Hello! I hope you're well. This week's ticket will have a lot of cardiology because this week's American cardiology congress was an e-congress. Enjoy your reading!
1/ Infectiology
First of all, a publication found that in the case of coronaviruses (but not influenza or rhinoviruses), surgical masks are effective in filtering particles larger than 5µm but also those smaller than 5µm, and would therefore be useful to avoid airborne (aerosol) transmission.
The French Academy of Medicine has issued a statement recommending the wearing of masks for exits during containment and the widespread use of masks to prepare for exit from containment. In situations of mask supply shortage, clothes masks are recommendedfor the public . For this, I refer you to the site stop-postillons.fr.
The BJGP compared methods of temperature measurement in children under 5 years, focusing on non-contact infrared thermometers, axillary (and tympanic) thermometers. The authors found a difference of 0.14°C between non-contact and axillary thermometers, which is quite good, but there were variations ranging from -1.57°C to +1.29°C, which is still a lot. The results for tympanic thermometers were similar. In short, the temperature measurements are always so variable depending on the instrument...
2/ Cardiovascular disease
Concerning the debate on ACE inhibitors and ARBs in patients suspected of having COVID, an editorial from the BMJ proposed an algorithm, which goes against the recommendations of the cardiology societies, since the benefit of preventive discontinuation in asymptomatic patients is not certain:
The COMPASS study in 2017 was reported in which the benefit of adding rivaroxaban to aspirin versus aspirin alone in post-infarction was moderate. This year, data from the study were analyzed by comparing diabetic patients to non-diabetic patients. I must admit that I do not really understand the interest of the paper, which repeats the same thing as the original publication, with results that are no longer significant on overall mortality in either diabetic or non-diabetic patients (whereas they were when all patients were analyzed). The authors calculated a "net" clinical benefit (cardiovascular mortality, infarction, stroke and major bleeding), and here this benefit is not significant.
Another article compared different non-vitamin K antagonist oral anticoagulants (NOACs) in a matched cohort study. The authors found no difference in efficacy between rivaroxaban, apixaban and dabigatran. However, rivaroxaban was responsible for more bleeding than dabiagatran (NNH=189) and apixaban (NNH=295). Compared to dabigatran, apixaban was responsible for more gastrointestinal bleeding (NNH=95). With all this and since the time it has been said, the risks of rivaroxaban are clearly superior to other NOACs for identical benefits . (see here and there, again here and there. At some point, it is necessary to stop the lobbying...).
A new treatment for heart failure has been developed. It is vericiguat, a oral soluble guanylate cyclase stimulator tested versus placebo in symptomatic patients with LVEF < 45% mostly treated with beta-blockers, ACE inhibitors and aldosterone antagonist. Treatment with vericiguat significantly improved the cardiovascular composite endpoint (NNT=24 patients per year) but without benefit on cardiovascular mortality or overall mortality. This is always worrying in a study that found more side effects in the placebo group compared to the treatment group. In short, a benefit that is not very important and a strategic position is hard to find given the benefit of neprilysine inhibitors compared to this treatment.
Finally, the ISCHEMIA study that I mentioned here has finally been officially published in the NEJM.
3/ Gynecology
One article talks about polycystic ovary syndrome (PCOS) in adolescents. The diagnostic criteria are refined:
- irregular menstrual cycles: cycles > 90 days (if menarche > 1 year), cycles less than 21 days or more than 45 days (if menarche between 1 and 3 years), cycles less than 21 days or more than 35 days (if menarche > 3 years) or primary amenorrhea (if age > 15 years or > 3 years post-tearche). Cycle irregularities are normal in the 1st year.
- hyperandrogenism: hirsutism (hair on areas usually hairless in women), severe acne or biological hyperandrogenism (free testosterone, SDHEA, LH, FSH, 17-OH progesterone to be performed 3 months after stopping all hormonal contraception). No dosage of AMH.
- Pelvic ultrasound: not to be done in young women before the 8th year after menarche because the ovaries are normally multifollicular at that time (avoid over-diagnosis).
Treatment includes menstrual hygiene and oestro-progestative contraception. The benefit of metformin is to be discussed on a case-by-case basis (but it doesn't work a lot, I had mentioned it here), and spironolactone can be used to counter hirsutism. (My other post on the PCOS and British guidelines: here)
- irregular menstrual cycles: cycles > 90 days (if menarche > 1 year), cycles less than 21 days or more than 45 days (if menarche between 1 and 3 years), cycles less than 21 days or more than 35 days (if menarche > 3 years) or primary amenorrhea (if age > 15 years or > 3 years post-tearche). Cycle irregularities are normal in the 1st year.
- hyperandrogenism: hirsutism (hair on areas usually hairless in women), severe acne or biological hyperandrogenism (free testosterone, SDHEA, LH, FSH, 17-OH progesterone to be performed 3 months after stopping all hormonal contraception). No dosage of AMH.
- Pelvic ultrasound: not to be done in young women before the 8th year after menarche because the ovaries are normally multifollicular at that time (avoid over-diagnosis).
Treatment includes menstrual hygiene and oestro-progestative contraception. The benefit of metformin is to be discussed on a case-by-case basis (but it doesn't work a lot, I had mentioned it here), and spironolactone can be used to counter hirsutism. (My other post on the PCOS and British guidelines: here)
4/ Diabetology
A study in diabetes care studied second-line treatments in type 2 diabetes from a cohort study. The metformin + sulfonamide combination was at higher risk of cardiovascular events, mortality and hypoglycemia than the other combinations. The most effective treatments with a lower risk of hypoglycemia were metformin + GLP-1 analogue or + SGLT2 inhibitor. It is also clear that metformin+DPP4 inhibitor or + basal insulin is less effective than metformin+GLP-1a or +SGLT2i combinations.
5/ The game of the week "Bad Bones"
For this month, I'm talking about "Bad Bones"! In this game, you play as a brave hero who must defend the village (below) against skeletal attacks. The skeletons move at each turn towards the famous village and you will have to counter them with the help of your hero, or by using defenses such as walls (to make them bounce and direct them away from the village), or catapults (to send them on the other players). The game is simple, fairly fast, and provides a good dose of stress with the number of skeletons growing over the turns!
@Dr_Agibus
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