Hello!
Dragi Weekly is written by @Dr_Agibus, MD, who works and lives in France but targets an international audience (free translation by @carttom). We may only be interested by our analyses on international scientific literature and not by the content aimed at French doctors (such as French guidelines, specific medication alerts, French articles). But we still want you to have access to this content if you want to. So, to improve the clarity of blog posts between France-specific parts, links in French and English parts and links, here is a colour code:
- International content remains written in black
- Links in English remain written in blue
- France-specific content will be written in green from now on
- Links in French will be displayed in red.
Dragi Weekly is written by @Dr_Agibus, MD, who works and lives in France but targets an international audience (free translation by @carttom). We may only be interested by our analyses on international scientific literature and not by the content aimed at French doctors (such as French guidelines, specific medication alerts, French articles). But we still want you to have access to this content if you want to. So, to improve the clarity of blog posts between France-specific parts, links in French and English parts and links, here is a colour code:
- International content remains written in black
- Links in English remain written in blue
- France-specific content will be written in green from now on
- Links in French will be displayed in red.
Have a good reading!
1/ COVID-19
Articles about COVID are getting rarer. Here is a retrospective Chinese study of 2,800 hospitalized patients for COVID infection, which finds out that patients with HBP have a higher death risk than patients without. Among HBP patients, those treated by ACEi or ARB did not have an increased mortality risk compared to those treated with other medications. But the HBP patients without any treatment had an increased risk of death.
In concordance to the previous study, the European Medicines Agency (EMA) states as well that it is better to continue ACEi and ARB medications for COVID patients, considering the absence of evidence of more severe forms of COVID among patients taking those drugs in the most recent studies.
A BMJ study had a look at protective personal gear (PPE). 400 physicians and nurses were equipped with masks, gloves, protection glasses, facial masks and gowns to do their daily work, including invasive procedures on COVID+ patients during 2 weeks of lockdown. At the end of the 2 weeks, no health professional had any symptom or a positive test (either nasopharyngeal PCR swab or serology). I think that an additional test the week after could have been useful but the authors say that they wanted the scientific community to profit from these results as soon as possible. By the way, the serology tests that were used in this study were quite reliable with a sensibility and a specificity of 88% and 99% for IgM and 98% and 98% for IgG, respectively.
2/ Rheumatology
Few months after the US guidelines, the French guidelines for gout have been published by the French Society of Rheumatology, thanks to a Delphi method including 9 rheumatologists, 3 GPs, 1 nephrologist, 1 cardiologist and 1 patient. 2/3 of the panel being rheumatologists, not sure how the other voices could be heard. Anyway, there are general recommendations: informing the patient that gout is linked to uric acid crystals and that one needs to change its habits to decrease uricemia. The first recommendation is to treat all gout patients with a preventive treatment... This a grade D guideline, evidence level 4 = expert consensus ; that is not found in other guidelines (only if >2 attacks/year or tophus or chronic kidney disease). 2nd recommendation is to decrease uricemia under 50 µmol/L (= 300 mg/L) in the best-case scenario, under 60 µmol/L (= 360 mg/L) otherwise. 3rd recommendation is to use allopurinol as first-line preventive treatment (except if GFR<30 mL/min, in this case febuxostat is recommended). 4th recommendation is to prescribe colchine at a 0.5-1 mg daily dose for 6 months to decrease the risks of gout attacks induced by introducing a long-term treatment. 5th recommendation is to screen for renal, cardiovascular and metabolic comorbidities (expert advice as well). So these guidelines will increase the prescription of hypouricemic therapies without enough evidence about their usefulness and do not talk about the true controversy in the gout treatment: colchicine or NSAIDs as the first-line drug for gout attacks.
3/ Infective diseases
Translator's comment: the following paragraph only applies to countries where rheumatic fever is no longer a concern. Please follow your local guidelines otherwise (for New Zealand see here for example).
The Cochrane Library has published a review regarding efficacy and safety of rapid tests for strep A sore throats (we already talked about it here). I remind you the 3 main different approaches: 1/ French: rapid test before antibiotherapy ; 2/British: antibiotherapy according to McIsaac score; 3/Nordic countries: no antibiotherapy except for abscess or phlegmon. So this review finds out that using a rapid test decreases by 25% the use of antibiotics compared to clinical exam only, but does not allow to decrease their dispensation — that means people do not directly buy their antibiotics after prescription (not the case in France!). It is possible that there are less infective complications for patients who had a rapid test, but the evidence level remains uncertain as the statistical result is not significant. The British and Nordic countries approach seems to be the most coherent with evidence showing that the efficacy of antibiotics is only in reducing symptoms duration by 16 hours.
Let us talk about bedbugs thanks to this NEJM article, written by authors from the French Academic Hospital Institute 'Méditerranée Infection'. The diagnosis is evoked thanks to repeated bites and papular or vesicular lesions on uncovered areas, usually around 3 to 5 lesions (breakfast, lunch and dinner for these bugs too !), sometimes described as 'packed' or 'linear' or 'zigzag'. However the lesions are not specific of bedbugs (shoot!). Their traces can be found on mattresses, tapestries, electric cables, thanks to their faeces which look like some piles of black dots and to their exoskeletons. Patients experience a heavy psychological burden because of the bites and the associated sleeping disorders. Management of bedbugs consists in using the vacuum cleaner to aspirate the bedbugs (and then throwing the suction bag away after closing it), then wash all clothes and linen at 60 °C (= 140 °F), but only the clothes with marks of infestation, not ALL the clothes. Commercial-grade insecticides should not be used because the parasites are resistant to them. French guidelines seem to exist here on this topic.
4/ Neurology
We already talked about the increase of cardiovascular risk caused by migraines. This JAMA article discusses it through a 20-year long cohort study of women. Among these women, with an average age of 55, 8% of women had migraines without aura and 5% with. The risk of cardiovascular events related to migraines with aura was superior to the risk caused by obesity, on par with the one caused by HBP, cardiovascular hereditary predisposition and dyslipidaemia, and inferior to the one caused by diabetes and active smoking.
5/ Urology
An article discusses varicoceles, which are present among 20% of all men. By increasing the testis temperature, they can alter the spermatogenesis, lower testosterone production and lead to infertility. Grade 1 and 2 varicoceles are usually asymptomatic. The diagnosis is mainly clinical and the ultrasound scan is rather to be used for symptomatic patients (after ruling out an infection if the main symptom is pain). The treatment (surgical or embolization) is only necessary in case of discomfort or infertility, with a success rate of around 80%.
6/ Diabetology
International guidelines (with the help of Abbott pharmaceutical company) were published to interpret continuous glucose monitoring data (CGM). The sensors have improved and the scientific societies are now in favour of a follow-up with CGM rather than with self-monitored blood glucose levels. 3 indicators are to be used:
- TIR: time in range: 3.9 to 10 mmol/L (= 70 to 180 mg/dL)
- TBR: time below range (= hypoglycemia)
- TAR: time above range (= hyperglycemia).
The most common target is for the patient to be 70% of total time in the target interval and a maximum of 4% of total time in hypoglycemia.
In the figure below, you can find these targets and their equivalence with HbA1c (but this remains quite approximative: being 70% in the normal range, but with 20% below and 10% over is not the same as being 25% over and 5% below). So, as you may have guessed, these targets are based on expert's advice and have not been evaluated on clinical criteria. I think that a maximum of 4% of total time in hypoglycemia is relevant but if we rely on the displayed correlation between HbA1c and TIR, a target of 60% TIR would me more relevant for a level of HbA1c at 7.5% (= 58 mmol/mol) than a 70% minimal target. Once again, having 70% of good values and effectively less than 4% hypoglycemia should be a "good target" but clinical studies must be performed to confirm it.
- TBR: time below range (= hypoglycemia)
- TAR: time above range (= hyperglycemia).
The most common target is for the patient to be 70% of total time in the target interval and a maximum of 4% of total time in hypoglycemia.
In the figure below, you can find these targets and their equivalence with HbA1c (but this remains quite approximative: being 70% in the normal range, but with 20% below and 10% over is not the same as being 25% over and 5% below). So, as you may have guessed, these targets are based on expert's advice and have not been evaluated on clinical criteria. I think that a maximum of 4% of total time in hypoglycemia is relevant but if we rely on the displayed correlation between HbA1c and TIR, a target of 60% TIR would me more relevant for a level of HbA1c at 7.5% (= 58 mmol/mol) than a 70% minimal target. Once again, having 70% of good values and effectively less than 4% hypoglycemia should be a "good target" but clinical studies must be performed to confirm it.
The DIRECT study showed that strict lifestyle changes could allow to obtain a remission of diabetes with a NNT figure between 2 and 3. This study has been replicated in Qatar and published in Lancet Diab&Endoc with the following protocol for 140 patients with a type 2 diabetes for less than 3 years: 12 weeks with a 800 Kcal (= 3347 kJ) daily diet then 12 weeks of diet rehabilitation, 10 000 steps to be done every day and 150 minutes of physical activity every week. The remission of diabetes was defined as an HbA1c < 48 mmol/mol (= 6.5%) but the primary outcome was the weight loss after 1 year. Weight loss was significantly more important in the intervention group (-12 kg vs -4 kg), but only 6.6 mmol/mol (= 0.6%) of difference on HbA1c (but significant difference in favour of the intervention group) and the remission rate of diabetes was 61% vs 12% (NNT=2).
Thanks for reading me this week and see you next week!
@Dr_Agibus (free translation by @carttom)
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