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Cardiovascular Medicine - Arrhythmias
Long-term monitoring for subclinical atrial fibrillation after stroke (June 2021)
Two new randomized trials support earlier evidence that prolonged cardiac event monitoring increases the detection of subclinical atrial fibrillation (AF) in patients with transient ischemic attack (TIA) or acute ischemic stroke. In the PER DIEM trial of patients with cryptogenic stroke, new AF was observed in 15.3 percent of patients in the insertable cardiac monitor group (placed for one year) compared with 4.7 percent in the external loop recorder group (worn for four weeks).2 In the STROKE-AF trial of patients with large- or small-vessel stroke, new AF was detected in 12.1 percent of patients in the insertable cardiac monitor group compared with 1.8 percent in the usual care group, who received site-specific external cardiac monitoring.3 Although rigorous evidence is lacking that anticoagulation of subclinical AF improves outcomes, we suggest anticoagulant therapy for patients initially diagnosed with cryptogenic stroke who have AF of any duration detected on long-term monitoring.
Dermatology - Atopic Dermatitis and Other Dermatitis
Upadacitinib for atopic dermatitis in adolescents and adults (July 2021)
Upadacitinib is an oral selective JAK inhibitor approved for the treatment of rheumatoid arthritis. Three multicenter randomized trials of similar design evaluated the efficacy of upadacitinib 15 or 30 mg once daily in adolescents and adults with moderate to severe atopic dermatitis as monotherapy or in combination with topical corticosteroids.4,5 At 16 weeks in all three studies, more patients in the upadacitinib groups than in placebo groups achieved a 75 percent improvement in the eczema area and severity index (EASI-75) and a rapid, clinically meaningful improvement in pruritus. Treatment was generally well tolerated. The most frequently reported, treatment-emergent adverse events were acne, elevation of creatine phosphokinase, and atopic dermatitis flares. Although these findings are promising, studies of longer duration are needed to evaluate upadacitinib's long-term efficacy and safety for moderate to severe atopic dermatitis.
Family Medicine - Adult General Internal Medicine
Survival benefit of bariatric surgery (June 2021)
Mounting evidence supports a survival benefit of bariatric surgery among adults with obesity. In a meta-analysis of 16 cohort studies and one trial (nearly 175,000 participants in total), compared with usual care, bariatric surgery was associated with reduced risk of death (hazard ratio 0.5) and prolonged life expectancy (median gain six years).1 Individuals with diabetes benefited more than those without (median gain in life expectancy: nine versus five years). Gastric bypass, adjustable gastric banding, and sleeve gastrectomy were similarly beneficial.
REFERENCES
1. Syn NL, Cummings DE, Wang LZ, et al. Association of metabolic-bariatric surgery with long-term survival in adults with and without diabetes: a one-stage meta-analysis of matched cohort and prospective controlled studies with 174 772 participants. Lancet 2021; 397:1830. [Context Link]
2. Buck BH, Hill MD, Quinn FR, et al Effect of Implantable vs Prolonged External Electrocardiographic Monitoring on Atrial Fibrillation Detection in Patients With Ischemic Stroke: The PER DIEM Randomized Clinical Trial. JAMA 2021; 325:2160. [Context Link]
3. Bernstein RA, Kamel H, Granger CB, et al Effect of Long-term Continuous Cardiac Monitoring vs Usual Care on Detection of Atrial Fibrillation in Patients With Stroke Attributed to Large- or Small-Vessel Disease: The STROKE-AF Randomized Clinical Trial. JAMA 2021; 325:2169. [Context Link]
4. Guttman-Yassky E, Teixeira HD, Simpson EL, et al Once-daily upadacitinib versus placebo in adolescents and adults with moderate-to-severe atopic dermatitis (Measure Up 1 and Measure Up 2): results from two replicate double-blind, randomised controlled phase 3 trials. Lancet 2021; 397:2151. [Context Link]
5. Reich K, Teixeira HD, de Bruin-Weller M, et al Safety and efficacy of upadacitinib in combination with topical corticosteroids in adolescents and adults with moderate-to-severe atopic dermatitis (AD Up): results from a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet 2021; 397:2169. [Context Link]
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