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Physician Burnout Reduced with Intervention Groups
Clinical question: Does an intervention involving a facilitated physician small group result in improvement in well-being and reduction in burnout?
Background: Burnout affects nearly half of medical students, residents, and practicing physicians in the U.S.; however, very few interventions have been tested to address this problem.
Study design: Randomized controlled trial (RCT).
Setting: Department of Medicine at the Mayo Clinic, Rochester, Minn.
Synopsis: Practicing physicians were randomly assigned to facilitated, small-group intervention curriculum for one hour every two weeks (N=37) or control with unstructured, protected time for one hour every two weeks (N=37). A non-trial cohort of 350 practicing physicians was surveyed annually. This study showed a significant increase in empowerment and engagement at three months that was sustained for 12 months, and a significant decrease in high depersonalization scores was seen at both three and 12 months in the intervention group. There were no significant differences in stress, depression, quality of life, or job satisfaction.
Compared to the non-trial cohort, depersonalization, emotional exhaustion, and overall burnout decreased substantially in the intervention arm and slightly in the control arm.
Sample size was small and results may not be generalizable. Topics covered included reflection, self-awareness, and mindfulness, with a combination of community building and skill acquisition to promote connectedness and meaning in work. It is not clear which elements of the curriculum were most effective.
Bottom line: A facilitated, small-group intervention with institution-provided protected time can improve physician empowerment and engagement and reduce depersonalization, an important component of burnout.
Citation: West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174(4):527-533.
Clinical question: Does an intervention involving a facilitated physician small group result in improvement in well-being and reduction in burnout?
Background: Burnout affects nearly half of medical students, residents, and practicing physicians in the U.S.; however, very few interventions have been tested to address this problem.
Study design: Randomized controlled trial (RCT).
Setting: Department of Medicine at the Mayo Clinic, Rochester, Minn.
Synopsis: Practicing physicians were randomly assigned to facilitated, small-group intervention curriculum for one hour every two weeks (N=37) or control with unstructured, protected time for one hour every two weeks (N=37). A non-trial cohort of 350 practicing physicians was surveyed annually. This study showed a significant increase in empowerment and engagement at three months that was sustained for 12 months, and a significant decrease in high depersonalization scores was seen at both three and 12 months in the intervention group. There were no significant differences in stress, depression, quality of life, or job satisfaction.
Compared to the non-trial cohort, depersonalization, emotional exhaustion, and overall burnout decreased substantially in the intervention arm and slightly in the control arm.
Sample size was small and results may not be generalizable. Topics covered included reflection, self-awareness, and mindfulness, with a combination of community building and skill acquisition to promote connectedness and meaning in work. It is not clear which elements of the curriculum were most effective.
Bottom line: A facilitated, small-group intervention with institution-provided protected time can improve physician empowerment and engagement and reduce depersonalization, an important component of burnout.
Citation: West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174(4):527-533.
Clinical question: Does an intervention involving a facilitated physician small group result in improvement in well-being and reduction in burnout?
Background: Burnout affects nearly half of medical students, residents, and practicing physicians in the U.S.; however, very few interventions have been tested to address this problem.
Study design: Randomized controlled trial (RCT).
Setting: Department of Medicine at the Mayo Clinic, Rochester, Minn.
Synopsis: Practicing physicians were randomly assigned to facilitated, small-group intervention curriculum for one hour every two weeks (N=37) or control with unstructured, protected time for one hour every two weeks (N=37). A non-trial cohort of 350 practicing physicians was surveyed annually. This study showed a significant increase in empowerment and engagement at three months that was sustained for 12 months, and a significant decrease in high depersonalization scores was seen at both three and 12 months in the intervention group. There were no significant differences in stress, depression, quality of life, or job satisfaction.
Compared to the non-trial cohort, depersonalization, emotional exhaustion, and overall burnout decreased substantially in the intervention arm and slightly in the control arm.
Sample size was small and results may not be generalizable. Topics covered included reflection, self-awareness, and mindfulness, with a combination of community building and skill acquisition to promote connectedness and meaning in work. It is not clear which elements of the curriculum were most effective.
Bottom line: A facilitated, small-group intervention with institution-provided protected time can improve physician empowerment and engagement and reduce depersonalization, an important component of burnout.
Citation: West CP, Dyrbye LN, Rabatin JT, et al. Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial. JAMA Intern Med. 2014;174(4):527-533.
NIH Study Details Adverse Health Effects of Marijuana Use
As the push for legalization of recreational and medical use of marijuana continues to gain momentum, Nora Volkow, MD, and colleagues urged caution about the potential for increased adverse health consequences resulting from more widespread use of the drug, in a report published June 5 in the New England Journal of Medicine.
“The popular notion seems to be that marijuana is a harmless pleasure, access to which should not be regulated or considered illegal,” stated Dr. Volkow, Director of the National Institute on Drug Abuse in Bethesda, Maryland. “Currently, marijuana is the most commonly used ‘illicit’ drug in the United States, with about 12% of people 12 years of age or older reporting use in the past year and particularly high rates of use among young people.”
Evidence “clearly indicates” that long-term marijuana use can lead to addiction, according to Dr. Volkow. The 2012 National Survey on Drug Use and Health, for example, found that an estimated 2.7 million people age 12 and older met the DSM-IV criteria for dependence on marijuana. Adolescents are particularly vulnerable to long-term adverse effects of marijuana use, she said, likely because the brain undergoes active development until about age 21.
“The negative effect of marijuana use on the functional connectivity of the brain is particularly prominent if use starts in adolescence or young adulthood, which may help to explain the finding of an association between frequent use of marijuana from adolescence into adulthood and significant declines in IQ,” stated Dr. Volkow.
In addition to marijuana’s possible role as a gateway drug, Dr. Volkow noted that regular marijuana use has been associated with an increased risk of anxiety and depression, as well as with a negative effect on school performance. Marijuana use has also been linked with a higher risk of motor vehicle accidents; a meta-analysis found that the overall risk of involvement in an accident increases by a factor of about 2 when a person drives soon after using marijuana.
Marijuana smoking has also been associated with inflammation of the large airways, increased airway resistance, and lung hyperinflation, “associations that are consistent with the fact that regular marijuana smokers are more likely to report symptoms of chronic bronchitis than are nonsmokers,” commented Dr. Volkow.
Some studies have shown beneficial effects of marijuana use for conditions such as multiple sclerosis, epilepsy, and chronic pain. However, Dr. Volkow emphasized the need to take advantage of those potential medical benefits “without exposing people who are sick to [marijuana’s] intrinsic risks.” Some physicians, she commented, “continue to prescribe marijuana for medicinal purposes despite limited evidence of a benefit. This practice raises particular concerns with regard to long-term use by vulnerable populations.”
Overall, marijuana use has been associated with substantial adverse effects, “some of which have been determined with a high level of confidence,” wrote Dr. Volkow. “Marijuana, like other drugs of abuse, can result in addiction…. Repeated marijuana use during adolescence may result in long-lasting changes in brain function that can jeopardize educational, professional, and social achievements.
“However, the effects of a drug (legal or illegal) on individual health are determined not only by its pharmacologic properties, but also by its availability and social acceptability,” Dr. Volkow continued. “In this respect, legal drugs (alcohol and tobacco) offer a sobering perspective, accounting for the greatest burden of disease associated with drugs not because they are more dangerous than illegal drugs but because their legal status allows for more widespread exposure. As policy shifts toward legalization of marijuana, it is reasonable and probably prudent to hypothesize that its use will increase and that, by extension, so will the number of persons for whom there will be negative health consequences.”
—Colby Stong
Suggested Reading
Volkow ND, Baler RD, Compton WM, Weiss SR. Adverse health effects of marijuana use. N Engl J Med. 2014;370(23):2219-2227.
As the push for legalization of recreational and medical use of marijuana continues to gain momentum, Nora Volkow, MD, and colleagues urged caution about the potential for increased adverse health consequences resulting from more widespread use of the drug, in a report published June 5 in the New England Journal of Medicine.
“The popular notion seems to be that marijuana is a harmless pleasure, access to which should not be regulated or considered illegal,” stated Dr. Volkow, Director of the National Institute on Drug Abuse in Bethesda, Maryland. “Currently, marijuana is the most commonly used ‘illicit’ drug in the United States, with about 12% of people 12 years of age or older reporting use in the past year and particularly high rates of use among young people.”
Evidence “clearly indicates” that long-term marijuana use can lead to addiction, according to Dr. Volkow. The 2012 National Survey on Drug Use and Health, for example, found that an estimated 2.7 million people age 12 and older met the DSM-IV criteria for dependence on marijuana. Adolescents are particularly vulnerable to long-term adverse effects of marijuana use, she said, likely because the brain undergoes active development until about age 21.
“The negative effect of marijuana use on the functional connectivity of the brain is particularly prominent if use starts in adolescence or young adulthood, which may help to explain the finding of an association between frequent use of marijuana from adolescence into adulthood and significant declines in IQ,” stated Dr. Volkow.
In addition to marijuana’s possible role as a gateway drug, Dr. Volkow noted that regular marijuana use has been associated with an increased risk of anxiety and depression, as well as with a negative effect on school performance. Marijuana use has also been linked with a higher risk of motor vehicle accidents; a meta-analysis found that the overall risk of involvement in an accident increases by a factor of about 2 when a person drives soon after using marijuana.
Marijuana smoking has also been associated with inflammation of the large airways, increased airway resistance, and lung hyperinflation, “associations that are consistent with the fact that regular marijuana smokers are more likely to report symptoms of chronic bronchitis than are nonsmokers,” commented Dr. Volkow.
Some studies have shown beneficial effects of marijuana use for conditions such as multiple sclerosis, epilepsy, and chronic pain. However, Dr. Volkow emphasized the need to take advantage of those potential medical benefits “without exposing people who are sick to [marijuana’s] intrinsic risks.” Some physicians, she commented, “continue to prescribe marijuana for medicinal purposes despite limited evidence of a benefit. This practice raises particular concerns with regard to long-term use by vulnerable populations.”
Overall, marijuana use has been associated with substantial adverse effects, “some of which have been determined with a high level of confidence,” wrote Dr. Volkow. “Marijuana, like other drugs of abuse, can result in addiction…. Repeated marijuana use during adolescence may result in long-lasting changes in brain function that can jeopardize educational, professional, and social achievements.
“However, the effects of a drug (legal or illegal) on individual health are determined not only by its pharmacologic properties, but also by its availability and social acceptability,” Dr. Volkow continued. “In this respect, legal drugs (alcohol and tobacco) offer a sobering perspective, accounting for the greatest burden of disease associated with drugs not because they are more dangerous than illegal drugs but because their legal status allows for more widespread exposure. As policy shifts toward legalization of marijuana, it is reasonable and probably prudent to hypothesize that its use will increase and that, by extension, so will the number of persons for whom there will be negative health consequences.”
—Colby Stong
As the push for legalization of recreational and medical use of marijuana continues to gain momentum, Nora Volkow, MD, and colleagues urged caution about the potential for increased adverse health consequences resulting from more widespread use of the drug, in a report published June 5 in the New England Journal of Medicine.
“The popular notion seems to be that marijuana is a harmless pleasure, access to which should not be regulated or considered illegal,” stated Dr. Volkow, Director of the National Institute on Drug Abuse in Bethesda, Maryland. “Currently, marijuana is the most commonly used ‘illicit’ drug in the United States, with about 12% of people 12 years of age or older reporting use in the past year and particularly high rates of use among young people.”
Evidence “clearly indicates” that long-term marijuana use can lead to addiction, according to Dr. Volkow. The 2012 National Survey on Drug Use and Health, for example, found that an estimated 2.7 million people age 12 and older met the DSM-IV criteria for dependence on marijuana. Adolescents are particularly vulnerable to long-term adverse effects of marijuana use, she said, likely because the brain undergoes active development until about age 21.
“The negative effect of marijuana use on the functional connectivity of the brain is particularly prominent if use starts in adolescence or young adulthood, which may help to explain the finding of an association between frequent use of marijuana from adolescence into adulthood and significant declines in IQ,” stated Dr. Volkow.
In addition to marijuana’s possible role as a gateway drug, Dr. Volkow noted that regular marijuana use has been associated with an increased risk of anxiety and depression, as well as with a negative effect on school performance. Marijuana use has also been linked with a higher risk of motor vehicle accidents; a meta-analysis found that the overall risk of involvement in an accident increases by a factor of about 2 when a person drives soon after using marijuana.
Marijuana smoking has also been associated with inflammation of the large airways, increased airway resistance, and lung hyperinflation, “associations that are consistent with the fact that regular marijuana smokers are more likely to report symptoms of chronic bronchitis than are nonsmokers,” commented Dr. Volkow.
Some studies have shown beneficial effects of marijuana use for conditions such as multiple sclerosis, epilepsy, and chronic pain. However, Dr. Volkow emphasized the need to take advantage of those potential medical benefits “without exposing people who are sick to [marijuana’s] intrinsic risks.” Some physicians, she commented, “continue to prescribe marijuana for medicinal purposes despite limited evidence of a benefit. This practice raises particular concerns with regard to long-term use by vulnerable populations.”
Overall, marijuana use has been associated with substantial adverse effects, “some of which have been determined with a high level of confidence,” wrote Dr. Volkow. “Marijuana, like other drugs of abuse, can result in addiction…. Repeated marijuana use during adolescence may result in long-lasting changes in brain function that can jeopardize educational, professional, and social achievements.
“However, the effects of a drug (legal or illegal) on individual health are determined not only by its pharmacologic properties, but also by its availability and social acceptability,” Dr. Volkow continued. “In this respect, legal drugs (alcohol and tobacco) offer a sobering perspective, accounting for the greatest burden of disease associated with drugs not because they are more dangerous than illegal drugs but because their legal status allows for more widespread exposure. As policy shifts toward legalization of marijuana, it is reasonable and probably prudent to hypothesize that its use will increase and that, by extension, so will the number of persons for whom there will be negative health consequences.”
—Colby Stong
Suggested Reading
Volkow ND, Baler RD, Compton WM, Weiss SR. Adverse health effects of marijuana use. N Engl J Med. 2014;370(23):2219-2227.
Suggested Reading
Volkow ND, Baler RD, Compton WM, Weiss SR. Adverse health effects of marijuana use. N Engl J Med. 2014;370(23):2219-2227.
Brain and Cognitive Reserve May Protect Against Cognitive Decline in MS
Patients with multiple sclerosis (MS) and larger maximal lifetime brain growth (MLBG) had less decline in cognitive efficiency, and patients with greater intellectual enrichment had a lower risk for decline in cognitive efficiency and memory over 4.5 years, according to a study published May 20 in Neurology.
James F. Sumowski, PhD, Senior Research Scientist of Neuropsychology and Neuroscience at the Kessler Foundation Research Center in West Orange, New Jersey, and colleagues evaluated cognitive efficiency and memory in 40 patients with MS at baseline and at a 4.5-year follow-up. The researchers used MRI to quantify disease progression and percentage change in T2 lesion volume.
Dr. Sumowski’s group found that the patients declined in cognitive efficiency and memory. MLBG moderated decline in cognitive efficiency, and larger MLBG protected against this decline. However, MLBG did not moderate memory decline. Also, intellectual enrichment moderated decline in cognitive efficiency and memory, and greater intellectual enrichment protected against decline. In addition, MS disease progression was more negatively associated with change in cognitive efficiency and memory among patients with lower versus higher MLBG and intellectual enrichment.
“Clinically, it is difficult to predict which patients with MS are at greatest risk of cognitive decline because it is difficult to accurately predict MS disease progression for any given patient,” stated the researchers. “MLBG and intellectual enrichment are important factors to consider when trying to predict cognitive decline in patients with MS, because patients with lower MLBG and/or lesser intellectual enrichment are at greatest risk of cognitive decline. These at-risk patients can be targeted for early-intervention cognitive rehabilitation, which may help prevent/delay the onset of functional impairment.
“Higher cardiorespiratory fitness may help preserve brain volume and cognitive efficiency, and preliminary data show that aerobic exercise training may result in improved memory, increased hippocampal volume, and increased hippocampal functional connectivity in patients with MS,” the investigators commented. “Finally, patients with MS should also be encouraged to engage in intellectual enrichment (eg, reading, hobbies, etc), because previous research and the current findings suggest that greater intellectual enrichment protects against cognitive decline.”
—Colby Stong
Suggested Reading
Sumowski JF, Rocca MA, Leavitt VM, et al. Brain reserve and cognitive reserve protect against cognitive decline over 4.5 years in MS. Neurology. 2014;82(20):1776-1783.
Patients with multiple sclerosis (MS) and larger maximal lifetime brain growth (MLBG) had less decline in cognitive efficiency, and patients with greater intellectual enrichment had a lower risk for decline in cognitive efficiency and memory over 4.5 years, according to a study published May 20 in Neurology.
James F. Sumowski, PhD, Senior Research Scientist of Neuropsychology and Neuroscience at the Kessler Foundation Research Center in West Orange, New Jersey, and colleagues evaluated cognitive efficiency and memory in 40 patients with MS at baseline and at a 4.5-year follow-up. The researchers used MRI to quantify disease progression and percentage change in T2 lesion volume.
Dr. Sumowski’s group found that the patients declined in cognitive efficiency and memory. MLBG moderated decline in cognitive efficiency, and larger MLBG protected against this decline. However, MLBG did not moderate memory decline. Also, intellectual enrichment moderated decline in cognitive efficiency and memory, and greater intellectual enrichment protected against decline. In addition, MS disease progression was more negatively associated with change in cognitive efficiency and memory among patients with lower versus higher MLBG and intellectual enrichment.
“Clinically, it is difficult to predict which patients with MS are at greatest risk of cognitive decline because it is difficult to accurately predict MS disease progression for any given patient,” stated the researchers. “MLBG and intellectual enrichment are important factors to consider when trying to predict cognitive decline in patients with MS, because patients with lower MLBG and/or lesser intellectual enrichment are at greatest risk of cognitive decline. These at-risk patients can be targeted for early-intervention cognitive rehabilitation, which may help prevent/delay the onset of functional impairment.
“Higher cardiorespiratory fitness may help preserve brain volume and cognitive efficiency, and preliminary data show that aerobic exercise training may result in improved memory, increased hippocampal volume, and increased hippocampal functional connectivity in patients with MS,” the investigators commented. “Finally, patients with MS should also be encouraged to engage in intellectual enrichment (eg, reading, hobbies, etc), because previous research and the current findings suggest that greater intellectual enrichment protects against cognitive decline.”
—Colby Stong
Patients with multiple sclerosis (MS) and larger maximal lifetime brain growth (MLBG) had less decline in cognitive efficiency, and patients with greater intellectual enrichment had a lower risk for decline in cognitive efficiency and memory over 4.5 years, according to a study published May 20 in Neurology.
James F. Sumowski, PhD, Senior Research Scientist of Neuropsychology and Neuroscience at the Kessler Foundation Research Center in West Orange, New Jersey, and colleagues evaluated cognitive efficiency and memory in 40 patients with MS at baseline and at a 4.5-year follow-up. The researchers used MRI to quantify disease progression and percentage change in T2 lesion volume.
Dr. Sumowski’s group found that the patients declined in cognitive efficiency and memory. MLBG moderated decline in cognitive efficiency, and larger MLBG protected against this decline. However, MLBG did not moderate memory decline. Also, intellectual enrichment moderated decline in cognitive efficiency and memory, and greater intellectual enrichment protected against decline. In addition, MS disease progression was more negatively associated with change in cognitive efficiency and memory among patients with lower versus higher MLBG and intellectual enrichment.
“Clinically, it is difficult to predict which patients with MS are at greatest risk of cognitive decline because it is difficult to accurately predict MS disease progression for any given patient,” stated the researchers. “MLBG and intellectual enrichment are important factors to consider when trying to predict cognitive decline in patients with MS, because patients with lower MLBG and/or lesser intellectual enrichment are at greatest risk of cognitive decline. These at-risk patients can be targeted for early-intervention cognitive rehabilitation, which may help prevent/delay the onset of functional impairment.
“Higher cardiorespiratory fitness may help preserve brain volume and cognitive efficiency, and preliminary data show that aerobic exercise training may result in improved memory, increased hippocampal volume, and increased hippocampal functional connectivity in patients with MS,” the investigators commented. “Finally, patients with MS should also be encouraged to engage in intellectual enrichment (eg, reading, hobbies, etc), because previous research and the current findings suggest that greater intellectual enrichment protects against cognitive decline.”
—Colby Stong
Suggested Reading
Sumowski JF, Rocca MA, Leavitt VM, et al. Brain reserve and cognitive reserve protect against cognitive decline over 4.5 years in MS. Neurology. 2014;82(20):1776-1783.
Suggested Reading
Sumowski JF, Rocca MA, Leavitt VM, et al. Brain reserve and cognitive reserve protect against cognitive decline over 4.5 years in MS. Neurology. 2014;82(20):1776-1783.
Does Cannabis Impair Cognition Among Patients With MS?
Patients with multiple sclerosis (MS) who smoke marijuana regularly have more cognitive deficits than patients with MS who do not smoke marijuana, according to research published May 27 in Neurology. Marijuana use may be associated with impairments in information processing speed, visual memory, and working memory among these individuals.
In a cross-sectional study, cannabis users had more diffuse cerebral activation during a test of working memory, compared with nonusers. The cannabis users also had increased activation in parietal and anterior cingulate brain regions implicated in working memory, relative to nonusers.
But investigators found no differences in brain structure between the study groups, and this finding is consistent with the results of cannabis imaging studies in healthy subjects.
Subjects Underwent Imaging and Neuropsychologic Tests
Bennis Pavisian, research assistant at Sunnybrook Hospital in Toronto, and colleagues recruited 39 patients (ages 18 to 60) with a confirmed diagnosis of MS for their study. They enrolled 20 participants who regularly used cannabis and whose urine tested positive for cannabis metabolites. The investigators asked participants not to use cannabis for 12 hours before the trial. Nineteen patients with MS who had never used cannabis were matched to the other participants using demographic and disease-related variables.
All participants underwent the Brief Repeatable Battery of Neuropsychological Tests in MS, which includes measures of verbal and visual memory, information processing speed, and attention.
The researchers assessed patients’ premorbid IQ with the Wechsler Test of Adult Reading, measured anxiety and depression with the Hospital Anxiety and Depression Scale, and gauged fatigue with the modified Fatigue Impact Scale.
All subjects also underwent the n-Back test of working memory, which had been modified to avoid verbal responses.
The investigators performed fMRI while the participants were taking the n-Back test. They also collected resting-state fMRI and structural MRI data, including lesion and normal-appearing brain tissue volumes and diffusion tensor imaging metrics.
Brain Activation Was More Diffuse Among Marijuana Users
Patients who used cannabis performed worse on the two-second Paced Auditory Serial Addition Test and the 10/36 Spatial Recall Test. Both groups had similar scores on the tests of fatigue, anxiety, and depression. Global cognitive impairment did not correlate with frequency of cannabis use or urine concentration of metabolites.
The investigators found no statistically significant between-group differences on fMRI for the 0- and 1-Back tests. The cannabis group gave fewer correct responses on the 2-Back trial, compared with controls, but had no difference in reaction times.
The researchers found no significant differences in resting state network activation between the two patient groups. During the n-Back test, all patients activated prefrontal, anterior cingulate, and posterior parietal circuits. Several secondary regions activated as well on the 0-Back and 2-Back tests, and the activation pattern was more diffuse in the cannabis group.
Parietal and anterior cingulate activations were only present in the cannabis group for both tasks, according to the investigators. Frontal activation was more prominent in the cannabis group across tasks.
—Erik Greb
Suggested Reading
Pavisian B, MacIntosh BJ, Szilagyi G, et al. Effects of cannabis on cognition in patients with MS: A psychometric and MRI study. Neurology. 2014;82(21):1879-1887.
Patients with multiple sclerosis (MS) who smoke marijuana regularly have more cognitive deficits than patients with MS who do not smoke marijuana, according to research published May 27 in Neurology. Marijuana use may be associated with impairments in information processing speed, visual memory, and working memory among these individuals.
In a cross-sectional study, cannabis users had more diffuse cerebral activation during a test of working memory, compared with nonusers. The cannabis users also had increased activation in parietal and anterior cingulate brain regions implicated in working memory, relative to nonusers.
But investigators found no differences in brain structure between the study groups, and this finding is consistent with the results of cannabis imaging studies in healthy subjects.
Subjects Underwent Imaging and Neuropsychologic Tests
Bennis Pavisian, research assistant at Sunnybrook Hospital in Toronto, and colleagues recruited 39 patients (ages 18 to 60) with a confirmed diagnosis of MS for their study. They enrolled 20 participants who regularly used cannabis and whose urine tested positive for cannabis metabolites. The investigators asked participants not to use cannabis for 12 hours before the trial. Nineteen patients with MS who had never used cannabis were matched to the other participants using demographic and disease-related variables.
All participants underwent the Brief Repeatable Battery of Neuropsychological Tests in MS, which includes measures of verbal and visual memory, information processing speed, and attention.
The researchers assessed patients’ premorbid IQ with the Wechsler Test of Adult Reading, measured anxiety and depression with the Hospital Anxiety and Depression Scale, and gauged fatigue with the modified Fatigue Impact Scale.
All subjects also underwent the n-Back test of working memory, which had been modified to avoid verbal responses.
The investigators performed fMRI while the participants were taking the n-Back test. They also collected resting-state fMRI and structural MRI data, including lesion and normal-appearing brain tissue volumes and diffusion tensor imaging metrics.
Brain Activation Was More Diffuse Among Marijuana Users
Patients who used cannabis performed worse on the two-second Paced Auditory Serial Addition Test and the 10/36 Spatial Recall Test. Both groups had similar scores on the tests of fatigue, anxiety, and depression. Global cognitive impairment did not correlate with frequency of cannabis use or urine concentration of metabolites.
The investigators found no statistically significant between-group differences on fMRI for the 0- and 1-Back tests. The cannabis group gave fewer correct responses on the 2-Back trial, compared with controls, but had no difference in reaction times.
The researchers found no significant differences in resting state network activation between the two patient groups. During the n-Back test, all patients activated prefrontal, anterior cingulate, and posterior parietal circuits. Several secondary regions activated as well on the 0-Back and 2-Back tests, and the activation pattern was more diffuse in the cannabis group.
Parietal and anterior cingulate activations were only present in the cannabis group for both tasks, according to the investigators. Frontal activation was more prominent in the cannabis group across tasks.
—Erik Greb
Patients with multiple sclerosis (MS) who smoke marijuana regularly have more cognitive deficits than patients with MS who do not smoke marijuana, according to research published May 27 in Neurology. Marijuana use may be associated with impairments in information processing speed, visual memory, and working memory among these individuals.
In a cross-sectional study, cannabis users had more diffuse cerebral activation during a test of working memory, compared with nonusers. The cannabis users also had increased activation in parietal and anterior cingulate brain regions implicated in working memory, relative to nonusers.
But investigators found no differences in brain structure between the study groups, and this finding is consistent with the results of cannabis imaging studies in healthy subjects.
Subjects Underwent Imaging and Neuropsychologic Tests
Bennis Pavisian, research assistant at Sunnybrook Hospital in Toronto, and colleagues recruited 39 patients (ages 18 to 60) with a confirmed diagnosis of MS for their study. They enrolled 20 participants who regularly used cannabis and whose urine tested positive for cannabis metabolites. The investigators asked participants not to use cannabis for 12 hours before the trial. Nineteen patients with MS who had never used cannabis were matched to the other participants using demographic and disease-related variables.
All participants underwent the Brief Repeatable Battery of Neuropsychological Tests in MS, which includes measures of verbal and visual memory, information processing speed, and attention.
The researchers assessed patients’ premorbid IQ with the Wechsler Test of Adult Reading, measured anxiety and depression with the Hospital Anxiety and Depression Scale, and gauged fatigue with the modified Fatigue Impact Scale.
All subjects also underwent the n-Back test of working memory, which had been modified to avoid verbal responses.
The investigators performed fMRI while the participants were taking the n-Back test. They also collected resting-state fMRI and structural MRI data, including lesion and normal-appearing brain tissue volumes and diffusion tensor imaging metrics.
Brain Activation Was More Diffuse Among Marijuana Users
Patients who used cannabis performed worse on the two-second Paced Auditory Serial Addition Test and the 10/36 Spatial Recall Test. Both groups had similar scores on the tests of fatigue, anxiety, and depression. Global cognitive impairment did not correlate with frequency of cannabis use or urine concentration of metabolites.
The investigators found no statistically significant between-group differences on fMRI for the 0- and 1-Back tests. The cannabis group gave fewer correct responses on the 2-Back trial, compared with controls, but had no difference in reaction times.
The researchers found no significant differences in resting state network activation between the two patient groups. During the n-Back test, all patients activated prefrontal, anterior cingulate, and posterior parietal circuits. Several secondary regions activated as well on the 0-Back and 2-Back tests, and the activation pattern was more diffuse in the cannabis group.
Parietal and anterior cingulate activations were only present in the cannabis group for both tasks, according to the investigators. Frontal activation was more prominent in the cannabis group across tasks.
—Erik Greb
Suggested Reading
Pavisian B, MacIntosh BJ, Szilagyi G, et al. Effects of cannabis on cognition in patients with MS: A psychometric and MRI study. Neurology. 2014;82(21):1879-1887.
Suggested Reading
Pavisian B, MacIntosh BJ, Szilagyi G, et al. Effects of cannabis on cognition in patients with MS: A psychometric and MRI study. Neurology. 2014;82(21):1879-1887.
Inhaled Corticosteroids Increase Risk of Serious Pneumonia in Patients with COPD
Clinical question: Does the risk of pneumonia vary for different inhaled agents?
Background: Inhaled corticosteroids (ICS) are known to increase the risk of pneumonia in COPD patients; duration, dosage, and various agents were investigated, especially fluticasone and budesonide.
Study design: Nested, case-control analysis.
Setting: Quebec health insurance database for new users with COPD, 1990-2005, with follow-up through 2007.
Synopsis: Investigators analyzed 163,514 patients, including 20,344 patients with serious pneumonia; current use of ICS was associated with a 69% increase in the rate of serious pneumonia (RR 1.69; 95% CI 1.63-1.75). The increased risk was sustained with long-term use but declined gradually to zero at six months after stopping ICS. The risk of serious pneumonia was higher with fluticasone (RR 2.01; 95% CI 1.93-2.10) than budesonide (RR 1.17; 95% CI 1.09-1.26).
Bottom line: Fluticasone was associated with an increased risk of pneumonia in COPD patients, consistent with earlier clinical trials, but the risk with budesonide was much lower.
Citation: Suissa S, Patenaude V, Lapi F, Ernst P. Inhaled corticosteroids in COPD and the risk of serious pneumonia. Thorax. 2013;68(11):1029-1036.
Clinical question: Does the risk of pneumonia vary for different inhaled agents?
Background: Inhaled corticosteroids (ICS) are known to increase the risk of pneumonia in COPD patients; duration, dosage, and various agents were investigated, especially fluticasone and budesonide.
Study design: Nested, case-control analysis.
Setting: Quebec health insurance database for new users with COPD, 1990-2005, with follow-up through 2007.
Synopsis: Investigators analyzed 163,514 patients, including 20,344 patients with serious pneumonia; current use of ICS was associated with a 69% increase in the rate of serious pneumonia (RR 1.69; 95% CI 1.63-1.75). The increased risk was sustained with long-term use but declined gradually to zero at six months after stopping ICS. The risk of serious pneumonia was higher with fluticasone (RR 2.01; 95% CI 1.93-2.10) than budesonide (RR 1.17; 95% CI 1.09-1.26).
Bottom line: Fluticasone was associated with an increased risk of pneumonia in COPD patients, consistent with earlier clinical trials, but the risk with budesonide was much lower.
Citation: Suissa S, Patenaude V, Lapi F, Ernst P. Inhaled corticosteroids in COPD and the risk of serious pneumonia. Thorax. 2013;68(11):1029-1036.
Clinical question: Does the risk of pneumonia vary for different inhaled agents?
Background: Inhaled corticosteroids (ICS) are known to increase the risk of pneumonia in COPD patients; duration, dosage, and various agents were investigated, especially fluticasone and budesonide.
Study design: Nested, case-control analysis.
Setting: Quebec health insurance database for new users with COPD, 1990-2005, with follow-up through 2007.
Synopsis: Investigators analyzed 163,514 patients, including 20,344 patients with serious pneumonia; current use of ICS was associated with a 69% increase in the rate of serious pneumonia (RR 1.69; 95% CI 1.63-1.75). The increased risk was sustained with long-term use but declined gradually to zero at six months after stopping ICS. The risk of serious pneumonia was higher with fluticasone (RR 2.01; 95% CI 1.93-2.10) than budesonide (RR 1.17; 95% CI 1.09-1.26).
Bottom line: Fluticasone was associated with an increased risk of pneumonia in COPD patients, consistent with earlier clinical trials, but the risk with budesonide was much lower.
Citation: Suissa S, Patenaude V, Lapi F, Ernst P. Inhaled corticosteroids in COPD and the risk of serious pneumonia. Thorax. 2013;68(11):1029-1036.
Ambulatory Patients with COPD Exacerbations Can Be Managed Without Antibiotics in the Absence of Increased Sputum Purulence, Elevated C-Reactive Protein
Clinical question: Which criteria identify ambulatory patients with exacerbations of mild to moderate COPD who do not need antibiotics?
Background: The Anthonisen criteria (increased dyspnea, sputum volume, sputum purulence) are commonly used to identify which patients with COPD exacerbations would benefit from antibiotics. These criteria, however, were derived in patients with severe COPD. It is unknown whether these criteria are predictive in patients with mild to moderate COPD.
Study design: Multivariate logistic regression analysis of placebo group of a double-blinded RCT.
Setting: Multicenter, ambulatory, primary care clinics in Spain.
Synopsis: The original RCT enrolled 310 ambulatory patients with exacerbations of mild to moderate COPD and tested the efficacy of amoxicillin/clavulanate. Clinical failure without antibiotics was 19.9% compared to 9.5% with antibiotics (P=0.022). Here they analyzed the 152 patients from the placebo group to identify factors associated with increased risk of clinical failure. Only increased sputum purulence (OR 6.1, CI 1.5-25; P=0.005) or C-reactive protein (CRP) >40 mg/L (OR 13.4, CI 4.5-38.8, P<0.001) were independently associated with increased risk of failure. Presence of both predicted a 63.7% failure without antibiotics.
The study did not define “increased sputum purulence,” but this is similar to real-life clinical practice. Placebo effect cannot be ruled out, but correlation of the objective measures with the clinical assessments suggests that the clinical assessments were accurate. The study did not have a protocol for administering co-medications such as steroids and inhalers. Despite these limitations, the criteria of increased sputum purulence and CRP >40 mg/L identified COPD patients likely to have a clinical failure without antibiotics.
Bottom line: Patients with exacerbations of mild to moderate COPD who do not have increased sputum purulence or CRP >40 mg/L can be safely managed without antibiotics.
Citation: Maravitlles M, Moravas A, Hernandez S, Bayona C, Llor C. Is it possible to identify exacerbations of mild to moderate COPD that do not require antibiotic treatment? Chest. 2013;144(5):1571-1577.
Clinical question: Which criteria identify ambulatory patients with exacerbations of mild to moderate COPD who do not need antibiotics?
Background: The Anthonisen criteria (increased dyspnea, sputum volume, sputum purulence) are commonly used to identify which patients with COPD exacerbations would benefit from antibiotics. These criteria, however, were derived in patients with severe COPD. It is unknown whether these criteria are predictive in patients with mild to moderate COPD.
Study design: Multivariate logistic regression analysis of placebo group of a double-blinded RCT.
Setting: Multicenter, ambulatory, primary care clinics in Spain.
Synopsis: The original RCT enrolled 310 ambulatory patients with exacerbations of mild to moderate COPD and tested the efficacy of amoxicillin/clavulanate. Clinical failure without antibiotics was 19.9% compared to 9.5% with antibiotics (P=0.022). Here they analyzed the 152 patients from the placebo group to identify factors associated with increased risk of clinical failure. Only increased sputum purulence (OR 6.1, CI 1.5-25; P=0.005) or C-reactive protein (CRP) >40 mg/L (OR 13.4, CI 4.5-38.8, P<0.001) were independently associated with increased risk of failure. Presence of both predicted a 63.7% failure without antibiotics.
The study did not define “increased sputum purulence,” but this is similar to real-life clinical practice. Placebo effect cannot be ruled out, but correlation of the objective measures with the clinical assessments suggests that the clinical assessments were accurate. The study did not have a protocol for administering co-medications such as steroids and inhalers. Despite these limitations, the criteria of increased sputum purulence and CRP >40 mg/L identified COPD patients likely to have a clinical failure without antibiotics.
Bottom line: Patients with exacerbations of mild to moderate COPD who do not have increased sputum purulence or CRP >40 mg/L can be safely managed without antibiotics.
Citation: Maravitlles M, Moravas A, Hernandez S, Bayona C, Llor C. Is it possible to identify exacerbations of mild to moderate COPD that do not require antibiotic treatment? Chest. 2013;144(5):1571-1577.
Clinical question: Which criteria identify ambulatory patients with exacerbations of mild to moderate COPD who do not need antibiotics?
Background: The Anthonisen criteria (increased dyspnea, sputum volume, sputum purulence) are commonly used to identify which patients with COPD exacerbations would benefit from antibiotics. These criteria, however, were derived in patients with severe COPD. It is unknown whether these criteria are predictive in patients with mild to moderate COPD.
Study design: Multivariate logistic regression analysis of placebo group of a double-blinded RCT.
Setting: Multicenter, ambulatory, primary care clinics in Spain.
Synopsis: The original RCT enrolled 310 ambulatory patients with exacerbations of mild to moderate COPD and tested the efficacy of amoxicillin/clavulanate. Clinical failure without antibiotics was 19.9% compared to 9.5% with antibiotics (P=0.022). Here they analyzed the 152 patients from the placebo group to identify factors associated with increased risk of clinical failure. Only increased sputum purulence (OR 6.1, CI 1.5-25; P=0.005) or C-reactive protein (CRP) >40 mg/L (OR 13.4, CI 4.5-38.8, P<0.001) were independently associated with increased risk of failure. Presence of both predicted a 63.7% failure without antibiotics.
The study did not define “increased sputum purulence,” but this is similar to real-life clinical practice. Placebo effect cannot be ruled out, but correlation of the objective measures with the clinical assessments suggests that the clinical assessments were accurate. The study did not have a protocol for administering co-medications such as steroids and inhalers. Despite these limitations, the criteria of increased sputum purulence and CRP >40 mg/L identified COPD patients likely to have a clinical failure without antibiotics.
Bottom line: Patients with exacerbations of mild to moderate COPD who do not have increased sputum purulence or CRP >40 mg/L can be safely managed without antibiotics.
Citation: Maravitlles M, Moravas A, Hernandez S, Bayona C, Llor C. Is it possible to identify exacerbations of mild to moderate COPD that do not require antibiotic treatment? Chest. 2013;144(5):1571-1577.
Pre-Operative Angiotensin Axis Blockade Increases Risk of Hypotension, Acute Kidney Injury with Major Orthopedic Surgery
Clinical question: Do patients receiving pre-operative angiotensin axis blockade (AAB) prior to elective major orthopedic surgery have an increased risk of peri-operative hypotension and acute kidney injury (AKI)?
Background: Patients with pre-operative AAB from angiotensin-converting enzyme inhibitors or angiotensin receptor blockers have an increased incidence of peri-operative hypotension. Patients undergoing cardiothoracic and vascular surgery with pre-operative AAB have increased incidence of post-operative AKI; however, there is scant literature evaluating the hypotensive and renal effects of pre-operative AAB prior to elective major orthopedic surgery.
Study design: Retrospective, cohort study.
Setting: Academic medical center.
Synopsis: Retrospective review of 922 patients undergoing spinal fusion, total knee arthroplasty, or total hip arthroplasty in one academic medical center in 2010 found that 37% received pre-operative AAB. Post-induction hypotension (systolic blood pressure ≤80 mm Hg for five minutes) was significantly higher in patients receiving AAB (12.2% vs. 6.7%; odds ratio [OR] 1.93, P=0.005). Post-operative AKI was significantly higher in patients receiving AAB (8.3% vs. 1.7%; OR 5.40, P<0.001), remaining significant after adjusting for intra-operative hypotension (OR 2.60, P=0.042). Developing AKI resulted in a significantly higher mean length of stay (5.76 vs. 3.28 days, P<0.001) but no difference in two-year mortality.
The findings suggest an association exists between pre-operative angiotensin-converting enzyme inhibitors/ARB, hypotension, and AKI following major orthopedic surgeries but does not demonstrate causality. A prospective, multi-center, randomized trial is needed to confirm that holding pre-operative AAB would decrease the incidence of AKI in patients undergoing major orthopedic procedures under general anesthesia.
Bottom line: Patients who underwent elective major orthopedic surgery who received pre-operative AAB therapy had an associated increased risk of post-induction hypotension and post-operative AKI, resulting in a greater hospital length of stay.
Citation: Nielson E, Hennrikus E, Lehman E, Mets B. Angiotensin axis blockade, hypotension, and acute kidney injury in elective major orthopedic surgery. J Hosp Med. 2014;9(5):283-288.
Clinical question: Do patients receiving pre-operative angiotensin axis blockade (AAB) prior to elective major orthopedic surgery have an increased risk of peri-operative hypotension and acute kidney injury (AKI)?
Background: Patients with pre-operative AAB from angiotensin-converting enzyme inhibitors or angiotensin receptor blockers have an increased incidence of peri-operative hypotension. Patients undergoing cardiothoracic and vascular surgery with pre-operative AAB have increased incidence of post-operative AKI; however, there is scant literature evaluating the hypotensive and renal effects of pre-operative AAB prior to elective major orthopedic surgery.
Study design: Retrospective, cohort study.
Setting: Academic medical center.
Synopsis: Retrospective review of 922 patients undergoing spinal fusion, total knee arthroplasty, or total hip arthroplasty in one academic medical center in 2010 found that 37% received pre-operative AAB. Post-induction hypotension (systolic blood pressure ≤80 mm Hg for five minutes) was significantly higher in patients receiving AAB (12.2% vs. 6.7%; odds ratio [OR] 1.93, P=0.005). Post-operative AKI was significantly higher in patients receiving AAB (8.3% vs. 1.7%; OR 5.40, P<0.001), remaining significant after adjusting for intra-operative hypotension (OR 2.60, P=0.042). Developing AKI resulted in a significantly higher mean length of stay (5.76 vs. 3.28 days, P<0.001) but no difference in two-year mortality.
The findings suggest an association exists between pre-operative angiotensin-converting enzyme inhibitors/ARB, hypotension, and AKI following major orthopedic surgeries but does not demonstrate causality. A prospective, multi-center, randomized trial is needed to confirm that holding pre-operative AAB would decrease the incidence of AKI in patients undergoing major orthopedic procedures under general anesthesia.
Bottom line: Patients who underwent elective major orthopedic surgery who received pre-operative AAB therapy had an associated increased risk of post-induction hypotension and post-operative AKI, resulting in a greater hospital length of stay.
Citation: Nielson E, Hennrikus E, Lehman E, Mets B. Angiotensin axis blockade, hypotension, and acute kidney injury in elective major orthopedic surgery. J Hosp Med. 2014;9(5):283-288.
Clinical question: Do patients receiving pre-operative angiotensin axis blockade (AAB) prior to elective major orthopedic surgery have an increased risk of peri-operative hypotension and acute kidney injury (AKI)?
Background: Patients with pre-operative AAB from angiotensin-converting enzyme inhibitors or angiotensin receptor blockers have an increased incidence of peri-operative hypotension. Patients undergoing cardiothoracic and vascular surgery with pre-operative AAB have increased incidence of post-operative AKI; however, there is scant literature evaluating the hypotensive and renal effects of pre-operative AAB prior to elective major orthopedic surgery.
Study design: Retrospective, cohort study.
Setting: Academic medical center.
Synopsis: Retrospective review of 922 patients undergoing spinal fusion, total knee arthroplasty, or total hip arthroplasty in one academic medical center in 2010 found that 37% received pre-operative AAB. Post-induction hypotension (systolic blood pressure ≤80 mm Hg for five minutes) was significantly higher in patients receiving AAB (12.2% vs. 6.7%; odds ratio [OR] 1.93, P=0.005). Post-operative AKI was significantly higher in patients receiving AAB (8.3% vs. 1.7%; OR 5.40, P<0.001), remaining significant after adjusting for intra-operative hypotension (OR 2.60, P=0.042). Developing AKI resulted in a significantly higher mean length of stay (5.76 vs. 3.28 days, P<0.001) but no difference in two-year mortality.
The findings suggest an association exists between pre-operative angiotensin-converting enzyme inhibitors/ARB, hypotension, and AKI following major orthopedic surgeries but does not demonstrate causality. A prospective, multi-center, randomized trial is needed to confirm that holding pre-operative AAB would decrease the incidence of AKI in patients undergoing major orthopedic procedures under general anesthesia.
Bottom line: Patients who underwent elective major orthopedic surgery who received pre-operative AAB therapy had an associated increased risk of post-induction hypotension and post-operative AKI, resulting in a greater hospital length of stay.
Citation: Nielson E, Hennrikus E, Lehman E, Mets B. Angiotensin axis blockade, hypotension, and acute kidney injury in elective major orthopedic surgery. J Hosp Med. 2014;9(5):283-288.
American College of Physicians Releases Clinical Practice Guideline for Treating Anemia in Heart Disease Patients
Clinical question: What is the recommended threshold for red blood cell (RBC) transfusion and erythropoiesis-stimulating agents (ESA) in anemic hospitalized patients with coronary heart disease?
Background: Anemia can worsen cardiac function and is associated with increased risk of hospitalization and death in patients with coronary heart disease (CHD) or congestive heart failure (CHF). It is unclear if treatments such as RBC transfusion, ESA, or iron replacement improve outcomes in patients with heart disease.
Study design: Systematic review.
Setting: Studies of hospitalized medical and surgical patients.
Synopsis: The guideline was developed by reviewing studies evaluating anemia treatment outcomes, including mortality, hospitalization, exercise tolerance, quality of life, and cardiovascular events. Six studies evaluated the benefits and harms resulting from RBC transfusion, each determined to be low-quality evidence. The current evidence showed no benefit when comparing liberal (hemoglobin (Hgb) >10 g/dL) versus restrictive (Hgb <10 g/dL) transfusion thresholds. Potential harms of transfusion included fever, transfusion-related acute lung injury, and CHF.
Given the low-quality evidence, the American College of Physicians (ACP) makes a weak recommendation for a restrictive transfusion strategy of Hgb 7-8 g/dL in patients with CHD.
A review of 16 RCTs (moderate-quality evidence) evaluated the effects of ESAs in mild to moderate anemia and showed no difference in outcomes for patients with CHD and CHF. Harms associated with ESA therapy included hypertension and venous thrombosis. The ACP makes a strong recommendation not to use ESAs in patients with heart disease.
Bottom line: The ACP recommends restrictive transfusion with hemoglobin threshold of 7-8 g/dL in hospitalized patients with CHD (weak recommendation, low-quality evidence) and recommends against using erythropoiesis-stimulating agents for mild to moderate anemia in patients with CHF or CHD (strong recommendation, moderate-quality evidence).
Citation: Qaseem A, Humphrey LL, Fitterman N, Starkey M, Shekelle P. Treatment of anemia in patients with heart disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2013;159(11):770-779.
Clinical question: What is the recommended threshold for red blood cell (RBC) transfusion and erythropoiesis-stimulating agents (ESA) in anemic hospitalized patients with coronary heart disease?
Background: Anemia can worsen cardiac function and is associated with increased risk of hospitalization and death in patients with coronary heart disease (CHD) or congestive heart failure (CHF). It is unclear if treatments such as RBC transfusion, ESA, or iron replacement improve outcomes in patients with heart disease.
Study design: Systematic review.
Setting: Studies of hospitalized medical and surgical patients.
Synopsis: The guideline was developed by reviewing studies evaluating anemia treatment outcomes, including mortality, hospitalization, exercise tolerance, quality of life, and cardiovascular events. Six studies evaluated the benefits and harms resulting from RBC transfusion, each determined to be low-quality evidence. The current evidence showed no benefit when comparing liberal (hemoglobin (Hgb) >10 g/dL) versus restrictive (Hgb <10 g/dL) transfusion thresholds. Potential harms of transfusion included fever, transfusion-related acute lung injury, and CHF.
Given the low-quality evidence, the American College of Physicians (ACP) makes a weak recommendation for a restrictive transfusion strategy of Hgb 7-8 g/dL in patients with CHD.
A review of 16 RCTs (moderate-quality evidence) evaluated the effects of ESAs in mild to moderate anemia and showed no difference in outcomes for patients with CHD and CHF. Harms associated with ESA therapy included hypertension and venous thrombosis. The ACP makes a strong recommendation not to use ESAs in patients with heart disease.
Bottom line: The ACP recommends restrictive transfusion with hemoglobin threshold of 7-8 g/dL in hospitalized patients with CHD (weak recommendation, low-quality evidence) and recommends against using erythropoiesis-stimulating agents for mild to moderate anemia in patients with CHF or CHD (strong recommendation, moderate-quality evidence).
Citation: Qaseem A, Humphrey LL, Fitterman N, Starkey M, Shekelle P. Treatment of anemia in patients with heart disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2013;159(11):770-779.
Clinical question: What is the recommended threshold for red blood cell (RBC) transfusion and erythropoiesis-stimulating agents (ESA) in anemic hospitalized patients with coronary heart disease?
Background: Anemia can worsen cardiac function and is associated with increased risk of hospitalization and death in patients with coronary heart disease (CHD) or congestive heart failure (CHF). It is unclear if treatments such as RBC transfusion, ESA, or iron replacement improve outcomes in patients with heart disease.
Study design: Systematic review.
Setting: Studies of hospitalized medical and surgical patients.
Synopsis: The guideline was developed by reviewing studies evaluating anemia treatment outcomes, including mortality, hospitalization, exercise tolerance, quality of life, and cardiovascular events. Six studies evaluated the benefits and harms resulting from RBC transfusion, each determined to be low-quality evidence. The current evidence showed no benefit when comparing liberal (hemoglobin (Hgb) >10 g/dL) versus restrictive (Hgb <10 g/dL) transfusion thresholds. Potential harms of transfusion included fever, transfusion-related acute lung injury, and CHF.
Given the low-quality evidence, the American College of Physicians (ACP) makes a weak recommendation for a restrictive transfusion strategy of Hgb 7-8 g/dL in patients with CHD.
A review of 16 RCTs (moderate-quality evidence) evaluated the effects of ESAs in mild to moderate anemia and showed no difference in outcomes for patients with CHD and CHF. Harms associated with ESA therapy included hypertension and venous thrombosis. The ACP makes a strong recommendation not to use ESAs in patients with heart disease.
Bottom line: The ACP recommends restrictive transfusion with hemoglobin threshold of 7-8 g/dL in hospitalized patients with CHD (weak recommendation, low-quality evidence) and recommends against using erythropoiesis-stimulating agents for mild to moderate anemia in patients with CHF or CHD (strong recommendation, moderate-quality evidence).
Citation: Qaseem A, Humphrey LL, Fitterman N, Starkey M, Shekelle P. Treatment of anemia in patients with heart disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2013;159(11):770-779.
Risk Stratification Model Predicts Continued Stability in Patients with Pulmonary Embolism
Clinical question: Can right ventricular (RV) dysfunction and troponin levels be used to risk stratify hemodynamically stable patients with acute pulmonary embolism (PE)?
Background: PE can present with varying degrees of clinical severity, necessitating appropriate risk stratification for decision making and management. Observational studies have demonstrated that RV dysfunction and injury provide important prognostic information in patients with acute PE, but this has not been confirmed in large prospective studies.
Study design: Prospective, cohort study.
Setting: Multicenter registry of academic and community hospitals in Italy.
Synopsis: Using the Italian Pulmonary Embolism Registry database of 860 hemodynamically stable patients with PE who underwent troponin measurement and echocardiogram, this study demonstrated that a model including RV dysfunction and injury has an incremental prognostic value for risk stratification of in-hospital death or clinical deterioration. The negative predictive value of negative echocardiography with negative troponin was 100% for in-hospital death and 99% for in-hospital clinical deterioration.
This study was limited by its observational approach; in addition, it did not provide its metrics for defining hemodynamic stability and did not standardize or report treatment strategies for these patients.
The predictive value of this study is impressive and could lead to the identification of patients in whom early discharge or brief hospitalization is appropriate; however, its application could be challenging in clinical environments where timely echocardiography resources are not readily available to a hemodynamically stable patient population.
Bottom line: Negative troponin and absence of RV dysfunction predict clinically stable pulmonary embolism.
Citation: Becattini C, Casazza F, Forgione C, et al. Acute pulmonary embolism: external validation of an integrated risk stratification model. Chest. 2013;144(5):1539-1545.
Clinical question: Can right ventricular (RV) dysfunction and troponin levels be used to risk stratify hemodynamically stable patients with acute pulmonary embolism (PE)?
Background: PE can present with varying degrees of clinical severity, necessitating appropriate risk stratification for decision making and management. Observational studies have demonstrated that RV dysfunction and injury provide important prognostic information in patients with acute PE, but this has not been confirmed in large prospective studies.
Study design: Prospective, cohort study.
Setting: Multicenter registry of academic and community hospitals in Italy.
Synopsis: Using the Italian Pulmonary Embolism Registry database of 860 hemodynamically stable patients with PE who underwent troponin measurement and echocardiogram, this study demonstrated that a model including RV dysfunction and injury has an incremental prognostic value for risk stratification of in-hospital death or clinical deterioration. The negative predictive value of negative echocardiography with negative troponin was 100% for in-hospital death and 99% for in-hospital clinical deterioration.
This study was limited by its observational approach; in addition, it did not provide its metrics for defining hemodynamic stability and did not standardize or report treatment strategies for these patients.
The predictive value of this study is impressive and could lead to the identification of patients in whom early discharge or brief hospitalization is appropriate; however, its application could be challenging in clinical environments where timely echocardiography resources are not readily available to a hemodynamically stable patient population.
Bottom line: Negative troponin and absence of RV dysfunction predict clinically stable pulmonary embolism.
Citation: Becattini C, Casazza F, Forgione C, et al. Acute pulmonary embolism: external validation of an integrated risk stratification model. Chest. 2013;144(5):1539-1545.
Clinical question: Can right ventricular (RV) dysfunction and troponin levels be used to risk stratify hemodynamically stable patients with acute pulmonary embolism (PE)?
Background: PE can present with varying degrees of clinical severity, necessitating appropriate risk stratification for decision making and management. Observational studies have demonstrated that RV dysfunction and injury provide important prognostic information in patients with acute PE, but this has not been confirmed in large prospective studies.
Study design: Prospective, cohort study.
Setting: Multicenter registry of academic and community hospitals in Italy.
Synopsis: Using the Italian Pulmonary Embolism Registry database of 860 hemodynamically stable patients with PE who underwent troponin measurement and echocardiogram, this study demonstrated that a model including RV dysfunction and injury has an incremental prognostic value for risk stratification of in-hospital death or clinical deterioration. The negative predictive value of negative echocardiography with negative troponin was 100% for in-hospital death and 99% for in-hospital clinical deterioration.
This study was limited by its observational approach; in addition, it did not provide its metrics for defining hemodynamic stability and did not standardize or report treatment strategies for these patients.
The predictive value of this study is impressive and could lead to the identification of patients in whom early discharge or brief hospitalization is appropriate; however, its application could be challenging in clinical environments where timely echocardiography resources are not readily available to a hemodynamically stable patient population.
Bottom line: Negative troponin and absence of RV dysfunction predict clinically stable pulmonary embolism.
Citation: Becattini C, Casazza F, Forgione C, et al. Acute pulmonary embolism: external validation of an integrated risk stratification model. Chest. 2013;144(5):1539-1545.
Accelerated Diagnostic Protocol for Chest Pain Results in Earlier Discharge of Low-Risk Patients
Clinical question: In patients with possible cardiac chest pain, does an accelerated diagnostic protocol result in higher rates of successful early discharge when compared with the standard care pathway?
Background: An accelerated diagnostic pathway (ADP), which combines TIMI [thrombolysis in myocardial infarction] score, EKG, and zero- and two-hour troponin levels, can identify low-risk patients presenting with chest pain; however, little is known about its effect on the rates of early, successful discharge in a real-world population.
Study design: RCT.
Setting: An academic general and tertiary care hospital in Christchurch, New Zealand.
Synopsis: This study of 542 patients ages 18 years and older who presented with chest pain demonstrated that when compared with a conventional pathway, an ADP results in nearly twice the proportion of patients (19.3% vs. 11.0%; P=0.008) achieving safe, early discharge from the ED, defined as discharge within six hours and no major adverse cardiac events within 30 days. This was a single-center trial in New Zealand, which limits its sample size and its generalizability; however, if larger studies led to the implementation of ADP by ED physicians, there would likely be fewer low-risk patients admitted to hospitalist services for evaluation of chest pain.
Bottom line: An accelerated diagnostic chest pain protocol results in earlier discharge of low-risk patients.
Citation: Than M, Aldous S, Lord SJ, et al. A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department: a randomized clinical trial. JAMA Intern Med. 2014;174(1):51-58.
Clinical question: In patients with possible cardiac chest pain, does an accelerated diagnostic protocol result in higher rates of successful early discharge when compared with the standard care pathway?
Background: An accelerated diagnostic pathway (ADP), which combines TIMI [thrombolysis in myocardial infarction] score, EKG, and zero- and two-hour troponin levels, can identify low-risk patients presenting with chest pain; however, little is known about its effect on the rates of early, successful discharge in a real-world population.
Study design: RCT.
Setting: An academic general and tertiary care hospital in Christchurch, New Zealand.
Synopsis: This study of 542 patients ages 18 years and older who presented with chest pain demonstrated that when compared with a conventional pathway, an ADP results in nearly twice the proportion of patients (19.3% vs. 11.0%; P=0.008) achieving safe, early discharge from the ED, defined as discharge within six hours and no major adverse cardiac events within 30 days. This was a single-center trial in New Zealand, which limits its sample size and its generalizability; however, if larger studies led to the implementation of ADP by ED physicians, there would likely be fewer low-risk patients admitted to hospitalist services for evaluation of chest pain.
Bottom line: An accelerated diagnostic chest pain protocol results in earlier discharge of low-risk patients.
Citation: Than M, Aldous S, Lord SJ, et al. A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department: a randomized clinical trial. JAMA Intern Med. 2014;174(1):51-58.
Clinical question: In patients with possible cardiac chest pain, does an accelerated diagnostic protocol result in higher rates of successful early discharge when compared with the standard care pathway?
Background: An accelerated diagnostic pathway (ADP), which combines TIMI [thrombolysis in myocardial infarction] score, EKG, and zero- and two-hour troponin levels, can identify low-risk patients presenting with chest pain; however, little is known about its effect on the rates of early, successful discharge in a real-world population.
Study design: RCT.
Setting: An academic general and tertiary care hospital in Christchurch, New Zealand.
Synopsis: This study of 542 patients ages 18 years and older who presented with chest pain demonstrated that when compared with a conventional pathway, an ADP results in nearly twice the proportion of patients (19.3% vs. 11.0%; P=0.008) achieving safe, early discharge from the ED, defined as discharge within six hours and no major adverse cardiac events within 30 days. This was a single-center trial in New Zealand, which limits its sample size and its generalizability; however, if larger studies led to the implementation of ADP by ED physicians, there would likely be fewer low-risk patients admitted to hospitalist services for evaluation of chest pain.
Bottom line: An accelerated diagnostic chest pain protocol results in earlier discharge of low-risk patients.
Citation: Than M, Aldous S, Lord SJ, et al. A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department: a randomized clinical trial. JAMA Intern Med. 2014;174(1):51-58.