141. Primary Care Burnout! TSH, Viagra, Hepatitis C screening and SGLT2 vs DDP4

henry ford once said “failure is simply the opportunity to begin again, this time more intelligently”
Designed to Fail? the Future of Primary Care
Journal of General Internal Medicine (2020)
Access to primary care has been shown to improve patient outcomes and lower cost although outcomes are debated the cost is not-
its because we can be the jack of all or the referral of all.
neither is wrong
the authors in this paper analyzed the 2019 “in-basket” activity of our clinical faculty at the University of Michigan to determine the average weekly activity by category of EMR tasks.
A full-time primary care faculty member had a total of 390 in-basket tasks per week or 17,542 in-basket tasks per year.
they surveyed 56 clinicians, and asked how much time, to the nearest minute, they spent on in-basket tasks: and a median time of 1199 min (~ 20 h) per week on these tasks
many task require further steps- like addressing lab work, or ordering follow up imaging, or doing a prior authorization ALL of which are unpaid. essentially PCP see patients full time then have another part time job they do for free in answering inbox messages and we wonder why pcp is a dying speciality that no one wants to go into. a change is needed


onto the next article

I have said many times that I love an article that answers a simple question

The Journal of Sexual Medicine
Are We Overstating the Risk of Priapism With Oral Phosphodiesterase Type 5 Inhibitors?
J Sex Med 2020 Jul 01;[EPub Ahead of Print], ME Rezaee, MS Gross

Viagra and cialis have the famous saying on their commericial to consult a dr. if you have an erection lasting longer than 4 hours. Well in this study they looked to answer the question how often does this actually occur!

They evaluated all cases of priapism reported to the FDA since 1998 which happens to be when viagra hit the market and they were able to identify a total of 411 cases due to Phosphodiesterase Type 5 Inhibitors

Now it is hard to get exact or precise numbers on number of viagra and cialis prescriptions out there but In the first year and a half of marketing in the United States, more than 15.6 million prescriptions of Viagra had been filled.

So even if there was not another single script of Viagra written for and we just went based on the first year and a half and we assumed each prescription was for only 3 pills then the rate of priapism would be 411/46.8million which in % terms comes out to 0.0008%-- basically nothing!! And that is just the first year scripts, obviously the numbers are much larger and we are over exaggerating the evidence.

Although PDE5i-induced priapism does occur, it appears less common than once suspected. When counseling patients, this should be considered.






Dean martin once said “Everybody loves somebody sometime” well it appread in medicine Everyone wants to treat subclinical hypothyroidism sometime –

Clearly seen in this paper -- https://jamanetwork.com/journals/jama/fullarticle/2768464?guestAccessKey=cafa97b4-33a8-49f3-9c5c-df1ebf349f84&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jama&utm_content=etoc&utm_term=072120

Effect of Levothyroxine on Left Ventricular Ejection Fraction in Patients With Subclinical Hypothyroidism and Acute Myocardial InfarctionA Randomized Clinical Trial

Where they sought to find if levothyroxine treatment improved left ventricular function in patients with subclinical hypothyroidism presenting with acute myocardial infarction?

A double-blind, randomized clinical trial took 95 participants with subclinical hypothyroidism and acute myocardial infarction, treatment with levothyroxine, compared with placebo
Levothyroxine treatment (n = 46) started at 25 µg titrated to aim for a TSH levels between 0.4 and 2.5 mU/L

And after 52 weeks-the authors nailed it when they say- “treatment with levothyroxine, compared with placebo, did not significantly improve left ventricular ejection fraction after 52 weeks."




Don't trust the person who has broken faith once.” – William Shakespeare. But I think what he meant to say was don’t trust a medical journal abstract--- clearly seen in

https://www.acpjournals.org/doi/10.7326/M20-0289
Sodium–Glucose Cotransporter-2 Inhibitors and the Risk for Diabetic Ketoacidosis
A Multicenter Cohort Study

In the abstract they say
Conclusion:
SGLT-2 inhibitors were associated with an almost 3-fold increased risk for DKA, with molecule-specific analyses suggesting a class effect

They looked at Electronic health care databases from 7 Canadian provinces and the United Kingdom and found a total of over 400,000 pateints on either a ddp4 or sglt2- mean follow up was almost one year. And during this time out of all those people there were only 521 cases of DKA.
And if you just go by the numbers then risk for DKA was 2 per thousand for the SGLT2 inhibitors and was 0.75 per 1000 person-years for the DDP4 inhibitors.

A three fold increase is scary! But the fact that no DDP4 has ever shown to be beneficial ofr the outcomes I care about like MACE and chronic kidney disease I think I and all my patients will take their chances.

Mr jones I can give you a medication that will put you in the hospital once every 500 yrs but out of every 20-50 people that take it we will prevent a heartattack or a death or a renal failure or a stroke

Or I can give you a drug that will only put you in the hospital for dka once every 1000 years but have never been shown to do anything. What would you like to do??
This is a strawman argue and a terrible comparible arm and a gentle and continued reminder to always question medicine and don’t trust the abstract

Reference
US Preventive Services Task Force. Screening for hepatitis C virus infection in adolescents and adults. US Preventive Services Task Force recommendation statement. JAMA 2020;323(10):970-975.
These recommendations replace the previous 2013 USPSTF recommendation of screening adults born between 1945 and 1965

In this updated 2020 review, the U.S. Preventive Services Task Force (USPSTF) found adequate evidence that hepatitis C virus (HCV) screening accurately detects HCV infection. Although there is no direct evidence on the benefit of screening for HCV infection on patient-oriented outcomes, there is convincing evidence that treatment results in a high proportion (95.5% - 98.9%) of adults who maintain a sustained virologic response (SVR), with a strong association between SVR and improved health outcomes. The task force also recommends screening for HCV in all pregnant women.




now is time when we have annual exam worth something hep c screening and hiv screening for everyone