Questioning Medicine

Alzheimers disease—doesn’t say what you think it says https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/10.1001/jamainternmed.2020.6432?guestAccessKey=807ca0d3-63aa-48f9-8a1d-16df0d828d42&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamainternalmedicine&utm_content=olf&utm_term=113020 Conclusions and Relevance Alzheimer disease and related dementias were associated with adverse financial events years prior to clinical diagnosis that become more prevalent after diagnosis I listen to a podcast and read articles and it seems omg this is great!! Maybe we look to see if people are missing payments or making poor financial decisions and screen them for alzheimers. Currently screening for alzheimers is difficult because we don’t have good treatment to slow or prevent the progression of the disease. Remember a few basic principles of screening are The condition should be an important health problem.There should be a treatment for the condition that can change

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2771041#:~:text=Conclusions%20and%20Relevance%20Initiation%20of,effective%20as%20brand%2Dname%20levothyroxine. Comparative Effectiveness of Generic vs Brand-Name Levothyroxine in Achieving Normal Thyrotropin LevelsJAMA Netw Open. 2020;3(9):e2017645. doi:10.1001/jamanetworkopen.2020.17645 Quick history lesson- levothyroxine was cleared and approved for generic use in 2004 – until then Synthroid had enjoyed a huge market share. The only market share. They were it and there is soooo much money when you are the only drug on the market and the most prescribed drug on the market—in 2002 the revenue was estimated at 1 billion dollars. I was alive in 2002 and I can tell you back then 1 billion dollars was a lot of money. But then 2004 there is now competition, a generic drug.! What does the drug company do? Use some of their small fortune to trash the drug, pay of some doctors to write a paper and later in 2004 there was a paper released by The Endocrine S

www.bmj.com/content/368/bmj.m149No one wants to get pregnant two minutes after having a baby. And also agrees that an IUD is most effective form of conception. However placing IUD after delivering a child seems to be a point of debate as the risk of expulsion seems to be significantly higher immediately post pregnancyIn this study titledAverbach SH, Ermias Y, Jeng G, et al. Expulsion of intrauterine devices after postpartum placement by timing of placement, delivery type, and intrauterine device type: a systematic review and meta-analysis. Am J Obstet Gynecol 2020;223:177-188.They looked at the different rates of IUD expulsion postpartum. As you can imagine the rates vary based on if the IUD was placed within 3 minutes of child delivery or 3 weeks after child delivery. There also seemed to be a difference between hormonal IUD (LNG-IUD) compared with a copper T-shaped IUD. Finally there was a difference whether she had a C-section or a vaginal delivery as you can imagine the vaginal delivery was associated wit

Questioning medicine dailyhttps://www.acpjournals.org/doi/10.7326/M20-7448 https://www.acpjournals.org/doi/10.7326/M20-6817 Effectiveness of Adding a Mask Recommendation to Other Public Health Measures to Prevent SARS-CoV-2 Infection in Danish Mask WearersFREEA Randomized Controlled Trial Masks!!!! Do they prevent COVID19 transmission by preventing spread from infected people to others OR do they work by protecting wearers OR is it both.We now have an answer to the second question, Do the mask work by protecting the wearers and in short the answer is no. Fresh out november 18. The DANMASK-19 trial It a trial designed to examine the masks' protective effect. Spring 2020 in Denmark, Social distancing recommendations were in effect, but masks were not recommended, they were rarely worn outside of hospitals, and the infection rate was modest around 2% per month which is pretty close to what we were seeing because remember we were around 1-3% here in american depending on where you lived with some places much muc

https://www.clinicalkey.com/#!/content/journal/1-s2.0-S0140673620322339?scrollTo=%23hl0000424 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32233-9/fulltext do statins work in old people?? This study in the lancet says- “In a contemporary primary prevention cohort, people aged 70–100 years with elevated LDL cholesterol had the highest absolute risk of myocardial infarction and atherosclerotic cardiovascular disease and the lowest estimated NNT in 5 years to prevent one event.’ researchers calculated that 80 adults aged 80–100 years — would need to receive a moderate-intensity statin for 5 years to prevent one MI.and145 adults aged 70–79 years — would need to receive a moderate-intensity statin for 5 years to prevent one MI.and to prevent just one ASCVD event, the numbers needed to treat were 42 and 88, respectively. But anytime you read the results you have to say “how did you come up with that number” what were your methods? In this study they took a sample of people from a large Danish

https://www.acpjournals.org/doi/10.7326/M20-2470 Pharmacologic Approaches to Glycemic Treatment of Type 2 Diabetes: Synopsis of the 2020 American Diabetes Association's Standards of Medical Care in Diabetes Clinical GuidelineFREEWhich is as the artciel suggest in a sypnopsis of the 2020 ADA guidelines metformin is still universal fist line but now the guideline says The choice of agent to add to metformin therapy should be individualized on the basis of patient characteristics, preferences, and drug-specific effects. The big rec from this paper isAmong patients with type 2 diabetes who have established ASCVD or established kidney disease, or heart failure, a sodium–glucose cotransporter-2 (SGLT2) inhibitor or glucagon-like peptide-1 receptor agonist (GLP-1 RA) with demonstrated cardiovascular disease benefit is recommended (Grade A recommendation). they go on to say maybe one of the key lines--------The addition of these medications should be considered independent from HbA1c level in this patient population

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2771093 meta-analysis of 78 original studies, looking to find the accuracy of ECG interpretation. In this analysis they looked at studies with med students, physiciansm even cardiologist and found on average we got the right diagnosis only 55% of the time. Obviously education goes up with more education 42.0% for medical students,55.8% for residents,68.5% for practicing physicians,and 74.9%) for cardiologists. in the end it I think it says a couple thingsWe all have room for improvement at reading EKGsWhen you don’t know what the EKG says the cardiologist only know the right answer an extra 6% of the timeI am not shocked by the results. Lots of these studies had you look at 10 ekgs and say what it is. I think most people can get the easy EKGS, it is the really hard ekgs that look like a four year old drawing that are challenging to name. I think a better question would have been if the providers knew what to do. Did the providers know

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2771670 trials are not real life. We know that. Realistically if your drug just barely hits 0.05 in a clinical trial then in the imperfect setting of the clinic of every day life the drug likely wont work. In this next study, in jama internal medicine titledConcordance Between Blood Pressure in the Systolic Blood Pressure Intervention Trial and in Routine Clinical Practice The authors used a prognostic study and took 3074 patients and wanted to see the difference between BPs obtained in routine clinical practice and the bp obtained during a clinical trial. Which trial you ask?? The sprint trial!! This is brilliant they basically took 3000 patients who were in the SPRINT trial, and as a reminder the sprint trial is the land mark trial of 2015 that showed- In patients at high risk for CVD but who do not have a history of stroke or diabetes, intensive BP control (target SBP <120 mm Hg) improved CV outcomes and overall survival compared to stand

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2771095 SO HOW DO YOU LOSE WEIGHT!! FASTING DOESN’T WORK or so says this study titled- Effects of Time-Restricted Eating on Weight Loss and Other Metabolic Parameters in Women and Men With Overweight and ObesityThe TREAT Randomized Clinical Trial100 overweight or obese adults were randomized to regular eating or to a restricted eating pattern where you could not eat between 8pm and 12 noon and the result were no statistical difference between the group that at three meals a day and the group that could only eat between 12 and 8. Here is the problem-People could eat anythingYou basically are only restricting breakfast. What grown adult eats a ton for breakfast. I mean sure there aer some but the majority of people I know maybe have a hard boiled egg or a piece of toast but never a huge meal. How many EXTRA calories are these people really getting??I think a better way to do this trial would have been 12 hours of fast but make the hours 5am to 5

Doc my heart is racing— Stop drinking—or so says this article in NEJM that found when they took 140 pts who severed from paroxysmal afib and who drank 17 drinks a week that when randomized to complete alcohol abstinence for 6 months there was significant reduction in afib recurrence.. how much of a difference?? 20% ABSOLUTE DIFFERENCE….. I have a rule of thumb that anytime someone says the improvement is any percent over 10% I almost always assume they are talking relative risk reduction, but this was 20% ABSOLUTE risk reduction. That is a NNT of 5. So when your patient says my heart goes piter pat pitter piter pat pat pat pitter what should I do, the answer is to stop drinking. Now let me grab a sip of bourbon and onto the next article. DOC there is a puddle on the floor..https://journals.lww.com/optvissci/Fulltext/2020/07000/Validation_of_a_More_Reliable_Method_of_Eye_Drop.7.aspx Tell them to close their eyes or so say this article in optometry and vision science that had 30 pts and on one visit, eye drop

Rapid fire articles- no deep dive. Just good a lot of questioning, questioning medicine. If you want any of the articles for your own review or have any questions you can always reach me at andrewbuelt@gmail.com

We stuck purely to the evidence. There was no evidence panel or committee to vote on the evidence like is often done by the American college of rheumatology and no expert opinion statements where their only citation is themselves like can be seen with the ACC. This was purely 100% evidence recommendations. So lets start try to make it quick because guidelines on a podcast a boring, I want to hit the high points and get out of here This guideline does not cover 1) adults < age 40 years old o2) patients with ejection fraction <35%3) pts with life expectancy less than 5 years4) Patients with genetic dyslipidemia conditions were also excluded Now to the recomendations . test a serum Cholesterol level every ten years!! Yes 10yrs. If you are testing more frequently than that you are likely seeing variability in the test and not a true change. Cholesterol levels are stable! If you see a change it is because you are seeing a change in the point estimate—remember it might say ldl 100 but there are CI around th

athlete heart covidhttps://www.the-scientist.com/news-opinion/college-athletes-experienced-heart-damage-after-covid-19-study-67929titiles like- “Images of the players’ hearts showed signs of inflammation consistent with myocarditis, a rare but potentially fatal condition.”“two dozen of Ohio State University players using cardiac magnetic resonance (CMR), they found evidence of myocarditis in 15 percent, while a further 30 percent had cellular damage or swelling “ The Ny york times said- https://www.nytimes.com/2020/09/16/well/move/is-coronavirus-affecting-the-hearts-of-college-athletes.html Is Coronavirus Affecting the Hearts of College Athletes? “In a new study of 26 college athletes who tested positive for coronavirus, four later showed signs of inflammation in their heart muscles.” and my favorite-- CNN sayshttps://www.cnn.com/2020/09/14/health/covid-heart-inflammation-athletes-study/index.html Covid-19 study suggests to screen recovering athletes for heart inflammation before they return to play “As ath

the thing about RCT is they are random and everything is equal. its why in table one of an RCT you should never see a pvalue because they are random and should be equal but in observational studies you see pvalues because it is not equal, it can’t be, its not random. In observational studies you try to account for all the confounders but you just cant ever make it equal to an RCT but lets look a look at observational data using a real world example. I will start with a question—is there an association between fluoroquinolone use and aortic aneurysm and aortic dissection (AA/AD).? You might say well in dec 2018 the FDA issued a warning recommending avoiding fluoroquinolone use in patients with AA/AD or who are at risk for these conditions But that was not the question I asked – I said “is there an association between c use and aortic aneurysm and aortic dissection (AA/AD).?” The answer is ‘it depends’—clearly seen in recent issue of JAMA Internal Medicine one paper –

Finance ethics committee, big pharma with deep pockets, mafia like arrangements, and a patient with a 40% increase risk of ischemia myocardial events have in common?I will say todays podcast was inspired by a tweet, yes a tweet from Dr. john Mandrola and he said “I am embarrassed to have not (really) known the details of the rosiglitazone affair. Teaching this to learners has to be 10x more valuable than the krebs cycle. My gosh – talk about lessons to learn. We have to promote more skeptical priors’ He attached a link to a paper titledThe rise and fall of rosiglitazoneEuropean Heart Journal, Volume 31, Issue 7, April 2010, Pages 773–776https://academic.oup.com/eurheartj/article/31/7/773/433556I also will say I did not know the details of the rosiglitazone affair but after spending the last 3 days digging through this paper and the sources to this paper and the sources to those papers and by the end you will know exactly what Finance ethics committee, big pharma with deep pockets, mafia like arrangements, and

In this study of a cohort of German patients recently recovered from COVID-19 infection, CMR revealed cardiac involvement in 78 patients (78%) and ongoing myocardial inflammation in 60 patients (60%), independent of preexisting conditions,this was a freak out statement if I have ever heard of one I mean Covid is doing something directly to the heart? and this thing it is doing to the heart is independent of preexisting conditions??this study was viewed over 500K times and on 196 news outlets with 12,000 tweetsthis is in and of itself one of the main reasons that the BIG TEN shut down football. of course we will never know for sure but it has been cited in many of the articles as one of the biggest concerns for player safety and potential damage to the heart!!Nevermind the fact that this mean age in the study was almost 50 and the mean age of a college football player is around 20. That is just a small detail and we need to shut down sports for the safety of the athletes because we the big ten have a HEART and

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2768888Serial Bone Density Measurement and Incident Fracture Risk Discrimination in Postmenopausal WomenCarolyn J. Crandall, MD, MS1; Joseph Larson, MS2; Nicole C. Wright, PhD3; et al OBJECTIVETo assess whether a second BMD measurement approximately 3 years after the initial assessment is associated with improved ability to estimate fracture risk beyond the baseline BMD measurement alone.In this prospective observational study 7419 women from The Women’s Health Initiative with a mean (SD) follow-up of 12.1 (3.4) years Incident major osteoporotic fracture (ie, hip, clinical spine, forearm, or shoulder fracture), hip fracture, baseline BMD, and absolute change in BMD were assesseda second bone mineral density (BMD) assessment approximately 3 years after the initial measurement was not associated with improved risk discrimination, beyond the initial BMD assessment, between women who did and did not experience hip fracture or major osteoporotic f

Sometime I wonder how the world will change post covid- or how the board questions will change? And that is clearly seen in this article titled- Yip L et al. Serious adverse health events, including death, associated with ingesting alcohol-based hand sanitizers containing methanol — Arizona and New Mexico, May–June 2020. MMWR Morb Mortal Wkly Rep 2020 Aug 14; 69:1070. hand sanitizing gels and foams containing ≥60% alcohol (either ethanol or isopropyl alcohol) has been proven to be effective -- Methanol is not an acceptable substitutein this paper they looked at 15 cases of methanol poisoning due to ingestion of methanol-containing hand sanitizers From May through June 2020 All patients had a history of ingesting alcohol-based hand sanitizerpresentation included visual disturbance, seizures, gastrointestinal involvement, altered mental status, and anion-gap acidosis with blood pH varying from 6.70 to 7.23.in the end Four patients died and three others were discharged with new visual impairment. I can see it no

henry ford once said “failure is simply the opportunity to begin again, this time more intelligently”Designed to Fail? the Future of Primary CareJournal of General Internal Medicine (2020) Access to primary care has been shown to improve patient outcomes and lower cost although outcomes are debated the cost is not-its because we can be the jack of all or the referral of all. neither is wrong the authors in this paper analyzed the 2019 “in-basket” activity of our clinical faculty at the University of Michigan to determine the average weekly activity by category of EMR tasks. A full-time primary care faculty member had a total of 390 in-basket tasks per week or 17,542 in-basket tasks per year.they surveyed 56 clinicians, and asked how much time, to the nearest minute, they spent on in-basket tasks: and a median time of 1199 min (~ 20 h) per week on these tasks many task require further steps- like addressing lab work, or ordering follow up imaging, or doing a prior authorization ALL of which are unpaid. essenti

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