Jane Morris Literature Psychology Medicine Motherhood Cullen Glasgow Edinburgh.
Highlights in the Medicine Literature from 2016-2017Highlights in the Medicine Literature from...
Transcript of Highlights in the Medicine Literature from 2016-2017Highlights in the Medicine Literature from...
“Weareconstantlymisledbytheeasewithwhichourmindsfallintotherutsofoneortwoexperiences.”
“Nohumanbeingisconstitutedtoknowthetruth,thewholetruth,andnothingbutthetruth;andeventhebestofmenmustbecontentwithfragments,withpartialglimpses,neverthefullfruition.”
-SirWilliamOsler
Objectives
• Deriveclinicalmeaningfrom3recentlypublishedarticles- RCTandotherdatatypes
• Discussthemeritsandflawsofeachtrial
• Decideifeachtrialismeaningfulenoughtoaffectorchangeone’scurrentpracticeinregardstotherelevantcondition
Background
• Syncope…Ugh.
• CurrentAHAguidelinesforw/udonot includeguidanceforwhetherweshouldr/oPE
• Shouldnon-massivePEphysiologicallycausesyncope?
TheStudy
• Cross-sectionalstudytodetermineprevalence• Patientsenrolled2012-2014• Patients:Adultsadmittedto11Italianhospitalsforafirstepisodeofsyncope– NOT:Outpatients,patientsdischargedfromED,recurrent/previousepisodessyncope,ptsonanticoag,pregnantpts
TheStudy:Protocol
• PEruledoutorinwithin48hrs ofadmissioninalleligiblepatients
WellsScore<4(lowprob)
>4(highprob)
D-dimer*Negative– RULEDOUT
*Usedlabcutoffateachcenter(250-500mcg/ml)
Positive
CTPEorV/Qscan
Results
• 717admittedpatients;157excluded(onanticoag orrecurrentsyncope)à 560patientsenrolled
• Ofthe560patientsincluded,97(17.3%)hadpulmonaryembolismconfirmedwithimaging
Discussion
• CouldsomeofthesePE’sbeincidentalomas?
• Isthereagoodpathophysiologicexplanationfornon-massivePEcausingcerebralhypoperfusion?
• Shouldwechangeourpractice???
Background
• QuittingsmokingisHARD
• 6monthquitratesinclinicaltrials
Placebo 10-12%
Nicotine replacementtherapy 17-20%
Bupropion 14-20%
Varenicline 21-28%Cahilletal.JAMA 2014311:193
TheStudyRandomizationtoabruptorgradualcessation(spouseswerepairedinrandomization)
Patientsaskedtosetaquitday2weeksoutGradual: askedtohalvesmokingweek1,
quarterweek2Abrupt:Noreductionpriortoquitdate
NRT:Gradualgotpatches+ short-actingpriortoquitdate;Abruptjustpatchesprior;Bothgotpatches+short-actingafterQD
Bothgotbehavioralsupportfrom2weekspriorto8weeksafterquitdate
Primaryoutcome: 4-weekabstinence(ITT)Secondary:8-weekand6-monthabstinence*AllvalidatedbyexhaledCO
Exclusioncrit:CurrentcessationtxContraind toNRT
Nodifferenceingroups Medianage:4950/50M/F93%white35-38%livedwithsmokerMediancigs/day:20Confidenceinquitting:4(scale1-6)
Results
Abstinencerates:
Abruptcessation
Gradualcessation
4weeks:
49%
39%
8weeks:
36%
29%
6months:
22%
15%
NNT:10(4weeks);14(6months)
Discussion
• Whatdoyoutellyourpatients?Isthissurprisingtoyou?
• Physiologicorpsychologicexplanation?
• Shouldthisstudychangeourpractice?
Background:SepsisandProtocols(EGDT)
Doearlygoal-directedtherapyprotocolsmakeadifference?
• Riversetall2001:YES!
• PROCESS2014:Nope.
TheStudy:Background
• AllNYhospitalsrequiredsepsisprotocols,includinga3-hrbundle– Bloodculturepriortoabx– Serumlactatemeasurement– Administrationofbroad-spectrumabx
• Anda6-hrbundle– 30cc/kgbolusIVFifhypotensionorlactate>4– Vasopressorsforrefractoryhypotension– Remeasurement ofserumlactate
TheStudy• Retrospectivestudyincludingpatient-leveldatafrom185NYhospitals(2014-2016)
• Patientsage>17;clinicallydefinedseveresepsisorsepticshock(accordingtoSepsis-22001)
• PatientshadprotocolinitiatedinED(ignoredhospital-acquiredsepsis)
• Excludedpatients:– 3-hrbundletook>12hours– Advancedirectiveslimitingtreatmentordeclinedtx– Hospitalswithfewerthan50casesofsepsis
TheStudy
• Primaryoutcome:In-hospitalmortality• Primaryexposure:Timetocompletionof3-hrbundle
• Risk-adjustmentmodeltodetermineassociationbetweenexposureandmortality– Bivariate(yes/nocompletionin3hrs)andcontinuousanalyses
Results82%ofpatientshad3-hrbundlecompletedwithin3hrs- Mediantime1.3hrs
Inprimaryanalysis(topgraph),eachhouroftimetocompletionof3-hrbundlewasassociatedwithhighermortality- OR1.04perhr (95%CI1.02-1.05)- P<0.001
Comparingptswhohadcompletion3-12hrsto<3hrs,mortalityOR1.14(95%CI1.07-1.21,P<0.001)
3-hrbundle
Abx
IVFbolus
Results
82%ofpatientshad3-hrbundlecompletedwithin3hrs- Mediantime1.3hrs
Nodifferencesincharacteristicofptsinwhomcompletedwithin3hrs andthoseinwhomcompletedbetween3-12hrs
Inprimaryanalysis(topgraph),eachhouroftimetocompletionof3-hrbundlewasassociatedwithhighermortality- OR1.04perhr (95%CI1.02-1.05)- P<0.001
Comparingptswhohadcompletion3-12hrsto<3hrs,mortalityOR1.14(95%CI1.07-1.21,P<0.001)
Results
• “Ourresultswouldberobustunlessanunmeasuredconfounderwasatleasttwiceasprevalentamongptswhohadthe3-hrbundlecompleted1hr later”
• Hospitalswithhigherrateofbundlecompletionwithin3hrs – morelikelytobesmaller,lesslikelyteachinghospitals
Discussion• Conflictingdataintheliterature– ThisoneNOTaRCT- confounding?
• “AnalysisoftimetocompletionofIVFbolusismostpronetoconfoundingbyindication”
• Downsidestoearlyadminofbroadspectrumabx?
• ArecertainelementsofEGDT/bundlesmoreimportantthanothers?– Recall,Rivers protocolincludedScvO2monitoring,PRBCtransfusion,inotropes)
• Reviewofstudiesinvestigatingmethodsandoutcomesofreduction/discontinuationofLTOT
• 67studiesmetcriteria(11RCT’s;only5studiesinprimarycaresettings)– Only3metUSPSTFcriteriaforgoodquality,13fair;reviewfocusedonthese16
Annals 2017167(3)
Conclusions:• Findingssuggestthatpain,function,QOLmayimprove during/afteropioiddosereduction
Caveats:• Maybereversecausation?• Moststudiesincludedwillingparticipants
Annals 2017167(3)
• RCTlookingatO2 vsnoO2 forpatientswithCOPDandrestingsats of89-93%
• Foundnodifferenceintimetodeathorhospitalization,rateofhospitalization,exacerbations,orothermeasures
NEJM 2016375;17
• Retrospectivecohortofpts(n=28,266)withEMRdoc’d ARtostatin(15-20%hadCAD/strokehistory)
• ComparedCVoutcomes/deathinpatientswhohadstatincontinued/reinitiatedvsthosewhodidn’t.
• 70%didhavereinitiated/continuedstatinrx• MI/stroke/deathoccurredin12.2%ofptswhohadcontinuedstatin,13.9%ofthosewhodidn’t
• NNT=59
Annals 2017167(4)