Aug 4, 2017

Quitting time

The story

Just like you can't decide whether to love or hate the attending who's super nice but lets rounds drag on forever, the FDA has its hands full with e-cigarettes. Does vaping influence quit rates? 

The background

After announcing last May that it was extending its regulatory powers to e-cigarettes, many thought big changes were imminent for the vaping industry. But the agency abruptly changed course last Friday and announced a delay in its plans. The push and pull is status-quo for e-cigarettes, which have been a source of non-stop controversy since their inception in the early 2000's. Advocates argue that they help smokers quit and reduce exposure to tobacco tar, while critics point to e-cigs as a trap for children. And if you can't tell an e-cigarette from your roommate's incense, here's a nuts and bolts tutorial to get you started. Try to ignore the pro-vaping tilt.

The study

A look at population-level tobacco survey data found that US smoking cessation rates increased for the first time in nearly two decades in 2014 - 2015. The rise is tied to the increased use of e-cigarettes. Vapers were 73% more likely to quit smoking than smokers. And while the increase in smoking cessation rate was a mere 1.2%, from 4.4% to 5.6%, that equates to an additional 350,000 successful US quitters. Since the quit rate hasn't budged since 1990 despite all kinds of new nicotine replacement strategies and anti-smoking meds, e-cigarettes look like a game-changing smoking cessation aide.

The takeaway

The long-term safety of e-cigarettes remains unknown, and important steps need to be taken to keep them away from children. But e-cigs are a potent anti-smoking tool. Expect more research on the subject as companies race to get their vaping devices approved as smoking cessation aides.

Say it on rounds

When the EMR crashes just before you save your note

Sometimes your best efforts are all for naught. While hospitals nationwide have implemented near-universal DVT prophylaxis programs in recent years, a look at Mayo Clinic hospitalizations between 2005, when 40% of hospitalized patients received DVT prophylaxis, and 2010, when 90% of patients received prophylaxis, found no difference in venous thromboembolism (VTE) event rates. VTE prophylaxis was only given during hospital admission, while 75% of VTEs occurred after hospital discharge. Median time to VTE following hospitalization was 20 days.

When you spend too much of your ICU shift renewing restraints

There's hope that statins can save you a few mouseclicks. A single-center retrospective cohort study compared 1,500 ICU patients on statins with control ICU patients not on statins. Statin use was associated with a 53% decrease in the risk of delirium, with somewhat larger decreases seen with simvastatin compared to atorvastatin. The authors suggest that statins may decrease inflammation in the brain, though prospective studies are needed to substantiate these findings.
Crit Care Med

When your med student asks you a biochemistry question

By now you've learned a million ways to dodge questions without admitting you don't know the answer. And by now you've probably heard of CRISPR, the gene-editing technique that sounds more like a Burger King menu item than the uber-powerful tool that's revolutionizing biology. In a first for the field, researchers used CRISPR to remove a harmful mutation – the genetic culprit behind hypertrophic cardiomyopathy – from early human embryos without detectable hazardous effects. Such gene-editing could one day be used to eliminate a host of congenital diseases, though ethically tricky concepts are at play.

Brush up

Subarachnoid hemorrhage

You already know to consider subarachnoid hemorrhage (SAH) when your patient says she has the worst headache of her life. But the disease is more common than you think: SAH accounts for 5 - 10% of US strokes and has an outsized representation in young patients. The majority of atraumatic incidents are due to aneurysm rupture. Head CT without contrast is crucial for diagnosis. Goals of initial therapy are to reduce the risk of rerupture, mainly through endovascular or surgical treatment of the initial ruptured aneurysm. 

What's the evidence

For sentinel headaches in SAH? Between 10 and 40% of patients who suffer SAH experience a sentinel headache 2 to 8 weeks before the event. A 2004 inception cohort of 480 patients found that sentinel headache patients who were incorrectly diagnosed at initial presentation were almost 5 times as likely to suffer from death or long-term disability as those who received appropriate initial evaluation with a head CT. Migraine and tension headache were the most common incorrect diagnoses. 

What your health policy friends are talking about

It's hard to make a splash in the political arena these days. In a move dwarfed by larger headlines, Senator Cory Booker of New Jersey introduced new legislation designed to remove the federal ban on marijuana. 

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