#472 DIGEST: cfDNA & cancer in Pregnancy, Vitamin K2 for Leg Cramps, PRN anti-hypertensives, GLP-1 Agonists for AUD, Short-Course Antibiotics

Summary

The Curbsiders Internal Medicine Podcast

Episode #472 – DIGEST: cfDNA & Cancer in Pregnancy, Vitamin K2 for Leg Cramps, PRN Antihypertensives, GLP-1 Agonists for AUD, Short-Course Antibiotics

Date: February 24, 2025
Panel: Dr. Matthew Watto (Host), Dr. Paul Williams (“America’s PCP,” co-host), Dr. Nora Taranto (Digest Editor), Dr. Laura Glick (Hospitalist & Guest)

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Episode Overview

This “Digest” episode brings together the Curbsiders team plus guests Nora Taranto and Laura Glick to discuss recent impactful studies covered in the Curbsiders' Digest newsletter. The discussion spans five hot topics in internal medicine: incidental cancer detection in pregnancy from cell-free DNA testing; vitamin K2 for nocturnal leg cramps; the safety and utility of PRN antihypertensive medications in the hospital; the intriguing potential of GLP-1 agonists in alcohol use disorder; and the latest evidence supporting shorter antibiotic courses for bacteremia. The panel unpacks data, clinical implications, and their own reactions—with plenty of trademark humor.

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Main Topics & Key Insights

1. Incidental Cancer Detection in Pregnancy via cfDNA Testing (IDENTIFY Study, NEJM, Dec 2024)

[03:16]

• Study Presented by: Dr. Nora Taranto
• Study Context: Non-invasive prenatal testing (NIPT) is increasingly used to screen for fetal chromosomal abnormalities, analyzing circulating cell-free DNA (cfDNA) in pregnant patients’ blood.
• Key Finding: Occasionally, these tests report “abnormal” or “non-reportable” results, which can signal maternal chromosomal abnormalities—sometimes incidentally identifying underlying malignancies in the mother.
• Study Design: Prospective follow-up of 107 women with abnormal/non-reportable NIPT results, evaluating for occult malignancy via whole-body MRI, labs, physical examination, and fecal occult blood testing.
  • ~50% (52/107) were found to have cancer, commonly lymphomas (especially Hodgkin’s), colorectal, and breast cancer.
  • Some cancers were early stage and treatable with curative intent.
• Practice Implications:
  • There's no guideline on managing “non-reportable” NIPT results.
  • Quote [09:52]: “...we are not really set up to get these whole body MRIs and do all this testing—but since this test is already being used and now this information's out there, you’re going to have to do something with these patients…” – Dr. Watto
  • Current infrastructure and insurance may not support workup like whole-body MRI, presenting a challenge if this becomes common.
• Panel Take: Not quite practice-changing, but a crucial trend to follow and one that may require new systems for triaging and workup.
  • Quote [12:34]: “I feel like most things I think about are in the ‘to be tracked closely’ category. And this is definitely one of those.” – Dr. Taranto

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2. Vitamin K2 for Nocturnal Leg Cramps

[17:24]

• Study Presented by: Dr. Watto
• Study Context: Nocturnal leg cramps are common in older adults, distressing but often benign. Prior studies examined pickle juice; now, focus turns to vitamin K2 (menaquinone-7, MK-7).
• Study Design: RCT (Tan et al., JAMA Intern Med, Dec 2024), adults ≥65 years with ≥2 nocturnal cramps in 2 weeks randomized to 180mcg K2 vs placebo nightly for 8 weeks.
  • K2 arm: ~2.7 fewer cramps/week compared to placebo, plus slight reductions in severity and duration.
  • No significant adverse events. Warfarin users excluded.
• Key Discussion Points:
  • Mechanism unclear; possibly involves calcium/muscle contraction.
  • Participants with diuretic use or neuropathy were excluded, so generalizability limited.
  • K2 is inexpensive and widely available.
  • Quote [23:34]: “As long as the person’s not taking a vitamin K antagonist like warfarin, then I don’t see the harm in trying this...buy a bottle, try it out, see if it helps.” – Dr. Watto
• Panel Take: Enthusiastic about low-risk, low-cost options for a common problem. Potential to recommend, especially given safe profile (except with anticoagulants).
  • Fun fact [24:45]: Vitamin K2 is rich in fermented foods, soft cheeses, eggs, meats, and possibly even pickle juice.

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3. PRN Antihypertensives in the Hospital — Risks Highlighted

[25:42]

• Study Presented by: Dr. Paul Williams
• Study Context: Routine use of PRN antihypertensives in-hospital for asymptomatic high BP is common but controversial; prior studies suggest possible harm.
• Study Design: Retrospective cohort, emulated RCT (JAMA Intern Med 2024), VA system, >130,000 admissions, comparing those who received PRN antihypertensives vs those who did not.
  • Outcomes: time to first acute kidney injury (AKI), composite of MI, stroke, or death.
  • Findings: 20% received PRN antihypertensives; those receiving IV PRNs had 64% higher risk of AKI; increased odds of rapid drops in BP and adverse composite outcomes.
  • Quote [27:05]: “Not surprisingly, the patients that received IV only PRN antihypertensives had a 64% increased risk of actually having the acute kidney injury, but all groups had an increased risk of acute kidney injury.”
• Key Discussion Points:
  • Cause for hypertension often not explored (pain, meds, anxiety, sleep disruption, etc).
  • The threshold for PRN order (often SBP ≥180) and order sets reinforce unnecessary use.
  • Limitation: mostly male VA cohort; AKI outcome uses sensitive but not always clinically significant definition.
  • Quote [31:33]: “It’s very easy to reflexively respond by ordering an antihypertensive medication to feel that you are doing something...but it is so, so important to realize that the use of these as-needed blood pressure meds may actively harm the patients.” – Dr. Laura Glick
• Panel Take: Yet another nail in the coffin for this routine practice, but culture/EMR inertia persists outside academic settings.
  • Quote [32:26]: “...it should hopefully be one nail in the coffin that will eventually close this practice.” – Dr. Watto

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4. GLP-1 Agonists for Alcohol Use Disorder (AUD)

[34:30]

• Study Presented by: Dr. Laura Glick
• Study Context: Animal and some human data suggest GLP-1 agonists (semaglutide, liraglutide) may reduce alcohol cravings and consumption.
• Study Design: Swedish registry cohort, >220,000 patients (ages 16–64) with AUD, median follow-up 8.8 years, compared periods on/off GLP-1 agonists.
  • Semaglutide/liraglutide associated with a significant decrease in AUD-related hospitalizations; not seen with other GLP-1s.
  • Standard AUD meds (naltrexone, disulfiram, acamprosate) had only modest benefit.
  • Limitations: Observational design, potential confounding (those who can access GLP-1s may be systematically different); can’t prove causality.
• Key Discussion Points:
  • Panel emphasized need for RCTs to confirm effect.
  • Ongoing/future RCTs of GLP-1s in AUD, opioid use disorder, and smoking noted.
  • Quote [38:14]: “There’s a lot of intangibles that are just hard to measure with these retrospective trials...the capacity for self-care...I don't know that they fully capture the medication effect in and of itself as opposed to the systems that allow that medication to be administered...” – Dr. Williams
  • Adverse effects and optimum duration for addiction indications unknown.
• Panel Take: Exciting avenue—worth considering for AUD patients who already meet approved GLP-1 indications (obesity, diabetes), but not yet practice-changing for alcohol use disorder alone.
  • Quote [42:24]: “It’s really not ready for primetime. It’s not practice-changing yet...But I do think it’s worthwhile considering these results when you’re treating patients with AUD plus obesity or type 2 diabetes...” – Dr. Laura Glick

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5. Short Course Antibiotics in Bloodstream Infections (Balance Trial)

[43:50]

• Study Presented by: Dr. Nora Taranto
• Study Context: Optimal antibiotic duration for “uncomplicated” bacteremia is debated.
• Study Design: NEJM, Nov 2024, the “BALANCE” trial: BActeremia Length Actually Needed for Clinical Effectiveness.
  • 7 days vs 14 days of antibiotics for adult patients with bloodstream infections, excluding S. aureus, untreated abscesses, immunocompromised, etc.
  • Primary outcome: 90-day all-cause mortality—14.5% in 7-day arm vs 16.5% in 14-day arm; met non-inferiority margin.
  • Broad spectrum of causative organisms: gram-positives and gram-negatives, sources included UTI, pneumonia, intra-abdominal infection.
• Quote [44:11]: “Bravo. God bless the ID doctors.” – Dr. Williams (on the trial acronym)
• Panel Take: Seven days is non-inferior to fourteen for most bacteremias (excluding key exceptions: S. aureus, prosthetic/septic joint, deep abscess, or immunocompromised). Encourages shorter courses to limit adverse effects, resistance, and cost.
  • Quote [46:45]: “I’ve definitely seen...a trend toward decreased duration of antibiotics. I’m not sure if we’re fully there, but I do think this study is very promising...” – Dr. Laura Glick

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6. Quick Take: Self-Collected HPV Screening

[48:29]

• Overview: USPSTF now supports self-collected (including in-clinic and likely soon home) HPV swabs for cervical screening, primarily for women age ≥30.
• Implications:
  • Home or self-swab collection has similar concordance to clinician-collected samples.
  • Could reduce barriers and improve screening uptake for patients avoiding in-office pelvic exams.
  • FDA approval for true “at home” mailing still pending; presently, only clinic self-collection is allowed.
  • Quote [51:14]: “Even if the patient has to be in the clinic to do the self-collected, it’s still more patient-centered than having the clinician do it.” – Dr. Watto

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Notable Quotes & Memorable Moments

• Acronym Banter:

  • [04:44] Dr. Williams: "Now just listen, you cowards. Straight-up acronyms or just don’t even bother."
  • [44:11] Dr. Williams: “Bravo. God bless the ID doctors.” (on BALANCE acronym)

• On PRN Antihypertensives:

  • [31:33] Dr. Glick: "It is so, so important to realize that the use of these as-needed blood pressure medications may actively harm the patients."

• On Practicality of cfDNA Cancer Workup:

  • [09:52] Dr. Watto: "But since this test is already being used and now this information’s out there, you’re going to have to do something with these patients when you come up with these results."

• On Vitamin K2 for Cramps:

  • [23:34] Dr. Watto: "...I don’t see the harm in trying this. It looks like it’s relatively cheap...buy a bottle, try it out, see if it helps."

• On GLP-1s and SDOH:

  • [38:14] Dr. Williams: "There’s a lot of intangibles that are just hard to measure with these retrospective trials...the capacity for self-care...I don't know that they fully capture the medication effect in and of itself as opposed to the systems that allow that medication to be administered..."

• On Short-Course Antibiotics:

  • [44:11] Dr. Williams: “Bravo. God bless the ID doctors.”
  • [46:45] Dr. Glick: “Very promising...a lot of hope...this is just kind of adding on some other good studies and data that maybe shortened antibiotics is where we’re going.”

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Timestamps for Major Segments

• [03:16] Incidental cancer detection with cfDNA in pregnancy (IDENTIFY study)
• [17:24] Vitamin K2 for nocturnal leg cramps
• [25:42] PRN antihypertensives in the hospital—risks and practice implications
• [34:30] GLP-1 agonists and alcohol use disorder (AUD)
• [43:50] Short-course antibiotics for bacteremia (BALANCE study)
• [48:29] Self-collected HPV screening: new guidelines and implications

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Language and Tone Notes

• Conversational, with gentle humor and frankness
• Panel frequently teases about study acronyms and clinical trivia
• Clear attempts to connect guidelines with everyday clinical scenarios
• Candid acknowledgment of study limitations, insurance/system barriers

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Takeaways for Clinical Practice

• cfDNA in Pregnancy: Incidental findings from NIPT that signal maternal risk of cancer may become a bigger issue—clinicians will need new workflows for risk assessment and triage.
• Leg Cramps: Vitamin K2 appears safe, low-cost, and modestly effective for refractory nocturnal cramps—an option for interested patients not on anticoagulant therapy.
• PRN Antihypertensives: Strong signal that reflexive PRN antihypertensives for asymptomatic inpatients should be avoided; focus instead on assessing cause of hypertension.
• GLP-1s for AUD: Intriguing but not ready for routine use; consider in patients with diabetes/obesity and AUD. Awaiting high-quality RCTs.
• Short-Course Antibiotics: 7 days non-inferior to 14 for uncomplicated bacteremia (non-S. aureus)—supports ongoing “shorter is better” movement.
• HPV Self-Screen: Self-collected swabs are now on par with clinician collection for screening—should expand accessibility once FDA approves at-home tests.

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[End of Digest Episode Summary]

Transcript

[A]

Hey, before we get to the show, I wanted to remind you to check out our [e-mail] curbsiders. If you haven't signed up yet, sign up now to get ad free episodes, twice monthly, bonus episodes, and a whole bunch of other cool [e-mail] curbsiders hey, Paul. My friend has fallen head over heels for a new girl. She's only a humble whiskey maker, but he loves her still.

[B]

That's not bad. Matt. I was talking to a Frenchman, a man from France, and I asked him if he liked video games.

[C]

And do you know what he said to me?

[A]

I don't know.

[B]

Oui. I feel like that was pretty solid.

[D]

Yeah.

[A]

Okay.

[C]

All right.

[E]

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

[A]

Welcome back to the curbsiders. I'm Dr. Matthew Frank Watto, here with my great friend and America's primary care physician, probably the primary care physician, Dr. Paul Nelson Williams. Hey, Paul, how are you doing tonight?

[B]

I'm great, Matt. How are you doing?

[A]

I'm doing well because this is a digest episode. It's been quite a while since we did one of these. We got some great articles to talk about some practice changing, maybe all of them. Practice changing. We'll decide in real time. And we have two great friends with us to help us do this, Paul. But before we introduce them or before you introduce them, remind people what is it that we do on Curbsiders.

[B]

Sure. Happy to, Matt.

[C]

As a reminder, we are the internal medicine podcast.

[B]

We use expert interviews to bring you clinical pearls and practice changing knowledge.

[C]

Most times, I mean, I guess that's still kind of the case this time around. This episode in particular is a little.

[B]

Bit different than our traditional format, as you know, the Digest episodes, where we recap some of the articles that have been talked about in the Curbsider's Digest or maybe are about to be talked about or should be talked about. And apropos of that, we are joined by our fearless editor of The Curbsider Digest, Dr. Nora Taranto. Hi, Nora.

[C]

How are you?

[A]

Good.

[D]

How are you guys?

[A]

Great.

[B]

We already answered this. We're also joined by Dr. Laura Glick, a hospital and frequent contributor to Curbsider's Digest. Laura, welcome to the show.

[F]

Thank you.

[A]

Nothing to worry about, Laura, this is going to go great. You're going to kill it. We're going to have a lot of fun. Paul's going to critique some trial names and it'll be great.

[F]

Can't wait.

[D]

This is reminding me of when I played doubles tennis in high school and my doubles partner was named Laura. So, Nora and Laura, going here today.

[A]

I'm going to venture to say you could probably destroy Paul and I in tennis because I don't play tennis and I don't know if Paul does either.

[B]

I barely move if I can help it. So, yeah, it would be a bad scene, I think.

[D]

You're not a pickleball guy.

[B]

Are you asking me or Matt? Matt is a well documented pickleball game.

[F]

Oh, really?

[B]

I don't even know how to play it.

[D]

Well, that was for you, Paul.

[B]

But yeah, I don't even know what it entails.

[A]

I've resorted to soccer now because I can't have too many hobbies, but pickleball, at some point, I'll return to it for sure. All right, well, let's go to our first article, which, Nora, you will be presenting it, and I believe. Is this the one that has the clever name? I think it does. The Identify study.

[D]

Yeah, exactly. This one is called Identify. And, Paul, what do you think that stands for? Knowing nothing about the study.

[B]

Yeah. I don't know how they managed to get cell free DNA and identify it together on the same trial name. So I have a feeling it's probably just gibberish nonsense they mashed together to make it work. Am I mistaken?

[D]

You're on the right track there. It does have some I's and D's, but. Yeah, so it stands for incidental detection of maternal neoplasia through non invasive cell free DNA analysis. So I similarly couldn't really figure out how exactly they got there, but it's catchy.

[F]

Yeah.

[B]

Because there's not a Y to be found in that. Right.

[A]

I think they use the Y from analysis.

[C]

Oh, the analysis.

[B]

Oh, yeah.

[A]

And they use the E from maternal, but everything else they got. So I think it's decent. I would say by your criteria, Paul, they got out of the 1, 2, 3. You know, they got. They got most all the letters, but two, that's pretty good.

[C]

Now just listen, you cowards. Straight up acronyms or Just don't even bother.

[B]

I'm just, I'm so.

[D]

That'S pretty much all I wanted to mention for this study. So I feel like we're done here.

[A]

I think we should apologize to the authors who are not, surely not cowards.

[B]

Yeah, yeah. Way to advance scientific knowledge, you idiots.

[D]

They should know how we read these studies, you know.

[B]

Yeah, that's on them.

[A]

Okay, Nora, so tell us about this. Let's get to the meat of this. Let's talk about it.

[F]

Yeah.

[D]

So this study is actually a really interesting study by Tariff et al. It was published in the New England Journal in December and was covered by Dr. Jen DeSalvo in Digest 60. And this study looked at patients who had undergone prenatal non invasive testing or nipd nipt. And this type of testing uses circulating cell free DNA in the mom, so in the blood to look for fetal chromosomal abnormalities. And it's now covered by insurance mostly and has overtaken a lot of the more invasive testing to look for fetal chromosomal abnormalities like amniocentesis and chorionic villus sampling, which are two kind of more invasive procedures to look for these. And so these non invasive tests, these blood tests, look for the free DNA that's floating around in the plasma of mothers to be and looks for these fetal chromosomal abnormalities, but it can also pick up abnormalities in the mom. And when it picks up abnormalities in the mom, these results are most frequently listed as abnormal or non reportable results because they can't actually tell you anything about the fetal status. And so there are no guidelines, despite the fact that these tests are reporting out non reportable results as to what to do when you get a non reportable result for a pregnant person.

[A]

Yeah, Nora, the reason I was interested in this is because, you know, there's these multi cancer detection tests now that also look at cell free DNA and there's one out there that looks like for like 50 different cancer types. And it's mostly recommended for people at like high risk for cancer. So adults over. But that's looking at like cell free DNA in just the patient's blood and it's looking for methylation patterns. But this is different. This is because it's mostly, this is just like a total incidental thing. Right. That they noticed that they were looking for these fetal chromosomal abnormalities and they accidentally are finding maternal chromosomal abnormalities. So what types of cancers are they finding in the mothers when they get these results?

[D]

Yeah. And so this study followed 107 patients who were either Pregnant at the time they came into the study or were within two years postpartum. And all of them had had this abnormal or non reportable result on non invasive prenatal testing. They looked at a couple of different things in cancer screening. They did whole body mri, they did blood tests, including tumor markers, they did physical examination and they also did a fecal occult blood test. And in the 107 patients, 52, so that's almost 50% were actually diagnosed with a cancer. So that's quite a high number in this population that was screened for cancer. And the majority of those patients were diagnosed with a lymphoma, including Hodgkin's lymphoma. In 20 of the 31 who were diagnosed with a lymphoma, the other 20 were diagnosed with solid tumors. So that includes colorectal cancer and breast cancer most frequently. Not all of those cancers were advanced stage. Some of them were actually slightly earlier stage. And then even some of the advanced stage cancers were able to be treated with curative intent. That's trying to get rid of them once and for all instead of just treating, treating palliatively.

[A]

And they used the whole body MRI because they could do those in pregnancy without radiation.

[D]

Exactly. And they had a slightly different protocol for the postpartum and the pregnant individuals, but they were able to do whole body MRI for all of those patients.

[A]

Yeah, I think this is gonna be more and more common as we get like for cancer screening. Cause this is just like, you know, it's, it's an easy way to screen a lot of people. I think the mess of it is we were talking about this offline before we started is like what's the cost of this going to be? And you're going to find tens of thousands of cancers if you do this in pregnant women. And then we're not really set up to get these whole body MRIs and to do all this testing. But since this test is already being used and now this information's out there, I think this is just going to like, you're going to have to do something with these patients when you come up with these results.

[D]

Yeah, I think that's exactly right. And one of the points that they made about the population was that patients went about 10 weeks from a non reportable result to entrance into the study. And so I do think there's probably a window to intervene and, or at least just guidelines that should be established for providers who are ordering these sorts of tests about. Like what exactly is the follow up that these patients should have Is that like a multidisciplinary group of people trying to figure out what's going on? Is that some imaging baseline, is that repeat sequencing that can confirm abnormalities, which they kind of got into in this study a bit as well, to try to characterize the different types of patterns and whether or not there were patterns that were strongly associated with those patients.

[A]

Who had cancer, Paul or Laura. Before Nora gives her final take home on this, any questions, concerns? Comments?

[F]

Yeah, I guess one thing I'm thinking about is the practicality of implementing these results. And I'd love to hear what you think, Nora, but doesn't seem like whole body MRI is really an imaging modality that is commonly ordered by these providers or that will be covered by insurance. So I'm interested to hear your thoughts in terms of the practicality.

[D]

Yeah, I mean, I think that's the huge challenge here, that this really doesn't have support to be implemented. As it stands, that doesn't mean that for certain cohorts of patients who are high risk based on a test like this, that will continue to be the case in the future. But right now, obviously, kind of whole body MRI is not something that we're ordering even for our cancer patients. That's not something that, that we are ordering. And like PET scans can't be followed for a lot of cancer patients. So I think that's going to be the one, one big challenge, though I do think that if, if there are, if the various societies who are, are invested in this kind of get together and decide what the right workflow is of testing, then that might change in terms of insurance and the like, infrastructure for it.

[B]

No, no, I really appreciate the point that we just.

[C]

I can see this test being ordered.

[B]

You get the results back, it's now reportable. And your response being, huh, that's weird. 50% of these patients have cancer. So I think having some sort of mechanism in place just to make sure they're triaged appropriately is obviously the next critical skeptic. Because I think in general, from a technology standpoint or this inflection point where we're seeing lots of stuff like this, where we have these novel technologies and ways of screening for things that will have unexpected results that we don't quite know what to do with, that will turn out to be important later. So I just, I thought that was a great point on your part.

[A]

Yeah. All right, Nora, so what do you think? Is this ready for prime time? Is this practice changing? Or is this sort of, you know, to be tracked closely however you want to categorize it.

[D]

I like that last category. I feel like most things I think about are in the to be tracked closely category. And this is definitely one of those. If I had the power to make these covered and to, like, create that infrastructure today, I would. But I do think. I think that's coming and that there's need for that infrastructure. So I imagine it will happen in this specific cohort of patients.

[A]

Right. You know, as someone who has a lot of cancer in their family, that is a top like this sort of detecting cancer early by blood testing is something that I'm very interested in. And the whole body MRI and all that stuff. I know that's very, like, certain groups of very wealthy people are just getting them every year just because, you know, trying to detect early cancer. And it's definitely something that I think will eventually be more widespread, like, as these technologies get cheaper and we know what to do with the results, we get processes in place. So good one to choose. All right, so next up is this one. Paul. Paul, are you using any vitamin K2 in your practice?

[C]

No.

[B]

I think you'll mention it, but I've been advocating heavily for pickle juice, but I have not made the transition to vitamin K2 yet.

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[A]

All right, so In Digest number 59, Hannah Smith covered an article by Tan et al on vitamin 2, vitamin K2 in managing nocturnal leg cramps. And this was a randomized controlled trial. It was in JAMA Internal Medicine in December of 2024. And as Paul mentioned, you know, we've talked about leg cramps on the show going way back with Joel Toff. And then we talked about the Pickles randomized controlled trial, which was done in patients with cirrhosis using pickle juice or pickle brine. And that was by our friend Elliot tapper back in 2022. And now this is vitamin K2, also known as menaquinone 7 or MK7. And this was previously studied by the same group in patients on dialysis. And they had positive results, which was surprising and just really intriguing. So, Nora, as a blood doctor, what do you think about this?

[D]

Well, I feel like my first instinct was I was a little worried about the warfarin component of this and the vitamin K antagonist part, but was reassured by reading the study and looking at the prior studies, though obviously they excluded patients who were on vitamin K antagonists.

[A]

Yes, they did. So this study was a randomized double blind placebo controlled trial and they were giving patients one capsule of 180 micrograms of MK7 at night, or they were giving them a placebo that looked pretty much identical. And the patients were 65 and over, and they had to have at least two episodes of nocturnal leg cramps in the two weeks prior to enrollment. Then they gave them either the drug or the placebo and they followed them for eight weeks. And then they looked at what was the difference in frequency, severity and duration of leg cramps in the groups. And the frequency at baseline was not that high. It was about 2.6 or 2.7 leg cramps per group in both the placebo group and the treatment group. And then curiously, during the study, the number of leg cramps increased in the placebo group and decreased in the K2 group, the treatment group. So at the end of the study, there was a reduction by about 2.67 leg cramps, nocturnal leg cramps, which was deemed to be significant. And then they also looked at the severity, which wasn't that severe, it was like a 3 and change on a scale of 1 to 10. It was like a 3 at baseline and it decreased slightly in the K2 group versus placebo. And the duration also decreased a little bit. So overall, this was a positive trial. And any questions, comments, concerns? Paul, you look like you have something to say.

[B]

No.

[C]

Just to clarify, the numbers that you're.

[B]

Throwing around, like the 2.7 and 3.1, these are, I think, leg cramps per week. These are weekly episodes. I just want to make sure that we're actually getting the numbers right because that wasn't exactly clear to me until I sort of dug deeper because I wasn't quite sure how they were quantified.

[A]

Yeah, mean weekly nocturnal leg cramps. So it's like episodes. So they were having between two and three episodes, you know, 2.67, but when they averaged it out, but it was so two to three episodes per person over the two weeks prior to the study, on average. And if they were having less than that, they weren't severe enough. They weren't included in the study. Anything else, Lara? Any. Have you used this or have you come across this in your practice? What did you think about this one?

[F]

Honestly, I have not come across it at all. I do think it's interesting and I think you have to be careful because nocturnal leg cramps, they can be incredibly uncomfortable, but they're overall generally benign, especially if you know the severity that the study talks about. And I think the results are promising. And K2 is widely available and inexpensive, so an overall promising safety profile for most people. But I do think you have to be careful because it's something that should be very safe given the benign nature, although very bothersome, of not trying to like cramps.

[A]

I think that's a good point. And so a couple things about this, like the mechanism, they're not exactly sure how it works. They think maybe it has something to do with calcium and muscle contraction, but you're not really sure. So in order to prove that something works, there has to be at least a biological plausibility. So I think that's a big piece that we're missing for this. But there is at least a theory as to how they work. And then another one is just that was this a really highly selected population? So they excluded about a third of the patients that they screened for the study, mostly because they didn't have at least two cramps in the two weeks leading up to the entry period. And then some people were excluded if they had, like, specific metabolic conditions. That would cause the cramps or neuropathy. And they excluded patients who were taking diuretics, which for me would exclude a lot of my patients who have leg cramps. So that would be a population that I would really want to know if this works for. So that being said, I mean my take on this was they really did not find any adverse events. As long as the person's not taking a vitamin K antagonist like warfarin, then I don't see the harm in trying this. It looks like it's relatively cheap. You can get the tablets come in between 100 and 300 microgram tablets. You might, I don't know if you can find 180 microgram tablets like they used on this in the US but people can look around. But to buy, like I could tell a patient that has nocturnal leg cramps, buy a bottle, try it out, see if it helps. If it doesn't, you know, that's fine. They did see a reduction in cramps pretty quickly in this. So, you know, they don't have to do it for more than a month or so. So I think it's worth doing. What about you, Paul, as America's pcp, will you be recommending anyone try this?

[C]

I'll probably give it a shot. Right.

[B]

Because it's. I think Laura's. Both of her points are really well taken. Like first of all, you want to make sure that your interventions are very low harm because these are not going to kill people. But on the other hand, these patients are miserable and if you think about the downstream workup of someone who comes in with leg cramps, you're checking lights, you're probably checking a tsh. Why? I don't know, because we check a TSH for everybody. They'll throw an affair in there because why not? Maybe God forbid you're doing low dose gabapentin at nighttime, just throw against the wall, see what sticks, their legs swell up or they fall out of bed. Even though it seems like a minor thing, I hear this all the time. There is workup that goes into it. So if there's a low cost, low harm intervention that may actually be effective, that's actually really fabulous news because I feel like I run into this in primary care a lot. So I was actually excited for this one.

[D]

One interesting thing that I don't just was thinking about because I did Stormy Toronto.

[F]

Yeah.

[A]

Get excited.

[D]

I did go down a rabbit hole of like trying to understand what vitamin K is and what vitamin K2 is in particular. And there's a nice review on like vitamin K in the human body and physiology, if you want to do that. But do you know what foods vitamin K2 is in?

[A]

Leafy greens.

[D]

No. So K2 is in like fermented foods and like soft cheeses, eggs, meats. And I just looked it up and I think there is a Decent amount of K2 in. In pickle juice. So.

[F]

Interesting.

[A]

Ooh, interesting, interesting. Then the authors didn't even put that together. Nora, that's.

[F]

Wow.

[A]

I think we might need to write this up.

[D]

Yeah, I mean, this is literally just based on googling vitamin K, pickle juice. So I'm not sure how good the evidence base is there, but do you.

[B]

Guys hear that ringing sound? Does anyone else hear that? Because I think it's the no mail committee calling. Very exciting.

[A]

Okay, all right, so that's enough on that one. Paul. I think, Paul, you have one to talk about and I don't. Does this one have a clever name? I don't know. I didn't come.

[C]

I could not find a fancy pants.

[A]

Trial name for this missed opportunity. All right, Paul, what are you talking about?

[B]

So we're talking about, as needed, blood pressure medications and adverse outcomes in VA hospitals. An article that came out this year in JAMA Internal Medicine. So, as you know, we've been banging.

[C]

The strum for years, like literally years.

[B]

At this point now at the use of PRN antihypertensives for hospitalized patients with asymptomatic hypertension. This is a group that, by and large, you know, it's about 70% of patients that are hospitalized have elevated blood pressures, and many of those patients don't have a diagnosis of hypertension. There's lots of reasons to be hypertensive, whether it's pain or volume overload or medication effects, and on and on and on. And yet still this practice persists of having, like, order sets with PR and antihypertensives to give her blood pressures greater than, you know, 180 systolic or whatever.

[C]

So this is yet another trial to.

[B]

Kind of look at are there harms associated with this? And not to give away the game, but yes, there are.

[C]

So it is a retrospective cohort trial.

[B]

But it is a emulated trial. So the way these work is they actually emulate a randomized controlled trial using information from retrospective trials that kind of meet their specific needs. So it's kind of a nifty design looking at hospitalized patients at the VA system. So these are overwhelmingly male patients, for what it's worth, and looked at data between 2015, 2020 and patients admitted, but not to the ICU. And they even included cardiovascular admissions, which previous studies do not always do. So you have a little bit more data that is useful to work with and a little bit more reflective of everyday practice.

[C]

And so they did this trial emulation looking at two groups, groups that received.

[B]

PRNA antihypertensives and patients that did not. Pretty straightforward. And their primary outcome that they were looking at was time to first acute kidney injury event, which I think is an interesting one, but it also makes sense because I guess it's relatively easy to kind of chart mine and kind of find that kind of detail out. And that, in case you're interested, is a rise in creatinine greater than 0.3 milligrams per deciliter from baseline within 48 hours, or 50% increase over seven days. And they started watching the day that you actually gave the as needed blood pressure medication. So I'll pause here to see if there are questions or thoughts or predictions as to what may have happened that can fit between these two groups.

[A]

I mean, I have some. I mostly have comments on the outcomes of this. I thought it was neat. I hadn't really. This emulated trial design I thought was pretty cool reading about how they did that. And I mean, I don't know, Paul. This was a VA population. It was mostly men. I mean, obviously that's gonna be a setup for some kind of limitation. And then we had talked about this a little bit before. They're composite of mi, stroke or death was based on the discharge summary. And then the way they determined if the MI or stroke happened during the hospitalization was if someone remembered to check present on admission when they were categorizing.

[B]

Bulletproof.

[A]

Yeah. So it seems like they might have miscategorized or maybe even missed some events. Cause sometimes you'll get a discharge summary and it says just one thing on it and you're like, you know, there was a lot more that happened that was addressed during that hospitalization. So maybe the VA system's different. But sometimes I'm seeing discharge summaries missing some of what has actually happened in the hospitalization. And then the AKI definition, 0 point creatinine rise of 0.3. Do we always really care about that? So I would have. That's a little bit of a soft endpoint. And if that's your primary outcome, it's a lot easier to show than if they said doubling of serum creatinine or, you know, 40% increase in serum creatinine. Some of the Ones that we see in some of the major adverse kidney event, you know, included as a major adverse kidney event in some of those renal trials.

[B]

Yeah, all well said. I should probably just give you the outcomes so that we can actually, so that your comments make a little bit more sense in context. So they looked at 130,771 veterans that were included in this acute kidney Andrea analysis specifically, and 20% of those folks actually received as needed antihypertensives. Just to give you a sense of how common this practice is, 18% received just IV, only 66 received oral, and then 15% received both. And then they actually looked at sort of subgroup analyses in terms of outcomes of these. And not surprisingly, the patients that received IV only PRN antihypertensives had a 64% increased risk of actually having the acute kidney injury, but all groups had an increased risk of acute kidney injury. And then not surprisingly, these patients also are more likely to have rapid drops in blood pressure as well, and again, less surprisingly, more likely to have the composite outcome, as you say, which is when you're doing this sort of chart mining, retrospective review, you're limited in terms of what to know, what to do with that information.

[C]

And even the administration that you're on.

[B]

Anti hypertensives, you can do all the matching you want, but it's kind of hard to know. Sicker patients probably need more medications and have more variability in blood pressure. So there's going to be some confounding stuff in here, but in general, I think this sort of adds the body of evidence. This article Itself refers to three other articles that were done in 2021 that looked at the same thing in terms of outcomes and intensification of blood pressure. And every time you look, those patients do worse. So it seems to be this should be a practice that is hopefully going away at some point.

[A]

Well, we have a hospitalist with us. Lara, what are you seeing and what do you think about this?

[F]

Yeah, definitely as an inpatient clinician, I see this all the time. And just as needed antihypertensive medications, either as kind of a one time dose or even as a recurring as needed medication. And I think this is yet another study showing that we should be treating the patient and not the actual number. And I think like Paul said, there's usually a lot of reasons that hospitalized patients are hypertensive and investigating why the patient is hypertensive or maybe hypertensive should be the first step. You know, it could be, is it related to sleep, Is it related to anxiety in the hospital? Are they withdrawing from alcohol or a substance? Could it be other medications the patient is receiving? Are they on steroids? I could keep going for a while and the truth is I receive pages all the time for this type of asymptomatic hypertension. And I think it's very easy to reflexively respond by ordering an antihypertensive medication to feel that you are doing something both for you, for the patient, for the nurse, for everybody involved. But it is so, so important to realize that the use of these as needed blood pressure medications may actively harm the patients. And I think we've seen studies over and over again that show that this is harmful. And I think we really need to be careful about doing it as needed at any point if they're asymptomatic.

[A]

Well, I still think, Paul, this is as much as you berate people when they do this, presenting patients to you in the hospital, this has been a tough practice to crack because there's no shortage of writing about how you should not do this, how you should look for why the blood pressure is elevated. But this, I don't think this article is going to be the final nail in the coffin of this practice, but it should hopefully be one nail in the coffin coffee that will eventually close this practice.

[C]

I think the needle is moving a.

[B]

Little bit because I will say that I think I post about this article in blue sky if I'm not mistaken. I was like hey this by the way parent anti hypertensive is still bad. And someone a younger it was either an early resident may have I think it was a resident replied people are using PR antihypertensives and hospitalized patients. So at least in one place that is a surprising thing to do. So hopefully it is. Well, I'm going to count that as an encouraging sign that this is slowly falling out of favor, but not really quickly enough.

[D]

I do wonder whether this is something that we need to think kind of intentionally about spreading not only on the medicine floors but also elsewhere. Obviously this specific study didn't actually include or they excluded surgical patients. But I do think that's probably a big area where we could improve our education around this. And I'm sure that a big part of that is is just people aren't aware of the many studies now that have have looked at this.

[F]

And I think also the emergency department, it's just such an easy thing to give without really thinking about kind of the harmful downstream effects. And I think it kind of makes everybody feel better in the short term. But that's not always the answer.

[A]

Yeah, I think you have to build it into the electronic record. Like, hey, are you sure you want to give this. Did you check for this, this and this? You could put some things in there that make it an easy decision for the person or maybe scare them off from doing it, but who knows? All right, well, Paul, any final comments before we go on to our next article? I know you're dying to talk about this one as well.

[C]

No, let's move on.

[F]

Okay.

[A]

So, Laura, what are you looking at? And again, I didn't look to see if this one had any clever name.

[F]

I don't, I don't think it's no clever name, unfortunately. You can make one up, but it does not have one.

[A]

Well, I think we chose some good topics tonight, Paul, but we really missed out on these. We only had one clever trial name so far, so hopefully.

[B]

We got some show off.

[F]

Maybe the future randomized control trial will have a name.

[A]

Yeah. Okay.

[F]

Yeah. So this is looking at GLP1 agonists and looking at the potential benefits of GLP1 agonists in patients with alcohol use disorder. So this is a recent cohort study published in JAMA Psychiatry. And in this study, researchers used a within individual design to study whether GLP1 agonist could decrease the risk of alcohol use disorder related hospitalizations. The researchers examined data from a national registry in Sweden and included over 220,000 patients ages 16 to 64 with the diagnosis of alcohol use disorder. The median follow up was 8.8 years. And the results showed that semaglutide and liraglutide use, but Interestingly not other GLP1 agonists was associated with a significant decrease in the primary outcome of alcohol use related hospitalizations as well as secondary outcomes including a decrease in substance use disorder hospitalizations and somatic hospitalizations. And they did not see a significant change in risk of suicide attempt. And I'm interested to hear your thoughts. I'll stop there for now.

[A]

You got to go to Paul for this.

[B]

No, this is, I mean, this has been an exciting area that has been looked at for a while now. People have been talking about and excited for it. I think the data are mounting that this is plausible. There have been animal studies that have shown it reduces sort of alcohol cravings. There have been a couple of retrospective studies that came out. There was one in October of 2024 that made a lot of sort of popular press. That was also a retrospective cohort study done in the States, not in Sweden, that also showed kind of similar outcomes. So it's an exciting area that I think probably has biologic plausibility and is certainly worth exploring. I'll have a bazillion other thoughts, but I think I'll pause right there.

[F]

Yeah, I think, interestingly, the proof medications for alcohol use disorder, including naltrexone, disulfiram and acamprosate, were associated with only a modest decrease in alcohol use related hospitalizations with an adjusted hazard ratio of 0.98. So they saw much more benefit from the GLP1 agonist in the study.

[A]

Yeah.

[D]

And we didn't see how the two did together. Right. In this study, at least if you're on both a GLP1 and naltrexone or disulfiram.

[F]

Right. So with this study design that you can't tease out exactly the. The specifics.

[A]

Yeah. So this was an observational study. I think it would just be hard to. The type of patient that typically gets prescribed naltrexone, acamprosate, disulfuram. I just, I imagine them having worse disease than the patients, as much as they might have tried to match the patients, because the outcomes were just worse in those patients that were on the conventional meds, which we know do have some benefit. So I think, and Paul was making this point off air that the type of patients that get access to a GLP1 agonist, they're harder to get access to those medications than to be prescribed those. So you're just looking at different groups of people, I think, and that may be part of why this was looking so good for GLP1 agonists, because maybe those patients just had better resources in general.

[B]

Yeah, thanks, Matt. I think. So Rahul Gadash and I were tweeting back and forth about the addiction study and this was sort of. My exact point is that the patient who has the organization to make it to routine primary care visits and actually obtain a once weekly injectable medication for which there are multiple insurance barriers for. There are just certain defining criteria that already exists within that patient. That person is markedly different from someone who is not able to achieve those things. So there's a lot of intangibles I.

[C]

Think are just hard to measure with.

[B]

These sort of retrospective trials. And I just, I don't know that they fully capture the medication effect in and of itself as opposed to the systems that allow that medication to be administered in the first place. And I actually went down a rabbit hole looking at how hard is it to get a GLP1 in Sweden. And believe it or not, that's actually harder to figure out than you might expect. So it seems like the access is relatively comparable. It's not like they're just giving out like candy there. But I just think there's a lot of systemic stuff that goes into access to those medications and capacity for self care and sort of engagement with the healthcare system in general that just all those things kind of have to exist for you to even have those medications. And I just think that that stuff's hard to measure in these studies. So until we actually there's. Sorry, I'm sorry to be talking so much of your part, Laura, but there we just did a curbsiders addiction medicine with Steve Holt on medication through alcohol use disorder where this point came up. And he's excited too. But until we have the randomized controlled trial that has this as a primary endpoint, it's gonna be hard to know what to do with these data specifically.

[F]

Yeah, and I think the researchers do acknowledge that the results of this need to be taken with a grain of salt. And I certainly agree with that. I think we already talked about the fact that it's an observational study, so it can't establish the causality there. And it uses a very interesting within individual model, meaning that the individual basically acts as their own control. So as such the comparators are different and the researchers are comparing individuals risk of hospitalization during periods of use of the medication versus periods of non use. And so I think there are some promising aspects to this including that it's a large cohort study, but data is from a registry in one country of Sweden. And these data do not capture all the relevant variables such as, you know, the amount of alcohol consumed or why patients were prescribed GLP1 to begin with or what is their adherence to the medication. So. So I think I'm hearing a lot of the concerns with the study and, you know, future the need for future studies.

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[A]

Yeah, and it seems like on clinicaltrials.gov there is a randomized controlled trial of semaglutide versus placebo that's gonna be done over 26 weeks in people with alcohol use disorder and obesity. So that should give a pretty good answer. And then they're using like liraglutide for opioid use disorder and another one for smoking cessation as well. So there's a bunch of trials with these agents coming out.

[B]

Yeah, I think dosing will be a consideration. And then because pancreatitis being a specific concern among both populations, there's gonna be a lot of sort of tweaking of data as we start to see, and.

[F]

It'S really not ready for primetime. It's not practice changing yet. And I think there will be a role, I suspect, of GLP1s to either complement existing treatments for alcohol use disorder or maybe replace them. But I think it's really too early to tell in what capacity. But I do think it's worthwhile considering these results when you're treating with patients with alcohol use disorder plus obesity or type 2 diabetes or something that these GLP1s are approved for because that will help with whatever indication with the potential added benefit of helping with alcohol use disorder. But. But I agree, until we have kind of a randomized clinical trial across a broader population, it's not practice changing yet.

[D]

There are also a fair number of questions that remain kind of across all of the GLP studies for whatever disease about the duration of treatment that I just don't. I feel like you're going to have exactly the same problem with this, if not a more serious one, where there's going to be real resistance and understandable resistance to coming off of a medication that's working, but we really have no idea, like, how long you need to be on this and how persistent the effects are.

[A]

Yeah, good point, good point. Okay, well, we have, I guess, two quick, quick takes on some recent, other recent stuff. Nora, you want to start first with this. Shorter course antibiotics in sepsis.

[F]

Yeah.

[D]

And this one I actually feel maybe has the best name of the day. So this is Balance, the Balance trial. And I'll just read the name and then we can judge the title. So bacteremia antibiotic length actually needed for clinical effectiveness.

[A]

Ooh, Paul.

[D]

I know, I like it. Yeah.

[B]

Bravo. God bless the ID doctors.

[A]

Paul, are you crying?

[B]

Just a single tear rolling down my cheek. You can't see it at home.

[F]

Not a lot of competition for names, but this one definitely puts out for today. Not even close.

[B]

Oh, heroes.

[D]

Heroes is what they are, truly. Yeah. It's the first trial in a long time where I've been like, that is exactly what we're doing here. And so this study was just published in the New England Journal in November and compared 7 versus 14 days of antibiotics in patients with bloodstream infections. And obviously, bloodstream infections can be very serious. And there's a lot of questions and uncertainty around the optimal duration of treatment for bloodstream infections. And so this trial sought to answer those questions. It had a non inferiority design and it randomized patients to either seven days of antibiotics compared to 14 days, which is a relatively standard kind of historical duration of antibiotics for bloodstream infections. And they used a non inferiority margin of 4% for their primary outcome of death from any cause at 90 days. It was a positive trial and they found that 14.5% of patients died in 90 days in the seven day treatment arm compared to 16.5% of patients in the 14 day arm. And this was supported in both the per protocol and the modified intention to treat analyses, leading to a conclusion of the non inferiority of seven days of antibiotics for bloodstream infections. So is this already in the hospitals, Laura? Is this what you're doing?

[F]

So I've definitely seen kind of a trend towards decrease in duration of antibiotics. I'm not sure if we're fully there, but I do think this study is very promising, especially given kind of building on so many other smaller trials before it. And I think what's especially exciting about this study is the potential benefits of a shorter antibiotic duration, including the possibility of fewer adverse reactions or events, decreased cost of the actual medication and possibly decreased hospital stay and then decrease antibiotic exposure and possible resistance. So I think there's a lot of hope and I think that the. This is just kind of adding on some other good studies and data that may be shortened antibiotics is where we're going.

[A]

Yeah. And Nora, just the limitations, just for people in practice before they apply this, the patients were on a couple days of antibiotics. The immunocompromised patients were not included in this either. So this is. You're just sort of standard patient that's in the hospital. Maybe they're super sick initially, but they get better when you put them on appropriate antibiotics within a few days and they're clinically stable. You feel comfortable stopping antibiotics at seven days.

[D]

Yeah. And I think the other important limitations to note are that they did not include patients with staph aureus bacteremia. So that's a big note to make. And then also did not include patients who had like uninterved upon abscesses, prosthetic joint infection, septic arthritis. So basically things for which you know you're going to need to treat longer. They didn't include, for somewhat obvious reasons, but they did include a number of, kind of a pretty broad spectrum of types of infections and sources of infections. 40% UTIs, a good handful of pneumonias, good handful of intra abdominal infections, and then a, a number of different organisms, specifically both gram negative and gram positive. So they did try to broaden the criteria for this study away from just gram negative bacteremia, which had been the focus of the prior smaller studies.

[F]

And I also hope that future studies will look at some of the excluded conditions because I wonder if it's possible that this treatment duration may be effective too in those certain cases that we haven't looked at.

[A]

All right. To round out the show, we wanted to just highlight. And this was covered, this is patient collected HPV screening. This was covered by Alyssa Mancini in digest number 60, did a really nice write up on that. And essentially the USPSTF has right now, maybe by the time this releases, it might be out of draft, but it's a draft recommendation for cervical cancer screening. It's not much change from the 2018 guideline, except they're now saying they're really putting more. We're moving towards, for women 30 and older, we're moving towards HPV testing as the primary method. And you can still do a CO test if you want with the Pap test and the HPV test, or you can just do an HPV test every five years. I guess some people will still get the cytology every three years if they want to stick with that. But the exciting thing about this is they're now saying that self collected or patient collected HPV testing is now recommended and right now it's only approved for in clinic collection. And there's a couple different companies you can go with to do this, but ultimately I think this is going to be like we can do with FIT testing and the stool DNA testing where that box knocks on your door and then you. Yeah, you supply a bowel movement. This is going to be home HPV testing. So with a self collected swab, I couldn't really find reason why it wasn't collected or why it wasn't approved because the evidence from studies says that self collected at home has good concordance with clinic collected by the clinician. Nora, did you see anything about that?

[D]

I think, I'm trying to remember if this is right, but I think the FDA approval was limited.

[A]

That's what it was. The FDA did not. Yeah, the USPSTF thought it would be okay, but the FDA did not, has not approved it for home testing yet.

[D]

I think that's right. And then there are these kind of, there's a series of different studies that are ongoing led by the NCI's Last Mile Initiative. Looking, trying to look at the different tests that are around and comparing them. But yes, you're totally right. Like all of the studies comparing the at home and clinic collected swabs have shown good concordance. And so I can't see why. I mean, that's the reason to start using these swabs, right?

[A]

I mean, I think it's just a matter of time. And even if it's, even if the patient has to be in the clinic to do the self collected, it's still more patient centered than having the clinician do it. But what do you think, Paul?

[B]

This is the exact point I was going to make as we made this transition to sort of self swabbing in general. I just, I think about a resident clinic where you have a resident, a preceptor, a chaperone in the room. In the old school days of doing the pelvic examination, the swabbing and the.

[C]

Gowning and the discomfort, as opposed to.

[B]

Nowadays, you'll have the patient go to the bathroom with the swab, come back out, and you have answers as opposed to the patient just declining the exam because it's awkward and terrible and you're sort of presumptively treating something. So I think the self collection, even if it has to happen in the clinic, will still lower the barriers enough that many more people will be screened. We'll still have actually things that are actionable.

[C]

So it's still hugely encouraging, regardless of.

[B]

The format, because it's still a step forward. Maybe step forward is not the right way to frame that, but it certainly, I think, will broaden the people who are accepting or sort of willing to go through screening just because it can be such a burden and it's so personal and certainly very uncomfortable for some. So I think this is. This is a positive.

[D]

However you spin it, it's also hard to get into clinic to get this done. So I feel like that in and of itself is a barrier. And so making it such that you could literally just go into lab and do it and then go home is amazing.

[A]

Yeah. And health systems have population health people that would mail these out to people the way they do with occult blood testing kits. So I really think that that's the way this will move in the future. And you know, Paul, with that, I think this has been an episode.

[B]

Do you want to keep going?

[C]

You're doing great.

[A]

No, I think we should go to an outro.

[C]

All right.

[B]

I mean, you're 90% of the way.

[C]

There, but this has been another episode.

[B]

Of the Curbsiders, Matt, bringing you a little knowledge food for your brain hole. This is exactly what I was hoping would happen.

[C]

Sorry, what was that?

[B]

Nora? You were going to say something and I cut you off.

[D]

Yummy.

[A]

There.

[B]

It was worth it.

[C]

Still hungry for more. Join our Patreon and get all of.

[B]

Our episodes ad free, plus twice monthly bonus episodes at patreon.com curbsiders.

[C]

You can find our show notes at.

[B]

The curbsiders.com and sign up for a mailing list of our weekly show notes in your inbox.

[C]

That includes this very Curbsiders digest that.

[B]

Recaps the latest practice changing article's guidelines as news and internal medicine.

[A]

And we're committed to high value practice changing knowledge. And to do that, we need your feedback. So please email [e-mail] a reminder that this and most episodes are available for CME credit through VCU Healthurbsiders vcuhealth.org and I wanted to give a special thanks to our whole team, Dr. Lara Glick, Dr. Nora Toronto, Dr. Paul Williams, America's PCP, for helping to write and produce this episode, and to our whole Curbsiders team. Our technical production is done by Podpaste. Elizabeth Brodo does our social media, Jen Watto runs our Patreon. Chris the Chew Manchu moderates our Discord. Stuart Brigham composed our theme music. And with all that, until next time, I've been Dr. Matthew Frank Waddo.

[F]

I've been Dr. Laura Gleck, I've been.

[D]

Dr. Nora Plout Toronto.

[C]

And as always, I remain Dr. Paul Nelson Williams.

[B]

Thank you and goodbye.