Questioning Medicine

https://heart.bmj.com/content/108/12/964https://www.ahajournals.org/doi/10.1161/JAHA.116.003815We have a study that says leads to increase all cause death with calcium supplementsWe have a study that says calcium supplement leads to increase in coronary artery calcium Foods that are high in calcium besides dairy include things like kale, spinach, broccoli, chia sees, collard greens…Hard for me to believe someone with a diet of excess kale and spinach will have an increase in all cause mortality anytime soon. It is easy for me to believe that supplements in a pill don’t fix the problems like we wish—we see this all the time with some many electrolytes and nutrients—there is a difference between taking a pill and eating a nutritious diet

https://evidence.nejm.org/doi/full/10.1056/EVIDoa2300311Peanut consumption, starting in infancy and continuing to age 5 years, provided lasting tolerance to peanut into adolescence irrespective of subsequent peanut consumption, demonstrating that long-term prevention and tolerance can be achieved in food allergy. (Funded by the National Institute of Allergy and Infectious Diseases and others; ITN070AD, ClinicalTrials.gov number, NCT03546413.)

https://jamanetwork.com/journals/jama/article-abstract/2819352Conclusions and Relevance  In this study, 10 years after diagnosis, 49% of men remained free of progression or treatment, less than 2% developed metastatic disease, and less than 1% died of their disease. Later progression and treatment during surveillance were not associated with worse outcomes. These results demonstrate active surveillance as an effective management strategy for patients diagnosed with favorable-risk prostate cancer.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11179824/This study did something smart in that they broke it down by white black Chinese and then also had 36 lab test they were looking at and they then found look for a black male this one particular blood test apo2 or whatever had better predictive value but that is cherry picking data with lots of data points and we don’t have risk calculators just for black or just for white or just for Chinese population. Blood test are hot things – we want to be able to drill down someone risk to a factions of a nats rear end but that just isn’t life—all the test and decision tools give us a rough estimate—the goal is to know are we looking at an 8% risk, an 18% risk or a 28% risk. It doesn’t really matter if it is 8.2  or 8.3 or 8.4 Botoom line—I get it we want to do more and be more precise but by getting extra blood test we are also costing the system more money and more energy so until you give me a study that shows it better with then a usuable risk calculator for that particular lab I think the use of these extra lipid labs should stay on the shelf or in the research only setting.

https://www.nejm.org/doi/full/10.1056/NEJMoa2309002In this placebo-controlled trial, postexposure prophylaxis with nirmatrelvir–ritonavir for 5 or 10 days did not significantly reduce the risk of symptomatic SARS-CoV-2 infection.https://www.nejm.org/doi/full/10.1056/NEJMoa2309003https://www.nejm.org/doi/full/10.1056/NEJMoa2118542Pfizer has some serious problems! #pfizer

Risk of Nonarteritic Anterior Ischemic Optic Neuropathy in Patients Prescribed Semaglutidethis paper out in JAMA makes you think this is an issue but likely just too much noise with only 17 patietns and didnt control for confoundershttps://jamanetwork.com/journals/jamaophthalmology/fullarticle/2820255

Be careful, most observational data have a large amount of confounders not accounted for and even when accounted for you can never account for all the confounders

https://www.ahajournals.org/doi/10.1161/CIR.0000000000001251. Diagnosis:To establish a PAD diagnosis, the resting ankle–brachial index (ABI) remains the initial test of choice in patients with suggestive history or exam findings. The ABI result should be reported as normal (1–1.4), borderline (0.91–0.99), abnormal (≤0.9) or noncompressible (>1.4). TREATMET Low-dose rivaroxaban 2.5mg BID, in addition to daily aspirin, is now recommended to decrease the risk for major adverse cardiovascular events (MACEs) and major adverse limb events in patients with symptomatic PAD who are not at increased bleeding risk. This is based on the COMPASS trial Cardiovascular Outcomes for People Using Anticoagulation Strategies - American College of Cardiology (acc.org) and as a reminder inclusion criteria was “Atherosclerosis in ≥2 vascular beds or two additional risk factors (current smoking, diabetes, renal insufficiency, heart failure, or nonlacunar ischemic stroke ≥1 month)” In pts with symptomatic PAD—single antiplatelet with clopidogrel 75mg daily (NOT ASPIRIN) to lower risk of MACE. If the patient can’t get clopidogrel then aspirin will work but clopidogrel preferred!  In patients with PAD and type 2 diabetes, the use of glucagon-like peptide-1 (GLP-1) agonists and sodium–glucose cotransporter-2 (SGLT-2) inhibitors are effective to reduce MACE.

https://jamanetwork.com/journals/jama/article-abstract/2818624Conclusion--“Cardiovascular biomarkers were strongly associated with fatal and nonfatal cardiovascular events and mortality. The addition of biomarkers to established risk factors led to only a small improvement in risk prediction metrics for atherosclerotic cardiovascular disease, but was more favorable for heart failure and mortality.” For 10-year incident atherosclerotic cardiovascular disease in younger people (aged <65 years), the combination of high-sensitivity cardiac troponin I, N-terminal pro-B-type natriuretic peptide, and high-sensitivity C-reactive protein resulted in a C statistic improvement from 0.812 (95% CI, 0.8021-0.8208) to 0.8194 (95% CI, 0.8089-0.8277)  So this paper is saying look “Cardiovascular biomarkers were strongly associated with fatal and nonfatal cardiovascular events and mortality.” Not wrong these labs improve outcomes but when you look at the c stats we go from 0.81 to 0.82… remember as we talked about yesterday C-statistic gives the probability a randomly selected patient who experienced an event (e.g. a disease or condition) had a higher risk score than a patient who had not experienced the event. A score of 1 is perfect. A score of 0.5 is a coin flip. A score of .8 is pretty good but the question we have to ask ourselves “is there a difference between 0.81 and 0.82. If you are getting a grade in school is there a real difference in the knowledge between someone that gets 81% and gets 82%. Bottom line- Authors might say something is beneficial and great but if they give you the c statistics you will know weather it is actually beneficial because now you know cstatics and how to use it within a study.

What are c statisticsC-statistic gives the probability a randomly selected patient who experienced an event (e.g. a disease or condition) had a higher risk score than a patient who had not experienced the event.Obviously there are people with low scores that still have events and people with high scores that never have events but the goal is the decision score gives us an idea of who is most likely. ·       The idea or educated estimate can be turned into a C score-  and c scores are kind of like grades== a score of 1 is absolue perfect model it means the model perfectly predicts those group members who will experience a certain outcome and those who will not.·       But we know in medicine that isn’t possible  IF ·       A value of 0.5 means that the model is no better than predicting an outcome than random chance.·       Values over 0.7 indicate a good model.·       Values over 0.8 indicate a strong model.