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The Clinical Chronicle
EDITION 3
Vijay Sam Nethala
December 05, 2024
Welcome to the Third Edition of The Clinical Chronicle!
Get ready to explore the forefront of medical innovation! In this issue, we’re unpacking the latest breakthroughs, from game-changing treatments to advanced diagnostic techniques that are redefining patient care. Whether you’re seeking practical clinical tips, strategies to navigate residency, or advice for fellowship applications, there’s something here for you. Plus, be sure to check out our events section for must-know conference dates and key deadlines. Stay informed, stay inspired—let’s dive in!
Are we overprescribing statins for primary prevention?
A recent analysis comparing the Predicting Risk of Cardiovascular Disease Events (PREVENT) equations to the 2013 Pooled Cohort Equations (PCEs) suggests that we may be overestimating statin eligibility for primary prevention. Using data from the National Health and Nutrition Examination Survey (2017–2020), researchers found that the average 10-year ASCVD risk was significantly lower with the PREVENT equations (4.3%) compared to the PCEs (8.0%). This discrepancy was most notable among older adults (70–75 years) and Black participants. If the PREVENT equations were applied, the number of adults eligible for statins would drop by 17.3 million, from 45.4 million to 28.3 million. Despite these differences, only 44.1% of those eligible under PREVENT guidelines are currently using statins, underscoring the importance of patient-provider discussions. These findings emphasize the need for more precise risk assessment tools to guide statin therapy and ensure that treatment decisions align with true cardiovascular risk.
Source: JAMA
JAMA
JAMA
In October 2024, the Advisory Committee on Immunization Practices (ACIP) updated pneumococcal vaccination guidelines to recommend vaccination for all adults aged 50 and older, regardless of risk factors. This represents a significant shift from the previous age threshold of 65 for healthy adults and 19 for individuals at higher risk of pneumococcal complications. The change is based on data showing a notable increase in pneumococcal disease starting at age 50 and the potential to reduce cases in underrepresented ethnic and racial groups.
CDC Director Mandy Cohen endorsed this recommendation, emphasizing the importance of protecting adults at an age when their risk begins to rise. Pneumococcal infections can lead to serious illnesses such as pneumonia, meningitis, and bloodstream infections, with older adults being particularly vulnerable. Adults aged 50 and above are encouraged to speak with their healthcare providers to ensure their vaccinations are up to date, especially with the winter respiratory season approaching.
Source: CDC
source web
The updated guidelines for managing glucagon-like peptide-1 (GLP-1) receptor agonists before surgery focus on balancing the risk of aspiration due to delayed gastric emptying with the potential consequences of discontinuing these medications, such as hyperglycemia. These medications, initially designed for type 2 diabetes but now widely used for weight loss, delay stomach emptying, raising concerns about aspiration during anesthesia.
Previously, a 1-week hold for injectables and a 1-day hold for oral GLP-1 drugs was recommended. The new guidance suggests a more patient-specific approach, advising a 24-hour liquid diet before elective surgery to mitigate risks. High-risk patients may require an ultrasound evaluation of stomach contents on the day of surgery. Additionally, for those in the early dose-escalation phase of GLP-1 treatment, elective procedures should be deferred until after this phase, when gastrointestinal symptoms subside.
Patients experiencing symptoms like nausea, vomiting, or abdominal pain should delay surgery, reinforcing the need for comprehensive preoperative evaluations. While the current recommendations are not fully evidence-based, they emphasize shared decision-making, balancing patient safety with the therapeutic benefits of GLP-1 drugs.
Source: ScienceDirect
health.com
The 2024 fellowship Match was the largest ever, with more than 14,000 applicants successfully obtaining positions. According to data from the NRMP, 6,116 programs submitted certified rank-order lists, offering 14,169 fellowship positions. Of these, 11,853 positions (83.7%) were filled, and 74% of programs filled all available spots. Out of 14,034 active applicants, 11,853 (84.5%) secured fellowship positions.
Applicant type:
Some subspecialties were more frequently filled by specific groups:
Highest percentage of U.S. MD graduates:
Gynecologic oncology: 90%.
Minimally invasive gynecologic surgery: 90%.
Female pelvic medicine and reconstructive surgery: 86.2%.
Reproductive endocrinology: 85.5%.
Maternal-fetal medicine: 85.4%.
Highest percentage of U.S. DO graduates:
Brain injury medicine: 46.2%.
Sports medicine: 37.5%.
Emergency medical services: 33.7%.
Forensic pathology: 33.3%.
Pain medicine: 27.1%.
Highest percentage of U.S. citizen international medical graduates (IMGs):
Interventional pulmonology: 23.3%.
Critical care medicine: 22.3%.
Addiction psychiatry: 22.2%.
Nephrology: 21.5%.
Highest percentage of non-U.S. citizen IMGs:
Endocrinology, diabetes, and metabolism: 37.7%.
Nephrology: 36.4%.
Medical genetics: 33.3%.
Interventional pulmonology: 32.6%.
Rheumatology: 31.5%.
Not matching:
About 15% of applicants did not secure a match. While disappointing, AMA’s Dr. John Andrews emphasizes that fellowship applicants are skilled physicians with broad opportunities to practice medicine. Those who don’t match can reapply in future cycles or explore other career pathways.
For those planning to apply for fellowships in the 2025 appointment year, tools like FREIDA™ provide comprehensive data on more than 13,000 accredited residency and fellowship programs.
Source: AMA
NRMP
The belief that acetaminophen is gentle on the stomach is being challenged by new research from the U.K., which found higher risks of gastrointestinal (GI) complications in older adults prescribed the drug. The study analyzed medical records from 1998 to 2018, comparing 180,483 acetaminophen users aged 65 and older to 402,478 non-users. It found that users had a 20% higher risk of developing peptic ulcers, a 24% higher risk of ulcer bleeding, and a 36% higher risk of lower GI bleeding. Other health risks included a 9% increase in heart failure, a 19% rise in chronic kidney disease, and a 7% higher risk of hypertension.
These risks increased with the number of prescriptions. Patients with nine or more prescriptions had a 39% higher risk of uncomplicated ulcers and a 44% higher risk of ulcer bleeding compared to non-users.
The researchers speculated that long-term acetaminophen use might inhibit prostacyclin synthesis, leading to GI damage, and may also cause kidney injury over time. However, the study did not track over-the-counter acetaminophen use or prescriptions beyond the first six months, limiting its scope.
This research raises concerns about acetaminophen’s safety in older adults and suggests reconsidering its use as a first-line pain reliever in this population.
Source: ACRJOURNALS
Pollution's impact on heart health varies by source and region
A study on fine particulate matter (PM2.5) and its association with atherosclerotic cardiovascular disease (ASCVD) mortality found that exposure to certain pollution sources—oil combustion, industrial pollution, coal and biomass burning, and motor vehicles—was linked to increased ASCVD deaths. Risk ratios ranged from 1.04 to 1.07 for these sources. Notably, soil and dust pollution showed no effect on ASCVD, and regional variations were observed: no link was found between motor vehicle pollution and ASCVD in the Southeast, while soil and dust pollution affected only the East and Midwest. Even in areas meeting the National Ambient Air Quality Standards (NAAQS) for PM2.5, ASCVD mortality was still linked to higher PM2.5 exposure, indicating that current standards (PM2.5 < 9 µg/m3) may be inadequate. The study suggests that a threshold of < 5 µg/m3, as recommended by the World Health Organization, should be considered. Despite some limitations like potential exposure misclassification, the findings highlight the importance of addressing region-specific pollution sources and local population factors in air quality assessments.
Source: NEJM
source: thelancet
The Biden administration has proposed a change that would allow Medicare and Medicaid recipients with obesity to access expensive GLP-1 receptor agonists, such as semaglutide (Wegovy) and tirzepatide (Zepbound). Currently, Medicare excludes weight-loss drugs, but CMS now acknowledges obesity as a chronic condition, prompting this shift. Chiquita Brooks-LaSure, CMS Administrator, stated that the revised rule would provide affordable access to treatments for obesity, similar to the coverage available for conditions like type 2 diabetes.
The new policy would cover anti-obesity medications that help reduce and maintain long-term weight loss in individuals with obesity. However, it would not apply to people who are merely overweight without obesity. CMS estimates the total cost for Medicare at $25 billion over the next decade, while Medicaid would incur $14.8 billion in costs, with the federal government covering most of this. CMS has called on drug manufacturers to offer reasonable prices to ensure broader access to these medications.
Source: WHITEHOUSE.GOV
A recent meta-analysis examined the effects of GLP-1 receptor agonists on kidney and cardiovascular disease outcomes across randomized controlled trials (RCTs). The analysis included 85,373 participants from 11 trials, evaluating the impact of these medications on type 2 diabetes patients and individuals with cardiovascular disease but without diabetes.
The findings showed that GLP-1 receptor agonists significantly reduced the composite kidney outcome by 18%, kidney failure by 16%, major adverse cardiovascular events (MACE) by 13%, and all-cause death by 12%, compared to placebo. Additionally, the benefits remained consistent when the SELECT trial (which included participants without diabetes) was factored in. Importantly, the risk of serious adverse events, such as acute pancreatitis and severe hypoglycemia, did not differ between groups, though treatment discontinuation due to adverse events was higher in the GLP-1 group.
These results indicate that GLP-1 receptor agonists significantly reduce clinically relevant kidney and cardiovascular events, offering promising benefits for patients with type 2 diabetes and those at risk for cardiovascular diseases.
Source: thelancet
A randomized clinical trial examined whether continuing renin-angiotensin system inhibitors (RASIs) before major non-cardiac surgery would improve postoperative outcomes compared to discontinuation. The study involved 2222 patients who had been on RASIs for at least 3 months and were scheduled for surgery. Patients were randomly assigned to either continue RASIs up until the day of surgery or to discontinue them 48 hours prior to surgery.
The primary outcome, a composite of all-cause mortality and major postoperative complications within 28 days, showed no significant difference between the two groups, with a 22% complication rate in both the continuation and discontinuation groups (risk ratio 1.02; P=0.85). However, the continuation group had more episodes of hypotension during surgery (54% vs. 41% in the discontinuation group, risk ratio 1.31).
Overall, the study found that continuing RASIs before surgery did not lead to higher postoperative complications than discontinuing them, although it did increase the risk of hypotension during surgery.
source: JAMA
A phase I study of an investigational bumetanide nasal spray for heart failure found it to be well-tolerated and demonstrated bioequivalence to oral and intravenous (IV) forms. The study involved 68 healthy participants and aimed to assess the absorption and safety of the nasal spray. Results showed that the nasal spray had comparable maximum concentration and concentration-time curve to both oral and IV bumetanide, with absorption variability similar to the IV form (27%), while oral bumetanide showed over 40% variability.
The nasal spray also induced similar urine output and had minimal adverse events, with no significant nasal irritation. Bumetanide, a loop diuretic commonly used for fluid overload in acute decompensated heart failure, often requires IV administration when oral absorption declines. The nasal spray offers a potentially more consistent bioavailability due to its absorption through the nasal mucosa.
Although the nasal spray showed promising results, experts noted that further studies are needed to confirm its effectiveness in reducing edema in heart failure patients. She also raised concerns about the ease of use for frail patients, as the nasal spray was administered by a nurse in the trial.
The researchers plan to conduct further trials in heart failure patients. The study also noted that treatment-emergent adverse events were generally mild, with hypovolemia and headache being the most common. No severe or life-threatening adverse events occurred.
Source: ahajournals
In Mayo Clinic Proceedings, experts advise against using certain phrases, termed "never-words," when talking to seriously ill patients. Words like "need" or "just" can shut down discussion, limit options, or unintentionally create a sense of helplessness.
For example, saying, "Your mother needs to be intubated" may prevent further exploration of alternatives. Instead, try, "Her condition is worsening; can we discuss what options we have moving forward?" This encourages a more collaborative conversation.
Similarly, the word "just" in phrases like "We can just focus on comfort care" implies one option is less significant. A better alternative would be, "We can prioritize her comfort while exploring other ways to improve quality of life."
Other examples of rephrasing include:
There's nothing else we can do" becomes, "The current treatment isn't working, but we have options to focus on symptom relief."
Instead of "withdrawing care," say, "We can shift to ensuring comfort, as the current treatment isn't effective."
Replace "Do you want us to do everything?" with, "Let’s talk about what’s most important to you as the situation progresses."
Effective communication is essential for building trust, especially in difficult conversations. Communication experts emphasize that while preparing certain phrases is helpful, doctors should adapt their language to fit each patient and situation. By focusing on empathy and openness, doctors can empower patients to be active participants in their care.
Source: mayoclinicproceedings
The U.S. Department of Health and Human Services (HHS) has announced a final rule that removes clinical research and institutional review board (IRB) approval requirements for kidney and liver transplants between HIV-positive donors and recipients. This change, part of the HIV Organ Policy Equity (HOPE) Act, is based on evidence showing the safety and effectiveness of such transplants.
By expanding the pool of available organs, the rule aims to reduce wait times and improve outcomes for transplant recipients with HIV. It also addresses health inequities and reduces stigma associated with HIV, helping more patients access life-saving transplants.
HHS Secretary Xavier Becerra emphasized the importance of removing barriers to care, while Assistant Secretary for Health Admiral Rachel L. Levine, M.D., highlighted the policy's evidence-based approach. This change builds on the administration's commitment to health equity and improving care for people with HIV.
The final rule applies specifically to kidney and liver transplants, with further research being conducted for other organ transplants like the heart, lungs, and pancreas. The NIH is seeking public comment on revisions to research criteria for these additional organs under the HOPE Act.
Source: HHS.GOV
A novel asthma burden score, incorporating asthma exacerbations and healthcare utilization, has shown promise in better reflecting disease severity and predicting asthma remission. This score, developed using data from two longitudinal asthma cohorts, demonstrated high sensitivity and specificity in predicting remission. A score of 0.15 or lower predicted remission with over 91% sensitivity and 99% specificity. The higher the burden score, the worse the lung function, asthma control, and quality of life.
The study, led by Joe Zein, MD, PhD, from Mayo Clinic, challenges existing treatment-based severity scores that fail to consider factors like symptom frequency and functional limitations. The proposed score includes factors such as exacerbations, emergency visits, hospitalizations, and SABA use, with weighted disability-adjusted life-years to reflect the real-world impact of asthma.
This score, based on data from the Severe Asthma Research Program (SARP III) and U-BIOPRED cohorts, correlates with increased asthma burden and inflammatory pathways. It also highlights a potential shift from traditional type 2 (T2) asthma mechanisms, with neutrophils showing a stronger link to asthma burden than eosinophils or exhaled nitric oxide.
While the score provides a comprehensive view of asthma's impact, study limitations include cohort differences, lack of data on exacerbations before the study, and reliance on self-reports for medication adherence. Further research across diverse populations and asthma severities is needed.
Source: thelancet
Upcoming Events & Deadlines
DDW 2025: Abstract submission Deadline: December 5, 2024
Society of Hospital Medicine (SHM): 22nd - 25th April, 2025
ACP 2025: April 3-5 New Orleans, LA