Good morning! Postcall here, smashing into your Thursday like a bull in an apothecary shop! 💊

Speaking of apothecaries…

❓Trivia question❓: The standard dose of ibuprofen is 200mg… But why is the standard dose of Tylenol or aspirin 325 mg? (Answer at the bottom of today’s issue!)

We’ve got an action-packed issue for you this week!

Driving these numbers: This past week saw the major indices hit their all-time highs again due to tech being back in full swing. We expect good news to continue rolling, as Apple, Alphabet, Microsoft, Amazon, and Meta all release their earnings (and cost-cutting measures). Non-tech sectors are still growing, but are a bit below their all-time highs.

The Rexulti Code🕵️🖼️

Guess who’s got a new gig? In May 2023, the FDA approved Rexulti (brexpiprazole), the multitasker for schizophrenia and depression, to tackle agitation in Alzheimer’s patients.

What happened: Otsuka Pharmaceutical and Lundbeck’s new drug was granted priority review by the FDA due to its “potential to substantially improve care for serious conditions.” After an in-depth review, the FDA gave their decision in 6 months rather than their typical 10 month period. With agitation affecting half of Alzheimer’s patients, manifesting as pacing, gesturing, shouting, and hitting, Rexulti is now approved for treating aggressive agitation resistant to non-pharmacological approaches. It’s a once-daily prescription with common side effects: headaches, urinary tract infections, and sleep disturbances.

Why it’s interesting: Greenlighting Rexulti for agitation is a game-changer, given the issue’s limited options. The approval could also open doors for future meds targeting Alzheimer’s psychiatric symptoms.

This becomes crucial as Black and Hispanic people are twice as likely to be diagnosed with Alzhemier’s disease. It's been reported that by 2025 the number of people in America to be diagnosed with Alzheimer's will climb to 7.1 million, a 40 percent increase from 2015.

Rexulti, a miracle pill?: Despite it’s approval the BMJ questions its benefits. 

• Clinical trials showed agitation symptoms with a 5.3-point difference on a 174-point scale (vs. 17 points experts consider indicative of real-world change). 

• Death risk spiked 4x vs. a placebo over 16 weeks. 

• The BMJ hinted the FDA might’ve lowered their standards on Rexulti.

Otsuka argued it's safer than its antipsychotic alternatives. But with $1 billion in sales at stake, the BMJ thinks maybe commercial interests talk louder than science.

Bottom line: As of now, Public Citizen Health says Rexulti's perks don't outweigh safety concerns. But if Postcall’s last issue on antibiotics is any hint, an unprepared 2050 might be the new 2012🌋.

Things your attending might pimp you on 🙋🏽‍♀️👨‍⚕️ 

1. Elbows UP! 

The CDC reported that respiratory illnesses are on the rise in the US, with 38 states experiencing “high activity” of illnesses like the flu amongst residents. This is a common annual trend as people return home from visiting family over the holidays. Still, health officials are urging Americans to get an updated flu and COVID-19 shot if eligible, and are asking people to stay home if they’re feeling under the weather.

2.  Guideline watch  👀

The American Gastroenterology Society has a new clinical practice guideline for using vasoactive agents and IV albumin in cirrhosis. Here’s a roundup of the relevant takeaways: 

• Initiate vasoactive drugs (octreotide) as soon as you suspect variceal hemorrhage and preferably before endoscopy. Continue for 2 to 5 days to prevent rebleeding.

• Give IV albumin at the time of large-volume (>5 L) paracentesis, but not for uncomplicated ascites. IV albumin can be considered in patients with SBP. 

• IV albumin is the volume expander of choice in hospitalized patients with cirrhosis and ascites who present with AKI.

3. Gabapentin? More like gaba-pantin’

A retrospective cohort study with over 10,000 participants has found that gabapentinoids are associated with severe COPD exacerbation. Gabapentinoid use was associated with significantly higher risk for severe COPD exacerbations requiring hospitalization (15.1% vs. 8.3% annually; adjusted hazard ratio, 1.4). New users of gabapentinoids also had significantly higher risks for respiratory failure (5.7% vs. 3.6% annually, aHR, 1.3) and moderate-to-severe COPD exacerbations (53% vs. 29% annually; aHR, 1.1). Gabapentin did not differ from pregabalin in risk for severe COPD exacerbations. This comes after a 2019 FDA warning about gabapentinoids causing breathing difficulties. 

The Doctor (and Their Scribe) Will See You Now 👩🏻‍⚕️ 🖥️

What happened? Some doctors say they’re fed up with spending more time taking illegible notes than listening to patient’s concerns.

Maybe they didn’t say exactly that, but 42% of doctors did say paperwork burnout makes them want to quit clinical practice. Lucky for them, companies like Microsoft and Amazon have created AI tech that can help reduce fatigue and increase productivity.

Why it’s interesting: Tools like Innovaccer and IRIS have the ability to transcribe, analyze, and summarize conversations between doctors and patients. The conversation is then converted into a “provider template” where it creates a list of tasks for the patient’s treatment. Before the information is filed, it’s reviewed by trained specialists and clinicians to ensure patient accuracy for doctor approval.

Like lab coats, one size does not fit all, and the same can be said about this new tech. While many doctors agree that the use of a transcriber can improve overall care, the fear of the “black box effect,” which occurs when AI produces results or advice without explanation, have some physicians second-guessing their decision to use the tech. This issue might cause doctors to misdiagnose a patient, or misunderstand the patient’s needs – as it can be difficult to trace the system’s thought processes.

Bottom line: Transcriber tools can be useful to alleviate doctors' heavy workload, but you shouldn’t start chanting “no more pencils, no more books” yet! Doctors and AI must work together in order to defeat their common enemy… paperwork. 

🍔 Quick Bites

1: 🧠 The future is… last weekend? According to X, the first human successfully received a Neuralink implant over the weekend. Though the “initial results show promising neuron spike detection,” Elon Musk added no more details about the patient.

2: 🎾 Jannik Sinner rallied from two sets down to win the men’s Australian Open final over Daniil Medvedev — his first grand slam title. (It probably won’t be his last.)

3: 🌿 Bayer has been ordered to pay $2.25B USD in the latest trial concerning its weedkiller, Roundup. The plaintiff said he developed non-Hodgkins lymphoma as a result of using Roundup for yard work at his house for several years.

4: 🏅 Almost two years after the Beijing 2022 Winter Olympics, Russian figure skater Kamila Valieva will be disqualified due to doping — including TMZ (used to treat angina).

5: 🦟 Last week, RTS,S — the world’s first malaria vaccine — began to roll out in routine immunizations for babies and children under 5 in Cameroon. According to WHO, the vast majority of malaria deaths worldwide occur in Africa, and kids under 5 are at high risk.

6: 👶🏽 A new study says that babies exposed to COVID in the womb are 3x more likely to develop respiratory distress. Infants whose mother received at least one dose of an mRNA vaccination were 67% less likely to suffer serious breathing problems, compared to unvaccinated mothers.

Postcall Picks ✅ 

💹 Save: CNBC did some math to show how much you need to save in order to save $5M — if you’re feeling ambitious.

🎧️ Listen: to last week’s WCI episode on side gigs that make a big impact on a physician’s financial life. Learn about how you could do expert witness work, open IV clinics, and taking medical surveys (Apple | Spotify)

👀 Watch (and eat): This aesthetic video of an old-school way of making chicken pie:

💳️ Buy: it for life (BIFL). Still committed to your New Years Resolution? We scoured the cyberspace to bring you our BIFL reco this week: Adidas — specifically their running shoes, which (1) look amazing, and (2) are currently on sale on their website.

🕹️ Game ⛳️

Time to flex those mental muscles!

First question: What is the most common type of brain cancer in kids?

Last week’s average time for puzzle solving: 4:29!

Want to prescribe mental exercise to someone else? If you liked today’s puzzle, please share the link! ☺️

❓Trivia Answer❓

Because of the apothecary system. This system of weights and measures came from England and France during the early Middle Ages. The base weight was the weight of a grain of barleycorn, or 64.8 mg. Aspirin was 5 grains (gr.) or 325 mg. But then, why Tylenol? It’s just following aspirin. 🤷‍♀️

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