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Initiating Pharmacologic Treatment in Tobacco-Dependent Adults. An Official American Thoracic Society Clinical Practice Guideline
https://www.atsjournals.org/doi/full/10.1164/rccm.202005-1982ST

ultimate take home- varenicline is first line!!
For Tobacco-Dependent Adults in Whom Treatment Is Being InitiatedShould Treatment Be Started with Varenicline or a Nicotine Patch?
40 more per 1,000 patients; Compared with a nicotine patch, varenicline increased long-term abstinence, measured at 6-month follow-up (RR, 1.20; 95% CI, 1.09 to 1.32; ARR, 40 more per 1,000 patients;)
For Tobacco-Dependent Adults in Whom Treatment Is Being Initiated Should Treatment Be Started With Varenicline or Bupropion?
77 more per 1,000 patients taking Varenicline increased tobacco abstinence at 6-month follow-up compared with bupropion (RR, 1.30; 95% CI, 1.19 to 1.42; ARR, 77 more per 1,000 patients;)
who andrew so just varenicline by itself?? thats it??
should Treatment Be Started with Varenicline plus Nicotine-Replacement Therapy or Varenicline Alone?
105 more per 1,000 patients; taking Varenicline plus a nicotine patch significantly increased abstinence compared with varenicline alone, (RR, 1.36; 95% CI, 1.07 to 1.72; ARR, 105 more per 1,000 patients; 95% CI, 21 more to 211 more; high certainty in the estimated effects)

they mention ecigs vs varenicline and admit we dont have direct evidence but indirect evidence says varenicline is better but they admit because we dont have good evidence and all we have is indirect evidence then base on that go with varenicline but it is given a conditional rec with very low certainty of evidence.


In Tobacco-Dependent Adults Who Are Not Ready to Discontinue Tobacco Use, Should Clinicians Begin Treatment with the Optimal Controller or Wait Until They Are Ready to Stop Tobacco Use?
to me this was huge maybe one of the biggest recommendation because I always wait till the person is ready to stop but in studies where people could stop or were not interested in stopping those started on varenicline were more like to stop smoking. my mind was blown!! and the evidence on this gives a strong recommendation, with moderate certainty in the estimated effects.
infact 173 more per 1,000 smokers were able to stop smoking at 6 months after starting varenicline despite the provider not waiting for affirmation of readiness (RR, 2.00; 95% CI, 1.70 to 2.35; ARR, 173 more per 1,000 patients; 95% CI, 121 more to 234 more; high certainty in the estimated effects).

Tobacco-Dependent Adults with Comorbid Psychiatric Conditions, Including Substance-Use Disorder, Depression, Anxiety, Schizophrenia, and/or Bipolar Disorder, for Whom Treatment Is Being Initiated, Should Clinicians Start with the Optimal Controller Identified for Patients without Psychiatric Conditions or Use a Nicotine Patch?
“boxed warning regarding possible neuropsychiatric adverse events for both varenicline and bupropion. These concerns stemmed from case reports and postmarketing surveillance, as no RCTs found evidence for these events and early observations suggested no significant increase in neuropsychiatric adverse events with pharmacotherapy compared with placebo, even among patients with preexisting mental illness.”
to summarize --with moderate certainty
compared with nicotine patches, varenicline 1) may result in a large benefit for nicotine abstinence and 2) compared with nicotine patches, varenicline would likely result in little to no difference in SAEs

and last but not least- if you are given the choice to write a script for an Extended-Duration (>12 wk) or Standard-Duration (6–12 wk) then with a strong recommendation and moderate certainty in the estimated effects you should always chose the longer- go with 12 weeks!





Guntupalli SR et al. Safety and efficacy of apixaban vs enoxaparin for preventing postoperative venous thromboembolism in women undergoing surgery for gynecologic malignant neoplasm: A randomized clinical trial. JAMA Netw Open 2020 Jun 1; 3:e207410.

Following surgery for gynecologic malignancies, The American Society of Clinical Oncology has developed guidelines for postoperative VTE prophylaxis and they recommend almost 1 month of subcutaneous low-molecular-weight heparin is recommended to prevent venous thromboembolism (VTE); however, patients' hate this!! giving shots!
randomized trial of 28 days of subcutaneous enoxaparin (40 mg daily) versus oral apixaban (2.5 mg twice daily) in 400 women (median age, 58) undergoing open or minimally invasive surgery for gynecologic cancer.
primary end point of this study was the incidence of major bleeding events occurring during the treatment phase and in the 30 days after treatment.
Major bleeding was defined as fatal bleeding and/or symptomatic bleeding in a critical area or organ or bleeding requiring the transfusion of 2 units of packed red blood cells.
Major bleeding was limited to one participant in each group, incidence of clinically relevant nonmajor bleeding (hematoma, bruising, epistaxis, and vaginal bleeding) was similar between groups (12 [apixaban] and 19 [enoxaparin]), and VTE occurred in 2 and 3 patients, respectively.
In the apixaban group, satisfaction was greater regarding ease of use (99% vs. 59%; Phaters will say --This study was underpowered because incidence of VTE and bleeding events was soooo much lower than anticipated, They are not wrong- they wanted to be able to tell a difference of 6% between the two groups but over all there were only 31 cases of bleeding in both groups which is only 7% of the whole population!! so very low rates of the primary outcome which likely can be attributed to the 90% compliance rate seen in this trial. over all I think we are seeing that the bans and trans work for anticoag in those with or without cancer

Carbone PS et al. Primary care autism screening and later autism diagnosis. Pediatrics 2020 Jul 6; [e-pub]. (https://doi.org/10.1542/peds.2019-2314)

screening instruments for autism spectrum disorder (ASD), such as the Modified Checklist for Autism in Toddlers (MCHAT), are ideal- we screen for autism and we catch these children with autism at 6-12-18 months!! what a great tool we an get them early treatment and therapy!! right
researchers examined electronic medical record (EMR) for 36,000 children who had 18- or 24-month well-child visits from 2013 to 2016.
same toddlers' charts were subsequently reviewed for autism diagnosis codes in 2019, was they were almost 5 yrs old. 67% of children with Autism had screened negative at 18- and/or 24-month visits-- which means the Modified Checklist for Autism in Toddlers (MCHAT), has a sensitivity, 33%), and the positive-predictive value was only 18%.
and that is a terrible screening test- but this is important to know because parents mght get a false sense of security. having a child with autism is by no means the end of the world but having a child with autism after they test negative for what you may think as the autism screening test would be shocking and something we should prepare parents for.



Link JO et al. Clinical targeting of HIV capsid protein with a long-acting small molecule. Nature 2020 Jul 1; [e-pub]. (https://doi.orLink JO et al. Clinical targeting of HIV capsid protein with a long-acting small molecule. Nature 2020 Jul 1; [e-pub]. (https://doi.org/10.1038/s41586-020-24038

We have many antiretroviral medications, but they require daily dosing, this is a problem.
what if we had a long acting hiv med???? GS-6207, now named lenacapavir, might be the answer is and entering phase 2/3 studies, it is dosed every 6 months.
In a study of healthy participants, a single subcutaneous injection produced GS-6207 levels that exceeded the concentration needed to inhibit HIV for >24 weeks. In a separate study, involving people with HIV, a single 450-mg subcutaneous injection of GS-6207 led to a decline in HIV RNA levels of 2.2 log10 copies/mL.