📘 TLDR Primary Care - Journal Club (#088)

In this issue:

❤️ Our PC study of the month: β-blockers with early coronary angiography

🔬 D-mannose prophylaxis in women with recurrent UTI

🦴 Calcium and vitamin D supplementation in postmenopausal women

🦠 Cefepime vs Zosyn in patients hospitalized with acute infection

☝️ Surgery vs injections for Dupuytren's contracture

STUDY OF THE MONTH

β-blockers with early coronary angiography

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❤️ What is the role of β-blockers in patients with myocardial infarction who underwent early coronary angiography and had a preserved ejection fraction?

• The Reduce-AMI trial (Apr 2024, n=5020) compared β-blockers (target dose of at least 100 mg daily metoprolol or 5 mg daily bisoprolol) to no β-blockers in adult patients with acute myocardial infarction who had undergone coronary angiography and had an ejection fraction ≥ 50%. The key exclusion criteria included an indication for or contraindication to β-blocker therapy. 
• There was no significant difference in death from any cause or a new myocardial infarction after a median follow-up period of 3.5 years (7.9% vs. 8.3%; HR 0.95, 95% CI 0.79 to 1.16). One of the secondary outcomes saw no significant difference in death from cardiovascular causes (1.5% vs. 1.3%; HR 1.15, 95% CI 0.72 to 1.84). 

Conclusion: In adult patients with acute myocardial infarction who had undergone coronary angiography and had an ejection fraction ≥ 50%, long-term β-blocker therapy was not superior to no β-blocker therapy with respect to death from any cause or a new myocardial infarction.

You’ll find more of the latest studies relevant to primary care below. For a more comprehensive catalog of recent practice-changing trials, head over to Pathway!

🔬 What is the role of D-mannose prophylaxis in women with recurrent UTI?

• The MERIT trial (Apr 2024, n=598) compared D-mannose (2 g daily D-mannose powder) to placebo (daily similar volume of fructose powder) in adult women with recurrent UTI. The key exclusion criteria included pregnancy/lactation, interstitial cystitis, or overactive bladder syndrome, among others. 
• There was no significant difference in the rate of proportion of women with a clinically suspected UTI within 6 months (51% vs. 55.7%; RR 0.92, 95% CI 0.8 to 1.05). There was also no significant difference in the mean number of microbiologically proven UTIs (0.4  vs. 0.4; IRR 0.97, 95% CI 0.63 to 1.48). 

Conclusion: In adult women with recurrent UTI, D-mannose was not superior to placebo with respect to the rate of proportion of women with a clinically suspected UTI within 6 months.

🧠 Ask Pathway AI:

1. Which patients should be on a beta blocker?

2. What therapies are helpful in preventing UTIs in females?

3. What is the evidence for vitamin D supplementation in postmenopausal women?

🦴 What is the role of long-term calcium and vitamin D supplementation in postmenopausal women?

• The WHI CaD post-hoc analysis (Mar 2024, n=35757) compared calcium and vitamin D (calcium carbonate 1,000 mg daily and vitamin D3 400 IU daily) to a matching placebo in postmenopausal women, aged 50-79 years, with no history of breast or colorectal cancer. The key exclusion criteria included no informed consent, death before enrollment, and a history of breast or colorectal cancer.
• There was a significant decrease in cancer mortality (0.5% vs. 0.54%; HR 0.93, 95% CI 0.87 to 0.99, NNT=2499). One of the secondary outcomes did show a significant increase in cardiovascular mortality (0.72% vs. 0.67%; HR 1.06, 95% CI 1.01 to 1.12).

Conclusion: In postmenopausal women, aged 50-79 years, with no history of breast or colorectal cancer, calcium and vitamin D were superior to placebo with respect to cancer mortality.

🦠 What is the role of cefepime in patients hospitalized with acute infection?

• The ACORN trial (Oct 2023, n=2511) compared cefepime (IV 2 g every 8 hours) to piperacillin/tazobactam (IV 3.375 g every 8 hours) in adult patients having an indication for antipseudomonal antibiotics within 12 hours of presentation to the hospital, in the emergency department or ICU. The key exclusion criteria included allergy to cephalosporins or penicillins or the receipt of > 1 dose of antipseudomonal cephalosporin or penicillin within the previous 7 days.
• There was no significant difference in the rate of stage 3 AKI or death by day 14 (14.6% vs. 13.5%; OR 0.95, 95% CI 0.8 to 1.13). One of the secondary outcomes did show a significant increase in delirium or coma (20.8% vs. 17.3%; AD 3.4%, 95% CI 0.3 to 6.6).

Conclusion: In adult patients having an indication for antipseudomonal antibiotics within 12 hours of presentation to the hospital, in the emergency department, or ICU, cefepime was not superior to piperacillin/tazobactam with respect to the rate of stage 3 AKI or death by day 14.

☝️ Is surgery superior to collagenase injection in patients with Dupuytren's contracture?

• The DETECT trial (Mar 2024, n=201) compared collagenase injection (injection of collagenase into the cord without local anesthesia, followed by manipulation of the finger to extension under local anesthesia 1-3 days later; repeat injections up to 3 times) to limited fasciectomy (exposing and excising the cord limiting the extension through a longitudinal zigzag incision) in patients with untreated Dupuytren's contracture. The key exclusion criteria included recurrent contracture, a  neurologic condition affecting finger function, contraindication for collagenase, pregnancy or breastfeeding, contracture > 135 degrees, and rheumatoid arthritis.
• There was no significant difference in success rate at 3 months (73% vs. 71%; AD 2%, 95% CI -0.38 to 4.38). One of the secondary outcomes did show a significant decrease in success rate at 2 years (65% vs. 78%; ARD -0.13, 95% CI -0.26 to -0.01).

Conclusion: In patients with untreated Dupuytren's contracture, collagenase injection was not superior to limited fasciectomy with respect to success rate at 3 months.

Acknowledgements:

• Editorial Team: Jeremy Swisher, MD, Cole Phillips, MD, Khudhur Moh, MD, Hovhannes K, MD

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