📘 TLDR Primary Care - Journal Club (#100)

In this issue:

✅ Summarized low back pain guidelines

🧠 Review the common signs and symptoms of low back pain

⭐ Review the updated options for treatment

📈 And more!

Learn your charting personality with this quiz to cut over an hour off your evening charting. Take quiz

📘 Journal Club: Fresh Off the Press

Bringing you the latest practice-changing updates in primary care

✅ Study of the Month: Dupilumab for COPD

🫁 What is the role of dupilumab in patients with COPD with type 2 inflammation?

• The NOTUS trial (May 2024, n=935) compared dupilumab (subcutaneous dose of 300 mg every 2 weeks) to a matching placebo in patients with COPD who had a blood eosinophil count ≥ 300 cells/mL. The key exclusion criteria included diagnosis or a history of asthma, COPD diagnosis for < 12 months prior to randomization, significant pulmonary disease other than COPD, and cor pulmonale.
• There was a significant decrease in the annualized rate of moderate or severe exacerbations (0.86 events/year vs. 1.3 events/year; RR 0.66, 95% CI 0.54 to 0.82). One of the secondary outcomes showed a significant increase in least-square mean improvement in prebronchodilator FEV1 at week 12 (0.139 L vs. 0.057 L; MD 0.082, 95% CI 0.04 to 0.12).

Conclusion: In patients with COPD who had a blood eosinophil count ≥ 300 cells/mL, dupilumab was superior to placebo with respect to the annualized rate of moderate or severe exacerbations.

A Message from Dr. Junaid Niazi, Prosperous Life MD

How Physicians Can Cut Over an Hour Off Their Evening Charting

Charting backlogs fuel physician burnout and moral injury. The endless heap of notes, in-basket items, and paperwork leads to late nights, missed family events, and anxiety.

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There are strategies to end late-night charting without scribes, complex templates, or magically finding 27 hours in every day.

Physicians fall into four main charting styles. Discovering your style is the first step to saving an hour (or more) each day.

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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 early meniscal surgery in patients with traumatic and nontraumatic meniscus tears?

• The DREAM trial (May 2024, n=121) compared meniscal surgery (arthroscopic partial meniscectomy or meniscal repair following standard procedures) to exercise therapy (supervised exercise and patient education for 12 weeks) in adult patients aged 18-40 years with traumatic and nontraumatic meniscus tears. The key exclusion criteria included previous surgery on the affected knee, displaced bucket-handle tear, fracture of the affected extremity within the previous 6 months, or complete rupture of one or more knee ligaments, among others.
• There was no significant difference in the mean improvement of the Knee injury and OA Outcome Score at 12 months for both traumatic and nontraumatic tears (Traumatic: 18.8 points vs. 16 points; MD 4.8, 95% CI -1.7 to 11.2. Nontraumatic: 20.6 points vs. 17.3 points; MD 7, 95% CI -3.7 to 17.7). There was a significant increase in mean improvement in Western Ontario Meniscal Evaluation Tool total scores at 12 months for traumatic tears (26.3 points vs. 18.8 points; MD 10.7, 95% CI 2.6 to 18.9). 

Conclusion: In adult patients aged 18-40 years with traumatic and nontraumatic meniscus tears, meniscal surgery was not superior to exercise therapy with respect to mean improvement in Knee injury and OA Outcome Score at 12 months.

🤕 What is the effect of atogepant in patients with episodic migraine who had previously failed conventional oral preventive treatments?

• The ELEVATE trial (April 2024, n=313) compared atogepant (at an oral dose of 60 mg/day) to a matching placebo in adult patients aged 18-80 years with episodic migraine who had previously failed 2-4 classes of conventional oral treatments for migraine prevention. The key exclusion criteria included clinically significant hematologic, endocrine, pulmonary, hepatic, gastrointestinal, or neurologic disease, ≥ 15 headache days/month 3 months prior to the first visit, history of migraine accompanied by diplopia or decreased level of consciousness or retinal migraine. 
• There was a significant reduction in the least square mean of monthly migraine days across 12 weeks (4.2 days vs. 1.9 days; MD 2.4, 95% CI 1.5 to 3.2). One of the secondary outcomes saw a significant increase in the number of patients that had a ≥ 50% reduction in monthly migraine days across 12 weeks (51% vs. 18%; OR 4.8, 95% CI 2.9 to 8.1). 

Conclusion: In adult patients aged 18-80 years with episodic migraine who had previously failed 2-4 classes of conventional oral treatments for migraine prevention, atogepant was superior to placebo with respect to the least square mean reduction in monthly migraine days across 12 weeks.

🚬 What is the role of a combination of varenicline and nicotine replacement therapy in hospitalized adult daily smokers?

• The VANISH trial (June 2024, n=320) compared NRT plus varenicline (nicotine replacement therapy 2 mg plus varenicline regimen for 12 weeks) to matching placebo lozenges plus varenicline regimen for 12 weeks in adult inpatients with a history of smoking ≥ 10 cigarettes/day who were interested in quitting. The key exclusion criteria included no informed consent, smoking < 10 cigarettes/day, pregnancy/breastfeeding, terminal illness, unstable cardiovascular status, or a new diagnosis of major psychiatric illness.
• There was no significant difference in biochemically verified sustained abstinence at 6 months (11.4% vs. 10.1%; OR 1.14, 95% CI 0.56 to 2.33). One of the secondary outcomes showed a significant increase in self-reported prolonged abstinence at 3 months (44.3% vs. 32.7%; OR 1.64, 95% CI 1.04 to 2.59) and a significant increase in self-reported prolonged abstinence at 12 months (29.9% vs. 19.1%; OR 1.77, 95% CI 1.05 to 3).

Conclusion: In adult inpatients with a history of smoking ≥ 10 cigarettes/day who were interested in quitting, NRT plus varenicline was not superior to placebo plus varenicline with respect to biochemically verified sustained abstinence at 6 months.

🧠 Ask Pathway AI:

What are the available treatments for smoking cessation and which has the most evidence?

What percentage of patients with COPD have type 2 inflammation and what does type 2 inflammation mean?

When should patients with migraine be given preventive therapy and what are the most effective treatment options?

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