Questioning Medicine

Characteristics and Strength of Evidenceof COVID-19 Studies Registeredon ClinicalTrials.gov Looked at ClinicalTrials.gov identified 1551 studies registered fromMarch 1, 2011, to May 19, 2020,Lets look at the gold standard RCTOf the 664 RCT (76.1%) were single center. PROBLEM! Weather analysis!Only half of the rct looked at clinical course with only 8% of the rct looking at mortality and this is a problem because blinding was only reported for half of the trials so half of the time your outcome is clinical course and half the time you are not blinding them to the treatment do you think the people you knowingly got the treatment drug will ‘get better’ faster. And maybe they got better because they knew they were getting the good stuff or maybe they got better because eh provider knew they were getting the active. Both can be bias when they know if the patient is getting placebo or active arm. The authors state it best “evidence, the large proportion of studies withan expected low level of evidence is concerni

Initiating Pharmacologic Treatment in Tobacco-Dependent Adults. An Official American Thoracic Society Clinical Practice Guidelinehttps://www.atsjournals.org/doi/full/10.1164/rccm.202005-1982STultimate take home- varenicline is first line!!For Tobacco-Dependent Adults in Whom Treatment Is Being InitiatedShould Treatment Be Started with Varenicline or a Nicotine Patch?40 more per 1,000 patients; Compared with a nicotine patch, varenicline increased long-term abstinence, measured at 6-month follow-up (RR, 1.20; 95% CI, 1.09 to 1.32; ARR, 40 more per 1,000 patients;) For Tobacco-Dependent Adults in Whom Treatment Is Being Initiated Should Treatment Be Started With Varenicline or Bupropion?77 more per 1,000 patients taking Varenicline increased tobacco abstinence at 6-month follow-up compared with bupropion (RR, 1.30; 95% CI, 1.19 to 1.42; ARR, 77 more per 1,000 patients;)who andrew so just varenicline by itself?? thats it??should Treatment Be Started with Varenicline plus Nicotine-Replacement Therapy or Varenicli

https://www.youtube.com/watch?v=EBhEjYhVoZkGoggin K et al. Reductions in parent interest in receiving antibiotics following a 90-second video intervention in outpatient pediatric clinics. J Pediatr 2020 Jun 15; [e-pub]. (https://doi.org/10.1016/j.jpeds.2020.06.027)acute respiratory tract illnesses (ARTIs; cough, congestion, sore throat, and earache) is a PROBLEM with a capital P. or maybe I should say its a pain in the A with a capital A and that A of course is referring to antibiotics-- parents want antibiotics, sometimes demand antibiotics and no matter what you say, its hard to say no time and time and time again and eventually EVERYONE and yes I mean everyone will eventually give an antibiotic when they in their heart of heart knows it is likely not indicated. BUT what if we could educate our pts before we walked in the room. In this study they surveyed 1051 parents about their knowledge of and interest in receiving antibiotics for their children. Surveys were conducted before and after parents watched a

Orkaby AR et al. Association of statin use with all-cause and cardiovascular mortality in US veterans 75 years and older. JAMA 2020 Jul 7; 324:68. (https://doi.org/10.1001/jama.2020.7848) retrospective cohort study of about 327,000 patients (age, ≥75; mean age, 81; mostly white men) without prior statin use, without a prior cardiovascular event; in total 326K vets that were 75yr old and older and had never had a cardiovascular event those started on statin therapy did better!!!all-cause mortality was 78.7 per 1000 person years in those started on a statin and 98.2 per 1000 person-years in those not a on a statin. BUT devel in the details-- they say they looked at 7.2 million vets- then once you took out the people that had prior statin exposure, and removed the people with missing data, and then excluded those with a prior cardiovascular event, and threw out those individuals who died in the first 150 days -- you then get the 326K. and of those about 57k got a statin prescription and 269K never got a statin p

Effect of Dexamethasone in Hospitalized Patients with COVID-19: Preliminary Report (RECOVERY) trial is a randomized, controlled, open-label, comparison of dexamethasone 6 mg given once daily for up to ten days vs. usual care alone.2104 patients randomly allocated to receive dexamethasone were compared with 4321 patients concurrently allocated to usual care. The primary outcome was 28-day mortality (21.6%) patients allocated dexamethasone vs (24.6%) patients in usual care died within 28 days (age-adjusted rate ratio [RR] 0.83; 95% confidence interval [CI] 0.74 to 0.92; P<0.001). No oxygen then dexamethasone did not reduce mortality at 28 17.0% vs. 13.2%, RR 1.22 [95% CI 0.93 to 1.61]; p=0.14).patients receiving oxygen without invasive mechanical ventilation dexamethasone did reduce mortality at 28days (21.5% vs. 25.0%,-- a number needed to treat around 30. And if you were intubated then dex 6mg for for to 10 days really was a show stopper with a nnt of 9 for mortality at 28days. Last case bias.but thing

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3792273/Does Rewording MRI Reports Improve Patient Understanding and Emotional Response to a Clinical Report?Remember few weeks ago when I talked about 50% of people knew that broken bone and fracture were the same thing or that 1 in 5 pts couldn’t describe nonweight baring? Well this study looked o see what would happen if we changed the language in MRI reports 100pts- list of all shoulder, elbow, wrist, and hand MR images ordered in 2011 was obtained from the radiology service-- The original reports were reworded to the recommended reading level for effective health education below the eighth-grade levelwords such as “tear” were replaced by more descriptive and accurate words such as hole, signal change, or defect. They also used analogies (eg, gray hair, bald spot) looked at bunch of outcomes but thing I care about was understanding—did the pt understand it and they used a 10 point scale- basically asked th pts. On 1-10 scale how did you understand that report-T

Covid infohttps://melwy.com/blog/lancet-paper-on-chloroquine-is-overhyped-real-world-data-should-not-be-a-black-box So I couldn’t miss the largest observational study published to date on the effects of (hydroxy-)chloroquine, in 96 032 hospitalised Covid-19 patients, from an international registry comprising 671 hospitals in six continents:Surgisphere is the company that put it all together is in the end it showed not only no benefit with hydroxychloriquine but also possible harm!No transparency- they dont really say how they got their data and wont release how they got there data and no review. Lancet being this all great academic journal wont mention or say who did peer review on this article. WHAT! one of the beliefs is Lancet editor-in-chief Richard Horton. Let it slip through the cracks cause he doesnt like trump. This is well known he doesnt like trump but then to intentionally release a bad or falsified study that disagrees with a drug that president trump has openly supported is just crazy!https:/

Prostate Cancer Incidence 5 Years After US Preventive Services Task Force Recommendations Against Screening JNCI: Journal of the National Cancer Institute, djaa068,——Published: 20 May 2020https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2762575?guestAccessKey=1c75486d-f2a4-4e1b-ac99-25ca247be690&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamainternalmedicine&utm_content=etoc&utm_term=050420Sex Differences in Salaries of Department Chairs at Public Medical Schools

Fox MT et al. Comparative effectiveness of antibiotic treatment duration in children with pyelonephritis. JAMA Netw vOpen 2020 May 1; 3:e203951. (https://doi.org/10.1001/jamanetworkopen.2020.3951) Rates of treatment failure did not differ significantly between the short and prolonged courses (11.2% and 9.4%). https://jamanetwork.com/journals/jama/fullarticle/2765729?guestAccessKey=2169ba8b-43fc-4360-bed7-acf7a31b1c9d&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jama&utm_content=etoc&utm_term=051220Effect of Biomechanical Footwear on Knee Pain in People With Knee Osteoarthritis: The BIOTOK Randomized Clinical TrialIn jama may 12 – look to see if special biomechanical footwear could help osteoarthirits knee pain-At 24 weeks of follow-up, the mean standardized WOMAC pain subscore improved from 4.3 to 1.3 in the biomechanical footwear group and from 4.0 to 2.6 in the control footwear group (between-group difference in scores at 24 weeks of follow-up, −1.3 [95% CI, −1.8 to

https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2762699Association Between Renin-Angiotensin System Blockade Discontinuation and All-Cause Mortality Among Persons With Low Estimated Glomerular Filtration RateThe answer was no; In a 5-year follow-up, ACE-I/ARB discontinuation was associated with an increased risk of both mortality (hazard ratio, 1.39; 95% CI, 1.20-1.60) and major adverse cardiovascular events (hazard ratio, 1.37; 95% CI, 1.20-1.56).https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2762509Lobbying Expenditures and Campaign Contributions by the Pharmaceutical and Health Product Industry in the United States, 1999-2018pharma makes a lot of money—how do they spend ithttps://www.ncbi.nlm.nih.gov/pubmed/31801739With the best way to treat gout according to his article in annals rheumatology disease titled the contact trial-“comparing naproxen and low-dose colchicine for treatment of gout flares in primary care ““electric scooter injuries and hospital admissions

https://science.sciencemag.org/content/early/2020/04/24/science.abb5793read an interesting paper title- Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period. Science 14 Apr 2020.First, some basics but still things that I learned: • The two corona virus currently in cirulation are HKU1 and OC43 and they are seasonal- mainly the winter months with peaks around oct, nov, dec. ; • HCoV-OC43 and HCoV-HKU1 infections, are the common circulating coronavirus and may be asymptomatic or are associated with mild to moderate upper respiratory tract illness” -- rarely do these kill you while obviously SARS-CoV-2 has been shown to be deadly even though the fast majority of people have been shown to be asymptomatic or with mild symptoms that can be controlled at home • Immunity to HKU1 and OC43 wanes fairly rapidly, over the course of about a year;https://www.ncbi.nlm.nih.gov/pubmed/2170159?dopt=AbstractEpidemiol Infect. 1990 Oct;105(2):435-46.“the time course of immune response to experimen

https://covid19treatmentguidelines.nih.gov/A National Institutes of Health panel has released new guidelinesagainst use of hydroxychloroquine plus azithromycin outside of clinical trials https://www.ncbi.nlm.nih.gov/pubmed/32001253Anaphylaxis—a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysisEpinephrine is the cornerstone of anaphylaxis management but continues to be underutilized ANTIBODY—https://jamanetwork.com/journals/jama/fullarticle/2764954 “Yet, according to Theel, several companies are marketing lateral flow assays as rapid point-of-care tests to identify active COVID-19, something the FDA announced it will take action against. “We do not really know how well these assays work at this point,” Theel said in a follow-up email.” https://www.sccgov.org/sites/covid19/Pages/press-release-04-21-20-early.aspxThey say the Santa Clara Medical Examiner identified two individuals who died at home on February 6, 2020 and Feb

More cover 19 information based on antibody testing, pregnancy and pre-symptomatic spreadhttps://www.medrxiv.org/content/10.1101/2020.03.30.20047365v1.full.pdfhttps://www.nejm.org/doi/full/10.1056/NEJMc2009316?utm_source=The+Scope&utm_campaign=86f20fbd35-Weekly_Scope_Jan_12_2018_COPY_01&utm_medium=email&utm_term=0_809ad7d22b-86f20fbd35-180869057

Remdesivir for compassionate use?? Recently published in the New England Journal of Medicine- Is this the COVID19 treatment we have all be hoping for.https://www.nejm.org/doi/full/10.1056/NEJMoa2007016https://jamanetwork.com/journals/jama/fullarticle/2764727?guestAccessKey=72e8a5f3-3754-4bf8-bb17-8c2f1cf358b0&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jama&utm_content=olf&utm_term=041320

Treatment that works-- MASK!https://annals.org/aim/fullarticle/2764367/effectiveness-surgical-cotton-masks-blocking-sars-cov-2-controlled-comparisonHigh Velocity Nasal Insufflation (HVNI) Therapy Application in Management ofCOVID-19 Have patients wear a surgical mask—in this computer study it showed that mask do help but not necessarily mask on you but mask on the pt.

Id be happy to send you links to any of the articles talked about in this podcast but I cover the new test on the corona virus that claims to be great but the devil in the details as well as talk about more hear-say medicine and the ever popular ACE inhibitor debate

https://www.medrxiv.org/content/10.1101/2020.03.22.20040758v1.full.pdf https://www.sciencedirect.com/science/article/pii/S0399077X20300858 https://first10em.com/chloroquine-for-covid-no-good-evidence-yet/

https://www.clinicaltrialsregister.eu/ctr-search/trial/2020-000890-25/FRhttps://www.sciencedirect.com/science/article/pii/S0924857920300996?via%3Dihub

Question Everything-- EBM not hear-say medicine

A listener wrote in with a question about a drug, this is my response. Let me know your thoughts? Would you prescribe this drug? Andrewbuelt@gmail.comhttps://www.nejm.org/doi/pdf/10.1056/NEJMoa1705848