Questioning Medicine

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2771093 meta-analysis of 78 original studies, looking to find the accuracy of ECG interpretation. In this analysis they looked at studies with med students, physiciansm even cardiologist and found on average we got the right diagnosis only 55% of the time. Obviously education goes up with more education 42.0% for medical students,55.8% for residents,68.5% for practicing physicians,and 74.9%) for cardiologists. in the end it I think it says a couple thingsWe all have room for improvement at reading EKGsWhen you don’t know what the EKG says the cardiologist only know the right answer an extra 6% of the timeI am not shocked by the results. Lots of these studies had you look at 10 ekgs and say what it is. I think most people can get the easy EKGS, it is the really hard ekgs that look like a four year old drawing that are challenging to name. I think a better question would have been if the providers knew what to do. Did the providers know

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2771670 trials are not real life. We know that. Realistically if your drug just barely hits 0.05 in a clinical trial then in the imperfect setting of the clinic of every day life the drug likely wont work. In this next study, in jama internal medicine titledConcordance Between Blood Pressure in the Systolic Blood Pressure Intervention Trial and in Routine Clinical Practice The authors used a prognostic study and took 3074 patients and wanted to see the difference between BPs obtained in routine clinical practice and the bp obtained during a clinical trial. Which trial you ask?? The sprint trial!! This is brilliant they basically took 3000 patients who were in the SPRINT trial, and as a reminder the sprint trial is the land mark trial of 2015 that showed- In patients at high risk for CVD but who do not have a history of stroke or diabetes, intensive BP control (target SBP <120 mm Hg) improved CV outcomes and overall survival compared to stand

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2771095 SO HOW DO YOU LOSE WEIGHT!! FASTING DOESN’T WORK or so says this study titled- Effects of Time-Restricted Eating on Weight Loss and Other Metabolic Parameters in Women and Men With Overweight and ObesityThe TREAT Randomized Clinical Trial100 overweight or obese adults were randomized to regular eating or to a restricted eating pattern where you could not eat between 8pm and 12 noon and the result were no statistical difference between the group that at three meals a day and the group that could only eat between 12 and 8. Here is the problem-People could eat anythingYou basically are only restricting breakfast. What grown adult eats a ton for breakfast. I mean sure there aer some but the majority of people I know maybe have a hard boiled egg or a piece of toast but never a huge meal. How many EXTRA calories are these people really getting??I think a better way to do this trial would have been 12 hours of fast but make the hours 5am to 5

Doc my heart is racing— Stop drinking—or so says this article in NEJM that found when they took 140 pts who severed from paroxysmal afib and who drank 17 drinks a week that when randomized to complete alcohol abstinence for 6 months there was significant reduction in afib recurrence.. how much of a difference?? 20% ABSOLUTE DIFFERENCE….. I have a rule of thumb that anytime someone says the improvement is any percent over 10% I almost always assume they are talking relative risk reduction, but this was 20% ABSOLUTE risk reduction. That is a NNT of 5. So when your patient says my heart goes piter pat pitter piter pat pat pat pitter what should I do, the answer is to stop drinking. Now let me grab a sip of bourbon and onto the next article. DOC there is a puddle on the floor..https://journals.lww.com/optvissci/Fulltext/2020/07000/Validation_of_a_More_Reliable_Method_of_Eye_Drop.7.aspx Tell them to close their eyes or so say this article in optometry and vision science that had 30 pts and on one visit, eye drop

Rapid fire articles- no deep dive. Just good a lot of questioning, questioning medicine. If you want any of the articles for your own review or have any questions you can always reach me at andrewbuelt@gmail.com

We stuck purely to the evidence. There was no evidence panel or committee to vote on the evidence like is often done by the American college of rheumatology and no expert opinion statements where their only citation is themselves like can be seen with the ACC. This was purely 100% evidence recommendations. So lets start try to make it quick because guidelines on a podcast a boring, I want to hit the high points and get out of here This guideline does not cover 1) adults < age 40 years old o2) patients with ejection fraction <35%3) pts with life expectancy less than 5 years4) Patients with genetic dyslipidemia conditions were also excluded Now to the recomendations . test a serum Cholesterol level every ten years!! Yes 10yrs. If you are testing more frequently than that you are likely seeing variability in the test and not a true change. Cholesterol levels are stable! If you see a change it is because you are seeing a change in the point estimate—remember it might say ldl 100 but there are CI around th

athlete heart covidhttps://www.the-scientist.com/news-opinion/college-athletes-experienced-heart-damage-after-covid-19-study-67929titiles like- “Images of the players’ hearts showed signs of inflammation consistent with myocarditis, a rare but potentially fatal condition.”“two dozen of Ohio State University players using cardiac magnetic resonance (CMR), they found evidence of myocarditis in 15 percent, while a further 30 percent had cellular damage or swelling “ The Ny york times said- https://www.nytimes.com/2020/09/16/well/move/is-coronavirus-affecting-the-hearts-of-college-athletes.html Is Coronavirus Affecting the Hearts of College Athletes? “In a new study of 26 college athletes who tested positive for coronavirus, four later showed signs of inflammation in their heart muscles.” and my favorite-- CNN sayshttps://www.cnn.com/2020/09/14/health/covid-heart-inflammation-athletes-study/index.html Covid-19 study suggests to screen recovering athletes for heart inflammation before they return to play “As ath

the thing about RCT is they are random and everything is equal. its why in table one of an RCT you should never see a pvalue because they are random and should be equal but in observational studies you see pvalues because it is not equal, it can’t be, its not random. In observational studies you try to account for all the confounders but you just cant ever make it equal to an RCT but lets look a look at observational data using a real world example. I will start with a question—is there an association between fluoroquinolone use and aortic aneurysm and aortic dissection (AA/AD).? You might say well in dec 2018 the FDA issued a warning recommending avoiding fluoroquinolone use in patients with AA/AD or who are at risk for these conditions But that was not the question I asked – I said “is there an association between c use and aortic aneurysm and aortic dissection (AA/AD).?” The answer is ‘it depends’—clearly seen in recent issue of JAMA Internal Medicine one paper –

Finance ethics committee, big pharma with deep pockets, mafia like arrangements, and a patient with a 40% increase risk of ischemia myocardial events have in common?I will say todays podcast was inspired by a tweet, yes a tweet from Dr. john Mandrola and he said “I am embarrassed to have not (really) known the details of the rosiglitazone affair. Teaching this to learners has to be 10x more valuable than the krebs cycle. My gosh – talk about lessons to learn. We have to promote more skeptical priors’ He attached a link to a paper titledThe rise and fall of rosiglitazoneEuropean Heart Journal, Volume 31, Issue 7, April 2010, Pages 773–776https://academic.oup.com/eurheartj/article/31/7/773/433556I also will say I did not know the details of the rosiglitazone affair but after spending the last 3 days digging through this paper and the sources to this paper and the sources to those papers and by the end you will know exactly what Finance ethics committee, big pharma with deep pockets, mafia like arrangements, and

In this study of a cohort of German patients recently recovered from COVID-19 infection, CMR revealed cardiac involvement in 78 patients (78%) and ongoing myocardial inflammation in 60 patients (60%), independent of preexisting conditions,this was a freak out statement if I have ever heard of one I mean Covid is doing something directly to the heart? and this thing it is doing to the heart is independent of preexisting conditions??this study was viewed over 500K times and on 196 news outlets with 12,000 tweetsthis is in and of itself one of the main reasons that the BIG TEN shut down football. of course we will never know for sure but it has been cited in many of the articles as one of the biggest concerns for player safety and potential damage to the heart!!Nevermind the fact that this mean age in the study was almost 50 and the mean age of a college football player is around 20. That is just a small detail and we need to shut down sports for the safety of the athletes because we the big ten have a HEART and

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2768888Serial Bone Density Measurement and Incident Fracture Risk Discrimination in Postmenopausal WomenCarolyn J. Crandall, MD, MS1; Joseph Larson, MS2; Nicole C. Wright, PhD3; et al OBJECTIVETo assess whether a second BMD measurement approximately 3 years after the initial assessment is associated with improved ability to estimate fracture risk beyond the baseline BMD measurement alone.In this prospective observational study 7419 women from The Women’s Health Initiative with a mean (SD) follow-up of 12.1 (3.4) years Incident major osteoporotic fracture (ie, hip, clinical spine, forearm, or shoulder fracture), hip fracture, baseline BMD, and absolute change in BMD were assesseda second bone mineral density (BMD) assessment approximately 3 years after the initial measurement was not associated with improved risk discrimination, beyond the initial BMD assessment, between women who did and did not experience hip fracture or major osteoporotic f

Sometime I wonder how the world will change post covid- or how the board questions will change? And that is clearly seen in this article titled- Yip L et al. Serious adverse health events, including death, associated with ingesting alcohol-based hand sanitizers containing methanol — Arizona and New Mexico, May–June 2020. MMWR Morb Mortal Wkly Rep 2020 Aug 14; 69:1070. hand sanitizing gels and foams containing ≥60% alcohol (either ethanol or isopropyl alcohol) has been proven to be effective -- Methanol is not an acceptable substitutein this paper they looked at 15 cases of methanol poisoning due to ingestion of methanol-containing hand sanitizers From May through June 2020 All patients had a history of ingesting alcohol-based hand sanitizerpresentation included visual disturbance, seizures, gastrointestinal involvement, altered mental status, and anion-gap acidosis with blood pH varying from 6.70 to 7.23.in the end Four patients died and three others were discharged with new visual impairment. I can see it no

henry ford once said “failure is simply the opportunity to begin again, this time more intelligently”Designed to Fail? the Future of Primary CareJournal of General Internal Medicine (2020) Access to primary care has been shown to improve patient outcomes and lower cost although outcomes are debated the cost is not-its because we can be the jack of all or the referral of all. neither is wrong the authors in this paper analyzed the 2019 “in-basket” activity of our clinical faculty at the University of Michigan to determine the average weekly activity by category of EMR tasks. A full-time primary care faculty member had a total of 390 in-basket tasks per week or 17,542 in-basket tasks per year.they surveyed 56 clinicians, and asked how much time, to the nearest minute, they spent on in-basket tasks: and a median time of 1199 min (~ 20 h) per week on these tasks many task require further steps- like addressing lab work, or ordering follow up imaging, or doing a prior authorization ALL of which are unpaid. essenti

https://twitter.com/NarducciDusty/status/1290044202852614145?s=20

Characteristics and Strength of Evidenceof COVID-19 Studies Registeredon ClinicalTrials.gov Looked at ClinicalTrials.gov identified 1551 studies registered fromMarch 1, 2011, to May 19, 2020,Lets look at the gold standard RCTOf the 664 RCT (76.1%) were single center. PROBLEM! Weather analysis!Only half of the rct looked at clinical course with only 8% of the rct looking at mortality and this is a problem because blinding was only reported for half of the trials so half of the time your outcome is clinical course and half the time you are not blinding them to the treatment do you think the people you knowingly got the treatment drug will ‘get better’ faster. And maybe they got better because they knew they were getting the good stuff or maybe they got better because eh provider knew they were getting the active. Both can be bias when they know if the patient is getting placebo or active arm. The authors state it best “evidence, the large proportion of studies withan expected low level of evidence is concerni

Initiating Pharmacologic Treatment in Tobacco-Dependent Adults. An Official American Thoracic Society Clinical Practice Guidelinehttps://www.atsjournals.org/doi/full/10.1164/rccm.202005-1982STultimate take home- varenicline is first line!!For Tobacco-Dependent Adults in Whom Treatment Is Being InitiatedShould Treatment Be Started with Varenicline or a Nicotine Patch?40 more per 1,000 patients; Compared with a nicotine patch, varenicline increased long-term abstinence, measured at 6-month follow-up (RR, 1.20; 95% CI, 1.09 to 1.32; ARR, 40 more per 1,000 patients;) For Tobacco-Dependent Adults in Whom Treatment Is Being Initiated Should Treatment Be Started With Varenicline or Bupropion?77 more per 1,000 patients taking Varenicline increased tobacco abstinence at 6-month follow-up compared with bupropion (RR, 1.30; 95% CI, 1.19 to 1.42; ARR, 77 more per 1,000 patients;)who andrew so just varenicline by itself?? thats it??should Treatment Be Started with Varenicline plus Nicotine-Replacement Therapy or Varenicli

https://www.youtube.com/watch?v=EBhEjYhVoZkGoggin K et al. Reductions in parent interest in receiving antibiotics following a 90-second video intervention in outpatient pediatric clinics. J Pediatr 2020 Jun 15; [e-pub]. (https://doi.org/10.1016/j.jpeds.2020.06.027)acute respiratory tract illnesses (ARTIs; cough, congestion, sore throat, and earache) is a PROBLEM with a capital P. or maybe I should say its a pain in the A with a capital A and that A of course is referring to antibiotics-- parents want antibiotics, sometimes demand antibiotics and no matter what you say, its hard to say no time and time and time again and eventually EVERYONE and yes I mean everyone will eventually give an antibiotic when they in their heart of heart knows it is likely not indicated. BUT what if we could educate our pts before we walked in the room. In this study they surveyed 1051 parents about their knowledge of and interest in receiving antibiotics for their children. Surveys were conducted before and after parents watched a

Orkaby AR et al. Association of statin use with all-cause and cardiovascular mortality in US veterans 75 years and older. JAMA 2020 Jul 7; 324:68. (https://doi.org/10.1001/jama.2020.7848) retrospective cohort study of about 327,000 patients (age, ≥75; mean age, 81; mostly white men) without prior statin use, without a prior cardiovascular event; in total 326K vets that were 75yr old and older and had never had a cardiovascular event those started on statin therapy did better!!!all-cause mortality was 78.7 per 1000 person years in those started on a statin and 98.2 per 1000 person-years in those not a on a statin. BUT devel in the details-- they say they looked at 7.2 million vets- then once you took out the people that had prior statin exposure, and removed the people with missing data, and then excluded those with a prior cardiovascular event, and threw out those individuals who died in the first 150 days -- you then get the 326K. and of those about 57k got a statin prescription and 269K never got a statin p

Effect of Dexamethasone in Hospitalized Patients with COVID-19: Preliminary Report (RECOVERY) trial is a randomized, controlled, open-label, comparison of dexamethasone 6 mg given once daily for up to ten days vs. usual care alone.2104 patients randomly allocated to receive dexamethasone were compared with 4321 patients concurrently allocated to usual care. The primary outcome was 28-day mortality (21.6%) patients allocated dexamethasone vs (24.6%) patients in usual care died within 28 days (age-adjusted rate ratio [RR] 0.83; 95% confidence interval [CI] 0.74 to 0.92; P<0.001). No oxygen then dexamethasone did not reduce mortality at 28 17.0% vs. 13.2%, RR 1.22 [95% CI 0.93 to 1.61]; p=0.14).patients receiving oxygen without invasive mechanical ventilation dexamethasone did reduce mortality at 28days (21.5% vs. 25.0%,-- a number needed to treat around 30. And if you were intubated then dex 6mg for for to 10 days really was a show stopper with a nnt of 9 for mortality at 28days. Last case bias.but thing

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3792273/Does Rewording MRI Reports Improve Patient Understanding and Emotional Response to a Clinical Report?Remember few weeks ago when I talked about 50% of people knew that broken bone and fracture were the same thing or that 1 in 5 pts couldn’t describe nonweight baring? Well this study looked o see what would happen if we changed the language in MRI reports 100pts- list of all shoulder, elbow, wrist, and hand MR images ordered in 2011 was obtained from the radiology service-- The original reports were reworded to the recommended reading level for effective health education below the eighth-grade levelwords such as “tear” were replaced by more descriptive and accurate words such as hole, signal change, or defect. They also used analogies (eg, gray hair, bald spot) looked at bunch of outcomes but thing I care about was understanding—did the pt understand it and they used a 10 point scale- basically asked th pts. On 1-10 scale how did you understand that report-T