Questioning Medicine

What Was Studied?The EMPA-KIDNEY trial followed 6,609 CKD patients at risk of disease progression. Participants were randomly assigned to receive empagliflozin (10 mg daily) or a placebo for a median of 2 years. After this ‘active’ phase, 4,891 patients entered a 2-year post-trial observational period where neither group received the trial drug, but doctors could prescribe open-label SGLT2 inhibitors. The goal? To see if empagliflozin’s benefits persisted after stopping treatment.Key Findings Sustained Kidney Protection:Over the entire 4-year period (active + post-trial), empagliflozin reduced the risk of kidney disease progression or cardiovascular death by 21% (HR 0.79). The number needed to treat (NNT) to prevent one event was 24 patients over 4 years. Post-Trial Benefits:Even after stopping the drug, the empagliflozin group saw a 13% lower risk of the primary outcome during the post-trial phase alone (HR 0.87). Specific Outcomes: Kidney disease progression: 23.5% (empagliflozin) vs. 27.1% (placebo).

Metformin while not necessarily first line therapy for diabetes depending on the patients co-morbid conditions it is certainly highly ranked on the list of medications! I know often metformin is stopped while coming into the hospital for fear of potentially lactic acidosis or an increase in AKI with contrast studies however this ‘belief’ is largely based on myth and misconception. Metformin's contraindications should be contraindicated - PMC I also know that often metformin is held at discharge if the patients GFR is near or around 30 However, two new studies. Stopping Versus Continuing Metformin in Patients With Advanced CKD: A Nationwide Scottish Target Trial Emulation Study - ClinicalKey 4,278 Scottish residents with a diagnosis of type 2 diabetes were identified as prevalent metformin users with incident CKD stage 4. (it was stopped when they reached CKD 5) Results:Compared with continuing metformin, stopping metformin was associated with a lower 3-year survival (63.7% [95% CI, 60.9-66.6] vs 70.5% [95% CI

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2825813Conclusions and Relevance  In this randomized clinical trial assessing simultaneous vs sequential administration of mRNA COVID-19 and IIV4 vaccines, reactogenicity was comparable in both groups. These findings support the option of simultaneous administration of these vaccines.

https://www.bmj.com/content/388/bmj-2024-081164systematic review and meta-analysis on prehabilitation before surgery, published in the BMJ in February 2025.Prehabilitation aims to prepare patients for surgery through interventions like exercise, nutrition, and psychological support. This study looked at which prehabilitation components are most effective for improving key outcomes after surgery.The researchers analyzed 186 randomized trials with over 15,000 participants. They used advanced statistical methods to compare different prehabilitation approaches.The key findings were: Exercise-only prehabilitation reduced complications by about 50% compared to usual care. Nutritional prehabilitation alone reduced complications by about 38%. Combining exercise, nutrition, and psychosocial support reduced complications by about 36%. For hospital length of stay, exercise plus psychosocial support was most effective, reducing stays by about 2.5 days on average. Multicomponent prehabilitation including exercise, nutriti

Mammograms

379. REPORT mammogram part 1

https://jamanetwork.com/journals/jama/article-abstract/2828218DCIS is a non-invasive form of breast cancer, meaning the abnormal cells are contained within the milk ducts. For years, the standard treatment has been surgery, often followed by radiation and/or hormone therapy - the same treatments used for invasive breast cancer. But is this aggressive approach always necessary for low-risk DCIS?(Transition Music - Short and subtle - 2 seconds) Host: That's the question the COMET trial, or Comparing an Operation to Monitoring, With or Without Endocrine Therapy for Low-Risk DCIS, set out to answer. This large, randomized trial enrolled nearly 1000 women with newly diagnosed, low-risk DCIS across 100 centers in the US between 2017 and 2023. Participants were randomly assigned to either guideline-concordant care, meaning surgery with or without radiation, or active monitoring, involving regular check-ups with imaging and physical exams, reserving surgery only if the DCIS progressed to invasive cancer. The study fo

Association of Duration of Recognized Hypertension and Stroke Risk: The REGARDS Study   (Transition Music - Short and subtle - 2 seconds)Host:  Hypertension is a well-known risk factor for stroke, but this study, led by Dr. George Howard and colleagues, asks a fascinating question: Does the duration of hypertension matter, even when blood pressure is managed? (Transition Music - Short and subtle - 2 seconds)Host: The researchers used data from the REGARDS study, a large, long-term study looking at racial and geographic differences in stroke. They followed over 27,000 stroke-free participants for over 12 years, tracking who developed stroke and how long they had been diagnosed with hypertension. Participants were grouped by duration of hypertension: normotensive (no hypertension), 5 years or less, 6 to 20 years, and 21 years or more. (Transition Music - Short and subtle - 2 seconds)Host:  So, what did they find? Several key findings emerged. First, people with longer durations of hypertension were taking more

Bloom CI et al. Association of dose of inhaled corticosteroids and frequency of adverse events. Am J Respir Crit Care Med 2025 Jan; 211:54. (https://doi.org/10.1164/rccm.202402-0368OC)  Bloom and colleagues' study, published in the American Journal of Respiratory and Critical Care Medicine in January 2025, provides significant insights into the safety profile of inhaled corticosteroids (ICS) for asthma patients7. The research, which analyzed data from two large UK databases, reveals important associations between ICS dosage and adverse events.  GINA GUIDELINES+ step 1 is ics formoterol OR low dose ICS--- as you move up ICS is always in the picture like a bad ex girlfriend in the family picture…. You can never just cut it out—sure you can go on photo shop and make em bigger or smaller like you can go with ICS but you cant cut them out. Key Findings Low-dose ICS: No significant increase in adverse events7. Medium to high-dose ICS: Associated with increased risks of: Major adverse cardiovascular events (MACE) C

Gao FM et al. A systematic review and meta-analysis on the safety and efficacy of sodium–glucose cotransporter 2 inhibitor use in hospitalized patients. Diabetes Care 2024 Dec 1; 47:2275. (https://doi.org/10.2337/dc24-0946) Trial ResultsSGLT-2 inhibitors, crucial in managing diabetes, kidney disease, and heart failure, have shown promising results in hospitalized patients1. The meta-analysis, covering 23 randomized controlled trials with 20,000 participants, revealed:No significant increase in ketoacidosis rates (0.21 vs. 0.14 per 100 person-years)1Lower mortality and fewer readmissions in heart failure patients1Reduced incidence of acute kidney injury overall1These findings suggest that SGLT-2 inhibitors can be safely continued or initiated in hospitalized patients, particularly those with heart failure1.LimitationsHowever, it's important to note some limitations: Potential underpowering: The study might not have had enough statistical power to detect small differences in ketoacidosis rates1. Risk underestim

Is accelerated surgery for hip fracture better for high-risk patients? A recent substudy of the HIP ATTACK trial has shed new light on this topic. The original trial, published in 2020, compared accelerated surgery (within 6 hours) to standard-timing surgery (within 24 hours) for hip fracture patients. While the initial results showed only marginal benefits, this new analysis focuses on a specific group: patients with elevated cardiac troponin levels at hospital arrival--- THE SICK GUYS7.Here's what the researchers found:For patients with elevated troponin levels - about a quarter of those tested - accelerated surgery was associated with significantly lower mortality. The numbers are striking: 10% mortality in the accelerated surgery group compared to 23% in the standard surgery group. This translates to a number needed to treat of just 87.Interestingly, for patients with normal troponin levels, there was no significant difference in mortality between the two surgical approaches7.These findings suggest that f

Today, we're discussing two groundbreaking studies from 2024 that challenge our understanding of β-blocker therapy for secondary prevention after myocardial infarction, or MI.Let's start with a Swedish study Beta-Blockers after Myocardial Infarction and Preserved Ejection Fraction | New England Journal of Medicine that included over 5,000 patients with normal left ventricular ejection fraction after an MI5. The researchers compared long-term beta-blocker therapy with no beta-blocker treatment. Surprisingly, after 3.5 years, there was no significant difference in the primary endpoint of all-cause death or recurrent MI between the two groups5. This suggests that for patients with preserved heart function after an MI, long-term beta-blocker use may not provide additional benefits.  Now, let's turn to a French study involving 3,700 patients who were already on β-blockers following an MI Beta-Blocker Interruption or Continuation after Myocardial Infarction | New England Journal of Medicine7. This trial compared co

Methods Monday  --- Accuracy of Event Rate and Effect Size Estimation in Major Cardiovascular Trials: A Systematic Review | Cardiology | JAMA Network Open | JAMA Network  During the design of a randomized clinical trial (RCT), estimation of the expected event rate and effect size is a key component to calculating the sample size. Overly optimistic estimation of event rates and effect sizes may lead to underpowered trials. If you expect 1 event per 100 people and you are looking for 5 events then you only need to enroll….. 500 people but if the actual event rate is 1 per 200 people then in order to get 5 events you need to enroll 1000 people!! You can see enrolling 500 people instead of 1000 would underpower your trial  This article, published in JAMA Network Open in April 2024, presents a systematic review of 344 contemporary cardiovascular randomized clinical trials (RCTs) to evaluate the accuracy of estimated event rates and effect sizes1. The key findings are:Event rates were frequently overestimated: Medi

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2821168A team of researchers set out to change that by developing a comprehensive algorithm.The process involved a multidisciplinary panel of 11 expertss with extensive experience in managing urinary retention. These experts evaluated about 100 clinical scenarios to create an initial flow sheet. The algorithm was then refined through interviews with 33 frontline clinicians from various specialties.So, what does this new algorithm recommend? Let's break it down:First, bladder scanning is the preferred method for evaluating patients with urinary retention symptoms. It's also recommended for asymptomatic patients who haven't voided in 3 hours.If a bladder scanner isn't available, the algorithm suggests using either an intermittent straight catheter (ISC) or an indwelling urinary catheter (IUC), with a preference for ISC initially.Now, let's talk about when to catheterize based on bladder scanner volumes. For symptomatic patients, catheterization is rec

https://jamanetwork.com/journals/jama/article-abstract/2822097Design, Setting, and Participants  Nested case-control study using population-based linked administrative datasets among adults aged 66 years or older who received at least 1 oral antibiotic between 2002 and 2022 in Ontario, Canada. Cases were those who had an emergency department (ED) visit or hospitalization for serious cADRs within 60 days of the prescription, and each case was matched with up to 4 controls who did not.Exposure  Various classes of oral antibiotics.Main Outcomes and Measures  Conditional logistic regression estimate of the association between different classes of oral antibiotics and serious cADRs, using macrolides as the reference group.Results  During the 20-year study period, we identified 21 758 older adults (median age, 75 years; 64.1% female) who had an ED visit or hospitalization for serious cADRs following antibiotic therapy and 87 025 matched controls who did not. In the primary analysis, sulfonamide antibiotics (adjuste

https://www.nejm.org/doi/full/10.1056/NEJMoa2407001ConclusionsNo participants receiving twice-yearly lenacapavir acquired HIV infection. HIV incidence with lenacapavir was significantly lower than background HIV incidence and HIV incidence with F/TDF. Among 5338 participants who were initially HIV-negative, 55 incident HIV infections were observed: 0 infections among 2134 participants in the lenacapavir group (0 per 100 person-years; 95% confidence interval [CI], 0.00 to 0.19), 39 infections among 2136 participants in the F/TAF group (2.02 per 100 person-years; 95% CI, 1.44 to 2.76), and 16 infections among 1068 participants in the F/TDF group (1.69 per 100 person-years; 95% CI, 0.96 to 2.74)

Allaudeen N et al. Medications for alcohol-use disorder and follow-up after hospitalization for alcohol withdrawal: A multicenter study. J Hosp Med 2024 Dec; 19:1122. (https://doi.org/10.1002/jhm.13458)   Hospital admission for alcohol withdrawal is a problem when it comes to readmission. They just come back--- In this retrospective study of ≈600 patients (96% men) admitted for alcohol withdrawal at 19 Veterans Affairs hospitals during 1 year (2018–2019), researchers evaluated prescription rates of medications for alcohol use disorder (AUD; e.g., naltrexone, acamprosate, disulfiram, gabapentin, topiramate) and scheduled follow-up appointments.The objective of this study was to evaluate the effects of medications for AUD and follow-up appointments on readmission and abstinence.Neither prescription of AUD agents (to 51% of patients) at hospital discharge nor scheduled follow-up appointments at discharge were associated with 30-day readmissions or 6-month alcohol abstinence.Only direct discharge to residential A

Real‐world use of glucocorticoids and clinical outcomes in adults hospitalized with community‐acquired pneumonia on medical wards - Malecki - 2024 - Journal of Hospital Medicine - Wiley Online Library This was a retrospective cohort study of 11,500 patients with CAP who were admitted to general medicine units in 7 Canadian hospitals, researchers compared outcomes for patients who received systemic corticosteroids. Patients were excluded if they were admitted to the intensive care units or had COPD or COVID-19 infection. Between those that got steroids and those that didn’t get steroids there was no differences in intensive care admissions, hospital length of stay, or 30-day readmissions. HOWEVER, In an adjusted analysis, patients who received systemic corticosteroids were significantly more likely to die in the hospital than were patients who didn't receive steroids (8.0% vs. 6.3%; P=0.03).  LET’S BE CLEAR THIS IS FOR NON-SEVERE PNA!! If you have severe pna and are going to the ICU then the evidence and guide

2024 ESC guidelines propose a simple new BP categorization: Non-elevated: less than 120/70 mm Hg in the office (pharmacological treatment is not recommended). Elevated: 120 to 139/70 to 89 mm Hg (pharmacological treatment is recommended for some, depending on cardiovascular disease [CVD] risk and follow-up BP measurements). Hypertension: 140/90 mm Hg or greater (confirmation and prompt pharmacological treatment is recommended).     lifestyle interventions are particularly critical for individuals with an elevated BP but a low predicted risk of CVD. Adults in this group are common and account for up to one-third of all CVD events,  2024 ESC Guidelines provide two major new lifestyle approaches for managing elevated BP and hypertension.  first new option is potassium supplementation, either by dietary supplementation or potassium-enriched salt substitutes. The mechanistic and observational data supporting the benefits of potassium supplementation on BP are not new. However, recent CVD outcomes trials demonstrat

Question  Does adding centralized mailed fecal immunochemical testing and patient navigation to usual care improve colorectal cancer (CRC) screening in US federally qualified health centers? pragmatic randomized clinical trial was conducted Patients were enrolled and randomly assigned to usual care alone (control group) or intervention (2,001 participants per group). Intervention participants received mailed screening outreach materials including an introductory letter, FIT kit packet with instructions and return postage, and two reminder letters if necessary, in addition to usual care. Navigation to facilitate follow-up colonoscopy was offered to intervention participants with positive results of mailed FIT. The researchers found that intervention participants were THREE TIMES more likely than controls to complete screening within six months of randomization (30.0 versus 9.7 percent). Overall, positive FIT results in the intervention arm completed follow-up colonoscopy within six months more often than those