Mar 29, 2019

Scan sparer

The story

Mixing scrubs and pajamas is a fashion choice, but mixing radiation and pregnancy is risky business. A new algorithm cuts down on unnecessary CT scans.

The background

Pulmonary embolism (PE) is a leading cause of maternal death in Western countries, but symptoms are hard to distinguish from the dyspnea, tachycardia, and edema of normal pregnancy. The absence of reliable clues creates a low threshold for use of CT pulmonary angiography (CTA) in pregnant women even though prevalence of PE in suspected cases is about 5%. Fortunately, PE diagnostic algorithms are evolving: a 2017 study found that the YEARS algorithm reduced unnecessary CTA by 15% compared to the Well's criteria in healthy adults. Mom and fetus could use similar help.  

The study

YEARS combines 3 clinical criteria – signs of DVT, hemoptysis, and PE as the most likely diagnosis – with d-dimer level to rule out PE or recommend further testing with CTA. A prospective study of 500 pregnant women with suspected PE found that a modified YEARS algorithm that included compression ultrasound for symptoms of DVT safely excluded PE without CTA in 39% of patients. Because d-dimer increases by trimester, the algorithm was most effective in the first trimester (65% of patients avoided CTA) and least effective in the third trimester (CTA avoided in 32% of patients).

The takeaway

The modified YEARS algorithm makes smart use of clinical data to avoid unnecessary tests in a sensitive population. Expect it to take hold in your ED soon. 

Say it on rounds

When your list turnover is out of control

Discharges are the strongest predictor of new admissions, and portal hypertension is the strongest predictor of decline from compensated to decompensated cirrhosis. A RCT of 200 patients with compensated cirrhosis and portal pressure > 10 mm Hg found that non-selective β blockers (e.g. propranolol) reduced the rate of clinical decompensation (16% vs. 27%) compared to placebo at 3 years, largely due to fewer episodes of ascites. Since portal pressure testing is invasive and not always feasible, how to apply these results to the broader pool of patients with compensated cirrhosis remains an open question.

When the post-lunch cookies look harmless

Let's hope so. A retrospective, single-center study of cannabis-related ED visits found that edibles were responsible for 11% of ED visits even though they accounted for only 0.3% of cannabis sales in Colorado. Edible visits were more likely to be due to acute psych symptoms, intoxication, and cardiovascular symptoms than inhaled cannabis visits, which were more likely to be due to cannabinoid hyperemesis syndrome. Experts warn that edibles, which take a much longer time to produce a high than inhaled cannabis, place users at an increased risk for overdose.

When data sharing feels like the rule rather than the exception

No surprises here. A study of 24 popular medicine-related Android apps found that 19 of 24 apps – including Lexicomp and Medscape – leaked consumer data to third parties like Amazon Web Services and Google. For the most part, data shared included app-related browsing (38% of apps) and user email address (also 38% apps), but in some cases the apps shared drug lists (25%) and medical conditions (17%). The authors say that such data sharing could pave the way for highly targeted marketing or even discrimination based on health conditions.

How much can you save when you refinance?

When you refinance with Laurel Road, an interest rate reduction of 2% could save you over $20,000 on average over the life of your student loans. Don’t believe us? Take a look for yourself!¹

Remember, medical students who’ve matched to a residency program can refinance their medical school loans and pay only $100 per month during training and up to six months into their professional practice!²

As a Scope reader, you’ll receive a $300 bonus³ when you refinance with Laurel Road. Click here to check your rate.

Brush up

Autosomal dominant polycystic kidney disease (ADPKD)

Count ADPKD as the fourth most common cause of kidney failure worldwide. Affected persons have a 50% risk of passing the disease to their children, though about 6 - 8% of cases are sporadic. Hypertension is the most common clinical manifestation and is preferentially treated with ACE inhibitors or ARBs. Ultrasound confirming large, cystic kidneys is the most common method of diagnosis. Be on the lookout for extra-renal manifestations including intracranial aneurysm and polycystic liver disease.

What's the evidence

For treatment to slow the progression of ADPKD? A 2017 phase 3 RCT  of 1,400 patients with late-stage ADPKD found that treatment with tolvaptan slowed the decline of glomerular filtration rate relative to placebo over 3-year follow-up. Previous studies have also shown that tolvaptan slows the rate of kidney volume expansion. The drug is FDA approved for rapidly progressing ADPKD.

What your anesthesia friends are talking about

Jo Cameron, 71, compared the pain of childbirth to a tickle. Scientists pinned her insensitivity to pain (and anxiety and fear) to a previously unidentified gene.

Spread the word

Send your interns something to look forward to


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¹ This 2% savings example is based on a loan of $180,000 and is for illustrative purposes only and may not reflect actual savings. Savings vary based on rate and term of your existing and refinanced loan(s). Review your loan documentation for total cost of your refinanced loan. Rates and terms offered are subject to credit approval.

²We may agree under certain circumstances to allow a borrower to make $100/month payments immediately after loan disbursement if the borrower is employed full‐time as an intern, resident, fellow, or similar postgraduate trainee at the time of loan disbursement. These payments may not be enough to cover all of the interest that accrues on the loan. Unpaid accrued interest will be added to your loan and monthly payments of principal and interest will begin when the post‐graduate training program ends. For APR and payment examples, go to

³ The Scope reader $300 cash bonus is offered for applications from active The Scope readers. The loan application must close in order to qualify for the bonus. Offer cannot be combined with other Laurel Road offers, including the Referral Program. Existing customers are not eligible.

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