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Questioning Medicine
Questioning Medicine
Category: Medicine
Location: Florida
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February 27, 2021 07:03 AM PST

SGLT2 inhibitors and GLP1 agonists administered without metformin compared to other glucose‐lowering drugs in patients with type 2 diabetes mellitus to prevent cardiovascular events: A systematic review - Escobar - 2021 - Diabetic Medicine - Wiley Online Library

Yes these fancy new drugs work with and without metformin but that does not mean these drugs should be first line!!

Effect of a Single High Dose of Vitamin D3 on Hospital Length of Stay in Patients With Moderate to Severe COVID-19: A Randomized Clinical Trial | Complementary and Alternative Medicine | JAMA | JAMA Network

Yep even 200,000IU of vit D does nothing except raise your vit d level.

Diet and acne: review of the evidence from 2009 to 2020 - Dall’Oglio - - International Journal of Dermatology - Wiley Online Library

What you eat does mess with your acne, or at least says this large observational trial.

Statin treatment and muscle symptoms: series of randomised, placebo controlled n-of-1 trials | The BMJ

The muscle aches with statins is a common event that it occurs as frequently with the active drug as it does with placebo

February 14, 2021 11:11 AM PST

Semaglutide works for weight loss but at what co$t?

BOARD CHANGER- New gonorrhea guidelines

Diabetes drugs are expensive for our patients and we can't forget that.

Children find it hard to tell what facial expression you are giving when you have a mask on!

https://www.nejm.org/doi/10.1056/NEJMoa2032183

industry-conducted trial published in the New England Journal of Medicine.
Researchers randomized nearly 2000 participants without diabetes who were either overweight with at least one weight-related comorbidity or obese to receive All2.4 mg subcutaneous semaglutide or placebo weekly for 68 weeks.
mean bmi 38. weighing at 105 lbs.

Mean weight loss was significantly greater with semaglutide than placebo (15% vs. 2%), as was the percentage of patients losing >5% of body weight (86% vs. 32%).

difference is 31lbs-- over 68weeks or 16 months.. the drug cost 734$ per month. that is 11,744 for treatment or 379 per pound. not worth it to me

twitter and say shouldnt you have the conversation?!?





BOARD CHANGER



The CDC now recommends treating uncomplicated gonorrhea with a single 500-mg intramuscular dose of ceftriaxone, according to updated guidelines in MMWR. The recommendation applies to urogenital, anorectal, and pharyngeal infections.
Previously, the CDC recommended ceftriaxone plus oral azithromycin. The authors note that azithromycin resistance is "an increasing concern." Nationwide, the percentage of N. gonorrhoeae isolates with reduced susceptibility to azithromycin increased from 0.6% in 2013 to 4.6% in 2018.
Among the recommendations:
People weighing ≥150 kg should be given a single 1-g dose of ceftriaxone.
In patients for whom a chlamydial infection has not been ruled out, doxycycline 100 mg orally twice a day for 7 days is also recommended.
For patients with cephalosporin allergy, an intramuscular dose of gentamicin (240 mg) plus an oral dose of azithromycin (2 g) may be considered.
In cases where intramuscular ceftriaxone can't be given, an oral dose of cefixime (800 mg) is an option, but the authors note it may not be as effective.
For pharyngeal gonorrhea, there are no reliable alternative therapies and test-of-cure is recommended.


Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 | MMWR
BOARD ANSWER CHANGER
https://news.wisc.edu/can-blocking-a-frown-keep-bad-feelings-at-bay/


remember that article back in 2010 which basically showed those people to get botox had decrease ability to defer emotions or facial expressions of others??

It was out of the university of wisconin and not they are back at it with this article----


https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0243708

Children’s emotion inferences from masked faces: Implications for social interactions during COVID-19


Plos one


This study took 81 7-13yr old child to see how children perceived others’ emotions as partial information about the face was presented

pictures of stereotypical facial configurations associated with sadness, anger, and fear posed by male and female models.

Pictures were presented in unaltered format (i.e., with no covering) or digitally altered to be (a) covered with a surgical face mask that obscured the mouth and nose, or (b) covered with sunglasses that obscured the eyes and eyebrows

The primary question addressed by this study is whether masks meaningfully degraded children’s ability to infer others’ emotions

“Accuracy between the faces that wore masks and shades did not differ”

And that was the others conclsuions

“These data suggest that while there may be some challenges for children incurred by others wearing masks, in combination with other contextual cues, masks are unlikely to dramatically impair children’s social interactions in their everyday lives”

But that doesn’t tell the whole story


Because when you look at the results you see that both sunglasses and mask did present a challenge for kids compared to no mask or no sunglasses. About a 10% absolute difference or a 33% realtive difference and althought you cant really use NNT in this type of trial if you were that would be a NNH of 10.

For every 10 kids, 1 kid has a dramatic impairment in their ability to infer others emotions with the use of mask or sunglasses

This is not me being antimask. This is not me saying that mask are the devil. This is me saying there are real effects to what we are doing and we have to be prepared for them and one of them might be children that are not able to infer emotions as well.




Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020

new guidelines regarding treatment of gonorrhea-
Prior recommendations had included treating a patient for both gonorrhea and chlamydia when there was a positive gonorrhea test regardless of chlamydia results. These updated guidelines recommend not treating a patient for chlamydia if the patient is diagnosed with gonorrhea if testing shows no chlamydia infection. Treatment for both is still recommended if chlamydia status is unknown. Dosing for gonorrhea treatment was also increased from ceftriaxone 250mg IM to 500mg IM, and treatment for coinfection with chlamydia was changed from azithromycin to doxycycline with a longer course of 7 days.

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/10.1001/jamainternmed.2020.
2922?guestAccessKey=3ed2a6bb-bc67-4b5e-955c-
08cc5b7bedf6&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-
jamainternalmedicine&utm_content=etoc&utm_term=120720

ben franklin is linked to the famous saying “a penny saved is a penny earned” well I wonder
what he would say about our next and last paper titled-
Out-of-Pocket Costs for Novel Guideline-Directed Diabetes Therapies Under Medicare Part D

Which did exactly as the article suggests and looked at the cost of novel diabetic agents under Medicare
part D which covers almost 45,000,000 people.
They reviewed 6 drug classes and projected annual out-of-pocket costs
Across near 3000 Part D plans commonly covered GLP-1RAs, SGLT2is, and DPP-4is had
monthly list prices between $434 to $935
compared with $3 to $11 for metformin, sulfonylureas, and TZDs.
What does that mean for your patient, how does that translate into real world information??
Well,
annual costs for common novel agents were $5202 to $11 225
with only $31 to $136 for traditional drugs
And the Projected annual out-of-pocket cost for novel drug regimen were $1231 to $1981,
compared with $250 to $355 for traditional regimens.

Considering at best these new agents have a NNT of 20 the variability to prevent one nonfatal
event that approaches 100K needs to be seriously looked at.

February 09, 2021 04:20 PM PST

Also ask yourself, did this study compare their treatment to the 'gold standard' and if the answer is no they compared it to a straw man, then think big Pharma, or authors that needed publication for their job. We can't treat what we don't know exist and 30-50% of the time COVID19 is asymptomatic. Combined Oral Contraception DO NOT have an increase risk of DVT and long term the risk are very minimal if a DVT does develop while on COC.

Speaking of studies that should have never been done- Multicentre, prospective, randomised study comparing the diagnostic yield of colon capsule endoscopy versus CT colonography in a screening population (the TOPAZ study) | Gut (bmj.com)


Diagnostic Yield of Colon Capsule Endoscopy vs CT Colonography in a Screening Population | PracticeUpdate

The authors of this multicenter, prospective, randomized study compared the diagnostic yield of colon capsule endoscopy (CCE) with that of CT colonography (CTC) for colon cancer screening in an average-risk adult population.
First you had either a CCE or a CTC and then the findings were confirmed with colonoscopy.

The sensitivity and specificity of CCE for polyps ≥6 mm were 79.2% and 96.3%, respectively, compared with 26.8% and 98.9%, respectively, with CTC. The sensitivity and specificity of CCE for polyps ≥10 mm were 85.7% and 98.2%, respectively, compared with 50% and 99.1%, respectively, with CTC.

They authors say this may work for people who refuse colonoscopy. Which is true it might but we have a fit test—it cost pennies—why in the world do we need this test?!? Its more money its more invasive its not better than FIT…..

This is a study we didn’t need
till I read the 30 line conflict of interest and I knew exactly why we needed this trial—to keep big pharm in business


Colon cancer is scary cause most of the time we don’t know we have it and speaking of thigs we don’t know we have

Asymptomatic SARS-CoV-2 Infections Among Persons Entering China From April 16 to October 12, 2020 | Global Health | JAMA | JAMA Network

China controlled their cases because

Beginning April 1, 2020, persons entering China via air, sea, or land have been mandatorily tested for SARS-CoV-2 infection by PCR test at border checkpoints.
retrospective cohort study looked at All international entrants found to have SARS-CoV-2 infection via a positive PCR test result at China’s border checkpoints from April 16 to October 12 were included in this study.
3103 had confirmed COVID-19 cases, AMONG THOSE 1612 (51.9%) never developed symptoms through day 13 and were considered to have asymptomatic SARS-CoV-2 infection.




The Proportion of SARS-CoV-2 Infections That Are Asymptomatic: A Systematic Review: Annals of Internal Medicine: Vol 0, No 0 (acpjournals.org)

Purpose:
To estimate the proportion of persons infected with SARS-CoV-2 who never develop symptoms.


And results found- about 1/3 of people had no symptoms and if you test positive and have no symptoms then about 75% of the time you will never have symptoms. WE will never be able to stop what we don’t even know about. WE can never and I repeat NEVER flatten a curve on something that you may not even know you have 33% of the time.






Efficacy and safety of antidepressants for the treatment of back pain and osteoarthritis: systematic review and meta-analysis | The BMJ

Prescribe antidepressants for depression not for pain

Design Systematic review and meta-analysis.

Objective To investigate the efficacy and safety of antidepressants for back and osteoarthritis pain compared with placebo.

Pain and disability were primary outcomes. Pain and disability scores were converted to a scale of 0 (no pain or disability) to 100 (worst pain or disability).


Results 33 trials (5318 participants) were included.

Back pain-

serotonin-noradrenaline reuptake inhibitors (SNRIs) reduced back pain (mean difference −5.30, 95% confidence interval −7.31 to −3.30) at 3-13 weeks
SNRIs reduced sciatica at two weeks or less (−18.60, −31.87 to −5.33) but not at 3-13 weeks (−17.50, −42.90 to 7.89).
tricyclic antidepressants (TCAs) did not reduce sciatica at two weeks or less but did at 3-13 weeks (−15.95, −31.52 to −0.39) and 3-12 months (−27.0, −36.11 to −17.89).
SNRIs reduced disability from back pain at 1-13 weeks around 1-3 points—TO WHAT SIGNIFCANT CLINCALY ON 100 point scale.

osteoarthritis-
SNRIs reduced osteoarthritis pain (−9.72, −12.75 to −6.69) at 3-13 weeks
TCAs and other antidepressants did not reduce pain or disability from back pain.

ReplyForward




8000 women from 2004-2006- to be included you could not be pregnant or postpartum and aged ≤ 50 years, without active cancer

There were 220 women had either a first distal dvt, first prox dvt, or a first PE

Of these women, 47.3% (n/N = 104/220) were on COC pills at the time of their VTE event.

Overall, 27.6% of patients developed venous thromboembolism (VTE) <12 months after starting OCPs.

BUT this article was great because it said what is the long term effect of this VTE caused by COC--- are their long term effects?

At 3‐year follow‐up, all women with COC‐associated distal DVTs were alive, and none had bled during anticoagulant treatment or had experienced a DVT or PE recurrence after stopping anticoagulants.

At 3‐year follow‐up, all women with COC‐associated PE were alive and none had bled during anticoagulant treatment or had experienced a DVT or PE recurrence after stopping anticoagulants.

At 3‐year follow‐up, all women with COC‐associated proximal DVT had a recurrence rate of 1.7% per patient‐year and there were no deaths or major bleeds

The take home is that DVTs and PE with COC are basically just as common in women . taking and not taking COC as long as they are not pregnant and not postpartum women less than 50yrs old without active cancer AND most importantly, The long term outcome or side effects are basically the same, just remember to stop the COC if they are on it and then treat with 3 months of anticoagulation..

February 04, 2021 05:45 PM PST

The Drug Addiction Treatment Act of Under the Act, physicians may apply for a waiver to prescribe buprenorphine for the treatment of opioid addiction or dependence outside of an opioid treatment program (OTP).

The Drug Addiction Treatment Act of 2000 was authored by Senator Orrin Hatch (R-UT), Senator Joe Biden (D-DE), and Senator Carl Levin (D-MI).

DATA 2000 waiver



Why would biden reverse this—it was one of the things I think we all agree upon is a good thing!!

I thought it must be the money – its always the money

But I found a few reasons reasons why

Confirmation bias--- Under the Act, physicians may apply for a waiver to prescribe buprenorphine for the treatment of opioid addiction or dependence outside of an opioid treatment program (OTP)
Money== Biden received $6.3m from pharma, compared to $1.6m for Trump,

Polack FP, Thomas SJ, Kitchin N, et al. Safety and efficacy of the BNT162b2 mRNA Covid-19 vaccine. N Engl J Med. 2020;383:2603-15. https://pubmed.ncbi.nlm.nih.gov/33301246


Randomized placebo-controlled trial.
Randomized placebo-controlled trial.
Of either BNT162b2 (BioNTech/Pfizer), given intramuscularly in two 30-mcg doses 21 days apart (n = 21 720 received vaccine), or saline placebo (n = 21 728).

Bottom line:

“ A two-dose regimen of BNT162b2 conferred 95% protection against Covid-19 in persons 16 years of age or older.”

BUT WHAT DOES THIS MEAN?!?!

Does it mean that if we inject everyone that only 5% of the population will get covid19?


January 31, 2021 05:36 PM PST

Autoimmune mothers likely don't actually have more ADHD kids. If you patient is in the hospital we now have a RCT to answer the question about ACEI starting or stopping. Finally, there are problems around COVID we don't even know about and it has nothing to do with contracting COVID19.

Association of Maternal Autoimmune Disease With Attention-Deficit/Hyperactivity Disorder in Children | Attention Deficit/Hyperactivity Disorders | JAMA Pediatrics | JAMA Network

Doesn't say what the authors think that it says – or perhaps it does and that is the problem with most studies in pregnancy….

The authors conclusions were “In this cohort study, maternal autoimmune diseases were associated with increased ADHD among children.”

Wiat autoimmune disorders in mom and boom big time risk of ADHD in children!

Better brain has true celiac so this is something I am interested—it sparked my attention!

population-based cohort analysis of 831,718 infants and mothers

in the end the researchers matched almost 13,000 children whose mother's had an autoimmune disease with approximately 50,000 children whose mothers did not have an autoimmune disease and when they crunch through all of the numbers those individuals whose mothers did not have an autoimmune disease were diagnosed with ADHD 5.48 cases per 1000 boys and 1.70 per 1000 girls BUT if your mom had an autoimmine disease then your risk of ADHD SHOT UP. From 5.5 for boys to 6.9 and from 1.7 for girls to 2.3. Yes that’s right an extra case of ADHD for every 700boys and an extra case of ADHD for every 2000 girls---

multiple things about the study- first of all not very impressed by the findings. Ousley is a cohort study so they're just looking at groups of patient's at different points of time. However may be the mothers who have autoimmune disorders are more likely to go to the doctor for their illness and thus more likely to take the child to the doctor. Or mothers who have autoimmune disorders are probably more likely to have health insurance for their medical condition and thus more likely once again to take their children to the doctor. After all he can be diagnosed with ADHD or any other illness unless you go to the doctor to get the diagnosis.

Next this is a perfectly example of absolute and relative risk reduction which is often miss under still by many medical students, resident's, and even attending physicians.

Left look at the event rate of ADHD in girls. It was 1.7 per thousand for those individuals who did not have a mother with an autoimmune disorder and the event rate went up to 2.3 cases of ADHD per thousand for those girls whose mother has an autoimmune disorder. The difference between 1.7 and 2.3 is 0.5. Thus you could say that if you have a mother with an autoimmune disease then there is a 0.5 per thousand increase rate of ADHD. Or since 0.5 is about a third or 33% of of 1.7- I could potentially say that having a mother with an autoimmune disorder increases your risk of ADHD as a female child by 33%.

In both statements I'm saying the same thing-------------- rant

A reminder- The authors conclusions were “In this cohort study, maternal autoimmune diseases were associated with increased ADHD among children.”

So maybe this article does say what the authors think that it said but unless you read the article you might be tricked into thinking that this was a substantial finding and worth long debates and discussion about.
One of many problems with pregnancy litature is the small almost insignificant findings.
you see there actually was an increase but that increase was so small---- the reason being is that most pregnancies go off without a hitch. Most pregnancies don't have any complications. Most pregnancies that are carried to term delivery are absolutely fine so when you find even a small increase in the numbers you can report regardless if it worth your time to know about or think about.


The next article is the ultimate questiongin medicine article

Effect of Discontinuing vs Continuing Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers on Days Alive and Out of the Hospital in Patients Admitted With COVID-19: A Randomized Clinical Trial | Critical Care Medicine | JAMA | JAMA Network


Remember at the beginning of covid I did a podcast and I talked about ACE and ARBs and said I am still writing for them. This belief the are bad comes from bad evidence

Actually not even evidence—just opinion pieces such as a piece in journal of htn back in may titled-

Like Can angiotensin receptor-blocking drugs perhaps be harmful i... : Journal of Hypertension (lww.com)

Can angiotensin receptor-blocking drugs perhaps be harmful in the COVID-19 pandemic?

Some of us stopped acei on everyone. You make a fancy little drawing and explaination of a possible mechanism and many people fall victim and believe you. This is why drug reps are so successful. For majority of physicians they don't actually have the prove any benefit or outcome just a bunch of drawings with fancy words and potential mechanisms of how it could work. Others of us demand hard outcomes and appropriate clinical trials
Well now we have our results in this JAMA article which is the first randomized control trial of roughly 650 patient's hospitalized with mild to moderate COVID-19 who were taking either an ACE inhibitor or an angiotensin II receptor blockers (ARBs) on admission.
Patient's were then randomized to either discontinue the ACE inhibitor or angiotensin II receptor blocker or to continue it.
The primary outcome was the number of days alive and out of the hospital after 30 days. The secondary outcomes included death, cardiovascular death, and COVID-19 progression

And there was absolutely no difference no matter what you looked at

Continue the ACE OR ARB when you patient is admitted to the hospital with mild to moderate covid19

And the last article should make you think
Make you think

Progression of Myopia in School-Aged Children After COVID-19 Home Confinement | Global Health | JAMA Ophthalmology | JAMA Network

There are problems with covid 19 we cant even see yet. They have nothing to do with getting covid. They have to do with not getting covid. The social isolation is one of them but another one is the concern is whether home confinement 4 children may have a burden on their eyes. Less time outside = less time playing and more time inside likely in front of some sort of screen whether it be a computer screen or a TV screen or a tablet screening.

So in the study the authors set out to fine if the prevalence of myopia in school children during Covid 19 was affected. The theory being that children are spending more time in front of a screen and less time outside and thus the eyes are not encouraged to grow any look for anything greater than something that is 2 feet in front of the face. This study was paced out of China however I think that the results of likely applicable to everyone. Photoscreenings have been performed annually on children in 10 elementary schools since 2015- this is usually over 100,000 children participating each year.

In each ear the authors calculated an estimated prevalence of myopia
And in 2020 the rates of myopia s/p covid quartine the changes were scary. For 8yr olds the prevalence in previous years was 27% and it jumped up to 37%. For seven year olds the prevalence was 16% and jumped up to 26% and for 6 year olds the prevelance of myopia was 5.7% and relatively speaking it jumped up 400% or and absolute of 21%

This substantial myopic shift was not seen in any other year-to-year comparison,

What does this mean?? Sure there is a change but what does it mean?? And the answer is we don’t totally know and we wont know

We do know currently that 1 in 3 people with high myopia becomes severely visually impaired, mostly at working age. So the potential health problem is very bad.

This is not me saying we shouldn’t have shut down at the beginning
But this is me saying that it is sad some of the problems we don’t even realize we have or will have because of the covid19 pandemic
Much of the pandemic became a political issue which only hurts the patient when medical clarity is clouded by political preference.



January 27, 2021 03:27 PM PST

HHS Expands Access to Treatment for Opioid Use Disorder | HHS.gov

U.S. Department of Health and Human Services
Announcement of practice guidelines for the administration of Buprenorphine for treating opioid use disorders

Jan 12- 20221
-physicians with a DEA license- only not all providers
-you can only treat patients located in the state you have a medical license in (basically no tele)
-Physicians utilizing this exemption will be limited to treating no more than 30 patients with buprenorphine for opioid use disorder at any one time (note: the 30 patient cap does not apply to hospital-based physicians, such as Emergency Department physicians).
-ONLY buprenorphine- does not apply to methadone for the treatment of OUD.
- Physicians utilizing this exemption shall place an "X" on the prescription and clearly identify that the prescription is being written for opioid use disorders

January 17, 2021 02:25 PM PST

They say every dog has its day and IT think every drug has its place

Anyone who says ‘that drug is bad’ or that test is bad or that anything is bad is just being closed minded or not aware of the evidence because evidence and medicine comes down to numbers.
The real statement should be I don’t think that drug is beneficial enough for the harm. However that is an opinion statement, it is what you think and that is when shared decision making comes into play because maybe your patient does think it is beneficial
No more clearly see than in this viewpoint in Jama titled

Balancing the Risks and Benefits of Benzodiazepines
https://jamanetwork.com/journals/jama/fullarticle/2775180?guestAccessKey=fe7dd94f-653f-4da0-ad1f-21fb8c60e420&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jama&utm_content=olf&utm_term=010821

Which talks about the risk and benefits of benzos. A drug that I often here so many providers dis on with no real evidence to back it up—how do I know there is no real evidence??
Because as the authors point out

To date, no published meta-analyses have compared benzodiazepines with selective serotonin reuptake inhibitors for anxiety
People will often cite data from morbitiy and mortality weekly and say that rates of abuse are on on the rise and as an example-
among US women aged 30 to 64 years, the rate of benzodiazepine-related deaths increased from approximately 0.5 per 100 000 population in 1999 to nearly 5 per 100 000 population in 2017;
BUT BUT “I said benzodiazepine-related deaths”
That is such a tricky number it just means that benzo were on board not that benzo killed them. If I said oxygen related deaths the number would be 100%. Everyone who breaths oxygen dies. and, these data do not distinguish benzodiazepine monotherapy related death from coadministration with other medications.
from 1993 to 2014, the rate of benzodiazepines and opioids combined increased from 9.8 to 62.5,
per 100 000 outpatient visits


Sure benzos can be addictive but so can SSRI!
Have you every tried to take someone off an SSRI?!? You can’t just stop it cold turkey most of the time and lets be honest if you are addicted to drugs you fix isnt coming from benzos.
in 2017 among 2 005 395 admissions to publicly funded substance abuse treatment programs only 1% identified benzodiazepines as their primary drug of abuse.
I am not saying benzos are perfect and give them to everyone. Of course not, and I agree fewer people needs benzos but
Every dog has its day and every drugs has its use
practice guideline from the American Psychiatric Association includes benzodiazepines among first-line pharmacologic treatment strategies for panic disorder
I bring all this up because
https://www.fda.gov/drugs/drug-safety-and-availability/fda-requiring-boxed-warning-updated-improve-safe-use-benzodiazepine-drug-class

September 2020, the US Food and Drug Administration (FDA) announced an update to the boxed warning on all benzodiazepines to explicitly “address the serious risks of abuse, addiction, physical dependence, and withdrawal reactions”

My fear is most physicians will see this headline, never critically think about it and mimic what they read and it will come off as “benzos are addictive, abusivie, and a terrible drug” with little thought to the limitations of the evidence.

They will likely then go on writing for their SSRI which also has addictive properties with results that are slower for onset and not better than the benzo.

I am not saying these are great drugs but if you are saying they are terrible drugs then you need to remember

Every dog has its day.



https://www.practiceupdate.com/c/111407/2/6/?elsca1=emc_enews_daily-digest&elsca2=email&elsca3=practiceupdate_primary&elsca4=primary-care&elsca5=newsletter&rid=MzU5ODQyMjUwMDM1S0&lid=20849334

Not all things are created equal and not test are created equal. This is no more clearly seen in this article in the New England Journal of Medicine tittled

Racial Bias in Pulse Oximetry Measurement

I often talk about exclusion and inclusion criteria on this podcast and did you know the pulse ox has not been validated in racial diverse populations.
https://www.nejm.org/doi/10.1056/NEJMc2029240

In the study looking at pulse oximetry the author’s were testing for occult hypoxemia which is basically an arterial oxygen saturation of less than 88% despite the pulse oximetry satting 92-96%. This is a big deal, if I walk in the room and I see a pulse oximetry reading 94 or 95% my patients actual oxygen level is certainly above 88%. However, in the study they found that almost 12% of black patient’s had a pulse oximetry between 92-96% but a blood gas oxygen of less than 88% and this only occurred 3-1/2% of the time in white patient’s.
So what you do with this information? Well I think the best way to use it is on the lower end of the pulse oximetry say 92 or 93 or 94% in your black patient’s you should consider increasing their oxygen as the percent of occult hypoxemia at increased as patient’s or approaching 92% pulse oximetry and started 0 cases of occult hypoxemia at 96% pulse oximetry. This may not be the most practice changing article of the year but certainly something I think is important for everyone to be aware of.



1 unhealthy lifestyle begets another unhealthy lifestyle. That is from JAMA network open in a paper titled


Maciejewski ML et al. Association of bariatric surgical procedures with changes in unhealthy alcohol use among US veterans. JAMA Netw Open 2020 Dec 21; 3:e2028117. (https://doi.org/10.1001/jamanetworkopen.2020.28117)


Which propensity matched just over 2000 patients that were getting Roux-en-Y gastric bypass surgery or a laparoscopic sleeve gastrectomy to individuals who were not getting bariatric surgery and after 8 years of follow-up those individuals who had surgery were almost twice as likely to have an healthy alcohol use disorder. Was at that the gastric bariatric surgeries caused alcohol use disorder? not likely. Realistically most people who are obese are eating from something. Most we will run 20 or 30 miles are running from something. And most he will drink in excess or drinking from something. While a simple surgery can fix your ability to eat and consume large amounts of food and can’t fix the underlying damage or trauma or mental state of mind which caused unhealthy consumption of food in the first place, thus 1 unhealthy lifestyle fixed with surgery begets another unhealthy lifestyle.



Less is more or so says this article in jama internal medicine titled -

Treatment and Outcomes of Inpatient Hypertension Among Adults With Noncardiac Admissions

Among adults with noncardiac admissions, is treatment of hypertension during the admission or antihypertensive treatment intensification at discharge associated with better outcomes?

We have all had the nurse or the pharmacist call us right before discharge and say this patient was give one or two doses of this bp med during this hospital stay, Do want them to go home with this dose?
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2774562?guestAccessKey=92cef46d-2a66-4714-870f-105561a4041c&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamainternalmedicine&utm_content=olf&utm_term=122820
Which sometimes can seem like a confusing question but in this study of almost 23,000 patient’s hospitalized for a non-cardiovascular diagnosis those individuals who were discharged with medications had worse outcomes at 30 days and at one year. What are these outcomes I’m referring to? Really important outcomes that we carry out such as stroke and myocardial infarction. In fact there was no interval in which hypertensive treated patients had better outcomes than those individuals who were left untreated.
The absolute numbers were small such as a myocardial infarction rate from 0.6 up to 1.2% and normally you might be used to me saying this is such a small increase why do we care about it but in this circumstance the reason we care is because we are giving medication in hopes that we are doing a good thing and preventing hypertension but in all actuality we are causing harm by doing more so as this segment states when he comes to the management of the med rec for a hypertensive patient while in the hospital….. Less seems to truly be more



January 10, 2021 12:10 PM PST

Dr sprouse--

Endo saying that Vit D below 30 leads to 2nd hyperparathyroidism due to calcium absorption deficiency and downstream consequences of that condition leads to poor bone health.

He agreed all the other outcomes don’t have good evidence.

I think 30 is the recommendation from the endo society.



MY RESPONSE


Well just to be clear they are right and they are wrong

Yes it MAY, key word is MAY (it’s a not a universal truth), cause a secondary hyperparathyroid. HOWEVER, as I am sure you have already thought, this is a lab value. WE DON’T CARE ABOUT LAB VALUES, we care about patients. We treat patients, not lab values. So realistically who cares!?!?!?

They will say well we care because it leads to broken bones and fractures!?!?!

Then say really?? Based on what data because in this trial of almost 700 women who underwent BMD testing at baseline and 2 years later there was no difference between vitamin d and placebo

https://asbmr.onlinelibrary.wiley.com/doi/full/10.1002/jbmr.3958

And they will say yes but that showed no difference because those individuals already had baseline high vit. D

And you say—OOOO so you think something magical happens at the cutoff of 30 that makes it so these patients now magically benefit from vit d

And they will say “that is correct”

And you say, “well what about this article that talks about the analytic and biological variance of vit d to be about 50%, which basically means that you need to see a 50% change to even say that there is a real difference and a lab value of 30 COULD actually mean the real number falls anywhere between about 19 and 41 because lab values are just point estimates but in all actually there are 95% CI that surround each lab value or point estimate.” “Thus shouldn’t this magical number actually be 41?”

https://www.bmj.com/content/368/bmj.m149

They will say “I have no idea what you are talking about, all lab values are 100% accurate” (this is a really really hard concept for people to grasp)



Then you say- “well that is really interesting because this study actually found those individuals with baseline enrollment vit d level of 30 actually had worse volumetric BMD when taking higher levels of vit d”

https://jamanetwork.com/journals/jama/fullarticle/2748796

They will say something like “yes, but that didn’t have a true placebo group and we fail to observe the rule of dose measurement” (which basically says that if you give some that is good and with increasing doses you should see more of an effect, it was be quantifiable to the same amount of the dose increase but it will be quantifiably greater. Think of blood pressure pills, you get most bang for your buck on the lowest dose, higher doses give you more but it is not at the same rate)

And you say “well I can see you are really stuck on this magical cutoff of 30 even though the lab measurement is variable and appears to be completely made up and you don’t believe in dose response BUT what about this article that took 260 women with vit levels between 8 and 26 and randomized them to vitamin d levels achieved above 30 (which ended up being 3500IU daily as baseline level was 22) for 3 years and found no difference in bone density between the placebo group and the vit d group”

https://asbmr.onlinelibrary.wiley.com/doi/full/10.1002/jbmr.3521

They will say, “Yes, but Andrew that is only one study and you can’t look at one study”

You then say, “O well what about this meta-analysis and SR in Lancet Endocrinology that looked at 81 RCT and over 53K people that found and I quote “Our findings suggest that vitamin D supplementation does not prevent fractures or falls, or have clinically meaningful effects on bone mineral density. There were no differences between the effects of higher and lower doses of vitamin D. There is little justification to use vitamin D supplements to maintain or improve musculoskeletal health. This conclusion should be reflected in clinical guidelines.”

https://www.clinicalkey.com/#!/content/journal/1-s2.0-S2213858718302651

They will say “Yes but you see it is those individuals with a vit d <30!!!”

Then you smile real big and say, “Luckily this paper even did a secondary analysis looking at those with vit D levels >30 and <30 and found

“no consistent evidence of different effects in subgroup analyses based upon potentially influential baseline variables including baseline 25OHD or study design characteristics, nor of different effects in trials of high-dose vitamin D or trials with higher achieved 25OHD concentrations.”

So said differently IT DOESN’T MATTER WHAT YOUR MADE UP NUMBER IS!

They will say, “we always treat under 30”

I have been fighting against the stream for 7 years now and the more I do the more I have realized that Upton Sinclair "It is difficult to get a man to understand something when his salary depends upon his not understanding it."

Sadly, as I have said on the podcast before, the belief of vitamin d is far greater than the evidence.

What I have learned is adult education can only be desired and can’t be taught. You can go to the best residency program in the world but when you get out you either keep reading and questioning or you just follow what someone else says like a blind dog. There is nothing wrong with either style and both want to do what they feel is best for the patient but no matter how hard you try, most of the time you can never make a blind dog see.

Best of luck.





COVID 19 vaccine
Dr. dodge and Dr. Layer appreciate you listening—and both have asked me variable questions about me getting the vaccine

Obviously the problem is we dont have long term data on this vaccine or even this type of vaccine. Those individuals who say o yes get the vaccine it is super safe are lying or at least not saying the whole truth. It is safe for now for the few months of data we have on it. I think in order to say yes this is safe we need long term data and its ok to say we just dont know at this time.

Luckily for me I have already had it

But then then you have people who have had and they are so concerned about immunity---says IGG titers go away after 6 to 8 months

When doctors say this I just shake my head



It is such simplistic thinking…..its almost like these doctors went to residency training with ob gyn and they forgot how to use their brain….. Sorry sorry I promise that will be one of the disses on the college of ob gyn
I refuse to believe this completely
The body is not that dumb
This is not cinderalla and the glass titers


When I was doing a deep dive on the flu vaccine one of the most interesting findings for me was that for the elderly individuals the flu vaccine one year was actually not that beneficial – its true go to Cochrane and look it up.

BUT BUT BUT if you were someone who got the flu shot every year then it was beneficial as you got older


How could this be

EXPERT OPINION ZONE

You have memory cells over time from all the vaccines!!!






https://science.sciencemag.org/content/early/2021/01/06/science.abf4063
·
Immunological memory to SARS-CoV-2 assessed for up to 8 months after infection


We analyzed multiple compartments of circulating immune memory to SARS-CoV-2 in 254 samples from 188 COVID-19 cases, including 43 samples at ≥ 6 months post-infection.

Spike-specific memory B cells were more abundant at 6 months than at 1 month post symptom onset.
Notably, memory B cells specific for the Spike protein or RBD were detected in almost all COVID-19 cases, with no apparent half-life at 5 to 8 months post-infection. Other studies of RBD memory B cells are reporting similar findings (50, 60). B cell memory to some other infections has been observed to be long-lived, including 60+ years after smallpox vaccination (61), or 90+ years after infection with influenza

December 24, 2020 05:10 PM PST

NEW covid19 vaccine

I am sure many of you have heard it is the first of its kind. It uses mRNA technology. I am not going to discuss what that means ebcasue so many people already have on other podcasts and publications but the question is should you get the vaccine. I have read many opinons on this from experts for example
Dr. Michal Elovitz, a preterm labor researcher and obstetrician at the University of Pennsylvania.
Said its possible the mRNA and the bubble it travels in, made of lipid nanoparticles, could cross the placenta, and This might, in theory, cause inflammation in utero that could be harmful to the developing fetal brain” she went on to say, “It’s also possible the new vaccines could be totally safe in pregnancy, like the flu shot.”

No pregnant patients were enrolled in the accessible trials, although some people got pregnant during the course of the study. Researchers are monitoring them to see how they do.

We have not even tested this on pregnant animals—we have no idea if this is safe for pregnant women and this is exactly what I am talking about when I say inclusion drift. It was something that big pharm thrives on.

You get your drug approved in one condition or pt population then you market the drug as this great drug and then quickly the providers forget that the benefit found in the trial was only under perfect conditions with mean age of 25 yrs old and no health problems…. The chance you will see the same benefit in your 75 year old HONDA is almost impossible….. BUT as long as you prescribe the drug they don’t care about your individual patient and their lack of benefit because they care about selling more drugs.. in the drug company world this is comparible to a bait and switch seen by car salesman. Show you the fancy benefits with the drug seen in their perfect patients and perfect environment then take your money or your patients money for much less impressive results.

Studying pregnant people requires extra effort in safe study design and recruitment efforts, Anything you do to a pregnant woman also has a chance of affecting the developing offspring


pregnant women are often just excluded altogether.


https://pubmed.ncbi.nlm.nih.gov/21766440/


a paper from 2011
Evolving knowledge of the teratogenicity of medications in human pregnancy

Which looked at all 172 FDA drugs approved from 2000 to 2010 and guess hoa many had known teratogenic risk??? Whatever you said the answer is wrong because they found most had “undetermined” risk -- in fact “The teratogenic risk in human pregnancy was "undetermined" for 168 (97.7%) of drug treatments approved between 2000 and 2010.”

“we have adequate data on the risk of birth defects in less than 10 percent of medications approved by the Food and Drug Administration since 1980. “

If someone on rounds says “med student, tell me the risk of this medication and in pregnancy” you are going to be right 9 out of 10 times if you say “we have no FDA proven data on that”


And speaking of the FDA what did they say about this --
F.D.A. left the choice of whether or not to get the Covid-19 vaccine up to pregnant women,



· The American College of Obstetricians and Gynecologists per usual isn’t worth their weight in feathers as they said- “ACOG recommends that COVID-19 vaccines should not be withheld from pregnant individuals who meet criteria for vaccination based on Advisory Committee on Immunization Practices recommended priority groups.”
I swear the ability to critically think or form your own opinion must occur some place around the second year of OB/gyn residency because their guidelines and opinions are almost always the least imformative or evidence based documents to ever be published. In their released statement they try to state some small crappy observational studies
One which showed if you were preg and had covid you were more likely to go to the ICU—well ist hat cause you are sick or because you are pregnant and have covid and realistically back in April if you were pregnant and had covid and even sneezed you were admitted to the ICU

The other was a morbidity and mortality weekly report which 598 hospitalized pregnant women with COVID-19- now most of these women were hospitalized for labor and delivery and then were asymptomatic and tested positive for covid19
And of those almost 600 women hospitalized lets get to the scary part
16.2% were admitted to an intensive care unit (ICU), and 8.5% required invasive mechanical ventilation.
Which sounds scary but we care about is pregnancy loss
And turns out 2.2% of the women had a pregnancy loss
Which is scary but we know spontaneous abortion is a real thing especially at <20weeks and it is almost impossible to tease out is this a spontaneous abortion in someone who has covid or is this covid causing a spontaneous abortion

Now rates of abortion after 20 weeks is much less.
So in this a morbidity and mortality weekly they estimate that risk of stillbirth was
5 per 458 which is about 1.6 per 160 covid births
And when you look at the CDC data on this they average the risk of stillbirth in the US is
Around 1/160
https://www.cdc.gov/mmwr/volumes/69/wr/mm6938e1.htm
BUT BUT BUT when you break that down by those women who had symptoms at initial presentation and those that did not have symptoms it tells a much different story
Remember the baseline risk of still birth is around 0.6%
If you came in with symptoms of COVID at time of admission your risk of still birth was 2.8%
4x greater risk of still birth if you came in with symptoms of covid19
Now if you didn’t have symptoms what was your rate of stillbirth? And the answer is 0.3%
Yes HALF the rate of still birth from the general if you didn’t come in with symptoms. You could make the hypothesis that those women who have covid but are asymptomatic are protected from having a still birth…
Which begs the questions of why do some have symptoms and why are some are asymptomatic---and what we seem to know from pure observation data is those individuals with co-morbid conditions or said differently those individuals who are already not living a healthy lifestyle are at great risk of getting a virus and dying from a virus. For many the thought that being unhealthy could lead to death or leave you prone to severe infection is a very new and foreign concept!

https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/aogs.13901
https://www.acog.org/en/clinical/clinical-guidance/practice-advisory/articles/2020/12/vaccinating-Pregnant-and-Lactating-Patients-Against-COVID-19

For those of you wondering the CDC has said – “Health care personnel who are pregnant may choose to be vaccinated.”
Which is what they should say because what they are really saying is “we are not going to stop you from doing it but we are certainly not going to promote you getting it”

December 21, 2020 11:56 AM PST

What you see is what you get- no more clearly seen then in
This paper titled

Nutritional Analysis of Foods and Beverages Depicted in Top-Grossing US Movies, 1994-2018

In JAMA internal medicine which looked at the nutritional quality of foods and beverages depicted in
the 250 top-grossing US movies from 1994 to 2018
these 250 movies sold 10 billion box office tickets and grossed $164 billion in theaters
worldwide. These are popular movies we all watch or are aware of
and what they put on the screen as a societal “norm”
in this study-
Two trained researchers viewed movies in their entirety and listed all
foods and beverages depicted in each scene.
they used the Nutrient Profile Index (NPI) to classify foods and beverages as healthy or not
penalizes components that should be limited like
sugar, sodium, and saturated fat and rewards fiber, protein, and fruit and vegetable
Now I understand this is not a one size fits all and the authors admit there is not portion control
on this so if the movie had a thimble full of high sugar intense soda and a whole garden of
lettuce the were considered “equal”
The results showed that-
nutrition ratings showed that 72.7% received a less healthy food nutrition score and 90.2%
received a less healthy beverage nutrition score.
But did it get better with time, I mean people use to smoke and now they don’t-
“We found no evidence of improvement over time in sugar, saturated fat, total fat, or sodium
content of foods or in sugar content of beverages”
part of the reason I bring up this article is because There were many disturbing findings like
G-rated movies, nearly 1 in 5 beverages (23 of 127 [18.1%]) were alcoholic beverage and 50%
of the time it was an alcoholic beverage in rated R movies!
the beverage sugar content was higher in movies targeting younger audiences --- on
average movies depicted 121 g (95% CI, 116-125 g) of total sugar per 2000 kcal, which is
higher than the total sugar content in 3 cans of Coca-Cola.
in summary- what you see is what you get and if you see your favorite actors eating junk food it
makes it ok to also eat junk food. . we already live in an obese society and any opportunity we
can to prvent or promote healthy eating should be done, even if that means during a movie
while you stuff your face with a 120oz coke and 620ounces of buttery popcorn.

But speakig of movies what do yu think of when you think of tom cruise or maybe I should say if
someone says the move “Jerry maguire” what do you think of?

I think “show me the money” which is a perfect segway to this paper in annals of IM titlted

https://www.acpjournals.org/doi/10.7326/M20-5665
Are Financial Payments From the
Pharmaceutical Industry Associated With
Physician Prescribing?
A Systematic Review
This was a systematic review to look to see if
payments from the drug industry is associated with physician prescribing practices.
The results were obvious, if you got money then you prescribed the drug companies drug more
often, and this was also associated with increase prescribing cost… the total cost and rates of
prescribing varied BUT NONE
And I repeat NONE OF THE identified studies had all null findings.
The easy answer is Receiving payments from a drug company may lead a physician to
prescribe more of that company's drug in the future.
Or you can sit back and question medicine and look at it from a different perspective--
prescribing may cause payments:
Drug companies may target payments to physicians who are already high prescribers of their
drugs. Both mechanisms are plausible.
The studies the look at temporal prescribing found substantial increases in prescribing immediately
after receipt of each industry payment.
Industry spending on drug promotion disproportionately targets drugs that are less effective or
offer little therapeutic advancement BECAUSE physicians want to use effective drugs
REGARDLESS OF THE PROMOTION!!! whereas marginally effective drugs require more
intensive promotion to increase prescribing!!
ASA after a stroke- we know it works, you odnt need to sell it to me
Statins after and MI- we know it works
Metformin for type 2 diabetes- we know it works

No need to show up at my door. I think the pharmacuetical industry is like the necessary evil, we
need them, they do great things and have the money to do fantastic trials because they have
the money to chase people down to get the outcome data we need but taking money from them
tugs on our need to prescribe their medications EVEN when our patients may benefit from
another or different or cheaper drug and if you think well this doesn’t apply to mean I want to
repeat what I said earlier
NONE OF THE identified studies had all null findings.
So unless you think you are magically different than every other provider that has ever been
studied then yes, even you are affected by drug money money and meals. Money talks so if you
cant stand the heat get out of the kitchen and speaking of heat
This next article titled
Associations between high temperatures in pregnancy and risk of preterm birth, low birth weight, and
stillbirths: systematic review and meta-analysis
Found a small but very real and consistent association between exposure to high enviromental
temperatures and pregnancy outcomes,
odds of a preterm birth rose 1.05-fold (95% confidence interval 1.03 to 1.07) per 1°C increase in
temperature and 1.16-fold (1.10 to 1.23) during heatwaves which were defined as two or more
days with temperatures above a predefined threshold.

This gives me two pieces of informtion which is those individuals who workout a lot should
probably avoid the hot yoga during pregnancy, stick to the regular yoga for 9 months and those
individuals with low economic status and no access to air conditioning will suffer and on a grand
scale will see higher rates of preterm delivery. This is sad and if a real finding it is one we will
never see on microscopic data remember it is only a 5% increase risk with the 95% confidence
interval going all the way down to 1.03% we are not good enough to pick up such small
differences in our day to day clinical practice but with macroscopic data. It becomes clear, I am
eager for more information on this in the future.

Remember when I said last year that according to me and now according to ACOG for almost
10 plus years we should let women get birth control over the counter!! When I told you that this
is insane that we has providers think we are so special they must come to us to get
contraception?? Well we are one step closer in this paper titled
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31785-
2/fulltext?utm_source=The+Scope&utm_campaign=f2254e45a6-
Weekly_Scope_Jan_12_2018_COPY_01&utm_medium=email&utm_term=0_809ad7d22b-
f2254e45a6-180869057

“Use of effective contraception following provision of the progestogen-only pill for women
presenting to community pharmacies for emergency contraception (Bridge-It): a pragmatic
cluster-randomised crossover trial”

pragmatic cluster-randomised crossover trial of almost 600 women receiving emergency
contraception in a pharmacy were randomized to either an intervention group or a control group.
In intervention group, women received a 3-month supply of the progestogen-only pill (75 μg
desogestrel) plus a rapid access card to a participating sexual and reproductive health clinic. In
the control group, pharmacists advised women to attend their usual contraceptive provider
The primary outcome was the use of effective contraception (hormonal or intrauterine) at 4
months.

Although there was a significant amount of people lost to follow up, almost 40% which was
higher than the expected 25% lost to follow up expected by the authors, however at 4 months
The proportion of women using effective contraception was 20·1% greater in the intervention
group, than in the control group. (mean 40·5%, 29·7–51·3 [adjusted for recruitment period,
treatment group, and centre]; p=0·011).

But taking birthcontrol or on BC is a surrogate outcomes so lets look at the secondary outcome-
--
Secondary outcomes were incidence of abortion in the 12 months following recruitment and an
economic evaluation of the intervention.
Sadly this study would have needed about 2000 patients to clearly tell a difference in
unexpected pregancy or abortion.
I guess the summary is that if you want women to be on birth control you have to make it easier
for them to acccess it and whatever format that is then fine, let them access it. Their risk of
children far exceeds your need for another easy RVU patient.

https://www.nejm.org/doi/full/10.1056/NEJMc2031173?utm_source=The+Scope&amp;utm_campaign
=f2254e45a6-
Weekly_Scope_Jan_12_2018_COPY_01&utm_medium=email&utm_term=0_809ad7d22b-
f2254e45a6-180869057

https://www.nejm.org/doi/suppl/10.1056/NEJMc2031173/suppl_file/nejmc2031173_appendix.pdf



https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/10.1001/jamainternmed.2020.283
4?guestAccessKey=4474ae2b-f5ad-45c1-a5b9-
4735927592c1&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-

But the next article is breath-taking

Titled- Managing Asthma in Adolescents and Adults2020 Asthma Guideline Update From the National
Asthma Education and Prevention Program

The important thing to know is
Those with mild persistent asthma should use either regular daily ICS with an as-needed
inhaled (SABA), or to use both ICS and SABA on an as-needed basis.
Those with moderate persistent asthma should use ICS and formoterol daily with additional
doses of the ICS/formoterol as needed
Some will say this is different than the gina guidelines which say ICS/formoterol right from the
start. I will say you are right this is different than the global initiative for asthma guidelines. And
you may be asking, well then what is the right thing to do and my answer is---
The only correct answer is not what you should be doing but what you should not be doing and
that means those individuals coming in with mild persistent asthma, the newly diagnosed
asthma patient really should no longer be on just prn albuterol. Those days are done, the data
and the guidelines agree. ----


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