Questioning Medicine

https://jamanetwork.com/journals/jama/article-abstract/2822097Design, Setting, and Participants  Nested case-control study using population-based linked administrative datasets among adults aged 66 years or older who received at least 1 oral antibiotic between 2002 and 2022 in Ontario, Canada. Cases were those who had an emergency department (ED) visit or hospitalization for serious cADRs within 60 days of the prescription, and each case was matched with up to 4 controls who did not.Exposure  Various classes of oral antibiotics.Main Outcomes and Measures  Conditional logistic regression estimate of the association between different classes of oral antibiotics and serious cADRs, using macrolides as the reference group.Results  During the 20-year study period, we identified 21 758 older adults (median age, 75 years; 64.1% female) who had an ED visit or hospitalization for serious cADRs following antibiotic therapy and 87 025 matched controls who did not. In the primary analysis, sulfonamide antibiotics (adjuste

https://www.nejm.org/doi/full/10.1056/NEJMoa2407001ConclusionsNo participants receiving twice-yearly lenacapavir acquired HIV infection. HIV incidence with lenacapavir was significantly lower than background HIV incidence and HIV incidence with F/TDF. Among 5338 participants who were initially HIV-negative, 55 incident HIV infections were observed: 0 infections among 2134 participants in the lenacapavir group (0 per 100 person-years; 95% confidence interval [CI], 0.00 to 0.19), 39 infections among 2136 participants in the F/TAF group (2.02 per 100 person-years; 95% CI, 1.44 to 2.76), and 16 infections among 1068 participants in the F/TDF group (1.69 per 100 person-years; 95% CI, 0.96 to 2.74)

Allaudeen N et al. Medications for alcohol-use disorder and follow-up after hospitalization for alcohol withdrawal: A multicenter study. J Hosp Med 2024 Dec; 19:1122. (https://doi.org/10.1002/jhm.13458)   Hospital admission for alcohol withdrawal is a problem when it comes to readmission. They just come back--- In this retrospective study of ≈600 patients (96% men) admitted for alcohol withdrawal at 19 Veterans Affairs hospitals during 1 year (2018–2019), researchers evaluated prescription rates of medications for alcohol use disorder (AUD; e.g., naltrexone, acamprosate, disulfiram, gabapentin, topiramate) and scheduled follow-up appointments.The objective of this study was to evaluate the effects of medications for AUD and follow-up appointments on readmission and abstinence.Neither prescription of AUD agents (to 51% of patients) at hospital discharge nor scheduled follow-up appointments at discharge were associated with 30-day readmissions or 6-month alcohol abstinence.Only direct discharge to residential A

Real‐world use of glucocorticoids and clinical outcomes in adults hospitalized with community‐acquired pneumonia on medical wards - Malecki - 2024 - Journal of Hospital Medicine - Wiley Online Library This was a retrospective cohort study of 11,500 patients with CAP who were admitted to general medicine units in 7 Canadian hospitals, researchers compared outcomes for patients who received systemic corticosteroids. Patients were excluded if they were admitted to the intensive care units or had COPD or COVID-19 infection. Between those that got steroids and those that didn’t get steroids there was no differences in intensive care admissions, hospital length of stay, or 30-day readmissions. HOWEVER, In an adjusted analysis, patients who received systemic corticosteroids were significantly more likely to die in the hospital than were patients who didn't receive steroids (8.0% vs. 6.3%; P=0.03).  LET’S BE CLEAR THIS IS FOR NON-SEVERE PNA!! If you have severe pna and are going to the ICU then the evidence and guide

2024 ESC guidelines propose a simple new BP categorization: Non-elevated: less than 120/70 mm Hg in the office (pharmacological treatment is not recommended). Elevated: 120 to 139/70 to 89 mm Hg (pharmacological treatment is recommended for some, depending on cardiovascular disease [CVD] risk and follow-up BP measurements). Hypertension: 140/90 mm Hg or greater (confirmation and prompt pharmacological treatment is recommended).     lifestyle interventions are particularly critical for individuals with an elevated BP but a low predicted risk of CVD. Adults in this group are common and account for up to one-third of all CVD events,  2024 ESC Guidelines provide two major new lifestyle approaches for managing elevated BP and hypertension.  first new option is potassium supplementation, either by dietary supplementation or potassium-enriched salt substitutes. The mechanistic and observational data supporting the benefits of potassium supplementation on BP are not new. However, recent CVD outcomes trials demonstrat

Question  Does adding centralized mailed fecal immunochemical testing and patient navigation to usual care improve colorectal cancer (CRC) screening in US federally qualified health centers? pragmatic randomized clinical trial was conducted Patients were enrolled and randomly assigned to usual care alone (control group) or intervention (2,001 participants per group). Intervention participants received mailed screening outreach materials including an introductory letter, FIT kit packet with instructions and return postage, and two reminder letters if necessary, in addition to usual care. Navigation to facilitate follow-up colonoscopy was offered to intervention participants with positive results of mailed FIT. The researchers found that intervention participants were THREE TIMES more likely than controls to complete screening within six months of randomization (30.0 versus 9.7 percent). Overall, positive FIT results in the intervention arm completed follow-up colonoscopy within six months more often than those

Packer M et al. Tirzepatide for heart failure with preserved ejection fraction and obesity. N Engl J Med 2024 Nov 16; [e-pub].https://doi.org/10.1056/NEJMoa2410027  In the industry-funded SUMMIT trial (NCT04847557), investigators examined cardiovascular outcomes of tirzepatide — an agonist of glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 receptors — over a longer period in patients with HFpEF and obesity.  The 731 study participants had elevated filling pressures or an elevated N-terminal pro–B-type natriuretic peptide (NT-proBNP) level, and a heart failure exacerbation event within the prior 12 months or a decreased estimated glomerular filtration rate <70 mL/min/1.73 m2. They were randomized to once-weekly subcutaneous tirzepatide (up to 15 mg) or placebo for at least 52 weeks with a median follow-up of 104 weeks.Compared with placebo, tirzepatide resulted in significantly fewer primary-endpoint events (adjudicated heart-failure worsening or cardiovascular death) — 10% vs. 15% (hazard rati

Wang Z et al. Safety of triptans in patients who have or are at high risk for cardiovascular disease: A target trial emulation. Mayo Clin Proc 2024 Nov; 99:1722. (https://doi.org/10.1016/j.mayocp.2024.03.023) How unsafe are triptans triptans — the mainstays of migraine therapy — are vasoactive, the U.S. FDA considers them to be contraindicated in patients with cardiovascular (CV) disease or elevated CV risk.  many patients with migraine (including those with CV disease) request triptans because they work how bad are they??Within 60 days of starting treatment, 52 patients who received triptans and 13 who received nontriptans experienced major adverse CV events — a significant difference (1.5% vs. 0.4%; relative risk, 4.0).  Compared with nontriptans, triptans are associated with elevated risk for major adverse CV events in patients with migraine and established CV disease or elevated CV risk; however, the absolute risk difference in this study was small (1.1%). 

STROKE part 3 CME

CME FOR FREEE 

CME --- Stroke- UIA, CHAD-VASC, HAS-BLED, SPARC, PFO

Beran A et al. Early diagnostic paracentesis improves outcomes of hospitalized patients with cirrhosis and ascites: A systematic review and meta-analysis. Am J Gastroenterol 2024 Nov; 119:2259. (https://doi.org/10.14309/ajg.0000000000002906) BOTTOM LINE (if you don’t like to read)- While it might not be fun to have the conversation with the ER provider saying you NEED A DIAGNOSTIC PARACENTESIS PRIOR TO THE PATIENT COMING TO THE FLOOR, just remember that every 33 times we have that conversation, we are saving a life and decreasing the length of stay by 5 days on average.  We have all had the admission from the ER on a patient that needs a paracentesis but it is the weekend so they are going to just admit for antibiotics and then IR can come do it on Monday.  Guidelines recommend diagnostic paracentesis in all patients hospitalized with cirrhosis and ascites, but they do not recommend specific timing of inpatient paracentesis. (Biggins SW et al. Diagnosis, evaluation, and management of ascites, spontaneous bact

Acupuncture vs Sham Acupuncture for Chronic Sciatica From Herniated Disk: A Randomized Clinical Trial | Complementary and Alternative Medicine | JAMA Internal Medicine | JAMA Network  In a randomized trial, acupuncture reduced pain and disability better than a sham procedure did.  In this trial from China, 216 adults (mean age, 51) were randomized to undergo 10 sessions of acupuncture or sham procedures during 4 weeks. All patients had moderate-to-severe unilateral leg pain attributed to imaging-confirmed disk herniation; mean duration of symptoms was 3 years (range, 1.3–10 years). Patients taking pain-modifying medications or with prior lumbar disk surgery were excluded.   The sham procedure consisted of blunt needles inserted into adhesive foam pads placed over non-acupoints. Patients who received acupuncture reported greater leg-pain relief at 4 weeks than did patients who received sham procedures (mean decrease on a 0–100-mm visual analog scale, 31 vs. 15 mm),    Improvements in pain and disability scores

And now a secondary analysis of the trial focused on the timing of major ischemic events and the potential tradeoffs of benefits and risks,------ maybe there is magic sauce where the benefit is drastically greater than risk and vice versa! Guan L et al. Duration of benefit and risk of dual antiplatelet therapy up to 72 hours after mild ischemic stroke and transient ischemic attack. Neurology 2024 Oct 8; 103:e209845. (https://doi.org/10.1212/WNL.0000000000209845)  The goal is less ischemic events with the DAPT but there is a risk of more bleeding and maybe if we tease out the data we can find the exact right time—not too much, not too little but just right.  They found the benefit of decrease ischemic stroke was front-loaded, with roughly a 1.5% absolute risk reduction (ARR) for major ischemic events in the first week, a 0.5% ARR in the second week, and a nonsignificant 0.29% ARR in the third week. The bleeding risk was constant right around ARR 0.1% Thus three weeks remains reasonable to rec DAPT—remember at

The full podcast -- not sure why the last one cut off early. Question and answer from ACOI

Liu H et al. Arm position and blood pressure readings: The ARMS crossover randomized clinical trial. JAMA Intern Med 2024 Oct 7; [e-pub]. (https://doi.org/10.1001/jamainternmed.2024.5213)   study replicated some of the “real-world” shortcuts that often occur when we check BP, such as measuring BP while the patient is sitting up on an exam table.===In this U.S. trial of 133 adults, researchers assessed the effect of nonstandard arm positions on BP readings by measuring each patient's BP in three different arm positions (order of measurement was determined by a randomization protocol): arm supported on a desk, with cuff at heart level (reference position) hand supported in the lap arm unsupported at the side Investigators otherwise followed standard guidance for office BP measurements.  Lap and side positions led to significantly higher readings (by 4 mm Hg to 6 mm Hg for both systolic and diastolic measurements) than did the desk position.     

Stopping Trials Early for Benefit: Insights From Recent Pivotal Trials in Chronic Kidney Disease - ScienceDirect   There are 4 major reasons why trials might be stopped early: 1) unequivocal benefit; 2) unacceptable harm; 3) futility; and 4) administrative reasons (enrollment or funding concerns).   trials stopped early for benefit tend to overestimate benefit, a phenomenon referred to as random-high.  trials that stopped early, especially those with <500 events, fail to provide reliable and valid estimates of treatment effect, often overestimating it by nearly 30% Trials stopped early for harm or futility are less problematic as such data are not used to promote medications. Published results were based on accrual of 69%, 75%, 93%, and 87% of planned events in CREDENCE, DAPA-CKD, EMPA-KIDNEY, and FLOW, respectively.

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 10% of hospitalized patients have penicillin allergy listed in their records, fewer than 1% of patients have true allergies. Use of more-expensive and broader-spectrum antibiotics is associated with longer and more-expensive hospital stays and more side effects, nosocomial infections, and resistant organisms.  Blumenthal KG et al. Reaction risk to direct penicillin challenges: A systematic review and meta-analysis. JAMA Intern Med 2024 Sep 16; [e-pub]. (https://doi.org/10.1001/jamainternmed.2024.4606)   researchers examined the safety of direct penicillin challenges (without preceding skin tests) for delabeling patients without true allergies. Among more than 9000 patients in these studies, 438 experienced reactions (3.5%), with only 5 reactions classified as severe: 3 episodes of anaphylaxis, 1 delayed rash with fever, and 1 kidney injury. No fatalities were reported.NNH of 1800  The PENFAST score is a good tool to help decide which patients can undergo direct oral challenge safely (NEJM JW Gen Med Aug 1 20

Efficacy and Safety of a Novel Low-Dose Triple Single-Pill Combination Compared With Placebo for Initial Treatment of HypertensionJ Am Coll Cardiol 2024 Aug 30;[EPub Ahead of Print], A Rodgers, A Salam, AE Schutte, WC Cushman, HA de Silva, GL Di Tanna, D Grobbee, K Narkiewicz, DB Ojji, NR Poulter, MP Schlaich, S Oparil, W Spiering, B Williams, JT Wright, A Gutierez, A Sanni, P Lakshman, D McMullen, G Ranasinghe, C Gianacas, M Shanthakumar, X Liu, N Wang, P Whelton    randomized, double-blind, placebo-controlled trial of a new single-pill combination comprising low doses of telmisartan, amlodipine, and indapamide for treating hypertension in 295 adults with mild to moderate hypertension. baseline systolic BP of 130 to 154 mm Hg during a placebo run-in, and had a low estimated 10-year risk for cardiovascular disease (<10%). The primary efficacy outcome was difference in change in home SBP from randomization to week 4  patients were randomized in a double-blind manner into three different arms: GMRx2 at a qua