By Karthik Bharadwaj, MD
Peer Reviewed
With medicine advancing at such a rapid pace, it is crucial for physicians to keep up with the medical literature. This can quickly become an overwhelming endeavor given the sheer quantity and breadth of literature released on a daily basis. Primecuts helps you stay current by taking a shallow dive into recently released articles that should be on your radar. Our goal is for you to slow down and take a few small sips from the medical literature firehose.
Adjunctive Intermittent Pneumatic Compression for Venous Thromboprophylaxis [1]
Randomized control trials have demonstrated the incidence of deep-vein thrombosis (DVT) to be approximately 50% lower with prophylaxis with unfractionated or low-molecular-weight heparin versus no thromboprophylaxis [1]. Current guidelines recommend the use of prophylaxis in all patients. However, critically ill patients have a DVT rate of 5-20% despite adequate thromboprophylaxis. This study seeks to determine whether intermittent pneumatic compression is indicated for thromboprophylaxis in critically ill patients [3].
This non-blinded, randomized, modified intention to treat trial included patients across centers in multiple countries (non-US); inclusion criteria were: body weight > 45kg, expected ICU stay >72hrs, and no contraindication to pharmacologic thromboprophylaxis. 2003 patients were randomized to receive pharmacologic thromboprophylaxis plus pneumatic compression (experimental) or pharmacologic thromboprophylaxis alone (control) with follow up at time of ICU discharge, death, or trial day 28. Primary outcome with intention to treat analysis measured was incident proximal DVT detected by ultrasonography twice weekly beginning the third calendar day after randomization. The primary outcome occurred in 37 of 957 patients (3.9%) in the pneumatic compression group and in 41 of 985 patients (4.2%) in the control group (relative risk, 0.93; 95% confidence interval [CI], 0.60 to 1.44; P=0.74). Venous thromboembolism (pulmonary embolism or any lower-limb deep-vein thrombosis) occurred in 103 of 991 patients (10.4%) in the pneumatic compression group and in 95 of 1012 patients (9.4%) in the control group (relative risk, 1.11; 95% CI, 0.85 to 1.44).
This study showed that in critically ill patients, pneumatic compression in addition to thromboprophylaxis did not result in lower incidence of DVT compared to thromboprophylaxis alone. Lower than expected incidence of the primary outcome in the control population reduced overall power of the study and the trial was not blinded. Although this study can provide guidance for a question that has a dearth of evidence, it remains to be seen whether these results can be demonstrated in a US population and with minimal variability in pneumatic compression devices.
Automatically Charting Symptoms From Patient-Physician Conversations Using Machine Learning [4]
Medical documentation can often be cumbersome for physicians and detract from patient care. Some institutions employ human scribes to expedite documentation. Automating medical record keeping through speech recognition could allow physicians to spend more time directly with patients [5].
In this retrospective, deidentified review, 90,000 human transcribed snippets across primary care and multiple specialties were labeled into 185 Review of Symptoms (ROS) symptoms by scribes. A symptom was considered “clearly mentioned” if 2 scribes independently assessed the symptom as “extremely likely” to be included in the ROS, other symptoms were labeled “unclear”. The input into the machine learning model was a sliding window of 5 snippets and output was each symptom mentioned, its relevance, and if the patient experienced it. Across the full test set, the sensitivity of the model to identify symptoms was 67.7% (5172/7637) and the positive predictive value of a predicted symptom was 80.6% (5172/6417). For clearly mentioned symptoms the sensitivity of the model was 92.2% (357/387). For unclear ones, it was 67.8% (280/413). The model would accurately document (correct identification of a symptom, correct classification of relevance to the note, and assignment of experienced or not) in 87.9% (340/387) of symptoms mentioned clearly and 60.0% (248/413) in ones mentioned unclearly.
This study brings to light the variability in how clearly symptoms are measured by the patient. Slightly less than half of symptoms mentioned were clear (387/800 [48.4%]). The model performed well on clearly mentioned symptoms but did not perform well on unclearly mentioned symptoms. This, however, is also seen in variability of documentation of vague symptoms by human scribes. Looking forward, specific changes in physician communication may be necessary to embolden the accuracy of speech recognition in medical interviewing.
Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation [6]
Recent guidelines for the treatment of recent-onset, symptomatic atrial fibrillation suggest immediate pharmacologic or electrical cardioversion with intention of restoring sinus rhythm [7]. Atrial fibrillation has been shown to terminate spontaneously, bringing into question whether immediate treatment is needed [8]. A “wait and see” approach for cardioversion has been used to avoid hospitalization and overtreatment [9]. This study seeks to determine whether a “wait and see” approach results in similar outcomes to immediate cardioversion in the setting of symptomatic, recent onset atrial fibrillation.
In this multicenter, randomized, open-label, noninferiority trial 427 patients (hemodynamically stable, onset of atrial fibrillation <36hrs prior, symptomatic) were grouped into immediate cardioversion and delayed cardioversion. Delayed cardioversion group received only rate control medication initially; cardioversion was only attempted if atrial fibrillation did not resolve within 48 hours. Both groups were evaluated for presence of sinus rhythm 4 weeks after randomization. 193 of 212 (91%) of delayed cardioversion group patient were in sinus rhythm at 4 weeks post randomization versus 202 of 215 (94%) of the early-cardioversion group (between-group difference, −2.9 percentage points; 95% confidence interval [CI], −8.2 to 2.2; P=0.005 for noninferiority).
This study suggests that recurrence of atrial fibrillation was not affected by management approach at onset. Although cardiovascular complications were infrequent, the study was not powered to detect safety. Intermittent monitoring likely resulted in an underestimation of the true recurrence rate of atrial fibrillation. This study does not address anticoagulation or address stroke risk; the authors noted that when duration of atrial fibrillation is not known, cardioversion (immediate or delayed) should not be attempted until anticoagulation is initiated or intraatrial thrombus is excluded on TEE.
Association Between Receipt of a Medically Tailored Meal Program and Health Care Use [10]
Medically tailored meal (MTM) delivery has been developed as a strategy to address food insecurity and other barriers to dietary adherence (physical disability, food deserts, lack of time) [11]. A registered dietitian nutritionist prepares meals tailored to the specific nutritional needs of the individual; this meal is then delivered to the individual’s home. MTMs have potential to reduce healthcare use and cost by preventing morbidities; a limited previous dual-eligible individual study showed that MTM delivery participation was associated with lower health care use [12]. This study seeks to determine if MTM recipients experienced reduced inpatient admissions, Skilled Nursing Facility (SNF) admissions, and health care costs.
This retrospective cohort study was performed with data from the 2011-2015 Massachusetts All-Payer Claims database linked with Community Servings (a nonprofit organization delivering MTMs). 499 MTM recipients were matched to 521 nonrecipients (total 1020 participants). Prior to matching and compared with nonrecipients in the same area, health care use, health care cost, and comorbidity were all significantly higher in recipients. In instrumental variable analyses, MTM receipt was associated with significantly fewer inpatient admissions (incidence rate ratio [IRR], 0.51; 95% CI, 0.22-0.80; risk difference, −519; 95% CI, −360 to −678 per 1000 person-years). Similarly, MTM receipt was associated with fewer skilled nursing facility admissions (IRR, 0.28; 95% CI, 0.01-0.60; risk difference, −913; 95% CI, −689 to −1457 per 1000 person-years). The models estimated that, had everyone in the matched cohort received treatment owing to the instrument (and including the cost of program participation), mean monthly costs would have been $3838 vs $4591 if no one had received treatment owing to the instrument (difference, −$753; 95% CI, −$1225 to −$280).
These data suggest that MTM delivery for eligible participants can result in fewer inpatient admissions, fewer SNF admissions, and decreased health care cost. However, the study has a few limitations that reduce generalizability. Access to supplemental health care and nutritional assistance was not controlled for between recipient and nonrecipient groups. Furthermore, other nonmodifiable drivers for health care costs were not taken into account.
Minicuts
Antithrombotic Therapy after Acute Coronary Syndrome or PCI in Atrial Fibrillation [13]
In this 2×2, randomized controlled trial, patients with Atrial Fibrillation presenting with Acute Coronary Syndrome or Percutaneous Coronary Intervention necessitating P2Y12 inhibitor therapy were randomized into apixaban or warfarin groups and aspirin or placebo groups. Apixaban is associated with a 4.2% absolute reduction in major or clinically relevant nonmajor bleeding when compared to warfarin at 180 days. Apixaban was also associated with a 3.9% absolute reduction in death or hospitalization when compared to warfarin (driven primarily by reduced hospitalization). Aspirin use in addition to oral anticoagulation and P2Y12 inhibitor therapy was associated with a 7.1% absolute increase in major or clinically relevant nonmajor bleeding. Overall thrombotic events were similar across patients randomized to anticoagulation with apixaban versus warfarin, and those randomized to aspirin versus placebo.
This meta-analysis looked at the effects of oral anticoagulants and non-steroidal anti-inflammatory drugs on faecal immunochemical testing. Use of OACs was associated with a PPVAN of 37.6% (95% CI 33.9 to 41.4) compared with 40.3% (95% CI 38.5 to 42.1) for non-users (p=0.75). Pooled PPVAN in aspirin/NSAID users was 38.2% (95% CI 33.8 to 42.9) compared with 39.4% (95% CI 37.5 to 41.3) for non-users (p=0.59).
This systematic review and meta-analysis assessed the associated between gastric emptying and upper GI symptoms. For studies that employed optimal gastric emptying test methodology, there were significant associations between gastric emptying and nausea (OR 1.6, 95% CI 1.4 to 1.8), vomiting (OR 2.0, 95% CI 1.6 to 2.7), abdominal pain (OR 1.5, 95% CI 1.0 to 2.2) and early satiety/fullness (OR 1.8, 95% CI 1.2 to 2.6) for patients with upper GI symptoms; gastric emptying and early satiety/fullness in patients with diabetes; gastric emptying and nausea in patients with gastroparesis.
Dr. Karthik Bharadwaj is a 1st year resident at NYU Langone Health
Peer reviewed by Dana Zalkin, MD, Chief Resident, Internal Medicine, NYU Langone Health
Image courtesy of BDNews24.com
References
- Arabi, Y. M., Al-Hameed, F., Burns, K. E., Mehta, S., Alsolamy, S. J., Alshahrani, M. S., … & Finfer, S. (2019). Adjunctive Intermittent Pneumatic Compression for Venous Thromboprophylaxis. New England Journal of Medicine. https://www.ncbi.nlm.nih.gov/pubmed/30779530
- Alhazzani, W., Lim, W., Jaeschke, R. Z., Murad, M. H., Cade, J., & Cook, D. J. (2013). Heparin thromboprophylaxis in medical-surgical critically ill patients: a systematic review and meta-analysis of randomized trials. Critical care medicine, 41(9), 2088-2098.
- Cook, D. J., & Crowther, M. A. (2010). Thromboprophylaxis in the intensive care unit: Focus on medical–surgical patients. Critical care medicine, 38, S76-S82.
- Rajkomar, A., Kannan, A., Chen, K., Vardoulakis, L., Chou, K., Cui, C., & Dean, J. (2019). Automatically Charting Symptoms From Patient-Physician Conversations Using Machine Learning. JAMA internal medicine. https://phgkb.cdc.gov/PHGKB/phgHome.action?action=forward&dbsource=phg&id=24846
- Verghese, A., Shah, N. H., & Harrington, R. A. (2018). What this computer needs is a physician: humanism and artificial intelligence. Jama, 319(1), 19-20.
- Pluymaekers, N. A., Dudink, E. A., Luermans, J. G., Meeder, J. G., Lenderink, T., Widdershoven, J., … & Alings, M. (2019). Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation. New England Journal of Medicine. https://www.ncbi.nlm.nih.gov/pubmed/30883054/
- January, C. T., Wann, L. S., Alpert, J. S., Calkins, H., Cigarroa, J. E., Cleveland, J. C., … & Murray, K. T. (2014). 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Journal of the American College of Cardiology, 64(21), e1-e76.
- Lindberg, S., Hansen, S., & Nielsen, T. (2012). Spontaneous conversion of first onset atrial fibrillation. Internal medicine journal, 42(11), 1195-1199.
- Doyle, B., & Reeves, M. (2011). “Wait and see” approach to the emergency department cardioversion of acute atrial fibrillation. Emergency medicine international, 2011.
- Berkowitz SA, Terranova J, Randall L, Cranston K, Waters DB, Hsu J. Association Between Receipt of a Medically Tailored Meal Program and Health Care Use. JAMA Intern Med. Published online April 22, 2019. doi:10.1001/jamainternmed.2019.0198 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2730768
- Coleman-Jensen A, Rabbitt MP, Gregory CA, Singh A. Household food security in the United States in 2016. United States Department of Agriculture. https://www.ers.usda.gov/publications/pub-details/?pubid=84972. Published September 2017. Accessed January 24, 2018.
- Berkowitz SA, Terranova J, Hill C, et al. Meal delivery programs reduce the use of costly health care in dually eligible Medicare and Medicaid beneficiaries. Health Aff (Millwood). 2018;37(4):535-542. doi:10.1377/hlthaff.2017.0999
- Lopes, R. D., Heizer, G., Aronson, R., Vora, A. N., Massaro, T., Mehran, R., … & Averkov, O. (2019). Antithrombotic Therapy after Acute Coronary Syndrome or PCI in Atrial Fibrillation. New England Journal of Medicine. https://www.ncbi.nlm.nih.gov/pubmed/30883055
- Nieuwenburg, S. A., Vuik, F. E., Kruip, M. J., Kuipers, E. J., & Spaander, M. C. (2019). Effect of anticoagulants and NSAIDs on accuracy of faecal immunochemical tests (FITs) in colorectal cancer screening: a systematic review and meta-analysis. Gut, 68(5), 866-872. https://www.ncbi.nlm.nih.gov/pubmed/29871970
- Vijayvargiya, P., Jameie-Oskooei, S., Camilleri, M., Chedid, V., Erwin, P. J., & Murad, M. H. (2019). Association between delayed gastric emptying and upper gastrointestinal symptoms: a systematic review and meta-analysis. Gut, 68(5), 804-813. https://www.ncbi.nlm.nih.gov/pubmed/29860241