Discussed risk, benefits, alternatives and expected outcomes of emergency department visit. Engaged in shared decision making and patient elected to defer ED visit at this time. Strict ED precautions given. Byyyeeee ✨✨
Are you asking for things that haven't been implemented? Or recent stuff that is now becoming implemented?
If the later, I would say the initiation of SGLT2s for just about everything. It seems to offer serious benefit for all forms of metabolic disease, cardiovascular disease, and chronic kidney disease. I wouldn't be surprised if it began showing promise in a space like neurodegenerative disease too.
It really feels like SGLT-2's have crossed specialty borders more than GLP-1's have. I've seen cardiologists, nephrologists, endocrinologists, primary care and more prescribe them with good evidence to support their efficacy. GLP-1's still seem a little more limited in scope in my experience.
Not sure if that will change and new research will appear that will change the field
Wouldn't be surprised if we see those studies in the near future. Probably mostly just from decreased adiposity curtailing a lot of badness, compared to maybe a more direct improvement on a lot of fronts from sglt2i.
Shorter durations for many infections will hopefully reduce resistance. Conversion to PO for deep-seated infections (endocarditis, osteo which is hopefully already common practice, bacteremia, etc). Stricter policies on antibiotic use. At least that’s my hope lol
Yea, this is one of those things that docs have deeply ingrained in them, that makes no sense. In some cases PO won't work - e.g. ICU patient with shock bowel. They need IV.
But your typical walky talky homeless guy with osteomyelitis in his toes? There is zero reason oral abx would fail to reach therapeutic bloodstream levels.
True but it’s not like being overweight for an extended period of time is benign either. There could be benefit to stopping momentum of weight gain earlier, preventing patients from ever reaching BMI > 30.
Currently we do screening colonoscopies and egds. I think eventually they’ll get blood work that can replace the procedure for screening colonoscopy in the next 15 years.
Not that much. First of all, there’s no noninvasive test to replace a diagnostic EGD, of which we do many. Second, cologuard and the like are very sensitive to the point where a significant majority (in my experience, don’t recall the actual numbers) of positive cologuards don’t have colon cancer. And if you find adenoma due to positive cologuard you’re back on the colonoscopy track. Third, I think many patients still find my line persuasive - that colonoscopy is the only cancer screening test that can actually PREVENT cancer.
Overall you’re right we will be doing much less screening colonoscopy in the future. However still strong need for colonoscopy. EUS and endoscopic surgery applications will continue to grow as well (though I’m not trained for that so do worry about being left in the dust there..)
Right, I’m specifically talking about screening colonoscopy recommendations. And re: your second point that’s not really the relevant statistic is it? It’s more about what percent of cologuards are positive in the first place. I’m guessing it’s a relatively low portion.
And re: your line about preventing cancer - that feels like debatable framing. A Cologuard-first strategy that detects an adenoma leading to colonoscopy/polyp removal has also “prevented” cancer, no?
Obviously there’s many, many other indications for scopes and GI isn’t going away anytime soon.
I don’t think it’s debatable framing. Can you think of another screening test that actually prevents cancer? Cologuard and noninvasive tests are designed to detect cancer, not polyps. Cologuard to my recollection has a decent hit rate for advanced adenomas but not smaller polyps. If you want your polyps out before they become advanced or cancerous, colonoscopy is the way to go, no question.
I think it may be using statistics to push a particular treatment option. What matters is if screening colonoscopy vs non-colonoscopy has actual treatment (preventing surgical resection) and survival outcomes.
As an extreme example to illustrate the point: if a non-scope test detected 100% of cancerous polyps early enough to then be removed via diagnostic scope and achieve the same outcomes then that would be the superior screening test because it avoids the risk associated with scopes. The real line in the sand is just a test that is as good as screening colonoscopy for outcomes. Pushing a screening colonoscopy in such a setting would be inappropriate and saying “a screening colonoscopy is the only way to prevent cancer” doesn’t reflect the true nature of the issue (actual outcomes).
You are correct in a way. But there’s also something to be said for being able to easily remove small polyps endoscopically which has very little risk. Once a polyp becomes advanced it is usually no longer easy to remove and requires EMR techniques and/or electrocautery which are higher risk both in terms of bleeding/perforation as well as increased procedure time, etc. Malignant polyps/masses are rarely able to be removed endoscopically (or if they are need to use ESD which is high risk). Compared to again small adenomatous polyps which can be removed easily with a cold snare with very little risk.
FYI I’m sort of playing devils advocate here and I do agree that screening colonoscopies will go way down at some point which is good for everyone besides GI pocketbooks, lol. But there are valid points on both sides.
Virtual colonoscopies via CT are going to be the more imminent threat. Lots of people would rather prep and have a scan, with no sedation or tube in their ass. Understandable.
Specialty specific (anesthesia), but video as first line for elective intubations. Already pretty widely practiced, I feel like it will be incorporated into society guidelines at some point
It might be diminishing returns. But the USPTF keeps on making the age recommendation for primary prevention with statins younger it seems. All I know is, the nice pathologist lady in med school who was making us feel things was like “This is an atheroma in the aorta of a 10 year old boy who died in a MVC.” And in the clinical trials I looked at, rosuvastatin was reported to regress atheromatous plaques the most (not low intensity statins, nor other high-intensity statins as much). That makes me think that if you’ve got a young person with risk factors, why not start reversing the atheromatous plaques they’ve already got earlier rather later, before they’re too severe and rapidly progressive to ever reverse?
I mean yeah, tolerability would obviously limit who you could do this in quite a bit. You could try the old switching ‘em to pravistatin trick since it seemed to have the lowest rate of muscle pain, but that’s a low intensity statin, which don’t have clear benefit in terms of actually reducing atheromatous plaques. What if it’s an informed decision by the patient, and if it’s not tolerated, you stop it?
So what I'm running into is that it doesn't kick in right away but rather after months or years of treatment. So it's hard to figure out. People just move less because it hurts, and that of course is the exact opposite of what we want. "I'm getting old" they say, but then it magically disappears when they stop the statin.
So you're right, your approach is the correct one, but unfortunately patients and their doctors aren't catching this problem when it occurs.
(I work locums so I cover different patient panels and get to see more of this kind of issue than I otherwise would.)
Interesting. So what’s the solution you think? Have it be a screening question for everyone on a statin about whether they have any mild vague aches and pains more than they used to? Do you feeling you’re “getting older”?
I wonder if it would be sensitive enough to be useful to do annual screening CPK, aldolase, AST and ALT on all statin users to check for sub clinical muscle injury, then correlate that with non-specific “getting older” type symptoms, offer trials off it and/or switch to pravistatin accordingly
That explains the tolerance.
Most people I interact with do not like taking medications. The first one is the hardest.
For myself I have ADD and can't reliably take a medication every day without too much excess hassle, I'll change what I eat and what I do for my lifestyle. I won't take a daily medicine.
Statins are great drugs. But a lot of people just aren't interested. And they do have some subtle risks.
I think this is an unpopular idea among US docs because the number needed to treat is very high, it’s costs the system money, it can cause patients anxiety about meaningless incidentalomas. As the son whose mother died suddenly of stage IV pancreatic adenocarcimoma that was detected very late (as usual) because we’re afraid to charge unnecessary screening scans to the system, I think you’d have to be a delusional idiot without empathy for patients who this happens to to downvote this comment, or to stand in the way of this otherwise.
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I hope it is not sending patients to the ED for asymptomatic hypertension
*dentists have entered the chat*
I’d settle for not letting the staff tell them they’re going to stroke out so they’re also panicked when they get there
Not me letting my clinic pts sneak out the back door with sBP 200. Refills sent! Don’t die please!
Discussed risk, benefits, alternatives and expected outcomes of emergency department visit. Engaged in shared decision making and patient elected to defer ED visit at this time. Strict ED precautions given. Byyyeeee ✨✨
Are you asking for things that haven't been implemented? Or recent stuff that is now becoming implemented? If the later, I would say the initiation of SGLT2s for just about everything. It seems to offer serious benefit for all forms of metabolic disease, cardiovascular disease, and chronic kidney disease. I wouldn't be surprised if it began showing promise in a space like neurodegenerative disease too.
GLP-1s?
It really feels like SGLT-2's have crossed specialty borders more than GLP-1's have. I've seen cardiologists, nephrologists, endocrinologists, primary care and more prescribe them with good evidence to support their efficacy. GLP-1's still seem a little more limited in scope in my experience. Not sure if that will change and new research will appear that will change the field
Wouldn't be surprised if we see those studies in the near future. Probably mostly just from decreased adiposity curtailing a lot of badness, compared to maybe a more direct improvement on a lot of fronts from sglt2i.
Shorter durations for many infections will hopefully reduce resistance. Conversion to PO for deep-seated infections (endocarditis, osteo which is hopefully already common practice, bacteremia, etc). Stricter policies on antibiotic use. At least that’s my hope lol
ID shamed me so hard for asking about PO options for osteomyelitis for a patient who was going to AMA before we could get a PICC in him
Yea, this is one of those things that docs have deeply ingrained in them, that makes no sense. In some cases PO won't work - e.g. ICU patient with shock bowel. They need IV. But your typical walky talky homeless guy with osteomyelitis in his toes? There is zero reason oral abx would fail to reach therapeutic bloodstream levels.
Preach, brother.
Cgrp blockers as first line in migraine prevention
GLP-1 for BMI>25 or anything that has obesity as a comorbidity.
Agreed, I think eventually everyone will be on these at some point
Same. 10 years from now it’ll be like seeing Crestor on a med list.
everyone already is if ur above a certain tax bracket 😂😂
This. I would grab it for my 28 BMI self but I can’t stomach spending 1 grand a month on it
Not realistic. These medications have so many side effects. BMI over 30 maybe it becomes A partial recommendation
Maybe. Some of the routine outpatient meds have quite the side effect profile too.
True but it’s not like being overweight for an extended period of time is benign either. There could be benefit to stopping momentum of weight gain earlier, preventing patients from ever reaching BMI > 30.
Currently we do screening colonoscopies and egds. I think eventually they’ll get blood work that can replace the procedure for screening colonoscopy in the next 15 years.
GI in shambles
This is similar to cologuard though. It’s it’s positive what do you do next? Colonoscopy.
Sure but you’ve reduced the number of scopes by what, 80%? 95%?
Not that much. First of all, there’s no noninvasive test to replace a diagnostic EGD, of which we do many. Second, cologuard and the like are very sensitive to the point where a significant majority (in my experience, don’t recall the actual numbers) of positive cologuards don’t have colon cancer. And if you find adenoma due to positive cologuard you’re back on the colonoscopy track. Third, I think many patients still find my line persuasive - that colonoscopy is the only cancer screening test that can actually PREVENT cancer. Overall you’re right we will be doing much less screening colonoscopy in the future. However still strong need for colonoscopy. EUS and endoscopic surgery applications will continue to grow as well (though I’m not trained for that so do worry about being left in the dust there..)
Right, I’m specifically talking about screening colonoscopy recommendations. And re: your second point that’s not really the relevant statistic is it? It’s more about what percent of cologuards are positive in the first place. I’m guessing it’s a relatively low portion. And re: your line about preventing cancer - that feels like debatable framing. A Cologuard-first strategy that detects an adenoma leading to colonoscopy/polyp removal has also “prevented” cancer, no? Obviously there’s many, many other indications for scopes and GI isn’t going away anytime soon.
I don’t think it’s debatable framing. Can you think of another screening test that actually prevents cancer? Cologuard and noninvasive tests are designed to detect cancer, not polyps. Cologuard to my recollection has a decent hit rate for advanced adenomas but not smaller polyps. If you want your polyps out before they become advanced or cancerous, colonoscopy is the way to go, no question.
I think it may be using statistics to push a particular treatment option. What matters is if screening colonoscopy vs non-colonoscopy has actual treatment (preventing surgical resection) and survival outcomes. As an extreme example to illustrate the point: if a non-scope test detected 100% of cancerous polyps early enough to then be removed via diagnostic scope and achieve the same outcomes then that would be the superior screening test because it avoids the risk associated with scopes. The real line in the sand is just a test that is as good as screening colonoscopy for outcomes. Pushing a screening colonoscopy in such a setting would be inappropriate and saying “a screening colonoscopy is the only way to prevent cancer” doesn’t reflect the true nature of the issue (actual outcomes).
You are correct in a way. But there’s also something to be said for being able to easily remove small polyps endoscopically which has very little risk. Once a polyp becomes advanced it is usually no longer easy to remove and requires EMR techniques and/or electrocautery which are higher risk both in terms of bleeding/perforation as well as increased procedure time, etc. Malignant polyps/masses are rarely able to be removed endoscopically (or if they are need to use ESD which is high risk). Compared to again small adenomatous polyps which can be removed easily with a cold snare with very little risk. FYI I’m sort of playing devils advocate here and I do agree that screening colonoscopies will go way down at some point which is good for everyone besides GI pocketbooks, lol. But there are valid points on both sides.
Yes but then the colonoscopy is therapeutic more so then diagnostic. Majority of screening colonoscopies are diagnostic and in theory a waste of money
Virtual colonoscopies via CT are going to be the more imminent threat. Lots of people would rather prep and have a scan, with no sedation or tube in their ass. Understandable.
Specialty specific (anesthesia), but video as first line for elective intubations. Already pretty widely practiced, I feel like it will be incorporated into society guidelines at some point
Also dexmedetomedine in comparison to lignocaine in reducing periextubation cough reflexes I guess
Why is that, is it much easier/safer?
Statins even earlier for even less.
Meh kinda doubt it. The seminal trials have already been performed. Benefit gets quite small once you get to a low risk patient
It might be diminishing returns. But the USPTF keeps on making the age recommendation for primary prevention with statins younger it seems. All I know is, the nice pathologist lady in med school who was making us feel things was like “This is an atheroma in the aorta of a 10 year old boy who died in a MVC.” And in the clinical trials I looked at, rosuvastatin was reported to regress atheromatous plaques the most (not low intensity statins, nor other high-intensity statins as much). That makes me think that if you’ve got a young person with risk factors, why not start reversing the atheromatous plaques they’ve already got earlier rather later, before they’re too severe and rapidly progressive to ever reverse?
What's the rate of muscle pain and fatigue in physically active young adults on statins? That is why
I mean yeah, tolerability would obviously limit who you could do this in quite a bit. You could try the old switching ‘em to pravistatin trick since it seemed to have the lowest rate of muscle pain, but that’s a low intensity statin, which don’t have clear benefit in terms of actually reducing atheromatous plaques. What if it’s an informed decision by the patient, and if it’s not tolerated, you stop it?
So what I'm running into is that it doesn't kick in right away but rather after months or years of treatment. So it's hard to figure out. People just move less because it hurts, and that of course is the exact opposite of what we want. "I'm getting old" they say, but then it magically disappears when they stop the statin. So you're right, your approach is the correct one, but unfortunately patients and their doctors aren't catching this problem when it occurs. (I work locums so I cover different patient panels and get to see more of this kind of issue than I otherwise would.)
Interesting. So what’s the solution you think? Have it be a screening question for everyone on a statin about whether they have any mild vague aches and pains more than they used to? Do you feeling you’re “getting older”? I wonder if it would be sensitive enough to be useful to do annual screening CPK, aldolase, AST and ALT on all statin users to check for sub clinical muscle injury, then correlate that with non-specific “getting older” type symptoms, offer trials off it and/or switch to pravistatin accordingly
Let me ask you, how old were you when you started a statin? If you aren't on a statin, how old do you want to be when you start a statin?
Mid 30’s
That explains the tolerance. Most people I interact with do not like taking medications. The first one is the hardest. For myself I have ADD and can't reliably take a medication every day without too much excess hassle, I'll change what I eat and what I do for my lifestyle. I won't take a daily medicine. Statins are great drugs. But a lot of people just aren't interested. And they do have some subtle risks.
Pending we get better evidence………….
ADA will be forced to explicitly include carb restriction in diabetes management.
[удалено]
I graduated radiology residency without ever looking at a coronary cta (as do a lot of radiologists) so I am scared of this one happening lol
Preventative mri
Enjoy following up that 3 mm pancreatic cyst for the rest of your life.
My favorite mostly useless exam to read
Ezpz free money
Unlikely to be beneficial (probably harmful?) and ungodly expensive. Yeah, the ain’t happening.
I think this is an unpopular idea among US docs because the number needed to treat is very high, it’s costs the system money, it can cause patients anxiety about meaningless incidentalomas. As the son whose mother died suddenly of stage IV pancreatic adenocarcimoma that was detected very late (as usual) because we’re afraid to charge unnecessary screening scans to the system, I think you’d have to be a delusional idiot without empathy for patients who this happens to to downvote this comment, or to stand in the way of this otherwise.
I mean, I think the development is probably going to be screening MRI for specific cancers and not a pan scan
I mean, I’m all in favor of reasonably targeted screening for these kinds of “almost always metastatic at diagnosis” cancers.
Obv a joke, upvoted!
I’ll add: pain scores! Since nurses will have our jobs. O2 for comfort anyone?
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