153. Weight Loss, Fever, Back Pain, EKGs

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2771093

meta-analysis of 78 original studies, looking to find the accuracy of ECG interpretation. In this analysis they looked at studies with med students, physiciansm even cardiologist and found on average we got the right diagnosis only 55% of the time.

Obviously education goes up with more education


42.0% for medical students,
55.8% for residents,
68.5% for practicing physicians,
and 74.9%) for cardiologists.

in the end it I think it says a couple things
We all have room for improvement at reading EKGs
When you don’t know what the EKG says the cardiologist only know the right answer an extra 6% of the time
I am not shocked by the results. Lots of these studies had you look at 10 ekgs and say what it is. I think most people can get the easy EKGS, it is the really hard ekgs that look like a four year old drawing that are challenging to name. I think a better question would have been if the providers knew what to do. Did the providers know to start cpr or now if given a vignette, or if they should shock or push epi…like a concerning mass found on imaging, sometimes you don’t need to know the diagnosis you just need to know what to do….





https://www.acpjournals.org/doi/10.7326/M20-4187

acute sciatica—not a lot of good options for this… what about PT??

that is titled

Physical Therapy Referral From Primary Care for Acute Back Pain With Sciatica
A Randomized Controlled Trial

single-blind, parallel-group randomized trial that took place in 2 Utah hospitals and randomized 220 to either receive early physical therapy (EPT) or UC.

all participants were given a copy of The Back Book (23), a patient education booklet with evidence-based messages about the favorable prognosis of LBP and the importance of remaining active and avoiding bed rest

The EPT protocol recommended 2 weekly sessions during the first 2 weeks and 1 to 2 sessions in weeks 3 and 4.

The primary outcome was score on the Oswestry Disability Index (OSW) score after 6 months., Oswestry Disability Index (OSW) is a 10-item measure of LBP-related disability. OSW Scores range from 0 to 100, with higher scores indicating greater disability.

our results found that EPT referral after an initial primary care visit for recent-onset LBP and sciatica resulted in greater improvement in disability

Participants in the EPT group had greater improvement from baseline to 6 months for the primary outcome (relative difference, −5.4 points [95% CI, −9.4 to −1.3 points]; P = 0.009).

But as they say in the paper---

Minimum important difference is 6 to 8 points for acute LBP and sciatica

So the results should have said “our results found that EPT referral after an initial primary care visit for recent-onset LBP and sciatica resulted in greater stastical improvement in disability but is arguable if these changes are clinically important”

The lesson is when you are using a scale to measure something in the study, also know or look for the minimally CLINICALLY important difference that is needed








https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2772373


Comparison of Acetaminophen (Paracetamol) With Ibuprofen for Treatment of Fever or Pain in Children Younger Than 2 YearsA Systematic Review and Meta-analysis

in children younger than 2 years what is better for short-term treatment of fever or pain do you choose ibuprofen or do you choose acetaminophen??

The anwer is it depends where you live and which guidelines you follow


For example the maximum daily dose of acetaminophen beyond the neonatal period varies from 60 mg/kg/d in New Zealand to 90 mg/kg/d in the United Kingdom and United States.5 Recommendations for ibuprofen also vary based on where you live -- The New Zealand Formulary for Children recommends ibuprofen at 5 mg/kg/dose 3 to 4 times daily starting at age 1 month with a MAX of 30mg/kg/d. The United States, ibuprofen max daily dose is 40 mg/kg/d and starting at 6months of age.

So this anytime there is more then one answer it means that likely neither are evidence based.


This systematic review and meta-analysis loked at19 studies that compare acetaminophen with ibuprofen for the short-term treatment of fever or pain in children younger than 2 years.
796 participants were included in the final pain analysis.

The primary outcomes were fever or pain within 4 hours of treatment onset.

and even after looking though 19 studies ONLY 796 participants were included in the final pain analysis. which point out that pediatric litature is terrible!!!! no one wants to enroll their kid in anything

and if you read the authors conclusions you will see that "Moderate-quality evidence from randomized studies showed that compared with acetaminophen, ibuprofen was associated with reduced temperature within 4 hours”

But I fyou go to figure two forest plot you will see the difference between ibuprofen and acetaminophen had a confidence interval that ALWAYS extended over the midline BUT that key is the point estimate for the odds ratio was ALWAYS on the side favoring motrin. Sure we can say each trial individually was not clinically significant but when combined they were stastically significant AND there was not a trial that even had a point estimate in favor of acetaminophen.

So we give ibuprofen to everyone right!!!????

Well not so fast- the authors did do a secondary analysis to see how young did a child need to be to get ibuprofen and still be considered safe and SADLY Only 2 randomized studies in the review had inclusion criteria which included those infants younger than 6 months and this was not enough information to draw any real conclusions.

So I guess at this point it is tylenol till age 6 then ibuprofen is probably ok.

The authors do mention that ibuprfen has been used for closure of patent ductus arteriosus in preterm infants and no notable harms in the short term BUT trials are needed so if you are a hospital with a nicu or just a hospital. Do the trial! From this trial those over the age of six get more benefit from ibuprofen is there something special at 6 months compared to 5 months??? My guess is no but we need the trial

Bottom line—acetaminaphen 0-6mths then ibuprofen is ok


From my childhood I can say my mother only told me two things growing up, don’t eat your boogers and you are what you eat and this is clearly seen in this article titled
https://www.nejm.org/doi/full/10.1056/NEJMoa2007448?query=pfwRS&jwd=000020154104&jspc=HOS

Weight Loss in Underserved Patients — A Cluster-Randomized Trial

In NEJM

Which looked do see the effectiveness of treatment for obesity delivered in primary care settings in underserved populations is lacking.

803 adults with obesity were enrolled randomly assigned to intensive lifestyle intervention or usual care—

The intensive lifestyle intervention focused on reduced caloric intake and increased physical activity, they had health coached and had The program consisted of weekly sessions for the first 6 months, followed by monthly sessions for the remaining 18 months. Patients received personalized food-intake and calorie-intake targets, were instructed to weigh themselves daily on digitally connected scales, and adjusted their eating and activity patterns, in consultation with coaches, to meet their weight-loss goals.

The primary outcome was the percent change from baseline in body weight at 24 months.

The mean BMI at start of the trial was 101kg or 222lbs—and maybe you are thinking well these people must have been really talll—there bmi was 37! When you weigh 222lbs you are either obese or really tall and these people were obese.

The percent weight loss at 24 months was significantly greater in the intensive-lifestyle group (change in body weight, −4.99%; 95% confidence interval [CI], −6.02 to −3.96) than in the usual-care group (−0.48%; 95% CI, −1.57 to 0.61), with a mean between-group difference of −4.51 percentage points (95% CI, −5.93 to −3.10) (P<0.001).

4.5% of 222lbs is around 10lbs.

This tells me one thing—1) these people were in a study had weekly meetings with health coaches and over the course of 2 years could only lose 10 pounds. Weight loss is really hard. Even when you are trying really hard and you have weight loss coaches and personalized food intake plans and calorie consumption targets individualized for you, weight loss is really hard and although my mother was not totally correct because else I would have turned into a cookie by now, it remains clear that twinkies will turn you into a sponge cake.