Brilliant Board Review & CME

Brilliant Board Review & CME
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🎙️ Brilliant Medicine: Your Internal Medicine Edge Stay sharp, stay current, and stay confident with Brilliant Medicine — the go-to podcast for Internal Medicine and Family Medicine physicians, residents, nurse practitioners, and physician assistants. Each episode delivers high-yield insights on the latest breakthroughs, practice-changing guidelines, and cutting-edge treatments in Internal Medicine — with just enough board review to keep your clinical reasoning razor-sharp. We cut through the noise, simplify complex studies, and translate new data into actionable knowledge for your daily practice. Whether you're prepping for boards or staying ahead in clinic, hospital, or telemed — we've got your back. 🩺 Fast. Practical. Evidence-based. This is the update your medical brain craves.

  1. 04/21/2025

    🎙️ Episode 45: Mind the Gap – Perioperative Pearls for Older Adults

    Send us a text 🧠 Clinical Context Patients over 65 undergoing inpatient surgery face unique risks. Cognitive impairment, frailty, and increased vulnerability to delirium demand a proactive and nuanced approach to anesthesia and postoperative care. 🔍 Preoperative Priorities Age ≥65 and inpatient status should automatically trigger a frailty and cognitive assessmentEngage a multidisciplinary team early—geriatrics, anesthesia, surgery, and nursing🛌 Postoperative Delirium: A Common Pitfall Use dexmedetomidine in the PACU or ICU setting for sedation/delirium preventionAvoid these culprits:BenzodiazepinesAntipsychoticsAnticholinergicsKetamineCorticosteroidsGabapentin💡 Practical Strategy Optimize environment: quiet, well-lit rooms with clocks and calendarsEncourage mobility and family engagementHydrate, monitor electrolytes, and manage pain thoughtfullyAvoid over-sedation and unnecessary polypharmacy🧩 Clinical Takeaway Older adults need tailored perioperative management. Screening for frailty and cognition is just as important as lab work and EKGs. Avoid high-risk meds, plan for delirium prevention, and build a team around the patient. 🎯 When it comes to older surgical patients: less is more, and team-based care is everything. Key Reference: Sieber F et al. 2025 ASA Practice Advisory for Perioperative Care of Older Adults. Anesthesiology. 2025 Jan;142(1):22–51. PMID: 39655991

    2 min

  2. 04/21/2025

    🎙️ Episode 44: Thiazide Throwdown: HCTZ vs Chlorthalidone in Real Life

    Send us a text 🧠 Clinical Context Hydrochlorothiazide (HCTZ) vs. Chlorthalidone—a classic cardio debate! ALHAT once hinted at chlorthalidone’s superiority, but did a modern head-to-head trial confirm that? Let's break it down. 🧪 Study Snapshot: The HEADS-UP Trial Design: Randomized, head-to-head trialPopulation: ~14,000 patients, age ≥65, already on HCTZ 25–50 mg + 1–2 antihypertensivesPrior CV disease: 15% had MI, stroke, or HFGroups:Continue HCTZSwitch to Chlorthalidone 12.5–25 mg dailyFollow-up: Median 2.4 years📈 Outcomes Primary endpoint: Composite of MI, stroke, HF, urgent revascularization, or non-cancer death → Occurred in 10% of both groupsBP Control: No significant differenceHypokalemia:Chlorthalidone: 4.4%HCTZ: 6.0%💡 What About CKD? 23% had GFR 60 at baseline, but…No strong data on severely reduced renal function for HCTZIn a 12-week placebo-controlled study, chlorthalidone lowered BP in GFR 15–30, but HCTZ didn’t have similar dataStill, in randomized trials: no difference in mortality or cardiovascular outcomes⚠️ Surprises & Caveats Despite historical bias toward chlorthalidone, outcomes and BP control were equivalentHypokalemia was actually slightly lower with chlorthalidoneMore robust data is still needed for advanced CKD patients🧩 Clinical Takeaway Despite all the hype, chlorthalidone isn’t clearly superior. In practice, both meds perform similarly for hypertension control and cardiovascular outcomes in older adults. But if your patient has significantly impaired renal function, chlorthalidone may edge ahead—at least for now. 💬 Bottom line? Choose the thiazide based on patient profile, tolerance, and renal function—not legacy dogma.

    3 min

  3. 04/21/2025

    🎙️ Episode 43: GLP-1s Under the Knife – A Gut Check on Surgery Risks

    Send us a text 🧠 Clinical Context GLP-1 receptor agonists have taken center stage for both type 2 diabetes and obesity management, but their gastric side effects are giving anesthesiologists pause. The ASA's recent guidance recommends holding these agents before surgery to reduce risks of gastroparesis, regurgitation, and pulmonary aspiration. 🔬 ASA Guidelines Overview Daily Dosing? Hold on the day of surgeryWeekly Dosing? Hold one week priorIf asymptomatic and held as above? Proceed as usual⚠️ But Here’s the Controversy There’s no strong evidence that holding GLP-1s as recommended reliably reduces gastric content risk.Recent endoscopy studies show no correlation between hold duration and gastric content retention.Gastroparesis risk may persist despite withholding the drug, especially in patients with:DiabetesObesityOpioid useAlcohol, marijuana, or TCA use🧪 What We Do Know Peak delay in gastric emptying appears within the first 12 weeks of therapy.Normalization of gastric motility might require holding meds for 5+ half-lives—often impractical.Meanwhile, GLP-1s improve glycemic control and may reduce post-op MACE (Major Adverse Cardiac Events).🧭 Pragmatic Recommendations All GLP-1 patients should be considered at elevated aspiration risk, regardless of symptom status or hold duration.Use pre-op gastric ultrasound to assess contents.Plan anesthesia accordingly:Airway protectionRapid sequence inductionAppropriate surgical location🍽️ Fasting Guidelines? A Gray Area ASA’s updated fasting guideline (2023) applies to healthy patients without reflux, obesity, diabetes, or delayed emptying—aka, not your typical GLP-1 patient. Recommendation: Modify fasting guidelines based on judgment. Don’t follow enhanced recovery protocols blindly. 🧩 Clinical Takeaway Don’t assume that simply holding a GLP-1 agonist clears the gut. Evidence is lacking. Every GLP-1 patient should be approached with caution: Assume delayed gastric emptyingUse tools like ultrasound for verificationCustomize fasting and airway protocols🔍 Until we have more data, err on the side of protecting your patient’s airway—not just the guideline. Key Reference: Ushakumari DS, Sladen RN. ASA Consensus-based Guidance. Anesthesiology. 2024 Feb;140(2):346–348. PMID: 37982170

    2 min

  4. 04/21/2025

    🎙️ Episode 42: DOACs Decoded: When to Dabble, When to Dodge

    Send us a text 🧠 Clinical Context DOACs (Direct Oral Anticoagulants) have revolutionized anticoagulation—goodbye routine INRs, hello convenience. But while they’ve made our lives easier, they’re not always a fit for every scenario. Here's how to navigate the DOAC jungle. ✅ When DOACs Are Preferred Venous Thromboembolism (VTE)Atrial Fibrillation⚠️ Exclude patients with:Mechanical heart valvesRheumatic mitral valve disease  (That’s why cardiologists note “non-rheumatic” AF in their documentation—treatment plan hinges on it.)⛔ When DOACs Are a No-Go Mechanical Heart Valves → Warfarin onlyRheumatic AF → Warfarin still rulesThrombotic Antiphospholipid Syndrome → WarfarinTranscatheter Aortic Valve Replacement (TAVR) → Antiplatelet therapyEmbolic Stroke of Undetermined Source → Antiplatelets preferred🤔 The Gray Zone: Uncertain Use Cases These aren’t absolute yes or no. Instead, cue shared decision-making and expert input: PregnancyNo strong evidence yet; avoid unless discussed with OB and hematology.End-Stage Renal Disease (ESRD)Initially excluded from DOAC trials.Some are doing well, but still a case-by-case basis.Others That Require Discussion:Left Ventricular ThrombusCatheter-Associated DVTSplanchnic Vein ThrombosisCerebral Venous Thrombosis🧩 Clinical Takeaway DOACs are game-changers—but they’re not plug-and-play for everyone. For classic AF and VTE? Go for it. For valves, rheumatic disease, or complex syndromes? Tread carefully. And when in doubt, involve the patient in the decision. 🎯 Bottom line: Not every clot deserves a DOAC—some still want warfarin or a platelet plan. Let me know when you're ready for the next one!

    4 min

  5. 04/21/2025

    🎙️ Episode 41: Stairway to Surgery: Cardiac Clues Before the Cut

    Send us a text 🧠 Clinical Context: You're prepping a patient for non-cardiac surgery—what's their cardiovascular risk? Turns out, it’s not always about echo reports or cath results. It starts with a stairs test (sort of). Duke Activity Status Index (DASI) and METs >4 can tell you if the heart's got enough reserve.🚶‍♂️ “Can you walk up a flight of stairs without gasping?” If yes, you’re likely good to go!If functional status is poor or unknown, consider labs:BNP, pro-BNP, or troponin — but evidence is weak.Elevated? Time to huddle with a multidisciplinary team (or at least buy time for the patient and lawyer to meet).🧪 Risk Tools, Not Rituals: Stress testing isn’t reflexively helpful anymore.Reserved for high-risk anatomy or major ischemia concerns.Studies show no outcome improvement in most cases.Important caveat: those with severe CAD were excluded from trials!🧊 Meds to Pause: SGLT2 Inhibitors (dapagliflozin, empagliflozin): 🔴 Stop 3–4 days pre-op to avoid euglycemic ketoacidosis.GLP-1 Agonists: ⏸️ Hold 1 week before due to risk of delayed gastric emptying, aspiration, and nausea under anesthesia.🫀 Post-op Cardiac Surveillance: Watch for MINS – Myocardial Injury after Noncardiac SurgeryTroponin trending may help spot silent ischemia post-op.Elevated levels? 🧠 Consider further cardio eval, especially in high-risk patients.🧩 Clinical Takeaway: Modern pre-op cardiac clearance is about functional fitness, thoughtful labs, and smart medication pauses. Don’t just tick boxes—evaluate risk in context. And yes, if grandma can climb stairs without wheezing, she might just be ready for her hip replacement.

    3 min

  6. 04/20/2025

    🎙️ Episode 40: Anticoag After Ischemic Stroke: Sooner May Be Safer

    Send us a text 🧠 Trial: DOAC started at 3 days vs 8–14 days post-stroke in AF patients. 📊 Results: No ↑ bleeding. No ↑ ischemic events. 🧩 Clinical Takeaway: Safe to start within 4 days in mild to moderate stroke. Still tailor based on infarct size and bleeding risk.

    2 min

  7. 04/20/2025

    🎙️ Episode 39: Vitamin K2: The Leg Cramp Secret?

    Send us a text 🧪 Study: Vitamin K2 (180 mcg) reduced nocturnal leg cramps in elderly. 📉 Results: Cramps/week ↓ from 3.6 → ~1 over 8 weeks. Safe and well-tolerated. 🧩 Clinical Takeaway: Consider a K2 trial in patients with chronic cramps — especially if sleep-disrupting. Avoid in patients on warfarin.

    2 min

  8. 04/20/2025

    🎙️ Episode 38: TXA for ICH: Not the Magic Bullet

    Send us a text 🧪 Study: TXA within 2 hrs of ICH did not reduce hematoma expansion. No benefit in functional outcome or mortality. ⚠️ Note: Slight ↑ in thromboembolic events (3% vs 1%). 🧩 Clinical Takeaway: No routine use for TXA in spontaneous ICH. Still potential niche use in select trauma cases.

    2 min
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🎙️ Brilliant Medicine: Your Internal Medicine Edge Stay sharp, stay current, and stay confident with Brilliant Medicine — the go-to podcast for Internal Medicine and Family Medicine physicians, residents, nurse practitioners, and physician assistants. Each episode delivers high-yield insights on the latest breakthroughs, practice-changing guidelines, and cutting-edge treatments in Internal Medicine — with just enough board review to keep your clinical reasoning razor-sharp. We cut through the noise, simplify complex studies, and translate new data into actionable knowledge for your daily practice. Whether you're prepping for boards or staying ahead in clinic, hospital, or telemed — we've got your back. 🩺 Fast. Practical. Evidence-based. This is the update your medical brain craves.

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