In the COBRRA Trial Apixaban Kicked The Asssssth of Rivaroxaban

This episode clarifies the difference between an elevated lactate level (hyperlactatemia) and true lactic acidosis, which requires evidence of metabolic acidosis (low pH or low bicarbonate). It discusses common causes of raised lactate, why mislabeling affects treatment location and mortality risk, and how EHRs and coding practices can perpetuate the confusion. Listeners will learn when to document lactic acidosis versus elevated lactate, the clinical implications for resuscitation and disposition, and the importance of precise medical terminology. If you find elevated ascorbic acid (Vitamin C) in the blood, you don't diagnose the patient as having an ascorbic acidosis. Likewise, just because lactic acid is elevated in the blood does not mean it is an acidosis (though sometimes it can be - learn the difference).

Fecalomas—rock‑hard impacted stool that cause obstruction, stercoral colitis, perforation, and even death—most often in immobile elderly patients or those on opioids. Standard treatments include aggressive bowel regimens, enemas, manual disimpaction, endoscopic fragmentation, and surgery. There are also case reports of using Coca‑Cola enemas to soften and reduce fecalomas when conventional measures failed. 

This episode examines the concerns about mouthwash and oral cancer. While ethanol can form the carcinogen acetaldehyde, how worried should we be? Strong antiseptic rinses can alter the oral microbiome and may reduce bacteria that help produce nitric oxide, with a small study showing a blunted post-exercise blood pressure drop; does that justify abandoning exercise or ignoring dental guidance?

Multiple studies in multiple journals are going against the norms and previous guidelines. The times they are a changing.

For acute treatment of Venous Thromboembolism the debate of which direct oral anticoagulant to use appears to now be settled.  

The double-blind, randomized phase III EMPEROR-Preserved trial showed a benefit of the sodium-glucose cotransporter-2 (SGLT2) inhibitor empagliflozin in patients with heart failure with preserved ejection fraction (HFpEF). Now let us dig a bit more into those headlines.  

An important recently published randomized control trial provides guidance on this controversy.

Almost nobody feels comfortable managing DELAYED gastric emptying (gastroparesis) and very few medical providers even think about RAPID gastric emptying in their diabetic patients. Even if you send these patients to GI specialists, your blood sugar co-management of these patients can be heavily impacted by these issues. Is delayed gastric emptying always a bad thing? When your patient has upper GI symptoms, how often is it a gastric emptying abnormality? Time for some answers.