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YES!! Marketing!! No man wants to admit his gonads dont work so they would never say I have hypogonadism. Most men would never say I have andropause cause that is too close to menopause but if you call it low testosterone then all of a sudden men come out of the wood work like cave men to get some of this magical drug they have heard so much about.YES LIKE LOW T WILL KILL YOU!!!! "could kill you". -https://abcnews.go.com/Health/ActiveAging/story?id=3247773&page=1https://www.acpjournals.org/doi/10.7326/M19-0882?_ga=2.162179964.190727375.1667239768-1195431333.1667239768&"It is estimated that approximately 35% of men older than 45 years of age and 30-50% of men with obesity or type 2 diabetes have hypogonadism".  from endocrine.org. https://www.endocrine.org/patient-engagement/endocrine-library/hypogonadism   However, for a 30 yr old male the low end of normal is around 300 ng/dL! YET this is what most websites and recommendations use as the treatment cutoff for all men. 50, 60, 70 yr olds. we compare those testosterone levels of 30 yrs old and make them the standard for 50, 60 ,70 yr olds.  ​​https://www.nejm.org/doi/full/10.1056/NEJMp038207study found that just watching sports can raise and lower your testosterone levels depending if your team wins or loses. https://pubmed.ncbi.nlm.nih.gov/9811365/ 20 minutes apart had variations between the two lab values of 18–28% half of the time and about 25% of the time the variation in the lab test between  27–54%!! Same blood, same person, 20 minutes a part and the test results are 15-54% different!!!!! There is no lab test in the world that i know of with such huge variation. DJ BrambillaAB O'DonnellAM Matsumotoet al.Clin Endocrinol2007;67:853–62A study from journal of urology in 2014 showed that testosterone differences in time appears to be of significant concern in those younger than 45 but those older than 45 can likely have their test time frame expanded with no harm or issue.    Welliver RC Jr, Wiser HJ, Brannign RE, et al. Validity of midday total testosterone levels in older men with erectile dysfunction. J Urol. 2014;192:165-169. https://pubmed.ncbi.nlm.nih.gov/26360789/#:~:text=Objective%3A%20Since%20testosterone%levels%20exhibit,diagnostic%20test%20for%20androgen%20deficiency.A study in jama internal medicine found that about 25% of those individuals prescribed testosterone had not even had a testosterone level measured even once in the previous year. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1691925?resultClick=3

coffee saves your life-- maybe, careful for confounders  heart failure hospital admission is really hard to prevent moderate dose statin is most important..but ezetmibe and moderate dose is equal to high dose statin I think we should take out all kidney stones and the evidence says there will be lest hospitalizations if we do that EHR can help us and remind us to check and PTH robotic surgery is not all that is seems to be-- or at least not yet vit. D and fish oil dont help dry eyes....or much of anything for that matter stop injecting Hyaluronic acid into the knee

 skin exam, ddp4, IUD, oral hypertension medication

https://www.ahajournals.org/doi/abs/10.1161/CIRCULATIONAHA.122.059410?af=RThe Biomarkers say REDUCE-IT was a scamhttps://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2791663NO! Just NO-- stick with the calculator for nowhttps://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.122.059038start the SLGT-2 inhibitors early! maybe an early dischargehttps://pubmed.ncbi.nlm.nih.gov/35849407/If we could get the EMR to do it automatically else you cant expect providers tohttps://pubmed.ncbi.nlm.nih.gov/35727595/the head CT for psych stuff can probably be put on holdhttps://eprints.whiterose.ac.uk/180135/continue the disease modifying agents

mammograms and pink ribbons-- lets talk evidence

mammograms-- we all know them, but lets discuss

Association of Receipt of the Fourth BNT162b2 Dose With Omicron Infection and COVID-19 Hospitalizations Among Residents of Long-term Care Facilities | Geriatrics | JAMA Internal Medicine | JAMA Network careful what you believe and always question medicine- even if it is about covid vaccineUse and Cost of Low-Value Health Services Delivered or Paid for by the Veterans Health Administration | Cancer Screening, Prevention, Control | JAMA Internal Medicine | JAMA Network   low value care exist in the VA but also in the community-- you need a comparative arm to figure out how bad you are doing or good you are doing. Supplemental Vitamin D and Incident Fractures in Midlife and Older Adults | NEJM You can also check a level if you are trying to make the diagnosis of rickets. ELSE no need to check anyone, if you really believe in it or your patient really believes in in then just start 2000IU and continue to take as long as they feel indicated because it likely is not doing any benefit but realistically it is not doing any harm at that dose either (there has been harm seen at super high doses 50,000IU) listener question---- My question is what is the smallest doses statin I need to convince patient to take to benefit. For me the answer is that yes high dose is better than moderate dose for those needing secondary prevention, but any dose is better than no dose for both primary and secondary prevention. If the patient isn’t taking the medication it doesn’t matter how good the drug is so ultimately if they are very serious about their risk reduction then go ahead and try and push higher dose statin else just take any dose the patient is willing to take and be happy they are you getting some sort of risk reduction that drastically beat ‘nothing’/placebo.

Weight regain and cardiometabolic effects after withdrawal of semaglutide: The STEP 1 trial extension - Wilding - - Diabetes, Obesity and Metabolism - Wiley Online Library       “”””One year after withdrawal of once-weekly subcutaneous semaglutide 2.4 mg and lifestyle intervention, participants regained two-thirds of their prior weight loss, with similar changes in cardiometabolic parameters.”””     investigators assessed the changes in body weight among patients who were started on semaglutide therapy and subsequently stopped.  The weight regain was accelerated immediately after treatment withdrawal and slowed at week 80.   The results showed that while on semaglutide, participants lost an average of 17.3% of their baseline weight. However, once semaglutide was discontinued, participants regained 11.6% of lost weight by the 1-year follow-up.  The net weight changes at week 120 were 5.6% (SD, 8.9) in the semaglutide arm and 0.1% (SD, 5.8) in the placebo arm.     Furthermore, cardiovascular in htn and glycemic category reverted back to baseline.   A life long drug and expensive.. this is sad but shows how chronic obesity is and it remains one of the biggest challenges in medicine         Papi A et al. Albuterol–budesonide fixed-dose combination rescue inhaler for asthma. N Engl J Med 2022 May 15; [e-pub]. (https://doi.org/10.1056/NEJMoa2203163. opens in new tab)      Global Initiative for Asthma (GINA) guidelines. opens in new tab recommend avoiding albuterol for all patients and using inhaled corticosteroids (ICS)/formoterol as a rescue inhaler. Although the National Asthma Education and Prevention Program (NAEPP) guidelines. opens in new tab have not gone that far, they do recommend using as-needed ICS/albuterol for mild asthma.     3100 adolescents and adults with uncontrolled moderate-to-severe asthma were randomized to either high- or low-dose albuterol/budesonide (180/160 µg or 180/80 µg) or albuterol alone (180 µg) as a rescue inhaler while continuing their current ICS or ICS/LABA (long-acting β-agonist) therapy. After 24 weeks, severe exacerbations requiring systemic steroids for rescue were significantly less common in both the low and the high-dose budesonide/albuterol group than in the albuterol group (annualized rate, 0.45 vs. 0.59).   This doesn’t tell us if ICS/fomoterol as rescue is better or worse than albuterol ICS but it does say or should remind us that albuterol alone is no longer indicated for maintenance for rescue for anything.   Ancel K, Keys M. How to Eat Well and Stay Well the Mediterranean Way. Coronary Artery Disease in Seven Countries. Circulation. 1975;41(4 Suppl):11-211.        1002 patients aged between 20 and 75 years with established coronary heart disease and randomly assigned them to either a Mediterranean diet or a low-fat diet. The follow-up period was 7 years.   The primary outcome was a composite of major CV events, myocardial infarction, revascularization, ischemic stroke, peripheral artery disease, and CV death.    To ensure that cost was not a barrier, extra-virgin olive oil was provided free of charge to the Mediterranean group (1 L per week per household), and free healthy food packs rich in complex carbohydrates were given to the low-fat group.   here were 111 events in the low-fat group and 87 events in the Mediterranean group, representing a 25% reduction in events in favor of the Mediterranean diet (HR, 0.745; P = ·040).    For men, the reduction was 33% (HR, 0.669; P = ·013). For women, there was no difference between the groups. However, there were only 175 women in the trial, so the lack of effect may be just due to the small number.   The lipid profile and glucose levels of the participants did not change significantly during the study—which is a huge knock for all the lipid hypothesis people out there.

a couple points over the last podcast

Acute low back pain, chronic low back pain, back pain with sciaticain the end unless red flags hold on imaging for 6weeksNSAIDS for acute low back painexercise and spinal manipulative therapy for chronic low back painbe conservative and don't write for drugs that don't work like gabapentin or pregablin

196. Medical Update -- PICC lines, PRE-Diabetes, Sleep in the Hospital, Ortho Surgery!

European Heart Journal Bariatric surgery and cardiovascular disease: a systematic review and meta-analysis Eur Heart J 2022 Mar 04;[EPub Ahead of Print], SL van Veldhuisen, TM Gorter, G van Woerden, RA de Boer, M Rienstra, EJ Hazebroek, DJ van Veldhuisen     39 studies, all prospective or retrospective cohort studies, showed Bariatric surgery is associated with a reduced hazard ratio (HR) of CV morality (0.59), all-cause mortality (0.55), incident HF (0.50), myocardial infarction (0.58) and stroke (0.64)   Authors state “”The present systematic review and meta-analysis suggests that bariatric surgery is associated with reduced all-cause and CV mortality, and lowered incidence of several CV diseases in patients with obesity. Bariatric surgery should therefore be considered in these patients.”””   Here is the problem and I have said it before—“no randomized control trials examining the effect of bariatric surgery on CV outcomes,” Among frail patients with AF, OAC treatment was associated with a positive net clinical outcome. Direct OACs provided lower incidences of stroke, bleeding, and mortality, compared with warfarin.   Just talked recently about continue doac in hospice and everyone agrees that is bad but ultimately there are very few conditions in which you should not resume anticoag—even in those with GI bleed, falls, or subachrnoid hemerage—the data suggest the pts are better off back on anticoag. Well this study looked at the frail.   In this retrospective cohort study analyzed 83 635 patients  with mean age 78.5 those individuals who were on ORAL anticoag(doac or warfarin) had overall lower risks of ischemic stroke (HR, 0.91) and cardiovascular death (HR, 0.52), with no significant difference in major bleeding (HR, 1.02),       Bottom line- restart the OAC – even in the frail to prevent the outcomes we really care about like stroke and death         Dave CV et al. Risks for anaphylaxis with intravenous iron formulations: A retrospective cohort study. Ann Intern Med 2022 Mar 29; [e-pub]. (https://doi.org/10.7326/M21-4009. opens in new tab)   Anaphylaxis occurs rarely with intravenous (IV) iron does happen but how often does it happen??  It is a mystery—till now   Using a retrospective cohort design, investigators assessed 167,000 U.S. Medicare patients who received IV iron products between 2013 and 2018. Patients who had received IV iron within the previous year and those with end-stage renal disease, HIV infection, history of anaphylactic reaction, or recent transfusions were excluded.   This is the perfect study for observational data. We know it happens so we look at a large data set and try to see how often it happens.   In this population of older adults, the rate of anaphylaxis for iron dextran was ≈0.1%, but it was closer to 0.01% for iron sucrose, ferric gluconate, and ferric carboxymaltose (can give once== carboxy and dextran). As indications have broadened for use of IV iron in managing various clinical conditions (e.g., heart failure, chronic kidney disease) when iron deficiency is present, clinicians might use these data to inform selection of a preparation.     A lot depends on cost and availability but these are good numbers to have in your head for the anaphylaxis event rate ...   Sure it might take 5 years or even 10 years but some of the outcomes like MI and HF will easily hit in the first 5-10 years!! This RCT could be done tomorrow! Instead we continue to do this observational studies and say look how great this procedure is!! Well maybe it is ‘healthy’ patient bias—you have two pts with BMI of 40 but one seems motivated is working out eating better- trying to take all the right steps and the other hasn’t left the couch in 6 years. The one that is active then gets referred for bariatric surgery and when we match them up we say LOOK AT THIS THE BARIATRIC SURGERY person did so much better. WEEELLLLLL that pt was likely going to do better anyways!!! AT this point everyone know that bariatric surgery seems to have great CV outcomes in retrospective and prospective observational trials we have done enough of them.. THIS analysis had 39 STUDIES—39!!!! We don’t need 30 more we need and RCT!!!           Katz PO et al. ACG clinical guideline for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol 2022 Jan; 117:27. (https://doi.org/10.14309/ajg.0000000000001538. opens in new tab)   Much of this guideline is worthwhile for nongastroenterologists.    An empirical 8-week trial of a proton-pump inhibitor (PPI), given once daily, is recommended for a patient who has classic heartburn and regurgitation but no alarm symptoms.  PPIs should be taken 30 to 60 minutes before a meal, because they bind to proton pumps that have been stimulated by meals. Bedtime dosing is discouraged because this is less effective than a predinner dose in acid control GERD is thought to contribute to various extraesophageal symptoms, including chronic cough, hoarseness, and laryngitis; however, a causal relation often is unclear in any given patient. For patients with extraesophageal symptoms — but no heartburn or regurgitation — the authors argue against empirical PPI therapy   After 8 weeks you STOP the PPI--PPI nonresponders, and PPI responders whose symptoms return after an 8-week PPI course, should be evaluated with Endoscopy about 2 to 4 weeks off PPIs.  If endoscopy is normal, ambulatory pH monitoring (off treatment) is the next step.  authors encourage intermittent or “on-demand” (rather than indefinite) PPI therapy in patients with no history of high-grade esophagitis or Barrett esophagus. IF requires ongoing PPI therapy for symptom control should use the lowest effective dose. I do like these guidelines cause they seem to be great at making sure PPI are stopped (ideally). I do hate these guidelines cause getting a scope after 8 weeks of a PPI with reoccurring symptoms seems like a lot of scopes will be done. Especially because some people get rebound gerd when going off of a PPI. As the authors state “One area of controversy relates to abrupt PPI discontinuation and potential rebound acid hypersecretion, resulting in increased reflux symptoms. Although rebound acid hypersecretion has been demonstrated to occur in healthy controls, strong evidence for an increase in symptoms after abrupt PPI withdrawal is lacking.”  -- none of this is super strong evidence!!! This seems like a lot of scopes. The fear of progression to adenocarcinoma with Barrett’s Esophagus would make for an easy decision for prolonged PPI use, however, a systematic review and meta-analysis published in PLoS One - Hu Q, Sun TT, Hong J, et al. Proton Pump Inhibitors Do Not Reduce the Risk of Esophageal Adenocarcinoma in Patients with Barrett's Esophagus: A Systematic Review and Meta-Analysis. PLoS One 2017;12(1):e0169691. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0169691 found no protective effect.1 And even though long term use of PPI is associated with many bad outcomes even the authors state -  “””“PPIs are the most effective medical treatment for GERD. Some medical studies have identified an association between the long-term use of PPIs and the development of numerous adverse conditions including intestinal infections, pneumonia, stomach cancer, osteoporosis-related bone fractures, chronic kidney disease, deficiencies of certain vitamins and minerals, heart attacks, strokes, dementia, and early death. “” the authors go on to say “””Those studies have flaws, are not considered definitive, and do not establish a cause-and-effect relationship between PPIs and the adverse conditions. High-quality studies have found that PPIs do not significantly increase the risk of any of these conditions except intestinal infections. .”””  THIS IS ALSO GARBAGE!!! The reason the high quality studies don’t show this is because most studies are only 8-12 weeks long PPI you need long term trials which most people are on and you have to power your study so large to find a super rare outcome that observational data is the best we are ever going to have for this particular finding. I know the authors knew this but it didn’t fit their agenda… Which is my last point—although we will never know—all but one of the authors has or is taking big pharma money.  Take home if you are following the guideslines-- start PPI only for Gerd like symptoms. Make sure taking the PPI correctly. Stop after 8 weeks. If it reoccurs then 2-4 weeks later off the PPI they need a scope and if the scope is normal then they need PH monitoring. Then the rec is for PRN PPI.    

SUMMARY-- What diuretic do you usually write for during CHF hospitalizations??   If you said furosemide you are not alone   One in a study in JACC 2013 looked at HF hospitalizations in 2009 and 2010 – In total 251,472 patients got a loop diuretic during their hospitalization and almost 87% got just furosemide, about 3% only got bumex, while only 0.4 received only torsemide. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4038646/#R11     What is the difference between bumetanide and furosemide?   Nothing—or at least nothing we care about. No hard outcomes, no patient oriented outcomes.   Bumetanide is stronger—An article from 2015 in American Heart Journal states bumetanide is about 40 times stronger than furosemide- thus at times you might have your sphincter tighten when you go to write for 120-160mg of furosemide but feel comfortable writing for 3-4mg of bumex. They also discuss how bumetanide also appears to have a higher more consistent bioavailability at around 80-100% while furosemide seems to range from 10-100% depending on the study. Conclusion: the benefits for bumetanide are there in theory but no hard outcomes that I could find.   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4346710/     What about torsemide?? The bioavailability of torsemide is 76% to 96% and as I mentioned before furosemide hangs out around 10% to 100%. In addition, furosemide bioavailability can decrease by up to 30% with food while torsemide is not affected by food consumption. https://oce.ovid.com/article/00006562-199701000-00009 https://pubmed.ncbi.nlm.nih.gov/3709617/     HOWEVER, no patient cares about bioavailability they want to know if they will live longer or live better (patient oriented outcomes)??     First paper- 2001 Nov;111(7):513-20. American Journal of Medicine we have a paper titled“Open-label randomized trial of torsemide compared with furosemide therapy for patients with heart failure”   This was open-label trial of 234 patients who were randomized to torsemide or furosemide and followed for 1 yr. The outcome was heart failure readmissions and it occurred significantly less in the torsemide group, only 17% of the time compared to 32% in the furosemide group. https://pubmed.ncbi.nlm.nih.gov/11705426/   That is almost a 50% relative reduction for heart failure hospitalization at one year! This is an outcome both patients and hospitalist would love to see!   Second paper- In 2002- a year later- European Journal of Heart Failure a paper titledTorasemide in chronic heart failure: results of the TORIC study This was the published results of the ‘TOrasemide In Congestive Heart Failure (TORIC)’ study- It was an open-label, non-randomised, post-marketing surveillance trial. The individuals who were prescribed torsemide on top of their other CHF medications for 12 months had almost a 50% relative reduction in mortality!! That may not seem like a lot but remember this is only 12 months and the outcome was DEATH! In absolute terms roughly 2% of participants died in the torsemide group and 4% died in the furosemide/other diuretic group. PLUS, those in the torsemide group also had an improvement in their NYHA functional heart class. https://pubmed.ncbi.nlm.nih.gov/12167392/     Finally, there is a meta-analysis from 2019 in Journal of Cardiovascular Medicine titledTorsemide versus furosemide and intermediate-term outcomes in patients with heart failure: an updated meta-analysis     Which looked at a total of 14 randomized trials and just over 8000 pts and found torsemide to have both fewer heart failure hospitalizations and those individuals taking torsemide were more likely to have an improvement in their new york heart association class but they didnt find a difference in mortality. https://pubmed.ncbi.nlm.nih.gov/30950982/   Currently there is 6000 pt randomized trial that is underway and will be done in august 2023.  https://clinicaltrials.gov/ct2/show/NCT03296813     That is it, that is all that I could find!!!!   However, with the evidence clearly in favor of torsemide, why have I never even considered it before doing this lecture??   Likely 2 problems   1) It is what we have always done and it is hard to change practice! Furosemide was approved for medical use in 1964.Torsemide was approved in 1993. We as providers get into a rut, the next drug we prescribe is likely to be one of the most recent drugs we prescribed. If you show me the last 10 hypertension medications you prescribed then with almost 90-100% certainty I can guess the next one that you are going to prescribe.    2) There use to be a cost issue when furosemide was generic and torsemide was not. However, now these are both old drugs and per goodrx down here in Florida they only differ by about 1.50$ per month, but we are saving hospitalizations which cost 1000$.   A paper from 2000 in Pharmacoeconomics titled “Healthcare costs of patients with heart failure treated with torasemide or furosemide” found torsemide average hospitalization cost per patient each year was $1000 while those in the furosemide group had an average cost of $1500 dollars, and this was back when torsemide wasn’t nearly as cheap as it is now.    I know I have given you a lot of numbers but a good take away is-   Torsemide compared to furosemide has a NNT at 10.5 months to prevent a heart failure hospitalization around 6!!!   https://pubmed.ncbi.nlm.nih.gov/10977385/   https://www.medscape.com/viewarticle/771976_8     Even if the number is off a little because of study design flaws like blinding and sample size the evidence does appear to continually point the direction of benefit towards torsemide. Even if you doubled it, a NNT of 12, it is still really good.

Gibbons RC et al. Ultrasound-versus landmark-guided medium-sized joint arthrocentesis: A randomized clinical trial. Acad Emerg Med 2022 Feb; 29:159. (https://doi.org/10.1111/acem.14396. opens in new tab)Use a ultrasound for arthrocentesis when possible Circ Arrhythm Electrophysiol 2022 Mar; 15:e010646. (https://doi.org/10.1161/CIRCEP.121.010646) Apple AirPods Pro and their wireless charging case, the Microsoft Surface Pen, and the Apple Pencil second generation — also have strong enough magnetic fields to affect current-generation CIEDs.https://pubmed.ncbi.nlm.nih.gov/34862940/first of all empiric therapy with clarithromycin is no longer effective for treating Helicobacter. You have two choices. The choices are thus: 14-day bismuth quadruple therapy or rifabutin triple therapy,Andreadis K, Chan E, Park M, et al. Imprecision and preferences in interpretation of verbal probabilities in health: a systematic review. J Gen Intern Med 2021;36(12):3820-3829. . The interpretation of "common" which means- accepted definition of 1% to 10%. But people thought it meant 59% (on average) --------59% is basically all the time that is great odds and would bankrupt vegas   TAKE HOME!! In studies asking for preference, a majority of patients prefer numbers rather than word-based estimates of risk. Risks and Benefits of Early Rhythm Control in Patients With Acute Strokes and Atrial Fibrillation: A Multicenter, Prospective, Randomized Study (the RAFAS Trial) | Journal of the American Heart Association (ahajournals.org)  The main findings were that early rhythm control led to a lower risk of stroke at 12 months (3 [1.7%] vs 6 [6.3%]; HR, 0.251; P = .034). There was no difference in risk of recurrent stroke at 3 months. 

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00572-9/fulltextOld calculators use old studies and can over exaggerate the calculated effecthttps://pubmed.ncbi.nlm.nih.gov/33970197/We know when to start medication but it is so hard to prospectively know when to stop medication like anticoagulationhttps://pubmed.ncbi.nlm.nih.gov/34074830/2 Kiwi a day will increase your bowel movementshttps://pubmed.ncbi.nlm.nih.gov/34100866/We want to believe routine checkups work but realistically they don't work for patient oriented outcomes--but they make people 'feel good'-- what we do isn't always the doing, it's just being therehttps://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01063-1/fulltextDAPT following a stent-- but then just maybe we should stay with plavix and not aspirin

https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2782015coffee is ok with atrial fibrillation -- just don't go crazy is probably good advicehttps://jamanetwork.com/journals/jamanetworkopen/fullarticle/2781351Hearing loss sucks and can really change your whole physical functionhttps://www.bmj.com/content/374/bmj.n1511elective orthopedic procedures with good evidence are limitedhttps://jamanetwork.com/journals/jama/fullarticle/2781859PRP injections -- work about as well as vitamin D-- just stophttps://www.bmj.com/content/374/bmj.n1446muscle relaxants for back pain improve pain at 2 weeks 8 points on 100 point scalehttps://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2781311STOP GIVING LEVOTHYROXINE to a majority of normal or subclinical normal peoplehttps://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2781806antibiotics will always be given if they are always given

Extended Follow-up of Local Steroid Injection for Carpal Tunnel Syndrome: A Randomized Clinical Trial | Neuropathy | JAMA Network Open | JAMA Network   Looked at just over 100 patients with carpal tunnel syndrome and randomized them to injection of 80 mg methylprednisolone, 40 mg methylprednisolone, or saline and there was no difference except for an extra 60 days delaying surgery but still surgery.Associations Between Sleep Position and Nocturnal Gastroesop... : Official journal of the American College of Gastroenterology | ACG (lww.com)     The aim of this study was to investigate the effect of spontaneous sleep positions on the occurrence of nocturnal gastroesophageal reflux and in the end stay on your left side. Lee CG et al. Effect of metformin and lifestyle interventions on mortality in the diabetes prevention program and diabetes prevention program outcomes study. Diabetes Care 2021 Dec; 44:2775. (https://doi.org/10.2337/dc21-1046. opens in new tab)DONT TREAT PRE-DMEffect of Anticoagulant Therapy for 6 Weeks vs 3 Months on Recurrence and Bleeding Events in Patients Younger Than 21 Years of Age With Provoked Venous Thromboembolism: The Kids-DOTT Randomized Clinical Trial | Pediatrics | JAMA | JAMA NetworkBIG TIME ARTICLE—FINALLY WE HAVE EVIDENCE cause nothing worse than saying—we have no evidence for that advances the field by bringing uniformity and consensus to the issue of length of anti-thrombotic therapy for a first-episode of provoked VTE in children.

Writing Group for the CODA Collaborative. Patient factors associated with appendectomy within 30 days of initiating antibiotic treatment for appendicitis. JAMA Surg 2022 Jan 12; [e-pub].   Now, investigators have explored in a secondary analysis of  The CODA Collaborative. A randomized trial comparing antibiotics with appendectomy for appendicitis. N Engl J Med 2020 Oct 5; [e-pub]. (data from a previous randomized antibiotics-versus-surgery trial (NEJM JW Gen Med Dec 1 2020 and N Engl J Med 2020; 383:1907). Have looke at the data to see could we predict factors that make you more likely to appendectomy and fail antibiotic therapy.    They identified 735 patients who had been randomized to antibiotic treatment; 154 (21%) of these patients underwent appendectomy within 30 days.  Overall, 29% of patients in the antibiotics group underwent appendectomy within 90 days (41% of those with appendicolith vs. 25% without).   The authors suggest hey maybe this appendicolith is the magic answer of who will fail therapy—maybe!!   BUT remember this is secondary analysis so this is only hypothesis generating even a secondary analysis of a rct is just hypothesis. You need a new RCT to actually show causation.    Also as stated in the editorialists note that in subsequent analyses of this same data set, nearly 50% of patients underwent appendectomy within 2 years, regardless of the presence of an appendicolith, so an initial nonsurgical approach might only delay surgery.   Some say 50% still going to surgery is terrible but I say even if 50% prevented from having surgery that is still 50% of people are being prevented from a surgery            Acetazolamide to Prevent Adverse Altitude Effects in COPD and Healthy Adults | NEJM Evidence   Trial 1 was a randomized, double-blind, parallel-design trial in which 176 patients with COPD were treated with acetazolamide capsules (375 mg/day) or placebo- COPD patients had oxygen saturation measured by pulse oximetry of 92% or greater    primary outcome in trial 1 was the incidence of the composite end point of altitude-related adverse health effects (ARAHE)== Criteria for ARAHE included acute mountain sickness (AMS) and symptoms or findings relevant to well-being and safety, such as severe hypoxemia, requiring intervention.  In trial 1 of patients with COPD, 68 of 90 (76%) receiving placebo and 42 of 86 (49%) receiving acetazolamide experienced ARAHE The number needed to treat (NNT) to prevent one case of ARAHE was 4 EVEN at NNT of 4 you  have to realize that still 50% of those with COPD required intervention to go back down to lower level.       Trial 2 comprised 345 healthy lowlanders. The primary outcome in trial 2 was the incidence of acute mountain sickness AMS assessed at 3100 m by the Lake Louise questionnaire score (the scale of self-assessed symptoms ranges from 0 to 15 points, indicating absent to severe, with 3 or more points including headache, indicating acute mountain sickness AMS). In trial 2 of healthy individuals, 54 of 170 (32%) receiving placebo and 38 of 175 (22%) receiving acetazolamide experienced acute mountain sickness AMS   The NNT to prevent one case of acute mountain sickness AMS was 10 (95% CI, 5 to 141). So use the acetazolamide still 1 in 5 individuals experience acute mountain sickness         Annals for Hospitalists Inpatient Notes - Clinical Pearls—Stopping, Starting, and Optimizing Guideline-Directed Medical Therapy in Patients Hospitalized for Heart Failure With Reduced Ejection Fraction | Annals of Internal Medicine (acpjournals.org)   Treat with?? Foundational medical therapy for HFrEF consists of comprehensive disease-modifying quadruple medical therapy, including angiotensin receptor–neprilysin inhibitors (ARNIs), β-blockers, mineralocorticoid receptor antagonists, and sodium–glucose cotransporter-2 inhibitors (1).   Quadruple medical therapy is estimated to cumulatively reduce the relative risk for death by 73% over 2 years, with a number needed to treat of 3.9 to save 1 life    compared with traditional therapy using an ACEI and a β-blocker, treating a 55-year-old patient with comprehensive disease-modifying quadruple therapy projects to increase life expectancy by more than 6 years   Approximately 1 in 4 patients hospitalized for worsening HFrEF die or are rehospitalized within 30 days of discharge --- Deferring in-hospital initiation is consistently associated with medications never being initiated in the outpatient setting, or initiated after substantial delay START THEM IN THE HOSPITAL -- There is no evidence to suggest that “go slow,” “one medication change at a time,” or “defer to outpatient” approaches improve medication tolerance or accomplish anything beneficial    If you mix a bunch of moon pies in a trash can you get what sounds like a great time but if you mix a bunch of cow pies in a trash can you just get poop   Clearly seen in this next article   Vitamin D supplementation for the treatment of migraine: A meta-analysis of randomized controlled studies - ClinicalKey     meta-analysis aims to explore the efficacy of vitamin D for migraine patients.   Six RCTs and 301 patients were included in the meta-analysis.   On average these people were having around 7 migraines per months and compared to control the vit d group decrease headache days by about 1.5 per month compared to placebo or UC   So you say vit d works for something!! Not so fast   Remember I would like a 25 yr old cut my hair by not 5 five year olds…. Sadly these studies were 5 yr olds   UC could be nothing. Well vit d beating nothing isn’t hard, we know placebo is real   Even beating placebo isn’t hard when it is open label or you are not blinded to the active arm.   If I say, yes you are getting this drug vit d that will help your headaches you are going to believe it much more than if I just give you a pamphlet.    The authors in the discussion state “Higher vitamin D levels is associated with lower risk of migraine “   Well ya that is true but having a higher vitamin d level is also associated with going outside more. And going outside more is associated with no having a migraine.    High vit d level is amazing!! I love it but replacing it still seems to do nothing however if you want a high level and want to go outside and get a high level then I think that is a great idea and speaking of great ideas—         Here is a sad but enlightening article—   Home pregnancy test use and timing of pregnancy confirmation among people seeking health care - ClinicalKey   The researchers found that 74% of survey respondents took a home pregnancy test as the first step in confirming a suspected pregnancy;    Respondents who took home pregnancy tests confirmed pregnancy 10 days earlier than those who first tested at a clinic. (duh statements- if you test at home you find out sooner, this is so obvious an a no brainer--- BUT   Confirmation of pregnancy at greater than 7 weeks' gestational age was higher among adolescents, Latina versus white women, food-insecure versus -secure women, and people with unplanned pregnancies.   Those that did not test at home cited concerns about test accuracy (42%) and difficulties accessing one (26%).   While overall 1/5 21% confirmed pregnancy at ≥7 weeks gestation,   confirmation at ≥7 weeks was higher among adolescents versus young adults (47%!! vs 13%, p = 0.001), Latina versus white women (28% vs 11%, p = 0.02), food insecure versus secure women (28% vs 17%, p = 0.06), and people with unplanned versus planned/mistimed pregnancies (25% vs 13%, p = 0.07).   Latina and food insecure women discover their pregnancy at the same time or rate as individuals with unplanned pregnancy!!!   one in 5 confirm pregnancy at 7 weeks gestation or later and in those Latina, poor, or unplanned It is ¼ at >7weeks this obviously effects prenatal care and Gestational bans in the first trimester will disproportionately prevent young people, people of color, and those living with food insecurity from being able to access abortion. This is tough but it is this data that reminds me and should remind us that life is not equal and healthcare is not equal and certain populations and groups do need our help more than others.

https://pubmed.ncbi.nlm.nih.gov/33734980/if you lay flat with a blood draw you may have psuedoanemiahttps://jamanetwork.com/journals/jama/fullarticle/2782300Men and UTI-- 7 dayshttps://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2782461don't get a UA prior to a procedure for screeninghttps://www.nejm.org/doi/full/10.1056/NEJMoa2026845cardiogenic shock- dobutamine vs milrinone https://pubmed.ncbi.nlm.nih.gov/34259820/Dont use a CAChttps://pubmed.ncbi.nlm.nih.gov/33637192/CKD = SBP <120https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2782564men are still more professional than women no matter what they wear-- or at least that is the perception among 36yr old patients

Yes this is a CME lecture but yes you get it for the expensive price of Free Fifty Free....