Systematic Review of Literature Citing the ISCHEMIA Trial.

PURPOSE OF REVIEW: Optimal therapy for patients with chronic coronary artery disease (CCD) has long been a topic under investigation and a subject of debate. Seeking to clarify appropriate management, the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial compared medical management versus coronary angiography for patients with stable ischemic heart disease. Its reception in the medical community has been met with both acclaim and criticism. In light of such disparate views of this trial, a systematic review of the literature citing the ISCHEMIA trial was performed. RECENT FINDINGS: All articles citing the ISCHEMIA trial on PubMed as of July 21, 2023, were compiled and underwent qualitative analysis. A total of 430 articles were evaluated; 109 (25.3%) did not offer substantial commentary on ISCHEMIA and cite it as background evidence for further study. Of the commentary articles, the majority (224, 52.1%) gave balanced, honest appraisals of the ISCHEMIA trial. A total of 46 (10.7%) strongly praised the trial while another 39 (9.1%) were strongly critical of the results. Almost three-quarters of the literature citing the ISCHEMIA trial was commentary in nature, with roughly equal distribution across the spectrum of praise and criticism. Despite being one of the largest studies on CCD and coronary revascularization ever conducted, the impact of ISCHEMIA on the cardiology community appears to be mixed.

Blood Culture Results and Overtreatment Associated With the Use of a 1-Hour Sepsis Bundle.

BACKGROUND: Some experts recommend using a 1-h sepsis bundle, but clinical data supporting this strategy are lacking. OBJECTIVES: We aimed to determine the rate of, and clinical predictors for, bacteremia for patients undergoing a 1-h sepsis bundle, and to determine the percentage of "code sepsis" patients who are ultimately diagnosed with sepsis or a bacterial infection. METHODS: This retrospective chart review evaluated code sepsis patients from three emergency departments (EDs) that utilize a 1-h sepsis bundle. The primary outcome was the rate of true-positive blood cultures. Secondarily, we analyzed various clinical factors using logistic regression analysis to determine which are associated with bacteremia. RESULTS: Of the 544 code sepsis patients analyzed, 33.8% (95% confidence interval [CI] 29.9-38.0%) were ultimately diagnosed with sepsis, and 54.6% (95% CI 50.3-58.8%) were diagnosed with a bacterial infection. Exactly 7.0% (95% CI 5.0-9.5%) of the blood cultures performed were true positives. On multivariate logistic regression analysis, temperature > 38°C (100.4°F) or < 36°C (96.8°F), lactate > 4 mmol/L, and indwelling line/device were found to be positively associated with true-positive blood cultures. CONCLUSION: In a group of code sepsis patients from facilities that use a 1-h sepsis bundle, the majority were ultimately not diagnosed with sepsis, and nearly half did not have a bacterial infection. A small minority of patients had bacteremia. Restricting blood culture ordering in patients with possible sepsis to only those who have increased risk for bacteremia could lead to a more judicious use of blood cultures.

Utilization of computerized tomography and magnetic resonance imaging for diagnosis of traumatic C-Spine injuries at a level 1 trauma center: A retrospective Cohort analysis.

BACKGROUND: Computerized tomography (CT) is a common imaging modality for trauma patients, but there is debate regarding the role of magnetic resonance imaging (MRI) in cervical (C)-spine clearance. We aim to investigate the utilization of CT and MRI imaging in traumatic C-spine clearance and associated outcomes on patients who undergo both imaging modalities. METHODS: A 4-year retrospective review was performed to evaluate the trauma patient imaging algorithm at our institution. The algorithm required CT as a screening examination for traumatic injury patients who are unexaminable because of distracting injury, altered mental status, an abnormal neurological examination, and/or central neck pain. MRI was performed after CT in patients with C-spine injuries identified on CT, those who remained unexaminable, had an abnormal neurological examination, or experienced persistent central neck tenderness. Univariate analyses and adjusted multivariate logistic regression were performed with significance defined as p < 0.05. RESULTS: 805 patients were analyzed. Compared to MRI, CT had a sensitivity of 50.2%, specificity of 76.6%, positive predictive value of 69.7%, and negative predictive value of 59.0% in detecting C-spine injuries. CT and MRI differed significantly in their ability to detect C-spine soft tissue injuries and C1 vertebral fractures (p < 0.05). CONCLUSIONS: MRI is more capable of detecting soft tissue injuries whereas CT is superior in detecting vertebral fractures. Our findings support the need to utilize CT and MRI in conjunction to detect both bony and soft tissue C-spine injuries in traumatically injured patients, who are either unexaminable, have an abnormal neurologic examination, or ongoing central neck tenderness.

Regional Population-Based Workforce Shortages in General Surgery by Practicing Surgeon and Resident Trainee.

BACKGROUND: The physician shortage in the United States (US) continues to become more apparent. We aimed to evaluate the relationship between the US physician distribution from 2012-2019 by specialty at the state/regional level relative to the corresponding population growth. METHODS: US matched residents and practicing physicians from 2012-2019 were extracted from the National Resident Matching Program and Association of American Medical College databases, respectively. Residents and practicing physicians were divided by geographic regions (West, Midwest, South, Northeast), states, and specialties (anesthesiology, emergency medicine, family medicine, general surgery (GS), internal medicine, obstetrics/gynecology and pediatrics). RESULTS: Entering residents and physicians increased across 7 specialties from 2012-2019 with the exception of GS, which showed .2% decrease in practicing physicians. GS experienced decreases in entering residents in all US regions except the South. All specialties showed a decrease in the people-per-physician (PPP) except GS and pediatrics, which had a 4.1% and 71.3% increase, respectively. EM showed the largest growth overall, both in entering residents and overall workforce. CONCLUSION: GS experienced slow growth of residents, decreases in practicing physicians and workforce overall, and an increase in PPP from 2012-2019. Our findings suggest that current population growth rate is exceeding the rate of physicians entering the field of GS and highlights the need for interventions to promote the recruitment of GS residents and retainment of attending physicians, particularly for rural areas. Future research to measure surgeon distribution in relation to patient outcomes and the efficacy of recent policy to address shortages can help define additional interventions to address physician shortages moving forward.