Jul 26, 2019

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The story

You'll never find an answer to some lingering questions (e.g. where does the hospital find all these fax machines?), but for others big data can help. Here's the latest on whether systolic or diastolic blood pressure matters most.

The background

Mega-hospital systems mean mega-data. So when researchers want to estimate the population level impact of hypertension, Kaiser Permanente Northern California and its 4 million patients have a lot to offer. The types of questions that surround HTN after big changes in the 2017 US hypertension guidelines – are lower treatment thresholds for high-risk patients necessary? Does overtreatment cause harm? – lend themselves to a large EMR-based retrospective study. Throw in the age old question of systolic vs. diastolic, and you've got yourself a paper.

The number crunch

Systolic blood pressure (SBP) is more closely linked to adverse outcomes than diastolic blood pressure (DBP), though both are important. The conclusions are drawn from a retrospective analysis of SBP, DBP and a composite outcome of MI and stroke in 36 million outpatient visits. 'Continuous' BP was estimated by taking an average of individual BP readings weighted by the time between visits over the 8 year study period. True to guidelines, the final adjusted analyses found that risk of adverse outcomes increased with SBP above 140 mmHg and DBP above 90 mmHg. 

The takeaway

With all the stats and data wrangling needed to get these numbers to behave, the results feel a few steps removed from day-to-day clinic. But the main message is to keep diastolic BP in mind and do your best to keep patients below guideline thresholds.

Say it on rounds

When you chart-stalk on your day off

Sometimes less is more. A retrospective cohort of 6,000 patients hospitalized with pneumonia found that 68% of patients received more than the shortest effective duration of antibiotics. Most excess antibiotic days were prescribed at discharge, and while excess treatment was not linked to improvements in clinical outcomes like death, readmissions, or ED visits, each excess day of antibiotics was associated with a 5% greater likelihood of patient-related adverse events like GI upset and diarrhea.

When your diet Coke addiction feels like a win

On the heels of an analysis linking sweetened beverages to heart disease, results from the 100,000-participant French Nutri-Net Santé prospective cohort found that self-reported consumption of sugary drinks was associated with an increased risk of overall cancer (HR 1.18 for 100 mL / d increase) and breast cancer (HR 1.22) in premenopausal women. Fruit juices were also implicated, though artificially sweetened beverages did not significantly increase cancer risk.

When you scroll Insta unconsciously

We feel you. The WHO recognizes both gaming addiction and excessive internet use as mental health disorders, and prevalence is rising. A randomized trial in Austria and Germany of 140 patients with internet and gaming addiction found that more patients in a cognitive behavioral therapy program achieved addiction remission (69% vs. 24%) than wait-list controls in an intent-to-treat analysis. Effects remained significant when adjusted for age, baseline addiction severity, and treatment center.
JAMA Psych

Brush up

Drug-induced liver injury

Your most frequent cause of acute liver failure in Western countries is drug-induced liver injury (DILI). There are no specific markers for DILI, so diagnosis in the acute setting is often based on exclusion. Among clinical phenotypes, direct hepatotoxicity, characterized by enzyme elevation with minimal clinical symptoms, is the most common form of presentation, while jaundice is present in about 30% of cases. Here's a chart of toxicity phenotypes and onset patterns. The NIH website LiverTox provides info on over 1,200 agents and their potential to cause liver injury.

What's the evidence

For the role of herbal and dietary supplements (HDS) in DILI? About one-third to one-half of US adults take herbal and dietary supplements. A 2014 study from the Drug Induced Liver Injury Network found that between 2004 and 2013, the fraction of liver injury due to HDS increased from 7% to 20%. About one-third of of liver injuries associated with HDS were due to bodybuilding supplements, though non-bodybuilding supplements appeared more dangerous (in terms of death and need for liver transplant) than bodybuilding HDS or medications.

What your OB friends are talking about

Can you feel the love tonight? The CDC reported that the US fertility rate dipped to an all-time low in 2018 among women aged 15 - 44. The birth rate remains below the population replacement rate.

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