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The Curbsiders Internal Medicine Podcast
#514 Hotcakes: Oral Semaglutide, Fish Oil in ESRD, IV Iron During Infection, New US Dietary Guidelines, & Anticoagulation after Ablation in AFib
01:10:19
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A
Hey, before we get to the show, I wanted to remind you to check out our patreon@patreon.com 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 stuff@patreon.com curbsiders.
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B
Paul.
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C
Let me know if you remember this one. What did the guy from New Jersey say when he saw the ocean?
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D
I feel like this will be like lightly offensive, but I don't recall a 1.
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C
C. Oof.
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D
Okay. No, I wouldn't have gotten there.
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C
That's a Stuart. That was a throwback to Stuart. But you know, it's been 10 years, Paul. We're running out of puns here.
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D
Going back to the well, great stuff.
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E
The Curbsiders podcast is for entertainment, education and information purposes only and the topics discussed should not be used solely diagnosed, treat, cure or prevent any diseases or conditions. Furthermore, the views and statements expressed on this podcast are solely those of hosts 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.
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B
Pretty much.
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E
We aren't responsible if you screw up. You should always do your own homework and let us know when we're working.
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C
Welcome back to the curbsiders. I'm Dr. Matthew Frank Watto, here with my great friend and America's primary care physician, Dr. Paul Nelson Williams. Hey, Paul.
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D
Hey, Matt. How are you?
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C
I'm doing well, Paul. This is a Hotcakes episode. That must mean that boy wonder, Dr. Rahul Ginatra is with us today. But Paul, why are we here? What are we going to do tonight?
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D
We've got a lot of boys Wonder on the show, I'm finding. We're always the internal medicine podcast. Usually we use expert interviews to bring you clinical pearls and practice changing knowledge. Tonight the experts are ostensibly yes, but not really. There's only. There's some experts here, but I'm not going to claim expertise of anything. We are doing, as you mentioned, our Hotcakes episode where we go through some articles that we found compelling or interesting and try to do some critical appraisal just. Just to kind of keep our wits sharp and make sure that we're still, you know, still in the game. And we are of course joined by some great co hosts to help us do so. We are joined, as you mentioned, by the great. Is he a boy Wonder? I don't think I realized that we gave him that. But Dr. Roholganacha was an epidemiologist.
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C
Yeah. I mean, he's got a family. I mean he's.
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B
Yeah.
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C
Probably unfair to call you Boy Wonder, Rahul. I'm sorry.
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B
That's fine. I'll take it. Yeah.
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C
You're aging wonderfully, Rahul.
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D
Thank you.
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B
Yeah, I was gonna say it sort of helps me feel younger, you know, like less bad about losing all my hair. So it's fine. We can stick with Boy Wonder.
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D
Well, if there is indeed a boy Wonder here, it would be our other co host. We are joined by Dr. Josh Gilman, who you may know from the Curbsider's Digest, who's always go through some episodes too. Josh, how are.
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F
Good, how are you, Paul?
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D
Great, thanks.
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C
Thanks for joining us, Josh. Great to have you on air. We love having people from the Digest hang out and we appreciate that you write for the Digest because Paul and I are not qualified to do so.
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A
And we're kind of lazy.
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C
So this is. It's great that other people do that.
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F
No problem. Glad I can fill the gap.
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C
All right, well, let's get to our first article which I will be presenting.
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And this is Paul. Did you know that oral semaglutide is.
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C
Now available and it's being advertised on television, that some of these online companies that'll sell you medications or advertising it. That's how I found out about it. I didn't realize that it was now officially approved.
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D
I'm going to bust out my hipster doofus card and say I don't actually watch much tv. So I was previously unaware of this.
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C
That's the only way you might find this out. But yeah, towards the end of 2025, oral semaglutide, which was approved for for treating diabetes, now is approved for treating obesity. And the trial that I'm going to talk about was by Wharton et al. It appeared in the New England Journal in 2025. And this was looking at oral semaglutide at a dose of 25 milligrams in adults with overweight or obesity. And the top line results of this were that this is a positive trial, that it did promote weight loss. At this dose, it was about 30, 13.6% weight loss in the treatment group versus 2.2% weight loss in the placebo group. So that's a difference of -11.4 percentage points, which is quite significant. And I will stop there and just ask Rahul. Anything surprise you about this trial? This is a drug we know works for other things. So now we're just kind of Confirming that the oral dose, if it's high enough, can work for obesity.
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B
Yeah, no, I mean, we were talking a little before we recorded these results are not particularly surprising. And a big reason for that is because the weight of evidence from other trials of injected and oral GLP1 receptor agonists really establishes beyond a doubt that these things work. So I view the sort of bar that this individual trial has to clear as being lowered because of that prior body of research. So. So yeah, I mean, I'm curious from, you know, those of you who take care of patients in the clinic, I mean, are you seeing patients on oral GLP1s that much, you know, for diabetes, or is it. I feel like I care for patients in the hospital setting who are mainly on injected medications. So I'm curious if, like, even though this has been approved for diabetes, is this a thing that people are seeing out in the wild?
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C
Josh, are you, do you have experience with this one? I mean, I can comment, but I want to hear from you.
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F
Not the oral, certainly. I mean, we have a fair amount of, or I have a fair amount of patients that are able to get injectables for weight loss related reasons, especially with those with, with underlying risk factors as well for cardiovascular disease. But I don't think I have any oral patients currently.
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C
Yeah. And semaglutide, the injectable. Semaglutide has an indication for if people have known cardiovascular disease. That was one of the ways that we would get it approved for patients with Medicare. Paul, what about you? Are you using any of the oral GLP1s?
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D
It's a last resort kind of option. You have to jump through, at least with the insurance that I've been dealing with. Flaming hoops to jump through. And they have to be the patient's needle averse and have not done well with other medications to get it sort of approved. So it's not easily prescribed. So it's not one that I reach for initially just because there are so many other good medications for diabetes that are out there right now.
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C
But the price is cheaper than the injectable because it doesn't have a pen device, which is. You're paying some of it, you're paying for the device. So some of the estimates I was looking at is that it would be like $300 a month even if you were paying out of pocket for the oral medication. So we'll see if that's actually going to be the case in practice. But I have used the oral and it comes in doses of 3, 7 or 14 if you're using it for diabetes. And now, you know, if you're treating weight loss, there will be a 25 milligram dose. But it's the same way you step up pens once a month, you step up the pills. So they would spend a month at 3 milligrams a month at 7, a month at 14, and then go up to 25. So it takes like 12 weeks to get up to the maintenance dose of this. But like you would expect, this trial, which was a phase three randomized controlled trial, they did find that GI side effects were the main limiting factor. And about 20% of people did not complete the trial because for various reasons I suspect a lot of it was they just didn't want to take the medication. They didn't like the way that it made them feel. So even with that, Rahul, do you think that that would really, would that change your results that so many people didn't complete the trial?
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B
Yeah, I mean, I was just thinking, just as I said, I was willing to believe any magical outcomes of GLP1s. You know, I should probably be a little more systematic about asking how could these results be wrong? I mean, for any, you know, positive superiority trial, I'm always thinking, what are the sources of chance, what are the sources of bias that could, you know, make us wrong about this? And you know, the ClinicalTrials.gov protocol shows that the primary outcome was unchanged. This seems like a fairly representative population of patients in whom we might want to use this medication. So not a highly cherry picked population. They used essentially an intention to treat analysis, which is kind of a conservative way of studying this question. So even though there was a small amount of crossover and people not completing the trial, you know, they still had a dramatically positive result. And the last thing I'll say is that randomized trials are almost always underpowered to detect adverse events. Okay. Because most of the time those are less common than the intended effects or the main effect. But as you point out with these medications, adverse effects are a real problem and do lead to discontinuation in a, in a substantial number of people. So, yeah, I mean, it does, you know, raise my concern that, you know, a large number of people aren't able to follow through with taking the medication. But I view that also as informative for real world practice. I mean, I'm struck that, you know, in the table of adverse events, like, you know, nausea experienced by almost half of people who took the study drug, and, you know, Paul, you pointed out that, you know, fully a third of People have vomiting.
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D
Vomiting, yeah, which is, I just looked it up, you know, I guess with injectable semaglutide the reported since vomiting is 25% which still seems staggeringly high. I just. Any medication that I prescribed a patient where those patients would then throw up as a result is something that gives me pause regardless of the efficacy.
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C
Well, let's keep in mind this is now almost like outdated tech in my mind like tirzepatide. I have significantly less GI side effects when I'm prescribing that for people. And that's the dual GIP GLP one. And I think the drug companies are gonna keep tweaking the formulation. Maybe it's a dual or tri peptide formulation that's going to give less side effects. So I think you know, it's better than exenatide which was like the first one that was around. But I think we'll get less and less side effects hopefully. But definitely tirzepatide. Paul, I don't know about for you, but for me I've been able. People that weren't able to tolerate semaglutide were able to tolerate tirzepatide for sure.
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D
That's my anecdotal experience. Yeah, I think you're right. This whole is probably the tip of the iceberg of a whole world of medications where I will not be able to prescribe them effectively for patients because insurances won't cover them. But it'll be exciting to have options to think about at least.
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C
So before I give my hotcakes rating, I just wanted to point out New England Journal of Medicine Clinician, which I guess is their new journal watch. They had an article about dysesthesia. Alan Brett wrote about dysesthesia as a side effect that's reported. It's dose dependent with GLP1 agonist with semaglutide. In this trial, about 5% of patients had dysesthesia. I've seen it in one patient and I had never heard of it so I thought it was just an idiosyncratic thing. But that is something that has been reported and it's dose dependent in studies where they went really high on the oral or subcutaneous dose like doses that aren't even available to prescribe. It went up to like 13 to 20% of patients had dysesthesia. So you should watch out for that because 5% of patients on either the 2.4 milligram injectable or the 25 milligram oral dose. Well might get that symptom. So you will see it clinically at the rate that this is being used. And I will give this, I guess, 3.5 out of 5 hotcakes. You know, it wasn't that exciting of a trial because it's not that surprising, the results of it. But I think it is important to know that it's out there. And I did want to mention that. And I wanted to mention this incidence of dysesthesia, which if people are like me, they might not have heard of.
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C
Paul, let's move on. My results were, were not surprising, but your results of your trial that you're about to present, I thought actually were surprising to me. So I want to hear you talk about it.
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D
Yeah, even more surprising where I just, I haven't heard a lot of buzz where I've, where I've been practicing. Maybe we're hearing other corners. I'll be excited to hear everyone else's experience, but I'm going to be talking about fish oil supplementation and cardiovascular events in hemodialysis patients. And this is an article in 2026. Oh, hot off the press's New England Journal of Medicine by Loch et al. Maybe it's Locke et al. I apologize if I mispronounced that. So the question here that we're asking is do patients who are receiving chronic hemodialysis benefit from supplementation with omega 3 polyunsaturated fatty acids? And the reason that they're asking this question is because as we know, patients with end stage renal disease on hemodialysis have a huge burden of cardiovascular disease. The number in the studies Cardiovascular mortality is 20 times higher compared to the general population. So a big deal to kind of find ways to possibly reduce risk. But there aren't a whole lot of medical interventions that we have. Like as I think we've all heard, it's not even recommended to initiate statin therapy in this patient population because of an efficacy. So their usual tools don't seem to cut it. But the authors are proposing, well, what about fish oil, I guess is kind of where we're at. So they hypothesized that treatment of hemodialysis patients who seem to have lower polyunsaturated fat levels, treatment with fish oils, would lead to lower rate of cardiovascular events compared to placebo. And so I Will tell you what they found. The rate of all the events was about 40% lower in the group that was treated with fish oil compared to the placebo group. So sort of a stunning number with a hazard ratio 0.57. And then they looked at non secondary or secondary endpoints, things like non fatal cardiovascular events which are all part of the composite endpoint PVD leading to amputation, non fatal stroke or death from any cause. And those all seem to tilt in the same direction, favoring treatment with fish oil over treatment with something oily that was not fish oil. Yeah, we can talk about the placebo and the deodorizing process later on, but I do want to pause there and actually I think I'm going to toss it to Josh if he doesn't mind. Sort of as the person in most our cardiology space and thinking about cardiovascular disease, like did this surprise you or sort of where are we at with fish oils right now?
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F
I think it's a good question. I, I, I want to say I don't know because I don't think anybody knows where we're currently at. I was surprised, I think that there's a lot of data to sort of sift through that has been very mixed with some earlier trials even back over 10 years ago of low dose fish oil really not showing much benefit. There are some trials that did show a little bit of a benefit in cardiovascular risk reduction or preventing mace mostly and even recently there's two large trials. The one that I think gets cited a lot is the reduce it trial where patients got a high dose of epa which is one of the agents in fish oil and there was a reduction but that has not been really replicated. So I think the sort of jury is out. I think sort of currently the guidelines are say to prescribe it in secondary prevention high triglyceride patients which was what was studied and reduce it. So I think that this sort of is kind of at odds with those prior data and reduce.
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C
It was like people who had had heart attack, right? Like these are people with cardiovascular disease. They weren't necessarily on dialysis.
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F
It was, yeah, no dialysis. I imagine that would have been an exclusion criteria to be honest with you. Although I don't know for sure it was mostly patients with known ASCVD or you had to have diabetes with additional risk factors for ascvd. And I think it was overwhelming majority of patients had known ascvd and all the patients in that trial had high triglycerides, which I think is one of the sort of niche that's what's, I think given epa, this sort of niche field for its use.
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C
Yeah, I think that this one used 4 grams of fish oil. I tried to look up what, like was it a brand that they used and they said it was like a research grade, you know, like a high grade.
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B
Canada.
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D
Yeah, they have like special made and imported from Canada. Well, not imported from Canada because it was a Canadian study.
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C
It was 4 grams daily which provided 1.6 grams EPA and 0.8 grams DHA. And I think it would just be hard, like if I think what most people are going to do is read the headline, oh, fish oil is good for people on dialysis. And they're going to take like a gram or two of like whatever over the counter brand CVS has. And you have to think like you're not comparing apples to apples there.
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D
Yeah, I think, I mean, I should mention actually how they did the study because I think I sort of glossed past that part. So this was double blinded, it was randomized, it was placebo controlled and it was at 26 sites in Canada and Australia. But they did, looking at the background demographics, fairly comparable to American dialysis population, which is something that they were sort of mindful of. The participants are randomized one to one to either oral supplementation, which as you save the fish oil, 4 grams of, and I'm quoting here, steam deodorized citrus flavored omega 3 polyunsaturated fatty acids in four 1 milligram capsules. So four capsules of. I'm going to say it again, steam deodorized citrus flavored oil versus citrus flavored corn oil placebo. And they actually, they measured adherence in a neat way. They took sort of a random sampling and actually looked for incorporation of omega 3 fatty acids into the plasma phospholipids in a random selection of participants just to make sure that people are actually taking the medication, which is a very cool and specific way to sort of look at things. And then they followed these folks for upwards of three and a half years. So it was actually a pretty good timeline. So I think in terms of a methodology standpoint, I had a hard time finding a whole lot of fault with how they actually conducted the trial. I did want to ask Rahul, the main question I had about this actually has to do with the types of patients they were looking at. So I did want to touch base about the exclusion criteria specifically. So heart failure was not included and I think that's reasonable. The reason being is that volume overload in dialysis Patients is kind of tricky to kind of tease out what's going on when that's happening. So they omitted heart failure patients. They also did not include patients who had a high blood pressure. I think the systolic pressure grade like 180, which they classified as malignant hypertension. You also couldn't have a recent hospitalization. You could not have an ICD in place because apparently there's a signal for arrhythmia with fish oil in patients who have ICDs. And so, in sum total, it seems like they were actually selecting for a pretty comparatively healthy cohort of patients who are receiving chronic hemodialysis. And I'm wondering, Rahul, what I should do with that information as I think about it in terms of how to interpret the results.
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B
These are patients on dialysis, so they have some cardiovascular proclivity towards disease, but they're not the sickest dialysis patients. The exclusion criteria kind of help ensure that. But in the placebo group, the event rate was 0.61 per 1,000 patient days. And then with the. In the fish oil group, it was 0.31 per 1,000 patient days. So that's, I like to think, in whole numbers. So that's, you know, three events per 10,000 patient days. The fact that we were able to find, you know, a difference, even despite that, to me, sounding like a relatively low event rate and that translating to a relative reduction of more than 40%, I mean, this seems like this is real. So I, you know, I talked with a preventative cardiologist at my branch of Cash, like Memorial, who, you know, had some thoughts to share on this. He kind of shared the observation that every couple years seems like, you know, trials on fish oil come out. Some are positive, some are null. And what he took from that is that if there is a benefit of fish oil, it's. It's likely to be modest and in particular or specific populations. So, you know, there's a. There was a trial of fish oil in patients with heart failure that we can link in. The show notes that, you know, also showed kind of a modest benefit.
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F
Right.
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B
And I'm ready to. To start giving this to patients if it's kind of harmless and something that leads to cardiovascular reduction. I'm curious if any of you have a sense for why this sort of hasn't really penetrated into common practice yet, knowing that there have been other trials over the years.
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C
Rahul, in my practice, you know, my primary care practice location has. Has changed. And like the. The demographic of patients, I'm, I'M seeing a lot of people who are the type of people that like to take supplements, which is fine. And like the things that everyone's on are like creatine, protein supplements, vitamin D, fish oil, okay, magnesium. Those are the ones that like, almost everybody, like, if they're like somebody that's like, oh, yeah, I take supplements, I can like predict that they'll be on like all those. But now are they all taking like high quality formulations of fish oil and are they getting it from the same place? That's a different story. But people love to take fish oil. It just has great marketing. I don't know. And there is a test called the Omega check or like the omega 3 index that you can get from various labs that'll like, sort of tell you is someone getting enough Omega 3 in their diet. And it's kind of like almost like an A1C for like Omega 3 intake. I don't think it's nearly as widely validated as a lot of the stuff we look at, but that is something that is out there and usually it costs something out of pocket to check it. So I usually tell that to patients if they're requesting it.
- [25:07]
F
But I do think one thing that's probably true is that the dose of the fish oil that patients are getting in all of these trials, even in this trial versus other cardiac trials that have happened in the past, is probably way higher than the dose that anybody is able to get in a supplement over the counter.
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C
Yeah.
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D
The authors did a lot of nice explaining in the discussion in terms of why the formulations they chose and why there does seem to be heterogeneity based on sort of what supplements and what formulations and how they were sort of put together in the discussion, which is worth a read and was mostly over my head.
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C
Yeah. Well, I think we should get to. Paul, we should get to your. Well, actually, Paul, what was this?
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A
Is this the Pisces trial?
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C
Is that a good name?
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D
This will go into my rating. I also want to shout out Joel Topf, who I read a post of his on Blue sky, which is how I was aware of this in the first place. And just for you to know, he has been incorporating this. He's like, I'm prescribing it for my patients now.
- [26:01]
C
Yeah, why not?
- [26:03]
D
So, yeah. And they did, by the way, they did look at bleeding as the potential adverse outcome here. And there does not seem to be a signal for that. So in terms of this being low harm, that really does seem to be the case. But yeah, as you mentioned, Matt, a study name. This is the reason I looked into this in the first place and it turns out it seems to be a really exciting study too. This is the Pisces trial, buddy. And that is protection against, well, forgive thee, against Incidences of Serious Cardiovascular Events study. So they nailed the acronym, knocked it out of the park. It is not nonsensical. And then Pisces being fish related, just a work to the authors and then the benefit of they may be saving lives on top of that as well. Just great stuff. So yeah, I was thrilled by this entire study. So I will give this a 5 out of 5. This might be my first full stack because I think it will be practice changing. I think the trial name is excellent. I thought the study was very well designed so I could not be more pleased. So kudos to the Pisces authors.
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C
Yeah, I want a more of a firm mechanism. That'll be my last comment on this trial because I don't think we. Exactly. It's kind of hand wavy how it's supposedly working. But let's go on to our next presenter, which is the wonder kid or no, the father of the year for Dr. Rahul Ginatra.
- [27:18]
B
I'm actually sitting out of a very contentious bedtime right now, so I do not feel like father of the year.
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D
No, no shrieking in the back.
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C
Okay, Raul, what do you got for us?
- [27:32]
B
All right. Okay, team, so before I tell you what this paper is, I first have to give a shout out to our Patreon crowd because the paper that we're going to discuss came from Chris Milhouse at the VA in Palo Alto. He brought this paper to our attention. So thanks, Chris. And I also want to thank my buddy Jason Freed, a hematologist at Beth Israel Deaconess, who helped me kind of sort out my thoughts on this paper. So this is a paper by Sohail and colleagues and it was just published online in a January issue of Blood. And this paper is entitled A Retrospective Real World study of IV iron use to treat Iron Deficiency Anemia during Acute Infection. So what was the research question that these authors were asking? Well, it's basically what is the impact on survival of IV iron administration in patients who are hospitalized with iron deficiency anemia in the setting of acute infections. So why is this study important? Well, iron deficiency anemia is a super common problem among inpatients and prior data on the risk of IV iron in proximity to infection has been kind of mixed. We know from systematic reviews that there is a modestly increased risk of infection associated with IV iron administration. And that has been sort of the basis for concern about, well, could IV iron when given during an active infection be dangerous? And you know, everyone learns in medical school about those specific bacteria that are iron loving and, you know, patient with like uncontrolled hemochromatosis cuts their foot at the beach and gets like a raging vibrio infection. So, like people have this idea that iron sort of matters for at least some infections. So that's why this is important. I'll get right to the the author's top line findings. I'm just going to read you a quote from, from the manuscript. The authors say administration of IV iron therapy during acute infections was associated with improved 14 day and 90 day sur. And they reported absolute risk reductions on the order of 1 to 4% at 14 days and 3 to 6% at 90 days across five different types of infections with relative risk reduction of about 50%. So before I get into the details, I'm just curious, initial reactions, is this what people were expecting? Is anybody curious or skeptical of these results? Does it sound like this should be part of the sepsis bundle? What do people think?
- [30:02]
C
I liked that they're looking at this because it is, it is common. It comes up all the time. Can we give IV iron to this person who's anemic and iron deficient, but they have an infection, so it's something that comes up. So it would be practice changing if we were very confident that this was something that is safe to do. But it was just surprising at the effect size, despite the hemoglobin not changing all that much. I just was surprised at such a large effect size. Like the absolute reduction that you're talking about in risk was a couple percentage points, but the relative was like 50% or something, right?
- [30:44]
B
Yeah. The hazard ratios for all five of the infection syndromes they included, which I'll tell you what they are in just a second, but basically they all spanned like 0.4 to 0.6, suggesting a large relative reduction in a hard endpoint in mortality. So I think your surprise about that magnitude is useful and well deserved. But you know, the whole question that I have about IV iron is not so much is it beneficial? More like is it at least with regard to mortality in the acute setting, but is it safe? Is it something that we can use to sort of safely and efficiently correct a problem that we know is going to affect people after they leave the hospital? So I'll tell you a little bit about how the study was done. This was a retrospective cohort study. And this was done using the Tri Net X database. And trinetx is a commercially available collection of de identified electronic health records.
- [31:39]
C
From.
- [31:40]
B
Many healthcare organizations around the world. And unfortunately, it's not specified in the paper and it wasn't really clear to me from their website, you know, what population, if any, the data in this study are sort of representative of. But what the authors did was patients who are hospitalized in and represented in the database with acute infections were identified by ICD10 codes. Patients who were included in this study also had to have an ICD10 code for iron deficiency anemia that was made within two days of their infection. Okay. And patients also needed to receive antibiotics for their infection. Within two days, they could see codes for medication administration. So these are people who are getting treated during their hospitalization. And then what they did was they defined two groups, patients who got IV iron. And that was basically patients who had an order for IV iron within seven days of the index date, which was just the later of the whether it was the infection diagnosis or the iron deficiency diagnosis versus people who did not get IV iron. And they couldn't have gotten IV iron within one month before or three months after the infection. Propensity score matching was used to control for differences in baseline covariates. And survival, among other things, was assessed at 14 days and 90 days. So I'm kind of curious. Are there any problems that, that you could anticipate that we might need to have a plan for in studying this question this way? Anything that anyone is worried about?
- [33:09]
C
You mean because this was a positive trial, so we're looking for sources of chance or bias? Is that what you're talking about?
- [33:16]
B
Yeah, exactly. And I should point out, you know, there are ways to sort of emulate a randomized controlled trial using retrospective data. You'll hear the phrase target trial emulation used a lot. This is not what this was. This was just a retrospective cohort study where, you know, they, they sort of, you know, attempted to kind of replicate what we would find in a randomized trial. But yes, this being a positive study, you know, potential sources of chance or bias that could explain that positive finding or even any worries that people have.
- [33:46]
C
Well, I want you to explain this immortal time thing that you've, you've drawn this immortal time like back of the napkin drawing here. And I've never heard of immortal time before in this context, so I would love to know what, what you mean by that.
- [34:00]
B
Yeah, okay. All right, so in my view, I'll bury the lead and just tell you I think that these results are at high risk of being fully explained by immortal time bias. Okay. So that's why we need to really take the time to understand what this is. So in this study, okay, it included 300,000 patients from the database, and they're all hospitalized with. I haven't actually told you what they are yet. MRSA, bacteremia, pneumonia, UTI, colitis, and cellulitis, okay? All identified by ICD 10 codes. These are patients in their 50s and 60s. Many comorbidities, you know, things were common. Diabetes, CHF, CKD, et cetera. So why are we kind of dancing around this topic of immortal time bias? Well, this study is a very clear example of how failing to account for this problem could basically completely explain the results, and it's a good opportunity to learn how to detect it. So what do we mean by immortal time? Well, this is basically time during which an outcome, by definition, cannot occur. And in this study, you really need a picture or a graphic to kind of understand, you know, how that operates. And so, you know, we'll put one in the show, notes that listeners can check out. But basically, in order for patients to get IV iron, they had to survive from the period of the diagnosis of their infection up until, you know, potentially seven days after that, when was the cutoff for their receipt of IV iron. If patients died during that time period, they were not eligible for inclusion in the study. Okay. So what that means is any patient who got IV iron kind of got credit for surviving up until the point where they could receive IV iron. And there's no possible way that their survival could be, you know, due to or influenced by IV iron because they hadn't received it yet. So this is a big problem. We can't really quantify precisely, you know, how much of a problem this is because individual data are not available. So I can't tell you how much person time in the iron group was immortal, but this definitely biases towards increased survival in that group and really limits our ability to draw inferences about the safety of IV iron in this population.
- [36:12]
C
So is this going to be practice changing for you based on this?
- [36:15]
B
You know, I should say, as a person who cares for lots of hospitalized patients with anemia, I really want it to be true that IV iron is safe in the setting of infection. And I want to try and sift through, you know, the. The flaws of this analysis to answer that question, like, well, is there a signal for harm? And at the end of the day, I'm not sure that this analysis really gets us Any closer to knowing whether or not IV iron is safe or harmful in these patients. I'm. I'm very mistrustful of, you know, the sort of 50% relative reduction in mortality at 14 and 90 days. That. That seems implausible to me. It's probably going to still be my practice, as it was before, to once a patient has been treated for an infection, the infection's been quenched, they're stable, they're kind of on the tail end of their antibiotic course. I felt comfortable giving them IV iron before and I think I still feel comfortable now. So not really a practice change, really. For me, this is more about learning to separate my feelings about wanting something to be true from my appraisal of the evidence about whether or not it is true.
- [37:20]
D
Yeah, I mean, with retrospective cohort studies, obviously very useful for a lot of things, but you can't assess intentionality. It's because there is this concern about potential harm in giving iron to patients with infections. My sense is that you would not do that unless the patients were really deemed to need the IV iron. You know what I mean? So that context would certainly be different than to sort of randomize someone to IV iron versus no IV iron with iron deficiency anemia. So, like, I just, just. I think in the absence of the clinical context for what was even going on, like, I just don't know how to interpret the results, even with this kind of tea leave reading of ICD10 codes. But maybe I'm being unkind.
- [37:56]
B
No, that's a limitation of the TriNetX data is we don't have individual patient data. A lot of laboratory values were missing. So it's basically guaranteed that there's going to be some residual confounding due to unmeasured covariates. And like you said, the people who are thought to need IV iron, the people who get IV iron are also the people who are thought to be sort of, you know, doing well enough that they're not going to have their infection be worsened. If that theoretical.
- [38:22]
D
I'm sure that's true.
- [38:24]
B
So, you know, what do I do with this? I. This is not going to change my practice. I really want it to be the case that, you know, if. If we are withholding a potentially, you know, useful treatment for people that we kind of get better data on this. I would love to see a randomized trial. I think it feels like it's sort of gen enough equipoise to justify that, but. Yeah.
- [38:44]
C
So how many hotcakes?
- [38:46]
B
This, for me is a one out of five hotcakes. Okay, because these results, I want them to be true. But I don't think that this analysis can really be used to show that IV iron is beneficial for patients with infections. And it doesn't answer the question about is IV iron safe? So want this to be true but only one steam deodorized citrus scented hotcake.
- [39:09]
D
Everything's topsy turvy. I don't know if mercury is in retrograde or there's a full moon. I gave it 5 out of 5. Rahul gave a 1 out of 5. Just everything seems. Everything seems wrong.
- [39:18]
C
Yeah.
- [39:22]
A
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C
And this is a tech savvy business.
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A
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- [42:15]
C
All right Rahul, we have a little bit of a fun one as a palate cleanser here before Josh gets to his article.
- [42:23]
D
So Rahul. Yeah. Share your 5 out of 5 hotcake study with us. Let's hear all about it.
- [42:28]
B
Is this a fun one?
- [42:30]
C
I think it's a fun one. So there was some updated guidance, dietary guidance for Americans. And what is your take on that?
- [42:38]
B
Rahul?
- [42:39]
C
Tell the audience, give them a little taste of that and then maybe Paul can comment.
- [42:45]
B
Okay. All right. So a little hot take, little palate cleanser. Many of you will be aware that the United States government just released their updated dietary guidance for Americans. Those of you who grew up in the millennial years like I did may remember a food pyramid hanging on the wall at your school. Well, this comes from the government. These are updated every five years. And these guidelines are important for determining what goes into federally funded nutrition programs, things like SNAP and the National School Lunch program. So these are important. The document is a 10 page PD you can definitely read. There is a 400 page scientific supplement that you, you know, can try your best with. But I just wanted to spend a little bit of time going through some of the highlights of this guidance. So the first thing to say is that there is a lot of good stuff in here. Okay. The guidelines take a firm stand on, you know, what we should eat less of. And they're really talking about added sugars, refined carbohydrates, highly processed foods and what we should eat more of. And you know that is gonna be consist prior guidelines talking about real food, fruits, vegetables, whole grains, and then there's some recommendations that are a big departure from prior guidelines and there are some that are really not supported by the accompanying scientific report. And you know the, the two that I wanted to bring up for your consideration are around protein and fat. So these guidelines recommend that healthy adults target a protein intake of 1.2 to 1.6 grams per kg per day, which is higher than the previously recommended daily allowance of 0.8 grams per kilogram. And that really doesn't appear in the scientific report. And, you know, it's worth noting that without accompanying resistance exercise, excess dietary protein, you know, is vulnerable to being converted to fat in the liver and contributing to visceral adiposity. So that's kind of out of step with, you know, available evidence. And the other thing to mention is there's kind of a lack of nuance around dietary fat. The guidelines, you know, recommend healthy sources of fat, but then they also say that, you know, butter and beef tallow are alternatives to things like olive oil, which really does not make a lot of sense to me, as we do have evidence that, you know, butter raises LDL and increases cardio cardiovascular mortality compared with plant oils. So I'm curious what the rest of your experience has been with this team, Paul, have you encountered the dietary guidelines yet?
- [45:26]
D
I've looked at them. I'm going to try to be measured. I'm going to ask the team a question. When do we think the last food pyramid was in existence?
- [45:38]
C
I don't remember. I did the MyPlate thing that they had before. It's much easier to understand.
- [45:43]
D
Yeah, that was the last iteration. The food pyramid has not existed since 2011. So this whole memeification, this ain't your daddy's food pyramid turning it upside down thing is dumb. So, again, trying to remain measured. Some of the elements here are good, but I do feel like this is in keeping with a larger practice of putting something that says, well, that certainly sounds reasonable, sort of as a vehicle to carry some junk science and some garbage that is not reasonable and is not actually backed by evidence. So this feels in part of an ethos, but I'm not too offended by them. Other than the, the points that Rahul raised, they don't differ all that much from the my plate. Right. Like, there is like, fruits, whole grains, fruits and vegetables, whole grains and modest portions of like. It's not. It's not really that substantively different. It's just sort of memeified and also carries some additional stuff that is not backed by any evidence, which just seems like a Trojan horse for some other junk science to kind of follow down the line. So that's, that's my, my tinfoil take on it that is not very scientific. In case anyone was curious.
- [46:40]
C
Josh, as a, as a cardiologist, do you worry that the public impression might be like, oh, I can eat as much butter and beef tallow as I want. Like that's my concern. But I don't know about you.
- [46:52]
F
I feel like when you look at it, I mean, I have the actual image up in front of me right now. The steak is the most visible thing on the top left corner, right next to the big thing of cheese and just next to the a slab of what I imagine is like full fat milk and yogurt. I feel like that whole top left corner. Yeah. Is pretty, pretty challenging for when we're trying to sort of guide patients towards higher unsaturated poly, higher polyunsaturated fats, you know, using more lean, lean meats like chicken or turkey. I also don't really understand why on the other side there's, there's fruits sort of all over from top to bottom. I don't understand what the sort of thought process on the placement orientation was. But that's a, that could just be an aesthetics thing of my own challenge.
- [47:47]
B
I didn't like the font, if that. You know, since we're talking about aesthetics.
- [47:50]
C
The American College of Cardiology commentary. I like how they said a counterclockwise turn of the pyramid to put like the fruits and vegetables at the top would have been, you know, like a good to put that kind of front and center. But you know, I think the. We talked about this on a cardiology episode coming up with Greg Katz where there is a group of like very healthy athletic people that are eating keto and that is very different than somebody who's eating a normal American diet and now gonna like double down on butter and steak and everything. You know what I mean? So I think it's still the long term cardiovascular health of like the keto diet. And everything to me is noti'm still a little confused about like should we be worried about that personthose people. And there's been some like ct. We talked about that. There's been a CT coronary angiogram study of some people that are on the keto diet kind of looking and it seems like they are progressing quickly. Although I think the keto that study that we talked about was even interpreted differently by the people that are on the diet than by the cardiology community. So I'm not 100% picking sides. I'm just saying if you are somebody who's eating the normal American diet and now you're going to double down on just lots of red meat and butter and heavy cream, I do not think that is a good idea. If you're 100% keto and you're following your biomarkers and, and working with a medical professional, whatever, I think that's a different story.
- [49:29]
D
Well, I appreciate Rahul's point that this is going to drive policy. That's sort of my larger concern and sort of what kids eat and that kind of stuff. I don't think the average person is turning to the FDA recommendations to guide their diets to the point that no one probably even knows that the MyPlate thing exists except for a few niche people. So I don't think this is truly going to be guiding Americans food intake because that's just not the way that people choose what they eat. But I do worry how it's going to impact federal programs and funding for things and that sort of stuff. And I think that is a very valid and real concern, especially if it's going to impact what kids are eating, because that's going to have later consequences potentially.
- [50:03]
F
Yeah.
- [50:04]
C
So I think the largely, you know, eat whole foods, please. People eat some vegetables, you know, and yeah, this, this will be interesting. I don't have a problem with the protein thing. People should be doing resistance training twice, at least twice a week. I know probably people are not, but I don't think the protein targets that they put in there are crazy high. And most people are probably getting 1.2 grams per kilogram if you look at ideal body weight anyway in the US Diet. So I don't think it's too far off from what people are actually doing. So that one I have less problems with. But again, Rahul, like you're saying it's like, I think right now protein's in a point where, where it's got such great marketing that like you slap protein on anything no matter what else is in that product. People are like, oh, it's high protein, so I can just eat it. It's got 200 grams of added sugars, but who cares? And it's got 50 grams of saturated fat, but it's high protein, so I'm just gonna go for it, you know.
- [51:03]
D
So I had a very dear friend actually just text me a picture of donuts that are higher in protein. Actually, just this past week, that was me. Yes, I know.
- [51:14]
C
I was like, I bet you this exists high protein donuts. And I look it up and it's like, sure enough, it exists.
- [51:20]
B
What could go wrong?
- [51:20]
D
I mean, it's got everything you need.
- [51:22]
C
The same site had high protein pop tarts. They had everything there.
- [51:26]
D
That's perfect. That reflects our food pyramid exactly right. So strong work protein donuts.
- [51:30]
C
All right, well, we Were just talking about our concern over the heart with people mainlining saturated fat. That Josh, let's talk about the heart, but let's get away from the arteries. Let's talk about afib.
- [51:45]
F
Nice segue. Yes, thank you. This paper that I'm going to talk about is called the Long Term Anticoagulation Discontinuation After Catheter Ablation for Atrial Fibrillation, which was done by Kim et al and published in JAMA back in August of 2025. And this paper and these researchers were asking the question of after successful ablation for atrial fibrillation, can you stop anticoagulation and why this sort of matters or the background about this is pretty much right now there's really minimal evidence on what to do in terms of anticoagulation strategy following someone's catheter ablation for atrial fibrillation. There are some guidelines. There are guidelines from the American Heart association and American College of Cardiology that do give a Class 1 recommendation for give a Class 1 recommendation to use the CHADS VASC score to guide anticoagulation strategies for patients who have undergone catheter ablation, meaning anticoagulate if you're a man and your chad's VASC is two or more if you're a woman and your chad's VAS as three or more. But they do cite that this is really based on extrapolated data from non ablated patients and that there really is no randomized data or minimal observational data in these cohorts of post ablation patients. This study basically was an open labeled multicenter superior design trial in South Korea where patients that were between the ages of 19 and 80 who had non valvular AFIB and underwent ablation and had no recurrence were then randomized to either continue their anticoagulation or not. And I'll just give you the top line results which the study was positive at two years, which was the follow up, the authors found that discontinuing anticoagulation led to lower rates of adverse events compared to continuing regulation. And just specifically there were very few events. One out of 417 patients in the discontinuation group had a outcome of combination of stroke, ischemic stroke, systemic embolism or major bleeding compared to 8 out of 423 patients in the continuation group. So a roughly absolute risk reduction of about 1.9%. So I'm going to stop there and sort of see what the rest of you guys think regarding this article Rahul.
- [54:32]
C
Can I throw it to you? The fact that there was such a small number of events in a positive trial, does that make you more or less confident in the results?
- [54:43]
B
Ooh, that's not what I was expecting you to ask.
- [54:46]
C
Or is that a source of chance or bias? That's what I'm saying.
- [54:49]
B
I love it. Well, I mean, it, it makes me think a little bit about, you know, the framing of whether a superiority trial or non inferiority trial for that matter, is positive or negative. Always kind of has to be, you know, made in reference to what the outcome actually is. So this being a, a positive superiority trial, all we mean by that is that a difference was shown between the two strategies. Right. And the primary outcome in this study, this composite outcome, included elements that had to do with both thrombosis and with bleeding. Okay. And that's really the way in which this trial was positive. This was sort of driven by a higher bleeding in the patients who were continued. So if this trial had ended up being negative, meaning that there was not a difference shown between the two groups, then I might wonder if the low event rate could be responsible for that. Could it be the case that if we studied this question in a higher risk population where the baseline rate was higher, or could we have seen a difference then? But, you know, because the, the driver of this positive outcome really was bleeding, I don't think the low event rate really worries me in this case. I mean, if anything, I feel kind of reassured that, you know, patients in the modern era really do not seem to experience stroke after catheter ablation. And one of the things that I, I sort of want to take from these results. And Josh, I'm curious what you, what advice you have about applying these results. But, you know, if patients have been a year after successful ablation, they haven't had recurrence, you know, is that kind of enough information to say that their, their stroke risk is low enough that, you know that the increased bleeding risk of anticoagulation is no longer justified?
- [56:32]
F
Yeah, that's a good question. And I think that sort of plays into continued monitoring and I think also an unknown moving forward through, but. And sort of brings you into a little bit more about what they exactly did in this trial where they gave patients, in between their ablation and randomization, they gave patients at least two sets of Holter monitors for 24 to 72 hours to make sure that they didn't have any documented atrial fibrillation episodes that may have been asymptomatic or symptomatic but they were looking mostly for sort of silent or subclinical atrial fibrillation. And so I think that this sort of reassures me that patients that really don't have symptoms at the 1 year mark or later that are doing well and have had successful ablation, may be able to tolerate being off anticoagulation with very low rates of stroke.
- [57:24]
C
And nowadays in practice, what are you seeing done in the real world after ablation for monitoring? Is it. Are people completing a Holter monitor every so often or are people getting loop recorders? Are you telling people to use wearables?
- [57:39]
F
Yeah, I think it's very, I imagine it's very variable. I can tell you certainly what I see, which is strong use of event monitors, like multi week long event monitors, probably at least two week event monitors and probably at least once or twice in the year. So certainly a larger duration of monitoring. In terms of wearables, I think that's, that's still mixed. Some patients have their own wearables and are much better at sort of tracking what's going on compared to others. I don't recommend patients get monitors like wearable monitors or anything like that currently just to look for atrial fibrillation, but I do sort of use that information if patients have them and come in with that information. I do though, think there probably are many places around the US or even around the world where catheter ablation is being done, where 24 to 48 hour event monitor or Holter monitor is the standard. So I think that that is actually a really big positive of this trial, is that this is very applicable and generalizable to other centers and other places.
- [58:47]
C
Yeah. Paul Williams, anything about the trial that you. Any questions, concerns or comments before?
- [58:55]
D
No, not to peel back the curtain like we talked a little bit about before recording. There's something about the composite endpoint that includes bleeding and then also strokes and thrombocytes. It seems like those things kind of go in the opposite direction for me and I wasn't quite sure how to feel without that, which is not very scientific. So I guess my question for Rahul or for Josh is does that impact the way that you sort of think about these results? Would it have made more sense to have to separate them out or sort of study bleeding rates as a primary endpoint than have sort of secondary endpoints of stroke or. I guess just, just that felt odd to me, but I can't really put it into words why it bothered me as much as it did.
- [59:34]
F
Yeah, I mean, I Think I do agree with Rahul that bad sort of outcomes in general are bad outcomes and you can kind of clump them all together. And that here I think from a statistical perspective allows you to reduce the sample size needed in order to try and see an absolute difference. But I don't really know from a more evidence based answer if there really is a benefit to sort of separating out a safety outcome and a primary outcome or however you want to separate these two different outcomes.
- [60:05]
B
Yeah, don't look at me. I actually don't have anything more sophisticated to say than that. I mean I do think it's kind of expedient from an event accrual standpoint to have more than one type of bad event count as an outcome. And it is kind of patient centered to say the primary outcome is all things that you might reasonably want to avoid. And you know, do you run the risk of having a false negative trial with those low event rates if the bleeding outcome was studied separately? You know, we, we might be asking that question if the primary outcome was defined differently. But I would still be motivated by the, the higher kind of bleeding risk in patients who continued without any apparent benefit. So I don't know.
- [60:50]
D
It's. Who can predict? I, I mean Matt and I, I know for sure. I've been practicing medicine long enough for a catheter ablation for afib tube when we started out was not a thing. Like it's. You got a shout out DC cardioversion. If that didn't do it, you know, sorry Charlie. I guess, I guess then you throw all sorts of toxic medications at them because we were just so bad at catheter ablation. So the fact that this is a conversation we're having now, like it just medicine remains endlessly exciting, which is not a great point to make, but I'm going to make it nevertheless.
- [61:14]
B
It is great.
- [61:15]
F
I just have such a, I see such a large number of patients who are thinking how do I, I get off anticoagulation? When is this going to end? And to sort of see this opportunity be there I think is really exciting.
- [61:30]
C
Can I break in to ask Paul and Paul, I have a joke. This alone af, it's like the punchline to a joke. Like what does a Gen Z say when their family leaves them? I don't know. Anyway. But Paul, what do you think about the trial Name here? Anticoagulation 1 year after ablation for atrial fibrillation in patients with atrial fibrillation alone.
- [61:56]
D
Af dude, this trial name is psychotic. And I'm Sorry to the authors. I was just praising them. I think this is fantastic. Did you hear what he just said? I'm going to read it again. Anticoagulation. One year after ablation for atrial fibrillation in patients with atrial. Atrial fibrillation is in the title seven times. Where is alone in this? What does alone have to do with anything? What are we. This is a maniac. I cannot believe this made it through an editorial process. I can't believe that there was more than one author that allowed this to happen. This is incredible to me. So thank you for asking.
- [62:26]
C
Paul, Maybe you can retire from being America's PCP and you can just be a consultant for trial names. And it seems like a service that we really need because this comes up all the time.
- [62:39]
D
This is my dream. I would.
- [62:40]
B
Would.
- [62:41]
D
Oh, my. And I do it in a heartbeat. So long, primary care. Happy to vet your journal article titles if it pays about the same. Yeah. I love it. DM me. My DMs are open on Blue sky.
- [62:50]
A
So, Josh, you want to give us.
- [62:52]
C
Your hotcakes rating and what you think? What's the bottom line here? Will this be practice changing?
- [62:59]
F
Yeah. So I give this a 4.5, maybe even a 4.7. 5 out of 5. I do think this will be practice changing. It's well designed. I think it's really reproducible, it's generalizable. And while, yeah, the sample or the event rate is small, I think that's the best thing about the trial. So I think it very much likely will lead to changes in the way patient prescribers are practicing or cardiologists or electrophysiologists are practicing.
- [63:32]
C
And this is for patients with a lower CHADS value, like two for men or three for women.
- [63:38]
F
Yeah, we should have said that. The average CHADS VASC included in the trial was about 2.1. There were no restrictions on the upper limit of CHADS. Vascular were about 10% of patients that had a CHADS VASC greater than 3. But on average, this was a 2.1, I believe, mean for CHADS VASC. So lower risk patients with no documentation of AFIB following their catheter ablation.
- [64:03]
C
And then there was a companion trial that went along with this that I know you wanted to just mention as well. The OCEAN trial.
- [64:09]
F
Yeah. So the Ocean trial, which I'm going to skip the acronym for now at least, was by Verma et al, was a similar trial that was just published in the New England Journal last month and also evaluated anticoagulation strategies Post catheter ablation for atrial fibrillation. They also randomized patients about a year after successful ablation to receive either Rivaroxaban was their anticoagulant versus in alone af. Most patients, any patients could basically be on any anticoagulant, but most patients were on pixaban. And in Ocean it was rivaroxaban versus aspirin monotherapy. And they were followed for three years. Years they did a similar composite endpoint of stroke, systemic embolism or new covert stroke, which was interesting. They looked basically at MRIs of patients regardless if they had symptoms or not at the three year mark to see if they had any silent strokes. And they were looking for big strokes. They looked for, I can't remember, but they were all greater than 1cm in size, so not like small foci punctate lesions. And their primary safety outcome was a composite of fatal and non fatal bleeding. They randomized about 1,200 patients. Mean Chad's VASC was about 2. And ultimately the study was negative. There was really no difference in the primary outcome between the two groups. There were five events in the patient, five outcome events in the rivaroxaban group compared to nine in the aspirin group. And there were 10 major bleeds in the rivaroxaban Group compared to four in the aspirin group. And I can pause there if any other comments or I can also just wrap up my sort of takeaway of this.
- [65:59]
B
I did want to point out, Josh, I mean you framed this nicely like, you know, the alone AF was a positive trial, Ocean was a negative trial. It's just a reminder to listeners and to anyone reading these things like, you know, the definition of the composite outcome is what makes that possible. I mean these two papers are sort of complementary and show the same thing. Even though, you know, it might be a little confusing at first blush. One's positive, one's negative. How can that be? It has to do with that definition of the primary outcome that we already discussed.
- [66:28]
F
Right, exactly. That's a really good segue to compare back. And I think this, whether you take away oh, there's a difference or no difference, is just that it shows the same thing that really alone AF shows, which is that the events are really, really low. Five strokes or systemic embolism out of roughly 600 patients in the rivaroxaban group compared to about nine in the aspirin group. So. So really, really low. And I think taken together, what I see from this is not only Is it practice changing? It just means that the Cha2d VASC score to me really doesn't make sense. In this group, the CHA2D VASC of 2 predicts about a 2.2% risk of stroke per year, but these patients are having stroke rates less than or about 1%. So can you even use the Chads VASC scoring system for these patients? Patients, I think that would be my hot take is that maybe we need to devise a new scoring system for patients that remain in normal sinus rhythm after catheter ablation.
- [67:30]
C
Fantastic point. Well, you're in fellowship, right? You have time for research. You should get into that.
- [67:36]
B
Yeah. This is the Gilman score.
- [67:37]
C
Yes.
- [67:38]
F
Yeah, yeah, that'd be pretty wild.
- [67:41]
C
That'll make your career first. Get working on that.
- [67:45]
B
Get cracking.
- [67:46]
C
All right, well, thanks Josh for, for joining us for this tonight. And Paul, I think it's time for an outro.
- [67:57]
D
This has been another episode of the Curbsiders bringing you a little knowledge food for your brain hole.
- [68:02]
B
Yummy.
- [68:03]
D
Oh, thank you, Raul. Still hungry for more? Join our Patreon. Get all of our episodes ad free, plus twice monthly bonus episodes at patreon patreon.com curbsiders. You can find our show notes@thecurbsiders.com and sign up for our mailing list to get our weekly show notes in your inbox. This includes our aforementioned Curbsiders Digest, which recaps the latest practice, changing articles, guidelines and news, and internal medicine.
- [68:23]
C
And we're committed to high value practice changing knowledge. And to do that, we want your feedback. So email us@askcurbsiders gmail.com reminder that this and most episodes are available for CME credit for all health professionals through VCU Health at curbsiders. VCU Health.org wanted to give a special thanks to Dr. Rahul Ganatra for helming this hotcake series and to Josh Gilman for helping us out with this episode. Our technical production is done by the team at Podpaste. Elizabeth Proto does our social media. Jen Wattle runs our Patreon. Chris the Chew Manchu moderates our discord. Stuart Brigham composed our theme music. And until next time, I've been Dr. Matthew Frank Watt.
- [69:03]
B
I've been Dr. Rahul Ganatra.
- [69:06]
F
I've been Dr. Joshua Gilman.
- [69:08]
D
Wow, the kids are pro. And as always, I mean Dr. Paul Nelson Williams. Thank you and goodbye.
- [69:25]
G
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A
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G
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