1. Inappropriateness
of Medication Prescriptions to Elderly Patients in the Primary Care Setting: A
Systematic Review
Opondo D, et al. PLoS ONE 2012;7(8): e43617
Background: Inappropriate medication prescription is a
common cause of preventable adverse drug events among elderly persons in the
primary care setting.
Objective: The aim of this systematic review is to quantify
the extent of inappropriate prescription to elderly persons in the primary care
setting.
Methods: We systematically searched Ovid-Medline and
Ovid-EMBASE from 1950 and 1980 respectively to March 2012. Two independent
reviewers screened and selected primary studies published in English that
measured (in)appropriate medication prescription among elderly persons (over 65
years) in the primary care setting. We extracted data sources, instruments for
assessing medication prescription appropriateness, and the rate of
inappropriate medication prescriptions. We grouped the reported individual
medications according to the Anatomical Therapeutic and Chemical (ATC)
classification and compared the median rate of inappropriate medication
prescription and its range within each therapeutic class.
Results: We included 19 studies, 14 of which used the Beers
criteria as the instrument for assessing appropriateness of prescriptions. The
median rate of inappropriate medication prescriptions (IMP) was 20.5% [IQR 18.1
to 25.6%.]. Medications with largest median rate of inappropriate medication
prescriptions were propoxyphene 4.52(0.10–23.30)%, doxazosin 3.96 (0.32 15.70)%,
diphenhydramine 3.30(0.02–4.40)% and amitriptiline 3.20 (0.05–20.5)% in a
decreasing order of IMP rate. Available studies described unequal sets of
medications and different measurement tools to estimate the overall prevalence
of inappropriate prescription.
Conclusions: Approximately one in five prescriptions to
elderly persons in primary care is inappropropriate despite the attention that
has been directed to quality of prescription. Diphenhydramine and amitriptiline
are the most common inappropriately prescribed medications with high risk
adverse events while propoxyphene and doxazoxin are the most commonly
prescribed medications with low risk adverse events. These medications are good
candidates for being targeted for improvement e.g. by computerized clinical
decision support.
Full-text (free): http://www.plosone.org/article/info:doi/10.1371/journal.pone.0043617
2. Clinical features,
management, and prognosis of spontaneous coronary artery dissection.
Tweet MS, et al. Circulation. 2012 Jul 31;126(5):579-88.
BACKGROUND: Spontaneous coronary artery dissection (SCAD) is
an acute coronary event of uncertain origin. Clinical features and prognosis
remain insufficiently characterized.
METHODS AND RESULTS: A retrospective single-center cohort
study identified 87 patients with angiographically confirmed SCAD. Incidence,
clinical characteristics, treatment modalities, in-hospital outcomes, and
long-term risk of SCAD recurrence or major adverse cardiac events were
evaluated. Mean age was 42.6 years; 82% were female. Extreme exertion at SCAD
onset was more frequent in men (7 of 16 versus 2 of 71; P less than 0.001), and
postpartum status was observed in 13 of 71 women (18%). Presentation was
ST-elevation myocardial infarction in 49%. Multivessel SCAD was found in 23%.
Initial conservative management (31 of 87) and coronary artery bypass grafting
(7 of 87) were associated with an uncomplicated in-hospital course, whereas percutaneous
coronary intervention was complicated by technical failure in 15 of 43 patients
(35%) and 1 death. During a median follow-up of 47 months (interquartile range,
18-106 months), SCAD recurred in 15 patients, all female. Estimated 10-year
rate of major adverse cardiac events (death, heart failure, myocardial
infarction, and SCAD recurrence) was 47%. Fibromuscular dysplasia of the iliac
artery was identified incidentally in 8 of 16 femoral angiograms (50%)
undertaken before closure device placement and in the carotid arteries of 2
others with carotid dissection.
CONCLUSIONS: SCAD affects a young, predominantly female
population, frequently presenting as ST-elevation myocardial infarction.
Although in-hospital mortality is low regardless of initial treatment,
percutaneous coronary intervention is associated with high rates of
complication. Risks of SCAD recurrence and major adverse cardiac events in the
long term emphasize the need for close follow-up. Fibromuscular dysplasia is a
novel association and potentially causative factor.
Essay on this article: http://www.medscape.org/viewarticle/768884
3. One-Hour Rule-out
and Rule-in of AMI Using High-Sensitivity Cardiac Troponin T
Reichlin T, et al. Arch Intern Med. Published online August
13, 2012. doi:10.1001/archinternmed.2012.3698
Background
High-sensitivity cardiac troponin (hs-cTn) assays seem to improve the
early diagnosis of acute myocardial infarction (AMI), but it is unknown how to
best use them in clinical practice. Our objective was to develop and validate
an algorithm for rapid rule-out and rule-in of AMI.
Methods A prospective
multicenter study enrolling 872 unselected patients with acute chest pain
presenting to the emergency department. High-sensitivity cardiac troponin T
(hs-cTnT) was measured in a blinded fashion at presentation and after 1 hour.
The final diagnosis was adjudicated by 2 independent cardiologists. An hs-cTnT
algorithm incorporating baseline values as well as absolute changes within the
first hour was derived from 436 randomly selected patients and validated in the
remaining 436 patients. The primary prognostic end point was death during 30
days of follow-up.
Results Acute
myocardial infarction was the final diagnosis in 17% of patients. After
applying the hs-cTnT algorithm developed in the derivation cohort to the
validation cohort, 259 patients (60%) could be classified as “rule-out,” 76
patients (17%) as “rule-in,” and 101 patients (23%) as in the “observational
zone” within 1 hour. Overall, this resulted in a sensitivity and negative
predictive value of 100% for rule-out, a specificity and positive predictive
value of 97% and 84%, respectively, for rule-in, and a prevalence of AMI of 8%
in the observational zone group. Cumulative 30-day survival was 99.8%, 98.6%,
and 95.3% (P less than .001) in patients classified as rule-out, observational
zone, and rule-in, respectively.
Conclusions Using a
simple algorithm incorporating hs-cTnT baseline values and absolute changes
within the first hour allowed a safe rule-out as well as an accurate rule-in of
AMI within 1 hour in 77% of unselected patients with acute chest pain. This
novel strategy may obviate the need for prolonged monitoring and serial blood
sampling in 3 of 4 patients.
_____________
Here are the criteria they used for ruling out AMI: baseline
hs-cTnT level under 12 ng/L and an absolute change within the first hour less
than 3 ng/L
And for ruling in AMI: baseline hs-cTnT of ≥52 ng/L or an
absolute change in biomarker levels within the first hour of ≥5 ng/L.
4. ESC: New
Definition of MI Unveiled
By Chris Kaiser, Cardiology Editor, MedPage Today. August
25, 2012. MUNICH -- An international, multispecialty task force has published a
new definition of myocardial infarction that was prompted by the new generation
of highly sensitive cardiac troponin (cTn) assays.
The highly sensitive assays are capable of detecting cTn in
conditions other than MI, such as pulmonary embolism, cardiomyopathy, and left
bundle branch block, and so result in false positives, according to the task
force writing group.
The expert consensus document dips into a controversial area
by setting levels of cTn for MI associated with percutaneous coronary
intervention (PCI) and coronary artery bypass grafting (CABG).
"This is one of the most controversial areas in the
definition of myocardial infarction," Anthony DeMaria, MD, from the
University of California in San Diego and editor-in-chief of the Journal of the
American College of Cardiology, told MedPage Today.
"There are a large number of people undergoing PCI in
the setting of an acute MI. It's almost impossible to know whether a subsequent
increase in troponin was part and parcel of the acute MI or related to the
procedure itself," DeMaria said.
The consensus document, titled "Third Universal
Definition of Myocardial Infarction," set the cTn levels for MI associated
with PCI as elevation of troponin greater than 5 times the 99th percentile
upper reference limit (URL) in patients with normal baseline levels or a rise
in troponin values greater than 20% if the baseline values are elevated and are
stable or falling.
"Some people speculate that troponin may be too
sensitive in this situation and what is needed is evidence that an elevation of
some degree of troponin following a procedure actually results in some
alteration of the natural history of the patient," DeMaria said. "In
other words, the definition of acute MI after a procedure really is of
significance if it increases the risk of subsequent events such as death."
In CABG, the task force set the troponin values as greater
than 10 x 99th percentile URL during the first 48 hours when baseline values
are normal.
DeMaria said there are several ongoing studies examining the
correlation of elevated cTn with subsequent events. As this is the third
definition of MI since 2000, there most likely will be more refinements as new
data emerge, he said.
The document is being copublished online in several journals
including the Journal of the American College of Cardiology, Circulation, the
European Heart Journal, and Global Heart.
The task force was in touch with the FDA during the
development of this new definition, which means it could be used as the basis
for clinical trial protocols designed according to FDA regulations.
"A universal definition for MI is of great benefit for
clinical studies, since it will allow a standardized approach for
interpretation and comparison across different trials," the task force
writing group explained.When different definitions have been used in trials, it
hampers "comparison and generalization between these trials," they
said.
Also of significance in this document is the inclusion of
imaging as a means to identify or confirm an MI. The document spells out the
strengths of echocardiography, nuclear imaging, MRI, and CT in the setting of
acute MI.
"Imaging is playing an increasingly important
role," DeMaria said. "In the absence of focal symptoms or with an
inconclusive ECG, it's important to recognize the concomitant potential of
ancillary measures, primarily imaging, to help with the diagnosis of a
myocardial infarction."
Full-text (free at Circ): http://circ.ahajournals.org/content/early/2012/08/23/CIR.0b013e31826e1058.full.pdf+html
5. CDC No Longer
Recommends Oral Cephalosporins for Gonorrhea
Laurie Barclay, MD. Medscape Medical News. August 10, 2012 —
The US Centers for Disease Control and Prevention (CDC) no longer recommends
oral cephalosporin treatment for gonococcal infections, according to their
updated guidelines, reported in the August 10 issue of the Morbidity and
Mortality Weekly Report. The new recommendations update the CDC's 2010 Sexually
Transmitted Diseases Treatment Guidelines.
"Infection with [Neisseria] gonorrhoeae is a major
cause of pelvic inflammatory disease, ectopic pregnancy, and infertility, and
can facilitate HIV transmission," write Carlos del Rio, MD, from the
Rollins School of Public Health at Emory University in Atlanta, Georgia, and
colleagues. "In the United States, gonorrhea is the second most commonly
reported notifiable infection, with more than 300,000 cases reported during
2011. Gonorrhea treatment has been complicated by the ability of N. gonorrhoeae
to develop resistance to antimicrobials used for treatment."
Urethral isolates of N gonorrhoeae collected in the United
States during 2006 through 2011 have shown declining susceptibility to
cefixime, according to an analysis of data from the CDC's Gonococcal Isolate
Surveillance Project.
Therefore, updated CDC recommendations for treatment of
gonorrhea now include the following:
·
For uncomplicated gonorrhoea of the urogenital
tract, rectum, or pharynx, the most reliably effective therapy is a combination
regimen of 250 mg intramuscular ceftriaxone and either an oral single dose of
azithromycin 1 g or a 7-day course of oral doxycycline 100 mg twice daily.
·
For first-line therapy of gonococcal infections,
the CDC no longer recommends cefixime at any dose.
·
Patients given cefixime as an alternative agent
should be reevaluated in 1 week for a test of cure at the infection site.
·
Patients with treatment failure, defined as
persistent infection after treatment with the recommended combination therapy
regimen, should undergo culture of appropriate specimens and antimicrobial
susceptibility testing of N gonorrhoeae isolates using disk diffusion, Etest,
or agar dilution. The laboratory should keep the isolate in case further
testing is needed.
·
Within 24 hours of diagnosis, the treating clinician
should report cases of treatment failure to the CDC and should obtain treatment
advice from an infectious disease specialist, an STD/HIV Prevention Training
Center, or the CDC.
·
Patients with treatment failure should undergo a
test of cure 1 week after retreatment.
·
Patients who have urogenital or rectal gonorrhea
but who have severe cephalosporin allergy should receive azithromycin 2 g in a
single oral dose plus test of cure in 1 week.
·
If ceftriaxone is not available, an alternative
regimen for uncomplicated gonorrhoea is a single oral dose of 400 mg cefixime
plus a single oral dose of azithromycin 1 g or doxycycline 100 mg orally twice
daily for 7 days, plus test of cure in 1 week.
·
Whenever possible, clinicians treating patients
with gonorrhea should promptly culture and treat their patient's sex partners
from the preceding 60 days. Heterosexual partners who cannot be promptly
evaluated and treated may receive expedited partner therapy with oral cefixime
400 mg and azithromycin 1 g delivered to the partner by the patient, a disease
investigation specialist, or via a collaborating pharmacy.
"Treatment of patients with gonorrhea with the most
effective therapy will limit the transmission of gonorrhea, prevent
complications, and likely will slow emergence of resistance," the report
authors conclude. "However, resistance to cephalosporins, including
ceftriaxone, is expected to emerge. Reinvestment in gonorrhea prevention and
control is warranted [and new] treatment options for gonorrhea are urgently
needed."
The authors have disclosed no relevant financial
relationships.
Morb Motal Wkly Rep. 2012;61:590-594. Full-text (free): http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6131a3.htm
6. ACEP Clinical
Policy: Critical Issues in the Initial Evaluation and Management of Patients
Presenting to the ED in Early Pregnancy
Hahn SA, et al. Ann Emerg Med 2012;60:381-390.e28
Abstract
This clinical policy from the American College of Emergency
Physicians is the revision of the 2003 Clinical Policy: Critical Issues in the
Initial Evaluation and Management of Patients Presenting to the Emergency
Department in Early Pregnancy.1 A writing subcommittee reviewed the literature
to derive evidence-based recommendations to help clinicians answer the
following critical questions: (1) Should the emergency physician obtain a
pelvic ultrasound in a clinically stable pregnant patient who presents to the
emergency department (ED) with abdominal pain and/or vaginal bleeding and a
beta human chorionic gonadotropin (β-hCG) level below a discriminatory
threshold? (2) In patients who have an indeterminate transvaginal ultrasound,
what is the diagnostic utility of β-hCG for predicting possible ectopic
pregnancy? (3) In patients receiving methotrexate for confirmed or suspected
ectopic pregnancy, what are the implications for ED management? Evidence was
graded and recommendations were developed based on the strength of the
available data in the medical literature.
A literature search was also performed for a critical
question from the 2003 clinical policy.1 Is the administration of anti-D
immunoglobulin indicated among Rh-negative women during the first trimester of
pregnancy with threatened abortion, complete abortion, ectopic pregnancy, or
minor abdominal trauma? Because no new, high-quality articles were found, the
management recommendations from the previous policy are discussed in the
introduction.
Introduction
Emergency physicians frequently evaluate and manage patients
with abdominal pain and/or vaginal bleeding in the first trimester of pregnancy
(also referred to here as “early pregnancy”). Their primary concern in this
group of patients is to identify ectopic pregnancy. The prevalence of ectopic
pregnancy in symptomatic emergency department (ED) patients is as high as 13%
in some series, which is much higher than the prevalence in the general
population.2, 3 With wide availability of bedside ultrasound in academic EDs
and increasing access in community settings, more providers are now routinely
using ultrasound in their evaluation of these patients.4
The term bedside ultrasound is used here to refer to pelvic
ultrasounds that are performed in the ED by the emergency clinician, rather
than in the radiology department. With the term pelvic ultrasound, the use of a
transvaginal approach is implied unless transabdominal images have identified
an intrauterine pregnancy. According to the 2006 ACEP policy statement
Emergency Ultrasound Imaging Criteria Compendium, the primary indication for
bedside ultrasound of the pelvis is to evaluate for the presence of intrauterine
pregnancy, minimizing the likelihood of an ectopic pregnancy when modifying
factors such as infertility treatment (putting patients at risk of heterotopic
pregnancy) are not present.5 A bedside ultrasonographer may or may not
visualize the adnexa. A recent meta-analysis found that bedside ultrasound
performed by emergency physicians can be used as a screening tool for ectopic
pregnancy.6 Pooled analysis included 10 studies and a total of 2,052 patients
with 152 ectopic pregnancies; of those with ectopic pregnancy, 99.3% (95%
confidence interval [CI] 96.6% to 100%) had no intrauterine pregnancy
identified on bedside ultrasound.6 A comprehensive ultrasound, in contrast, is
usually performed in a radiology department and is expected to include views of
the uterus, adnexa, and cul-de-sac. Studies using either or both categories of
ultrasound were reviewed and this distinction was highlighted in the text and
Evidentiary Table. This policy is not intended to review the evidence
supporting the use of bedside ultrasound by emergency physicians.
Ultrasound has facilitated the evaluation of complications
of early pregnancy; however, diagnostic algorithms still vary considerably
among providers and institutions. Algorithms guiding the evaluation of
abdominal pain or vaginal bleeding in early pregnancy generally incorporate the
results of quantitative serum β-hCG measurements and pelvic ultrasonography.
Many algorithms apply the principle of the discriminatory threshold,
historically defined as the level at which the sensitivity of ultrasound was thought
to approach 100% for the detection of intrauterine pregnancy; the presumptive
diagnosis of ectopic pregnancy is made if an intrauterine pregnancy is not
visualized when the β-hCG is above a defined cutoff. This threshold depends on
what ultrasound criteria are used to define an intrauterine pregnancy and is
institution, operator, and patient dependent, but is commonly reported as
ranging from 1,000 to 2,000 mIU/mL for radiologist-performed transvaginal
sonography.7, 8 Although the traditionally defined discriminatory threshold is
widely used, its applicability to ED practice is not as well established, and
the concept itself has recently been called into question.9, 10 For these
reasons, this policy refers to the general concept of a discriminatory threshold,
where appropriate, but the discussion is not limited to any specific β-hCG
cutoff.
The first critical question deals with the diagnostic and
management variability that occurs when the clinician obtains a β-hCG result,
and it is below a commonly defined discriminatory threshold. Some clinicians
may not perform an ultrasound in these patients based on the incorrect
assumption that an ectopic pregnancy is unlikely because the β-hCG level is
low. In some settings, the emergency physician may be unable to obtain a
comprehensive ultrasound in the radiology department for the same reason.
However, it is well documented that ectopic pregnancies can present at almost
any β-hCG level, high or low.7 Some clinicians may defer an ultrasound when the
β-hCG level is below the discriminatory threshold because they think that the
risk of rupture is low. However, rupture has been documented at very low β-hCG
levels.7, 11 Other clinicians may defer imaging in these cases because they
believe that the diagnostic utility of pelvic ultrasound is low when the β-hCG
level is below the discriminatory threshold or assume that there is little harm
in delaying the diagnostic ultrasound.
The emergency physician is faced with another diagnostic and
management question when an ultrasound is indeterminate, also called
“nondiagnostic” or a “pregnancy of unknown location.” The second critical
question examines this subgroup of patients with indeterminate ultrasounds and
addresses whether the initial β-hCG level can help risk-stratify these
patients.
The third critical question explores the implications of
methotrexate therapy for emergency medicine practice. Administration of
methotrexate is an accepted and widely used alternative to laparoscopic surgery
for the management of known or suspected ectopic pregnancy.12, 13, 14
Methotrexate therapy is a complex intervention, and complications of therapy
are frequently evaluated in the ED…
The remainder (full-text free): http://www.annemergmed.com/article/S0196-0644(12)00406-4/fulltext
7. Images in Clinical
Medicine
Coronary Arteritis
Bilateral Anterior Shoulder Dislocation
28-year-old woman with RUQ pain
Woman With Painful Purpura
Male With Abdominal Pain
Man With Sudden Onset of Bilateral Flank Pain
Tattoo Ink–Related Nontuberculous Mycobacterial Infection
Associated editorial from the FDA: http://www.nejm.org/doi/full/10.1056/NEJMp1206063
8. 2012 ACCF/AHA Focused Update of the Guideline
for the Management of Patients With USA/Non-STEMI (Updating
the 2007 Guideline and Replacing the 2011 Focused Update): A Report of the ACC
Foundation/AHA Task Force on Practice Guidelines
Keeping pace with the stream of new data and evolving
evidence on which guideline recommendations are based is an ongoing challenge
to timely development of clinical practice guidelines. In an effort to respond
promptly to new evidence, the American College of Cardiology Foundation
(ACCF)/American Heart Association (AHA) Task Force on Practice Guidelines (Task
Force) has created a “focused update” process to revise the existing guideline
recommendations that are affected by the evolving data or opinion. New evidence
is reviewed in an ongoing fashion to more efficiently respond to important
science and treatment trends that could have a major impact on patient outcomes
and quality of care. Evidence is reviewed at least twice a year, and updates
are initiated on an as-needed basis and completed as quickly as possible while
maintaining the rigorous methodology that the ACCF and AHA have developed
during their partnership of more than 20 years.
These focused updates are prompted following a thorough
review of late-breaking clinical trials presented at national and international
meetings in addition to other new published data deemed to have an impact on
patient care (Section 1.1, Methodology and Evidence Review). Through a
broad-based vetting process, the studies included are identified as being
important to the relevant patient population. The focused update is not
intended to be based on a complete literature review from the date of the
previous guideline publication but rather to include pivotal new evidence that
may affect changes to current recommendations…
Full-text (free): http://circ.ahajournals.org/content/126/7/875.full
9. Predicting early
death in patients with traumatic bleeding: development and validation of
prognostic model
Perel P, et al. BMJ 2012;345:e5166
Objective To develop and validate a prognostic model for
early death in patients with traumatic bleeding.
Design Multivariable logistic regression of a large
international cohort of trauma patients.
Setting 274 hospitals in 40 high, medium, and low income
countries
Participants Prognostic model development: 20 127 trauma
patients with, or at risk of, significant bleeding, within 8 hours of injury in
the Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage
(CRASH-2) trial. External validation: 14 220 selected trauma patients from the
Trauma Audit and Research Network (TARN), which included mainly patients from
the UK.
Outcomes In-hospital death within 4 weeks of injury.
Results 3076 (15%) patients died in the CRASH-2 trial and
1765 (12%) in the TARN dataset. Glasgow coma score, age, and systolic blood
pressure were the strongest predictors of mortality. Other predictors included
in the final model were geographical region (low, middle, or high income
country), heart rate, time since injury, and type of injury. Discrimination and
calibration were satisfactory, with C statistics above 0.80 in both CRASH-2 and
TARN. A simple chart was constructed to readily provide the probability of
death at the point of care, and a web based calculator is available for a more
detailed risk assessment (http://crash2.lshtm.ac.uk).
Conclusions This prognostic model can be used to obtain
valid predictions of mortality in patients with traumatic bleeding, assisting
in triage and potentially shortening the time to diagnostic and lifesaving
procedures (such as imaging, surgery, and tranexamic acid). Age is an important
prognostic factor, and this is of particular relevance in high income countries
with an aging trauma population.
Full-text (free): http://www.bmj.com/content/345/bmj.e5166
10. Head Injury:
Comparing CT Head Rules
A. Prediction Value
of the Canadian CT Head Rule and the New Orleans Criteria for Positive Head CT
Scan and Acute Neurosurgical Procedures in Minor Head Trauma: A Multicenter
External Validation Study
Bouida W, et al. Ann Emerg Med. 2012; in press
Study objective: The New Orleans Criteria and the Canadian
CT Head Rule have been developed to decrease the number of normal computed
tomography (CT) results in mild head injury. We compare the performance of both
decision rules for indentifying patients with intracranial traumatic lesions
and those who require an urgent neurosurgical intervention after mild head
injury.
Methods: This was an observational cohort study performed
between 2008 and 2011 on patients with mild head injury who were aged 10 years
or older. We collected prospectively clinical head CT scan findings and outcome.
Primary outcome was need for neurosurgical intervention, defined as either
death or craniotomy, or the need of intubation within 15 days of the traumatic
event. Secondary outcome was the presence of traumatic lesions on head CT scan.
New Orleans Criteria and Canadian CT Head Rule decision rules were compared by
using sensitivity specifications and positive and negative predictive value.
Results: We enrolled 1,582 patients. Neurosurgical
intervention was performed in 34 patients (2.1%) and positive CT findings were
demonstrated in 218 patients (13.8%). Sensitivity and specificity for need for
neurosurgical intervention were 100% (95% confidence interval [CI] 90% to 100%)
and 60% (95% CI 44% to 76%) for the Canadian CT Head Rule and 82% (95% CI 69%
to 95%) and 26% (95% CI 24% to 28%) for the New Orleans Criteria. Negative
predictive values for the abovementioned clinical decision rules were 100% and
99% and positive values were 5% and 2%, respectively, for the Canadian CT Head
Rule and New Orleans Criteria. Sensitivity and specificity for clinical
significant head CT findings were 95% (95% CI 92% to 98%) and 65% (95% CI 62%
to 68%) for the Canadian CT Head Rule and 86% (95% CI 81% to 91%) and 28% (95%
CI 26% to 30%) for the New Orleans Criteria. A similar trend of results was
found in the subgroup of patients with a Glasgow Coma Scale score of 15.
Conclusion: For patients with mild head injury, the Canadian
CT Head Rule had higher sensitivity than the New Orleans Criteria, with higher
negative predictive value. The question of whether the use of the Canadian CT
Head Rule would have a greater influence on head CT scan reduction requires
confirmation in real clinical practice.
B. Head CT Use in the
ED for Mild TBI: Integrating Evidence Into Practice for the Resident Physician
Morton MJ, et al. Ann Emerg Med. 2012;60;361-367.
Introduction
There is a large gap between the recommendations of
high-quality evidence-based guidelines and use of this evidence in routine
patient care. The 2001 Institute of Medicine report titled Crossing the Quality
Chasm reported that clinicians' adherence to well-established evidence is
“highly uneven.”1 Multiple barriers to acceptance and implementation of
evidence exist, including lack of awareness or familiarity, variable agreement,
questioning of self-efficacy and outcome, and inertia.2 Given that emergency
departments (EDs) manage millions of patients each year, improving evidence
uptake and reducing variability in resource use will potentially yield
significant benefits in terms of efficacy of care and cost-effectiveness. One
example in which there is a potential gap in uptake of evidence in emergency
medicine is use of head computed tomography (CT) scans in patients with mild
traumatic (TBI) brain injury.
Use of emergency neuroimaging for mild traumatic brain
injury has increased dramatically during the past 15 years. According to the
Centers for Disease Control and Prevention, patients with mild traumatic brain
injury are defined as “those in which the injury to the brain itself is
diagnosed as mild at the time the person is initially evaluated. Most…recover
fully from a mild traumatic brain injury, but occasionally serious long-term
consequences may occur.”3 According to recent estimates, 1.7 million patients
present to US EDs annually for traumatic brain injuries3; the majority of these
patients receive diagnoses of mild traumatic brain injury, most of whom are
evaluated with a head CT scan despite a low incidence of clinically significant
findings on head CT (5% to 9% in recent large cohorts).4, 5, 6 However, even
patients initially receiving a diagnosis of mild traumatic brain injury may
experience subsequent clinical deterioration to other categories of brain
injury, which increases the complexity of decisionmaking with regard to this
patient population.7, 8 Approximately 125,000 patients annually experience
long-term consequences of traumatic brain injury,9 and the costs of mild
traumatic brain injury alone are estimated at $17 billion per year.10
According to the American College of Radiology, diagnostic
imaging is the fastest-growing medical expenditure in the United States, with
an annual growth rate of 9%.11 Between 1995 and 2004, the number of CT scans
and magnetic resonance imaging studies ordered in US EDs almost quadrupled.12
One single-center study reported a 51% increase in the number of head CT scans
ordered in an adult ED between 2000 and 2005.13 Overuse of CT scans in EDs not
only increases health care costs to patients and the overall cost of US health
care but also exposes patients to high doses of ionizing radiation. The high
prevalence of presentations for mild traumatic brain injury to EDs, as well as
the potential public health implications of unnecessary CT imaging,
necessitates increased resident education about clinical decisionmaking for
mild TBI…
The remainder of the article (full-text free): http://www.annemergmed.com/article/S0196-0644(11)01990-1/fulltext
C. Does This Patient
With Minor Head Trauma Need Neuroimaging?
Cooper DD, et al. Ann Emerg Med. 2012;60:368-369.
11. SHOCK II: Intraaortic
Balloon Pump Use for Cardiogenic Shock Questioned
By Peggy Peck, Editor-in-Chief, MedPage Today, August 27,
2012
When myocardial infarction (MI) is complicated by
cardiogenic shock, use of intraaortic balloon counterpulsation (IABP) did not
reduce mortality among patients scheduled for revascularization--a finding that
calls into question current guidelines for treating cardiogenic shock in this
population.
At 30 days, only 60% of the patients treated with IABP were
still alive, a mortality that was no different from the rate in the control
group (39.7% versus 41.3% relative risk 0.96, 95% CI 0.79-1.17, P=0.69),
according to findings from the IABP-SHOCK II trial reported online by the New
England Journal of Medicine.
The findings were simultaneously reported as a Hot Line
presentation at the European Society of Cardiology meeting in Munich.
Holger Thiele, MD, from University of Leipzig-Heart Center,
Leipzig, Germany, and colleagues recruited 600 patients for a randomized,
prospective, open-label, multicenter trial and assigned 300 to IABP.
While there was no mortality benefit for IABP, there also
was no apparent harm:
·
Rates of major bleeding: 3.3% versus 4.4% in
controls (P=0.53)
·
Rates of sepsis: 15.7% versus 20.5% (P=0.15)
·
Rates of stroke: 0.7% versus 1.7% (P=0.28)
·
Rates of peripheral ischemic complications: 4.3%
versus 3.4% (P=0.53)
Current American College of Cardiology/American Heart
Association guidelines for treatment of STEMI support use of IABP in this
population, but that recommendation comes from a trial "that did not
address this question, it really looked at the question of revascularization of
these patients," said Mariell Jessup, MD, of the University of Pennsylvania
Perelman School of Medicine in Philadelphia.
The earlier trial, called SHOCK (Should We Emergently
Revascularize Occluded Coronaries for Cardiogenic Shock), "was really
about bypass surgery in these patients," she said.
Jessup, who is president-elect of the American Heart
Association, told MedPage Today, that the results of the IABP-SHOCK II trial
"may very well be the most important finding to be reported at this
meeting." She said the current Class I recommendation is for use of
IABP when the patient is not stable. "It is possible that this [IABP-SHOCK
II] could completely change this guideline."
Jessup noted that use of IABP has become the norm for
treating these patients and she suggested that physicians will find it hard to
resist using IABP because "it is hard for physicians to not do something
for these patients."
Christopher O'Connor, MD, and Joseph Rogers, MD, echoed
Jessup's view in an NEJM editorial. They are from Duke University in Durham,
N.C.
Under the title, "Evidence for Overturning the
Guidelines in Cardiogenic Shock" O'Connor and Rogers wrote that data from
IABP-SHOCK II, and a number of recent meta-analyses, "do not support the
routine use of IABP in patients with acute myocardial infarction complicated by
cardiogenic shock, and the level I guideline recommendation is now strongly
challenged. Members of guideline committees and clinicians should take note of
another example of a recommendation that is based on insufficient data."
Patients in the IAPB-SHOCK trial were recruited from June
16, 2009 through March 3, 2012 at 37 centers in Germany. Thirty of the 299 patients assigned to the control group did
eventually undergo IABP, usually within 24 hours of randomization, and 26 of
those patients were classified as protocol violations. Likewise, 13 patients
assigned to IABP did not undergo the treatment, with death being the most
common reason.
The authors noted a number of limitations, starting with
lack of blinding, and the failure to obtain "hemodynamic measurements or
assess laboratory inflammatory markers other than blood pressure, heart rate,
and C-reactive protein levels."
Also, the mortality rate in both arms was lower than
anticipated -- 40% versus a range of 42% to 48% in other studies -- suggesting
that most patients in this study had mild or moderate cardiogenic shock, which
could limit the generalizability of these results, they cautioned.
"Finally, we do not yet have any information about
longer-term outcomes. Since a balloon intraaortic counterpulsation was used for
a median of only 3 days, it seems unlikely that any beneficial effect will
become evident later than 30 days," they wrote.
Thiele H, et al. Intraaortic Balloon Support for Myocardial
Infarction with Cardiogenic Shock
N Engl J Med 2012; published online Aug 27, 2012 Abstract: http://www.nejm.org/doi/full/10.1056/NEJMoa1208410
12. External
Validation of the Vancouver Chest Pain Rule
Sensitivity was high, but the rule missed 1.4 percent of
patients with acute coronary syndrome events at 30 days.
To study the validity of the Vancouver Chest Pain Rule,
researchers prospectively evaluated its performance in a convenience sample of
593 consecutive patients aged 25 and older who presented with acute chest pain
to an emergency department in Iran in 2009. The primary outcome was development
of acute coronary syndrome (ACS; diagnosed according to predefined criteria)
within 30 days of presentation.
The rule categorizes patients younger than 40 as low risk
for ACS if they have normal initial electrocardiogram (ECG) and no history of
ischemic chest pain. Patients aged 40 and older are categorized as low risk if
they have normal initial ECG, no history of ischemic chest pain, chest pain
that does not radiate or increase with deep breath or palpation, and either
initial CK-MB below 3.0 µg/mL or CK-MB 3.0 µg/mL along with no ECG change or
CK-MB or troponin rise within 2 hours of presentation (see figure).
Use of the rule would have categorized 49.2% of study
patients as low risk and eligible for discharge. Four of those patients (1.4%)
developed ACS within 30 days; none of them died. The rule had a sensitivity for
ACS within 30 days of 95.1%, a specificity of 56.3%, and negative and positive
predictive values of 98.6% and 25.9%, respectively. Two of the four patients
missed by the rule would have been identified by adding troponin-T measurement
to the algorithm.
Comment: In determining which low-risk chest pain patients are
safe to discharge from the ED, the Vancouver Chest Pain rule isn't perfect, but
it comes pretty close. This external validation study shows that the rule
remains highly sensitive when applied outside the institution where it was
developed. Although the rule doesn't integrate troponin measurement, this
additional information may improve its performance.
— Diane M. Birnbaumer, MD, FACEP. Published in Journal Watch
Emergency Medicine August 24, 2012. Citation: Jalili M et al. Validation of the
Vancouver Chest Pain Rule: A prospective cohort study. Acad Emerg Med 2012 Jul;
19:837. Abstract: http://www.ncbi.nlm.nih.gov/pubmed/22805631
The Vancouver Chest Pain Rule: http://www.ncbi.nlm.nih.gov/pubmed/16387209
13. Diagnosis and
Management of Hereditary Angioedema: An Emergency Medicine Perspective
Moellman JJ, et al. J Emerg Med. 2012;43:391-400.
Background: Hereditary angioedema (HAE) is a rare and often
debilitating condition associated with substantial morbidity and mortality in
the absence of appropriate intervention. An underlying deficiency in functional
C1-inhibitor (C1-INH) protein induces a vulnerability to unchecked activation
of the complement, contact, and coagulation/fibrinolytic systems. The clinical
consequence is a pattern of recurring attacks of non-pitting, non-pruritic
edema, the urgency of which varies by the affected site. Laryngeal edema can
escalate rapidly to asphyxiation, and severe cases of abdominal swelling can
lead to hypovolemic shock.
Objectives: This report reviews the emergency diagnosis and
treatment of hereditary angioedema and the impact of recently introduced treatments
on treatment in the United States.
Discussion: Until recently, emergency physicians in the
United States were hindered by the lack of rapidly effective treatment options
for HAE attacks. In this article, general clinical and laboratory diagnostic procedures
are reviewed against the backdrop of two case studies: one patient presenting
with a known history of HAE and one with previously undiagnosed HAE. In many
countries outside the United States, plasma-derived C1-INH concentrate has for
decades been the first-line treatment for acute attacks. The end of 2009
ushered in a new era in the pharmacologic management of HAE attacks in the
United States with the approval of two new treatment options for acute
treatment: a plasma-derived C1-INH concentrate and a kallikrein inhibitor.
Conclusion: With access to targeted and effective
treatments, emergency physicians are now better equipped for successful and
rapid intervention in urgent HAE cases.
14. Some children
genetically predisposed to convert codeine to dangerous levels of morphine
Aug. 15 (HealthDay News) -- Some children may be at risk for
serious adverse events, including death, after taking codeine for relief of
pain following tonsillectomy and/or adenoidectomy for obstructive sleep apnea,
according to a safety communication issued Aug. 15 by the U.S. Food & Drug
Administration.
The agency issued the alert after reviewing recent reports
of three deaths and one case of severe respiratory depression in children 2 to
5 years of age who took the pain reliever after surgery. The children were
given the pain reliever within a normal range of dosage, but each had an
inherited genetic ability to convert the painkiller into life-threatening or
fatal amounts of morphine.
The FDA is currently conducting a safety review of the drug
to see if other children have died or overdosed after ingesting codeine and, if
so, whether or not they were taking the drug for reasons other than pain relief
after surgery to treat obstructive sleep apnea.
According to the FDA, "Health care professionals should
be aware of the risks of using codeine in children, particularly in those who
have undergone tonsillectomy and/or adenoidectomy for obstructive sleep apnea
syndrome. If prescribing codeine-containing drugs, the lowest effective dose
for the shortest period of time should be used on an as-needed basis."
15. Systemic
corticosteroid monotherapy for clinically diagnosed acute rhinosinusitis: a
randomized controlled trial (shows no benefit)
Venekamp RP, et al. CMAJ 2012 Aug 7. [Epub ahead of print]
Background: Patients with acute rhinosinusitis are
frequently encountered in primary care. Although corticosteroids are being
increasingly used for symptom control, evidence supporting their use is
inconclusive. We conducted a randomized controlled trial to examine the
effectiveness of systemic corticosteroid monotherapy for clinically diagnosed,
uncomplicated acute rhinosinusitis.
Methods: We conducted a block-randomized, double-blind,
placebo-controlled clinical trial at 54 primary care practices (68 family
physicians) in the Netherlands between Dec. 30, 2008, and Apr. 28, 2011. Adult
patients with clinically diagnosed acute rhinosinusitis were randomly assigned
to receive either prednisolone 30 mg/d or placebo for 7 days and asked to
complete a symptom diary for 14 days. The primary outcome measure was the
proportion of patients with resolution of facial pain or pressure on day 7.
Results: Of the 185 patients included in the trial (93 in
the treatment group, 92 in the placebo group), 2 withdrew from the study and 9
were excluded from the primary analysis because of incomplete symptom
reporting. The remaining 174 patients (88 in the treatment group, 86 in the
placebo group) were included in the intention-to-treat analysis. The
proportions of patients with resolution of facial pain or pressure on day 7
were 62.5% (55/88) in the prednisolone group and 55.8% (48/86) in the placebo
group (absolute risk difference 6.7%, 95% confidence interval –7.9% to 21.2%).
The groups were similar with regard to the decrease over time in the proportion
of patients with total symptoms (combined symptoms of runny nose, postnasal
discharge, nasal congestion, cough and facial pain) and health-related quality
of life. Adverse events were mild and did not differ significantly between the
groups.
Interpretation: Systemic corticosteroid monotherapy had no
clinically relevant beneficial effects among patients with clinically diagnosed
acute rhinosinusitis.
16. ECG of the Month
at Medscape
Here’s a good collection of images with questions and interpretations
17. Radiation
exposure from CT scans in childhood and subsequent risk of leukaemia and brain
tumours: a retrospective cohort study.
Pearce MS, et al. Lancet. 2012 Aug 4;380(9840):499-505.
BACKGROUND: Although CT scans are very useful clinically,
potential cancer risks exist from associated ionising radiation, in particular
for children who are more radiosensitive than adults. We aimed to assess the
excess risk of leukaemia and brain tumours after CT scans in a cohort of
children and young adults.
METHODS: In our retrospective cohort study, we included
patients without previous cancer diagnoses who were first examined with CT in
National Health Service (NHS) centres in England, Wales, or Scotland (Great
Britain) between 1985 and 2002, when they were younger than 22 years of age. We
obtained data for cancer incidence, mortality, and loss to follow-up from the
NHS Central Registry from Jan 1, 1985, to Dec 31, 2008. We estimated absorbed
brain and red bone marrow doses per CT scan in mGy and assessed excess
incidence of leukaemia and brain tumours cancer with Poisson relative risk
models. To avoid inclusion of CT scans related to cancer diagnosis, follow-up
for leukaemia began 2 years after the first CT and for brain tumours 5 years
after the first CT.
FINDINGS: During follow-up, 74 of 178,604 patients were
diagnosed with leukaemia and 135 of 176,587 patients were diagnosed with brain
tumours. We noted a positive association between radiation dose from CT scans
and leukaemia (excess relative risk [ERR] per mGy 0·036, 95% CI 0·005-0·120;
p=0·0097) and brain tumours (0·023, 0·010-0·049; p less than 0·0001). Compared
with patients who received a dose of less than 5 mGy, the relative risk of
leukaemia for patients who received a cumulative dose of at least 30 mGy (mean
dose 51·13 mGy) was 3·18 (95% CI 1·46-6·94) and the relative risk of brain
cancer for patients who received a cumulative dose of 50-74 mGy (mean dose
60·42 mGy) was 2·82 (1·33-6·03).
INTERPRETATION: Use of CT scans in children to deliver
cumulative doses of about 50 mGy might almost triple the risk of leukaemia and
doses of about 60 mGy might triple the risk of brain cancer. Because these
cancers are relatively rare, the cumulative absolute risks are small: in the 10
years after the first scan for patients younger than 10 years, one excess case
of leukaemia and one excess case of brain tumour per 10,000 head CT scans is
estimated to occur. Nevertheless, although clinical benefits should outweigh
the small absolute risks, radiation doses from CT scans ought to be kept as low
as possible and alternative procedures, which do not involve ionising
radiation, should be considered if appropriate.
FUNDING: US National Cancer Institute and UK Department of
Health.
18. Clinical Reviews
A. A Primer on the
Surgical Airway
Rich Levitan, MD, Emergency Physicians Monthly. August 5,
2012
B. Dopamine Versus
Norepinephrine for the Treatment of Septic Shock
Sandifer JP, et al. Ann Emerg Med 2012;60:372-373.
Take-Home Message: Dopamine administration is associated
with a higher incidence of arrhythmias and increased risk of death compared
with norepinephrine in the treatment of septic shock.
Full-text (free): http://www.annemergmed.com/article/S0196-0644(12)00395-2/fulltext
19. Hospital-Wide
Solutions Needed to Reduce ED Crowding
Troy Brown. Medscape Medical News. August 10, 2012 —
Crowding in hospital emergency departments (EDs) harms patients and limits
hospitals' ability to meet national safety and quality goals. Instead of
focusing only on ED practices, administrators need to improve the way admitted
patients are moved out of the ED and into inpatient beds, according to an
article published in the August issue of Health Affairs.
Elaine Rabin, MD, an assistant professor in the Department
of Emergency Medicine at the Mount Sinai School of Medicine in New York City,
and colleagues both describe the problems associated with the practice of
boarding patients in the ED and offer potential solutions.
The authors report that a national survey published in 2010
showed that in the week before the survey, 84.9% of hospitals had boarded
patients.
Dangerous for Patients, Costly for Hospitals
Patient boarding occurs when the order to admit the patient
has been written, but there is no inpatient bed available. When this happens,
patients are typically kept on a stretcher or bed in the ED hall until a bed
becomes available. They are then cared for by members of the ED staff, who must
also care for their full load of ED patients. Patients kept as boarders have
increased morbidity and mortality, longer hospital stays, inadequate pain
control, and inferior care in general.
"Holding admitted patients in crowded conditions
carries well-documented risks, including prolonged illness and worse outcomes
for stroke, cardiac, and intubated patients; exposure to hospital-acquired
infections; and lapses in daily medications and other routine care from
overtaxed emergency department staff," the authors write.
Patient boarding costs hospitals money by decreasing the
number of patients the ED can care for and lengthening the time patients must
wait to get treated. Physicians also may be less inclined to send patients to
EDs that are known for long wait times. "One Pennsylvania hospital
estimated that boarding patients more than two hours costs the hospital more
than $3 million annually when it must turn away new patients," the authors
write.
A number of factors throughout the system influence the
availability of inpatient beds, note the authors. "Theoretically, backups
occur at the following points in time: when hospital capacity is exceeded, and
the hospital is full of patients who need inpatient care; when the hospital
inefficiently manages and discharges inpatients, unnecessarily tying up
inpatient beds; or when empty beds exist but are unavailable to emergency
department patients — for example, when beds are reserved for other possible
admissions," they write.
Most problems result not from exceeded hospital capacity
but, rather, from inefficiencies that can be fixed. For example, many hospitals
offer certain services only during business hours, which can delay patient
discharges. Better management of these types of services can help facilitate
discharges.
In addition, the authors explain, according to "queuing
theory, boarding occurs before hospitals and units are 100 percent occupied,
usually around 80–85 percent capacity. This is partly because specific bed
types, such as beds for males or beds for isolation cases, fill earlier than
other types."
Solutions Exist, Are Underused
Some of the solutions to the problem of patient boarding are
actually fairly simple, the authors say. One such remedy is to move admitted
patients from the ED hallway to a hallway on an inpatient unit. Patients are
happier there because it is quieter, and they usually get better care because
patient–nurse ratios there are lower than in the ED. In addition, the authors
report that inpatient beds are often found quickly for patients boarding on
inpatient units.
Reducing the number of unused hospital beds will also help
decrease the need for patient boarding. "One recent informal survey found
that more than 60 percent of teaching hospitals board patients in the emergency
department even when beds are empty elsewhere in the hospital," the
authors write.
Many times empty hospital beds are reserved for patients
expected from other hospitals or in anticipation of possible admissions after
elective procedures. Sometimes beds remain empty for geographic or staffing
reasons, either to keep patients with certain conditions in close proximity to
each other or to make it easier for hospital staff.
"Surgical schedule smoothing" eliminates some of
the peaks that occur as a result of many surgeons' preference for scheduling
surgeries early in the week; spacing elective procedures throughout the week
ensures that beds will be available.
Current methods aimed at reducing patient boarding are a
good start, but they could be strengthened, the authors note. Beginning in
2014, the Centers for Medicare and Medicaid Services will institute a
pay-for-reporting program with financial incentives for reporting on hospital
performance metrics including ED length-of-stay for admitted and discharged
patients and boarding times. The authors suggest that the pay-for-performance
program should also incur penalties for failing to reduce wait times.
The Joint Commission has recently required hospitals to
address boarding for the purposes of accreditation; these requirements could be
strengthened by making them more specific in terms of percentages of patients
expected to board in the ED for less than 4 hours.
"Boarding is a systemwide problem, and successful
responses require the endorsement of hospital leaders," the authors
conclude. "Proven strategies to reduce boarding are grossly
underused."
Educating hospital administrators and patients may not be
enough. "If continued education of hospital managers and the public does
not result in change, enhanced regulation will be necessary to protect
patients," the authors add.
The authors are all members of the Emergency Department
Crowding Interest Group of the Society for Academic Emergency Medicine, and the
article was submitted on the group’s behalf. The authors have disclosed no
relevant financial relationships.
Health Aff. 2012;31:1757-1766. Abstract: http://content.healthaffairs.org/content/31/8/1757.abstract
20. Utilization and
Yield of Chest CT Angiography Associated with Low Positive D-dimer Levels
Huckins DS, et al. J Emerg Med. 2012;43:211-220.
Background: It is unclear to what degree broadly applied
D-dimer testing combined with a low threshold for imaging with even minimally
positive results may be contributing to the utilization of chest computed
tomographic angiography (CTA).
Study Objectives: To determine what proportion of chest CTAs
for suspected pulmonary embolism (PE) were performed in the setting of
minimally elevated D-dimer levels, and to determine the prevalence of PE in
those patients when stratified by clinical risk.
Methods: Retrospective chart review of all patients who had
chest CTA for the evaluation of suspected PE during the years 2002–2006 in a
suburban community teaching hospital emergency department.
Results: There were 1136 eligible patient visits, of which
353 (31.1%) were found to have D-dimer levels in the low positive range
(0.5–0.99 μg/mL). Of these 353 patients, 9 (2.6%; 95% confidence interval [CI]
0.9–4.2%) were diagnosed with PE. There were also 109 patients (9.6%) who had
normal D-dimer levels (below 0.5 μg/mL). Two of these 109 (1.8%; 95% CI 0–4.2%)
were diagnosed with PE. When stratified by the Pulmonary Embolism Rule-out
Criteria, 99 of 353 patients with low positive D-dimer levels (28.0%; 95% CI
23.4–32.7%), and 14 of 109 with normal D-dimer levels (12.8%; 95% CI 6.6–19.1%)
were classified as low risk, none of whom had PE.
Conclusions: Nearly one-third of all chest CTAs were done
for patients with minimally elevated D-dimer levels, and another 9.6% for
patients with normal D-dimer levels with very low yield. Further research to
define clinical criteria identifying patients with minimal risk of PE despite
low positive D-dimer levels represents an opportunity to improve both patient
safety and utilization efficiency of chest CTA.
21. Burnout and
Satisfaction With Work-Life Balance Worse Among US Physicians Relative to the
General US Population
Shanafelt TD, et al. Arch Intern Med. August 20, 2012. [epub
ahead of print]
Background Despite
extensive data about physician burnout, to our knowledge, no national study has
evaluated rates of burnout among US physicians, explored differences by
specialty, or compared physicians with US workers in other fields.
Methods We conducted
a national study of burnout in a large sample of US physicians from all
specialty disciplines using the American Medical Association Physician
Masterfile and surveyed a probability-based sample of the general US population
for comparison. Burnout was measured using validated instruments. Satisfaction
with work-life balance was explored.
Results Of 27 276
physicians who received an invitation to participate, 7288 (26.7%) completed
surveys. When assessed using the Maslach Burnout Inventory, 45.8% of physicians
reported at least 1 symptom of burnout. Substantial differences in burnout were
observed by specialty, with the highest rates among physicians at the front
line of care access (family medicine, general internal medicine, and emergency
medicine). Compared with a probability-based sample of 3442 working US adults,
physicians were more likely to have symptoms of burnout (37.9% vs 27.8%) and to
be dissatisfied with work-life balance (40.2% vs 23.2%) (P less than .001 for
both). Highest level of education completed also related to burnout in a pooled
multivariate analysis adjusted for age, sex, relationship status, and hours
worked per week. Compared with high school graduates, individuals with an MD or
DO degree were at increased risk for burnout (odds ratio [OR], 1.36; P less
than .001), whereas individuals with a bachelor's degree (OR, 0.80; P = .048),
master's degree (OR, 0.71; P = .01), or professional or doctoral degree other
than an MD or DO degree (OR, 0.64; P = .04) were at lower risk for burnout.
Conclusions Burnout
is more common among physicians than among other US workers. Physicians in
specialties at the front line of care access seem to be at greatest risk.
22. Beware the Nocebo
Effect
By Paul Enck and Winfried Huaser. New York Times. August 10,
2012
EVERYONE knows that a placebo — a fake medication or sham
procedure, typically used as a control in a medical trial — can nonetheless
have a positive effect, relieving real symptoms like pain, bloating or a
depressed mood. The placebo effect is a result of the patient’s expectation
that the treatment will help.
But expectations can also do harm. When a patient
anticipates a pill’s possible side effects, he can suffer them even if the pill
is fake. This “nocebo” effect has been largely overlooked by researchers,
clinicians and patients. In an article recently published in the journal
Deutsche Ärzteblatt International [see link to full-text below], we and our
colleague Ernil Hansen reviewed 31 studies, conducted by us and other
researchers, that demonstrated the nocebo effect. We urge doctors and nurses to
be more mindful of its dangers, particularly when informing patients about a
treatment’s potential complications.
Consider the number of people in medical trials who, though
receiving placebos, stop participating because of side effects. We found that
11 percent of people in fibromyalgia drug trials who were taking fake
medication dropped out of the studies because of side effects like dizziness or
nausea. Other researchers reported that the discontinuation rates because of
side effects in placebo groups in migraine or tension drug trials were as much
as 5 percent. Discontinuation rates in trials for statins ranged from 4 percent
to 26 percent.
In a curious study, a team of Italian gastroenterologists
asked people with and without diagnosed lactose intolerance to take lactose for
an experiment on its effects on bowel symptoms. But in reality the participants
received glucose, which does not harm the gut. Nonetheless, 44 percent of
people with known lactose intolerance and 26 percent of those without lactose
intolerance complained of gastrointestinal symptoms.
In one remarkable case, a participant in an antidepressant
drug trial was given placebo tablets — and then swallowed 26 of them in a
suicide attempt. Even though the tablets were harmless, the participant’s blood
pressure dropped perilously low.
The nocebo effect can be observed even when people take
real, non-placebo drugs. When medical professionals inform patients of possible
side effects, the risk of experiencing those side effects can increase. In one trial,
the drug finasteride was administered to men to relieve symptoms of prostate
enlargement. Half of the patients were told that the drug could cause erectile
dysfunction, while the other half were not informed of this possible side
effect. In the informed group, 44 percent of the participants reported that
they experienced erectile dysfunction; in the uninformed group, that figure was
only 15 percent.
In a similar experiment, a group of German psychologists
took patients with chronic lower back pain and divided them into two groups for
a leg flexion test. One group was told that the test could lead to a slight
increase in pain, while the other group was told that the test had no effect on
pain level. The first group reported stronger pain and performed fewer leg
flexions than the second group did.
A doctor’s choice of words matters. A team of American
anesthesiologists studied women about to give birth who were given an injection
of local anesthetic before being administered an epidural. For some women, the
injection was prefaced by the statement, “We are going to give you a local
anesthetic that will numb the area so that you will be comfortable during the
procedure.” For others, the statement was, “You are going to feel a big bee
sting; this is the worst part of the procedure.” The perceived pain was
significantly greater after the latter statement, which emphasized the downside
of the injection.
The nocebo effect presents doctors and nurses with an
ethical dilemma: on one hand, they are required to tell patients about the
potential complications of a treatment; on the other hand, they want to
minimize the likelihood of side effects. But if merely telling patients about
side effects increases their likelihood, what is to be done?
Better communication is the answer. When talking with
patients, doctors and nurses often say things with unintended negative
suggestions, like “it’s just going to bleed a bit” or “you must avoid lifting
heavy objects — you don’t want to end up paralyzed.” We recommend more
extensive training in communication for doctors and nurses, to help them use
the power of their words appropriately. As the great cardiologist Bernard Lown
once said, “Words are the most powerful tool a doctor possesses, but words,
like a two-edged sword, can maim as well as heal.”
Paul Enck is a professor of psychology at the University of
Tübingen. Winfried Häuser is an associate professor of psychosomatic medicine
at the University of Munich.
Häuser W, Hansen E, Enck P. Nocebo phenomena in medicine: their
relevance in everyday clinical practice. Dtsch Arztebl Int. 2012
Jun;109(26):459-65. Full-text (free): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3401955/
23. Just FYI
A. The Beginning of
the End of AIDS?
Havlir D, et al. N Engl J Med 2012; 367:685-687
We are at a moment of extraordinary optimism in the response
to the human immunodeficiency virus (HIV). A series of scientific
breakthroughs, including several trials showing the partial efficacy of oral
and topical chemoprophylaxis1,2 and the first evidence of efficacy for an HIV
vaccine candidate,3 have the potential to markedly expand the available
preventive tools. There is evidence of the first cure of an HIV-infected person.
And most important, the finding that early initiation of antiretroviral therapy
can both improve individual patient outcomes and reduce the risk of HIV
transmission to sexual partners by 96%4 has led many to assert what had so long
seemed impossible: that control of the HIV pandemic may be achievable…
The remainder of the essay (full-text free): http://www.nejm.org/doi/full/10.1056/NEJMp1207138
B. Bariatric Surgery Reduces
Incident Type 2 Diabetes among Obese Patients
In this report from the Swedish Obese Subjects study, the
rate of incident type 2 diabetes in usual-care and bariatric-surgery groups was
28.4 and 6.8 cases per 1000 person-years, respectively. These findings suggest
that surgery is much more efficient than usual care.
C. Trial Will Test
Methotrexate for MI, Stroke Prevention
By John Gever, Senior Editor, MedPage Today. Published: August 23, 2012
The possibility that the immunosuppressant drug methotrexate
can prevent major cardiovascular events will be tested in a 7,000-patient
randomized trial funded by the federal government.
Called the Cardiovascular Inflammation Reduction Trial
(CIRT), the 4-year secondary prevention study is sponsored by the National
Heart, Lung, and Blood Institute (NHLBI) and will be led by Paul Ridker, MD, of
Brigham and Women's Hospital and Harvard Medical School in Boston, as principal
investigator.
The remainder of the essay: http://www.medpagetoday.com/Cardiology/Prevention/34349?utm
D. West Nile Virus
Information for
Patients
Goodman DM, et al. JAMA. Published online August 24, 2012.
Physician Update from
CDC
E. Detecting
Obstructive Coronary Disease With CT Angiography and Noninvasive Fractional
Flow Reserve
Patel MR, et al. JAMA. Published online August 26, 2012.
Physicians commonly encounter patients reporting chest
discomfort. In these cases, the physician needs to determine whether the
patient has obstructive coronary artery disease (CAD), and if so, whether the
patient is at increased risk of future cardiovascular events. The ultimate goal
of this evaluation is to direct optimal medical therapy and potentially lead to
ischemia-driven coronary revascularization. The fractional flow reserve (FFR)
performed during invasive coronary angiography has been shown to provide lesion-specific
data on ischemia, which, when used to direct revascularization, leads to
improved clinical outcomes.1 - 2 Fractional flow reserve is the ratio of the
mean coronary artery pressure distal to an obstructive coronary lesion relative
to the mean aortic pressure during maximal coronary blood flow and represents a
physiologic measure of coronary stenosis.
Current guidelines recommend that this evaluation should be
differential based on patient pretest risk assessment. Low-risk patients should
receive only expectant management, intermediate-risk patients should be
referred for noninvasive testing, and high-risk patients should undergo
invasive cardiac catheterization.3 To date, noninvasive tests have performed
this evaluation by taking either an anatomic approach such as computed
tomographic (CT) angiography to identify obstructive CAD or a functional
approach to determine ischemia by perfusion or wall motion function via a
variety of stress and imaging modes. Therefore, technologies that provide both a
highly sensitive anatomic evaluation for obstructive disease and a highly
specific physiologic evaluation for ischemia represent the “holy grail” for
noninvasive imaging for CAD.
It is with this background that Min et al4 report the
findings of the DeFACTO study in this issue of JAMA evaluating CT angiography
with a novel noninvasive FFR computed from CT (FFRCT) compared with the
reference standard of invasive FFR determined by conventional coronary
angiography…
The remainder of the editorial (full-text currently free): http://jama.jamanetwork.com/article.aspx?articleid=1352970
Cf also Diagnostic
Accuracy of Fractional Flow Reserve from Anatomic CTA for CAD
Min JK, et al. JAMA Published online August 26, 2012
Full-text (free): http://jama.jamanetwork.com/article.aspx?articleid=1352969
