1 00:00:00,000 --> 00:00:02,700 Tracey: she whips out her phone with a picture and it had one red line on it. 2 00:00:02,760 --> 00:00:04,590 I'm like, that's not a positive test. 3 00:00:04,590 --> 00:00:06,390 She says, but look, it's got a C next to it. 4 00:00:06,390 --> 00:00:07,350 It means I have COVID. 5 00:00:07,404 --> 00:00:10,405 I said, no, the C is control, not positive for COVID. 6 00:00:18,004 --> 00:00:21,454 Joe: Welcome to the Evidence-Based Urgentology podcast from EB Medicine, 7 00:00:21,454 --> 00:00:23,734 where urgent care meets evidence. 8 00:00:23,844 --> 00:00:27,084 I'm Joe Toscano, senior research editor for Emergency Medicine Practice, 9 00:00:27,144 --> 00:00:29,874 and a member of the evidence-based Urgent Care editorial board. 10 00:00:31,179 --> 00:00:32,679 Tracey: Hi there, and I'm Tracy Davidoff. 11 00:00:32,679 --> 00:00:35,949 I'm editor in chief of Evidence-Based Urgent Care, and we're practicing 12 00:00:35,949 --> 00:00:38,829 urgent care physicians with years of experience, probably too many years 13 00:00:38,829 --> 00:00:40,569 of experience, on the front lines. 14 00:00:40,629 --> 00:00:44,499 And for us, diagnosis is detective work and the clues are in the history, 15 00:00:44,499 --> 00:00:46,209 the exam, and of course the evidence. 16 00:00:46,449 --> 00:00:48,609 That thrill of solving the patient's puzzle is really 17 00:00:48,609 --> 00:00:49,749 what keeps us coming back. 18 00:00:50,384 --> 00:00:54,824 Joe: Each month we unpack the latest issue of evidence-based urgent care tackling 19 00:00:54,824 --> 00:00:56,624 common chief complaints from presentation. 20 00:00:56,624 --> 00:01:00,494 Through diagnosis to disposition, we highlight the best evidence, the key 21 00:01:00,494 --> 00:01:01,724 takeaways, and the clinical pearls. 22 00:01:02,594 --> 00:01:05,714 Tracey: And by the end of every episode, you'll have sharper skills, deeper 23 00:01:05,714 --> 00:01:09,434 knowledge, and more sound strategies that you can use on your very next shift. 24 00:01:09,824 --> 00:01:10,784 So let's dive in. 25 00:01:10,784 --> 00:01:11,924 The evidence starts now. 26 00:01:12,074 --> 00:01:17,354 And remember, you can always find more at www.ebmedicine.net. 27 00:01:17,852 --> 00:01:21,852 Welcome everybody to this episode of Evidence-Based Urgentology 28 00:01:21,872 --> 00:01:23,372 with me, Tracy Davidoff 29 00:01:23,422 --> 00:01:24,662 Joe: And me Joe Toscano. 30 00:01:25,292 --> 00:01:27,459 Before we get started, we have some promos to announce. 31 00:01:27,859 --> 00:01:34,039 The three free sale is going on from October 30th, 2025 to January 6th, 2026. 32 00:01:34,549 --> 00:01:37,939 This is three free additional months added to any subscription. 33 00:01:38,089 --> 00:01:39,859 That's 15 months for the price of 12. 34 00:01:40,309 --> 00:01:42,469 Emergency medicine practice, peds emergency medicine 35 00:01:42,469 --> 00:01:46,039 practice, evidence-based urgent care, or the bundles. 36 00:01:46,129 --> 00:01:48,329 Promo code for this is 3FREE. 37 00:01:48,349 --> 00:01:51,619 That's the number three, and then FREE. 38 00:01:52,129 --> 00:01:55,219 And then also EB Medicine has its thankful sale. 39 00:01:55,864 --> 00:01:57,184 For Thanksgiving, I guess, huh? 40 00:01:57,524 --> 00:02:02,294 20% off all courses, and that'll be running from November 25th, 2025 to 41 00:02:02,294 --> 00:02:06,074 December 2nd, 2025, so only a short time window to take advantage of that. 42 00:02:06,374 --> 00:02:09,774 The promo code for that one is Thankful2025. 43 00:02:09,794 --> 00:02:12,764 T-H-A-N-K-F-U-L 2025. 44 00:02:13,364 --> 00:02:15,554 Tracey: Also, the December issue of evidence-based urgent 45 00:02:15,554 --> 00:02:18,464 care and the podcast for the discussion will be on hypertension. 46 00:02:18,794 --> 00:02:21,674 This is really timely because the American College of Cardiology and the 47 00:02:21,674 --> 00:02:25,534 American Heart Association recently released new guidelines in August, 48 00:02:25,594 --> 00:02:29,254 and the next issue and the Urgentology podcast will cover all you need to know 49 00:02:29,254 --> 00:02:33,004 about the key changes, specifically about lowered blood pressure targets, 50 00:02:33,394 --> 00:02:37,474 earlier intervention, and an increased focus on lifestyle modifications. 51 00:02:38,584 --> 00:02:39,274 Joe: That sounds cool. 52 00:02:39,934 --> 00:02:43,804 Well, right now let's discuss the November issue titled laboratory 53 00:02:43,804 --> 00:02:47,044 testing and urgent care best practices for choosing and interpreting 54 00:02:47,044 --> 00:02:49,114 respiratory and genital urinary tests. 55 00:02:49,414 --> 00:02:53,374 We're actually here in person with the authors, Chris Chao and Joe Hwang to 56 00:02:53,374 --> 00:02:54,874 discuss some of the important points. 57 00:02:54,904 --> 00:02:58,414 Chris works as a physician and medical director at WakeMed in Raleigh, North 58 00:02:58,414 --> 00:03:03,844 Carolina, and Joe works as a PA at a proxy urgent care in Madison, Alabama as well. 59 00:03:03,844 --> 00:03:08,164 He is laboratory director at Urgent Care of Oconee in Athens, Georgia, and he's 60 00:03:08,164 --> 00:03:12,244 also adjunct faculty member at Mercer University and South College in Atlanta. 61 00:03:12,799 --> 00:03:13,549 So let's get into it. 62 00:03:14,449 --> 00:03:14,929 Tracey: Awesome. 63 00:03:14,959 --> 00:03:16,429 Yeah, this is so great to do it live. 64 00:03:16,429 --> 00:03:19,069 We did this once about a year ago, and we just had so much fun doing 65 00:03:19,069 --> 00:03:21,721 it, and I'm really looking forward to chatting with some of my friends 66 00:03:21,721 --> 00:03:25,321 about this issue, which I think was just really spectacular and I hope 67 00:03:25,321 --> 00:03:27,271 everybody really digs into the article. 68 00:03:27,701 --> 00:03:30,191 I've had a lot of people that have told me that, what do you mean a test 69 00:03:30,191 --> 00:03:31,541 is not just positive and negative? 70 00:03:31,541 --> 00:03:32,771 I have to interpret it. 71 00:03:32,771 --> 00:03:34,451 I mean, it is positive and negative, right? 72 00:03:34,961 --> 00:03:36,161 No, it's not. 73 00:03:36,161 --> 00:03:38,741 And you really need to know how to interpret these tests and this issue 74 00:03:38,741 --> 00:03:41,531 really kind of digs into that and teaches you how to interpret tests. 75 00:03:42,401 --> 00:03:45,371 So guys, we know from your discussion that molecular testing is more 76 00:03:45,371 --> 00:03:46,781 sensitive than antigen testing. 77 00:03:47,366 --> 00:03:50,216 But we have to acknowledge that those tests are definitely more expensive. 78 00:03:50,216 --> 00:03:53,366 So we have to factor that into any analysis about the pros and cons 79 00:03:53,366 --> 00:03:54,566 of which tests you're gonna use. 80 00:03:55,046 --> 00:03:58,286 But are there any reasons why a clinician would not want to use a molecular 81 00:03:58,286 --> 00:04:00,206 test over an antigen test every time? 82 00:04:00,596 --> 00:04:04,256 And are there times where for the clinician decision making and accuracy 83 00:04:04,256 --> 00:04:08,036 that an antigen test might actually be preferred over a molecular test? 84 00:04:08,306 --> 00:04:09,236 And let's start with Chris. 85 00:04:09,731 --> 00:04:12,581 Chris: Well, I think first of all, Tracy and Joe, we have to consider 86 00:04:12,581 --> 00:04:16,571 that for the end user, they may not have a choice between whether or not 87 00:04:16,571 --> 00:04:18,551 they choose antigen or molecular test. 88 00:04:18,581 --> 00:04:18,851 Tracey: True. 89 00:04:18,881 --> 00:04:21,641 Chris: If you're working at an urgent care center, that 90 00:04:21,641 --> 00:04:23,171 decision's often made for you. 91 00:04:23,196 --> 00:04:27,481 You have to test at hand, but if you do have a choice, we do know that 92 00:04:27,511 --> 00:04:29,701 molecular test is more sensitive. 93 00:04:30,121 --> 00:04:34,651 It's more sensitive in that it can pick up disease states earlier than antigen test. 94 00:04:34,981 --> 00:04:37,441 But one of the drawbacks of the molecular test. 95 00:04:37,756 --> 00:04:39,406 It's called a post-test residual. 96 00:04:39,796 --> 00:04:43,756 We know that from COVID-19, that testing someone with a molecular 97 00:04:43,756 --> 00:04:48,346 test can be positive for months after the acute infection. 98 00:04:48,736 --> 00:04:53,676 Every disease state has a post-test positive phase, and it is very 99 00:04:53,676 --> 00:04:56,346 interesting to see that some are shorter and some are longer. 100 00:04:57,036 --> 00:05:02,886 In terms of accuracy and clinical decision making, you have to realize 101 00:05:03,066 --> 00:05:06,246 when is an antigen test good enough? 102 00:05:07,026 --> 00:05:11,586 There are clinical disease states where antigen test is probably good enough. 103 00:05:11,736 --> 00:05:16,986 The example of that would be an antigen test for strep, in an adult population 104 00:05:16,986 --> 00:05:19,746 over 18, or in children under three. 105 00:05:20,346 --> 00:05:25,296 But there are also disease states where antigen test is almost never appropriate. 106 00:05:25,716 --> 00:05:30,726 For example, an antigen test for RSV just does not hit the detection 107 00:05:30,726 --> 00:05:33,186 thresholds in an adult population. 108 00:05:33,666 --> 00:05:36,396 Therefore the molecular test is really the only test that's 109 00:05:36,396 --> 00:05:37,926 gonna give you a reliable result. 110 00:05:38,856 --> 00:05:40,116 Joe, do you have anything else to add? 111 00:05:40,866 --> 00:05:44,796 Joe Wong: Just from a workflow perspective, generally, antigen tests are 112 00:05:44,796 --> 00:05:46,926 a little bit faster than molecular tests. 113 00:05:46,926 --> 00:05:50,706 Although as molecular tests get better and better, that turnaround time decreases. 114 00:05:50,706 --> 00:05:54,216 So if you have the option to do both, you know, you've gotta consider during busy 115 00:05:54,216 --> 00:05:58,566 season if you're trying to get patients in and out, is that increased turnaround 116 00:05:58,566 --> 00:05:59,776 time worth it for molecular tests? 117 00:06:00,441 --> 00:06:05,851 Chris: Yeah and one other thing too is that antigen tests are often standalone. 118 00:06:05,851 --> 00:06:09,635 They're lateral flow tests, so you just pull it out of a cartridge, put 119 00:06:09,635 --> 00:06:11,286 the test, in , you get a result. 120 00:06:11,736 --> 00:06:16,536 Whereas a molecular test generally has to have interpretive reader and amplification 121 00:06:17,231 --> 00:06:19,421 platform or amplification technique. 122 00:06:19,691 --> 00:06:22,361 So it is definitely much more robust. 123 00:06:22,361 --> 00:06:25,421 You can have antigen tests, you can just pull it out and run it 124 00:06:25,421 --> 00:06:30,191 without electricity, without any other technology, and that is a 125 00:06:30,191 --> 00:06:33,931 consideration where you're looking at antigen tests versus molecular test.. 126 00:06:34,571 --> 00:06:35,261 Joe: Great points. 127 00:06:35,411 --> 00:06:35,681 Tracey: Awesome. 128 00:06:36,711 --> 00:06:39,321 Joe: You know, The clinical pathways in this issue were great. 129 00:06:39,361 --> 00:06:43,051 In the one for STIs, there's a decision branch for patients who 130 00:06:43,051 --> 00:06:44,431 are asymptomatic, are worried. 131 00:06:44,431 --> 00:06:47,641 Well, I think clinicians may wonder why we shouldn't just test for 132 00:06:47,641 --> 00:06:50,731 everything if someone has general concerns, you guys appropriately 133 00:06:50,731 --> 00:06:53,641 recommend using sexual history and risk factors to guide the workup. 134 00:06:54,221 --> 00:06:55,151 Can you elaborate on that? 135 00:06:56,081 --> 00:06:56,351 Joe Wong: Sure. 136 00:06:56,351 --> 00:06:58,691 So absolutely we get a lot of patients come in and they just 137 00:06:58,691 --> 00:07:00,191 want to be tested for everything. 138 00:07:00,191 --> 00:07:03,671 We hear that a lot and I think as clinicians we really need to help 139 00:07:03,671 --> 00:07:06,371 guide the patients into what's actually needed and what's not. 140 00:07:06,371 --> 00:07:10,911 So inappropriate testing, over testing and picking up things that are not 141 00:07:11,061 --> 00:07:15,141 pathologic, can lead to overtreatment and really confusing, especially in 142 00:07:15,141 --> 00:07:18,441 the urgent care setting where you're not always following your own patient. 143 00:07:18,441 --> 00:07:21,291 Sometimes you're picking up someone else's results and you can 144 00:07:21,291 --> 00:07:22,641 only go off their clinical note. 145 00:07:22,641 --> 00:07:26,251 So, appropriate testing at the onset is very, very important. 146 00:07:26,581 --> 00:07:32,124 So, generally as far as asymptomatic presentation, if there is a 147 00:07:32,184 --> 00:07:35,299 known exposure, that's kind of generally where I'll start with. 148 00:07:35,299 --> 00:07:38,389 And kind of the most common testing here is gonna be gonorrhea, 149 00:07:38,419 --> 00:07:39,649 chlamydia, and trichomonas. 150 00:07:39,709 --> 00:07:41,689 A lot of those tests are bundled together. 151 00:07:42,259 --> 00:07:45,829 Depending on the patient's history and risk factors it's 152 00:07:45,829 --> 00:07:47,789 gonna also guide your specimen. 153 00:07:47,909 --> 00:07:52,764 So if there's been history, potential of oral sex that we want to consider swabbing 154 00:07:52,824 --> 00:07:57,264 the pharynx if you're not gonna pick that up on just a vaginal or a urine specimen. 155 00:07:57,504 --> 00:08:01,094 So asking the appropriate questions, getting a good HPI and Rs and 156 00:08:01,094 --> 00:08:04,404 really having that discussion can help guide the initial testing. 157 00:08:04,744 --> 00:08:07,684 I think some of the important things to keep in mind are, 158 00:08:07,954 --> 00:08:12,604 bacterial vaginosis, these pathogens potentially that could be normal. 159 00:08:12,634 --> 00:08:17,584 And if there's not any symptoms, there's no fishy odor, there's no vaginal itching, 160 00:08:17,584 --> 00:08:21,214 irritation, and you just test a bunch of people, you're gonna get positives. 161 00:08:21,214 --> 00:08:22,174 And what do you do with that? 162 00:08:22,364 --> 00:08:26,514 We don't wanna put everybody on metronidazole if they're asymptomatic. 163 00:08:26,514 --> 00:08:30,564 And so again, having that conversation upfront, knowing what the symptoms 164 00:08:30,564 --> 00:08:33,744 are, if there are any, and directing the initial test is very important. 165 00:08:34,344 --> 00:08:36,174 Chris: Yeah, I think to add on to what Joe said. 166 00:08:37,149 --> 00:08:40,719 Everything about testing is assessing the pretest probability 167 00:08:40,719 --> 00:08:41,889 and the predictive value. 168 00:08:42,519 --> 00:08:46,879 Your approach is going to be different if someone is truly asymptomatic 169 00:08:46,879 --> 00:08:51,069 exposure with low risk versus someone who is symptomatic with exposure, 170 00:08:51,579 --> 00:08:54,909 because regardless of what the test shows, if it's a send out test, 171 00:08:54,909 --> 00:08:56,349 you don't have immediate results. 172 00:08:56,659 --> 00:08:59,299 There's a difference between whether or not you want to empirically treat 173 00:08:59,359 --> 00:09:03,139 the patient with antibiotics or if you want to basically wait for the test. 174 00:09:03,529 --> 00:09:06,097 Also, depending on what type of kind of testing platform we do. 175 00:09:06,097 --> 00:09:12,157 For example, in a female patient, we know that urine GC and chlamydia 176 00:09:12,157 --> 00:09:17,527 testing are going to be less sensitive than a swab molecular test. 177 00:09:18,037 --> 00:09:22,447 And if the patient is truly asymptomatic, pretest probability is gonna be 178 00:09:22,447 --> 00:09:23,797 different than someone who's symptomatic. 179 00:09:24,547 --> 00:09:28,387 And that helps guide test selection as well as interpreting the test 180 00:09:28,387 --> 00:09:29,827 in terms of predictive value. 181 00:09:30,277 --> 00:09:32,857 This may have been in the article, I just can't remember. 182 00:09:32,917 --> 00:09:34,717 I used the term spray and pray. 183 00:09:34,944 --> 00:09:37,131 The worst thing you can do is when someone comes in and 184 00:09:37,131 --> 00:09:39,431 says, Hey, I want STI testing. 185 00:09:40,031 --> 00:09:41,171 I need to know their risk. 186 00:09:41,171 --> 00:09:43,091 I need to know what to test them for. 187 00:09:43,541 --> 00:09:46,991 And there is a whole litany of tests that we can run. 188 00:09:47,321 --> 00:09:50,461 The ones that are particularly problematic or could be ureaplasma 189 00:09:50,476 --> 00:09:55,031 and mgen mycoplasm genitalium, because the interpretation of a positive 190 00:09:55,031 --> 00:09:56,981 test is very, very, very difficult. 191 00:09:57,341 --> 00:10:00,701 If you just blast test out and test everything, you're gonna get 192 00:10:00,701 --> 00:10:04,451 positive test results that may not be clinically significant, and it's 193 00:10:04,451 --> 00:10:06,896 gonna actually be a problem if we have to explain that to the patient. 194 00:10:07,751 --> 00:10:08,951 Joe Wong: I got one more thing here. 195 00:10:08,981 --> 00:10:14,011 Some of our clinics are using different labs that have preset panels, right? 196 00:10:14,011 --> 00:10:16,951 And so if you order a vaginitis panel, it's gonna be different 197 00:10:16,951 --> 00:10:18,511 depending on which lab you use. 198 00:10:18,511 --> 00:10:20,881 Some of them it's just gonna be BV and yeast. 199 00:10:21,151 --> 00:10:25,591 Other of those are going to include ureaplasma and mycoplasma, where that's 200 00:10:25,591 --> 00:10:27,781 not an appropriate test off at the onset. 201 00:10:27,781 --> 00:10:33,076 So initially when we brought on a lab, we saw a lot of these vaginitis 202 00:10:33,076 --> 00:10:36,256 panels being ordered, and a lot of people receiving doxycycline because 203 00:10:36,256 --> 00:10:39,989 clinicians just weren't used to seeing a name of a pathogen on a panel. 204 00:10:39,989 --> 00:10:43,629 When they see something that's there it's not gonna tell you that it's normal flora. 205 00:10:44,009 --> 00:10:46,919 And they're going to usually go throw an antibiotic at it. 206 00:10:47,004 --> 00:10:47,294 Yeah. 207 00:10:47,459 --> 00:10:47,699 Tracey: Yeah. 208 00:10:47,729 --> 00:10:48,479 That happens a lot. 209 00:10:48,479 --> 00:10:51,689 I mean, you really gotta know what you're testing for and 210 00:10:51,689 --> 00:10:53,069 how to interpret the results. 211 00:10:53,069 --> 00:10:54,809 Again, it's not just positive or negative. 212 00:10:54,809 --> 00:10:57,783 It does require some degree of interpretation, which people 213 00:10:57,783 --> 00:10:58,903 really need to be aware of. 214 00:10:59,180 --> 00:11:03,200 Chris: Tracy, the other thing too is that once upon a time, some urgent 215 00:11:03,200 --> 00:11:08,000 cares would not do asymptomatic screening, and what we found out is 216 00:11:08,000 --> 00:11:10,130 that patients would lie, oh, I'm sorry. 217 00:11:10,160 --> 00:11:11,720 We don't do asymptomatic screening. 218 00:11:11,840 --> 00:11:13,430 Well, I'm having discharge. 219 00:11:13,520 --> 00:11:13,820 Tracey: Yeah. 220 00:11:13,910 --> 00:11:19,430 Chris: Okay, so from a medical director standpoint, instead of basically trying 221 00:11:19,430 --> 00:11:22,867 to define, do you do asymptomatic screening or is it diagnostic? 222 00:11:23,287 --> 00:11:25,777 I just want the patient to be very truthful with me. 223 00:11:25,877 --> 00:11:26,807 What is your worry? 224 00:11:27,017 --> 00:11:28,457 What is your pre-test risk? 225 00:11:28,557 --> 00:11:33,657 'Cause that greatly affects how I implement testing, what tests I use, and 226 00:11:33,657 --> 00:11:35,367 whether or not do an empiric treatment. 227 00:11:36,237 --> 00:11:36,687 Tracey: Definitely. 228 00:11:37,047 --> 00:11:37,497 Definitely. 229 00:11:38,067 --> 00:11:39,177 All right, so let's shift a little bit. 230 00:11:39,177 --> 00:11:40,587 We're seeing all sorts of home tests. 231 00:11:40,587 --> 00:11:41,967 It seems like they're popping up every day. 232 00:11:41,967 --> 00:11:44,757 You can actually buy a test for GC and chlamydia on Amazon these 233 00:11:44,757 --> 00:11:46,107 days, which is kind of ridiculous. 234 00:11:46,517 --> 00:11:49,727 This kind of seemed to start with COVID when they initially started doing COVID 235 00:11:49,727 --> 00:11:53,227 home testing, which was kind of a game changer with how we dealt with COVID. 236 00:11:53,747 --> 00:11:58,257 And also recently we have some influenza home testing and similar, there's 237 00:11:58,257 --> 00:12:00,417 home tests and results for UTIs. 238 00:12:00,867 --> 00:12:03,597 We're even seeing this, like I said, the send out test for the GC and 239 00:12:03,597 --> 00:12:08,187 chlamydia and the send out blood sticks for herpes and other STIs. 240 00:12:08,727 --> 00:12:11,697 How should patients coming in with positive tests of things that they've 241 00:12:11,697 --> 00:12:15,067 done at home and wanting to be treated, how should you handle that? 242 00:12:15,067 --> 00:12:16,117 Do you retest them? 243 00:12:16,117 --> 00:12:18,247 Do you go back to whatever their result is? 244 00:12:18,487 --> 00:12:22,177 Do you just start all over again with an h and p and deal with it from there? 245 00:12:22,607 --> 00:12:25,877 How do we understand the sensitivity and specificity of all these home tests? 246 00:12:26,177 --> 00:12:29,047 This is just, an incredibly loaded question, so go ahead. 247 00:12:29,047 --> 00:12:29,557 Have at it. 248 00:12:30,367 --> 00:12:32,756 Chris: Well, it's a loaded question, but it's a very fair question. 249 00:12:32,816 --> 00:12:32,996 Tracey: Yeah. 250 00:12:33,056 --> 00:12:36,086 Chris: We are seeing a lot of home tests and home testing options. 251 00:12:36,536 --> 00:12:39,176 I think there's a couple of comments I'd like to make. 252 00:12:39,446 --> 00:12:44,396 Just because a test is offered by a CLIA accredited lab doesn't mean 253 00:12:44,396 --> 00:12:46,406 that they're doing a good test. 254 00:12:46,796 --> 00:12:50,726 In fact, some of these testing centers will test for things that are 255 00:12:50,726 --> 00:12:54,266 clinically irrelevant and then you're the one that has to deal with it. 256 00:12:54,776 --> 00:12:56,816 Let's start with the simplest situations. 257 00:12:57,716 --> 00:13:01,203 If someone comes in with a positive COVID test, they have COVID. 258 00:13:01,833 --> 00:13:02,133 Okay? 259 00:13:02,323 --> 00:13:03,163 That's easy peasy. 260 00:13:03,163 --> 00:13:04,903 You do not need to repeat the test. 261 00:13:05,233 --> 00:13:06,073 Same with flu. 262 00:13:06,553 --> 00:13:10,193 If the flu home test is positive, then they have flu. 263 00:13:11,143 --> 00:13:12,673 Tracey: I have one caveat to that though. 264 00:13:12,673 --> 00:13:14,833 I make the patients show me the, on their phone. 265 00:13:14,843 --> 00:13:16,133 'Cause they all take pictures of it, right? 266 00:13:16,183 --> 00:13:18,613 So I make them show me on the phone because a lot of times they 267 00:13:18,613 --> 00:13:19,783 don't interpret it correctly. 268 00:13:20,113 --> 00:13:23,383 I had one lady the other day, not too long ago that she's like, but there was a, 269 00:13:23,383 --> 00:13:27,063 and my nurse went and tested her anyway, even though she had a positive test. 270 00:13:27,213 --> 00:13:28,803 I tell 'em not to, 'cause what am I gonna do? 271 00:13:28,833 --> 00:13:30,123 Tell you no, you don't have COVID. 272 00:13:30,223 --> 00:13:31,333 When you had a positive home test. 273 00:13:31,768 --> 00:13:33,748 But anyway, so I said you're negative here. 274 00:13:33,748 --> 00:13:35,248 And the lady says, well, that's not possible. 275 00:13:35,278 --> 00:13:37,028 'cause I was positive at home, see? 276 00:13:37,228 --> 00:13:40,018 and she whips out her phone with a picture and it had one red line on it. 277 00:13:40,078 --> 00:13:41,908 I'm like, that's not a positive test. 278 00:13:41,908 --> 00:13:43,708 She says, but look, it's got a C next to it. 279 00:13:43,708 --> 00:13:44,668 It means I have COVID. 280 00:13:44,723 --> 00:13:47,723 I said, no, the C is control, not positive for COVID. 281 00:13:48,023 --> 00:13:51,533 So, confirm that positive test at home before you jump all over that. 282 00:13:51,653 --> 00:13:52,613 Chris: No, absolutely. 283 00:13:52,613 --> 00:13:56,718 In fact, when we were looking at occupational health and certifying people 284 00:13:56,718 --> 00:14:01,548 with COVID, one of the requirements was you had to have a picture of the test with 285 00:14:01,548 --> 00:14:05,118 the date written on it and attest to it. 286 00:14:05,598 --> 00:14:09,708 But generally, I think if someone comes in with a positive COVID test or positive 287 00:14:09,708 --> 00:14:14,208 flu test and have symptoms consistent with the disease, it's gonna be very, 288 00:14:14,208 --> 00:14:17,778 very, very hard for me to basically say, no, this is probably invalid. 289 00:14:17,828 --> 00:14:21,578 You really do have to look at the epidemiological distribution of 290 00:14:21,578 --> 00:14:23,078 what's going around in your community. 291 00:14:23,078 --> 00:14:25,898 I mean, if COVID is prevalent, you probably don't even need 292 00:14:25,898 --> 00:14:27,658 a test to call it COVID. 293 00:14:27,748 --> 00:14:33,118 But I understand that we are in the world where patients want testing, 294 00:14:33,118 --> 00:14:34,708 and clinicians want testing. 295 00:14:35,128 --> 00:14:39,618 I do have a little bit more of a issue with finger sticks and having blood 296 00:14:39,618 --> 00:14:45,038 samples sent for other tests like herpes and other pathogens, because some of those 297 00:14:45,038 --> 00:14:46,808 you just don't know how to interpret. 298 00:14:46,808 --> 00:14:49,388 You don't know the context, you don't know the laboratory. 299 00:14:49,388 --> 00:14:52,628 You don't know what was actually done. 300 00:14:53,318 --> 00:14:55,448 And so the question is, do you retest? 301 00:14:55,988 --> 00:14:58,118 you can't answer that as a yes or no. 302 00:14:58,178 --> 00:15:01,598 It's gonna have to be based on the clinical situation, based on what 303 00:15:01,598 --> 00:15:07,408 the patient is coming in for and what the potential treatment options are. 304 00:15:07,981 --> 00:15:08,341 Joe Wong: Sure. 305 00:15:08,341 --> 00:15:13,051 I think there's sometimes in my clinic where especially in busy seasons, the 306 00:15:13,051 --> 00:15:15,301 patients get swabbed before I see them. 307 00:15:15,631 --> 00:15:16,231 The time as clinician. 308 00:15:16,231 --> 00:15:16,291 Yeah. 309 00:15:16,741 --> 00:15:19,771 And sometimes it will it'll be different than their home tests, positive 310 00:15:19,771 --> 00:15:21,271 home tests negative in the clinic. 311 00:15:21,331 --> 00:15:25,136 I do have a little bit of conversation with the patient about how they did 312 00:15:25,136 --> 00:15:26,546 the test, how long did it sit for? 313 00:15:26,546 --> 00:15:27,596 Did it sit overnight? 314 00:15:27,866 --> 00:15:31,686 Is there some backflow in that lateral assay that's causing a false positive. 315 00:15:31,686 --> 00:15:35,723 But in general, the specificity of these tests is pretty high . And 316 00:15:35,723 --> 00:15:40,313 sensitivity might be a little less, but overall a positive is if it's 317 00:15:40,313 --> 00:15:41,889 consistent with clinical symptoms. 318 00:15:41,889 --> 00:15:43,719 I agree with Chris And no need to retest. 319 00:15:44,034 --> 00:15:44,324 Yeah. 320 00:15:44,439 --> 00:15:47,879 Chris: Yeah, I think the key point is positive is generally valid. 321 00:15:48,179 --> 00:15:52,244 It's the negative test of the home tests that are the problem, because 322 00:15:52,244 --> 00:15:56,234 those are the ones where they could be a false negative or the swab was done 323 00:15:56,234 --> 00:16:01,475 incorrectly, or the actual test was performed incorrectly but I do think 324 00:16:01,475 --> 00:16:06,442 that as we see more and more home testing options, including laboratory options, 325 00:16:06,832 --> 00:16:09,982 the urgent care clinician is going to have to face more and more of these 326 00:16:09,982 --> 00:16:13,102 decisions, ultimately go back to basics. 327 00:16:13,102 --> 00:16:14,032 Take the history. 328 00:16:14,437 --> 00:16:19,207 Understand what the test is trying to achieve diagnostically and 329 00:16:19,207 --> 00:16:21,217 make a decision with the patient. 330 00:16:21,667 --> 00:16:21,937 Joe: Yeah. 331 00:16:22,467 --> 00:16:22,587 Yeah. 332 00:16:22,587 --> 00:16:25,767 It's almost like you have to go back to square one and do the h and p that 333 00:16:25,767 --> 00:16:29,997 wasn't done prior to the person doing their own test and then put it together 334 00:16:29,997 --> 00:16:32,850 with the results to, to figure out, like you said, Interpreting a positive test. 335 00:16:32,850 --> 00:16:35,190 Most people don't worry about interpreting positive tests. 336 00:16:35,190 --> 00:16:38,340 A positive test is positive, but there are times where you don't 337 00:16:38,340 --> 00:16:39,820 necessarily treat a positive test. 338 00:16:39,840 --> 00:16:39,990 so 339 00:16:40,553 --> 00:16:43,113 Hey in the issue you talked about, and we'll talk about herpes again, 340 00:16:43,113 --> 00:16:47,113 I guess as a specific example the kind of problems with interpreting 341 00:16:47,530 --> 00:16:49,060 serologic testing for herpes. 342 00:16:49,110 --> 00:16:50,940 And that's also one of those send out tests. 343 00:16:51,120 --> 00:16:53,560 What's the best approach for diagnosing this infection? 344 00:16:53,580 --> 00:16:55,450 You have a good algorithm in there. 345 00:16:55,870 --> 00:16:56,710 If you could summarize it. 346 00:16:57,610 --> 00:16:57,880 Joe Wong: Sure. 347 00:16:57,880 --> 00:17:00,790 Typically herpes simplex is a clinical diagnosis. 348 00:17:00,790 --> 00:17:04,030 It's not like we're unroofing every single one of these vesicles and sending 349 00:17:04,030 --> 00:17:06,317 it off for molecular confirmation. 350 00:17:06,627 --> 00:17:10,692 Um, So generally yeah, if there's a vesicle there, it is clear, then 351 00:17:10,692 --> 00:17:13,777 you go ahead and treat with your antiviral if that's appropriate. 352 00:17:14,227 --> 00:17:17,857 As far as confirmation testing goes the best way is to, if there's 353 00:17:17,857 --> 00:17:21,197 active lesion there, unroof it, swab that vesicular fluid, send it 354 00:17:21,197 --> 00:17:23,277 off, that is the best way to do it. 355 00:17:23,557 --> 00:17:26,447 Some of these labs have actually taken off some of the serologies, 356 00:17:26,467 --> 00:17:30,767 particularly IGM because it's just not a good test in the acute phase. 357 00:17:30,797 --> 00:17:33,047 It doesn't show up quickly. 358 00:17:33,147 --> 00:17:36,792 There's confusion and interference between type one and type two. 359 00:17:36,792 --> 00:17:37,812 So it's just not a great test. 360 00:17:37,812 --> 00:17:39,462 Some of them don't even offer it anymore. 361 00:17:39,802 --> 00:17:44,368 We get a lot of patients that want serologic testing for HSV just to see 362 00:17:44,548 --> 00:17:47,948 if they're positive, and it kind of goes back to the I want be tested for 363 00:17:47,948 --> 00:17:50,618 everything, or my partner has herpes. 364 00:17:50,618 --> 00:17:51,638 I I need to be tested. 365 00:17:51,638 --> 00:17:56,106 You ask them, well, have you ever had an outbreak before uh, cold sore genital 366 00:17:56,106 --> 00:17:58,056 lesions that look like little pimples? 367 00:17:58,056 --> 00:17:59,136 And the answer is no. 368 00:17:59,616 --> 00:18:01,506 What do you do with that test result? 369 00:18:01,821 --> 00:18:05,701 I mean, if it comes back positive there's a risk of a false positive, 370 00:18:05,701 --> 00:18:08,259 there's a chance that they're exposed to it sometime in the past. 371 00:18:08,283 --> 00:18:10,563 But that doesn't necessarily mean they'll ever have an 372 00:18:10,563 --> 00:18:12,178 outbreak or ever need treatment. 373 00:18:12,473 --> 00:18:14,903 So it just makes it really confusing for the patient. 374 00:18:14,903 --> 00:18:18,593 A negative test could also provide false assurance that they don't have 375 00:18:18,593 --> 00:18:19,883 it or haven't been exposed to it. 376 00:18:19,883 --> 00:18:23,243 So, serology testing I'm not a big fan of, I don't really bring 377 00:18:23,243 --> 00:18:24,773 this up with most patients. 378 00:18:24,773 --> 00:18:28,813 If they do bring it up, I'll have that conversation with them and try to dissuade 379 00:18:28,813 --> 00:18:30,863 them generally from testing for that. 380 00:18:31,043 --> 00:18:34,823 I think the one exception would be if there's been recent vesicular 381 00:18:34,823 --> 00:18:37,083 lesions that have fully resolved. 382 00:18:37,458 --> 00:18:40,158 Then we can talk about IgG testing for HSV. 383 00:18:40,665 --> 00:18:43,281 Chris: Actually, Joe, I'm gonna double down and actually go a 384 00:18:43,281 --> 00:18:44,721 little bit stronger on that. 385 00:18:44,751 --> 00:18:49,071 I think serology testing for herpes simplex is inappropriate for urgent care. 386 00:18:49,071 --> 00:18:49,341 Absolutely. 387 00:18:49,341 --> 00:18:54,445 And there's several reasons why the readers and what the listeners really need 388 00:18:54,445 --> 00:18:59,365 to let it sink in is that for HSV one, there is a significant percentage of the 389 00:18:59,365 --> 00:19:06,627 population that will have antibodies to HSV one and a less significant population 390 00:19:06,627 --> 00:19:08,907 with HSV two, but it's not insignificant. 391 00:19:08,907 --> 00:19:14,217 It's like 16% globally, so that means one outta six patients who go test positive. 392 00:19:14,697 --> 00:19:20,937 It never fails that at least one or two times a month, we get a patient come 393 00:19:20,937 --> 00:19:26,547 into urgent care saying, well, I got herpes testing and it says I'm positive. 394 00:19:27,042 --> 00:19:28,122 What does this mean? 395 00:19:28,242 --> 00:19:31,062 Because they went to a testing center, they got the result, and 396 00:19:31,062 --> 00:19:34,302 they now test IgG HSV one positive. 397 00:19:34,332 --> 00:19:35,802 And they're like, what does this mean? 398 00:19:36,252 --> 00:19:40,812 And hey it's, good for us because that's a really easy visit. 399 00:19:41,262 --> 00:19:43,002 You ask, well, what do you tell the patient? 400 00:19:43,302 --> 00:19:45,132 I just explained to them what I just said. 401 00:19:45,372 --> 00:19:50,482 Yeah that just simply means that we have detected antibodies to HSV one. 402 00:19:50,567 --> 00:19:51,792 Well, what does that mean? 403 00:19:51,942 --> 00:19:54,642 Does that mean that I'm gonna have a future outbreak? 404 00:19:54,957 --> 00:19:58,580 Well, I can't tell you if it's gonna be in the oral area or if 405 00:19:58,580 --> 00:20:02,180 it's gonna be in a genital area, but you may never get a lesion. 406 00:20:02,250 --> 00:20:02,610 Ever. 407 00:20:03,213 --> 00:20:07,470 And so it kind of goes back to the earlier question that you guys asked. 408 00:20:07,830 --> 00:20:11,077 Is there ever a test that is a potentially bad test? 409 00:20:11,077 --> 00:20:12,547 Do you just test for everything? 410 00:20:12,847 --> 00:20:16,777 Well, if you know how to interpret this and explain this to the patient, 411 00:20:17,227 --> 00:20:18,132 then I think that's one thing. 412 00:20:18,817 --> 00:20:22,627 But some of these labs will just run to test at the whim and then 413 00:20:22,627 --> 00:20:24,197 it's like, go figure it out. 414 00:20:24,397 --> 00:20:25,407 That's no bueno. 415 00:20:26,063 --> 00:20:26,243 Tracey: Yeah. 416 00:20:26,243 --> 00:20:27,323 I just wanna add the other thing. 417 00:20:27,323 --> 00:20:31,013 You know, The HSV one versus HSV two, I mean, there was a time, whereas if you 418 00:20:31,013 --> 00:20:34,853 had HSV one that meant you had a cold sore and it was herpes labialis, and if 419 00:20:34,853 --> 00:20:36,623 you had two, it meant you had genitalia. 420 00:20:37,013 --> 00:20:39,183 We can't say that anymore, because of. 421 00:20:39,285 --> 00:20:43,645 You know, Sexual practices over the years, one and two doesn't mean anything. 422 00:20:43,645 --> 00:20:45,302 You know it's a clinical diagnosis. 423 00:20:45,302 --> 00:20:47,492 If you have it on your lip, you have herpes labialis. 424 00:20:47,492 --> 00:20:51,362 If you have it in your genitals, it's herpes genitalia, so you can't 425 00:20:51,362 --> 00:20:52,982 really go by the herpes one and two. 426 00:20:52,982 --> 00:20:56,072 And I hear people all the time, telling people that, oh, it's 427 00:20:56,072 --> 00:20:59,522 just a cold sore 'cause it's one, no, that's not the case anymore. 428 00:20:59,522 --> 00:21:00,632 You can't say that anymore. 429 00:21:00,722 --> 00:21:02,126 I think our listeners need to know that 430 00:21:02,194 --> 00:21:02,374 . Chris: Yeah. 431 00:21:02,404 --> 00:21:02,601 Joe. 432 00:21:02,601 --> 00:21:04,616 Hit it right on the spot where he says. 433 00:21:05,286 --> 00:21:07,686 Really the test that you deroof the lesion. 434 00:21:07,716 --> 00:21:07,896 Yeah. 435 00:21:07,956 --> 00:21:09,817 You send it for molecular NAA. 436 00:21:10,056 --> 00:21:10,326 Right. 437 00:21:10,326 --> 00:21:14,196 That is really the only appropriate test in urgent care. 438 00:21:14,286 --> 00:21:17,559 Tracey: I tell people, you know, if you have no lesions, I can't test you. 439 00:21:17,709 --> 00:21:18,279 And that's it. 440 00:21:18,519 --> 00:21:18,909 Right there, 441 00:21:19,119 --> 00:21:19,689 Joe: concur. 442 00:21:19,959 --> 00:21:20,169 Yeah. 443 00:21:20,229 --> 00:21:22,449 And for the purposes of treatment, you're only gonna really, unless you're 444 00:21:22,449 --> 00:21:25,839 talking about prophylaxis, which takes more than a test result, you're only 445 00:21:25,839 --> 00:21:28,269 gonna treat active disease anyway. 446 00:21:28,269 --> 00:21:30,369 People have all these questions about what their results are and 447 00:21:30,369 --> 00:21:33,759 who'd they get it from, which is even harder thing to figure out sometimes. 448 00:21:34,129 --> 00:21:36,939 But yeah, the treatment part of it requires active disease and 449 00:21:36,969 --> 00:21:39,099 sometimes you can't even wait for the test results to come back 450 00:21:39,099 --> 00:21:40,059 'cause you wanna start treatment. 451 00:21:40,269 --> 00:21:44,709 If you make the clinical diagnosis, the test result would confirm 452 00:21:44,709 --> 00:21:47,379 it, but you're still gonna treat based on your clinical diagnosis. 453 00:21:47,379 --> 00:21:47,529 Yeah. 454 00:21:48,459 --> 00:21:48,609 Tracey: All right. 455 00:21:48,609 --> 00:21:50,799 Let's shift gears a little bit and let's start talking about 456 00:21:50,799 --> 00:21:52,359 some PCR testing for strep. 457 00:21:52,746 --> 00:21:55,826 You know, Traditionally we were all using antigen tests, which, honestly 458 00:21:55,826 --> 00:21:57,446 I think is probably still good enough. 459 00:21:57,446 --> 00:21:59,786 The sensitivity and specificity on that is high enough. 460 00:22:00,381 --> 00:22:02,511 But you know, now we have the PCR testing. 461 00:22:03,051 --> 00:22:06,368 So what happens if you think that somebody has a clinical concern for strep 462 00:22:06,368 --> 00:22:09,788 pharyngitis and you're kind of surprised that your antigen comes back negative. 463 00:22:10,148 --> 00:22:12,938 Can you walk through the process of, you know, should we do 464 00:22:12,938 --> 00:22:14,408 PCR, should we do culture? 465 00:22:14,408 --> 00:22:15,428 Or how should we do that? 466 00:22:15,858 --> 00:22:18,618 And should we do that for everybody or should we just do that for kids? 467 00:22:19,323 --> 00:22:21,107 does the h and p factor into any of that? 468 00:22:21,179 --> 00:22:25,109 Chris: actually, Tracy, the historical gold standard was culture. 469 00:22:25,469 --> 00:22:25,889 Of course. 470 00:22:25,889 --> 00:22:28,889 It wasn't until we actually had antigen tests that we started 471 00:22:28,889 --> 00:22:31,139 having a point of care solution 472 00:22:31,139 --> 00:22:33,179 Tracey: kind of scary, but I remember that and so does Joe. 473 00:22:33,179 --> 00:22:33,269 Chris: Sure. 474 00:22:34,139 --> 00:22:34,829 Oh, come on. 475 00:22:34,829 --> 00:22:36,179 You guys are showing your age now. 476 00:22:36,239 --> 00:22:36,899 Yeah, we are. 477 00:22:36,899 --> 00:22:37,379 Definitely. 478 00:22:37,379 --> 00:22:37,589 Yeah. 479 00:22:37,906 --> 00:22:41,544 The nice thing is the listeners can't tell our age, but you guys just outed yourself. 480 00:22:42,024 --> 00:22:42,324 There you go. 481 00:22:42,744 --> 00:22:46,284 Yeah, so, so I think that strep is actually very interesting because. 482 00:22:46,859 --> 00:22:50,089 I'm gonna say a few things that may shock some of our listeners 483 00:22:50,089 --> 00:22:55,849 that at the end of the day, most strep is a self-limited disease. 484 00:22:55,879 --> 00:22:56,269 Tracey: Absolutely. 485 00:22:56,629 --> 00:23:00,769 Chris: And the two primary reasons why we treat for strep is one to 486 00:23:00,769 --> 00:23:03,589 prevent non suppurate of complications. 487 00:23:03,589 --> 00:23:08,539 Specifically acute rheumatic fever that in the 1920s, rheumatic fever 488 00:23:08,539 --> 00:23:11,929 and strep was actually leading cause of morbidity and mortality. 489 00:23:12,439 --> 00:23:18,469 And once we had widespread use of penicillin and antibiotics, we 490 00:23:18,469 --> 00:23:22,849 started noticing a significant drop in the rate of rheumatic fever. 491 00:23:23,419 --> 00:23:27,709 Now, there are several reasons why we think that is, and that one of 492 00:23:27,709 --> 00:23:34,579 the primary ones is that strep has various variants, and that over time 493 00:23:34,609 --> 00:23:39,409 we have selected out the strep that is much more tolerant, which is why 494 00:23:39,409 --> 00:23:40,724 we're seeing more colonizations. 495 00:23:41,449 --> 00:23:46,559 And that the strep that actually causes rheumatic fever is not circulating or is 496 00:23:46,559 --> 00:23:49,619 very rare, at least in the United States. 497 00:23:49,979 --> 00:23:54,249 So the question then goes to why is an antigen test good 498 00:23:54,249 --> 00:23:59,079 enough for certain populations and why is antigen test require 499 00:23:59,079 --> 00:24:01,269 confirmation for other populations? 500 00:24:01,689 --> 00:24:05,769 And it all boils down to what is the population that is at the 501 00:24:05,769 --> 00:24:09,804 highest risk for rheumatic fever, and that is ages three to 18. 502 00:24:10,539 --> 00:24:15,519 And that is the specific population where a confirmation test is recommended. 503 00:24:16,119 --> 00:24:21,399 Now, if you have an adult who has strep, there are some very special cases. 504 00:24:21,599 --> 00:24:24,899 We may have touched it in the article, but we didn't really elaborate. 505 00:24:25,409 --> 00:24:31,109 If you have a patient that has a history of rheumatic fever, if you have 506 00:24:31,109 --> 00:24:35,999 a patient that has come from an area where rheumatic fever is endemic, okay. 507 00:24:37,469 --> 00:24:40,499 If you have a patient that is significantly or severely 508 00:24:40,499 --> 00:24:45,059 immunocompromised, those are some of the special circumstances where 509 00:24:45,209 --> 00:24:49,199 even in an adult, an antigen test may need confirmation testing. 510 00:24:50,189 --> 00:24:55,969 So the other thing that we need to keep in mind is that IDSA pulled 511 00:24:55,969 --> 00:25:02,599 a little bit of a surprise on us, specifically in mid-October, right after 512 00:25:02,839 --> 00:25:05,149 our article had gone to peer review. 513 00:25:05,539 --> 00:25:11,989 And in validation, they basically made it a recommendation to use clinical decision 514 00:25:11,989 --> 00:25:16,549 trees as a factor into who should test. 515 00:25:16,549 --> 00:25:21,649 The previous recommendation was test everyone with pharyngitis unless there's 516 00:25:21,709 --> 00:25:25,234 overt evidence of viral infection. 517 00:25:26,044 --> 00:25:29,274 Joe Wong: Again, we see patients with sore throat a lot and even 518 00:25:29,274 --> 00:25:31,844 a lot of them come in with tonsil or hypertrophy and exudates. 519 00:25:31,844 --> 00:25:36,284 They even might have that strep smell and comes back as negative. 520 00:25:36,384 --> 00:25:42,084 With the increasing popularity of molecular testing, I'm not saying 521 00:25:42,084 --> 00:25:45,874 that we need to do molecular testing in any of the cases in fact in 522 00:25:45,874 --> 00:25:49,654 the article the recommendation is just to look at group A strep. 523 00:25:50,239 --> 00:25:52,299 But every now and then you get, you know, some other people 524 00:25:52,299 --> 00:25:53,904 who order a pharyngitis panel. 525 00:25:54,084 --> 00:25:57,754 And I think in school a lot of times we're taught, if it's tonsil exudates 526 00:25:57,754 --> 00:25:59,284 and strep negative, think about mono. 527 00:25:59,854 --> 00:26:04,354 We're seeing a lot more adenovirus and rhinovirus causing these 528 00:26:04,384 --> 00:26:09,214 tonsil hypertrophy and exudates lymphadenopathy than Epstein Barr virus. 529 00:26:09,214 --> 00:26:11,804 And so, again, following the guidelines. 530 00:26:12,209 --> 00:26:15,693 American Academy of Pediatrics, uh, CDC guidelines, three to 18 years 531 00:26:15,693 --> 00:26:16,983 old with a negative rapid strep. 532 00:26:17,343 --> 00:26:20,823 Get a group a strep culture in with the exceptions that Chris talked about. 533 00:26:20,823 --> 00:26:23,703 Everybody else we can treat it as a viral infection and they're 534 00:26:23,703 --> 00:26:25,433 gonna be a self-limited condition. 535 00:26:25,943 --> 00:26:29,006 Chris: Yeah I think what we need to pay attention to is that the 536 00:26:29,006 --> 00:26:33,866 vast majority of pharyngitis or sore throat is not caused by strep. 537 00:26:34,466 --> 00:26:39,626 And some of this may actually be a function of the widespread development 538 00:26:39,656 --> 00:26:43,376 of molecular testing so that we now can start looking to see what is 539 00:26:43,376 --> 00:26:45,986 actually causing the pharyngitis. 540 00:26:46,286 --> 00:26:50,096 So it, it just is very interesting because there's a lot more to 541 00:26:50,096 --> 00:26:54,926 strep and it's probably worthy of a greater discussion in the future. 542 00:26:55,589 --> 00:26:56,969 Tracey: All right, so we got one more question. 543 00:26:57,069 --> 00:26:58,209 Let's talk about test of cure. 544 00:26:58,209 --> 00:27:01,199 I don't think we're used to doing those and we shouldn't really have 545 00:27:01,199 --> 00:27:04,368 to for most infections, but usually recovering from disease is really good 546 00:27:04,368 --> 00:27:07,488 enough but what infections require test of cure and what you do if 547 00:27:07,488 --> 00:27:09,312 somebody asks you for a test of cure. 548 00:27:10,211 --> 00:27:10,601 Joe Wong: sure. 549 00:27:11,111 --> 00:27:14,801 Primarily this is gonna be in the setting of sexually transmitted infections. 550 00:27:15,041 --> 00:27:18,731 So test of cure for gonorrhea, chlamydia primarily. 551 00:27:19,251 --> 00:27:22,761 And generally if you're giving the first line treatment and patients are recovered, 552 00:27:22,761 --> 00:27:27,341 you don't need a test of cure . if for some reason they couldn't take first line 553 00:27:27,341 --> 00:27:31,506 treatment, if they got second or third line treatment, maybe there's concern that 554 00:27:31,511 --> 00:27:33,281 they didn't finish out the full course. 555 00:27:33,636 --> 00:27:37,386 Or that they're still having symptoms, then you would do a test of cure. 556 00:27:37,626 --> 00:27:40,686 And generally that's gonna be done about four weeks after 557 00:27:40,786 --> 00:27:42,606 the initial onset of treatment. 558 00:27:43,026 --> 00:27:45,936 I think the one exception that we mentioned in the article that would 559 00:27:45,936 --> 00:27:50,446 get tested a little bit sooner is gonna be your gonococcal pharyngitis. 560 00:27:50,746 --> 00:27:54,521 Antibiotics in that area of the body are not as potent and it's 561 00:27:54,521 --> 00:27:55,811 a little bit harder to treat. 562 00:27:56,051 --> 00:27:59,416 So there's higher failure rates with treating gonoccocal pharyngitis 563 00:27:59,656 --> 00:28:03,536 and the recommendation's seven to 14 days, a preference for 14 days 564 00:28:03,536 --> 00:28:05,116 as far as test of cure for that. 565 00:28:05,316 --> 00:28:10,206 Just because of the potential for a molecular test being so sensitive that 566 00:28:10,206 --> 00:28:12,246 it's picking up dead bits of bacteria. 567 00:28:12,972 --> 00:28:17,342 Chris: Joe, I think it's very interesting that we think of test of cure as being 568 00:28:17,372 --> 00:28:23,432 STIs, but I assure you that in urgent care we see patients come in for test of 569 00:28:23,432 --> 00:28:29,942 cure for probably everything, including strep, including flu, including COVID. 570 00:28:30,656 --> 00:28:35,846 What I'd like the listeners to really keep in mind is that there's always 571 00:28:35,846 --> 00:28:41,696 going to be a period of time when a test is gonna remain positive, even 572 00:28:41,696 --> 00:28:47,261 though the patient may be cured, or if the patient is non-infectious. 573 00:28:47,441 --> 00:28:51,911 It's gonna be much more lengthy with a molecular test. 574 00:28:52,001 --> 00:28:56,771 But even an antigen test can persist positive even past an infectious state. 575 00:28:57,341 --> 00:29:04,091 In terms of test of cures, it really is a conversation to have with the patient. 576 00:29:04,781 --> 00:29:06,581 Why are you interested in test a cure? 577 00:29:06,671 --> 00:29:08,111 What are your concerns? 578 00:29:08,381 --> 00:29:12,836 Usually a patient is gonna want to test a cure because they don't feel 579 00:29:12,836 --> 00:29:16,736 like they're a hundred percent better or because they want to make sure, 580 00:29:16,766 --> 00:29:21,606 like in STDs, that they are clear to be intimate with their partner. 581 00:29:22,056 --> 00:29:26,636 So there are certain disease states where a test of cure is not recommended. 582 00:29:27,116 --> 00:29:30,536 There's certain disease states where a test of cure is recommended and Joe 583 00:29:30,536 --> 00:29:36,386 mentioned the oropharyngeal gonorrhea as one that is definitely recommended. 584 00:29:37,886 --> 00:29:40,746 Joe Wong: That is an interesting point that now we're in respiratory 585 00:29:40,746 --> 00:29:44,136 season, it usually is the patient that's coming in wanting to visit 586 00:29:44,136 --> 00:29:45,606 a family member who's high risk. 587 00:29:45,706 --> 00:29:47,926 Should I get a negative test before I go? 588 00:29:47,926 --> 00:29:50,116 And then you just get into this gray area. 589 00:29:50,356 --> 00:29:52,456 I mean, just because you're negative doesn't mean you're 590 00:29:52,456 --> 00:29:53,956 still not contagious anymore. 591 00:29:53,956 --> 00:29:58,621 Remember it's gonna be dependent on how good of a swab you got on the viral load. 592 00:29:58,681 --> 00:30:01,451 And again, antigen tests not as sensitive. 593 00:30:01,991 --> 00:30:04,991 The molecular of the test is gonna be tricky to interpret also, because it's 594 00:30:04,991 --> 00:30:08,621 gonna be persistent, false positive for a longer time down the end. 595 00:30:08,831 --> 00:30:11,441 So again, it's that conversation of helping patients kind of understand 596 00:30:11,441 --> 00:30:16,131 what the testing is for, the pros and cons, and then, in those specific cases, 597 00:30:16,171 --> 00:30:20,631 making a patient provider decision on testing negative before seeing, 598 00:30:20,761 --> 00:30:24,841 their grandmother who's got several comorbidities that's at high risk. 599 00:30:25,131 --> 00:30:27,291 Chris: Joe, that's a really, really, really good point. 600 00:30:27,411 --> 00:30:31,491 'cause we see patients come in, generally he's right. 601 00:30:31,791 --> 00:30:34,311 People come in for test of cure because they wanna make sure 602 00:30:34,311 --> 00:30:35,901 they're okay to go back to work. 603 00:30:35,931 --> 00:30:38,451 They're okay to go see grandma, they're okay. 604 00:30:38,451 --> 00:30:43,491 And some employers actually require a test of cure before they allow 605 00:30:43,491 --> 00:30:44,721 someone to come back to work. 606 00:30:45,141 --> 00:30:45,756 Joe: Still still doing that. 607 00:30:45,776 --> 00:30:46,041 Oh yeah. 608 00:30:46,041 --> 00:30:46,371 Chris: Still do. 609 00:30:46,746 --> 00:30:47,286 I've had a few, yeah. 610 00:30:47,571 --> 00:30:48,141 Still do. 611 00:30:48,261 --> 00:30:48,501 Joe: Yeah. 612 00:30:48,551 --> 00:30:53,966 Chris: And so it is education, but also recognizing what the best practices, 613 00:30:54,056 --> 00:30:56,576 guidelines for return to work? 614 00:30:56,846 --> 00:31:01,406 For most upper respiratory viral illnesses, it's gonna be fever free plus 615 00:31:01,406 --> 00:31:03,836 symptom improvement, minimum three days. 616 00:31:04,406 --> 00:31:07,766 But that doesn't mean that for something like hand foot mouth 617 00:31:07,766 --> 00:31:10,496 disease, you can shed virus for longer. 618 00:31:10,826 --> 00:31:15,686 So it is a conversation that weighs in what is the ultimate risk that the 619 00:31:15,686 --> 00:31:19,926 patient has and what is the situation that the patient wants to test of cure. 620 00:31:20,642 --> 00:31:21,132 Tracey: Good point. 621 00:31:21,412 --> 00:31:21,602 Yeah. 622 00:31:21,822 --> 00:31:22,072 Alright. 623 00:31:22,092 --> 00:31:23,592 That was a fantastic discussion. 624 00:31:23,592 --> 00:31:24,282 Thank you guys. 625 00:31:24,332 --> 00:31:28,702 Again, this article is fantastic and anybody who doesn't subscribe, please do 626 00:31:28,702 --> 00:31:32,402 so that you can read this article because it really, it takes your interpretation 627 00:31:32,402 --> 00:31:33,572 of testing to the next level. 628 00:31:33,672 --> 00:31:36,522 I certainly learned something from it and I think my practice has 629 00:31:36,522 --> 00:31:38,552 definitely improved after reading it. 630 00:31:38,552 --> 00:31:40,747 So I strongly suggest that you read the article. 631 00:31:41,402 --> 00:31:42,602 Joe: Yeah, definitely. 632 00:31:42,602 --> 00:31:44,616 You guys are acknowledged, experts on this. 633 00:31:44,716 --> 00:31:47,580 It was great To have you write the article and a real pleasure to speak with you. 634 00:31:47,700 --> 00:31:48,390 Thanks very much. 635 00:31:48,390 --> 00:31:48,660 Thank you so much for coming. 636 00:31:48,660 --> 00:31:48,960 I add 637 00:31:49,470 --> 00:31:51,090 Chris: one, one closing comment. 638 00:31:51,090 --> 00:31:51,660 Sure, of course. 639 00:31:51,900 --> 00:31:57,630 keep in mind that the technology of testing changes rapidly. 640 00:31:58,170 --> 00:31:58,585 Tracey: Good point. 641 00:31:59,070 --> 00:32:04,180 Chris: And one of the biggest asks that I have is that in some of my 642 00:32:04,180 --> 00:32:10,986 previous talks, I said, please keep up to date by subscribing to a resource 643 00:32:10,986 --> 00:32:14,706 like evidence-based urgent care or whatever resource you want to do, 644 00:32:15,246 --> 00:32:22,070 because relying on outdated information is going to lead to poor results. 645 00:32:22,326 --> 00:32:27,816 It changes so rapidly because if you took a time warp and went back 20 646 00:32:27,816 --> 00:32:32,736 years ago, the standard of care for chlamydia and gonorrhea was culture. 647 00:32:32,836 --> 00:32:33,136 Okay. 648 00:32:33,616 --> 00:32:33,676 Yeah. 649 00:32:33,676 --> 00:32:33,946 Well there was 650 00:32:33,946 --> 00:32:34,876 Tracey: nothing for chlamydia. 651 00:32:35,086 --> 00:32:35,296 Yeah. 652 00:32:35,296 --> 00:32:35,476 There, 653 00:32:35,476 --> 00:32:36,076 Chris: there was nothing. 654 00:32:36,076 --> 00:32:37,846 Tracey: If the gonorrhea was negative, it must be chlamydia. 655 00:32:37,846 --> 00:32:38,326 You treat it 656 00:32:38,541 --> 00:32:42,231 Chris: And molecular testing has been a game changer. 657 00:32:42,501 --> 00:32:42,801 Yeah. 658 00:32:42,891 --> 00:32:48,201 Now is molecular tests always gonna be this gold standard or standard of care? 659 00:32:48,261 --> 00:32:50,841 There is newer technology that's out there. 660 00:32:51,141 --> 00:32:55,671 Some of it hasn't been proven using ai, photo detection, 661 00:32:56,061 --> 00:32:58,401 using host-based diagnostics. 662 00:32:58,641 --> 00:33:00,831 These are technologies that are evolving. 663 00:33:01,356 --> 00:33:05,676 And it is absolutely critical that as a clinician, you keep up to date with 664 00:33:05,676 --> 00:33:10,026 this because otherwise you're gonna be using outdated information and 665 00:33:10,086 --> 00:33:11,916 potentially not following best practices. 666 00:33:11,916 --> 00:33:12,636 Tracey: So true. 667 00:33:12,636 --> 00:33:14,986 And that's not just for testing, too, that's treatment as well. 668 00:33:15,906 --> 00:33:16,536 Joe: Fantastic. 669 00:33:16,536 --> 00:33:17,826 Well, thanks everyone. 670 00:33:18,156 --> 00:33:18,426 Tracey: Yeah. 671 00:33:18,426 --> 00:33:20,736 So next time we got uh, hypertension. 672 00:33:20,736 --> 00:33:21,756 Hypertension, which is really awesome. 673 00:33:21,756 --> 00:33:24,726 And then January is gonna be motor vehicle accidents written 674 00:33:24,726 --> 00:33:26,616 by um, Shelly Jansen, which I've. 675 00:33:27,216 --> 00:33:28,716 I've had a peek at it, believe it or not. 676 00:33:28,863 --> 00:33:30,758 And it's really phenomenal and fantastic. 677 00:33:30,758 --> 00:33:32,948 So we got some really good stuff coming down the pike. 678 00:33:32,978 --> 00:33:36,073 Stuff that, we all need to know as urgent care clinicians and that 679 00:33:36,073 --> 00:33:38,449 we could definitely use some help doing a little bit better at. 680 00:33:38,449 --> 00:33:40,039 So look forward to those. 681 00:33:40,549 --> 00:33:41,419 Joe: Alright, take care everyone. 682 00:33:41,599 --> 00:33:41,869 Yeah. 683 00:33:41,869 --> 00:33:42,834 Thanks for having Happy holidays. 684 00:33:42,834 --> 00:33:43,834 Bye bye-Bye bye. 685 00:33:44,631 --> 00:33:47,791 Tracey: I want to thank everybody to listening to this month's evidence based 686 00:33:47,791 --> 00:33:52,192 urgentology podcast . Just a reminder that subscribers can go to ebmedicine.net 687 00:33:52,382 --> 00:33:55,932 and read the full issue if you want more information, if you haven't already, 688 00:33:56,830 --> 00:33:58,720 Joe: And if you're not a subscriber head to the site. 689 00:33:58,890 --> 00:34:01,660 That's ebmedicine.net to check out what they have. 690 00:34:01,984 --> 00:34:05,594 If you subscribe you'll get access to the article as well as future articles 691 00:34:05,614 --> 00:34:08,214 and the whole archive of all past issues. 692 00:34:08,667 --> 00:34:09,817 Tracey: Look forward to seeing you there.