Archives of Internal Medicine

GI Bleeds: Benefits of Conservative Transfusion Strategy Seem Confirmed .

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A conservative transfusion strategy for acute upper gastrointestinal bleeding appears to confer a greater survival benefit than liberal treatment, according to a New England Journal of Medicine study.

Investigators randomized some 900 patients either to a conservative strategy (transfusion when hemoglobin fell below 7 g/dL) or to a liberal strategy (transfusion when hemoglobin fell below 9). About half those treated conservatively received transfusions, as opposed to 85% of those assigned to the liberal strategy.

Those on conservative treatment showed a 45% relative risk reduction in all-cause mortality at 45 days (absolute mortality, 5% vs. 9% on liberal treatment). Similarly, further bleeding was less frequent on conservative treatment, as was the rate of adverse events. However, patients with severe cirrhosis (Child-Pugh class C) did not show a survival benefit.

An editorialist, noting that the findings “justify current recommendations,” concludes that “most patients with upper gastrointestinal bleeding, with or without portal hypertension, should have blood transfusions withheld until the hemoglobin level drops below 7.”

Source: NEJM

Asthma Linked To Menstrual Cycle; Hormones Affect Respiratory Symptoms In Women.

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A new study suggests that a woman’s menstrual cycle can affect respiratory symptoms, potentially exacerbating conditions such as asthma.

According to the BBC, Norwegian researchers studied thousands of women with regular menstrual cycles and found that respiratory symptoms became more severe around the time of ovulation.

“The effects of the menstrual cycle on respiratory symptoms in the general population have not been well studied,” said lead author Ferenc Macsali of Norway’s Haukeland University Hospital. “In a cohort of nearly 4,000 women, we found large and consistent changes in respiratory symptoms according to menstrual cycle phase, and, in addition, these patterns varied according to body mass index (BMI), asthma, and smoking status.”

Outcome Magazine summarized the findings:

Significant variations over the menstrual cycle were found for each symptom assessed in all subjects and subgroups. Reported wheezing was higher on cycle days 10-22, with a mid-cycle dip near the putative time of ovulation (~days 14-16) in most subgroups.

Shortness of breath was highest on days 7-21, with a dip just prior to mid-cycle in a number of subgroups. The incidence of cough was higher just after putative ovulation for asthmatics, subjects with BMI ≥ 23kg/m2, and smokers, or just prior to ovulation and the onset of menses in subgroups with a low incidence of symptoms.

The BBC notes that “of those studied, 28.5 percent were smokers and 8 percent had been diagnosed with asthma.”

The study was published online Nov. 9 in the American Thoracic Society‘s American Journal of Respiratory and Critical Care Medicine.

“Our finding that respiratory symptoms vary according to the stage of the menstrual cycle is novel, as is our finding that these patterns vary according to BMI and smoking status,” Macsali said in a journal news release, according to HealthDay News. “These relationships indicate a link between respiratory symptoms and hormonal changes through the menstrual cycle.”

Macsali added that the results may help women with asthma better manage their symptoms.

“Our results point to the potential for individualizing therapy for respiratory diseases according to individual symptom patterns,” he said. “Adjusting asthma medication, for example, according to a woman’s menstrual cycle might improve its efficacy and help reduce disability and the costs of care.”

Dr. Samantha Walker of charity Asthma UK concurred.

“This research is really interesting, and could help women with asthma to manage their condition better,” Walker told the BBC. “Asthma can be triggered by many different things, and this varies from person to person — but we always encourage people with asthma to be aware of things that trigger their symptoms so that they can take steps to control them.

Though this study may be “novel” in its findings, it would not be the first to find a link between a woman’s menstrual cycle and changes in asthma symptoms.

In 1996, the New York Times reported that a study published in the Archives of Internal Medicine had provided evidence to support this connection.

The study, which had looked at the menstrual phase of 182 female patients who needed emergency-room treatment for asthma at hospitals in Pennsylvania, found that “hormonal changes that occur as menstruation starts may make some asthmatic women more vulnerable to attacks.” Specifically, researchers found that 20 percent of the patients were preovulatory and 24 percent were in the ovulatory phase when the attacks occurred.

The Times also pointed out that the possibility of such a link had been first reported in a medical journal in 1931, though it was a connection that had “never been proved or studied extensively” before.

According to statistics provided by the Asthma and Allergy Foundation of America, nearly 25 million Americans suffer from asthma and more than 3,300 die from the condition every year. The condition is also said to be more prevalent among adult women than men.

Clinical Trials Analysis Finds Acupuncture Effective for Treating Chronic Pain.

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Although acupuncture has long been used to treat chronic pain, its effectiveness remains a controversial topic among physicians and scientists. This is largely because no biological mechanism has been identified to explain how the insertion and stimulation of specialized needles at specific points on the body generates lasting effects, such as decreased pain many months after a treatment.

Now, in an extensive analysis of data from nearly 18,000 individuals involved in 29 high-quality clinical trials, Memorial Sloan-Kettering health outcomes researcher Andrew Vickers and colleagues have determined that acupuncture is an effective treatment for chronic back and neck pain, osteoarthritis, shoulder pain, and headaches.

Clinical Trial and Patient Data Examined

The review article, published in the September 10 issue of the Archives of Internal Medicine, was based on an evaluation of clinical trials conducted in the United States, Germany, Spain, and Sweden. The analysis included data from only the highest-quality trials: those that determined at random whether a patient would receive acupuncture.

In the studies, patients were randomly assigned to actual acupuncture, sham acupuncture (in which needles are inserted superficially or at nontraditional sites), or standard care without acupuncture. After selecting the trials, Dr. Vickers and colleagues requested the original patient data from the study investigators to use in their analysis.

“There have been many clinical trials of acupuncture for chronic pain,” Dr. Vickers says, “but the quality of these studies has been questionable. In our study, we only used data from trials that were very carefully designed to avoid bias. And by obtaining the original data, we could make sure that the statistical analyses were as accurate as possible.”

Implications for Patients and Doctors

An estimated three million Americans have acupuncture treatments each year, in most cases to address conditions causing chronic pain. Dr. Vickers explains that several factors likely contribute to the benefits that patients report.

“People receiving acupuncture for pain experience a benefit beyond that gained from the correct insertion of needles,” he says. “There is probably some benefit to needle insertion regardless of whether it is at a correct acupuncture point. And of course there is often an effect related to believing that the treatment will be helpful.”

According to the Archives study, acupuncture does result in a pain relief benefit over sham acupuncture for chronic back and neck pain, osteoarthritis, shoulder pain, and headache — and its effectiveness over standard treatment without acupuncture is much greater.

“This has major implications for clinical practice,” Dr. Vickers says. “Our findings provide the most-robust evidence to date that doctors are justified in making referrals to acupuncture for their patients with chronic pain. I hope that our findings help inform future clinical and policy decisions for acupuncture.”

Source: MSKCC.

 

Newer Oral Anticoagulants Associated with ‘Dramatic Increase’ in Bleeding After ACS .

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When used to prevent thrombotic events after an acute coronary syndrome, the newer oral anticoagulants (for example, apixaban, dabigatran, and rivaroxaban) are associated with increased rates of major bleeding that offset their antithrombotic benefit, according to an Archives of Internal Medicine meta-analysis.

Researchers examined seven randomized controlled trials comprising over 30,000 patients who were hospitalized with ACS and received antiplatelet therapy. Compared with placebo recipients, those on new-generation oral anticoagulants had “a dramatic increase in major bleeding events.” Significant (but moderate) reductions in the risks for stent thrombosis and other ischemic events were seen, but there was no significant effect on overall mortality.

An editorialist concludes that routine use of these drugs in patients with ACS “is unwarranted.”

Source: Archives of Internal Medicine

 

Resuming Warfarin After a GI Bleed: Benefits Appear to Outweigh the Risks .

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Many patients who’ve had a warfarin-associated gastrointestinal bleed can safely resume warfarin therapy soon after the bleeding event, according to an industry-funded, retrospective study in the Archives of Internal Medicine.

Researchers identified some 440 adults who experienced a GI bleed while taking warfarin; nearly 60% either stayed on warfarin continuously or resumed treatment within about a week (median time to retreatment, 4 days). Compared with patients who did not restart warfarin, those who continued or resumed treatment had a significantly lower 90-day incidence of thrombosis (0.4% vs. 5.5%) and death (6% vs. 20%). The most common causes of death were cancer, infection, and cardiac disease.

Patients who continued or restarted warfarin did have more recurrent GI bleeds (10% vs. 6%), but this difference did not achieve statistical significance. None of the recurrent bleeds were fatal.

Archives commentators conclude: “We believe that most patients with warfarin-associated GI bleeding and indications for continued long-term antithrombotic therapy should resume anticoagulation within the first week following the hemorrhage.”

Source: Archives of Internal Medicine

Preoperative Hyponatremia May Heighten Mortality Risk .

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The presence of even mild hyponatremia before surgery is associated with increased perioperative mortality, according to a cohort study in the Archives of Internal Medicine.

Nearly 1 million U.S. adult patients in a surgical-quality registry had their sodium levels measured within 90 days before surgery. About 8% of patients had hyponatremia (defined as a serum sodium level under 135 mEq/L), with most of these being only mildly hyponatremic (values ranging from 130 to 134 mEq/L).

The study’s primary outcome, mortality within 30 days after surgery, was higher in those with hyponatremia than in those with normal sodium levels (5.2% vs. 1.3%); the difference remained significant even after adjustment for other risk factors such as smoking and functional health status.

Editorialists comment that the findings are not surprising, given the comorbidities associated with hyponatremia. They say it remains an open question whether elective surgery should be postponed in the face of mild hyponatremia, “but the diagnosis should contribute to the informed consent process.”

Source:Archives of Internal Medicine

 

Burnout burden high among US physicians.

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Burnout appears to be more common among physicians than among other adults working in the United States, with nearly half of those who participated in a national survey reporting at least one symptom of burnout, data published in the Archives of Internal Medicine suggest.

Previous studies have examined the link between burnout and quality of care, increased risk for error and its role in physicians’ relationships, alcohol abuse and suicidal ideation. However, according to the study researchers, the June 2011 national survey is the first to evaluate the rates of burnout among a large, diverse sample of US physicians.

Study results

Tait D. Shanafelt, MD, of the department of internal medicine at Mayo Clinic in Rochester, Minn., and colleagues obtained a sample of physicians from all specialties from the American Medical Association Physician Masterfile. Of the 27,276 physicians who received an initial invitation to participate, 7,288 physicians completed the surveys. To develop a comparison with the general US population, researchers also surveyed a probability-based sample of 3,442 working US adults aged 22 to 65 years.

 

Researchers measured three domains of burnout — emotional exhaustion, depersonalization and low personal accomplishment — using the Maslach Burnout Inventory. The Primary Care Evaluation of Mental Disorders assessment was used to measure symptoms of depression, and other questions were asked to assess work–life balance concerns.

According to data, 45.8% of physicians reported at least one symptom of burnout; 37.9%, high emotional exhaustion; 29.4%, high depersonalization; and 12.4% expressed a low level of personal accomplishment.

Study researcher Liselotte N. Dyrbye, MD, MHPE, associate director of research applications in the department of medicine program on physician well-being at Mayo Clinic in Rochester, Minn., told Endocrine Today that characteristics of the job may account for the high prevalence of burnout among physicians.

“Given that nearly 50% of physicians have burnout, the problem stems from environment/work-related factors rather than character flaws/personal characteristics of a few susceptible physicians,” Dyrbye said.

Physicians in emergency medicine (P<.001), general internal medicine (P<.001), neurology (P<.01), radiology (P=.02) and family medicine (P=.001) had the highest rates of burnout. Those in pathology, dermatology, general pediatrics and preventive medicine, including occupational health and environmental medicine, had the lowest rates, researchers wrote.

Moreover, compared with the general population control group, physicians were more likely to have symptoms of burnout (37.9% vs. 27.8%) and be dissatisfied with work–life balance (40.2% vs. 23.2%).

“The study confirms that there is an alarmingly high prevalence of burnout among physicians, with the highest among physicians who are in the front line of care (family medicine, general internal medicine, ER) and among those who work longer hours. Burnout and struggles with work–life balance are greater for physicians than other US workers,” Dyrbye said.

A pooled multivariate analysis adjusted for age, sex, relationship status and hours worked per week also revealed an association between level of education and burnout. When compared with workers with high school degrees, physicians with DO or MD degrees had a higher risk for burnout (OR=1.36; P<.001) than those with bachelor’s degrees (OR=0.8; P=.048), master’s degrees (OR=0.71; P=.01) or professional or doctoral degrees other than DO or MD (OR=0.64; P=.04).

Implications

Drybye said the researchers hope the study results will generate discussion on how to address the problem of burnout.

“We hope that this study will fuel a national dialogue about how to minimize burnout. Efforts are needed to identify and address the work-related factors that are contributing to burnout among physicians. To date, the issue of physician burnout has not surfaced in any meaningful way during discussions of how to reform health care delivery,” Dyrbye said.

Besides this study, Dyrbye said she and Shanafelt have also written an article on how burnout threatens the success of health care reform regarding the Affordable Care Act.

“It isn’t so much preventive medicine subspecialists, but rather general internal medicine, general pediatrics and family medicine physicians who are most likely to be seeing more patients. This will place an additional strain on physicians in the front lines — many of whom are already struggling with burnout,” Dyrbye said.

The researchers wrote that it is up to policymakers and health care organizations to address this problem “for the sake of physicians and their patients.” – by Samantha Costa

For more information:

Shanafelt TD. Arch Intern Med. 2012;doi:10.1001/archinternmed.2012.3199.

Andrew F. Stewart

  • This is an interesting and important paper documenting that burnout and adverse work–life balance issues affect physicians disproportionately as compared to other US workers; and to explore the reasons for this. The results suggest, with appropriate cautions regarding limitations and confounders, that certain specialties within medicine are more severely affected than others.

With regard to the field of endocrinology, no specific information is available, since the many disparate general internal medicine subspecialties are combined into a single group. Thus, high-earning proceduralists (eg, cardiology, pulmonary, GI physicians with better personnel support systems) are lumped together with lower earning RVU/E&M coding non-proceduralists (eg, rheumatology, endocrinology, infectious disease physicians with little personnel or other ancillary support). One might reasonably infer that endocrinologists are most akin to family practitioners and general internal medicine physicians who are disproportionately affected by burnout and work–life balance issues. The authors may want to share their database with subspecialties for subset analysis, or analyze it more deeply themselves to see whether trends exist in specific subspecialties. This information would be of value to the Department of Health and Human Services, the AMA and other agencies interested in managing and financing health care reform.

As the authors point out, most studies in this area offer little in the way as to guidance regarding burnout- and life balance-prevention measures, other than counseling and support measures, and fail to address the organizational, procedural and support issues that lead to the occurrence of what is an obvious problem.

As they also point out, work–life balance issues and burnout predict both work force dropout and lower levels of quality of patient care.  There is no attempt to quantify these in the current study. This would be an attractive area for further study.

Overall, this is a timely and important study, although much more remains to be done analytically, and also with regard to interventions.

Source: Endocrine Today.

 

Certain Antihypertensive Drugs Associated with Risk for Lip Cancer.

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Some commonly used antihypertensive drugs — hydrochlorothiazide and nifedipine — might increase the risk for lip cancer, according to a case-control study in the Archives of Internal Medicine.

Using a California-based cancer registry, researchers matched some 700 non-Hispanic white adults diagnosed with lip cancer to some 23,000 controls free of lip cancer. Patients who filled three or more prescriptions for hydrochlorothiazide, hydrochlorothiazide-triamterene, and nifedipine — all photosensitizing agents — had roughly double the risk for lip cancer relative to those with no prescriptions filled. Risks increased with duration of use. Atenolol, which is non-photosensitizing, was not associated with increased risk.

The authors write that photosensitizing drugs may absorb energy from sunlight, which leads to the release of electrons. This then produces free radicals that can cause inflammation.

An Archives‘ editor writes: “When initiating use of photosensitizing agents for our patients, we need to remind them of … simple measures to avoid sun exposure.”

Source: Archives of Internal Medicine