CME for the cost of free fifty free

 (https://www.healthquality.va.gov/guidelines/MH/mdd/VADoDMDDCPGFinal508.pdf) clearly state there is insufficient evidence to support this activity and testing. This is mainly because of low quality evidence and concern of bias given commercially funded studies. 

 (https://www.aafp.org/pubs/afp/issues/2023/0100/poems-pharmacogenic-testing-antidepressants.html)

American Psychiatric Association Psychiatry.org - Genetic Testing to Improve Psychiatric Medication Choice

Harvard https://www.health.harvard.edu/blog/gene-testing-to-guide-antidepressant-treatment-has-its-time-arrived-2019100917964

First prime

As I mention in my response email PRIME the primary outcomes per clinnicaltrials.gov were depression remission at 24 weeks, which was not statically significant. And then a use of fewer medications that have a potential gene-drug interaction which from what I can find was a ‘theoretical’ interaction not an actual increase in adverse events. Effect of Pharmacogenomic Testing for Drug-Gene Interactions on Medication Selection and Remission of Symptoms in Major Depressive Disorder: The PRIME Care Randomized Clinical Trial | Depressive Disorders | JAMA | JAMA Network

“The PREPARE Study

 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5113234/#:~:text=Open%2Dlabel%20placebo%20reduced%20minimum,0.02%25%20in%20the%20TAU%20arm. When patients were told they were getting placebo for back pain and it helped their back pain!

The current VA/DoD guidelines clearly state, “For patients who cannot tolerate a statin, we suggest a washout period followed by a rechallenge with the same or a different statin or lower dose, and if that fails, a trial of intermittent (nondaily) dosing”. 

https://www.healthquality.va.gov/guidelines/CD/lipids/VADoDDyslipidemiaCPG5087212020.pdf (full disclosure and bias I helped write them)

 N-of-1 Trial of a Statin, Placebo, or No Treatment to Assess Side Effects | NEJM was published in the NEJM and then a few weeks later Statin treatment and muscle symptoms: series of randomised, placebo controlled n-of-1 trials (bmj.com) was published in the BMJ. 

Around that same time a publication in JAMA https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2773490 showed that using pharmacogenetic testing resulted in no worse LDL levels (soft endpoint) at one year but also no better

I give CME and you listen for free. You can't collect the CME but YOU CAN be a little smarter. These are some must know articles you need to know if you are a hospitalist. 

What about oral??

1. Lewis GD et al. Effect of oral iron repletion on exercise capacity in patients with heart failure with reduced ejection fraction and iron deficiency: The IRONOUT HF randomized clinical trial. JAMA 2017 May 16; 317:1958. (http://dx.doi.org/10.1001/jama.2017.5427. opens in new tab)

randomized, 225 patients with symptomatic systolic HF for 16-weeks to either  oral iron polysaccharide 150 mg twice daily and placebo in 225 patients with symptomatic systolic HF (median left ventricular ejection fraction, 25%)

At 16 weeks, the groups did not differ on the primary endpoint of peak oxygen consumption (VO2) or on secondary endpoints, including 6-minute walk distance and quality of life as measured with the Kansas City Cardiomyopathy Questionnaire.

Thus as you mentioned not only is it not well tolerated it also doesn’t appear to work which might be a better reason to not give it.

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0279166

Vitamin D2 supplementation was associated with a 48.8% reduction in suicide/self-harm risks, and vitamin D3 with a 44.8% reduction, both highly significant (P < .001).   this sounds great but it is purely relative reduction not absolute because the absolute numbers were

Unadjusted suicide attempt/intentional self-harm rates in the D2 sample were 0.27% for those treated versus 0.52% for those untreated. The corresponding percentages for D3 were 0.20% versus 0.36%, respectively.

Which equals a NNT of roughly 400 and 625 over 8 yrs, respectfully.

IF this was true then that actually isn’t too bad (not good or great but not terrible) but this was a retrospective observational trial so they just looked at a lot of people and said what can we find and publish.

So what are other reasons that someone would not commit suicide??

My first thought is ‘you only get put on vit d if you go to the doctor” (which is true)

And typically the people that go to the doctor for their health care a little more about their health than someone who commits suicide

Clearly this isn’t a universal answer but possible

Another thought is

the vet that goes to the doctor and gets prescribed vit d feels like someone “cares for him/her” so maybe it has nothing to do with the vit d but just the sense of reassurance that someone cares about them??

Based on this I still wouldn’t/wont write for vitamin d unless you need cheap placebo since we cant actually write for placebo

D'Andrea E et al. Comparing effectiveness and safety of SGLT2 inhibitors vs DPP-4 inhibitors in patients with type 2 diabetes and varying baseline HbA1c levels. JAMA Intern Med 2023 Feb 6; [e-pub].

Sodium–glucose cotransporter-2 (SGLT-2) inhibitors are used to manage type 2 diabetes but also have protective cardiovascular and renal effects. 

 Do these benefits and adverse effects vary according to baseline level of hyperglycemia

SGLT-2 inhibitors were compared with propensity-score–matched patients who initiated dipeptidyl peptidase-4 (DPP-4) inhibitors, within three categories of HbA1c: <7.5%, 7.5% to 9%, and >9%.

After mean follow-up of 8 months, initiation of SGLT-2 inhibitors was associated with significantly lower risks for major adverse cardiovascular events and hospitalization for heart failure,

DUH we know this works in people that don’t have diabetes why is it a surprise that it works in those with uncontrolled or controlled diabetes.

To me this points to the problem that A1C is a number, it is not the problem, a bad A1C says there could be a problem in the future but in itself the A1C is a number!

Buelt, Andrew
| Apr 19, 2023, 3:25 PM |
|

to me

Treat-to-Target or High-Intensity Statin in Patients With Coronary Artery Disease: A Randomized Clinical Trial | Cardiology | JAMA | JAMA Network

JAMA. 2023;329(13):1078-1087. doi:10.1001/jama.2023.2487

 randomized noninferiority trial 4400 patients 

Question  Is treatment to a goal low-density lipoprotein cholesterol (LDL-C) level between 50 and 70 mg/dL noninferior to a strategy using high-intensity statin therapy among patients with coronary artery disease?

 To assess whether a treat-to-target strategy is noninferior to a strategy of high-intensity statins for long-term clinical outcomes in patients with coronary artery disease.

Patients were randomly assigned to receive either the LDL-C target strategy, with an LDL-C level between 50 and 70 mg/dL as the target, or high-intensity statin treatment, which consisted of rosuvastatin, 20 mg, or atorvastatin, 40 mg.

Which isn’t HIGH in my book that that is fine.

Primary end point was a 3-year composite of death, myocardial infarction, stroke, or coronary revascularization with a noninferiority margin of 3.0 percentage points.

The primary end point occurred in (8.1%) in the treat-to-target group and (8.7%) in the high-intensity statin group 

Worst conclusion ever

“Conclusions and Relevance  Among patients with coronary artery disease, a treat-to-target LDL-C strategy of 50 to 70 mg/dL as the goal was noninferior to a high-intensity statin therapy for the 3-year composite of death, myocardial infarction, stroke, or coronary revascularization. These findings provide additional evidence supporting the suitability of a treat-to-target strategy that may allow a tailored approach with consideration for individual variability in drug response to statin therapy.”

Let's see if something that's much more difficult and costly and more blood draws and more work and more office appointments is non inferior to something that's easier such as take this medication and that it………………………………... Then why it is, we recommend the much more difficult thing.

Treat-to-Target or High-Intensity Statin in Patients With Coronary Artery Disease: A Randomized Clinical Trial | Cardiology | JAMA | JAMA Network

JAMA. 2023;329(13):1078-1087. doi:10.1001/jama.2023.2487

 randomized noninferiority trial 4400 patients 

Question  Is treatment to a goal low-density lipoprotein cholesterol (LDL-C) level between 50 and 70 mg/dL noninferior to a strategy using high-intensity statin therapy among patients with coronary artery disease?

 To assess whether a treat-to-target strategy is noninferior to a strategy of high-intensity statins for long-term clinical outcomes in patients with coronary artery disease.

Patients were randomly assigned to receive either the LDL-C target strategy, with an LDL-C level between 50 and 70 mg/dL as the target, or high-intensity statin treatment, which consisted of rosuvastatin, 20 mg, or atorvastatin, 40 mg.

Which isn’t HIGH in my book that that is fine.

Primary end point was a 3-year composite of death, myocardial infarction, stroke, or coronary revascularization with a noninferiority margin of 3.0 percentage points.

The primary end point occurred in (8.1%) in the treat-to-target group and (8.7%) in the high-intensity statin group 

Worst conclusion ever

“Conclusions and Relevance  Among patients with coronary artery disease, a treat-to-target LDL-C strategy of 50 to 70 mg/dL as the goal was noninferior to a high-intensity statin therapy for the 3-year composite of death, myocardial infarction, stroke, or coronary revascularization. These findings provide additional evidence supporting the suitability of a treat-to-target strategy that may allow a tailored approach with consideration for individual variability in drug response to statin therapy.”

Let's see if something that's much more difficult and costly and more blood draws and more work and more office appointments is non inferior to something that's easier such as take this medication and that it………………………………... Then why it is, we recommend the much more difficult thing.

Hydrochlorothiazide and Prevention of Kidney-Stone Recurrence | NEJM

N Engl J Med 2023; 388:781-791

Thiazide diuretic agents are widely used for prevention of the recurrence of kidney stones, but data regarding the efficacy of such agents as compared with placebo are limited.

double-blind RCT

patients with recurrent calcium-containing kidney stones were randomized to hctz 12.5 mg, 25 mg, or 50 mg once daily or placebo once daily. 

primary end point, a composite of symptomatic or radiologic recurrence of kidney stones. Symptomatic= The visible passage of a stone and radiologic =Appearance of new stones on CT

416 patients were randomized and followed for almost 3yrs

primary end-point event occurred in (59%) in the placebo group

(59%) in the 12.5-mg hydrochlorothiazide group 

(56%) in the 25-mg group

(49%) in the 50-mg group  (rate ratio, 0.92; 95% CI, 0.63 to 1.36)

No difference in any of the subgroups that was looked at there was no difference in the stone composition if it was calcium oxalate or calcium phosphate there was no difference

Some women and people of race were underrepresented in this study but when you have a well done study that is the best we have the burden of proof now falls on you to prove there is benefit… for me this goes against board questions and what I thought was true and will lead me to stopping HCTZ if I am using it for prevention of kidney stones.

Lindholt JS, Søgaard R, Rasmussen LM, et al. Five-year outcomes of the Danish cardiovascular screening (DANCAVAS) trial. N Engl J Med 2022;387(15):1385-1394.

Study design: Randomized controlled trial (nonblinded)

Looking to see if intensive screening protocol for cardiovascular disease reduce cardiovascular events or mortality in older men?

Danish study, 46,611 men aged 65 to 74 years were randomly assigned to receive an invitation to screening or usual care

The screening program included non-contrast electrocardiographically gated CT to measure coronary artery calcium, look for aneurysms, and detect atrial fibrillation; ankle-brachial index measurements for peripheral arterial disease (PAD) and hypertension; and blood tests for diabetes and hyperlipidemia

Those who accepted screening were more educated, more likely to be employed, and had a somewhat lower rate of hospitalization for cardiovascular events in the previous 5 years. (the rich white gullible ceo male)

The screened group was more likely to be given lipid-lowering drugs and antithrombotics, and they were more likely to have repair of an aortic aneurysm.

In the entire population, stroke was less likely (HR 0.93; 0.86 - 0.99) but there were no significant differences in myocardial infarction, aortic dissection, or aortic rupture.

The authors estimated that 97.4% of men who received preventive therapy of some kind as a result of screening experienced no mortality benefit after almost 6 yrs of follow up.

This is basically a really small absolute benefit which we could also see in just placing a pt on a statin. We don’t need vip medicine we need pcp that have time to calculate risk and place pt on statin when indicated.

Goldberg RB, Orchard TJ, Crandall JP, et al, for the Diabetes Prevention Program Research Group. Effects of long-term metformin and lifestyle interventions on cardiovascular events in the diabetes prevention program and its outcome study. Circulation 2022;145(22):1632-1641.

Study design: Randomized controlled trial (nonblinded)

What is the long-term impact of treating prediabetes on mortality and cardiovascular outcomes?

Go way back

original Diabetes Prevention Program study randomized 3234 overweight or obese adults with impaired glucose tolerance ("prediabetes") to receive metformin 850 mg twice daily, an intensive exercise program, or placebo and followed them for 3 years

Patients were invited to participate in a long-term open-label follow-up study This article reports long-term cardiovascular and mortality outcomes for each group.

Patients in the intervention groups were less likely to have been given a diagnosis of T2DM (55% for metformin and 53% for lifestyle vs 60% for placebo; P = .001; number needed to treat [NNT] = 17)

There was no difference between either intervention group and placebo with regard to the risk of cardiovascular death, nonfatal stroke, or nonfatal myocardial infarction. There was also no significant difference in the composite of all 3 outcomes for the original metformin group versus the placebo group (hazard ratio [HR] 1.03; 95% CI 0.78 - 1.37) or for those in the original lifestyle group versus the placebo group (HR 1.14; 0.87 - 1.50).

More is less or rather more meds is less diagnosis but no difference in things we actually care about

Skjerven HO, Lie A, Vettukattil R, et al. Early food intervention and skin emollients to prevent food allergy in young children (PreventADALL): a factorial, multicentre, cluster-randomised trial. Lancet 2022;399(10344):2398-2411.

Study design: Randomized controlled trial (single-blinded)

Does the early introduction of allergenic foods prevent the development of food allergy?

investigators randomized healthy newborns, singletons or twins, with at least 35 weeks' gestational age (concealed allocation) to receive no intervention (n = 597), a skin intervention (n = 575), a food intervention (n = 642), or a combined intervention (n = 583).

The skin intervention consisted of 5- to 10-minute baths with added petrolatum-based emulsified oil followed by topical cetirizine cream applied to the face. This intervention was to occur at least 4 days per week from age 2 weeks to 8 months,

The food allergy intervention consisted of sequentially adding allergenic foods (peanuts, cow’s milk, wheat, then eggs) to the infants’ regular diet at weekly intervals starting at age 3 months.

Overall, 95% of the infants in each group were breastfed at 3 months

The researchers had final data on 99.9% of the participants!

based on structured parental interviews, skin testing, and oral challenges  The researchers classified the development of food allergy at 36 months as probable, none, or unclear. 

There was no significant difference, however, between the infants who were exposed to skin interventions and those who were not exposed (2.1% vs 1.6%).

BUT BUT BUT

Food allergy occurred in 1.1% of infants in the interventions using food (food intervention and combination intervention) compared with 2.6% in not using food (no intervention and skin intervention; number needed to treat = 63; 95% CI 37-196).

Lewis E, Merghani K, Robertson I, et al. The effectiveness of leucocyte-poor platelet-rich plasma injections on symptomatic early osteoarthritis of the knee: the PEAK randomized controlled trial. Bone Joint J 2022;104-B(6):663-671.

Study design: Randomized controlled trial (double-blinded)

Allocation: Concealed

recruited adults with at least 4 months of knee pain (with or without swelling) who had mild degeneration on their x-rays (if plain x-rays found no signs of degeneration, they used magnetic resonance imaging to confirm the diagnosis).

The participants were randomized to receive 3 weekly saline injections (n = 28), or

a single PRP injection followed by 2 weekly saline injections (n = 47), or

3 weekly PRP injections (n = 27).

. The clinician performing the injections was unmasked but had no other involvement in the study procedures.

the participants were evaluated at 6 weeks, 12 weeks, 6 months, and 12 months after enrollment

Using intention-to-treat analysis looking at pain, function, and quality of life, at no point in the study were PRP injections, singly or serially, superior to saline injections.

Efficacy and Safety of Intensive Versus Nonintensive Supplemental Insulin With a Basal-Bolus Insulin Regimen in Hospitalized Patients With Type 2 Diabetes: A Randomized Clinical Study | Diabetes Care | American Diabetes Association (diabetesjournals.org)

 randomized noninferiority study from Emory University, 224 hospitalized patients with longstanding type 2 diabetes 

 Both groups received basal/bolus insulin; both the starting dose and subsequent changes were specified by the study protocol. Additional premeal SSI was added to scheduled premeal bolus doses.

randomized to either intensive SSI (at BG >140 mg/dL) or nonintensive SSI (at BG >260 mg/dL) before meals and at bedtime. 

Mean baseline glycosylated hemoglobin (HbA1c) was 9%, and 60% of patients were using insulin at home. Patients with a presenting glucose level of >400 mg/dL or diabetic ketoacidosis were excluded.

Outcome---Mean daily BG level, hypoglycemia, severe hyperglycemia, percent of BGs in the target range (70–180 mg/dL), and the amount of total, basal, or prandial insulin used did not differ between groups. However, significantly fewer patients in the nonintensive group than in the intensive group received SSI (34% vs. 91%).

COMMENT

Although this is a single-center study, its results are persuasive and suggest that a less-intense SSI regimen can achieve similar glucose outcomes in hospitalized patients with type 2 diabetes who are receiving basal/bolus insulin. It also could decrease nursing treatment burden. As we move slowly toward more continuous glucose monitoring in hospitals, reducing use of SSI is another opportunity to achieve similar results with less staff burden and more patient comfort.

Comparative Effectiveness and Safety Between Apixaban, Dabigatran, Edoxaban, and Rivaroxaban Among Patients With Atrial Fibrillation: A Multinational Population-Based Cohort Study: Annals of Internal Medicine: Vol 175, No 11 (acpjournals.org)

In a retrospective study, investigators accessed five electronic health databases from Europe and the U.S. to compare >500,000 new DOAC users with newly diagnosed atrial fibrillation. Follow up varied from 1.5 to 4.5 years.

In propensity score–adjusted analyses, patients who received apixaban had significantly less gastrointestinal (GI) bleeding did those who received any of the other three drugs (hazard ratios, 0.7–0.8). This result was consistent among older patients and those with chronic kidney disease (CKD). Risk for stroke or other systemic embolism, intracranial hemorrhage, and all-cause mortality did not differ significantly among DOACs.

COMMENT

This is the largest comparison of individual DOACs, and it demonstrates similar efficacy among all agents. Although apixaban was associated with less GI bleeding, absolute percentages of GI bleeds ranged from ≈2% to ≈3.5% for all DOACs; therefore, apixaban's statistically significant safety benefit might amount to marginal clinical benefit for any individual patient. I might turn to apixaban for patients at high risk for GI bleeding (and those with CKD), but all DOACs remain reasonable options for preventing thromboembolism in most patients with atrial fibrillation.

Ellenbogen MI et al. Safety and effectiveness of apixaban versus warfarin for acute venous thromboembolism in patients with end-stage kidney disease: A national cohort study. J Hosp Med 2022 Oct; 17:809. (https://doi.org/10.1002/jhm.12926. opens in new tab)

. In an industry-funded retrospective study, investigators used a national database (years, 2014–2018) and propensity score–adjusted analysis to compare outcomes among >11,500 patients with ESRD and newly diagnosed VTE who received either apixaban or warfarin.

Only 2% of patients received apixaban in 2014, but 47% received apixaban in 2018.

during the 6 months following initiation of therapy, apixaban — compared with warfarin 

associated with significantly lower incidence of major bleeding (10% vs. 14%), including intracranial bleeding (1.8% vs. 2.5%) and gastrointestinal bleeding (8.6% vs. 10.4%). 

Recurrent VTE and all-cause mortality were similar in the two groups.

VTE and creatine clearence less than 30 then I think apixaban is the drug of choice—I would like to see this study don’t with afib and done with exclusively <15 gfr but we take what we can get and the take home is venous thromboembolism (VTE) and gfr <30 go ahead and fire away with apixaban

The EMPA-KIDNEY Collaborative Group. Empagliflozin in patients with chronic kidney disease. N Engl J Med 2022 Nov 4; [e-pub]. (https://doi.org/10.1056/NEJMoa2204233. opens in new tab)

dapagliflozin is FDA-approved to slow progression of chronic kidney disease (CKD) 

empa wanted in on the fun and money

industry-supported researchers randomized 6600 patients with or without type 2 diabetes. with CKD to receive empagliflozin (10 mg daily) or placebo.

 Enrollment criteria included estimated glomerular filtration rate (GFR) between 20 and 45 mL/minute/1.73 m2 regardless of proteinuria, or GFR between 45 and 90 mL/minute in patients with substantial proteinuria.

follow-up of 2 years,

primary composite outcome — largely comprising a 40% decline in GFR or cardiovascular-related or renal-related death

was significantly lower with empagliflozin than with placebo (13% vs. 17%).

Less progression of CKD with empagliflozin accounted for this difference; no significant differences between groups were noted for mortality

Normally I would say a decrease progression of CKD is a bs ending and this isn’t patient oriented outcome. HOWEVER,

Initiation of dialysis or receipt of a renal transplant occurred significantly less often with empagliflozin than with placebo (3.3% vs. 4.8%). At a NNT of 66.

But once again empag cost 560$ per month. Follow up was 24 months. Which means 65 people have to take a $500 per month drug for 2 years which is This is a whopping 873,000$ spent for one person to be saved renal transplant or starting dialysis.

Zheng J et al. Cost-effectiveness of empagliflozin in patients with heart failure with preserved ejection fraction. JAMA Intern Med 2022 Nov 7; [e-pub]. (https://doi.org/10.1001/jamainternmed.2022.5010. opens in new tab)

At its current price, this drug provides low value in patients with heart failure with preserved ejection fraction.

The authors did something great here and said hey if you assume a  9% reduction in cardiovascular-related mortality (the nonsignificant reduction noted in the trial), cost-effectiveness would have been somewhat more acceptable

However they also usethe cost as 327$ per month… which is very generous as I can not find that number any place!!! So even with their generous calculation it still is not worth it-- yet

YES!! Marketing!! No man wants to admit his gonads dont work so they would never say I have hypogonadism. Most men would never say I have andropause cause that is too close to menopause but if you call it low testosterone then all of a sudden men come out of the wood work like cave men to get some of this magical drug they have heard so much about.

YES LIKE LOW T WILL KILL YOU!!!! "could kill you". -https://abcnews.go.com/Health/ActiveAging/story?id=3247773&page=1

https://www.acpjournals.org/doi/10.7326/M19-0882?_ga=2.162179964.190727375.1667239768-1195431333.1667239768&

"It is estimated that approximately 35% of men older than 45 years of age and 30-50% of men with obesity or type 2 diabetes have hypogonadism". 

from endocrine.org. https://www.endocrine.org/patient-engagement/endocrine-library/hypogonadism

However, for a 30 yr old male the low end of normal is around 300 ng/dL! YET this is what most websites and recommendations use as the treatment cutoff for all men. 50, 60, 70 yr olds. we compare those testosterone levels of 30 yrs old and make them the standard for 50, 60 ,70 yr olds. 

​​https://www.nejm.org/doi/full/10.1056/NEJMp038207


study found that just watching sports can raise and lower your testosterone levels depending if your team wins or loses. https://pubmed.ncbi.nlm.nih.gov/9811365/

20 minutes apart had variations between the two lab values of 18–28% half of the time and about 25% of the time the variation in the lab test between  27–54%!! Same blood, same person, 20 minutes a part and the test results are 15-54% different!!!!! There is no lab test in the world that i know of with such huge variation.

DJ BrambillaAB O'DonnellAM Matsumotoet al.Clin Endocrinol2007;67:853–62

A study from journal of urology in 2014 showed that testosterone differences in time appears to be of significant concern in those younger than 45 but those older than 45 can likely have their test time frame expanded with no harm or issue. 

Welliver RC Jr, Wiser HJ, Brannign RE, et al. Validity of midday total testosterone levels in older men with erectile dysfunction. J Urol. 2014;192:165-169.

https://pubmed.ncbi.nlm.nih.gov/26360789/#:~:text=Objective%3A%20Since%20testosterone%levels%20exhibit,diagnostic%20test%20for%20androgen%20deficiency.


A study in jama internal medicine found that about 25% of those individuals prescribed testosterone had not even had a testosterone level measured even once in the previous year.

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1691925?resultClick=3

coffee saves your life-- maybe, careful for confounders 

heart failure hospital admission is really hard to prevent

moderate dose statin is most important..but ezetmibe and moderate dose is equal to high dose statin

I think we should take out all kidney stones and the evidence says there will be lest hospitalizations if we do that

EHR can help us and remind us to check and PTH

robotic surgery is not all that is seems to be-- or at least not yet

vit. D and fish oil dont help dry eyes....or much of anything for that matter

stop injecting Hyaluronic acid into the knee

 skin exam, ddp4, IUD, oral hypertension medication

https://www.ahajournals.org/doi/abs/10.1161/CIRCULATIONAHA.122.059410?af=R

The Biomarkers say REDUCE-IT was a scam

https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2791663

NO! Just NO-- stick with the calculator for now

https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.122.059038

start the SLGT-2 inhibitors early! maybe an early discharge

https://pubmed.ncbi.nlm.nih.gov/35849407/

If we could get the EMR to do it automatically else you cant expect providers to

https://pubmed.ncbi.nlm.nih.gov/35727595/

the head CT for psych stuff can probably be put on hold

https://eprints.whiterose.ac.uk/180135/

continue the disease modifying agents