• Early Menopause Tied to Increased Heart, Mortality Risk
• Monitoring of Early Prostate Cancer Tied to Higher Risk for Metastases
• Electroacupuncture Tied to Improvements in Chronic Constipation
• Nifedipine Might Not Help Chronic Chilblains
• Syringes Better Than Cups for Oral Pediatric Dosing by Parents
• Youth Soccer-Related Concussions Show Large Increase Over Last 25 Years
• Half of Physician Time Spent on EHRs and Paperwork
Early Menopause Tied to Increased Heart, Mortality Risk
By Amy Orciari Herman, Edited by Susan Sadoughi, MD, and Richard Saitz, MD, MPH, FACP, FASAM
Women who experience natural menopause before age 45 face significantly increased risks for heart disease and mortality, according to a meta-analysis in JAMA Cardiology.
Researchers analyzed data from some 30 studies that examined age at menopause onset and cardiovascular and mortality outcomes in 300,000 women. After multivariable adjustment, women who were aged 44 and under at menopause onset had a 50% increased risk for coronary heart disease, 19% increased risk for cardiovascular mortality, and 12% increased risk for overall mortality, relative to those aged 45 and older at the start of menopause.
The authors propose several mechanisms for the observed associations. In particular, early loss of ovarian function might start processes that lead to endothelial dysfunction, inflammation, and immune dysfunction.
Commentators conclude: "The recognition that women with early reproductive decline constitute a population at increased vascular risk provides important opportunities for early intervention in terms of both risk factor modification and, when appropriate, hormonal treatment."
http://cardiology.jamanetwork.com/article.aspx?articleid=2551981
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Monitoring of Early Prostate Cancer Tied to Higher Risk for Metastases
By Kelly Young, Edited by Susan Sadoughi, MD, and Richard Saitz, MD, MPH, FACP, FASAM
Active monitoring of early prostate cancer is associated with higher rates of metastases and disease progression relative to radical treatments, but 10-year mortality rates are similar, according to a New England Journal of Medicine study.
Roughly 1600 men aged 50–69 who were diagnosed with localized prostate cancer were randomized to active monitoring, radical prostatectomy, or radiotherapy. After a median 10 years’ follow-up, prostate-cancer survival was around 99% in all three groups. Active monitoring, compared with surgery or radiotherapy, was associated with higher rates of disease progression (23 vs. 9 per 1000 person-years) and metastatic disease (6 vs. 2–3 per 1000).
An editorialist writes: “If a man wishes to avoid metastatic prostate cancer ... monitoring should be considered only if he has life-shortening coexisting disease such that his life expectancy is less than the 10-year median follow-up of the current study.”
In a companion NEJM study, the active monitoring group initially had better urinary and sexual function than did the radical treatment groups, but these measures got worse with time due to age-related changes and more men choosing radical treatments.
http://www.nejm.org/doi/full/10.1056/NEJMoa1606220?query=
pfw&jwd=000101421649&jspc=
http://www.nejm.org/doi/full/10.1056/NEJMoa1606221?query=
pfw&jwd=000101421649&jspc=
http://www.nejm.org/doi/full/10.1056/NEJMe1610395?query=
pfw&jwd=000101421649&jspc=
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Electroacupuncture Tied to Improvements in Chronic Constipation
By Kelly Young, Edited by David G. Fairchild, MD, MPH, and Jaye Elizabeth Hefner, MD
Electroacupuncture improves symptoms of chronic constipation, according to an Annals of Internal Medicine study.
Over 1000 patients with chronic, severe functional constipation were randomized to receive 28 sessions of either electroacupuncture or sham acupuncture. The electroacupuncture group had needles inserted 30–70 mm deep into three acupoints; two points were electrically stimulated. In the sham group, needles were inserted shallowly into three nonacupoints; the electroacupuncture device did not have current output.
During 8 weeks' treatment, the electroacupuncture group had a greater increase in complete, spontaneous bowel movements per week over baseline than did the sham group (1.76 vs. 0.87 more BMs). The results remained significant at week 20. The treatment group also had higher quality-of-life scores.
Previous studies have found that acupuncture can help gastrointestinal motility, the authors note. They conclude that acupuncture “might be recommended as a valuable and promising new therapeutic option for patients” with chronic, severe functional constipation.
http://annals.org/article.aspx?articleid=2552074
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MM: This study refers to oral nifedipine but we have seen many patients benefit from compounded prescription trandermal nifedipine or diltiazem applied directly to the hands and/or feet for this condition and other related situations such as Raynaud's Syndrome. We have also seen benefits from these compounded products for severe wounds where the body has shut down blood flow to the area. We have seen healing to the area speed up remarkably from this increase in local blood flow.
Nifedipine Might Not Help Chronic Chilblains
By Kelly Young, Edited by David G. Fairchild, MD, MPH, and Jaye Elizabeth Hefner, MD
The calcium-channel blocker nifedipine is not associated with improvements in chilblains, contrary to advice recommending its use, according to a small, crossover study in the Annals of Family Medicine.
Dutch researchers randomized nearly 40 adults with chronic chilblains to receive either oral nifedipine (administered once daily for 2 weeks, then twice daily for 4 weeks) first or placebo first. After 6 weeks, patients received the other option.
Following treatment, there was no significant difference between groups for patient-reported symptoms or disability. Nifedipine was associated with significantly lower mean systolic blood pressure (135 vs. 147 mm Hg) and more peripheral edema.
The authors conclude: “Current advice to prescribe nifedipine for chilblains should be revisited, and clinicians should weigh and discuss with patients evidence on the potential benefits and harms of various treatment options before making treatment decisions.”
Definition: Chilblains (CHILL-blayns) are the painful inflammation of small blood vessels in your skin that occur in response to repeated exposure to cold but not freezing air. Also known as pernio, chilblains can cause itching, red patches, swelling and blistering on your hands and feet. www.mayoclinic.org/diseases-conditions/chilblains/home/ovc-20165478
http://www.annfammed.org/content/14/5/453
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Syringes Better Than Cups for Oral Pediatric Dosing by Parents
By Cara Adler, Edited by Susan Sadoughi, MD, and André Sofair, MD, MPH
Dosing errors were almost five times more likely when parents used cups to measure liquid medications than when they used oral syringes. The findings appear in Pediatrics.
Researchers asked parents at three pediatric clinics to measure three doses of liquid medication (2.5, 5, and 7.5 mL) using three tools (30-mL dosing cup, syringe marked in 0.2-mL increments, and syringe marked in 0.5-mL increments), in random order. Parents were randomized into five groups that were given different pairings of units on the medication labels and on the tools.
Of roughly 2100 parents enrolled, 84% made at least one dosing error in the nine measurements, mostly overdoses. Overall, 21% of parents measured out an amount more than twice the dose on the label. Dosing errors were 4.6 times more common with cups than syringes.
Dr. John D. Cowden of NEJM Journal Watch Pediatrics and Adolescent Medicine commented: "Evidence from this large randomized trial gives us reason to hope that changes in practice (e.g., eliminating the use of cups for measuring liquid medications) can improve medication safety. It also shows that standardization of units and tools is not enough. Hands-on parent education methods ... hold promise for giving parents and providers more confidence about medication measurement." (See background link below.)
http://pediatrics.aappublications.org/content/early/recent
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Youth Soccer-Related Concussions Show Large Increase Over Last 25 Years
By Amy Orciari Herman, Edited by Susan Sadoughi, MD, and André Sofair, MD, MPH
The annual rate of soccer-related concussion or other closed head injuries among U.S. children increased by approximately 1600% — from roughly 2 to 35 per 10,000 participants — from 1990 to 2014, aPediatrics study finds.
Using national injury and sports participation databases, researchers estimated that nearly 3 million children aged 7 to 17 years were treated for soccer-related injuries in U.S. emergency departments during the 25 years. The overall annual injury rate more than doubled during this period. Sprains/strains accounted for 35% of injuries, fractures for 23%, soft-tissue injuries for 22%, and concussions for 7%.
Children aged 12 to 17 accounted for nearly three-fourths of injuries and were more likely than younger children to experience concussions/closed head injuries. Those with concussions/closed head injuries were twice as likely to be admitted to the hospital as those with other injuries.
http://pediatrics.aappublications.org/content/early/recent
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Half of Physician Time Spent on EHRs and Paperwork
By Kelly Young
For every hour spent with patients, physicians spend 2 hours on electronic health records (EHR) and desk work, according to an Annals of Internal Medicine study.
Researchers observed nearly 60 physicians from 16 practices during office hours. Physicians completed diaries documenting after-hours work.
Based on 430 hours of observation, 49% of physicians' office hours were spent on EHR and desk work while 27% was spent directly with patients. When meeting with patients, physicians spent 37% of their time on EHR and desk work. After office hours, physicians worked a mean of 1.5 hours per day, with most of that time dedicated to EHR tasks.
Physicians who had documentation support, such as dictation or a documentation assistant, had more direct interaction time with patients than physicians without support. An editorialist writes: "Learning colleagues' strategies to alleviate some of the practice hassles related to EHRs is a great way to move forward and make improvements."
William E. Chavey, MD, MS: Most physicians probably feel like they could have written the conclusion of this study before it was conducted. That said, the quantification of the EHR burden is significant and hopefully can drive operational changes.
André Sofair, MD, MPH: All of us can relate to the findings of this article. Hopefully this will give physicians added support to request direct assistance with documentation to allow them more time with their patients.
http://annals.org/article.aspx?articleid=2546704
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