Weekly Medical Update 175

1- make sure pts follow up on positive FIT test
2. symptom severity — driven particularly by catching/locking and clicking/popping — correlated significantly with the burden of cartilage damage. CARTILAGE DAMAGE!!
3. U.S. Food and Drug Administration announced it is allowing the use of the Binx Health Assay for point-of-care testing for Chlamydia trachomatis and Neisseria gonorrhoeae
4. In patients with atrial fibrillation and a bioprosthetic mitral valve, rivaroxaban was noninferior to warfarin
5. ADHD- “results favored using methylphenidate in children and adolescents, and amphetamines in adults as first-line, short-term (12 weeks or under) treatment.”
6. when it comes to PAD it is true what they say! no pain no gain- but maybe they should say no walking pain less loss and more walking pain much bigger gains in 6minute walking distance




The Push for Timely Follow-up After Abnormal At-home Colon Cancer Screening Results | Cancer Screening, Prevention, Control | JAMA | JAMA Network



The pandemic has brough on way more things done at home which Is good and bad

More stay at home school- bad

More stay at home colon cancer screening- good

Article talked about a need to make sure pts if positive then get the colonoscopy. Poit out one study where only 44% completed a colonoscopy within 6 months of a positive FIT result even though 89% received a referral,

Reasons for the low rates are complex. Patients who are reluctant to get a colonoscopy. and physicians don’t always convey the importance of follow-up. Other factors such as inadequate insurance, lack of transportation, or a facility backlog may be out of a patient’s control.

I think in the end we just have to make sure we do our part and while I wouldn’t say scare them make sure they know the importance of this test and how likely it is that they have colon cancer based on it being positive



And as a reminder

Zorzi M, Hassan C, Capodaglio G, et al. Long-term performance of colorectal cancer screening programmes based on the faecal immunochemical test. Gut 2018;67(12):2124-2130.

Over a 10-year period, the rates of detection of colorectal cancer (CRC) and advanced adenomas using fecal immunochemical testing (FIT) are similar to those seen in studies of screening colonoscopy.



But how good is it you ask?



Imperiale TF, Ransohoff DF, Itzkowitz SH, et al. Multitarget Stool DNA Testing for Colorectal-Cancer Screening. N Engl J Med 2014;370(14):1287-1297.

FIT was 74% sensitive and 95% specific.

Which in pt terms means for every 11 positive FIT there was 1 cancer detected on colonoscopy



A positive fit has you down to a 1 in 10 chance of cancer—get the follow up!









And speaking of follow up

Patient-reported catching or locking of the knee and other “mechanical symptoms” (i.e., popping, clicking, or pain on pivoting) Usually gets a follow up with an ortho surgeon


That patient usually goes to get an arthroscopic knee surgery for symptoms attributed to meniscal tears.

BUT BUT BUT what if the text book and board question of pain or instabilitiy with (i.e., popping, clicking, or pain on pivoting) Isn’t a meniscus problem at all??



Meniscal and Mechanical Symptoms Are Associated with Cartila... : JBJS (lww.com)

Farina EM et al. Meniscal and mechanical symptoms are associated with cartilage damage, not meniscal pathology. J Bone Joint Surg Am 2021 Mar 3; 103:381. (https://doi.org/10.2106/JBJS.20.01193)







Researchers prospectively evaluated 565 patients (mean age, 48) who had arthroscopic knee surgery for symptoms connected to meniscus pathology. Pts were asked about the presence and severity of symptoms prior to surgery and then while in surgery, the surgeon recorded characteristics of meniscal tears and the severity of cartilage damage.



In the end “We did not observe an association between meniscal pathology and preoperative patient-reported knee symptoms."



Instead they found overall symptom severity — driven particularly by catching/locking and clicking/popping — correlated significantly with the burden of cartilage damage.



CARTILAGE DAMAGE!!



And if you had tricompartmental cartilage damage (i.e., medial, lateral, and patellofemoral). Then there was even greater symptoms severity…almost a dose response of cartilage damage to symptoms severity



Perhaps the observations in this study help to explain why arthroscopic meniscal surgery has not consistently proven to be better than conservative management in randomized trials







FDA Allows for First Point-of-Care Chlamydia and Gonorrhea Test to be Used in More Near-Patient Care Settings | FDA



the U.S. Food and Drug Administration announced it is allowing the use of the Binx Health Assay for point-of-care testing for Chlamydia trachomatis and Neisseria gonorrhoeae,



The test, which uses female vaginal swabs and male urine specimens, takes about 30 minutes and can be done right there in the office



This is the first point of care test approved for Chlamydia trachomatis and Neisseria gonorrhoeae testing



And I have no idea how much it will cost but my guess is a pretty penny





Next article



Rivaroxaban in Patients with Atrial Fibrillation and a Bioprosthetic Mitral Valve | NEJM



The primary outcome was a composite of death, major cardiovascular events (stroke, transient ischemic attack, systemic embolism, valve thrombosis, or hospitalization for heart failure), or major bleeding at 12 months.

In this open-label design Randomized trial of 1005 patients who were randomized to either

20 mg once daily rivaroxaban vs dose-adjusted warfarin in patients with atrial fibrillation and a bioprosthetic mitral valve



In the end



In patients with atrial fibrillation and a bioprosthetic mitral valve, rivaroxaban was noninferior to warfarin When it came to the composite primary outcome of death, major cardiovascular events, or major bleeding at 12 months.





I have a couple problems

Industry funded and open-label design – immediate bias into event rates. People doing the trial get paid ot do the trial and enroll people. They want this to work, they will try to show benefit as much as possible whenever possible. Nothing wrong with them, just human nature.
This is for bioprosthetic mitral valves NOT mechanical valves


HOWEVER

This does seem to be consistent with observational and subgroup analysis from other studies and likely will change practice going forward.









ADHD is real and what do you write for- well what if we could just get a large meta-analysis of almost 24K people



Well we are in luck



Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis - The Lancet Psychiatry



Researchers examined efficacy and tolerability of data of the drugs used to treat attention-deficit/hyperactivity disorder from published and unpublished double-blind, randomized, controlled trials. In total they had 133 trials and included close to 14,000 children and 10,000 adults. They analysis was able to do indirect comparison which is when you take one study active arm and compare it to another study active arm and in the bit of statistical magic you get what appears to be results between the two active arms. So aspirin vs placebo and then Plavix vs placebo and then you can do an indirection comparison and BOOM stat magic and you have results for aspirin vs Plavix. Is it perfect? NO but is it better than nothing, usually.

Some interesting results

For children based on teachers' ratings only methylphenidate and modafinil were more effective compared to placebo

BUT

In adults modafinil didn’t beat placebo

The best drug for adults was amphetamines

I think one of the authors who commented on this said it best

“results favored using methylphenidate in children and adolescents, and amphetamines in adults as first-line, short-term (12 weeks or under) treatment.”

The authors did look for data at 26 and 52 weeks but found insufficient evidence. Which is to be expected as most mental health drugs only show improvement in the short instead of long duration but it also speaks to the importance of drug holidays when possible. These drugs have evidence for 12 weeks we have no idea what the good or bad long term effects are when taken for 12, 22, 32, or 42 years.









Effect of Low-Intensity vs High-Intensity Home-Based Walking Exercise on Walk Distance in Patients With Peripheral Artery Disease: The LITE Randomized Clinical Trial | Cardiology | JAMA | JAMA Network



How long or fast do you need to walk if you have PAD



Does a low-intensity work just as good at high intensity?

305 participants with PAD Randomized to either low-intensity exercise, high-intensity exercise, and a nonexercise control group



Participants in the walk groups were asked to walk 5 times per week for up to 50 minutes per session wearing an accelerometer to document exercise intensity and time.

low-intensity group walked at a pace without ischemic leg symptoms. The high-intensity group walked at a pace eliciting moderate to severe ischemic leg symptoms.



There were weekly phone calls with their ‘coach’ to help with adherence. Adherence was pretty good at around 85%!!! THAT ALONE IS IMPRESSIVE



All participants did a 6 minute walk test at the beginning of the study and then again at the end of the study



The primary outcome was mean change in 6-minute walk distance at 12 months



In the end if you did Nothing then you decreased in for walk test distance by −15m,

high intensity group GAIN 35m on their 6 minute walk test,

but what about the low intensity- that is what we all care about is just a little bit of exercise beneficial. Is it ok to walk at a pace that is slow and doesn’t produce any pain and

THOSE randomized to the load intensity group showed a DECREASE in their 6minute walk distance! They went down by -6.4M!



No pain no gain! If you have PAD you can just lolly gag your walk around the block you have to push it. Sure a lolly gag pace wont lose you as much as doing nothing but if you push it you will see gains!



I guess when it comes to PAD it is true what they say!

no pain no gain

but maybe they should say no walking pain less loss and more walking pain much bigger gains in 6minute walking distance