Questioning Medicine – Détails, épisodes et analyse

STROKE part 3 CME

CME FOR FREEE 

 10% of hospitalized patients have penicillin allergy listed in their records, fewer than 1% of patients have true allergies.

Use of more-expensive and broader-spectrum antibiotics is associated with longer and more-expensive hospital stays and more side effects, nosocomial infections, and resistant organisms.

Blumenthal KG et al. Reaction risk to direct penicillin challenges: A systematic review and meta-analysis. JAMA Intern Med 2024 Sep 16; [e-pub]. (https://doi.org/10.1001/jamainternmed.2024.4606)

 researchers examined the safety of direct penicillin challenges (without preceding skin tests) for delabeling patients without true allergies. Among more than 9000 patients in these studies, 438 experienced reactions (3.5%), with only 5 reactions classified as severe: 3 episodes of anaphylaxis, 1 delayed rash with fever, and 1 kidney injury. No fatalities were reported.

NNH of 1800

The PENFAST score is a good tool to help decide which patients can undergo direct oral challenge safely (NEJM JW Gen Med Aug 1 2023 and JAMA Intern Med 2023; 183:883). In general, if a patient has a history of severe immediate reaction (angioedema or anaphylaxis), a recent urticarial reaction (within 5 years), or any severe delayed reaction (e.g., Stevens–Johnson syndrome, serum sickness, drug reaction with eosinophilia, drug-induced cytopenia, organ injury), I would refer to an allergist for evaluation.

Bottom line

We have far more patients who should have their penicillin allergy delabeled than we have allergists to perform these challenges. Primary care clinicians and hospitalists can do this easily by giving one dose of amoxicillin (500 mg) and watching the patient for 1 to 2 hours; intramuscular epinephrine and oral antihistamines must be available, but are seldom needed. 

Nurse Practitioners prescribe medications off the beers list at the same rate at primary care physicians, hard to tell what this means for patient care and patient outcomes. 


https://www.acpjournals.org/doi/10.7326/M23-0827?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed

Using the Brain Care Score seem to be effective in predicting the risk of dementia

• For participants under 50, each five-point higher BCS is associated with a 50% lower risk of dementia or stroke
• For participants under 50, each five-point higher BCS is associated with a 59% lower risk of dementia 
  
  THE SCORE IS HERE ---->. https://www.massgeneral.org/assets/mgh/pdf/neurology/mccance-center/brain-care-score.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10725202/#:~:text=A%20five%2Dpoint%20higher%20BCS,%25)%20among%20those%20aged%20%3E59.

Even when starting DAPT within 72hours of symptom onset for individuals with minor stroke or TIA the benefit of DAPT for the first 21 days was still seen at 90 day follow up in the form of less recurrent stroke

https://www.nejm.org/do/10.1056/NEJMdo007334/full/

In those high risk patients -- usually with lung or GI cancer they did benefit from primary prevention VTE prophalaxis with a NNT of 6-7 for VTE and death at 6 months. 

https://pubmed.ncbi.nlm.nih.gov/37733336/#:~:text=Conclusions%20and%20relevance%3A%20In%20this,safety%20concerns%2C%20and%20with%20reduced

Just get he biopsy at less than 6 weeks after starting therapy as the yield was the same at 2 weeks as it was at 4-6 weeks


https://pubmed.ncbi.nlm.nih.gov/36642440/

Evidence against baby walker is not enough regarding its negative effect on child development. This subject needs to be addressed more, considering a large number of baby walker users worldwide.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5703622/


Surveillance System data from 1990 to 2014 

 230 676 children <15 months old were treated for infant walker–related injuries in US emergency departments from 1990 to 2014.

9 out of every 10 injuries were to the head and neck and 74% were injuries secondary to falling down the stairs in an infant walker

https://publications.aap.org/pediatrics/article-abstract/142/4/e20174332/37420/Infant-Walker-Related-Injuries-in-the-United?redirectedFrom=fulltext?autologincheck=redirected

During average follow-up of in this study the incidence of prostate cancer was less than 1% — and not significantly different 
 Remember most of these pts had testosterone levels around 350 ish give or take so the safety of longer-duration treatment — or treatment resulting in higher blood levels of testosterone — remains unclear.

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2813293