Key Papers from the Most Recent Literature Relevant to Anesthesiologists
Length of hospital stay after hip fracture and risk of early mortality after discharge in New York State: Retrospective cohort study. BMJ 2015; 351:h6246.
The question as to whether the length of hospital stay for hip fracture can affect a patient’s risk of death 30 days after discharge remains unanswered. This retrospective cohort included 188,211 patients aged 50 yr or more receiving surgical or nonsurgical treatment between 2000 and 2011. The primary outcome measure was the mortality rate 30 days after hospital discharge. Hospital stays of 11 to 14 days for hip fracture were associated with a 32% increased odds of death 30 days after discharge, compared with stays lasting 1 to 5 days (odds ratio, 1.32; 95% confidence interval, 1.19 to 1.47). The 30-day mortality rate after discharge was 4.5% for surgically treated patients and 10.7% for nonsurgically treated patients. In contrast with recent findings in Sweden, decreased length of hospital stay for hip fracture was associated with reduced rates of early mortality in a U.S. cohort in New York State. This could reflect critical system differences in the treatment of hip fractures between Europe and the United States.
Effect of opioids vs NSAIDs and larger vs smaller chest tube size on pain control and pleurodesis efficacy among patients with malignant pleural effusion: The TIME1 randomized clinical trial. JAMA 2015; 314:2641–53.
For treatment of malignant pleural effusion, nonsteroidal antiinflammatory drugs (NSAIDs) are avoided because they may reduce the efficacy of pleurodesis. Smaller chest tubes may be less painful than larger tubes, but the effect on the efficacy of pleurodesis is unclear. This randomized controlled trial enrolled 320 patients with malignant pleural effusion to assess the effect of chest tube size and analgesia (NSAIDs vs. opiates) on pain and clinical efficacy of pleurodesis. Primary outcome was pain while chest tube was in place (0- to 100-mm visual analog scale 4 times per day; superiority comparison) and efficacy of pleurodesis at 3 months (failure defined as need for further pleural intervention; noninferiority comparison; margin, 15%). It was found that use of NSAIDs versus opiates resulted in no significant difference in pain scores but was associated with more rescue medication. NSAID use resulted in noninferior rates of effective pleurodesis at 3 months.
Prevalence of depression and depressive symptoms among resident physicians: A systematic review and meta-analysis. JAMA 2015; 314: 2373–83.
Physicians in training are at high risk for depression. This systematic review and meta-analysis aimed to provide a summary estimate of depression or depressive symptom prevalence among resident physicians. The primary goal was point or period prevalence of depression or depressive symptoms as assessed by structured interview or validated questionnaire. The overall pooled prevalence of depression or depressive symptoms was 28.8%, markedly higher than the general population. No statistically significant differences were observed between cross-sectional versus longitudinal studies, studies of only interns versus only upper-level residents, or studies of nonsurgical versus both nonsurgical and surgical residents. Further research is warranted to identify effective strategies for preventing and treating depression among physicians in training.
The immune response—learning to leave well enough alone. N Engl J Med 2015; 373:2378–9.
The immune system is important in various situations encountered by anesthesiologists, including organ or bone marrow transplantation. The immune system must learn to ignore self-antigens as well as learn to be accepting of certain foreign antigens. This concise and well-illustrated paper written for the nonexpert in immunology appears in the Clinical Implications of Basic Research section of the New England Journal of Medicine. The author explains how the recent findings in engineered mice with an impairment of a subset of innate lymphoid cells called ILC3 cells may have direct relevance to the pathophysiology of Crohn disease.
Erythropoietin in traumatic brain injury (EPO-TBI): A double-blind randomised controlled trial. Lancet 2015; 386:2499–506.
Erythropoietin has been hypothesized to have neurocytoprotective effects. This multicenter randomized trial examined its effect on neurologic recovery, mortality, and venous thrombotic events in patients with traumatic brain injury. Within 24 h of brain injury, 606 patients were randomly assigned by a concealed Web-based computer-generated randomization schedule to receive erythropoietin (40,000 units subcutaneously) or placebo (0.9% sodium chloride subcutaneously) once per week for a maximum of three doses. The primary outcome was improvement in the patients’ neurologic status, summarized as a reduction in the proportion of patients with an Extended Glasgow Outcome Scale of 1 to 4 (death, vegetative state, and severe disability). Compared with placebo, erythropoietin did not reduce the number of patients with severe neurologic dysfunction (Extended Glasgow Outcome Scale level 1 to 4) or increase the incidence of deep venous thrombosis of the lower limbs. In terms of safety, erythropoietin did not significantly affect 6-month mortality versus placebo. This trial does not support the use of erythropoietin at the early phase of moderate to severe trauma brain injury.
Hypothermia for intracranial hypertension after traumatic brain injury. N Engl J Med 2015; 373:2403–12. Getting warmer on critical care for head injury. N Engl J Med 2015; 373:2469–70.
In patients with traumatic brain injury, hypothermia can reduce intracranial hypertension, but the benefit of hypothermia on functional outcome is unclear. In this prospective, randomized, multicenter trial, 387 adults with an intracranial pressure of more than 20 mmHg despite stage 1 treatments (including mechanical ventilation and sedation) were randomized to standard care (control group) or hypothermia (32 to 35°C) plus standard care. In the control group, stage 2 treatments (e.g., osmotherapy) were added as needed to control intracranial pressure. In the hypothermia group, stage 2 treatments were added only if hypothermia failed to control intracranial pressure. The primary outcome was the score on the Extended Glasgow Outcome Scale (range, 1 to 8, with lower scores indicating a worse functional outcome) at 6 months. It was found that therapeutic hypothermia plus standard care to reduce intracranial pressure did not result in outcomes better than those with standard care alone. New approaches are needed for the control of intracranial pressure in order to design trials and treatments for severe traumatic brain injury.
Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med 2015; 175:1913–20.
Limiting the unnecessary use of diagnostic testing and treatment interventions is a major goal in efforts to contain medical costs and improve the quality of medical care. One recent effort in the United States has been the Choosing Wisely campaign involving the identification of low-value tests and treatments as assembled by various specialty societies. The effect of this effort on a list of seven low-value services was assessed over a 2- to 3-yr period. The list of services included several of relevance to anesthesiology and pain management specialists, including the use of preoperative chest x-rays, imaging for uncomplicated headache and low back pain without red-flag conditions, and nonsteroidal antiinflammatory drugs for patients with cardiovascular and kidney disease. Any changes in the use of these tests and treatments over the surveillance period were modest. The authors concluded that focused interventions (financial incentives, electronic decision support, and others) along with the provision of lists of specific tests and treatments to avoid may be needed to alter medical practices.
Entrustment decision making in clinical training. Acad Med 2016; 91:191–8.
The old adage in medical educational of “see one, do one, teach one” has been replaced in the era of the Next Accreditation System with the more thoughtful paradigm of Entrustable Professional Activities (EPAs). The concept of EPAs is the development of trust by the teacher for the student to perform critical tasks with the progression from full supervision to independent practice. The vital question for educators and students alike is, how is this trust acquired and measured? In this article, thought leaders in the field of medical education report on their discussions of this topic during a 2-day conference. They articulate how decisions of trust leading to increasing independence are determined based on both ad hoc and summative observations. These decisions are impacted by several factors including “trainee, supervisor, situation, [and] task,” as well as “the relationship between trainee and supervisor.” The authors describe nuances within each of these categories that influence our decisions to trust trainees. This report provides a framework for building EPAs for faculty and trainees.