RCT: Yoga vs Strength Exercise for Knee Osteoarthritis Pain
BACKGROUND AND PURPOSE:
- Exercise therapy is recommended as a first-line treatment for knee osteoarthritis (OA), but it’s not clear whether different types of exercise have a greater benefit
- Abafita et al. (JAMA Network Open, 2025) compared the effectiveness of yoga vs strengthening exercise for reducing knee pain in patients with knee OA
METHODS:
- Single-center, assessor-blinded, parallel-arm, active-controlled, superiority randomized clinical trial
- Participants
- Adults ≥40 years
- Knee OA
- Knee pain levels of ≥40 on a 100-mm VAS
- Interventions
- Yoga exercise
- Strengthening exercise
- Both groups received
- Weeks 1 to 12: 2 supervised and 1 home-based session per week
- Weeks 13 to 24: 3 unsupervised home-based sessions per week
- Study design
- There was a prespecified noninferiority margin of 10 mm
- Analysis was by intention to treat
- Primary outcome
- Difference in VAS score over 12 weeks
- Secondary outcomes
- Knee pain over 24 weeks using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)
- Quality of life scores
- 25 other outcomes
RESULTS:
- Yoga: 58 participants | Strengthening: 59 participants
- The between group mean difference in VAS knee pain change over 12 weeks was not statistically different, and remained within the noninferiority margin
- –1.1 mm (95% CI, –7.8 to 5.7)
- Of the 27 secondary outcomes assessed over 12 and 24 weeks, 7 were statistically significant in favor of yoga
- WOMAC pain: −44.5 mm (95% CI, −70.7 to −18.3)
- WOMAC function: −139 mm (95% CI, −228.3 to −49.7)
- WOMAC stiffness: −17.6 mm (95% CI, −30.9 to −4.3)
- Patient global assessment: −7.6 mm (95% CI, −15.1 to −0.2)
- 40-m fast-paced walk test: 1.8 (95% CI, 0.4 to 3.2)
- Depression at 12 weeks: −1.1 (95% CI, −1.9 to −0.2)
- Quality of life at 24 weeks: 0.04 (95% CI, 0.0 to 0.07)
- Adverse events were similar in both groups and mild
CONCLUSION:
- Both yoga and strength-based training reduced knee pain for patients with knee OA
- Yoga did significantly improve several other outcomes, compared to strength-based training, including depression, quality of life and knee function
- The authors state
Overall, these findings suggest that integrating yoga as an alternative or complementary exercise option in clinical practice may help in managing knee OA
Learn More – Primary Sources:
Yoga or Strengthening Exercise for Knee Osteoarthritis: A Randomized Clinical Trial
Does Exposure to Smoking Cessation Drugs During Pregnancy Increase the Risk of Major Malformations?
BACKGROUND AND PURPOSE:
- Smoking cessation pharmacotherapies may be used by pregnant people who wish to quit smoking during pregnancy, but evidence on fetal safety is limited
- Tran et al. (JAMA Intern Med, 2025) assessed whether prenatal use of smoking cessation pharmacotherapies like nicotine replacement therapy (NRT), varenicline, and bupropion was associated with increased risks of major congenital malformations (MCMs)
METHODS:
- Retrospective cohort study
- Common protocol in New South Wales (NSW, Australia), New Zealand (NZ), Norway, and Sweden
- Data derived from national registers
- Births between 2001 and 2020
- Population
- All births to women who
- Smoked during the first trimester or
- Received smoking cessation pharmacotherapy
- All births to women who
- Exposures
- Receipt of smoking cessation pharmacotherapy 90 days before conception or during the first trimester
- NRT | Varenicline | Bupropion
- Unexposed: smoking during the first trimester, but no pharmacotherapy
- Receipt of smoking cessation pharmacotherapy 90 days before conception or during the first trimester
- Study design
- Propensity score matching used to match exposed infants to unexposed infants
- Primary outcome
- Major congenital malformations
RESULTS:
- 267,522 women | 391,474 infants
- Exposed to NRT: 9325 infants | Varenicline: 3031 | Bupropion: 1042
- Compared with unexposed infants, there were no differences in prevalence of MCMs overall following exposure to any of the pharmacotherapies
- NRT
- Exposed: 37.6 per 1000 live births | Unexposed: 34.4
- Adjusted relative risk (aRR) 1.10 (95% CI, 0.98 to 1.22)
- Varenicline
- Exposed: 32.7 per 1000 live births | Unexposed: 36.6
- aRR 0.90 (95% CI, 0.73 to 1.10)
- Bupropion
- Exposed: 35.5 per 1000 live births | Unexposed: 38.8
- aRR 0.93 (95% CI, 0.67 to 1.29)
- NRT
- For NRT, there was no difference in the risk of MCMs by most subtypes
- Heart | Limbs | Genital organs | Kidney/urinary tract | Respiratory system | Orofacial clefts
- There was a higher risk of digestive organ MCMs with NRT but not statistically significant after multiple comparisons
- Exposed: 3.8 per 1000 live births | Unexposed: 2.5
- aRR 1.53 (95% CI, 1.05 to 2.23) | P=0.41
- For varenicline, there was also no difference in the risk of MCMs by most subtypes with enough data
- Heart | Limbs | Genital organs
- There was a higher risk of kidney/urinary tract MCMs but not statistically significant after multiple comparisons (small sample set)
- Exposed: 11.5 | Unexposed: 4.2 per 1000 live births
- aRR 2.75 (95% CI, 1.42 to 5.34) | P=0.09
- For bupropion, data were too sparse to estimate the risk of MCM by subtype
CONCLUSION:
- Use of nicotine replacement therapy, varenicline, and bupropion was not associated with an increased risk of congenital malformations vs smoking
- The authors state
Overall, our findings are reassuring given the extensive detrimental effects of smoking on maternal and child health
Larger studies providing more robust estimates of risk for the remaining malformation subgroups are needed
Learn More – Primary Sources:
Risk of Major Congenital Malformations Following Prenatal Exposure to Smoking Cessation Medicines
US Poll Results: Public Utilization and Confidence in AI for Healthcare Information
BACKGROUND AND PURPOSE:
- Orrall and Rekito (JAMA, 2025) report results of a poll conducted to investigate adults’ trust in AI to inform their health decisions
METHODS:
- Poll administered by KFF
- KFF is an endowed national nonprofit organization that integrates policy research, polling, and journalism to serve as a reliable and independent source of healthcare information
- Population
- Nationally representative sample of Black, Hispanic and White adults in the US
- Study design
- Questions asked about
- Frequency of AI use
- Trust in AI sources
- Whether participants thought AI was doing more to help or hurt people trying to find accurate health information online
- Questions asked about
RESULTS:
- 2428 participants
- Reported ever using AI: 63%
- Reported using several times per day: 11%
- Younger adults were more likely to use AI than older adults
- Adults that report using AI chatbots (e.g. ChatGPT) to receive health information at least once per month: 17%
- Adults <30 years old: 25%
- Adults ≥65 years old: 10%
- Most adults who used AI were not that confident it provided accurate health information
- Reported being “not too confident” or “not at all confident” in the accuracy of AI-generated health information: 63%
- Reported being “very confident” in it: 5%
- Respondents did say they were more confident that AI provided accurate information about practical tasks such as cooking or home maintenance
- Most adults weren’t sure whether AI was helping or hurting people seeking accurate health information
- “Not sure” among users of AI: 49%
- “AI is doing more to hurt” among users: 21%
- “AI is doing more to help” among users: 30%
CONCLUSION:
- In this poll of US adults, nearly one in five reported using AI to find health information at least once per month
- Users tended to be younger
- However, most (63%) were not confident that AI provided accurate information
- The authors state
Although only about 1 in 3 respondents reported trusting AI-derived health information, a larger percentage said they trusted chatbots to provide accurate information about other topics
More than half of total adults said they had a “great deal” or “fair amount” of trust in AI for practical tasks, like cooking and home maintenance
Learn More – Primary Sources:
Poll: Trust in AI for Accurate Health Information Is Low
Is The Incidence of Cervical Cancer Higher in Rural Counties vs Urban Ones?
BACKGROUND AND PURPOSE:
- Amboree et al. (JAMA Network Open, 2025) assessed rural-urban disparities in cervical cancer incidence and mortality
METHODS:
- Cross-sectional study
- Population
- Cervical cancer cases in National Program of Cancer Registries and Surveillance, Epidemiology, and End Results (NPCR-SEER) database
- Between 2001 and 2019
- Exposures
- Rurality
- Study design
- Cervical cancer rates were corrected to account for hysterectomy prevalence
- Joinpoint regression was used to calculate trends in incidence and derive annual percentage change (APC)
- Primary outcome
- Annual incidence
- Age-adjusted 5-year mortality rates per 100,000 women
RESULTS:
- Cervical cancer cases: 222,425
- From urban counties: 84.3% | Non-Hispanic White: 59.9%
- Hysterectomy-corrected incidence rates
- Rural counties: 11.9 per 100,000 women
- Urban counties: 10.0 per 100,000 women
- After decreasing from 2001 to 2012, incidence increased in rural counties between 2012 to 2019
- 2012 to 2019: APC 0.85% (95% CI, 0.08 to 2.05)
- Incidence also decreased in urban counties between 2001 and 2013, but plateaued from 2013 to 2019
- 2013 to 2019: APC –0.03% (95% CI, –0.89 to 2.00)
- The gap between rural and urban incidence rates widened from 2013 to 2019
- 2013: rate ratio 1.16 (95% CI, 1.10 to 1.22)
- 2019: rate ratio 1.25 (95% CI, 1.19 to 1.31)
- During 2012 to 2019, among rural White women, cervical cancer incidence increased
- 1.05% per year (95% CI, 0.24 to 2.33)
- Incidence also increased among non-Hispanic Black women, but this was not statistically significant
- 9.07 (95% CI, –2.84 to 17.84)
- Incidence declined among rural Hispanic women
- Incidence declined or plateaued for all women in urban counties
- Mortality was higher in rural vs urban counties during 2015 to 2019
- 1.42 (95% CI, 1.33 to 1.51)
- Compared with their urban counterparts, mortality among rural women was higher
- Hispanic women: rate ratio 1.33 (59% CI, 1.12 to 1.58)
- Black women: rate ratio 1.58 (95% CI, 1.32 to 1.90)
- White women: rate ratio 1.54 (95% CI, 1.43 to 1.67)
CONCLUSION:
- The incidence of cervical cancer cases has recently risen by 0.85% per year among rural women, especially rural White women
- Both incidence and mortality were higher among rural vs urban counties
- The authors state
The increase in incidence and mortality in rural US counties may reflect lower screening coverage and lower utilization of diagnostic and therapeutic care, likely resulting from heightened access barriers experienced in rural areas
Additionally, if unaddressed, lower human papillomavirus (HPV) vaccine uptake in rural areas may contribute to further widening disparities in the future
Learn More – Primary Sources:
Rural-Urban Disparities in Cervical Cancer Incidence and Mortality Among US Women
Meta-Analysis: Which Migraine Treatment Methods Are Most Effective?
BACKGROUND AND PURPOSE:
- Gartlehner et al. (Annals of Internal Medicine, 2025) compared benefits and harms of pharmacologic treatments for acute attacks of episodic migraine in adults
METHODS:
- Systematic review and meta-analysis
- Inclusion criteria
- Head-to-head and placebo-controlled trials
- Studies that included adult patients who received initial treatment or second-step treatment for acute attacks of episodic migraine, comparing pharmacologic interventions to other interventions or placebo
- Study design
- Risk of bias was assessed
- Certainty of evidence was assessed with GRADE criteria
- Primary outcomes
- Pain freedom at 2 hours and 48 hours
- Need for rescue medication
- Nausea or vomiting
RESULTS:
- 21 head-to-head studies | 164 placebo-controlled trials
- Triptans were more effective than acetaminophen and NSAIDS for pain outcomes at 2 hours and pain freedom at 48 hours
- Pain freedom at 2 hours, compared to acetaminophen
- Absolute risk difference (ARD) 0.16 (95% CI, 0.02 to 0.38)
- Risk ratio (RR) 1.64 (95% CI, 1.08 to 2.49)
- Low certainty
- Pain freedom at 2 hours, compared to NSAIDs
- ARD 0.10 (95% CI, 0.06 to 0.16)
- RR 1.42 (95% CI, 1.23 to 1.65)
- High certainty
- Pain freedom at 2 hours, compared to acetaminophen
- Triptan and acetaminophen combinations were more effective than acetaminophen alone
- ARD 0.30 (95% CI, 0.04 to 0.74)
- RR 2.17 (95% CI, 1.17 to 4.03)
- Moderate certainty
- Triptan and acetaminophen combinations were not more effective than a triptan alone
- ARD 0.13 (95% CI, –0.10 to 0.53)
- RR 1.33 (95% CI, 0.75 to 2.34)
- Low certainty
- Triptan and NSAID combinations were more effective for pain outcomes at 2 hours and pain freedom up to 48 hours compared with
- Acetaminophen (low COE)
- RR 1.91 (95% CI, 1.21 to 3.00)
- Low certainty
- Gepants
- RR 1.96 (95% CI, 1.50 to 2.56)
- Low certainty
- NSAIDs
- ARD 0.11 (95% CI, 0.06 to 0.17)
- RR 1.66 (95% CI, 1.35 to 2.05)
- High certainty
- Triptan monotherapy
- ARD 0.04 (95% CI, –0.01 to 0.09)
- RR 1.17 (95% CI, 0.97 to 1.40)
- Moderate certainty
- Acetaminophen (low COE)
- Triptans had a higher risk of adverse events
- One study found triptans more cost-effective than ditan and gepant
CONCLUSION:
- When treating episodic migraine, triptans or a combination or triptan and NSAID was most effective at achieving pain relief at 2 hours and sustained pain freedom at 48 hours
- These findings are reflected in the new ACP migraine guidelines (see ‘Learn More – Primary Sources’ below)
Learn More – Primary Sources:
RCT Results: Which Hereditary Cancer Risk Assessment Strategies are Most Likely to be Successful in a Primary Care Setting?
BACKGROUND AND PURPOSE:
- Many cancers are caused by heritable factors that can be readily identified with multigene test
- Swisher et al. (JAMA Network Open, 2025) compared two population-based engagement strategies for identifying primary care patients with a family or personal history of cancer and offering eligible individuals genetic testing for cancer susceptibility
METHODS:
- Clinical cluster-randomized trial
- EDGE (Early Detection of Genetic Risk) trial
- Participants
- English-speaking patients ≥25 years old
- Primary care visit between April 2021 and March 2022
- Interventions
- Point of care (POC) engagement: Cancer history assessment conducted by staff immediately preceding clinical appointments
- Direct patient engagement (DPE): Letter and email outreach facilitated at-home completion of cancer history assessment
- Study design
- Patients who completed risk assessment and met prespecified criteria were offered at home genetic testing at no cost
- Logistic regression models were used to compare approaches
- Analysis was by intention-to-treat
- Primary outcomes
- Proportion of patients who completed risk assessment
- Proportion of patients who completed genetic testing
RESULTS:
- 95,623 patients had a primary care visit
- Completed risk assessment: 13,705
- Patients who completed the risk assessment were
- Predominantly female: 64.7%
- Predominantly 65 to 84 years: 39.6%
- The POC approach resulted in a higher proportion of patients completing risk assessment
- POC: 19.1% | DPE: 8.7%
- Adjusted odds ratio (aOR) 2.68 (95% CI, 1.72 to 4.17) | P<0.001
- Neither approach was better at getting patients to complete testing
- POC: 1.5% | DPE: 1.6%
- aOR 0.96 (95% CI, 0.64 to 1.46) | P=0.86
- Among those eligible for testing, POC test completion was approximately half of that for the DPE approach
- POC: 24.7% | DPE: 44.7%
- aOR 0.49 (95% CI, 0.37 to 0.64) | P<0.001
- The proportion of tested patients identified with an actionable pathogenic variant was significantly lower for the POC approach than the DPE approach
- POC: 3.8% | DPE: 6.6%
- aOR 0.61 (95% CI, 0.44 to 0.85) | P=0.003
CONCLUSION:
- Patients who received point of care cancer history assessment during primary care visits were more likely to complete the risk assessment than patients who received a letter or email asking them to complete the assessment
- Both approaches led to similar rates of genetic testing completion but the email group had a higher rate of pathogenic mutations
- The authors state
Relative to patients in the POC arm, those in the DPE arm who completed screening were more likely to have a personal history of cancer and 2 or more first-degree relatives with cancer, resulting in a higher proportion who were eligible for testing
Using a combination of engagement strategies may be the optimal approach for greater reach and impact
Learn More – Primary Sources:
Pneumococcal Vaccination Guidelines
Background:
Streptococcus pneumonia (pneumococcus) can cause pneumonia, meningitis, bacteremia, otitis media and sinusitis, with older adults being most at risk for serious illness and death. Pneumococcal bacteria are spread via direct contact with respiratory secretions e.g., saliva or mucus. Vaccination is the best way to prevent infection. After the introduction of pneumococcal vaccinations for adults and children in the US in the early and mid 2000s, the rates of invasive pneumococcal disease decreased substantially.
Types of Vaccine:
- Pneumococcal conjugate vaccines (PCVs): PCV15 | PCV20 | PCV21
- Pneumococcal polysaccharide vaccine: PPSV23
- Each vaccine protects against different serotypes of pneumococcal bacteria
NOTE: New formulations and changes in guidelines have occurred over the past few years which has led to confusion regarding timing and selection of vaccine types, especially in adults who have already received a single dose of PPSV23 or PCV13. The CDC has created an application (‘PneumoRecs VaxAdvisor’) specifically for individualized guidance tailored for your patient (see under “Learn More” below)
Vaccine Recommendations:
- All adults age ≥ 50 years
- If PCV 20 or 21 used vaccination is considered complete, and no further doses are necessary
- If PCV 15 used, administer a dose of PPSV23 one year later OR at least 8 weeks in adults with immunocompromising conditions | cochlear implant | CSF leak
- Adults aged 19-49 with certain underlying health conditions e.g, Chronic Lung, Liver or Heart Disease | Diabetes Mellitus| Asplenia | Sickle Cell Disease | Immunosuppression | Cochlear Implant | Malignancy | Alcoholism
- Depending on age and type(s) of vaccine received, patients may be recommended to receive additional pneumococcal vaccines
- Adults 65 years or older have the option to get PCV20 or PCV21 to increase the number of pneumococcal serotypes covered, or they may elect not get additional pneumococcal vaccines. They can get PCV20 or PCV21 if they have received both:
- PCV13 (but not PCV15, PCV20, or PCV21) at any age and
- PPSV23 at or after the age of 65 years old
Special Considerations:
- Native Americans and Alaskan Indians populations should receive PCV20 alone or PCV15 and PPSV23 in series given the high prevalence of Serotype 4 Pneumococcal disease that is not covered by PCV 21
Learn More – Primary Resources:
CDC Pneumococcal Vaccine Recommendations
CDC MMWR Expanded Recommendations for Use of Pneumoccoccal Vaccination Jan 2025
Serotype 4 Pneumoccocal Disease increase in Native American/Alaskan Indian Populations
Have 2023 Cancer Screening Rates Rebounded After the COVID-19 Pandemic-Related Screening Declines?
BACKGROUND AND PURPOSE:
- Cancer screening rates declined during COVID and in the immediate aftermath, leading to increased cancer diagnoses at later stages
- Star et al. (JAMA, 2025) estimated post-pandemic cancer screening rates in 2023 relative to previously documented declines through 2021
METHODS:
- Analysis of screening trends
- Data from National Health Interview Survey
- Population
- Nationally representative cross-sectional cohort of noninstitutionalized US adults
- Exposures
- Before the COVID-19 pandemic: 2019
- During: 2021
- After: 2023
- Study design
- Adjustments were made for nonresponse bias
- Screening eligibility and strategies were defined according to the USPSTF recommendations
- Logistic regression models estimated adjusted prevalence ratios (aPRs)
- Adjustments: was Age | Race and ethnicity | Education | Insurance | Region
- Primary outcomes
- Self-reported breast | Cervical | Colorectal cancer screening
RESULTS:
- 2023 eligibility for screening
- Breast cancer: 6829 | Cervical cancer: 8888 | Colorectal cancer: 13,144
- Between 2019 and 2023, reported past-year breast and colorectal cancer screening increased
- Breast: 7% increase
- Prevalence estimate 59.7 to 64.9%
- aPR 1.07 (95% CI, 1.04 to 1.10)
- Colorectal: 12%
- Prevalence estimate: 21.2 to 24.3%
- aPR 1.12 (95% CI, 1.06 to 1.18)
- Breast: 7% increase
- Underlying these increases were
- Rebounds between 2021 and 2023 in breast cancer screening
- 56.9 to 64.9%
- aPR 1.14 (95% CI, 1.11 to 1.18)
- Rebounds between 2021 and 2023 in colonoscopy screening
- 13.8 to 15.7%
- aPR 1.13 (95% CI, 1.06 to 1.22)
- Sustained increases in stool testing
- 2019: 6.6%
- 2021: 10.1%
- 2023: 10.1%
- Rebounds between 2021 and 2023 in breast cancer screening
- Reported cervical cancer screening in 2023 remained below 2019 estimates
- 14% decrease
- Prevalence estimate 46.8 to 40.9%
- aPR 0.86 (95% CI, 0.82 to 0.90)
- Colorectal cancer screening increased between 2019 and 2023 for college graduates, but did not change in individuals with a high school degree or less
- Breast cancer screening met or exceeded 2019 levels across screening groups as screening rebounded between 2021 and 2023
- Cervical cancer screening rebounded between 2021 and 2023 among college graduates, but remained below 2019 levels for most education groups
CONCLUSION:
- Reported breast and colorectal cancer screening rates rebounded after pandemic-related decreases
- In 2023 screening rates were higher than pre-pandemic levels
- Cervical cancer screening remained below pre-pandemic levels
- The authors state
Cervical cancer screening rates remained below prepandemic levels, a troubling trend as early-stage diagnoses continued to decrease in 2021
The persistent decline may in part reflect longer-term declines in patient knowledge and clinician recommendation of cervical cancer screening
Learn More – Primary Sources:
Cancer Screening 3 Years After the Onset of the COVID-19 Pandemic
Is There an Increased Risk of Stroke and Heart Attack Associated with Modern Hormonal Contraceptive Use?
BACKGROUND AND PURPOSE:
- Some studies have found a link between hormonal contraception and stroke and myocardial infarction
- However, there is also contradictory evidence, and research has mostly focused on the combined oral contraceptive pill
- Yonis et al. (BMJ, 2025) evaluated the association between contemporary hormonal contraceptive use and the risk of incident ischemic stroke and myocardial infarction
METHODS:
- Nationwide, prospective cohort study
- Nationwide prospective cohort study of all Danish women
- Participants
- All women aged 15 to 49 living in Denmark between 1996 and 2021
- No history of
- Arterial or venous thrombosis | Cancer (except non-melanoma skin cancer) | Thrombophilia | Liver disease | Kidney disease | Use of antipsychotics | Infertility treatment | Hormone therapy use | Oophorectomy | Hysterectomy | PCOS | Endometriosis
- Exposures
- Hormonal contraceptive use and type
- Study design
- Poisson regression used to estimate adjusted incidence rate ratios
- Primary outcome
- First time diagnosis of ischemic stroke or myocardial infarction
RESULTS:
- 2,025,691 women | 22,209,697 person years of follow-up
- Ischemic stroke: 4730 | Myocardial infarction: 2072
- Standardized ischemic stroke rate
- No hormonal contraceptive use: 18 (95% CI, 18 to 19) per 100,000 person years
- Combined pill: 39 (95% CI, 36 to 42) per 100,000 person years
- Progestin-only pill: 33 (95% CI, 25 to 44) per 100,000 person years
- IUD: 23 (95% CI, 17 to 29) per 100,000 person years
- Standardized myocardial infarction rate
- No hormonal contraceptive use: 8 (95% CI, 8 to 9) per 100,000 person years
- Combined pill: 18 (95% CI, 16 to 20) per 100,000 person years
- Progestin-only pill: 13 (95% CI, 8 to 19) per 100,000 person years
- IUD: 11 (95% CI, 7 to 16) per 100,000 person years
- Compared with no use, current use of combined oral contraception was associated with a higher rate of stroke and myocardial infarction
- Stroke: adjusted rate ratio (aRR) 2.0 (95% CI, 1.9 to 2.2)
- Extra strokes per 100,000 person years: 21 (95% CI, 18 to 24)
- Myocardial infarction: aRR 2.0 (95% CI, 1.7 to 2.2)
- Extra myocardial infarctions per 100,000 person years: 10 (95% CI, 7 to 12)
- Stroke: adjusted rate ratio (aRR) 2.0 (95% CI, 1.9 to 2.2)
- Compared with no use, current use of combined oral contraception was also associated with a higher rate of stroke and myocardial infarction
- Stroke: aRR 1.6 (95% CI, 1.3 to 2.0)
- Extra strokes per 100,000 person years: 15 (95% CI, 6 to 24)
- Myocardial infarction: aRR 1.5 (95% CI, 1.1 to 2.1)
- Extra myocardial infarctions per 100,000 person years: 4 (95% CI, –1 to 9)
- Stroke: aRR 1.6 (95% CI, 1.3 to 2.0)
- Increased arterial thrombotic risk was also observed with use of the
- Combined vaginal ring
- Stroke: aRR 2.4 (95% CI, 1.5 to 3.7)
- Myocardial infarction: aRR 3.8 (95% CI, 2.0 to 7.3)
- Patch
- Stroke: aRR 3.4 (95% CI, 1.3 to 9.1)
- No myocardial infarctions
- Progestin-only implant
- Stroke: aRR 2.1 (95% CI, 1.2 to 3.8)
- ≤3 myocardial infarctions
- Combined vaginal ring
- There was no increased risk of arterial thrombosis with the progestin-only IUD
- Stroke: aRR 1.1 (95% CI, 1.0 to 1.3)
- Myocardial infarction: aRR 1.1 (95% CI, 0.9 to 1.3)
CONCLUSION:
- Use of most modern contraceptive methods was associated with an increased rate of ischemic stroke and, in some cases, myocardial infarction
- Absolute risk remained small
- The progestin-only IUD was not associated with increased rates of either stroke or myocardial infarction
- Limitation of this study include observational design vs RCT and therefore possible residual confounding
- The authors state in an opinion paper
Our findings underscore the critical need for continued research into the cardiovascular effects of hormonal contraception
Future studies should focus on identifying potential biological mechanisms underlying these risks, exploring how individual factors such as genetic predisposition, lifestyle, and comorbidities interact with contraceptive use
Learn More – Primary Sources:
Editorial: Arterial thrombosis in users of contemporary hormonal contraception
Opinion: Research on hormonal contraceptives is needed to monitor their evolving safety profile
Do Inflammatory Markers Predict Who is at Higher Risk of Developing Long COVID?
BACKGROUND AND PURPOSE:
- Dysregulated inflammation may provide a biological mechanism for post-acute sequelae of severe acute respiratory coronavirus 2 (SARS-CoV-2) infection (PASC)
- Ng et al. (Menopause et al, 2025) examined the association of inflammatory markers, measured ~25 years prior to the pandemic with PASC
METHODS:
- Long-term cohort study
- Data from Women’s Health Initiative
- Population
- Postmenopausal
- Blood specimens collected pre-pandemic (1993 through 1998)
- Completed a COVID-19 survey in 2021 or 2022
- Exposures
- Leukocyte count
- High-sensitivity C-reactive protein (hsCRP) concentrations
- Study design
- Multivariable regression models were used with adjustment for patient characteristics
- Primary outcome
- PASC
- PASC severity
- Defined as the sum of PASC symptoms
- PASC associated cognitive outcomes
RESULTS:
- 1237 women
- Both log e-transformed leukocyte count (used to normalize data) and leukocyte count ≥5.5 × 1,000 cells/µL were associated with more severe PASC
- Leukocyte count
- β=0.27 (95% CI, 0.07 to 0.47) | P=0.009
- Leukocyte count ≥5.5 × 1,000 cells/µL
- β=0.13 (95% CI, 0.02 to 0.23) | P=0.02
- Leukocyte count
- Leukocyte count was not associated with PASC occurrence or PASC-related cognitive outcomes
- Concentration of hsCRP was not associated with PASC outcomes but was underpowered due to only 27% of participants having this marker available for analysis
CONCLUSION:
- Higher leukocyte count is an inflammatory marker that is associated with more severe long COVID in postmenopausal women
- The authors state
Our study extends the evidence that low-grade inflammation is not only a correlate or an outcome of PASC severity, but also precedes the acute COVID-19 infection leading to this debilitating outcome, further supporting a role of inflammation in the etiology of PASC
Learn More – Primary Sources:
How Common are Second Primary Cancers Among Individuals with Breast Cancer and BRCA1/BRCA2 Pathogenic Variants?
BACKGROUND AND PURPOSE:
- Carriers of BRCA1 and BRCA2 pathogenic variants are at higher risk of developing breast and ovarian cancer, and these variants have also been associated with increased risk of other cancer types
- Allen et al. (Journal of Clinical Oncology, 2024) estimated relative and absolute risks of second primary cancer (SPC)
METHODS:
- Retrospective cohort study
- Data from UK National Disease Registration Service and Hospital Episode Statistics
- Population
- Male and female individuals diagnosed with breast cancer
- Tested for germline BRCA1/BRCA2 pathogenic variants (between 1995 and 2019)
- Exposures
- BRCA1/BRCA2 pathogenic variant carriers
- Non carriers
- Study design
- Individuals were followed until
- SPC diagnosis | Death | Migration | Contralateral breast/ovarian surgery plus 1 year | End of 2020
- Standardized incidence ratios (SIRs) were calculated using English population incidences
- Hazard ratios (HR) were calculated using Cox regression
- Individuals were followed until
- Primary outcome
- Second primary cancer
RESULTS:
- Females with breast cancer: 25,811 | Males with breast cancer: 480
- BCRA1 carriers: 1840 | BRCA2 carriers: 1750
- Compared with population incidences, female BRCA1 carriers had elevated incidence of SPCs
- Contralateral breast cancer: SIR 15.6 (95% CI, 11.8 to 20.2)
- Ovarian: SIR 44.0 (95% CI, 31.4 to 59.9)
- Combined nonbreast/ovarian: SIR 2.18 (95% CI, 1.59 to 2.92)
- Colorectal: SIR 4.80 (95% CI, 2.62 to 8.05)
- Endometrial: SIR 2.92 (95% CI, 1.07 to 6.35)
- BRCA1 carriers had elevated incidence of SPCs
- Contralateral breast cancer: SIR 7.70 (95% CI, 5.45 to 10.6)
- Ovarian: SIR 16.8 (95% CI, 10.3 to 26.0)
- Pancreatic: SIR 5.42 (95% CI, 2.09 to 12.5)
- Combined nonbreast/ovarian: SIR 1.68 (95% CI, 1.24 to 2.23)
- Compared with females without BRCA1/BRCA2 pathogenic variants, BRCA1 carriers had higher risk of
- Contralateral breast cancer: HR 3.60 (95% CI, 2.65 to 4.90)
- Ovarian: HR 33.0 (95% CI, 19.1 to 57.1)
- Combined nonbreast/ovarian: HR 1.45 (95% CI, 1.05 to 2.01)
- Colorectal: HR 2.93 (95% CI, 1.53 to 5.62)
- BRCA2 carriers had higher risk of
- Contralateral breast cancer: HR 2.40 (95% CI, 1.70 to 3.40)
- Ovarian: HR 12.0 (95% CI, 6.70 to 21.5)
- Pancreatic: HR 3.56 (95% CI, 1.34 to 9.48)
- Ten-year cumulative risk for second primary cancers were
- For BRCA1 carriers
- Contralateral breast cancer: 16%
- Ovarian: 6.3%
- Combined nonbreast/ovarian cancer: 7.8%
- For BRCA2 carriers
- Contralateral breast cancer: 12%
- Ovarian: 3.0%
- Combined nonbreast/ovarian cancer: 6.2%
- For noncarriers
- Contralateral breast cancer: 3.6%
- Ovarian: 0.4%
- Combined nonbreast/ovarian cancer: 4.9%
- For BRCA1 carriers
- Compared to noncarriers, male BRCA2 carriers had higher risk of
- Contralateral breast cancer: HR 13.1 (95% CI, 1.19 to 146)
- Prostate: HR 5.61 (95% CI, 1.96 to 16.0)
CONCLUSION:
- Breast cancer survivors with BRCA1/BRCA2 pathogenic variants are at increased risk of developing several types of second primary cancer, and increased surveillance may be warranted for this population
Learn More – Primary Sources:
Second Primary Cancer Risks After Breast Cancer in BRCA1 and BRCA2 Pathogenic Variant Carriers
Is Cannabis Exposure in Pregnancy Associated with Worse Offspring Executive Functioning?
BACKGROUND AND PURPOSE:
- The impacts of cannabis exposure in utero are not well understood, even though use in pregnancy is increasing
- Studies have been inconsistent especially related to caregiver perceptions
- Keim et al. (JAMA Pediatrics, 2024) investigated the association of prenatal cannabis exposure with executive function and aggressive behavior at age 5 years
METHODS:
- Prospective cohort study
- The Lifestyle and Early Achievement in Families (LEAF) cohort
- Derived from women enrolled during pregnancy into the Ohio Perinatal Research Network Perinatal Research Repository (PRR)
- Participants
- Patients who gave birth at age 16 to 50 years
- 5-year-old children
- Exposure
- Cannabis
- Measurements: Urine toxicology | Maternal self-report | Obstetric record abstraction
- Cannabis
- Primary outcome
- Executive function and aggressive behavior
- Measurement: Multimodal assessment by staff masked to exposure status
- Executive function and aggressive behavior
RESULTS:
- 250 children
- Exposed to cannabis: 32%
- Exposure to other substances (e.g., tobacco, drugs, and alcohol) also common
- Majority of families were living in poverty
- Non-Hispanic Black: 62% | Hispanic: 4% | 2 or more races: 14% | Non-Hispanic White: 20%
- Age-corrected standard scores for children’s attention and inhibitory control (National Institutes of Health Toolbox) were lower for those exposed to cannabis compared with unexposed
- β −6.1 points (95% CI, −10.8 to −1.4)
- Exposed children exhibited poorer task-based planning ability and more observed aggression
- Caregiver ratings were not different based on exposure status
CONCLUSION:
- Children exposed to cannabis in utero displayed some evidence of reduced executive function and increased aggression
- The authors state
These outcomes are relevant to long-term academic and adaptive functioning
The present findings may inform counseling by clinicians to avoid cannabis use during pregnancy, particularly given its recent increase
Learn More – Primary Sources:
Prenatal Cannabis Exposure and Executive Function and Aggressive Behavior at Age 5 Years
VITAL Ancillary Study: Do Vitamin D or Omega-3 Supplements Improve Physical Performance in Adults?
BACKGROUND AND PURPOSE:
- Data on the effects of vitamin D supplementation and omega-3 fatty acids on muscle mass and physical performance has been inconsistent
- Chou et al. (The Journal of Clinical Endocrinology & Metabolism, 2024) examined whether supplementation with vitamin D3 or omega-3 fatty acids vs placebo improves physical performance measures
METHODS:
- Ancillary study of a double-blind placebo-controlled randomized trial
- Parent RCT: VITamin D and OmegA-3 TriaL (VITAL)
- Primary endpoints: No change in CVD or cancer outcomes
- Parent RCT: VITamin D and OmegA-3 TriaL (VITAL)
- Participants
- Men ≥50 years and women ≥55 years
- 2 years follow-up
- Interventions
- Supplemental vitamin D3 (cholecalciferol, 2000 IU/day)
- Supplemental omega-3 fatty acids (1 g/day)
- Placebo
- Study design
- Participants were randomized to interventions using a 2×2 factorial design
- Primary outcomes
- 2-year changes in physical performance measures
- Grip strength | Walking speed | Standing balance | Repeated chair stands | Timed-up and Go (TUG) test
- 2-year changes in physical performance measures
RESULTS:
- 1054 adults
- At the 2-year follow-up, all groups, supplemented and placebo, had worse walking speed and TUG
- When comparing vitamin D to placebo, or omega-3 to placebo, there were no changes in
- Grip strength
- Walking speed
- Short Physical Performance Battery (composite of walking speed, balance, and chair stands)
- TUG
- There were no differences in effect by
- Sex | Age | BMI | Baseline total or free 25-hydroxyvitamin D (25[OH]D) or plasma omega-3 index
- TUG became slightly worse with vitamin D supplementation, compared to placebo, in participants with baseline total 25(OH)D levels above the median
- P=0.01 | Pinteraction=0.04
CONCLUSION:
- In a healthy mid-life US adult population, vitamin D and omega-3 supplementation for 2 years had no effect on physical performance measures
- The authors state
These findings do not support supplementation with vitamin D or omega-3 acids for muscular health in the general population
Along with other findings from VITAL, these data suggest that public health guidelines should recommend against vitamin D supplementation for the prevention of adverse musculoskeletal health outcomes in healthy midlife to older adults
Learn More – Primary Sources:
Scabies, Bedbug, and Body Lice Infestations
SUMMARY:
Scabies, bedbugs, and body lice are all common ectoparasitic diseases that cause similar dermatologic reactions of pruritis and rash. In most cases, a careful history and physical exam can differentiate the three from one another to ensure appropriate therapy. Scabicides are first-line treatment for patients with scabies and their close contacts. All ectoparasitic infestations must be eradicated with decontamination measures to prevent persistent disease and spread.
Table of Contents
KEY POINTS:
Scabies
Pathophysiology
- Caused by an infestation of the mite Sarcoptes scabiei var hominis
- Mites live in the human epidermis and cause a delayed skin hypersensitivity reaction 4-6 weeks after eggs hatch
- Transmission typically requires 15-20 minutes of direct skin-to-skin contact
- Transmission risk is increased in overcrowded shared living spaces, such as shelters, child-care centers, carceral settings, and long-term care facilities
Clinical Presentation
- Classically presents with pruritic, curvilinear lesions ending in an erosion or vesicle on the webbing of fingers and toes, volar wrists, ankles, axillae, buttocks, male genitalia, and areolae.
- Severely pruritic, often leading to excoriations | lichenifications | superinfection with bacteria such as Staphylococcus aureus
- These findings can mimic other dermatologic disease, such as eczema or urticaria
Diagnosis
- Mites are microscopic and not visible to the naked eye at any point in their life cycle
- Skin scraping for microscopy can be performed by putting a drop of mineral oil on a sterile surgical blade and scraping the skin
- 2020 International Alliance for the Control of Scabies consensus criteria for scabies diagnosis:
- Confirmed diagnosis requires microscopic evidence of mites | eggs | feces
- Clinical diagnosis:
- Burrows or typical lesions in male genital area or typical lesions in typical distributions and 2 positive historical findings (itch |positive contact history)
- Suspected diagnosis:
- Typical lesions in a typical distribution and 1 historical feature or atypical lesions/atypical distribution and 2 historical features
- In the case of clinical or suspected scabies, treatment is reasonable if other differential diagnoses are less likely than scabies
Treatment
- Topical permethrin 5% cream is the most effective treatment for scabies.
- Can be used for patients 2 months of age and older
- Common adverse effects include skin irritation and itching, which may limit use.
- Oral Ivermectin used if topical therapy administration not feasible due to lack of privacy or skin irritation
- Other treatments include crotamiton 10% cream or lotion | spinosad 0.9% topical suspension
- Treat clothes and linens by washing in hot water or enclosing in a plastic bag for at least 72 hours to avoid fomite transmission
- All close contacts of patients with scabies should be treated even if asymptomatic
Bedbugs
Pathophysiology
- Caused by infestation of insects in the Cimicacidae family
- Insects take blood meals from humans throughout the insect life cycle
- Blood meals lead to skin reactions
- Thrive in warm, dark environments e.g. mattresses| furniture | flooring | walls
- Visible to the naked eye
- Often infest areas with high turnover | hotels | motels | hostels | shelters
Clinical Presentation & Diagnosis
- Pruritic, erythematous papules on exposed areas
- New lesions on awakening (bedbugs are nocturnal)
Treatment
- Primary treatment is to eradicate the infestation with professional treatment
- Skin reactions typically resolve on their own after 1 week
- Midpotency topical corticosteroids can be used for symptom control
Body Lice
Pathophysiology
- Caused by infestation of the body lice in individuals who are unable to maintain personal hygiene, such as persons experiencing homelessness | displacement | mental illness
- Live on clothing and visible to the naked eye
- Take blood meals from humans leading to hypersensitivity reaction | pruritis
Clinical Presentation
- Erythematous macules | papules| plaques with associated excoriations and occasional hyperpigmentation or lichenification
- Typically located where clothing seams touch the skin: waistline | medial and lateral legs | upper back
- Secondary bacterial infections have been demonstrated in some populations
Treatment
- First-line treatment is eradication of the infestation with regular bathing and laundering
- Oral ivermectin or topical permethrin can be considered for individuals who are unable to maintain regular hygiene, though their effectiveness is limited
- Mid-potency topical corticosteroids e.g. triamcinolone 0.1% can be used for symptom control if needed
Learn More – Primary Sources
Scabies, Bedbug, and Body Lice Infestations: A Review
CDC: Clinical Care of Head Lice
CDC: Caring for Patients with Bed Bug Bites
Management of BPH
SUMMARY:
Benign prostatic hyperplasia (BPH) is a common medical condition that affects older men as smooth muscle and epithelial cells within the prostate proliferate with increasing age. Patients with BPH leading to benign prostate enlargement (BPE) can develop lower urinary tract symptoms (LUTS) that range from a mild impact on quality of life to severe and life-threatening urinary retention. Medical and surgical therapies are available to manage symptoms and ameliorate potential complications.
Evaluation
- BPH is common in older men and anyone with functioning testes
- Prevalence increases starting in a patient’s 40s and affects 80% of men by the age 80
- Not in men castrated before puberty or with atrophic prostate glands
- Not everyone with BPH will develop benign prostatic enlargement (BPE) or subsequent lower urinary tract symptoms
- Lower urinary tract symptoms (LUTS) include:
- Storage: Urgency | Frequency | Nocturia | Incontinence
- Voiding: Hesitancy | Slow stream | Dribbling | Straining | Dysuria
- Postmicturition: Incomplete emptying | Post urination dribbling
- Patients presenting with complaints of LUTS should undergo: Physical exam | Clinical history | Medication review | Urinalysis testing | International Prostate Symptom Score (IPSS) (see “Learn More” below)
- Patients treated for LUTS should have follow up within 4 to 12 weeks to reassess symptoms and response to therapy/modifications
- Repeat IPSS is helpful in assessing trend of symptom burden and BPH severity
Treatment
- Treatment for LUTS due to BPH and BPE should include shared decision-making discussing the main treatment options: Lifestyle/Behavior modification | Medical therapy | Surgical/Procedural therapy
Lifestyle Modifications
- Limit fluid intake, especially prior to bedtime or expected long periods away from a bathroom (e.g., Travel | Social gatherings)
- Avoid diuretics (e.g., Medications | Alcohol | Caffeine)
- Avoid constipation
- Maintain a healthy weight | Regular exercise
Medical Therapy
- Alpha blockers: Alfuzosin (Uroxatral) | Doxazosin (Cardura) | Silodosin (Rapaflo) | Tamsulosin (Flomax) | Terazosin (Hytrin)
- All have similar efficacy and can expect to improve IPSS scores by 5 to 8 points
- Treatment failure of one alpha blocker should not be followed by trial of a different alpha blocker
- Poorly tolerated side effects can be a reason to switch between different alpha blockers
- Non-specific alpha blockers can affect blood pressure (e.g., Doxazosin (Cardura) | Terazosin (Hytrin)) and their BP effects can be potentiated by concomitant PDE5 use
- Selective alpha blockers (e.g., Silodosin (Rapaflo) | Tamsulosin (Flomax) | Alfuzosin (Uroxatral)) have lower potential to cause orthostatic hypotension and syncope
- Alpha blockers increase risk of intraoperative floppy iris syndrome (IFIS) and should be held for 5 to 7 days before cataract surgery
- Alpha blockers should be initiated in any patient with acute urinary retention (AUR) prior to attempting a voiding trial for at least 3 days
- 5- Alpha Reductase inhibitor (5-ARI): Finasteride (Proscar) | Dutasteride (Avodart)
- Used in patients with one of the following: Prostate volume of > 30g | Prostate specific antigen (PSA) > 1.5ng/mL | Palpable prostate enlargement on digital rectal exam
- Can shrink the prostate by 15 to 25% after 6 months of treatment
- Patients should be counseled on expected time delay for symptom improvement if used as monotherapy
- If future prostate surgery is planned for treatment of BPE, use of 5-ARI in the months preceding may decrease bleeding in the peri- and post-operative period
- 5-ARIs may be helpful in treating refractory hematuria due to BPE
- Side effects may limit use and include: Sexual dysfunction | Gynecomastia
- Phosphodiesterase-5 Inhibitor (PDE5): Tadalafil (Cialis) | Sildenafil (Viagra)
- Tadalafil 5mg daily has been shown to improve LUTS symptoms in patients with BPH, even in the absence of erectile dysfunction
- Tadalafil 5mg had similar efficacy to Tamsulosin 0.4mg in improvement of IPSS
- Tadalafil is the only PDE5 that is FDA approved for LUTS, but studies have shown efficacy with Sildenafil as well
- Combination therapy
- For patients starting on a 5-ARI, the addition of an alpha blocker can help reduce LUTS symptoms in the first few weeks
- Clinicians may offer the combination of low-dose daily 5mg tadalafil with alpha blockers OR a 5-ARI for the treatment of LUTS
- Patients without clinical improvement over 4 weeks (following initiation of an alpha blocker or PDE5) or over 6 to 12 months (for patients started on 5-ARI) should be referred to a specialist to consider additional work up and treatment options
- Patients who have clinical improvement but develop intolerable medication-related side effects should also be referred to urology for consideration of surgical interventions
Surgical Therapy
- Prior to consideration of surgical interventions, patients should consider undergoing preoperative testing including
- Assessment of prostate size and shape (e.g., Transrectal or abdominal ultrasound | Cystoscopy | MRI | CT)
- Post-void residual (PVR): PVR >300 mL is considered large
- Uroflowmetry | Pressure flow studies
- Surgery should be offered to patients with complications due to their BPH/BPE including
- Renal insufficiency | Refractory urinary retention | Recurrent urinary tract infections | Recurrent bladder stones | Gross hematuria | BPH/LUTS refractory to other therapies | BPH/LUTS symptoms unwilling to trial other therapies
- Surgical options are plentiful and should be chosen based on patient characteristics and comorbid conditions, as well as operator expertise
- Transurethral Resection of the Prostate (TURP)
- Simple Prostatectomy
- Transurethral Incision of the Prostate (TUIP)
- Transurethral Vaporization of the Prostate (TUVP)
- Photoselective Vaporization of the Prostate (PVP)
- Prostatic Urethral Lift (PUL)
- Water Vapor Thermal Therapy (WVTT)
- Laser Enucleation
- Robotic Waterjet Treatment (RWT)
- Prostate Artery Embolization (PAE)
- Temporary Implanted Prostatic Devices (TIPD)
KEY POINTS:
- Benign prostatic hyperplasia is an exceedingly common medical condition in older men that can lead to prostate enlargement and the development of lower urinary tract symptoms
- Symptoms and signs of BPH can range for mild (e.g., Frequency | Slow stream) to severe (e.g., Hematuria | Renal insufficiency | Acute urinary retention)
- Treatment includes behavior and lifestyle modifications, as well as medical and/or surgical therapy
- Medical therapy is comprised of mono- or combination therapy with alpha blockers, 5-alpha reductase inhibitors, and phosphodiesterase-5 Inhibitors
- Surgical therapy should be offered to patients who fail to improve with medical therapy or have significant complications from their BPH
Primary Sources – Learn More
International Prostate Symptom Score (IPSS)
Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline
Association of 5α-Reductase Inhibitors With Prostate Cancer Mortality
Carpal Tunnel Syndrome
SUMMARY:
Carpal tunnel syndrome (CTS) is a disease of the hand caused by compression of the median nerve as it travels through the carpal tunnel, a narrow and rigid passageway in the wrist enclosed by carpal bones and the transverse carpal ligament. Patients often present with intermittent hand pain, numbness and tingling. When diagnosis and treatment is delayed, prolonged compression of the median nerve can lead to irreversible damage and permanent neurologic deficits of the hand. Treatment includes splinting, local corticosteroid injections, and surgical decompression.
Clinical Presentation
Diagnosis
Treatment
Clinical Presentation
- Patients typically present with gradually worsening symptoms in one or both hands
- Symptoms can be intermittent at the start and become more constant as the disease progresses
- Mild disease: Intermittent symptoms | Pain | Paresthesia | No neuro deficits
- Moderate disease: Constant symptoms | Pain | Frequent nighttime awakenings | Hand clumsiness
- Severe disease: Thenar muscle atrophy | Motor deficits evident on exam | Constant symptoms
- Pain is predominantly in the first four fingers (i.e., sparing the pinky finger) following the innervation path of the median nerve
- Numbness | Tingling | Burning | Shooting
- Pain may travel up the forearm to the shoulder
- Later in the course of the disease patients may develop weakness and motor function losses
- Clumsiness of the hand | Dropping object
- Loss of fine motor control | Loss of proprioception
- Symptoms often worsen with
- Sleep: Patients often sleep with wrists bent aggravating median nerve compression | Pain can disrupt sleep and cause nighttime awakenings
- Holding something for a prolonged period (e.g., Reading a book | Driving)
- Symptoms can improve with: Moving or shaking the hand
- Risk factors for CTS
- Family history of CTS | Repetitive hand use | Prolonged hand flexion/extension | Pregnancy | Diabetes | Arthritis | Hypothyroidism | Obesity | Female sex
Diagnosis
- Obtain detailed history and physical exam
- Include neck and upper arm exam to rule out:
- Cervical radiculopathy | Thoracic outlet | Pronator teres pathology | Ulnar and radial tunnel syndromes
- Physical exam should include CTS provocative testing (see Learn More below)
- Tinel sign: Rapidly tap on the volar surface of the wrist proximal over the carpal tunnel | Testing positive if pain/paresthesia are elicited in the median nerve distribution | Sensitivity 50% | Specificity 77%
- Phalen test: Flex patient’s wrist 90 degrees with elbow in full extension for 60 seconds | Testing positive if pain/paresthesia are elicited in the median nerve distribution | Sensitivity 68% | Specificity 73%
- Closed fist sign: Patient makes a fist for 60 seconds | Testing positive if pain/paresthesia are elicited in the median nerve distribution
- Hand elevation test: Patient raises hand above their head for 60 seconds | Testing positive if pain/paresthesia are elicited in the median nerve distribution
- Manual carpal compression test: Apply direct pressure on the volar wrist surface over the carpal tunnel for 30 seconds | Testing positive if pain/paresthesia are elicited in the median nerve distribution | Sensitivity 64% | Specificity 83%
- Loss of two-point discrimination: Inability to discriminate between two points held ≤ 5 mm apart from one another on the palmar side of the first, second, or third digits
- No single testing is completely predictive of CTS
- Exception: In severe cases, thenar muscle atrophy has a 99% specificity of CTS
- Recommended to use a combination of physical exam findings and clinical presentation to make the diagnosis
- Consider using the CTS-6 Evaluation Tool (under Learn More) to assist with diagnosis
- Score of ≥ 12 has an 80% probability for CTS
- In typical mild cases of CTS, imaging and further invasive testing are not needed
- Consider obtaining electrodiagnostic studies in cases of: Diagnostic uncertainty | Rule out additional pathology | Determine severity for surgical interventions
- Nerve conduction studies (NCS) | Electromyogram (EMG)
Treatment
- Treatment of CTS depends on severity
- Many patients with non-severe symptoms will resolve spontaneously within 2 years
- Non-surgical treatment should be offered for patients with mild to moderate CTS
- Surgical treatment is recommended for patients with severe CTS or abnormal NCS/EMG studies
Non-surgical
- Activity changes
- Use of keyboards with reduced strike force
- If computer mouse related, consider alternative options
- Limit activities that trigger CTS
- Physical therapy | Yoga | Occupational therapy | Therapeutic ultrasound
- Splinting
- Neutral wrist splint is 1st line for mild to moderate CTS
- Low risk | Low cost | Easy to access
- Night only splinting is as effective as continuous wear and is better tolerated
- Can consider wearing during the day for tasks that aggravate CTS symptoms
- Wear for at least 1 to 2 months | Expect symptom improvement after 2 weeks
- Oral medications
- OTC anti-inflammatories (e.g., Acetaminophen | NSAIDs) have not been shown to be helpful in CTS
- Oral steroids may be effective for control of short-term symptoms but are associated with significant risks (e.g., Hyperglycemia | Adrenal insufficiency) and use should be limited
- Local corticosteroid injection
- Provides significant improvement in symptoms and function
- Can take 3 months for full effect | Symptom improvement lasts roughly 6 months
- No significant difference among steroid formulations
- Combination of splinting and steroid injection had no additional benefits
- Local perineural dextrose 5% injection
- Limited evidence that it may be effective for up to 6 months
- Second line therapy after: Splinting | Steroid injection
Surgical
- Carpal tunnel release procedures are recommended for
- Severe CTS | Abnormal EMG/NCS testing | Failure of non-surgical treatments
- Effective in most patients | Low risk | Requires referral to ortho or hand specialist
- Endoscopic and open tunnel release techniques are equally effective
- Endoscopic approach may have less complications and a faster return to daily activities
- Complications include: Bleeding | Infection | Wound healing issues | Nerve aggravation or injury
- Clinical improvement and resolution of CTS symptoms may take several months post-operatively and recovery will depend on extent of pre-operative nerve damage
KEY POINTS:
- Carpal tunnel syndrome (CTS) is a common disease of the hand caused by median nerve compression as it passes through the carpal tunnel
- Diagnosis is based on a clinical picture of hand pain and paresthesia in a median nerve distribution in addition to suggestive physical exam findings
- Further testing with EMG/NCS can be considered in atypical cases or to help determine severity of CTS
- 1st line treatment for mild to moderate CTS is neutral wrist splinting and local corticosteroid injections
- Patients with severe CTS or those who have failed non-surgical therapy should be referred for carpal tunnel decompression
Primary Sources – Learn More
AAFP: Carpal Tunnel Syndrome: Rapid Evidence Review
Carpal Tunnel Syndrome: A Summary of Clinical Practice Guideline Recommendations
2024 AHA/ASA Guideline for the Primary Prevention of Stroke
SUMMARY:
After 10 years, the American Heart Association and American Stroke Association come together to provide updated guidelines on primary stroke prevention. 600,000 Americans suffer a first stroke each year, and over half could be prevented with better risk factor control. With an emphasis on social determinants of health, the updated guideline provides recommendations to aid primary care clinicians as well as administrators and policymakers in closing the prevention gap for primary stroke events. Please see original guidelines under “Learn More” below for level of evidence behind each recommendation.
KEY POINTS:
- Adverse social determinants of health play a major role in stroke risk.
- Incorporate screening and community support to address these non-medical risk factors for first stroke
- Assess ASCVD risk every 1-5 years in adults 40-79 years of age
- Use CHA2DS2-VASc score to guide anticoagulation use in individuals with atrial fibrillation (AF)
- Periodically screen for stroke risk factors in all adults ≥18 years of age T such as hypertension | cigarette smoking | diabetes | dyslipidemia | physical inactivity | sleep disorders | SDOH
- AHA/ASA organizes evidence-based health behaviors to lower risk of stroke and cardiovascular disease into eight categories (“Life’s Essential 8”): diet | physical activity | BMI | sleep health | blood glucose | blood pressure | lipids | nicotine exposure
- Continued recommendations include following a Mediterranean diet, routine physical activity, statin use for qualifying patients and tobacco cessation/abstinence
- Notable new recommendations for primary stroke prevention:
- Limiting sedentary behavior
- GLP-1 use for diabetics and those with high CV risk
- Routine use of ≥2 antihypertensive medications for most patients who require pharmacologic treatment of hypertension due to RCTs that show BP control in only 30% of patients on medication
Disease-Specific Recommendations
Asymptomatic carotid artery stenosis
Asymptomatic cerebral small vessel disease (CSVD)
Migraine, with or without aura
Sickle cell disease (SCD)
Genetic stroke syndromes
Recent MI
Autoimmune
Malignancy
Infection
Heavy alcohol and illicit drug use (including cannabis)
Pregnancy
Contraception
Menopause
Transgender women
Hypogonadism
Heart Disease
Antiplatelets
Asymptomatic carotid artery stenosis
- Do not routinely screen for carotid artery stenosis in asymptomatic patients to reduce stroke risk.
- If stenosis is >70%, shared decision-making on whether medical management (HIS[RK2] statin use) and/or revascularization is the best option
- If stenosis >50% consider annual monitoring
Asymptomatic cerebral small vessel disease (CSVD)
- Definition: radiographic evidence of white matter hyperintensities | recent small subcortical infarct | lacune of presumed vascular origin| cerebral microbleeds | enlarged perivascular spaces| cerebral atrophy
- If patients do not otherwise qualify for statin use, consider low-intensity statins
- Unclear if the use of aspirin or other antiplatelet therapy outweighs the risks
Migraine, with or without aura
- Known to increase stroke risk
- Mitigate other risk factors (ie tobacco use, hypertension)
- Avoid estrogen-containing contraception in favor of progesterone-only or nonhormonal methods.
Sickle cell disease (SCD)
- Perform transcranial Doppler (TCD) for children ages 2-16 yo
- Increased velocity on TCD is correlated with increased stroke risk
- If TCD demonstrates increased risk, treatment options include blood transfusions or hydroxyurea
Genetic stroke syndromes
- Examples: Fabry disease and hereditary hemorrhagic telangiectasia
- Require additional screening and multidisciplinary care to reduce stroke risk.
Recent MI
- Consider adding low dose colchicine to intensive statin therapy
Autoimmune
- Use antiplatelet therapy for patients with antiphospholipid syndrome or SLE.
- No strong disease-specific recommendations for most other autoimmune conditions
Malignancy
- Too variable to make broad recommendations for stroke risk reduction among cancer patients.
Infection
- Transient increased stroke risk may be mitigated with good dental hygiene in the case of periodontal disease.
Heavy alcohol and illicit drug use (including cannabis)
- Increases stroke risk independent of other cardiovascular risk factors
- Screen for and treat substance use disorders
Pregnancy
- Pregnant or early postpartum (within 6 weeks of delivery):
- BP-lowering treatment to a target <160/110 mm Hg as soon as possible is recommended to reduce the risk of fatal maternal ICH
- For all hypertensive disorders of pregnancy (HDP), a treatment goal of <140/90 mm Hg is reasonable to reduce risk of pregnancy-associated stroke.
- Clinicians should screen for a history of adverse pregnancy outcomes i.e. HDP | preterm birth | gestational diabetes | placental disorders since these are associated with an increased risk of chronic hypertension and stroke later in life.
Contraception
- Use the lowest effective dose of estrogen
- Avoid estrogen-containing contraception in those with specific stroke risk factors:
- Age >35 years
- Tobacco use
- Hypertension
- Migraine with aura
Menopause
- Endometriosis, premature ovarian failure (before 40 years of age), and early-onset menopause (before 45 years of age) are all associated with an increased risk for stroke.
- Evaluate and modify concurrent stroke risk factors in such patients
- Use shared decision-making to continue estrogen replacement in postmenopausal women if:
- ≥60 years of age
- More than 10 years after natural menopause
- Have other factors increasing their risk of stroke
Transgender women
- Estrogen use increases stroke in this population
- Evaluate and modify concurrent stroke risk factors in such patients
Hypogonadism
- Testosterone can safely be continued in patients with confirmed hypogonadism and does not itself confer additional stroke risk
Heart Disease
- Anticoagulation is no longer indicated to reduce stroke risk in this population.
- Stroke prevention in atrial fibrillation | valvular heart disease| congenital heart disease| acute MI covered in other recent and more specific guidelines
Antiplatelets
- Avoid aspirin in:
- Adults ≥70 years of age
- Individuals of any age with CKD
- Its effectiveness in younger patients with diabetes or other vascular risk factors is not well established.
- Long-term dual-antiplatelet therapy with ticagrelor and aspirin may be beneficial to reduce risk of ischemic stroke in patients with established, stable CAD and low bleeding risk.
