Questioning Medicine

STROKE part 3 CME

CME FOR FREEE 

CME --- Stroke- UIA, CHAD-VASC, HAS-BLED, SPARC, PFO

Beran A et al. Early diagnostic paracentesis improves outcomes of hospitalized patients with cirrhosis and ascites: A systematic review and meta-analysis. Am J Gastroenterol 2024 Nov; 119:2259. (https://doi.org/10.14309/ajg.0000000000002906)

BOTTOM LINE (if you don’t like to read)- While it might not be fun to have the conversation with the ER provider saying you NEED A DIAGNOSTIC PARACENTESIS PRIOR TO THE PATIENT COMING TO THE FLOOR, just remember that every 33 times we have that conversation, we are saving a life and decreasing the length of stay by 5 days on average.

We have all had the admission from the ER on a patient that needs a paracentesis but it is the weekend so they are going to just admit for antibiotics and then IR can come do it on Monday.

Guidelines recommend diagnostic paracentesis in all patients hospitalized with cirrhosis and ascites, but they do not recommend specific timing of inpatient paracentesis. (Biggins SW et al. Diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: 2021 practice guidance by the American Association for the Study of Liver Diseases. Hepatology 2021 Aug; 74:1014. 

BUT NOW we have a meta-analysis of 7 observational studies (>78,000 patients), patients who underwent diagnostic paracentesis within 12 to 24 hours after admission had significantly better outcomes compared with patients who had more-delayed or no paracentesis!

Those that underwent diagnostic paracentesis within 12 to 24 hours after admission had significantly lower rates of acute kidney injury (24% vs. 35%. NNT 9). They had shorter hospital LOS (5 fewer days!), and lower in-hospital mortality (7% vs 10% NNT 33).

When you looked at the subgroup of patients that underwent paracentesis within 12 hours of admission —in-hospital mortality also was significantly lower with paracentesis within 12 hours versus later paracentesis (12% vs. 26% NNT 7).

Acupuncture vs Sham Acupuncture for Chronic Sciatica From Herniated Disk: A Randomized Clinical Trial | Complementary and Alternative Medicine | JAMA Internal Medicine | JAMA Network

In a randomized trial, acupuncture reduced pain and disability better than a sham procedure did.

In this trial from China, 216 adults (mean age, 51) were randomized to undergo 10 sessions of acupuncture or sham procedures during 4 weeks. All patients had moderate-to-severe unilateral leg pain attributed to imaging-confirmed disk herniation; mean duration of symptoms was 3 years (range, 1.3–10 years). Patients taking pain-modifying medications or with prior lumbar disk surgery were excluded.

The sham procedure consisted of blunt needles inserted into adhesive foam pads placed over non-acupoints.

Patients who received acupuncture reported greater leg-pain relief at 4 weeks than did patients who received sham procedures (mean decrease on a 0–100-mm visual analog scale, 31 vs. 15 mm),

 Improvements in pain and disability scores from baseline began persisted to 1 year. 

At first I thought WHOA this is amazing-

We do 10 sessions and you are better 1 yr later! Seems to good to be true and like free money, it probably is

And now a secondary analysis of the trial focused on the timing of major ischemic events and the potential tradeoffs of benefits and risks,------ maybe there is magic sauce where the benefit is drastically greater than risk and vice versa!

Guan L et al. Duration of benefit and risk of dual antiplatelet therapy up to 72 hours after mild ischemic stroke and transient ischemic attack. Neurology 2024 Oct 8; 103:e209845. (https://doi.org/10.1212/WNL.0000000000209845)

The goal is less ischemic events with the DAPT but there is a risk of more bleeding and maybe if we tease out the data we can find the exact right time—not too much, not too little but just right.

They found the benefit of decrease ischemic stroke

was front-loaded, with roughly a 1.5% absolute risk reduction (ARR) for major ischemic events in the first week, a 0.5% ARR in the second week, and a nonsignificant 0.29% ARR in the third week.

The bleeding risk was constant right around ARR 0.1%

Thus three weeks remains reasonable to rec DAPT—remember at three weeks the decrease ischemic event rate in absolute terms was 0.3 and the bleeding risk was around 0.1……. the real magic does appear to be in the first week when the risk of repeart event is around 1.5%

The full podcast -- not sure why the last one cut off early. 

Question and answer from ACOI

Liu H et al. Arm position and blood pressure readings: The ARMS crossover randomized clinical trial. JAMA Intern Med 2024 Oct 7; [e-pub]. (https://doi.org/10.1001/jamainternmed.2024.5213)

• study replicated some of the “real-world” shortcuts that often occur when we check BP, such as measuring BP while the patient is sitting up on an exam table.===

In this U.S. trial of 133 adults, researchers assessed the effect of nonstandard arm positions on BP readings by measuring each patient's BP in three different arm positions (order of measurement was determined by a randomization protocol):

Investigators otherwise followed standard guidance for office BP measurements.

Lap and side positions led to significantly higher readings (by 4 mm Hg to 6 mm Hg for both systolic and diastolic measurements) than did the desk position. 

some of the common questions and answers from ACOI

Stopping Trials Early for Benefit: Insights From Recent Pivotal Trials in Chronic Kidney Disease - ScienceDirect

There are 4 major reasons why trials might be stopped early: 1) unequivocal benefit; 2) unacceptable harm; 3) futility; and 4) administrative reasons (enrollment or funding concerns). 

 trials stopped early for benefit tend to overestimate benefit, a phenomenon referred to as random-high.

trials that stopped early, especially those with <500 events, fail to provide reliable and valid estimates of treatment effect, often overestimating it by nearly 30%

Trials stopped early for harm or futility are less problematic as such data are not used to promote medications.

Published results were based on accrual of 69%, 75%, 93%, and 87% of planned events in CREDENCE, DAPA-CKD, EMPA-KIDNEY, and FLOW, respectively.