Episode 146: Weekly Medical Update 180 (I'm Back)

itunes pic

Delay of Pregnancy Among Physicians vs Nonphysicians JAMA Intern Med 2021 May 03;[EPub Ahead of Print], MC Cusimano, NN Baxter, R Sutradhar, E McArthur, JG Ray, AX Garg, S Vigod, AN Simpson It has been hypothesized based on just rumor and people repeating it that women physicians are more likely to delay childbearing than nonphysicians. This population-based retrospective cohort study looked to see if that was true. They compared childbirth rates among physician and compared it to nonphysicians Physicians were less likely to experience childbirth at younger ages (HR for childbirth at 15–28 years, 0.15; P < .001) and more likely to experience childbirth at an older age (HR for 29–36 years, 1.35; P < .001; HR for ≥37 years, 2.62; P < .001). BUT BUT BUT do they delay child birth all together?? Well in simple terms, NO. female physicians have children rates equal to that of nonphysician women over time, although the time Basically this says what lots of us know in the women try not to have children during med school or residency because the cutoff was age 28 and if you go through it as fast as possible you are 29-30 provided you take the fast route possible. I think this makes sense an I would have liked to see them separate it out by age even a little more but overall I think residency and med schools should change the mantra and how the handle women becoming pregnant during training. It seems odd to me that so much emphasis these days is on burn out and making sure you have family time but often women are punished for having children during training years…..you cant have your cake and eat it to, you cant say one thing but do another…..although to me that is exactly what it seems like. Gender, Race, Ethnicity, and Sexual Orientation of Editors at Leading Medical and Scientific Journals: A Cross-sectional Survey | Medical Journals and Publishing | JAMA Internal Medicine | JAMA Network You have to know who was in the room… If a bunch of old white men created the machine or law or toy then it will be bias towards then and on the counter to that if a bunch of black or asiain people made the same law, toy, machine then it will be bias towards them and their perception of reality. It is our own individual bias that exist no matter how hard we try to fight it. This paper looked to see what is the general break down of the editorial staff of major medical and science journals and while there was a nice almost 50/50 split of men and women the mean age was 51 yrs old and white made up 77% with Hispanic and black only making up 5% COMBINED!! I am not saying we need to hire all Hispanic or black editors for major medical journals but maybe a few more… I say it like this, if I was an editor for lets say Jama internal medicine and in my previous life I was a vascular surgeon, Don’t you think even if I fought it that my bias would be to publish more papers that have something to do with vascular surgery or could somehow be related to vascular surgery. Our perception of reality is what we choose to see and the publication of paper is no different Annals for Hospitalists Inpatient Notes - A Critical Look at Procalcitonin Testing in Pneumonia | Annals of Internal Medicine (acpjournals.org) We all want a test that will help us—we all would love for procal to work but does it?? In addition, the 2019 joint guideline on community-acquired pneumonia (CAP) from the American Thoracic Society and Infectious Diseases Society of America recommends against the use of PCT testing to guide initiation of empirical antibiotic therapy for radiologically confirmed pneumonia (strong recommendation, moderate evidence) This is largely based on a study of 1735 patients admitted with CAP who had bronchs or procedures to identify pathogens… viral and bacterial pathogens were identified in 24% and 14% of cases, respectively. the negative predictive value of a PCT value less than 0.1 ng/mL was 82.4% (95% CI, 71.2% to 86.9%). Said differently, approximately 1 in 5 patients with microbiologically confirmed bacterial CAP had a negative PCT test result (2). failing to initiate antibiotics in nearly 20% of patients with confirmed bacterial CAP is unacceptable and not a good test! Now you could say but andrew—24% plus 14% is only roughly 40% what about the other 60% of people that didn’t have a confirmed source you cant just throw them out.. sure you are correct and if you include everyone then the egative predictive value of PCT increased to 93.9% (CI, 91.9% to 95.5%). BUT that is still missing 1 in 10 which is a lot! We think NNT of 25 at 2-3 years of a trial are good. This is if we should start therapy for an infection that could kill you or at least put you in the ICU and it is missing 1 in 10! If you really don’t know the diagnosis then can a procal be helpful in the context of the rest of your History and physical, sure, it is not completely worthless it is another data point. However, I will say I almost never order it but if it is already ordered I wont not look at it. My fear is that in much of the country procal became this golden, it can never be wrong, lab test and that is just simply not true. Sure there is an idea to trend procal and maybe we will discontinue antibiotics early but a major of pna is community acquired pna and the recommendations are for only 5 days of antibiotics as is. So maybe you decrease it by a day—is there really that much resistance that occurs from day 4 to day 5?? I doubt it but I have no evidence for or against that statement so I will leave it to you. The Problem of Aducanumab for the Treatment of Alzheimer Disease | Annals of Internal Medicine (acpjournals.org) Fda0 nov 2020- FDA statistician recommended this drug not be approved But via the “accelerated approval” pathway It was approved Accelerated approval is intended for products expected to provide a meaningful advantage over available therapies for a serious disease but for which there is uncertainty about clinical benefit. Under accelerated approval, a drug is approved on the basis of its effect on a surrogate marker of a disease—in this instance, brain β-amyloid levels—rather than clinical outcomes, such as signs or symptoms of Alzheimer disease. I will grant you we have nothing good for alzheimers and I do seriously mean there is no good medication for it but to approve it based on no clinical outcomes is potentially harmful or just a really expensive placebo because it will have no effect just like every other drug we have tried Aducanumab's phase 1 study showed lower levels of β-amyloid levels for those on the drug BUT SADLY aducanumab's phase 3 trials shows an unclear relationship between β-amyloid reductions and cognitive improvements so we have a drug the improves a surrogate outcome of amyloid levels but decreasing amyloid levels have never consistently proven or shown to improve cognitive outcomes EVEN IN THEIR OWN PHASE THREE TRIALS the company says it will continue to do research while the drug is on the market and expect it done by 2030 BUT until that time they are going to be collecting a lot of money for the next 9 years The drug's annual price per patient—$56 000— 56k per patient per yar for the next 9 years on a drug that we don’t know if it works for anything that we care about! This is a sad day—or a sad approval by the FDA and I can only wonder who was paying who to make this happen as the last line of this paper almost perfectly states “The FDA has approved a first-in-class product for Alzheimer disease on the basis of reduction in β-amyloid plaques. We all must wait for evidence of whether this in fact benefits patients." And with that! 

2356 232