Questioning Medicine

a couple points over the last podcast

Acute low back pain, chronic low back pain, back pain with sciaticain the end unless red flags hold on imaging for 6weeksNSAIDS for acute low back painexercise and spinal manipulative therapy for chronic low back painbe conservative and don't write for drugs that don't work like gabapentin or pregablin

196. Medical Update -- PICC lines, PRE-Diabetes, Sleep in the Hospital, Ortho Surgery!

European Heart JournalBariatric surgery and cardiovascular disease: a systematic review and meta-analysisEur Heart J 2022 Mar 04;[EPub Ahead of Print], SL van Veldhuisen, TM Gorter, G van Woerden, RA de Boer, M Rienstra, EJ Hazebroek, DJ van Veldhuisen  39 studies, all prospective or retrospective cohort studies, showed Bariatric surgery is associated with a reduced hazard ratio (HR) of CV morality (0.59), all-cause mortality (0.55), incident HF (0.50), myocardial infarction (0.58) and stroke (0.64) Authors state “”The present systematic review and meta-analysis suggests that bariatric surgery is associated with reduced all-cause and CV mortality, and lowered incidence of several CV diseases in patients with obesity. Bariatric surgery should therefore be considered in these patients.””” Here is the problem and I have said it before—“no randomized control trials examining the effect of bariatric surgery on CV outcomes,”Among frail patients with AF, OAC treatment was associated with a positive net clinical outc

SUMMARY--What diuretic do you usually write for during CHF hospitalizations??   If you said furosemide you are not alone  One in a study in JACC 2013 looked at HF hospitalizations in 2009 and 2010 – In total 251,472 patients got a loop diuretic during their hospitalization and almost 87% got just furosemide, about 3% only got bumex, while only 0.4 received only torsemide.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4038646/#R11  What is the difference between bumetanide and furosemide? Nothing—or at least nothing we care about. No hard outcomes, no patient oriented outcomes.  Bumetanide is stronger—An article from 2015 in American Heart Journal states bumetanide is about 40 times stronger than furosemide- thus at times you might have your sphincter tighten when you go to write for 120-160mg of furosemide but feel comfortable writing for 3-4mg of bumex. They also discuss how bumetanide also appears to have a higher more consistent bioavailability at around 80-100% while furosemide seems to range from 10-100% d

Gibbons RC et al. Ultrasound-versus landmark-guided medium-sized joint arthrocentesis: A randomized clinical trial. Acad Emerg Med 2022 Feb; 29:159. (https://doi.org/10.1111/acem.14396. opens in new tab)Use a ultrasound for arthrocentesis when possible Circ Arrhythm Electrophysiol 2022 Mar; 15:e010646. (https://doi.org/10.1161/CIRCEP.121.010646)Apple AirPods Pro and their wireless charging case, the Microsoft Surface Pen, and the Apple Pencil second generation — also have strong enough magnetic fields to affect current-generation CIEDs.https://pubmed.ncbi.nlm.nih.gov/34862940/first of all empiric therapy with clarithromycin is no longer effective for treating Helicobacter. You have two choices. The choices are thus: 14-day bismuth quadruple therapy or rifabutin triple therapy,Andreadis K, Chan E, Park M, et al. Imprecision and preferences in interpretation of verbal probabilities in health: a systematic review. J Gen Intern Med 2021;36(12):3820-3829. . The interpretation of "common" which means- accepted defi

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00572-9/fulltextOld calculators use old studies and can over exaggerate the calculated effecthttps://pubmed.ncbi.nlm.nih.gov/33970197/We know when to start medication but it is so hard to prospectively know when to stop medication like anticoagulationhttps://pubmed.ncbi.nlm.nih.gov/34074830/2 Kiwi a day will increase your bowel movementshttps://pubmed.ncbi.nlm.nih.gov/34100866/We want to believe routine checkups work but realistically they don't work for patient oriented outcomes--but they make people 'feel good'-- what we do isn't always the doing, it's just being therehttps://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01063-1/fulltextDAPT following a stent-- but then just maybe we should stay with plavix and not aspirin

https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2782015coffee is ok with atrial fibrillation -- just don't go crazy is probably good advicehttps://jamanetwork.com/journals/jamanetworkopen/fullarticle/2781351Hearing loss sucks and can really change your whole physical functionhttps://www.bmj.com/content/374/bmj.n1511elective orthopedic procedures with good evidence are limitedhttps://jamanetwork.com/journals/jama/fullarticle/2781859PRP injections -- work about as well as vitamin D-- just stophttps://www.bmj.com/content/374/bmj.n1446muscle relaxants for back pain improve pain at 2 weeks 8 points on 100 point scalehttps://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2781311STOP GIVING LEVOTHYROXINE to a majority of normal or subclinical normal peoplehttps://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2781806antibiotics will always be given if they are always given

Extended Follow-up of Local Steroid Injection for Carpal Tunnel Syndrome: A Randomized Clinical Trial | Neuropathy | JAMA Network Open | JAMA Network Looked at just over 100 patients with carpal tunnel syndrome and randomized them to injection of 80 mg methylprednisolone, 40 mg methylprednisolone, or saline and there was no difference except for an extra 60 days delaying surgery but still surgery.Associations Between Sleep Position and Nocturnal Gastroesop... : Official journal of the American College of Gastroenterology | ACG (lww.com)  The aim of this study was to investigate the effect of spontaneous sleep positions on the occurrence of nocturnal gastroesophageal reflux and in the end stay on your left side. Lee CG et al. Effect of metformin and lifestyle interventions on mortality in the diabetes prevention program and diabetes prevention program outcomes study. Diabetes Care 2021 Dec; 44:2775. (https://doi.org/10.2337/dc21-1046. opens in new tab)DONT TREAT PRE-DMEffect of Anticoagulant Therapy for 6 Week

Writing Group for the CODA Collaborative. Patient factors associated with appendectomy within 30 days of initiating antibiotic treatment for appendicitis. JAMA Surg 2022 Jan 12; [e-pub]. Now, investigators have explored in a secondary analysis of  The CODA Collaborative. A randomized trial comparing antibiotics with appendectomy for appendicitis. N Engl J Med 2020 Oct 5; [e-pub]. (data from a previous randomized antibiotics-versus-surgery trial (NEJM JW Gen Med Dec 1 2020 and N Engl J Med 2020; 383:1907). Have looke at the data to see could we predict factors that make you more likely to appendectomy and fail antibiotic therapy.  They identified 735 patients who had been randomized to antibiotic treatment; 154 (21%) of these patients underwent appendectomy within 30 days. Overall, 29% of patients in the antibiotics group underwent appendectomy within 90 days (41% of those with appendicolith vs. 25% without). The authors suggest hey maybe this appendicolith is the magic answer of who will fail therapy—maybe!! 

https://pubmed.ncbi.nlm.nih.gov/33734980/if you lay flat with a blood draw you may have psuedoanemiahttps://jamanetwork.com/journals/jama/fullarticle/2782300Men and UTI-- 7 dayshttps://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2782461don't get a UA prior to a procedure for screeninghttps://www.nejm.org/doi/full/10.1056/NEJMoa2026845cardiogenic shock- dobutamine vs milrinone https://pubmed.ncbi.nlm.nih.gov/34259820/Dont use a CAChttps://pubmed.ncbi.nlm.nih.gov/33637192/CKD = SBP <120https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2782564men are still more professional than women no matter what they wear-- or at least that is the perception among 36yr old patients

Yes this is a CME lecture but yes you get it for the expensive price of Free Fifty Free....

Contraception 2021 Sep 20;[EPub Ahead of Print], D Grossman, S Raifman, N Morris, A Arena, L Bachrach, J Beaman, MA Biggs, C Hannum, S Ho, EB Schwarz, M GoldSTUDY DESIGNThis is an interim analysis of an ongoing prospective cohort study conducted at five sites. Clinicians assessed patients in clinic and, if they were eligible for medication abortion and ≤63 days' gestation, electronically sent prescriptions for mifepristone 200 mg orally and misoprostol 800 mcg buccally to a mail-order pharmacy, which shipped medications for next-day delivery. Participants completed surveys three and 14 days after enrollment, and we abstracted medical chart data for this interim analysis.  In this prospective cohort study, researchers estimated the effectiveness, feasibility, and acceptability of medication abortion with mifepristone dispensed by a mail-order pharmacy with next-day delivery after in-person clinical assessment. The researchers found that complete medication abortion occurred for 96.9% of participants; 88.4% re

Davidson KW et al. Screening for prediabetes and type 2 diabetes: US Preventive Services Task Force recommendation statement. JAMA 2021 Aug 24; 326:736. (https://doi.org/10.1001/jama.2021.12531)  The Task Force found moderate-certainty evidence that screening is beneficial for nonpregnant adults (age range, 35–70) who are overweight (i.e., body-mass index [BMI], ≥25 kg/m2) or obese (BMI, ≥30 kg/m2) and have no symptoms of diabetes. Referring patients for, or directly providing, effective preventive interventions is recommended (B recommendation).  The main change from the 2015 recommendation is the lower age threshold for screening — 35 rather than 40. The decision was made because of the increasingly younger age of onset for diabetes and the known benefits of intervention at a wide range of ages. Notably, the USPSTF found little direct evidence that screening improves clinical outcomes;   Lifestyle modifications and metformin are considered appropriate interventions for preventing or delaying onset of diabet

I've found that I can often increase compliance with statins by having pt take them 3x/week or QOD.  I try this often especially in my secondary prevention group. I understand "any statin is better than none", but do data support this approach?   -- any is better than none! No rct with this but yes data supports every other day but that is observational..what about vascepa in reducing CAD risk both primary and secondary risk? Vascepa is now the first and only drug approved by the FDA as an adjunct to maximally tolerated statin therapy to reduce the risk of myocardial infarction, stroke, coronary revascularization, and unstable angina requiring hospitalization in adult patients with elevated triglyceride (TG) levels (≥150 mg/dL) and established cardiovascular disease or diabetes mellitus and two or more additional risk factors for cardiovascular diseaseReduce it trial---The big trial which showed all the promise used mineral oil as a placeboAND then we have evaporate trial—which showed steady plaqueThe groups

DYSh out information on DYSlipidemia: An Evidence-based Update on Cholesterol ManagementPlease contact me for more information:    Andrew Buelt, D.O.  andrewbuelt@gmail.com Questioning Medicine PodcastAthrosclerotic Cardiovascular Disease Risk Calculator (ASCVD) 10 yr ASCVD risk calculator developed in 2013 ASCVD event defined as nonfatal myocardial infarction, coronary heart disease (CHD) death, fatal or nonfatal stroke Development of ASCVD calculator used African-American and White men and women age 40 to 79 yrs old (not hispanic, watch for inclusion drift)  Risk assessment should occur every 5 yrs in moderate risk individuals and can occur more frequently if the patient is nearing a cutoff for treatment Serum Lipid Level Lipid levels are stable over long durations of time Serum lipid lab values have high intra-test variability Testing more frequently than every 10 years leads to overdiagnosis from lab error and not true changes in serum lipid levels.  Primary PreventionTreatment Statins are the

part 1-- you dont get the CME but you get the information

PodcastGregory J, Huynh B, Tayler B, et al. High-dose vs standard-dose amoxicillin plus clavulanate for adults with acute sinusitis. A randomized clinical trial. JAMA Network Open 2021;4(3):e212713Study design: Randomized controlled trial (double-blinded) primary care offices with sinus symptoms consistent with currently accepted clinical criteria for acute bacterial sinusitis. andomly received (concealed allocation assignment) either a standard-dose regimen of amoxicillin 875 mg plus clavulanate 125 mg plus placebo twice daily for 7 days or a high-dose regimen of amoxicillin 875 mg plus clavulanate 125 mg plus amoxicillin 875 mg twice daily for 7 days. They planned to have 240 patients enrolled in the trial but then COVID happened and the authors say “  At an unplanned interim analysis prompted by COVID-19 restrictions” made us look at the data and then stop the trial. They found that there was NO difference between the high dose and the standard dosea global rating of "a lot better" or "no symptoms" occurre

Delay of Pregnancy Among Physicians vs Nonphysicians JAMA Intern Med 2021 May 03;[EPub Ahead of Print], MC Cusimano, NN Baxter, R Sutradhar, E McArthur, JG Ray, AX Garg, S Vigod, AN Simpson It has been hypothesized based on just rumor and people repeating it that women physicians are more likely to delay childbearing than nonphysicians. This population-based retrospective cohort study looked to see if that was true. They compared childbirth rates among physician and compared it to nonphysicians Physicians were less likely to experience childbirth at younger ages (HR for childbirth at 15–28 years, 0.15; P < .001) and more likely to experience childbirth at an older age (HR for 29–36 years, 1.35; P < .001; HR for ≥37 years, 2.62; P < .001). BUT BUT BUT do they delay child birth all together?? Well in simple terms, NO. female physicians have children rates equal to that of nonphysician women over time, although the time Basically this says what lots of us know in the women try not to have children durin

1) nurses commit more suicide and average population (doctors don't)2) AK will turn in to SCC at a rate of about 2% per year3) STOP SMOKING (even if you gain weight)4) zofran is about equal to the rest for pregnant patients and the outcomes we care about5) Tubes in the ear for children with acute otitis media?? It works about the same as medical managementAssociation of US Nurse and Physician Occupation With Risk of Suicide | Nursing | JAMA Psychiatry | JAMA Network This retrospective cohort study used US data from 159 372 suicides reported in the National Violent Death Reporting System from 2007 to 2018. Researchers found that suicide was more common among nurses compared with the general population (sex-adjusted incidence, 23.8 per 100,000 vs 20.1 per 100,000; RR, 1.18). By sex, the physician suicide rate was not different from that of the general population Ten-Year Follow-up of Persons With Sun-Damaged Skin Associated With Subsequent Development of Cutaneous Squamous Cell Carcinoma | Dermatology | JAMA