Update in Primary Care, Feb 2019

I’m just back from┬áthe always fun┬áSouthern SGIM Annual meeting, in Houston, TX. I had the pleasure of presenting an Update in Primary Care with the great Peter Phan. It’s a great reminder of our evidence base in outpatient medicine, so wanted to share it here as well. Plus a certain Master Educator called me out in his Unknown Vignette discussion, so I heard that I might have some new followers- Welcome!

Here goes!

First up: this RCT published in October 2018 in JAMA compared PT to Arthroscopic surgery for meniscal injury. A big caveat is that patients with locking of the knee were excluded, so this likely is focused on patients with degenerative meniscal injury.

Here are the results: This was a non-inferiority trial, so a low p value means that PT was NON-INFERIOR.

There was no difference in knee function between PT and Surgery at 3, 6, 9, and 24 months. There may have been a improvement at 12 months, but it disappeared by studies end.

Next, what happens to patients with documented Penicillin Allergy? This study from June 2018 in BMJ looked at just that. This was a matched, prospective cohort study that enrolled over 300K adults.

The authors looked at risk of MRSA or C.Diff infections, and controlled for a variety of potential confounders, including: PPI, Antibiotic or steroid use, admission to SNF or hospital, and others.

Patients with a documented Penicillin allergy were 69% more likely to have MRSA and 26% more likely to have C. Diff.

Interesting side note, most patients (95%!) with a documented penicillin allergy are not, in fact, actually allergic to penicillin. So it is worth investigating- get a good history, and consider allergist evaluation even if the allergy seems legit.

Number 3, Aspirin, Aspirin, Aspirin. This has been a super hot topic this year, with lots of studies. We reviewed ASCEND in NEJM, published in October.

This study looked at diabetics on aspirin for primary prevention. This was a prospective RCT that enrolled over 15K diabetics and followed them for 7.5 years.

They were randomized to 100mg of ASA or placebo. 75% of the patients were also on statins. They evaluated a combined CV endpoint (death, MI, TIA, stroke) as well as colon cancer incidence. They also measured major bleeding events.

There was a risk reduction of first vascular event for patients on aspirin, RRR 12%, NNT 91.

However, there was also a 29% increased relative risk of major bleeding in those patients. And no change in cancer rates. So harm from ASA seems to outweigh the benefits in diabetics.

And check these other papers in NEJM: ASPIRE and ASPREE. Also showing more harm than help for aspirin in patients over 70. There is a great Curbsiders episode on this- check that out on your favorite podcast app, and see the link above for the show notes.

There is the first half! Second half coming up soon!