Saturday, December 26, 2015

Lit Bits: Dec 26, 2015

From the recent medical literature...

1. BMJ’s Light-hearted 2015 Christmas Edition Articles

A. “Gunslinger’s gait”: a new cause of unilaterally reduced arm swing

Objective To postulate a new possible cause of a unilaterally reduced arm swing in addition to the known medical conditions such as shoulder pathology, Erb’s palsy, stroke, and Parkinson’s disease.

Methods Analysis of YouTube videos depicting the gait of highly ranked Russian officials.

Results We found a similar walking pattern in President Vladimir Putin, Prime Minister Dmitry Medvedev and three other highly ranked Russian officials, all presenting with a consistently reduced right arm swing in the absence of other overt neurological abnormalities.

Conclusions We propose that this new gait pattern, which we term “gunslinger’s gait,” may result from a behavioural adaptation, possibly triggered by KGB or other forms of weapons training where trainees are taught to keep their right hand close to the chest while walking, allowing them to quickly draw a gun when faced with a foe. This should be included in the differential diagnosis of a unilaterally reduced arm swing.

B. Austin Powers bites back: a comparison of US and English national oral health surveys

There is a longstanding belief in the United States that the British have terrible teeth, much worse than US citizens. However, before now no study had directly compared levels of oral health and oral health inequalities between England and the US.

C. Plenty of moustaches but not enough women: study of medical leaders

Medicine, a historically male dominated discipline, has undergone considerable change in sex representation in recent decades. In 1960, women accounted for only 9% of medical students in the United States, but for the past 15 years, almost 50% of medical students have been women. The proportion of women in academic medicine, however, remains low and drops with increasing academic rank: 38% of full time faculty, 21% of full professors, and 16% of deans are women.1 2 This is a problem not only because of the strong ethical argument for equality but also for practical reasons: in business having more women leaders has been linked with better performance. For example, one study found that top firms experience positive returns on the date that female directors are announced, and another found that the Fortune 500 companies (the 500 largest US corporations by total revenue) with the highest representation of women in senior management experience significantly higher returns on equity.3 4

We want to increase the representation of women in academic medical leadership by drawing attention to sex disparities. We compared the proportion of women in leadership positions with the proportion of individuals with moustaches. We chose to study moustaches as the comparator because they are rare (less than 15% of men from the most recent measures available),5 and we wanted to learn if women were even rarer. Our hypothesis was that fewer women lead academic medical departments in the US than individuals with moustaches.

D. Bloodcurdling movies and measures of coagulation: Fear Factor crossover trial

For centuries the term “bloodcurdling” has been used to describe feeling extreme fear under frightening situations.2 Similar terms are used in other countries, such as “das blut in den Adern erstarrt” in Germany, “à vous glacer le sang” in France, and “bloedstollend” in the Netherlands. The term dates back to medieval times and is based on the concept that fear or horror would “run the blood cold” or “curdle” (congeal) blood.3 The validity of this theory has, however, never been studied. Several studies have explored the effects of physical stress on the coagulation system.4 For example, chronic anxiety in patients with psychiatric disorders (and associated therapies which may influence blood coagulation) is associated with increased levels of coagulation markers,5 6 and increased coagulation activity has been observed in healthy volunteers after bungee jumping.7 Yet the effects of excitement and profound physical activity are not necessarily equal to those of acute fear, because, for example, actions such as bungee jumping are performed voluntarily and this was seen as deviating from an ideal study design.8

We investigated the effect of acute fear without physical exercise on markers of coagulation. We hypothesised that acute fear activates the coagulation system and that this poses an important evolutionary benefit, by preparing the body for blood loss during life threatening situations.

E. Black medicine: an observational study of doctors’ coffee purchasing patterns at work

The stimulating effect of caffeine is also well known, and doctors, who often work long hours, sometimes depend on the stimulation of coffee to perform at their best. Perhaps tellingly the “fatigue management strategy” of Queensland Health (Australia) suggests the “strategic use of caffeine” in tired and overworked doctors.15 They proposed 400 mg of caffeine per working day to stay awake in the job. This is a huge dose, equivalent to six cups of coffee. Although, to our knowledge, such strategies are not in place in Europe, daily caffeine boosts are the norm for many doctors.16 It is not known, however, whether different specialties are more or less dependent on coffee to get through the day.

We accessed data for coffee purchasing as a proxy measure of consumption at a large teaching hospital in Switzerland over one calendar year (2014). Precise information on type of coffee, time of sale, and number of products bought was recorded through the hospital’s electronic payment system, which is linked to the individual’s ID badge.

2. New film tackles dangers of concussions in the NFL

Dr. Bennet Omalu was working in a Pittsburg coroner's office when he was asked to examine the body of a local football hero. What he discovered would bring new attention to the hazards of head injuries. A new film, "Concussion," chronicles the NFL's early efforts to discredit the research. Jeffrey Brown reports.

3. Failure to Obtain CT Imaging in Head Trauma: A Review of Relevant Case Law

Lindor RA, et al. Acad Emerg Med. 2015 Nov 17 [Epub ahead of print].

Objectives: The objectives were to describe lawsuits against providers for failing to order head computed tomography (CT) in cases of head trauma and to determine the potential effects of available clinical decision rules (CDRs) on each lawsuit.

Methods: The authors collected jury verdicts, settlements, and court opinions regarding alleged malpractice for failure to order head CT in the setting of head trauma from 1972 through February 2014 from an online legal research tool (WestlawNext). Data were abstracted onto a standardized data form. The performance of five CDRs was evaluated.

Results: Sixty relevant cases were identified (52 adult, eight children). Of 48 cases with known outcomes, providers were found negligent in 10 cases (six adult, four pediatric), settled in 11 cases (nine adult, two pediatric), and were found not liable in 27 cases. In all 10 cases in which providers were found negligent, every applicable CDR studied would have indicated the need for head CT. In all eight cases involving children, the applicable CDR would have suggested the need for head CT or observation.

Conclusions: A review of legal cases reported in a major online legal research system revealed 60 lawsuits in which providers were sued for failing to order head CTs in cases of head trauma. In all cases in which providers were found negligent, CT imaging or observation would have been indicated by every applicable CDR.

4. Patients less satisfied when physicians focus on computer in exam room

A small study reported in JAMA Internal Medicine found that physicians who spend a lot of time using a computer during clinical visits could find that relationships with patients suffer. The research revealed that 48% of patients whose doctors were heavily focused on computers during visits reported that they got excellent care, compared with 83% of participants whose doctors spent little time using the technology.

By Dennis Thompson. HealthDay. MONDAY, Nov. 30, 2015 (HealthDay News) -- Doctors who rely heavily on computers while in the exam room may run the risk of harming their relationships with their patients, a new study suggests. Patients are less likely to rate their care as excellent when clinicians spend a lot of time on the computer when they are seeing a patient, said study author Dr. Neda Ratanawongsa. She is an associate professor at the University of California, San Francisco (UCSF), School of Medicine.

The study authors think patients might feel slighted if their doctor spends more time focused on a computer screen than looking over their ailments or listening to their concerns. "It may be that they aren't getting the attention or connecting with their provider in a way that they used to, or that they still do with other providers," Ratanawongsa said.

Federal health care reform has placed great emphasis on the use of electronic health records, making computers a "third wheel in the exam room" that's "been insinuated into the doctor-patient relationship," said Dr. Wanda Filer, president of the American Academy of Family Physicians.

Doctors frequently spend much of an office visit at the keyboard, inputting information into a health record rather than giving the patient a once-over, said Filer, who is a family physician in York, Penn. "We've taken this technology and we've embraced it, but I think a lot of us don't believe it's ready for prime-time," she said. "We've got this interloper in the exam room, but it's not there to help with the medical side as much as it's there to check boxes for insurers."

The two-year UCSF study involved 71 encounters among 47 patients and 39 clinicians at a safety net clinic, which serves people with less access to health care. About 83 percent of patients whose doctors barely bothered with the computer rated their care as excellent in follow-up surveys, the study showed. On the other hand, only 48 percent of patients whose doctors engaged in heavy computer use felt they'd received excellent care, according to the research published online Nov. 30 in the journal JAMA Internal Medicine.

Doctors who spend a lot of time looking at the computer may not be as focused on their patient and can miss crucial information provided during the encounter, Ratanawongsa said. "If you're not paying attention to a person, you can miss very important cues, especially nonverbal cues like the expression on their face or their body language," she said.

Link to article (subscription required):

5. Thromboembolic Events after Vit K Antagonist Reversal With 4-Factor PCC: Exploratory Analyses of Two Randomized, Plasma-Controlled Studies.

Milling TJ Jr. et al. Ann Emerg Med. 2016;67(1):96–105.e5.

STUDY OBJECTIVE: We evaluated thromboembolic events after vitamin K antagonist reversal in post hoc analyses of pooled data from 2 randomized trials comparing 4-factor prothrombin complex concentrate (4F-PCC) (Beriplex/Kcentra) with plasma.

METHODS: Unblinded investigators identified thromboembolic events, using standardized terms (such as "myocardial infarction," "deep vein thrombosis," "pulmonary embolism," and "ischemic stroke"). A blinded safety adjudication board reviewed serious thromboembolic events, as well as those referred by an independent unblinded data and safety monitoring board. We descriptively compared thromboembolic event and patient characteristics between treatment groups and included detailed patient-level outcome descriptions. We did not power the trials to assess safety.

RESULTS: We enrolled 388 patients (4F-PCC: n=191; plasma: n=197) in the trials. Thromboembolic events occurred in 14 of 191 patients (7.3%) in the 4F-PCC group and 14 of 197 (7.1%) in the plasma group (risk difference 0.2%; 95% confidence interval -5.5% to 6.0%). Investigators reported serious thromboembolic events in 16 patients (4F-PCC: n=8; plasma: n=8); the data and safety monitoring board referred 2 additional myocardial ischemia events (plasma group) to the safety adjudication board for review. The safety adjudication board judged serious thromboembolic events in 10 patients (4F-PCC: n=4; plasma: n=6) as possibly treatment related. There were 8 vascular thromboembolic events in the 4F-PCC group versus 4 in the plasma group, and 1 versus 6 cardiac events, respectively. Among patients with thromboembolic events, 3 deaths occurred in each treatment group. All-cause mortality for the pooled population was 13 per group. We observed no relationship between thromboembolic event occurrence and factor levels transiently above the upper limit of normal; there were no notable differences in median factor or proteins C and S levels up to 24 hours postinfusion start in patients with and without thromboembolic events.

CONCLUSION: The incidence of thromboembolic events after vitamin K antagonist reversal with 4F-PCC or plasma was similar and independent of coagulation factor levels; small differences in the number of thromboembolic event subtypes were observed between treatment groups.

6. Drugs for the treatment of n/v in adults in the ED setting are no better than placebo

Furyk JS, et al. Cochrane Database Syst Rev. 2015 Sep 28;9:CD010106.

BACKGROUND: Nausea and vomiting is a common and distressing presenting complaint in emergency departments (ED). The aetiology of nausea and vomiting in EDs is diverse and drugs are commonly prescribed. There is currently no consensus as to the optimum drug treatment of nausea and vomiting in the adult ED setting.

OBJECTIVES: To provide evidence of the efficacy and safety of antiemetic medications in the management of nausea and vomiting in the adult ED setting.

SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 8), MEDLINE (OvidSP) (January 1966 to August 2014), EMBASE (OvidSP) (January 1980 to August 2014) and ISI Web of Science (January 1955 to August 2014). We also searched relevant clinical trial registries and conference proceedings.

SELECTION CRITERIA: We included randomized controlled trials (RCTs) of any drug in the treatment of nausea and vomiting in the treatment of adults in the ED. Study eligibility was not restricted by language or publication status.

DATA COLLECTION AND ANALYSIS: Two review authors independently performed study selection, data extraction and assessment of risk of bias in included studies. We contacted authors of studies to obtain missing information if required.

MAIN RESULTS: We included eight trials, involving 952 participants, of which 64% were women. Included trials were generally of adequate quality, with six trials at low risk of bias, and two trials at high risk of bias. Three trials with 518 participants compared five different drugs with placebo; all reported the primary outcome as mean change in visual analogue scale (VAS) (0 to 100) for nausea severity from baseline to 30 minutes. Trials did not routinely report other primary outcomes of the change in nausea VAS at 60 minutes or number of vomiting episodes. Differences in mean VAS change from baseline to 30 minutes between placebo and the drugs evaluated were: metoclopramide (three trials, 301 participants; mean difference (MD) -5.27, 95% confidence interval (CI) -11.33 to 0.80), ondansetron (two trials, 250 participants; MD -4.32, 95% CI -11.20 to 2.56), prochlorperazine (one trial, 50 participants; MD -1.80, 95% CI -14.40 to 10.80), promethazine (one trial, 82 participants; MD -8.47, 95% CI -19.79 to 2.85) and droperidol (one trial, 48 participants; MD -15.8, 95% CI -26.98 to -4.62). The only statistically significant change in baseline VAS to 30 minutes was for droperidol, in a single trial of 48 participants. No other drug was statistically significantly superior to placebo. Other included trials evaluated a drug compared to "active controls" (alternative antiemetic). There was no convincing evidence of superiority of any particular drug compared to active control. All trials included in this review reported adverse events, but they were variably reported precluding meaningful pooling of results. Adverse events were generally mild, there were no reported serious adverse events. Overall, the quality of the evidence was low, mainly because there were not enough data.

AUTHORS' CONCLUSIONS: In an ED population, there is no definite evidence to support the superiority of any one drug over any other drug, or the superiority of any drug over placebo. Participants receiving placebo often reported clinically significant improvement in nausea, implying general supportive treatment such as intravenous fluids may be sufficient for the majority of people. If a drug is considered necessary, choice of drug may be dictated by other considerations such as a person's preference, adverse-effect profile and cost. The review was limited by the paucity of clinical trials in this setting. Future research should include the use of placebo and consider focusing on specific diagnostic groups and controlling for factors such as intravenous fluid administered.

7. Effectiveness of Patient Choice in Nonoperative vs Surgical Management of Pediatric Uncomplicated Acute Appendicitis

Minneci PC, et al. JAMA Surg. 2015 December 16 [Epub ahead of print].

Importance  Current evidence suggests that nonoperative management of uncomplicated appendicitis is safe, but overall effectiveness is determined by combining medical outcomes with the patient’s and family’s perspective, goals, and expectations.

Objective  To determine the effectiveness of patient choice in nonoperative vs surgical management of uncomplicated acute appendicitis in children.

Design, Setting, and Participants  Prospective patient choice cohort study in patients aged 7 to 17 years with acute uncomplicated appendicitis presenting at a single pediatric tertiary acute care hospital from October 1, 2012, through March 6, 2013. Participating patients and families gave informed consent and chose between nonoperative management and urgent appendectomy.

Interventions  Urgent appendectomy or nonoperative management entailing at least 24 hours of inpatient observation while receiving intravenous antibiotics and, on demonstrating improvement of symptoms, completion of 10 days of treatment with oral antibiotics.

Main Outcomes and Measures  The primary outcome was the 1-year success rate of nonoperative management. Successful nonoperative management was defined as not undergoing an appendectomy. Secondary outcomes included comparisons of the rates of complicated appendicitis, disability days, and health care costs between nonoperative management and surgery.

Results  A total of 102 patients were enrolled; 65 patients/families chose appendectomy (median age, 12 years; interquartile range [IQR], 9-13 years; 45 male [69.2%]) and 37 patients/families chose nonoperative management (median age, 11 years; IQR, 10-14 years; 24 male [64.9%]). Baseline characteristics were similar between the groups. The success rate of nonoperative management was 89.2% (95% CI, 74.6%-97.0%) at 30 days (33 of 37 children) and 75.7% (95% CI, 58.9%-88.2%) at 1 year (28 of 37 children). The incidence of complicated appendicitis was 2.7% in the nonoperative group (1 of 37 children) and 12.3% in the surgery group (8 of 65 children) (P = .15). After 1 year, children managed nonoperatively compared with the surgery group had fewer disability days (median [IQR], 8 [5-18] vs 21 [15-25] days, respectively; P less than .001) and lower appendicitis-related health care costs (median [IQR], $4219 [$2514-$7795] vs $5029 [$4596-$5482], respectively; P = .01).

Conclusions and Relevance  When chosen by the family, nonoperative management is an effective treatment strategy for children with uncomplicated acute appendicitis, incurring less morbidity and lower costs than surgery.

Editorial1: Should Patients Choose Their Care?

Editorial2: Abx vs Surgery for Acute Appendicitis: Toward a Pt-Centered Treatment Approach

8. Reconsidering the effectiveness and safety of carotid sinus massage as a therapeutic intervention in patients with SVT

Collins NA, et al. Am J Emerg Med. 2015;33(6):807-9.

OBJECTIVE: The objectives of our investigation were to review the evidence for the efficacy and safety of carotid sinus massage in terminating supraventricular tachycardia and to determine if other potentially less harmful interventions have been established to be safer and more effective.

METHODS: A search using PubMed, Ovid, and COCHRANE databases was performed using the terms supraventricular tachycardia, carotid sinus massage, SVT, and CSM. Articles not written in English were excluded. There was a paucity of randomized controlled trials comparing various supraventricular tachycardia (SVT) interventions. However, articles of highest quality were selected for review and inclusion. In addition, articles examining potential hazards of carotid sinus massage in case report format were reviewed, even when performed for other indications other than SVT, as the maneuver is identically performed. Selected articles were reviewed by both authors for relevance to the topic.

RESULTS: Summarizing the findings of this review leads to these 3 fundamental conclusions. First, a therapeutic intervention should only be performed when the benefit of the procedure outweighs its risk. Carotid sinus massage exposes the patient to rare but potentially devastating iatrogenic harm. Second, a therapeutic intervention should be efficacious. The efficacy of carotid sinus massage in terminating supraventricular tachycardia appears to be modest at best. Third, other readily available, easily mastered, and potentially safer and more efficacious alternative interventions are available such as Valsalva maneuver and pharmacologic therapy.

CONCLUSION: Based on the limited evidence available, we believe that carotid sinus massage should be reconsidered as a first-line therapeutic intervention in the termination of SVT.

9. The $40 Billion Snake Oil Industry

The government finally is cracking down on the unregulated dietary supplement industry.

SHADY. The Daily Beast. 11.17.15

Principal Deputy Assistant Attorney General Ben Mizer took the podium Tuesday to announce a multi-faceted approach to “stem the tide of unlawful dietary supplements” in the U.S.—one that’s motivated by a spate of lawsuits and severe illness resulting from the substances.

According to the National Institutes of Health the “majority of adults” take a dietary supplement either every day or occasionally. Since the Federal Drug Administration does not approve the substances, the $40 billion industry remains unregulated, which leaves room for companies to hide a cocktail of ingredients within their product.

A study from April of this year published in the Drug Testing and Analysis journal found the presence of synthetic speed that’s never been tested in humans in 11 different supplements. A 2014 study published in the Journal of the American Medical Association found “two thirds of supplements previously recalled by the FDA were still tainted with prescription drugs.”

Beyond unethical, the hidden ingredients can prove widely dangerous.

A paper published this October in The New England Journal of Medicine found an estimated 23,000 emergency room visits each year to be related to dietary supplements. Twenty-eight percent involved young adults between the ages of 20-34, must of whom suffered cardiovascular problems.

Tuesday’s announcement marks the biggest effort to clean up the supplement industry thus far.

The “sweep of actions” to be taken in the following months includes plans from the Federal Trade Commission, the FDA, the U.S. Postal Services, the Department of Defense, and the Anti-Doping Agency.

On the legal front, Mizer said the attorney general’s office intends to pursue civil and criminal cases against the makers of these products for knowingly selling dangerous drugs. He announced a new case against the maker of a workout/weight loss supplement, USP Labs. Sold under names like Jack3d and OxyElitePro, the best-selling supplement is made with chemicals from China that Mizer said the company knew were dangerous and used anyway…

10. Who is prescribing controlled medications to patients who die of prescription drug abuse?

Lev R, et al. Am J Emerg Med. 2016 Jan;34(1):30-5.

BACKGROUND: Prescription drug-related fatalities remain a significant issue in the United States, yet there is a relative lack of knowledge on the specialty-specific prescription patterns for drug-related deaths.

METHODS: We designed a study that investigated medical examiner reports of prescription drug-related deaths that occurred in San Diego County during 2013. A Prescription Drug Monitoring Program search was performed on each of these cases to ascertain which physician specialties had prescribed controlled substances to these patients. The data were analyzed for each specialty, including pills per prescription, type of prescription, doctor shoppers (4 physicians + 4 pharmacies over 1 year), and chronic users (≥3 consecutive months of medications).

MAIN FINDINGS: In 2013, 4.5% of all providers in San Diego County wrote a prescription for a patient who died a prescription-related death. There were a total of 713 providers who prescribed 4,366 medications totaling 328,928 pills. Overall, emergency physicians gave the lowest number of prescriptions per provider (1.6), whereas pain management provided the highest amount per provider (12.9). Most prescriptions went to doctor shoppers (over 50%) and chronic users (95.8%). Hydrocodone was the most frequently prescribed medication to those patients whose deaths were related to prescription drugs.

CONCLUSIONS: Emergency physicians appear to provide fewer prescriptions to those patients who die due to prescription drugs. Emergency physicians do, however, account for a significant proportion of total providers in this study. These results highlight the need to use Prescription Drug Monitoring Program data to closely monitor prescription patterns and to intervene when necessary.

11. Saline Flush after Bolus Rocuronium Shortens Onset of Neuromuscular Blockade

Ishigaki S, et al. Saline Flush After Rocuronium Bolus Reduces Onset Time and Prolongs Duration of Effect: A RCT. Anesth Analg 2015 Nov 23 [Epub ahead of print].  

BACKGROUND: Circulatory factors modify the onset time of neuromuscular-blocking drugs. Therefore, we hypothesized that infusion of a saline flush immediately after rocuronium administration would shorten the onset time without influencing the duration of the rocuronium effect.

METHODS: Forty-eight patients were randomly allocated to the control or saline flush group. Anesthesia was induced and maintained with propofol and remifentanil, and all patients received 0.6 mg/kg rocuronium in 10 mL of normal saline. In the saline flush group, 20 mL normal saline was immediately infused after rocuronium administration. Neuromuscular blockade was assessed using acceleromyography at the adductor pollicis muscle with train-of-four (TOF) stimulation. The neuromuscular indices for rocuronium were calculated as follows: the latent onset time, defined as the time from the start of rocuronium infusion until first occurrence of depression of the first twitch of the TOF (T1) ≥5%; onset time, defined as the time from the start of rocuronium infusion until first occurrence of depression of the T1 ≥95%; clinical duration, defined as the time from the start of rocuronium administration until T1 recovered to 25% of the final T1 value; recovery index, defined as the time for recovery of T1 from 25% to 75% of the final T1 value; and the total recovery time, defined as the time from the start of rocuronium administration until reaching a TOF ratio of 0.9. Significance was designated at P less than 0.05.

RESULTS: The measured latent onset time and onset time were significantly shorter in the saline flush group than the control group by 15 seconds (95.2% confidence interval, 0-15, P = 0.007) and 15 seconds (0-30, P = 0.018), respectively. Saline flush significantly depressed the T1 height at 30, 45, and 60 seconds after the rocuronium bolus by 17%, 24%, and 14%, respectively. In addition, the recovery phase was significantly prolonged in the saline flush group. The mean clinical duration (5th-95th percentile range) in the saline flush group and control group was 35 minutes (27-63 minutes) and 31 minutes (19-48 minutes; P = 0.032), respectively; the recovery index was 13 minutes (8-25 minutes) and 10 minutes (7-19 minutes; P = 0.019), respectively; and the total recovery time was 61 minutes (44-108 minutes) and 50 minutes (35-93 minutes; P = 0.048), respectively.

CONCLUSIONS: Administering a 20-mL saline flush immediately after infusion of 0.6 mg/kg rocuronium in 10 mL normal saline shortened the onset time and prolonged the recovery phase of neuromuscular blockade.

12. The medical response to multisite terrorist attacks in Paris

Hirsch M, et al Lancet. 2015 November 25 [Epub ahead of print]

Friday, Nov 13, 2015. It's 2130 h when the Assistance Publique-Hôpitaux de Paris (APHP) is alerted to the explosions that have just occurred at the Stade de France, a stadium in Saint-Denis just outside Paris. Within 20 min, there are shootings at four sites and three bloody explosions in the capital. At 2140 h, a massacre takes place and hundreds of people are held hostage for 3 h in Bataclan concert hall (figure).

The emergency medical services (service d'aide médicale d'urgence, SAMU) are immediately mobilised and the crisis cell at the APHP is opened. The APHP crisis unit is able to coordinate 40 hospitals, the biggest entity in Europe with a total of 100 000 health professionals, a capacity of 22 000 beds, and 200 operating rooms. It is very quickly confirmed that the attacks are multiple and that the situation is highly scalable and progressing dangerously. These facts led to a first decision: the activation of the “White Plan” (by the APHP Director General) at 2234 h—mobilising all hospitals, recalling staff, and releasing beds to cope with a large influx of wounded people. The concept of the White Plan was developed 20 years ago, but this is the first time that the plan has been activated. It is a big decision, and timing is key: it would lose its effectiveness if taken too late. On the night of Friday Nov 13 to Saturday Nov 14, the activation of the White Plan had a critical effect. At no time during the emergency was there a shortage of personnel.

During these hours, as the number of victims increased, with a sharp increase after the assault was launched inside the Bataclan, we were able to reassure the public and government that our abilities matched the demand. And when we felt that it might be necessary to deal with an influx of severely injured people, two further “reservoir” capacities were prepared: other hospitals in the area were put on alert, together with some university hospitals, more distant from Paris, but with the ability to mobilise ten helicopters to organise the transport of the wounded. These other two reservoirs have not been used, and we believe that despite this unprecedented number of wounded, the available services were far from being saturated. While hospitals were receiving and directing patients to specific institutions based on capacity and specialty, a psychological support centre was set up. 35 psychiatrists, together with psychologists, nurses, and volunteers were gathered in a central Paris hospital, Hôtel Dieu. Most of them had played a similar role during the attacks against Charlie Hebdo. Most of the emergency workers and health professionals working on the evening of Nov 13 had already been involved in serious crises, were used to working together, and had participated, especially in recent months, in exercises or in updating emergency plans.

In this report, we present the prehospital and hospital management of this unprecedented multisite attack in Paris from the viewpoint of the emergency physician, the trauma surgeon, and the anaesthesiologist. This is a testimony on behalf of the health professionals involved in the night of Nov 13.

13. Images in Clinical Practice

Woman With Wrist Pain After Falling

Elderly Man With Abdominal Pain and Shortness of Breath

Man With Facial Nerve Palsy and Ear Pain

Elderly Man With Chest Pain

Male With Fever and Flank Pain

Pylephlebitis as a Complication of Diverticulitis

Left ventricular thrombus

Squamous-Cell Carcinoma of the Nail Bed

Cullen’s and Grey Turner’s Signs in Acute Pancreatitis

Achalasia with Megaesophagus

14. Triage sepsis alert and sepsis protocol lower times to fluids and antibiotics in the ED

Hayden GE, et al. Am J Emerg Med. 2016 Jan;34(1):1-9.

BACKGROUND: Early identification of sepsis in the emergency department (ED), followed by adequate fluid hydration and appropriate antibiotics, improves patient outcomes.

OBJECTIVES: We sought to measure the impact of a sepsis workup and treatment protocol (SWAT) that included an electronic health record (EHR)-based triage sepsis alert, direct communication, mobilization of resources, and standardized order sets.

METHODS: We conducted a retrospective, quasiexperimental study of adult ED patients admitted with suspected sepsis, severe sepsis, or septic shock. We defined a preimplementation (pre-SWAT) group and a postimplementation (post-SWAT) group and further broke these down into SWAT A (septic shock) and SWAT B (sepsis with normal systolic blood pressure). We performed extensive data comparisons in the pre-SWAT and post-SWAT groups, including demographics, systemic inflammatory response syndrome criteria, time to intravenous fluids bolus, time to antibiotics, length-of-stay times, and mortality rates.

RESULTS: There were 108 patients in the pre-SWAT group and 130 patients in the post-SWAT group. The mean time to bolus was 31 minutes less in the postimplementation group, 51 vs 82 minutes (95% confidence interval, 15-46; P value less than .01). The mean time to antibiotics was 59 minutes less in the postimplementation group, 81 vs 139 minutes (95% confidence interval, 44-74; P value less than .01). Segmented regression modeling did not identify secular trends in these outcomes. There was no significant difference in mortality rates.

CONCLUSIONS: An EHR-based triage sepsis alert and SWAT protocol led to a significant reduction in the time to intravenous fluids and time to antibiotics in ED patients admitted with suspected sepsis, severe sepsis, and septic shock.

15. Warning Symptoms Are Associated With Survival from Sudden Cardiac Arrest

Marijon E, et al. Ann Intern Med. 2015 Dec 22 [Epub ahead of print]

Background: Survival after sudden cardiac arrest (SCA) remains low, and tools for improved prediction of patients at long-term risk for SCA are lacking. Alternative short-term approaches aimed at preemptive risk stratification and prevention are needed.

Objective: To assess characteristics of symptoms in the 4 weeks before SCA and whether response to these symptoms is associated with better outcomes.

Design: Ongoing prospective population-based study.

Setting: Northwestern United States (2002 to 2012).

Patients: Residents aged 35 to 65 years with SCA.

Measurement: Assessment of symptoms in the 4 weeks preceding SCA and association with survival to hospital discharge.

Results: Of 839 patients with SCA and comprehensive assessment of symptoms (mean age [SD], 52.6 [8] years; 75% men), 430 patients (51%) had warning symptoms (50% of men vs. 53% of women; P = 0.59), mainly chest pain and dyspnea. In most symptomatic patients (93%), symptoms recurred within the 24 hours preceding SCA. Only 81 patients (19%) called emergency medical services (911) to report symptoms before SCA; these persons were more likely to be patients with a history of heart disease (P less than 0.001) or continuous chest pain (P less than 0.001). Survival when 911 was called in response to symptoms was 32.1% (95% CI, 21.8% to 42.4%) compared with 6.0% (CI, 3.5% to 8.5%) in those who did not call (P less than 0.001).

Limitation: Potential for recall and response bias, symptom assessment not available in 24% of patients, and missing data for some patients and SCA characteristics.

Conclusion: Warning symptoms frequently occur before SCA, but most are ignored. Emergent medical care was associated with survival in patients with symptoms, so new approaches are needed for short-term prevention of SCA.

16. Software tools help patients remember, understand care plans

Software developed at Lenox Hill Hospital in New York City gives patients a video of their MRI or CT scans as well as instructions from their office visits or hospital discharges so they can review and better understand the information and their treatments. Twenty facilities in the US use the Good to Go electronic discharge system, which allows nurses to make audiotapes of what patients should and should not do after their release from the hospital, and those facilities have seen declines in readmission rates.

What Patients Need to Remember After Leaving the Hospital

New tools help patients retain critical information to continue the healing process once they get home

By LUCETTE LAGNADO. Wall Street Journal. Nov. 30, 2015 1:32 p.m. ET

When Emily Monato went to see her neurosurgeon in October, she learned she had a potentially fatal lesion in her brain and needed surgery.

After receiving disturbing news, many patients retain little of what they were told, doctors say. But Ms. Monato was able to take advantage of an unusual new tool her physician gave her: a six-minute video from her office visit comprising a series of screen captures of her brain MRI transmitted from her doctor’s computer along with his assessment. Using an app on her iPhone, Ms. Monato watched and listened as the surgeon explored images of her brain, using his cursor to outline a walnut-size mass of vascular tissue he said needed quickly to be removed.

Then she watched the video again and again. At least five times. Replaying the video helped her “grasp these big chunks of information” and allay at least some fears, such as, “Am I going to for get how to count to 10?,” she says.

Ms. Monato, 49 years old, shared the video with others. She told her anxious father, a retired doctor in Florida: “You know, Dad, I am not even going to try to explain. Please watch the video.” She encouraged her friends and even her children, ages 8 and 12, to see it, too.

Ms. Monato, who lives near Princeton, N.J., is a participant in a project by David Langer, chief of neurosurgery at Lenox Hill Hospital in New York City, to use technology to record crucial steps of a patient’s experience in the hospital. Dr. Langer, who helped develop the software with a tech partner, says he believes it takes some of the confusion out of doctor-patient exchanges.

Patients “would go home and call back and say they didn’t understand, and then ask me the same questions,” he says. Part of the problem: “Doctors often do a terrible job at educating their patients.”

Research shows patients don’t absorb much of the medical information they receive from their physician and are often wrong about what they do remember. Patients “immediately” forget 40% to 80% of what the doctor told them, according to a 2003 paper in Britain’s Journal of the Royal Society of Medicine.

Some 50% of patients discharged from hospitals make mistakes in their aftercare with medications, and many end up back in the hospital, says Brian Jack, chief of family medicine at Boston Medical Center, who is leading a research effort he hopes will retool the discharge process in U.S. hospitals. “We throw papers and throw words at patients. It is crazy to think they would understand,” he says. This is especially true of older patients and those who are depressed…

17. Suturing no better than conservative management of small lacerations of the hand: randomised controlled trial.

Quinn J, et al. BMJ. 2002;325(7359):299.

OBJECTIVE: To assess the difference in clinical outcome between lacerations of the hand closed with sutures and those treated conservatively.

DESIGN: Randomised controlled trial.

SETTING: Emergency department in a tertiary hospital.

PARTICIPANTS: Consecutive patients presenting between 16 February and 30 November 2000 with uncomplicated lacerations of the hand (full thickness less than 2 cm; without tendon, joint, fracture, or nerve complications) who would normally require sutures. 154 patients were eligible, 58 refused, and 5 were missed; 91 patients with 95 lacerations were enrolled.

INTERVENTION: Participants were randomised to suturing or conservative treatment.

MAIN OUTCOME MEASURES: Primary outcome was cosmetic appearance after three months, rated on a previously validated visual analogue scale. Duration of treatment, pain during treatment, patients' assessment of their outcome, and the time for patients to resume normal activities were also measured.

RESULTS: Participants treated with sutures and those treated conservatively did not differ significantly in the assessment of cosmetic appearance by independent blinded doctors after three months: 83 mm v 80 mm, (mean difference 3 (95% confidence interval -1 to 8) mm) on the visual analogue scale. The mean time to resume normal activities was the same in both groups (3.4 days). Patients treated conservatively had less pain (difference 18 (12 to 24) mm) and treatment time was 14 (10 to 18) min shorter.

CONCLUSION: Similar cosmetic and functional outcomes result from either conservative treatment or suturing of small uncomplicated lacerations of the hand, but conservative treatment is faster and less painful.

18. Firearm-Related Injury and Death in the United States: A Call to Action from 8 Health Professional Organizations and the American Bar Association

Weinberger SE, et al. Ann Intern Med. 2015;162(7):513-6.

Firearm-related injury and death in the United States: a call to action from 8 health professional organizations and the American Bar Association.

The ABEM, the American Bar Association and other professional organizations are calling for an end to the federal funding ban on research on gun violence.

Deaths and injuries related to firearms constitute a major public health problem in the United States. In response to firearm violence and other firearm-related injuries and deaths, an interdisciplinary, interprofessional group of leaders of 8 national health professional organizations and the American Bar Association, representing the official policy positions of their organizations, advocate a series of measures aimed at reducing the health and public health consequences of firearms. The specific recommendations include universal background checks of gun purchasers, elimination of physician “gag laws,” restricting the manufacture and sale of military-style assault weapons and large-capacity magazines for civilian use, and research to support strategies for reducing firearm-related injuries and deaths. The health professional organizations also advocate for improved access to mental health services and avoidance of stigmatization of persons with mental and substance use disorders through blanket reporting laws. The American Bar Association, acting through its Standing Committee on Gun Violence, confirms that none of these recommendations conflict with the Second Amendment or previous rulings of the U.S. Supreme Court.

Across the United States, physicians have first hand experience with the effects of firearm-related injuries and deaths and the impact of such events on the lives of their patients. Many physicians and other health professionals recognize that this is not just a criminal violence issue but also a major public health problem (1–2).

Because of this, we, the executive staff leadership of 7 physician professional societies (whose members include most U.S. physicians), renew our organizations' call for policies to reduce the rate of firearm injuries and deaths in the United States and reiterate our commitment to be a part of the solution in mitigating these events. We represent the American Academy of Family Physicians, American Academy of Pediatrics, American College of Emergency Physicians, American Congress of Obstetricians and Gynecologists, American College of Physicians, American College of Surgeons, and American Psychiatric Association. The American Public Health Association, which is committed to improving the health of the population, and the American Bar Association (ABA), which is committed to helping lawyers and the public understand that the Second Amendment does not impede reasonable measures to limit firearm violence, join the physician organizations in articulating the principles and consensus-based recommendations summarized herein.

The recommendations presented here are based substantially on the various positions approved and adopted by our organizations (3–12).

19. The medical marriage: a national survey of the spouses/partners of US physicians.

Shanafelt TD, et al. Mayo Clin Proc. 2013;88(3):216-25.

OBJECTIVE: To evaluate physician relationships from the perspective of their spouses/partners.

METHODS: Nearly all data on satisfaction with physician relationships come from the perspective of the physician rather than their spouse/partner. We conducted a national study of the spouses/partners of US physicians from August 17, 2011, through September 12, 2011. Responding spouses/partners provided information on demographic characteristics, their own work life, and the work life of their physician partners. Spouses/partners also rated relationship satisfaction and the effect of the work life of their physician partner on the relationship.

RESULTS: Of the 1644 spouses/partners of physicians surveyed, 891 (54.2%) responded. Most spouses/partners (86.8%) reported that they were satisfied with their relationship with their physician partner. Satisfaction strongly related to the amount of time spent awake with their physician partners each day. Despite their overall satisfaction, spouses/partners reported their physician partners frequently came home irritable, too tired to engage in home activities, or preoccupied with work. On multivariate analysis, minutes spent awake with their physician partners each day was the strongest predictor of relationship satisfaction, exhibiting a dose-response effect. No professional characteristic of the physician partners (eg, hours worked per week, specialty area, and practice setting) other than the number of nights on call per week correlated with relationship satisfaction on adjusted analysis.

CONCLUSION: The spouses/partners of US physicians report generally high satisfaction with their relationships. The mean time spent with their physician partners each day appears to be a dominant factor associated with relationship satisfaction and overshadows any specific professional characteristic of the physicians' practice, including specialty area, practice setting, and work hours.

Also, Dyrbye LN, et al. A survey of U.S. physicians and their partners regarding the impact of work-home conflict. J Gen Intern Med. 2014;29(1):155-61.

20. Performance of the 4-way range of motion test for radiographic injuries after blunt elbow trauma.

Vinson DR, et al. Am J Emerg Med. 2015 Oct 24 [Epub ahead of print].

OBJECTIVES: Acute elbow injuries are common in the acute care setting. A previous study observed that limited active range of motion (ROM) was highly sensitive for radiographic injuries after blunt trauma. Our aim was to validate these findings in patients ≥5 years old with an acute (less than 24 hours) nonpenetrating elbow injury.

METHODS: This prospective study included a convenience sample of patients undergoing plain radiographs of an injured elbow in 3 emergency departments. Before imaging, treating clinicians completed a standardized data collection sheet including mechanism of injury and 4-way ROM findings (full extension, flexion to 90°, full pronation and supination). Radiographic interpretation by a staff radiologist was used to ascertain the presence of fracture or joint effusion.

RESULTS: The median age of the 251 patients was 24 years. Ninety-two patients (36.7%) had active 4-way ROM, and 159 patients (63.3%) demonstrated limited ROM. Negative radiographs were present in 152 patients (60.6%), whereas 99 patients (39.4%) had abnormal radiographs: 75 with explicit fractures and 24 with only joint effusions. The 4-way ROM elbow test had a sensitivity of 0.99 (95% confidence interval [CI], 0.94-1.00), specificity of 0.60 (95% CI, 0.52-0.68), positive predictive value of 0.62 (95% CI, 0.54-0.69), and negative predictive value of 0.99 (95% CI, 0.94-1.00).

CONCLUSIONS: Active 4-way ROM test is 99% sensitive for all radiographic injures following blunt elbow trauma and 100% sensitive for injuries requiring surgical intervention. Caution should be used in relying on this test in the pediatric population until it is validated in a larger cohort.

21. Literature Reviews from Ann Emerg Med

A. Are Oral Antibiotics as Effective as a Combination of Intravenous and Oral Antibiotics for Kidney Infections in Children?

For well-appearing children older than 1 month with pyelonephritis, oral antibiotics alone appear to be as effective as intravenous (3 to 4 days) followed by oral therapy when completing 10 to 14 days of treatment.

B. Managing Anterior Shoulder Dislocation

C. What Are the Most Useful Red Flags for Suspected Vertebral Fracture in Patients With Low Back Pain in the Emergency Department?

According to data of only moderate quality, individual red flags appear to be mostly unhelpful for identifying vertebral fracture.

Low back pain is the most common musculoskeletal complaint presenting to the ED and can be resource intensive, mostly because of the pursuit of high-risk diagnoses. Clinical practice guidelines and review articles commonly recommend assessing for vertebral fracture with “red flags” such as trauma history, osteoporosis, corticosteroid use, older age (men over 65 years; women over 75 years), and female sex. Supporting evidence for the utility of such red flags, however, is weak. Furthermore, false-positive red flags can lead to excessive unnecessary imaging.

In this updated review, few red flags were discriminatory when assessed in isolation. The use of red-flag combinations, however, did have some clinical utility, although in the primary care setting. The presence of spinal contusion or abrasion (LR+ 31) and vertebral trauma with neurologic abnormalities (LR+ 14) both strongly suggested the presence of fracture. Perhaps most important, the review found that small numbers, bias, heterogeneity, and inconsistent reporting plague available data, and suggest that higher-quality evidence is badly needed.

D. Does Mannitol Reduce Mortality From Traumatic Brain Injury?

There is insufficient evidence to support the routine use of mannitol in the management of severe traumatic brain injury.

E. What Is the Prognosis of Nontraumatic Hypotension and Shock in the Out-of-Hospital and ED Setting?

Patients with undifferentiated, nontraumatic hypotension are at high risk of short-term mortality, ranging from 12% to 52%, depending on the setting and definition of shock.

22. Morning Report at the Royal Free Hospital, London, from the Lancet: Sudden-onset Headache

The Interactive Grand Round includes videos, audio interviews with doctors involved in the patient’s care as well as x-rays and photographs. The cases range from the very complex to everyday cases.

Test your skills of differential diagnosis and management in these interactive cases.

A 55-year old gentleman presented to the emergency room complaining of a four day history of bifrontal and occipital headache. What is the most likely cause of this gentleman's presentation?

23. Femur fractures should not be considered distracting injuries for cervical spine assessment.

Dahlquist RT, et al. Am J Emerg Med. 2015;33(12):1750–1754.

INTRODUCTION: The National Emergency X-Radiography Utilization Study (NEXUS) clinical decision rule is extremely sensitive for clearance of cervical spine (C-spine) injury in blunt trauma patients with distracting injuries.

OBJECTIVES: We sought to determine whether the NEXUS criteria would maintain sensitivity for blunt trauma patients when femur fractures were not considered a distracting injury and an absolute indication for diagnostic imaging.

METHODS: We retrospectively analyzed blunt trauma patients with at least 1 femur fracture who presented to our emergency department as trauma activations from 2009 to 2011 and underwent C-spine injury evaluation. Presence of C-spine injury requiring surgical intervention was evaluated.

RESULTS: Of 566 trauma patients included, 77 (13.6%) were younger than 18 years. Cervical spine injury was diagnosed in 53 (9.4%) of 566. A total of 241 patients (42.6%) had positive NEXUS findings in addition to distracting injury; 51 (21.2%) of these had C-spine injuries. Of 325 patients (57.4%) with femur fractures who were otherwise NEXUS negative, only 2 (0.6%) had C-spine injuries (95% confidence interval [CI], 0.2%-2.2%); both were stable and required no operative intervention. Use of NEXUS criteria, excluding femur fracture as an indication for imaging, detected all significant injuries with a sensitivity for any C-spine injury of 96.2% (95% CI, 85.9%-99.3%) and negative predictive value of 99.4% (95% CI, 97.6%-99.9%).

CONCLUSIONS: In our patient population, all significant C-spine injuries were identified by NEXUS criteria without considering the femur fracture a distracting injury and indication for computed tomographic imaging. Reconsidering femur fracture in this context may decrease radiation exposure and health care expenditure with little risk of missed diagnoses.

24. Three factors contribute to infants' overall SIDS risk

Sleeping environment, a natural predisposition to sudden infant death syndrome and being in a critical period of development are the factors that contribute to an infant's overall risk of SIDS, according to a study in Pediatrics. Researchers analyzed the rates of SIDS in the US between 1983 and 2012 and found a 38% decline in SIDS between 1992 and 1996 after the American Academy of Pediatrics recommended placing babies on their backs to sleep.

25. Are Lower Trimethoprim–Sulfamethoxazole Doses Effective for Pneumocystis Pneumonia?

Creemers-Schild D et al. Infection 2015 Oct 15.   

Half of the currently recommended dose may be sufficient, and patients who improve rapidly can be switched to a low dose.

BACKGROUND: The recommended treatment of Pneumocystis jirovecii pneumonia (PCP) is high-dose trimethoprim-sulfamethoxazole (TMP-SMX) in an equivalent of TMP 15-20 mg/kg/day and SMX 75-100 mg/kg/day for 2 or 3 weeks. High rates of adverse events are reported with this dose, which raises the question if lower doses are possible.

METHODS: All adult patients diagnosed with PCP in various immune dysfunctions and treated with TMP-SMX between January 1, 2003 and July 1, 2013 in a tertiary university hospital were included. Per institutional protocol, patients initiated treatment on intermediate-dose TMP-SMX (TMP 10-15 mg/kg/day) and could be stepped down to low-dose TMP-SMX (TMP 4-6 mg/kg/day) during treatment. Clinical variables at presentation, relapse rate and mortality rates were compared between intermediate- and step-down treatment groups by uni- and multivariate analyses.

RESULTS: A total of 104 patients were included. Twenty-four patients (23 %) were switched to low-dose TMP-SMX after a median of 4.5 days (IQR 2.8-7.0 days). One relapse (4 %) occurred in the step-down group versus none in the intermediate-dose group. The overall 30-day mortality was 13 %. There was 1 death in the step-down group (4 %) compared to 13 deaths (16 %) in the intermediate-dose group.

CONCLUSIONS: We observed high cure rates of PCP by treatment with intermediate-dose TMP-SMX. In addition, a step-down strategy to low-dose TMP-SMX during treatment in selected patients appears to be safe and does not compromise the outcome of treatment.

26. Science journal’s list of the leading stories for 2015:
  •  The thermostat in your office may be sexist
  • Did natural selection make the Dutch the tallest people on the planet?
  •  Internet search engines may be influencing elections
  • Rats forsake chocolate to save a drowning companion
  • Did dark matter kill the dinosaurs?
  • Want to influence the world? Map reveals the best languages to speak
  • Shattered chromosome cures woman of immune disease
  • Rare African plant signals diamonds beneath the soil
  • Winged monster’ on ancient rock art debunked by scientists
  • How long would it take you to fall through Earth? 

27. Micro Bits

A. Television viewing and mortality risk

Television viewing is associated with increased risk of cardiovascular disease and cancer mortality, but the association with other leading causes of death is unknown. This study examined the association between TV viewing and leading causes of death in individuals aged 50–71 years in the US who were free of chronic disease at baseline. After an average follow-up of 14.1 years, adjusted mortality risk for a 2-hour/day increase in TV viewing was significantly higher for the following causes of death: cancer, heart disease, chronic obstructive pulmonary disease, diabetes, influenza/pneumonia, Parkinson disease, liver disease and suicide.

B. Pre-exposure Prophylaxis to Cut HIV Infections Underused

Dec. 2, 2015 — A recent Morbidity and Mortality Weekly Report suggests wider use of pre-exposure prophylaxis (PrEP) could greatly reduce the number of new HIV infections. In fact, daily PrEP can reduce the risk of sexually acquired HIV infection by more than 90 percent; in IV drug users, the risk drops by more than 70 percent.

C. On-Demand Preexposure Prophylaxis in Men at High Risk for HIV-1 Infection

Conclusion: The use of TDF-FTC before and after sexual activity provided protection against HIV-1 infection in men who have sex with men. The treatment was associated with increased rates of gastrointestinal and renal adverse events.

D. Mother-to-child HIV transmission may be eliminated in 17 countries in Americas

Seventeen countries and territories across the Americas, including the US, several Caribbean islands and Cuba, may have eliminated mother-to-child transmission of HIV and syphilis, according to the UN World Health Organization and the Pan American Health Organization. New infections dropped by half since 2010, said Carissa Etienne, head of PAHO/WHO, with the decrease attributed to improvements in women's access to prenatal care, HIV testing and antiretroviral treatment.

E. Early Exposure to Dogs and Farm Animals and the Risk of Childhood Asthma

Dogs decrease asthma. Cool!

F. 78% of patients with heart scarring are unaware of silent heart attack

A study published in the Journal of the American Medical Association found 78% of US adults with heart damage were unaware that they had experienced a heart attack. Researchers examined heart scans from a multi-ethnic pool of over 1,800 people without any heart conditions. Almost 8% had heart scarring after 10 years, but 78% of those heart attacks were "silent." Men, smokers, those with atherosclerosis, people carrying excess weight and those taking hypertension medication were at greater risk.

G. Effects of Optimism and Gratitude on Physical Activity, Biomarkers, and Readmissions after an Acute Coronary Syndrome

Background—Positive psychological constructs, such as optimism, are associated with beneficial health outcomes. However, no study has separately examined the effects of multiple positive psychological constructs on behavioral, biological, and clinical outcomes after an acute coronary syndrome (ACS). Accordingly, we aimed to investigate associations of baseline optimism and gratitude with subsequent physical activity, prognostic biomarkers, and cardiac rehospitalizations in post-ACS patients.

Conclusions—Post-ACS optimism, but not gratitude, was prospectively and independently associated with superior physical activity and fewer cardiac readmissions. Whether interventions that target optimism can successfully increase optimism or improve cardiovascular outcomes in post-ACS patients is not yet known, but can be tested in future studies.

H. Mind the phone

As roughly 20 million Fitbit owners can attest, the idea of the "quantified self" is enticing. Consumers are turning to their smartphones and wearable devices to count their steps, their calories, or their hours of sleep; to help them quit smoking, drinking, or stressing; or to help manage chronic illness. And this life-tracking craze has produced something that many clinical researchers covet: a deluge of intimate data about individuals' moment-to-moment behavior, and the chance to influence that behavior in real time, through activities built into an app or strategically timed alerts and messages. Major university health centers and government funding agencies hope "mHealth" will finally make a dent in intractable public health problems, from obesity to tobacco use to depression. But harnessing the self-tracking trend to promote healthier behavior is far from a sure bet, as the first generation of mobile health researchers are discovering.

I. Pain catastrophizing, fear of movement, and work disability

Pain catastrophizing and fear of movement have been identified as key predictors of prolonged work disability following whiplash injury. However, little is known about the processes by which these issues impact on return to work. This study investigated the mediating role of expectancies on the relations between pain catastrophizing and return to work, and fear of movement and return to work following whiplash injury. Consistent with previous research, analyses revealed that expectancies, pain catastrophizing, and fear of movement were significant predictors of return to work at one-year follow-up. The predictive and mediating role of expectancies on return to work argues for the inclusion of expectancies as a specific target of intervention for individuals with whiplash injury.

J. Shingles increases short-term risk of stroke, heart attack for seniors

A study published in the journal PLOS Medicine found that seniors who develop shingles face a short-term jump in heart attack and stroke risk. Stroke risk more than doubled in the first week after diagnosis, while heart attack risk rose almost as much. The study, based on 43,000 Medicare patients, found that risk returned to normal levels after six months.

K. CDC issues guidelines on opioid prescribing for chronic pain

The CDC has released draft guidelines on prescribing opioids for chronic pain days after the National Center for Health Statistics reported a 16.3% jump in opioid overdose-related deaths in 2014. The guidelines, which don't apply to pain associated with serious diseases or end-of-life care, call for primary care clinicians to be more conservative when prescribing pain drugs and consider prioritizing physical therapy and other non-opioid treatments. When opioids are needed, prescribers should use the minimum effective dose and short-acting versions of the drugs.

L. CBT, antidepressants achieve similar outcomes in depression, study finds

Research published in The BMJ found cognitive-behavioral therapy provided similar response and remission rates when compared with second-generation antidepressants for patients with major depressive disorder. The study analyzed data from 11 randomized, controlled trials that compared the two treatment options.

M. Almost 29% of medical residents have signs of depression

Researchers who analyzed data from 54 studies conducted over 50 years found almost 29% of medical residents had signs of depression, and depression rates for these young physicians are increasing. Senior author Srijan Sen of the University of Michigan said more needs to be done by medical schools and hospitals to protect medical residents' mental health.

N. CDC: Drug overdose mortality hits new peak

Drug overdose deaths in the US reached 47,055 last year, up 6.5% from 2013, according to the CDC. Sixty-one percent of overdose deaths were attributed to prescription opioids and heroin, an increase of 14%. West Virginia, New Mexico, New Hampshire, Kentucky and Ohio had the highest overdose mortality rates, the agency said.