Acute alcohol exposure and electrocardiographic changes: Finding from the HOLIDAY trial.

BACKGROUND: Alcohol consumption is associated with a higher increased risk of atrial fibrillation (AF), but the acute effects on cardiac electrophysiology in humans remain poorly understood. The HOw ALcohol InDuces Atrial TachYarrhythmias (HOLIDAY) Trial revealed that alcohol shortened pulmonary vein atrial effective refractory periods, but more global electrophysiologic changes gleaned from the surface ECG have not yet been reported. METHODS: This was a secondary analysis of the HOLIDAY Trial. During AF ablation procedures, 100 adults were randomized to intravenous alcohol titrated to 0.08% blood alcohol concentration versus a volume and osmolarity-matched, masked, placebo. Intervals measured from 12­lead ECGs were compared between pre infusion and at infusion steady state (20 min). RESULTS: The average age was 60 years and 11% were female. No significant differences in the P-wave duration, PR, QRS or QT intervals, were present between alcohol and placebo arms. However, infusion of alcohol was associated with a statistically significant relative shortening of the JT interval (r: -14.73, p = 0.048) after multivariable adjustment. CONCLUSION: Acute exposure to alcohol was associated with a relative reduction in the JT interval, reflecting shortening of ventricular repolarization. These acute changes may reflect a more global shortening of refractoriness, suggesting immediate proarrhythmic effects pertinent to the atria and ventricles.

Valvular disease burden in the modern era of percutaneous and surgical interventions: the UK Biobank.

BACKGROUND: The burden of valvular heart disease (VHD) has increased significantly among ageing populations, yet remains poorly understood in the present-day context of percutaneous and surgical interventions. OBJECTIVE: To define the incidence, clinical correlates and associated mortality of VHD in the UK Biobank cohort. METHODS: We interrogated data collected in the UK Biobank between 1 January 2000 and 30 June 2020. VHD incidence was determined using International Classification of Disease-10 codes for aortic stenosis (AS), aortic regurgitation (AR), mitral stenosis, mitral regurgitation (MR) and mitral valve prolapse. We calculated HRs for incident VHD and all-cause mortality. Clinical correlates of VHD included demographics, coronary artery disease, heart failure and atrial fibrillation. Surgical and percutaneous interventions for mitral and aortic VHD were considered time-dependent variables. RESULTS: Among 486 187 participants, the incidence of any VHD was 16 per 10 000 person-years, with highest rates for MR (8.2), AS (7.2) and AR (5.0). Age, heart failure, coronary artery disease and atrial fibrillation were significantly associated with all types of VHD. In our adjusted model, aortic and mitral VHD had an increased risk of all-cause death compared with no VHD (HR 1.62, 95% CI 1.44 to 1.82, p<0.001 and HR 1.25, 95% CI 1.09 to 1.44, p=0.002 for aortic and mitral VHD, respectively). CONCLUSION: VHD continues to constitute a significant public health burden, with MR and AS being the most common. Age and cardiac comorbidities remain strong risk factors for VHD. In the modern era of percutaneous and surgical interventions, mortality associated with VHD remains high.

Use of a Real-Time Locating System to Assess Internal Medicine Resident Location and Movement in the Hospital.

Importance: The patient-physician clinical encounter is the cornerstone of medical training, yet residents spend as little as 12% of their time in direct patient contact. Objectives: To use a real-time locating system (RTLS) to characterize intern work experiences in the hospital, understand factors associated with time spent at patients' bedsides, and inform future interventions to increase time spent with patients. Design, Setting, and Participants: This cross-sectional study was conducted from July 1, 2018, to June 30, 2019 (ie, the academic year 2018-2019). Internal medicine residents from postgraduate year 1 (interns) at an academic medical center wore an infrared badge that recorded location and duration (eg, patient room, ward hall, physician workroom). Data were analyzed from September 1, 2020, to August 30, 2021. Main Outcomes and Measures: Main outcome was time (in minutes) at the bedside; the unit of analysis was a 24-hour intern day or interval of time within the day (eg, rounding period). Descriptive statistics are reported overall, by intern, and for 5 clinical service categories. Multilevel modeling assessed the association of intern, service, and calendar time with time spent at the bedside. Results: Data from 43 of 52 interns (82.7%) encompassing 95 275 hours of observations were included for analyses. Twenty-six interns (60.5%) were women. Interns were detected for a mean (SD) of 722.8 (194.4) minutes per 24-hour period; 13.4% of this time was spent in patient rooms (mean [SD] time, 96.8 [57.2] minutes) and 33.3% in physician workrooms (mean [SD] time, 240.9 [228.8] minutes). Mean percentage of time at the bedside during a 24-hour period varied among interns from 8.8% to 18.3%. Mean (SD) percentage of time at the bedside varied by service for the 24-hour period from 11.7% (6.6%) for nononcology subspecialties to 15.4% (6.0%) for oncology, and during rounds from 8.0% (12.4%) for nononcology subspecialties to 26.5% (12.1%) for oncology. In multilevel modeling, the individual intern accounted for 8.1% of overall variance in time spent at the bedside during a 24-hour period, and service accounted for 18.0% of variance during rounds. Conclusions and Relevance: The findings of this cross-sectional study support previous evidence suggesting that interns spend only a small proportion of time with hospitalized patients. The differences in time spent in patients' rooms among interns and during rounds constitute an opportunity to design interventions that bring trainees back to the bedside.

Association of Peripheral Serum MicroRNAs With Persistent Phantom Limb Pain in Individuals With Amputation.

OBJECTIVE: Individuals with major limb amputation(s) frequently experience phantom limb sensations, which are described as vivid impressions of either parts or entire missing limb(s). Despite the high incidence and prevalence of phantom limb pain, the underlying pathophysiology of phantom limb pain remains poorly understood. The objective of this study was to evaluate a possible role of microRNAs in the pathophysiology of phantom limb pain. DESIGN: Adults with acquired limb amputation and varying degrees of phantom limb pain consented to provide clinical data and blood samples. One hundred forty participants with single or multiple limb amputation(s) were enrolled. The Visual analog scale and neuropathic pain symptom inventory were administered to evaluate the pain. Serum samples were analyzed for microRNA expression and bioinformatic analysis was performed. RESULTS: Sixty-seven participants did not experience phantom limb pain, whereas 73 participants experienced varying severities of phantom limb pain measured on a pain scale. Linear regression analysis suggested that the time since amputation is inversely related to severity of the pain. A significantly increased expression of 16 microRNAs was observed in participants experiencing phantom limb pain. Bioinformatic analysis shows a possible role of these microRNAs in regulating genes expressed in peripheral neuropathy. CONCLUSIONS: This study provides the first evidence of association of microRNA in phantom limb pain.

Characteristics of phantom limb pain in U.S. civilians and service members.

OBJECTIVES: The population of Americans with limb loss is on the rise, with a different profile than in previous generations (e.g., greater incidence of amputation due to diabetes). This study aimed to identify the key characteristics of phantom limb sensation (PLS) and pain (PLP) in a current sample of Americans with limb loss. METHODS: This cross-sectional study is the first large-scale (n=649) study on PLP in the current population of Americans with limb loss. A convenience sample of military and civilian persons missing one or more major limbs was surveyed regarding their health history and experience with phantom limb phenomena. RESULTS: Of the participants surveyed, 87% experienced PLS and 82% experienced PLP. PLS and PLP typically first occurred immediately after amputation (47% of cases), but for a small percentage (3-4%) onset did not occur until over a year after amputation. Recent PLP severity decreased over time (ß=0.028, 95% CI: -0.05-0.11), but most participants reported PLP even 10 years after amputation. Higher levels of recent PLP were associated with telescoping (ß=0.123, 95% CI: 0.04-0.21) and higher levels of pre-amputation pain (ß=0.104, 95% CI: 0.03-0.18). Those with congenitally missing limbs experienced lower levels of recent PLP (t (37.93)=3.93, p<0.01) but there were no consistent differences in PLP between other amputation etiologies. CONCLUSIONS: Phantom limb phenomena are common and enduring. Telescoping and pre-amputation pain are associated with higher PLP. Persons with congenitally missing limbs experience lower levels of PLP than those with amputation(s), yet PLP is common even in this subpopulation.

Feasibility and perception of a question prompt list in outpatient cancer care.

INTRODUCTION: Management of cancer is often characterized by difficult decisions. The National Coalition for Cancer Survivorship (NCCS) has developed the "Know Yourself" tool, a question prompt list (QPL) to enable patients to participate in these decisions. METHODS: We investigated the feasibility of using the NCCS tool by oncologists and their patients with cancer in a before-and-after pilot study at a tertiary medical center. We also measured patient reported decision preparedness, anxiety, satisfaction with care, trust in physician, discussion of care with their primary care physician (PCP), and general state of health, and solicited feedback from clinicians and patients on use of the form. RESULTS: Ninety patients and fifteen clinicians participated. Most patients reported the Tool was easy to use (91%) and would recommend it to others (73%) however fewer reported discussing the Tool at the visit (31%) or felt that it improved the quality of care (45%) or communication with the oncologist (56%). Clinicians reported Tool use in only 16 of 60 visits (27%); in these visits the Tool was helpful in identifying areas of concern (74%), guiding the clinical interaction (67%), promoting communication (62%), identifying areas of need (70%), and improving quality of care (71%). Decision preparedness, trust in physicians, uncertainty about care, anxiety, patient satisfaction and discussion of care with the PCP was unchanged with Tool use compared to non-use. CONCLUSIONS: The Know Yourself tool had poor uptake but was favorably received among both patients and clinicians who used it. These findings suggest some patients could benefit from QPLs. Future work should test how implementation strategies might achieve greater use.

Factors Influencing Overuse of Breast Cancer Screening: A Systematic Review.

BACKGROUND: Excessive breast cancer screening with mammography or other modalities often burdens patients with false-positive results and costs. Yet, screening patients beyond the age at which they will benefit or at too frequent intervals persists. This review summarizes the factors associated with overuse of breast cancer screening. METHODS: We searched Medline and Embase from January 1998 to March 2017 for articles addressing the overuse of breast cancer screening and hand-searched the reference lists of included articles. Studies were included if they were written in English, pertained to a U.S. population, and identified a factor associated specifically with overuse of breast imaging. Paired reviewers independently screened abstracts, extracted data, and assessed quality. RESULTS: We included 15 studies: 3 cohort, 5 cross-sectional, 6 surveys, and 1 in-depth interview. White women (non-Hispanic) were less vulnerable than other racial groups to overuse in 3 of 5 studies. Physician specialty was consistently associated with screening overuse in three of three studies. Abundant access to primary care and a patient desire for screening were associated with breast cancer screening overuse. Lower self-confidence, lower risk taking tendencies, higher perception of conflict in expert recommendations, and a belief in screening effectiveness were clinician traits associated with overuse of screening in the surveys. CONCLUSIONS: The literature supports that liberal access to care and clinicians' recommendations to screen, possibly influenced by conflicting guidelines, increase excessive breast cancer screening. Overuse might conceivably be reduced with more concordance across guidelines, physician education, patient involvement in decision-making, thoughtful insurance restrictions, and limitations on the supply of services; however, these will need careful testing regarding their impact.

Factors Associated With the Overuse of Colorectal Cancer Screening: A Systematic Review.

This systematic review examined factors associated with overuse of colorectal cancer (CRC) screening. The authors searched MEDLINE and EMBASE from January 1998 to March 2017. Studies were included if they were written in English, contained original data, involved a US population, and examined factors potentially associated with overuse of CRC screening. Paired reviewers independently screened abstracts, assessed quality, and extracted data. In 8 studies, the associations between patient factors, including age, sex, race, and number of comorbidities, were tested and were inconsistently associated with CRC screening overuse. Overuse of screening was greater in the Northeast/Mid-Atlantic regions and in urban areas and was lower in academically affiliated centers. Although the literature supports important overuse of CRC screening, it remains unclear what drives these practices. Future research should thoroughly explore these factors and test the impact of interventions to reduce overuse of screening.

Older Adults' Perceptions of the Causes and Consequences of Healthcare Overuse: A Qualitative Study.

BACKGROUND: Overuse of healthcare is pervasive in the United States, often exposing patients to harm with little likelihood of benefit. Older Americans are particularly vulnerable to overuse and impacted by it, yet it is unknown whether older patients perceive overuse as a consequential problem. OBJECTIVE: To explore the experiences and perspectives of older adults with respect to healthcare overuse in order to develop a framework for understanding and reducing overuse in older adults. DESIGN: Qualitative study using focus group methodology. PARTICIPANTS: Five focus groups were held with people ≥65 years of age (N = 38) in four senior centers in Baltimore, Maryland, in 2016. APPROACH: Transcripts were analyzed using qualitative content analysis to identify major themes. KEY RESULTS: Of the 38 participants, 28 were women and 29 were African-American; 31 had at least a 12th grade education. While virtually all reported experience with what they perceived to have been healthcare overuse, some expressed concern that they had been denied appropriate care. They perceived overuse to have occurred when interventions were applied in the absence of symptoms (excluding cancer screening), did not improve symptoms, were discordant with their preferences, or were duplicative. Some defined overuse as interventions that were offered before less intensive options or too early in the course of disease. Suggested contributors to overuse were poor quality communication between patients and healthcare providers, and between different healthcare providers. Participants reported suffering from treatment effects, high costs, worry, and inconvenience from what they perceived to be overuse. They suggested that overuse may be reduced when the patient is involved in decision making and has a trusted primary care doctor. CONCLUSIONS: The experience of older adults highlights potential sites of intervention to reduce healthcare overuse. Engaging patients in shared decision making and enhancing communication and knowledge transfer should be tested as interventions to reduce perceived overuse.

Factors associated with imaging overuse in the emergency department: A systematic review.

BACKGROUND: Emergency departments (ED) are sites of prevalent imaging overuse; however, determinants that drive imaging in this setting are not well-characterized. We systematically reviewed the literature to summarize the determinants of imaging overuse in the ED. METHODS: We searched MEDLINE® and Embase® from January 1998 to March 2017. Studies were included if they were written in English, contained original data, pertained to a U.S. population, and identified a determinant associated with overuse of imaging in the ED. RESULTS: Twenty relevant studies were included. Fourteen evaluated computerized tomography (CT) scanning in patents presenting to a regional ED who were then transferred to a level 1 trauma center; incomplete transfer of data and poor image quality were the most frequently described reasons for repeat scanning. Unnecessary pre-transfer scanning or repeated scanning after transfer, in multiple studies, was highest among older patients, those with higher Injury Severity Scores (ISS) and those being transferred further. Six studies explored determinants of overused imaging in the ED in varied conditions, with overuse greater in older patients and those having more comorbid diseases. Defensive imaging reportedly influenced physician behavior. Less integration of services across the health system also predisposed to overuse of imaging. CONCLUSIONS: The literature is heterogeneous with surprisingly few studies of determinants of imaging in minor head injury or of spine imaging. Older patient age and higher ISS were the most consistently associated with ED imaging overuse. This review highlights the need for precise definitions of overuse of imaging in the ED.

Death and Cardiac Arrest in U.S. Triathlon Participants, 1985 to 2016: A Case Series.

BACKGROUND: Reports of race-related triathlon fatalities have raised questions regarding athlete safety. OBJECTIVE: To describe death and cardiac arrest among triathlon participants. DESIGN: Case series. SETTING: United States. PARTICIPANTS: Participants in U.S. triathlon races from 1985 to 2016. MEASUREMENTS: Data on deaths and cardiac arrests were assembled from such sources as the U.S. National Registry of Sudden Death in Athletes (which uses news media, Internet searches, LexisNexis archival databases, and news clipping services) and USA Triathlon (USAT) records. Incidence of death or cardiac arrest in USAT-sanctioned races from 2006 to 2016 was calculated. RESULTS: A total of 135 sudden deaths, resuscitated cardiac arrests, and trauma-related deaths were compiled; mean (±SE) age of victims was 46.7 ± 12.4 years, and 85% were male. Most sudden deaths and cardiac arrests occurred in the swim segment (n = 90); the others occurred during bicycling (n = 7), running (n = 15), and postrace recovery (n = 8). Fifteen trauma-related deaths occurred during the bike segment. Incidence of death or cardiac arrest among USAT participants (n = 4 776 443) was 1.74 per 100 000 (2.40 in men and 0.74 in women per 100 000; P < 0.001). In men, risk increased substantially with age and was much greater for those aged 60 years and older (18.6 per 100 000 participants). Death or cardiac arrest risk was similar for short, intermediate, and long races (1.61 vs. 1.41 vs. 1.92 per 100 000 participants). At autopsy, 27 of 61 decedents (44%) had clinically relevant cardiovascular abnormalities, most frequently atherosclerotic coronary disease or cardiomyopathy. LIMITATIONS: Case identification may be incomplete and may underestimate events, particularly in the early study period. In addition, prerace medical history is unknown in most cases. CONCLUSION: Deaths and cardiac arrests during the triathlon are not rare; most have occurred in middle-aged and older men. Most sudden deaths in triathletes happened during the swim segment, and clinically silent cardiovascular disease was present in an unexpected proportion of decedents. PRIMARY FUNDING SOURCE: Minneapolis Heart Institute Foundation.

Symptoms of PTSD Associated With Painful and Nonpainful Vicarious Reactivity Following Amputation.

Although the experience of vicarious sensations when observing another in pain have been described postamputation, the underlying mechanisms are unknown. We investigated whether vicarious sensations are related to posttraumatic stress disorder (PTSD) symptoms and chronic pain. In Study 1, 236 amputees completed questionnaires about phantom limb phenomena and vicarious sensations to both innocuous and painful sensory experiences of others. There was a 10.2% incidence of vicarious sensations, which was significantly more prevalent in amputees reporting PTSD-like experiences, particularly increased arousal and reexperiencing the event that led to amputation (φ = .16). In Study 2, 63 amputees completed the Empathy for Pain Scale and PTSD Checklist-Civilian Version. Cluster analyses revealed 3 groups: 1 group did not experience vicarious pain or PTSD symptoms, and 2 groups were vicarious pain responders, but only 1 had increased PTSD symptoms. Only the latter group showed increased chronic pain severity compared with the nonresponder group (p = .025) with a moderate effect size (r = .35). The findings from both studies implicated an overlap, but also divergence, between PTSD symptoms and vicarious pain reactivity postamputation. Maladaptive mechanisms implicated in severe chronic pain and physical reactivity posttrauma may increase the incidence of vicarious reactivity to the pain of others.

Mechanisms of traumatic brain injury.

The authors describe the mechanisms of traumatic brain injury (TBI), examining in depth the characteristics of closed head, penetrating, and blast-related TBI. Events on a structural as well as cellular level are reviewed. Blast-related brain injury, in particular, affects military service members preferentially, but is also relevant in cases of industrial accidents as well as terrorist events.

Observation of limb movements reduces phantom limb pain in bilateral amputees.

BACKGROUND: Mirror therapy has been demonstrated to reduce phantom limb pain (PLP) experienced by unilateral limb amputees. Research suggests that the visual feedback of observing a limb moving in the mirror is critical for therapeutic efficacy. OBJECTIVE: Since mirror therapy is not an option for bilateral lower limb amputees, the purpose of this study was to determine if direct observation of another person's limbs could be used to relieve PLP. METHODS: We randomly assigned 20 bilateral lower limb amputees with PLP to visual observation (n = 11) or mental visualization (n = 9) treatment. Treatment consisted of seven discrete movements which were mimicked by the amputee's phantom limbs moving while visually observing the experimenter's limbs moving, or closing the eyes while visualizing and attempting the movements with their phantom limbs, respectively. Participants performed movements for 20 min daily for 1 month. Response to therapy was measured using a 100-mm visual analog scale (VAS) and the McGill Short-Form Pain Questionnaire (SF-MPQ). RESULTS: Direct visual observation significantly reduced PLP in both legs (P < 0.05). Amputees assigned to the mental visualization condition did not show a significant reduction in PLP. INTERPRETATION: Direct visual observation therapy is an inexpensive and effective treatment for PLP that is accessible to bilateral lower limb amputees.