Clinical Pearl with Links and Articles

Among nulliparous participants who were undergoing augmentation of labor, a high-dose oxytocin regimen, compared with standard dosing, did not affect the cesarean birth risk but significantly reduced labor duration and clinical chorioamnionitis frequency without adverse effects on perinatal outcomes. 

Oxy_Regimen.pdf

This systematic review suggests that future resident wellness initiatives should focus on grounding interventions in educational theory, forging consensus on wellness instruments with validity evidence, and examining the impact of initiatives on patient outcomes. A logic model can provide a framework for designing and implementing effective wellness interventions.

 Wellnes Interventions- SR.pdf

Ivermectin had no significant effect on preventing hospitalization of patients with COVID-19. Patients who received ivermectin required invasive MVS earlier in their treatment. No significant differences were observed in any of the other secondary outcomes.

https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-021-06348-5 

Despite more diagnoses of gestational diabetes with the one-step approach (2 hour GTT) than with the two-step approach (1 hour GTT and then, if abnormal, 3 hour GTT) , there were no significant between-group differences in the risks of the primary outcomes relating to perinatal and maternal complications.

Once-weekly treatment with insulin icodec had glucose-lowering efficacy and a safety profile similar to those of once-daily insulin glargine U100 in patients with type 2 diabetes. 

 Once-Weekly Insulin for T2D.pdf

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for vitamin D deficiency in asymptomatic adults. (I statement) 

vitamin-d-deficiency-screening-final-recommendation.pdf

Initial cryoablation for patients with paroxysmal AF is superior to initial antiarrhythmic drug therapy.

https://www.aafp.org/afp/2021/0700/p97.html 

Catheter ablation for a-fib - SR.pdf

All 3 treatment strategies were effective, but based on these findings, withdrawal therapy combined with preventive medication from the start of withdrawal is recommended as treatment for MOH.

https://jamanetwork.com/journals/jamaneurology/fullarticle/2766518 

Empagliflozin reduced the combined risk of cardiovascular death or hospitalization

for heart failure in patients with heart failure and a preserved ejection

fraction, regardless of the presence or absence of diabetes.

Intensive BP-lowering treatment decreases risk for OH. Orthostatic hypotension, before or in the setting of more intensive BP treatment, should not be viewed as a reason to avoid or de-escalate treatment for hypertension

In an open-label trial involving adults with mild asthma, budesonide–formoterol used as needed was superior to albuterol used as needed for the prevention of asthma exacerbations.

Controlled Trial of Budesonide–Formoterol as Needed for Mild Asthma.pdf

In older adults, aspirin treatment had an adverse effect on later stages of cancer evolution. These findings suggest that in older persons, aspirin may accelerate the progression of cancer and, thus, suggest caution with its use in this age group. 

NCI 2021 Effect of Aspirin on Cancer Incidence and Mortality in Older Adults.pdf

In this study, PEN-FAST was found to be a simple rule that accurately identified low-risk penicillin allergies that do not require formal allergy testing. The results suggest that a PEN-FAST score of less than 3, associated with a high negative predictive value, could be used by clinicians and antimicrobial stewardship programs to identify low-risk penicillin allergies at the point of care. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7076536/

In this systematic review, non-drug interventions were found to be more efficacious than drug

interventions for reducing symptoms of depression in people with dementia without a major depressive

disorder.

The reduction in stage III or IV disease incidence in the screening group was not sufficient to translate into lives saved, illustrating the importance of specifying cancer mortality as the primary outcome in screening trials. Given that screening did not significantly reduce ovarian and tubal cancer deaths, general population screening cannot be recommended. 

Ovarian cancer screening.pdf

In conclusion, the results of our meta-analysis demonstrated that colchicine treatment may reduce the risk of future cardiovascular events in CAD patients. 

Colchicine for CAD secondary prevention- SR.pdf

The USPSTF recommends the use of low-dose aspirin (81 mg/d) as preventive medication for preeclampsia after 12 weeks of gestation in persons who are at high risk for preeclampsia. (B recommendation) 

Aspirin for preeclampsia prevention-USPSTF.pdf

Among adults with methamphetamine use disorder, the response over a period of 12 weeks among participants who received extended-release injectable naltrexone plus oral extended-release bupropion was low but was higher than that among participants who received placebo. 

Bupropion and Naltrexone in Methamphetamine Use Disorder.pdf

In rotator cuff disorder, a progressive exercise program was not superior to a single session of best practice physiotherapy advice, and corticosteroid injection did not differ from no corticosteroid for pain or function over 12 months. But pain relief was significantly better at 8 weeks with corticosteroid injection (but not in later follow-up). So one session of teaching exercises (if you have time) and giving a handout might do as well as referring to PT and/or steroid injection.

Rotator cuff treatment.pdf

Expansion of direct-to-patient telemedicine abortion service in the US

Clinical and service delivery implications of omitting US before medication abortion

This direct-to-patient telemedicine service was safe, effective, and acceptable, and supports the claim that there is no medical reason for mifepristone to be dispensed in clinics as required by the Food and Drug Administration. In some cases, participants did not need to visit any facilities to obtain the service, which was critical to protecting patient safety during the COVID-19 pandemic. 

https://www.contraceptionjournal.org/article/S0010-7824(21)00091-3/fulltext

Compared to patients who had pre-abortion ultrasound, patients who had no-test MA via telemedicine were more likely to have abortions that were not complete with pills alone and/or unplanned clinical encounters. However, both no-test and test-MA patients had similar and very low rates of ongoing pregnancy and hospitalization or blood transfusion.

https://pubmed-ncbi-nlm-nih-gov.libproxy.unm.edu/34329607/

There is moderate-quality evidence that coenzyme Q10 probably reduces all-cause mortality and hospitalization for heart failure.

Coenzyme Q and CHF- Cochrane (2).pdf

Early treatment with molnupiravir reduced the risk of hospitalization or death in

at-risk, unvaccinated adults with Covid-19.

https://www.nejm.org/doi/10.1056/NEJMoa2116044?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed 

In adults with overweight and obesity, phentermine–topiramate and GLP-1 receptor agonists proved the best drugs in reducing weight; of the GLP-1 agonists, semaglutide might be the most effective. 

A strategy with early treatment of a fixed-dose quadruple quarter-dose combination achieved and maintained greater blood pressure lowering compared with the common strategy of starting monotherapy. This trial demonstrated the efficacy, tolerability, and simplicity of a quadpill-based strategy. 

QUARTET trial for HTN.pdf

Among patients prescribed stable, long-term, higher-dose opioid therapy, tapering events were significantly associated with increased risk of overdose and mental health crisis. Although these findings raise questions about potential harms of tapering, interpretation is limited by the observational study design 

ACP Journal Club Review - In long-term, higher-dose opioid use, dose tapering was linked to over.pdf

Article - Association of Dose Tapering With Overdose or Mental Health Crisis.pdf

Long COVID was characterized by symptoms of fatigue, headache, dyspnea and anosmia and was more likely with increasing age and body mass index and female sex. Experiencing more than five symptoms during the first week of illness was associated with long COVID.

 long covid Nature Oct2021.pdf.      long COVID study.docx

Considerable uncertainty exists about the clinical efficacy and safety of muscle relaxants. Very

low and low certainty evidence shows that nonbenzodiazepine antispasmodics might provide

small but not clinically important reductions in pain intensity at or before two weeks and might increase the risk of an adverse event in acute low back pain, respectively. Large, high quality, placebo controlled trials are urgently needed to resolve uncertainty.

Consider folate at a dose of <5 mg/day or methylfolate at a dose of 15 mg/day as an adjunct to SSRI therapy in patients with MDD. This recommendation is based on low-quality evidence as assessed by GRADE.

Folate for Depression - SR .pdf  

The first was a systematic review comparing increasing the dose of an antidepressant vs continuation of the same standard dose. The conclusion is that there is evidence for lack of efficacy or further improvement from increasing the dose.

The second article is a systematic review comparing efficacy of a combination of antidepressants vs monotherapy, showing that combination therapy, especially as first-line treatment, is significantly more effective than monotherapy. The effective combinations were a SSRI, SSNRI or TCA combined with trazodone or mirtazapine.

Combining Antidepressants vs Antidepressant Monotherapy.pdf

This systematic review and meta-analysis found that using LNCSBs as an intended substitute for SSBs was associated with small improvements in body weight and cardiometabolic risk factors without evidence of harm and had a similar direction of benefit as water substitution. The evidence supports the use of LNCSBs as an alternative replacement strategy for SSBs over the moderate term in adults with overweight or obesity who are at risk for or have diabetes.

 Alternative Sweeteners and Body Weight.pdf

There is high-certainty evidence that airline passengers similar to those in this review can expect a substantial reduction in the incidence of symptomless DVT and low-certainty evidence that leg oedema is reduced if they wear compression stockings. There is moderate-certainty evidence that superficial vein thrombosis may be reduced if passengers wear compression stockings.

Clarke_et_al-2021-Cochrane_Database_of_Systematic_Reviews.pdf

AAFP Bryce et al.pdf  

COVID-19 vaccination during pregnancy, compared with vaccination after pregnancy and with no vaccination, was not significantly associated with increased risk of adverse peripartum outcomes.  

COVID Vaccination in Pregnancy.pdf

Midodrine can reduce the recurrence of syncope in healthy, younger patients with a high syncope burden. 

https://pubmed.ncbi.nlm.nih.gov/34339231/

In rotator cuff disorder, a progressive exercise program was not superior to a single session of best practice physiotherapy advice, and corticosteroid injection did not differ from no corticosteroid for pain or function over 12 months.

 GRASP Trial - PT vs Home Exercis w or wo Steroid injection for rotator cuff disorders.pdf

ACP Review of Rotator Cuff PT w wo corticosteroid injection.pdf

Treatment of symptomatic Covid-19 with nirmatrelvir plus ritonavir resulted in a risk of progression to severe Covid-19 that was 89% lower than the risk with placebo, without evident safety concerns 

Oral Nirmatrelvir COVID-19 5_2_2022.docx

nejmoa2118542.pdf

Among patients with ankle osteoarthritis, intra-articular PRP injections, compared with placebo injections, did not significantly improve ankle symptoms and function over 26 weeks. The results of this study do not support the use of PRP injections for ankle osteoarthritis.

 jama_paget_2021_oi_210107_1635192374.9207.pdf

Among adults with overweight or obesity without diabetes, once-weekly subcutaneous semaglutide compared with once-daily subcutaneous liraglutide, added to counseling for diet and physical activity, resulted in significantly greater weight loss at 68 weeks. 

jama_rubino_2022_oi_210142_1641310203.77797.pdf

This study of four primary care clinics in Idaho, Washington, and Wyoming, spanning urban and rural settings, highlights that most patients desire contraception services and miscarriage management to be available in primary care. 

SRH_PCP (1).pdf

Considerable uncertainty exists about the clinical efficacy and safety of muscle relaxants. Very low and low certainty evidence shows that nonbenzodiazepine antispasmodics might provide small but not clinically important reductions in pain intensity at or before two weeks and might increase the risk of an adverse event in acute low back pain, respectively. Large, high quality, placebo controlled trials are urgently needed to resolve uncertainty. 

back pain_bmj.n1446.full (1).pdf

back pain_poem (1).pdf

The Association Between Proton Pump Inhibitor Exposure and Key Liver-Related Outcomes in Patients With Cirrhosis

PPI exposure is associated with increased risk of infection and decompensation in cirrhosis, which may mediate liver-related mortality. However, PPI use was associated with reduced all-cause mortality in those with prior GIB, suggesting benefit in the presence of an appropriate indication.

Based on evidence from more than 1.9 million patients presenting in primary care, the findings provide estimated PPVs that could be used to guide specialist referral decisions, considering the PPVs of common abdominal symptoms for cancer alongside that for IBD and their composite outcome (cancer or IBD), taking into account the variable PPVs of different abdominal symptoms for different cancers sites. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8367005/pdf/pmed.1003708.pdf

In this cohort study, nighttime MUCH was common and associated with LVH and poor kidney outcomes among patients with hypertension and nondialysis CKD. These findings suggest that ambulatory blood pressure monitoring was inadequately used in patients with CKD and hypertension, calling for more widespread use, even in patients with controlled office hypertension.   

Nighttime HTN and Adverse Outcomes.pdf