1/ COVID-19
Let's begin with the French Medicine Agency and a pharmacovigilance alert about the use of drugs such as chloroquine/hydroxychloroquine in the community. Indeed, there are already reports of sudden death and heart problems being reported. So if you consider the underreporting bias... In short, drugs with no proven benefit are not to be used without monitoring or clinical studies.
The French Health Authority has issued a guideline on the use of chest CTscan for COVID. They must be carried out in a hospital structure for patients with a respiratory disorder and an indication for hospitalisation. It is also not recommended to do a chest X-ray or cardiac ultrasound to screen for COVID.
This guidelines talk about maintaining physical activity during periods of confinement. To summarize, it is necessary for children under 6 years of age to do 15 minutes of physical activity every hour (i.e. 3 hours a day), then 1 hour a day for 6-17 year olds and 30 minutes a day for adults.
At the therapeutic level, we are still waiting for good quality studies. The NEJM proposes an article finding that giving compassionate remediation to patients with severe inpatient COVID could improve clinical outcomes. It is incredible that such a study could be published in a "big" journal... But since the publishers know they're going to be cited, they're taking...
A manuscript under revision at the NEJM was leaked and talks about a quasi-randomized study including patients hospitalized for COVID (in fact, one hospital was giving chloroquine following the rapid diagnosis of COVID at 24 hours of hospitalization, and another gave it after 5-7 days because their tests were slower). In short, there would be a significant worsening of respiratory conditions and a non-significant increase (because few patients) in mortality in the chloroquine group. Let us wait for the publication and randomized trials on the subject.
2/ Infectiology
The French immunization schedule 2020 has has been published, with an important modification: the generalization of HPV vaccination in boys (as in Belgium, in the United States, in the United Kingdom...) between 11 and 14 years old by gardasil 9 (gardasil will be withdrawn from the market at the end of 2020). This recommendation will only apply from 2021 (as the vaccine is lacking worldwide). Concerning BCG vaccine, it is noted that the Parisian area is always a risk factor that should motivate vaccination (even if it is specified afterwards that in a context of supply tension, it must be associated to another risk factor, in accordance with the opinion of the French council of public Health). Finally, concerning MMR, any health professional, born before 1980, not vaccinated and without a history of measles or rubella, should receive 1 dose of vaccine.
3/ Pneumology
The GINA has updated asthma recommendations for the year 2020. The guidelines for COVID are simple: continue background treatments and give oral corticosteroids if needed because the risk of mortality from an untreated asthma attack is higher than with COVID. On follow-up, the authors confirm the need (without real proof) for the combination of inhaled corticosteroids + formoterol as a first-line treatment (see here), but this only concerns children over 12 years and adults. Before the age of 12 years, the classic regimen with b2 stimulant (SABA) on request is kept, with SMART therapy being only one possible alternative. Note the maximum treatments per day:
- budesonide-formoterol Turbuhaler 200/6 (symbicort): 12 puffs per day max.
- beclometasone-formoterol 100/6 (innovair): max. 6 puffs per day.
Finally, what to do first? The following diagram helps to decide:
- budesonide-formoterol Turbuhaler 200/6 (symbicort): 12 puffs per day max.
- beclometasone-formoterol 100/6 (innovair): max. 6 puffs per day.
Finally, what to do first? The following diagram helps to decide:
4/ Gynecology
The USPSTF has published guidelines against routine screening for asymptomatic bacterial vaginosis during pregnancy in women without a high risk of preterm birth. This is primarily related to the fact that treatments have not demonstrated a reduction in prematurity or low birth weight although these infections are risk factors. I don't think it's very clear to me what they're looking for in terms of vaginosis, particularly if they include the research on carrying streptococcus agalactiae recommended in France, but I get the impression that they also don't think it's useful based on the bibliography they've done.
5/ Gastro-enterology
The JAMA examined the mortality of patients with celiac disease in a Swedish cohort study. The authors found that these patients had a slightly higher risk of mortality than the general population (absolute difference of 1.2 per 1000 person.year), particularly related to cardiovascular, cancer and respiratory causes. It should be noted that the patients were more frequently affected by other autoimmune pathologies as well (type 1 diabetes, thyroiditis, IBD, rheumatoid arthritis).
6/ Rhumatology
Finally, an NEJM study compared corticosteroid infiltrations (3/year max) versus rehabilitation in knee osteoarthritis in primary care. The authors found a superior improvement of WOMAC at 1 year in patients treated with physiotherapy. It is a pity that there was no corticoid + physiotherapy group to see if corticoids could bring an added value. This study follows the one saying that surgery doesn't do better than physiotherapy, the only treatments that have really demonstrated efficacy being physiotherapy and physical activity.
7/ The qualitative study of the week by @DrePetronille
This article looks at midwives' assessment of the mental health of pregnant women through a thematic focus group analysis of 9 midwives in the south of England.
- The first consultation may be the opportunity to ask the questions of the Whooley test already mentioned there, if time allows, after management of 1st trimester symptoms... in a context of time-limited consultation with a heavy workload and difficulties in care coordination.
- One explanation put forward for the insufficient screening in consultation was the great social and cultural variability present in Great Britain, which could explain difficulties in communication between midwives and patients, with a lack of understanding of the questions, or a different representation of depression. Finally, culturally, some patients come with their partner, which could be a real obstacle to screening.
- Mutual trust was an important element of the interviews in terms of whether or not to talk about mental health issues during pregnancy. Patients are afraid to talk about it and to be stigmatized; conversely, Midwives may think that women are not telling the whole truth.
- The first consultation may be the opportunity to ask the questions of the Whooley test already mentioned there, if time allows, after management of 1st trimester symptoms... in a context of time-limited consultation with a heavy workload and difficulties in care coordination.
- One explanation put forward for the insufficient screening in consultation was the great social and cultural variability present in Great Britain, which could explain difficulties in communication between midwives and patients, with a lack of understanding of the questions, or a different representation of depression. Finally, culturally, some patients come with their partner, which could be a real obstacle to screening.
- Mutual trust was an important element of the interviews in terms of whether or not to talk about mental health issues during pregnancy. Patients are afraid to talk about it and to be stigmatized; conversely, Midwives may think that women are not telling the whole truth.
Thank you and see you next week!
No comments:
Post a Comment