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.
PBS Video (8
min): http://www.pbs.org/newshour/bb/new-film-tackles-dangers-of-concussions-in-the-nfl/
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.
The remainder
of the essay: http://consumer.healthday.com/general-health-information-16/doctor-news-206/doctor-patient-relationship-may-suffer-when-technology-takes-over-study-705698.html
Link to
article (subscription required): http://archinte.jamanetwork.com/article.aspx?articleid=2473628
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.
Full-text
(free): http://www.annemergmed.com/article/S0196-0644(15)00387-X/fulltext
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? http://archsurg.jamanetwork.com/article.aspx?articleid=2475968
Editorial2: Abx
vs Surgery for Acute Appendicitis: Toward a Pt-Centered Treatment Approach http://archsurg.jamanetwork.com/article.aspx?articleid=2469648
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…
The remainder
of the essay: http://www.thedailybeast.com/articles/2015/11/17/the-40-billion-snake-oil-industry.html
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.
Full-text
(free): http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01063-6/fulltext
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…
The remainder
of the essay here: http://www.wsj.com/articles/what-patients-need-to-remember-after-leaving-the-hospital-1448908354
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.
See also the
associated editorial: http://www.mayoclinicproceedings.org/article/S0025-6196(13)00062-1/fulltext
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.
Commentary
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.
Full-text
(free): http://www.annemergmed.com/article/S0196-0644(15)00375-3/fulltext
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.
Full-text
(free): http://www.annemergmed.com/article/S0196-0644(15)00533-8/fulltext
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.
Full-text
(free): http://www.annemergmed.com/article/S0196-0644(15)00587-9/fulltext
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.
Abstract
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.
Abstract: http://circoutcomes.ahajournals.org/content/early/2015/12/08/CIRCOUTCOMES.115.002184.abstract
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.
Washington
Post: https://www.washingtonpost.com/news/to-your-health/wp/2015/12/14/hoping-to-curb-the-prescription-opioid-epidemic-cdc-proposes-new-guidelines-for-doctors/
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.
