Episode 185: 185. USPSTF, Lupus, Diabetes Risk Factor, C. Diff

Davidson KW et al. Screening for prediabetes and type 2 diabetes: US Preventive Services Task Force recommendation statement. JAMA 2021 Aug 24; 326:736. (https://doi.org/10.1001/jama.2021.12531)

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  The Task Force found moderate-certainty evidence that screening is beneficial for nonpregnant adults (age range, 35–70) who are overweight (i.e., body-mass index [BMI], ≥25 kg/m2) or obese (BMI, ≥30 kg/m2) and have no symptoms of diabetes. Referring patients for, or directly providing, effective preventive interventions is recommended (B recommendation).

The main change from the 2015 recommendation is the lower age threshold for screening — 35 rather than 40. The decision was made because of the increasingly younger age of onset for diabetes and the known benefits of intervention at a wide range of ages. Notably, the USPSTF found little direct evidence that screening improves clinical outcomes;

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  Lifestyle modifications and metformin are considered appropriate interventions for preventing or delaying onset of diabetes; however, metformin is not approved for this specific use by the U.S. FDA. ---- NO NO NO NO NO NO NO you cant do that..

Aringer M et al. European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) SLE classification criteria item performance. Ann Rheum Dis 2021 Feb 10; 80:775. (https://doi.org/10.1136/annrheumdis-2020-219373)

Diagnosising SLE—its always lupus till its not lupus but new diagnosis criteria

In 2019, the European League Against Rheumatism and the American College of Rheumatology published the following classification criteria for systemic lupus erythematosus (SLE; Ann Rheum Dis 2019; 78:1151):

· Positive antinuclear antibody (ANA) test with titer ≥1:80 is a required “entry criterion.”

· If the ANA criterion is met, points are assigned from seven clinical categories and three immunologic test categories; a criterion is not counted if another cause is more likely than SLE.

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  A score ≥10 is considered to be consistent with SLE.

When these criteria were validated, sensitivity for SLE was 96%, and specificity was 93%.

But ANA what about ANA

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  Sensitivity and specificity of ANA were 99.5% and 19.4%, respectively.

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Gómez-Outes A et al. Meta-analysis of reversal agents for severe bleeding associated with direct oral anticoagulants. J Am Coll Cardiol 2021 Jun 22; 77:2987. (https://doi.org/10.1016/j.jacc.2021.04.061)

Use of direct oral anticoagulants (DOACs) is associated with about a 3% annual risk for major bleeding, though that varies by age, comorbidity profile, and concomitant therapies. investigators examined clinical outcomes associated with the use of 4-factor prothrombin complex concentrate (4PCC), idarucizumab, or andexanet for severe DOAC-associated bleeding.

These drugs are great

But if you do bleed then about 20% of the time we cant get hemostasis with mortality around 18% DESPITE getting reversal agents..

This is good to talk to your patients about—

The risk of bleeding in 1 and 33 per year..

Out of every 3300 people treated about 20 people will have a bleed that isn’t controlled and 18 of those people will die.

It sounds like a lot but remember without these drugs the risk of stroke is much much higher, of course depending on your comorbid conditions.

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Cardiovascular risk prediction in type 2 diabetes before and after widespread screening: a derivation and validation study - ClinicalKey

Lancet, The, 2021-06-12, Volume 397, Issue 10291, Pages 2264-2274, Copyright © 2021 Elsevier Ltd

Formulas for cardiovascular (CV) risk calculations are based on population studies and generally include diabetes as a major risk factor. Do formulas that were derived when diabetes usually was diagnosed at later stages overestimate CV risk for people in whom diabetes is diagnosed early?? Basically long ago we diagnosed in DM at a1c of 12 not we diagnosis it at a1c of 6-6.5-7—even prediabetes at a1c of 5.5……

Those are not the same population so now are we over diagnosing CV risk??? The answer for this new zeeland study was yes--

In this modern diabetic population, the median 5-year risk for an adverse CV event, as estimated by the new formula, was 4.0% in women and 7.1% in men. The older formula overestimated median risk in women (14.7%) and in men (17.1%).

This is has to do with new Zealand not the the more recent and commonly used American pooled cohort equation but even that I would love to see put through the ringer as many of the studies were done back in the 90s, over thirty years ago, when we were quite as sharp about diagnosing diabetes yet…either way you have to remember the ascvd risk score is for discussion it is not evidence based gold it is a conversation starter

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DVT – I am always confused when people say airline travel is a risk factor. I have sat on my couch for 6 hours without moving and I never got a dvt so why would being on a plane for 3 hours. Well maybe it is something I don’t understand about air travel because as this paper

Munger JA et al. Television viewing, physical activity and venous thromboembolism risk: The REasons for Geographic and Racial Differences in Stroke (REGARDS) study. J Thromb Haemost 2021 Jun 2; [e-pub].

They looked to see if tv watching was associated with DVT and it was not – it didn’t matter if you just watched a little bit of tv per day or over 4 hours of tv per day, there was no association with increase DVT and TV hours per day once accounting for total activity.. yes those that are watching TV move less and are more obese but is it he TV watching or just all the risk factors…. This article says it is the risk factors.

Last article

Kelly CR et al. Prevention, diagnosis, and treatment of Clostridioides difficile infections. Am J Gastroenterol 2021 Jun; 116:1124. (https://doi.org/10.14309/ajg.0000000000001278)

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  Oral vancomycin or fidaxomicin generally is favored for treating patients with nonsevere CDI, but metronidazole is acceptable for low-risk patients — especially when cost is a factor.
• Patients with severe CDI should be treated with either oral vancomycin or fidaxomicin (but not metronidazole). Severe disease is defined as having a leukocytosis >15,000 white blood cells/mm3 or a creatinine level of >1.5 mg/dL.
• Fecal microbiota transplantation (FMT) should be considered for refractory or severe CDI.
• *******A first recurrence should be treated with tapering/pulsed-dose vancomycin or fidaxomicin if it was not the initial therapy. ********A patient experiencing a second or further recurrence of CDI should be treated with FMT, delivered via a colonoscope or capsules, with enemas used when colonoscopy or capsules are not available. Repeat FMT can be used to treat a recurrence within 8 weeks of initial FMT.
• *****Patients with recurrent CDI who are not FMT candidates or have relapsed after FMT can be given long-term oral vancomycin prophylaxis to prevent recurrences. Oral vancomycin prophylaxis also can be considered when patients with recurrent CDI are given systemic antibiotics.