Short on time but hungry for knowledge? Curbsiders’ Journal Club gives you the speedy article analysis you crave. We provide brief summaries of recent research and news items in the field of internal medicine, so you can save time and stay on top of the literature. On this episode, we were joined by Kashlak Memorial’s very own Chair of Medicine, Dr. Robert Centor AKA @medrants on Twitter or “Uncle Bob” to the Curbsider Crew. This month’s topics include: estimating atherosclerotic cardiovascular disease risk, whether CT pulmonary angiography (CTPA) effectively rules out pulmonary embolism, discharging low risk patients with pulmonary embolism from the ED, metformin and risk of acidosis in patients with CKD, treating opioid use disorder after a nonfatal overdose, Canagliflozin and renal protection in type 2 diabetes, screening for diabetes among patients below age 40, and the association between nose-picking and staphylococcus. ACP members can claim free CME-MOC at acponline.com/curbsiders (goes live 0900 EST on podcast release date).
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The 2013 ASCVD score “overestimated 10-year risk by roughly 20% overall, with even higher overestimates among black adults. Nearly 12 million adults who have a 10-year CV risk estimate of 7.5% or greater using PCEs — thus qualifying them for statin therapy — would no longer be considered high risk under newer calculations.”
Strengths?
Complex statistical techniques and validation methods.
Weaknesses?
Validation needs to be done on the suggested revised PCEs before clinical practice can be adjusted.
Bottom line?
This is practice changing and the PCEs will need to have continuous calibration in the future as the populations grows and changes. May need to consider other ways of risk assessment (eg. MESA risk score) until validation is done with updated equations.
See also:
This NEJM Journal Watch post summarizing the article.
What’s the clinical question? Who is the patient population?
Does negative CT pulmonary angiography (CTPA) effectively rule out pulmonary embolism in all risk groups?
Strengths?
This was a non-industry funded meta-analysis of 22 prospective studies that examined the negative predictive value (NPV) of CTPA based on the pretest probability of different pooled subgroups <20%, 20-29%, 30-39%, >40%. It included 11,872 participants of whom 7,863 patients had a negative CTPA. No publication bias was detected for the included studies.
Weaknesses?
It used prevalence of pulmonary embolism in each subgroup as a surrogate marker for pretest probability for each subgroup.
Bottom line?
Overall, venous thromboembolism (VTE) occurred in 2.4% of patients with a negative CTPA. VTE occurred in 8.1% of patients with a pretest probability >40% (equivalent of Wells score above 6). We should consider additional testing to rule out VTE in patients at the highest risk. The authors suggest lower extremity doppler US, or CT venography (of the lower extremities) as possible additional tests since most of the VTE events were accounted for by DVT.
See also:
NEJM Journal Watch post discussing this article.
What’s the clinical question? Who is the patient population?
Can low risk patients with pulmonary embolism (defined as a negative Hestia criteria) be safely discharged from the ED on oral rivaroxaban?
Strengths?
This was a pragmatic study that utilized intention-to-treat analysis. The treating clinician was able to choose any FDA approved therapy for PE in the standard of care arm.
Weaknesses?
This industry funded study failed to meet its predefined enrollment of 150 patients per arm.
Bottom line?
Patients with low risk pulmonary embolism as determined by Hestia score of zero can be safely discharged from the emergency department on rivaroxaban. This underpowered study, though underpowered, found no increased risk of bleeding, recurrent venous thromboembolism, or mortality at 90 days for patients discharged from the ED on rivaroxaban. Not surprisingly, early discharge resulted in a reduced length of stay by more than 28 hours and a median cost reduction of $2,738 ($1,496 versus $4,234) at 30 days after randomization.
See also:
NEJM Journal Watch discussion of this study.
What’s the clinical question? Who is the patient population?
Looking at the risk of acidosis in patients with CKD. Two large retrospective cohorts of patients with DM2, there was no significant association of incident acidosis with eGFR >30.
Strengths?
Large cohort study over clinically appropriate population
Weaknesses?
Observational study, wide time frame between medication initiation and baseline eGFR measurement.
Bottom line?
Initiation of metformin in eGFR 30-44 may be reasonable as first line therapy. We recommend exercising caution in those susceptible to dehydration or at risk for continued worsening renal function.
What’s the clinical question? Who is the patient population?
How is medication for opioid use disorder (MOUD) associated with mortality after nonfatal overdose? Retrospective cohort study using several datasets in Massachusetts. Three type of MOUD where examined including methadone maintenance treatment (MMT), buprenorphine and naltrexone.
Strengths?
This was a large prospective cohort study (17,568 opioid overdose survivors over 12 months after overdose)
Weaknesses?
Limited number of patients who receive naltrexone
Bottom line?
MMT and buprenorphine were associated with decreased all-cause mortality with adjusted hazard ratios (AHR) of 0.47, and 0.63 respectively. Naltrexone did not have a mortality benefit. This study also showed a gross underuse of MOUD and an alarming rate of prescriptions for opioids and benzodiazepines even in the 12 months after overdose. Evidence that expansion of MOUD to more providers may impact population health as we face the trend of increasing heroin overdoses in the US.
See also:
Sordo L et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ. 2017. PMID: 28446428
What’s the clinical question? Who is the patient population?
CANVAS Program shows the canagliflozin reduced rates of major adverse cardiac events (MACE) and suggested renal benefit in DM2 patients who were at high risk for cardiovascular disease (CVD). Two double blind, placebo control RCTs were included. Hgba1c values ranged from 7-10.5%. CANVAS had 3 arms – canaglifozin 100 mg or 300 mg, and placebo. CANVAS-R had 2 arms – canagliflozin 100 mg daily with up-titration to 300 mg or matching placebo.
Strengths?
667 centres in 30 countries.
Weaknesses?
Length of follow-up not long enough for hard renal endpoints.
Bottom line? Canagliflozin associated with renal protection (slower eGFR decline, microalbumin lower) in pt’s with DM2. May need longer dedicated studies to really make these claims.
See also:
Lancet commentary: “Keep Calm and Carry on.”
What’s the clinical question? Who is the patient population?
Recommendation that clinicians screen earlier than 40 years of age for diabetes in those with other risk factors listed in the USPSTF guidelines. The limited criteria (40-70 and overweight/obese) vs Expanded Criteria (family history of DM, history of gestational DM, history of PCOS, non-white race) were studied via cross-sectional analysis.
Strengths?
NHANES is a robust database.
Weaknesses?
Due to nature of the NHANES data, confirmatory diagnosis of dysglycemia (prediabetes or diabetes) with repeat testing could not be done (overestimated prevalence?)
Bottom line?
This study provides good evidence that use of the expanded USPSTF criteria would improve the sensitivity for detecting dysglycemia and might help reduce disparate outcomes for disadvantaged groups.
What’s the clinical question? Who is the patient population?
Does picking your nose increase your risk for Staphylococcus aureus carriage? This study investigates ENT patients and “Healthy Volunteers” who either identify as nose pickers and correlates this with exam findings consistent with persistent nose picking.
Strengths?
Let’s face it, there aren’t very many articles that cover nose picking and S. aureus, so it’s breaking new ground (or mucosa) so to speak.
Weaknesses?
Requires the participants to be honest. According to a recent non-scientific survey, everyone picks their nose. It is very difficult to find the article for review. (Sorry!)
Bottom line?
Don’t pick your nose!
Disclosures: Dr Centor reports no relevant financial disclosures. Dr Chiu reports no relevant financial disclosures. Sarah Roberts reports no relevant financial disclosures. Dr Watto reports no relevant financial disclosures. Dr Williams reports no relevant financial disclosures. Dr Brigham reports no relevant financial disclosures.
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