👋 Happy Friday. Sorry I’m late. But I promised you medical news today! So as you settle in for bed, here’s a short medicine-themed lullaby. 🤝 

Here’s what we got:

• 🥳 Leng Review Teaser Trailer: PA’s are Getting a Rebrand

• 👨‍🦯‍➡️Is Common Sense Common? Not in The Case of Surgical Fraility

• 🩸 Antiplatelet Wars: Clopidogrel Strikes Back

• #TheMoreYouKnow: Other Top Stories of The Week

NHS NEWS

Leng Review Teaser Trailer: PA’s are Getting a Rebrand

Vindication is finally on the horizon. Leng is actually going to rebrand PA’s 🥳

After months of soul searching, introspection, rumination and reviewing the evidence, Professor Leng has reached this groundbreaking conclusion: Dressing like a doctor, speaking like a doctor and identifying as a medical professional might actually be confusing to the general public. 

Huh, who would have thought?

For those who don’t know, The Leng Review - A formal investigation into whether patient safety is at increased risk with the rise in Physician Associates - is underway. 

Wes Streeting commissioned Professor Gillian Leng(Royal Society of Medicine president) to conduct the review starting last November . This came as a result of several incidents resulting in patient morbidity and mortality when they thought they were being treated by a doctor. 

Yes sure, there are some very competent PA’s out there. But a 2 year post-degree course pales in comparison to 5-6 it takes doctors to qualify. There really shouldn’t be a who's who debate.

Although it’s not confirmed, one of the top recommendations is piped to be this title change. Rebranding the Physician Associate back to a ‘Physician Assistant’ like it was 30 years ago. Or maybe ‘Doctors’ Assistant’ 👀

The BMA welcomes the changes, saying on their X account: 

“Reports of a potential title change for Physician Associates are welcome. The BMA has long called for the return of the name ‘assistant’. We look forward to reviewing the full recommendations as soon as they’re published.”

It’s a good start. Now, we just have to get over that pesky issue of our “assistants” getting paid more than we do…

RESEARCH UPDATE

Is Common Sense Common? Not In The Case of Surgical Frailty

Headline: Older Patients Are More Likely To Experience Complications After Surgery 🤯

And the crowd goes… silent. My mouth snaps shut. I’m in complete and utter belief.

Because of course they are. 

It’s hardly a surprise that older patients face more complications–delirium, VTE’s and death. The usual post-op bingo card. What is surprising is that most hospitals still don’t bother checking if those patients are frail before operating. 

We’re talking about 71% of hospitals skipping frailty assessment in patients over 60. Which is funny, because 1 in 5 of these surgical patients are actually frail!

This was all uncovered in a study called SNAP-3, published in the British Journal of Anaesthesia. The aim of the study was to investigate how frailty and multimorbidity impact postoperative outcomes in UK patients aged 60+ undergoing surgery. 

This was an observational cohort study where researchers tracked over 7,000 people across 214 hospitals. All aged 60 and up. All going in for surgery. All in one single, glorious five-day data grab in March 2022.

Frailty was defined as a Clinical Frailty Scale score of 5 or higher. Multimorbidity meant two or more chronic conditions. And if that sounds like every older person you’ve ever met, well… that’s kind of the point.

The primary end points focused on were:

• Length of hospital stay (LOS)

• Postoperative delirium

• Morbidity (complications)

• Mortality at 30 days, 120 days, and 1 year.

The results are in, and they showed:

1. Length of stay: increased frailty was associated with longer hospital stays. Even patients with mild frailty (CFS 4) had a median LOS 0.75 days longer than non-frail patients; those with moderate frailty (CFS 5) had LOS 2.69 days longer. 3 days extra managing with the flimsy plastic water cups. Fun 

2. Delirium: Frailty significantly increased odds of developing delirium. Patients with severe frailty (CFS 7-8) had more than double the odds of delirium compared to non-frail patients(aOR 2.33). Multimorbidty had no significant effect

3. Complications: Both frailty and multimorbidity increased the odds of complications. Multimorbidity increasing it by 46%

4. Mortality(30 days, 120 days, 1 year): Frailty was associated with a clear, stepwise increase in mortality at all time points. The frailest patients(CFS7-8) had 4x the odds of 1-year mortality compared to non-frail patients. Multimorbidty had no significant effect

So what now?

The researchers behind SNAP-3 have a simple suggestion:

Just check. Use the Clinical Frailty Scale. It takes, what…two minutes? A quick chat, a basic mobility check, maybe observe if they call a nurse “love” and complain about the tea. Boom. You’ve got the data.

So next time you’re with an over 60 in pre-op, remember this:

Check the blood pressure.
Cou check the labs.
Check the frailty.

Simple. Obvious. Long overdue.

RESEARCH UPDATE

🩸 Antiplatelet Wars: Clopidogrel Strikes Back

Hell yeah! Sorry to nerd out, but nothing is better than a head-to-head intervention study. Nothing. Not even…well… you know 😏

We’ve had Ozempic Vs Zepbound. We’ve had Prostate Biopsies Vs Rectal Ultrasounds. This week it’s Aspirin Vs Clopidogrel. 

Because STEMI management had a problem… 

The current management pathway following Percutaneous Coronary Intervention(PCI) is simple. Wack em’ on Dual Antiplatelet Therapy(DAPT) and a blister pack of other goodies and send them on their merry way. After 12 months drop the Clopidogrel and keep them on the aspirin forever ✨

So let me ask you this… 
Why do we drop the Clopidogrel and keep the aspirin? 
You don’t know? I don’t know! No one knows! 

There’s not really been any direct evidence justifying aspirins long-term dominance over Clopidogrel as monotherapy. 

It’s just the way it’s always been. You can blame historical interia and aspirin’s dirt-cheap price. 

These researchers wanted to be different so bad, they conducted a meta-analysis which got published in the BMJ.

They sought to compare contemporary P2Y12 inhibitors(Clopidogrel and Ticagrelor) against aspirin over a long time horizon(median 3.7-year follow up)

They took data from 5 RCT’s which totalled 16,117 post-PCI patients who all completed 12 months of DAPT.  

• Group 1 only had P2Y12 inhibitors after DAPT. 

• Group 2 only had Aspirin after DAPT.

The primary outcome measured were major adverse cardiac/cerebrovascular events(MACCE) - think strokes and MI. As well as major bleeding events.

What did they find out?

1. There was a 23% lower risk of MACCE in the P2Y12 group than Aspirin group. (Hazard Ratio of .77)

2. There was an statistically insignificant risk difference in terms of bleeding events (Hazard Ratio of 1.26)

3. There was 32% lower risk with P2Y12 inhibitors of Myocardial Infarctions (Hazard Ratio of 0.68)

4. There was a 34% lower risk with P2Y12 inhibitors of Strokes (Hazard Ratio of 0.66)

Hmm, so here in the uk we have around 200,000 PCI’s a year. Assuming a 23% risk reduction, we could potentially prevent about 4400 MACCE’s a year without any increased bleeding risk. 

Not bad. Not bad at all.

Aspirin, it’s been a good run, but it might be time to leave the game before the game leaves you. Guidelines haven’t changed yet, but if this study is anything to go by, their time is coming. It’s always better to bow out gracefully.

OTHER NEWS YOU SHOULD KNOW

• Pulmonary Fibrosis Drug Made By AI, Trailed In Humans

• Type 2 Diabetics: Big Brother Is Watching You 👀 

• Women Are Less Likely to be Diagnosed With Aortic Stenosis

• Guideline Updates To Migraine Management

Handover Over 🫡 

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