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The Articles of 2012*

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.

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The Articles of 2012*

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  1. The Articles of 2012* What was important… …at least to some of us

  2. Sources • Essential Evidence • Journal Watch • Our faculty • Prioritized: • key areas of FM practice • might directly change clinical practice • might be leading to paradigm changes

  3. Continuing Some Themes of 2011

  4. 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)

  5. 1000 Men Screened q1-4 years, for 10 Years Pros Cons 0-1 will not die (background risk is 5 in 1000) Arch Intern Med 2012; 157 (2) • 100-120 will have a false positive (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: • 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

  6. Decreasing amount of useless things routinely done

  7. Kale, M. S. et al. Arch Intern Med 2011;171:1856-1858.

  8. http://www.choosingwisely.org

  9. Diabetes Management

  10. 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 CareJanuary 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)

  11. 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

  12. More Blood Pressure Issues

  13. 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

  14. 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.

  15. Studies Included

  16. Studies Included

  17. 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

  18. So What Should We Do Again for Type 2 DM? 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

  19. Outpatient Misc

  20. 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: • 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

  21. 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)

  22. 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.

  23. 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

  24. 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

  25. 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

  26. Women’s Health

  27. Long Acting Reversible Contraception (LARC) • Long acting contraception associated with low failure rate • 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) ObstetGynecol 2012; 120(6):1291-1297 • Associated with reduction in repeat abortion Am J ObstetGynecol 2012; 206(1):37

  28. A Couple Good Articles for Review

  29. 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

  30. 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

  31. In the Hospital

  32. 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

  33. 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

  34. Some other things…

  35. 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.

  36. 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)

  37. Quick tidbits • Azithromycin associated with increased risk of CV death- NNTH high, but statistically significant (retrosepctive cohort) N Eng J Med 2012: 366(20)

  38. Does anything actually work?

  39. Dartmouth Health Atlas

  40. Simpson’s Paradox Definition: A trend that appears in different groups of data disappears when these groups are combined and the reverse trend appears to be true for the aggregate data

  41. Simpson’s Paradox

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