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Psyllium cut frequency of abdominal pain in pediatric IBS trial
Consuming psyllium fiber significantly reduced the frequency, but not the severity, of abdominal pain in children with irritable bowel syndrome in a randomized, double-blind, placebo-controlled trial reported in the May issue of Clinical Gastroenterology and Hepatology (2016 Nov;14[11]:1667).
Psyllium therapy did not reduce the self-reported severity of abdominal pain, Robert J. Shulman, MD, of Baylor College of Medicine in Houston reported with his associates in Clinical Gastroenterology and Hepatology. Psyllium was associated with shifts in intestinal microbiota, compared with baseline, although the changes did not reach statistical significance when compared with placebo, the researchers added. “Further studies are needed to investigate the potential mechanism whereby psyllium decreases abdominal pain frequency in children with irritable bowel syndrome [IBS],” they wrote.
IBS affects up to 20% of school-aged children. Consuming psyllium is thought to improve abdominal pain and stooling symptoms in adults with IBS, but data are inconclusive, and few randomized trials have evaluated fiber in childhood IBS. Therefore, the investigators randomly assigned 103 children (average age, 13 years; standard deviation, 3 years) with IBS who had responded inadequately to an 8-day carbohydrate elimination diet to receive a single daily dose of either psyllium or placebo maltodextrin for 6 weeks. Children aged 7-11 years received 6 g of fiber, while those aged 12-18 years received 12 g of fiber. Patients filled out a daily pain and stool diary during a 2-week baseline assessment period and again during the final 2 weeks of the trial. They also underwent breath hydrogen and methane testing, gut permeability testing, and a stool microbiota assessment during the final weekend of treatment.
At baseline, the trial arms resembled each other in terms of frequency and severity of abdominal pain, psychological characteristics, percentage of normal stools, baseline hydrogen production, and gastrointestinal permeability, the researchers said. During the final 2 weeks of treatment, the psyllium arm reported an average of 8.2 (standard deviation, 1.2) fewer episodes of abdominal pain, compared with baseline, while the control arm reported a mean reduction of 4.1 (SD, 1.3) episodes of abdominal pain (P = .03). At the end of treatment, the arms did not significantly differ in percentage of breath hydrogen or methane production, gastrointestinal permeability, or percentage of normal stools or diarrhea. However, controls had a significantly greater reduction in constipation compared with the psyllium group (P = .048).
Stool microbiome assessments of 33 children revealed a trend toward a greater increase in Bacteroidetes and a greater decrease in Firmicutes bacteria in the fiber group, compared with the control group (P = .068). The fiber group was also “marginally enriched” in bacteria of class Bacteroidia, while the placebo group was enriched in bacteria of class Clostridia (P = .094). However, the groups did not differ at narrower taxonomic levels, the researchers said. A larger sample size might have facilitated better detection of differences between groups, such as in breath hydrogen production or interactions between abdominal pain and psychological symptoms, they added.
The study was supported in part by the National Institutes of Health, the Daffy’s Foundation, and the USDA/ARS. The investigators reported having no conflicts of interest.
Consuming psyllium fiber significantly reduced the frequency, but not the severity, of abdominal pain in children with irritable bowel syndrome in a randomized, double-blind, placebo-controlled trial reported in the May issue of Clinical Gastroenterology and Hepatology (2016 Nov;14[11]:1667).
Psyllium therapy did not reduce the self-reported severity of abdominal pain, Robert J. Shulman, MD, of Baylor College of Medicine in Houston reported with his associates in Clinical Gastroenterology and Hepatology. Psyllium was associated with shifts in intestinal microbiota, compared with baseline, although the changes did not reach statistical significance when compared with placebo, the researchers added. “Further studies are needed to investigate the potential mechanism whereby psyllium decreases abdominal pain frequency in children with irritable bowel syndrome [IBS],” they wrote.
IBS affects up to 20% of school-aged children. Consuming psyllium is thought to improve abdominal pain and stooling symptoms in adults with IBS, but data are inconclusive, and few randomized trials have evaluated fiber in childhood IBS. Therefore, the investigators randomly assigned 103 children (average age, 13 years; standard deviation, 3 years) with IBS who had responded inadequately to an 8-day carbohydrate elimination diet to receive a single daily dose of either psyllium or placebo maltodextrin for 6 weeks. Children aged 7-11 years received 6 g of fiber, while those aged 12-18 years received 12 g of fiber. Patients filled out a daily pain and stool diary during a 2-week baseline assessment period and again during the final 2 weeks of the trial. They also underwent breath hydrogen and methane testing, gut permeability testing, and a stool microbiota assessment during the final weekend of treatment.
At baseline, the trial arms resembled each other in terms of frequency and severity of abdominal pain, psychological characteristics, percentage of normal stools, baseline hydrogen production, and gastrointestinal permeability, the researchers said. During the final 2 weeks of treatment, the psyllium arm reported an average of 8.2 (standard deviation, 1.2) fewer episodes of abdominal pain, compared with baseline, while the control arm reported a mean reduction of 4.1 (SD, 1.3) episodes of abdominal pain (P = .03). At the end of treatment, the arms did not significantly differ in percentage of breath hydrogen or methane production, gastrointestinal permeability, or percentage of normal stools or diarrhea. However, controls had a significantly greater reduction in constipation compared with the psyllium group (P = .048).
Stool microbiome assessments of 33 children revealed a trend toward a greater increase in Bacteroidetes and a greater decrease in Firmicutes bacteria in the fiber group, compared with the control group (P = .068). The fiber group was also “marginally enriched” in bacteria of class Bacteroidia, while the placebo group was enriched in bacteria of class Clostridia (P = .094). However, the groups did not differ at narrower taxonomic levels, the researchers said. A larger sample size might have facilitated better detection of differences between groups, such as in breath hydrogen production or interactions between abdominal pain and psychological symptoms, they added.
The study was supported in part by the National Institutes of Health, the Daffy’s Foundation, and the USDA/ARS. The investigators reported having no conflicts of interest.
Consuming psyllium fiber significantly reduced the frequency, but not the severity, of abdominal pain in children with irritable bowel syndrome in a randomized, double-blind, placebo-controlled trial reported in the May issue of Clinical Gastroenterology and Hepatology (2016 Nov;14[11]:1667).
Psyllium therapy did not reduce the self-reported severity of abdominal pain, Robert J. Shulman, MD, of Baylor College of Medicine in Houston reported with his associates in Clinical Gastroenterology and Hepatology. Psyllium was associated with shifts in intestinal microbiota, compared with baseline, although the changes did not reach statistical significance when compared with placebo, the researchers added. “Further studies are needed to investigate the potential mechanism whereby psyllium decreases abdominal pain frequency in children with irritable bowel syndrome [IBS],” they wrote.
IBS affects up to 20% of school-aged children. Consuming psyllium is thought to improve abdominal pain and stooling symptoms in adults with IBS, but data are inconclusive, and few randomized trials have evaluated fiber in childhood IBS. Therefore, the investigators randomly assigned 103 children (average age, 13 years; standard deviation, 3 years) with IBS who had responded inadequately to an 8-day carbohydrate elimination diet to receive a single daily dose of either psyllium or placebo maltodextrin for 6 weeks. Children aged 7-11 years received 6 g of fiber, while those aged 12-18 years received 12 g of fiber. Patients filled out a daily pain and stool diary during a 2-week baseline assessment period and again during the final 2 weeks of the trial. They also underwent breath hydrogen and methane testing, gut permeability testing, and a stool microbiota assessment during the final weekend of treatment.
At baseline, the trial arms resembled each other in terms of frequency and severity of abdominal pain, psychological characteristics, percentage of normal stools, baseline hydrogen production, and gastrointestinal permeability, the researchers said. During the final 2 weeks of treatment, the psyllium arm reported an average of 8.2 (standard deviation, 1.2) fewer episodes of abdominal pain, compared with baseline, while the control arm reported a mean reduction of 4.1 (SD, 1.3) episodes of abdominal pain (P = .03). At the end of treatment, the arms did not significantly differ in percentage of breath hydrogen or methane production, gastrointestinal permeability, or percentage of normal stools or diarrhea. However, controls had a significantly greater reduction in constipation compared with the psyllium group (P = .048).
Stool microbiome assessments of 33 children revealed a trend toward a greater increase in Bacteroidetes and a greater decrease in Firmicutes bacteria in the fiber group, compared with the control group (P = .068). The fiber group was also “marginally enriched” in bacteria of class Bacteroidia, while the placebo group was enriched in bacteria of class Clostridia (P = .094). However, the groups did not differ at narrower taxonomic levels, the researchers said. A larger sample size might have facilitated better detection of differences between groups, such as in breath hydrogen production or interactions between abdominal pain and psychological symptoms, they added.
The study was supported in part by the National Institutes of Health, the Daffy’s Foundation, and the USDA/ARS. The investigators reported having no conflicts of interest.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
Key clinical point: Compared with placebo maltodextrin, consuming psyllium fiber significantly reduced the self-reported frequency of abdominal pain in children with irritable bowel syndrome.
Major finding: Children who received psyllium reported an average of 8.2 fewer pain episodes, compared with baseline, while controls reported a mean reduction of 4.1 pain episodes (P = .03).
Data source: A randomized, double-blind trial of 103 children aged 12-18 years of age with irritable bowel syndrome.
Disclosures: The study was supported in part by the National Institutes of Health, the Daffy’s Foundation, and the USDA/ARS. The investigators reported having no conflicts of interest.
ACS New SSR Offers Webinar Training Sessions
The American College of Surgeons (ACS) has announced the launch of the new Surgeon Specific Registry (SSR), hosted by QuintilesIMS. The new SSR is set to go live in this spring. The latest version of the registry will have several enhanced features, including improved reporting capabilities, delegate-level access to enter data, and the ability to add custom fields for additional relevant variables.
To help you prepare for this transition, the SSR team will host several educational webinars to demonstrate the new system’s capabilities and features. The ACS encourages both current and potential users to participate. To view the available times and register for one of the upcoming webinars, visit the SSR News and Updates web page at facs.org/quality-programs/ssr/news.
Contact [email protected] if you have any questions.
The American College of Surgeons (ACS) has announced the launch of the new Surgeon Specific Registry (SSR), hosted by QuintilesIMS. The new SSR is set to go live in this spring. The latest version of the registry will have several enhanced features, including improved reporting capabilities, delegate-level access to enter data, and the ability to add custom fields for additional relevant variables.
To help you prepare for this transition, the SSR team will host several educational webinars to demonstrate the new system’s capabilities and features. The ACS encourages both current and potential users to participate. To view the available times and register for one of the upcoming webinars, visit the SSR News and Updates web page at facs.org/quality-programs/ssr/news.
Contact [email protected] if you have any questions.
The American College of Surgeons (ACS) has announced the launch of the new Surgeon Specific Registry (SSR), hosted by QuintilesIMS. The new SSR is set to go live in this spring. The latest version of the registry will have several enhanced features, including improved reporting capabilities, delegate-level access to enter data, and the ability to add custom fields for additional relevant variables.
To help you prepare for this transition, the SSR team will host several educational webinars to demonstrate the new system’s capabilities and features. The ACS encourages both current and potential users to participate. To view the available times and register for one of the upcoming webinars, visit the SSR News and Updates web page at facs.org/quality-programs/ssr/news.
Contact [email protected] if you have any questions.
Applications for 2018 Alliance Scholar Awards Accepted through June 30
Applications for 2018 Alliance Scholar Awards Accepted through June 30
The Alliance for Clinical Trials in Oncology Foundation is accepting applications for the 2018 Alliance Scholar Awards. Applications must be submitted by 12:00 midnight (CST) on June 30.
Alliance Scholar Award applicants must be oncology junior faculty at Alliance institutions within five years of training (rank below associate professor) and have completed training in an oncology clinical specialty (medical, surgical, radiation, gynecologic, and so on). Additionally, proposals must include a letter of support from the appropriate Alliance Scientific Committee Chair to ensure the proposal is closely tied to the Alliance’s research agenda of the Alliance.
Alliance Scholar Award recipients will receive a two-year, non-renewable cancer research grant of $40,000 in direct costs per year, plus 10 percent in indirect costs for each of the two years. Successful applicants will be announced at the plenary session at the 2017 Alliance Fall Group Meeting held in Chicago, IL, November 2–4. Funding will begin approximately January 1, 2018. For application requirements and the link to the online submission portal, visit the Alliance Scholar Awards page on the Alliance website at http://bit.ly/1JMXkwS.
The Alliance/American College of Surgeons Clinical Research Program offers opportunities for surgeons to become involved in the research and development of evidence-based practices in surgical oncology. If you would like to participate in oncology clinical research or oncology-related projects, contact [email protected].
Applications for 2018 Alliance Scholar Awards Accepted through June 30
The Alliance for Clinical Trials in Oncology Foundation is accepting applications for the 2018 Alliance Scholar Awards. Applications must be submitted by 12:00 midnight (CST) on June 30.
Alliance Scholar Award applicants must be oncology junior faculty at Alliance institutions within five years of training (rank below associate professor) and have completed training in an oncology clinical specialty (medical, surgical, radiation, gynecologic, and so on). Additionally, proposals must include a letter of support from the appropriate Alliance Scientific Committee Chair to ensure the proposal is closely tied to the Alliance’s research agenda of the Alliance.
Alliance Scholar Award recipients will receive a two-year, non-renewable cancer research grant of $40,000 in direct costs per year, plus 10 percent in indirect costs for each of the two years. Successful applicants will be announced at the plenary session at the 2017 Alliance Fall Group Meeting held in Chicago, IL, November 2–4. Funding will begin approximately January 1, 2018. For application requirements and the link to the online submission portal, visit the Alliance Scholar Awards page on the Alliance website at http://bit.ly/1JMXkwS.
The Alliance/American College of Surgeons Clinical Research Program offers opportunities for surgeons to become involved in the research and development of evidence-based practices in surgical oncology. If you would like to participate in oncology clinical research or oncology-related projects, contact [email protected].
Applications for 2018 Alliance Scholar Awards Accepted through June 30
The Alliance for Clinical Trials in Oncology Foundation is accepting applications for the 2018 Alliance Scholar Awards. Applications must be submitted by 12:00 midnight (CST) on June 30.
Alliance Scholar Award applicants must be oncology junior faculty at Alliance institutions within five years of training (rank below associate professor) and have completed training in an oncology clinical specialty (medical, surgical, radiation, gynecologic, and so on). Additionally, proposals must include a letter of support from the appropriate Alliance Scientific Committee Chair to ensure the proposal is closely tied to the Alliance’s research agenda of the Alliance.
Alliance Scholar Award recipients will receive a two-year, non-renewable cancer research grant of $40,000 in direct costs per year, plus 10 percent in indirect costs for each of the two years. Successful applicants will be announced at the plenary session at the 2017 Alliance Fall Group Meeting held in Chicago, IL, November 2–4. Funding will begin approximately January 1, 2018. For application requirements and the link to the online submission portal, visit the Alliance Scholar Awards page on the Alliance website at http://bit.ly/1JMXkwS.
The Alliance/American College of Surgeons Clinical Research Program offers opportunities for surgeons to become involved in the research and development of evidence-based practices in surgical oncology. If you would like to participate in oncology clinical research or oncology-related projects, contact [email protected].
Nominate an Inspiring Woman for WiSC Award
The American College of Surgeons (ACS) Women in Surgery Committee (WiSC) is accepting nominations for the second annual Dr. Mary Edwards Walker Inspiring Women in Surgery Award, which will be presented at Clinical Congress 2017 in San Diego, CA. The award will be accorded in recognition of an individual’s significant contributions to the advancement of women in the field of surgery. Nominations are due April 30.
The award honors Dr. Mary Edwards Walker for the example she set for future generations as the first woman surgeon to serve as a U.S. Army physician and the only woman to ever receive the U.S. Armed Forces Medal of Honor for bravery.
All nominations must be accompanied by the following documents:
• A letter of nomination outlining how the candidate has contributed to the advancement of women in the field of surgery
• An up-to-date curriculum vitae
Self-nominations are acceptable and should include a letter of reference. Nominations and questions should be submitted to Connie Bura at [email protected].
The American College of Surgeons (ACS) Women in Surgery Committee (WiSC) is accepting nominations for the second annual Dr. Mary Edwards Walker Inspiring Women in Surgery Award, which will be presented at Clinical Congress 2017 in San Diego, CA. The award will be accorded in recognition of an individual’s significant contributions to the advancement of women in the field of surgery. Nominations are due April 30.
The award honors Dr. Mary Edwards Walker for the example she set for future generations as the first woman surgeon to serve as a U.S. Army physician and the only woman to ever receive the U.S. Armed Forces Medal of Honor for bravery.
All nominations must be accompanied by the following documents:
• A letter of nomination outlining how the candidate has contributed to the advancement of women in the field of surgery
• An up-to-date curriculum vitae
Self-nominations are acceptable and should include a letter of reference. Nominations and questions should be submitted to Connie Bura at [email protected].
The American College of Surgeons (ACS) Women in Surgery Committee (WiSC) is accepting nominations for the second annual Dr. Mary Edwards Walker Inspiring Women in Surgery Award, which will be presented at Clinical Congress 2017 in San Diego, CA. The award will be accorded in recognition of an individual’s significant contributions to the advancement of women in the field of surgery. Nominations are due April 30.
The award honors Dr. Mary Edwards Walker for the example she set for future generations as the first woman surgeon to serve as a U.S. Army physician and the only woman to ever receive the U.S. Armed Forces Medal of Honor for bravery.
All nominations must be accompanied by the following documents:
• A letter of nomination outlining how the candidate has contributed to the advancement of women in the field of surgery
• An up-to-date curriculum vitae
Self-nominations are acceptable and should include a letter of reference. Nominations and questions should be submitted to Connie Bura at [email protected].
Everything We Say and Do: Discussing advance care planning
Editor’s note: “Everything We Say and Do” is an informational series developed by the Society of Hospital Medicine’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experiences of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”
What I say and do
I empower all of my patients by giving them the opportunity to consider advance care planning.
Why I do it
Everyone deserves advance care planning, and every health care encounter, including a hospitalization, is an opportunity to better identify and document patients’ wishes for care should they become unable to express them. If we wait for patients to develop serious advanced illness before having advance care planning conversations, we risk depriving them of the care they would want in these situations. Additionally, we place a huge burden on family members who may struggle with excruciatingly difficult decisions in the absence of guidance about their loved one’s wishes.
How I do it
I start by identifying which components of advance care planning each patient needs, using a simple algorithm (see figure). All of my patients are queried about code status, and I give them the opportunity to better understand the value of having a healthcare proxy and advance directives, if they are not already in place.
For the remainder of this column, I’m going to focus on patients who have an acute and/or chronic treatable illness – those who require simpler advance-care-planning conversations.
To comfortably initiate the conversation about advance care planning, I always start by asking permission. I commonly say, “There are a couple of important items I discuss with all of my patients to make sure they get the care they want. Would it be okay for us to talk about those now?” This respectfully puts the patient in control. I then initiate a discussion of code status by saying, “It’s important that all of us on your care team know what you would like us to do if you got so sick that we couldn’t communicate with you. I’m not expecting this to happen, but I ask all my patients this question so that we have your instructions.” From there, the conversation evolves depending on whether the patient has any familiarity with this question and its implications.
To introduce the concept of a health care proxy and advance directives, I ask, “Have you ever thought about who you might choose to make medical decisions on your behalf if you became too sick to make those decisions yourself?” Then, finally, I share the following information, usually referring to the blank advance directives document they received in their admission packet: “There is a valuable way to put your wishes about specific care options in writing so others will know your wishes if you’re unable to communicate with them. Would you like to talk about that right now?” Again, this gives the patient control of the situation and an opportunity to decline the conversation if they are not interested or comfortable at that time.
It’s important to document the nature and outcome of these conversations. Keep in mind, advance care planning discussions need not occur at the time of admission. In fact, admission may be the worst time for some patients, further underscoring the importance of documentation so that subsequent providers can see whether advance care planning has been addressed during the hospital stay.
Note: For useful educational resources that address goals-of-care conversations in patients toward the end of life, the Center to Advance Palliative Care (www.capc.org) has a number of educational courses that address these important communication skills.
Dr. Rudolph is vice president of physician development and patient experience for Sound Physicians, Tacoma, Wash. and chair of the SHM Patient Experience Committee .
Reference
1. Moss, A.H., Ganjoo, J, Sharma S, et al. Utility of the “Surprise” Question to Identify Dialysis Patients with High Mortality. Clinical Journal of the American Society of Nephrology: CJASN. 2008;3(5):1379-84. doi:10.2215/CJN.00940208.
Editor’s note: “Everything We Say and Do” is an informational series developed by the Society of Hospital Medicine’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experiences of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”
What I say and do
I empower all of my patients by giving them the opportunity to consider advance care planning.
Why I do it
Everyone deserves advance care planning, and every health care encounter, including a hospitalization, is an opportunity to better identify and document patients’ wishes for care should they become unable to express them. If we wait for patients to develop serious advanced illness before having advance care planning conversations, we risk depriving them of the care they would want in these situations. Additionally, we place a huge burden on family members who may struggle with excruciatingly difficult decisions in the absence of guidance about their loved one’s wishes.
How I do it
I start by identifying which components of advance care planning each patient needs, using a simple algorithm (see figure). All of my patients are queried about code status, and I give them the opportunity to better understand the value of having a healthcare proxy and advance directives, if they are not already in place.
For the remainder of this column, I’m going to focus on patients who have an acute and/or chronic treatable illness – those who require simpler advance-care-planning conversations.
To comfortably initiate the conversation about advance care planning, I always start by asking permission. I commonly say, “There are a couple of important items I discuss with all of my patients to make sure they get the care they want. Would it be okay for us to talk about those now?” This respectfully puts the patient in control. I then initiate a discussion of code status by saying, “It’s important that all of us on your care team know what you would like us to do if you got so sick that we couldn’t communicate with you. I’m not expecting this to happen, but I ask all my patients this question so that we have your instructions.” From there, the conversation evolves depending on whether the patient has any familiarity with this question and its implications.
To introduce the concept of a health care proxy and advance directives, I ask, “Have you ever thought about who you might choose to make medical decisions on your behalf if you became too sick to make those decisions yourself?” Then, finally, I share the following information, usually referring to the blank advance directives document they received in their admission packet: “There is a valuable way to put your wishes about specific care options in writing so others will know your wishes if you’re unable to communicate with them. Would you like to talk about that right now?” Again, this gives the patient control of the situation and an opportunity to decline the conversation if they are not interested or comfortable at that time.
It’s important to document the nature and outcome of these conversations. Keep in mind, advance care planning discussions need not occur at the time of admission. In fact, admission may be the worst time for some patients, further underscoring the importance of documentation so that subsequent providers can see whether advance care planning has been addressed during the hospital stay.
Note: For useful educational resources that address goals-of-care conversations in patients toward the end of life, the Center to Advance Palliative Care (www.capc.org) has a number of educational courses that address these important communication skills.
Dr. Rudolph is vice president of physician development and patient experience for Sound Physicians, Tacoma, Wash. and chair of the SHM Patient Experience Committee .
Reference
1. Moss, A.H., Ganjoo, J, Sharma S, et al. Utility of the “Surprise” Question to Identify Dialysis Patients with High Mortality. Clinical Journal of the American Society of Nephrology: CJASN. 2008;3(5):1379-84. doi:10.2215/CJN.00940208.
Editor’s note: “Everything We Say and Do” is an informational series developed by the Society of Hospital Medicine’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively impact patients’ experiences of care. Each article will focus on how the contributor applies one or more of the “key communication” tactics in practice to maintain provider accountability for “everything we say and do that affects our patients’ thoughts, feelings, and well-being.”
What I say and do
I empower all of my patients by giving them the opportunity to consider advance care planning.
Why I do it
Everyone deserves advance care planning, and every health care encounter, including a hospitalization, is an opportunity to better identify and document patients’ wishes for care should they become unable to express them. If we wait for patients to develop serious advanced illness before having advance care planning conversations, we risk depriving them of the care they would want in these situations. Additionally, we place a huge burden on family members who may struggle with excruciatingly difficult decisions in the absence of guidance about their loved one’s wishes.
How I do it
I start by identifying which components of advance care planning each patient needs, using a simple algorithm (see figure). All of my patients are queried about code status, and I give them the opportunity to better understand the value of having a healthcare proxy and advance directives, if they are not already in place.
For the remainder of this column, I’m going to focus on patients who have an acute and/or chronic treatable illness – those who require simpler advance-care-planning conversations.
To comfortably initiate the conversation about advance care planning, I always start by asking permission. I commonly say, “There are a couple of important items I discuss with all of my patients to make sure they get the care they want. Would it be okay for us to talk about those now?” This respectfully puts the patient in control. I then initiate a discussion of code status by saying, “It’s important that all of us on your care team know what you would like us to do if you got so sick that we couldn’t communicate with you. I’m not expecting this to happen, but I ask all my patients this question so that we have your instructions.” From there, the conversation evolves depending on whether the patient has any familiarity with this question and its implications.
To introduce the concept of a health care proxy and advance directives, I ask, “Have you ever thought about who you might choose to make medical decisions on your behalf if you became too sick to make those decisions yourself?” Then, finally, I share the following information, usually referring to the blank advance directives document they received in their admission packet: “There is a valuable way to put your wishes about specific care options in writing so others will know your wishes if you’re unable to communicate with them. Would you like to talk about that right now?” Again, this gives the patient control of the situation and an opportunity to decline the conversation if they are not interested or comfortable at that time.
It’s important to document the nature and outcome of these conversations. Keep in mind, advance care planning discussions need not occur at the time of admission. In fact, admission may be the worst time for some patients, further underscoring the importance of documentation so that subsequent providers can see whether advance care planning has been addressed during the hospital stay.
Note: For useful educational resources that address goals-of-care conversations in patients toward the end of life, the Center to Advance Palliative Care (www.capc.org) has a number of educational courses that address these important communication skills.
Dr. Rudolph is vice president of physician development and patient experience for Sound Physicians, Tacoma, Wash. and chair of the SHM Patient Experience Committee .
Reference
1. Moss, A.H., Ganjoo, J, Sharma S, et al. Utility of the “Surprise” Question to Identify Dialysis Patients with High Mortality. Clinical Journal of the American Society of Nephrology: CJASN. 2008;3(5):1379-84. doi:10.2215/CJN.00940208.
Celebrating our accomplishments
I recently had the good fortune to read a commentary written by Dr. Peter Angelos in ACS Surgery News entitled, The Right Choice? Surgeons, confidence, and humility (2017, February, p. 11). The essay touches on the philosophy, psychology, and attitudes that surgeons adopt and express in their daily interactions with the public.
The article refers to “the balance between lack of confidence and overconfidence, and between thoughtful introspection and paralyzing fear of future complications.” This is a critically important struggle in the mind of the surgeon. I would like to propose an exercise to bolster self-esteem in the psyche of the surgeon, particularly in the formative stages of one’s career, without fostering false or pathological bravado.
I certainly see the benefit in this tradition of analyzing and reviewing surgical misadventures and discussing the proper management of uninvited complications. It is a process rooted in the concepts of honesty, transparency, introspection, reflection, collaboration, and trust.
What I would like to propose is not the cessation of the M & M conference, but the addition of a complementary conference, which I refer to as Success and Survival conference. This meeting would showcase clinical scenarios in which a given patient should have succumbed to his illness but, instead, thrived as a result of the exemplary care provided by the surgical team involved. This would shine a bright spotlight on what it is that we do, and why our profession is so extraordinary. It would serve as a wonderful reminder for surgeons at all stages of their careers as to why we chose such a rigorous, challenging, and difficult vocation as our life’s work.
Such a venue would provide young surgeons an opportunity – not to flaunt – but to share and take well-deserved pride in their victories. I believe this conference would be as effective in terms of its educational value as the M & M, but it would not be associated with negative emotions of guilt, shame, and fear. The S & S would be a setting in which the young surgeon could shine in front of his or her peers as well as the attending staff and faculty.
The academic culture that prides itself on adages such as, “Whatever doesn’t kill you makes you stronger,” “The only problem with being on call every other night is that you miss half the pathology,” and “Eat when you can, sleep when you can, and don’t mess with the pancreas,” is long overdue in celebrating the accomplishments of surgeons publicly and on a regular basis
In the end, we should want to promote future generations of surgeons who are technically sound, demonstrate excellent judgment under the most difficult circumstances, and who are able to achieve, ideally, their full surgical potential by arriving at a true harmony between self-assurance and uncertainty.
Dr. Chuback is a vascular surgeon in private practice in Paramus, N.J.
I recently had the good fortune to read a commentary written by Dr. Peter Angelos in ACS Surgery News entitled, The Right Choice? Surgeons, confidence, and humility (2017, February, p. 11). The essay touches on the philosophy, psychology, and attitudes that surgeons adopt and express in their daily interactions with the public.
The article refers to “the balance between lack of confidence and overconfidence, and between thoughtful introspection and paralyzing fear of future complications.” This is a critically important struggle in the mind of the surgeon. I would like to propose an exercise to bolster self-esteem in the psyche of the surgeon, particularly in the formative stages of one’s career, without fostering false or pathological bravado.
I certainly see the benefit in this tradition of analyzing and reviewing surgical misadventures and discussing the proper management of uninvited complications. It is a process rooted in the concepts of honesty, transparency, introspection, reflection, collaboration, and trust.
What I would like to propose is not the cessation of the M & M conference, but the addition of a complementary conference, which I refer to as Success and Survival conference. This meeting would showcase clinical scenarios in which a given patient should have succumbed to his illness but, instead, thrived as a result of the exemplary care provided by the surgical team involved. This would shine a bright spotlight on what it is that we do, and why our profession is so extraordinary. It would serve as a wonderful reminder for surgeons at all stages of their careers as to why we chose such a rigorous, challenging, and difficult vocation as our life’s work.
Such a venue would provide young surgeons an opportunity – not to flaunt – but to share and take well-deserved pride in their victories. I believe this conference would be as effective in terms of its educational value as the M & M, but it would not be associated with negative emotions of guilt, shame, and fear. The S & S would be a setting in which the young surgeon could shine in front of his or her peers as well as the attending staff and faculty.
The academic culture that prides itself on adages such as, “Whatever doesn’t kill you makes you stronger,” “The only problem with being on call every other night is that you miss half the pathology,” and “Eat when you can, sleep when you can, and don’t mess with the pancreas,” is long overdue in celebrating the accomplishments of surgeons publicly and on a regular basis
In the end, we should want to promote future generations of surgeons who are technically sound, demonstrate excellent judgment under the most difficult circumstances, and who are able to achieve, ideally, their full surgical potential by arriving at a true harmony between self-assurance and uncertainty.
Dr. Chuback is a vascular surgeon in private practice in Paramus, N.J.
I recently had the good fortune to read a commentary written by Dr. Peter Angelos in ACS Surgery News entitled, The Right Choice? Surgeons, confidence, and humility (2017, February, p. 11). The essay touches on the philosophy, psychology, and attitudes that surgeons adopt and express in their daily interactions with the public.
The article refers to “the balance between lack of confidence and overconfidence, and between thoughtful introspection and paralyzing fear of future complications.” This is a critically important struggle in the mind of the surgeon. I would like to propose an exercise to bolster self-esteem in the psyche of the surgeon, particularly in the formative stages of one’s career, without fostering false or pathological bravado.
I certainly see the benefit in this tradition of analyzing and reviewing surgical misadventures and discussing the proper management of uninvited complications. It is a process rooted in the concepts of honesty, transparency, introspection, reflection, collaboration, and trust.
What I would like to propose is not the cessation of the M & M conference, but the addition of a complementary conference, which I refer to as Success and Survival conference. This meeting would showcase clinical scenarios in which a given patient should have succumbed to his illness but, instead, thrived as a result of the exemplary care provided by the surgical team involved. This would shine a bright spotlight on what it is that we do, and why our profession is so extraordinary. It would serve as a wonderful reminder for surgeons at all stages of their careers as to why we chose such a rigorous, challenging, and difficult vocation as our life’s work.
Such a venue would provide young surgeons an opportunity – not to flaunt – but to share and take well-deserved pride in their victories. I believe this conference would be as effective in terms of its educational value as the M & M, but it would not be associated with negative emotions of guilt, shame, and fear. The S & S would be a setting in which the young surgeon could shine in front of his or her peers as well as the attending staff and faculty.
The academic culture that prides itself on adages such as, “Whatever doesn’t kill you makes you stronger,” “The only problem with being on call every other night is that you miss half the pathology,” and “Eat when you can, sleep when you can, and don’t mess with the pancreas,” is long overdue in celebrating the accomplishments of surgeons publicly and on a regular basis
In the end, we should want to promote future generations of surgeons who are technically sound, demonstrate excellent judgment under the most difficult circumstances, and who are able to achieve, ideally, their full surgical potential by arriving at a true harmony between self-assurance and uncertainty.
Dr. Chuback is a vascular surgeon in private practice in Paramus, N.J.
QI enthusiast turns QI leader
Editor’s note: This new series highlights the professional pathways of quality improvement leaders. This month features the story of Kevin O’Leary, MD, MS, SFHM, chief of hospital medicine at Northwestern University Feinberg School of Medicine in Chicago.
Kevin O’Leary, MD, MS, SFHM, chose a career path in hospital medicine for the reasons that attract many to the specialty – a love of “a little bit of everything, clinically” and the opportunity to problem-solve a diverse range of professional challenges on a daily basis.
“I was frustrated with our internal inefficiencies, and motivated by wanting to provide optimal care to patients,” Dr. O’Leary said, recalling his entry into the world of quality improvement. “It was the first time as a physician that I felt like quality was a problem that I owned – and if anyone was going to address it, it would have to be a hospitalist.”
That epiphany 16 years ago led Dr. O’Leary, now chief of hospital medicine at the same institution, on a path of enacting change. He began volunteering on small improvement projects around the hospital, which led to an invitation to chair the Quality Management Committee in the hospital medicine department. He continued to build his skills by enrolling in Six Sigma training and in Northwestern University’s Master in Healthcare Quality and Patient Safety program.
“That was transformative,” Dr. O’Leary said. “The master’s program, coupled with performance training, changed the trajectory of my career in quality improvement.”
While he encourages anyone with an interest in QI to seek additional training opportunities, he says personal qualities – tenacity, curiosity, and a willingness to collaborate—are better predictors of success. For those wondering how to get started, “look for a niche, an unmet need that is valuable to your organization, and fill it,” he advised. “You don’t have to be an expert in that area, but you can become one.”
Making strong connections within the hospital system is essential. Reach out to the contacts you know, he said, and if they are not the ones to help you solve the problem, they often know who can.
“That’s key to quality improvement success, as well as career success,” he said. “Find a mentor. It might be someone who is more senior within the hospitalist group, in medicine, or even outside the hospital. Meet with them regularly and ask them for feedback on your ideas.”
Newcomers to QI should embrace opportunities to change care and not get discouraged when a project has unintended outcomes.
“Failure is when a team never gets to the point of implementing the intervention or when a team doesn’t know whether the intervention has actually changed results,” he said. “Learning why an intervention isn’t effective can be as valuable as implementing one that is. If every project is successful, it just means that you’re not taking enough risks.”
Dr. O’Leary spends about 25% of his professional time providing clinical care, and another 15% meeting his responsibilities as division chief. He uses the other protected time in his schedule to lead QI and teach QI skills in programs like Northwestern Medicine’s Academy for Quality and Safety Improvement (AQSI).
As a former faculty member in SHM’s Quality and Safety Educator’s Academy (QSEA), he has trained medical educators to develop curricula in quality improvement and patient safety. He says both AQSI and QSEA are especially effective because they encourage interaction, which is valuable to professionals at all levels looking to advance their skill in QI.
“Even in a teaching capacity,” he noted, “what I learned from other faculty and participants in QSEA was critical.”
Residents and junior hospitalists often have the impression that they lack the skills to lead quality initiatives, but Dr. O’Leary says medical school provides the nuts and bolts – analytical skills, statistical knowledge, critical thinking. He encouraged hospitalists to move ahead, even without formal QI training.
“If you have strong interpersonal skills – the willingness to make friends and build connections – you will be successful,” he said.
It’s also an excellent way to learn about the ins and outs of the hospital system and the work of other departments and specialties. Dr. O’Leary especially enjoys that aspect of his work, as well as the ability to address systemic issues that he values.
“I get the greatest fulfillment from the opportunity to be creative … and to implement projects that are important to me and help patients,” he said. “As long as the projects align with organizational goals, I can usually find the support we need to be successful.”
Claudia Stahl is a content manager for the Society of Hospital Medicine.
Editor’s note: This new series highlights the professional pathways of quality improvement leaders. This month features the story of Kevin O’Leary, MD, MS, SFHM, chief of hospital medicine at Northwestern University Feinberg School of Medicine in Chicago.
Kevin O’Leary, MD, MS, SFHM, chose a career path in hospital medicine for the reasons that attract many to the specialty – a love of “a little bit of everything, clinically” and the opportunity to problem-solve a diverse range of professional challenges on a daily basis.
“I was frustrated with our internal inefficiencies, and motivated by wanting to provide optimal care to patients,” Dr. O’Leary said, recalling his entry into the world of quality improvement. “It was the first time as a physician that I felt like quality was a problem that I owned – and if anyone was going to address it, it would have to be a hospitalist.”
That epiphany 16 years ago led Dr. O’Leary, now chief of hospital medicine at the same institution, on a path of enacting change. He began volunteering on small improvement projects around the hospital, which led to an invitation to chair the Quality Management Committee in the hospital medicine department. He continued to build his skills by enrolling in Six Sigma training and in Northwestern University’s Master in Healthcare Quality and Patient Safety program.
“That was transformative,” Dr. O’Leary said. “The master’s program, coupled with performance training, changed the trajectory of my career in quality improvement.”
While he encourages anyone with an interest in QI to seek additional training opportunities, he says personal qualities – tenacity, curiosity, and a willingness to collaborate—are better predictors of success. For those wondering how to get started, “look for a niche, an unmet need that is valuable to your organization, and fill it,” he advised. “You don’t have to be an expert in that area, but you can become one.”
Making strong connections within the hospital system is essential. Reach out to the contacts you know, he said, and if they are not the ones to help you solve the problem, they often know who can.
“That’s key to quality improvement success, as well as career success,” he said. “Find a mentor. It might be someone who is more senior within the hospitalist group, in medicine, or even outside the hospital. Meet with them regularly and ask them for feedback on your ideas.”
Newcomers to QI should embrace opportunities to change care and not get discouraged when a project has unintended outcomes.
“Failure is when a team never gets to the point of implementing the intervention or when a team doesn’t know whether the intervention has actually changed results,” he said. “Learning why an intervention isn’t effective can be as valuable as implementing one that is. If every project is successful, it just means that you’re not taking enough risks.”
Dr. O’Leary spends about 25% of his professional time providing clinical care, and another 15% meeting his responsibilities as division chief. He uses the other protected time in his schedule to lead QI and teach QI skills in programs like Northwestern Medicine’s Academy for Quality and Safety Improvement (AQSI).
As a former faculty member in SHM’s Quality and Safety Educator’s Academy (QSEA), he has trained medical educators to develop curricula in quality improvement and patient safety. He says both AQSI and QSEA are especially effective because they encourage interaction, which is valuable to professionals at all levels looking to advance their skill in QI.
“Even in a teaching capacity,” he noted, “what I learned from other faculty and participants in QSEA was critical.”
Residents and junior hospitalists often have the impression that they lack the skills to lead quality initiatives, but Dr. O’Leary says medical school provides the nuts and bolts – analytical skills, statistical knowledge, critical thinking. He encouraged hospitalists to move ahead, even without formal QI training.
“If you have strong interpersonal skills – the willingness to make friends and build connections – you will be successful,” he said.
It’s also an excellent way to learn about the ins and outs of the hospital system and the work of other departments and specialties. Dr. O’Leary especially enjoys that aspect of his work, as well as the ability to address systemic issues that he values.
“I get the greatest fulfillment from the opportunity to be creative … and to implement projects that are important to me and help patients,” he said. “As long as the projects align with organizational goals, I can usually find the support we need to be successful.”
Claudia Stahl is a content manager for the Society of Hospital Medicine.
Editor’s note: This new series highlights the professional pathways of quality improvement leaders. This month features the story of Kevin O’Leary, MD, MS, SFHM, chief of hospital medicine at Northwestern University Feinberg School of Medicine in Chicago.
Kevin O’Leary, MD, MS, SFHM, chose a career path in hospital medicine for the reasons that attract many to the specialty – a love of “a little bit of everything, clinically” and the opportunity to problem-solve a diverse range of professional challenges on a daily basis.
“I was frustrated with our internal inefficiencies, and motivated by wanting to provide optimal care to patients,” Dr. O’Leary said, recalling his entry into the world of quality improvement. “It was the first time as a physician that I felt like quality was a problem that I owned – and if anyone was going to address it, it would have to be a hospitalist.”
That epiphany 16 years ago led Dr. O’Leary, now chief of hospital medicine at the same institution, on a path of enacting change. He began volunteering on small improvement projects around the hospital, which led to an invitation to chair the Quality Management Committee in the hospital medicine department. He continued to build his skills by enrolling in Six Sigma training and in Northwestern University’s Master in Healthcare Quality and Patient Safety program.
“That was transformative,” Dr. O’Leary said. “The master’s program, coupled with performance training, changed the trajectory of my career in quality improvement.”
While he encourages anyone with an interest in QI to seek additional training opportunities, he says personal qualities – tenacity, curiosity, and a willingness to collaborate—are better predictors of success. For those wondering how to get started, “look for a niche, an unmet need that is valuable to your organization, and fill it,” he advised. “You don’t have to be an expert in that area, but you can become one.”
Making strong connections within the hospital system is essential. Reach out to the contacts you know, he said, and if they are not the ones to help you solve the problem, they often know who can.
“That’s key to quality improvement success, as well as career success,” he said. “Find a mentor. It might be someone who is more senior within the hospitalist group, in medicine, or even outside the hospital. Meet with them regularly and ask them for feedback on your ideas.”
Newcomers to QI should embrace opportunities to change care and not get discouraged when a project has unintended outcomes.
“Failure is when a team never gets to the point of implementing the intervention or when a team doesn’t know whether the intervention has actually changed results,” he said. “Learning why an intervention isn’t effective can be as valuable as implementing one that is. If every project is successful, it just means that you’re not taking enough risks.”
Dr. O’Leary spends about 25% of his professional time providing clinical care, and another 15% meeting his responsibilities as division chief. He uses the other protected time in his schedule to lead QI and teach QI skills in programs like Northwestern Medicine’s Academy for Quality and Safety Improvement (AQSI).
As a former faculty member in SHM’s Quality and Safety Educator’s Academy (QSEA), he has trained medical educators to develop curricula in quality improvement and patient safety. He says both AQSI and QSEA are especially effective because they encourage interaction, which is valuable to professionals at all levels looking to advance their skill in QI.
“Even in a teaching capacity,” he noted, “what I learned from other faculty and participants in QSEA was critical.”
Residents and junior hospitalists often have the impression that they lack the skills to lead quality initiatives, but Dr. O’Leary says medical school provides the nuts and bolts – analytical skills, statistical knowledge, critical thinking. He encouraged hospitalists to move ahead, even without formal QI training.
“If you have strong interpersonal skills – the willingness to make friends and build connections – you will be successful,” he said.
It’s also an excellent way to learn about the ins and outs of the hospital system and the work of other departments and specialties. Dr. O’Leary especially enjoys that aspect of his work, as well as the ability to address systemic issues that he values.
“I get the greatest fulfillment from the opportunity to be creative … and to implement projects that are important to me and help patients,” he said. “As long as the projects align with organizational goals, I can usually find the support we need to be successful.”
Claudia Stahl is a content manager for the Society of Hospital Medicine.
Marijuana abuse linked to increased MI risk
Washington – Marijuana abuse was independently associated with an eye-opening doubled risk of acute MI in a large, retrospective, age-matched cohort study, Ahmad Tarek Chami, MD, reported at the annual meeting of the American College of Cardiology.
The link was strongest by far in young adult marijuana abusers, with an adjusted 3.2-fold increased risk of MI in 25- to 29-year-olds with marijuana abuse noted in their medical records, compared with age-matched controls and a 4.56-fold greater risk among the 30- to 34-year-old cannabis abusers, according to Dr. Chami of Case Western Reserve University in Cleveland.
These data constitute a signal warranting further research. Public opinion regarding potheads has undergone a huge shift. Medical and/or recreational marijuana is now legal in 28 states and the District of Columbia. Surveys indicate that, in 2015, 8.3% of Americans aged 12 years and older had used marijuana during the previous month, and 13.5% had used it within the past year.
“Cardiologists and other physicians are more likely than ever before to encounter patients who use marijuana or even ask them to prescribe it,” Dr. Chami said.
The cannabis plant contains more than 60 cannabinoids. Although marijuana is widely prescribed for treatment of nausea, anorexia, neuropathic pain, glaucoma, seizure disorders, and other conditions, the long-term effects of marijuana on the cardiovascular system are largely unknown, he continued.
This ambiguity was the impetus for Dr. Chami’s study. In it, he utilized a database incorporating 26 health care systems across the United States with nearly 50 million patients, which is maintained by Explorys, an 8-year-old Cleveland-based company.
Dr. Chami identified 210,700 patients with cannabis abuse noted in their medical records, covering provider/patient encounters between October 2011 and September 2016. Their mean age was 36.8 years. The abusers were age-matched to 10,395,060 non–marijuana abuser controls.
The 5-year cumulative incidence of MI in this skewed–young patient population was significantly higher than in the marijuana abuser group: 1.28%, compared with 0.89%, for a 44% increase in relative risk.
However, the marijuana abusers also had a significantly higher burden of cardiovascular risk factors than did their non–cannabis abusing counterparts. They were 2.85 times more likely to have hypertension, 1.59 times more likely to be dyslipidemic, and 7.2 times more likely to be cigarette smokers, and they had a 2.8 times greater prevalence of diabetes. Of note, they were also 17.6 times more likely to have been diagnosed with alcohol abuse, and 61 times more likely to abuse cocaine.
In a multivariate analysis adjusted for these and other potential confounders, marijuana abuse remained independently associated with a 1.73-fold increased risk of acute MI. Moreover, after eliminating patients with known coronary artery disease, the strongest risk factor for MI, from the analysis, marijuana abuse was independently associated with a twofold increased risk of MI.
This was a retrospective study, one limitation of which was the standard caveat regarding the possibility of unrecognized confounders that couldn’t be taken into account.
Another study limitation is the uncertainty regarding the diagnosis of “cannabis abuser” in patients’ charts. The Explorys cloud-based database relies on ICD codes to capture data. It doesn’t include specific information on how much marijuana a patient who was labeled as an abuser was actually using. This limitation raises an unanswered question: Were young adults who abused marijuana at highest risk for MI because of heavier use, or are younger patients’ coronary arteries somehow more vulnerable to marijuana’s potential adverse cardiovascular effects?
Several audience members called Dr. Chami’s study “very provocative.” Aaron D. Kugelmass, MD, said that the fundamental question in his mind is whether the cardiovascular hazard of marijuana identified in this study is the result of the practice of smoking the raw product, usually associated with illicit marijuana abusers.
Today, legalized marijuana is often consumed in the form of edible products, tinctures, and other derivatives that don’t involve inhalation of smoke. Whether these alternative forms of consumption pose any cardiovascular risk is an important unresolved issue in this era of widespread decriminalization of cannabis, noted Dr. Kugelmass, chief of cardiology and medical director of the Heart and Vascular Center at Baystate Medical Center in Springfield, Mass.
Dr. Chami reported having no financial conflicts regarding his study.
Washington – Marijuana abuse was independently associated with an eye-opening doubled risk of acute MI in a large, retrospective, age-matched cohort study, Ahmad Tarek Chami, MD, reported at the annual meeting of the American College of Cardiology.
The link was strongest by far in young adult marijuana abusers, with an adjusted 3.2-fold increased risk of MI in 25- to 29-year-olds with marijuana abuse noted in their medical records, compared with age-matched controls and a 4.56-fold greater risk among the 30- to 34-year-old cannabis abusers, according to Dr. Chami of Case Western Reserve University in Cleveland.
These data constitute a signal warranting further research. Public opinion regarding potheads has undergone a huge shift. Medical and/or recreational marijuana is now legal in 28 states and the District of Columbia. Surveys indicate that, in 2015, 8.3% of Americans aged 12 years and older had used marijuana during the previous month, and 13.5% had used it within the past year.
“Cardiologists and other physicians are more likely than ever before to encounter patients who use marijuana or even ask them to prescribe it,” Dr. Chami said.
The cannabis plant contains more than 60 cannabinoids. Although marijuana is widely prescribed for treatment of nausea, anorexia, neuropathic pain, glaucoma, seizure disorders, and other conditions, the long-term effects of marijuana on the cardiovascular system are largely unknown, he continued.
This ambiguity was the impetus for Dr. Chami’s study. In it, he utilized a database incorporating 26 health care systems across the United States with nearly 50 million patients, which is maintained by Explorys, an 8-year-old Cleveland-based company.
Dr. Chami identified 210,700 patients with cannabis abuse noted in their medical records, covering provider/patient encounters between October 2011 and September 2016. Their mean age was 36.8 years. The abusers were age-matched to 10,395,060 non–marijuana abuser controls.
The 5-year cumulative incidence of MI in this skewed–young patient population was significantly higher than in the marijuana abuser group: 1.28%, compared with 0.89%, for a 44% increase in relative risk.
However, the marijuana abusers also had a significantly higher burden of cardiovascular risk factors than did their non–cannabis abusing counterparts. They were 2.85 times more likely to have hypertension, 1.59 times more likely to be dyslipidemic, and 7.2 times more likely to be cigarette smokers, and they had a 2.8 times greater prevalence of diabetes. Of note, they were also 17.6 times more likely to have been diagnosed with alcohol abuse, and 61 times more likely to abuse cocaine.
In a multivariate analysis adjusted for these and other potential confounders, marijuana abuse remained independently associated with a 1.73-fold increased risk of acute MI. Moreover, after eliminating patients with known coronary artery disease, the strongest risk factor for MI, from the analysis, marijuana abuse was independently associated with a twofold increased risk of MI.
This was a retrospective study, one limitation of which was the standard caveat regarding the possibility of unrecognized confounders that couldn’t be taken into account.
Another study limitation is the uncertainty regarding the diagnosis of “cannabis abuser” in patients’ charts. The Explorys cloud-based database relies on ICD codes to capture data. It doesn’t include specific information on how much marijuana a patient who was labeled as an abuser was actually using. This limitation raises an unanswered question: Were young adults who abused marijuana at highest risk for MI because of heavier use, or are younger patients’ coronary arteries somehow more vulnerable to marijuana’s potential adverse cardiovascular effects?
Several audience members called Dr. Chami’s study “very provocative.” Aaron D. Kugelmass, MD, said that the fundamental question in his mind is whether the cardiovascular hazard of marijuana identified in this study is the result of the practice of smoking the raw product, usually associated with illicit marijuana abusers.
Today, legalized marijuana is often consumed in the form of edible products, tinctures, and other derivatives that don’t involve inhalation of smoke. Whether these alternative forms of consumption pose any cardiovascular risk is an important unresolved issue in this era of widespread decriminalization of cannabis, noted Dr. Kugelmass, chief of cardiology and medical director of the Heart and Vascular Center at Baystate Medical Center in Springfield, Mass.
Dr. Chami reported having no financial conflicts regarding his study.
Washington – Marijuana abuse was independently associated with an eye-opening doubled risk of acute MI in a large, retrospective, age-matched cohort study, Ahmad Tarek Chami, MD, reported at the annual meeting of the American College of Cardiology.
The link was strongest by far in young adult marijuana abusers, with an adjusted 3.2-fold increased risk of MI in 25- to 29-year-olds with marijuana abuse noted in their medical records, compared with age-matched controls and a 4.56-fold greater risk among the 30- to 34-year-old cannabis abusers, according to Dr. Chami of Case Western Reserve University in Cleveland.
These data constitute a signal warranting further research. Public opinion regarding potheads has undergone a huge shift. Medical and/or recreational marijuana is now legal in 28 states and the District of Columbia. Surveys indicate that, in 2015, 8.3% of Americans aged 12 years and older had used marijuana during the previous month, and 13.5% had used it within the past year.
“Cardiologists and other physicians are more likely than ever before to encounter patients who use marijuana or even ask them to prescribe it,” Dr. Chami said.
The cannabis plant contains more than 60 cannabinoids. Although marijuana is widely prescribed for treatment of nausea, anorexia, neuropathic pain, glaucoma, seizure disorders, and other conditions, the long-term effects of marijuana on the cardiovascular system are largely unknown, he continued.
This ambiguity was the impetus for Dr. Chami’s study. In it, he utilized a database incorporating 26 health care systems across the United States with nearly 50 million patients, which is maintained by Explorys, an 8-year-old Cleveland-based company.
Dr. Chami identified 210,700 patients with cannabis abuse noted in their medical records, covering provider/patient encounters between October 2011 and September 2016. Their mean age was 36.8 years. The abusers were age-matched to 10,395,060 non–marijuana abuser controls.
The 5-year cumulative incidence of MI in this skewed–young patient population was significantly higher than in the marijuana abuser group: 1.28%, compared with 0.89%, for a 44% increase in relative risk.
However, the marijuana abusers also had a significantly higher burden of cardiovascular risk factors than did their non–cannabis abusing counterparts. They were 2.85 times more likely to have hypertension, 1.59 times more likely to be dyslipidemic, and 7.2 times more likely to be cigarette smokers, and they had a 2.8 times greater prevalence of diabetes. Of note, they were also 17.6 times more likely to have been diagnosed with alcohol abuse, and 61 times more likely to abuse cocaine.
In a multivariate analysis adjusted for these and other potential confounders, marijuana abuse remained independently associated with a 1.73-fold increased risk of acute MI. Moreover, after eliminating patients with known coronary artery disease, the strongest risk factor for MI, from the analysis, marijuana abuse was independently associated with a twofold increased risk of MI.
This was a retrospective study, one limitation of which was the standard caveat regarding the possibility of unrecognized confounders that couldn’t be taken into account.
Another study limitation is the uncertainty regarding the diagnosis of “cannabis abuser” in patients’ charts. The Explorys cloud-based database relies on ICD codes to capture data. It doesn’t include specific information on how much marijuana a patient who was labeled as an abuser was actually using. This limitation raises an unanswered question: Were young adults who abused marijuana at highest risk for MI because of heavier use, or are younger patients’ coronary arteries somehow more vulnerable to marijuana’s potential adverse cardiovascular effects?
Several audience members called Dr. Chami’s study “very provocative.” Aaron D. Kugelmass, MD, said that the fundamental question in his mind is whether the cardiovascular hazard of marijuana identified in this study is the result of the practice of smoking the raw product, usually associated with illicit marijuana abusers.
Today, legalized marijuana is often consumed in the form of edible products, tinctures, and other derivatives that don’t involve inhalation of smoke. Whether these alternative forms of consumption pose any cardiovascular risk is an important unresolved issue in this era of widespread decriminalization of cannabis, noted Dr. Kugelmass, chief of cardiology and medical director of the Heart and Vascular Center at Baystate Medical Center in Springfield, Mass.
Dr. Chami reported having no financial conflicts regarding his study.
At ACC 17
Key clinical point:
Major finding: Marijuana abuse was associated with a twofold increased risk of acute MI independent of cardiovascular risk factor levels.
Data source: A retrospective cohort study including 210,700 patients with cannabis abuse noted in their medical record and 10,395,060 age-matched controls.
Disclosures: The study presenter reported having no financial conflicts.
A Game for All Seasons
Sports and sports figures provide both a welcome relief from the stress of dealing with life and death in the ED and memorable ways of characterizing serious health care issues. When the Institute of Medicine issued its 2006 report “Hospital-Based Emergency Care: At the Breaking Point,” we thought that a quote about a popular restaurant by the late, great New York Yankees catcher Yogi Berra better described the severely overcrowded EDs and ambulance diversion: “Nobody goes there anymore—it’s too crowded.”
In late winter and early spring of this year, after vigorous attempts to repeal/revise the 2010 Affordable Care Act (ACA), a replacement bill was withdrawn immediately prior to a Congressional vote on March 24 due to a lack of support. Seven years earlier, when President Obama also seemed to have little chance of getting the ACA through Congress, we thought that there would be “many more balks before the president and Congress finally pitched a viable health care package to the nation.” Only a month later, however, with the ACA now the law, we suggested that our erroneous prediction was similar to that of “a father who convinces his son to leave for the parking lot during the bottom of the ninth inning of a 3-0 game only to hear the roar of the crowd from the exit ramp as the rookie batter hits a grand-slam home run to win the game.”
In June 2012, when the Supreme Court ruled on the constitutionality of the ACA, many reporters quickly read the Court’s rejection of the first two arguments defending the ACA, and rushed to report that it was dead, without considering that the government had “one more out to go…[the one] casting ACA as a tax—considered to be the weakest player in the lineup—[which] managed to score the winning run to uphold ACA. Game over. Final score: ACA wins 5 to 4.”
But with the 2017 baseball season finally underway, it is a recent football game that provides the perfect paradigm for emergency medicine (EM) and emergency physicians (EPs). The New England Patriots were slight favorites to win Super Bowl 51 over the Atlanta Falcons on February 5,and the first quarter ended with no score. But by halftime, Atlanta was leading 21-3. In 50 years of Super Bowls, no team had ever overcome more than a 10-point deficit to win the game, and with a little over 8 minutes left in the third quarter, the deficit had widened even further to 28-3. Then the Patriots began to turn things around. Though the Patriots never led during regulation play, and no Super Bowl had ever gone into overtime, the fourth quarter ended in a 28-28 tie, and the Patriots went on to win 34-28 in overtime.
Coming out of the locker room to play the second half of that game in front of over 111 million viewers must have been a daunting experience for the Patriots, but no more so than the experience depicted in EP/cinematographer Ryan McGarry’s award-winning documentary “Code Black,” in which he shows young EM residents walking through a packed waiting room to begin their shift, realizing that in the next 12 hours, they could never treat all of the ill patients waiting to be seen. But the young residents proceeded to treat one patient after another without ever giving up or losing their idealism, until in the end, they, too, had won the game against all odds.
Many patients arrive in EDs so ill that there is no reasonable expectation any intervention can save them, but we nevertheless try and sometimes succeed in doing the seemingly impossible. It is the type of medicine we have chosen to devote our careers to, and we are no less heroes than were the Patriots on February 5, 2017. Each time we go out to “play ball” in our overcrowded EDs, it is worth remembering another famous Yogi Berra quote: “It ain’t over till it’s over.”
Sports and sports figures provide both a welcome relief from the stress of dealing with life and death in the ED and memorable ways of characterizing serious health care issues. When the Institute of Medicine issued its 2006 report “Hospital-Based Emergency Care: At the Breaking Point,” we thought that a quote about a popular restaurant by the late, great New York Yankees catcher Yogi Berra better described the severely overcrowded EDs and ambulance diversion: “Nobody goes there anymore—it’s too crowded.”
In late winter and early spring of this year, after vigorous attempts to repeal/revise the 2010 Affordable Care Act (ACA), a replacement bill was withdrawn immediately prior to a Congressional vote on March 24 due to a lack of support. Seven years earlier, when President Obama also seemed to have little chance of getting the ACA through Congress, we thought that there would be “many more balks before the president and Congress finally pitched a viable health care package to the nation.” Only a month later, however, with the ACA now the law, we suggested that our erroneous prediction was similar to that of “a father who convinces his son to leave for the parking lot during the bottom of the ninth inning of a 3-0 game only to hear the roar of the crowd from the exit ramp as the rookie batter hits a grand-slam home run to win the game.”
In June 2012, when the Supreme Court ruled on the constitutionality of the ACA, many reporters quickly read the Court’s rejection of the first two arguments defending the ACA, and rushed to report that it was dead, without considering that the government had “one more out to go…[the one] casting ACA as a tax—considered to be the weakest player in the lineup—[which] managed to score the winning run to uphold ACA. Game over. Final score: ACA wins 5 to 4.”
But with the 2017 baseball season finally underway, it is a recent football game that provides the perfect paradigm for emergency medicine (EM) and emergency physicians (EPs). The New England Patriots were slight favorites to win Super Bowl 51 over the Atlanta Falcons on February 5,and the first quarter ended with no score. But by halftime, Atlanta was leading 21-3. In 50 years of Super Bowls, no team had ever overcome more than a 10-point deficit to win the game, and with a little over 8 minutes left in the third quarter, the deficit had widened even further to 28-3. Then the Patriots began to turn things around. Though the Patriots never led during regulation play, and no Super Bowl had ever gone into overtime, the fourth quarter ended in a 28-28 tie, and the Patriots went on to win 34-28 in overtime.
Coming out of the locker room to play the second half of that game in front of over 111 million viewers must have been a daunting experience for the Patriots, but no more so than the experience depicted in EP/cinematographer Ryan McGarry’s award-winning documentary “Code Black,” in which he shows young EM residents walking through a packed waiting room to begin their shift, realizing that in the next 12 hours, they could never treat all of the ill patients waiting to be seen. But the young residents proceeded to treat one patient after another without ever giving up or losing their idealism, until in the end, they, too, had won the game against all odds.
Many patients arrive in EDs so ill that there is no reasonable expectation any intervention can save them, but we nevertheless try and sometimes succeed in doing the seemingly impossible. It is the type of medicine we have chosen to devote our careers to, and we are no less heroes than were the Patriots on February 5, 2017. Each time we go out to “play ball” in our overcrowded EDs, it is worth remembering another famous Yogi Berra quote: “It ain’t over till it’s over.”
Sports and sports figures provide both a welcome relief from the stress of dealing with life and death in the ED and memorable ways of characterizing serious health care issues. When the Institute of Medicine issued its 2006 report “Hospital-Based Emergency Care: At the Breaking Point,” we thought that a quote about a popular restaurant by the late, great New York Yankees catcher Yogi Berra better described the severely overcrowded EDs and ambulance diversion: “Nobody goes there anymore—it’s too crowded.”
In late winter and early spring of this year, after vigorous attempts to repeal/revise the 2010 Affordable Care Act (ACA), a replacement bill was withdrawn immediately prior to a Congressional vote on March 24 due to a lack of support. Seven years earlier, when President Obama also seemed to have little chance of getting the ACA through Congress, we thought that there would be “many more balks before the president and Congress finally pitched a viable health care package to the nation.” Only a month later, however, with the ACA now the law, we suggested that our erroneous prediction was similar to that of “a father who convinces his son to leave for the parking lot during the bottom of the ninth inning of a 3-0 game only to hear the roar of the crowd from the exit ramp as the rookie batter hits a grand-slam home run to win the game.”
In June 2012, when the Supreme Court ruled on the constitutionality of the ACA, many reporters quickly read the Court’s rejection of the first two arguments defending the ACA, and rushed to report that it was dead, without considering that the government had “one more out to go…[the one] casting ACA as a tax—considered to be the weakest player in the lineup—[which] managed to score the winning run to uphold ACA. Game over. Final score: ACA wins 5 to 4.”
But with the 2017 baseball season finally underway, it is a recent football game that provides the perfect paradigm for emergency medicine (EM) and emergency physicians (EPs). The New England Patriots were slight favorites to win Super Bowl 51 over the Atlanta Falcons on February 5,and the first quarter ended with no score. But by halftime, Atlanta was leading 21-3. In 50 years of Super Bowls, no team had ever overcome more than a 10-point deficit to win the game, and with a little over 8 minutes left in the third quarter, the deficit had widened even further to 28-3. Then the Patriots began to turn things around. Though the Patriots never led during regulation play, and no Super Bowl had ever gone into overtime, the fourth quarter ended in a 28-28 tie, and the Patriots went on to win 34-28 in overtime.
Coming out of the locker room to play the second half of that game in front of over 111 million viewers must have been a daunting experience for the Patriots, but no more so than the experience depicted in EP/cinematographer Ryan McGarry’s award-winning documentary “Code Black,” in which he shows young EM residents walking through a packed waiting room to begin their shift, realizing that in the next 12 hours, they could never treat all of the ill patients waiting to be seen. But the young residents proceeded to treat one patient after another without ever giving up or losing their idealism, until in the end, they, too, had won the game against all odds.
Many patients arrive in EDs so ill that there is no reasonable expectation any intervention can save them, but we nevertheless try and sometimes succeed in doing the seemingly impossible. It is the type of medicine we have chosen to devote our careers to, and we are no less heroes than were the Patriots on February 5, 2017. Each time we go out to “play ball” in our overcrowded EDs, it is worth remembering another famous Yogi Berra quote: “It ain’t over till it’s over.”
Paraspinous Cervical Nerve Block for Primary Headache
Headaches—pain or discomfort in the head, scalp, or neck—are a very common reason for ED visits.1 In 2011, the World Health Organization estimated that 46.5% of the population in North and South America aged 18 to 65 years old experienced at least one headache within the previous year.1
Migraine is a recurrent headache disorder that afflicts 18% of US women and 9% of US men,2 resulting in at least 1.2 million visits to US EDs annually.1 The economic cost resulting from migraine-related loss of productive time in the US workforce is more than $13 billion per year, most of which is in the form of reduced work productivity.3 Management and treatment for migraine headache in the ED commonly include intravenous (IV) or intramuscular (IM) medications, fluids, or oxygen. While ultimately effective, these methods require nursing care and additional time for posttreatment monitoring, both of which adversely affect patient flow.
In 2006, Mellick et al4 described the safety and effectiveness of paraspinous cervical nerve block (PCNB) to abort migraine headaches. Despite its demonstrated efficacy and safety, a decade later, PCNB is still rarely used. Friedman et al5 ranked peripheral nerve blocks as the fourth step in management suggestions for primary headache.
Case Reports of Headache Patients
We report on seven headache patients we treated in our ED with PCNB who had good-to-complete resolution of pain, suggesting that PCNB is efficacious and can potentially shorten the ED length of stay. This series of seven patients (six female, one male) was a convenience sample of primary headache patients who presented over a 10-month period and were safely and rapidly treated with PCNB (Table).
In each case, the PCNB procedure was explained to the patient and consent was obtained. Each patient was treated with a total of 3 cc of 0.5% bupivacaine with epinephrine injected into the posterior neck according to the method described by Mellick et al.4 Our seven patients achieved an average 5-point reduction in pain on a 10-point pain scale, with 0 = no pain and 10 = worse possible pain.
Other than the provision of medications, no nursing assistance was required. Only one of the patients required further treatment after the PCNB, and none had an adverse reaction. All of the patients reported that their headaches were similar in nature to past headaches. Based on their history and physical examination, none were diagnosed to be experiencing a secondary, more serious cause of headache, and none subsequently returned to our institution with a secondary type of headache.
The Paraspinal Cervical Nerve Block
Paraspinous cervical nerve block requires less time to administer and recovery is shorter than that from IM or IV opioids, sedatives, or neuroleptics. It is an easy technique to teach since it requires bilateral injections.
Technique
Prior to the procedure, cleanse the bilateral paravertebral zones surrounding C6 and C7 with chlorhexidine. Next, fill a 3 cc syringe using 0.5% bupivacaine with epinephrine.
Once the injection is complete, withdraw the needle completely, and compress and massage the injection site to facilitate anesthetic diffusion to surrounding tissues.
Indications
Paraspinous cervical nerve block is an appropriate treatment only for patients who are having a typical episode of chronic, recurring headaches, whose history and physical examination do not suggest the need for any further diagnostic work-up, and who, in the judgment of the treating clinician, require only pain relief.
Contraindications
A patient should not be considered for PCNB if he or she has a new-onset headache, fever, altered mental status, focal neurological deficits, meningismus, findings suggestive of meningitis, papilledema, increased intracranial pressure from a space-occupying lesion, recent head trauma with concern for intracranial hemorrhage, or suspicion of an alternate diagnosis.
Efficacy and Patient Response
Paraspinous cervical nerve block has been shown to decrease pain in patients who had failed standard migraine therapy and patients reported no complications. Of the seven patients in this case report, only one patient received opioids in the ED and none received prescriptions for opioids upon discharge for outpatient use.
Mellick and Mellick6 have postulated that pain may be modified due to the PCNB effect on the convergence of the trigeminal nerve with sensory fibers from the upper cervical roots. Since cervical innervation provides feeling to the head and upper neck, blocking this input can ameliorate pain.6
Summary
This series of seven patients provides further evidence of the effectiveness of PCNB in relieving headache symptoms for patients with recurrent, primary headaches when a secondary, more serious cause has been clinically excluded. Each of the seven patients had marked improvement of their pain and required only minimal nursing attention; moreover, all stated they would willingly undergo the procedure for future painful episodes.
Although there were no reported complications, this series is too small to demonstrate complete safety of the procedure. While this report is limited by a small sample size, it demonstrates that this is a quick, effective, and easily learned method of addressing a common ED complaint that obviates the need for parenteral medications and offers a potentially decreased patient length of stay.
Paraspinous cervical nerve block is a promising modality of treatment of ED patients who present with headache and migraine symptoms who do not respond to their outpatient “rescue” therapy. This procedure should be considered as an early treatment for migraine and other primary headaches unless contraindicated.
1. World Health Organization. Atlas of headache disorders and resources in the world 2011. http://www.who.int/mental_health/management/who_atlas_headache_disorders_results.pdf. Accessed February 9, 2017.
2. Victor TW, Hu X, Campbell JC, Buse DC, Lipton RB. Migraine prevalence by age and sex in the United States: a life-span study. Cephalalgia. 2010;30(9):1065-1072. doi:10.1177/0333102409355601.
3. Chawla J. Migraine headache. http://emedicine.medscape.com/article/1142556-overview. Accessed February 9, 2017.
4. Mellick LB, McIlrath ST, Mellick GA. Treatment of headaches in the ED with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 417 patients. Headache. 2006;46(9):1441-1449.
5. Friedman BW, West J, Vinson DR, et al. Current management of migraine in US emergency departments: an analysis of the National Hospital Ambulatory Medical Care Survey. Cephalalgia. 2015;35:301-309.
6. Mellick GA, Mellick LB. Lower cervical intramuscular bupivacaine injections—another treatment option for headaches. http://www.neurologist-doctor.com/images/Mellick_Headache_injections.pdf. Accessed February 9, 2017.
Headaches—pain or discomfort in the head, scalp, or neck—are a very common reason for ED visits.1 In 2011, the World Health Organization estimated that 46.5% of the population in North and South America aged 18 to 65 years old experienced at least one headache within the previous year.1
Migraine is a recurrent headache disorder that afflicts 18% of US women and 9% of US men,2 resulting in at least 1.2 million visits to US EDs annually.1 The economic cost resulting from migraine-related loss of productive time in the US workforce is more than $13 billion per year, most of which is in the form of reduced work productivity.3 Management and treatment for migraine headache in the ED commonly include intravenous (IV) or intramuscular (IM) medications, fluids, or oxygen. While ultimately effective, these methods require nursing care and additional time for posttreatment monitoring, both of which adversely affect patient flow.
In 2006, Mellick et al4 described the safety and effectiveness of paraspinous cervical nerve block (PCNB) to abort migraine headaches. Despite its demonstrated efficacy and safety, a decade later, PCNB is still rarely used. Friedman et al5 ranked peripheral nerve blocks as the fourth step in management suggestions for primary headache.
Case Reports of Headache Patients
We report on seven headache patients we treated in our ED with PCNB who had good-to-complete resolution of pain, suggesting that PCNB is efficacious and can potentially shorten the ED length of stay. This series of seven patients (six female, one male) was a convenience sample of primary headache patients who presented over a 10-month period and were safely and rapidly treated with PCNB (Table).
In each case, the PCNB procedure was explained to the patient and consent was obtained. Each patient was treated with a total of 3 cc of 0.5% bupivacaine with epinephrine injected into the posterior neck according to the method described by Mellick et al.4 Our seven patients achieved an average 5-point reduction in pain on a 10-point pain scale, with 0 = no pain and 10 = worse possible pain.
Other than the provision of medications, no nursing assistance was required. Only one of the patients required further treatment after the PCNB, and none had an adverse reaction. All of the patients reported that their headaches were similar in nature to past headaches. Based on their history and physical examination, none were diagnosed to be experiencing a secondary, more serious cause of headache, and none subsequently returned to our institution with a secondary type of headache.
The Paraspinal Cervical Nerve Block
Paraspinous cervical nerve block requires less time to administer and recovery is shorter than that from IM or IV opioids, sedatives, or neuroleptics. It is an easy technique to teach since it requires bilateral injections.
Technique
Prior to the procedure, cleanse the bilateral paravertebral zones surrounding C6 and C7 with chlorhexidine. Next, fill a 3 cc syringe using 0.5% bupivacaine with epinephrine.
Once the injection is complete, withdraw the needle completely, and compress and massage the injection site to facilitate anesthetic diffusion to surrounding tissues.
Indications
Paraspinous cervical nerve block is an appropriate treatment only for patients who are having a typical episode of chronic, recurring headaches, whose history and physical examination do not suggest the need for any further diagnostic work-up, and who, in the judgment of the treating clinician, require only pain relief.
Contraindications
A patient should not be considered for PCNB if he or she has a new-onset headache, fever, altered mental status, focal neurological deficits, meningismus, findings suggestive of meningitis, papilledema, increased intracranial pressure from a space-occupying lesion, recent head trauma with concern for intracranial hemorrhage, or suspicion of an alternate diagnosis.
Efficacy and Patient Response
Paraspinous cervical nerve block has been shown to decrease pain in patients who had failed standard migraine therapy and patients reported no complications. Of the seven patients in this case report, only one patient received opioids in the ED and none received prescriptions for opioids upon discharge for outpatient use.
Mellick and Mellick6 have postulated that pain may be modified due to the PCNB effect on the convergence of the trigeminal nerve with sensory fibers from the upper cervical roots. Since cervical innervation provides feeling to the head and upper neck, blocking this input can ameliorate pain.6
Summary
This series of seven patients provides further evidence of the effectiveness of PCNB in relieving headache symptoms for patients with recurrent, primary headaches when a secondary, more serious cause has been clinically excluded. Each of the seven patients had marked improvement of their pain and required only minimal nursing attention; moreover, all stated they would willingly undergo the procedure for future painful episodes.
Although there were no reported complications, this series is too small to demonstrate complete safety of the procedure. While this report is limited by a small sample size, it demonstrates that this is a quick, effective, and easily learned method of addressing a common ED complaint that obviates the need for parenteral medications and offers a potentially decreased patient length of stay.
Paraspinous cervical nerve block is a promising modality of treatment of ED patients who present with headache and migraine symptoms who do not respond to their outpatient “rescue” therapy. This procedure should be considered as an early treatment for migraine and other primary headaches unless contraindicated.
Headaches—pain or discomfort in the head, scalp, or neck—are a very common reason for ED visits.1 In 2011, the World Health Organization estimated that 46.5% of the population in North and South America aged 18 to 65 years old experienced at least one headache within the previous year.1
Migraine is a recurrent headache disorder that afflicts 18% of US women and 9% of US men,2 resulting in at least 1.2 million visits to US EDs annually.1 The economic cost resulting from migraine-related loss of productive time in the US workforce is more than $13 billion per year, most of which is in the form of reduced work productivity.3 Management and treatment for migraine headache in the ED commonly include intravenous (IV) or intramuscular (IM) medications, fluids, or oxygen. While ultimately effective, these methods require nursing care and additional time for posttreatment monitoring, both of which adversely affect patient flow.
In 2006, Mellick et al4 described the safety and effectiveness of paraspinous cervical nerve block (PCNB) to abort migraine headaches. Despite its demonstrated efficacy and safety, a decade later, PCNB is still rarely used. Friedman et al5 ranked peripheral nerve blocks as the fourth step in management suggestions for primary headache.
Case Reports of Headache Patients
We report on seven headache patients we treated in our ED with PCNB who had good-to-complete resolution of pain, suggesting that PCNB is efficacious and can potentially shorten the ED length of stay. This series of seven patients (six female, one male) was a convenience sample of primary headache patients who presented over a 10-month period and were safely and rapidly treated with PCNB (Table).
In each case, the PCNB procedure was explained to the patient and consent was obtained. Each patient was treated with a total of 3 cc of 0.5% bupivacaine with epinephrine injected into the posterior neck according to the method described by Mellick et al.4 Our seven patients achieved an average 5-point reduction in pain on a 10-point pain scale, with 0 = no pain and 10 = worse possible pain.
Other than the provision of medications, no nursing assistance was required. Only one of the patients required further treatment after the PCNB, and none had an adverse reaction. All of the patients reported that their headaches were similar in nature to past headaches. Based on their history and physical examination, none were diagnosed to be experiencing a secondary, more serious cause of headache, and none subsequently returned to our institution with a secondary type of headache.
The Paraspinal Cervical Nerve Block
Paraspinous cervical nerve block requires less time to administer and recovery is shorter than that from IM or IV opioids, sedatives, or neuroleptics. It is an easy technique to teach since it requires bilateral injections.
Technique
Prior to the procedure, cleanse the bilateral paravertebral zones surrounding C6 and C7 with chlorhexidine. Next, fill a 3 cc syringe using 0.5% bupivacaine with epinephrine.
Once the injection is complete, withdraw the needle completely, and compress and massage the injection site to facilitate anesthetic diffusion to surrounding tissues.
Indications
Paraspinous cervical nerve block is an appropriate treatment only for patients who are having a typical episode of chronic, recurring headaches, whose history and physical examination do not suggest the need for any further diagnostic work-up, and who, in the judgment of the treating clinician, require only pain relief.
Contraindications
A patient should not be considered for PCNB if he or she has a new-onset headache, fever, altered mental status, focal neurological deficits, meningismus, findings suggestive of meningitis, papilledema, increased intracranial pressure from a space-occupying lesion, recent head trauma with concern for intracranial hemorrhage, or suspicion of an alternate diagnosis.
Efficacy and Patient Response
Paraspinous cervical nerve block has been shown to decrease pain in patients who had failed standard migraine therapy and patients reported no complications. Of the seven patients in this case report, only one patient received opioids in the ED and none received prescriptions for opioids upon discharge for outpatient use.
Mellick and Mellick6 have postulated that pain may be modified due to the PCNB effect on the convergence of the trigeminal nerve with sensory fibers from the upper cervical roots. Since cervical innervation provides feeling to the head and upper neck, blocking this input can ameliorate pain.6
Summary
This series of seven patients provides further evidence of the effectiveness of PCNB in relieving headache symptoms for patients with recurrent, primary headaches when a secondary, more serious cause has been clinically excluded. Each of the seven patients had marked improvement of their pain and required only minimal nursing attention; moreover, all stated they would willingly undergo the procedure for future painful episodes.
Although there were no reported complications, this series is too small to demonstrate complete safety of the procedure. While this report is limited by a small sample size, it demonstrates that this is a quick, effective, and easily learned method of addressing a common ED complaint that obviates the need for parenteral medications and offers a potentially decreased patient length of stay.
Paraspinous cervical nerve block is a promising modality of treatment of ED patients who present with headache and migraine symptoms who do not respond to their outpatient “rescue” therapy. This procedure should be considered as an early treatment for migraine and other primary headaches unless contraindicated.
1. World Health Organization. Atlas of headache disorders and resources in the world 2011. http://www.who.int/mental_health/management/who_atlas_headache_disorders_results.pdf. Accessed February 9, 2017.
2. Victor TW, Hu X, Campbell JC, Buse DC, Lipton RB. Migraine prevalence by age and sex in the United States: a life-span study. Cephalalgia. 2010;30(9):1065-1072. doi:10.1177/0333102409355601.
3. Chawla J. Migraine headache. http://emedicine.medscape.com/article/1142556-overview. Accessed February 9, 2017.
4. Mellick LB, McIlrath ST, Mellick GA. Treatment of headaches in the ED with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 417 patients. Headache. 2006;46(9):1441-1449.
5. Friedman BW, West J, Vinson DR, et al. Current management of migraine in US emergency departments: an analysis of the National Hospital Ambulatory Medical Care Survey. Cephalalgia. 2015;35:301-309.
6. Mellick GA, Mellick LB. Lower cervical intramuscular bupivacaine injections—another treatment option for headaches. http://www.neurologist-doctor.com/images/Mellick_Headache_injections.pdf. Accessed February 9, 2017.
1. World Health Organization. Atlas of headache disorders and resources in the world 2011. http://www.who.int/mental_health/management/who_atlas_headache_disorders_results.pdf. Accessed February 9, 2017.
2. Victor TW, Hu X, Campbell JC, Buse DC, Lipton RB. Migraine prevalence by age and sex in the United States: a life-span study. Cephalalgia. 2010;30(9):1065-1072. doi:10.1177/0333102409355601.
3. Chawla J. Migraine headache. http://emedicine.medscape.com/article/1142556-overview. Accessed February 9, 2017.
4. Mellick LB, McIlrath ST, Mellick GA. Treatment of headaches in the ED with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 417 patients. Headache. 2006;46(9):1441-1449.
5. Friedman BW, West J, Vinson DR, et al. Current management of migraine in US emergency departments: an analysis of the National Hospital Ambulatory Medical Care Survey. Cephalalgia. 2015;35:301-309.
6. Mellick GA, Mellick LB. Lower cervical intramuscular bupivacaine injections—another treatment option for headaches. http://www.neurologist-doctor.com/images/Mellick_Headache_injections.pdf. Accessed February 9, 2017.
