Dear Colleagues!

Have You noticed remarkable changes after Covid-era? I know there other modifying factors, too, wars next and far to us, globalisation, new rules etc , but Covid made a strong fingerprint on all of us, 

Have your and coworkers and patients attitude, feelings or healthcare indicators changed? 

We meet more younger ones and older patients with highrisk comorbidity requiring polihistiric attitude in mean stream internal medicine, neurology and psychiatry, more emergency occurances and more difficoult social problems .

I feel all around exhaustion, anxiety, the loss of presumed safty.

What about You?

Best regards

As more countries and states legalize medical aid in dying (MAiD), discussions around ethics, legality, and access have taken center stage. However, one critical question remains underexplored: Do we fully understand the safety, efficacy, and potential complications of the drugs used in assisted dying? While these medications are meant to provide a peaceful, dignified passing, research suggests that complications, prolonged deaths, and inconsistent protocols may pose significant concerns.

Unlike most medical treatments, there is no single standardized drug regimen for assisted dying. Different countries, and even states within the U.S., use varying combinations of medications to induce death. These protocols typically involve a combination of barbiturates, benzodiazepines, opioids, muscle relaxants, or cardiac-affecting drugs, yet research on their effectiveness and potential complications remains limited. For example, in Oregon, over 70% of cases in 2022 used a combination of diazepam, digoxin, morphine sulfate, amitriptyline, and phenobarbital (DDMAPh), while 28% used a slightly modified version without phenobarbital (DDMA). Meanwhile, Canada has adopted a protocol using midazolam, propofol, and rocuronium, whereas the Netherlands primarily relies on high-dose barbiturates. These inconsistencies raise concerns about whether some regimens may be more effective or humane than others.

Despite the assumption that assisted dying is quick and painless, medical reports suggest that complications do occur. A 2024 study published in JAMA Internal Medicine found that while most cases followed expected trajectories, some patients experienced prolonged deaths, vomiting, or muscle spasms (myoclonus). In some cases, death took as long as 47 hours—raising ethical concerns about patient suffering. Other reported issues include:

• Delayed absorption of drugs, leading to extended or unpredictable time of death.
• Difficulty in maintaining IV access, requiring multiple attempts or additional interventions.
• Incomplete sedation, leading to distress before full unconsciousness.

These challenges highlight the need for more research into the pharmacokinetics and optimal drug combinations to ensure predictable, painless outcomes.

Most of the medications used in assisted dying were not originally designed for this purpose—many were repurposed from anesthesia or palliative care. Physicians administering MAiD often rely on trial-and-error adjustments to protocols based on patient response, yet there is no universally accepted "gold standard" for ensuring rapid, painless, and complication-free death. What happens when drugs do not work as expected? How often do patients experience unanticipated suffering? These are difficult but necessary questions that require more research and transparency.

Moreover, reporting on assisted dying outcomes is inconsistent. In some jurisdictions, data collection is minimal, making it difficult to assess how frequently complications occur or which protocols are most effective. A 2023 study found that in some cases, complications were significantly underreported, making it hard to develop evidence-based improvements in drug administration. As more jurisdictions legalize assisted dying, there is a growing need for clinical research into the most effective, humane, and reliable drug regimens. However, due to ethical concerns and regulatory barriers, controlled trials on assisted dying drugs remain a gray area in medical research. What are your thoughts?

The latest meeting of the U.S. Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (ACIP) has been postponed indefinitely to allow time for public comments to be collected, according to federal health officials, Reuters has reported.

ACIP usually holds multiple meetings each year to review scientific data and make recommendations to the director of the CDC. This particular meeting, originally scheduled for Feb. 26 to 28, was to include several important votes, including one about how a key government vaccine distribution program should handle influenza inoculations. The draft agenda also indicated reviews of the GSK meningococcal vaccine and AstraZeneca flu shot.

According to the U.S. Department of Health and Human Services, the public is normally allowed time to submit written comments in advance of ACIP meetings through a federal portal. Prior to the inauguration of President Trump last month, the CDC had posted a formal notice of the February ACIP meeting, noting that comments could be submitted between Feb. 3 and 17. However, a letter to the newly appointed Secretary of the U.S. Department of Health and Human Services, Robert F. Kennedy Jr., signed by more than 50 medical experts and organizations, states that the portal has been "absent," Reuters reported. The signatories also requested the "critical" meeting be rescheduled.

The American College of Physicians echoed that sentiment. "Our country is currently facing the worst epidemic of influenza in several decades, a measles outbreak in Texas, and an ongoing national outbreak of pertussis," Isaac O. Opole, M.B.Ch.B., Ph.D., president of the American College of Physicians, said in a statement. "The CDC must promptly reschedule this critical meeting. We call on Secretary Kennedy and other officials to ensure that the advice of epidemiologists, researchers, physicians, and other experts in disease and immunizations remains primary in helping to ensure the public's health."

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For older adults with type 2 diabetes (T2D), use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) is associated with a modestly lower risk for depression compared with dipeptidyl peptidase-4 inhibitor (DPP-4i) use, according to a study published online Feb. 25 in the Annals of Internal Medicine.

Huilin Tang, Ph.D., from the University of Florida College of Pharmacy in Gainesville, and colleagues compared the risk for depression in older adults with T2D initiating treatment with GLP-1 RAs versus sodium-glucose cotransporter-2 inhibitors (SGLT-2is) or DPP-4is in a target trial emulation study using national Medicare administrative data from January 2014 to December 2020. Adults aged 66 years or older with T2D initiating treatment with a GLP-1 RA were propensity score-matched to those initiating treatment with an SGLT-2i (14,665 matched pairs) or a DPP-4i (13,711 matched pairs).

The researchers found that the rate difference of depression was 3.48 per 1,000 person-years between GLP-1 RA users and SGLT-2i users (hazard ratio, 1.07; 95 percent confidence interval, 0.98 to 1.18). The rate difference was −5.78 per 1,000 person-years for GLP-1 RA users versus DPP-4i users (hazard ratio, 0.90; 95 percent confidence interval, 0.82 to 0.98).

"These results, if confirmed in randomized controlled trials, could have important implications for the management of T2D, especially in older patients at risk for depression," the authors write.

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For patients with type 2 diabetes (T2D) and chronic obstructive pulmonary disorder (COPD), sodium-glucose cotransporter-2 inhibitors (SGLT-2is) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are associated with a reduced risk for moderate or severe COPD exacerbations compared with dipeptidyl peptidase 4 inhibitors (DPP-4is), according to a study published online Feb. 10 in JAMA Internal Medicine.

Avik Ray, M.D., from Brigham and Women's Hospital and Harvard Medical School in Boston, and colleagues conducted a comparative effectiveness study to assess the risk for moderate or severe COPD exacerbations among patients aged 40 years or older with T2D and active COPD who initiated treatment with SGLT-2is versus DPP-4is; GLP-1 RAs versus DPP-4is; and SGLT-2is versus GLP-1 RAs (27,991; 32,107; and 36,218 pairs, respectively).

The researchers found that the risk for moderate or severe COPD exacerbation was lower among those treated with SGLT-2is versus DPP-4is and among those treated with GLP-1 RAs versus DPP-4is (9.26 versus 11.4 per 100 person-years [hazard ratio, 0.81] and 9.89 versus 11.49 per 100 person-years [hazard ratio, 0.86], respectively), with minimal differences observed among those treated with SGLT-2is versus GLP-1 RAs. Across sensitivity and subgroup analyses, the results were consistent.

"These findings suggest that SGLT-2is and GLP-1 RAs may be preferable to DPP4is when deciding among glucose-lowering medications for patients with T2D and active COPD," the authors write. "However, given the observational nature of the study, there is potential for residual or unmeasured confounding, and findings from similar clinical studies and clinical trials will help corroborate these results."

Several authors disclosed ties to the pharmaceutical industry; one author disclosed being an expert witness in litigation against inhaler manufacturers.

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The Trump administration changed course on Tuesday, deciding to keep the government's free COVID test program running, just minutes before the website, COVIDtests.gov, was set to shut down.

Earlier that day, The Washington Post reported that officials were preparing to end the program and possibly destroy tens of millions of unused tests worth more than a half-billion dollars.

But 12 minutes before the shutdown, Andrew Nixon, a spokesman for the Department of Health and Human Services (HHS), announced the site would remain active.

“With COVID-19 infections decreasing after a winter peak, we are in the process of regular discussions on closing this round of the COVID-19 test ordering program. At this point, the program is still open, and we will share additional updates as needed,” he said in a statement.

Internal documents showed that HHS officials had been debating two options: Disposing of more than 160 million COVID tests, or continuing to ship them to U.S. households. The stockpile is maintained by the Administration for Strategic Preparedness and Response (ASPR).

Only a small fraction of the tests had expired, and tens of thousands were still being ordered daily, Dawn O’Connell, an ASPR chief under the Biden administration, told The Post.

“It’s expensive to stockpile these tests,” she said. “Destruction costs a significant amount of money, but hanging on to them costs a significant amount of money.”

The reversal followed concerns from public health experts about losing a valuable tool during flu season and future COVID surges.

In his first days back in office, President Donald Trump rescinded many of former President Joe Biden’s COVID-related executive orders, including one aimed at expanding national testing strategy.

“The virus is not posing a major public health threat now,” said Dr. Ashish Jha, who led the White House COVID response from March 2022 to April 2023 under Biden.

Jha, now the dean of Brown University School of Public Health, told The Post that trashing the tests “feels like an act of self-destruction here. It’s going to be expensive. And it takes away a tool that the administration would want to use in the scenario that we get a highly immune-evasive variant."

While COVID cases have decreased after the winter peak, experts warn that free testing remains critical to control infection.

“Destroying an asset that was paid for by the American people, that doesn’t make any sense,” said Dr. Tom Inglesby, who was White House national coordinator for COVID testing from the end of 2021 to April 2022. He's now the director of the Johns Hopkins Center for Health Security at the Bloomberg School of Public Health.

In the event of a resurgence, “we need to be able to figure out who is sick, who is not sick, who needs medicine, who is, in fact, contagious, who may be someone who’s vulnerable," Inglesby told The Post. "These diagnostics really help you make really good decisions, help families make good decisions about how to stay healthy.”

ASPR has distributed more than 2 billion free tests since January 2020, including 900 million sent directly to households through COVIDtests.gov, in partnership with the U.S. Postal Service.

The program has been paused and restarted many times, including seven shutdowns since its launch.

Most recently, it was paused in March 2024 and reopened in September right before the winter respiratory illness season.

More information

The U.S. Food and Drug Administration has more on at-home over-the-counter COVID tests.

SOURCE: The Washington Post, media report, Feb. 18, 2025

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National increases in online searches for gambling addiction occurred after legalization of sportsbooks, according to a study published online Feb. 17 in JAMA Internal Medicine.

Atharva Yeola, from the University of California, San Diego, and colleagues assessed how U.S. sports betting evolved after the Murphy v National Collegiate Athletic Association U.S. Supreme Court decision. Aggregate U.S. internet search trends for gambling addiction and wagers on sports were compared before and after the emergence of legalized sportsbooks.

The researchers found that the number of states with operational sportsbooks increased from one in 2017 to 38 in 2024, while total sports wagers increased from $4.9 billion in 2017 to $121.1 billion during 2023. The vast majority of 2023 wagers (94 percent) were placed online. After the Supreme Court decision, there were 23 percent more searches nationally for gambling addiction help-seeking. After the opening of any sportsbooks, there were 47, 34, 37, and 50 percent more searches than expected in Massachusetts, New Jersey, New York, and Pennsylvania, respectively. Opening of online sportsbooks corresponded with a larger increase in searches than retail openings.

"These findings emphasize the need for public health efforts to study and address the potential harms associated with the rapid growth of sports betting," the authors write.

Two authors disclosed ties to the biotechnology and data analytics industries.

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For patients with acute coronary syndrome (ACS) undergoing drug-eluting stent (DES) implantation, de-escalating dual antiplatelet therapy (DAPT) to P2Y12 inhibitor monotherapy is associated with lower bleeding risk, without an increase in ischemic events, according to a review published online Feb. 18 in the Annals of Internal Medicine.

Yong-Joon Lee, M.D., from Severance Hospital at the Yonsei University College of Medicine in Seoul, South Korea, and colleagues compared the effects of de-escalating DAPT to ticagrelor monotherapy versus standard DAPT using data from randomized clinical trials involving patients with ACS. Individual patient data were obtained from three trials, including 9,130 randomized patients with ACS: 3,132 with ST-segment elevation myocardial infarction (STEMI); 3,023 with non-STEMI (NSTEMI); and 2,975 with unstable angina.

The researchers found no difference in the rate of the primary ischemic end point (composite of death, nonprocedural [spontaneous] myocardial infarction, or stroke) between the ticagrelor monotherapy and standard DAPT groups (1.7 versus 2.1 percent; hazard ratio, 0.85; 95 percent confidence interval, 0.63 to 1.16). The ticagrelor monotherapy group had a lower rate of the primary bleeding end point (0.8 versus 2.5 percent; hazard ratio, 0.30; 95 percent confidence interval, 0.21 to 0.45). The findings were consistent across STEMI, NSTEMI, and unstable angina.

"Our findings suggest that de-escalating DAPT to ticagrelor monotherapy will reduce aspirin-associated major bleeding while preserving the anti-ischemic benefits of antiplatelet therapy for patients with ACS of all types undergoing DES implantation," the authors write.

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Rates of major bleeding and intracranial hemorrhage are similar for apixaban and dabigatran versus aspirin, while rates are higher for rivaroxaban, according to a review published online Feb. 11 in the Annals of Internal Medicine.

Michael Ke Wang, M.D., from McMaster University in Hamilton, Ontario, Canada, and colleagues estimated the differences in bleeding risks between therapeutic-dose nonvitamin K oral anticoagulants (NOACs) and single antiplatelet therapy using data from nine randomized controlled trials with 26,224 participants. All of the studies used aspirin as the antiplatelet therapy.

The researchers found that apixaban had similar rates of major bleeding and intracranial hemorrhage compared with aspirin (risk differences, 0.0 [95 percent confidence interval, −1.3 to 2.6] and −0.2 [95 percent confidence interval, −0.6 to 1.4] percentage points, respectively). Dabigatran also had similar rates of major bleeding and intracranial hemorrhage compared with aspirin (risk differences, 0.5 [95 percent confidence interval, −2.1 to 19.6] and 0.0 [95 percent confidence interval, −1.1 to 24.5] percentage points, respectively). Rivaroxaban had higher rates of major bleeding and intracranial hemorrhage than aspirin (risk differences, 0.9 [95 percent confidence interval, −0.1 to 3.7] and 0.3 [95 percent confidence interval, −0.1 to 79.7] percentage points, respectively). The certainty of evidence varied from low to moderate.

"Our findings are similar to those reported by a previous network meta-analysis, which found indirect evidence that therapeutic-dose rivaroxaban had the highest risk for bleeding out of the NOACs compared with aspirin when used for extended anticoagulation in this population," the authors write.

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Clinical decision support (CDS) aimed at reducing overuse of care in seniors does not yield durable changes in terms of prostate-specific antigen (PSA) screening in older men, but is durable for reducing urinary overtesting, according to a research letter published online Feb. 11 in the Annals of Internal Medicine.

Lucia C. Petito, Ph.D., from the Northwestern University Feinberg School of Medicine in Chicago, and colleagues examined whether the effectiveness of a behavioral intervention to reduce overtesting and overtreatment of older adults in three areas persisted in the 12 months after intervention discontinuation. The pragmatic, cluster randomized controlled trial was conducted at 60 primary care practices in Chicago, which enrolled 371 clinicians to receive intervention (CDS delivered through the electronic health record) or control for 18 months.

The researchers found that the intervention group, but not the control group, had an increase in the annual rate of PSA testing per 100 patients during the postintervention year. Per 100 eligible patients, the annual rate of urinalysis or urine culture was lower in the intervention versus the control group at the end of the postintervention period; neither rate changed meaningfully during the following year. At the beginning of the postintervention period, the annual rate of diabetes overtreatment per 100 eligible patients was slightly lower in the intervention group, but rates were indistinguishable between the intervention and control groups at the end of the postintervention period.

"These findings suggest that to maintain benefits, CDS interventions aimed at reducing low-value care should generally be left in place or be provided on a less frequent schedule to reduce alert fatigue," the authors write.

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In a clinical guideline issued by the American College of Physicians and published online Feb. 4 in the Annals of Internal Medicine, recommendations are presented regarding the use of pharmacologic treatments for the prevention of episodic migraine headache in nonpregnant adults in outpatient settings.

Amir Qaseem, M.D., Ph.D., from the American College of Physicians in Philadelphia, and colleagues examined the comparative effectiveness of medications that are beneficial for preventing episodic migraine to help clinicians select which medication to use.

The guidelines include three recommendations. Monotherapy to prevent episodic migraine headache in nonpregnant adults in outpatient settings is suggested by choosing one of the following: beta-adrenergic blocker (metoprolol or propranolol), the antiseizure medication valproate, the serotonin and norepinephrine reuptake inhibitor venlafaxine, or the tricyclic antidepressant amitriptyline. To prevent episodic migraine headache in nonpregnant adults in outpatient settings who do not tolerate or inadequately respond to a trial or trials of one of these medications, monotherapy with a calcitonin gene-related peptide (CGRP) antagonist-gepant or a CGRP monoclonal antibody is suggested. Monotherapy with the antiseizure medication topiramate is suggested to prevent episodic migraine for those who do not respond to the suggestions in recommendations 1 and 2. An informed decision-making approach should be used, and benefits, harms, costs, patient values and preferences, contraindications, pregnancy and reproductive status in females, clinical comorbidities, and medication availability should be discussed when selecting pharmacologic treatment.

"Adherence to pharmacologic treatment is crucial because improvement may occur gradually after initiation of a long-term treatment option for prevention of episodic migraine, with an effect that may become apparent after the first few weeks of treatment," the authors write.

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Epstein-Barr virus (EBV)-seronegative recipients of EBV-seropositive donor (EBV D+/R−) kidneys have an increased risk for posttransplant lymphoproliferative disorder (PTLD), according to a study published online Jan. 28 in the Annals of Internal Medicine.

Vishnu S. Potluri, M.D., M.P.H., from the Hospital of the University of Pennsylvania, and colleagues conducted a retrospective cohort study to examine the associations between pretransplant EBV D+/R− and recipient EBV-seropositive status (R+) and the outcomes of PTLD and graft and patient survival in adult recipients of kidney transplant.

The final cohort included 104 EBV D+/R− recipients matched to 312 EBV R+ recipients. The researchers found that 50 (48.1 percent) of the EBV D+/R− recipients developed EBV DNAemia, with a median time of 198 days after transplant. At a median of 202 days after transplant, 23 (22.1 percent) EBV D+/R− recipients had PTLD. Higher all-cause graft failure was seen in EBV D+/R− recipients (hazard ratio, 2.21; 95 percent confidence interval, 1.06 to 4.63), and mortality was higher but the increase was not statistically significant (hazard ratio, 2.19; 95 percent confidence interval, 0.94 to 5.13).

"Our findings highlight the need for strategies to attenuate the effect of donor-derived EBV infection among EBV-seronegative recipients and for counseling prospective EBV D+/R− recipients about the elevated risk for early PTLD," the authors write.

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U.S. internal medicine (IM) residents from ethnicities and races underrepresented in medicine (URIM) remain underrepresented compared with their program's county population, according to a study published online Jan. 30 in JAMA Network Open.

Jung G. Kim, Ph.D., M.P.H., from New York University Langone Health in New York City, and colleagues explored county-level racial and ethnic representation of U.S. IM residents and examined racial and ethnic concordance between residents and their communities in a retrospective cross-sectional study. The analysis included data from 4,848 IM residents (15.7 percent classified as URIM) training across 205 counties.

The researchers found that among URIM groups, American Indian and Alaska Native (mean representation quotients [RQ], 0.00), Black (mean RQ, 0.09), Hispanic and Latinx (mean RQ, 0.00), and Native Hawaiian and other Pacific Islander (mean RQ, 0.00) residents were grossly underrepresented versus their training sites’ county-level representation. One quarter of counties (24.8 percent) with IM programs had no URIM residents. In counties with more minority-serving institutions, Black and Hispanic or Latinx residents had higher representation (mean RQ, 0.19). In counties with more academic health centers, Hispanic or Latinx residents were less represented (mean RQ, 0.00). In counties with more minority-serving institutions, Asian residents had lower RQs (mean RQ, 6.00). White residents had higher representation in counties with greater presence of academic health centers (mean RQ, 0.77).

"These findings should inform racial and ethnic diversity policies to address the continuing underrepresentation among graduate medical education physicians, which adversely impacts the care of historically underserved communities," the authors write.

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COVID-19 was associated with more severe disease outcomes than influenza or respiratory syncytial virus (RSV) during the 2022 to 2023 season, according to a study published online Jan. 27 in JAMA Internal Medicine.

Kristina L. Bajema, M.D., from Veterans Affairs Portland Health Care System in Oregon, and colleagues compared disease severity of COVID-19, influenza, and RSV among U.S. veterans in a retrospective cohort study. The cumulative incidence and risk differences were calculated for the primary outcomes of 30-day hospitalization, intensive care unit admission, and death.

The researchers found that the 30-day risk for hospitalization was similar for COVID-19 and influenza (16.2 versus 16.3 percent) and was lower for RSV (14.3 percent) during the 2023 to 2024 season. The 30-day risk for death was slightly higher for COVID-19 compared with influenza or RSV during the 2022 to 2023 season (1.0 percent versus 0.7 and 0.7 percent), but was similar during the 2023 to 2024 season. At 180 days, mortality risk was higher for COVID-19 during both seasons. In both seasons, higher mortality was seen for veterans without COVID-19 vaccination in the previous year compared with those without seasonal influenza vaccination. In contrast, no mortality differences were seen at any time point between COVID-19 and influenza among those vaccinated against their respective infections.

"Severe acute respiratory syndrome coronavirus 2 was far more common than influenza or RSV and resulted in more severe disease outcomes, including short-term hospitalization and mortality through six months," the authors write. "This was most apparent among older adults and attenuated by updated COVID-19 vaccination."

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Differences in blood pressure (BP) readings obtained in public spaces versus private spaces are minimal and non-clinically important, according to a study published online Jan. 28 in the Annals of Internal Medicine.

Junichi Ishigami, M.D., M.P.H., from the John Hopkins Bloomberg School of Public Health in Baltimore, and colleagues examined the effect of noise and public environment on BP readings in a study conducted among 108 community-dwelling adults. Study measures were obtained in a clinical research office and a public food market, which had average noise levels of 37 and 74 dB, respectively. Participants were randomly assigned to the order in which they underwent triplicate BP measurements in each of three settings: private quiet office (reference), noisy public space, and noisy public space plus earplugs (private quiet, public loud, and public quiet, respectively).

The researchers found mean systolic BPs of 128.9, 128.3, and 129.0 mm Hg in private quiet, public loud, and public quiet spaces, respectively. The corresponding diastolic BPs were 74.2, 75.9, and 75.7 mm Hg. Minimal, non-clinically important differences were seen for public loud and public quiet BPs versus private quiet BPs (public loud: Δ: −0.66 and 1.65 mm Hg for systolic and diastolic BP, respectively; public quiet: Δ: 0.09 and 1.45 mm Hg for systolic and diastolic BP, respectively). Across subtypes, these patterns were generally consistent.

"These results suggest that public spaces are reasonable settings to conduct hypertension-screening programs," the authors write.

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For patients with diabetes undergoing Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG), overall expenditures decrease in the postsurgical period, with no differences seen following the first six months after surgery, according to a study published online Jan. 28 in the Annals of Internal Medicine.

Matthew L. Maciejewski, Ph.D., of Duke University in Durham, North Carolina, and colleagues compared health expenditures three years before and 5.5 years after bariatric surgery among patients with diabetes undergoing RYGB (3,147 patients) or SG (3,510 patients) from 2012 to 2019.

The researchers found that per six-month period, there was about a 30 percent decrease in expenditures for both groups, from $4,039.06 to $2,441.13 before and after RYGB and from $3,918.37 to $2,658.15 before and after SG. Through 5.5 years, there was no significant difference between the groups in total expenditures after surgery, except for the first six months, when expenditures were transiently higher in the RYGB group (difference, $564.32). This was driven by a higher rate of inpatient admission. Magazine Postsurgical outpatient and medication expenditures did not differ between the groups.

"These findings suggest that RYGB and SG do not substantially differ in reducing long-term health care costs for patients with type 2 diabetes," the authors write. "The substantial cost savings observed are primarily driven by reductions in medication expenditures, highlighting the economic benefits of bariatric surgery in managing diabetes."

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In clinical practice guidelines jointly issued by the U.S. Department of Veterans Affairs and U.S. Department of Defense and published online Jan. 21 in the Annals of Internal Medicine, updated recommendations are presented for the management of stroke rehabilitation.

Blessen C. Eapen, M.D., from the David Geffen School of Medicine at the University of California, Los Angeles, and colleagues in a guideline development workgroup, developed 47 recommendations and an algorithm for stroke rehabilitation in both inpatient and outpatient settings. The group identified the strongest evidence to support guidelines in areas that are relevant to primary care: transition to community; motor therapy; dysphagia, aphasia, and cognition; and mental health.

Recommendations include using case management services at time of discharge to improve activities of daily living and functional independence, as well as task-specific practice to improve motor function, gait, posture, and activities of daily living. Suggestions include use of interventions to improve patient and caregiver depression; psychosocial education to improve family function, patient functional independence, and quality of life; mirror therapy; neuromuscular electrical stimulation to improve motor outcomes; botulinum toxin for focal spasticity; and a selective serotonin reuptake inhibitor or a serotonin norepinephrine reuptake inhibitor, psychotherapy, or mindfulness-based therapies for depression.

"Magazine Poststroke rehabilitation requires an interdisciplinary, holistic approach to the management, treatment, and rehabilitation of stroke sequelae, with the patient and caregivers as vital members of the team," the authors write.

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For patients with localized prostate cancer (PCa), tissue-based genomic classifiers (GCs) do not consistently influence risk classification or treatment decisions, according to a review published online Jan. 21 in the Annals of Internal Medicine.

Amir Alishahi Tabriz, M.D., Ph.D., M.P.H., from the Moffitt Cancer Center in Tampa, Florida, and colleagues conducted a systematic review to summarize the impact of the Decipher, Oncotype DX Genomic Prostate Score (GPS), and Prolaris GCs on risk stratification and patient-clinician decisions regarding treatment choice among patients with localized PCa considering first-line treatment. Studies on risk classification and treatment choice after GC testing were independently identified by two investigators.

The researchers identified 10 studies that reported on risk reclassification after GC testing. Very low-risk or low-risk patients with PCa were more likely to have their risk levels classified as the same or lower in observational studies with a low risk for bias (GPS: 100 to 88.1 percent; Decipher: 87.2 to 82.9 percent; Prolaris: 76.9 percent). GC testing with GPS reclassified 34.5 and 29.4 percent of very low-risk and low-risk patients, respectively, to a higher risk category in one randomized study. Treatment decisions after GC testing either remained unchanged or slightly favored active surveillance based on 12 observational studies; however, in analyses from a single randomized trial, fewer choices for active surveillance after GPS testing were seen.

"Although GC tests do not consistently influence risk classification or treatment decisions, the differences observed between observational and randomized studies highlight a need for well-designed trials to explore the role of GC tests in patients with newly diagnosed PCa considering first-line treatment," the authors write.

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