Questioning Medicine

Primary Outcome: Composite of deaths from cardiovascular causes or hospitalizations and urgent visits for heart failureDeath was not improved!NNT of 5 for hospitalizations and urgent visits -- However, results are not reported separately for hospitalizations and urgent visits, which are not equal events https://www.nejm.org/doi/full/10.1056/NEJMoa2030183

NNT of 20 to prevent 1 hospitalization at 16 months of follow upThey composite outcome was driven by decrease hospitalizations NOT deathhttps://www.nejm.org/doi/full/10.1056/NEJMoa2022190

NNT of 21 over 18 months to prevent a composite of worsening heart failure or cardiovascular deathNNT for hospitalization = 27NNT for Cardiovascular Death = 53N Engl J Med 2019; 381:1995-2008

Dapagliflozin and HFpEF did happen to improve the composite outcome but this was based mainly on hospitalizations not on death and comes at a big price tag with the NNT around 36 at 2.3yrs. N Engl J Med 2022; 387:1089-1098

Hospitalization for heart failure occurred in 8.6% of patients in the empagliflozin group and 11.8% patients in the placebo group (hazard ratio, 0.71; 95% CI, 0.60 to 0.83)number needed to treat [NNT] = 32 per 26 months But the drug company did a great job of writting the paper so you think there is mortality benefithttps://www.nejm.org/doi/full/10.1056/NEJMoa2107038

EMPA-REG OUTCOME back in 2015 this was the first SGLT2 trial to set the world on fire with Primary Outcome: death from cardiovascular causes: NNT 46 per 3.1 yrs (at $600 a month, 1 million dollars per life saved)nonfatal myocardial infarction: NS∞nonfatal stroke: NS∞https://www.nejm.org/doi/full/10.1056/nejmoa1504720

Forty-two percent of patients had a PPI on their medication list without indication 8 weeks after discharge, and more than half of these patients still were using PPIs 1 year later.  Compared with propensity-score matched patients without PPI use after discharge, patients with continued PPI use were 27% more likely to develop pneumonia, 17% more likely to develop experience cardiac events, 34% more likely to be .readmitted to the hospital in the subsequent year and 17% greater risk of in increased mortality at two years.https://journals.lww.com/ccmjournal/fulltext/2024/02000/timely_cessation_of_proton_pump_inhibitors_in.4.aspx

These results are reassuring for management of both underweight and overweight patients with AF. That said, I would still have reservations about prescribing DOACs in the small minority of patients with BMI >45 kg/m2 or body weight >330lbs due to their underrepresentation in the pivotal trials and when you look at the supplementary data you will see a weight of 262 was 95% tile so >330 would be around the 99th %tile of weight.https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.123.066279

Nurse Practitioners prescribe medications off the beers list at the same rate at primary care physicians, hard to tell what this means for patient care and patient outcomes. https://www.acpjournals.org/doi/10.7326/M23-0827?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed

Using the Brain Care Score seem to be effective in predicting the risk of dementia For participants under 50, each five-point higher BCS is associated with a 50% lower risk of dementia or stroke For participants under 50, each five-point higher BCS is associated with a 59% lower risk of dementia THE SCORE IS HERE ---->. https://www.massgeneral.org/assets/mgh/pdf/neurology/mccance-center/brain-care-score.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10725202/#:~:text=A%20five%2Dpoint%20higher%20BCS,%25)%20among%20those%20aged%20%3E59.

Even when starting DAPT within 72hours of symptom onset for individuals with minor stroke or TIA the benefit of DAPT for the first 21 days was still seen at 90 day follow up in the form of less recurrent strokehttps://www.nejm.org/do/10.1056/NEJMdo007334/full/

In those high risk patients -- usually with lung or GI cancer they did benefit from primary prevention VTE prophalaxis with a NNT of 6-7 for VTE and death at 6 months. https://pubmed.ncbi.nlm.nih.gov/37733336/#:~:text=Conclusions%20and%20relevance%3A%20In%20this,safety%20concerns%2C%20and%20with%20reduced

Just get he biopsy at less than 6 weeks after starting therapy as the yield was the same at 2 weeks as it was at 4-6 weekshttps://pubmed.ncbi.nlm.nih.gov/36642440/

Evidence against baby walker is not enough regarding its negative effect on child development. This subject needs to be addressed more, considering a large number of baby walker users worldwide.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5703622/Surveillance System data from 1990 to 2014  230 676 children <15 months old were treated for infant walker–related injuries in US emergency departments from 1990 to 2014.9 out of every 10 injuries were to the head and neck and 74% were injuries secondary to falling down the stairs in an infant walkerhttps://publications.aap.org/pediatrics/article-abstract/142/4/e20174332/37420/Infant-Walker-Related-Injuries-in-the-United?redirectedFrom=fulltext?autologincheck=redirected

During average follow-up of in this study the incidence of prostate cancer was less than 1% — and not significantly different  Remember most of these pts had testosterone levels around 350 ish give or take so the safety of longer-duration treatment — or treatment resulting in higher blood levels of testosterone — remains unclear.https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2813293

From a mean score of 45 points at baseline, mood improved by about 5 points in the placebo group and 6 points in the testosterone group — a statistically significant but small difference. I think you will be hard pressed to find anyone that thinks this is clinically significant except for maybe the authors of the paper when they write that it is beneficial in their conclusionhttps://academic.oup.com/jcem/advance-article-abstract/doi/10.1210/clinem/dgae026/7516050?redirectedFrom=fulltext&login=true

Erectile disfunction should be treated with the appropriate medications like the PDE5 inhbitors—not testosterone—testosterone may make it so you flirt half a time more a day but that is not likely worth the harm that comes with even in the placebo small doses seen in the traverse trialhttps://academic.oup.com/jcem/article-abstract/109/2/569/7244351?redirectedFrom=fulltext&login=true

even at very small some would argue barely even treating doses of testosterone patients had an increase rate of fractures with a NNH of 100—when you add this to the 1 risk of aki and 2 percent risk of arthymia the harms vs benefit conversation to use testosterone seems to be leaning heavy towards harmshttps://www.nejm.org/doi/full/10.1056/NEJMoa2308836?query=recirc_curatedRelated_article

Risk of progression from prediabetes to diabetes did not differ significantly between testosterone and placebo groups- and they looked for a change at 6,12,24,36,48 months of follow upNot to sound like a broken record butRisk of progression from diabetes to not having diabetes did not differ significantly between testosterone and placebo groups- and they looked for a change at 6,12,24,36,48 months of follow uphttps://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2814401?guestAccessKey=d63bbb99-4d14-4f17-a4ac-b208633827e2&utm_source=twitter&utm_medium=social_jamaim&utm_term=12573820072&utm_campaign=article_alert&linkId=310108953

Take awayThe drug companies will say look how safe testosterone therapy is there was no difference in death from cardiovascular causes or myocardial infarction or stroke in those individuals randomized to testosterone therapy over placebo but in actuality this trial really showed nothing and it did show that when using placebo or minimal doses of testosterone -- ones that barely change blood levels of testosterone and have so little effect on how people feel that 60% of them stop the active arm of the trial, then and only then are the patients safe from cardiovascular risk at less than 2 years of follow up. And I am sure they will forget to mention the harm associated with testerone that was in the form of cardiac arrhythmias and acute kidney injury.https://www.nejm.org/doi/full/10.1056/NEJMoa2215025