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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 4

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: 

We've got so many incredible pearls this week with Dr. Rebecca Sudore in 
Episode #295 Advance Your Care Planning


Alyssa Mancini MD and Nora Taranto MD 
Delivered in super tasty, bite-sized morsels. 
(And if these summaries are a little too long and you just want a one-liner for each, click HERE
  • For patients with mild to moderate acute pancreatitis, starting a low-fat solid diet upon hospital admission may mean a shorter hospital stay and fewer complications. A multi-center RCT recently published in Annals of Surgery looked at how timing of diet initiation affected hospital length-of-stay (LOS), complication rate, and health costs (among other things) in patients with mild to moderate acute pancreatitis. Patients who were started on a low-fat solid diet immediately had a mean LOS of 3.4 days compared to 8.8 days for those who were started on a progressive diet only once things started to improve (clinically and based on labs). They also had fewer complications (8% vs. 26%), and health costs were twice as low. 
  • In adult patients with obesity, bariatric surgery is associated with lower all-cause mortality and longer life expectancy, compared to usual care. A meta-analysis published in Lancet, which included nearly 175,000 participants, found that bariatric surgery was associated with a reduction in the hazard rate of death of 49.2% and a median life expectancy that was 6.1 years longer than with usual care.  These survival benefits were much more pronounced for people with pre-existing diabetes than those without. Notably, treatment effects did not differ between gastric bypass, banding, and sleeve gastrectomy. Refer early and often to metabolic/bariatric clinics--they often have multidisciplinary teams at their disposal who can approach metabolic syndrome and its consequences in novel and life-prolonging ways! 
  • Contrary to popular belief, coffee consumption may actually be associated with a lower risk of cardiac arrhythmia(!).  JAMA Internal Medicine recently published a prospective cohort study of more than 300,000 participants (mean age 56, a little more than 50% female) that found that each additional daily cup of coffee was associated with a 3% reduced risk of developing an arrhythmia (i.e. atrial fibrillation or flutter, SVT, VT, PACs, and PVCs). This was after adjustment for demographics, comorbid conditions, and lifestyle habits. They also found that associations were not significantly modified by genetic variants that affect caffeine metabolism. So really, how much coffee is too much coffee?!
  • The AHA/ASA have released their latest Guidelines on Secondary Stroke/TIA Prevention, recommending only single-agent anti-platelet/anticoagulant therapy daily for most patients and intense risk factor modification, with dual anti-platelet therapy or additional anticoagulation depending on clinical factors. They recommend a thorough diagnostic workup (See Figure 2), including EKG, imaging to confirm stroke and evaluate for carotid stenosis, and labs to assess risk factors. Anticoagulation in Atrial Fibrillation should be initiated regardless of CHADS-Vasc score, as should tight blood pressure and cholesterol/triglyceride control. The Guidelines also emphasize the importance of lifestyle modifications, including exercise, smoking cessation, and sodium restriction/Mediterranean diet adherence for all patients. 
  • Here’s the uncertain skinny on Ivermectin.  Last week, we talked about the JAMA-published double-blind RCT on Ivermectin in COVID, which found no difference in median time to resolution of symptoms.  A Cochrane Review on Ivermectin in COVID from July ‘21 has now evaluated the evidence in 14 studies (1678 participants) comparing Ivermectin to no treatment, placebo, or standard of care (but not compared to any intervention with proven efficacy).  Doses and treatment duration varied, and ⅓ studies were judged to be at high risk of bias.  Most of the studies were small, with few events (death or need for ventilation).  They reported conflicting results, with most confidence intervals crossing 1--i.e. low-certainty evidence. There are 31 trials ongoing.  TLDR: The Cochrane jury is still out, and uncertain as to whether Ivermectin is safe or better than no treatment, placebo, or standard of care for COVID-19 infection.

Palate Cleanser 

Nora Taranto MD
This week, we are taking a pause to remember
September 17th is National Physician Suicide Awareness Day.   
Too many of us in medicine have had experiences with depression, mental health challenges, or suicide among close friends, family members, colleagues, or ourselves in our careers (listen to Curbsiders Ep. #129 for an in-depth and real discussion of depression and suicide in medicine with expert Dr. Elizabeth Poorman). The mental health crisis in medicine has only grown as the trauma of providing medical care has increased during the COVID Pandemic.  Burnout doesn’t even begin to describe this problem.  We remember those we have lost to suicide in our profession, in September and always, and we seek to improve our community supports and the culture of silence in medicine. We will do better. 
If you are suffering in silence, please know that you are not alone.  Reach out to your supports (whether that’s a friend, a loved one, a dean, a program director, or an anonymous help line) so that they--and we--can help support you through this. 

If you are seeking help (or this is triggering, given the sensitivity of the topic), the national suicide hotline number is 1-800-273-8255.  If anyone needs or wants guidance on available resources,  please reach out to us on twitter or over email. We are happy to talk and see that you get the support you need. 

The Main Course

Alexander Chaitoff MD, MPH 
The Vaccine Mandate

What's Happening?
On September 16th, the Biden Administration provided more details about the executive orders requiring most federal employees and contractors “without a legally required exception…to be fully vaccinated by November 22, 2021, regardless of where they are working.”

Déjà vu?
With all the vaccine mandate news floating around, you’d be forgiven for thinking you’d heard this news before.  A host of companies, ranging from Google to Walmart, have announced mandates for at least portions of their staff, and many health systems have also implemented vaccine mandates over the last several months, with consequences such as job termination for those who fail to comply and have no exemption. The Biden Administration actually first made a splash with their executive orders two weeks ago on September 9, but the initial executive orders were light on details.  We now have more important practical information required for operationalizing the orders.  This means figuring out who is covered, the timeline for implementation, and what documentation should be kept by which agencies.
What’s OSHA? And What's Next? 
It’s now the Occupational Safety and Health Administration’s (OSHA) turn to make vaccine mandate headlines. Created in 1970, the agency was created to police workplace safety, and unlike the most recent executive orders, its power extends to the private sector.   The Biden Administration has instructed them to issue a COVID-19 Vaccination Emergency Temporary Standard (ETS) to require vaccination that could soon affect over 80 million private sector workers. 

The ETS process, first laid out in the OSH Act of 1970, allows the Department of Labor to issue and enforce rules when it finds situations of “grave danger” to workers--like the COVID-19 Pandemic.  The last ETS was issued in June 2021 regarding healthcare workplace safety to minimize the spread of COVID.  Before that, the ETS clause had not been utilized in almost 40 years, given court involvement for many of the 10 ETS issuances since OSHA’s creation.  The details of the timeline and enforcement for the mandate still remain unclear (but check out this Congressional Research Service Report on COVID and ETS for more).  Only time will tell how the current executive orders and upcoming private sector mandates, combined with other company-specific mandates, will affect the labor market, vaccination rates, and public health.
Read the full Executive Order Here
Read about Vaccine Mandate Implementation Details Here


Before you go....
This week, we had a TON of amazing picks of the week on the Pod. They were too good not to share, so we’re including them here for all of you! 
And, because I can’t help myself, and I watch way, way too much TV, I’ll also give one. We’re going to the year 2000. We’re going back to middle school. We’re going female comedy. It’s very exciting, utterly cringe worthy, and also hilarious and heart-warming.  Yes, it’s PEN15. (Nora)

Comments for the Chef

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Thanks so much for joining us on this new adventure (and share with all your friends so they can reserve their own copy here!).

Until next time, keep that brain hole digesting! 

The Curbsiders Digest
Vol. 1, Issue 4 

Editor in Chief: Nora Taranto MD
Banner: Kate Grant  MBChB, DipGUMed

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