Questioning Medicine

Bottom line Do I think if you stop drinking alcohol in the next thirty days you are less likely to come to the hospital for a heart attack? A stroke? Pneumonia? copd exacerbations or CHF exacerbations?? The answer is no!! not in thirty days.. sure if you drag that out for months or years then yes you are at greater risk but for only 30 days of follow up realistically should be no difference in coming back to the hospital for things that are not alcohol related. However there was still a significant improvement or decrease in alcohol related return to the hospital.-- This is what most supporters will look at and say ‘see we should give this medication to everyone’ This get tricky because they lump together alcojol related ED visit and alcohol related readmission in their definition of alcohol related return to the hospital---- well hello!!!! You cant get readmitted if you don’t go to the ED so the real ‘return to the hospital’ is just alcohol return to the ED and by including alcohol relatated readmission with alcohol related ED visit you are just trying to artificially inflate your finding. I know that they were just trying to artificially manipulate their finidings because as they say “””Alcohol-related ED visits did not reach statistical significance in relative terms (IRR, 0.61 [95% CI, “”” If your patient wants fda approved medications for alcohol use disorder then give it to them!! We shouldn’t without these medications but if you are giving it to them thinking it is some magical pill with a nnt of 4 to prevent death and the patient returning to the hospital then you will be sad!https://pubmed.ncbi.nlm.nih.gov/38551564/

In a retrospective cohort study of Veterans Affairs (VA) nursing home residents during 2006 to 2019, researchers identified 13,000 residents who initiated a first or additional antihypertensive medication and 52,000 propensity score–matched controls (mean age, 78). The primary outcome was a composite of pelvic fracture, surgically treated hip fracture, and fractures of the humerus, radius, and ulna that required intervention within 30 days of starting antihypertensive medication. Initiating medication also was associated with elevated risks for falls that required emergency room visits or hospitalizations (aHR, 1.8) and elevated risks of syncope (aHR, 1.7). Fracture risks were elevated, compared with controls, in initiators with a  systolic blood pressure ≥140 mm Hg (aHR, 3.1), diastolic blood pressure ≥80 mm Hg (aHR, 4.4), and no recent antihypertensive medication use (aHR, 4.8).

SGLT-2 inhibitors have not been evaluated in patients with stage 5 CKD (CKD 5; eGFR, ≤15 mL/minute/1.73 m2). Investigators in Taiwan retrospectively assessed 5 years of outcome data for nearly 48,000 patients with type 2 diabetes and CKD 5 — half of patients had newly initiated SGLT-2 inhibitors, and half were not taking these drugs.compared with no SGLT2i use, SGLT2i use was associated with lower risks for dialysis (hazard ratio [HR], 0.34 [95% CI, 0.27 to 0.43]), hospitalization for heart failure (HR, 0.80 [CI, 0.73 to 0.86]), AMI (HR, 0.61 [CI, 0.52 to 0.73]), DKA (HR, 0.78 [CI, 0.71 to 0.85]), and AKI (HR, 0.80 [CI, 0.70 to 0.90]), but there was no difference in the risk for all-cause mortality (HR, 1.11 [CI, 0.99 to 1.24]).    So almost higher rates of mortality if you are betting man with 95% confidencehttps://www.acpjournals.org/doi/10.7326/M23-1874

glucagon-like peptide-1 (GLP-1) receptor agonists can delay gastric emptying, the American Society of Anesthesiologists (ASA) say For patients on daily dosing consider holding GLP-1 agonists on the day of the procedure/surgery. For patients on weekly dosing consider holding GLP-1 agonists a week prior to the procedure/surgery.  Now, the American Gastroenterological Association (AGA) has published a “Rapid Clinical Practice Update,” note that evidence is insufficient to make strong recommendations about continuing or withholding GLP-1 agonists prior to endoscopy. The AGA suggests an individualized approach: GLP-1 agonists “could be withheld” in patients who take the drugs solely for obesity, but the authors worry that omitting a dose in a patient with diabetes might confer more risk than benefit. They say the scope should go on as long as the pt has been on an 8 hour solid fast and a 2 hour liquid fasthttps://www.sciencedirect.com/science/article/pii/S1542356523008698?via%3Dihub

But now we have RCT data—278 adults with moderate CAP who were hospitalized (but not in intensive care) to receive either a β-lactam antimicrobial plus clarithromycin or a β-lactam alone. (all patients met sepsis or severe sepsis criteria) composite primary endpoint of improved respiratory symptoms and improved SOFA score by day 4 occurred in significantly more patients in the dual-antibiotic group (68% vs. 38%; number needed to treat, ≈3). Individuals on dual antibiotics also were significantly less likely to develop sepsis (13% vs. 24%; NNT, 10), significantly more likely to be discharged and alive at 3 months (79% vs. 62%; NNT, 6), and less likely to be readmitted within 90 days (8% vs. 15%; NNT, 14; P=0.09)https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S2213260023004125?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS2213260023004125%3Fshowall%3Dtrue&referrer=https:%2F%2Fwww.jwatch.org%2F

AI technology was highly accurate at identifying malignancies and tumor origins — as accurate as senior pathologists, and significantly more accurate than junior pathologists.   Patients with cancer of unknown primary site who received treatment concordant with tumor origins predicted by AI had significantly longer overall survival than those whose treatment was discordant with AI predictions (27 vs. 17 months).https://www.nature.com/articles/s41591-024-02915-w

HERE IS WHEN IT IS RECOMMENDED TO USE ALBUMIN In patients with cirrhosis and spontaneous bacterial peritonitis, to substantially limit kidney impairment and mortality (low-certainty evidence) THIS IS THE ONLY THING YOU HAVE TO REMEMBER FORGET THE REST! In patients with cirrhosis and ascites who undergo large volume paracentesis (LVP; >5 L) to significantly lower the incidence of paracentesis-induced hypotension, but they had no substantial improvement in recurrent ascites or renal impairment and no mortality benefit. (very-low–certainty evidence) New guidelines on the use of albumin (remember albumin is a blood product so if you have a Jehovah’s witness or any patient that avoids blood products you need to ask them if it is ok)https://www.sciencedirect.com/science/article/pii/S001236922400285X?via%3Dihub

The results for weight loss was  Tirzepatide also known as mounjaro – 8.5 kg  Semaglutide also known as Ozempic -3.1 kg lost Liraglutide aka Victoza – 1.3 kg lostTirzepatide also known as mounjaro – 8.5 kg But almost all of these weight loss drugs seem to lose the effect over time and as you increase the dose and increase the weight loss you can expect to increase the GI side effects https://www.bmj.com/content/384/bmj-2023-076410

41 adults (mean age, 59) with obesity (mean weight, 99 kg) and prediabetes or diet-controlled diabetes – everyone got the same diet. Same  micro- and macronutrient composition; same calorie amounts Food was prepared in a study kitchen and consumed onsite or taken home.Key differenceThe intervention group was instructed to eat between 8 a.m. and 6 p.m. and to consume 80% of calories by 1 p.m. The control group was instructed to eat between 8 a.m. and midnight, with 55% of calories after 5 p.m.Weight loss in the two groups was similar at 12 weeks (about 2.4 kg).3 months—and no difference—https://www.acpjournals.org/doi/10.7326/M23-3132

recipients were more likely than placebo recipients to report much or very much improvement (55% vs. 25%) which isn’t shocking because half of the people were not getting medicinethey also report that the medication arm had improvement on CT imaging of the sinuses which also seems like another Duh moment as I am sure it was better than nothing my concern is this new drug or deliver of the drug is a cash price of about 800-1000 per month while just simple fluticasone is around 10$ a month. I think for now stick with the normal 10$ fluticasone but if there is no success and continue to have severe symptoms then maybe consider this if they have good insurance bottom line is there is a new drug out there that is basically fluticasone in a fancy delivery device.. for almost all my patients and family members they will be getting regular fluticasone not this fancy delivery device that goes but the name XHANCEhttps://www.clinicalkey.com/#!/content/playContent/1-s2.0-S221321982301365X?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS221321982301365X%3Fshowall%3Dtrue&referrer=https:%2F%2Fwww.jwatch.org%2F

https://onlinelibrary.wiley.com/doi/10.1111/joim.13757ECG abnormalities were present in 40% of hypokalemic patients and included t-wave flattening/inversion, ST-segment depression, QTc prolongation, longer QRS duration, and high heart rate.    after adjustment for potential confounders, only heart rate >100 beats per minute and not the ECG abnormalities was associated with those adverse outcomes, and this association was noted only when potassium levels were <3.0 mmol/L. hypokalemia is not good and certainly not hypokalemia < 3.0 but its not the proarrhythmic effects of hypokalemia that is bad it is the acute illness it is the under lying reason the patient has a potassium of less than 3. 

https://www.acpjournals.org/doi/10.7326/M23-3225researchers randomized 160 patients with mostly unilateral hip OA to two 60-minute sessions weekly for 12 weeks,you were randomized to receive either neuromuscular exercise (NEMEX; focusing on postural and functional stability) or progressive resistance training (PRT; focusing on muscle strength).  primary outcome was the “chair stand test,” in which patients go from sitting to standing as many times as possible within 30 seconds. At 12 weeks, this outcome did not differ between the NEMEX and PRT groups; mean improvement in both groups was 1.5 repetitions (from a baseline of ≈11.5 repetitions). 1.5 repetitions did not meet anyones expections or criteria for clinically meaningful improvement.

adult smokers who are given e-cigarettes are significantly more likely to be abstinent at 6 months from a target quit date with a  (NNT = 8) but those individuals were not more likely to be abstinent from any nicotine product. In this study, the cost of e-cigarettes was paid by the study, so in the real world where patients have to buy their own e-cigarettes the results may be less favorable. The best nicotine replacement is the one the patient will actually use as the nnt is around 10 give or take for all of them.https://pubmed.ncbi.nlm.nih.gov/38354139/

However, screening is not recommended because it has not been shown to improve patient outcomes.. Lifestyle recommendations include moderating alcohol use, quitting smoking, exercising, and losing weight if obese. Good news: Coffee need not be restricted.The authors recommend using a risk score such as CHADS2-VASC to determine the patient’s risk of stroke; if the annual risk of stroke is between 1% and 2% anticoagulation should be considered, and if the annual risk of stroke is greater than 2% then anticoagulation is strongly recommended.For patients who are low risk (< 1%) — for example, younger than 65 years and without any risk factors for stroke — anticoagulation is not recommended. The guidelines also do not recommend aspirin or aspirin plus clopidogrel for these patients unless there is another indication, such as coronary heart disease.  With regard to the choice of anticoagulant, a standard dose of a direct oral anticoagulant (DOAC) is recommended over vitamin K antagonists like warfarin. The exceptions are patients who those with moderate to several mitral stenosis, and those with a mechanical heart valve.

https://journals.lww.com/ajg/fulltext/2024/03000/american_college_of_gastroenterology_guidelines_.14.aspx2 of the 3 following criteria: (i) abdominal pain consistent with the disease, (ii) serum amylase and/or lipase greater than 3 times the upper limit of normal, and/or (iii) characteristic findings from abdominal imaging Fluid--Moderately aggressive fluid resuscitation with lactated Ringer's solution should be started (NEJM JW Gen Med Oct 1 2023 and Am J Gastroenterol 2023; 118:2258), defined as a bolus of 10 mL/kg followed by infusion of 1.5 mL/kg/hour (NEJM JW Gen Med Oct 15 2022 and N Engl J Med 2022; 387:989), and additional boluses can be given if a patient has evidence of hypovolemia.Feeding-- Early oral feeding (within 24–48 hours) should begin with a low-fat solid diet (as opposed to liquid) for patients with mild AP.Surgery- Patients with mild acute biliary pancreatitis should undergo cholecystectomy early, preferably before discharge. Following a second episode of AP with no identifiable cause, in patients fit for surgery, we suggest performing a cholecystectomy to reduce the risk of recurrent episodes of AP.

Bottom line-Elevated cholesterol as a child into an adult is bad but we still don’t know if treating children with medication improves this badness but we can say if you have elevated cholesterol as a child and it resolves as an adult then that is a good sign and puts you at equal risk to someone who never had dyslipidemiahttps://jamanetwork.com/journals/jama/article-abstract/2817700

Weight gain <5 kg was not associated with risk for the composite outcome among women with class 1 and 2 obesity (BMIs, ≥30–39.9 kg/m2). Weight gain <5 kg and weight loss were associated with lower risk for the composite outcome, compared with recommended weight gain, in women with class 3 obesity (BMIs, ≥40 kg/m2; rate ratio, 0.81) As the authors suggest—my take away bottom lineThese findings suggest that a low amount of weight gain or weight loss is safe in pregnant women with obesity, and might even be beneficial for those with class 3 obesity.https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S0140673624002551?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS0140673624002551%3Fshowall%3Dtrue&referrer=https:%2F%2Fwww.jwatch.org%2F

Chair placement was not associated with a difference in patients’ ability to name their physician (P=1.0), ability to successfully identify their reason for hospital admission (P=0.82), or perceptions of time (P=0.2) (see supplemental table 5).  Overall if you put a chair at bedside and have medstudents following then yes a provider is more likely to sit down. However- this only minimally changes patient satisfaction score 3.9% on a 100 point scale. This would take hospital change. And set up change. This although touted as positive is a negative trial for those in HR and adminhttps://www.bmj.com/content/383/bmj-2023-076309

primary outcome was Duration of the first stage of labor was the primary outcome. AND It was 179 minutes shorter (95% CI 146 - 213) in the intervention group than in the control group (392 minutes; standard deviation [SD] 122 vs 571 minutes; SD 188). Intensity of pain, was reported on a visual analog scale of 0 to 10 at several points in time, was on average 2.0 to 2.7 points lower in the intervention group. The absolute rate of cesarean delivery was reduced by 14 percentage points in the intervention group (26 vs 12; absolute risk reduction = 14; 3 - 25; number needed to treat = 7).Main limitation here was that those in the intervention group were trained and had a professional physiotherapist with them at all times. This is not reasonable. https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S1836955323001212?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS1836955323001212%3Fshowall%3Dtrue&referrer=https:%2F%2Fpubmed.ncbi.nlm.nih.gov%2F

In older adults, mildly elevated TSH levels normalized in about 50% of cases during 1 to 2 years of observation.https://academic.oup.com/jcem/article/109/3/e1167/7325863?login=true