Editor's Choice
M-A | Cognitive behavior therapy vs. other treatments for depression
28 Mar, 2023 | 15:05h | UTCCommentary: Is cognitive behavioural therapy the best we’ve got for depression? – The Mental Elf
Perspective | The use of ChatGPT and other large language models in surgical science
28 Mar, 2023 | 15:01h | UTCThe use of ChatGPT and other large language models in surgical science – BJS Open
ChatGPT vs. NCI: analyzing the quality of cancer information on myths and misconceptions
28 Mar, 2023 | 15:00h | UTCNews Release: Looking for cancer information: Can ChatGPT be counted on? – Huntsman Cancer Institute
Brief Review | Antifungal stewardship in critically ill patients
28 Mar, 2023 | 14:57h | UTCAntifungal stewardship in critically ill patients – Intensive Care Medicine (if the link is paywalled, try this one)
Commentary on Twitter
Antifungal stewardship in #ICU
🧪 biomarkers
⬇️ de‑escalation
🍄 other methods to improve AFs use
Empirical AFs commonly used (poor prognosis if inappropriate/delayed): AFS can ⬆️ performance measures/⬇️ AFs consumption, no negative impact on outcome
🖇️ https://t.co/eS9EJdjo2a pic.twitter.com/4FMV9NBndb— Intensive Care Medicine (@yourICM) March 24, 2023
Coffee consumption vs. caffeine avoidance: cardiac ectopy, daily steps, and sleep impacts
27 Mar, 2023 | 13:32h | UTCSummary: A prospective, randomized, case-crossover trial studied the acute health effects of caffeinated coffee consumption in 100 ambulatory adults.
Participants were monitored using continuous electrocardiogram devices, wrist-mounted accelerometers, and ongoing glucose monitoring systems for 14 days. They received daily text messages instructing them to either consume caffeinated coffee or abstain from caffeine.
The primary outcome was the mean number of daily premature atrial contractions. Results indicated that caffeinated coffee consumption didn’t lead to significantly more daily premature atrial contractions compared to caffeine avoidance. However, it was associated with a higher number of daily premature ventricular contractions, increased daily steps, and reduced nightly sleep.
Article: Acute Effects of Coffee Consumption on Health among Ambulatory Adults – New England Journal of Medicine (link to abstract – $ for full-text)
Commentaries:
What to know about new research on coffee and heart risks – Associated Press
CRAVE Trials Offers Most Comprehensive Overview Yet of Impact of Coffee, Caffeine Intake – HCP Live
Acute Effects of Coffee Consumption on Health – American College of Cardiology
M-A | Examining shorter antibiotic treatment durations for community acquired pneumonia in adults
27 Mar, 2023 | 13:29h | UTCSummary: The systematic review and duration-effect meta-analysis included nine randomized trials with a total of 2,399 patients, analyzing antibiotic treatment durations for community-acquired pneumonia (CAP) in adults. The primary outcome was clinical improvement on day 15, with secondary outcomes including all-cause mortality, serious adverse events, and clinical improvement on day 30.
The study found that shorter treatment durations (3–9 days) were likely to be non-inferior to the standard 10-day treatment, and no significant difference in all-cause mortality or serious adverse events was observed. The study suggests that a 3–5 day treatment duration likely offers the optimal balance between efficacy and treatment burden if patients are clinically stable. However, the results are limited by the small number of included studies, the overall moderate-to-high risk of bias, and the varying severity of CAP among patients in the studies. Therefore, further research focusing on the shorter duration range is required.
Related:
Top POEMs (Patient-Oriented Evidence that Matters) of 2022 for choosing wisely in practice
27 Mar, 2023 | 13:30h | UTCSummary: Top POEMs of 2022 for choosing wisely in practice are based on Canadian Medical Association member ratings. These recommendations promote evidence-based and cost-effective clinical practices while reducing unnecessary treatments and diagnostic procedures.
Key recommendations from the article:
- Hypnotic agents are effective for insomnia but have adverse effects; avoid benzodiazepines as the first choice for older adults.
- For type 2 diabetes in older adults, avoid medications causing hypoglycemia to achieve A1c <7.5%; moderate control is better.
- Postoperative opioids provide no better pain relief than nonopioids; avoid prolonged use beyond the immediate postoperative period.
- Arthroscopic debridement is not recommended as the primary treatment for knee osteoarthritis.
- Proton pump inhibitor (PPI) use is associated with an increased risk of gastric cancer, although the association is observational and does not imply causation. Use the lowest dose and duration possible.
- For children with community-acquired pneumonia, low-dose amoxicillin for 3 days is noninferior to high-dose for 7 days.
- White blood cells in urine do not equate to bacterial cells; avoid urine dip tests or cultures unless urinary tract symptoms are present.
- Avoid measuring vitamin D in low-risk adults as a routine test.
- Antidepressants should not be routinely used as first-line treatment for mild or subsyndromal depressive symptoms in adults.
- ACG guideline for GERD management: try discontinuing PPIs after an 8-week trial in patients with classic GERD symptoms & no alarming symptoms.
- British Society of Gastroenterology guidelines for IBS management: colonoscopy only for alarming signs or microscopic colitis risk.
- USPSTF advises against ASA initiation for primary prevention of cardiovascular disease in adults >60.
Top POEMs of 2022 for choosing wisely in practice – Canadian Family Physician
See complete lists of low-value practices: Choosing Wisely U.S. / Choosing Wisely UK / Choosing Wisely Australia AND Choosing Wisely Canada
Dissecting coffee’s impact: high consumption lowers blood pressure, raises LDL-cholesterol
27 Mar, 2023 | 13:25h | UTC
Expanding Organ Usage: UK study finds organs from patients with a primary brain tumor are a viable option
27 Mar, 2023 | 13:27h | UTCSummary: A national cohort study in the UK investigated the risk of cancer transmission from deceased donors with primary brain tumors to organ recipients. The study found no cases of brain tumor transmission among 778 transplants from 282 donors with primary brain tumors, including 262 from donors with high-grade tumors. Organ transplant survival was equivalent to that in matched controls, and some organs from donors with high-grade tumors were less likely to be transplanted.
The results suggest that the risk of cancer transmission in transplants from deceased donors with primary brain tumors is lower than previously thought. Furthermore, the study indicated that donors with brain tumors provided good-quality organs with favorable risk markers and excellent transplant outcomes. Some organs from donors with high-grade tumors were underutilized, indicating a possible aversion by transplant clinicians or patients to use these organs.
These findings imply that it may be possible to safely expand organ usage from donors with primary brain tumors without negatively impacting outcomes, potentially benefiting many patients waiting for a transplant. Although this might lead to a slight rise in transplant numbers in the UK, the findings may hold particular significance for nations with stricter guidelines, such as the United States. The study’s findings can help transplant clinicians discuss the risks and benefits of accepting organ offers from such donors.
SR | Interventions to reduce repetitive ordering of low-value inpatient laboratory tests
27 Mar, 2023 | 13:22h | UTC
Selected articles from the Annual Update in Intensive Care and Emergency Medicine 2023
27 Mar, 2023 | 13:23h | UTCHemodynamic Implications of Prone Positioning in Patients with ARDS
Host Response Biomarkers for Sepsis in the Emergency Room
Quality improvement in the determination of death by neurologic criteria around the world
Setting and Monitoring of Mechanical Ventilation During Venovenous ECMO
A structured diagnostic algorithm for patients with ARDS
Interrogating the sepsis host immune response using cytomics
Managing the Physiologically Difficult Airway in Critically Ill Adults
Metagenomic Sequencing in the ICU for Precision Diagnosis of Critical Infectious Illnesses
The Role of Transcriptomics in Redefining Critical Illness
Study shows increased bleeding complications in ESKD patients undergoing AF ablation
24 Mar, 2023 | 13:09h | UTCSummary: The study analyzed 347 procedures in 307 patients with end-stage kidney disease (ESKD) undergoing atrial fibrillation (AF) catheter ablation in 12 referral centers in Japan.
Despite a vast majority of patients having subtherapeutic international normalized ratio (INR) values during the peri-procedural period, 35 patients (10%) experienced major complications, with the majority being major bleeding events (19 patients; 5.4%), including 11 cases of cardiac tamponade (3.2%). There were also two peri-procedural deaths (0.6%), both related to bleeding events. A pre-procedural INR value of 2.0 or higher was identified as the only independent predictor of major bleeding.
Current peri-procedural anticoagulation guidelines state that patients undergoing AF ablation should be under therapeutic anticoagulation throughout the peri-procedural period. The findings of this study suggest that these guidelines may not be appropriate for ESKD patients undergoing the procedure, and the role of peri-procedural anticoagulation in this population should be further investigated.
Commentary on Twitter
Peri-procedural anticoagulation in patients with end-stage kidney disease undergoing #afib ablation 👉 despite undertreatment with warfarin, the rate of haemorrhagic complications is high! https://t.co/3W8gEtZYdy#kidney #afib #anticoagulation #ablation #cardiotwitter #europace pic.twitter.com/vI27UeIpRf
— European Society of Cardiology Journals (@ESC_Journals) March 16, 2023
Study reveals high rates of nonadherence to antimicrobial prophylaxis guidelines, often due to unnecessary vancomycin use
23 Mar, 2023 | 13:13h | UTCSummary: The study evaluated adherence to surgical antimicrobial prophylaxis guidelines in 825 US hospitals for elective surgeries from 2019-2020. The study found that 41% of surgical prophylaxis regimens were nonadherent to the American Society of Health-System Pharmacists guidelines.
Unnecessary vancomycin use was the most common reason for nonadherence to surgical antimicrobial prophylaxis guidelines, accounting for 77% of nonadherent regimens and occurring in 31% of all surgeries. It’s noteworthy that when vancomycin was used, it was often unnecessarily combined with cefazolin, and patients who received this combination had a 19% higher risk of acute kidney injury compared to those who received cefazolin alone.
The authors suggest that quality-improvement efforts aimed at reducing unnecessary vancomycin use and potential guideline revisions may offer impactful strategies for improving the risk-benefit profile of antimicrobial prophylaxis.
Study reveals overuse of surveillance colonoscopy in older adults with limited life expectancy
23 Mar, 2023 | 13:11h | UTCSummary: This study investigated the association between estimated life expectancy, surveillance colonoscopy findings, and follow-up recommendations among older adults. The study utilized data from the New Hampshire Colonoscopy Registry and included adults over 65 who underwent colonoscopy for surveillance after prior polyps.
Life expectancy was estimated using a validated prediction model and categorized into three groups: less than 5 years, 5 to less than 10 years, and 10 or more years.
Out of the 9,831 adults included in the study, 8% had advanced polyps or CRC. Among the 5,281 patients with available recommendations, 86.9% were advised to return for a future colonoscopy. Surprisingly, 58.1% of older adults with less than 5 years of life expectancy were also recommended to return for future surveillance colonoscopy.
The study concluded that many older adults with limited life expectancy are still recommended for future surveillance colonoscopy. This data could help refine decision-making about pursuing or stopping surveillance colonoscopy in older adults with a history of polyps.
Article: Association of Life Expectancy With Surveillance Colonoscopy Findings and Follow-up Recommendations in Older Adults – JAMA Internal Medicine (link to abstract – $ for full-text)
JAMA Patient Page: What Should I Know About Stopping Routine Cancer Screening?
Commentary on Twitter
Findings suggest that recommending against future surveillance colonoscopy in older adults with low-risk colonoscopy findings and/or limited life expectancy should be considered more frequently than is currently practiced. https://t.co/7jKpYyuZON
— JAMA Internal Medicine (@JAMAInternalMed) March 13, 2023
Cohort Study | Opioid use for pain relief after birth appears to pose no significant risk to breastfed infants
23 Mar, 2023 | 13:08h | UTCSummary: This large study from Canada found that infants born to mothers prescribed opioids after delivery, mainly following a cesarean, are at no greater risk of harm shortly after birth than infants of mothers not prescribed opioids. This suggests that breastfeeding is likely safe for babies whose mothers are taking opioids for pain relief.
The study included 865,691 mother-infant pairs discharged from Ontario hospitals within seven days of delivery between September 2012 and March 2020. Researchers matched mothers who filled an opioid prescription within seven days of discharge to those who did not.
Among the infants admitted to the hospital within 30 days, 2,962 (3.5%) were born to mothers who filled an opioid prescription compared with 3,038 (3.5%) born to mothers who did not, showing that infants of mothers prescribed opioids were no more likely to be admitted to the hospital for any reason. These children were only marginally more likely to visit the emergency department in the subsequent 30 days, and no differences were found for other serious outcomes, including breathing problems or admission to a neonatal intensive care unit, and no infant deaths occurred.
Although the study has some limitations, the high initial breastfeeding rates in Canada (90%) and the consistency of the findings with the fact that millions of new mothers are prescribed opioids after delivery each year provide confidence in the conclusions.
Editorial: Opioid analgesia for breastfeeding mothers – The BMJ
News Release: Infants of mothers given opioids after birth are at low risk of harm – BMJ Newsroom
AHA Scientific Statement | Supervised exercise training for chronic heart failure with preserved ejection fraction
22 Mar, 2023 | 13:46h | UTCNews Release: Exercise therapy is safe, may improve quality of life for many people with heart failure – American Heart Association
Key Points: Supervised Exercise Training for Chronic HFpEF – American College of Cardiology
RCT | Hydrocortisone reduces mortality in severe community-acquired pneumonia
22 Mar, 2023 | 13:44h | UTCSummary: Practice-changing! In a phase 3, multicenter, double-blind, randomized controlled trial involving 800 patients with severe community-acquired pneumonia admitted to the ICU, hydrocortisone treatment was found to reduce the risk of death by day 28 compared to a placebo group. The hydrocortisone group had a 6.2% death rate, while the placebo group had an 11.9% death rate.
Hydrocortisone also led to fewer endotracheal intubations among patients not on mechanical ventilation at baseline and reduced the need for vasopressor therapy in patients not receiving it at baseline. There was no significant difference in hospital-acquired infections or gastrointestinal bleeding between the two groups, but patients in the hydrocortisone group required higher daily doses of insulin during the first week of treatment.
Article: Hydrocortisone in Severe Community-Acquired Pneumonia – New England Journal of Medicine (link to abstract – $ for full-text)
Commentary: Steroid drug reduces death rate in severe pneumonia, study shows – STAT
Commentary on Twitter
In this randomized trial, hydrocortisone treatment decreased mortality among patients with severe community-acquire pneumonia in the ICU. https://t.co/DZadFMcA5o#ISICEM23 pic.twitter.com/yhkVCjBMWX
— NEJM (@NEJM) March 21, 2023
RCT | Low-calorie, low-protein feeding improves recovery time in ventilated adults with shock
22 Mar, 2023 | 13:42h | UTCSummary: The NUTRIREA-3 study aimed to determine the optimal calorie and protein intakes during the acute phase of severe critical illness. The study was a randomized, controlled, multicenter, open-label, parallel-group trial conducted in 61 French intensive care units (ICUs) involving 3044 adults receiving invasive mechanical ventilation and vasopressor support for shock. During the first seven ICU days, participants were randomly assigned to early nutrition with either low or standard calorie and protein targets. The primary endpoints were time to readiness for ICU discharge and day 90 all-cause mortality, while key secondary outcomes included secondary infections, gastrointestinal events, and liver dysfunction.
The study found that early calorie and protein restriction did not decrease mortality. However, it was associated with faster recovery and fewer complications compared to standard calorie and protein targets. The low-calorie, low-protein group had a shorter median time to readiness for ICU discharge and lower proportions of patients with vomiting, diarrhea, bowel ischemia, and liver dysfunction. The proportions of patients with secondary infections did not differ significantly between the two groups.
In conclusion, the NUTRIREA-3 study provides evidence that patients may benefit from restricted calorie and protein intakes during the acute phase of critical illness, as it expedites recovery and reduces the risk of complications.
Article: Low versus standard calorie and protein feeding in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group trial (NUTRIREA-3) – The Lancet Respiratory Medicine (free registration required)
Commentary on Twitter
NEW Research—Early calorie & protein restriction did not decrease mortality but was associated w/ faster recovery & fewer complications than standard intake targets
NUTRIREA-3 from Prof Jean Reignier & co https://t.co/VCS72qxLPD
Being presented @ISICEM today! #ISICEM23 pic.twitter.com/TpoJnwHP8P
— The Lancet Respiratory Medicine (@LancetRespirMed) March 21, 2023
Opinion | The rapid growth of mega-journals: threats and opportunities
22 Mar, 2023 | 13:40h | UTCThe Rapid Growth of Mega-Journals: Threats and Opportunities – JAMA (free for a limited period)
RCT | 4F-PCC fails to reduce blood product consumption and raises thromboembolic events in trauma patients
22 Mar, 2023 | 13:41h | UTCSummary: The PROCOAG Randomized Clinical Trial aimed to investigate the efficacy and safety of 4-factor prothrombin complex concentrate (4F-PCC) in trauma patients at risk of massive transfusion. Conducted in 12 French trauma centers, this double-blind, randomized, placebo-controlled superiority trial involved 324 patients. All patients were treated according to European traumatic hemorrhage guidelines and received early ratio-based transfusion (packed red blood cells:fresh frozen plasma ratio of 1:1 to 2:1). The primary outcome measured was 24-hour blood product consumption (efficacy), while arterial or venous thromboembolic events were assessed as a secondary outcome (safety).
The trial revealed no significant difference in 24-hour blood product consumption between the 4F-PCC and placebo groups, with median consumption of 12 units and 11 units, respectively. However, the study identified a statistically significant higher risk of thromboembolic events in the 4F-PCC group, with 35% of patients experiencing at least one event compared to 24% in the placebo group.
In conclusion, the study found no beneficial effect of incorporating 4F-PCC into a ratio-based transfusion strategy for patients with severe trauma at risk of massive transfusion. Furthermore, the higher rate of thromboembolic events in the 4F-PCC group indicated potential harm. The findings do not support the routine use of 4F-PCC in patients experiencing trauma who are at risk for extensive transfusion.
Article: Efficacy and Safety of Early Administration of 4-Factor Prothrombin Complex Concentrate in Patients With Trauma at Risk of Massive Transfusion: The PROCOAG Randomized Clinical Trial – JAMA (free for a limited period)
See also: Visual Abstract
Review | Diagnosis and treatment of chronic lymphocytic leukemia
22 Mar, 2023 | 13:39h | UTCDiagnosis and Treatment of Chronic Lymphocytic Leukemia: A Review – JAMA (free for a limited period)
Audio clinical review: Diagnosis and Management of Chronic Lymphocytic Leukemia – JAMA
Cohort study | Professional soccer players are at increased risk of Alzheimer’s disease and other dementias
21 Mar, 2023 | 13:46h | UTCSummary: The article reports on a cohort study conducted in Sweden to investigate whether male soccer players in the top division are at increased risk of neurodegenerative disease compared to matched controls from the general population. This is a topic of concern as there is a hypothesis that the repetitive mild head trauma sustained through heading the ball and concussions might cause neurodegenerative disease.
The study included 6007 football players and 56,168 controls and used nationwide registers to identify diagnoses of neurodegenerative disease. The study revealed that male professional soccer players in Sweden had a higher risk of neurodegenerative disease, particularly Alzheimer’s disease and other dementias, and outfield players had a higher risk than goalkeepers.
News Release: Elite football players are more likely to develop dementia, suggests Swedish study – Lancet
Commentaries:
Dementia risk higher for outfield players than goalkeepers – study – BBC
Neurodegenerative Diseases Are the Cost of Sports – Health Policy Watch
Related:
Dementia risk in former professional footballers is related to player position and career length.
Study: Neurodegenerative Disease Mortality Increased Among Former Professional Soccer Players
Position Paper | Patient sleep during hospitalization
21 Mar, 2023 | 13:47h | UTCSociety of Anesthesia and Sleep Medicine Position Paper on Patient Sleep During Hospitalization – Anesthesia & Anesthesia (free for a limited period)
Comparative study highlights women’s lower susceptibility to sudden cardiac arrest during sports
21 Mar, 2023 | 13:44h | UTCSummary: This study assessed the incidence, characteristics, and outcomes of sports-related sudden cardiac arrest (Sr-SCA) in women. Data from three European registries were analyzed, identifying 34,826 SCA cases between 2006 and 2017, with 760 cases (2.2%) being Sr-SCA, including 54 in women.
The average annual incidence of Sr-SCA in women was 0.19 per million, over 10 times lower than in men (2.63 per million). When extrapolated to the European population, this translates to 98 cases per year in women and 1,350 cases in men.
Characteristics, bystander response, time to defibrillation, and survival rates did not significantly differ between women and men. The findings highlight the considerably lower risk of Sr-SCA in women compared to men and should be considered when designing preparticipation screening strategies in the future.
Article: Incidence of Cardiac Arrest During Sports Among Women in the European Union – Journal of the American College of Cardiology (link to abstract – $ for full-text)
Commentary: Incidence of Cardiac Arrest During Sports Among Women – American College of Cardiology
Commentary on Twitter
Women are at very low risk of cardiac arrest during sports: incidence in women was calculated to be 13 times lower than in men in 3 European registries, w/ no differences in profile, circumstances, mgmt or outcomes. https://t.co/CLl6amlIHO#JACC #CardioTwitter #SportsCardio pic.twitter.com/ADpakbwUKt
— JACC Journals (@JACCJournals) March 15, 2023
The paradox of endurance training: higher coronary plaque prevalence found in lifelong athletes
21 Mar, 2023 | 13:42h | UTCSummary: The Master@Heart study aimed to investigate the relationship between lifelong endurance exercise and coronary atherosclerosis measured by computed tomography coronary angiography (CTCA) in a cohort of 191 lifelong master endurance athletes, 191 late-onset athletes, and 176 healthy non-athletes. All participants were male with a low cardiovascular risk profile.
The study found that lifelong endurance sport participation was not associated with a more favorable coronary plaque composition compared to maintaining a healthy lifestyle. In fact, lifelong endurance athletes exhibited a higher prevalence of coronary plaques, including more non-calcified plaques in proximal segments, than fit and healthy individuals with a similarly low cardiovascular risk profile.
Further research is needed to understand how these findings on CTCA might translate into clinical events in endurance athletes.
Article: Lifelong endurance exercise and its relation with coronary atherosclerosis – European Heart Journal
Commentaries:
Lifelong Endurance Exercise and Coronary Atherosclerosis – American College of Cardiology
MASTER@HEART: Long-term Endurance Athletes Not Immune to Atherosclerosis – TCTMD