Questioning Medicine
274 episodes - English - Latest episode: 3 days ago - ★★★★★ - 63 ratingsJoin Andrew on a medical rollercoaster as we ask a medical question and answer it based on recent published papers.
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Episodes
Episode 279: 278. Does a Swiss Ball Help During Labor and Delivery?
April 26, 2024 00:00 - 8 minutes - 8.14 MBprimary outcome was Duration of the first stage of labor was the primary outcome. AND It was 179 minutes shorter (95% CI 146 - 213) in the intervention group than in the control group (392 minutes; standard deviation [SD] 122 vs 571 minutes; SD 188). Intensity of pain, was reported on a visual analog scale of 0 to 10 at several points in time, was on average 2.0 to 2.7 points lower in the intervention group. The absolute rate of cesarean delivery was reduced by 14 percenta...
Episode 278: 277. What Do You Do With Subclinical Hypothyroidism?
April 25, 2024 00:00 - 4 minutes - 5.33 MBIn older adults, mildly elevated TSH levels normalized in about 50% of cases during 1 to 2 years of observation. https://academic.oup.com/jcem/article/109/3/e1167/7325863?login=true
Episode 277: 276. REDUCE-MI Trial- Should we still Give BBlockers Post-MI?
April 24, 2024 00:00 - 6 minutes - 7.1 MBA study that was done before the widespread use of troponin only measurements for ACS (and certainly before high sensitively trop EVER EXISTED), a trial that took place before the first statin was even FDA approved, a trial that had no idea what DAPT was and took place PRIOR to the publication of the trial that would ultimately make aspirin post MI a standard of care, a trial that existed before a standard 90 minute door to balloon time. As a reminder this trial (ISIS) didn’t ...
Episode 276: 275. Do SSRI Increase The Rate Of Bleeding With Anticoagulants?
April 23, 2024 00:00 - 5 minutes - 6.09 MBThis translates into an absolute excess risk of ≈9 events per 1000 person-years or 1 per 110 person years. Sad differently if you treat 110 people for 1 year with a doac and an SSRI you will have one more bleed that requires hospitalization or death than if there was no SSRI. This Risk was similar for various types of bleeding (e.g., intracranial, gastrointestinal) and did not vary with potency of SSRI. In patients with strong indications for both drugs, the relatively small abso...
Episode 275: 274. Do Your Genes ACTUALLY Make You Obese?
April 22, 2024 00:00 - 8 minutes - 8.09 MBDuring follow-up participants walked on average 8300 steps and those individuals in the lowest genetic risk score developed obesity defined as a BMI greater than 30 approximately 13% of the time while those individuals in the highest genetic risk or developed obesity 43% of the time. participants at the 75th percentile of PRS risk needed to walk 2280 more steps daily than participants at the 50th percentile to have the same relative risk reduction. Conversely, participants at th...
Episode 274: 273. Does Telerehabilitation Work For Chronic Knee Pain?
April 19, 2024 00:00 - 8 minutes - 8.09 MBAnd in the end it did not really matter because at 3 months individuals only reported a 0.16 difference in pain and a 1.6 difference in function which both were well within the noninferiority boundary. In case you are wondering there is no difference in adverse events. bottom line For the outcomes of pain and function Telerehabilitation with a physiotherapist is non-inferior to in-person rehabilitation for patients with chronic knee pain https://www.clinicalkey.com/#!/content/pl...
Episode 273: 272. Does Bariatric Surgery Work in Diabetics For Cardiovascular Events
April 18, 2024 00:00 - 8 minutes - 8.09 MBAt 1 year 50% of those individuals who had bariatric surgery were able to achieve diabetic remission but after 12 years the very same individuals that received bariatric surgery had just a 13% success rate in the remission of diabetes. Bariatric surgery certainly has an improvement in hemoglobin A1c and diabetic remission that is most evident in the first year but remains after 12 years of follow-up the patient oriented outcomes of major adverse cardiovascular events do not seem to...
Episode 272: 271. Cologaurd Has a New Test? How Good is it?
April 17, 2024 00:00 - 5 minutes - 6.01 MBThe company that developed Cologuard also developed this “next generation” multitarget stool DNA test, and has applied for U.S. FDA approval. The new test appears to have similar sensitivity and higher specificity than its predecessor — which means fewer false positives. Positive predictive value (the proportion of positive tests that were true positives for cancer or advanced neoplasia) was 11%. Negative predictive value (the proportion of negative tests that were true negatives...
Episode 271: 270. Aprocitentan, How Well Does it Work for Resistant Hypertension?
April 16, 2024 00:00 - 6 minutes - 6.84 MB730 Patients were randomized to receive daily oral aprocitentan or placebo, plus a fixed-dose combination of amlodipine, valsartan, and hydrochlorothiazide. After 4 weeks, mean change in office systolic BP was 15 mm Hg with aprocitentan and 11 mm Hg with placebo; this 4 mm difference was statistically significant. What is the cost? What is the long term effects? Why didn't they compare this to the standard of care spironolactone? https://www.hcplive.com/view/fda-approves-aprociten...
Episode 270: 269. What is the Harm in Aspirin?
April 15, 2024 00:00 - 4 minutes - 5.19 MBThe trial was terminated after 1015 patients with atrial cardiopathy had been randomized to receive either apixaban or aspirin for a mean follow-up of 1.8 years, recurrent stroke rates were identical (40 events per group; 4.4% annualized rate). There were 7 symptomatic intracranial hemorrhages in the aspirin group and none in the apixaban group, though other major hemorrhages occurred at similar rates Aspirin is not benign and has real risk-- BTW don't give anticoagulation if ...
Episode 268: 268. New Guidelines For Total Hip and Knee Joint Replacement
April 12, 2024 00:00 - 7 minutes - 7.68 MBTJA should not be delayed for trials of physical therapy, anti-inflammatory drug use, bracing, intra-articular steroid injections, or hyaluronic acid injections. For patients with obesity, proceed to TJA without delay, regardless of BMI. For patients with poorly controlled diabetes, recommend delaying TJA to improve glycemic control, but don't define poor control or specific HbA1c requirements. For smokers, recommend delaying TJA for a trial of smoking reduction or cessation. https://a...
Episode 269: 267. Beta Blockers DON'T Help Post-MI
April 11, 2024 00:00 - 6 minutes - 7.16 MBrandomized trial comparingbeta-blocker therapy (metoprolol or bisoprolol) with no beta-blocker in 5020 patients who had a normal left-ventricular ejection fraction (LVEF) after AMI median follow-up of 3.5 years, the primary composite endpoint — all-cause death or recurrent AMI — did not differ significantly between participants randomized to a beta-blocker versus no beta-blocker (7.9% vs. 8.3%, respectively). https://www.nejm.org/doi/10.1056/NEJMoa2401479
Episode 267: 266. How Many Years Of Smoking Cessation Do You Need?
April 10, 2024 00:00 - 5 minutes - 5.94 MBDuring a mean 11 years of follow-up, current smokers' risks for cardiovascular-, cancer-, and respiratory-related deaths were 2, 3, and 13 times higher, respectively, than never smokers' risks. Former smokers who had quit <10 years before enrollment avoided roughly 50% to 60% of these excess risks. By 30 years after quitting, excess mortality was virtually eliminated. https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2811807
Episode 266: 265. Semaglutide and Cardiovascular Events in Non-Diabetics (secondary prevention) SELECT TRIAL
April 09, 2024 00:00 - 8 minutes - 8.48 MBThe primary cardiovascular end point was a composite of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke in a time-to-first-event analysis. Improvement in nonfatal stroke was not statistically significant death from cardiovascular causes was no significant but hold on it does appear nonfatal MI was significant and is what really drove the entire composite outcome All the way down to the discussion to find “An important limitation of this tria...
Episode 265: 264. Does a Lidocaine Patch Work for Neck Pain?
April 05, 2024 00:00 - 5 minutes - 6.19 MBBottom line (ZTLido 1.8%) is a brand name lidocaine patch currently approced for postherpetic neuralgia and will stay that why for now as it did not beat placebo for the treatment of patients with chronic nonspecific neck pain For both pain scores the pain decreased by 1.0 point with lidocaine and by 0.5 points with placebo. These differences were neither statistically significant nor deemed to be clinically important! https://pubs.asahq.org/anesthesiology/article/140/3/513/139530...
Episode 264: 263. Rates of Atrial Fibrillation 12 months After Onset of Hospitalized Transient AF
April 04, 2024 00:00 - 7 minutes - 7.55 MBpatients who have new-onset transient AF detected during a hospitalization for noncardiac surgery or medical illness and are discharged in sinus rhythm, approximately 1 in 3 have AF detected in the year after hospital discharge. Those that did not have afib only had a 5% risk (1 in 20) -- we dont know what this means for rates of patient oriented outcomes https://www.acpjournals.org/doi/10.7326/M23-1411?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed ...
Episode 263: 262. Does Omalizumab Help For Peanut Allergy?
April 03, 2024 00:00 - 8 minutes - 8.2 MBBottom line Omalizumab does seem to improve allergic reactions to peanuts but comes at a steep price tag. Likely only allergist will prescribe this drug but it is worth know about If you know or take care of anyone with severe peanut allergy. After 16 weeks, 67% of patients who took omalizumab could tolerate a 600-mg peanut protein challenge (≈2 peanuts) versus 7% of controls. Variability among patients was large: 44% of omalizumab patients could tolerate 25 peanuts whereas 14...
Episode 262: 261. Are Combined Oral Contraceptives Effective for Treating Acne?
April 02, 2024 00:00 - 9 minutes - 9.14 MBAt ~24 weeks, ~80-90% of females report improvement in their acne with COCs, compared to 50-80% placebo, and 30-50% will have clear-almost clear skin versus 10-40% on placebo. Efficacy appears similar between individual COCs. Limitations: Most COC RCTs unblinded, many COC RCTs prohibited concurrent topical agents, no RCTS comparing COCs to topical agents, many industry-funded. https://cfpclearn.ca/tfp362/
Episode 260: QM on Spring Break
March 20, 2024 00:00 - 52 seconds - 1.56 MBQM on Spring Break-- but do you like the new format? [email protected]
Episode 261: 260. SGLT2 Summary Recap
March 19, 2024 00:00 - 6 minutes - 6.84 MBDiabetic patient- Empagliflozin prevents death from cardiovascular causes: NNT 46 per 3.1 yrs ($600 a month, 1 million dollars per life saved) -HFpEF- SGLT2 inhibitors do not prevent death and cost roughly $364,000 to prevent one hospitalization -HFrEF -Using Cox models, only Dapagliflozin has mortality benefit (NNT 53) and comes at a cost of $229,914 prevent one cardiovascular death. (117,126$$$ dap for hospitalization)
Episode 259: 259. EMPULSE Trial- Empagliflozin and Win Ratios
March 18, 2024 00:00 - 9 minutes - 9.7 MBThese findings indicate that initiation of empagliflozin in patients hospitalized for acute heart failure is well tolerated and results in significant clinical benefit in the 90 days after starting treatment. They combined HFpEF and HFrEF They used win ratios Individual trials didn’t show mortality benefit but now there is? https://pubmed.ncbi.nlm.nih.gov/35228754/
Episode 258: 258. SOLOIST-WHF -- Sotagliflozin in Patients with Diabetes and Recent Worsening Heart Failure
March 15, 2024 00:00 - 9 minutes - 9.84 MBPrimary Outcome: Composite of deaths from cardiovascular causes or hospitalizations and urgent visits for heart failure Death was not improved! NNT of 5 for hospitalizations and urgent visits -- However, results are not reported separately for hospitalizations and urgent visits, which are not equal events https://www.nejm.org/doi/full/10.1056/NEJMoa2030183
Episode 257: 256. EMPEROR-Reduced- Cardiovascular Outcomes with Empagliflozin in Heart Failure
March 14, 2024 00:00 - 9 minutes - 9.75 MBNNT of 20 to prevent 1 hospitalization at 16 months of follow up They composite outcome was driven by decrease hospitalizations NOT death https://www.nejm.org/doi/full/10.1056/NEJMoa2022190
Episode 256: 256. DAPA-HF- Dapagliflozin and Heart Failure with Reduced Ejection Fraction - DAPA-HF
March 13, 2024 00:00 - 8 minutes - 8.14 MBNNT of 21 over 18 months to prevent a composite of worsening heart failure or cardiovascular death NNT for hospitalization = 27 NNT for Cardiovascular Death = 53 N Engl J Med 2019; 381:1995-2008
Episode 255: 255. Dapagliflozin and Heart Failure with Preserved Ejection Fraction
March 12, 2024 00:00 - 10 minutes - 10.1 MBDapagliflozin and HFpEF did happen to improve the composite outcome but this was based mainly on hospitalizations not on death and comes at a big price tag with the NNT around 36 at 2.3yrs. N Engl J Med 2022; 387:1089-1098
Episode 254: 254. Empagliflozin For Heart Failure with Preserved Ejection Fraction- EMPEROR-Preserved
March 08, 2024 00:00 - 8 minutes - 8.12 MBHospitalization for heart failure occurred in 8.6% of patients in the empagliflozin group and 11.8% patients in the placebo group (hazard ratio, 0.71; 95% CI, 0.60 to 0.83) number needed to treat [NNT] = 32 per 26 months But the drug company did a great job of writting the paper so you think there is mortality benefit https://www.nejm.org/doi/full/10.1056/NEJMoa2107038
Episode 253: 253. EMPA-REG OUTCOME - Type 2 Diabetes and Empagliflozin- How Much Money To Save How Many People?
March 07, 2024 00:00 - 10 minutes - 10.2 MBEMPA-REG OUTCOME back in 2015 this was the first SGLT2 trial to set the world on fire with Primary Outcome: death from cardiovascular causes: NNT 46 per 3.1 yrs (at $600 a month, 1 million dollars per life saved) nonfatal myocardial infarction: NS∞ nonfatal stroke: NS∞ https://www.nejm.org/doi/full/10.1056/nejmoa1504720
Episode 252: 252. After Admission to the ICU How Many Patients Remain on a PPI?
March 06, 2024 00:00 - 7 minutes - 8 MBForty-two percent of patients had a PPI on their medication list without indication 8 weeks after discharge, and more than half of these patients still were using PPIs 1 year later. Compared with propensity-score matched patients without PPI use after discharge, patients with continued PPI use were 27% more likely to develop pneumonia, 17% more likely to develop experience cardiac events, 34% more likely to be .readmitted to the hospital in the subsequent year and 17% greater...
Episode 251: 251. Does Weight/BMI Change DOAC Efficacy?
March 05, 2024 00:00 - 5 minutes - 6.23 MBThese results are reassuring for management of both underweight and overweight patients with AF. That said, I would still have reservations about prescribing DOACs in the small minority of patients with BMI >45 kg/m2 or body weight >330lbs due to their underrepresentation in the pivotal trials and when you look at the supplementary data you will see a weight of 262 was 95% tile so >330 would be around the 99th %tile of weight. https://www.ahajournals.org/doi/10.1161/CIRCULATION...
Episode 250: 250. Do Nurse Practitioners Prescribe More or Less Medications From the Beers List?
March 01, 2024 00:00 - 5 minutes - 5.57 MBNurse Practitioners prescribe medications off the beers list at the same rate at primary care physicians, hard to tell what this means for patient care and patient outcomes. https://www.acpjournals.org/doi/10.7326/M23-0827?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
Episode 249: 249. Is There A Way To Predict Your Risk Of Dementia?
February 29, 2024 00:00 - 6 minutes - 6.46 MBUsing the Brain Care Score seem to be effective in predicting the risk of dementia For participants under 50, each five-point higher BCS is associated with a 50% lower risk of dementia or stroke For participants under 50, each five-point higher BCS is associated with a 59% lower risk of dementia THE SCORE IS HERE ---->. https://www.massgeneral.org/assets/mgh/pdf/neurology/mccance-center/brain-care-score.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10725202/#:~:text=A%20five...
Episode 248: 248. Should DAPT To Be Started >24hours After Minor Stroke OR High Risk TIA?
February 28, 2024 00:00 - 5 minutes - 5.94 MBEven when starting DAPT within 72hours of symptom onset for individuals with minor stroke or TIA the benefit of DAPT for the first 21 days was still seen at 90 day follow up in the form of less recurrent stroke https://www.nejm.org/do/10.1056/NEJMdo007334/full/
Episode 247: 247. Should Patients With Cancer Be On Primary Prevention VTE Prophylaxis?
February 27, 2024 00:00 - 5 minutes - 5.82 MBIn those high risk patients -- usually with lung or GI cancer they did benefit from primary prevention VTE prophalaxis with a NNT of 6-7 for VTE and death at 6 months. https://pubmed.ncbi.nlm.nih.gov/37733336/#:~:text=Conclusions%20and%20relevance%3A%20In%20this,safety%20concerns%2C%20and%20with%20reduced
Episode 246: 246. In Giant Cell Arteritis How Soon Do You Need To Get A Biopsy After Starting Steroids?
February 23, 2024 00:00 - 4 minutes - 4.92 MBJust get he biopsy at less than 6 weeks after starting therapy as the yield was the same at 2 weeks as it was at 4-6 weeks https://pubmed.ncbi.nlm.nih.gov/36642440/
Episode 245: 245. Do Baby Walkers Cause Developmental Delays?
February 22, 2024 00:00 - 20 minutes - 19.3 MBEvidence against baby walker is not enough regarding its negative effect on child development. This subject needs to be addressed more, considering a large number of baby walker users worldwide. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5703622/ Surveillance System data from 1990 to 2014 230 676 children <15 months old were treated for infant walker–related injuries in US emergency departments from 1990 to 2014. 9 out of every 10 injuries were to the head and neck and 74% were inju...
Episode 244: 244. Does Testosterone CAUSE Prostate Cancer?
February 20, 2024 00:00 - 4 minutes - 5.28 MBDuring average follow-up of in this study the incidence of prostate cancer was less than 1% — and not significantly different Remember most of these pts had testosterone levels around 350 ish give or take so the safety of longer-duration treatment — or treatment resulting in higher blood levels of testosterone — remains unclear. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2813293
Episode 243: 243. Can Testosterone Improve or Treat Depression?
February 19, 2024 00:00 - 6 minutes - 6.28 MBFrom a mean score of 45 points at baseline, mood improved by about 5 points in the placebo group and 6 points in the testosterone group — a statistically significant but small difference. I think you will be hard pressed to find anyone that thinks this is clinically significant except for maybe the authors of the paper when they write that it is beneficial in their conclusion https://academic.oup.com/jcem/advance-article-abstract/doi/10.1210/clinem/dgae026/7516050?redirectedFrom=fu...
Episode 242: 242. Does Testosterone Improve Sexual Function and Erectile Dysfunction?
February 16, 2024 00:00 - 8 minutes - 8.7 MBErectile disfunction should be treated with the appropriate medications like the PDE5 inhbitors—not testosterone—testosterone may make it so you flirt half a time more a day but that is not likely worth the harm that comes with even in the placebo small doses seen in the traverse trial https://academic.oup.com/jcem/article-abstract/109/2/569/7244351?redirectedFrom=fulltext&login=true
Episode 241: 241. Does Testosterone Therapy Prevent or Cause Fractures?
February 15, 2024 00:00 - 5 minutes - 5.98 MBeven at very small some would argue barely even treating doses of testosterone patients had an increase rate of fractures with a NNH of 100—when you add this to the 1 risk of aki and 2 percent risk of arthymia the harms vs benefit conversation to use testosterone seems to be leaning heavy towards harms https://www.nejm.org/doi/full/10.1056/NEJMoa2308836?query=recirc_curatedRelated_article
Episode 240: 240. Does Testosterone Prevent the Progression of Pre-diabetes to Diabetes?
February 14, 2024 00:00 - 5 minutes - 5.94 MBRisk of progression from prediabetes to diabetes did not differ significantly between testosterone and placebo groups- and they looked for a change at 6,12,24,36,48 months of follow up Not to sound like a broken record but Risk of progression from diabetes to not having diabetes did not differ significantly between testosterone and placebo groups- and they looked for a change at 6,12,24,36,48 months of follow up https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/28...
Episode 239: 239. TRAVERSE Study...Is Testosterone Therapy Safe for the Heart?
February 13, 2024 00:00 - 10 minutes - 10.2 MBTake away The drug companies will say look how safe testosterone therapy is there was no difference in death from cardiovascular causes or myocardial infarction or stroke in those individuals randomized to testosterone therapy over placebo but in actuality this trial really showed nothing and it did show that when using placebo or minimal doses of testosterone -- ones that barely change blood levels of testosterone and have so little effect on how people feel that 60% of them stop ...
Episode 238: 238. What to do With Low Risk Pulmonary Embolism?
February 12, 2024 00:00 - 5 minutes - 5.48 MBUse the PE Severity Index. If low risk and that is the only reason for admission, then the patient is safe for discharge https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60824-6/abstract https://www.acpjournals.org/doi/10.7326/M23-2442
Episode 237: 237. Big Take Away from ACP Update to Colon Cancer Screening
February 09, 2024 00:00 - 5 minutes - 5.71 MBamerican college of physicians says- No need to start colon cancer screening prior to 50. stop at age 75 or with 10 yrs of life left and FIT testing can be every other year and Cologuard is not recommended. https://www.acponline.org/acp-newsroom/acp-issues-updated-guidance-for-colorectal-cancer-screening-of-asymptomatic-adults
Episode 236: 236. Is Weight Loss Beneficial For Hip Osteoarthritis?
February 08, 2024 00:00 - 4 minutes - 4.85 MBWhile weight loss may be beneficial for individuals with knee osteoarthritis, it does not see to have a protective or beneficial effect for those with hip osteoarthritis. https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18371
Episode 235: 235. When Should A Patient With HIV Be Started On Statin Therapy?
February 07, 2024 00:00 - 4 minutes - 5.14 MBIn patients with HIV and cv risk score of 4.5% there was a NNT of 106 at 5 yrs of follow up to prevent 1 MACE https://www.acpjournals.org/doi/10.7326/M22-2643?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
Episode 234: 234. Does Size Matter...BP Cuff Size
February 06, 2024 00:00 - 5 minutes - 5.71 MBA cuff 1-2 sizes too large underestimated bp by 4-9mm Hg BUT a cuff 1-2 sizes too small overestimated the BP 4-20mm Hg https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2807853
Episode 233: 233. Do GLP1 agonist actually delay gastric emptying?
February 05, 2024 00:00 - 6 minutes - 6.64 MBGLP1 agonist likely lead to retained gastric products but this effect is larger for once weekly injections than once daily pills. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10204182/
Episode 232: 232. Is the HPV vaccine that good?
February 02, 2024 00:00 - 8 minutes - 8.77 MBDuring 28 months of follow-up, absolute risks for progression from CIN2 to CIN3 (or worse) were as follows: 23% among women vaccinated before age 15 32% among women vaccinated between ages 15 and 20 38% among women vaccinated after age 20 38% among unvaccinated women Krog L et al. Risk of progression of cervical intraepithelial neoplasia grade 2 in human papillomavirus–vaccinated and unvaccinated women: A population-based cohort study. Am J Obstet Gynecol 2023 Dec 30; [e-pub]. (https:/...
Episode 231: 231. Is Cancer Actually Associated with Weight Loss?
February 01, 2024 00:00 - 5 minutes - 5.56 MB>10% unintentional weight loss is most likely associated with gastrointestinal, liver, pancreatic, and biliary cancers (relative risks, 3.1–7.4); Leukemia (RR, 4.2) Breast, prostate, and gynecologic cancers were not associated with >10% weight loss Wang Q-L et al. Cancer diagnoses after recent weight loss. JAMA 2024 Jan 23/30; 331:318. (https://doi.org/10.1001/jama.2023.25869)
Episode 230: 230. Are PDE5i Bad for Your Health and Cardiovascular Disease?
January 31, 2024 00:00 - 9 minutes - 9.23 MBPDE5i are bad if your health if you have cardiovascular disease and a provider that didn't read the paper and only looked at the abstract. Go ahead and write for PDE5i for your patients that need it and do not change your practice based on this study. https://www.sciencedirect.com/science/article/pii/S0735109723080749?via%3Dihub#mmc1