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Nighttime Measures of Blood Pressure Might Be a Good Predictor of Risk

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From Journal Watch 3. nov 2020
Compared with participants whose BP declined during sleep (so-called dippers), those whose BP rose (“risers”) had higher risks at a mean follow-up of 4.5 years for heart failure and atherosclerotic cardiovascular disease events, independent of office or 24-hour measurements of systolic BP. Also, each 20 mm Hg elevation in nighttime systolic BP was associated with a 36% increase in risk for heart failure and a 21% increase in risk for cardiovascular events in analyses adjusting for demographic and clinical variables.

Covid19 vaccination programs in Healthcare workers

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Vaccination against the Covid19 virus in HC workers has shown clear lovering of incidence already 2 weeks after the first vaccination.
1. In a hospital in Texas infections occurred in 2.5% of nonvacc 1.8% in partially vacc and 0.05 in fully vacc. employees.
2. Of 28.000 receiving 2 doses only 0.05 tested positive over 8 days after the second vacc.
3. In Israel infections began to drop after 2 weeks from 1. vacc. This reduction occurred even though the B.1.1.7 variant was around. A very important issue.

Bariatric surgery and alchohol misuse

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Unknown dangers of obesity surgeries seem to be an increase in mental problems, self harm and suicide. A new study has shown consumption of alchohol to be increased after operation.
8 years after surgery with Roux en Y, 9,2% had unhealthy alchohol use and those who underwent sleeve gastrectomy had 7,9%.
Continous surveillance seems appropriate for mental health issues and alchohol use.
JAMA netw open 2020

Allergic reactions to Covid vaccines

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CDC report on anaphylaxis (serious allergic reaction) when two vaccines were given:

Pfizer-Biontech 2 million first doses: adverse reactions 0,2%.
21 cases of anaphylaxis occurred, 90% in women, median age 40. Onset within 13 minutes and 71% within 15 min. 14% within 30 min and 14% after 30 min. No deaths.

Moderna vaccine had 10 cases of anaphylaxis among 4 mill receiving first dose. Mostly within 15 min.
Other allergic reactions were similar in the two groups.

Reference: Journal Watch march 2021

Early MRI in back pain inappropriate

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Choosing to send back pain sufferers for MRI examination may cause problems. Of a group of 400.000 with low back pain 10.000 had an early MRI. “Early” is within 6 weeks.
The results of this? Likelihood of operation was 13 times higher in the year after, they were more likely to be treated with opioid drugs and final pain scores were worse. The cost of this was also significantly higher. It therefore seems wise to follow the rules…
From Journal Watch feb 2021

Fibromyalgia: drug treatment in vain?

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Journal Watch okt 2020
Evidence is insufficient to support most treatments for fibromyalgia, according to a meta-analysis in JAMA Internal Medicine.

Researchers examined data from over 220 randomized trials among nearly 30,000 people with fibromyalgia. High-quality evidence suggested a statistically significant benefit for cognitive behavioral therapy for improving pain in the short term. High-quality evidence also favored antidepressants and central nervous system depressants for improving pain in the medium term, antidepressants for improving quality of life (QOL) in the short term, and antidepressants and central nervous system depressants for improving QOL in the medium term.

However, none of these outcomes met the researchers’ criteria for a clinically important benefit. In addition, high- or moderate-quality evidence did not support any treatment for pain or QOL in the long term.

The researchers conclude, “Clinicians should be aware that current evidence for most of the available therapies for the management of fibromyalgia is limited to small trials of low methodological quality.”

Weight Loss in Overweight Children: Is Directing Treatment at Parents Enough?

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Weight Loss in Overweight Children: Is Directing Treatment at Parents Enough?
By Amy Orciari Herman
Edited by David G. Fairchild, MD, MPH, and Lorenzo Di Francesco, MD, FACP, FHM

Weight loss interventions for children may be just as effective when only parents attend treatment sessions as when children also attend, a JAMA Pediatrics study finds.
Some 150 overweight or obese children aged 8–13 years and their parents were randomized to family-based or parent-based treatment for 6 months. With family-based treatment, parents attended twenty 1-hour group sessions, children attended simultaneous 1-hour sessions, and children and parents had twenty 30-minute sessions with a behavioral coach. Parent-based treatment followed the same schedule, but children didn’t attend any meetings. Treatment included nutrition and exercise recommendations, parenting skills, and behavior modification strategies.
At 18 months’ posttreatment, children in both groups had achieved significant weight loss, with no difference between the groups. Parent-based treatment was also noninferior to family-based treatment for secondary outcomes including parent weight loss, parent and child calorie consumption, and physical activity.

Oxygen treatment in acutely ill patients

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Medical directives keep changing and this new rec. which is discussed in BMJ is certainly one which causes raised eyebrows…

New guidelines recommend that acutely ill patients requiring supplemental oxygen therapy
maintain peripheral capillary oxygen saturation levels (SpO2) of 96% or less (strong recommendation).
Higher levels have been linked to elevated mortality risk.

The guidelines, written by an expert panel and published in The BMJ, note that the ideal upper limit may be closer to 94%.

Among the recommendations for patients with acute stroke or myocardial infarction:

• The panel suggests not starting oxygen when SpO2 is between 90% and 92%, as it may not be beneficial (weak recommendation).
• Supplemental oxygen shouldn’t be started at or above 93% saturation (strong recommendation).
• The panel writes that there are “probably no benefits to initiating oxygen therapy when SpO2 is >92%, and it may cause harm.”

Low back and radicular pain: is treatment futile?

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“New guidelines, several meta-analyses and a few new studies show that neither medication nor nonpharmacologic approaches confer much benefit” (JWatch.org jan 2018)

A few studies have been done on Gabapentin and Pregabalin for back pain with radicular pain and not been found to have any effect. One study with Pregabalin titrated to 600mg and continued for 8 weeks was ineffective. It had the same effect as “sugar” pills.

Six studies of gabapentin versus placebo or pregabalin against another analgesic in pat. with LBP (about 500 pat) showed no clinically meaningful benefits and substantial side effects.

Diazepam as extra medication in 114 pat. w LBP who were given naproxen did not improve pain or function at 1 week.

NSAIDS (ex. naproxen, ibuprofen) have also been in the storm of questioning their effect and shown to have only modest effect in LBP w/wo radicular pain. One would need to treat 6 patients for 1 to have benefit.

Nonpharmacological treatments:
1. intradiscal steroids in pat. w MRI evidence of vertebral endplate inflammation: after 1 mo some improvement, after 3 mo worse, after 12 mo no difference.
2. Radiofrequency denervation for pat. w pain from facet joints, SI joints or intervert discs showed no incremental benefit when added to typical exercise therapy.
3. Spinal manipulation a meta analysis of 26 randomised trials for acute LBP showed statistically significant but modest benefit að 6 weeks with a high frequency of moderate side effects.

So: drugs dont work, injections and denervations dont work, manipulation seems to help a little bit but you pay a considerable sum of money and waste time doing repeated manipulations.

It may be considered a relief that you dont need to take any medication, you dont need to go to the doctor, physiotherapist or chiropractor, you just wait for a few weeks knowing that there is sound reason to expect spontaneous recovery.
If the back pain is chronic, which indeed is a very common condition; medication with pain medication is not advisable as the risk of addiction is considerable and the effect is small according to research.

Note: these are not to be considered guidelines for every back pain situation!