Sep 29, 2017

Get physical

The story

Writing notes doesn't count as exercise, even if it hurts your back and makes you feel tired. And with a steady stream of data singing the praises of regular activity, you may be a tad more inclined to take the stairs.

The background

You already know that physical activity is good, but a quick foray into the numbers says to expect a 20% reduction in early mortality with moderate exercise. The findings, drawn from a 2015 meta-analysis of six large trials from high-income countries, were dose dependent, meaning higher levels of leisure-time activity correlated with increased mortality benefits. Less is known about activity in low-income countries, where recreational physical activity is less common, and the burden of heart disease and other sequelae of the Western diet is rising quickly.

The benefits

The PURE study used questionnaires to assess physical activity in a prospective cohort of 130,000 adults in 17 countries. Moderate physical activity was linked to a 28% lower risk of mortality and a 20% lower risk of cardiovascular disease in results held across high, middle, and low-income countries. Benefits were similar for recreational and non-recreational activity, so playing tennis, biking to work, or wheeling patients to CT scans will all get the job done.

The time commitment

Big-time risk reductions were seen between participants who perform 150 minutes (2.5 hours) of moderate activity per week  – in line with current US recommendations – and those who fall short of that. Additional benefits were seen as exercise time increased from 2.5 weekly hours to 12.5 weekly hours, after which risk reductions plateaued.

The takeaway

With a number needed to treat of 5 or less, moderate physical activity sits head and shoulders above the best preventative medicines for sedentary patients. From a public health perspective, the results suggest that resource-poor settings could see big dividends from initiatives designed to increase activity.

Say it on rounds

When you see A1cs more than your significant other

That's not about to change, but bariatric surgery can help. A 12-year observational follow-up of 1,100 patients who chose whether or not to undergo Roux-en-Y gastric bypass found sustained metabolic improvements for surgical patients. The surgical group was one tenth as likely to develop new diabetes as the non-surgical group, and about half of surgical patients with diabetes had an A1c < 6.5% 12 years after surgery. A third of patients became normotensive following surgery, and 60% saw LDL cholesterol return to normal levels. One key caveat: surgical patients were linked to an unexplained increase in suicide.

When you show up late to everything

Non-compliance remains as big a hurdle in HIV treatment as it is in your social life. A phase 2b study of treatment-naive HIV patients found that both 4-week and 8-week injections with intramuscular cabotegravir and rilpivirine were equally effective as conventional oral therapy at maintaining viral suppression. Injections were well tolerated, with injection site pain the most common side effect followed by nasopharyngitis and diarrhea. We'll await phase 3 data, but long-acting injections appear to have a bright future in low-compliance settings.

When the squad’s posting selfies, and you're renewing Foleys in the ICU

Residency is painful, but intrauterine devices (IUDs) don't have to be. A study of 95 young women found that paracervical block with lidocaine reduced peri-procedural and insertional pain compared to sham during placement of the levonorgestrel IUD. Because fear of pain is one of the primary deterrents to IUD use, many hope effective analgesia can increase acceptance and reduce unintended pregnancies.
Obstet Gynecol

Brush up

Eosinophilic esophagitis 

It's hard to swallow sick pull coverage the day after program happy hour. Eosinophilic esophagitis is gaining prominence as a cause of dysphagia and food impaction. Once thought to be GERD-related, the disease is now thought to be allergy-mediated. A lack of microbe exposure in infancy, birth by C-section, and the absence of breastfeeding are known risk factors. Consider the disease in patients with allergy symptoms and dysphagia that doesn’t respond to proton pump inhibitors. Biopsy is the gold-standard for diagnosis.

What's the evidence

For steroids in eosinophilic esophagitis? A 2010 double-blind trial of budesonide vs. placebo found a reduction in eosinophilia and an improvement in dysphagia scores in the budesonide group. Avoidance of common triggers including wheat, milk, soy, nuts, eggs, and seafood has also shown benefit. Refractory disease may require endoscopic dilation.

What your health policy friends are talking about

The Graham-Cassidy bill died well before this writing team had the chance to understand it. Here's Atul Gawande's breakdown of what the GOP hoped to accomplish. Among his questions: how did Bill Cassidy go from 25 years of service as a physician in hospitals for the uninsured to writing a bill that would effectively end current-day Medicaid?

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