NEJM Evidence

Volume 3 Issue 5 of 𝘕𝘌𝘑𝘔 𝘌𝘷𝘪𝘥𝘦𝘯𝘤𝘦 is now available! Here is a preview of the latest content:      𝗢𝗿𝗶𝗴𝗶𝗻𝗮𝗹 𝗔𝗿𝘁𝗶𝗰𝗹𝗲𝘀  CDK4/6 Inhibitor Efficacy in ESR1-Mutant Metastatic Breast Cancer https://eviden.cc/3U5CDpX     A Trial of Automated Outbreak Detection to Reduce Hospital Pathogen Spread https://eviden.cc/3JtpamN    Intranasal Oxytocin for Obesity https://eviden.cc/3UvTFz2    Prostate Cancer Foundation Screening Guidelines for Black Men in the United States https://eviden.cc/3W8AwnI    𝗥𝗲𝘃𝗶𝗲𝘄 𝗔𝗿𝘁𝗶𝗰𝗹𝗲  Diagnostics for Public Health — Infectious Disease Surveillance and Control https://eviden.cc/4djcexI     𝗠𝗼𝗿𝗻𝗶𝗻𝗴 𝗥𝗲𝗽𝗼𝗿𝘁   A 73-Year-Old Man with Shortness of Breath, Edema, and Weight Gain https://eviden.cc/4b2w0vk     𝗖𝘂𝗿𝗯𝘀𝗶𝗱𝗲 𝗖𝗼𝗻𝘀𝘂𝗹𝘁  How Do I Manage Acute Pain for Patients Prescribed Buprenorphine for Opioid Use Disorder? https://eviden.cc/3UtSwqv     Explore all the latest original research and specialty articles in the May issue: https://eviden.cc/current  

Randomized trials are widely regarded as providing the most robust evidence for guiding patient management and informing public health policy. A typical individual-randomized trial (IRT) randomly assigns individual participants into treatment and control groups and then compares their outcomes to estimate the intervention effect. However, sometimes individual randomization may not be feasible or optimal, prompting the consideration of a cluster-randomized trial (CRT), where groups of individuals are randomly assigned to different treatment conditions.    In an editorial, Rui Wang, PhD, explains why selecting the unit of randomization is key in the design of randomized clinical trials and discusses the rationale for, as well as the potential pitfalls of, using a CRT design.    Read the editorial “Choosing the Unit of Randomization — Individual or Cluster?” by Rui Wang, PhD: https://eviden.cc/4aoEpsJ    𝗙𝗨𝗥𝗧𝗛𝗘𝗥 𝗥𝗘𝗔𝗗𝗜𝗡𝗚  📄 Original Article by Robert M. Rodriguez, MD, et al.: Promotion of Influenza Vaccination in the Emergency Department https://eviden.cc/4ajX0pI  📄 Editorial by Zanthia Wiley, MD, and Annelys Roque Gardner, MD: Adult Influenza Vaccination — Seizing Every Opportunity https://eviden.cc/4a0VDg7      #EmergencyMedicine   

A 70-year-old woman presented to the otorhinolaryngology department of a tertiary care center for evaluation of a persistent sensation of something moving in her nose. She had recently returned home to Switzerland after traveling for 6 months with her husband through South America. She first noticed the sensation after visiting a rainforest in Bolivia about 4 weeks into the trip. A few days later, she had a similar sensation on her right upper arm. She then noticed that her left nostril and face were swollen and painful, and she started to have intermittent discolored nasal discharge. She had no fevers or chills. There had been no trauma or notable event that preceded the onset of symptoms. She sought evaluation at a local facility and received treatment with antibiotics for presumed cellulitis. The facial swelling and discomfort on her arm subsided, but the nasal discomfort persisted. She took acetaminophen as needed to help manage the pain throughout the rest of the trip and sought evaluation when she arrived back in Switzerland.    Read the Morning Report “A 70-Year-Old Woman with a Sensation of Something Moving in Her Nose” by Marlene M. Speth, MD, MA, Raphael Brändle, MD, and Hesham Saleh, MD: https://eviden.cc/3IMTx7l  

Racial and ethnic disparities in influenza vaccination uptake and disease severity persist. During 13 influenza seasons between 2009 and 2022, Black, Hispanic, and American Indian or Alaska Native (AI/AN) adults had age-adjusted hospitalization rates an average of 1.2 to 1.8 times the rates of non-Hispanic White adults. During most of these seasons, rates were the highest in Black adults, with a range of 1.5 to 2.4 times that of White adults. Adult influenza vaccination coverage has also been consistently lower among Hispanic, AI/AN, and Black adults compared with White and non-Hispanic Asian adults since the 2010 to 2011 season. In the 2021 to 2022 influenza season, Hispanic adults had an overall vaccination coverage of only 37.9%, compared with AI/AN (40.2%), Black (42.0%), non-Hispanic White (53.9%), and Asian (54.2%) adults. Additionally, influenza vaccination coverage among foreign-born adults is substantially lower than that of United States–born adults. Culturally competent efforts to promote influenza vaccination confidence and mitigate these disparities are warranted and should be considered in unconventional settings, such as emergency departments, to reach those who are most vulnerable.    Continue reading the editorial “Adult Influenza Vaccination — Seizing Every Opportunity” by Zanthia Wiley, MD, and Annelys Roque Gardner, MD: https://eviden.cc/4a0VDg7    𝗙𝗨𝗥𝗧𝗛𝗘𝗥 𝗥𝗘𝗔𝗗𝗜𝗡𝗚  📄 Original Article by Robert M. Rodriguez, MD, et al.: Promotion of Influenza Vaccination in the Emergency Department  https://eviden.cc/4ajX0pI  📄 Editorial by Rui Wang, PhD: Choosing the Unit of Randomization — Individual or Cluster? https://eviden.cc/4aoEpsJ    #EmergencyMedicine 

Machine learning–based approaches that seek to accomplish individualized treatment effect prediction have gained traction; however, some salient challenges lack wider recognition.      Rishi Desai, MS, PhD, et al. describe key methodologic considerations for individualized treatment effect prediction models using data from the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist Trial for spironolactone in heart failure with preserved ejection fraction. The causal survival forest algorithm was used for model development. Calibration and discrimination were evaluated using a bootstrapping-based internal validation procedure. Observed benefits were described for predicted benefit quartiles and quartiles of a known effect modifier: ejection fraction. A negative control analysis with noncardiovascular death as the outcome was implemented to detect confounding.    Read the Original Article “Individualized Treatment Effect Prediction with Machine Learning — Salient Considerations” by Rishi Desai, MS, PhD, et al.: https://eviden.cc/4cupGhU    𝗙𝗨𝗥𝗧𝗛𝗘𝗥 𝗥𝗘𝗔𝗗𝗜𝗡𝗚  Editorial by Christopher J. Yarnell, MD, PhD, and Michael Fralick, MD, PhD: Heterogeneity of Treatment Effect — An Evolution in Subgroup Analysis https://eviden.cc/3TuT2DP 

An estimated 1.1 billion people currently smoke cigarettes, and 50 to 70% likely will die from tobacco-related causes. This translates to 550 to 770 million expected tobacco deaths among those who currently smoke. Many additional deaths will accrue in successive generations if the status quo continues.    Of interest is the reversibility of the excess mortality risk of smoking. The meta-analysis by Cho et al. of four large national cohorts of nearly 1.5 million adults followed on average 14.8 years yielded 23.0 million person-years of observational data with over 120,000 deaths identified through linked death registries. In their analysis, continued smoking carried an almost threefold greater risk of death than never smoking; quitting was associated with more than 50% lower risk. For men and women, current smoking compared with never smoking was associated with dying on average 12 years prematurely. Quitting smoking was associated with large differences in risk within the first 3 years, and by 10 or more years it was associated with mortality risk at levels largely resembling never smoking. Consistent with earlier studies, the findings of Cho et al. escalate the evidence for advancing health through eradicating smoking.    Continue reading the editorial “Smoking Cessation, or How to Avert Half a Billion Premature Deaths — Now” by John P. A. Ioannidis, MD, DSc, and Judith J. Prochaska, PhD: https://eviden.cc/3wmUwrV    𝗙𝗨𝗥𝗧𝗛𝗘𝗥 𝗥𝗘𝗔𝗗𝗜𝗡𝗚  📄 Original Article by Eo Rin Cho, PhD, Ilene K. Brill, MPH, Inger Torhild Gram, MD, Patrick E. Brown, PhD, and Prabhat Jha, MD: Smoking Cessation and Short- and Longer-Term Mortality https://eviden.cc/3Ux9ANV  📄 Editorial by Sharon-Lise T. Normand, PhD: Questioning a Sensible Result https://eviden.cc/42SoHDv    #MedicalResearch 

Influenza vaccine uptake is low among underserved populations whose primary health care access occurs in emergency departments. Robert M. Rodriguez, MD, et al. sought to determine whether implementation of two interventions would increase 30-day influenza vaccine uptake in unvaccinated patients in the emergency department.    This three-group, prospective, cluster randomized controlled trial compared two interventions with a control group in noncritically ill, adult patients in the emergency department who were not vaccinated for influenza in the current vaccine season. The unit of randomization was individual calendar days. Participants received either Intervention M (an influenza vaccine messaging platform consisting of a video, one-page flyer, and scripted message, followed by a vaccine acceptance question and provider notification if participants indicated vaccine acceptance), Intervention Q (no messaging but the vaccine acceptance question and provider notification), or control (usual care/no intervention). The primary outcome was receipt of an influenza vaccine at 30 days ascertained by electronic health record review and telephone follow-up, comparing the Intervention M group with the control group. Secondary outcomes included comparisons of 30-day vaccine uptake in Intervention Q versus control and Intervention M versus Intervention Q.    Read the Original Article “Promotion of Influenza Vaccination in the Emergency Department” by Robert M. Rodriguez, MD, et al. https://eviden.cc/4ajX0pI    𝗙𝗨𝗥𝗧𝗛𝗘𝗥 𝗥𝗘𝗔𝗗𝗜𝗡𝗚  📄 Editorial by Rui Wang, PhD: Choosing the Unit of Randomization — Individual or Cluster? https://eviden.cc/4aoEpsJ  📄 Editorial by Zanthia Wiley, MD, and Annelys Roque Gardner, MD: Adult Influenza Vaccination — Seizing Every Opportunity https://eviden.cc/4a0VDg7 #EmergencyMedicine

Intestinal ischemia can result from various pathologic conditions. The presentations of ischemia can range from acute to subacute and mild to severe. Diagnosis of this condition may pose challenges, particularly in the early, potentially salvageable, stages of disease. A review by Sheina Theodore, MD, Tony Xia, MD, and Noelle Saillant MD, FACS, offers an evidence-based approach to understanding the diagnosis and management of inadequate intestinal perfusion.    Read “The Evaluation and Management of Intestinal Ischemia,” the second of a two-part review on intestinal ischemia, by Sheina Theodore, MD, Tony Xia, MD, and Noelle Saillant MD, FACS, from Boston University School of Medicine: https://eviden.cc/43vPd66    Read part one, “Intestinal Ischemia — Etiology and Foundational Concepts”: https://eviden.cc/48uEJok    #Surgery 

A 52-year-old woman was brought by family members to the emergency department for evaluation of weakness and confusion. She first felt unwell 1 week ago, with sudden onset of diffuse abdominal pain and generalized weakness. The abdominal pain lessened after a few days, but the weakness persisted. One day before presentation, she started to slur her speech, had difficulty with word finding, and became confused. She had received a glucocorticoid injection in the left hip for treatment of arthritis a few weeks earlier, but otherwise, there were no notable events antecedent to the illness. The patient had no chest pain, shortness of breath, nausea, constipation, diarrhea, or headaches.    Read the Morning Report “A 52-Year-Old Woman with Weakness and Confusion” by Halli Krzyzaniak, MD, Martina Vergouwen, BN, Gregory Kline, MD, Jason Lord, MD, Paul Cantle, MD, and Kenton Rommens, MD, from the University of Calgary: https://eviden.cc/48tmNdW #MedicalEducation

Clinical research often generates new findings that challenge and inform current practice. The editors of NEJM Evidence have curated a collection of research articles across multiple specialties that, through varied methodologic approaches, each add important evidence in areas of either clinical or policy uncertainty. The research is accompanied by commentary that contextualizes the work or sheds light on the methods utilized to generate the evidence.    Each of the NEJM Evidence articles in this collection clarifies and builds on current medical evidence — answering previously open questions, challenging current clinical practices, or creating dialogue around health policies where more evidence and study is required.    Inside this collection, discover:    🥜 A randomized trial of oral immunotherapy for young children with a peanut allergy 💉 A randomized clinical trial evaluating dosing regimens for HPV vaccination by assessing 2 versus 3 doses of a 9-valent HPV vaccine among 15–26-year-olds 🤰 An observational study evaluating the association between hypertensive disorders in pregnancy and the later risk of stroke among Black women in the U.S. 🩺 A study exploring the common clinical question of how quickly or slowly to correct sodium in patients with severe hyponatremia    Download the collection now: https://eviden.cc/43LLilH