NEJM Journal Watch: What is the effect of coffee consumption on mortality?

“Moderate consumption of unsweetened or sugar-sweetened coffee was associated with lower mortality in an observational study.“

Comment:

“Associations between coffee consumption and mortality surely are confounded by numerous factors. If there is really a causal protective link, it might be related to coffee’s chlorogenic acids, which — in addition to caffeine — have an antioxidant effect and inhibit platelet aggregation, as an editorialist notes. A study limitation is that, on average, only 4 g of sugar were added to sweetened coffee (likely less than many Americans add). Nevertheless, this study reaffirms that even sweetened coffee is likely not harmful and might even be beneficial.”

Dressler DD. Coffee and Mortality: Sweetening the Pot NEJM Journal Watch. (June 16, 2022)

Citations:

Liu D et al. Association of sugar-sweetened, artificially sweetened, and unsweetened coffee consumption with all-cause and cause-specific mortality: A large prospective cohort study. Ann Intern Med 2022 May 31

Wee CC. The potential health benefit of coffee: Does a spoonful of sugar make it all go away? Ann Intern Med 2022 May 31

_____________________________________

“Two studies confirm an association between coffee intake and lower risk for death in diverse populations.”

Comment:

“These studies provide support that moderate coffee intake (2–5 cups daily) is safe and associated with reduced risk for death, probably in a dose-dependent fashion. If you’re still debating the health benefits of coffee for your patients, you may want to do it over a cup of joe.”

Dressler DD. Moderate Coffee Consumption and Mortality: Good News NEJM Journal Watch. (July 11, 2017)

Citations

Park S-Y et al. Association of coffee consumption with total and cause-specific mortality among nonwhite populations. Ann Intern Med 2017 Jul 11; [e-pub].

Gunter MJ et al. Coffee drinking and mortality in 10 European countries: A multinational cohort study. Ann Intern Med 2017 Jul 11; [e-pub].

Guallar E et al. Moderate coffee intake can be part of a healthy diet. Ann Intern Med 2017 Jul 11; [e-pub].

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NEJM Journal Watch: Physician Attire: Is All Dress Created Equal (in Patients’ Eyes)? / Physicians Attire — Does It Matter to Patients?

Patients prefer formal attire with white coat for their primary care and hospital-based physicians.

Comment: “This is the largest study of U.S. patient preferences for physician attire and the only one that addresses both inpatient and outpatient physicians’ attire. Findings make a statement on how attire might affect patient satisfaction — now measured and reported by healthcare institutions — and could have implications for dress codes or guidelines based on clinical settings and physician practices.”

Dressler DD. Physician Attire: Is All Dress Created Equal (in Patients’ Eyes)? NEJM Journal Watch. (July 3, 2018)

Citation:

Petrilli CM et al. Understanding patient preference for physician attire: A cross-sectional observational study of 10 academic medical centres in the USA. BMJ Open 2018 May 29.

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In a survey, white coats were rated more highly than other attire; women were rated as less professional than men, regardless of attire.

Scwenk TL. Physicians Attire — Does It Matter to Patients?. NEJM Journal Watch. (Aug 10, 2021).

Comment: “Isolating patient assessments of physicians based solely on pictures of attire obviously does not capture the nature of a physician’s demeanor or communication skills, but this study and another similar one suggest there is something about white coats that has meaning for patients. This study also reinforces the known and unfortunately persistent sex bias that causes patients to discount the role and experience of female physicians.”

Citation:

Xun H et al. Public perceptions of physician attire and professionalism in the US. JAMA Netw Open 2021 Jul 30.

EUH Morning Report:What is the approach to managing the patient with alcohol withdrawal syndrome?

The Bottom Line:

Gottlieb

“A sudden decrease in serum alcohol concentrations can result in alcohol withdrawal syndrome symptoms within 6 to 8 hours, typically peaking at 72 hours and diminishing by 5 to 7 days. These signs and symptoms can be vague, including anxiety, tremors, headache, nausea/vomiting, diaphoresis, or palpitations, which can progress to delirium tremens. If initial alcohol withdrawal syndrome symptoms do not progress to a more severe stage, they will often resolve within 48 hours.” (Gottlieb)

Midtown Morning Report: What is the approach to the patient with cholecystitis?

The Bottom Line: “Acute cholecystitis must be differentiated from other diseases that cause right upper quadrant abdominal pain and nausea or vomiting, such as biliary colic and acute cholangitis.” “Acute cholangitis is defined by fever, jaundice, and right upper quadrant pain with the ultrasound revealing dilated intra-hepatic and extrahepatic biliary ducts. Other diagnoses to consider in a patient presenting with symptoms of acute cholecystitis include acute gastritis, peptic ulcer disease, hiatal hernia, acute pancreatitis, acute viral hepatitis, acute appendicitis, and myocardial infarction.” “Acute, complicated cholecystitis is defined as cholecystitis with the presence of either gallbladder necrosis, perforation, pericholecystic abscess, or cholecystoenteric fistula. Patients with these complications are at higher risk for adverse outcomes after cholecystectomy. Even though antibiotic therapy should be initiated at the time of presentation, nonoperative management is not appropriate for these patients because antibiotics will be inadequate in the setting of necrotic tissue or abscess.” (Gallaher)

Gallaher

EUH Morning Report: What is the reliability of the physical examination of the chest and accuracy of findings for diagnosing pleural effusion?

The Bottom Line: The interobserver reliability of the physical examination of the chest in patients with respiratory conditions has been found to be relatively low (Metlay). But the physical examination can be used to gain diagnostic certainty with pulmonary effusion, specifically the findings of dullness to percussion and asymmetric chest expansion, and confirmed with a chest radiograph (Wong).

“The calculated interobserver reliability among the physicians for several chest signs…  presented in the form of both mean pair observer agreement rates and κ values, which account for rates of chance agreement ranging from 0, when agreement is no better than chance, to 1, when there is perfect agreement. In fact, 2 of the most reliable findings, dullness to percussion and wheezes on auscultation, had only fair to good κ values of 0.52 and 0.51, corresponding to agreement rates of 77% and 79%, respectively. Crackles had a κ value of 0.41 (agreement rate of 72%), and several findings such as whispered pectoriloquy and increased tactile fremitus had κ values indicating poor agreement (range, 0.01-0.11), in part explained by the rarity of these findings overall.” (Matley)

(Matley)

“Of the 8 physical examination maneuvers, the presence of dullness to conventional percussion (summary positive LR, 8.7; 95% CI, 2.2-34) and asymmetric chest expansion (positive LR, 8.1; 95% CI, 5.2-13) were most accurate in diagnosing pleural effusion. The diagnostic OR of the 2 studies that compared conventional percussion (summary diagnostic OR, 34; 95% CI, 16-72) with auscultatory percussion (summary diagnostic OR, 8.1; 95% CI, 4.7-14.0) favored conventional percussion. The extremely low negative LR for auscultatory percussion popularized by Guarino (negative LR, 0.05; 95% CI, 0.02-0.11) has not been replicated in other studies (negative LR range, 0.50-1.0).” (Wong)

Midtown Morning Report: What is the differential for foot drop?

The Bottom Line:     Differential Diagnosis of foot drop

• Upper motor neuron involvement – CVA can cause weakness of the whole extremity. Due to spasticity, the limb is artificially long. To ambulate, the person rotates the leg in a semicircular fashion, also referred to as circumduction. Dysphagia, aphasia, or upper limb weakness are also evident.
• Cerebellar gait – The cerebellum is responsible for the smoothness and balance of gait. Cerebellar gait deficits are seen as ataxia and failure to walk in tandem.
• Ataxic gait – Presentation is bilateral. Due to the involvement of long tracks of the spinal cord, position and vibration senses are lost. This leads to high steppage and side to side sway, as can be seen in alcohol use disorder.
• Severe L5 lumbar radiculopathy
• Parkinsonian gait – Involvement of substantia nigra causes failure of the smooth transition of the gait cycle leading to initiation problems coupled with short and fast steps called festinate gait.
• Lumbar plexus involvement such as autoimmune, compressive-tumor,
• Diabetic amyotrophy
• Conversion reaction, somatization disorder, and malingering should be considered if the workup is unremarkable, and there is potential for substantial secondary gain, depression, anxiety, or other suspected psychological issues. (Nori)

Carolus

EUH Morning Report: Review of Mitochondrial Diseases

The Bottom Line: “Most diagnostic algorithms [for mitochondrial diseases] recommend evaluation of selected mitochondrial biomarkers in blood, urine, and spinal fluid. These typically include measurements of lactate and pyruvate in plasma and cerebrospinal fluid (CSF), plasma, urine, and CSF amino acids, plasma acylcarnitines, and urine organic acids.” (Parikh)

“The key to any successful diagnostic algorithm for mitochondrial diseases is astute clinical observation and awareness. The recognition of mitochondrial disease syndromes or specific clinical features can permit targeted genetic analysis, which enables the rapid diagnosis of patients and family members. For example, cardiomyopathy and cataracts are frequently associated with AGK mutations (Sengers syndrome). Equally, detailed clinical and laboratory tests are vital for the accurate interpretation of new genetic mutations that are identified through next generation sequencing technologies. The diagnostic algorithm is heavily influenced by the age of the patient, and the presence of consanguinity and common genetic founder mutations in certain parts of the world.” (Gorman)

(Gorman)

EUH Morning Report: What are the diagnostic accuracy of the Kernig and Brudzinski sings for diagnosing adult meningitis? Part 2

The Bottom Line: “In the broad spectrum of adults with suspected meningitis, 3 classic meningeal signs did not have diagnostic value; better bedside diagnostic signs are needed.” (Thomas)

See Part 1 on the Kernig and Brudzinski signs: https://emorymedicine.wordpress.com/2024/03/14/euh-morning-report-what-are-the-sensitivity-and-specificity-of-the-kernig-and-brudzinski-sings-for-diagnosing-adult-meningitis/

Thomas et. al’s prospective study found that “the 3 classic meningeal signs—Kernig’s sign, Brudzinski’s sign, and nuchal rigidity—were of limited clinical diagnostic value for adults with suspected meningitis. None of these meningeal signs were able to accurately discriminate patients with meningitis (⩾6 WBCs/mL of CSF) from those without it. Furthermore, no significant correlation existed between these meningeal signs and moderate meningeal inflammation (⩾100 WBCs/mL of CSF) or between these meningeal signs and microbiological evidence of CSF infection. Only for the 4 patients with severe meningeal inflammation (⩾1000 WBCs/mL of CSF) did nuchal rigidity have 100% sensitivity, 100% negative predictive value, and LR+ : LR- that approached infinity.” (Thomas)

“The sensitivity of both Kernig’s sign and Brudzinski’s sign was 5%, which suggests that these bedside diagnostic tools did not reliably identify the need for lumbar puncture among patients with meningitis. Although the specificity of both signs was 95%, the high specificity values were a result of the overall paucity of positive results of examination for Kernig’s sign and Brudzinski’s sign, rather than a reflection of the discriminating ability of these indicators. The positive and negative predictive values for Kernig’s sign (27% and 72%, respectively), Brudzinski’s sign (27% and 72%, respectively), and nuchal rigidity (26% and 73%, respectively) also indicate that none of the classic meningeal signs were clinically discriminating indicators of the presence or absence of meningitis” (Thomas)

(Thomas)

EUH Morning Report: What are the important clinical features for diagnosing the different types of inflammatory myopathies?

The Bottom Line: “Idiopathic inflammatory myopathy (IIM) includes dermatomyositis (DM), polymyositis (PM), overlap myositis (OM), sporadic inclusion body myositis (IBM) and necrotising autoimmune myopathy (NAM), also known as immune-mediated necrotising myopathy. DM, OM and NAM all present similarly, with proximal weakness and elevated creatine kinase (CK) level. By contrast, IBM preferentially involves the long finger flexors and quadriceps, and presents with a normal or only mildly elevated CK. Developments in serological testing and imaging are shifting the diagnostic paradigm away from a reliance on histopathology.” (Ashton)

“There is some debate as to whether PM exists as a discrete entity, or is an ill-defined condition encompassing connective tissue disease (CTD) associated myositis, or OM, and the previously poorly recognised NAM” (Ashton)

(Greenberg & Amato)

“Epidemiologic studies suggest that the incidence of IM grouped together is >4 cases per 100,000 with prevalence in the range of 14–32 per 100,000. Defining the actual incidence and prevalence of the individual myositides is limited, however, by the different diagnostic criteria employed in various epidemiologic studies, increasing recognition of AS, and frequent misdiagnosis of IBM and IMNM. Idiopathic PM without signs of an overlap syndrome is quite rare, while DM, IBM, and IMNM occur in roughly similar frequencies. DM can occur in children (juvenile DM), while IBM always occurs in adults and is the most common cause of myopathy in those aged >50. DM, PM, and AS are more common in women, while IBM is more common in men.” (Greenberg & Amato)

EUH Morning Report: What are the criteria for a patient with a stroke to receive a thrombectomy?

The Bottom Line: “Endovascular therapy (particularly mechanical thrombectomy with stent retriever) is a treatment option to achieve reperfusion in adults with functionally disabling acute ischemic stroke up to 24 hours after stroke onset. Eligibility includes large vessel occlusion on imaging and expected favorable outcomes after reperfusion if ≤ 6 hours after stroke onset or if there is evidence of salvageable brain tissue if 6-24 hours after onset.” (Dynamed)

From the Guidelines for the Early Management of Patients With Acute Ischemic Stroke from the American Heart Association and American Stroke Association (Powers):

“3.7.2. 0 to 6 Hours From Onset

1. Patients should receive mechanical thrombectomy with a stent retriever if they meet all the following criteria: (1) prestroke mRS score of 0 to 1; (2) causative occlusion of the internal carotid artery or MCA segment 1 (M1); (3) age≥18 years; (4) NIHSS score of≥6; (5) ASPECTS of≥6; and (6) treatment can be initiated (groin puncture) within 6 hours of symptom onset
2. Direct aspiration thrombectomy as first-pass mechanical thrombectomy is recommended as noninferior to stent retriever for patients who meet all the following criteria: (1) prestroke mRS score of 0 to 1; (2) causative occlusion of the internal carotid artery or M1; (3) age ≥18 years; (4) NIHSS score of ≥6; (5) ASPECTS ≥6; and (6) treatment initiation (groin puncture) within 6 hours of symptom onset.
3. Although the benefits are uncertain, the use of mechanical thrombectomy with stent retrievers may be reasonable for carefully selected patients with AIS in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have causative occlusion of the MCA segment 2 (M2) or MCA segment 3 (M3) portion of the MCAs.
4. Although its benefits are uncertain, the use of mechanical thrombectomy with stent retrievers may be reasonable for patients with AIS in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have prestroke mRS score >1, ASPECTS<6, or NIHSS score <6, and causative occlusion of the internal carotid artery (ICA) or proximal MCA (M1)
5.  Although the benefits are uncertain, the use of mechanical thrombectomy with stent retrievers may be reasonable for carefully selected patients with AIS in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have causative occlusion of the anterior cerebral arteries, vertebral arteries, basilar artery, or posterior cerebral arteries.

3.7.3. 6 to 24 Hours From Onset:

1. In selected patients with AIS within 6 to 16 hours of last known normal who have LVO in the anterior circulation and meet other DAWN or DEFUSE 3 eligibility criteria, mechanical thrombectomy is recommended.
2.  In selected patients with AIS within 16 to 24 hours of last known normal who have LVO in the anterior circulation and meet other DAWN eligibility criteria, mechanical thrombectomy is reasonable” 

(Summary of criteria in Powers from Ganesh)

EUH Morning Report: What are the ECG changes in hypokalemia?

The Bottom Line: “Although the ECG findings are more subtle in the case of hypokalemia compared to hyperkalemia, it is important that clinicians are alert to these. ECG changes in hypokalemia include increased amplitude of P-waves, prolonged PR interval, prolonged QT-interval, ST-segment depression and appearance of pathologic U-waves or bifid T-waves. The understanding of ECG changes in electrolyte disturbances is important both in the diagnosis and implementation of timely and appropriate treatment to these patients.” (Khan)

Khan

EUH Morning Report: What are the diagnostic criteria and treatment for thyroid storm?

The Bottom Line: “Thyroid storm is diagnosed as a combination of thyroid function studies showing low to undetectable thyroid stimulating hormone (TSH) (<0.01mU/L) with elevated free thyroxine (T4) and/or triiodothyronine (T3), positive thyroid receptor antibody (TRab) (if Graves’ disease is the underlying etiology), and with clinical signs and symptoms of end organ damage. Treatment involves bridging to a euthyroid state prior to total thyroidectomy or radioactive iodine ablation to limit surgical complications such as excessive bleeding from highly vascular hyperthyroid tissue or exacerbation of thyrotoxicosis.” (De Almeida)

“The diagnosis of thyroid storm should be made clinically in a severely thyrotoxic patient with evidence of systemic decompensation. Adjunctive use of a sensitive diagnostic system should be considered. Patients with a Burch– Wartofsky Point Scale (BWPS) of ‡45 or Japanese Thyroid Association ( JTA) categories of thyroid storm 1 (TS1) or thyroid storm 2 (TS2) with evidence of systemic decompensation require aggressive therapy. The decision to use aggressive therapy in patients with a BWPS of 25–44 should be based on clinical judgment.” (Ross)

(Ross)