July 22, 2016

Global stroke

The story

Your clinic chair is old and overbooked, but the world's largest case-control study says it's the best place to prevent stroke.

The phases

INTERSTROKE, a global case-control study designed to evaluate population-level risk factors for stroke, released its phase I results in 2010. It found that common, modifiable risk factors accounted for the vast majority of strokes in 6,000 patients in 22 countries. This week's complete trial results produced similar findings, confirming 10 risk factors as responsible for 90% of the population attributable risk (PAR) for stroke in 27,000 patients in 32 countries. The aggregate PAR of the identified risk factors remained consistent in different regions of the world, though the prevalence of individual risk factors varied substantially.

The factors

The 10 identified risk factors look a lot like the usual suspects: hypertension, sedentary lifestyle, serum apolipoprotein ratios, diet, central obesity, stress / psychosocial factors, current smoking, atrial fibrillation, alcohol consumption, and diabetes. Hypertension remains your number one clinic target with a group-leading 48% PAR.

The takeaway

A few months on the wards will show you the devastating consequences of stroke. Case-control studies are subject to many biases, but the size of INTERSTROKE and the magnitude of its findings prove that primary care clinics and public health programs have a lot of work to do.

Say it on rounds

When moonlighting doubles your disposable income

Tacking on some extra time can provide a serious boost. The same goes for aromatase inhibitor (AI) therapy in hormone-receptor-positive early breast cancers in post-menopausal women, where five years of AI produces long-term remission in 91% of patients. The MA.17R trial found that adding an additional 5 years of AI therapy, for ten total years of treatment, improved 5-year disease-free survival to 95% vs. placebo. The 10-year therapy patients were about one third less likely to have breast cancer recurrence or new malignancy in the contralateral breast.

When your black weekend has you feeling hormonal

You'll probably be fine. Take a nod from in-vitro fertilization (IVF), where supra-physiologic surges in estradiol and progesterone during ovarian stimulation do not appear to be associated with breast cancer. A 25,000 woman cohort study from the Netherlands found no significant differences in breast cancer risk for those who received IVF at 20-year follow-up, helping to ease a long-held patient and clinician concern.

When you need to fill out your new white coat

Don't break your back. A study of light vs. heavyweight resistance training in 49 young men found that both activities similarly increased muscle mass at 12 weeks when repetitions were performed until muscles fatigued. The investigators suggest that muscles respond to 'volitional failure', rather than load, to add mass. 
J Appl Physiol

Brush up

Get practical

A wide range of anxiety disorders run wild in your outpatient clinic. Since there's little evidence to recommend psychotherapy vs. pharmacotherapy as first-line treatment for most anxiety disorders, mix and match based on patient preferences. If you choose meds, start with low-dose SSRIs and uptitrate slowly since anxious patients are often more sensitive to side effects. Continue therapy for at least one year before judging efficacy, and be careful when stopping since relapse rates are as high as 40%.  

Get meta

With cognitive behavioral therapy (CBT) in anxiety. A 2008 evaluation of 27 CBT vs. placebo RCTs found that patients were four times as likely to respond to treatment with CBT across studies, with the largest effects seen in obsessive compulsive disorder and acute stress disorder. It can be hard to refer patients to CBT if it's not offered in your area, but internet options are efficacious and increasingly available.

Residency science

Place a bunch of sleep-deprived overnight residents in a driving simulator, and you'll see delayed reaction time and lapses in attention when comparing performance with day shift residents. Uber, anyone?
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