1. High Prevalence of PE among Patients Hospitalized for Syncope:
Really?
Prandoni P, et
al. for the PESIT Investigators. N Engl J Med 2016; 375:1524-1531
BACKGROUND
The
prevalence of pulmonary embolism among patients hospitalized for syncope is not
well documented, and current guidelines pay little attention to a diagnostic
workup for pulmonary embolism in these patients.
METHODS
We performed
a systematic workup for pulmonary embolism in patients admitted to 11 hospitals
in Italy for a first episode of syncope, regardless of whether there were
alternative explanations for the syncope. The diagnosis of pulmonary embolism
was ruled out in patients who had a low pretest clinical probability, which was
defined according to the Wells score, in combination with a negative d-dimer
assay. In all other patients, computed tomographic pulmonary angiography or
ventilation–perfusion lung scanning was performed.
RESULTS
A total of
560 patients (mean age, 76 years) were included in the study. A diagnosis of
pulmonary embolism was ruled out in 330 of the 560 patients (58.9%) on the
basis of the combination of a low pretest clinical probability of pulmonary
embolism and negative d-dimer assay. Among the remaining 230 patients,
pulmonary embolism was identified in 97 (42.2%). In the entire cohort, the
prevalence of pulmonary embolism was 17.3% (95% confidence interval, 14.2 to
20.5). Evidence of an embolus in a main pulmonary or lobar artery or evidence
of perfusion defects larger than 25% of the total area of both lungs was found
in 61 patients. Pulmonary embolism was identified in 45 of the 355 patients (12.7%)
who had an alternative explanation for syncope and in 52 of the 205 patients
(25.4%) who did not.
CONCLUSIONS
Pulmonary
embolism was identified in nearly one of every six patients hospitalized for a
first episode of syncope.
2. New Guidelines: RBC Transfusion Thresholds and Storage
Carson JL, et
al. JAMA. 2016 Oct 12 [Epub ahead of
print].
Importance More than 100 million units of blood are
collected worldwide each year, yet the indication for red blood cell (RBC)
transfusion and the optimal length of RBC storage prior to transfusion are
uncertain.
Objective To provide recommendations for the target
hemoglobin level for RBC transfusion among hospitalized adult patients who are
hemodynamically stable and the length of time RBCs should be stored prior to
transfusion.
Evidence
Review Reference librarians conducted a
literature search for randomized clinical trials (RCTs) evaluating hemoglobin
thresholds for RBC transfusion (1950-May 2016) and RBC storage duration
(1948-May 2016) without language restrictions. The results were summarized
using the Grading of Recommendations Assessment, Development and Evaluation
method. For RBC transfusion thresholds, 31 RCTs included 12 587 participants and
compared restrictive thresholds (transfusion not indicated until the hemoglobin
level is 7-8 g/dL) with liberal thresholds (transfusion not indicated until the
hemoglobin level is 9-10 g/dL). The summary estimates across trials
demonstrated that restrictive RBC transfusion thresholds were not associated
with higher rates of adverse clinical outcomes, including 30-day mortality,
myocardial infarction, cerebrovascular accident, rebleeding, pneumonia, or
thromboembolism. For RBC storage duration, 13 RCTs included 5515 participants
randomly allocated to receive fresher blood or standard-issue blood. These RCTs
demonstrated that fresher blood did not improve clinical outcomes.
Findings It is good practice to consider the
hemoglobin level, the overall clinical context, patient preferences, and
alternative therapies when making transfusion decisions regarding an individual
patient. Recommendation 1: a restrictive RBC transfusion threshold in which the
transfusion is not indicated until the hemoglobin level is 7 g/dL is
recommended for hospitalized adult patients who are hemodynamically stable,
including critically ill patients, rather than when the hemoglobin level is 10
g/dL (strong recommendation, moderate quality evidence). A restrictive RBC
transfusion threshold of 8 g/dL is recommended for patients undergoing
orthopedic surgery, cardiac surgery, and those with preexisting cardiovascular
disease (strong recommendation, moderate quality evidence). The restrictive
transfusion threshold of 7 g/dL is likely comparable with 8 g/dL, but RCT
evidence is not available for all patient categories. These recommendations do
not apply to patients with acute coronary syndrome, severe thrombocytopenia
(patients treated for hematological or oncological reasons who are at risk of
bleeding), and chronic transfusion–dependent anemia (not recommended due to
insufficient evidence). Recommendation 2: patients, including neonates, should
receive RBC units selected at any point within their licensed dating period
(standard issue) rather than limiting patients to transfusion of only fresh
(storage length: less than 10 days) RBC units (strong recommendation, moderate
quality evidence).
Conclusions
and Relevance Research in RBC
transfusion medicine has significantly advanced the science in recent years and
provides high-quality evidence to inform guidelines. A restrictive transfusion
threshold is safe in most clinical settings and the current blood banking
practices of using standard-issue blood should be continued.
3. Your Surgeon Is Probably a Republican, Your Psychiatrist
Probably a Democrat
Margot
Sanger-Katz. New York Times, Oct. 6, 2016
We know that
Americans are increasingly sorting themselves by political affiliation
into friendships, even into
neighborhoods. Something similar seems to be happening with doctors and their
various specialties.
New data show
that, in certain medical fields, large majorities of physicians tend to share
the political leanings of their colleagues, and a study suggests ideology could
affect some treatment recommendations. In surgery, anesthesiology and urology,
for example, around two-thirds of doctors who have registered a political
affiliation are Republicans. In infectious disease medicine, psychiatry and
pediatrics, more than two-thirds are Democrats.
The
conclusions are drawn from data compiled by researchers at Yale. They joined
two large public data sets, one listing every doctor in the United States and
another containing the party registration of every voter in 29 states.
Eitan Hersh,
an assistant professor of political science, and Dr. Matthew Goldenberg, an
assistant professor of psychiatry (guess his party!), shared their data with
The Upshot. Using their numbers, we found that more than half of all doctors
with party registration identify as Democrats. But the partisanship of
physicians is not evenly distributed throughout the fields of medical practice.
The new
research is the first to directly measure the political leanings of a large
sample of all doctors. Earlier research — using surveys of physicians and
medical students, and looking at doctors’ campaign contributions — has reached
somewhat similar conclusions. What we found is that though doctors, over all,
are roughly split between the parties, some specialties have developed distinct
political preferences.
It’s possible
that the experience of being, say, an infectious disease physician, who treats
a lot of drug addicts with hepatitis C, might make a young physician more
likely to align herself with Democratic candidates who support a social safety
net. But it’s also possible that the differences resulted from some initial
sorting by medical students as they were choosing their fields….
The remainder
of the essay: http://www.nytimes.com/2016/10/07/upshot/your-surgeon-is-probably-a-republican-your-psychiatrist-probably-a-democrat.html
4. Will This Hemodynamically Unstable Patient Respond to a Bolus
of IV Fluids?
Bentzer P, et
al. JAMA. 2016;316(12):1298-1309.
Importance Fluid overload occurring as a consequence of
overly aggressive fluid resuscitation may adversely affect outcome in
hemodynamically unstable critically ill patients. Therefore, following the
initial fluid resuscitation, it is important to identify which patients will
benefit from further fluid administration.
Objective To identify predictors of fluid
responsiveness in hemodynamically unstable patients with signs of inadequate
organ perfusion.
Data Sources
and Study Selection Search of MEDLINE
and EMBASE (1966 to June 2016) and reference lists from retrieved articles,
previous reviews, and physical examination textbooks for studies that evaluated
the diagnostic accuracy of tests to predict fluid responsiveness in
hemodynamically unstable adult patients who were defined as having refractory
hypotension, signs of organ hypoperfusion, or both. Fluid responsiveness was
defined as an increase in cardiac output following intravenous fluid
administration.
Data
Extraction Two authors independently
abstracted data (sensitivity, specificity, and likelihood ratios [LRs]) and
assessed methodological quality. A bivariate mixed-effects binary regression
model was used to pool the sensitivities, specificities, and LRs across
studies.
Results A total of 50 studies (N = 2260 patients)
were analyzed. In all studies, indices were measured before assessment of fluid
responsiveness. The mean prevalence of fluid responsiveness was 50% (95% CI,
42%-56%). Findings on physical examination were not predictive of fluid
responsiveness with LRs and 95% CIs for each finding crossing 1.0. A low
central venous pressure (CVP) (mean threshold less than 8 mm Hg) was associated
with fluid responsiveness (positive LR, 2.6 [95% CI, 1.4-4.6]; pooled
specificity, 76%), but a CVP greater than the threshold made fluid
responsiveness less likely (negative LR, 0.50 [95% CI, 0.39-0.65]; pooled
sensitivity, 62%). Respiratory variation in vena cava diameter measured by
ultrasound (distensibility index over 15%) predicted fluid responsiveness in a
subgroup of patients without spontaneous respiratory efforts (positive LR, 5.3
[95% CI, 1.1-27]; pooled specificity, 85%). Patients with less vena cava
distensibility were not as likely to be fluid responsive (negative LR, 0.27
[95% CI, 0.08-0.87]; pooled sensitivity, 77%). Augmentation of cardiac output or
related parameters following passive leg raising predicted fluid responsiveness
(positive LR, 11 [95% CI, 7.6-17]; pooled specificity, 92%). Conversely, the
lack of an increase in cardiac output with passive leg raising identified
patients unlikely to be fluid responsive (negative LR, 0.13 [95% CI,
0.07-0.22]; pooled sensitivity, 88%).
Conclusions
and Relevance Passive leg raising
followed by measurement of cardiac output or related parameters may be the most
useful test for predicting fluid responsiveness in hemodynamically unstable
adults. The usefulness of respiratory variation in the vena cava requires
confirmatory studies.
5. More Bleeds With Rivaroxaban in Real-World Comparison than
with Dabigatran in Medicare data
by Larry
Husten. CardioBrief October 05, 2016
Patients who
take rivaroxaban (Xarelto) may be more likely to have serious bleeding events
than patients who take dabigatran (Pradaxa), an observational study found.
In a paper
published in JAMA Internal Medicine, David Graham, MD, MPH, and colleagues at
the FDA performed a retrospective analysis of 118,000 Medicare patients with
atrial fibrillation who started therapy with either rivaroxaban or dabigatran.
They found that rivaroxaban was associated with:
Statistically
significant increases in intracranial hemorrhage, resulting in an excess of 2.3
cases per 1,000 person-years after an adjustment for baseline differences
between groups
Significant
excesses in major extracranial bleeding (an excess of 13 cases per 1,000
person-years), including an increase in major GI bleeds (9.4 cases per 1,000
person-years)
A
non-significant reduction in thromboembolic stroke associated with rivaroxaban,
resulting in 1.8 fewer cases per 1,000 person-years
While there
was no significant difference in mortality, the authors noted a significant
increase with rivaroxaban over dabigatran in the subgroup of patients 75 or
older with a CHADS2 score over 2.
The authors
noted that, in 2014, rivaroxaban was used two to three times more often than
dabigatran by U.S. patients with atrial fibrillation. They speculated that this
might be due to "prescriber misperceptions about bleeding risks with
dabigatran, arising from U.S. Food and Drug Administration receipt of a large
number of postmarketing case reports following its approval. Ironically, we
found substantially higher bleeding risks with use of rivaroxaban than
dabigatran."
Both
non-vitamin K oral anticoagulants (NOACs) have been the subject of controversy
and criticism: Dabigatran has been plagued by reports of bleeding complications
since shortly after its approval. More recently, there have been reports
critical of the pivotal rivaroxaban ROCKET AF trial because of the use of a
defective monitoring device in the trial.
The authors
acknowledged that a "randomized direct comparison between dabigatran and
rivaroxaban would be optimal," but that "such a study is unlikely to
be undertaken by the manufacturer of either product."
Outside
experts expressed concern about conclusions derived from observational studies
based on Medicare claims. Comparative effectiveness studies based on claims do
not provide "very strong evidence," commented Harlan Krumholz, MD, of
Yale. Sanjay Kaul, MD, MPH, of Cedars-Sinai Medical Center in Los Angeles,
warned that "drawing strong inferences from a claims database is a
slippery slope."
In an
editor's note, on the other hand, Rita Redberg, MD, and Anna Parks, MD, both of
the University of California San Francisco, offered strong support for the study's
real world application: "The additional information should lead us to
prescribe dabigatran over rivaroxaban for patients with atrial fibrillation.
Also, it can help inform further investigation of NOAC monitoring and tailored
dosing, as others have previously recommended for dabigatran. In addition,
knowing that a patient prescribed rivaroxaban is at comparatively increased
risk of bleeding might encourage clinicians to more vigilantly identify and
mitigate modifiable risk factors. Finally, it offers important guidance to
consumers on relative efficacy and safety profiles that drive NOAC selection,
particularly for those at greatest risk of hemorrhage."
I asked
Redberg if she had any concerns about basing recommendations on observational
studies. "Clearly, I would prefer randomized controlled trial data,"
she responded. "But currently there are multiple NOACs on the market,
there are no randomized controlled trials that compare them, and I know of none
in the works. Thus, the best data we will get right now to help inform patient
care is from high-quality observational studies."
Source: Graham
DJ, et al. Stroke, Bleeding, and Mortality Risks in Elderly Medicare
Beneficiaries Treated With Dabigatran or Rivaroxaban for Nonvalvular Atrial
Fibrillation. JAMA Intern Med. 2016 Oct 3 [Epub ahead of print].
6. Physicians beat symptom trackers for getting correct
diagnosis
A study comparing
23 symptom-checker websites or apps with physicians found doctors got the
correct diagnosis 72% of the time, compared with 34% for the digital platforms,
researchers reported in JAMA Internal Medicine. Researchers said 84% of
physicians listed the correct diagnosis in the top three options, compared with
51% of the symptom checker programs.
Semigran HL,
et al. Comparison of Physician and Computer Diagnostic Accuracy. JAMA Intern
Med. 2016 Oct 10 [Epub ahead of print].
The Institute
of Medicine recently highlighted that physician diagnostic error is common and
information technology may be part of the solution.1 Given advancements in
computer science, computers may be able to independently make accurate clinical
diagnoses.2 While studies have compared computer vs physician performance for
reading electrocardiograms,3 the diagnostic accuracy of computers vs physicians
remains unknown. To fill this gap in knowledge, we compared the diagnostic
accuracy of physicians with computer algorithms called symptom checkers.
Symptom
checkers are websites and apps that help patients with self-diagnosis. After
answering a series of questions, the user is given a list of rank-ordered
potential diagnoses generated by a computer algorithm. Previously, we evaluated
the diagnostic accuracy of 23 symptom checkers using 45 clinical vignettes.4
The vignettes included the patient’s medical history and had no physical
examination or test findings. In this study we compared the diagnostic
performance of physicians with symptom checkers for those same vignettes using
a unique online platform called Human Dx.
Methods
Human Dx is a web- and app-based platform on which physicians generate differential diagnoses for clinical vignettes. Since 2015, Human Dx has been used by over 2700 physicians and trainees from 40 countries who have addressed over 100 000 vignettes.
The 45 vignettes, previously developed for the systematic assessment of online symptom checkers,4 were disseminated by Human Dx between December 2015 and May 2016 to internal medicine, family practice, or pediatrics physicians who did not know which vignettes were part of the research study. There were 15 high, 15 medium, and 15 low-acuity condition vignettes and 26 common and 19 uncommon condition vignettes.4 Physicians submitted free text ranked differential diagnoses for each case. Each vignette was solved by at least 20 physicians.
Given that physicians provided free text responses, 2 physicians (S.N. and D.M.L.) hand-reviewed the submitted diagnoses and independently decided whether the participant listed the correct diagnosis first or in the top 3 diagnoses. Interrater agreement was high (Cohen κ, 96%), and a third study physician (A.M.) resolved discrepancies (n = 60).
We used χ2 tests of significance to compare in physicians’ performance. Physician diagnosis accuracy was compared with previously reported symptom checker accuracy for these same vignettes using 2-sample tests of proportion.4 The study was exempt from Harvard’s institutional review board and participants were not compensated.
Results
Of the 234 physicians who solved at least 1 vignette, 211 (90%) were trained in internal medicine and 121 (52%) were fellows or residents (Table 1).
Physicians listed the correct diagnosis first more often across all vignettes compared with symptom checkers (72.1% vs 34.0%, P less than .001) as well as in the top 3 diagnoses listed (84.3% vs 51.2%, P less than .001) (Table 2).
Across physicians, they were more likely to list the correct diagnosis first for high-acuity vignettes (vs low-acuity vignettes) and for uncommon vignettes (vs common vignettes). In contrast, symptom checkers were more likely to list the correct diagnosis first for low-acuity vignettes and common vignettes (Table 2).
Discussion
In what we believe to be the first direct comparison of diagnostic accuracy, physicians vastly outperformed computer algorithms in diagnostic accuracy (84.3% vs 51.2% correct diagnosis in the top 3 listed).4 Despite physicians’ superior performance, they provided the incorrect diagnosis in about 15% of cases, similar to prior estimates (10%-15%) for physician diagnostic error.5 While in this project we compared diagnostic performance, future work should test whether computer algorithms can augment physician diagnostic accuracy.6
Key limitations included our use of clinical vignettes, which likely do not reflect the complexity of real-world patients and did not include physical examination or test results. Physicians who chose to use Human Dx may not be a representative sample of US physicians and therefore may differ in diagnostic accuracy. Symptom checkers are only 1 form of computer diagnostic tools, and other tools may have superior performance.
Methods
Human Dx is a web- and app-based platform on which physicians generate differential diagnoses for clinical vignettes. Since 2015, Human Dx has been used by over 2700 physicians and trainees from 40 countries who have addressed over 100 000 vignettes.
The 45 vignettes, previously developed for the systematic assessment of online symptom checkers,4 were disseminated by Human Dx between December 2015 and May 2016 to internal medicine, family practice, or pediatrics physicians who did not know which vignettes were part of the research study. There were 15 high, 15 medium, and 15 low-acuity condition vignettes and 26 common and 19 uncommon condition vignettes.4 Physicians submitted free text ranked differential diagnoses for each case. Each vignette was solved by at least 20 physicians.
Given that physicians provided free text responses, 2 physicians (S.N. and D.M.L.) hand-reviewed the submitted diagnoses and independently decided whether the participant listed the correct diagnosis first or in the top 3 diagnoses. Interrater agreement was high (Cohen κ, 96%), and a third study physician (A.M.) resolved discrepancies (n = 60).
We used χ2 tests of significance to compare in physicians’ performance. Physician diagnosis accuracy was compared with previously reported symptom checker accuracy for these same vignettes using 2-sample tests of proportion.4 The study was exempt from Harvard’s institutional review board and participants were not compensated.
Results
Of the 234 physicians who solved at least 1 vignette, 211 (90%) were trained in internal medicine and 121 (52%) were fellows or residents (Table 1).
Physicians listed the correct diagnosis first more often across all vignettes compared with symptom checkers (72.1% vs 34.0%, P less than .001) as well as in the top 3 diagnoses listed (84.3% vs 51.2%, P less than .001) (Table 2).
Across physicians, they were more likely to list the correct diagnosis first for high-acuity vignettes (vs low-acuity vignettes) and for uncommon vignettes (vs common vignettes). In contrast, symptom checkers were more likely to list the correct diagnosis first for low-acuity vignettes and common vignettes (Table 2).
Discussion
In what we believe to be the first direct comparison of diagnostic accuracy, physicians vastly outperformed computer algorithms in diagnostic accuracy (84.3% vs 51.2% correct diagnosis in the top 3 listed).4 Despite physicians’ superior performance, they provided the incorrect diagnosis in about 15% of cases, similar to prior estimates (10%-15%) for physician diagnostic error.5 While in this project we compared diagnostic performance, future work should test whether computer algorithms can augment physician diagnostic accuracy.6
Key limitations included our use of clinical vignettes, which likely do not reflect the complexity of real-world patients and did not include physical examination or test results. Physicians who chose to use Human Dx may not be a representative sample of US physicians and therefore may differ in diagnostic accuracy. Symptom checkers are only 1 form of computer diagnostic tools, and other tools may have superior performance.
7. Medicaid Coverage Increases ED Use over Two Years — Further
Evidence from Oregon’s Experiment
Finkelstein
AN, et al. N Engl J Med 2016; 375:1505-1507.
The effect of
Medicaid coverage on health and the use of health care services is of
first-order policy importance, particularly as policymakers consider expansions
of public health insurance. Estimating the effects of expanding Medicaid is
challenging, however, because Medicaid enrollees and the uninsured differ in
many ways that may also affect outcomes of interest. Oregon’s 2008 expansion of
Medicaid through random-lottery selection of potential enrollees from a waiting
list offers the opportunity to assess Medicaid’s effects with a randomized
evaluation that is not contaminated by such confounding factors. In a previous
examination of the Oregon Health Insurance Experiment, we found that Medicaid
coverage increased health care use across a range of settings, improved
financial security, and reduced rates of depression among enrollees, but it
produced no detectable changes in several measures of physical health,
employment rates, or earnings.1-4
A key finding
was that Medicaid increased emergency department (ED) visits by 40% in the
first 15 months after people won the lottery.3 This finding was greeted with
considerable attention and surprise, given the widespread belief that expanding
Medicaid coverage to more uninsured people would encourage the use of primary
care and thereby reduce ED use. Many observers speculated that the increase in
ED use would abate over time as the newly insured found alternative sites of
care or as their health needs were addressed and their health improved. One
commentator, for example, raised the question, “But why did these patients go
to the ED and not to a primary care office?” He hypothesized that “Despite the
earlier finding that coverage increased outpatient use, many of these newly
insured patients probably had not yet established relationships with primary
care physicians. If so, the excess ED use will attenuate with time.”5
We have now
analyzed additional data in order to address these questions: Does the increase in ED use caused by
Medicaid coverage represent a short-term effect that is likely to dissipate
over time? And does Medicaid coverage encourage the newly insured to substitute
physician office visits for ED visits? We used the lottery to implement a
randomized, controlled evaluation of the causal effect of Medicaid coverage on
health care use, applying a standard instrumental variables approach. More
detail on the lottery, data, and methods is available elsewhere1-3 as well as
in the Supplementary Appendix (available at NEJM.org), which also provides
additional results.
Extending our
ED administrative data by a year to span the 2007–2010 period, we analyzed the
pattern of the effect of Medicaid coverage on ED use over a 2-year period after
the 2008 lottery. The graphs show the effect of Medicaid coverage over time —
both in terms of the mean number of ED visits per person (Panel A) and whether
a person had any ED visits (Panel B) — measured separately for the four 6-month
periods after lottery notification. There is no statistical or substantive
evidence of any time pattern in the effect on ED use on either variable.
Medicaid coverage increased the mean number of ED visits per person by 0.17
(standard error, 0.04) over the first 6 months or about 65% relative to the
mean in the control group of individuals not selected in the lottery; over the
subsequent three 6-month periods, the point estimates are similar and, for the
most part, statistically indistinguishable from each other. For example, we
cannot reject (P=0.80) the hypothesis that the 0.17 increase in ED visits
attributable to Medicaid coverage in the first 6 months is the same as the 0.15
increase in visits in months 18 to 24. Thus, using another year of ED data, we
found no evidence that the increase in ED use due to Medicaid coverage is
driven by pent-up demand that dissipates over time; the effect on ED use
appears to persist over the first 2 years of coverage. We repeated a similar
analysis for hospital admissions and once again found no evidence of any time patterns in the effects of Medicaid coverage
over the first 2 years (see the Supplementary Appendix for details)…
One possible
reason for this finding is that the type of people who use more care when they
gain Medicaid coverage are likely to increase use across multiple settings,
including both the ED and the physician’s office. Another possible reason is
that by increasing the use of primary care, Medicaid coverage may end up
driving greater use of emergency care. For example, primary care providers may
sometimes encourage patients to seek such care. One study participant we
interviewed told us, “I went to the doctor’s office one time and they said, no,
you need to go to the ER because your blood sugar is way too high. It’s going
to take us hours to get it down. So you need to go to the ER.”
For
policymakers deliberating about Medicaid expansions, our results, which draw on
the strength of a randomized, controlled design, suggest that newly insured
people will most likely use more health care across settings — including the ED
and the hospital — for at least 2 years and that expanded coverage is unlikely
to drive substantial substitution of office visits for ED use.
8. Propofol or Ketofol for Procedural Sedation and Analgesia in
Emergency Medicine-The POKER Study: A Randomized Double-Blind Clinical Trial.
Ferguson I,
et a l. Ann Emerg Med. 2016;68(5): 574–582.e1.
STUDY
OBJECTIVE: We determine whether emergency physician-provided deep sedation with
1:1 ketofol versus propofol results in fewer adverse respiratory events
requiring physician intervention when used for procedural sedation and
analgesia.
METHODS: Consenting
patients requiring deep sedation were randomized to receive either ketofol or
propofol in a double-blind fashion according to a weight-based dosing schedule.
The primary outcome was the occurrence of a respiratory adverse event
(desaturation, apnea, or hypoventilation) requiring an intervention by the
sedating physician. Secondary outcomes included hypotension and patient
satisfaction.
RESULTS: Five
hundred seventy-three patients were enrolled and randomized, 292 in the
propofol group and 281 in the ketofol group. Five percent in the propofol group
and 3% in the ketofol group met the primary outcome, an absolute difference of
2% (95% confidence interval [CI] -2% to 5%). Patients receiving propofol were
more likely to become hypotensive (8 versus 1%; difference 7%; 95% CI 4% to
10%). Patient satisfaction was very high in both groups (10/10; interquartile
range 10 to 10/10), and although the ketofol group was more likely to
experience severe emergence delirium (5% versus 2%; difference 3%; 95% CI 0.4%
to 6%), they had lower pain scores at 30 minutes postprocedure. Other secondary
outcomes were similar between groups.
CONCLUSION:
Ketofol and propofol resulted in a similar incidence of adverse respiratory
events requiring the intervention of the sedating physician. Although propofol
resulted in more hypotension, the clinical relevance of this is questionable,
and both agents are associated with high levels of patient satisfaction.
9. If This Public Figure Wrote a Research Paper…
Below are the
opening paragraphs of a fictitious research article crafted in the style of a
well-known public figure. After reading the opener and before linking to the
full-text, guess what figure is being caricaturized.
a. Oprah
Winfrey
b. Jimmy
Fallon
c. Donald
Trump
d. Dr. Oz
A title for a really great piece of
research, just the best, really
Introduction
The current
research, and it is really great research, it really is. It relies on the
theory — and I have the best theories, you know, I use the best theories in my
research. It really is quite amazing just how great the theory is, but I’m not
really, in fact — it is a theory. A really good one and I’ve talked to people
and, lots of people actually, and they all think what I said. It has a lot of
appeal. It’s really just all there and what it is. If people, you know, losers
and whatever, if they don’t get it, then what are you going to do? It’s not
like the idea isn’t there and that, you know, it’s what it is. I have to shake
my head. Everyone is just shaking their heads. It really is. Along with the
theory, there’s other work. Existing data — and again, I have the best data.
You would
really, if you had the same great data, be completely happy and the data are
there. And they are really, you know, data and we have all kinds. The best
kinds. And that is what we base the current work, which is great work, that I
did and it’s great. If other people want to be walked through like babies or
something, then I don’t know what their problem is. The data just are there so
get off your lazy butts and stop looking for handouts…
Full-text
(free): http://imgur.com/BYn8rVv
10. Images in Clinical Practice
Right ventricular
myocardial infarction
Hemorrhagic
Bullae in a Primary Varicella Zoster Virus Infection
Worms in the
Eye
Young Man
With Severe Abdominal Pain
Male With
Pain in His Neck
Child With
Sore Throat
Adolescent
Athlete With Sudden Groin Pain
Elderly Male
With Mass on Right Thumb
Young Man
With Epigastric Pain
Male With
Hypertension
Neonate With
a Swollen Thigh
Emphysematous
Pyelonephritis
Cutaneous
Lupus — “The Pimple That Never Went Away”
First
Branchial Cleft Cyst
Congenital
Rubella
Reversible
Acute Mesenteric Ischemia
11. Letter to the Doctors and Nurses Who Cared for My Wife
By Peter
DeMarco, New York Times. Oct. 6, 2016
After his
34-year-old wife suffered a devastating asthma attack and later died, the
Boston writer Peter DeMarco wrote the following letter to the intensive care
unit staff of CHA Cambridge Hospital who cared for her and helped him cope.
As I begin to
tell my friends and family about the seven days you treated my wife, Laura
Levis, in what turned out to be the last days of her young life, they stop me
at about the 15th name that I recall. The list includes the doctors, nurses,
respiratory specialists, social workers, even cleaning staff members who cared
for her.
“How do you
remember any of their names?” they ask.
How could I
not, I respond.
Every single
one of you treated Laura with such professionalism, and kindness, and dignity
as she lay unconscious. When she needed shots, you apologized that it was going
to hurt a little, whether or not she could hear. When you listened to her heart
and lungs through your stethoscopes, and her gown began to slip, you pulled it
up to respectfully cover her. You spread a blanket, not only when her body
temperature needed regulating, but also when the room was just a little cold,
and you thought she’d sleep more comfortably that way.
You cared so
greatly for her parents helping them climb into the room’s awkward recliner,
fetching them fresh water almost by the hour, and by answering every one of
their medical questions with incredible patience. My father-in-law, a doctor
himself as you learned, felt he was involved in her care. I can’t tell you how
important that was to him.
Then, there
was how you treated me. How would I have found the strength to have made it
through that week without you?
How many
times did you walk into the room to find me sobbing, my head down, resting on
her hand, and quietly go about your task, as if willing yourselves invisible?
How many times did you help me set up the recliner as close as possible to her
bedside, crawling into the mess of wires and tubes around her bed in order to
swing her forward just a few feet?
How many
times did you check in on me to see whether I needed anything, from food to
drink, fresh clothes to a hot shower, or to see whether I needed a better
explanation of a medical procedure, or just someone to talk to?
How many
times did you hug me and console me when I fell to pieces, or ask about Laura’s
life and the person she was, taking the time to look at her photos or read the
things I’d written about her? How many times did you deliver bad news with
compassionate words, and sadness in your eyes?
When I needed
to use a computer for an emergency email, you made it happen. When I smuggled
in a very special visitor, our tuxedo cat, Cola, for one final lick of Laura’s
face, you “didn’t see a thing.”…
The remainder
of the essay: http://www.nytimes.com/2016/10/06/well/live/a-letter-to-the-doctors-and-nurses-who-cared-for-my-wife.html
2-min video
NBC News: https://www.youtube.com/watch?v=ljTTrGumLxA
12. Time to Treatment with Endovascular Thrombectomy and
Outcomes From Ischemic Stroke: A Meta-analysis
Saver JL, et
al. JAMA. 2016;316(12):1279-1288.
Importance Endovascular thrombectomy with
second-generation devices is beneficial for patients with ischemic stroke due
to intracranial large-vessel occlusions. Delineation of the association of
treatment time with outcomes would help to guide implementation.
Objective To characterize the period in which
endovascular thrombectomy is associated with benefit, and the extent to which
treatment delay is related to functional outcomes, mortality, and symptomatic
intracranial hemorrhage.
Design,
Setting, and Patients Demographic,
clinical, and brain imaging data as well as functional and radiologic outcomes
were pooled from randomized phase 3 trials involving stent retrievers or other
second-generation devices in a peer-reviewed publication (by July 1, 2016). The
identified 5 trials enrolled patients at 89 international sites.
Exposures Endovascular thrombectomy plus medical
therapy vs medical therapy alone; time to treatment.
Main Outcomes
and Measures The primary outcome was
degree of disability (mRS range, 0-6; lower scores indicating less disability)
at 3 months, analyzed with the common odds ratio (cOR) to detect ordinal shift
in the distribution of disability over the range of the mRS; secondary outcomes
included functional independence at 3 months, mortality by 3 months, and
symptomatic hemorrhagic transformation.
Results Among all 1287 patients (endovascular
thrombectomy + medical therapy [n = 634]; medical therapy alone [n = 653])
enrolled in the 5 trials (mean age, 66.5 years [SD, 13.1]; women, 47.0%), time
from symptom onset to randomization was 196 minutes (IQR, 142 to 267). Among
the endovascular group, symptom onset to arterial puncture was 238 minutes
(IQR, 180 to 302) and symptom onset to reperfusion was 286 minutes (IQR, 215 to
363). At 90 days, the mean mRS score was 2.9 (95% CI, 2.7 to 3.1) in the endovascular
group and 3.6 (95% CI, 3.5 to 3.8) in the medical therapy group. The odds of
better disability outcomes at 90 days (mRS scale distribution) with the
endovascular group declined with longer time from symptom onset to arterial
puncture: cOR at 3 hours, 2.79 (95% CI, 1.96 to 3.98), absolute risk difference
(ARD) for lower disability scores, 39.2%; cOR at 6 hours, 1.98 (95% CI, 1.30 to
3.00), ARD, 30.2%; cOR at 8 hours,1.57 (95% CI, 0.86 to 2.88), ARD, 15.7%;
retaining statistical significance through 7 hours and 18 minutes. Among 390
patients who achieved substantial reperfusion with endovascular thrombectomy,
each 1-hour delay to reperfusion was associated with a less favorable degree of
disability (cOR, 0.84 [95% CI, 0.76 to 0.93]; ARD, −6.7%) and less functional
independence (OR, 0.81 [95% CI, 0.71 to 0.92], ARD, −5.2% [95% CI, −8.3% to
−2.1%]), but no change in mortality (OR, 1.12 [95% CI, 0.93 to 1.34]; ARD, 1.5%
[95% CI, −0.9% to 4.2%]).
Conclusions
and Relevance In this individual patient
data meta-analysis of patients with large-vessel ischemic stroke, earlier
treatment with endovascular thrombectomy + medical therapy compared with
medical therapy alone was associated with lower degrees of disability at 3
months. Benefit became nonsignificant after 7.3 hours.
13. Do Peripheral Thermometers Accurately Correlate to Core Body
Temperature?
Hernandez JM,
et al. Ann Emerg Med 2016;68(5):562-3.
Take-Home
Message
Peripheral
thermometers lack accuracy compared with central thermometers; therefore, use
central thermometers when accurate temperature measurements are needed to guide
diagnosis and patient management.
Commentary
Changes in
body temperature are important for clinical decisions in the acute care setting
and may point the clinician toward certain diagnoses3,4 or predict mortality in certain patient
populations.5,6 As such, accurate assessment of temperature is essential,
especially in the setting of possible fever (over 38°C [100.4°F]) or
hypothermia (less than 36°C [96.8°F]). Although temperature measurement from a
central site (pulmonary artery catheter, urinary bladder, esophageal, or
rectal) has shown accuracy and reliability,7, 8 it is currently commonplace in
the emergency department (ED) to measure temperature from a peripheral site
(eg, tympanic membrane, oral). Approximately 1 in 5 febrile patients is
initially missed by peripheral temperature measurements in the ED.8
The results
of this meta-analysis demonstrate that temperature measurements with peripheral
thermometers do not adequately estimate body temperature compared with central
thermometers. This was especially evident in clinical situations that may
affect diagnosis, clinical management, and outcomes (ie, fever and
hypothermia). Although the specificity of peripheral thermometers is adequate
to confirm fever when detected, the low sensitivity cannot exclude fever;
peripheral thermometers gave readings as much as 1°C to 2°C (1.80°F to 3.60°F)
lower than those of central thermometers. If normothermia is due to inaccurate
temperature measurement, potentially harmful time-dependent omissions in hypo-
or hyperthermia management (eg, sepsis, bacteremia) may occur.
In
conclusion, clinicians should use central thermometers when accurate
temperature measurement will guide diagnosis and management in high-risk
patient populations. Rectal thermometers can generally be used for most
patients in this circumstance.
14. A Pragmatic Randomized Evaluation of a Nurse-Initiated
Protocol to Improve Timeliness of Care in an Urban Emergency Department.
Douma MJ, et
al. Ann Emerg Med. 2016;68(5):546–552.
STUDY OBJECTIVE:
Emergency department (ED) crowding is a common and complicated problem
challenging EDs worldwide. Nurse-initiated protocols, diagnostics, or
treatments implemented by nurses before patients are treated by a physician or
nurse practitioner have been suggested as a potential strategy to improve
patient flow.
METHODS: This
is a computer-randomized, pragmatic, controlled evaluation of 6 nurse-initiated
protocols in a busy, crowded, inner-city ED. The primary outcomes included time
to diagnostic test, time to treatment, time to consultation, or ED length of
stay.
RESULTS:
Protocols decreased the median time to acetaminophen for patients presenting
with pain or fever by 186 minutes (95% confidence interval [CI] 76 to 296
minutes) and the median time to troponin for patients presenting with suspected
ischemic chest pain by 79 minutes (95% CI 21 to 179 minutes). Median ED length
of stay was reduced by 224 minutes (95% CI -19 to 467 minutes) by implementing
a suspected fractured hip protocol. A vaginal bleeding during pregnancy
protocol reduced median ED length of stay by 232 minutes (95% CI 26 to 438
minutes).
CONCLUSION:
Targeting specific patient groups with carefully written protocols can result
in improved time to test or medication and, in some cases, reduce ED length of
stay. A cooperative and collaborative interdisciplinary group is essential to
success.
15. Comparison of acyclovir and famciclovir for the treatment of
Bell's palsy.
Kim HJ, et
al. Eur Arch Otorhinolaryngol. 2016 Oct;273(10):3083-90.
The relative
effectiveness of acyclovir and famciclovir in the treatment of Bell's palsy is
unclear. This study therefore compared recovery outcomes in patients with
Bell's palsy treated with acyclovir and famciclovir. The study cohort consisted
of patients with facial palsy who visited the outpatient clinic between January
2006 and January 2014. Patients were treated with prednisolone plus either
acyclovir (n = 457) or famciclovir (n = 245). Patient outcomes were measured
using the House-Brackmann scale according to initial severity of disease and
underlying disease. The overall recovery rate tended to be higher in the
famciclovir than in the acyclovir group. The rate of recovery in patients with
initially severe facial palsy (grades V and VI) was significantly higher in the
famciclovir than in the acyclovir group (p = 0.01), whereas the rates of
recovery in patients with initially moderate palsy (grade III-IV) were similar
in the two groups. The overall recovery rates in patients without hypertension
or diabetes mellitus were higher in the famciclovir than in the acyclovir
group, but the difference was not statistically significant. Treatment with
steroid plus famciclovir was more effective than treatment with steroid plus
acyclovir in patients with severe facial palsy. Famciclovir may be the
antiviral agent of choice in the treatment of patients with severe facial
palsy.
16. Midazolam-Droperidol better than either Droperidol or
Olanzapine for Acute Agitation: A RCT
Taylor DM, et
al.
Study
objective
We aim to
determine the most efficacious of 3 common medication regimens for the sedation
of acutely agitated emergency department (ED) patients.
Methods
We undertook
a randomized, controlled, double-blind, triple-dummy, clinical trial in 2
metropolitan EDs between October 2014 and August 2015. Patients aged 18 to 65
years and requiring intravenous medication sedation for acute agitation were
enrolled and randomized to an intravenous bolus of midazolam 5 mg–droperidol 5
mg, droperidol 10 mg, or olanzapine 10 mg. Two additional doses were
administered, if required: midazolam 5 mg, droperidol 5 mg, or olanzapine 5 mg.
The primary outcome was the proportion of patients adequately sedated at 10
minutes.
Results
Three hundred
forty-nine patients were randomized to the 3 groups. Baseline characteristics
were similar across the groups. Ten minutes after the first dose, significantly
more patients in the midazolam-droperidol group were adequately sedated
compared with the droperidol and olanzapine groups: differences in proportions
25.0% (95% confidence interval [CI] 12.0% to 38.1%) and 25.4% (95% CI 12.7% to
38.3%), respectively. For times to sedation, the differences in medians between
the midazolam-droperidol group and the droperidol and olanzapine groups were 6
(95% CI 3 to 8) and 6 (95% CI 3 to 7) minutes, respectively. Patients in the
midazolam-droperidol group required fewer additional doses or alternative drugs
to achieve adequate sedation. The 3 groups’ adverse event rates and lengths of
stay did not differ.
Conclusion
Midazolam-droperidol
combination therapy is superior, in the doses studied, to either droperidol or
olanzapine monotherapy for intravenous sedation of the acutely agitated ED
patient.
17. Probiotics and the Prevention of Antibiotic-Associated Diarrhea
in Infants and Children
Johnston BC,
et al. JAMA. 2016;316(14):1484-1485.
Excerpts:
Clinical
Question: In children prescribed an
antibiotic, is the co-administration of a probiotic associated with lower rates
of antibiotic-associated diarrhea without an increase in clinically important
adverse events?
Bottom Line: Moderate-quality evidence suggests that
probiotics are associated with lower rates of antibiotic-associated diarrhea in
children (aged 1 month to 18 years) without an increase in adverse events.
Discussion
Among 23 studies comparing probiotics with control for the prevention of antibiotic-associated diarrhea, probiotics were associated with lower rates of diarrhea and were not associated with higher rates of adverse events. No trials reported serious adverse events attributable to probiotics.
Limitations
… The findings are based on an aggregate data meta-analysis; therefore, it was impossible to explore patient- and intervention-level variables that may be associated with antibiotic-associated diarrhea. For example, the largest prospective cohort of children (n = 650) who were followed up for antibiotic-associated diarrhea risk suggests that younger children (aged less than 2 years) and those exposed to amoxicillin/clavulanate are at the highest risk for antibiotic-associated diarrhea (18% and 23%, respectively).3
Comparison of Findings With Current Practice Guidelines
Our findings are consistent with the European Society for Pediatric Gastroenterology, Hepatology and Nutrition recommendations, the only published guideline based on systematic reviews addressing antibiotic-associated diarrhea, which suggests that L rhamnosus or S boulardii at 5 to 40 billion colony-forming units/d may be reasonable to consider among otherwise healthy children receiving antibiotics.6
Among 23 studies comparing probiotics with control for the prevention of antibiotic-associated diarrhea, probiotics were associated with lower rates of diarrhea and were not associated with higher rates of adverse events. No trials reported serious adverse events attributable to probiotics.
Limitations
… The findings are based on an aggregate data meta-analysis; therefore, it was impossible to explore patient- and intervention-level variables that may be associated with antibiotic-associated diarrhea. For example, the largest prospective cohort of children (n = 650) who were followed up for antibiotic-associated diarrhea risk suggests that younger children (aged less than 2 years) and those exposed to amoxicillin/clavulanate are at the highest risk for antibiotic-associated diarrhea (18% and 23%, respectively).3
Comparison of Findings With Current Practice Guidelines
Our findings are consistent with the European Society for Pediatric Gastroenterology, Hepatology and Nutrition recommendations, the only published guideline based on systematic reviews addressing antibiotic-associated diarrhea, which suggests that L rhamnosus or S boulardii at 5 to 40 billion colony-forming units/d may be reasonable to consider among otherwise healthy children receiving antibiotics.6
Full-text
(subscription required): http://jamanetwork.com/journals/jama/article-abstract/2565735
Incidence of
diarrhea: https://www.ncbi.nlm.nih.gov/pubmed/12827001
ESPG
Guideline: https://www.ncbi.nlm.nih.gov/pubmed/26756877
18. Study outlines strategies to reduce physician burnout
A study in
The Lancet found "clinically meaningful reductions" in physician
burnout may be achieved through the use of strategies such as mindfulness,
stress management training and small group discussions. Researchers said
studies found no single intervention to be superior, and that both individual
and structural or organizational interventions are probably needed.
Interventions to prevent and reduce
physician burnout: a systematic review and meta-analysis
West CP, et
al. Lancet 2016 September 28 [Epub ahead of print]
Background
Physician
burnout has reached epidemic levels, as documented in national studies of both
physicians in training and practising physicians. The consequences are negative
effects on patient care, professionalism, physicians' own care and safety, and
the viability of health-care systems. A more complete understanding than at
present of the quality and outcomes of the literature on approaches to prevent
and reduce burnout is necessary.
Methods
In this
systematic review and meta-analysis, we searched MEDLINE, Embase, PsycINFO,
Scopus, Web of Science, and the Education Resources Information Center from
inception to Jan 15, 2016, for studies of interventions to prevent and reduce
physician burnout, including single-arm pre-post comparison studies. We
required studies to provide physician-specific burnout data using burnout measures
with validity support from commonly accepted sources of evidence. We excluded
studies of medical students and non-physician health-care providers. We
considered potential eligibility of the abstracts and extracted data from
eligible studies using a standardised form. Outcomes were changes in overall
burnout, emotional exhaustion score (and high emotional exhaustion), and
depersonalisation score (and high depersonalisation). We used random-effects
models to calculate pooled mean difference estimates for changes in each
outcome.
Findings
We identified
2617 articles, of which 15 randomised trials including 716 physicians and 37
cohort studies including 2914 physicians met inclusion criteria. Overall
burnout decreased from 54% to 44% (difference 10% [95% CI 5–14]; p less than 0·0001;
I2=15%; 14 studies), emotional exhaustion score decreased from 23·82 points to
21·17 points (2·65 points [1·67–3·64]; p less than 0·0001; I2=82%; 40 studies),
and depersonalisation score decreased from 9·05 to 8·41 (0·64 points
[0·15–1·14]; p=0·01; I2=58%; 36 studies). High emotional exhaustion decreased
from 38% to 24% (14% [11–18]; p less than 0·0001; I2=0%; 21 studies) and high
depersonalisation decreased from 38% to 34% (4% [0–8]; p=0·04; I2=0%; 16
studies).
Interpretation
The
literature indicates that both individual-focused and structural or
organisational strategies can result in clinically meaningful reductions in
burnout among physicians. Further research is needed to establish which
interventions are most effective in specific populations, as well as how
individual and organisational solutions might be combined to deliver even
greater improvements in physician wellbeing than those achieved with individual
solutions.
19. Therapeutic Hypothermia Worsened Survival after In-Hospital
Cardiac Arrest.
Chan PS, et
al; American Heart Association’s Get With the Guidelines–Resuscitation
Investigators. JAMA. 2016 Oct 4;316(13):1375-1382.
Importance:
Therapeutic hypothermia is used for patients following both out-of-hospital and
in-hospital cardiac arrest. However, randomized trials on its efficacy for the
in-hospital setting do not exist, and comparative effectiveness data are
limited.
Objective: To
evaluate the association between therapeutic hypothermia and survival after
in-hospital cardiac arrest.
Design,
Setting, and Patients: In this cohort study, within the national Get With the
Guidelines-Resuscitation registry, 26 183 patients successfully resuscitated
from an in-hospital cardiac arrest between March 1, 2002, and December 31,
2014, and either treated or not treated with hypothermia at 355 US hospitals
were identified. Follow-up ended February 4, 2015.
Exposure:
Induction of therapeutic hypothermia.
Main Outcomes
and Measures: The primary outcome was survival to hospital discharge. The
secondary outcome was favorable neurological survival, defined as a Cerebral
Performance Category score of 1 or 2 (ie, without severe neurological
disability). Comparisons were performed using a matched propensity score
analysis and examined for all cardiac arrests and separately for nonshockable
(asystole and pulseless electrical activity) and shockable (ventricular
fibrillation and pulseless ventricular tachycardia) cardiac arrests.
Results:
Overall, 1568 of 26 183 patients with in-hospital cardiac arrest (6.0%) were
treated with therapeutic hypothermia; 1524 of these patients (mean [SD] age,
61.6 [16.2] years; 58.5% male) were matched by propensity score to 3714
non-hypothermia-treated patients (mean [SD] age, 62.2 [17.5] years; 57.1%
male). After adjustment, therapeutic hypothermia was associated with lower
in-hospital survival (27.4% vs 29.2%; relative risk [RR], 0.88 [95% CI, 0.80 to
0.97]; risk difference, -3.6% [95% CI, -6.3% to -0.9%]; P = .01), and this
association was similar (interaction P = .74) for nonshockable cardiac arrest
rhythms (22.2% vs 24.5%; RR, 0.87 [95% CI, 0.76 to 0.99]; risk difference,
-3.2% [95% CI, -6.2% to -0.3%]) and shockable cardiac arrest rhythms (41.3% vs
44.1%; RR, 0.90 [95% CI, 0.77 to 1.05]; risk difference, -4.6% [95% CI, -10.9%
to 1.7%]). Therapeutic hypothermia was also associated with lower rates of
favorable neurological survival for the overall cohort (hypothermia-treated
group, 17.0% [246 of 1443 patients]; non-hypothermia-treated group, 20.5% [725
of 3529 patients]; RR, 0.79 [95% CI, 0.69 to 0.90]; risk difference, -4.4% [95%
CI, -6.8% to -2.0%]; P less than .001) and for both rhythm types (interaction
P = .88).
Conclusions
and Relevance: Among patients with in-hospital cardiac arrest, use of
therapeutic hypothermia compared with usual care was associated with a lower
likelihood of survival to hospital discharge and a lower likelihood of
favorable neurological survival. These observational findings warrant a
randomized clinical trial to assess efficacy of therapeutic hypothermia for
in-hospital cardiac arrest.
20. Evaluation of CT in patients with atypical angina or CP
clinically referred for invasive coronary angiography: RCT
BMJ
2016;355:i5441
Objective To
evaluate whether invasive coronary angiography or computed tomography (CT)
should be performed in patients clinically referred for coronary angiography
with an intermediate probability of coronary artery disease.
Design
Prospective randomised single centre trial.
Setting
University hospital in Germany.
Participants
340 patients with suspected coronary artery disease and a clinical indication
for coronary angiography on the basis of atypical angina or chest pain.
Interventions
168 patients were randomised to CT and 172 to coronary angiography. After
randomisation one patient declined CT and 10 patients declined coronary
angiography, leaving 167 patients (88 women) and 162 patients (78 women) for
analysis. Allocation could not be blinded, but blinded independent
investigators assessed outcomes.
Main outcome
measure The primary outcome measure was major procedural complications within
48 hours of the last procedure related to CT or angiography.
Results
Cardiac CT reduced the need for coronary angiography from 100% to 14% (95%
confidence interval 9% to 20%, P less than 0.001) and was associated with a
significantly greater diagnostic yield from coronary angiography: 75% (53% to
90%) v 15% (10% to 22%), P less than 0.001. Major procedural complications were
uncommon (0.3%) and similar across groups. Minor procedural complications were
less common in the CT group than in the coronary angiography group: 3.6% (1% to
8%) v 10.5% (6% to 16%), P=0.014. CT shortened the median length of stay in the
angiography group from 52.9 hours (interquartile range 49.5-76.4 hours) to 30.0
hours (3.5-77.3 hours, P less than 0.001). Overall median exposure to radiation
was similar between the CT and angiography groups: 5.0 mSv (interquartile range
4.2-8.7 mSv) v 6.4 mSv (3.4-10.7 mSv), P=0.45. After a median follow-up of 3.3
years, major adverse cardiovascular events had occurred in seven of 167
patients in the CT group (4.2%) and six of 162 (3.7%) in the coronary
angiography group (adjusted hazard ratio 0.90, 95% confidence interval 0.30 to
2.69, P=0.86). 79% of patients stated that they would prefer CT for subsequent
testing. The study was conducted at a University hospital in Germany and thus
the performance of CT may be different in routine clinical practice. The
prevalence was lower than expected, resulting in an underpowered study for the
predefined primary outcome.
Conclusions
CT increased the diagnostic yield and was a safe gatekeeper for coronary
angiography with no increase in long term events. The length of stay was shortened
by 22.9 hours with CT, and patients preferred non-invasive testing.
Full-text (free):
http://www.bmj.com/content/355/bmj.i5441
21. Micro Bits
A. The Supplement Paradox: Negligible
Benefits, Robust Consumption
Cohen PE. JAMA. 2016;316(14):1453-1454.
Dietary supplements encompass a
wide variety of products from vitamins, minerals, and botanicals to probiotics,
protein powders, and fish oils.1 During the past 2 decades, a steady stream of
high-quality studies evaluating dietary supplements has yielded predominantly
disappointing results about potential health benefits, whereas evidence of harm
has continued to accumulate. How consumers have responded to these scientific
developments is not known. In this issue of JAMA,2 the report by Kantor and
colleagues sheds light on this important question.
To place the results of the study
by Kantor et al in context, it is helpful to understand the regulatory changes
predating their study. In the late 1980s, 36% of men and 48% of women used
vitamins, minerals, and other supplements.3 These high consumption levels
increased further after the passage of the Dietary Supplement Health and
Education Act of 1994 (DSHEA), a law that continues to define supplement policy
to this day. Under DSHEA, all supplements are assumed to be safe until the US
Food and Drug Administration (FDA) detects evidence of harm,1 usually only
after consumers have been extensively exposed to the product. The lax DSHEA
requirements for proof of product safety led to a rapid increase in the number
of supplements in the marketplace, from an estimated 4000 in 1994 to 55 000 in
2012.4 Dietary supplements had grown into a greater than $32 billion industry
by 2012.5
The period Kantor and colleagues
studied, 1999 through 2012, was an era of intense investigation into the health
effects of supplements. The National Institutes of Health (NIH) invested more
than $250 million to $300 million per year funding dietary supplement
research.4,5 Many major clinical studies were published, but the results
generally failed to demonstrate beneficial effects on health. According to a
recent summary of this extensive investment: “most of the larger NIH-supported
clinical trials of [dietary supplements] failed to demonstrate a significant
benefit compared to control groups.”4 Prominent examples of high-quality
studies published during this era and showing no benefits of supplements
include an evaluation of multivitamins to prevent cancer and heart disease,6
echinacea to treat the common cold,7 St John’s wort to treat major depression,8
and vitamin E to prevent prostate cancer.9
At the same time, the health
risks of supplements were also becoming better understood. In the late 1990s
and early 2000s, supplements containing ephedra were linked to many serious
adverse events including myocardial infarctions, seizures, strokes, and sudden
deaths.10 By 2002, national poison centers were receiving more than 10 000
calls related to ephedra poisonings per year.10 Long-term risks began to be recognized
as well, for example, beta-carotene supplements were found to actually increase
the risk of lung cancer among smokers.11…
B. Higher CV Risk Seen With Calcium
Supplements
But observational study suggests
benefit from dietary sources
Calcium supplements might
increase cardiovascular risk, whereas dietary calcium was associated with a
protective effect, a new observational study found.
Many people -- in particular,
older women -- take calcium supplements to prevent or treat osteoporosis,
though the supporting evidence for this use is quite thin. In recent years,
several studies have raised concerns that calcium supplements might be linked
to increased cardiovascular risk. But the precise relationship between calcium
-- both from dietary sources and from supplements -- and atherosclerosis has
not been carefully studied in randomized trials.
In a paper published in the
Journal of the American Heart Association, Erin Michos, MD, MHS, of Johns
Hopkins, and colleagues analyzed data from more than 2,700 participants in the
MESA (Multi-Ethnic Study of Atherosclerosis) study who did not have diagnosed
cardiovascular disease. Among the 1,567 participants who had no coronary artery
calcium at baseline, the group in the highest quintile of calcium intake (as
assessed by a food questionnaire and medication inventory) had a significant
27% lower likelihood of development of coronary artery calcium (CAC) at 10
years, after adjustment for differences in baseline risk.
But the investigators found a
potentially important difference in effect based on the calcium source. Calcium
from supplements was associated with a 22% higher risk of CAC. Any adverse
effect of calcium supplements could have broad importance, because 43% of U.S.
adults take calcium supplements.
C. Kaiser Permanente
embraces telemedicine
California-based
Kaiser Permanente conducted 52% of patient transactions using virtual visits,
online portals or its telehealth apps last year, company CEO Bernard Tyson
said, noting that as health care professionals assume risk under value-based
care models such as bundled payments, interest in telehealth has increased.
Kaiser also saw 4 million appointments scheduled online, 37 million tests
viewed online and 20 million health care professional e-mail collaborations in
2014-2015.
D. Zika: Worse Than Thalidomide?
Jeff Lyon. JAMA.
2016;316(12):1246.
A moment of truth is at hand for
health experts tracking Zika virus in Latin America and the Caribbean.
Thousands of pregnant women who were infected in the past year by Zika, just as
it was unmasked as a devastating threat to fetuses, are at the point of giving
birth.
Alarmed by the scientific
consensus that the Zika virus was behind a 20-fold spike in microcephaly cases
reported last year in Brazil, investigators are anxious to see what befalls
this new wave of mothers and infants.
Research suggests that nearly a
third of deliveries in mothers infected with Zika will involve severe birth
complications, including microcephaly, fetal cerebral calcification, and
central nervous system alterations (Brasil P et al. NEJM.
doi:10.1056/NEJMoa1602412 [published online March 4, 2016]). But as evidence
mounts that the virus’ strong affinity for neural stem cells may also cause
subtler central nervous system damage, the medical community fears that the
current tragedy may give way to an equally horrific second act that will play
out over years as exposed children who seemed unscathed at birth exhibit
serious neurological ills as they age. Expectations range from auditory and
visual problems to cognitive delays and seizure disorders.
Accordingly, the World Health
Organization recently called for broadening the definition of Zika-related
pathology beyond microcephaly, noting “Zika virus is an intensely neurotropic
virus that particularly targets neural progenitor cells, but also—to a lesser
extent—neuronal cells in all stages of maturity. … [I]t is possible that many
thousands of infants will incur moderate to severe neurological disabilities.”
(http://www.who.int/bulletin/volumes/94/6/16-176990/en/)
The outlook is bleak enough that
some authorities speak of the Zika epidemic in the same breath as the
thalidomide and rubella disasters of the 1960s. Citing these earlier crises,
Hal C. Lawrence III, MD, chief executive officer of the American College of
Obstetricians and Gynecologists, predicted that the Zika virus’ full toll may
not be known “for years downstream.”
E. Explosion Injuries from E-Cigarettes
N Engl J Med 2016; 375:1400-1402
Electronic nicotine-delivery
systems (ENDS) include electronic cigarettes (e-cigarettes) and personal
vaporizers. The prevalence of ENDS use is increasing among current, former, and
never smokers. E-cigarettes share a basic design; common components include an
aerosol generator, a flow sensor, a battery, and a solution storage area.1 Many
users do not understand the risk of “thermal runaway,” whereby internal battery
overheating causes a battery fire or explosion.
At our center, from October 2015
through June 2016, we treated 15 patients with injuries from e-cigarette
explosions due to the lithium-ion battery component. Such explosions were
initially thought to be rare, but there have been reports, primarily in the
media, of 25 separate incidents of e-cigarette explosions from 2009 through
2014 across the United States.2 More recently, there have been case reports in
the medical literature.3
The e-cigarette explosion
injuries seen among our patients included flame burns (80% of patients),
chemical burns (33%), and blast injuries (27%) (Figure 1Figure 1
Injuries of the Face, Hands, and
Thighs Caused by E-Cigarette Explosions.
). Patients have presented with
injuries to the face (20%), hands (33%), and thigh or groin (53%) — injuries
that have substantial implications for cosmetic and functional outcomes. Blast
injuries have led to tooth loss, traumatic tattooing, and extensive loss of
soft tissue, requiring operative débridement and closure of tissue defects. The
flame-burn injuries have required extensive wound care and skin grafting, and
exposure to the alkali chemicals released from the battery explosion has caused
chemical skin burns requiring wound care…
F. Study shows physicians
spend hours on administrative tasks
Each hour a
physician spent on face-to-face clinical time with patients meant almost two
additional hours of time during clinic hours spent on documentation tasks,
electronic health records and paperwork, according to a study in the Annals of
Internal Medicine. Researchers said the study, which included physicians in
family medicine, internal medicine, cardiology and orthopedics, showed many
physicians also spend an hour or two per night on work at home, and they noted
that decreased face time with patients contributes to the growing problem of
physician burnout in the U.S.
G. For Acute MI, Better Hospital May Mean
Longer Life
More than a year of life
expectancy difference seen in Medicare study
CONCLUSIONS
In this study, patients admitted
to high-performing hospitals after acute myocardial infarction had longer life
expectancies than patients treated in low-performing hospitals. This survival
benefit occurred in the first 30 days and persisted over the long term.
H. Your devices are probably ruining your
productivity. Here’s why
BY Lesley McClurg, KQED Science October 17, 2016
I’ll admit it. I even take my
phone with me to fire off a few texts when I go to the restroom. Or I’ll scroll
through my email when I leave the office for lunch. My eyes are often glued to
my phone from the moment I wake up, but I often reach the end of my days
wondering what I’ve accomplished.
How the Digital Age Zaps
Productivity
My productivity mystery was
solved after reading “The Distracted Mind: Ancient Brains in a High Tech
World,” by University of California, San Francisco neuroscientist Adam
Gazzaley. He explains why the brain can’t multitask, and why my near-obsessive
efforts to keep up on emails is likely lowering my creative output.
I visited Gazzaley in his UCSF
laboratory, Neuroscape, to learn more about the science of distraction.
Gazzaley pulled up, on a TV screen, a 3-D image of a brain, created from an MRI
Scan. He pointed to different sections to explain what’s going on when our
attention flits between tasks.
The habit of multitasking could
lower your score on an IQ test.
“The prefrontal cortex is the
area most challenged,” Gazzely says. “And then visual areas, auditory areas,
and the hippocampus — these networks are really what’s challenged when we are
constantly switching between multiple tasks that our technological world might
throw at us.”
When you engage in one task at a
time, the prefrontal cortex works in harmony with other parts of the brain, but
when you toss in another task it forces the left and right sides of the brain
to work independently. The process of splitting our attention usually leads to
mistakes.
In other words, each time our
eyes glance away from our computer monitor to sneak a peak at a text message,
the brain takes in new information, which reduces our primary focus. We think
the mind can juggle two or three activities successfully at once, but Gazzaley
says we woefully overestimate our ability to multitask.
“An example is when you attempt
to check your email while on a conference call,” says Gazzaley. “The act of
doing that makes it so incredibly obvious how you can’t really parallel process
two attention-demanding tasks. You either have to catch up and ask what
happened in the conversation, or you have to read over the email before you
send it — if you’re wise!”
Responding to an Email Could Cost
You 28 Minutes
Gazzaley stresses that our
tendency to respond immediately to emails and texts hinders high-level
thinking. If you’re working on a project and you stop to answer an email, the
research shows, it will take you nearly a half-hour to get back on task…
The rest of the essay: http://www.pbs.org/newshour/rundown/devices-probably-ruining-productivity-heres/
I. A Randomized Trial of Long-Term Oxygen for
COPD with Moderate Desaturation
Conclusions
In patients with stable COPD and
resting or exercise-induced moderate desaturation, the prescription of
long-term supplemental oxygen did not result in a longer time to death or first
hospitalization than no long-term supplemental oxygen, nor did it provide
sustained benefit with regard to any of the other measured outcomes.
K. Diagnosis of Acute Gout: A Clinical
Practice Guideline From the American College of Physicians
Full-text (free): http://annals.org/aim/article/2578527/diagnosis-acute-gout-clinical-practice-guideline-from-american-college-physicians
L. Life expectancies getting shorter for
Americans, study finds
The long-standing trend of
Americans' life expectancies becoming longer appears to be reversing, based on
a Society of Actuaries study. The shortening of life expectancy applies to men
and women and every age group from 25 to 85.
Article: http://www.bloomberg.com/news/articles/2016-10-28/americans-are-dying-faster-millennials-too
M. Researchers examine efficacy of migraine
drugs in youths
Fifty-two percent and 55% of
children who received migraine drugs amitriptyline and topiramate,
respectively, had a 50% reduction in the number of headache days, compared with
61% of those who received a placebo pill, according to a study in the New
England Journal of Medicine. The findings, based on data from a 24-week randomized
clinical trial involving 328 youths with migraines ages 8 to 17, also showed
significantly higher risks of side effects such as dry mouth, fatigue, mood
changes, and tingling in the hands, arms, legs or feet among those who received
the prescription medicines.
N. Empathy predicts an experimental pain
reduction during touch
Studies have provided evidence
for pain-alleviating effects of tactile stimulation, yet the effects of social
touch are still unexplored. This study examined the analgesic effects of social
touch and tested the moderating role of the toucher's empathy. Tonic heat
stimuli were administered to females; their partners either watched or touched
their hands, a stranger touched their hands, or no one interacted with them.
The results revealed diminished levels of pain during partners' touch compared
with all other control conditions. The authors note that pain perception models
should be extended, taking into account psychological characteristics of
observers.
Full-text (free): http://www.jpain.org/article/S1526-5900%2816%2930108-0/fulltext
O. No survival difference found based on
blood storage time
A randomized study in the New
England Journal of Medicine involving about 31,500 patients at six hospitals in
the US, Australia, Israel and Canada found no significant difference in
survival rates based on the freshness of transfused blood, with an in-hospital
mortality rate of 9.1% for those who received the newest blood in the study
compared with 8.7% for those who received the oldest. "Our study provides
strong evidence that transfusion of fresh blood does not improve patient
outcomes, and this should reassure clinicians that fresher is not better,"
said researcher Nancy Heddle of the McMaster Centre for Transfusion Research in
Canada.
