What s New, What s True, and What s Poo Part 1

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1 What s New, What s True, and What s Poo Part 1 Tina Korowynk and Mike Kolber PEER Group What s New? What s True? What s Poo? 1

2 Anti-Depressants Meta-Analysis (Network): 522 RCTs ( pts) Mean duration 8 weeks. Two Outcomes: Versus Placebo Efficacy ( 50% depression scale improvement): Odds Ratio was for 19 of 21 anti-depressants. Elavil was 2.13 and Reboxetine Tolerability (not dropping out): All same as placebo except aglomelatine (OR=0.84) & Fluoxetine (OR=0.88) and clomipramine (OR=1.30) Newer drugs seemed better (?) Bottom-Line: Nothing new. Anti-depressants work marginally well. They are very similar. Cipriani A, et al. Lancet 2018 e pub Remeasuring BP better than Treating? 38,620 pts with 80,864 visits: mean age 61, 41% male Initial BP >140/90 on visits (39% of visits) Remeasured 26,089 of those (83% of the time) BP improved 8mmHg systolic on average (range 2-17) 36% had normal (<140/90) on repeat measure. Just repeating BP, increased overall BP control from 61% to 73% In patients with initial BP : ~43% had <140/90 when remeasured. Bottom-Line: Remeasure BP. It will result in less meds and better BP control for your practice JAMA Internal Medicine. 2018; 178:

3 An Aspirin a Day moderate risk (10-20%), 100mg ASA vs placebo x 6 yrs 1 Sponsor Bayer, Intellectual COI. MACE: ~4% each arm Any GI bleed: 1% vs 0.5% (NNH=200) DMs, 100 mg ASA vs placebo, x 7 yrs 2 CVD: 8.5% v 9.6%, NNT~100 Major Bleeds: 4.1% v 3.2%, NNH ~100 No difference mortality, cancers 1 ARRIVE Lancet 2018; 2 ASCEND NEJM 2018; Sept 1, DOI G Day Older Mates: ASA Older Adults 19,114 older (X= 74yrs) health adults. 100mg ASA vs placebo, FU 5 years. 3 Terminated early. Death, disability, dementia: no diff CVD: 3.5% v 3.9%, NSS Major Bleed: 3.8 vs 2.8%: NNH=100 Death: 5.9 vs 5.2%: NNH=143 Cancer Death: 3.1 vs 2.3%, NNH=125 Bottom-Line: In low & moderate risk primary prevention, diabetics and elderly: potential harms of ASA exceed benefits. ASPREE Study, McNeil JJ. NEJM

4 Bath Additives for Eczema RCT (482 kids), age 1-11 (mean 5), 49% male, Mean POEM 10 (0-28, 8-16 is moderate). Emollient Bath Additive of choice vs no additive 45% Oilatum, 26% Aveeno oil, 4.5% Balneum oil, & 30% other Outcomes: over 16 weeks and at 1 yr. 50% adherence to bath additive: 93% bath additive vs 8% Bath Additive improved 0.41 (-0.27 to 1.1) more. MCID=3 Subgroup: if bath 5x/wk: POEM 2.3 ( ) better No difference in exacerbations, quality of life, steroid use, etc Bottom-Line: Bath additives don t add to eczema treatment (except maybe if there are lots of baths). BMJ 2018;361:k1332 NPH vs Insulin Analogues 9 yr retrospective cohort - large health registry (pharm, EMR, lab, ER/hospital) 25,000 insulin starts 60 yo, 47%, 60% white, 20% Hispanic, 9% black 90% NPH: encouraged NPH, co-pay $ for analogues Outcomes: ER /hospitalization for hypo (Matched for confounding) Outcome NPH Analogue ER / Hospital 9/ /1000 Starting A1c End A1c Bottom-Line: NPH likely not inferior to insulin Analogues (and about 50% the price) JAMA 2018;320(1):53 4

5 Smoking Cessation, Weight Gain and Mortality Three ~20 year US cohorts, q 2 year surveys. Smoking (current, recent, never), post weight gain (0, < 5kg, 5-10 kg, > 10 kg) and mortality N Engl J Med 2018;379:623 Smoking Cessation, Weight Gain and Mortality Three ~20 year US cohorts, q 2 year surveys. Smoking (current, recent, never), post weight gain (0, < 5kg, 5-10 kg, > 10 kg) and mortality You are healthier if you quit smoking. At any weight! And those gained 5-10kg did best! N Engl J Med 2018;379:623 5

6 Pediatric Asthma Action Plan: 5x Inhaled Steroid is the new 2x RCT (254 kids): age 5-11 (mean 8), 64% male, Required daily low-dose steroid + one exacerbation last year. Fluticasone 44µg BID then yellow 220µg BID (or stay 44µg) Outcomes: Exacerbation=oral steroids Exacerbation: No effect, 0.48/yr vs 0.33/yr, RR=1.3 ( ) No difference in time to first exacerbation, ER or urgent care visits, rescue inhaler use, symptom burden, etc. Growth: 5.43 cm vs 5.65 (diff=0.23 cm, p=0.06) Bottom-Line: When asthma symptoms worsen in children, giving 5 times the dose of inhaled steroids does not help. It have small reductions on growth. N Engl J Med 2018;378: Adult Asthma Action Plan: 4x inhaled Steroid is the new 2x RCT (1922): mean age 57, 32% male, 1 year, unblinded Required daily low-dose steroid + one exacerbation last year. Median dose: 800µg beclomethasone. Quadruple if worsening Outcomes: Exacerbation=oral steroids or unscheduled visit Time to 1 st Exacerbation: HR 0.81 ( ) 1 exacerbation: 45% vs 52%, RR 0.87 ( ). NNT 15 Individual outcomes (steroids or unscheduled visits) better. Mini Asthma Quality of Life Questionnaire 0.2 better (0.5 MCID). Adverse events (mostly thrush and dysphonia): 7% vs 2%. NNH 20 Bottom-Line: Quadrupling steroid dose in adult asthmatic will help avoid exacerbations for 1 in 15 per year but will cause thrush/dysphonia for 1 in 20. N Engl J Med 2018;378:

7 RESEAR CH What can Facebook tell us about friendship? Humans have friendship in categories of expanded size, generally 5 (support), 15 (sympathy), 50, 150 (friends), 500 (acquaintances), 1500 (people you know). Most respondents see ~25% of FaceBook friends as genuine Core friend numbers similar on social media or in-person (real) interaction. Similar by age (except? teens who boost on-line friends due to smaller off-line #s) Men have less friends on-line (~150 and females have ) and likely off-line Note: females have greater social skills Bottom-Line: Social Networking mirrors in-person friendship and most people (but not all) can sort who are the real friends, R. Soc. open sci. 3:

8 Self-Colonoscopy 2018 Nobel Ig Prize Could be a valuable research tool repetitively study the effects of therapies Small-caliber c-scope Results: cecum in 4 minutes. So easy à 3 more Xs in 8 weeks mild discomfort, each one different Conclusion: In our personal experience, self colonoscopy proved not only possible but simple and efficient. But may need a special chair GASTROINTESTINAL ENDOSCOPY 2006; 63 (1): 119 Renal Stone: Off to Disney World A pyelocalyceal renal model (could not use animal models) 3 different stones (4.5 mm, 13.5mm, and 65mm) 20 rides on Big Thunder Mountain Railroad roller coaster at Walt Disney World in Orlando, Florida. Seating varied. Passage to ureter was 64% when in roller-coaster rear vs 17% in front. Upper (69%) better than lower (29%), due to gravity, but size no difference! Bottom-Line: Patients should consider riding moderateintensity roller coasters to promote passage of small stones/ fragments. J Am Osteopath Assoc. 2016;116(10):

9 Compared to women: men with the flu: Take 3 versus 1.5 days off work Spend more on OTC remedies Possible immunity gap or evolutionary: Lying on couch = Energy conservation caregivers should go that extra mile to care for us (men) when we are stricken with it, so that future shelves can be erected cars maintained and football stadia can be well attended BMJ 2017;359:j5560 doi: /bmj.j5560 9