Hello everyone! Quite a bunch of interesting articles this week and I did not manage to stop myself... Have a good reading!
1/ Pharmacovigilance
We already talked about the superior addiction and mortality risks of tramadol. A new study, that was presented at the European congress of rheumatology, has similar findings. Indeed, patients treated with tramadol had a higher risk of death compared to NSAIDs users, and the use of tramadol was also associated to an increase in cardiovascular events, venous thrombotic events and hip fracture.
2/ COVID-19
The Infectious Diseases Society of America has developed guidelines about the diagnosis of COVID. What is emphasized is that RT-PCR on a nasopharyngeal swab is the reference and can be repeated in case of high suspicion for a symptomatic patient. For an asymptomatic patient, it is recommended to do a test in case of exposure or hospitalization for another reason if the prevalence is high in the community or if the patient is immunodeficient or before surgery and other acts with high risk of aerosolisation.
The European CDC has published guidelines regarding the use of air conditioning and fans in the context of COVID-19. A bad use of ventilation in tiny interior spaces is associated to an increase in the risk of transmission of respiratory diseases. Some studies emit the hypothesis that ventilation may increase the risk of COVID transmission but it could also be because these studies are done indoors. So, air conditioning can spread the droplets over longer distances indoors but air conditioning can also participate to air circulation which decreases the risk of transmission. However, fans that only spread particles without renewing indoor air with outdoor air are to be avoided.
The Québec Society of Public Health has emitted advice on COVID+ patients who are deemed cured but who get a new positive PCR test. If the first positive test dates from less than 3 months ago, the patient is considered as cured with a persistence of the viral RNA and another cause for the current symptoms is to be sought. If the first positive test dates from more than 3 months and the patient is symptomatic, the test must be repeated, the number of "thermal cycles" must be counted and another cause should be looked for: in case of the absence of any other cause, the patient can be viewed as reinfected. Overall, the authors think that the immunity is protective for only 3 months after the iinital infection.
3/ Cardiovascular medicine
The BMJ offers an article regarding the management of peripheral oedema when caused by heart failure. After excluding another cause (renal failure, DVT, cellulitis, venous insufficiency, lymphoedema and medication adverse effects), the cause of the cardiac decompensation must be sought (non-adherence, insufficient treatment, acute kidney injury, BP surge, (N)STEMI, cardiac arrythmia, infection or iatrogeny such as NSAIDs). Then, one must look for other signs such as jugular venous pressure: it is measured with the patient inclined at 30-45° and the highest reflux point should not be 4 cm (= 1.57 inches) above the sternal angle of Louis (see picture). BNP dosing is only useful to establish the diagnosis of cardiac oedema, it is not useful for patients with known heart failure (see here and there).
For treatment, it is of course diuretics, especially loop diuretics. They must be started at small doses or by doubling the previous dose for patients already taking them. The efficacy is monitored 24 hours later with an increase in diuresis and a weight loss. If the diuresis does not increase, the diuretic dose can be increased (because of a threshold effect discussed here). It is advised not to go over 80 to 120 mg of furosemide daily. 40 mg of furosemide are equivalent of 1 mg of bumetanide. An increase of creatinine can be accepted up to 25% (or a GFR decrease up to 20%). After the acute episode, the diuretics have to be kept until the next consultation with the cardiologist except if the cause of the failure has been resolved.
4/ Screening
The USPSTF discusses the screening of illicit drugs use among teenagers and young adults. Its prevalence is estimated at 8% for use during the past month and 50% by the time they graduated from high school. So it is something that has been screened for a while, but it seems there is a lack of studies to evaluate the benefit-risk balance of this screening. More evidence on this topic shall be published!
This article from Annals of Family Medicine studied the applicability of community-based lung cancer screening since the American Academy of Family Physicians does not support it. Over 6,000 screenings that were performed, 15% of patients had a supplementary investigation, 6.6% an invasive procedure and 1.5% had a cancer diagnosed. There were 0.6% of adverse effects among all the patients (respectively 10% of those who had had an invasive procedure and 2% of mortality among those who had surgery performed on them). These figures are coherent with known data but overdiagnosis was not studied here.
Here is an article about a saliva test looking for high-risk HPV subtypes in order to diagnose oropharyngeal cancer. But is it relevant for larger screening procedures?
5/ Pneumology
A new study, ETHOS, compared triple therapy (ICS, LAMA and LABA) versus double therapy (LAMA+LABA) in COPD patients with CAT-score over 10 and with 2 episodes of exacerbation over the past year (only one was required if FEV1 < 50%) despite a double inhaled therapy. The authors found out that patients with triple therapy had a lower number of moderate or severe exacerbations by 24% per year for high steroid doses. It is even seen that patients with triple therapy had a lower mortality than those with double inhaled therapy (NNT=100)! The tritherapy is indeed superior for these patients and the increased risk of pneumonia (NNH=59) is not enough to decrease the mortality benefit. However, we know that ICS benefit is a staple for asthma, yet despite patients with asthma were excluded from the study, 30% patients from the study were positive for reversibility on spirometry after bronchodilatators. Morevover, the patients with an uncontrolled CAT and exacerbation episodes despite a bitherapy are classified as GOLD D stage and so have an indication for a triple therapy. Overall, this study only shows that current guidelines are adapted for patients not controlled with a double therapy (and it is one of the few times that a benefit on mortality is found out) and is absolutely not in favour of a triple therapy for patients of lower severity ; for the latter, the pneumonia risk weighs the balance in favour of the risks rather than benefits.
6/ Nephrology
A long time ago, a study was supposing that allopurinol could slow down the progress of CKD, but it was not that clear. This randomized controlled trial from the NEJM, including patients with an average GFR of 31 mL/min has not found any benefit from allopurinol on the decline of the renal function after 2 years.
7/ The qualitative study by @DrePetronille
About the choice of medical careers, this qualitative study of the week interrogated Canadian and British students during focus groups about their perception of the intellectual stimulation of general practice, in order to understand why GP positions are less chosen than other medical specialties. In favour of the choice of GP, the participants discussed the intellectual stimulation obtained thanks to the diversity of the consultations and patients, the high skill level that is required to deal with those and the incertitude about the activities of the day. They also evoked the possible career arrangements over time. On the contrary, some participants described GP as a speciality in which one does always the same thing, with the necessity to refer patients to specialists. This negative image of GP might have been favored by the image that medicine teachers project about this job across med school, the one of a speciality 'by default'. The interrogated students did not associate research with general practice, as research seemed to be more dedicated to specialists. GP teachers were seen as less visible than teachers from the other specialties by the students, who therefore do not have any role model. This study brings some leads to understand the perception of intellectual stimulation for the choice of speciality but should be completed with other studies regarding other aspects of the job: healthcare organization, administrative management.
Have a good week!
@Dr_Agibus (free translation by @carttom)
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