-out when listing our Correspondents. Thanks to Kate Grant for her beautiful cover image. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps  00:00 Intro 01:18 Getting to know Chris Chiu introduction 03:07 Picks of the week and 06:10 Picks of the year and discussion of vancomycin and pip-tazo causing AKI 11:41 Recap of Scott Weingart and EM vs IM episode 17:45 Discussion of Lipids, PCSK9, CAC, CCTA 27:10 Asthma pearls recapped 32:43 Dizziness and vertigo recapped 38:40 Diuretics, diuretic resistance, and secondary hypertension diagnosis and treatment 44:35 Diuretic dosing 46:25 Hyponatremia, volume status, solute loads and SIADH 50:08 CKD, when to refer, and an argument about low protein diets 54:25 Matt, Paul, and Chris reflect on important lessons learned from 2017 59:32 Listener questions and comments 63:35 Wrap-up, and shout outs 66:22 Announcements for 2018 67:25 Outro Tags: hyponatremia, salt, kidney, ckd, asthma, vancomycin, zosyn, injury, weingart, emcrit, emergency, lipids, pcsk9, statin, dizziness, vertigo, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, meded, medical, medicine, practitioner, professional, primary, physician, resident, student
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69 min
December 22, 2017
#74: Opioid use disorder, pain, detox, tapers, health policy, and more!
Combat opioid use disorder and the opioid epidemic as we review common clinical scenarios with addiction medicine specialists, Dr. Stefan Kertesz, University of Alabama at Birmingham School of Medicine and Dr. Ajay Manhapra from the VA Hampton Medical Center in Hampton,Virginia. We need all hands on deck, and that means you! Learn the basics of opioid use disorder treatment as Dr. Manhapra gives us the scoop on “bup, bup, bup” (buphrenophine), and Dr. Kertesz primes us on opioid related health care policy and reminds us that “We can all do something about the opioid crisis”. Plus, Stuart and Paul express some concerns about how to approach these patients. Do not miss this episode filled with clinical pearls, policy, and joy! Special thanks to writers and producers, Dr. Carolyn Chan and Elena Gibson (MD Candidate, MS4), for their hard work on both of our addiction medicine episodes. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Intro 01:35 Guest Bios 03:10 Picks of the week 06:22 Case from Kashlak Memorial 07:20 Controversy: Is opioid addiction a real disease? 10:16: Vietnam Heroin Study (4) 12:52 Counseling patients on treatment options for opioid use disorder 17:32 Detox and initiation of medical treatment 18:50 Psychosocial needs and treatment (5) 20:50 How effective is Narcotic Anonymous? 21:36 80/20 rule 25:50 Inpatient vs outpatient treatment, complex discharge planning 27:03 Shared decision making for treatment options 31:50 Medical treatment is strongly recommend for OUD 32:17 Viewpoint: harms reduction in residential programs with polysubstance use 32:29 Taper, abstinence, and long-term treatment with buprenorphine 34:50 How to prescribe buprenorphine - Take the leap! 39:30 Medical education and the opioid epidemic 42:02 1980 NEJM article (6) 43:00 Complex persistent dependence patients (7) 46:40 Post-op pain and risk of addiction 51:34 Approach to increasing pain medications 54:50 Health Policy Intro 54:59 Opioid thresholds for patients and policy 61:39 Medicaid expansion and opioid epidemic (10) 66:25 Take home points 69:50 Round Table 73:56 Outro Tags: opioid, use, abuse, addiction, disorder, dependence, buprenorphine, suboxone, naloxone, methadone, taper, abstinence, heroin, fentanyl, drug, substance, overdose, chronic, pain, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, meded, medicine, medical, primary, physician, policy, resident, student
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75 min
December 18, 2017
#73: Opioid Addiction, Chronic Pain, and Abstinence
Take the pain out of pain management with clinical pearls from addiction medicine specialists Dr. Stefan Kertesz at the University of Alabama at Birmingham School of Medicine and Dr. Ajay Manhapra from the VA Hampton Medical Center in Hampton,Virginia. They walk us through an approach to pain management in the recovered addict, discuss treatment options for opioid use disorders, plus hot tips on how to interpret guidelines surrounding opioids, and more! What are you waiting for? Hit the play button! Special thanks to Elena Gibson and Carolyn Chan for writing and producing this show. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Intro 01:58 Host picks of the week 04:10: Intro to the episode 04:35: Guest Bios 12:32: Case from Kashlak Memorial 13:40 Define substance dependence, substance abuse, hazardous use 17:42 Where to go next conversation about pain control 17:54: Assessing risk of relapse 19:35 Screening Tools 20:10 Risk factors for developing OUD when initiating opioids. 25:10: CDC Guidelines length of prescription and risk of substance use disorder (7) 27:00: Defining optimal length of opioid after common surgical procedures  (6) 30:30: Long term receipt of opiates and addiction 33:50: OUD treatment options 37:30: Duration of buprenorphine/naloxone treatment, tapering risks (8) 38:50: POATs: Prescription opioids (9) 40:05 Social support and mental health services for addiction management 41:10 Risk of abstinence and adverse outcomes 42:35 Protracted withdrawal 43:35: Editorial BMJ Golden Month of Opioid use disorder (10) 44:00 Overdose risk in patients on long term opioids 44:40 Op-Ed on the Hill (11) 45:40 Example of protracted withdrawal syndrome 47:40 Reducing Harms: Naloxone, who to prescribe to? 50:30 Take home points 53:40 Outro Tags: opioid, use, abuse, addiction, disorder, dependence, buprenorphine, suboxone, naloxone, methadone, taper, abstinence, heroin, fentanyl, drug, substance, overdose, chronic, pain, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, meded, medicine, medical, primary, physician, resident, student
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54 min
December 11, 2017
#72: Transgender Care in Primary Care
Trans patients need excellent primary care and you can provide it with expert tips from endocrinologists, Dr Vin Tangpricha, Professor of Medicine at Emory University School of Medicine, and Dr Jeffrey Colburn, Assistant Professor of Medicine at Uniformed Services University. Learn practical tips in caring for transgender patients including: defining terms like gender dysphoria, gender nonconformity, transgender; use of pronouns; patient counseling; fertility concerns; initiating and monitoring hormonal therapy; surgical options; and how to help trans patients navigate the complexities of gender affirming therapy. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Intro and disclaimer 01:00 Guest bios 03:27 Getting to know our guest 08:00 Clinical case of a trans female 09:00 Defining terms and discussion of gender 14:15 What’s the difference between transgender and transexual? 16:05 How to handle mistakes in use of pronouns 17:12 How to set up a welcome practice environment 19:03 Maintaining confidentiality 20:37 Back to the case: What needs to be done before starting hormone therapy? 25:20 Evaluating for comorbidities, mental health issues and social risk factors 27:26 Is gender dysphoria driven by biology? 27:54 Evidence for hormone therapy and surgery as treatment for gender dysphoria 29:00 Cost and availability of medical and surgery therapy 34:00 Initial history and laboratory evaluation prior to hormone therapy 36:00 Choice of hormonal agent and route of administration 37:38 Fertility in trans women and men 40:30 When to expect body changes after starting therapy 43:00 Dr Tangpricha’s take home points 45:25 Monitoring of trans female on hormone therapy 46:57 Therapy and Monitoring of trans male on hormone therapy 49:56 Surgical therapy for MtF transition 52:33 Surgical therapy for FtM transition 55:50 Mental health clearance prior to surgery 57:54 Dr Colburn’s take home points 60:16 Outro Tags: gender, sex, identity, role, trans, transgender, hormone, therapy, surgery, nonconformity, dysphoria, transition, MtF, FtM, lgbt, diversity, wpath, fertility, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, meded, medicine, medical, primary, physician, resident, student
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61 min
December 4, 2017
#71: Asthma Made Simple
Knock the wind out of asthma with tips from Dr Denitza Blagev, a pulmonologist and intensivist who currently serves as Director for the Schmidt Chest Clinic at Intermountain Medical Center in Murray, Utah. We simplify the approach to diagnosis, spirometry, patient counseling, choice of agent, stepwise therapy, and de-escalation...plus, a little myth busting. Special thanks to Dr Cyrus Askin for writing and producing this episode and to Dr Bryan Brown for his wonderful infographics. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.  Time Stamps 00:00 Disclaimer 00:32 Intro 01:44 Picks of the week 04:38 Guest bio 06:20 Getting to know our guest 11:50 Clinical case and approach to the patient with dyspnea 16:38 How to explain asthma to a patient 17:22 Are PFTs needed for diagnosis and management of asthma? 18:44 Methacholine challenge and who needs one 21:15 Is imaging needed? 22:09 Typical PFT patterns in asthma 24:23 Utility and use of peak expiratory flows 25:45 Cough variant asthma 26:34 Physical exam in patient with asthma 27:45 Lab workup 29:07 Initial treatment and inhaler teaching 33:10 Stepwise therapy for asthma 37:27 De-escalation of therapy 39:18 Levalbuterol versus albuterol 40:20 Asthma action plans 43:06 Who needs a sputum sample 45:25 How to treat asthma exacerbations 48:05 Asthma therapy for hospitalized patients 51:10 Azithromycin and asthma 53:40 Who needs a referral 55:24 Are beta blockers safe in asthma? 56:08 Anticholinergic therapy and asthma 57:26 Take home points 58:58 Paul tells a story about asthma 59:55 Outro  Tags: asthma, inhaler, teaching, eosinophilia, albuterol, cough, variant, methacholine, spirometry, xray, pft, peak, flow, fev1, sputum, step, laba, lama, beta, agonist, azithromycin, symptoms, steroids, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, meded, medical, medicine, practitioner, professional, primary, physician, resident, student
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62 min
December 1, 2017
#70: KevinMD: Kevin Explains Everything
Dr Kevin Pho, founder KevinMD.com “Social Media’s Leading Physician Voice" schools Matt, Paul and Stuart on a potpourri of topics including physician advocacy, the dangers and benefits of social media, the pros and cons of electronic health records, health policy, health advocacy and lastly primary care and the integration of advanced practice providers/clinicians. Special thanks to Dr Chris Chiu who helped produce the show and write our show notes. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.  Time Stamps: 00:00 Intro 00:54 Picks of the week 06:58 Getting to know our guest 10:30 Why physicians need to understand health policy 11:21 Best advice Dr Poh has received in his career and why variety is important to avoid burnout 13:45 Advice to young physicians about to start using social media 16:40 Why are physicians afraid of social media 18:54 Risks of social media 21:20 Discussion of “Twitter bates” aka debates 23:20 Physician advocacy and social media 26:18 The next big health care debate...is it a right? 31:03 Why electronic health records are so painful to use? 34:49 How can charting be worked into clinic workflow? 37:50 Conspiracy theories on EHRs 39:11 Advanced practice providers/clinicians 46:40 Primary care shortage 50:16 Growth of medical administrators and how to take back control as physicians 52:38 Advice on how to break into medical writing 54:08 Paul ends the show with some wisdom and steals the show 55:59 Outro  Tags: kevinmd, advocacy, policy, health, care, ehr, chart, advanced, practice, clinician, physician, meded, foamed, social, media, twitter, kevin, pho, nurse, practitioner, medicine, internal, family, primary, education, internist, hospitalist
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57 min
November 27, 2017
#69: CKD Prescribing Do’s and Dont’s with @kidney_boy, Joel Topf
Making all your nephrology dreams come true with part 2 of our interview with  @kidney_boy, Joel Topf, MD Salt Whisperer and Chief of Nephrology at Kashlak Memorial Hospital. Flush away your bad prescribing habits when it comes to nephrotoxic drugs in this fast paced run down of the medications which must stay on or off Santa’s naughty-list, backed up with a sack full of memorable research studies. Special thanks to Annie Medina, Justin Berk and Kate Grant for writing/producing this show and to physician artist, Kate Grant for her lovely/hilarious artwork (more at paintscientific.com). Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Intro 03:00 Which medications should we exercise caution over in CKD? 03:31 Bactrim (Trimethoprim+Sulfamethoxazole) 07:00 NSAIDS 08:29 NSAIDS and the ‘Precision’ Trial NEJM 2016 looking at cardiovascular safety 12:50 The Male Physician Study JAMA 2001 13:50 Discussion about Nurses Health Study and use of analgesia, and CKD 15:15 Acute Interstitial Nephritis, Beta Lactam Antibiotics, and the risk of Acute kidney injury +/- CKD with Proton Pump Inhibitors 18:20 Advice for co-prescribing NSAIDS,ACE inhibitors and diuretics 20:39 Creatinine levels and ACE/ARB prescribing. How High can you go? 24:55 Facebook question from listener: measures to reduce proteinuria in hypertensive patients 27:20 Empagliflozin and renal protection in diabetic patients 32:00 Contrast Induced Nephropathy, the AMACING trial 2016. 38:00 Take Home Points 39:57 Outro Tags:  chronic, kidney, disease, nephrology, renal, glomerular, filtration, crcl, gfr, creatinine, medications, pharmacology, bactrim, nsaids, ace-i, contrast, metformin, empagliflozin, nephropathy, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, meded, medicine, medical, primary, physician, resident, student  
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41 min
November 20, 2017
#68: Tremors: One degree of Kevin Bacon?
Steady your hand and annihilate tremor with tips from Neurologist, and Movement Disorder specialist, Andres Deik, MD, Assistant Professor of Clinical Neurology at Kashlak Memorial Hospital (we can’t tell you where he really works: ) We teach you to differentiate benign causes of tremor from Parkinson’s disease with simple history and physical exam skills, plus nonpharmacologic and pharmacologic therapies for tremor. Special thanks to Beth Garbitelli and Chris Thrash who wrote and produced this episode and the show notes! Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Intro and disclaimer 01:08 Listener feedback - Paul is not fired. 02:09 Picks of the week. 05:35 Dr. Deik intro 07:19 Icebreaker questions 12:20 Wikipedia definition 13:02 Classifying tremor 14:33 Postural tremor vs. reemerging rest tremor 15:48 Important history questions 17:58 Medications that can induce tremor 21:39 Physical exam techniques 27:30 Exam characteristics between typical PD tremor and ET 28:36 History components to distinguish between PD and ET 34:10 Misdiagnosis of Parkinson’s 36:54 Imaging workup 39:03 Case from Dr Deik 41:33 Nonpharmacologic management 44:18 Pharmacologic management 49:06 Dosing propranolol 51:07 Distinguishing between physiologic tremor and pathologic tremor’ 54:06 Website recommendations 55:50 Handwriting 59:14 Take home points 61:34 Outro Tags: tremor, essential, postural, neurology, Parkinsons, disease, beta, blockers, primidone, movement, disorders, antidepressants, occupational, therapy, rest, intention, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, meded, medicine, medical, primary, physician, resident, student
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63 min
November 13, 2017
#67: Chronic Kidney Disease Pearls with @kidney_boy, Joel Topf
Take control of chronic kidney disease with tools, and tips from @kidney_boy, Joel Topf, MD Salt Whisperer and Chief of Nephrology at Kashlak Memorial Hospital. Learn which equation is best for eGFR, how to counsel patients about progression/prognosis, how to monitor patients in CKD, and who needs a referral to Nephrology. Special thanks to Annie Medina, and Justin Berk for writing/producing this show and to physician-artist, Kate Grant for her lovely and hilarious artwork (more at paintscientific.com).  Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.  Time Stamps 00:00 Intro 03:13 Pick of the weeks 08:49 Clinical Case 09:36 How to explain CKD to patients 12:16 Loss of GFR with age 13:22 Which equation should be used to estimate GFR 18:05 Creatinine clearance from 24 hour urine collection 22:25 Initial workup upon diagnosis of CKD 25:40 Interpreting tests for proteinuria 26:52 Staging and prognosis in CKD 32:00 Completing the initial workup for CKD 33:52 Who needs a referral to nephrology? 35:53 What labs to check in CKD and a discussion of secondary hyperparathyroidism 40:32 Take home points 42:30 Outro Tags: chronic, kidney, disease, nephrology, renal, glomerular, filtration, crcl, gfr, creatinine, prognosis, monitoring, iron, pth, proteinuria, hypertension, nephropathy, diabetes, albumin, protein, anemia, hyperparathyroidism, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, meded, medicine, medical, primary, physician, resident, student
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44 min
November 6, 2017
#66: Hepatitis C: Workup and Treatment in Primary Care
Hiding from Hep C? Dive in with experts Dr. Gina Simoncini, MD, MPH Associate Professor of Clinical Medicine at Temple University Hospital, & Dr. David Koren, PharmD, BCPS, AAHIVP,  board-certified pharmacotherapy specialist and infectious diseases clinical pharmacist at Temple University Hospital. They walk us through a simplified approach on whom to screen, how to start antiviral therapy, what to follow up on, and how to navigate insurance waters along the way. Special thanks to Sarah Roberts and Jordana Kozupsky who wrote and produced this episode and the show notes! Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Intro 01:00 Guest bios 03:00 Getting to know our guests 05:35 Picks of the week 10:05 Clinical case 10:54 Diagnosing HCV 12:00 ASCEND study 13:14 Restrictions on HCV treatment 15:17 Ordering and interpreting pre-treatment tests 19:30 Prescribing medication 22:00 Genotyping and drug resistance 24:10 Patient counseling 25:49 Understanding drug classes 27:33 Drug interactions 30:06 Multidisciplinary approach to treatment 33:01 Follow-up 36:47 Reinfection/cure rates 39:35 Patient counseling revisited 41:25 Side effects of treatment 42:53 Screening 44:02 Take home points Tags: hepatitis, virus, hcv, direct-acting, antiviral, therapy, management, primary, care, liver, ultrasound, fibrosis, cirrhosis, side, effects, monitoring, hcc, hiv, infectious, disease, assistant, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, meded, medicine, medical, primary, physician, resident, student
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53 min
October 30, 2017
#65: Scott Weingart of EMCrit on Emergency versus Internal Medicine: The Devil of the Gaps
Fighting with Emergency Medicine colleagues is stupid. Learn how EM doctors think and avoid the petty infighting with tips from Dr. Scott Weingart, MD FCCM FUCEM DipHTFU, host of the EMCrit podcast, Clinical Associate Professor and Chief, Division of Emergency Critical Care at Stony Brook Hospital, NY. We discuss decision making, how to avoid anchoring bias, the devil of the gaps, why the elderly always get admitted, how to build relationships with the ED, and Scott’s pet peeves. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Intro 01:10 Picks of the week 05:28 Guest bio 07:00 Getting to know our guest 12:00 Do EM and IM docs hate each other? 14:04 Where conflicts arise. 17:05 System 1 versus system 2 thinking 20:19 When the patient doesn’t match the story 23:55 Why does every 85 year old get admitted? 26:05 Transitions of care: form ED to medical ward 32:08 Is face-to-face signoff only needed for sick patients? 36:28 The devil in the gaps 41:03 Scott’s beer recommendation 42:17 BP cutoff for discharge home 43:44 Scott’s biggest pet peeve with primary care 45:04 How to make friends and collaborate with your EM colleagues 47:14 Take home points 50:35 Outro Tags: emergency, department, room, em, ed, im, conflict, devil, gaps, post-test, probability, illness, serious, system, one, bias, heuristic, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, meded, medical, medicine, practitioner, professional, primary, physician, resident, student
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51 min
October 27, 2017
#64: Stuff You Should Know About Health Policy
Get schooled on medical homes, payer reform, and what the future might look like for primary care with Dr. Sue Bornstein, MD, FACP and Executive Director of the Texas Medical Home Initiative and Chair of the Health and Public Policy Committee at the ACP. Dr Alex Lane of Cooper University Hospital joins Matt as cohost! Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Intro 02:42 Guest CV and background 04:42 Getting to know our guest 10:40 Helpful resources for learning health policy 12:10 Who are the major players/influencers in health care and how do their interests align 15:02 Defining “medical home” 18:45 Where did the idea for a “medical home” originate 22:33 How does medical home affect cost 29:45 Payer reform and the quality payment program (QPP) 33:06 Recap and defining terms 37:18 How will the QPP be implemented? 41:04 Repeal and replace 43:37 Cuts in funding for safety net hospitals that care for the poorest, sickest patients 46:59 Take home points 48:55 Outro Tags: medicare, medicaid, health, care, policy, spending, quality, improvement, advanced, payment, macra, mips, qpp, apm, medical, home, pcmh, affairs, super, utilizer, texas, physician, doctor, assistant, nurse, practitioner, foamed, meded
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50 min
October 23, 2017
#63: Medical Marijuana: Is it really dope?
Expand your consciousness around medical cannabis (aka marijuana) with expert Dr Donald Abrams, Chief of the Hematology-Oncology Division at San Francisco General Hospital and a Professor of Clinical Medicine at the University of California San Francisco. We explain the cannabinoid system, THC, CBD aka cannabidiol, limitations surrounding cannabis research, current and future medical uses for medical cannabis (marijuana), and potential conditions it may benefit. We take a deep dive on the potential harms of medical cannabis and how to counsel patients on safe use. Plus, the return past guest and new correspondent, Dr Molly Heublein, Assistant Professor of Medicine from UCSF. Thanks to Dr Molly Heublein for writing and producing this episode and it’s show notes! Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Clinical case from Kashlak Memorial:  MM is a 62 yo woman with a history of osteoarthritis and breast cancer, now on an aromatase inhibitor. She struggles with aching and stiffness in her hands, shoulders, knees, and hips. A friend suggested she try medical marijuana. She wants her provider’s opinion on if this is safe and effective. Time Stamps 00:00 Intro 01:30 Picks of the week 03:40 Guest bio 05:11 Getting to know our guest 11:03 Clinical case 11:40 Limitations for cannabis research 12:59 Discussion of THC and cannabidiol 14:50 Smoking versus ingesting cannabis products 16:40 Recap of cannabinoid mechanism of action 18:30 Cannabis and cannabinoid products available 20:20 Synthetic THC (dronabinol) 21:46 How “recommending” cannabis and dispensaries work 25:46 Conditions that respond to medical cannabis 29:15 Potential harms of medical cannabis 34:51 Future directions of cannabinoid medicine research 37:24 Cannabis induced hyperemesis syndrome 39:00 Possible lung cancer risk 40:12 Take home points 42:54 The Curbsiders recap and share their views on the medical cannabis controversy 49:40 Outro Tags: marijuana, medical, cannabis, weed, pot, oil, budtender, law, psychoactive, thc, cbd, cannabinoids, endocannabinoid, system, receptor, substance, harm, adverse, safety, pain, nausea, emesis
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50 min
October 16, 2017
#62: Pod Save Health Care: The Curbsiders Foray into health policy
Remedy your ignorance as we review some basics of health care policy with Dr. Fatima Syed, Chair of the Council of Residents and Fellows for the American College of Physicians. Dr. Syed is early career physician whose work is already affecting health policy at a national level. You can do it too and we’ll teach you where to start along with defining basic, but poorly understood concepts like The Affordable Care Act, universal health care, single payer health care, MACRA, MIPS, and how “quality” is really measured. Don’t miss this part one in our health care policy for beginners series. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.  Time Stamps 00:00 Intro 03:20 Getting to know our guest 07:23 How to get involved in a professional organization 09:37 Resources to learn health policy 14:06 The Affordable Care Act and ObamaCare 17:56 What is MACRA, MIPS and how do they affect physicians? 23:09 Nationalized health care in the US versus other countries 25:33 Universal and “single payer” health care defined 27:00 How is quality health care defined? Why is the US rated so poorly? 32:53 Recap and summary of what we’ve learned 34:09 Dr. Syed’s take home points 35:36 Outro Tags: policy, healthcare, macra, mips, aca, affordable, care, act, health, acp, advocacy, quality, payments, reimbursement, kaiser, commonwealth, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, meded, medical, medicine, practitioner, professional, primary, physician, resident, student
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36 min
October 9, 2017
#61: Vasculitis and Giant-Cell Arteritis: ‘Rheum’ for improvement
Keep your cool in the face of inflammation, and make the path to vasculitis diagnosis less tortuous with Dr. Rebecca Sharim, Rheumatologist and Assistant Professor of Medicine at Temple University. In this episode, we go with the flow from large vessel to small vessel vasculitides, and then learn how to make the diagnosis and management of Giant Cell Arteritis (GCA) and polymyalgia rheumatica (PMR) less of a headache. Correspondent, Dr. Bryan Brown cohosts!  Special thanks to Dr. Bryan Brown for writing our show notes, and creating figures for our handouts. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Case from Kashlak Memorial:  A 75 year-old woman with a PMHx of hypertension presents to the ED with three days of worsening left sided headache, now with left sided vision loss during a Norwegian folk festival. On review of systems, she also endorses a week of soreness of her shoulders and hips. This has never happened to her before. Time Stamps 00:00 Intro 03:07 Picks of the week 09:13 Getting to know our guest 15:00 Clinical case of vasculitis 15:59 Defining and classifying vasculitis 20:55 Workup for suspected vasculitis 23:17 How to explain GCA to a patient 25:08 Typical symptoms of vasculitis 28:00 Chewing gum test 29:34 Interpreting ESR 32:54 Basic exam and lab workup for vasculitis 35:23 Headache and suspicion for GCA/temporal arteritis 38:10 Is a temporal artery biopsy still mandatory? 39:20 Polymyalgia rheumatica 40:59 Steps to take when GCA/temporal arteritis suspected in clinic 43:55 PCP prophylaxis with high dose steroids 46:30 DMARDs and steroid sparing agents 48:12 Imaging studies to aid in diagnosis of GCA 50:50 Complications of long term steroid therapy 52:31 Take home points 53:26 Outro Tags: giant, cell, arteritis, gca, vasculitis, steroids, temporal, biopsy, artery, esr, pmr, polymyalgia, rheumatica, vessel, headache, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, meded, medical, medicine, practitioner, professional, primary, physician, resident, student
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54 min
October 2, 2017
#60: Masters of MKSAP on Medical Education
How to individualize learning for yourself, and your learners with tips from Dr. Philip A. Masters, editor-in-chief of MKSAP and IM Essentials, Vice President of Membership/International Programs at the American College of Physicians (ACP) and an Adjunct Professor of Medicine at the University of Pennsylvania School of Medicine. Dr. Masters schools us on work life balance, how to recognize and diagnose struggling learners, what resources to use, teaching exercises, and how to generate a study plan. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Intro 01:50 Listener feedback 04:18 Announcements 04:58 Picks of the Week 10:37 Guest bio and credentials 12:36 Getting to know our guest 18:05 Wellness and work life balance 22:55 How medical education has changed 28:55 Choosing resources as a learner 38:00 Case of a struggling learner 41:50 Learners with knowledge deficits and the role of the clinician (non-professional educator) 47:56 Resources to improve your skills as a medical educator 51:01 Take home points  Tags: study, resources, MKSAP, acp, learner, educator, academic, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, meded, medical, medicine, primary, physician, resident, student  
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54 min
September 25, 2017
#59: Back pain and Sciatica: Straighten out your practice
Solidify your approach to back pain and sciatica with Dr. Chris Miles, Assistant Professor, Family & Community Medicine and Associate Director, Sports Medicine program, Wake Forest Baptist Medical Center. He schools us on red/yellow flags, physical exam maneuvers, when to order imaging, and practical tools and tips for evidence-based management! Correspondent Dr. Shreya Trivedi cohosts! Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Case from Kashlak Memorial: 53 yo M construction worker with a BMI of 29 and PMhx of DM2, HTN, depression presenting with right low back pain. He can't remember any trauma or injury. Denies radiation, no bowel or bladder dysfunction, saddle anesthesia, weakness Case from Kashlak Memorial: 48 yo F nurse who has had intermittent back pain for years presented with acute flare after helping lift a patient. The pain similar to previous episodes but more severe and also radiates to her left foot. She has tried naproxen and exercises/mindful stress reduction for months without improvement. It is unbearable for her to work. Time Stamps 00:00 Intro 02:14 Listener feedback 03:44 Announcements 05:14 Picks of the week 08:20 Millenial learners 10:40 Topic intro and guest bio 12:06 Getting to know our guest 17:30 Clinical case of back pain 20:18 How to hand sensory deficits 21:51 Red and yellow flag symptoms 25:44 How to approach patient with yellow flag symptoms 28:00 Physical exam for back pain 30:00 Special testing: Trendelenburg, Slump test, and Straight leg raise 35:48 Classifying types of back pain and a quick recap of teaching points so far 39:28 How to manage patient expectations 40:42 Treatment of non-radicular back pain 46:33 Home exercises and YouTube training 49:31 When to follow up after initial treatment trial 51:35 The patient with severe acute pain 53:33 Some pearls on muscle relaxants 55:22 Clinical case and how to treat radicular pain 59:40 Invasive treatment of back pain 65:04 Back pain treatments that don’t work 66:06 Take home points 67:34 Outro Tags: back, pain, radicular, radiculopathy, sciatica, lumbar, disk, herniated, facet, arthritis, spine, muscle, relaxant, tramadol, nsaids, exam, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, medicine, medical, primary, physician, resident, student
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70 min
September 18, 2017
#58: Concussion, traumatic brain injury, and post-concussive syndrome
Summary: Get a-HEAD of concussions (aka traumatic brain injuries) with tools, tips, and tricks from The Concussion Guy, Dr. Evan Ratner, Medical Director of Gridiron Heroes. Learn to recognize concussions/traumatic brain injury, what questions to ask, physical exam maneuvers, and how to counsel patients and families on safe return-to-learn/play. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Case from Kashlak Memorial: 29F with no significant PMH presents to primary care office less than 24 hours after she accidentally struck her head on the metal of her car door. She experienced temporary altered consciousness lasting about one hour along with a headache. No nausea, vomiting, speech, or vision changes. She rested at home last night, but didn’t feel up to reading, or watching TV. She drove herself to your office today. Time Stamps 00:00 Intro 02:33 Listener feedback 05:35 Picks of the week 12:15 Getting to know our guest 19:41 Defining and classifying concussion 23:00 What questions to ask your patient 26:34 Physical exam for patient with concussion 28:50 Use of neurocognitive testing in concussion 30:45 Specifics of testing eye movements and balance 35:00 Who needs imaging? 41:51 Recap of what we’ve learned so far 43:40 Can you let someone with a concussion go to sleep? 47:08 Return-to-learn protocol 50:30 Return-to-play protocol 52:30 Post-concussive syndrome 53:55 Medications for post-concussive symptoms 58:58 Second impact syndrome 64:40 Counseling the patient with multiple concussions 67:08 Take home points 69:09 The Curbsiders recap their favorite teaching points 71:30 Outro Tags: concussion, post, concussive, syndrome, tbi, traumatic, brain, injury, return, play, school, cognitive, rest, treatment, diagnosis, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, medicine, medical, primary, physician, resident, student
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73 min
September 15, 2017
#57: Polypharmacy and deprescribing Part 2: More thinking and thoughts
Improve your prescribing practices with tips from The Curbsiders as Matt, Stuart and Paul “Pwilliams” discuss safe prescribing in frail, older adults with diabetes, chronic kidney disease, hypertension, and/or dementia in this part two episode on polypharmacy and deprescribing. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Tags: polypharmacy, deprescribing, prescribing, cascade, pharmacist, drug, therapy, medications, side, effects, adverse, reaction, beers, criteria, interaction, disease, anticholinergic, diabetes, hypertension, kidney, chronic, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, medicine, medical, primary, physician, resident, student
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24 min
September 11, 2017
#56: Polypharmacy and deprescribing Part 1: Living better through chemicals
Avoid common pitfalls, recognize prescribing cascades, and deprescribe like a champ with tips from Clinical Pharmacist, Dr. Sean M. Jeffery, Clinical Professor of Pharmacy at the University of Connecticut School of Pharmacy, and Chair of the Polypharmacy Special Interest Group for the American Geriatrics society. We discuss how to create better medication lists, tools and tips for deprescribing, how to counsel patients on polypharmacy, and safe use of medication in the elderly. Special thanks to the American Geriatrics Society for setting up this interview. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Intro 01:12 Listener feedback 01:56 Picks of the week 06:28 Topic intro and guest bio 07:49 Getting to know our guest 13:05 Defining polypharmacy and related terms 16:30 Clinical Case of polypharmacy 20:34 Making better medication lists 25:01 Clinical Case from Kashlak Memorial 28:40 Beers Criteria 35:41 Statins in frail, elderly patients 38:00 Treating insomnia in the elderly 44:15 Dosing of meds in patients with CKD 45:50 Tool for analysis of drug-drug interactions 48:10 Take home points from Dr. Jeffery 50:00 Outro Tags: polypharmacy, deprescribing, prescribing, cascade, pharmacist, drug, therapy, medications, side, effects, adverse, reaction, beers, criteria, interaction, disease, anticholinergic, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, medicine, medical, primary, physician, resident, student  
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51 min
September 4, 2017
#55: Eating disorders: Specified and Not Otherwise Specified
Enhance your skills in the identification and management of eating disorders with clinical pearls from Dr. Rosalind Kaplan, Clinical Associate Professor of Medicine at Thomas Jefferson University and a Primary Care Physician in Jefferson Women's Primary Care. We learn who to screen for eating disorders, what questions to ask, criteria for diagnosis, common complications, and how to manage them. This is a must listen if you’re like us and don’t know much about eating disorders specified and not otherwise specified. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Case from Kashlak Memorial Hospital: 24yo F medical student with history of anxiety, weight loss, and restricting food senior year of high school. She regained weight with psychotherapy. Now she is a medical student who is over exercising, and abusing laxatives. She passes out one day after class and is referred to you at Kashlak. Time Stamps: 00:00 Intro 01:19 Listener feedback 02:43 Picks of the week 06:50 Topic intro and guest bio 09:10 Getting to know our guest 15:18 Clinical case  20:15 Broad overview of eating disorders 26:40 Eating disorder not otherwise specified 29:19 Underreporting and under diagnosis in men 30:25 Who to screen and how to do it 34:33 Questionnaires: SCOFF, ESP, and Binge Eating Disorder Inventory 38:42 Initial lab workup for eating disorders 42:38 Bone density screening, treatment 45:41 Back to the case: Initial patient counseling  49:22 Medical therapy 52:20 Can we use bupropion? 54:02 What’s the role for primary care? 58:14 Hyponatremia in eating disorders 60:34 Complications of purging 66:25 How to be an ally for your patient 69:12 Treatment for binge eating 72:51 Take home points 74:30 Outro Tags: anorexia, nervosa, bulimia, eating, disorder, weight, loss, binge, binging, purge, electrolytes, not, otherwise, specified, ideal, body, image, treatment, screening, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, medicine, medical, primary, physician, resident, student
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76 min
August 28, 2017
#54: Upper Respiratory Infections: Coughs, colds, gargling, and antibiotic underuse?!
Don’t miss life threatening upper respiratory infections, and stop underusing antibiotics with tools and tips from our wonderful guests: Dr. Robert Centor, Professor of Medicine at University of Alabama, known for developing the Centor Criteria for pharyngitis, and his excellent blog and Twitter feed @medrants; and Dr. Alexandra Lane, Assistant Professor of Medicine, and Director of the Resident Clinic at Cooper University Hospital. We cover red flag signs in upper respiratory tract infections, diagnostic testing, physical exam maneuvers, antibiotic therapy, and symptom management. Plus, we’ll teach you have to counsel patients about upper respiratory infections and recommend some great learning resources. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Case from Kashlak Memorial Hospital: 39 yo F with obesity, HTN, fibromyalgia who presents with 3 days of chills, subjective fevers, sinus pressure/congestion, post-nasal drip, and cough with some green/yellow mucus. She says, “I get this every year and it only goes away with antibiotics. They usually give me a z-pack”. Tags: upper, respiratory, infections, cough, cold, nasal, pharyngitis, bronchitis, rhinosinusitis, sinusitis, decongestant, spray, symptoms, management, pneumonia, pertussis, influenza, antibiotics, overuse, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, medicine, medical, primary, physician, resident, student
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68 min
August 21, 2017
#53: Urinary Incontinence: Tips and strategies to stay dry.
Get control of urinary incontinence with tips from Internist and Women’s Health Specialist, Dr. Molly Heublein, Assistant Clinical Professor of Medicine at UCSF. This is a must listen if you’re still uncomfortable managing urinary incontinence. We learn nonpharmacologic strategies like pelvic floor muscle therapy, bladder training, timed voiding, foods to avoid, and run through the available medical therapies, their efficacy and side effects. Plus, a brief review of next line therapies like percutaneous tibial nerve stimulation, and botox injections for overactive bladder. Full show notes available at http://thecurbsiders.com/podcast Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Case: 79 yo F with at least 10 years of urinary urgency with occasional loss of small amounts of urine and rare full bladder emptying. She drinks 1 cup of coffee every morning and about 2-3 glasses of water per day. She tries to minimize liquids due to her incontinence. She has HTN and takes HCTZ. Has been on oxybutynin for 10 years and wants to try something else. Time Stamps 00:00 Intro 01:06 Listener feedback 02:43 Announcements 03:43 Picks of the week 09:07 Getting to know our guest 14:27 Case of urinary incontinence (UI) 15:30 Epidemiology of UI 16:34 Screening for UI 17:30 The 3IQ Questionnaire 18:44 Additional testing in UI 21:23 Classifying UI 24:00 Nonpharmacologic therapy for UI 32:42 Effectiveness of pharmacologic versus nonpharmacologic therapy 34:50 Case continued. Changing medications 37:42 Mirabegron as an alternative to anticholinergics 40:18 More options for stress UI management 41:40 Next line therapies for urge UI, overactive bladder 44:38 Surgery for stress urinary incontinence 45:50 Botox therapy for urge UI, overactive bladder 48:30 Do we need any more fancy diagnostic tests? 50:30 Take home points 55:05 Stuart schools us on urinary incontinence in men and timing of BPH meds 56:40 Outro Tags: urinary, urine, incontinence, urge, stress, mixed, bladder, training, kegels, pelvic, floor, muscle, therapy, anticholinergic, botox, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, medicine, medical, primary, physician, resident, student
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58 min
August 14, 2017
#52: Anemia: Tips, and tools for diagnosis and treatment
Master the anemia algorithm, and take a deep dive on iron deficiency, anemia of chronic kidney disease, anemia of chronic inflammation, causes of macrocytic anemia and more in this discussion with international expert, Dr. David P. Steensma, Senior Physician from Dana Farber Institute, and Associate Professor of Medicine at Harvard Medical School. Full show notes available at http://thecurbsiders.com/podcast Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Cases from Kashlak Memorial: 62 yo M with diabetes and CKD with asymptomatic Hgb 10, MCV 90, and Cr. 1.9? 72 yo F with HTN with asymptomatic Hgb of 11, MCV 85 and Cr. 0.6. 72 yo F with breast cancer in remission after lumpectomy, adjuvant chemo, and XRT treated 6 years ago presents with fatigue and some dyspnea on exertion. Hgb 9.6, MCV 102. Time Stamps 00:00 Intro 01:18 Listener feedback 04:05 Announcement: We’re looking for on air correspondents to join The Curbsiders 05:05 Picks of the week 11:12 Getting to know our guest 17:50 Case #1 Normocytic anemia 19:15 Defining anemia (WHO criteria) 21:10 Epidemiology of anemia 23:45 Normocytic anemia 25:55 Erythropoietin for diagnosis and treatment 28:22 Anemia of CKD or chronic inflammation? 31:37 Discussion of ferritin and soluble transferrin receptor 33:47 Case #1 Conclusion 35:45 Hemoglobin targets in CKD 36:53 Case #2 Microcytic anemia 37:43 Correct reticulocyte count and reticulocyte index 40:45 Deciding on dose and route for iron repletion 43:44 Does vitamin C improve iron absorption? 45:27 Case #3 Macrocytic anemia 46:54 Vitamin B12 deficiency 51:54 Medication related B12 deficiency 52:35 Myelodysplastic syndrome 55:00 Side effects of common MDS treatments 56:18 Take home points 57:35 The Curbsiders post game analysis 64:16 Outro Tags: anemia, hemoglobin, iron, supplementation, B12, vitamin, ferritin, kidney, chronic, inflammation, deficiency, oral, therapy, myelodysplastic, syndrome, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, medicine, medical, primary, physician, resident, student
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66 min
August 7, 2017
#51: Diabetes treatment in 2017: New meds, insulin, and cardiac risk reduction
Get cozy with these new drugs for diabetes. Don’t be scared, they won’t bite. On this episode,  we interview Endocrinologist and current president of AACE, Dr. Jonathan D. Leffert, MD, FACP, FACE, ECNU about how to utilize the myriad of new diabetes drugs on the marketplace including SGLT2 inhibitors, DPP4 inhibitors, GLP1 agonists, and new ultra long acting insulins. Plus, we’ll teach you how to choose between agents, common side effects, A1C goals, and the cardiovascular benefits of these newer agents. Full show notes available at http://thecurbsiders.com/podcast Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Case: Case from Kashlak Memorial Hospital: 49 yo M with HTN, BMI 29, hyperlipidemia, family history of premature CAD (dad age 45yo), and DM2 with A1C increase from 6.4% to 9% while on metformin monotherapy. Time Stamps 00:00 Intro 04:33 Getting to know our guest 09:50 Clinical case of diabetes 12:40 Latent autoimmune diabetes 15:16 Life expectancy and A1C goal 16:47 Anemia’s effect on A1C 18:40 Back to our case, choice of agent 20:57 Lifestyle changes effect on A1C 22:55 Starting an SGLT2 inhibitor, what to look for 26:45 SGLT2 inhibitor use in patient already on diuretic 27:53 Discussion of CV risk reduction and newer DM meds 33:27 Euglycemic DKA 34:30 Choice of agent GLP1 vs SGLT2 37:10 Use of DPP4 inhibitors 38:55 Back to the case 39:37 Degludec, long acting insulin 41:34 Clinical case conclusion 43:03 Take home points 45:15 Outro Tags: diabetes, medications, glucose, insulin, oral, therapy, drug, hypoglycemia, a1c, blood, cardiac, risk, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, medicine, medical, primary, physician, resident, student
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46 min
July 31, 2017
#50: How to read the medical literature like a journal editor
Master this practical approach to reading the medical literature (*No statistics needed!) with expert tips from Dr. Christine Laine, Editor in Chief, Annals of Internal Medicine, and Dr. Darren Taichman, Executive Deputy Editor, Annals of Internal Medicine. They teach us what we should be reading, and detail their thought processes as they appraise an article. Topics covered include: Is 3 minute critical appraisal possible? What’s the deal with P-values? What are common sources of bias? How does the approach differ with clinical trials versus observational studies versus meta-analyses? *Minimal statistics needed ; ) Full show notes available at http://thecurbsiders.com/podcast Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Intro 01:13 Listener comment on Entresto 02:50 Picks of the week 09:36 Getting to know our guests 14:00 How to stay up on the medical literature 17:15 Three minute critical appraisal 19:15 Step 1: Assess the outcome being studied 20:50 Statistical versus clinical significance 22:33 Evaluating composite endpoints 24:47 Statistical power 28:58 Evaluating for bias 34:40 Recap of what we’ve learned so far 36:33 Is PICO useful? 39:01 Observational studies and bias 41:09 Evaluating a meta-analysis 46:05 Take home points 50:35 The Curbsiders recap the episode 53:02 Outro Tags: literature, appraisal, meta, analysis, analyze, critical, read, medical, journal, study, randomized, observational, systematic, review, clinical, trial, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, medicine, medical, primary, physician, resident, student
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55 min
July 24, 2017
#49: Vertigo and Dizziness: How to Treat, Who to Send Home and Who Might Have a Stroke
A simplified approach to dizziness/vertigo with tips from international expert, Dr. David Newman-Toker, Professor of Neurology, Ophthalmology and Otolaryngology at Johns Hopkins University. We learn how to differentiate stroke from other causes of dizziness/vertigo; how to approach the differential diagnosis in dizziness/vertigo; how to perform the Dix-Hallpike test, Epley maneuver, and HINTS exam; plus, who benefits from medical therapy and vestibular rehab. Special thanks to Dr. Cyrus Askin who found our expert, wrote the questions for this episode, and acted as our cohost. Full show notes available at http://thecurbsiders.com/podcast Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Case: A 45-year-old man presents to the emergency department because of continuous dizziness, nausea, vomiting and unsteady gait that began 18 hours earlier. Time Stamps 00:00 Intro 04:16 Getting to know our guest 11:56 Clinical Case 13:13 Why can’t patients describe their dizziness? 15:20 Classifying dizziness 18:35 The 3 vestibular syndrome buckets defined 22:14 Episodic vestibular syndrome differential diagnosis 26:49 Acute vestibular syndrome differential diagnosis 28:08 Chronic vestibular syndrome differential diagnosis 30:15 Challenges of medical history taking 32:10 Approach to the acute vestibular syndrome/HINTS 33:38 How to evaluate nystagmus 38:00 How to perform the head impulse test (aka head thrust) 45:56 How to perform “test of skew” (alternate cover testing) 47:45 Recap of HINTS exam and discussion of MRI 50:50 Signs and symptoms of cerebellar stroke 55:17 Use of Dix-Hallpike for episodic vertigo 57:00 How to perform Dix-Hallpike 59:50 How to perform the Epley maneuver 64:17 What happens when you choose the wrong test 66:10 Continuous versus triggered dizziness, or vertigo 67:40 Meclizine use in BPPV 69:25 How to cure horizontal canal BPPV 71:00 Treatment for vestibular neuritis 72:56 Treatment for Meniere’s disease 74:32 Who benefits from vestibular rehab/exercises 77:23 Dizziness and giddiness 78:15 Take home points 81:06 Outro Tags: vertigo, dizziness, presyncope, ataxia, stroke, BPPV, Meniere’s, disease, neuritis, vestibular, syndrome, episodic, meclizine, migraine, gait, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, medicine, medical, primary, physician, resident, student
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82 min
July 17, 2017
#48: Hyponatremia Deconstructed
Step up your salt game. We deconstruct hyponatremia with expert tips from our Chief of Nephrology, Dr. Joel Topf aka @kidney_boy aka The Salt Whisperer. Topics include: true versus false hyponatremia, SIADH, tea and toast/beer potomania, safe rates of sodium correction, fluid restriction, salt tablets, IV fluid choice, DDAVP clamps, and more. Full show notes available at http://thecurbsiders.com/podcast Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Case: 85yo F with anxiety, asthma, HTN (on a CCB), hypothyroidism with TSH of 3 on therapy. Sodium was 128 from previous values 134-137 mg/dL. She is more fatigued than usual. Time Stamps 00:00 Intro 03:00 Guest interview 06:45 Pick of the week w/Dr. Topf 15:50 Clinical case of hyponatremia 17:18 False hyponatremia normal osmolality 19:04 False hyponatremia high osmolality 20:06 Understanding why osmolality matters 22:58 Workup false hyponatremia 24:15 Recap of discussion so far 25:10 ADH dependent vs independent hyponatremia 26:30 Psychogenic polydipsia 28:45 Renal failure and hyponatremia 29:33 Tea and toast, and Beer Drinker’s potomania 34:42 ADH dependent hyponatremia 37:45 Volume versus osmolality 39:30 Volume status exam 44:44 Additional testing with urine lytes and uric acid 47:00 Treatment for SIADH 52:12 Discussion of the vaptans 57:51 Additional testing in SIADH 62:20 When to admit patient for hyponatremia 63:29 Clinical case of hyponatremia complications 68:26 Fluids and rate of correction 73:06 DDAVP clamp 76:00 Moderate hyponatremia 78:05 Diuretic dosing DOES matter! 81:29 Loop diuretics for SIADH 83:55 Take home points 86:55 Outro Tags: hyponatremia, salt, sodium, SIADH, ADH, vasopressin, fluids, electrolytes, kidney, nephrology, osmolality, urine, concentration, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, medicine, medical, primary, physician, resident, student
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88 min
July 10, 2017
#47: Osteoporosis Part 2: bone markers, fracture risk, and more on calcium and Vitamin D
Solidify your knowledge of osteoporosis and osteopenia in this discussion with Endocrinologists and osteoporosis guideline authors, Dr. Rachel Pessah-Pollack, and Dr. Dan Hurley from the American Association of Clinical Endocrinologists (AACE). Learn when to start therapy after an acute hip fracture, how to use bone turnover markers to assess fracture risk, more on how to dose calcium and vitamin D, and finally, we discuss the new American College of Physicians (ACP) guidelines and how they differ from the AACE guidelines on osteoporosis. For a more basic talk on osteoporosis check out episode #18 w/Dr. Pauline Camacho. Full show notes available at http://thecurbsiders.com/podcast Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Intro 03:00 Picks of the week 07:31 Guest and topic intro 10:25 Rapid fire questions 14:45 Clinical Case and defining osteoporosis 17:00 FRAX score 20:35 Secondary evaluation for cause of bone loss 20:54 Bone turnover markers (telopeptides) 23:17 Alkaline phosphatase 26:30 Calcium and Vit D 29:35 Recap of teaching points so far 31:25 Antiresorptive versus anabolic therapy 32:40 Aromatase inhibitors increase fracture risk 34:28 When to start therapy after fracture 35:44 Mechanism of action recombinant PTH 41:38 Vitamin D assay and dosing 46:53 Calcium intake, and formulations 49:45 Take home points 50:54 Recap and discussion of AACE vs ACP guidelines by The Curbsiders 59:42 Outro Tags: bone, osteoporosis, anabolic, osteopenia, vitamin D, calcium, fracture, density, AACE, guidelines, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, medicine, medical, primary, physician, resident, student
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62 min
July 3, 2017
#46: Chest pain, coronary CT angiography, and coronary artery disease
Master the evaluation of acute and chronic chest pain with coronary CT angiography (CCTA). We deconstruct this game changing technology w/experts from the Society for Cardiovascular Computed Tomography (SCCT), Dr. Todd Villines and Dr. Ahmad Slim. We’ve got answers on what to do when a patient with chest pain has a prior CAC score of zero, and/or a CCTA with non-obstructive disease. Plus: how to select, prepare, and counsel patients; how to interpret reports; choosing between myocardial perfusion study and CCTA, and more! Special thanks to Dr. Emilio Fentanes from SCCT for setting up this interview. Full show notes available at http://thecurbsiders.com/podcast Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Case: 45 yo F active duty Colonel with chronic chest pain syndrome despite negative conventional stress test and CAC score of zero. Time Stamps 00:00 Intro 04:00 Rapid fire questions 08:23 Book recommendations 10:14 Defining terms CCTA vs CAC 12:47 Script for counseling patient about CCTA 14:34 Prep for CCTA 16:40 Why is CCTA controversial? 19:37 Patient selection for CCTA both acute and chronic 25:20 Chronic chest pain and CCTA 27:58 CAC and CCTA in high risk occupations 33:25 Clinical case 36:10 Acute chest pain in patient w/CAC score zero 39:18 Acute chest pain in patient w/CAC score zero and previous CCTA w/non-obstructive CAD 41:22 How to read a CCTA report 45:48 CCTA versus conventional testing and risk MI, death 49:18 Use of CCTA in outpatients 52:16 Plaque characteristics and risk ACS 55:51 CCTA w/non-obstructive disease in patients with acute chest pain 58:14 When is myocardial perfusion scanning better? 61:00 Listener question on small vessel disease 62:09 Take home points 65:00 Curbsiders recap 69:33 Outro
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68 min
June 26, 2017
#45: Heart failure: update and guidelines review
Update your management of heart failure (HF) with expert tips from Cardiologist Dr. Eric Adler, Associate Professor of Medicine and Director of Cardiac Transplant and Mechanical Circulatory Support at UC San Diego. We cover how to use BNP, a simple way to examine jugular venous distention, medical therapy for heart failure, the PARADIGM-HF trial, and how to use sacubitril/valsartan (Entresto). Full show notes available at http://thecurbsiders.com/podcast Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Intro 04:25 Rapid fire questions 06:00 Palliative care and heart failure 08:40 Book recommendation 10:20 Advice for teachers and learners 12:27 Clinical case of HF 13:38 Classification and staging of HF 17:07 Discussion of BNP 19:35 How to perform neck vein exam for JVD 21:20 BNP for prognosis 23:00 BNP at hospital discharge 26:36 Factors that affect BNP 27:25 Initial patient counseling 32:35 Exercise in HF 34:00 Additional testing at time of diagnosis 36:28 Initial medical therapy 38:30 Discussion of diuretics and dosing 42:50 Aldosterone antagonists 44:30 PARADIGM-HF and entresto 51:27 Medications to avoid in HF 54:14 Digoxin 57:30 Dr. Adler’s take home points 59:11 Stuart questions dosing conventions 60:48 Outro Tags: arni, assistant, care, diuretics, doctor, education, failure, family, foam, foamed, health, heart, hospitalist, hospital, internal, internist, neprilysin, nurse, management, medicine, medical, physician, practitioner, primary, resident, sacubitril, student
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62 min
June 19, 2017
#44: Obesity Medication Overview from AACE 2017
Master the safe and effective use of obesity medications with Endocrinologist, Dr. Karl Nadolsky (co-author of 2016 AACE Obesity guidelines), Director of the Diabetes, Obesity & Metabolic Institute at Walter Reed National Military Medical Center. We get under the hood of each FDA approved obesity medication plus some of our normal hijinks. Check out episode #23 for a more general overview of obesity. Full show notes available at http://thecurbsiders.com/podcast Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Intro 03:12 Picks of the week 08:44 Rapid fire questions 13:00 Counsel patients about obesity 14:40 Pathophysiology of obesity 18:00 Case 22:46 Phentermine/topiramate (Qsymia) 26:20 Bupropion/naltrexone (Contrave) 29:18 Liraglutide (Saxenda) 34:32 Orlistat (Alli, Xenical) 37:35 Cost issues 40:18 Lifelong medical therapy for obesity 42:44 Dr. Nadolsky’s take home points 44:45 The Curbsiders recap and discuss their experience with obesity medications 52:28 Outro Tags: assistant, care, doctor, education family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, medicine, medical, physician, practitioner, primary, resident, student, obesity, pharmacotherapy, weight loss, safety, side effects, orlistat, alli, naltrexone, bupropion, contrave, phentermine, topiramate, qsymia, lorcaserin, belviq, FDA
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54 min
June 12, 2017
#43: Random Clinical Pearls: ACP Highlights and Recap Part 2
Load up on clinical pearls for your practice in this wide ranging discussion with expert clinician educator, Dr. Jon M. Sweet, Associate Professor of Medicine from Virginia Tech Carilion School of Medicine. Topics include cellulitis, tinea infections, dermatologic emergencies, smoking cessation, heart failure, hormone replacement therapy, iron supplementation, and vocal cord dysfunction. Plus, Stuart gives Paul a new nickname! Special thanks to the Dr. Patrick Alguire and Dr. Darilyn Moyer from the American College of Physicians for setting up this episode. Full show notes available at http://thecurbsiders.com/podcast Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Intro 02:12 Picks of the week 05:10 Guest intro 07:13 Rapid fire questions 15:25 Tinea infections 18:22 Misdiagnosis of cellulitis 23:53 AGEP (Dermatology) 29:03 DRESS syndrome (Dermatology) 35:28 Smoking cessation 36:55 Back pain, acetaminophen and acupuncture 41:42 Hot flashes and hormone therapy 43:05 Iron supplementation 49:55 Heart failure and sacubitril/valsartan 53:33 Vocal cord dysfunction 56:50 Response from Stuart and Paul 62:20 Outro Tags: AGEP, ARNI, assistant, back pain, care, cellulitis, cessation, dermatology, DRESS, doctor, education family, foam, foamed, health, heart failure, hospitalist, hospital, internal, internist, nurse, medicine, medical, physician, practitioner, primary, resident, smoking, student, tobacco, vocal cord dysfunction
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64 min
June 5, 2017
#42: The Diabetic Foot: Diagnose, prevent, and treat ulcers and infections
Diagnose, prevent, and treat diabetic foot ulcers and infections like international expert, Dr. Andrew Boulton, Professor of Medicine at the University of Manchester (England). From how to perform a proper foot exam, to foot care, to ulcers and infections we cover the essentials for your practice. For full show notes visit http://thecurbsiders.com/podcast Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Tags: assistant, care, diabetes, diabetic, doctor, education, family, foam, foamed, foot, health, hospitalist, hospital, infection, internal, internist, nurse, medicine, medical, physician, practitioner, primary, resident, student, ulcer
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45 min
May 29, 2017
#41: HIV, PrEP, and STI screening
Prevent HIV infections with pre-exposure prophylaxis (PrEP), and learn to perform appropriate screening for sexually transmitted infections with tips from expert, Dr. Gina Simoncini, Associate Professor of Medicine at Temple University Hospital. Learn how to implement PrEP in your practice, plus tips on vegetable gardens, fellowships, and where to get the best samosas, in this wide ranging discussion. Full show notes available at http://thecurbsiders.com/podcast Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Intro 04:50 Rapid fire questions 16:23 Defining preexposure prophylaxis 18:50 Who benefits from PrEP 21:43 Case discussion 23:45 PrEP during pregnancy, breastfeeding 24:45 Baseline testing and STI screening before PrEP use 28:15 Counseling on adherence, side effects 31:25 Adverse effects of PrEP 34:00 Monitoring patients on PrEP 36:46 Collaborative practice 37:30 Discussion of high risk behaviors on PrEP 39:30 Does PrEP promote viral resistance? 41:51 Insurance reimbursement for PrEP 42:50 Take home points 44:24 Outro Tags: assistant, care, doctor, education, emtricitabine, family, foam, foamed, health, HIV, hospitalist, hospital, infection, internal, internist, nurse, meded, medicine, medical, physician, practitioner, primary, prophylaxis, resident, sti, student, tenofovir
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45 min
May 22, 2017
#40: Pseudo endocrine disorders, fatigue, and the Schmerbsiders?
Learn “weird” endocrine stuff! How to approach vague complaints like fatigue and weight gain. Reverse T3 syndrome, Wilson’s T3 syndrome, and adrenal fatigue; Do they exist? Learn how to help the challenging patient who is convinced they have an endocrine disorder in this discussion recorded live from AACE 2017 with Dr. Michael T. McDermott, Professor of Medicine, University of Colorado Denver School of Medicine. For full show notes visit http://thecurbsiders.com/podcast Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Intro 05:36 Guest intro 07:50 Definition of “pseudo” endocrine 10:02 Case introduction 13:39 “Reverse T3 Syndrome”, the thyroid and fatigue 20:45 Growth hormone 25:10 Fatigue, and where to start 33:00 Adrenal fatigue 38:00 Lab testing 39:34 Take home points 42:12 Stuart on the thyroid and reverse T3 45:30 Paul’s approach to multisystem complaints 51:12 Outro Tags: adrenal, assistant, care, doctor, education, endocrine, family, fatigue, foam, foamed, growth, health, hormone, hospitalist, hospital, internal, internist, nurse, medicine, medical, physician, practitioner, primary, resident, student, thyroid, t3
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54 min
May 15, 2017
#39: Secondary hypertension, hyperaldosteronism, Cushing’s, and pheochromocytoma
Expert tips on the diagnosis and management of secondary hypertension in this conversation with Dr. Richard Auchus MD, PhD, Professor of Pharmacology and Internal Medicine & Director of the Diabetes, Endocrinology, & Metabolism Fellowship Program at the University of Michigan. Topics include: primary hyperaldosteronism, use of spironolactone, Cushing’s syndrome, pheochromocytoma, and which tests to utilize. Full show notes available at http://thecurbsiders.com/podcast Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Tags: assistant, care, cushing's, doctor, education, endocrine, family, foam, foamed, health, hospitalist, hospital, hypertension, internal, internist, nurse, medicine, medical, pheochromocytoma, physician, practitioner, primary, resident, resistant, spironolactone, student
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41 min
May 8, 2017
#38: Hospice and palliative care: How to manage end of life symptoms
Recognize and manage end of life symptoms with competence and confidence. In this extensive discussion with Dr. Brooke Worster, Assistant Professor of Medicine at Sydney Kimmel Medical College and Medical Director, of the Palliative Care Service at Thomas Jefferson University Hospitals we discuss scripts for having difficult conversations, managing patient/family expectations, what comes in the hospice “E” kit, terminal delirium, the “death rattle”, air hunger, and more. Full show notes available at http://thecurbsiders.com Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Intro 03:10 Rapid fire questions 08:33 Defining hospice and palliative care 11:28 Case discussion 21:28 Gunderson, MI and Respecting Choices 24:25 How to counsel patients about home hospice? 37:10 Hospice “E” kit and how to use it 42:09 Air hunger, terminal delirium, death rattle, and Cheyne Stokes breathing 52:48 What is the PCM’s role while patient is on hospice? 58:19 Cancer survivorship and palliative care 60:33 Take home points 62:20 Outro Tags: assistant, care, doctor, end, education, family, foam, foamed, health, hospice, hospitalist, hospital, internal, internist, life, nurse, medicine, medical, palliative, physician, practitioner, primary, resident, student, symptom
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63 min
May 1, 2017
#37: Lipids, PCSK9, and ezetimibe: Lower is better.
Learn the latest in lipid lowering therapy in this extensive discussion with Dr. Paul S. Jellinger, MD, MACE, Professor of Medicine at the University of Miami and Chair of the writing committee for the American Association of Clinical Endocrinologists (AACE) 2017 Guidelines for the Management of Dyslipidemia and Prevention of Cardiovascular Disease (CVD). Topics include ezetimibe, PCSK9, FOURIER trial, statin myopathy, CoQ10, fish oil, fibrates and more. For a more basic discussion of dyslipidemia check out episode #10. Full show notes are available at http://thecurbsiders.com/podcast Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Intro 03:10 Rapid fire questions 08:15 Dyslipidemia defined 10:26 Classifying dyslipidemia 13:21 Diagnosing Familial Hypercholesterolemia 17:48 A difficult lipid case discussed 22:40 Lp (a), Apo B and LDL particle concentration 28:40 What labs to order 31:31 ACC/AHA versus other risk scores 38:21 IMPROVE-IT 41:35 Non-statin medications discussed 45:05 Hypertriglyceridemia fibrates and fish oil 48:25 How often to check the lipid panel 49:58 Statin Myopathy and CoQ10 54:17 FOURIER, PCSK9 and very low LDLs 59:43 Extreme risk category discussed 62:34 Is plaque regression possible? 64:12 Take home points 67:08 Outro Tags: assistant, care, cholesterol, doctor, education family, fish oil, foam, foamed, health, hospitalist, hospital, internal, internist, ldl, lipid, medicine, medical, myopathy, nurse, pcsk9, physician, practitioner, primary, statin, resident, student
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68 min
April 24, 2017
#36: Random Clinical Pearls: ACP Highlights and Recap Part 1
A recap and highlights from ACP 2017, Internal Medicine's largest national conference, with Dr. Alan Dow MD, MSHA, FACP, Professor of Medicine from Virginia Commonwealth University. We discuss iron supplementations, shellfish allergies and IV contrast, proton pump inhibitors, and more! For full show notes visit http://thecurbsiders.com/podcast. Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Tags: acp, allergy, assistant, care, contrast, doctor, education, family, foam, foamed, health, hepcidin, hospitalist, hospital, internal, internist, iron, nurse, medicine, medical, physician, ppi, practitioner, primary, resident, shellfish, student
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33 min
April 17, 2017
#35: Depression: MDD with DJ MMC
Master the management of major depressive disorder (MDD) with clinical pearls from Dr. Marius Marcel Commodore, Associate Professor of Clinical Medicine and Psychiatry from Temple University Hospital. We cover diagnosis, patient counseling, choice of agent, dose titration, augmentation...and DJ names? For full show notes visit http://thecurbsiders.com/podcast Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Intro 02:08 Rapid fire questions 11:04 Initial diagnosis and screening 13:06 Tools for diagnosis discussed 17:07 Shared decision making in choice of agent 19:40 Monitoring and follow up 21:51 Choice and comparison of agents 27:38 Augmentation and the STAR-D study 31:03 Quick recap 33:52 Cognitive behavior therapy 40:58 Medication titration and duration of therapy 45:18 Bipolar disorder screening 47:38 Screening for suicidality 49:58 Difficulty getting patients into specialty care 53:38 Mood disorders in health care providers 58:31 Listener Questions 60:48 Take home points 64:10 Outro Tags: antidepressant, assistant, care, depression, doctor, education family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, medicine, medical, mood, physician, practitioner, primary, psychiatry, ssri, snri, resident, student
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65 min
April 10, 2017
#34: Super Utilizers, hot spotting, and difficult patients
An approach to super utilizers, and difficult patients with Dr. Alex Lane, Assistant Professor of Medicine at Cooper University Hospital. In this wide ranging discussion we cover books, learning, super utilizers, hot spotting, and how to approach difficult patients. For full show notes visit http://thecurbsiders.com/podcast Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Time Stamps 00:00 Intro 02:04 Getting to know you 06:12 Best advice 07:13 Alex’s tips on keep up with EBM 11:22 Something about Alex we won’t forget 13:06 Listener Mail 15:00 Super Utilizers defined 17:00 Hot spotting defined 24:55 ACE score discussed 30:15 Team based approach to care 33:16 Getting involved in your community 36:18 Outro Tags: assistant, care, difficult, doctor, education family, foam, foamed, health, hot, hospitalist, hospital, internal, internist, nurse, medicine, medical, patient, physician, practitioner, primary, resident, spotting, student, super, utilizer
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37 min
April 3, 2017
#33: The Dementia Episode You Won’t Forget
Dominate the diagnosis and management of dementia with tips from international expert Dr. Stephen Dekosky, Professor of Neurology, and deputy director of the McKnight Brain Institute at the University of Florida. Filled with clinical pearls, we cover everything from basic testing to advanced imaging modalities, as well as current and future therapies for dementia. This episode is a must listen. Big thanks to the American Academy of Neurology for setting up this interview. Full show notes are available at http://thecurbsiders.com/podcast Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.  Time Stamps 00:00 Intro 02:20 Rapid fire questions 04:40 Defining dementia 08:40 Choosing a clinical test for dementia 17:20 Diagnostic labs 19:00 Genetic and CSF testing 25:46 Advanced brain imaging 28:18 Preclinical Alzheimer’s disease (AD) 32:17 Routine CNS imaging 36:18 Initiating medical therapy 39:35 Differentiating MCI and dementia 41:45 Vascular Dementia 44:10 CSF testing for AD 45:15 Vitamins, supplements, and foods as treatment or prevention 50:56 Mental exercise for AD prevention 52:36 Anticholinergic, benzos and dementia 54:46 Future directions 57:55 Outro Tags: Alzheimers, assistant, care, education, dementia, disease, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, neurology, nurse, medicine, medical, mri, pet, primary, physician, resident, student, vascular      
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60 min
March 27, 2017
#32: Syncope Deconstructed
Dominate syncope with tools, tips, and tricks from The Curbsiders. No guest on this episode, just doctors Watto, Brigham, and Williams deconstructing the frustrating topic of syncope to provide listeners with some shiny clinical pearls and practice changing knowledge. For full show notes visit http://thecurbsiders.com/podcast Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.   Tags: assistant, cardiology, care, doctor, education, epilepsy, family, foam, foamed, guideline, health, hospitalist, hospital, internal, internist, nurse, medicine, medical, physician, practitioner, presyncope, primary, resident, student, syncope
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63 min
March 20, 2017
#31: Diuretics, leg cramps, and resistant hypertension with The Salt Whisperer
Dominate leg cramps, diuretic therapy, and resistant hypertension. Our guest, Dr. Joel Topf, is a clinical nephrologist, pioneer in the use of social media for medical education, and Assistant Clinical Professor at Oakland University William Beaumont School of Medicine, best known for his blog, Precious Bodily Fluids, and hilarious/informative Twitter feed @kidney_boy. We start with basic renal physiology and build up to the treatment of resistant hypertension. For full show notes visit http://thecurbsiders.com/podcast. Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Tags: assistant, care, diuretics, doctor, education family, foam, foamed, health, hospitalist, hospital, hypertension, internal, internist, nephrology, nurse, media, medicine, medical, physician, physiology, practitioner, primary, social, renal, resident, resistant, student  
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61 min
March 13, 2017
#30: Mastering Menopause
Dominate the treatment of menopause with tips from expert, Dr. Amy Tremper, Assistant Professor of Obstetrics and Gynecology at the University of Michigan Medical School. We discuss hormone replacement therapy, the Women’s Health Initiative, bio-identical hormones...and game shows?! For full show notes visit http://thecurbsiders.com/podcast. Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.   Tags: assistant, care, doctor, education family, foam, foamed, health, hormone, hospitalist, hospital, hot flashes, internal, internist, nurse, medicine, medical, menopause, physician, practitioner, primary, replacement, resident, student, therapy
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60 min
March 6, 2017
#29: Neuropathy Deconstructed
Stop the madness! Diagnose and treat neuropathy like expert guest, Dr. Grace Kimbaris, Assistant Professor of Clinical Neurology from University of Pennsylvania. We cover the basics along with some random pearls on fluoroquinolones, small fiber neuropathy, alpha lipoic acid, and more!  For full show notes visit http://thecurbsiders.com/podcast.  Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.     Tags: assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, medical, medicine, nerve, neuropathy, primary, physician, resident, student
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49 min
February 27, 2017
#28: Coronary artery calcium scoring: The ultimate cardiovascular risk assessment
Individualize cardiovascular risk, and optimize risk reduction using cardiac CT with coronary artery calcium (CAC) scoring. Our expert guests from The Society for Cardiovascular Computed Tomography (SCCT), Dr. Harvey Hecht, Professor of Medicine from Mount Sinai, and Dr. Matthew Budoff, Professor of Medicine from UCLA, school us on the use of this powerful tool. Special thanks to Dr. Emilio Fentanes from the SCCT for setting up this interview. Join our newsletter mailing list. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com. Get full show notes at http://thecurbsiders.com/category/podcast   Tags/keywords: artery, assistant, cac, calcium, care, cardiovascular, coronary, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, medicine, medical, primary, physician, resident, student
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41 min
February 20, 2017
#27: Conquer Irritable Bowel Syndrome
Diagnose and treat irritable bowel syndrome (IBS) like master clinician, Dr. Brooks Cash of the American College of Gastroenterology. This condition frustrates clinicians and patients alike, but we’ll give you the tools to conquer IBS. Now with our theme song included! Recommend a guest or topic and give feedback at thecurbsiders@gmail.com   Get full show notes at http://thecurbsiders.com/category/podcast   Tags: assistant, bowel, care, doctor, education, family, foam, foamed, gastroenterology, health, hospitalist, hospital, internal, internist, irritable, nurse, medicine, medical, primary, physician, resident, student, syndrome
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46 min
February 13, 2017
#26: What’s the deal with Radiation Oncology?
Anticipate, and dominate the side effects of radiation therapy. On this episode we interview Dr. John J. Cuaron, Radiation Oncologist from Memorial Sloan Kettering Cancer Center in New York to better understand, “What’s the deal with radiation oncology?”. Recommend a guest or topic and give feedback at thecurbsiders@gmail.com   Get full show notes at http://thecurbsiders.com/category/podcast   Tags: assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, internal, internist, nurse, medicine, medical, primary, physician, resident, student 
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32 min
February 6, 2017
#25: Master hyperglycemia and DKA
Master the management of hyperglycemia, DKA, and learn to avoid common pitfalls. This episode is packed with clinical pearls from repeat guest, Endocrinologist, Dr. Jeffrey Colburn. Recommend a guest or topic and give feedback at thecurbsiders@gmail.com   Get full show notes at http://thecurbsiders.com/category/podcast   Tags: assistant, care, diabetes, dka, doctor, endocrinology, family, health, hospitalist, hospital, hyperglycemia, internal, internist, ketoacidosis, nurse, medicine, medical, primary, physician, student, resident
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46 min
January 30, 2017
#24: Curbside Round Table: Pondering Obesity
Summary: More tools, tips, and tricks so you can master obesity in clinic. On this first roundtable episode, The Curbsiders give their take on the management of obesity, and offer their own practice changing tips. Also, Paul announces his goal to watch 365 movies in 365 days, and the guys give more great book, movie, and TV recommendations. Got feedback? Email thecurbsiders@gmail.com   Picks of the week Matt’s pick - Never Eat Alone by Keith Ferrazzi Paul’s pick - Sing Street (film) Stuart’s pick - Lemony Snicket's: A series of unfortunate events Clinical pearls (from Recap and response OR Brief topic review) Obesity is a DISEASE. Not a lifestyle choice. Percent weight loss by intervention Diet and lifestyle 5-10% Medications >10% Bariatric surgery >30% Utilize specialist referral to gain resources e.g. dietician, and psychologist through bariatric surgery referral Put faith in your patients ability to change and they will hold themselves accountable Coding tips If BMI >35 then code “morbid obesity” to increase medical decision making Code “BMI” in addition “Morbid obesity” Be sure to code comorbid conditions e.g. hypertension, diabetes, hyperlipidemia, OSA Time Stamps 00:00 Intro 01:29 Picks of the week 06:07 Recap and responses to our obesity interview with Dr. Garvey 08:55 Mechanisms of obesity 10:15 Discussion of relapse rates, weight gain 11:23 Percent weight loss per therapy 14:35 Treating obesity on a budget 18:51 Coding tips 20:43 Diet, lifestyle counseling and how to leverage resources 26:38 Closing remarks 28:40 Outro Disclosures: The Curbsiders report no relevant financial disclosures, but as always hope to have lots of them in the future. Links from the show: Tomlinson, S et al. Mechanisms, Pathophysiology, and Management of Obesity. NEJM 2016; 376(3) http://www.nejm.org/doi/full/10.1056/NEJMra1514009 E&M University website http://emuniversity.com ICD10Data.com http://www.icd10data.com Matt’s pick - Never Eat Alone by Keith Ferrazzi Paul’s pick - Sing Street (film) Stuart’s pick - Lemony Snicket's: A series of unfortunate events   Tags: care, doctor, family, health, hospitalist, hospital, internal, internist, medicine, medical, obesity, primary, physician, student, resident  
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30 min
January 16, 2017
#23: The Obesity Epidemic: The Curbsiders size it up
Obesity is of epidemic proportions in the United States and, unfortunately, many physicians are ill-equipped to tackle this disease.  In this episode, we talk with Dr. Timothy Garvey, MD, FACE, one of the world’s leading experts in obesity research.  We asked the American Association of Clinical Endocrinology to recommend an obesity expert and they gave us the best! Got feedback? Email thecurbsiders@gmail.com  Clinical Pearls: Obesity is a DISEASE. Not a lifestyle choice! Obesity is known to be associated with many of the most common preventable diseases and, thus, should be an important component of any treatment program. BMI goals differ between ethnic groups (for example, east Asians developing heart disease with a BMI greater than 23). Weight loss treatment should focus on the disease burden and not on body image. While diet and exercise are independently important, failure to address the underlying sedentary lifestyle will likely prove fruitless.  The American College of Sports Medicine recommends avoiding any sedentary activity greater than 90 minutes at a time and at least 150 minutes of moderate activity weekly. Always ask permission before talking about weight loss; otherwise, you might negatively impact the physician-patient relationship. In order to prevent weight-related complications, aim for approximately 10% weight loss. Weight regain is a REAL problem that should be anticipated (decreased BMR, hormonal implications, and many other issues); weight loss medications help to fight against these pathophysiological mechanisms. Weight loss medications (Orlistat [inhibits fat absorption], Lorcaserine [5HT2C agonist, blunts appetite], Liraglutide [GLP1-RA] at higher dosages [3mg/day], Phentermine/Topiramate [“...most effective…”], Naltrexone/Bupropion) are under-utilized across the board, but before using these medications, the physicians should understand how to use these medications and consider them as part of a weight loss treatment plan that includes lifestyle modifications (i.e. dietary assessment and exercise “prescription”). Liraglutide, Phentermine/Topiramate, and Naltrexone/Bupropion are the most effective medications. If the patient does not lose at least 5% of their weight by three months, stop that specific medication and consider trying another medication. Follow-up with your weight loss patients frequently over the telephone (2 weeks after starting a medication) and in the office (at least monthly). Minimal data supports using weight loss medications in the elderly (>70 years of age) Dr. Garvey’s “Take-Home” Points: Obesity is a DISEASE not a lifestyle choice! Don’t be afraid to use weight loss medications! Weight loss should be a tool to improve HEALTH, not appearance. Disclosures: Dr. Garvey reports several financial disclosures for this talk: Scientific Advisory Board:  Novo Nordisk, Eisai, Janssen, Vivus, Liposcience, Takeda, Astra Zeneca, Alexion, Merck Research Funding (university administered):  Merck, Astra Zeneca, Weight Watchers, Eisai, Sanofi, Pfizer, Novo Nordisk, Lexicon, Elcelyx Stock Ownership (publicly traded):  Eli Lilly, Pfizer, Novartis, Merck, Isis, Bristol-Myers-Squibb, Affymetrix Learning objectives: By the end of this podcast listeners will be able to: Understand the impact obesity has on overall health and disease burden. Identify the weight loss medications and which might be appropriate for your patient(s). Have a general understanding of the impact that each individual treatment modality (lifestyle modification, medications, and surgery) has on weight loss. Links from the show: Dr. Timothy Garvey’s bio (UAB):  https://www.uab.edu/medicine/diabetes/faculty/faculty-bios/111-w-timothy-garvey Dr. Timothy Garvey’s app recommendation, “Lose It,” available from https://www.loseit.com/. Dr. Timothy Garvey’s book recommendation:  “House of God” available https://www.amazon.com/House-God-Samuel-Shem/dp/0425238091/ref=sr_1_1?ie=UTF8&qid=1484443555&sr=8-1&keywords=House+of+God. AACE 2016 Obesity Guidelines:  https://www.aace.com/files/final-appendix.pdf AACE Obesity Treatment Algorithm (highly recommended):  https://www.aace.com/files/guidelines/ObesityAlgorithm.pdf Naltrexone/Bupropion SR for Weight Loss:  Method-of-use study of naltrexone sustained release (SR)/bupropion SR on body weight in individuals with obesity.  Obesity (Silver Spring). 2016 Dec 27. doi: 10.1002/oby.21726. Phentermine/Topiramine for Weight Loss (Review Article):  Combination phentermine and topiramate extended release in the management of obesity.  Expert Opin Pharmacother. 2015 Jun;16(8):1263-74. doi: 10.1517/14656566.2015.1041505.
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44 min
January 15, 2017
Meet The Curbsiders
Supercharge your learning and enhance your practice with this Internal Medicine Podcast featuring board certified Internists as they interview national and international experts to bring you clinical pearls and practice changing knowledge. Doctors Matthew Watto, Stuart Brigham, and Paul Williams deliver some knowledge food for your brain hole. Comments or questions? Email thecurbsiders@gmail.com
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5 min
January 2, 2017
#22: Best of 2016 Recap and Recommendations
Summary: Consolidate your knowledge and reinforce the learning you’ve done with us in 2016. Enjoy this holiday helping of knowledge food for your brain hole. The guys offer their best of recommendations for 2016 and recap key teaching points from the past year so you have the tools to dominate 2017. Recommend a guest or topic and give feedback at thecurbsiders@gmail.com   Clinical Pearls: SPRINT trial debate Bias effects results seen in this trial. e.g. stopped early Blood pressure (BP) control may have been overestimated based on how BP was measured leading to increased CV events (Stuart’s view). BP measurements in trial likely reflected out of office BP so results are useful (Paul’s view). Lower BP is probably safe, even in the elderly so be reluctant to back off on meds. HTN Urgency Verify BP reading and measurement technique Evaluate for pain, anxiety, volume overload, nonadherence, or noncompliance Treat high BP with long term goals in mind (i.e. go up on chronic/long-acting meds) Anticoagulation Avoid warfarin in patients with gastric bypass or Crohn’s with ileitis. Use SPARC tool to visually demonstrate risks and benefits of anticoagulation in Afib. Physicians commonly underestimate benefit of anticoagulation in older sicker patients and overestimate risk of bleeding. Fibromyalgia and chronic pain Recognize the constellation of fatigue, memory problems, sleep disturbance, and multifocal pain as fibromyalgia. Use the 2011 American College of Rheumatology criteria for diagnosis. No tender point exam required! Nonpharmacologic therapies and education are most effective (see video links below). Chronic painful conditions like rheumatoid arthritis, or lupus can lead to fibromyalgia. Functional Medicine At least 80% of your food should be whole foods. Use the Dirty Dozen and Clean 15 to guide organic food choices. Knowledge of pathophysiology and biochemistry can be used to treat disease e.g. treating small intestinal bacterial overgrowth can fix iron deficiency and indirectly treat iron deficiency. Lipids Lowering LDL is key. Some statin is better than none, so consider intermittent dosing (three times weekly) of atorvastatin or rosuvastatin. Statins have a 20 year safety record, are cheap, and will remain king for now. Check baseline LDL and monitor percent decrease on statin therapy to ensure desired effect (e.g. 50% drop in LDL for patient requiring high intensity). Withdrawal of statins at end of life is warranted and safe. Insomnia Nonpharmacologic therapy is as good or better than pharmacologic therapy. Benefits of nonpharmacologic therapy persist 1-2 years after discontinuation. Identify problem with sleep initiation versus maintenance, or both, then choose agent. Use long taper of sleep agent (several months) along with CBT for nightly problems with sleep. Intermittent dosing of sleep agent okay if only intermittent sleep trouble. Osteoporosis If secondary hyperparathyroidism present, then target normal PTH not just a Vit D level 30-50 ng/ml. After hip fracture, first normalize Vit D and/or PTH, then treat with bone conserving agent. Drug holiday stops when bone density falls, fracture occurs, or risk increases (e.g. steroid use). Patients may require multiple courses of bisphosphonates or other bone conserving drugs. In-flight emergencies Know contents of standard medical kit include: Be prepared to improvise. Lessons learned Failure is essential to learning and improving. Don’t fall victim to “fear of being left out”. Saying “No” protects you from being spread thin. Overcome the “curse of knowledge” by teaching the basics and gearing lesson to level of learner. Disclosures: The Curbsiders report no relevant financial disclosures, but hope to have a long list of them in the future. Time Stamps 00:00 Intro 02:54 Best of 2016 Articles 07:45 Best of 2016 Book recommendations 12:44 Best of 2016 Apps 15:49 SPRINT trial 24:34 Hypertensive urgency 27:05 Anticoagulation 33:00 Fibromyalgia and chronic pain 38:38 Functional Medicine 42:05 Lipids 48:09 Insomnia 52:13 Osteoporosis 56:29 In-flight emergencies 59:09 Lessons learned in 2016 1:03:45 Outro Links from the show: Articles Blood pressure as a risk factor for headache and migraine: a prospective population-based study.  Eur J Neurol. 2015 Jan;22(1):156-62, e10-1. doi: 10.1111/ene.12547. Epub 2014 Aug 25. Imbalanced insulin action in chronic overnutrition: Clinical harm, molecular mechanisms, and a way forward. Atherosclerosis. 2016 Apr;247:225-82 Sniffing out significant “Pee values”: genome wide association study of asparagus anosmia http://www.bmj.com/content/355/bmj.i6071 Books How Doctors Think by Jerome Groupman Multipliers: How the Best Leaders Make Everyone Smarter by Liz Wiseman: Spook Country by William Gibson Carter Beats the Devil by Glen David Gold Evidence Based Physical Diagnosis by Steven McGee Apps Download Google Drive UptoDate My Fitness Pal Map My Run Other links SPARC Tool for anticoagulation in atrial fibrillation Warfarin use in heart failure patients may have a mortality benefit Fibroguide.com Chronic Pain is it all in their head Five minute video on Chronic Pain from Australia (not the VA!) EWG.org (environmental work group) - gives the Dirty Dozen and the Clean 15
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65 min
December 19, 2016
#21: Find a dream job and jumpstart your career
Summary: Advance your career and expertly navigate the job hunt with guidance from Dr. Alia Chisty of Temple University Hospital.  Highlights include Dr. Chisty offering up her personal email address for mentorship and Dr. Watto announcing our first contest. This episode is full of wisdom to enhance your career whether you're gainfully employed or looking for your first job. Clinical Pearls: Meet with your mentors at the start of the process. They can: Help clarify your goals Activate your network Look for jobs 9 months in advance. An ideal job: incorporates your interests, skills, and values. Leverage your network (friends, mentors, program director) to identify available opportunities Email your cover letter (typically an email) and CV to the division chair or section chief Craft your elevator pitch. Do your homework. Explain how you will add value. When interviewing: Give yourself credit! Highlight experiences in your CV (e.g. conference attendance, lectures given, etc.) Have someone review and proofread your CV. If an employer makes a promise, then have it included in your contract. Don’t just take their word! Have a lawyer review your contract. Goal: Listeners will learn to craft a systematized approach to finding their perfect job. Learning objectives: By the end of this podcast listeners will: Recognize timeline for applications and finding or switching jobs. Design an effective CV and cover letter. Recognize the importance and utility of mentors in the application process Disclosures: Dr. Chisty reports no relevant financial disclosures. Time Stamps 0:20 Intro 03:40 Rapid fire questions 07:10 When to start looking for jobs 09:22 How to narrow your focus 11:33 Too many choices may be worse 13:05 Asking yourself the right questions 14:40 Quick recap of what we’ve learned 15:20 Who to contact, and what to send 19:30 Recruiters 22:25 How to prepare for your interview 26:05 Ramit Sethi on finding your dream job and negotiating your salary 27:36 Where to look for jobs (including social media) 31:10 Discussion of social media 33:18 What to include in your CV 35:25 Our first contest (send us your CV!) 36:30 So you’ve been offered a job (s) 38:38 Take home points 40:15 Outro Links from the show: NEJM career center: http://www.nejmcareercenter.org/jobs/internal-medicine/ JAMA career source: http://www.jamacareercenter.com/resources_overview.cfm Zerzan, J.T. et al.  2009.  Making the most of mentors: a guide for mentees.  Academic Medicine 84: 140-144. https://www.ncbi.nlm.nih.gov/pubmed/19116494 Ramit Sethi on finding your dream job http://www.iwillteachyoutoberich.com/find-your-dream-job/ Ramit Sethi on negotiating your salary http://www.iwillteachyoutoberich.com/blog/salary-negotiation/ Pride and Prejudice by Jane Austen Harry Potter and the Goblet of Fire by JK Rowling NEJM Journal Watch http://www.jwatch.org AHRQ ePSS app  https://itunes.apple.com/us/app/ahrq-epss/id311852560?mt=8 8j38tuq3
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43 min
December 5, 2016
#20: Hypertensive urgency and severe hypertension
Summary: On this episode we’ll teach you to dominate hypertensive urgency and severe hypertension (HTN) in the clinic, the ER, or on the hospital wards. The Curbsiders offer you this delicious serving of knowledge food so you can manage high blood pressure (BP) without making the same egregious errors that we made during our more formative years. Of note, The Curbsiders are guestless for this episode. Guestless? Is that a word? Our guest for this episode was supposed to be Dr. Wallace Johnson, a Cardiologist, and expert on HTN from the University of Maryland. He did a fantastic job, but, unfortunately, technical difficulties caused us to lose any useable audio. Our sincerest gratitude and deepest apologies to Dr. Johnson. Nevertheless, we pressed on and used one of our own, the illustrious Dr. Paul Williams, as our expert guest. Clinical Pearls: Hypertensive crisis is divided into hypertensive emergency and hypertensive urgency. “Emergency” needs IV therapy NOW “Urgency” needs increased oral therapy over next 24-72 hours History, physical exam, and familiarity with the patient are key for triage (e.g. verify BP readings, assess compliance, etc.) Severe HTN and hypertensive urgency can often be treated in the outpatient setting IV agents are not indicated outside of true hypertensive emergency (i.e. objective end organ damage) We recommend increasing dose or frequency of existing BP meds as 1st line (better long-term solution) Intermittent dosing of oral labetalol, clonidine, and captopril can be considered as 2nd line (short-term solution) Rule out uncontrolled pain, volume overload, alcohol withdrawal, illicit drug, and missed medications as cause of severe HTN Evidence from observational studies suggests that headaches are NOT caused by HTN Untreated severe HTN was historically fatal in months to years prior to development of antihypertensives Goal: Listeners will become proficient in the appraisal of severe hypertension/ hypertensive urgency and employ safe and practical management strategies. Learning objectives: By the end of this podcast listeners will: Confidently triage patients with severe hypertension and provide appropriate disposition in a variety of settings Employ a safe and common sense approach to the treatment of severe hypertension in the clinic, the ER, or on the wards Be familiar with pharmacologic management of severe hypertension in a variety of settings Recognize the common causes of severe blood pressure elevation in the inpatient setting Counsel patients on the relationship of severe hypertension and headache Recall the natural history of untreated severe hypertension Disclosures: The Curbsiders report no relevant financial disclosures, but hope to become successful enough to display an absurd list of disclosures in the future. Time Stamps 0:00 Hook 0:26 Intro 1:38 Rapid fire questions 03:45 Triage of patient with severe HTN 05:05 Case example HTN in office 07:05 Does HTN cause a headache? 08:30 Workup of severe HTN in the office 10:20 Stuart discusses HTN and headaches 11:30 In office treatment of blood pressure 14:28 Recap 15:50 Stuart discuss HTN emergency at normal BP 17:00 Acute treatment of HTN in ER 18:10 Approach to the inpatient with HTN 20:50 Choice of agent for inpatient HTN 23:23 Italian study of HTN crisis in the ER 24:20 Outcomes in asymptomatic patients with severe HTN 26:15 Sleep apnea and HTN 27:10 Natural history of untreated severe HTN 29:10 Take home points 30:50 Outro Links from the show: Blood Meridian by Cormack McCarthy Horton Hears a Who by Dr. Seuss ASCVD risk calculator http://tools.acc.org/ASCVD-Risk-Estimator/ Epocrates. Download it here Dr. Johnson’s excellent review article on hypertensive crisis https://www.ncbi.nlm.nih.gov/pubmed/23102030 Another great review with tables on oral drug therapy and dosing for hypertensive crisis https://www.ncbi.nlm.nih.gov/pubmed/18710665 Fascinating article from 1928 on The Syndrome of Malignant Hypertension* http://archinte.jamanetwork.com/article.aspx?articleid=535650 Observational study from Italy characterizing symptoms and outcomes in hypertensive crisis https://www.ncbi.nlm.nih.gov/pubmed/8591878 JNC 7 recommendations for hypertensive crisis: See page 54 of this PDF for details http://www.nhlbi.nih.gov/files/docs/guidelines/express.pdf Most recent review we could find on hypertensive crisis https://www.ncbi.nlm.nih.gov/pubmed/25575271 Migraine and subsequent risk of stroke in the Physicians' Health Study. https://www.ncbi.nlm.nih.gov/pubmed/7848119 Blood pressure as a risk factor for headache and migraine: a prospective population-based study. https://www.ncbi.nlm.nih.gov/pubmed/25155744 Blood pressure and risk of headache: a prospective study of 22,685 adults in Norway. https://www.ncbi.nlm.nih.gov/pubmed/11909904
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32 min
November 21, 2016
#19: How to respond to in-flight emergencies
Summary: Does the thought of responding to an in-flight emergency ruin your air travel? Then tune in because on this episode, Angelica Zen, MD, Chief Resident of Internal Medicine at UCLA, recounts a harrowing tale of heroism at 30,000 feet and schools us on how to throw down in an in-flight emergency. We review what’s available in the standard medical kit, common conditions encountered, and the medical legal implications of responding to in-flight emergencies. This episode is a must listen before you next step on a plane.   Clinical Pearls: Stay Calm!  If you freak out, so will everyone else. Think outside the box and be prepared to improvise from available resources. (e.g. ask another passenger for a glucometer) Standard medical kit contains - manual BP cuff, stethoscope (cheap), gloves, oropharyngeal airways, CPR masks, bag-valve masks, IV set, 500 ml saline, needles, syringes, analgesic tabs, antihistamine (tabs or injection), aspirin, atropine, inhaler (bronchodilator), Dextrose 50%, Epi (1:1000 and 1:10000), IV lidocaine, nitroglycerin tabs, supplemental oxygen. Don’t forget to utilize the ground medical team! Legal repercussions very unlikely unless there is “gross neglect” or “intentional harm”. DON’T treat patients if YOU’VE BEEN DRINKING! Common emergencies in order of decreasing frequency - syncope and presyncope, dyspnea, acute coronary syndrome, altered mental status, psychiatric emergencies, stroke, cardiac arrest Goal: Listeners will understand their role and potential liabilities during in-flight emergencies and effectively utilize available resources for triage, patient care, and decisions about diverting the plane. Learning objectives: By the end of this podcast listeners will: Be familiar with the contents of the standard medical kit Think outside the box to identify, improvise and utilize available resources for patient care Recognize the medical legal consequences of providing emergency medical care on a plane Confidently evaluate and manage common in-flight emergencies using the available resources Disclosures: Dr. Zen reports no relevant financial disclosures. Time Stamps 00:26 Intro 02:06 Start of Interview 03:02 Rapid Fire Questions 07:08 Dr. Zen tells her story 17:27 Monitoring your patient in-flight 18:05 Contents of the standard in-flight medical kit 20:10 What Dr. Zen would have done differently 21:05 How to use available resources in-flight 22:20 Medical legal implications 26:07 How to respond to common in-flight emergencies and how to respond 27:35 Syncope and presyncope 29:52 Hypoxia altitude simulation test (HAST) 31:15 Altered mental status 31:52 Anaphylaxis 33:19 Stroke and acute coronary syndrome 34:51 Dr. Zen’s take home points 36:40 Outro Links from the show: Baby delivered in-flight by Angelica Zen, MD http://newsroom.ucla.edu/stories/ Pharmacy article detailing supplies in standard medical kit on plane http://www.ashp.org/menu/News/PharmacyNews/NewsArticle Great review article on In-Flight Emergencies. Nable JV, Tupe CL, Gehle BD, Brady WJ.  In-Flight Medical Emergencies during Commercial Travel. N Engl J Med. 2015 Sep 3;373(10):939-45. doi: 10.1056/NEJMra1409213. Article on the hypoxia (or high) altitude simulation test (HAST) https://www.ncbi.nlm.nih.gov/pubmed/18398121 Interesting article: Passenger safely defibrillated 21 times during International Flight. Harve H1, Hämäläinen O, Kurola J, Silfvast T. AED use in a passenger during a long-haul flight: repeated defibrillation with a successful outcome. Aviat Space Environ Med. 2009 Apr;80(4):405-8. How Doctors Think by Jerome Groupman: Amazon.com link NEJM Physicians First Watch http://www.jwatch.org/medical-news
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38 min
November 7, 2016
#18: Osteoporosis, bone health and the calcium, vitamin D controversy.
Summary: On this episode, we got served! Endocrinologist, Dr. Pauline Camacho, current president of AACE and Professor of Medicine at Loyola University Chicago makes it rain clinical pearls as she schools us on the use of calcium, Vitamin D, bisphosphonate therapy and drug holidays. This is a must listen for anyone treating osteoporosis. Make sure to check out the new 2016 AACE guidelines, which include infographics for patients and their easy to use algorithm. Clinical Pearls: Vitamin D Vitamin D for postmenopausal osteoporosis prevention (women ≥ 50 yo) Optimum Vit D level between 30-50 ng/ml recommend Check PTH if Vit D is very low If secondary hyperparathyroidism then treat until PTH normalizes Usual dose is Vit D2 or D3 1000 to 2000 IU daily Weekly dosing may be required for loading Vit D3 preferred if malabsorption (e.g. post gastric bypass) Vitamin D2 or D3 50,000 IU dosed monthly or biweekly is probably safe despite trials suggesting increased falls2-3 Calcium Calcium recommended total daily intake through diet +/- supplements postmenopausal women 1200 mg daily Men 1000 mg Calcium citrate has better absorption, especially in the elderly or those on PPI Osteoporosis and drug therapy AACE’s four criteria for diagnosis osteoporosis T-score –2.5 or below in the lumbar spine, femoral neck, total, and/or 33% (one-third) radius Low-trauma spine or hip fracture (regardless of BMD) Osteopenia or low bone mass (T-score between –1 and –2.5) with a fragility fracture of proximal humerus, pelvis, or possibly distal forearm Low bone mass or osteopenia and high FRAX® fracture probability based on country-speci c thresholds Bisphosphonate therapy Treat for 5-10 years with oral or 3-6 years with IV bisphosphonates High fracture risk: elderly patients or those with hx of fracture then consider IV agents 1st line (zoledronic acid, denosumab, teriparatide) Therapy is successful if: Stable bone mineral density (BMD) Increasing BMD Diminishing levels bone turnover markers (e.g. N-terminal and C-terminal cross-linked telopeptides)4 Therapy is a failure if: Significant or progressive loss of BMD (using a reliable machine) Fracture occurs Drug holiday may last several years, but ends if: Fracture occurs BMD declines significantly Rising bone turnover markers (telopeptides) After drug holiday the clock resets. Meaning patient may start another full treatment course with bisphosphonate, denosumab or teriparatide After a hip fracture Check Vit D level and replete Start bisphosphonate once Vit D level corrected (usually takes 2-3 months) Routine testing of BMD is recommended for men >70 yo If you can get it covered! Disclosures: Dr. Camacho did not report any relevant financial disclosures. Learning objectives: By the end of this podcast listeners will be able to: Make recommendations for daily intake of vitamin D, recognize appropriate levels, and treat secondary hyperparathyroidism Ensure adequate calcium intake through diet and/or supplementation and counsel patients on risks and benefits Select appropriate bone preserving therapy, treatment course, and learn to monitor for treatment failure Identify appropriate timing of drug holidays and reinitiation of drug therapy  Links from the show: Hot off the press! 2016 AACE Guidelines for postmenopausal osteoporosis https://www.aace.com/files/final-appendix-sept-7.pdf Monthly High-Dose Vitamin D Treatment for the Prevention of Functional Decline RCT JAMA Int Med Jan 2016 Annual High-Dose Oral Vitamin D and Falls and Fractures in Older Women JAMA 2010 Eastell R et al. Bone turnover markers and bone mineral density response with risedronate therapy: relationship with fracture risk and patient adherence. J Bone Miner Res. 2011 Jul;26(7):1662-9. doi: 10.1002/jbmr.342.  Further recommended reading: Calcium intake and bone mineral density: systematic review and meta-analysis Calcium intake and risk of fracture: systematic review Dr. Camacho responds to reader response about physiologic norm for Vit D level http://ajcn.nutrition.org/content/101/2/413.2.full.pdf Dr. Camacho’s review article on prediction of fracture risk from Jul 2015 https://www.ncbi.nlm.nih.gov/pubmed/26236988 Differing Vit D levels by latitude challenge idea of a physiologic norm https://www.ncbi.nlm.nih.gov/pubmed/25008852 VITAL Study for Vit D and Omega 3 fatty acids for prevention of cancer, heart attack and stroke http://www.vitalstudy.org              
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31 min
October 31, 2016
#17: Sore throat? Absent cough? Ask Doctor Centor.
  Summary: Dr. Robert Centor’s Knowledge Food, Part 2!  On this episode of The Curbsiders, we continue our discussion with the legendary Dr. Centor, focusing on pharyngitis and the highly entertaining origin of the Centor Criteria.  Not only do we learn how to dominate pharyngitis, but we also uncover one of Dr. Watto’s knowledge deficits - Lemierre’s Syndrome.  (He owes us a two minute talk on Lemierre’s Syndrome in case you’re wondering. I know I am.) Clinical Pearls: Admit your own limitations!  Many overestimate their skills as a clinical educator. Preadolescents get streptococcal pharyngitis (...or it’s nothing). Adolescents are much more complicated with streptococcus, EBV, CMV, acute HIV, fusobacterium, and multiple other causes. Important: Separate the causes of pharyngitis in preadolescents and adolescents. General rule: Sore throats should not cause rigors; if present then admit patient, obtain blood cultures, and start antibiotics. Do NOT miss a peritonsillar abscess or Lemierre’s Syndrome in acute pharyngitis. Pharyngitis improves within three to five days.  Failure to improve should prompt a more thorough investigation. Lemierre’s Syndrome (1 in 70,000 untreated pharyngitis patients) is septic thrombophlebitis of the internal jugular vein.  The treatment is IV antibiotics and NOT anticoagulation.   Dr. Centor and the IDSA recommends Amoxicillin once daily and, if penicillin allergic, Clindamycin.  The most recent IDSA update recommends a 10-day course of Amoxicillin (50mg/kg up to 1000mg once daily). Dr. Centor’s “Take-Home” Points: Adolescents tend to have more complicated pharyngitis Pharyngitis and rigors?  Admit, obtain cultures, and start antibiotics. Sore throats don’t get worse and, if they do, you need to rethink the case Disclosures: Dr. Centor reports no relevant financial disclosures for this topic. Learning objectives: By the end of this podcast listeners will be able to: Identify the limitations of the Centor Criteria in regards to (a) preadolescents and (b) adolescents, taking special precautions in the adolescent population Understand which acute pharyngitis patients require a more thorough investigation Be able to identify Amoxicillin as the treatment of choice for acute bacterial pharyngitis with Clindamycin as the second-line antibiotics choice. Links from the show: Check our Dr. Centor’s wonderful blog, at http://www.medrants.com or on twitter https://twitter.com/medrants Centor’s Criteria (MDCalc) -- http://www.mdcalc.com/modified-centor-score-for-strep-pharyngitis/ IDSA Guidelines on Diagnosis and Management of Group A Streptococcus Pharyngitis - http://cid.oxfordjournals.org/content/early/2012/09/06/cid.cis629.full.pdf+html Original article using the Centor score for pharyngitis https://www.ncbi.nlm.nih.gov/pubmed/6763125?dopt=abstract Dr. Centor’s article on fusobacterium Centor RM, et al. The clinical presentation of Fusobacterium-positive and streptococcal-positive pharyngitis in a university health clinic: a cross-sectional study. Ann Intern Med. 2015 Feb 17;162(4):241-7. doi: 10.7326/M14-1305.
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26 min
October 24, 2016
#16: Teach Internal Medicine like Master Educator Robert Centor MD
Summary: Dr. Robert Centor’s Knowledge Food, Part 1.  This Halloween, the “Curse of Knowledge” is REAL!  So you think you can teach? This master clinician educator, known for “Centor’s Criteria,” schools us the most common errors made by medical educators and how to improve learner retention.  While we only scratch the surface, Season 1’s arguably penultimate episode should NOT be missed.  After all, how else are you going to learn about Pretty Pimpin’?  Stay tuned for Part Duex when we briefly review Pharyngitis and Dr. Watto finally learns about Lemierre’s Syndrome!  As always, you’re welcome. Clinical Pearls: Don’t fall victim to the “Curse of Knowledge!”  Remember that your students/residents do not know what you know! Effective rounding should include a healthy mixture of both table-top and bedside rounds. Feedback should be specific, timely (even immediate!), and focused on improvement.   Allow the learner to self-evaluate before providing specific feedback and invite all members of the team to provide collaborative feedback. Always remember that feedback should be positive as well as constructive. There are multiple courses available to further your own skills as a medical educator The physician-educator should embody the “servant leader” and prioritize medical education (the “service” you are providing). Consider blogging to improve your own writing! Dr. Centor’s “Take-Home” Points: The “Curse of Knowledge” is real -- never assume the basics are known. The attending physician should embody service before self. Dr. Centor’s playlist -- Matt Duncan, Lawrence, Saint Paul and the Broken Bones, Houndmouth, Kurt Vile Disclosures: Dr. Centor reports no relevant financial disclosures for this topic. Learning objectives: By the end of this podcast listeners will be able to: Understand the basics concepts that underscore effective feedback (specific, timely, and collaborative) Identify the tenants that underscore effective rounding Re-evaluate your own teaching style and consider training seminars to improve your skills as a medical educator Links from the show: Dr. Centor’s Blog -- http://www.medrants.com/ Dr. Bradley Sharpe’s profile -- http://profiles.ucsf.edu/bradley.sharpe Stanford Faculty Development Course -- http://sfdc.stanford.edu/ UCSF Workshop - “Developing Skills in the Art of Effective Feedback” -- http://meded.ucsf.edu/radme/developing-skills-art-effective-feedback Ten Tips for Receiving Feedback -- http://med-ed-online.net/index.php/meo/article/view/25141 Who should take statins? -- https://www.washingtonpost.com/news/to-your-health/wp/2016/10/04/who-should-take-statins-a-vicious-debate-over-cholesterol-drugs-side-effects/?postshare=1551475707596812&tid=ss_tw Kurt Vile - “Pretty Pimpin” -- https://www.youtube.com/watch?v=659pppwniXA 7 Habits of Highly Effective People by Stephen Covey Made to Stick: Why Some Ideas Survive and Others Die by Chip and Dan Heath
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30 min
October 10, 2016
#15: Functional Medicine Returns! Elimination diets and healing with food
Summary: Stop feeling helpless in the face of vague complaints like fatigue, digestive problems, mood swings, inability to lose weight, etc. Learn to treat any chronic disease without writing more prescriptions. Heal yourself and your patients with the power of food. Join us for the return of Functional Medicine physician, Dr. Yousef Elyaman, as he schools us on elimination diets, phytonutrients, liver detoxification, going “paleo” and more. This is a deluxe episode so we’ve included a time key below. You’re welcome. Clinical Pearls: Use the 80:20 rule. Try to make 80% of your food paleolithic (unprocessed). Eliminate the chemicals when possible (processed foods, plastics, cleaning products, cosmetics, etc.) Workarounds for your budget: home garden and/or frozen foods. Preserve phytonutrients - Avoid microwaves. Lightly saute or eat veggies raw. Try an elimination diet for one month then reintroduce foods one at a time. Assess patient readiness and prescribe diet that fits their degree of commitment. Basic lab panel to consider: Check homocysteine, zinc, 25OH Vit D, B12, RBC folate, RBC magnesium (use diagnosis of fatigue). More specialized labs:  SpectraCell - Micronutrient panel. NutraEval Plasma by Genova Diagnostics. Check for MTHR mutation (if off then patient needs methylfolate). Dr. E's Four steps to healing with food Ensure a nutritionally dense diet. Remove bothersome foods. Replace deficiencies. Rebalance the system. Disclosures: Dr. Elyaman reports no relevant financial disclosures for this topic. Learning objectives: By the end of this podcast listeners will be able to: Appraise the quality of a patient’s diet and identify potential sources of intolerance/food sensitivity Counsel patients on sustainable dietary changes to remove potentially bothersome foods and chemicals Perform a basic laboratory evaluation to identify deficiencies Identify resources for patients and providers to facilitate education and adherence Show breakdown 0:00 Intro. 02:30 Welcome Dr. Elyaman. 03:15 Stuart bums everyone out with a current event. 04:30 Functional Medicine defined. 07:10 Logistics of educating patients on dietary changes. 11:15 Four steps to healing with food. 15:00 Use food to treat chronic disease. 16:45 Fats and a nutritionally dense diet. 20:00 Alzheimer’s and food. 23:45 Phytonutrients. 27:45 Eating on a budget. 33:40 Genetically modified foods, lectins and autoimmune disease. 40:30 Elimination diets. 46:00 Multiple sclerosis, Milk and casein. 50:00 Autism’s interplay with diet, genes, folate metabolism. 53:00 How to boost liver detoxification. 56:00 The Wahl’s protocol for multiple sclerosis. 58:30 Paleo diet. 1:00:00 Patient adherence. 1:07:35 Testing for and repleting vitamin deficiencies. 1:11:15 Fast food salad and inflammatory markers (Stuart derails the show again). 1:14:30 Dr. E’s Take home points.   Links from the show: The Institute of Functional Medicine's Elimination Diet Plan Stanford FODMAP Diet Handout Visit Dr. E's website for Absolute Health Institute of Functional Medicine website - https://www.functionalmedicine.org Learn the basics - Intro To Functional Medicine by Dr. David Jones and Sheila Quinn MSQ questionnaire from Dr. Hyman's website - assess medical symptoms and toxicity DASS 21 questionnaire - for anxiety, depression, stress A study of macronutrient type on ApoE levels in ApoE2, E3, E4 genotypes Video on the “10 Americans” study by the Environmental Working Group - chemicals in cord blood https://youtu.be/0-kc3AIM_LU EWG.org (environmental work group) - gives the Dirty Dozen and the Clean 15 Gluten free diet removes anti islet cell Ab in a child https://www.ncbi.nlm.nih.gov/pubmed/12434905 Dr. Terry Wahls TED Talk - Diet for Multiple Sclerosis (the Wahls protocol) The Paleo Diet book can be purchased here Handful of nuts per day lowers mortality in both of these studies https://www.ncbi.nlm.nih.gov/pubmed/25833976 and https://www.ncbi.nlm.nih.gov/pubmed/26548503 23 and Me genetic testing SpectraCell - Micronutrient panel NutraEval Plasma by Genova Diagnostics Stuart’s Omron blood pressure cuff
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78 min
September 26, 2016
#14: Treat chronic pain in the elder...Use more opioids?!
Learn to treat non cancer pain in the elderly. Managing persistent pain in the elderly can be...painful. On this episode Matt and Paul interview Dr. Marissa Galicia-Castillo, a Professor of Geriatrics from Eastern Virginia Medical School board certified in Internal Medicine, Geriatrics, Hospice/Palliative Medicine. Are we being too stingy with opioid prescriptions? How do you assess and treat pain in patients with advanced dementia? We’ve got your answers. Clinical Pearls: Persistent pain in the elderly is underrecognized and undertreated Nonpharmacologic therapy is still first line (get off the couch!) Scheduled acetaminophen is a valid first line Consider low dose oxycodone IR as a second line (assuming NSAIDS contraindicated) Diversion of medication by family members is a concern and may cause treatment failure Opiates can be a great tool. Don’t be afraid to use them with careful patient selection. Follow quality of life and functional status as your end points for pain control. Pain in cognitively impaired may present as behavior problems. Treat the pain and treat the behavior. Disclosures: Dr. Galicia-Castillo reports no relevant financial disclosures. Learning objectives: By the end of this podcast listeners will be able to: Recognize that pain in the elderly is often underrecognized and undertreated. Recognize the signs and symptoms of pain in patients with cognitive impairment. Utilize opiates safely and effectively for the management of noncancer pain in the elderly Formulate a basic therapeutic approach to noncancer pain utilizing nonpharmacologic and pharmacologic therapy  Links from the show: Dr. Galicia-Castillo’s article on use of opioids for persistent noncancer pain in older adults http://www.ccjm.org/current-issue/issue-single-view/opioids-for-persistent-pain-in-older-adults/a136ddc8a922abd74237073a1ab89d4f.html CDC guidelines on prescribing opioids for chronic pain (#8 discusses criteria for naloxone prescribing) https://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf World Health Organization Pain Ladder http://www.geriatricpain.org/Content/Management/Interventions/Documents/WHO%20ladder.pdf Observational study of Naloxone administration along with opiate prescriptions (NEJM Journal Watch 2016). http://www.jwatch.org/na41676/2016/07/19/should-naloxone-be-prescribed-patients-taking-opioids Effect size seen with opiates and tramadol were small in this review, but adverse event rates were high. This is why a trial with monitoring of functional  status is recommended. http://www.ncbi.nlm.nih.gov/pubmed/21472151 A RCT looking at Tramadol for knee osteoarthritis with underwhelming results. http://www.ncbi.nlm.nih.gov/pubmed/20215961 EULAR 2016 guidelines for treatment of fibromyalgia http://ard.bmj.com/content/early/2016/07/04/annrheumdis-2016-209724.abstract Dr. Clauw’s YouTube Video Chronic Pain: Is it all in their head? Dr. Clauw’s University of Michigan website for patient self education on fibromyalgia Fibroguide.com  
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45 min
September 12, 2016
#13: Physician wellness, burnout, and Clinical Informatics. Get well and avoid the 54 percent
Summary: Fifty four percent of physicians report at least one symptom of burnout. On this episode Dr. Philip Kroth an Internist and Chief of Clinical Informatics from the University of New Mexico schools us on how electronic health records (EHR) relate to burnout and tips to promote physician wellness. Miss this episode and you might get burned...out. I refuse to apologize for that pun. Enjoy!   Clinical Pearls: *Check out the article by Shanafelt below to view breakdown of burnout by specialty. *24/7 access to EHRs is a double-edged sword. You have to protect your own time. *Turn off email alerts. *Limit your screen time when off the clock. Kids are only allowed 1 hour per day! *Take the EHR training and become a MASTER. *Keep in mind these four domains related to burnout and try to mitigate your risk. Health information technology and documentation burden Stress versus control and support. You need to balance the “seesaw” Health policy and regulation (e.g. ACOs, MACRA) Physician culture of endurance (e.g. giving yourself an IV when sick instead of going home) Disclosures: None reported. Links from the Show: 1. Article by Shanafelt finding burnout in 54 percent of physicians. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014 Shanafelt, Tait D. et al. Mayo Clinic Proceedings , Volume 90 , Issue 12 , 1600 - 1613 2. Turnover of primary care doctors cost about $250,000 in 1991! Buchbinder, SB et al. Estimates of Costs of Primary Care Physician Turnover. Am J Manag Care. 1999 Nov;5(11):1431-8. 3. Maslach Burnout Inventory http://www.mindgarden.com/117-maslach-burnout-inventory 4. Volkswagen stops sending emails in the evening. http://www.bbc.com/news/technology-16314901
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38 min
August 29, 2016
#12: Insomnia: Don’t be afraid of the dark
Do complaints of insomnia stress you out? Well, never fear. In this episode our guest is Dr. Karl Doghramji, Professor of Psychiatry, Neurology and Medicine and the Medical Director of the Sleep Disorders Center at Thomas Jefferson University Hospital in Philadelphia. With his help we deconstruct the “dread pirate” insomnia (as I call it) so you can dominate it in your daily practice. Disclosures: Dr. Doghramji reports recent relationships with Merck (stock) and consulting work for Merck, Xenoport, Jazz, Inspire, Teva and Pfizer. He has a current research grant from Inspire. Clinical Pearls: *Pathophysiology: Likely biological, neurobehavioral and psychological hyperarousal. Possible genetic component. *Depression, anxiety or PTSD may be their primary disorder. Many insomniacs unaware of their depression. Need a high index of suspicion. *Sleep apnea is probably cause in 10-20% of patients who present with insomnia. *GERD can present with insomnia and night time awakenings as its primary symptom. *CBT works as well as pharmacotherapy and has lasting potential even 1-2 years after discontinuation of therapy. *High yield nonpharmacologic therapy: Get up at the same time every morning. Don’t sleep in, even if bedtime or sleep onset was delayed. *Melatonin: It’s effect depends on time administered (see below). It’s not as safe as you think (insulin resistance, low sperm count) 1. Administer very low dose (under 3 mg) four to five hours prior to bed for delayed sleep phase (usually occurs in teens). 2. Administer higher dose (3-5 mg) one hour before bed for sleep initiation (adults with fragmented sleep). *Agents for sleep initiation: zaleplon, zolpidem, ramelteon *Agents for sleep maintenance: zolpidem ER, eszopiclone, doxepin (low dose of 3mg or 6mg), gabapentin (off label) *Suvorexant (orexin antagonist) treats both sleep initiation and maintenance: Start 10 mg and go up 5 mg every few weeks to max 20 mg daily. Orexins are deficient in narcolepsy. Orexins seem to mediate a switch system between arousal and sleepiness. *Doxepin, gabapentin and ramelteon have very lose risk for abuse.  *Off-label use of diphenhydramine for sleep is not recommended ("dirty drug"). Trazodone and mirtazapine also have uncertain benefit. *Mirtazapine 7.5 mg is the dose for insomnia (more sedating). Lower dose favors histamine receptor. Links from the Show: 1. This is one possible site for online CBT https://www.sleepio.com as referenced in this study 2. Melatonin associated with impaired glucose tolerance http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173928/ 3. American Academy of Sleep Medicine 4. This site below has easy to understand information on sleep related disorders and links to videos explaining sleep hygiene. You can also download sleep logs, get info. SleepEducation.org Website 5. Review on use of mindfulness and meditation for insomnia. http://www.ncbi.nlm.nih.gov/pubmed/26390335
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63 min
August 15, 2016
#11: Wait! There’s a lung microbiome?!
Summary: In this episode our guest is Dr. Robert Dickson a Pulmonologist from the University of Michigan who studies the respiratory microbiome. We discuss how the lung microbiome differs in health, chronic illness and acute disease states like pneumonia, sepsis and ARDS. The lung microbiome has the ability to predict frequency of exacerbations and even severity and progression of certain lung diseases. We’ll explore all of this plus Dr. Dickson’s new paper published last month in Nature Microbiology, which had the surprise of finding gut bacteria in the lungs during critical illness. Please enjoy this wide ranging discussion   Disclosures: Dr. Dickson did not report any disclosures.   Clinical Pearls 1. The lungs are constantly bombarded by microbes and the largest host to microbe interface in the body where bacteria come within millimeters of the blood stream. 2. The lung microbiome is altered in both acute and chronic diseases 3. The lung microbiome is altered by antibiotics, corticosteroids, PPIs and probably lots of other things we are just beginning to discover.   Links from the Show: Dr. Dickson’s latest article reporting gut bacteria in the lungs during critical illnesses. Dickson, R et al. Enrichment of the lung microbiome with gut bacteria in sepsis and the acute respiratory distress syndrome. Nature Microbiology 1, Article number: 16113 (2016). doi:10.1038/nmicrobiol.2016.113   A link to Dr. Dickson’s podcast discussing the role of microbiome and the care and treatment of critically ill patients. The role of microbiome: The Lancet Respiratory Medicine: January 2016   Dr. Dickson’s recent publication in The Lancet. Robert Dickson. The microbiome and critical illness. The Lancet. Published Online: 11 December 2015. DOI: http://dx.doi.org/10.1016/S2213-2600(15)00427-0   Five clinical pearls on the Pulmonary microbiome Robert P. Dickson and Gary B. Huffnagle. The Lung Microbiome: New Principles for Respiratory Bacteriology in Health and Disease. PLoS Pathog. 2015 Jul; 11(7): e1004923. Published online 2015 Jul 9. doi:  10.1371/journal.ppat.1004923 PMCID: PMC4497592   A comprehensive review of the Pulmonary Microbiome field Dickson, RJ et al. The Microbiome and the Respiratory Tract. Annu Rev Physiol. 2016;78:481-504. doi: 10.1146/annurev-physiol-021115-105238. Epub 2015 Nov 2.  
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44 min
July 25, 2016
#10: Cholesterol, lipids, statins, fish oil. Become a Master Lipidologist.
Summary: In this episode our guest is Master Lipidologist, Dr. Peter Howard Jones from Baylor College of Medicine and the National Lipid Association. My guest host is Dr. Paul Williams, Clinician Educator extraordinaire from Philadelphia. We explore everything you’ll ever want to know about cholesterol and lipids. Are statins still king when it comes to cholesterol lowering? Should we be rushing to use PCSK9 inhibitors? Should we throw away older drugs like fibrates? Are nonpharmacologic therapies like niacin and fish oil worthwhile? Join us for this extensive conversation.   Disclosures: Dr. Jones is the Chief Science Officer at the National Lipid Association. He has served as a scientific advisor to Merck, Amgen and Sanofi.   Learning objectives: 1. Identify each individual's risk for cardiovascular disease and counsel them on benefits of therapy. 2. Learn to lower atherogenic lipids by any means necessary and understand the effects of the common lipid lowering drugs 3. Effectively counsel patients on benefits of lipid lowering drugs to promote patient buy in and adherence.   Clinical Pearls 1. Omega 3 fatty acids at 1,000 mg daily or more is useful for prevention of sudden death in post ACS patients. 2. Omega 3 fatty acids at dose of 4,000 mg per day is needed to lower triglycerides. Indicated if TG remain above 500 on first line therapy. 3. Hypertriglyceridemia with level above 500 on optimal statin dose, then consider addition of fibrate and/or omega-3 fatty acids. Uncertain clinical benefit in patient with moderate elevation (200-300) of triglycerides. 4. Statin intolerance can be overcome in most patients using the following methods: a. Same statin at lower dose b. Different statin c. Use of rosuvastatin or atorvastatin 3 times weekly 5. Statins are safe to take for at least 20 years and probably longer (this data is still being collected, but will be available in the future) 6. Withdrawal of statins at the end of life is not harmful and may be beneficial.   Links from the Show:   Studies that used fibrates for preventions of CV events: Helsinki Heart Study for primary prevention NEJM 1987 VA HIT Study for secondary prevention NEJM 1999   Withdrawal of statins at the end of life http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4618294/   Expert Consensus on use of Non-Statin Drugs http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2016/03/30/11/58/2016-acc-expert-consensus-decision-pathway-on-the-role-of-nonstatin   National Lipid Association recommendations for patient-centered management of dyslipidemia https://www.lipid.org/sites/default/files/Recommendations-Part-1.pdf   Recommended websites National Lipid Association The Heart.org (Medscape) Journal of Clinical Lipidology
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65 min
July 8, 2016
#9: C diff, and fecal transplants
Treat C. diff, choose the correct antibiotic regimen, and identify who needs fecal transplant as we “curbside” Gastroenterologist, Dr. Adam Ehrlich from Temple University Hospital. On the show, we cover the ins-and-outs of procuring, preparing and performing transplants as well as future directions in this burgeoning field e.g. IBD, obesity, metabolic syndrome and more. Take Home Points: Clostridium difficile infection is the only indication for which FMT is allowed by the FDA without special authorization FMT is VERY effective in these C difficile patients compared to standard of care (approximately 90% cure vs 30%) We are just beginning to understand the role of the microbiome in human health, and I anticipate many changes in the years ahead where modifying the microbiome will be used to help treat a number of diseases.  Links from the Show: Recommended reading... NEJM Journal Watch for Gastroenterology - register here Review on novel uses for fecal transplantation Rossen NG, et al. Fecal microbiota transplantation as novel therapy in gastroenterology: A systematic review. World J Gastroenterol. 2015 May 7;21(17):5359-71. doi: 10.3748/wjg.v21.i17.5359. Randomized controlled trial of fresh vs frozen fecal transplantation Fresh vs Frozen Fecal Microbiota Transplant for C diff Recurrent C difficile infection. JAMA 2016 Review on mechanisms for gut microbiota on metabolic syndromes Qian LL, et al. Effect of the Gut Microbiota on Obesity and Its Underlying Mechanisms: an Update. Biomed Environ Sci. 2015 Nov;28(11):839-47. doi: 10.3967/bes2015.117.
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51 min
May 30, 2016
#8: Functional Medicine: Return to the basics, personalize care and enhance your practice
In this episode Dr. Yousef Elyaman from the Institute of Functional Medicine schools us on how the biochemistry and pathophysiology we’ve forgotten from medical school can be used to cure illness. FODMAP diet and Antibiotics to cure restless legs syndrome? Melatonin to treat gastroesophageal reflux disease?  This is just a little taste of the knowledge food served up on this introduction to Functional Medicine.
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60 min
May 11, 2016
#7: Become a Fibromyalgia and Chronic Pain Master, Part 2
This episode, part 2 of our last episode, is a must listen if you’ve ever felt helpless in the face of fibromyalgia and chronic pain. Keep listening for part 2 of our “curbside” with expert clinician and prominent researcher Dr. Daniel Clauw, from the University of Michigan’s Chronic Pain and Fatigue Research Center. The show is chock full of clinical pearls for the mastery of chronic pain syndromes.
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31 min
May 4, 2016
#6: Become a Fibromyalgia and Chronic Pain Master, Part 1
This episode, part 1 of 2, is a must listen if you’ve ever felt helpless in the face of fibromyalgia and chronic pain. Listen as we “curbside” expert clinician and prominent researcher Dr. Daniel Clauw, from the University of Michigan’s Chronic Pain and Fatigue Research Center. The show is chock full of clinical pearls for the mastery of chronic pain syndromes.
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34 min
April 20, 2016
#5: Want to dominate chest pain? Wield the power of cardiac imaging and stress testing.
In this episode we “curbside” SoCal Cardiologist, Dr. Neel Patel. If you’re like us and confused by the smorgasbord of cardiac imaging and stress testing then this show is a must listen. Whether you’re in the clinic or on call for Internal Medicine, Dr. Patel has your answers on coronary artery calcium scoring, coronary CT scans and all types of stress testing.  
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58 min
March 30, 2016
#4: Are You Afraid of Patients with Migraines? An approach to diagnosis and management of chronic migraine headache.
If headache patients strike fear in your heart, then this is the episode for you. In this episode The Curbsiders interview Internist and Headache Specialist Dr. Glen D. Solomon to deconstruct the topics of migraine and chronic tension type headaches. Dr. Solomon is currently a Professor and Chair of the Department of Internal Medicine at Wright State University and a former director of the Headache Medicine Fellowship at the Cleveland Clinic. Join them as they discuss the approach to diagnosis and management of chronic headaches. 
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60 min
March 15, 2016
#3: For Anticoagulation, These Times They are a-Changin'
In this part 1 of 2 episode on the non-Vitamin K oral anticoagulants, The Curbsiders discuss these novel medications and other changes associated with the updated 2016 CHEST guidelines for anticoagulation. 
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33 min
March 1, 2016
#2: SPRINT trial and Hypertension
In this interview, Matt speaks with Dr. Paul Williams about the SPRINT Trial of Intensive blood pressure control and how it is likely to change clinical practice. Tony and Stuart discuss their own take-home points from the trial. Discussion of ARBs you've never heard of and the holy grail of blood pressure cuffs ensues. Tags: assistant, blood, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, hypertension, internal, internist, nurse, medicine, medical, pressure, primary, physician, resident, student
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30 min
February 16, 2016
#1: Testosterone and hypogonadism: Miracle Cure or Libido Band Aid?
In this inaugural episode, join the Curbsiders as they tackle the hot topic of male hypogonadism and low testosterone by curbsiding Endocrinologist Dr. Jeff Colburn, a leading clinician and educator in San Antonio, Texas   Tags: androgen, andropause, assistant, care, education, doctor, family, foam, foamed, health, hospitalist, hospital, hypogonadism, internal, internist, libido, low T, medical, medicine, nurse, primary, physician, resident, student, testosterone
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33 min
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