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 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)

Midtown Morning Report: What is the association of bactrim induced hemolysis in the setting of G6PD deficiency?

The Bottom Line: “Drug-induced immune hemolytic anemia is a rare occurrence that results from drug-induced antibodies. A DAT result is positive in patients with this condition.  The progression of the condition is typically gradual, and treatment involves removal of the offending agent.” (Phillips)

Phillips

EUH Morning Report: Should physicians consider patients in or formerly in the military with occupational exposure to radar higher risk for hemolymphatic cancers?

The Bottom Line: Though there is a possible connection supported by some case reports and a few retrospective cohort studies, a definitive causation of military occupational exposure to radar with hemolymphatic and other cancers has not been established. However, physicians can still consider hemolymphatic cancer in their differential diagnosis if they know their patient has had occupational exposure to radar.

In their retrospective cohort study of a previously published case series of 47 patients diagnosed with cancer following years of occupational exposure to radiofrequency radiation (RFR), Peleg (2018) found “the consistent association of RFR and highly elevated HL cancer risk in the four groups spread over three countries, operating different RFR equipment types and analyzed by different research protocols, suggests a cause-effect relationship between RFR and HL cancers in military/occupational settings.”

In 2023, Peleg et. al published a second study analyzing data from a new case series of 46 patients diagnosed with cancer that had exposure to radar in a military setting and comparing them with similar groups from other studies, finding “a consistent, statistically significant, and well-documented atypically high HL PF, distinctly higher than expected in the community (Cancer Registry) or computed from unexposed comparison groups.”

(Peleg)

EUH Morning Report: What are the Helpful Clinical Findings from the Physical Examination for Detecting Heart Failure?

The Bottom Line: “Patients with symptoms of heart failure and those with risk factors should be examined for pulmonary rales, jugular venous distention, a third heart sound, and peripheral edema and should have an ECG and chest radiograph” (Badgett)

“Very helpful findings [for detection of heart failure] are radiographic redistribution and jugular venous distention. These findings, when used alone, only help when they are abnormal and so can confirm the presence of increased filling pressure in patients with known severe systolic dysfunction. Among patients referred for consideration of cardiac transplant with a high (73%) prevalence of increased filling pressure, radiographic redistribution indicates an 80% to 90% probability and jugular venous distention, an85% to 100% probability of increased filling pressure. The absence of either finding cannot rule out increased filling pressure. In patients with lesser probabilities of increased filling pressure, such as those without known severe systolic dysfunction, isolated findings may not be useful. Somewhat helpful findings include dyspnea and abnormal vital signs. Radiographic cardiomegaly is somewhat helpful but loses its specificity after the initial detection of increased filling pressure because it can be a permanent finding and not fluctuate with changes in filling pressure. Dependent edema is helpful only when present. Edema is highly specific for increased filling pressure, although it has poor sensitivity.” (Badgett)

(Badgett)

“Patients with heart failure can have decreased exercise tolerance with dyspnea, fatigue, generalized weakness, and fluid retention, with peripheral or abdominal swelling and possibly orthopnea. Patient history and physical examination are useful to evaluate for alternative or reversible causes. Nearly all patients with heart failure have dyspnea on exertion. However, heart failure accounts for only 30 percent of the causes of dyspnea in the primary care setting. The absence of dyspnea on exertion only slightly decreases the probability of systolic heart failure, and the presence of orthopnea or paroxysmal nocturnal dyspnea has a small effect in increasing the probability of heart failure (positive likelihood ratio [LR+] = 2.2 and 2.6).” (King)

EUH Morning Report: What are the recommendations for antifungal therapy for catheter line infections?

The Bottom Line: “Antifungal therapy is recommended for all cases of [catheter-related bloodstream infection] CRBSI due to Candida species, including cases in which clinical manifestations of infection and/or candidemia resolve after catheter withdrawal and before initiation of antifungal therapy” (Mermel)

“Fluconazole administered at a dosage of 400 mg daily for 14 days after the first negative blood culture result is obtained is equivalent to amphotericin B in the treatment of candidemia caused by Candida albicans and azole-susceptible strains [184]. For Candida species with decreased susceptibility to azoles (e.g., C. glabrata and C. krusei), echinocandins (caspofungin administered with a 70-mg intravenous loading dose, followed by 50 mg daily administered intravenously; micafungin at a dosage of 100 mg daily administered intravenously or anidulafungin with a 200-mg intravenous loading dose followed by 100 mg daily administered intravenously) or lipid formulations of amphotericin B (ambisome or amphotericin B lipid complex) administered intravenously at a dosage of 3–5 mg/kg daily are highly effective [185–187]. Conventional amphotericin B therapy is also effective but is associated with more adverse effects.” (Mermel)

“The administration of appropriate antimicrobial treatment more than 12 h after the first positive blood sample for culture is drawn is associated, at least by multivariable analysis, with hospital mortality. This underscores the clinical importance of providing early appropriate treatment to patients with fungal bloodstream infections. Future studies are needed to define the optimal strategy for the empiric treatment of fungal bloodstream infections. Until such data become available, clinicians may consider the use of empiric antifungal therapy in patients at high risk for this infection to avoid delays in treatment.” (Morrell)

(Morrell)

Midtown Morning Report: What are the outcomes for treating Streptococcus pneumoniae meningitis with steroids?

The Bottom Line: “An analysis for different bacteria causing meningitis showed that patients with meningitis due to Streptococcus pneumoniae (S pneumoniae) treated with corticosteroids had a lower death rate (29.9% versus 36.0%.”
“Subgroup analyses for causative organisms showed that corticosteroids reduced mortality in Streptococcus pneumoniae (S pneumoniae) meningitis (RR 0.84, 95% CI 0.72 to 0.98.” (Brouwer)

Huppert