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The Curbsiders Digest!

Effortlessly absorb important medical news, with our twice monthly newsletter featuring easily digestible analysis of the latest practice-changing articles, and of course...bad puns. 


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Volume 1, Issue 5

Appetizers (to whet your appetite) 
Palate Cleanser (aka the melon part of the meal) 
The Main Course
A Digestif or two 

This Week on The Curbsiders: 

There are so many pain pearls in Episode #299 with Dr. Melissa Weimer, it'll make your neurons go wild!  


Brought to you hot off the stove, from a variety of specialties.
Delivered in super tasty, bite-sized morsels.
  • The higher the LDL over time, the greater the risk of heart disease (as the statin-lovers were hoping would be the case), per this JAMA Cardiology study.  This cohort study looked at 18288 individuals between 1971 and 2017 and measured LDL exposure during young adulthood and middle age, as well as incidence of coronary heart disease (CHD), ischemic stroke, and heart failure.  Cumulative LDL exposure during young adulthood and middle age was associated with greater risk of coronary artery disease, regardless of what midlife LDL level might be--but not associated with an increased risk of ischemic stroke or heart failure.  Statins should be in the water, it seems.
  • You needn’t immediately drain infected, necrotizing pancreatitis. This NEJM randomized superiority trial by the Dutch Pancreatitis Study Group looked at immediate drainage (within 24 hours of diagnosis) versus later drainage, and compared rates of complications within 6 months.  104 patients were enrolled after diagnosis (via CT or FNA) of infected, necrotizing pancreatitis and divided between immediate and postponed drainage. There was no significant difference in Comprehensive Complication Index between groups.  19 patients in the postponed-drainage group were treated only with antibiotics.  Think twice about sending your patients immediately for drainage--some may be able to avoid drainage all together. 
  • Don’t give probiotics to your ventilated patients to prevent pneumonia, according to this randomized-control trial in JAMA.  Ventilator-associated pneumonias (VAPs) are a huge, difficult-to-prevent problem for intubated patients in the ICU. To test the theory that probiotic administration might help prevent bad bacterial overgrowth and infection, this international study randomized > 2500 pts in 44 ICUs to receive enteral Lactobacillus or placebo. Rates of VAP were similar between groups, including across subgroups, and there were no differences in duration of ventilation or ICU stay,  nor in incidence of diarrhea or C.Diff infection.  11 patients (in the probiotic group) had Lactobacillus in the blood. For now, keep that probiotic yogurt away from your ventilated patients! 
  • Consider recommending cycling to adult patients with diabetes, when counseling on lifestyle modifications. This prospective cohort study published in JAMA Internal Medicine, which included nearly 7500 adults with diabetes from the EPIC study, found that cycling was associated with a 24% lower all-cause mortality rate when compared with noncyclists, and that, over 5 years, cyclists had a 35% lower risk of all-cause mortality when compared with consistent noncyclists. However, results also suggested that those who initially cycled and then stopped by the 5-year mark lost the mortality benefit. Counsel your patients that they’d benefit the most if they stay in it for the long haul. 
  • Wondering when to refer patients with obstructive sleep apnea (OSA) for surgery? The American Academy of Sleep Medicine (AASM) recently published new recommendations in Journal of Clinical Sleep Medicine (also featured in ACP Internist Weekly). The AASM made strong recommendations (i.e. they recommend) that clinicians  should discuss referral to a sleep surgeon with adults who have OSA and BMI < 40 who do not tolerate or accept positive airway pressure (PAP), and referral to a bariatric surgeon with adults who have OSA and BMI > 35 who do not tolerate or accept PAP (and where there’s overlap, would discuss referral to both).

Palate Cleanser 

The melon part. To get rid of the taste of those pesky apps, and fill your brain with some fun facts. 

Ever wondered
about when and how we started being able to transfuse blood? Paul Offit lends a nice perspective and history from the lens of evaluating risk in The Scientist. 

The history of transfusion bleeds all the way back to 1665, when Richard Lower performed live transfusions between a healthy and a bleeding dog, and the dog survived.  Several animal-to-human transfusions were performed, with patients experiencing transfusion reactions but ultimately surviving.  Shortly after, the Pope banned transfusions (too close to playing God). Then we skip several centuries, and in 1901, a young Viennese researcher identified red blood cell surface markers (A/B), and saw destruction of blood from folks with one type of blood when mixed with the other--this was the foundation of human-to-human transfusions which began in 1907 at Mount Sinai.  With the introduction of sodium citrate to preserve blood, blood banks were established--and the infectious risks of receiving transfusion began to be quantified (from measles, malaria, and syphilis, to hepatitis B and C, and HIV).  Tests were then developed to screen blood for viruses. Since then, transfusion-associated infections plummeted. 

What infections do we test blood for today?  Blood is now tested for Hepatitis B and C, HIV, West Nile, Zika, and several different bacteria (See the CDC list for more details).  But by no means do we test for everything--and the tests that we perform on blood vary by state depending on endemic nature of, say, tick-borne diseases like Babesia.

The Main Course

The DOAC Bleeding Dilemma: Today, we’re diving into the literature on GI bleeding and direct-acting oral anticoagulants (DOACs).  We start patients on DOACs somewhat frequently in the hospital, after diagnosis with a pulmonary embolism, deep vein thrombosis, or atrial fibrillation. And perhaps just as commonly, we’re trying to figure out what to do with anticoagulation after GI bleed.  But how do we choose to minimize that risk of GI bleed, and is there a right initial choice? Here, we discuss a new study in the Annals of Internal Medicine looking at how the different bleeding risks compare among different DOACs, and the increased risk of GI bleed with rivaroxaban. 

Breaking it down: In this nationwide, population-based cohort study in Iceland, Ingason et al. found a higher rate of GI bleed in patients on rivaroxaban, compared to apixaban and dabigatran. They looked at bleeding rates in 5868 patients newly on any of the three DOACs from 2014 to 2019 at national hospitals ( 2157 on apixaban, 494 on dabigatran, and 3217 on rivaroxaban).  For both apixaban and rivaroxaban, 80% were on standard dose and 20% were on low dose (dabigatran had roughly equal standard and low-dose cohorts).  Patients were followed until 2019, until the primary end point (GI bleed) occurred, or until a switch of DOAC, with a mean follow-up time of 1.2 - 1.8 years, depending on the DOAC. There were 241 overall GI bleed events, with 56% (135) lower GI bleeds  and 61% (146)  major bleeding events.  Patients on rivaroxaban had higher rates of overall and major GI bleed compared to apixaban (3.2 vs 2.5 events per 100-person-years/Hazard Ratios of 1.42/CI 1.04-1.93 and 1.9 vs 1.4 events per 100-p-y/HR1.5/CI 1-2.24, respectively). Rivaroxaban compared to dabigatran had similar increased risk, though, notably, the confidence intervals were wider and crossed zero. 

What does this mean? Several prior studies (See 2017 Am J Cardiology and 2017 Gastroenterology studies for more) based on US claims data had already found GI bleeds occurred more frequently among rivaroxaban users, though these studies notably focused on patients with medicare (and therefore a majority older than 65).  Other studies in patients with cancer have found increased risk of GI bleed for patients on DOACs compared to heparin products for patients with GI malignancies, but the jury’s still out on how the DOACs compare to one another in this population.  The novelty: This study required chart confirmation to identify location of GI bleed, did not limit the indication for anticoagulation to atrial fibrillation, and found a higher event rate of GI bleed than other studies.  The limits:  The small size of the dabigatran group, the wide confidence intervals, and the difference in rate of low versus standard dose administration in this group compared to the other two.  Overall, this study builds upon prior meta-analyses suggesting that Rivaroxaban is associated with higher GI bleeding rates than other DOACs, perhaps because of once daily dosing and therefore higher peak plasma concentrations (some also posit better adherence, because of the daily dosing).
Read the original study here.
Consolidate your learning! Take our Quiz (ok, so it’s only 2 questions...)

Molecular Gastronomy 

Post-vasectomy ejaculation counting is a thing. A UK study in BMJ Sex Reprod Health compared strategies to help patients submit their semen samples for analysis to confirm vasectomy occlusive success. They were given the choice to submit the sample in person or mail a sample in for analysis.  79.5% compliance of patients that mailed their samples for analysis, compared to 59.1% of in-person submission. Not only was it more convenient but it also allowed more patients to receive clearance to discontinue other contraception, or news of vasectomy failure at 3 months. The postal service is reliable and convenient! 


Before you go....
  • A teaser: We’ll talk next digest about the USPSTF recommendations cautioning against low-dose aspirin for primary prevention of CVD, given the risk of bleeding. If you want to check it out early, read more here.
  • Comments for the Chef: Please share your feedback and ideas in this Survey!

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Until next time, keep that brain hole digesting! 

The Curbsiders Digest
Vol. 1, Issue 5 

Editor in Chief: Nora Taranto MD
Appetizers: Alyssa Mancini MD, Nora Taranto MD 
Palate Cleanser and Main Course: Nora Taranto MD 
Molecular Gastronomy: Kate Grant  MBChB, DipGUMed
Banner: Kate Grant  MBChB, DipGUMed

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