Episode 189: Medical Update 189 (Vit d., Pregnancy test, Heart Failure, Acetazolamide)

Writing Group for the CODA Collaborative. Patient factors associated with appendectomy within 30 days of initiating antibiotic treatment for appendicitis. JAMA Surg 2022 Jan 12; [e-pub].

Now, investigators have explored in a secondary analysis of The CODA Collaborative. A randomized trial comparing antibiotics with appendectomy for appendicitis. N Engl J Med 2020 Oct 5; [e-pub]. (data from a previous randomized antibiotics-versus-surgery trial (NEJM JW Gen Med Dec 1 2020 and N Engl J Med 2020; 383:1907). Have looke at the data to see could we predict factors that make you more likely to appendectomy and fail antibiotic therapy.

They identified 735 patients who had been randomized to antibiotic treatment; 154 (21%) of these patients underwent appendectomy within 30 days.

Overall, 29% of patients in the antibiotics group underwent appendectomy within 90 days (41% of those with appendicolith vs. 25% without).

The authors suggest hey maybe this appendicolith is the magic answer of who will fail therapy—maybe!!

BUT remember this is secondary analysis so this is only hypothesis generating even a secondary analysis of a rct is just hypothesis. You need a new RCT to actually show causation.

Also as stated in the editorialists note that in subsequent analyses of this same data set, nearly 50% of patients underwent appendectomy within 2 years, regardless of the presence of an appendicolith, so an initial nonsurgical approach might only delay surgery.

Some say 50% still going to surgery is terrible but I say even if 50% prevented from having surgery that is still 50% of people are being prevented from a surgery

Acetazolamide to Prevent Adverse Altitude Effects in COPD and Healthy Adults | NEJM Evidence

Trial 1 was a randomized, double-blind, parallel-design trial in which 176 patients with COPD were treated with acetazolamide capsules (375 mg/day) or placebo- COPD patients had oxygen saturation measured by pulse oximetry of 92% or greater

primary outcome in trial 1 was the incidence of the composite end point of altitude-related adverse health effects (ARAHE)== Criteria for ARAHE included acute mountain sickness (AMS) and symptoms or findings relevant to well-being and safety, such as severe hypoxemia, requiring intervention.

In trial 1 of patients with COPD, 68 of 90 (76%) receiving placebo and 42 of 86 (49%) receiving acetazolamide experienced ARAHE

The number needed to treat (NNT) to prevent one case of ARAHE was 4

EVEN at NNT of 4 you have to realize that still 50% of those with COPD required intervention to go back down to lower level.

Trial 2 comprised 345 healthy lowlanders.

The primary outcome in trial 2 was the incidence of acute mountain sickness AMS assessed at 3100 m by the Lake Louise questionnaire score (the scale of self-assessed symptoms ranges from 0 to 15 points, indicating absent to severe, with 3 or more points including headache, indicating acute mountain sickness AMS).

In trial 2 of healthy individuals, 54 of 170 (32%) receiving placebo and 38 of 175 (22%) receiving acetazolamide experienced acute mountain sickness AMS

The NNT to prevent one case of acute mountain sickness AMS was 10 (95% CI, 5 to 141).

So use the acetazolamide still 1 in 5 individuals experience acute mountain sickness

Annals for Hospitalists Inpatient Notes - Clinical Pearls—Stopping, Starting, and Optimizing Guideline-Directed Medical Therapy in Patients Hospitalized for Heart Failure With Reduced Ejection Fraction | Annals of Internal Medicine (acpjournals.org)

Treat with??

Foundational medical therapy for HFrEF consists of comprehensive disease-modifying quadruple medical therapy, including angiotensin receptor–neprilysin inhibitors (ARNIs), β-blockers, mineralocorticoid receptor antagonists, and sodium–glucose cotransporter-2 inhibitors (1).

Quadruple medical therapy is estimated to cumulatively reduce the relative risk for death by 73% over 2 years, with a number needed to treat of 3.9 to save 1 life

compared with traditional therapy using an ACEI and a β-blocker, treating a 55-year-old patient with comprehensive disease-modifying quadruple therapy projects to increase life expectancy by more than 6 years

Approximately 1 in 4 patients hospitalized for worsening HFrEF die or are rehospitalized within 30 days of discharge --- Deferring in-hospital initiation is consistently associated with medications never being initiated in the outpatient setting, or initiated after substantial delay

START THEM IN THE HOSPITAL

-- There is no evidence to suggest that “go slow,” “one medication change at a time,” or “defer to outpatient” approaches improve medication tolerance or accomplish anything beneficial

If you mix a bunch of moon pies in a trash can you get what sounds like a great time but if you mix a bunch of cow pies in a trash can you just get poop

Clearly seen in this next article

Vitamin D supplementation for the treatment of migraine: A meta-analysis of randomized controlled studies - ClinicalKey

meta-analysis aims to explore the efficacy of vitamin D for migraine patients.

Six RCTs and 301 patients were included in the meta-analysis.

On average these people were having around 7 migraines per months and compared to control the vit d group decrease headache days by about 1.5 per month compared to placebo or UC

So you say vit d works for something!!

Not so fast

Remember I would like a 25 yr old cut my hair by not 5 five year olds…. Sadly these studies were 5 yr olds

UC could be nothing. Well vit d beating nothing isn’t hard, we know placebo is real

Even beating placebo isn’t hard when it is open label or you are not blinded to the active arm.

If I say, yes you are getting this drug vit d that will help your headaches you are going to believe it much more than if I just give you a pamphlet.

The authors in the discussion state “Higher vitamin D levels is associated with lower risk of migraine “

Well ya that is true but having a higher vitamin d level is also associated with going outside more. And going outside more is associated with no having a migraine.

High vit d level is amazing!! I love it but replacing it still seems to do nothing however if you want a high level and want to go outside and get a high level then I think that is a great idea and speaking of great ideas—

Here is a sad but enlightening article—

Home pregnancy test use and timing of pregnancy confirmation among people seeking health care - ClinicalKey

The researchers found that 74% of survey respondents took a home pregnancy test as the first step in confirming a suspected pregnancy;

Respondents who took home pregnancy tests confirmed pregnancy 10 days earlier than those who first tested at a clinic. (duh statements- if you test at home you find out sooner, this is so obvious an a no brainer--- BUT

Confirmation of pregnancy at greater than 7 weeks' gestational age was higher among adolescents, Latina versus white women, food-insecure versus -secure women, and people with unplanned pregnancies.

Those that did not test at home cited concerns about test accuracy (42%) and difficulties accessing one (26%).

While overall 1/5 21% confirmed pregnancy at ≥7 weeks gestation,

confirmation at ≥7 weeks was higher among adolescents versus young adults (47%!! vs 13%, p = 0.001), Latina versus white women (28% vs 11%, p = 0.02), food insecure versus secure women (28% vs 17%, p = 0.06), and people with unplanned versus planned/mistimed pregnancies (25% vs 13%, p = 0.07).

Latina and food insecure women discover their pregnancy at the same time or rate as individuals with unplanned pregnancy!!!

one in 5 confirm pregnancy at 7 weeks gestation or later and in those Latina, poor, or unplanned It is ¼ at >7weeks this obviously effects prenatal care and Gestational bans in the first trimester will disproportionately prevent young people, people of color, and those living with food insecurity from being able to access abortion.

This is tough but it is this data that reminds me and should remind us that life is not equal and healthcare is not equal and certain populations and groups do need our help more than others.