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Oct 19, 2018

Number cruncher

The story

For you, big data is having all labs drawn and results posted before you present on rounds. But there’s more to explore in the EMR, including how weight loss surgery affects outcomes in diabetes.

The problem

Some questions are hard to answer. Others are complicated or expensive. So if you want to use a randomized trial to see how bariatric surgery impacts rare but important outcomes like heart attack and stroke in patients with type 2 diabetes (T2D), you better make sure someone’s footing the bill. Prior RCTs have focused on easier-to-measure metrics like weight loss and glycemic control, while observational studies have shown a trend towards decreased micro-and macrovascular events. Can more info be found in the medical chart?

The dataset

Bariatric surgery cut the rate of macrovascular events (myocardial infarction or stroke) in half (4.3% vs. 2.1%) over 5-year follow-up compared to controls in a large retrospective cohort of obese patients with T2D. The cohort featured 5,000 patients who underwent Roux-en-Y gastric bypass, sleeve gastrectomy, or adjustable gastric banding and 15,000 matched controls from 4 integrated healthcare systems. Improvements were most notable in coronary artery disease and all-cause mortality. And while retrospective data is prone to bias, results for weight loss and glycemic control were on par with outcomes from prior RCTs.
JAMA

The takeaway

As evidence mounts that bariatric surgery improves short and long-term outcomes in obese patients, surgical options have not yet been included in standard prevention workflows for T2D. Validating the above results in prospective data is an important next step.

Say it on rounds

When you begin writing for Tylenol the moment you get paged

The vast majority of pages are predictable, and the vast majority of fractures in postmenopausal women occur in women with osteopenia rather than osteoporosis. An RCT of 2,000 postmenopausal women with osteopenia found that administration of zoledronate every 18 months reduced fragility fractures and height loss compared to placebo. The NNT to prevent one fragility fracture was 15, a remarkable finding for this recently generic med. Women in this trial were older and at higher risk than women in previous studies that failed to show a benefit for bisphosphonate therapy.
NEJM

When you need a wet read, but instead you're on hold

There's an app for that? A retrospective review looked at the use of deep learning algorithms to identify red flag abnormalities on non-contrast head CTs in India. Using a database of over 280,000 head CTs, algorithms were able to accurately predict (AUC ≥ 0.85) intracranial hemorrhage, calvarial fracture, midline shift, and mass effect in two validation data sets that used the consensus opinion of 3 radiologists as the gold standard for diagnosis. No word yet on whether the machines can appear gruff and disinterested over the phone.
Lancet

When you’re addicted to two-day weekends

Wrong field. But for those addicted to opiates, a prospective cohort of treatment-seeking patients in Vancouver found that heavy cannabis users were more likely to remain on therapy. Those who used cannabis at least daily were 21% more likely to remain in methadone or buprenorphine / naloxone based treatment programs at 6 months compared to those who didn’t, and the findings held regardless of other substances used. The authors suggest that self-medicated cannabis can partially substitute for crack, alcohol, opiates, and others. 
Addiction

Brush up

Cystic fibrosis

Over 80,000 people worldwide have cystic fibrosis (CF). Failure of CFTR to clear mucus leads to build up of thick secretions in the airways and other organs. Common manifestations include recurrent respiratory infections, pancreatic insufficiency, distal ileal obstruction, biliary cirrhosis, and infertility. Multi-modality therapy including anitbiotics, airway clearance, pancreatic enzyme supplementation and new drugs designed to correct CFTR function have greatly improved median life expectancy (now over 40 years) for affected patients. 

What's the evidence

For CFTR modulators in CF? A 2017 RCT of 500 patients homozygous for Phe508del – the most prevalent CFTR mutation – found that combination therapy with tezacaftor and ivacaftor, drugs that help CFTR reach the cell membrane and secrete mucus, reduced pulmonary exacerbations by 35% compared to placebo over 24 weeks and slowed declines in lung function. A third CFTR modulator may provide additional benefit and is currently in development.

What your research friends are talking about

You can't always believe what you read. Noted stem cell researcher Dr. Piero Anversa, who claimed stem cells could regenerate injured heart tissue, falsified data in 31 studies. The deception has upended clinical trials and companies that have sought to capitalize on his work.

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