Questioning Medicine

https://www.nejm.org/doi/10.1056/NEJMoa2314063 Randomized trials have shown the benefit of endovascular thrombectomy in patients with acute stroke due to large-artery occlusion in the anterior circulation and a large baseline infarct (core) In these trials, 1-5 a large core was defined by an ASPECTS value of 5 or less, but because of concerns about the deleterious effects associated with the reper...

https://www.ahajournals.org/doi/full/10.1161/STROKEAHA.124.047438 We studied the risk of IS and ICH in women using LG-IUDs—aka mirana-- compared to women not using hormonal contraceptives.     The commonly used combined hormonal contraceptives with progestins and ethinylestradiol are associated with an increased risk of ischemic stroke (IS).      In this Danish historical cohort study (2004-2021)...

  A noninferiority trial is a type of randomized trial that aims to establish if treatmenet X effectiveness is not substantially less than the existing standard . Unlike superiority trials that are designed to show that one treatment is better than another, a non-inferiority trial is designed to show that a new treatment is ‘not unacceptably worse’ than the current standard therapy . You want to s...

https://shmpublications.onlinelibrary.wiley.com/doi/abs/10.1002/jhm.13350 Xu J et al. Hospital-associated venous thromboembolism prophylaxis use by risk assessment at a large integrated health care network in Northern California. J Hosp Med 2024 Jun; 19:449.   Authors took 850,000 adult nonsurgical, non–intensive care unit (ICU) hospitalizations at 21 Kaiser Permanente hospitals in northern Califo...

https://www.bmj.com/content/385/bmj-2024-079329 Overprescription of antibiotics by primary care clinicians is a major modifiable driver of antibiotic resistance. Evidence suggests that peer-comparison feedback can reduce antibiotic overprescription, but the optimal content and delivery of such feedback is unclear       Researchers randomized 5000 family physicians in Ontario, Canada, to receive ei...

Kityo C et al. Switch to long-acting cabotegravir and rilpivirine in virologically suppressed adults with HIV in Africa (CARES): Week 48 results from a randomised, multicentre, open-label, non-inferiority trial. Lancet Infect Dis 2024 May 28; [e-pub]. ( https://doi.org/10.1016/S1473-3099(24)00289-5 )307

95% CI does NOT mean there is a 95% chance the true value is in the interval. It means that if you continually resample, 95% of your confidence intervals (which will vary every time you resample), will contain the true or real value of the intervention. 

https://academic.oup.com/jcem/advance-article/doi/10.1210/clinem/dgae290/7685305?login=true Children aged 1-18 years to prevent rickets and to potentially lower the risk for respiratory tract infections Pregnant people to lower the risk for maternal and fetal or neonatal complicatio Adults older than 75 years to lower the risk for mortality Adults with prediabetes to lower the risk for type 2 diab...

  What is the power of a study—what is the power calculation?   Often say it is the number of people in a study. Power is the probably to correctly reject the null hypothesis. Said differently power is the probability we will correctly get a small pvalue   But a power calculation is slightly more than that it is the number of people required to adequetyly statistically calculate the number of peop...

Question   What is the strength of association between surrogate markers used as primary end points in clinical trials to support Food and Drug Administration (FDA) approval of drugs treating nononcologic chronic diseases and clinical outcomes?       often surrogate markers are used as primary end points in clinical trials to support FDA approval of drugs   I get it    Surrogate markers offer the...

The incidence of new-onset diabetes was basically the same but statistically significantly higher for those individuals on low-to-moderate–intensity statins compared with placebo 1.2 vs 1.3% annually which is a very small difference.   But with  high-intensity statins compared with placebo (4.8% vs. 3.5% annually)   Among patients with known diabetes at baseline, glycemia worsened slightly with st...

At change in c stats of 0.007 or 0.0009 is not a meaningful change so I cant say we should use this over the PCE—yes this new calculator has the benefit of removal of race, and the use race-based algorithms.   We don’t know that this leads to better outcomes—is the the race algorithms that lead to worse outcomes or was it access to care or is it some other factor we don’t know yet.   I think this...

The problems with observation data is real—    randomized trial, U.K. researchers identified 519 patients (mean age, 68) with mostly moderate COPD (mean forced expiratory volume in 1 second [FEV1], 50%), ≥2 exacerbations during the previous year, and no cardiovascular (CV) indications for β-blockers.    Patients were randomized to receive the cardioselective β-blocker bisoprolol (initially 1.25 mg...

When you want to do an RCT but you realize there might be some cross contamination so instead of randomizing individuals you randomize cluters or groups   Lets say you want to do fluids--- what is better LR or NS instead of doing individuals and room you just put whole hospitals in either LR or NS   Or you want to test if mask work for some virus—you would say this city gets all the mask in the wo...

1° outcome: hemostatic efficacy = which was defined as; (A) Hematoma expansion ≤ 35% at 12h (B) increase in NIHSS ≤ 7 at 12h (C) No rescue therapy 3-12h         Results hemostatic efficacy: 76.7% andexanet vs 64.6% usual care     30 day mortality: no difference 30 day Modified Rankin Score ≤3: no difference Thrombotic events: almost x2 with andexanet 10.3% vs 5.6% - statistically significant. Most...

In patients with atrial fibrillation (AF), how do CHA2DS2-VASc 1 subgroups compare with one another        64 141 patients with a first AF diagnosis    Patients were categorized as CHA2DS2-VASc 1 if they had any 1 of age 65 to 74 years, congestive heart failure (HF), hypertension, diabetes, or vascular disease    found no large differences in ischemic stroke, transient cerebral ischemia, or system...

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 c...

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 uln...

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 lowe...

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 publishe...

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 g...

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 (...

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-in...

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 lost Tirzepatide 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   htt...

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 difference The intervention group was instructed to eat between 8 a.m. and 6 p.m. and to consume 80% of calories by 1 p.m. T...