Weekly Medical Update 179

1) nurses commit more suicide and average population (doctors don't)
2) AK will turn in to SCC at a rate of about 2% per year
3) STOP SMOKING (even if you gain weight)
4) zofran is about equal to the rest for pregnant patients and the outcomes we care about
5) Tubes in the ear for children with acute otitis media?? It works about the same as medical management


Association of US Nurse and Physician Occupation With Risk of Suicide | Nursing | JAMA Psychiatry | JAMA Network

This retrospective cohort study used US data from 159 372 suicides reported in the National Violent Death Reporting System from 2007 to 2018.

Researchers found that suicide was more common among nurses compared with the general population (sex-adjusted incidence, 23.8 per 100,000 vs 20.1 per 100,000; RR, 1.18). By sex, the physician suicide rate was not different from that of the general population



Ten-Year Follow-up of Persons With Sun-Damaged Skin Associated With Subsequent Development of Cutaneous Squamous Cell Carcinoma | Dermatology | JAMA Dermatology | JAMA Network

authors use Kaiser Permanente Northern California data to investigate a patient’s risk of SCC after an AK in more than 200,000 patients with AKs (
they give a bunch of fancy results but I am just going to tell you exactly what you need to know or want to know and that is what is the risk of AK turning into SCC

and the answer is about 2% per year. An absolute risk is straightforward to use when thinking about patients: these results suggest that, if you see 10 patients with AKs on a given clinic day, one of them will have an SCC in the next 5 years.



People don’t want to quit smoking, usually because it is addictive but some of the things they tell themselves is they smoke to stay skinny

Sahle BW et al. Weight gain after smoking cessation and risk of major chronic diseases and mortality. JAMA Netw Open 2021 Apr 1; 4:e217044. (https://doi.org/10.1001/jamanetworkopen.2021.7044)

prospective cohort study, looked at weight gain and associated mortality in about 17,000 adults over 8 years,
during the 8 years of follow up 47% never smoked, 22% continued to smoke, and 31% quit smoking.

participants who quit smoking gained on average 3.1 kg or almost 7 pounds compared with those who continued to smoke

those who quit and gained weight had a hazard ratio for all-cause mortality around 0.30 compared to those who continued to smoke.

This means if your risk of dying is 1 if you continue to smoke then if you stop smoking your risk of dying goes down to 0.3!
This is insanely large, we have no drugs that give this big of a benefit and certainly not for mortality. That is a 70% decrease in mortality
It just goes to show that although treatment is good, prevention, and discontinuing cigarette smoking is better.

Comparison of Pregnancy Outcomes of Patients Treated With Ondansetron vs Alternative Antiemetic Medications in a Multinational, Population-Based Cohort | Clinical Pharmacy and Pharmacology | JAMA Network Open | JAMA Network

Ondansetron is frequently used to treat nausea and vomiting during pregnancy. Although some studies reported important safety signals, few studies have been sufficiently large to assess rare pregnancy outcomes.

Data from 456 963 pregnancies were included to evaluate exposure to ondansetron during pregnancy was compared with exposure to other commonly used antiemetics to minimize confounding by indication.

primary outcome was fetal death, defined as either spontaneous abortion or stillbirth.

there was no association between ondansetron exposure during pregnancy and increased risk of fetal death, spontaneous abortion, stillbirth, or major congenital malformations compared with exposure to other antiemetic drugs.





Somethings we do in medicine we do because no one really questions it—

Tympanostomy Tubes or Medical Management for Recurrent Acute Otitis Media | NEJM

performance of tympanostomy-tube placement for recurrent acute otitis media has been the commonplace observation—OBSERVATION!!

Previous trials of tympanostomy-tube placement for recurrent acute otitis media historically have many flaws

For Example
most were conducted before the introduction of pneumococcal vaccine (which is important later)
they are of small size
uncertain validity of diagnoses of acute otitis media
short periods of follow-up

so what if we could have a study that
made acute otitis media diagnoses by a validated otoscopists,
used a standardized protocol for treating episodes
looked at 250 children
and used a follow up of at least 2 yrs


what if we could have that study????

WE ARE IN LUCK
Tympanostomy Tubes or Medical Management for Recurrent Acute Otitis Media | NEJM

this trial involves 250 children 6 to 35 months of age who had a history of recurrent acute otitis media to undergo tympanostomy-tube placement or receive nonsurgical medical management, with the option of tympanostomy-tube placement in the event of treatment failure

The primary measure was the average number of episodes of acute otitis media per child-year (rate) during the 2-year follow-up period.

episodes of acute otitis media per child-year during a 2-year period was 1.48±0.08 in the tympanostomy-tube group and 1.56±0.08 in the medical-management group (P=0.66).


episodes of acute otitis media per child-year during a 2-year period was 1.48±0.08 in the tympanostomy-tube group and 1.56±0.08 in the medical-management group (P=0.66). – which mean NO DIFFERENCE

to be fair the authors did a per protocol analysis which is inappropriate, you should do an intention to treat.

Intention to treat is real life, it is what group is the person assigned to. If they are assigned to a drug or a treatment and don’t get the drug or treatment or in this case procedure, that is real life that is what really happens but when you want to find a positive outcome you do a per protocol analysis.

A per protocol is just the people that finished the protocol, it will typically over exaggerate the effects of treatment.

Well in this study 10% of the children in the tympanostomy-tube group did not undergo tympanostomy-tube placement and 16% of the children in the medical-management group underwent tympanostomy-tube placement at parental request, the per-protocol analysis, which gave corresponding episode rates of 1.47±0.08 and 1.72±0.11, respectively—which was significant.

However that is not how you should ever look at data from an RCT and I find it interesting that the authors did in this paper.

The true take home and conclusions of this paper are stated perfectly by the authors---

‘Among children 6 to 35 months of age with recurrent acute otitis media, the rate of episodes of acute otitis media during a 2-year period was not significantly lower with tympanostomy-tube placement than with medical management. ‘



And although not powered for this they did show that among children who received pneumococcal vaccine tympanostomy-tube placement was not superior to medical management in reducing the rate of episodes of acute otitis media.

So maybe this is not only a win for getting your kid vaccinated but a dagger for pediatric ENT physician everywhere.

I can see it now, all the ENT physicians move to California where all the of the antivaxers live!