🤝Your Medical Order Has Been Delivered

👋 Happy Friday. So what do you call medical news that turns up in your inbox once(or twice) a week with little jokes in between so sometimes you don’t know what satire and what’s real?

You’ve got the length of this email to work it out… in the meantime here’s what we’ve got:

• 💦 Fluid Clash: Hartmanns VS Normal Saline

• 🦠 COVID’s Not Done Quiet Yet

• 🧠 #TheMoreYouKnow: Other Top Stories of The Week

If you want to read any previous editions of The Handover, you can on our website.

RESEARCH UPDATE
Fluid Clash: Hartmanns VS Normal Saline

Alright. Let’s put the conversation to bed. Another head to head trial. Hartmanns VS Normal Saline.

You can confide in me. I know you’ve spent several lunch breaks daydreaming about fluid bags. I’ve done it too 😌

Hartmann’s or Saline. Saline or Hartmann’s. Epitome of a first world problem.

Your consultant says Hartmann's is king. Less chloride, less hyperchloremic acidosis. Your reg shrugs. “Mate, it’s just salty water.”

Who is right? Let’s look at the FLUID trial.

In a new paper, published in the New England Journal of Medicine, researchers set out to compare the effectiveness of a hospital-wide policy using lactated Ringers solution (aka Hartmann's) vs normal saline for IV fluid. 

This open-label, two-sequence RCT took place across seven hospitals in Ontario, Canada – with 43,626 patients included in the trial 

The hospitals were randomised to give either Hartmann's or normal saline to their patients. Randomised hospital-wide fluid protocols. No in-between.

Twelve weeks of Hartmann’s.
Twelve weeks of Saline.
Then swap.

One fluid per site, per period. No mix ‘n’ match. You get what the trolley says.

The primary aim of the game was to see what the difference in deaths and readmission would be, between the two groups, 90 days after the initial admission. 

So…What did they find?

• Primary outcome: The mean incidence of the composite primary outcome was 20.3% with Hartmann's whilst it was 21.4%. Marking a non-significance difference on patient outcomes regardless of fluid choice.

• Secondary outcome: For all the secondary measures (ED visits, dialysis initiation, length of hospital stay, or discharge to facility other than home) there was also no significant difference.

• Safety: No serious adverse events attributed to the trial fluids. Phew

Of course, no study is without its flaws. The trial initially wanted 16 hospitals involved, but a pesky virus called COVID-19 meddled with their plans. Only the 7 completed its trial, thus limiting the sample size. Maybe more importantly, compliance with the assigned fluid did vary. 93.6% normal saline, but 78.2% with the Hartmann's. 

All in all, That settles it. Hartmann’s == Normal Saline. Pick your poison. If you have balls, take this study to that hardheaded consultant. Just hope they're not a reader of the Handover too. 

Bonus: Here is a nice infographic illustrating the trial.

IN PARTNERSHIP WITH KENHUB
You thought it was over…

Who cares about anatomy?
It’s a relic. A fossil from your pre-clinical past.
You’ve moved on to real medicine. Real patients. 
Onto more important stuff – like discharge summaries and ward notes.

Until it hits you.
Theatre.
A scan.
A neuro exam.

All those years of knowledge. All that time spent learning Dubin-Johnson syndrome. Perfecting your handover. 

All for the consultant to ask, “What runs in the carotid sheath?”...you’re completely lost.

Need a refresher on how the body fits together? Kenhub can help you. 

Kenhub is the GOAT of anatomy learning. Used by over 6 million medics to actually remember how the body works. It included:

• Their famous anatomy articles and videos - truly best-in-class for visualisation.

• Histology resources - everyone hates histology, Kenhub will make you hate it less.

• Physiology too - Less pattern recognition, more first principles. Kenhub makes the fundamentals click.

And yes, a ton of it is free.

That includes all articles, anatomy atlas illustrations, They’ve even chucked in a couple quizzes, videos and charts to test your knowledge. 

Check out Kenhub today
And to unlock the full experience, use this link for 10% off a premium subscription.

RESEARCH UPDATE
COVID’s Not Done Quite Yet

The pandemic may be over, but the legend of COVID-19 is lives on…

Lockdown memories told like war stories to toddlers too young to remember it, and geriatric patients too old to remember anything. 

Whilst most of us had moved on from COVID-19. It turns out, COVID-19 had not moved on from us. According to WHO, 800 million survivors are at risk of a major non-respiratory complication: vascular ageing.

It would seem COVID infections have the ability to age up your arteries faster than Prince Williams hairline recession.

Mechanistically, it’s got a few tricks:

• Party Crashing: Getting into vascular endothelial cells is an invite-only kinda thing. The virus gets in through a backdoor, the ACE2 receptor. The cell doesn’t like this, leading to endothelitis then vascular damage

• Overstaying their welcome: Even when the virus has been cleared, its viral RNA likes to float about leading to systemic inflammatory cytokines also causing more damage.

The CARTESIAN study, published in the European Society of Cardiology aimed to see if theory checks out. They wanted to determine whether COVID 19-infection actually accelerates vascular ageing. 

It was a massive cohort study across 18 countries, with 2,390 participants split into four groups: one non-COVID control, and three COVID-positive groups ranging from non-hospitalised to ICU cases.

To measure vascular ageing, they used pulse wave velocity (PWV) – a gold-standard for arterial stiffness. It was checked at 6 and 12 months post-infection, giving things a bit of time to marinate.

What did they find?

• Overall population: After adjusting for confounders, all COVID-19 positive groups showed a significantly higher PWV compared to the non-COVID group - +0.4m/s in COVID +ve vs control at 6 months. 

• Sex-stratified analysis: Women had significantly higher PWV compared to the control. But there was no difference in COVID +ve or -ve men. 

• Group Differences:The increase was similar for non-hospitalized and hospitalized women (+0.55 and +0.60 m/s, respectively), while it was more than double for women hospitalized in the ICU (+1.09 m/s).

• Long term effects: At 12 months, the COVID positive groups PWV stayed the same or mildly decreased. The control’s PWV progressed as expected within normal ageing.

So not only is COVID increasingly accelerating your vascular age, it’s also sexist??? Funnily enough, I always get red-pill vibes from that virus 😑.

Now putting it into perspective, that +0.5-1.0m/s increase is the equivalent of 5-10 years of vascular ageing. From one infection.

It’s almost poetic. You survive the virus, but your aorta comes out looking like it did a 40 year stint in accounting and has two mortgages to pay off.

Cause for concern? Not necessarily, these results were pre-vaccine at the peak of the pandemic. Just be sure to give extra consideration to that booster vaccine.

QUICKBITS: OTHER NEWS YOU SHOULD KNOW

• NICE Rock the Diabetes World - In whats dubbed to be the “biggest shake-up in type 2 diabetes care in a decade”, NICE are altering diabetes management by making Ozempic first-line line. Just kidding. It’s actually the SGLT-2 inhibitors (-glifozins) will be recommended first line in patients who can’t tolerate Metformin. There are a couple other changes you can check out here.

• PA’s Lose The High Court Appeal - Well that was fast. The United Medical Associate Professionals (UMAPs) have lost their appeal to cancel the Leng Review. I don’t think a motion has been turned down so fast. Did they even make it through the front door? UMAPs say the “fight goes on”, with the aim of going for Gillian Leng directly. It’s not just Leng and Streeting they’re taking to court. NHS England is going too — not even the deceased can escape their wrath.

•  IBD Has a New Treatment - Ulcerative Colitis, watch out. Crohns, watch out. Guselkumab —a biologic used to treat plaque psoriasis— has now been approved by NICE for moderate-severe IBD. Trial evidence suggests 50% remission after 44 weeks compared to placebo which is promising. Currently never had a head-to-head with the current treatments, so watch this space on that.

• Yesterday’s Price is Not Today’s Price - It’s not just your local chippy thats prices are rocketing. Mounjaro price is set to rise by 170% from £122 to £330. This comes as Trump wasn’t a fan of how cheap it was being supplied to the UK compared to other HIC’s. It’s $1000 in the states! An Eli Lilly spokesperson said the “NHS patient is likely to see no effect”. The NHS will have to foot that bill. Sorry.

Handover Over 🫡 

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