Karna K. Sundsted

Preanesthesia medical evaluation for electroconvulsive therapy: A review of the literature

Objective Electroconvulsive therapy (ECT) is widely used for the treatment of psychiatric disorders, yet there is few published literature to guide the practitioner in the preprocedural evaluation of patients. Based on a review of the literature, we sought to develop a concise, algorithmic approach to be used when evaluating patients for ECT, including those with underlying conditions, such as cardiovascular and neurological disorders. Methods The databases of Ovid MEDLINE, PubMed, the Web of Knowledge, and PsychINFO were searched from January 2000 through December 2011. All abstracts were reviewed for relevancy to preprocedural ECT evaluation, and full articles of selected abstracts were reviewed in full, along with bibliographies of each. Algorithms were then constructed using the clinical information obtained from the selected articles. Results Our review of the literature located 275 articles using the search criteria. After review, 38 articles were selected. A total of 167 articles were excluded because they did not pertain to medical comorbidities in patients undergoing ECT, and an additional 70 were excluded because they did not pertain to ECT. Bibliography review of the selected articles located an additional 10 articles. Conclusions Although ECT is generally a safe and effective therapy, some patient subgroups, such as those with certain cardiac conditions or history of cerebrovascular disease, require additional evaluation or, rarely, postponement of ECT. Chronic medical conditions should be optimized before undergoing ECT. Most patient populations are able to undergo ECT safely and effectively.

Update in General Internal Medicine: Evidence Published in 2016

Three general internists reviewed articles from the 2016 issues of 7 general internal medicine journals with high impact factors: New England Journal of Medicine, The Lancet, JAMA, BMJ, Annals of Internal Medicine, JAMA Internal Medicine, and PLoS Medicine. Two other internists identified articles by reviewing 2016 editions of ACP Journal Club, NEJM Journal Watch, Evidence Updates (now called Evidence Alerts), the BMJ database Evidence Based Medicine, and the Cochrane Database of Systematic Reviews. We used a modified Delphi method to select 8 studies on the basis of their clinical impact, relevance to everyday practice, strength of evidence, and breadth of application. The articles we selected compare strategies for smoking cessation, define when to use aspirin for primary prevention, offer guidelines for the management of patients receiving long-term opioids, determine whether acetaminophen is effective for treating low back pain, evaluate the role of oxygen in patients with chronic obstructive pulmonary disease (COPD), examine the association between proton-pump inhibitors (PPIs) and chronic kidney disease (CKD), assess how the route of estrogen replacement affects the risk for ischemic stroke in postmenopausal women, and compare the bleeding risks associated with different anticoagulants. Preventive Health Smokers Who Quit Abruptly Are More Likely to Achieve Abstinence Than Smokers Who Quit Gradually Lindson-Hawley N Banting M West R et al Gradual versus abrupt smoking cessation: a randomized, controlled noninferiority trial. Ann Intern Med 2016 164 585 92 26975007 Background: Some smokers who want to quit smoking prefer gradual reduction to abrupt cessation. Prior research comparing gradual reduction with abrupt cessation has yielded conflicting results. A 2012 Cochrane meta-analysis demonstrated no difference between cessation methods (1), whereas an observational study suggested that abrupt cessation was more effective than gradual reduction (2). Thus, whether smoking cessation through gradual reduction is as effective as abrupt cessation is unclear. This randomized, controlled study was done to determine whether abstinence rates achieved through gradual smoking reduction were noninferior to abstinence rates achieved through abrupt cessation at 4 weeks (the primary end point) and 6 months. Findings: Smokers in England (n= 697; mean age, 49 years; 50% male) were randomly assigned to quit smoking abruptly or to quit smoking gradually. The gradual cessation group reduced cigarette use by 50% by the end of 1 week and 75% by the end of 2 weeks, and then quit. Both groups used a 21-mg patch for nicotine replacement therapy. The gradual cessation group used patches before and after the quit date, whereas the abrupt cessation group used patches only after the quit date. Both groups received weekly behavioral support for 4 weeks after the quit date and then again at 8 weeks. At 4 weeks, 39% of the participants in the gradual cessation group and 49% in the abrupt cessation group were abstinent (relative risk, 0.80 [95% CI, 0.66 to 0.93]). At 6 months, 16% of the gradual cessation group and 22% of the abrupt cessation group were abstinent (relative risk, 0.71 [CI, 0.46 to 0.91]). Participants who were more interested in quitting abruptly at baseline were more likely to be abstinent at 4 weeks regardless of whether they had been assigned to the abrupt cessation group or the gradual cessation group. Cautions: The study was unblinded. Ninety-four percent of participants were white. The behavioral support that participants received may not be widely available and may be necessary to achieve these high quit rates. Implications: Clinicians can advise patients interested in smoking cessation that compared with quitting gradually, quitting abruptly is more likely to lead to abstinence at 4 weeks and 6 months. Low-Dose Aspirin Is Modestly Beneficial for Primary Prevention of Cardiovascular Events and Colorectal Cancer Bibbins-Domingo K; U.S. Preventive Services Task Force. Aspirin use for the primary prevention of cardiovascular disease and colorectal cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2016;164:836-45. [PMID: 27064677] doi:10.7326/M16-0577 Bibbins-Domingo K U.S. Preventive Services Task Force Aspirin use for the primary prevention of cardiovascular disease and colorectal cancer: U.S. Preventive Services Task Force recommendation statement Ann Intern Med 2016 164 836 45 27064677 Background: Aspirin is beneficial for secondary prevention of cardiovascular disease, but its role in primary prevention of cardiovascular disease and colorectal cancer is uncertain. Findings: Three systematic reviews (35) by the U.S. Preventive Services Task Force (USPSTF) support the following recommendations. Aspirin is recommended for primary prevention in some people with a risk for cardiovascular disease exceeding 10% (6), average bleeding risk, a life expectancy of 10 years or more, and a willingness to take daily low-dose aspirin for at least 10 years. For people aged 50 to 59 years, the USPSTF recommends aspirin for the primary prevention of myocardial infarction, ischemic stroke, and colorectal cancer, because the moderate, combined benefit of preventing these conditions outweighs the small risk for bleeding. For people aged 60 to 69 years, the USPSTF recommends individualizing the decision to use aspirin for primary prevention of these conditions because the combined benefit outweighs the risk by a smaller amount. For people younger than 50 years and those aged 70 years or older, evidence is insufficient to support any recommendation for aspirin as primary prevention of cardiovascular disease, and thus there is no recommendation for aspirin as primary prevention of the combined conditions. In addition, the guidelines do not recommend using aspirin only for primary prevention of colorectal cancer. The systematic reviews showed that aspirin reduced nonfatal myocardial infarction by 22%, with no consistent reduction in nonfatal stroke (except for the Womens Health Study, which reported a 19% reduction in nonfatal stroke). The pooled estimates for mortality from cardiovascular disease and mortality from all other causes showed only minimal or no benefit from aspirin. The incidence of and mortality from colorectal cancer were similar in people who did and did not take aspirin for 10 or fewer years. In contrast, for people who took aspirin for more than 10 years, it reduced colorectal cancer incidence by 40%, and after 20 years, it reduced colorectal cancer mortality by 33%. Even with low doses, the risk for major gastrointestinal bleeding increased by 58%, but the absolute bleeding risk varied. Older age, male sex, use of concomitant medications, and a history of ulcers or gastrointestinal bleeding increased the risk for bleeding. Some studies also reported an increased risk for hemorrhagic stroke. Cautions: The optimal dose of aspirin is not known. The USPSTF supports the use of 81 mg/d, but trials have included dosages from 75 mg/d to 325 mg/d. Implications: The decision to use aspirin for the primary prevention of cardiovascular events and colorectal cancer is most beneficial in patients aged 50 to 59 years who have a 10% or greater risk for cardiovascular disease during the next 10 years. Aspirin seems to reduce the incidence of colorectal cancer after 10 years and to reduce mortality from colorectal cancer after 20 years, but its use is not recommended for the primary prevention of colorectal cancer alone because the benefits do not outweigh the harms. Treatment of Common Disorders in Internal Medicine CDC Provides Recommendations on Prescribing Opioids for Chronic Pain Not Secondary to Cancer, Palliation, or End-of-Life Care Dowell D Haegerich TM Chou R CDC Guideline for prescribing opioids for chronic painUnited States, 2016. JAMA 2016 315 1624 45 26977696 Background: Prescription opioid overdose led to more than 20000 deaths in 2015, and an additional 2.1 million Americans were addicted to these medications (7). Despite these problems, opioids continue to be widely prescribed to treat the estimated 25.3 million Americans with chronic pain (8). To address these issues, the Centers for Disease Control and Prevention (CDC) updated its 2014 systematic review and released guidelines for primary care clinicians to use when prescribing opioids to patients with chronic pain unrelated to cancer, palliation, or end-of-life care. Findings: The CDC recommends assessment of the following 3 areas: risk and benefit when opioids are being started or continued, short-term and long-term effectiveness to guide decisions about dose adjustment and discontinuation, and misuse and harm in combination with risk mitigation. The CDC released 12 recommendations. The primary recommendation is to treat chronic pain with nonopioid therapies. Opioids should be prescribed only when benefits exceed risks. Benefits and risks should be reassessed within days of starting opioids to ensure that pain and function have improved. If opioids are continued, risks and benefits should be reassessed at least every 3 months. Reassessments should include a review of records for all prescribers if the state has a comprehensive drug-monitoring program to identify additional sources of opioids and other drugs that might complicate opioid use. Only immediate-release opioids should be prescribed initially, prescribers should reassess benefits and risks before prescribing more than 50 morphine milligram equivalents per day, and they should avoid prescribing more than 90 morphine milligram equivalents per day. Prescribers should consider naloxone coprescriptions to treat overdose, and they should offer treatment when an opioid use disorder is identified. Cautions: These guidelines apply to primary care clinicians who are caring for patients with chronic pain that is not related to cancer, palliation, or end-of-life care. Implications: P

Primary Care Physicians Practicing Preventive Medicine in the Outpatient Setting

Background: Preventive care is an important part of primary care medicine, yet much variation in its practice exists. The aim of this study is to assess physicians’ perspectives of practicing preventive medicine and evaluate which topics are deemed most important. Methods: All primary care medicine providers at two separate academic medical centers (Mayo Clinic, MN and Mayo Clinic, FL) were surveyed via an E-mail questionnaire assessing physicians’ perception of the role of preventive medicine during both acute/routine and yearly visits, physicians’ perception of patients’ response to preventive medicine topics, and which preventive medicine topics are commonly practiced. Results: Of 445 providers meeting inclusion criteria, a total of 183 (41.1%) responded. Providers were more likely to engage patients in preventive medicine during yearly visits more so than acute visits (3.82 vs. 4.72, range 1–5 Likert Scale), yet providers were very likely to partake in such practices during both visits. Providers perceived that patients received the practice of preventive medicine very well (4.13 on 1–5 Likert Scale). No significant difference between provider practice and patient perception was noted between the two sites, although there was some variation based on clinical experience of the provider. Providers were found to most commonly practice topics recommended by the United States Preventive Services Task Force. Conclusions: Our study found a high predisposition to practicing preventive medicine. Providers seem to practice according to published evidence-based medicine recommendations.

Update in perioperative medicine: practice-changing evidence published in 2015

ABSTRACT Evidence in perioperative medicine is published in a wide variety of journals, given the multidisciplinary nature of its practice which spans medicine and its subspecialties, as well as surgery and anesthesiology. It can be difficult to identify new and important evidence, as perioperative practice continues to evolve in multiple areas such as medication management, anticoagulation and cardiac risk stratification, among others. New, high-quality evidence is published each year, and must be placed into the context of not only existing literature, but also practical real-world patient care. We sought to systematically identify, critically evaluate and concisely summarize the practice implications of 10 articles published in 2015 for the practicing perioperative clinician.

79-Year-Old Woman With Jaundice and Anemia

Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN (M.T.); Resident in Clinical Pathology, Brigham and Women’s Hospital, Boston, MA (J.L.D.); Advisor to residents and Consultant in General Internal Medicine, Mayo Clinic, Rochester, MN (K.K.S.). A 79-year-old woman was referred by her primary care physician to the emergency department for evaluation and management of a 2-week history of jaundice, bilateral leg edema, and increased dyspnea. A complete blood count (CBC) obtained by her primary care physician was remarkable (reference ranges provided parenthetically) for a hemoglobin level of 5.8 g/dL (12.0-15.5 g/dL), which had decreased from 11.0 g/dL 4 months before presentation. She reported a 2-month history of intermittent right upper-quadrant pain, generalized weakness, fatigue, increased urinary frequency, decreased appetite, and subjective fevers and chills. She described dark-colored urine that began 2 days before her admission and progressive back and hip pain during the preceding year. Review of systems was negative for hemoptysis, melena, and hematochezia. She reported that she had had no sick contacts, recent travel, or recent illnesses. She had no history of venous thromboembolism, personal or family history of hematologic or autoimmune diseases, Raynaud’s phenomenon, or association of her symptoms with coldtemperature exposure. Her medical history was notable for severe chronic obstructive pulmonary disease, chronic hypoxia on home oxygen, history of transient ischemic attack, coronary artery disease, myocardial infarction with coronary stent placed 15 years earlier, hypertension, and hypothyroidism. Medications at the time of presentation included albuterol, apixaban, levothyroxine, lisinopril, furosemide, metoprolol, and simvastatin. She was not on any known nonprescription medications or supplements. On admission, her blood pressure was 143/ 48 mm Hg; heart rate, 78 beats per min; temperature, 36.8 C (oral); and respiratory rate, 21 breaths/min. Her SpO2 fluctuated between 85% and 95% on 3 L/min via nasal cannula.

Update in Outpatient General Internal Medicine: Practice-changing Evidence Published in 2014

Identifying new practice-changing articles is challenging. To determine the 2015 practice-changing articles most relevant to outpatient general internal medicine, 3 internists independently reviewed the titles and abstracts of original articles, synopses of single studies and syntheses, and databases of syntheses. For original articles, internal medicine journals with the 7 highest impact factors were reviewed: New England Journal of Medicine, Lancet, Journal of the American Medical Association (JAMA), British Medical Journal, Public Library of Science Medicine, Annals of Internal Medicine, and JAMA Internal Medicine. For synopses of single studies and syntheses, collections in American College of Physicians Journal Club, Journal Watch, and Evidence-Based Medicine were reviewed. For databases of synthesis, Evidence Updates and the Cochrane Library were reviewed. More than 100 articles were identified. Criteria for inclusion were as follows: clinical relevance, potential for practice change, and strength of evidence. Clusters of important articles around one topic were considered as a single-candidate series. The 5 authors used a modified Delphi method to reach consensus on inclusion of 7 topics for in-depth appraisal.

Update in Perioperative Medicine: Evidence Published in 2014

This summary highlights 9 key articles in perioperative medicine published in 2014. To identify these articles, we searched PubMed by using the keywords perioperative or preoperative or postoperative or noncardiac surgery (NCS) and limiting the search to a publication date of 2014, human study subjects, and English language. We then screened the 14771 resulting abstracts. In addition, we used ACP JournalWise to identify high-quality, clinically relevant publications related to perioperative care. Fifty-six unique full-text articles were considered for inclusion. In selecting the 9 articles to highlight, we used the predetermined criteria of clinical relevance to internal medicine physicians, potential for practice change, and strength of the evidence. We gave priority to practice guidelines or meta-analyses that addressed clinical questions important to perioperative care. The selected represent topic areas ranging from perioperative cardiac and pulmonary medicine to venous thromboembolism prophylaxis and medication management. Perioperative Cardiac Medicine Updated Guideline on Perioperative Cardiovascular Evaluation Fleisher LA Fleischmann KE Auerbach AD et al 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol 2014 64 e77 137 25091544 Background: The American College of Cardiology (ACC)/American Heart Association (AHA) guideline provides evidence- and expert opinionbased recommendations for preoperative risk assessment, cardiovascular testing, perioperative pharmacologic management, timing of surgery after percutaneous intervention, and perioperative monitoring of patients with (or at risk for) cardiovascular disease who undergo NCS. Findings: The guideline recommends an algorithmic approach to preoperative cardiac risk assessment to help determine whether cardiac stress testing is indicated. The suggested algorithm incorporates 1) surgical urgency, 2) presence of acute coronary syndromes, 3) combined clinical and surgery-specific risk for major adverse cardiac events (as determined by using the American College of Surgeons National Surgical Quality Improvement Program calculator [1] or the Revised Cardiac Risk Index [RCRI] [2, 3]), and 4) functional capacity in metabolic equivalents. For nonlow-risk surgical procedures, electrocardiography (ECG) is reasonable in patients with coronary or peripheral artery disease, arrhythmia, cerebrovascular disease, or structural heart disease, and preoperative assessment of left ventricular function is reasonable in patients with dyspnea or unstable heart failure symptoms. Coronary revascularization before NCS is recommended only if indicated outside of the surgical context and not exclusively to reduce perioperative risk. Optimal delays in surgery are 1 year after placement of a drug-eluting stent, 30 days after placement of a bare-metal stent, and 14 days after balloon angioplasty, to allow uninterrupted dual-antiplatelet therapy. Dual-antiplatelet therapy should be continued in patients undergoing urgent NCS during the first 4 to 6 weeks after placement of a bare-metal stent or drug-eluting stent unless the risk for bleeding outweighs the risk for stent thrombosis. If dual-antiplatelet therapy is interrupted, use of aspirin should be continued and full therapy resumed as soon as possible after surgery. Patients who receive -blockers or statins on a long-term basis should continue to do so in the perioperative period. It may be reasonable to initiate treatment with -blockers in the perioperative period for patients with ischemia or more than 3 RCRI risk factors, but initiation should take place long enough in advance of surgery to assess safety and tolerability and should not occur on the day of surgery. It is reasonable to initiate statin therapy preoperatively in patients undergoing vascular surgery or a nonlow-risk surgery who have at least 1 RCRI risk factor. Troponin measurement and ECG are recommended only for patients with signs or symptoms of cardiac ischemia. Cautions: Where randomized, controlled trial (RCT) evidence was unavailable, recommendations were based on observational data or expert opinion. Implications: Clinicians who provide perioperative care should familiarize themselves with this guideline. Careful Patient Selection Is Needed When Considering Perioperative -Blockers Blessberger H Kammler J Domanovits H et al Perioperative beta-blockers for preventing surgery-related mortality and morbidity. Cochrane Database Syst Rev 2014 9 CD004476 25233038 Background: The 2014 ACC/AHA guidelines on perioperative cardiovascular evaluation and management added a Class III harm recommendation against starting -blockers on the day of surgery (4), and a more conservative approach is recommended for initiation of -blocker therapy in high-risk patients. However, questions remain, including whether certain patients may benefit from perioperative -blockade. Findings: This systematic review of 89 RCTs (19211 participants) analyzed cardiac surgery and NCS populations separately. In cardiac surgery (53 trials), there was no increase in 30-day all-cause mortality among patients taking -blockers versus those who were not (relative risk [RR], 0.73 [95% CI, 0.35 to 1.52]). In addition, no significant difference was found for many secondary outcomes in the cardiac surgery group, including acute myocardial infarction (MI) (RR, 1.04 [CI, 0.71 to 1.51]) and myocardial ischemia (RR, 0.51 [CI, 0.25 to 1.05]). -Blockers did significantly reduce the occurrence of ventricular and supraventricular tachycardias in cardiac surgery patients. In NCS (36 trials), -blockers potentially increased 30-day all-cause mortality (RR, 1.27 [CI, 1.01 to 1.59]) and cerebrovascular events (RR, 1.59 [CI, 0.93 to 2.71)], but they significantly reduced the occurrence of acute MI (RR, 0.73 [CI, 0.61 to 0.87]) and myocardial ischemia (RR, 0.43 [CI, 0.27 to 0.70]) while increasing the risk for bradycardia and hypotension. Cautions: Most of the results in this meta-analysis were driven by 1 large trial: POISE (PeriOperative ISchemic Evaluation) (5), which represented 71% of the weight of the meta-analysis. In the POISE trial, a generous dose of long-acting -blocker was administered 2 to 4 hours before surgery and postoperatively. Sensitivity analyses were conducted with and without the POISE trial results to account for this. Implications: This review highlights the continued need for careful patient selection and caution with regard to perioperative use of -blockers. There may be less risk and more potential benefit in cardiac surgery patients. There is also potential risk reduction with regard to perioperative acute MI and cardiac ischemia in NCS patients, but this must be carefully weighed against the possible increased risk for mortality, stroke, and hemodynamic instability. If -blocker therapy is started preoperatively, the meta-analysis highlights the importance of allowing enough time after initiation for dose titration and assessment of medication tolerance. Postoperative Troponin Elevation Has Myocardial Injury Implications After NCS Botto F Alonso-Coello P Chan MT et al Vascular events In noncardiac Surgery patients cOhort evaluatioN (VISION) Writing Group Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology 2014 120 564 78 24534856 Background: Whether troponin levels should be obtained postoperatively in the absence of ischemic symptoms presents a clinical conundrum. Data, including those from this study, have demonstrated an association between asymptomatic elevated troponin levels postoperatively and 30-day mortality (6). However, the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation recommends against routine postoperative troponin screening in unselected patients and cites uncertain benefit in high-risk patients without ischemic symptoms (4). This study sought to define diagnostic criteria, characteristics, predictors, and 30-day outcomes of myocardial injury after NCS (MINS). Findings: This international prospective cohort study included 15065 participants aged 45 years or older who underwent NCS requiring at least overnight observation. Patients with elevated postoperative troponin T levels were assessed for ischemic ECG changes or ischemic symptoms. With a cutoff value for troponin T of 0.03 ng/mL or greater, 1200 patients (8%) met the criteria for MINS. The primary outcome was postoperative 30-day mortality; rates were 9.8% among patients with MINS compared with 1.1% among patients without MINS (odds ratio [OR], 10.07 [CI, 7.84 to 12.94]). Four perioperative complications (MINS, sepsis, stroke, and pulmonary embolism) were independent predictors of 30-day mortality in multivariate analysis. Not unexpectedly, 87.1% of MINS events occurred within the first 2 days of surgery. Among patients who met the criteria for MINS, 84.2% did not experience ischemic symptoms and 58% did not fulfill the universal definition of MI. Patients with MINS were also at higher risk for nonfatal cardiac arrest, congestive heart failure, and stroke. Cautions: This study design is able to establish an association between mortality and other adverse events in patients with MINS, but it cannot definitively establish a causal relationship. It also does not tell us whether intervention when the troponin T level is elevated would improve outcomes. Implications: The results of this study suggest that regardless of ischemic features, postoperative elevation of the troponin T level is relatively common and has important prognostic implications. The significant number of patients with MINS (over one half of whom were completely asymptomatic) and the associated 10-fold increase

69-Year-Old Woman With Dyspnea and Cough Productive of White Sputum

A 69-year-old woman was admitted to our institution with progressive dyspnea and cough productive of white sputum. Three months earlier, the patient was hospitalized elsewhere for evaluation of fever, headache, and fatigue. Results of a right temporal artery biopsy were consistent with giant cell arteritis (GCA). She was treated with prednisone (50 mg/d) and initially improved, but after 6 weeks of therapy, she again experienced feelings of malaise. Her erythrocyte sedimentation rate (ESR) remained elevated at 75 mm/h. The patient’s rheumatologist then added methotrexate (MTX) to her treatment regimen. One week after starting MTX, the patient developed a vesicular rash on the left side of her chest that resolved without intervention, and she did not seek medical attention. Three weeks later, she was admitted to her local facility with complaints of chest pain, dyspnea, fever, and cough productive of white sputum. An adenosine stress test yielded negative results. A ventilation-perfusion lung scan revealed low probability for pulmonary embolism. Chest radiography findings were normal. In addition to deep venous thrombosis (DVT) prophylaxis with heparin, she was treated with intravenous levofloxacin, vancomycin hydrochloride, and ceftazidime. No sputum studies were obtained. After 3 days of antimicrobial therapy, the patient was transferred to our facility because of continued fever and dyspnea.