Nov 2, 2018

The big chill

The story

That chilly look from your ex isn't doing your heart any favors, and neither is the November weather. Here's how cold and dark days trigger the STEMI pager. 

The background

If you ever needed an excuse for an afternoon Mai Tai on the beach, consider this: myocardial infarctions (MIs) are picky. Peak onset is in the morning, peak season is the winter, and peak susceptibility is shortly after the flu and other respiratory viruses. But that's about where the knowledge stops. Whether these patterns are due to intrinsic physiology, such as a link between cold weather and coronary vasospasm, or extrinsic factors like stress and behavior patterns hasn't been proven. The first step is to tease out a role for weather vs. other seasonal changes.

The mash up

SWEDEHEART prospectively tracked MIs in Sweden from 1998 - 2013, while the Swedish Meteorological and Hydrological Institute kept note of atmospheric conditions at every hospital location. Mix the two for a population-based cohort of 275,000 MIs across temperatures, pressures, and seasons. MIs, as measured by incidence rate, were more likely when air temperature was low, winds were high, and sunshine was in short supply. The strongest association was seen for air temperature, where a 7°C rise in temp was associated with a 3% decrease in MI risk.  
JAMA Cards

The takeaway

The winter is a time for your frail patients to take extra care. Flu shots and warm clothing look increasingly like important tools in the fight against heart disease.

Say it on rounds

When you get attention for all the wrong reasons

Fresh off the heels of a FDA-led recall of NMDA-contaminated valsartan in August, angiotensin converting enzyme inhibitors (ACEi) were linked to an increased incidence of lung cancer in a British cohort of 1 million patients beginning antihypertensive therapy. The increased risk was small overall – 1.6 vs. 1.2 events per 1000-person years for patients on ACEi therapy – but grew with time on treatment. Some have called for the use of other antihypertensive drugs in smokers (already at high risk for lung cancer) while the relationship is investigated in more detail.

When you're thinking of adding in a little role play

Don't get too frisky. But know that a randomized trial of 200 ICU nurses in France found that a 5-day intervention course designed to help participants cope with stressful situations through education, role-play, and debriefing dramatically reduced job strain among participants. At 6 months, prevalence of job strain was 13% in the intervention group and 67% among controls, and more nurses in the control group (12 vs. 4 in the intervention group) chose to leave ICU work.

When you get 3 admissions before noon

It's better to know early. A 30-year prospective cohort that screened 45,000 at-risk women for ovarian cancer found that yearly transvaginal ultrasound (TVUS) caught cancers at an earlier stage and led to improved disease specific survival compared to unscreened women treated at the same institution. Women over age 50 and women over age 24 with a positive family history were screened. While disease incidence was low in the study population, TVUS was cheap and could be effective if applied to higher-risk patients.  
Obstet Gynecol

Brush up


Like a lot of things, measles shouldn’t really be a problem anymore, but there have been 11 outbreaks in the US so far in 2018. The virus causes 100,000 deaths annually worldwide, down from 2 million prior to the advent of vaccination. Symptoms include fever, cough, coryza, and conjunctivitis followed by a downward-spreading rash. The disease effects organs throughout the body, but most morbidity comes from pneumonia.

What's the evidence

For herd immunity in measles? The virus is highly contagious, with a basic reproduction number that puts influenza, smallpox, and ebola to shame. A 2014 epidemiology analysis found that 95% or more of the population would need to be immunized to stop spread during an outbreak, and even more if one allows for less than perfect vaccine efficacy. A 2015 Disneyland outbreak was linked to low vaccination rates in the affected communities.

What your music festival friends are talking about

The FDA thinks magic mushrooms may be good for more than viewing tapestries at Coachella. The agency granted Breakthrough Therapy designation for the use of psilocybin-assisted therapy in refractory depression. 
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