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Cardiovascular Medicine - Arrhythmias
Personalized accelerated pacing in patients with heart failure with preserved ejection fraction (April 2023)
Pacing may improve cardiac performance among patients with heart failure with preserved ejection fraction (HFpEF), but trials of pacing in this population have not demonstrated benefit. In a recent trial that included over 100 patients with asymptomatic or mild HFpEF who had a pre-existing pacing system, patients randomly assigned to personalized accelerated programming (ie, a backup pacing rate determined by an algorithm) had improved quality-of-life scores when compared with those programmed to a back-up rate of 60 beats per minute.2 However, the trial's small sample size, incomplete blinding, and subjective outcome limit the broad application of this approach. Optimal therapy for HFpEF includes self-care, pharmacologic therapy, and pacing with standard programming for any underlying rhythm abnormality.
Family Medicine - Adult General Internal Medicine
Health benefits of Mediterranean diet in adults at risk of cardiovascular disease (April 2023)
A Mediterranean diet, typically high in fruits, vegetables, whole grains, beans, nuts, and seeds, is thought to have health benefits. In a meta-analysis of 40 trials comparing seven dietary patterns in over 35,000 adults at increased risk of cardiovascular disease (CVD), a Mediterranean diet resulted in lower risk of several outcomes, including all-cause mortality, cardiovascular mortality, stroke, and nonfatal myocardial infarction, when compared with usual care dietary advice.3 UpToDate encourages all patients, especially those at higher risk of CVD, to consume a healthy diet, such as a Mediterranean diet.
Dermatology - Skin Cancer
Nicotinamide does not prevent skin cancer in solid organ transplant recipients (March 2023)
Oral nicotinamide has been shown to reduce the incidence of nonmelanoma skin cancers (NMSC) in immunocompetent individuals with a previous history of NMSC. However, data on solid organ transplant recipients, who have a greatly increased risk of NMSC, are limited and inconsistent. In a recent randomized trial that included 158 solid organ transplant recipients receiving nicotinamide 500 mg or placebo twice daily for 12 months, the number of new NMSCs and actinic keratoses developed during the study period were similar in both groups.4 Patient education on strict sun protection, frequent skin checks, and prompt treatment of precancerous lesions remain the mainstay of NMSC prevention in this population.
Allergy and Immunology - Food Allergy and Intolerance
Cow's milk elimination alone for eosinophilic esophagitis (March 2023, Modified April 2023)
Dietary treatment of eosinophilic esophagitis (EoE) traditionally has involved removal of multiple foods/food groups simultaneously. However, this approach is associated with poor adherence and can cause nutritional deficiencies. In a multicenter randomized trial of 129 adults with EoE that compared elimination of mammalian milk (1 food elimination diet [FED]) with removal of six foods/food groups (6FED), rates of histologic remission were similar between the two groups at six weeks (34 versus 40 percent, respectively).1 Improvements in disease-related quality-of-life scores and peak eosinophil counts were also similar. These results confirm earlier findings in a pediatric trial. For most patients with EoE who opt for a dietary approach to treatment, we suggest an initial empiric elimination diet of cow's milk (all forms of dairy/milk) plus cross-reacting mammalian milk (eg, goat's milk).
1. Kliewer KL, Gonsalves N, Dellon ES, et al One-food versus six-food elimination diet therapy for the treatment of eosinophilic oesophagitis: a multicentre, randomised, open-label trial. Lancet Gastroenterol Hepatol. 2023;8(5):408. Epub 2023 Feb 28. [Context Link]
2. Reddy YNV, Koepp KE, Carter R, et al Rate-Adaptive Atrial Pacing for Heart Failure With Preserved Ejection Fraction: The RAPID-HF Randomized Clinical Trial. JAMA. 2023;329(10):801. [Context Link]
3. Karam G, Agarwal A, Sadeghirad B, et al Comparison of seven popular structured dietary programmes and risk of mortality and major cardiovascular events in patients at increased cardiovascular risk: systematic review and network meta-analysis. BMJ. 2023;380:e072003. Epub 2023 Mar 29. [Context Link]
4. Allen NC, Martin AJ, Snaidr VA, et al Nicotinamide for Skin-Cancer Chemoprevention in Transplant Recipients. N Engl J Med. 2023;388(9):804. [Context Link]
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