Transcript Slide 1

The Articles of 2012*
WHAT WAS IMPORTANT…
…AT LEAST TO SOME OF US
Sources
 Essential Evidence
 Journal Watch
 Our faculty
 Prioritized:
 key areas of FM practice
 might directly change clinical practice
 might be leading to paradigm changes
Continuing Some Themes of
2011
PSA Screening in Asymptomatic Men
 2011
 “Draft Recommendation” 10/31/11 by USPSTF- to make PSA
screening “D” grade rec
 Multiple editorials, controversies, politics
 2012
 Finalized Rec (Grade D: “Moderate to high certainty of no net
benefit, or the harms outweigh the risks)
1000 Men Screened q1-4 years, for 10 Years
Pros
Cons
0-1 will not die
 100-120 will have a false positive
(background risk is 5 in 1000)
(usually leading to biopsy)
 110 true positives: correctly
diagnosed cancers that would
have never led to symptoms, but
they may opt for treatment. Of
those:
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Arch Intern Med 2012; 157 (2)
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29 will develop Erectile Dysfunction
from rx
18 will develop urinary incontinence
from rx
2 will develop serious cardiovascular
events from rx
1 will develop thromboembolic event
Decreasing amount of useless
things routinely done
Kale, M. S. et al. Arch Intern Med 2011;171:1856-1858.
http://www.choosingwisely.org
Diabetes Management
2012 ADA Position Statement
 “Glycemic management in type 2 diabetes mellitus has
become increasingly complex and, to some extent,
controversial…mounting concerns about their potential
adverse effects and new uncertainties regarding the
benefits of intensive glycemic control”
Diabetes Care January 2012 vol. 35 no. Supplement 1 S11-S63
 Rec’d Move to “Patient Centered” approach
 Current evidence” tight Glycemic Control Continues to
have little effect on mortality, macrovascular and
microvascular endpoints
(ACCORD, ADVANCE, VADT trials)
2013 ADA Guidelines: A1C Goals (not much new)
 Reduce A1C for most to <7
 <6.5 might be good when: short duration of
diabetes, long life expectancy
 <8 may be appropriate for: patients with a
history of severe hypoglycemia, limited life
expectancy, sick people, etc.
Diabetes Care January 2013 36:S4-S10; doi:10.2337/dc13-S004
More Blood Pressure Issues
Treatement for Mild Htn in pts without CV
disease
 Cochrane Review
 Definition of Mild Hypertension: 140-159/90-99
 4 studies, 8912 pts, treated over 5 years (some large
studies not included due to methodology)
Results
 No difference in mortality, CAD, Stoke, CV events
 Trend towards (not stat sig) decrease in stroke and
mortality, and increase in CAD
 Downside: low rates in untreated pts make it hard to
show benefit
Cochrane Database Syst Rev 2012 Aug 15; 8
BP Goals in DM 2
 Meta-analysis
 Patients with DM2
 intensive target (<130/80) vs standard targets (140-
160/85-100)
 Done over 5 years
 No Mortality or MI difference
 Small decrease in stroke rates
Arch Intern Med. 2012;172(17):1296-1303.
Studies Included
Studies Included
What Do the 2013 ADA Guidelines Say?
“People with diabetes and hypertension should
be treated to a systolic blood pressure goal of
140 mmHg. Lower systolic targets (such as
<130 mmHg) may be appropriate for certain
individuals, such as younger patients, if it can
be achieved without undue treatment burden”
Diabetes Care January 2013 36:S4-S10; doi:10.2337/dc13-S004
So What Should We Do Again for Type 2 DM?
1.
2.
3.
4.
5.
6.
Reasonable/Individualized glycemic control
Metformin first, probably even in lower GFRs
BP control probably ≤140/90
Address CV risk factors: Lipids, smoking, obesity
Encourage Exercise
Not insist on self-monitoring for pts not on insulin
Outpatient Misc
Is fasting necessary before lipid panels?
 Canadian Study, looked at lipid levels for 209k people, how long they had been
fasting
 Looked at lipid levels vs amount of fasting, mean cholesterol levels varied by:
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Less than 2% of total cholesterol and HDL
Less than 10% for LDL (lower)
 Levels similar fasting vs post-prandial (except triglycerides), but low risk
population, and most were fasting
 Pts with TG greater than 400 mg/dL, may have inaccurate LDL-C
 Certainly not yet standard of care- especially high-risk individuals (like
diabetes)
Arch Intern Med. 2012 Dec 10
Steroid Injections
Traced to contaminated vials of methylprednisolone
Mass Dept of Health: “Floor mats near sterile drug-mixing
areas were visibly soiled with assorted debris” (etc)
Epidural Steroid Injections
 Meta-analysis of 23 RCT, About 2k pts
 Steroid injections vs placebo for sciatica
 Significant, (but small) effect for leg pain and disability in the short
term, not for back pain
 Long term (usually 1 year) pooled effects were smaller and not
statistically significant
 Clinically Meaningful?
Ann Intern Med. 2012;157:865-877.
Jogging adds years to your life, but can you
overdo it?
A couple recent studies:
1. Prospective Observational Study
 52k people followed up to 3o years
 14k runners in study had a 19% lower risk of death compared with the
38k non-runners.
 Those who ran over 20 or 25 miles per week seemed to lose their
survival advantage over the non-runners
 Similar pattern for speed
2. The Copenhagen City Heart Study
 Followed 20 000 Danes since 1976
 joggers lived about 6 years longer than the non-runners
 Those who did best: people who jogged at a slow to average pace, for
one to 2.5 h per week total, accumulated during two or three sessions
Reference: Run for your life…at a comfortable speed and
not too far Heart. 2012 Nov 29
TED Talk
http://www.youtube.com/watch?v=Y6U728AZnV0
 Exercise patterns for maximizing CV fitness/ peak
aerobic capacity are very different from those that
best confer CV health, durability and overall
longevity.
 Rec: generally limit vigorous exercise to 30– 50
min/day
 Marathon/triathalon training: maybe don’t do too
many
Women’s Health
Long Acting Reversible Contraception (LARC)
 Long acting contraception associated with low failure
rate
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Pill, Patch or Ring: 4.8%/7.8%/9.4% (year 1/2/3)
LARC: 0.3%/0.7%/0.7%
Depo: 0.1%/0.7%/0.7%
N Eng J Med 2012: 366(21)
 Access to free LARC associated with decreased
unintended pregnancy (and increased LARC usage)
Obstet Gynecol 2012; 120(6):1291-1297
 Associated with reduction in repeat abortion
Am J Obstet Gynecol 2012; 206(1):37
A Couple Good Articles for
Review
Preventing the First Cesarean Delivery
 Review of available information on maternal and fetal
factors, labor management and induction, and
nonmedical factors leading to the first cesarean delivery
 Review of the implications of the first cesarean delivery
on future reproductive health
Obstet Gynecol. 2012 Nov;120(5):1181-93
Review of Neonatal Cutaneous Findings
Kanada KN, Merin MR, Munden A, Friedlander SF. A prospective study of cutaneous findings in
newborns in the United States: correlation with race, ethnicity, and gestational status using updated
classification and nomenclature. J Pediatr 2012;161(2):240-245
In the Hospital
Using a 3 Step Pathway to Reduce LOS in CAP
(Inpatients)
 RCT, 400 total pts
 3 steps: 1)early mobilization, 2)switch from IV to oral
when pts stable, 3)Discharge when on oral abx,
baseline mental status, >90% on RA, or back on
usual pt O2
 LOS 6 days for usual care, 3.9 days for intervention
group
 Decreased duration of IV abx (4 vs 2 days)
Arch Intern Med 2012; 172:922-928
Transfusions- less is more
 American Association of Blood Banks developed
guidelines based on recent Cochrane review
 Transfuse less: Hb level of 7-8 for stable hospitalized
pts.
 Similar for pts with preexisting cardiovascular
disease, (perhaps if Hb <8)
 More data is needed for ACS
Article: Ann Intern Med 2012 Mar 26
Cochrane Review: Cochrane Database Syst Rev. 2012 Apr 18;4
Some other things…
Quick Tidbits
 Malaria vaccine somewhat effective in children. Funded
by Gates Foundation and GSK (cut rates in ½).
Pediatrics 2012; 161(2):240-45
 Honey improves cough in children
Pediatrics 2012; 130(3) 465-471
 Probiotics prevent Clostridium difficile-associated
diarrhea- reduced the incidence of CDAD by 66%
(relative risk) in a metanalysis.
Ann Int Med 2012 Dec 18;157(12):878-88.
Quick tidbits
 CRP of little value for cardiac risk stratification.
N Eng J Med 2012: 367
 Aspirin following anticoagulation prevents recurrent
VTE
N Eng J Med 2012 Nov 4
 Routine Replacement of IVs in hospitalized pts not
necessary
Lancet 2012; 380(9847)
 Screening for type 2 DM: 10 year mortality not
improved
Lancet 2012; 380(9855)
Quick tidbits
 Azithromycin associated with increased risk of CV
death- NNTH high, but statistically significant
(retrosepctive cohort)
N Eng J Med 2012: 366(20)
Does anything actually work?
Dartmouth Health Atlas
Simpson’s Paradox
Definition:
1. A trend that appears in different groups of data
2. disappears when these groups are combined
3. and the reverse trend appears to be true for the aggregate data
Simpson’s Paradox
Simpson’s Paradox
How can you stay current?