Editor's Choice
RCT: Lower oxygenation target improves days alive without life support in severe COVID-19 hypoxemia
21 Mar, 2024 | 13:46h | UTCStudy Design and Population: This multicenter randomized clinical trial investigated the impact of different oxygenation targets on the survival of adult patients with COVID-19 and severe hypoxemia in the ICU. Conducted across 11 European ICUs from August 2020 to March 2023, the study involved 726 patients requiring at least 10 L/min of oxygen or mechanical ventilation. Participants were randomly assigned to receive an oxygenation target of either 60 mm Hg (lower oxygenation group, n=365) or 90 mm Hg (higher oxygenation group, n=361) for up to 90 days.
Main Findings: The primary outcome was the number of days alive without life support at 90 days post-intervention. Patients in the lower oxygenation group achieved a median of 80.0 days alive without life support compared to 72.0 days in the higher oxygenation group, a difference that was statistically significant (P=0.009). Although there was a slight reduction in mortality at 90 days in the lower oxygenation group (30.2% vs 34.7% in the higher group), this was not statistically significant. No significant differences were observed in the proportion of patients with serious adverse events or the number of days alive and out of hospital.
Implications for Practice: Targeting a lower Pao2 of 60 mm Hg in ICU patients with COVID-19 and severe hypoxemia appears to increase the days alive without life support compared to a higher target of 90 mm Hg, without increasing serious adverse events. This finding suggests that a lower oxygenation target could be more beneficial for this patient population, potentially guiding clinical practice in managing oxygen therapy for severe COVID-19 cases.
Reference
Reference: Nielsen FM et al. (2024). Randomized Clinical Trial: Effect of Oxygenation Targets on Survival Without Life Support in COVID-19 Patients with Severe Hypoxemia. JAMA, Published online March 19, 2024. DOI: 10.1001/jama.2024.2934. Access the study here: [Link]
Cohort Study: Elevated autism spectrum disorder risk in children exposed to valproate during pregnancy
21 Mar, 2024 | 13:16h | UTCStudy Design and Population: This cohort study utilized two health care utilization databases in the United States, covering the period from 2000 to 2020, to investigate the association between prenatal exposure to antiseizure medications and the risk of autism spectrum disorder (ASD) in children. The study compared children exposed to topiramate, valproate, or lamotrigine during the second half of pregnancy to those unexposed to any antiseizure medication, specifically focusing on a population-based cohort of pregnant women and their offspring.
Main Findings: The cumulative incidence of ASD at 8 years of age was found to be higher in children exposed to these medications compared to the general population. Notably, the incidence was 6.2% for children exposed to topiramate, 10.5% for valproate, and 4.1% for lamotrigine among children born to mothers with epilepsy. However, after adjusting for potential confounders, the increased risk of ASD remained significant only for valproate exposure, with a hazard ratio of 2.67, indicating a substantial risk compared to unexposed children. Topiramate and lamotrigine showed no significant increase in risk after adjustment.
Implications for Practice: The findings underscore the importance of carefully considering the risks and benefits of using antiseizure medications during pregnancy. Specifically, valproate should be used with caution, if at all, given its significant association with an increased risk of ASD in offspring. This study supports the need for targeted counseling and monitoring of pregnant women with epilepsy and highlights the necessity for further research to fully understand the neurodevelopmental impact of prenatal exposure to antiseizure medications.
Reference: Sonia Hernández-Díaz et al. (2024). Cohort Study: Assessing Autism Spectrum Disorder Risk in Children Exposed to Antiseizure Medications During Pregnancy. N Engl J Med, 390(13), 1069-1079. DOI: 10.1056/NEJMoa2309359. Access the study here: [Link]
Meta-Analysis: No mortality benefit of early vs. delayed/selective coronary angiography in out-of-hospital cardiac arrest without ST-elevation
21 Mar, 2024 | 11:40h | UTCStudy Design and Population: This article presents a systematic review and meta-analysis of five randomized controlled trials comparing early/immediate versus delayed/selective coronary angiography (CAG) in 1512 patients who experienced out-of-hospital cardiac arrest (OHCA) without ST-segment elevation. The population had a mean age of 67 years, with 26% female and 23% having a prior myocardial infarction. Follow-up duration was at least 30 days across included studies.
Main Findings: The analysis revealed no significant difference in the odds of all-cause death between early/immediate and delayed/selective CAG strategies (Odds Ratio [OR] 1.12, 95% CI 0.91–1.38). Similar results were found for the composite outcome of all-cause death or neurological deficit (OR 1.10, 95% CI 0.89–1.36). Subgroup analysis showed no significant effect modification based on age, initial cardiac rhythm, history of coronary artery disease, the presumed ischemic cause of arrest, or time to return of spontaneous circulation. Interestingly, a trend toward increased odds of death was observed in women receiving early CAG compared to men, although this finding approached but did not reach statistical significance.
Implications for Practice: The findings suggest that for OHCA patients without ST-segment elevation, an early/immediate CAG strategy does not confer a mortality benefit over a delayed/selective approach across major subgroups. Notably, the potential for increased mortality risk in women with early CAG warrants further investigation. Clinicians should consider these results when deciding on the timing of CAG in this patient population, keeping in mind the overall lack of mortality benefit and the nuanced differences among subgroups.
Reference: Fardin Hamidi et al. (2023). Early versus delayed coronary angiography in patients with out-of-hospital cardiac arrest and no ST-segment elevation: a systematic review and meta-analysis of randomized controlled trials. Clinical Research in Cardiology, 113(561–569). Access the study here: [Link]
ACG Guideline: Management of Acute Pancreatitis
20 Mar, 2024 | 21:49h | UTCThis guideline, crafted by the American College of Gastroenterology, provides essential strategies for managing acute pancreatitis, offering a concise overview of diagnosis, treatment, and prevention recommendations for healthcare professionals. Here is a summary of the key information contained in the document:
- Introduction and Epidemiology: Acute pancreatitis (AP) is one of the most common gastrointestinal diseases leading to hospitalization in the United States, with about 300,000 admissions annually and a cost of over 2.5 billion dollars. The incidence of AP has been increasing annually, although the mortality rate has remained stable due to advancements in management.
- Etiology and Diagnosis: AP is typically caused by gallstones and alcohol consumption. Diagnosis is made based on the presence of two of the following three criteria: characteristic abdominal pain, serum amylase and/or lipase levels more than three times the upper limit of normal, and/or characteristic findings on abdominal imaging.
- Initial Management and Hydration: Initial management emphasizes the importance of moderate to aggressive intravenous hydration, preferably with lactated Ringer’s solution over normal saline, due to its potential benefit in reducing systemic inflammation and preventing complications.
- Nutrition: Patients with mild AP are encouraged to start early oral feeding within 24 to 48 hours as tolerated, preferring a low-fat solid diet over a progressive approach from liquids to solids.
- Management of Complications: The document addresses the management of complications such as pancreatic necrosis, suggesting the use of antibiotics only in cases of infected necrosis and highlighting a preference for minimally invasive methods of debridement and necrosectomy.
- Prevention of Recurrence and Role of ERCP: To prevent recurrences in biliary pancreatitis, cholecystectomy is recommended. In selected cases of acute biliary pancreatitis without cholangitis, medical therapy is preferred over early ERCP.
- Use of Antibiotics: The guidelines discourage the prophylactic use of antibiotics in cases of severe AP without evidence of infection, due to the lack of demonstrated benefit and potential risks.
Tenner, S. et al (2024). American College of Gastroenterology Guidelines: Management of Acute Pancreatitis. The American Journal of Gastroenterology, 119(3), 419-437. https://doi.org/10.14309/ajg.0000000000002645
Phase 2 RCT: Low-dose aspirin significantly reduces hepatic fat in MASLD patients without cirrhosis
20 Mar, 2024 | 17:48h | UTCStudy Design and Population: This phase 2, randomized, double-blind, placebo-controlled clinical trial was carried out over six months at a single hospital in Boston, Massachusetts. The study included 80 participants aged 18 to 70 years diagnosed with metabolic dysfunction–associated steatotic liver disease (MASLD) but without cirrhosis. Participants were randomly assigned to receive either 81 mg of daily aspirin (n=40) or placebo (n=40).
Main Findings: The trial revealed that aspirin significantly reduced the mean absolute change in hepatic fat content by -10.2% compared with placebo, as measured by proton magnetic resonance spectroscopy (MRS), with a statistically significant difference (P=0.009). Furthermore, aspirin treatment notably decreased relative hepatic fat content, increased the proportion of patients achieving a 30% or greater reduction in hepatic fat, and reduced both absolute and relative hepatic fat content as assessed by magnetic resonance imaging proton density fat fraction (MRI-PDFF). Adverse events were mostly minor, with upper respiratory infections and arthralgias being the most common.
Implications for Practice: These findings suggest that low-dose aspirin may be an effective intervention for reducing liver fat in adults with MASLD without cirrhosis, potentially offering a simple, accessible treatment option. However, the results are preliminary and call for further confirmation in larger, more diverse populations. The study underscores the importance of considering low-dose aspirin as part of management strategies for MASLD, pending further research.
Reference
Simon TG et al. (2024). Randomized Clinical Trial: Low-Dose Aspirin Significantly Reduces Hepatic Fat in MASLD Patients Without Cirrhosis. JAMA, 331(11), 920-929. DOI: 10.1001/jama.2024.1215. Access the study here: [Link]
Prospective Study: Enhanced detection of colorectal cancer and precancerous lesions with next-generation stool DNA testing
20 Mar, 2024 | 17:41h | UTCStudy Design and Population:
This prospective study evaluated the efficacy of a next-generation multitarget stool DNA test for colorectal cancer screening in asymptomatic adults aged 40 and older. The study encompassed 20,176 participants undergoing screening colonoscopy to determine the test’s sensitivity and specificity in detecting colorectal cancer and advanced neoplasia, including advanced precancerous lesions.
Main Findings:
The next-generation stool DNA test demonstrated a sensitivity of 93.9% for detecting colorectal cancer and a specificity of 90.6% for advanced neoplasia, significantly outperforming the fecal immunochemical test (FIT) in sensitivity for both colorectal cancer and advanced precancerous lesions. However, the test showed slightly lower specificity for advanced neoplasia compared to FIT. No adverse events were reported, indicating the test’s safety for screening purposes.
Implications for Practice:
The findings suggest that the next-generation multitarget stool DNA test offers a superior option for colorectal cancer screening, with significantly higher sensitivity for detecting cancer and advanced precancerous lesions than the currently available FIT. This advance in non-invasive screening technology could lead to earlier detection and treatment of colorectal cancer, potentially improving patient outcomes. Further research may focus on optimizing the balance between sensitivity and specificity to enhance the clinical utility of stool DNA testing.
Reference:
Introducing IntelliDoctor: The Future of Medical Inquiry for Medical Professionals
26 Feb, 2024 | 11:21h | UTCWe are thrilled to introduce IntelliDoctor, an innovative platform designed specifically for medical professionals, aiming to revolutionize the way medical inquiries are addressed. At IntelliDoctor, we understand the critical need for accurate, timely, and evidence-based information in the medical field. Our platform leverages advanced AI technology, including sophisticated prompt engineering and Retrieval Augmented Generation (RAG), to provide precise answers to clinical questions.
IntelliDoctor’s core mission is to support healthcare professionals by delivering real-time academic insights. Our AI system meticulously searches open academic sources to offer reliable responses based on verifiable research. This process ensures that every answer we provide is not only immediate but also grounded in credible data, with a typical response time of 10-15 seconds.
Our platform is user-friendly and designed to be accessible to medical professionals worldwide. Currently available in English (https://www.intellidoctor.ai/en) and Portuguese (https://www.intellidoctor.ai/pt), IntelliDoctor welcomes users to experience its capabilities in any language, adapting to the global nature of the medical community. For a limited time, we are offering free access to our platform, allowing medical professionals to explore and benefit from our advanced AI-driven solutions.
Getting started with IntelliDoctor is straightforward: no personal information is required, just a Gmail account. We invite you to join us in this medical revolution, where AI technology meets clinical expertise to enhance patient care and support medical professionals. Experience the future of medical inquiry with IntelliDoctor and be part of the transformation in healthcare innovation.
AI-Powered GPTs for Doctors: Evidence-Based Medicine & Clinical Decision Support Prompts
17 Dec, 2023 | 18:39h | UTCWelcome to IntelliDoctor’s innovative collection of AI-Powered GPT Prompts, specifically designed for doctors seeking to enhance their clinical practice with evidence-based information. Utilizing the latest Natural Language Processing (NLP) technology, our prompts provide decisive support in various aspects of medicine, from identifying drug interactions to differential diagnoses, treatments, and more. Each prompt has been meticulously developed to provide accurate and up-to-date information, assisting healthcare professionals in quickly accessing crucial data for patient care decision-making. Important: access to these specialized prompts requires a GPT-4 subscription. With our tool, doctors can easily obtain relevant clinical insights, optimizing time and improving the quality of medical care. Explore our 6 specialized prompts and discover how artificial intelligence can transform your medical practice.
Disclaimer: These tools are intended for use by doctors and healthcare professionals only, and are not recommended for use by other individuals. GPT models can make errors, so please use them with extreme caution and always verify the information before applying it to patient care.
- All Purpose: Comprehensive solutions for general medical inquiries.
- Medications: Detailed information on various medications.
- Interactions: Analysis of potential drug interactions.
- Diseases: Information on a wide range of diseases.
- Signs and Symptoms: Assistance in interpreting clinical signs and symptoms.
- Differential Diagnosis: A tool to aid in differential diagnosis.
RCT: No difference in ICU length of stay or 90-day mortality between tight and liberal glucose control
2 Oct, 2023 | 11:25h | UTCStudy Design and Population: This randomized controlled trial assessed the effects of tight versus liberal glucose control on the length of ICU stay in critically ill patients. A total of 9,230 patients were included, with 4,622 in the liberal-control group (insulin initiation when blood glucose levels exceeded 215 mg/dL) and 4,608 in the tight-control group (blood glucose targeted between 80 and 110 mg/dL). In both groups, parenteral nutrition was withheld during the first week of ICU admission. The primary endpoint was the duration of ICU stay, and 90-day mortality served as a key safety outcome.
Main Findings: No significant differences were observed in the primary endpoint, the length of ICU stay, between the two groups (hazard ratio 1.00; 95% CI, 0.96 to 1.04; P=0.94). The 90-day mortality rates were also similar (10.1% in the liberal-control group vs. 10.5% in the tight-control group, P=0.51). Incidences of severe hypoglycemia were low and statistically similar in both groups (1.0% in the tight-control group vs. 0.7% in the liberal-control group). Secondary outcomes, including new infections and the duration of respiratory and hemodynamic support, showed no significant differences. However, lower incidences of severe acute kidney injury and cholestatic liver dysfunction were observed in the tight-control group.
Implications & Limitations: The study supports existing evidence that tight glucose control doesn’t provide substantial benefits in reducing ICU stay duration or mortality. This suggests that a more liberal approach to glucose control may be preferable in most ICU settings, especially to minimize hypoglycemia risk. Key limitations of the study include its narrow focus on the absence of early parenteral nutrition, which could limit generalizability, and the inability to blind caregivers to treatment assignments. Future research should investigate the impact of tight glucose control in various patient subgroups and under different nutritional conditions.
RCT: Propafenone leads to quicker sinus rhythm restoration than amiodarone in supraventricular arrhythmias related to septic shock
1 Oct, 2023 | 15:19h | UTCStudy Design & Population: The research was a two-center, prospective, controlled parallel-group, double-blind trial involving 209 septic shock patients who had new-onset supraventricular arrhythmia and a left ventricular ejection fraction above 35%. Patients were randomized to receive either intravenous propafenone (70 mg bolus followed by 400–840 mg/24 h) or amiodarone (300 mg bolus followed by 600–1800 mg/24 h).
Main Findings: The primary outcomes focused on the proportion of patients in sinus rhythm 24 hours post-infusion, time to the first sinus rhythm restoration, and arrhythmia recurrence rates. No significant difference was observed in 24-hour sinus rhythm rates between the propafenone (72.8%) and amiodarone (67.3%) groups (p=0.4). Time to the first rhythm restoration was significantly shorter for the propafenone group (median 3.7 hours) compared to the amiodarone group (median 7.3 hours, p=0.02). Recurrence of arrhythmia was notably lower in the propafenone group (52%) than in the amiodarone group (76%, p<0.001). In the subgroup of patients with a dilated left atrium, amiodarone appeared to be more effective.
Implications & Limitations: The study suggests that while propafenone doesn’t offer better rhythm control at 24 hours compared to amiodarone, it does provide faster cardioversion and fewer arrhythmia recurrences, especially in patients with a non-dilated left atrium. No significant differences were observed in clinical outcomes, such as ICU or long-term mortality, between propafenone and amiodarone in the trial. Limitations include potential underpowering of the study and the inability to fully account for the impact of multiple covariates involved in the complex therapy of septic shock.
Commentary on Twitter:
Propafenone💉70 mg bolus+ 400-840 mg/24h vs amiodarone💉300 mg + by 600-1800 mg/24h for SVA in septic shock, RCT
🫀propafenone not better for rhythm control at 24h but excellent hemodynamic safety profile, cardioverting faster & fewer recurrences#FOAMCc
🔓https://t.co/GVuoxPD7Hy pic.twitter.com/rRlj00x71p— Intensive Care Medicine (@yourICM) September 13, 2023
LinksMedicus.com: operations paused for the foreseeable future.
23 Aug, 2023 | 12:44h | UTCDear LinksMedicus Subscribers,
I regret to inform you that LinksMedicus.com will be pausing operations for the foreseeable future. After 12 years and over 30.000 curated articles in all specialties, I will now focus on my clinical practice.
Best regards to all.
Euclides Cavalcanti
São Paulo, Brazil
Crossover RCT | Using one-size cuff results in major inaccuracy in BP readings across varying arm sizes
11 Aug, 2023 | 15:41h | UTCEffects of Cuff Size on the Accuracy of Blood Pressure Readings: The Cuff(SZ) Randomized Crossover Trial – JAMA Internal Medicine (free for a limited period)
Commentaries:
When it comes to blood pressure cuffs, size matters – MedicalResearch.com
One-size-fits-all blood pressure cuffs ‘strikingly inaccurate,’ study says – CNN
Related:
Commentary on Twitter
Using a regular blood pressure (BP) cuff regardless of individual’s arm size resulted in 3.6 mmHg lower systolic BP when a regular cuff was one size too-large, and 4.8 and 19.5 mmHg higher when a regular cuff was one and two sizes too small. https://t.co/ZKnGfWc9fy
— JAMA Internal Medicine (@JAMAInternalMed) August 7, 2023
Perspective | Clinicians debate the usefulness of NAFLD name change
11 Aug, 2023 | 15:39h | UTCClinicians debate the usefulness of NAFLD name change – MDedge
Original article: From NAFLD to MASLD | New consensus changes fatty liver disease terminology to avoid stigmatization
Presented at ASRS Meeting | Studies link GLP-1 agonists to progression of diabetic retinopathy
11 Aug, 2023 | 15:38h | UTCStudies link GLP-1 agonists to progression of diabetic retinopathy – MDedge
Study | The high financial and human cost of quality metric reporting in hospitals
11 Aug, 2023 | 15:36h | UTCThe Volume and Cost of Quality Metric Reporting – JAMA (link to abstract – $ for full-text)
Author Interview: The Costs of Quality Reporting – JAMA
Commentaries:
The Cost of “Quality” – Emergency Medicine Literature of Note
How John Hopkins spent $5m and 108,478 hours on quality reporting in one year – HealthLeaders
The cost of quality metric reporting – Becker’s Hospital Review
Study | Uncovering the potential overuse of laboratory tests by combining cost, abnormal result proportion, and physician variation
11 Aug, 2023 | 15:34h | UTC
[News Release] RCT | Semaglutide 2.4 mg reduces cardiovascular risk by 20% in adults with CVD & obesity
9 Aug, 2023 | 15:40h | UTCCommentaries:
SELECT: Semaglutide Cuts CV Events in Adults With Overweight or Obesity – TCTMD
Perspective | Creation and adoption of large language models in medicine
9 Aug, 2023 | 15:38h | UTCCreation and Adoption of Large Language Models in Medicine – JAMA (free for a limited period)
Commentary: Rethinking large language models in medicine – Stanford Medicine
Perspective | An AI-enhanced electronic health record could boost primary care productivity
9 Aug, 2023 | 15:36h | UTCAn AI-Enhanced Electronic Health Record Could Boost Primary Care Productivity – JAMA (free for a limited period)
Perspective | Large language models answer medical questions accurately, but can’t match clinicians’ knowledge
9 Aug, 2023 | 15:35h | UTCLarge Language Models Answer Medical Questions Accurately, but Can’t Match Clinicians’ Knowledge – JAMA (free for a limited period)
Perspective | Artificial-intelligence search engines wrangle academic literature
9 Aug, 2023 | 15:33h | UTCArtificial-intelligence search engines wrangle academic literature – Nature
Research Letter | GPT-3.5 and GPT-4 show low accuracy in citing journal articles
9 Aug, 2023 | 15:31h | UTCAccuracy of Chatbots in Citing Journal Articles – JAMA Network Open
Commentary on Twitter
21% of medical journal articles cited by GPT-4 were found to be fake; GPT-3.5 cited an estimated 98% fake articles. Narrower topics had more fake articles than broader topics. Despite its promise, ChatGPT is currently not a reliable source of medical data. https://t.co/DCTIkT1OkZ
— JAMA Network Open (@JAMANetworkOpen) August 9, 2023
M-A | Nearly 37% of elderly outpatients are at risk due to potentially inappropriate medication use
8 Aug, 2023 | 13:37h | UTC
M-A | Approximately 25 min/day of walking can boost function and cut adverse events in acutely hospitalized elders
8 Aug, 2023 | 13:35h | UTC
Proposed algorithm for appropriate fluid management in acute pancreatitis
8 Aug, 2023 | 13:33h | UTCFluid treatment in acute pancreatitis: a careful balancing act – British Journal of Surgery
Related:
Update on the management of acute pancreatitis – Current Opinion in Critical Care
Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis – New England Journal of Medicine
Acute Pancreatitis: Diagnosis and Treatment – Drugs
Evidence-Based Disposition of Acute Pancreatitis – emDocs
Pancreatitis – National Institute for Health and Care Excellence
Research: Endoscopic or Surgical Step-up Approach for Infected Necrotising Pancreatitis
Evidence-Based Approach to the Surgical Management of Acute Pancreatitis – The Surgery Journal