Episode 337: 336. 24 Hours After a Stroke for EVT- 2 yr Follow-Up

10/18/24 • 6 min

Huijberts I et al. Collateral-based selection for endovascular treatment of acute ischaemic stroke in the late window (MR CLEAN-LATE): 2-year follow-up of a phase 3, multicentre, open-label, randomised controlled trial in the Netherlands. Lancet Neurol 2024 Sep; 23:893. (https://doi.org/10.1016/S1474-4422(24)00228-X)

The modified Rankin Scale (mRS) score at 2 years was the primary outcome. The median mRS at 2 years was 4 in the EVT group and 6 in the control group. For functional independence (mRS, 0–2), the rates were 35% in the EVT patients and 27% in the control group. Mortality at 2 years did not differ between the treatment groups.

However, about 12 patients need to be treated to provide one additional patient with functional independence, a higher number needed to treat than observed in studies of EVT provided in the early time window (e.g., N Engl J Med 2015; 372:2285)

Still 24 hours AFTER a stroke!! amazing

Still 24 hours AFTER a stroke!! amazing

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Episode 336: 335. Do GLP-1 Cause Residual Gastric Contents

Because glucagon-like peptide-1 (GLP-1) receptor agonists can slow gastric emptying, they might confer risk for residual gastric contents — and possibly aspiration!!!! Should we stop the glp-1

Should we stop the glp-1-- Anesthesiologists and gastroenterologists have weighed in on this concern and on QM I say just do whatever the anesthesiologist want because they have the final say!!

Sen S et al. Glucagon-like peptide-1 receptor agonist use and residual gastric content before anesthesia. JAMA Surg 2024 Jun; 159:660.

per American Society of Anesthesiologists [ASA] guidelines; Prior to surgery, patients had fasted at least 2 hours for clear liquids, 6 hours for light meals, and 8 hours for full meals

researchers performed gastric ultrasound just prior to elective surgery in 62 patients who were using weekly injected GLP-1 agonists (semaglutide, dulaglutide, or tirzepatide) and in 62 nonusers (controls).

The prevalence of residual gastric contents was significantly higher in the GLP-1 group than in the control group (56% vs. 19%). After adjustment for confounders, GLP-1 users remained significantly more likely than controls to have residual gastric contents.

Sen S et al. Glucagon-like peptide-1 receptor agonist use and residual gastric content before anesthesia. JAMA Surg 2024 Jun; 159:660.

We still don't know the overall clinical consequences of residual gastric contents in GLP-1 users who undergo elective surgery under anesthesia. For now, clinicians who provide preoperative consultation should try to find out policies of local anesthesiology groups.

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Episode 338: 337. What is the ideal Vitamin D Level to target?

In 2011, the Endocrine Society published a guideline on “Evaluation, Treatment, and Prevention of Vitamin D Deficiency”

Now, the Society has issued an updated guideline, Demay MB et al. Vitamin D for the prevention of disease: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2024 Aug; 109:1907. (https://doi.org/10.1210/clinem/dgae290)

Previously, the Endocrine Society had labeled vitamin D status as “deficient” when serum hydroxyvitamin D (25[OH]D) was lower than 20 ng/mL, and “insufficient” when serum 25(OH)D was 20 ng/mL to 29 ng/mL. Now, the Society “no longer endorses specific 25(OH)D levels to define vitamin D sufficiency, insufficiency, and deficiency.”

Why is that--- because no clinical research has not established distinct thresholds of serum levels that can be tied confidently to specific clinical outcomes.

In the general population of adults (age range, 19–74), neither routine vitamin D supplementation nor routine testing of 25(OH)D levels are recommended.

What about >75—NOT RECOMMENDED! They do suggest vit sup for possible to lower mortality but acknowledge that this effect was small and bordline statistical significance ___ relative risk, 0.96; 95% confidence interval, 0.93–1.00 – to it hit the line of no effect on flawed bias studies! Come on!!!!!

An evidence review showed no conclusive evidence that supplementation lowered risks for fractures, falls, or infections in this age group

The common practice of ordering routine 25(OH)D levels is not recommended,. Obtaining serum 25(OH)D levels in relatively healthy people and prescribing vitamin D supplements to get levels ≥30 ng/mL (or even higher) is not supported by this guideline.

FINALLY—you want to give then go ahead and give a reasonable amount but don’t test. Don’t research. Don’t target a level. JUST DONT