What was important

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The Articles of 2012

• What was important
• at least to some of us

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Sources

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

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Continuing Some Themes of 2011
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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)

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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

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Decreasing amount of useless things routinely done
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Kale, M. S. et al. Arch Intern Med
20111711856-1858.
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http//www.choosingwisely.org
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Diabetes Management
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2012 ADA Position Statement

• Glycemic management in type 2 diabetes mellitus
  has become increasingly complex and, to some
  extent, controversialmounting 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
• Recd 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)

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2013 ADA Guidelines A1C Goals (not much new)

• Reduce A1C for most to lt7
• lt6.5 might be good when short duration of
  diabetes, long life expectancy
• lt8 may be appropriate for patients with a
  history of severe hypoglycemia, limited life
  expectancy, sick people, etc.
• Diabetes Care January 2013 36S4-S10
  doi10.2337/dc13-S004

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More Blood Pressure Issues
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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

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BP Goals in DM 2

• Meta-analysis
• Patients with DM2
• intensive target (lt130/80) vs standard targets
  (140-160/85-100)
• Done over 5 years
• No Mortality or MI difference
• Small decrease in stroke rates
• Arch Intern Med. 2012172(17)1296-1303.

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Studies Included
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Studies Included
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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 lt130 mmHg)
  may be appropriate for certain individuals, such
  as younger patients, if it can be achieved
  without undue treatment burden
• Diabetes Care January 2013 36S4-S10
  doi10.2337/dc13-S004

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So What Should We Do Again for Type 2 DM?

1. Reasonable/Individualized glycemic control
2. Metformin first, probably even in lower GFRs
3. BP control probably 140/90
4. Address CV risk factors Lipids, smoking, obesity
5. Encourage Exercise
6. Not insist on self-monitoring for pts not on
   insulin

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Outpatient Misc
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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

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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)

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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. 2012157865-877.

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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

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• Reference Run for your lifeat a comfortable
  speed and not too far Heart. 2012 Nov 29
• TED Talk
• http//www.youtube.com/watch?vY6U728AZnV0

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• 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 dont do too
  many

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Womens Health
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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)
• Obstet Gynecol 2012 120(6)1291-1297
• Associated with reduction in repeat abortion
• Am J Obstet Gynecol 2012 206(1)37

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A Couple Good Articles for Review
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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 Nov120(5)1181-93

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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 2012161(2)240-245
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In the Hospital
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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, gt90 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 172922-928

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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 lt8)
• More data is needed for ACS
• Article Ann Intern Med 2012 Mar 26
• Cochrane Review Cochrane Database Syst Rev. 2012
  Apr 184

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Some other things
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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-associate
  d diarrhea- reduced the incidence of CDAD by 66
  (relative risk) in a metanalysis.
• Ann Int Med 2012 Dec 18157(12)878-88.

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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)

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Quick tidbits

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

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Does anything actually work?
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Dartmouth Health Atlas
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Simpsons 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

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Simpsons Paradox
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Simpsons Paradox
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How can you stay current?