Thursday, July 09, 2015

Lit Bits: July 9, 2015

From the recent medical literature...

1. Cardiac Arrest: ACC Treatment Algorithm for Emergent Invasive Cardiac Procedures in the Resuscitated Comatose Patient

Rab T, et al. J Am Coll Cardiol. July 07, 2015,66(1):62-73

Patients who are comatose after cardiac arrest continue to be a challenge, with high mortality. Although there is an American College of Cardiology Foundation/American Heart Association Class I recommendation for performing immediate angiography and percutaneous coronary intervention (when indicated) in patients with ST-segment elevation myocardial infarction, no guidelines exist for patients without ST-segment elevation. Early introduction of mild therapeutic hypothermia is an established treatment goal. However, there are no established guidelines for risk stratification of patients for cardiac catheterization and possible percutaneous coronary intervention, particularly in patients who have unfavorable clinical features in whom procedures may be futile and affect public reporting of mortality. An algorithm is presented to improve the risk stratification of these severely ill patients with an emphasis on consultation and evaluation of patients prior to activation of the cardiac catheterization laboratory.

2. NOAC Antidote Promising in Phase III Trial: Idarucizumab for Dabigatran Reversal.

Pollack CV Jr, et al.  N Engl J Med. 2015 Jun 22 [Epub ahead of print].

Background Specific reversal agents for non-vitamin K antagonist oral anticoagulants are lacking. Idarucizumab, an antibody fragment, was developed to reverse the anticoagulant effects of dabigatran.

Methods We undertook this prospective cohort study to determine the safety of 5 g of intravenous idarucizumab and its capacity to reverse the anticoagulant effects of dabigatran in patients who had serious bleeding (group A) or required an urgent procedure (group B). The primary end point was the maximum percentage reversal of the anticoagulant effect of dabigatran within 4 hours after the administration of idarucizumab, on the basis of the determination at a central laboratory of the dilute thrombin time or ecarin clotting time. A key secondary end point was the restoration of hemostasis.

Results This interim analysis included 90 patients who received idarucizumab (51 patients in group A and 39 in group B). Among 68 patients with an elevated dilute thrombin time and 81 with an elevated ecarin clotting time at baseline, the median maximum percentage reversal was 100% (95% confidence interval, 100 to 100). Idarucizumab normalized the test results in 88 to 98% of the patients, an effect that was evident within minutes. Concentrations of unbound dabigatran remained below 20 ng per milliliter at 24 hours in 79% of the patients. Among 35 patients in group A who could be assessed, hemostasis, as determined by local investigators, was restored at a median of 11.4 hours. Among 36 patients in group B who underwent a procedure, normal intraoperative hemostasis was reported in 33, and mildly or moderately abnormal hemostasis was reported in 2 patients and 1 patient, respectively. One thrombotic event occurred within 72 hours after idarucizumab administration in a patient in whom anticoagulants had not been reinitiated.

Conclusions Idarucizumab completely reversed the anticoagulant effect of dabigatran within minutes. (Funded by Boehringer Ingelheim; RE-VERSE AD number, NCT02104947.).

Associated Editorial
Bauer KA. Targeted Anti-Anticoagulants. N Engl J Med. 2015 Jun 22 [Epub ahead of print].

Four direct oral anticoagulants have been approved for use in many countries. These drugs are valuable alternatives to vitamin K antagonists, such as warfarin, for many patients requiring anticoagulation to prevent stroke due to nonvalvular atrial fibrillation and to treat and prevent venous thromboembolism. The mechanism of these agents is to selectively inhibit either thrombin or factor Xa, which are critical enzymes in the common pathway of blood coagulation. Dabigatran etexilate inhibits thrombin, whereas apixaban, edoxaban, and rivaroxaban inhibit factor Xa.

Direct oral anticoagulants have several pharmacologic advantages over vitamin K antagonists, including a wider therapeutic window, a rapid onset of action, and shorter half-lives that range between 7 hours and 14 hours in healthy persons. Direct oral anticoagulants are administered at fixed doses to adults without laboratory monitoring, which is more convenient than warfarin with its requirement for monitoring of the international normalized ratio and periodic dose adjustments. In randomized trials with good anticoagulation management (i.e., with international normalized ratios generally in the desired therapeutic range of 2 to 3 for over 60% of the time), direct oral anticoagulants were noninferior, and in some cases superior, to dose-adjusted warfarin for the prevention and treatment of thrombosis. As compared with warfarin, direct oral anticoagulants reduced the rate of major bleeding by 28% and the rates of intracranial and fatal hemorrhage by 50%.1

Despite the better bleeding profile of direct oral anticoagulants, as compared with warfarin, some physicians and patients have been unwilling to consider these drugs in the absence of an established way to reverse their anticoagulant activity. Although the anticoagulant activity of warfarin can be reversed with vitamin K, fresh-frozen plasma, and prothrombin complex concentrates, major bleeding events that occur in patients taking this drug often lead to poor outcomes; approximately 10% of patients who are hospitalized with warfarin-related bleeding die within 90 days,2,3 and the mortality among patients with intracranial hemorrhage can be as high as 50%.4,5 The high mortality is attributable in part to coexisting conditions in this patient population. Experimental data suggest that nonspecific reversal agents such as prothrombin complex concentrates, activated prothrombin complex concentrates, or recombinant factor VIIa can reduce the anticoagulant effect of direct oral anticoagulants in vitro, in animal models, and in human volunteers.6 However, these agents are of unproven benefit in improving hemostasis in patients with bleeding related to direct oral anticoagulant use, and they carry a risk of thrombosis; thus, they are currently reserved for patients with severe bleeding who cannot be treated with supportive measures.

With the growing use of direct oral anticoagulants, it would be advantageous to have reversal agents that can rapidly and completely neutralize the anticoagulant activity of the drug and restore normal hemostasis. Specific reversal agents in clinical development include andexanet alfa, a recombinant factor Xa variant that specifically binds all the oral factor Xa inhibitors but lacks coagulant activity.7 There is also a nonspecific reversal agent in clinical development, PER977, which binds to several of the direct oral anticoagulants by means of electrostatic interactions.8 Given that there are no established reversal strategies for the direct oral anticoagulants, it is appropriate to undertake clinical trials of these agents without a control group.

Idarucizumab is a humanized monoclonal antibody fragment with high affinity for the oral direct thrombin inhibitor dabigatran that selectively and immediately neutralizes its anticoagulant activity.9 Pollack et al.10 now report in the Journal the results of an interim analysis of data from 90 patients who were taking dabigatran and who presented with either serious bleeding or the need for urgent surgery or intervention and received intravenous idarucizumab. This multicenter observational study evaluated the effect of a single 5-g dose of antibody in eligible patients who were judged by the treating clinician to require a reversal agent. The major end points of the study were pharmacodynamic assessments of the ability of idarucizumab to neutralize the anticoagulant activity of dabigatran. The data are convincing that the antidote effectively and immediately neutralized the activity of dabigatran with a satisfactory safety profile. Normal hemostasis was reported in more than 90% of the patients who underwent procedures after the administration of idarucizumab.

Without a control group, it is difficult to assess the clinical benefit that is conferred by the administration of idarucizumab in patients with dabigatran-related bleeding…

The remainder of the essay (full-text free):

3. Societies recommend thrombectomy for eligible stroke patients after thrombolytics

by Crystal Phend. Senior Staff Writer, MedPage Today

Stent retriever thrombectomy should be performed for selected stroke patients at specialized centers after tissue plasminogen activator (tPA), the American Heart Association/American Stroke Association recommended.

That focused update to 2013 guidelines, published online in Stroke, included acute ischemic stroke patients meeting all of the following criteria:
  • Prestroke modified Rankin Scale score 0 to 1
  • IV tPA given within 4.5 hours of onset
  • Causative occlusion of the internal carotid artery or proximal middle cerebral artery (M1)
  • National Institutes of Health Stroke Scale (NIHSS) score of 6 or higher
  • Alberta Stroke Program Early CT score (ASPECTS) of at least 6
  • Groin puncture for endovascular treatment feasible within 6 hours of symptom onset 

"Use of stent retrievers is indicated in preference to the MERCI device," the update noted, also with a Class I, level of Evidence A recommendation.

The update came as no surprise to J Mocco, MD, director of the Cerebrovascular Center at Mount Sinai Health System in New York City. “These guidelines reflect the recent avalanche of positive trials demonstrating the overwhelming benefit of removing clots from clogged brain arteries for patients that are suffering from stroke,” he told MedPage Today in an email. “There have been many of us who have long believed in the benefit of this approach, but the positive data published over the past year have now convinced the larger community of the importance of this approach.”

William J. Powers, MD, of the University of North Carolina at Chapel Hill, and colleagues analyzed results from eight randomized clinical trials of endovascular treatment published since 2013 as "pivotal new evidence that justifies changes in current recommendations."
The first three were done primarily with intra-arterial fibrinolysis and first generation thrombectomy devices without showing any advantage either as a substitute for tPA or subsequent to it.

The latest five -- MR CLEAN, EXTEND-IA, ESCAPE, SWIFT-PRIME, and REVASCAT -- almost exclusively used stent retrievers with uniformly higher recanalization rates and benefits in functional outcome compared with thrombolysis or usual care alone.

While two of those allowed salvage intra-arterial fibrinolysis, the data wasn't sufficient to say more than it "may be reasonable to employ in some clinical circumstances," the guideline noted.

Although the time window for enrollment in the positive trials varied, the recommendations settled on 6 hours as the best supported thrombectomy window. Beyond that point, the guidelines didn't say endovascular treatment is pointless but did note that its effectiveness is "uncertain."

Likewise, for other criteria outside the recommended set, such as mechanical clot removal in strokes from occlusion of the M2 or M3 or in people under age 18, the updated guide suggested treatment could be appropriate in carefully selected individuals.

The data wasn't definitive on anesthesia use, but the guide concluded: "On balance, data from published data broadly indicate that conscious sedation might be safer and more effective than general anesthesia in the setting of endovascular therapy for acute ischemic stroke."

The guidelines still recommended transport of patients to the closest certified primary stroke center or comprehensive stroke center, but now also argued for regional systems of care to be organized around endovascular treatment as well.

"This additional treatment is more difficult than tPA, which can be given by most doctors in the emergency room," Powers said in a press release.

The update was endorsed by the American Association of Neurological Surgeons, Congress of Neurological Surgeons, American Society of Neuroradiology, and Society of Vascular and Interventional Neurology, while the American Academy of Neurology "affirms the value" as an educational tool.

4. Patient controlled analgesia better than routine care for ED pts with non-traumatic abdominal pain—but not for pts with trauma pain: two RCTs

A. PAin SoluTions In the Emergency Setting (PASTIES)-patient controlled analgesia versus routine care in emergency department patients with non-traumatic abdominal pain: randomised trial.

Smith JE, et al. PASTIES research team. BMJ. 2015 Jun 21;350:h3147.

OBJECTIVE: To determine whether patient controlled analgesia (PCA) is better than routine care in providing effective analgesia for patients presenting to emergency departments with moderate to severe non-traumatic abdominal pain.

DESIGN: Pragmatic, multicentre, parallel group, randomised controlled trial

SETTING: Five English hospitals.

PARTICIPANTS: 200 adults (66% (n=130) female), aged 18 to 75 years, who presented to the emergency department requiring intravenous opioid analgesia for the treatment of moderate to severe non-traumatic abdominal pain and were expected to be admitted to hospital for at least 12 hours.

INTERVENTIONS: Patient controlled analgesia or nurse titrated analgesia (treatment as usual).

MAIN OUTCOME MEASURES: The primary outcome was total pain experienced over the 12 hour study period, derived by standardised area under the curve (scaled from 0 to 100) of each participant's hourly pain scores, captured using a visual analogue scale. Pre-specified secondary outcomes included total morphine use, percentage of study period in moderate or severe pain, percentage of study period asleep, length of hospital stay, and satisfaction with pain management.

RESULTS: 196 participants were included in the primary analyses (99 allocated to PCA and 97 to treatment as usual). Mean total pain experienced was 35.3 (SD 25.8) in the PCA group compared with 47.3 (24.7) in the treatment as usual group. The adjusted between group difference was 6.3 (95% confidence interval 0.7 to 11.9). Participants in the PCA group received significantly more morphine (mean 36.1 (SD 22.4) v 23.6 (13.1) mg; mean difference 12.3 (95% confidence interval 7.2 to 17.4) mg), spent less of the study period in moderate or severe pain (32.6% v 46.9%; mean difference 14.5% (5.6% to 23.5%)), and were more likely to be perfectly or very satisfied with the management of their pain (83% (73/88) v 66% (57/87); adjusted odds ratio 2.56 (1.25 to 5.23)) in comparison with participants in the treatment as usual group.

CONCLUSIONS: Significant reductions in pain can be achieved by PCA compared with treatment as usual in patients presenting to the emergency department with non-traumatic abdominal pain.Trial registration European Clinical Trials Database EudraCT2011-000194-31; Current Controlled Trials ISRCTN25343280.

B. PAin SoluTions In the Emergency Setting (PASTIES)-patient controlled analgesia versus routine care in emergency department patients with pain from traumatic injuries: randomised trial.

Smith JE, et al. BMJ. 2015 Jun 21;350:h2988.

Conclusion: PCA provided no statistically significant reduction in pain compared with routine care for emergency department patients with traumatic injuries.

5. Twiddle Me This! A Look at Twiddler’s Syndrome

Shoenberger J, et al. Ann Emerg Med. 2015;66:20–22

Annals Case
“A 53-year-old female 3 days status post pacemaker/defibrillator placement presented to the emergency department (ED) after a syncopal episode. The pacemaker was placed for intermittent complete heart block leading to recurrent syncope. Since discharge, she had complained of incisional pain but denied fever, erythema, or exudate from her incision. On arrival an ECG showed an intermittently paced regular rhythm. The patient became symptomatic with light-headedness when her pulse rate decreased to the rage of 38-42 beats/min. The physical examination result was unremarkable. However, the patient was noted by nursing to be frequently touching her incision.”1

Riddle me this: have you heard of twiddler’s syndrome? Does it have to do with Twizzlers? Tiddlywinks? Twitter? None of those? Troubleshooting a dysfunctional pacemaker can be a challenge, and arriving at a diagnosis that you’ve never heard of can be even more difficult. Fortunately, a simple chest radiograph can help you rule out this problem in a matter of seconds!

Mom Was Right: Keep Your Hands at Your Side!
The first implantable pacemaker was placed in the United States in 1960.2

It was only a matter of time before problems with pacemakers started to arise, including battery failure, lead fracture and displacement, failure to pace, oversensing, and a host of other issues. It took 8 years for the medical literature to publish the first case of a pacer lead being displaced as a result of the pulse generator rotating in its implanted site.3

This rotation typically occurs accidentally because the subcutaneous pocket, in which the pulse generator is placed, is generously sized. This allows the generator enough room to rotate on its own or, more likely, with the help of a patient who fiddles with or “twiddles” it intentionally or subconsciously, causing it to rotate. That being said, perhaps we shouldn’t be so quick to judge because the rotation may also occur as a result of arm movement.4

Regardless, given that the leads are attached to the generator, twisting of the generator may cause the leads to also twist and coil up like a fishing reel line, displacing the pacer lead from its intended site. Voilà! You’ve now got pacer dysfunction and a diagnosis of twiddler’s syndrome…

The image (free): Woman with Syncope

6. Emergency physician perceptions of medically unnecessary advanced diagnostic imaging.

Kanzaria HK, et al. Acad Emerg Med. 2015;22(4):390-8.

OBJECTIVES: The objective was to determine emergency physician (EP) perceptions regarding 1) the extent to which they order medically unnecessary advanced diagnostic imaging, 2) factors that contribute to this behavior, and 3) proposed solutions for curbing this practice.

METHODS: As part of a larger study to engage physicians in the delivery of high-value health care, two multispecialty focus groups were conducted to explore the topic of decision-making around resource utilization, after which qualitative analysis was used to generate survey questions. The survey was extensively pilot-tested and refined for emergency medicine (EM) to focus on advanced diagnostic imaging (i.e., computed tomography [CT] or magnetic resonance imaging [MRI]). The survey was then administered to a national, purposive sample of EPs and EM trainees. Simple descriptive statistics to summarize physician responses are presented.

RESULTS: In this study, 478 EPs were approached, of whom 435 (91%) completed the survey; 68% of respondents were board-certified, and roughly half worked in academic emergency departments (EDs). Over 85% of respondents believe too many diagnostic tests are ordered in their own EDs, and 97% said at least some (mean = 22%) of the advanced imaging studies they personally order are medically unnecessary. The main perceived contributors were fear of missing a low-probability diagnosis and fear of litigation. Solutions most commonly felt to be "extremely" or "very" helpful for reducing unnecessary imaging included malpractice reform (79%), increased patient involvement through education (70%) and shared decision-making (56%), feedback to physicians on test-ordering metrics (55%), and improved education of physicians on diagnostic testing (50%).

CONCLUSIONS: Overordering of advanced imaging may be a systemic problem, as many EPs believe a substantial proportion of such studies, including some they personally order, are medically unnecessary. Respondents cited multiple complex factors with several potential high-yield solutions that must be addressed simultaneously to curb overimaging.

Commentary: Pro/Con: ‘Unnecessary’ Testing

by William Sullivan, DO, JD, Jerome Hoffman, MD, Hemal Kanzaria, MD, Marc Probst, MD & Judith Tintinalli, MD. Emergency Physicians Monthly, June 29, 2015

In March, the Journal of Academic Emergency Medicine published a study entitled ‘Emergency Physician Perceptions of Medically Unnecessary Advanced Diagnostic Imaging’. The study, authored by Kanzaria, Hoffman, Probst, Caloyeras, Berry & Brook, concluded that “many EPs believe a substantial proportion of [advanced imaging] studies, including some they personally order, are medically unnecessary.” This garnered headlines in the lay press, as well as a blog post on EPM’s site, which prompted a response from Jerry Hoffman, one of the study authors. Hoffman asserted that the study’s conclusions had been “slightly distorted” in the mainstream media.

To address the concerns, and potential distortion, we asked EPM senior editor William Sullivan, DO, JD and editor-in-chief Judith Tintinalli, MD, to explain their concerns with the way this study characterizes “unnecessary” testing. We then asked study co-authors Jerome Hoffman, MD, Hemal Kanzaria, MD, and Marc Probst, MD to respond.

Full-text (free):

Editorial: Throwing Stones

by Mark Plaster 

One of the most memorable scenes in the iconic movie Jerry Maguire is when Tom Cruise comes to Cuba Gooding Jr. in the locker room and gives his imploring, desperate “Help me help you” speech. When Gooding finally erupts in laughter and Cruise starts to walk away, the camera pans back to the now-naked Gooding, who says, “Oh come on Jerry, you think we’re fighting and I think we’re finally talking!.” I’ve tried to reference this scene with my wife when we have been locked in an argument before, but for some reason it doesn’t seem to land. Maybe she’d listen if I had Cuba’s abs. But let’s be honest: she sees me more as the Cuba Gooding Jr. from Daddy Day Camp.

Be that as it may, it is true that sometimes we have to really get into an argument to start talking about the important topics. Drs. Hemal Kanzaria, Jerry Hoffman and Marc Probst et al touched a nerve with their study confirming what we all have had queasy feelings about for a long time. Don’t tell anybody, but it’s possible that doctors sometimes order tests where they already know the result, feel that the test result is irrelevant to the treatment of the case, or are only ordering the test in case someone sues for some unknown reason. That is what many of us would call an “unnecessary” test. But as Bill Sullivan points out on page 24, maybe the test isn’t really “unnecessary” after all, even if we kinda sorta feel it could be. After all, every now and then the test results surprise us. If I had a hundred dollars for every surprise test result I’ve ordered, I’d have, well, at least a few hundred dollars. But he is right that we need to count the cost of blabbing to the whole world that emergency physicians are knowingly ordering countless expensive tests that they themselves don’t think are necessary.

This argument is, however, worth having – behind closed doors – because it involves several great principles of our practice…

The remainder of the essay:    

7. What’s a sensible, evidence-based approach to the diagnosis of PE?

Here’s how Jeff Kline and Chris Kabrhel read the literature.

1. Emergency Evaluation for Pulmonary Embolism, Part 1: Clinical Factors that Increase Risk. J Emerg Med. 2015 Jun;48(6):771-80.

2. Emergency Evaluation for Pulmonary Embolism, Part 2: Diagnostic Approach. J Emerg Med. 2015 Jul;49(1):104-117.

Related article: Chen YA, et al. Variation in the utilization and positivity rates of CT pulmonary angiography among emergency physicians at a tertiary academic ED. Emerg Radiol 2015;22(3):221-9

Summary: This single-center cross-sectional study observed considerable inter-physician variability in the utilization and PE positivity rates of CTPA. These results suggest an opportunity for a more standardized approach to the use of CTPA among EPs.

8. Comparison of traditional otoscope to iPhone otoscope in the pediatric ED.

Richards JR, et al. Am J Emerg Med. 2015 Aug;33(8):1089-92.

OBJECTIVE: Acute otitis media (AOM) is a common diagnosis under age 5 years. The primary objective was to determine if the CellScope Oto (CSO) improves tympanic membrane (TM) visualization and diagnostic precision compared to traditional otoscope. The secondary objective was to determine physician, patient, and parent device preference.

METHODS: This is a prospective cross-sectional study of patients younger than 18 years presenting with ear pain, fever, or upper respiratory infection symptoms. Patients were examined by a resident then attending physician with a traditional wall-mounted otoscope followed by CSO. Each was blinded to the other's findings. Intrarater and interrater diagnostic agreement was compared. Physicians, parents, and patients were surveyed regarding their experience.

RESULTS: A total of 51 patients completed the study. There was substantial intrarater agreement between traditional otoscope and CSO for residents: right ear (κ = 0.74) and left ear (κ = 0.74); CSO use changed reported view for 16 of 102 TM examinations (16%), of which 7 (7%) had clinically relevant change in diagnosis to/from AOM. There was substantial to almost-perfect agreement for attending physicians: right: (κ = 0.86) and left (κ = 0.79); CSO use changed reported view for 12 (12%), with 6 (6%) clinically relevant. Resident/attending physician interrater agreement was moderate for both traditional otoscope (κ = 0.40) and CSO (κ = 0.47). Physicians agreed CSO was easy to use, enhanced TM visualization and diagnostic precision, and was a good teaching tool. Patients and parents also found the CSO images very helpful.

CONCLUSION: CellScope Oto was preferred by physicians, patients, and parents. Use of the CSO changed final diagnosis a significant number of times, including clinically relevant changes to/from AOM.

Manufacturer’s webpage:

9. The Diseconomies of Queue Pooling: An Empirical Investigation of ED Length of Stay

Song H, Tucker AL, Murrell KL. Man Sci. 2015 May 28 [Epub ahead of print].

We conduct an empirical investigation of the impact of queue management on patients’ average wait time and length of stay (LOS). Using an emergency department’s (ED) patient-level data from 2007 to 2010, we find that patients’ average wait time and LOS are longer when physicians are assigned patients under a pooled queuing system with a fairness constraint compared to a dedicated queuing system with the same fairness constraint. Using a difference-in-differences approach, we find the dedicated queuing system is associated with a 17% decrease in average LOS and a 9% decrease in average wait time relative to the control group—a 39-minute reduction in LOS and a four-minute reduction in wait time for an average patient of medium severity in this ED.

Interviews and observations of physicians suggest that the improved performance stems from the physicians’ increased ownership over patients and resources that is afforded by a dedicated queuing system, which enables physicians to more actively manage the flow of patients into and out of ED beds. Our findings suggest that the benefits from improved flow management in a dedicated queuing system can be large enough to overcome the longer wait time predicted to arise from nonpooled queues. We conduct additional analyses to rule out alternate explanations for the reduced average wait time and LOS in the dedicated system, such as stinting and decreased quality of care. Our paper has implications for healthcare organizations and others seeking to reduce patient wait time and LOS without increasing costs.

DRV note: So, what do they mean by queue pooling? In their words: “In this paper, we consider two different types of queuing systems in the context of an ED. In a pooled queuing system—which is typical for most EDs in the United States—a physician is assigned to a patient only once the patient is placed in an ED bed. This means patients in the waiting room remain in a pooled queue while waiting for an open bed. In a dedicated queuing system, physicians are assigned to patients at the point of triage. Here, patients in the waiting room are, in effect, waiting to be seen by a specific physician. In the dedicated queuing system, each physician thus has a greater ownership over his or her workload even before the patient is placed in an ED bed.”

This is akin to the Team Assignment System, published in Ann Emerg Med in 2005:

10. Annals Brief Lit Reviews

A. Do Glycoprotein IIb/IIIa Inhibitors Improve Outcomes in Acute Ischemic Stroke?

Bottom Line: Given the lack of benefit and the significantly increased risk of bleeding, glycoprotein IIb/IIIa inhibitors cannot be recommended for acute ischemic stroke. Moreover, the rate of harms appears high enough that future trials investigating their use in stroke are unlikely.

B. Does a Restricted Fluid Resuscitation Strategy Decrease Mortality in Trauma Patients?

Take home: There is currently insufficient evidence to recommend for or against restricted fluid resuscitation in trauma patients.

C. Do Intravenous Nitrates Improve Dyspnea in Acute Heart Failure Syndromes More Than Alternative Pharmacologic Interventions?

Take home: Intravenous nitrate vasodilators produce similar symptom improvement in acute heart failure syndromes compared with alternative therapies, though evidence is limited.

D. What Is the Role of Procalcitonin in Early Diagnosis of Infective Endocarditis?

Take home: Evidence is inadequate to support the use of procalcitonin as a test to rule in or rule out the diagnosis of endocarditis.

11. Images in Clinical Practice

Esophageal Intubation in an Infant


Blue skin (gotta answer a multiple choice question first)

Visual loss (gotta answer a multiple choice question first)

Abdominal wall signs (gotta answer a multiple choice question first)

Ping-Pong Gaze

Elderly Female With Abdominal Pain

Diffuse Soft Tissue Calcinosis

Coral Dermatitis

12. Placebo Effects in Medicine

Kaptchuk TJ, et al. N Engl J Med 2015; 373:8-9.

Placebo effects are often considered the effects of an “inert substance,” but that characterization is misleading. In a broad sense, placebo effects are improvements in patients' symptoms that are attributable to their participation in the therapeutic encounter, with its rituals, symbols, and interactions. These effects are distinct from those of discrete therapies and are precipitated by the contextual or environmental cues that surround medical interventions, both those that are fake and lacking in inherent therapeutic power and those with demonstrated efficacy. This diverse collection of signs and behaviors includes identifiable health care paraphernalia and settings, emotional and cognitive engagement with clinicians, empathic and intimate witnessing, and the laying on of hands.

Placebo effects rely on complex neurobiologic mechanisms involving neurotransmitters (e.g., endorphins, cannabinoids, and dopamine) and activation of specific, quantifiable, and relevant areas of the brain (e.g., prefrontal cortex, anterior insula, rostral anterior cingulate cortex, and amygdala in placebo analgesia).1 Many common medications also act through these pathways. In addition, genetic signatures of patients who are likely to respond to placebos are beginning to be identified.2 Such basic mechanistic discoveries have greatly enhanced the credibility of placebo effects. Moreover, recent clinical research into placebo effects has provided compelling evidence that these effects are genuine biopsychosocial phenomena that represent more than simply spontaneous remission, normal symptom fluctuations, and regression to the mean.1 So what have we learned about placebo effects to date, and what does our current understanding say about medicine?

First, though placebos may provide relief, they rarely cure. Although research has revealed objective neurobiologic pathways and correlates of placebo responses, the evidence to date suggests that the therapeutic benefits associated with placebo effects do not alter the pathophysiology of diseases beyond their symptomatic manifestations; they primarily address subjective and self-appraised symptoms. For example, there is no evidence that placebos can shrink tumors; however, experiments demonstrate that common symptoms of cancer and side effects of cancer treatment (e.g., fatigue, nausea, hot flashes, and pain) are responsive to placebo treatments. Similarly, an experiment in patients with asthma showed that placebos do not affect patients' forced expiratory volume in 1 second (FEV1) but can nonetheless dramatically relieve perceived symptoms.3 This conclusion tracks evidence related to many conditions, such as musculoskeletal, gastrointestinal, and urogenital disorders.

Second, placebo effects are not just about dummy pills: the effects of symbols and clinician interactions can dramatically enhance the effectiveness of pharmaceuticals. For example, a recent study of episodic migraine demonstrated that when patients took rizatriptan (10 mg) that was labeled “placebo” (a treatment that theoretically had “pure pharmacologic effects”), the outcomes did not differ from those in patients given placebos deceptively labeled “rizatriptan” (pure expectation effect). However, when ritzatriptan was correctly labeled “rizatriptan,” its analgesic effect increased by 50%.4 Similar results have been observed when other drugs, including morphine, fentanyl, and diazepam, have been administered openly and covertly and with procedures such as deep-brain stimulation for mobility symptoms in Parkinson's disease.

Third, the psychosocial factors that promote therapeutic placebo effects also have the potential to cause adverse consequences, known as nocebo effects. Not infrequently, patients perceive side effects of medications that are actually caused by anticipation of negative effects or heightened attentiveness to normal background discomforts of daily life in the context of a new therapeutic regimen. For example, nocebo effects were demonstrated in a study of benign prostatic hypertrophy treated with finasteride: patients informed of the sexual side effect of this drug reported sexual side effects at three times the rate that patients who were not so informed did. In trials of anticonvulsants for migraine, patients receiving placebos report memory problems and anorexia, whereas in trials of triptans for migraine, patients receiving placebos report different side effects. Research reviews have estimated that 4 to 26% of patients who are randomly assigned to placebos in trials discontinue their use because of perceived adverse effects. It thus seems not unlikely that patients are often treated for adverse medication effects that are actually anticipatory nocebo effects. Finding a way to balance the need for full disclosure of potential adverse effects of drugs with the desire to avoid inducing nocebo effects is a pressing issue in health care…

The remainder of the essay (free):

Audio interview with Prof. Ted Kaptchuk on the outlook for harnessing the benefits of placebo effects in medicine (12:51)—link above.

13. Supplemental Oxygen Is Not Needed for STEMI Patients with Normal Oxygen Saturations

Outcomes were either similar or worse for STEMI patients given supplemental oxygen, compared with those who maintained a saturation ≥94% on their own

Stub D, et al. AVOID Investigators*. Air Versus Oxygen in ST-Segment-Elevation Myocardial Infarction. Circulation. 2015 Jun 16;131(24):2143-50.

BACKGROUND: Oxygen is commonly administered to patients with ST-elevation-myocardial infarction despite previous studies suggesting a possible increase in myocardial injury as a result of coronary vasoconstriction and heightened oxidative stress.

METHODS AND RESULTS: We conducted a multicenter, prospective, randomized, controlled trial comparing oxygen (8 L/min) with no supplemental oxygen in patients with ST-elevation-myocardial infarction diagnosed on paramedic 12-lead ECG. Of 638 patients randomized, 441 patients had confirmed ST-elevation-myocardial infarction and underwent primary end-point analysis. The primary end point was myocardial infarct size as assessed by cardiac enzymes, troponin I, and creatine kinase. Secondary end points included recurrent myocardial infarction, cardiac arrhythmia, and myocardial infarct size assessed by cardiac magnetic resonance imaging at 6 months. Mean peak troponin was similar in the oxygen and no oxygen groups (57.4 versus 48.0 μg/L; ratio, 1.20; 95% confidence interval, 0.92-1.56; P=0.18). There was a significant increase in mean peak creatine kinase in the oxygen group compared with the no oxygen group (1948 versus 1543 U/L; means ratio, 1.27; 95% confidence interval, 1.04-1.52; P=0.01). There was an increase in the rate of recurrent myocardial infarction in the oxygen group compared with the no oxygen group (5.5% versus 0.9%; P=0.006) and an increase in frequency of cardiac arrhythmia (40.4% versus 31.4%; P=0.05). At 6 months, the oxygen group had an increase in myocardial infarct size on cardiac magnetic resonance (n=139; 20.3 versus 13.1 g; P=0.04).

CONCLUSION: Supplemental oxygen therapy in patients with ST-elevation-myocardial infarction but without hypoxia may increase early myocardial injury and was associated with larger myocardial infarct size assessed at 6 months.

14. Motor Vehicle Crash Fatalities in States with Primary versus Secondary Seat Belt Laws: A Time-Series Analysis

Lee LK, et al. Ann Intern Med. 2015 23 June [Epub ahead of print]

Background: Motor vehicle crashes (MVCs) remain a leading cause of U.S. injury-related deaths. Primary seat belt laws allow vehicle occupants to be ticketed solely for not wearing seat belts, and secondary laws allow ticketing only for failure to wear seat belts in the setting of other violations.

Objective: To determine the association between MVC fatality rates and primary versus secondary seat belt laws.

Design: Retrospective time-series analysis.

Setting: United States, 2001 to 2010.

Participants: MVC fatalities in occupants aged 10 years or older identified in the Fatality Analysis Reporting System.

Measurements: Population-based rates of fatal crashes.

Results: There were 283 183 MVC fatalities in occupants aged 10 years or older from 2001 to 2010 (overall rate, 13.0 per 100 000 persons). In 2001, the mean fatality rate was 14.6 per 100 000 persons, 16 states had primary seat belt laws, and 33 states had secondary laws. In 2010, the mean fatality rate was 9.7 per 100 000 persons, 30 states had primary seat belt laws, and 19 states had secondary laws. In the multivariate regression model, states with primary seat belt laws had lower MVC fatality rates than states with secondary laws (adjusted incidence rate ratio, 0.83 [95% CI, 0.78 to 0.90]).

Limitation: Only fatalities were analyzed from the database, and the degree of law enforcement could not be ascertained.

Conclusion: States with primary seat belt laws had lower rates of MVC fatalities than those with secondary laws. Adoption of primary seat belt laws may offer optimal occupant protection.

15. Prochlorperazine-Induced Hemidystonia Mimicking Acute Stroke

You EM-RAP fans may remember the LIN Session from January this year when she interviewed Zlatan Coralic, PharmD, (UCSF) about the role of tPA for stroke in pregnancy. Here’s how she opened the interview: “You work in a busy Emergency Department. You are notified that there is a stroke patient being transported by EMS. The patient arrives. It is a woman in her mid-thirties presenting with slurred speech. The only thing she can say is, ‘Help me.’ She has obvious left-sided paralysis.”

We decided to publish this as a case report.

Coralic Z, et al. West J Emerg Med. 2015 July 2 [Epub ahead of print].

Prochlorperazine is frequently used in the treatment of refractory nausea and migraines. Known side effects include extrapyramidal symptoms such as akathisia and dystonia. We report a pregnant patient taking prochlorperazine for hyperemesis gravidarum who developed hemidystonia, which triggered an acute code stroke response from prehospital, emergency medicine and neurology providers. We suspect this report to be the first case of prochlorperazine-induced hemidystonia as a stroke mimic.

16. Researchers ID Predictors of Biphasic Reactions in Children with Anaphylaxis

OTTAWA, Ontario -- June 22, 2015 -- Children are more likely to have a repeat, delayed anaphylactic reaction from the same allergic cause, depending on the severity of the initial reaction. The first paediatric study to look at the predictors for this phenomenon was published today in Annals of Allergy, Asthma & Immunology.

Some children are at risk of biphasic anaphylactic reactions. Delayed reactions occur when the initial symptoms of allergic reaction go away but then return hours or days later without exposure to the initial substance that caused the reaction.

Researchers at the Children's Hospital of Eastern Ontario (CHEO) Research Institute, Ottawa, Ontario, looked at the frequency and severity of biphasic allergic reactions. From a sample size of 484 patient records, the incidence of biphasic reaction occurred in 15% of the study population, and two thirds occurred within 6 hours from the onset of the initial reaction. At least half of the biphasic reactions were serious in nature, and required treatment with epinephrine.

The study unveiled that biphasic reactions were more likely to happen if the initial allergic reaction was severe or if it was not treated with epinephrine. Furthermore, the anaphylaxis tended to be more severe when the administration of epinephrine was delayed.

“The key message here for patients, parents, caregivers, teachers, and first-responder health professionals is: to prevent an anaphylactic reaction from worsening, administer epinephrine immediately after the onset of the early symptoms of an allergic reaction,” said Waleed Alqurashi, MD, CHEO, and the University of Ottawa. “Our team has created an evidence-based prognostic tool so that physicians can monitor the more serious cases appropriately.”

The team identified 5 independent, evidence-based predictors of biphasic reactions in children, including:
• Delay in presentation to the emergency department (ED) or delay in epinephrine administration of more than 90 minutes from the onset of the initial allergic reaction.
• Wide pulse pressure at triage.
• Treatment of the initial allergic reaction with more than 1 dose of epinephrine.
• Respiratory distress that requires administration of inhaled salbutamol in the ED.
• Children aged 6 to 9 years.

“It's clear that children with severe initial reactions would benefit from a prolonged period of observation in the Emergency Department,” said Dr. Alqurashi. “On the flip side, knowing what to look for helps to better utilise resources so that children with mild allergic reaction, who do not match any of the identified predictors can go home faster.”

17. Study shows how efficient information exchange use could cut hospital costs by reducing ED radiology and lab tests

A study in the Journal of the American Medical Informatics Association found that effective use of health information exchanges could provide savings to hospitals by cutting the number of examinations and tests ordered for ED patients. Researchers revealed that health information exchange use could cut the number of ordered radiology tests per patient by 36% and laboratory tests by 52%.

An Empirical analysis of the financial benefits of health information exchange in emergency departments

Yaraghi N. J Amer Med Inform Assn. 2015 June 27 [Epub ahead of print]

Objective To examine the impact of health information exchange (HIE) on reducing laboratory tests and radiology examinations performed in an emergency department (ED).

Materials and Methods The study was conducted in an ED setting in Western New York over a period of 2 months. The care of the patients in the treatment group included an HIE query for every encounter, while the care of other patients in the control group did not include such queries. A group of medical liaisons were hired to query the medical history of patients from an HIE and provide it to the ED clinicians. Negative binomial regression was used to analyze the effects of HIE queries on the number of performed laboratory tests and radiology examinations. The log files of the HIE system since 1 year before the ED admission were used to analyze the differences in outcome measures between the 2 groups of patients.

Results Ceteris paribus, HIE usage is associated with, respectively, 52% and 36% reduction in the expected total number of laboratory tests and radiology examinations ordered per patient at the ED.

Conclusions The results indicate that access to additional clinical data through the HIE will significantly reduce the number of laboratory tests and radiology examinations performed in the ED settings and thus support the ongoing HIE efforts.

18. Quantifying Patient-Physician Communication and Perceptions of Risk during Admissions for Possible ACS.

Newman DH, et al. Ann Emerg Med. 2015 Jul;66(1):13-18.e1.

STUDY OBJECTIVE: Disposition decision for patients with possible acute coronary syndrome in the emergency department (ED) is driven primarily by perception of short-term risks. We sought to evaluate communication between patient and physician about these risks by ascertaining the content of discussions surrounding disposition decision.

METHODS: We conducted matched-pair surveys of patients admitted for possible acute coronary syndrome and their physicians in 2 academic, inner-city EDs. After disposition conversation, trained research assistants administered surveys querying perceived and communicated risk estimates and purpose of admission. Primary exclusion criteria were ECG or troponin value diagnostic of acute coronary syndrome. The primary outcome measure was agreement in assessment of the risk of myocardial infarction, defined as the proportion of patient-physician pairs whose risk estimates were within 10% of each other.

RESULTS: A total of 425 patient-physician survey pairs were collected. Fifty-three percent of patients were men. Patients reported discussing the likelihood of their symptoms' being due to myocardial infarction in 65% of cases, whereas physicians reported this in 46%. After their discussion, physicians' (n=415) median estimate of short-term risk was 5% (95% confidence interval [CI] 3% to 7%), whereas patients' (n=401) was 8% (95% CI 5% to 11%). Most patients (63%; 95% CI 57% to 67%) reported that this estimate remained the same or increased after their conversation. Risk agreement within 10% occurred in 36% of cases (n=404; 95% CI 32% to 41%). Patients' median estimates of the mortality of myocardial infarction at home versus in the hospital were 80% (n=398; 95% CI 76% to 84%) and 10% (n=390; 95% CI 7% to 13%), respectively, whereas physician estimates were 15% (n=403; 95% CI 12% to 18%) and 10% (n=398; 95% CI 7% to 13%).

CONCLUSION: Our survey demonstrates poor communication, with overestimation of both the risks of myocardial infarction and potential benefit of hospital admission. These findings suggest that communication surrounding disposition decisions in chest pain patients may at times be ineffective or misleading.

19. A Stinging Sensation: An Interactive Case from the NEJM

Lee-Sarwar K, et al. N Engl J Med 2015; 372:e35

Approximately 10 minutes after being stung on the right lower leg by a yellow jacket (a type of wasp), a 45-year-old man began to feel light-headed and nauseated. He called emergency medical services, and paramedics arrived 10 minutes later. They found him to be alert but anxious, with scattered areas of erythema on his trunk and a small, localized area of tenderness, swelling, and erythema . . .

20. A Sea Change in Treating Heart Attacks

The death rate from coronary heart disease has dropped 38 percent in a decade. One reason is that hospitals rich and poor have streamlined emergency treatment.

By GINA KOLATA. New York Times. JUNE 19, 2015
CAMDEN, N.J. — Yvette Samuels was listening to jazz late one night when she felt a stabbing pain down her left shoulder. She suspected a heart attack — she had heard about the symptoms from watching a Rosie O’Donnell standup routine on television — and managed to scratch on the door that connected her single room to her neighbor’s. He found her collapsed on the floor.

Paramedics arrived minutes later and slapped electrocardiogram leads on her chest, transmitting the telltale pattern of a heart attack to Our Lady of Lourdes Medical Center here.

As the ambulance raced through the streets, lights swirling, sirens screaming, Ms. Samuels, who took phone orders for a company that delivers milk, asked the paramedic, “Can this kill me?” He murmured yes, then told the driver, “Step on it!” She thought to herself, “This will be my last view of the world, the last time I will see the night sky.”

Instead, she survived, her heart undamaged, the beneficiary of the changing face of heart attack care. With no new medical discoveries, no new technologies, no payment incentives — and little public notice — hospitals in recent years have slashed the time it takes to clear a blockage in a patient’s arteries and get blood flowing again to the heart.

The changes have been driven by a detailed analysis of the holdups in treating patients and a nationwide campaign led by the American College of Cardiology, a professional society for specialists in heart disease, and the American Heart Association. Hospitals across the country have adopted common-sense steps that include having paramedics transmit electrocardiogram readings directly from ambulances to emergency rooms and summoning medical teams with a single call that sets off all beepers at once.

From 2003 to 2013, the death rate from coronary heart disease fell about 38 percent, according to the American Heart Association citing data from the Centers for Disease Control and Prevention. The National Heart, Lung and Blood Institute, the primary federal agency that funds heart research, says this decline has been spurred by better control of cholesterol and blood pressure, reduced smoking rates, improved medical treatments — and faster care of people in the throes of a heart attack.

“It may not be long before cardiovascular disease is no longer the leading cause of death” in the United States, said Dr. Michael Lauer, the director of the Division of Cardiovascular Sciences at the National Heart, Lung and Blood Institute.

And care has improved not just in elite medical centers, but in local hospitals like Our Lady of Lourdes, here in a city littered with abandoned buildings and boarded-up homes that is among the poorest in America, according to the Census Bureau. Disparities that used to exist, with African-Americans, Hispanics and older people facing the slowest treatment times, have disappeared, Dr. Harlan Krumholz, a cardiologist at Yale, and his colleagues said in a paper in Archives of Internal Medicine.

The reinvention of protocols to hasten treatment is part of a broad rethinking of how to tackle coronary heart disease, which accounts for one of every seven deaths in the United States or 375,000 a year. Just this month, powerful drugs from the first new class of medicines to lower bad cholesterol levels in a generation neared approval by the Food and Drug Administration, raising hopes that they will further reduce the death rate from heart disease. At the same time, new, less invasive methods for replacing aged heart valves are raising hopes that ailing patients will be able to live longer. And researchers are immersed in resolving issues that remain unsettled: the utility of stents to treat the heart pain known as angina and the ideal level for blood pressure…

21. No Surprise: ED Crowding Leads to Lower Quality of Care

A systematic review found three measures have been most frequently linked to quality: waiting room volume, ED occupancy, and number of ED boarders.

Stang AS, et al. Crowding Measures Associated With the Quality of Emergency Department Care: A Systematic Review. Acad Emerg Med. 2015 Jun;22(6):643-56

OBJECTIVES: Despite the substantial body of literature on emergency department (ED) crowding, to the best of our knowledge, there is no agreement on the measure or measures that should be used to quantify crowding. The objective of this systematic review was to identify existing measures of ED crowding that have been linked to quality of care as defined by the Institute of Medicine (IOM) quality domains (safe, effective, patient-centered, efficient, timely, and equitable).

METHODS: Six major bibliographic databases were searched from January 1980 to January 2012, and hand searches were conducted of relevant journals and conference proceedings. Observational studies (cross-sectional, cohort, and case-control), quality improvement studies, quasi-experimental (e.g., before/after) studies, and randomized controlled trials were considered for inclusion. Studies that did not provide measures of ED crowding were excluded. Studies that did not provide quantitative data on the link between crowding measures and quality of care were also excluded. Two independent reviewers assessed study eligibility, completed data extraction, and assessed study quality using the Newcastle-Ottawa Quality Assessment Scale (NOS) for observational studies and a modified version of the NOS for cross-sectional studies.

RESULTS: The search identified 7,413 articles. Thirty-two articles were included in the review: six cross-sectional, one case-control, 23 cohort, and two retrospective reviews of performance improvement data. Methodologic quality was moderate, with weaknesses in the reporting of study design and methodology. Overall, 15 of the crowding measures studied had quantifiable links to quality of care. The three measures most frequently linked to quality of care were the number of patients in the waiting room, ED occupancy (percentage of overall ED beds filled), and the number of admitted patients in the ED awaiting inpatient beds. None of the articles provided data on the link between crowding measures and the IOM domains reflecting equitable and efficient care.

CONCLUSIONS: The results of this review provide data on the association between ED crowding measures and quality of care. Three simple crowding measures have been linked to quality of care in multiple publications.

22. Micro Bits

A. The science of sleeping in, and why you probably shouldn’t

Nsikan Akpan, PBS News, July 3, 2015

I hate sleeping in, but that’s mainly because I can’t. Almost every day, since I was a teen, regardless of whether it’s a weekday, weekend or holiday, I wake up at 6 am.

As an early bird, I admit to some delusions of morning grandeur — “Let’s wake up early Saturday and climb a mountain!” — but being a morning lark has proved annoying to others in my life, particularly those who function by “catching up” on sleep over the weekends.

Maybe you’ve experienced this too? Your boyfriend/girlfriend/life partner/spouse groans as you roll out of bed at the crack of dawn, eager to climb mountains. Brunch invitations are a logistical quagmire; do you starve yourself for hours or eat breakfast twice in one morning?

Night owls have the opposite problem. I’ve heard them hoot, “If only I could go to bed early and wake up early. I’d be so productive!”

Is this true though? Does waking early improve productivity? Is there a downside to shifting the sleep schedule from weekday to weekend? Would we be better off if we could switch our sleep schedule preference, known as our chronotype? PBS NewsHour tracked down two sleep experts to explain the science of sleep.

B. New CDC STD Guidelines

These updated guidelines discuss 1) alternative treatment regimens for Neisseria gonorrhoeae; 2) the use of nucleic acid amplification tests for the diagnosis of trichomoniasis; 3) alternative treatment options for genital warts; 4) the role of Mycoplasma genitalium in urethritis/cervicitis and treatment-related implications; 5) updated HPV vaccine recommendations and counseling messages; 6) the management of persons who are transgender; 7) annual testing for hepatitis C in persons with HIV infection; 8) updated recommendations for diagnostic evaluation of urethritis; and 9) retesting to detect repeat infection.

C. Trainees Using Video Laryngoscopy Are Less Likely to End Up in the Esophagus

The odds of an emergency medicine resident intubating a patient's esophagus were nearly seven times higher with direct, rather than video, laryngoscopy.

D. ED Clinicians Struggle to Diagnose Influenza on Clinical Grounds Alone

With PCR as the gold standard, clinical diagnosis had a sensitivity of only 36%.

Dugas AF et al. Am J Emerg Med 2015 Jun.   

E. National trends in resource utilization associated with ED visits for syncope

Conclusions: Despite substantial efforts by medical researchers and professional societies, resource utilization associated with ED visits for syncope appears to have actually increased. There have been no apparent improvements in diagnostic yield for admissions. Novel strategies may be needed to change practice patterns for such patients.

F. Revisiting the “Golden Hour”: An Evaluation of Out-of-Hospital Time in Shock and Traumatic Brain Injury

Conclusion: Among out-of-hospital trauma patients meeting physiologic criteria for shock and traumatic brain injury, there was no association between time and outcome. However, the subgroup of shock patients requiring early critical resources and arriving after 60 minutes had higher mortality.

G. Preventable risk factors tied to 50% of CVD deaths in U.S. adults

Between 50% and 54% of heart disease deaths among U.S. adults ages 45 to 79 in 2010 could have been prevented if risk factors such as diabetes, obesity, high cholesterol, high blood pressure and smoking were completely eliminated, according to a study in the Annals of Internal Medicine. Researchers also said that nearly 5% of these deaths would have been prevented if all states were able to lower the levels of those risk factors to that of states with the lowest levels, such as Colorado.

H. Patients with diabetes may reduce dementia risk with pioglitazone, study finds

German researchers found that patients with type 2 diabetes who had prescriptions for pioglitazone for at least two years reduced their risk of dementia by 47%, compared with those without the disease. The findings in the Annals of Neurology also revealed that patients with diabetes who did not take the peroxisome proliferator-activated receptor agonist had a 23% increased dementia risk.

I. Kaiser Permanente’s Tyson in AJMC: Shift Focus To Maximize “Healthy Life” Years

In the June issue of The American Journal of Managed Care, Kaiser Permanente Chairman and CEO Bernard J. Tyson calls for shifting healthcare resources forward in the life span to improve quality deliver more value for the healthcare dollar. His commentary is part of a series marking the 20th year of the journal’s publication.

J. Bariatric Surgery Bests Diet and Exercise Against Diabetes
Up to 40% partial or full diabetes remission versus none with lifestyle intervention.

K. ACIP: All patients ages 16-23 should get MenB vaccination

The CDC’s Advisory Committee on Immunization Practices issued a recommendation that all patients ages 16-23 receive serogroup B meningococcal vaccine. Previously, the recommendation covered only patients ages 10 and older at high risk of contracting MenB. "[T]his is a very deadly disease that's devastating for families, and if we didn't have a B recommendation (and, consequently, mandatory insurance coverage), there would be inequity as to who could afford it," said AAFP liaison to the ACIP Jamie Loehr, M.D. ACIP also issued recommendations for the influenza and pneumococcal vaccines.

L. Gluten-free not recommended for people who don't have celiac disease 

Up to a third of Americans may have reduced their consumption of gluten-containing foods, but for people who do not have celiac disease, a gluten-free diet could result in nutritional deficiencies, damage to healthy gut flora and weight gain, doctors say. Some people do have non-celiac gluten sensitivity, but there is no definitive test for the condition and the only way to confirm it is through a gluten challenge. People who suspect they may have celiac disease or NCGS should not alter their diet, which can result in inaccurate test results, and should see a doctor for a celiac disease test, doctors say.

M. Stroke's effect on cognition is like aging 8 years, study finds

A stroke slows cognitive speed and impairs the memory to an extent equal to aging almost eight years, a study in the journal Stroke found. Researchers revealed that test results of participants who had suffered a stroke fell as much as if they had aged 7.9 years. The study included data on 4,900 patients who participated in cognitive and memory testing from 1998 to 2012.

N. Survey: Most doctors continue working while sick despite risk to patients

A survey of 480 attending physicians and 256 advanced practice clinicians found that while nearly all respondents believe working while sick raises potential risk for patients, 83% revealed they still went to work while feeling ill at least once in the last year. Doctors who worked while they were sick expressed concern over continuity of patient care and professional responsibility, with 98% of respondents worried about their co-workers and 94% citing staffing concerns.