Narrator - Dr. Abel 00:00 Welcome to HelixTalk, an educational podcast for healthcare students and providers, covering real life clinical pearls, professional pharmacy topics and drug therapy discussions. Narrator - ? 00:11 This podcast is provided by pharmacists and faculty members at Rosalind Franklin University, College of Pharmacy. Narrator - Dr. Abel 00:17 This podcast contains general information for educational purposes only. This is not professional advice and should not be used in lieu of obtaining advice from a qualified health care provider. Narrator - ? 00:27 And now on to the show. Dr. Sean Kane 00:31 Welcome to HelixTalk, Episode 39 I'm your co host, Dr. Kane. I'm Dr. Schuman, and I'm Dr. Patel. So before we get into this week's episode, I just wanted to give a brief mention of something that's pretty exciting here at Rosalind Franklin University. Speaker 1 00:42 Franklin University. It's Yes indeed. It's very exciting that two of our students, William o'legria and Haley spouting, have placed a first place at the ash P's clinical skills competition where 129 Speaker 2 00:55 schools competed. And what this was, it was an interactive team based analysis of a clinical scenario they were given with patient labs, patient case, and what they were to do is come up with a care plan there, looking at a listing of different drug therapy problems, prioritizing them, triaging the patient, as well as potentially imagining a scenario where they would provide clinical collaborative practice for physicians towards direct patient care. Dr. Sean Kane 01:18 So again, congratulations. We're very proud of you, and we'll go ahead and get into the show today, we're talking briefly about nausea and vomiting the pregnancy, with a particular focus on a newer product called diclegis. Speaker 1 01:30 The historical perspective on diclegis involves controversial lawsuits for the birth defects causing the withdrawal from the market and then it was re approved, we're going to talk about how the statistical significance is only half the truth. What looks good number wise might not mean anything clinically. And then, for some reason, we have decided to talk about Kim Kardashian. So it's going to be a little bit dramatic today. Dr. Sean Kane 01:57 For a little bit of background, the drug diclegis is a combination of doxylamine with pyridoxine, which is vitamin b6 and doxylamine is an antihistamine. This product, what we now call diclegis, was actually on the market decades ago in the form of a different drug called bendectin. So this was approved all the way back in 1957 and then it was actually removed from the market in 1983 Speaker 1 02:21 so you're saying the vitamin b6 and doxilomine, sounds like both of these agents are available individually over the counter. Is that correct? Dr. Sean Kane 02:28 Exactly? So they're both available over the counter, but they're available in different doses, and we'll talk a little bit about the differences. But essentially, this was a single tablet that had both of these active ingredients in them at the time. You know, back in the 50s, 60s, 70s, this was actually a very common medication. Bendectin was, and it's estimated that anywhere from about a quarter to all the way up to maybe a third of the US pregnant population was taking this for nausea, vomiting of pregnancy, also known as morning sickness. Speaker 2 02:57 So about 25 years later, though, it comes out of them, comes off the market in 1983 with all these lawsuits saying birth defects. And that was after multiple reports from the FDA saying that it's safe in pregnancy, it's safe in pregnancy, it's safe in pregnancy. Dr. Sean Kane 03:11 What's interesting about that is it wasn't removed from the market because it was not safe. It was removed because the manufacturer of Bendectin said, Hey, this is way too expensive to fight these lawsuits. We've got good data, but it's just not worth it in terms of the expense of the lawsuit. So we're just going to stop making it. Speaker 1 03:27 And a company in Canada then decided to make it, start making the combo product, so kind of get out of the US market, got into the Canadian market, and it's still available today. Dr. Sean Kane 03:36 And it was able to do that because at the time in 1983 it was off patent, so anyone could manufacture it, but of course, they would potentially be at risk for lawsuits, just like bendectin was at the time in the US Speaker 2 03:47 All right, so we kind of fast forward back to the present, and we look at this medication approved in April 201 dosed as two delayed release tablets at bedtime. Yeah. Dr. Sean Kane 03:57 And then diclegis, as we said, is the US product, and the dose is a little interesting in that it's kind of self titrated by the patient. So Dr. Schuman, like you said, you start with two tablets at night, and these are extended release tablets. And if you continue to have symptoms on day three of your titration, you can have one tablet in the morning in addition to your two at night. And then if you still have symptoms, you can have one in the morning, one basically at lunch, and then two in the evening, for a total of four tablets per day. And that would be kind of the max dose that you could ever have. Is four tablets per day of the diclegis. Speaker 1 04:31 And most times, patients are asked to take it on an empty stomach, because if you take it with food, it reduces the absorption or bio availability of pyridoxine, which is vitamin b6 by about 50% but as you increase like twice a day to thrice a day to even four times a day, becomes harder for patients to do it an empty stomach, but assuming they have nausea and vomiting going, they might not have whole lot of oral intake. Anyways, that might work out. Dr. Sean Kane 04:57 And in terms of adverse effects, you know, we have a lot of. Data on doxylamine and pyridoxine, there's almost no adverse effect to pyridoxine or vitamin b6 which is a water soluble vitamin. In terms of doxylamine, we think of our classic anticholinergic antihistamine like adverse effects, but the main one that we see in clinical trials, especially in phase three clinical trials that got diclegis approved, was just somnolence, and it actually wasn't all that common. So patient reported somnolence was 14% with diclegis versus about 12% with placebo, which is really not that different, you Speaker 2 05:30 know, if you think about it, right, let me get to kind of the big question, though, about, you know, what is the pregnancy category for this medication? Speaker 1 05:38 And that essentially ties up with the safety of the medication, and we found a meta analysis of about 16 cohorts and 11 case control trials, which showed no fetal harm in the first trimester with either of the components, so either with the pyridoxine or the doxylamine. And the second meta analysis included about 12 cohorts and five case control trials. And again, this showed no harm as well. And this analysis and stuff, they included the cohorts they're ranging back in the days ever since, like 1963 so and Bendectin was approved about that time. Dr. Sean Kane 06:14 And then also, they included some of the data from the Canadian product, which, as we said, post 1983 that was the product that was available as a combination product. So even though it wasn't in the US, it did offer us basically more patient data points to analyze to see if there was any teratogenic effect or fetal harm effect. And there wasn't. We didn't see anything. Speaker 1 06:35 So now we know the medication is safe. Big question comes up if it's effective or not. Speaker 2 06:41 And we can see, though, that they in the studies, they included pregnant women seven to 14 weeks post gestation. And then, just for completeness sake, no pregnant men were included. So I guess that could could hurt your external validity. Dr. Sean Kane 06:54 We'll have to keep that in mind when we have any pregnant men that may present to clinic with nausea and vomiting the pregnancy. So absolutely we cannot prescribe this medication, I would say, probably not, but I'd have to look at the packaging Speaker 2 07:06 All right. So in the studies, they randomized patients to 14 days of diclegis versus placebo, and they could do the dose taper up as needed, again, using some of that protocol we talked about before, about 20% of the individuals got the two tablets. 20% got three tablets, and 60% got four tablets, which, as we discussed earlier, is, is the max you can get with this medication. Speaker 1 07:27 So it sounds like to maintain their nausea and vomiting obey they had to be taking. Most patients in the trial needed to take the four Max tablets per day, dose correct. Dr. Sean Kane 07:37 And if you think about it, for any trial that involves more subjective things. And Dr. Shu, and I'm sure you're well aware of the issues of, if it's not a black and white thing, you kind of have to come up with scoring systems to objectively assess efficacy of a medication. So in this the psych world as an example, there's no black and white. Do you have symptoms or not? There has to be some validated scale or questionnaire, things like that, Speaker 2 08:01 certainly, and with especially just bring up psych sometimes, the issue too, is how it was validated. Is this an internally designed study used by the design sometimes, you know, they may design their own study and then validate themselves and use it versus one that's more clinically known. Unknown Speaker 08:16 So what kind of score did this study come up with? Dr. Sean Kane 08:18 So in this particular study, and with many other pregnancy studies, they use something called the pregnancy unique quantification of emesis scale, or survey, which is a score from three to 15. So it's basically a 13 point scale. Speaker 2 08:32 Now, I may be going far with this, but it sounds like so P, U, Q, E, puke. Is that correct? Dr. Sean Kane 08:38 Absolutely correct. So this would be the puke score, which has a very fitting name for what we're studying. Speaker 1 08:44 So I'm thinking this probably was derived by of an insensitive man, because it sounds like a very dry humor to name a score with the puke rather studying nausea and vomiting in pregnancy, I Dr. Sean Kane 08:55 think that's probably a fair assessment. And just for completeness, the puke score, or the scoring system is basically three different questions, and the patient rates each of those questions on a point value of one to five. For these three different questions, that's where you get a max potential score of 15. It's a very, very brief survey that the patient fills out. Speaker 2 09:13 And one thing about this score is it does use a mixture of some subjective and objective. So subjectively, you can say, in the last 12 hours, for how long has the individual felt nauseated or sick to their stomach? That can be, again, somewhat subjective, based on what they determine as severe enough nauseous sickness. But then you can also count the number of times an individual is monitored or thrown up, as well as the number of times retching or dry heat without bringing anything up. So the latter two are particular. Can be a little bit more quantitative Dr. Sean Kane 09:39 there, and I think that that's those kinds of questions are what would want to see in a survey like this, because pregnant women could be nauseous but not vomit, and if we can help with their nausea, that's probably good thing. And if we can, if they vomit a couple times, but maybe the nausea is pretty quick, we want to also be able to capture these vomiting episodes. So it's really a good mixture of. Both nausea plus vomiting. And although we're not individually assessing both, they're kind of combined into this puke score. It's a good thing that we're assessing it that way. Speaker 2 10:09 So we look at the study the baseline puke again, I just enjoy saying that word. I guess puke score was around nine in both groups. And again, the scale ranges from three to 15. And then they looked at the day 15 scores versus baseline, and they saw that diclegis reduced the scores by 4.8 so about five points versus placebo, which reduced it by 3.9 or about four points. Speaker 1 10:30 So the treatment difference you're saying Dr. Schuman was just point seven point reduction with diclegis, right Speaker 2 10:35 with about a 95% confidence interval from point two to 1.2 Dr. Sean Kane 10:39 so in other words, if you take diclegis for 14 days and you're within the seven to 14 week gestational age of pregnancy, your puke score out of 13 points will decrease anywhere from point two to 1.2 but as a mean, or a point estimate, you'll have a point seven point reduction in your puke score. Speaker 1 11:00 That makes me think I would really want to look at the price of this medication, whether it's really worth, you know, shelling my pocket out. Speaker 2 11:06 Yeah, like we've talked about in in previous weeks, where we have, you know, this statistically significant. But if we think about again, a scale that, you know, numbers three to 15, if we if we're getting, you know, less than a point difference, what is that really doing for the individual? Maybe they're going from three to four times, or five to six to three to four times a day of having retching or dry heat, but then everything else has been held constant, essentially, yeah, Dr. Sean Kane 11:27 and I tried very hard to find basically a pre specified what was a clinically relevant change in a puke score, and I wasn't able to find it. What you'll find with many scoring systems is somewhere, if it's a 10 point scale, somewhere around a half a point to one point is usually considered relevant. But again, this is a separate scoring system, and I think part of it has to be up to the practitioner and the patient to decide whether a point seven out of 13 point scale is sufficient enough to take the medication, right. Speaker 1 11:56 And if you look at like I mentioned earlier, most women in this trial needed to use four times a day dosing. Now we all know as the frequency in real life. You know, if a medication goes up, the compliance decreases. So when you're talking about getting this medication three times a day, four times a day, we don't know if the patients are going to be compliant, and are we going to be able to see the same result in the real life. Dr. Sean Kane 12:19 I think in terms of compliance too. You also have to think, in this patient population, they may want to take it, but they can't because they're nauseous. So another, you know, factor that we don't commonly see with many other medications. Speaker 2 12:32 Again, one thing, nice thing to think about, though, is, you know, this is a medication. The safety profile seems relatively benign given the information we have right now, someone was wasn't very common, or at least, at least in this study in particular. Dr. Sean Kane 12:45 Yeah, and Dr. Patel, as you mentioned earlier, one thing to also think about is the drug cost. So it would be one thing if this was a very inexpensive medication with an seemingly excellent safety profile, which is great, but if it costs a lot of money, maybe this very, very small impact on efficacy. Isn't that Speaker 1 13:04 beneficial? So what are we talking here? Number wise. Dr. Sean Kane 13:07 So diclegis is a combo, as we said, of 10 milligrams of doxylamine and 10 milligrams of vitamin b6 and the manufacturer of diclegis was actually really smart and making a delayed release tablet, which we don't have delayed release versions of these over the counter products, and that could potentially impact something like somnolence, where you have kind of more prolonged peak effect, or the peak effect primarily happens while you're sleeping, as opposed to right when you take it. So there's argument that the delayed release matters. And then also the doses that they picked weren't doses that you can find over the counter. So 10 milligrams of each of those components, you just can't buy those over the counter. The lowest for each of those is 25 milligrams, and at least for vitamin b6, a more common dose is 100 milligrams. So they were smart to make it so that you can't find an exact comparator as an over the counter product. But as we'll talk about, I think that you can probably find something pretty close. Speaker 2 14:00 And then, just for clarity, silver theme, doxylamine would be UNISOM is a common brand name. Again, some different anti histaminative products will either use and again, you have to look at the name some of the pm types of Mets, sometimes they use doxylamine, sometimes they use diphenhydramine. But in this case, Unison would be the brand if you were looking at the closest thing to doxylamine over the counter, but again, immediate release, not delayed release. Dr. Sean Kane 14:23 So Dr. Patel, to answer your question, one tablet of diclegis as a cash price product is somewhere between five and $6 per tablet. So that means that if you're taking four tablets per day, which would be the maximum dose, the out of pocket, cash price would be around 600 to $700 Speaker 1 14:40 so you're saying, If I took a dose and then I had to puke right after it, I basically pooped out $6 you threw Speaker 2 14:47 up an Abraham, yep, right now, I've gotta, I've gotta ask. So we you hyped it up. Dr. Patel at the beginning. So how does Kim Kardashian fit into all this? I've got to know, Speaker 1 14:57 you know, I really would have been fit if. I were watching keeping up with the Kardashian, because there was probably some mention of her promoting this medication stuff, but I'm gonna let Dr. Sean talk about this Kim Kardashian issue. Dr. Sean Kane 15:12 So just for background, Kim Kardashian is a celebrity that has a lot of different areas where you can watch her on TV and things like that, but one thing that she promotes is her Instagram profile, and she has 40 million Instagram followers, and she actually partnered with the manufacturer of diclegis to basically make a promotional Instagram post, and I'll read an excerpt from it. OMG. Have you heard about this? As you guys know, my hashtag morning sickness has been pretty bad. I tried changing things about my lifestyle, like my diet, but nothing helped. So I talked to my doctor. He prescribed me hashtag diclegis, and I felt a lot better. And most importantly, it's been studied and there was no increased risk to the baby. I'm so excited and happy to see my results that I'm partnering with the drug company to raise awareness about treating morning sickness. If you have morning sickness, be safe and sure to ask your doctor about the pill with the pregnant woman on it and find more@diclegis.com so just for background, the tablet does have a pink emblem of a pregnant lady on it, which is kind of an interesting tablet, all right. So if I Speaker 2 16:15 see one of those tablets on the street, at least now I know what it is, but I gotta say, OMG and hashtag. I imagine if Takeda and avid and every other company used these great marketing strategies, I could just see it now in the commercials. Speaker 1 16:29 But something tells me that something was missing in this commercial, most commercial direct to consumer ads that I've seen, there's a long list of effects and then long list of side effects they're talking about. Looks like Kim was not given the script about side effects. Dr. Sean Kane 16:45 Yeah, so in all fairness to Kim, it was her impression that having the link to the website would be sufficient, but this would be the equivalent of having a link on a commercial on TV, not talking about any side effects, and then assuming that the consumer will go to the link to read about the downsides of the medication after you basically upsell how important and how useful the medication is, and that's actually what happened. So the FDA wrote a letter to the manufacturer saying, even though it's social media, we don't care. You can't just talk about the upsides of a drug without talking about the downsides. And a link to the website is not sufficient to outline the downsides. Unknown Speaker 17:20 Nothing like hashtag litigation to get in the way. Speaker 1 17:23 So then what did Kim had to do? She had to post the entire prescribing information on her profile. Dr. Sean Kane 17:28 Essentially, that's what happened. So she posted a corrective post that had most of the prescribing information and kind of an apology, in essence. But it really highlights the importance of, you know, especially a celebrity, bringing up a medication without talking about any downsides. And in all fairness, diclegis has very few downsides, aside from cost. But if this was, let's say, a psychiatric medication that caused diabetes and weight gain, and they just said, Hey, I feel so much better. My schizophrenia is just resolved. That wouldn't really be fair for the consumer to not have the other side of the picture. Yes, since you Speaker 2 18:01 brought it up, it's actually interesting, just real quick, like Russell Wilson with his water that could prevent concussions and actually, or the fact that lithium is available on Amazon as a salt form, that's not FDA approved. So, yeah, these things do happen. We have to be careful Dr. Sean Kane 18:14 about Absolutely. So, you know, we've talked a lot about diclegis. I think it's important to have kind of an overview of where diclegis fits in the picture. And as of September 2015, a cod, which is the American College of Obstetricians and Gynecologists, actually has basically a guideline statement involving nausea and vomiting of pregnancy. Speaker 2 18:34 And if you look through it, it gives some of those non pharmacologic methods, again, that Kim Kardashian did mention. But yeah, that's going to be your first line here. So avoiding your sensory stimuli, strong odors, heat, humidity, noise, flickering lights. Maybe looking at eating small meals one or two out every one to two hours, rather than big, huge meals three times a day, avoiding a full stomach and some high protein snacks. And then some other things they looked at, avoiding spicy, fatty foods, blank dry foods. So again, yeah, looking at those benign ones, you know, trying to avoid your salt, pepper, spices on them, and they're really looking at avoiding some iron containing pills, again, for some of that risk of upset stomach, Dr. Sean Kane 19:13 in terms of the iron containing prenatal vitamins, is actually interesting. There is evidence that iron does upset your stomach. We know that when we give patients iron supplementation, whether a small amount of iron in the prenatal vitamins matters or not, I think is a little bit debatable, but there is some data that says that if you switch out your prenatal, if it is iron containing to a non iron containing prenatal, that you could actually help with your nausea and vomiting symptoms. Speaker 1 19:38 And one of the interesting recommendation a cog made was to try some crackers in the bed before you wake up. So you, you know, basically, get up from the bed and eat some saltine crackers and then start your day, because that's where usually the bouts of nausea and vomiting comes. Yeah. Speaker 2 19:54 Just hope it's not going to help insomnia the next night, because you're rolling around with this crunching sound in your. Dr. Sean Kane 20:00 Easier. So in terms of some of the other recommendations in the guideline, one thing that they said, and it's kind of only applicable if you're planning to become pregnant, is that there's some data that if you start your prenatal three months before you actually conceive, that that may help reduce incidence and severity of nausea and vomiting once you do become pregnant, Speaker 1 20:18 and they do consider the vitamin b6 alone or in combination with doxylamine being the first line therapy. Dr. Sean Kane 20:26 I think it's important that in the guidelines, they do discuss that there is this prescription product called diclegis, but they are also fairly open about saying that there are OTC versions of these medications, right? Speaker 2 20:37 So that's what I was gonna ask. So they so they don't specifically say first line is extended or delayed release, Dr. Sean Kane 20:42 they do not so keeping keeping in mind that we've had this combination product and the over the counter products since the 1950s we have good data that there is no fetal risk for either medication or in combination. And even though the doses are slightly different, especially if cost is a concern, I think it's very reasonable for a patient to start with b6 alone, which isn't as efficacious as a combination, but I think starting somewhere is reasonable, and then escalating up to the combo, and then if that doesn't work, I think considering diclegis is reasonable, knowing that no matter what you do, the efficacy is not going to dramatically reduce your nausea and bonding. What I find Speaker 2 21:20 interesting too, is they also gave level B evidence, whether described as limited or inconsistent evidence, to an herbal product, ginger, so that that could be considered as non pharmacologic therapy. And as I cover, you know, herbal medications, again, that's one that seems to come up a lot, is, you know, a lot of these diverse uses. So that's that's very interesting, yeah. Speaker 1 21:36 And I think one thing consumers or listeners need to be aware of that they're actually asking patients to use natural form of ginger. So like, try to include more ginger in your diet instead of taking supplements from outside. One thing to consider pregnant female, on top of being nauseated and having vomiting issues and stuff, they also have common complaint of heartburn, and if you talk back to Ayurveda, Ginger is considered one of the warmer type of remedy, and so it kind of causes or can exaggerate the symptoms of heartburn. So if it suits the patient, yes, they can go for it, but if not, then they should avoid it. Dr. Sean Kane 22:14 The guidelines had two other mentions of drug therapy that weren't specific recommendations, and it related to metoclopramide (Reglan), and then also on ondansetron or Zofran. Speaker 1 22:25 And working back in the days in the pharmacy, I remember we received prescriptions for ondansetron, left and right, for pregnant female to treat their nausea and vomiting. And I wonder if at that point, the prescribers were just failing to recommend some of these non Pharm or benign regimens such as vitamin b6 doxylamine or even ginger to them. Dr. Sean Kane 22:45 Absolutely, I think that as we know and as we've discussed, the efficacy of whatever we do is not going to be dramatically effective. So certainly, many patients will basically fail non farm therapy, b6 and doxylamine therapy, and they want to reach for something different, because at least up through, you know, most of the first trimester and part of the second trimester, they could potentially have pretty severe nausea and vomiting. So the recommendations from ACOG related to Metoclopramide was that they don't necessarily recommend it or not recommend it. They say that there's some safety data in terms of teratogenicity that appears safe, definitely not as good of data with the combo that we discussed. But their concern with metoclopramide is a lack of efficacy for medical provided, specifically in nausea and vomiting of Speaker 1 23:33 pregnancy, and some of the recommendations that are not part of the ACOG that we have used commonly, some of the non farm things, such as the acupuncture, acupressure, hypnosis have been used as well. And then one thing patients or listeners need to know about this too is if they have a very high, severe version of nausea and vomiting of pregnancy, which is usually we call it hyperemesis gravidarum. If you followed the media after Kim Kardashian, you probably followed Kate Middleton too, and you know that she was in the hospital with hyperemesis gravidarum during her first pregnancy, and this person working at the hospital leaked the reports of her, you know, treatments that were going on, and it was a huge issue. But so, you know, usually that situation is treated with IV medication. Patients gonna be NPO, and the agent we usually use is methylprednisolone, right? So that's a Speaker 2 24:25 great point of kind of where we talk from for pharmacy students, about working in different settings, about when to know when to refer when to treat over the counter. And so Dr. Patel, that's a great example of a place in which you would say, Hmm, this is something that, from your description, seems fairly severe. And instead of recommending maybe some of those herbals you may say you may want to get that looked out in in another, more acute setting. Speaker 1 24:45 Absolutely and when they come and ask you questions about their nausea and vomiting and describe them, one thing to assess is their hydration level as well. You know, are they keeping up with the oral intake? Because dehydration can cause equally of complications. That can put them in the hospital. So while they're taking all these medications, one thing as a non farm therapy, we want to make sure they have is replenishment, hydration. Dr. Sean Kane 25:10 So to review and thinking about the guidelines and where diclegis fits in the guidelines, the individual components are recommended as first line therapy by ACOG the 2015, guidelines for nausea and vomiting their pregnancy. So diclegiest does fit under that, but they aren't specifically saying that diclegis is the first line therapy. They do have some dietary recommendations, avoiding sensory stimuli that may trigger or worsen nausea and vomiting, especially in the morning. They do recommend that, if you can help it, taking your prenatal vitamins before you get pregnant, which is a good recommendation anyway. And then also they recommend ginger as a potential non pharmacologic therapy, but it was kind of evidence B, which is limited or inconsistent data. And then they do make a mention of ondansetron or Zofran and also metoclopramide or reglan. But for both of those, they had some issues with basically lack of data for safety and efficacy depending on the setting it's used in, Speaker 1 26:02 and looking at the Diclegis in particular, the dosing is pretty interesting. So you know, it varies from being on two tablets at bedtime, and then, based on the symptoms, you add one additional tablet in the morning, and the fourth day, you can add one in the afternoon, to make a maximum dose of four tablets per day, and Speaker 2 26:21 then just to compare it to the other form. So again, the ACOG guidelines talk about use of this combination doxylamine and or B vitamin, but in this case, with pyridoxine, it's a delayed release formulation here. So that's one distinctive piece of it, as well as the fact that this does have some good pregnancy data based upon the information that's out there, and these meta analyzes no risk of harm in the first trimester with either one of these individual agents. Dr. Sean Kane 26:45 So with that, we'll go ahead and wrap up. If you haven't done so already, if you could please go to iTunes and give us a five star rating. It helps us climb up on the rankings in iTunes, so that other listeners are more prone to be able to find us. We're also available at HelixTalk.com We'd love emails of episode or topic suggestions, and with that, I'm Dr. Kane, I'm Dr Unknown Speaker 27:05 Schuman, and I'm Dr. Patel. And study hard. Narrator - Dr. Abel 27:08 If you enjoyed the show, please help us climb the iTunes rankings for medical podcasts by giving us a five star review in the iTunes Store. Search for HelixTalk and place your review there Narrator - ? 27:19 to suggest an episode or contact us. We're online at HelixTalk.com thank you for listening to this episode of HelixTalk. This is an educational production copyright Rosalind Franklin University of Medicine and Science.