Sensible Medicine

We try to answer the remainder of your AUA questions. We will be back in the new year with more article discussions! Here are a few of the things we referenced. GDMT Bugs Me: A bit of a rant against the standard of care A Plan to Refocus Primary Care Sacrificing patient care for prevention: distortion of the role of general practice The Great Colonoscopy Debate Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

We cover questions from Amy J, Benjamin Hourani, Diana Stiles Friou, Chris Costas, Errol Laurie, Jim Healthy, Elizabeth Fama, Never Dull, Rod Rodriguez, Ellison Burns, David Araujo, and George. We have more to come! One nice reference I found while looking into some of the topics: DMSO Is Not a Cure-All. But the FDA’s Panic Over It Birthed a Myth This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Vascular and inflammatory diseases after COVID-19 infection and vaccination in children and young people in England: a retrospective, population-based cohort study using linked electronic health records Comparison of an Initial Risk-Based Testing Strategy vs Usual Testing in Stable Symptomatic Patients With Suspected Coronary Artery Disease: The PRECISE Randomized Clinical Trial This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

European Study of Prostate Cancer Screening — 23-Year Follow-up Association Between Baseline Diastolic Blood Pressure and the Efficacy of Intensive vs Standard Blood Pressure–Lowering Therapy Further Reading * Effects of intensive blood-pressure control in type 2 diabetes mellitus * A Randomized Trial of Intensive versus Standard Blood-Pressure Control Sensible Medicine is 100% reader-supported. If you appreciate our work, consider becoming a free or paid subscriber. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Effects of Intensive Blood Pressure Control in Patients With Frailty: A Post Hoc Analysis From ESPRIT * Lowering systolic blood pressure to less than 120 mm Hg versus less than 140 mm Hg in patients with high cardiovascular risk with and without diabetes or previous stroke: an open-label, blinded-outcome, randomised trial * Reduction of Antihypertensive Treatment in Nursing Home Residents Polysaccharide Conjugate Vaccine against Pneumococcal Pneumonia in Adults * A trial to evaluate the safety and immunogenicity of a 20-valent pneumococcal conjugate vaccine in populations of adults ≥65 years of age with different prior pneumococcal vaccination This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Total cholesterol and all-cause mortality by sex and age: a prospective cohort study among 12.8 million adults * The Ideal Cholesterol Level ... Depends...And Cannot Be Determined From Observational Studies Structured vs Self-Guided Multidomain Lifestyle Interventions for Global Cognitive Function: The US POINTER Randomized Clinical Trial * Can We Please Stop Asking if Crossword Puzzles Prevent Dementia? This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Two papers this week, with a bunch of articles that we referenced in the conversation. Also, the last Fortnight podcast was accidentally posted behind a paywall. It is now up and free to listen to. My apologies. Sensible Medicine is reader-supported. If you appreciate our work, consider becoming a free or paid subscriber. Folinic acid improves verbal communication in children with autism and language impairment: a randomized double-blind placebo-controlled trial * Folate Receptor Alpha Autoantibodies in Autism Spectrum Disorders: Diagnosis, Treatment and Prevention * Association Between Maternal Use of Folic Acid Supplements and Risk of Autism Spectrum Disorders in Children * Cerebral folate receptor autoantibodies in autism spectrum disorder * What Is Leucovorin, the Medicine Being Approved for Autism Treatment? * Clinicaltrial.gov search Effects of Glucagon-Like Peptide 1 Receptor Agonist Initiation in Patients With Heart Failure With Reduced Ejection Fraction and Implantable Cardiac Devices * Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes * Effects of Once-Weekly Exenatide on Cardiovascular Outcomes in Type 2 Diabetes * Effects of Liraglutide on Clinical Stability Among Patients With Advanced Heart Failure and Reduced Ejection Fraction * Increased Risk of Heart Failure Hospitalization With GLP-1 Receptor Agonists in Patients With Reduced Ejection Fraction: A Meta-Analysis of the EXSCEL and FIGHT Trials This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

We go all observational this week. A look at data suggesting the safety of GLP-1s and a re-examination of data on patient/doctor race concordance/discordance (a topic Adam said we should not study, and then John forces him to). GLP-1 Receptor Agonists and Cancer Risk in Adults With Obesity Physician–patient racial concordance and newborn mortality Original, 2020 article: Physician–patient racial concordance and disparities in birthing mortality for newborns This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

NT is a 55-year-old man admitted to the general medicine service with cellulitis of his left leg. When the attending sees him the morning after admission, he notices the patient’s “Medical Center Trustee” hospital ID on his bedside table. After gathering a history and examining the leg, the attending leaves the room. In the hallway, he crosses paths with the hospital president, who is there to make a “social call”. She smiles and says to the attending, “Don’t let anything bad happen.” Sensible Medicine is reader-supported. If you appreciate our work, consider becoming a free or paid subscriber. Every clinician is familiar with the Very Important Patient, the VIP. Defining the VIP is challenging. In the most general sense, the VIP is a patient whose care imposes an additional burden on the clinician. The VIP is perceived to have an elevated social status, typically due to fame, wealth, connections, or power. The VIP may come to his or her status in several ways. The VIP might claim that status herself. The status might be granted by a third party, such as the source of the referral, or outside realities (fame, fortune, power). Sometimes, VIP status is granted by the physician alone. The physician recognizes that an untoward outcome in the care of the VIP — clinical or otherwise, expected or unexpected — will be acknowledged by a wider community and might be particularly unpleasant for the treating physician. VIP patients are a threat to healthcare. They need to be eradicated from hospitals and clinics as ruthlessly as we would eradicate E. coli from a well, Pseudomonas from a hot tub, or Legionella from a hotel HVAC system. Why should we eliminate the VIP? Because a patient’s wealth, station, or connections should have no bearing on the tests that are done, the treatments that are offered, or the haste with which care is provided. I have heard people argue about whether basic healthcare is a human right. I have heard people who agree that basic healthcare is a human right argue about what makes up basic healthcare and who should decide what qualifies. I have never heard people argue about whether people deserve different care based on their identity. The most obvious threat the VIP poses is to himself. We recognize that when people are treated as special, they are at risk of getting worse healthcare. This fact underlies the guidance that physicians avoid caring for close friends and relatives. The AMA Code of Medical Ethics states: When the patient is an immediate family member, the physician’s personal feelings may unduly influence his or her professional medical judgment. Or the physician may fail to probe sensitive areas when taking the medical history or to perform intimate parts of the physical examination. Physicians may feel obligated to provide care for family members despite feeling uncomfortable doing so. They may also be inclined to treat problems that are beyond their expertise or training. You could easily replace family member with VIP. While we can all avoid treating family members and close friends, VIPs are a reality in every physician’s life. Transferring their care to another physician usually does not change the circumstances. Ben Kean, an exceptionally colorful character and my parasitology teacher in medical school, shared a story about the risks VIP healthcare poses to the VIP. He once suggested that a patient with pneumonia — a patient who was also famous, wealthy, and important — be transferred from a private hospital to a public one, and treated under a pseudonym. "But why a public hospital, when I have a good private clinic here with the best doctors and nurses?" "There are two ingredients essential to your recovery," I explained, "that can't be found here and that you cannot buy. These are things found only at a large public institution, where hundreds of patients are seen each day, many of whom suffer from pneumonia. First, you need a large house staff -- bright, young people with new...

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Last week, John was at the European Society of Cardiology conference in Madrid, and Adam was at the Preventing Overdiagnosis 2025 International Conference in Oxford. A conversation about what we learned. Digitoxin in Patients with Heart Failure and Reduced Ejection Fraction Beta-Blockers Post-MI: A Clear Clinical Message Aspirin in Patients with Chronic Coronary Syndrome Receiving Oral Anticoagulation How does decontextualised risk information affect clinicians’ understanding of risk and uncertainty in primary care diagnosis? A qualitative study of clinical vignettes How do we talk about overdiagnosis of mental health conditions without dismissing people’s suffering? This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Metformin for Treatment of Knee Osteoarthritis in Patients With Overweight or Obesity Once-Weekly Semaglutide in Persons with Obesity and Knee Osteoarthritis Semaglutide or Tirzepatide and Optic Nerve and Visual Pathway Disorders in Type 2 Diabetes This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

TR is a 72-year-old woman, a retired executive, who had been in excellent health until she began experiencing exertional dyspnea and palpitations. After waiting out the symptoms for about a month, she called and made an appointment to see her primary care doctor. The day before her appointment, she awoke unable to move her entire right side. With difficulty, she reached for her phone and called her daughter. Her daughter was unable to understand her and called 911. This Substack is reader-supported. If you appreciate our work, consider becoming a free or paid subscriber. Someday, I will close up my practice and be left with an enormous hole in my life. I will miss the 12-24 people I get to spend time with every day during their appointments. I will miss the sometimes-intense relationships with a fantastic diversity of people. I will miss working to make people’s lives better and longer. I will miss the diagnostic puzzles and the reward of seeing someone “get better” over days, or weeks, or months. I will also miss my colleagues, the clinicians who have chosen to dedicate their careers to helping people. I will miss meeting the next generation of doctors, nurses, psychologists, physical therapists, pharmacists, and the like. I will not miss The Look. I was well into my career when I first recognized The Look. I had just returned to our inpatient service after a leave to care for my mother, who had experienced a serious, life-altering illness. A few days after my return, my team admitted TR. She had been in excellent health until a few months before admission, when she began to lose weight and have some trouble sleeping. More recently, the symptoms had progressed to include exertional dyspnea and palpitations. Our evaluation revealed hyperthyroidism from a toxic multinodular goiter, leading to atrial fibrillation, leading to a large, embolic, left middle cerebral artery stroke. From a medical perspective, the case was classic and straightforward. My resident assigned TR to a medical student as she thought it was a perfect teaching case. On the second day of TR’s admission, I met her daughter and learned more about TR. She had grown up on Chicago’s South Side and had always been a star student. She excelled in the public school system and was eventually awarded a full scholarship to the University of Illinois. When she left for Urbana-Champaign, it marked the first time she had left Chicago. She graduated summa cum laude from U of I and began working in a corporate office back in Chicago. She excelled in this world as well, eventually managing a fifty-person team. She had one daughter, whom she adored, and two grandchildren. She retired just before her 70th birthday. She was thriving in retirement, traveling alone and with friends, and serving on two corporate boards. She loved her work on boards because it enabled her to meet a small group of African American women executives of her generation who shared similar experiences. The Look on her daughter’s face was familiar to me. I recognized it because I knew I had worn it a few weeks before, caring for my mother. The Look reflected the emotions TR’s daughter articulated to (and for) me. There was sadness and anger for what her mother had lost. There was anxiety about what was next for her mother. There was a realization that her mother’s situation would affect her. Their relationship had permanently changed. TR’s daughter spoke of how her mom had always been her foundation. Overnight, the daughter had become the middle of the sandwich. She now had to care for her kids and her mother. There was also a little bit of guilt. How can I worry about the impact this will have on my life when my mother is now disabled? Seeing The Look that I knew we shared, the empathy I felt for TR’s daughter made it difficult for me to play my usual role in counseling and planning. I told my resident and the case manager they would have to “do this one without me.” Since that day ten years...

A “manel” reviewing trials and studies that explore the benefits and harms of hormone replacement therapy. The Women’s Health Initiative * Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial * The Women's Health Initiative Randomized Trials and Clinical Practice: A Review * The Women’s Health Initiative Hormone Therapy Trials: Update and Overview of Health Outcomes During the Intervention and Post-Stopping Phases Meta-analysese * A systematic review and meta-regression analysis to examine the ‘timing hypothesis’ of hormone replacement therapy on mortality, coronary heart disease, and stroke * Mortality Associated with Hormone Replacement Therapy in Younger and Older Women History: Observational HRT Data * Postmenopausal estrogen and progestin use and the risk of cardiovascular disease * Hormone therapy to prevent disease and prolong life in postmenopausal women This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Primary Articles * As-Needed Albuterol–Budesonide in Mild Asthma * Early versus Later Anticoagulation for Stroke with Atrial Fibrillation Referenced Articles * Albuterol–Budesonide Fixed-Dose Combination Rescue Inhaler for Asthma * Stopping Randomized Trials Early for Benefit and Estimation of Treatment Effects: Systematic Review and Meta-regression Analysis This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

Primary articles discussed: * First myocardial infarction: risk factors, symptoms, and medical therapy * Oral vs Extended-Release Injectable Naltrexone for Hospitalized Patients With Alcohol Use DisorderA Randomized Clinical Trial Articles referenced: * Pharmacotherapy for Alcohol Use Disorder: A Systematic Review and Meta-Analysis * General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

A visit brings back the memories of patients and the lessons they taught. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

No association between preprocedural fasting and witnessed pulmonary aspiration: A systematic review and meta-analysis Here are a couple of other older articles to give you the history of preprocedural fasting. Reducing the Risk of Acid Aspirations During Cesarean Section Fasting from midnight — the history behind the dogma CT Angiography, Healthy Lifestyle Behaviors, and Preventive Therapy This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

This Substack is reader-supported. If you appreciate our work, consider becoming a free or paid subscriber. Clinical Validation of a Circulating Tumor DNA–Based Blood Test to Screen for Colorectal Cancer If you want a deeper dive into cancer screening, we have covered the topic a lot on Sensible Medicine. There is a video debate Vinay, John, and Adam had about colon cancer screening. We also posted two follow-up articles for that debate. Adam has written six different articles about screening. The Effect of Severe Sepsis and Septic Shock Management Bundle (SEP-1) Compliance and Implementation on Mortality Among Patients With Sepsis : A Systematic Review Goodhart's law Last but not least, a link to or our “Merch Page”, so you too can sport a Sensible Medicine t-shirt. This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

We are beginning a new series today. John and Adam will discuss a couple of articles we found interesting. Please let us know your thoughts. This week: Phase 3 Trial of Semaglutide in Metabolic Dysfunction–Associated Steatohepatitis Tiotropium Initiation and Dementia Risk in Chronic Obstructive Pulmonary Disease This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe