Dec 15, 2017

Forget me not

The story

In residency, each holiday you spend on call is an exercise in delayed gratification. But through all of the years of education and training, are you unwittingly playing the long game with dementia prevention? Research into Alzheimer's disease is hopeful.

The background

Think of dementia the way you think of the salary difference between you and your friends in other fields: easy-to-recognize, but hard to do much about. The lack of effective treatment options has led many researchers to focus on prevention. This summer, an expert commission on dementia care identified 9 modifiable risk factors, led by hearing loss, as contributors. Studies to date are largely observational, and therefore prone to biases like self-reporting or reverse causation.

The study

One way to remove bias is to link traits – e.g. intelligence or predisposition to heavy coffee consumption – to specific gene loci, and then see how these genes are related to disease. Researchers applied this approach, termed a Mendelian randomization analysis, to data from the International Genomics of Alzheimer's Project to see which modifiable risk factors had the biggest impact on Alzheimer's disease. Out of 24 known risk factors, educational attainment (or genes associated with educational attainment, to be precise) had the clearest link to a decreased risk of dementia. College completion also was associated with decreased risk, while the data for smoking, alcohol and coffee were inconclusive.

The takeaway

If you think the associations-upon-associations needed to make these conclusions are kind of sketchy, we hear you. But it is encouraging that more and more data points to education as protective against dementia.  

Say it on rounds

When your scarred by what you accidentally find in the patient's bed

You'll get over it. But patients with scar tissue from prior myocardial infarction or myocarditis remain at high risk for arrhythmia and death. In a case series of 5 high-risk patients with ventricular tachycardia (VT) refractory to ablation, investigators electrically mapped arrhythmia-provoking scar regions and then targeted them with a single dose of stereotactic radiation. At 1-year follow-up, patients saw near total elimination of VT burden after the initial post-procedural period. Since the approach is noninvasive, even the sickest patients may be candidates for treatment. Up next: a phase I study.

When it's sundown and you still haven't started the day's first note

If only technology could finish your work for you. Machine learning, where computers learn to recognize pathology by looking at large datasets, has obvious applications in radiology and pathology. An evaluation of 32 deep learning algorithms in the detection of breast cancer lymph node metastasis found that 7 of the algorithms showed greater discrimination than an expert panel of 11 pathologists. And while machines aren't ready to replace humans yet – some say the expert panel did not have adequate time to complete its work – robot pathologists could be a part of your hospital's workflow in the not-too-distant future.

When your medicine consult pager won't stop buzzing

Not all sinus tachycardia requires a work up, and not all falls among the elderly require an ED visit. About 70% of elderly patients who go to the emergency room after falls are sent home without an admission. A single-system cohort study investigated whether an EMS protocol for falls, which included a physician consult via phone, could reduce ED visits. Even though the protocol chose not to admit 65% of falls, there were no changes in complications or mortality over almost 4 years of study follow up.

Brush up

Necrotizing fasciitis

Necrotizing soft-tissue infections carry high mortality rates. Patients are most at risk after skin breaches or non-penetrating soft tissue injuries. Look for swelling, erythema, pain out of proportion to injury and notable absence of pus in a patient with systemic signs of infection. Elevated creatine kinase and C-reactive protein levels are common laboratory findings. If you have high clinical suspicion, initiate broad-spectrum antibiotics and call surgery for emergent debridement.

What's the evidence

Behind clinical suspicion for necrotizing fasciitis (NF)? A 2015 retrospective case control compared cases of NF with cellulitis. Recent surgery, pain-out-of-proportion, diarrhea, hypotension, altered mental status, erythema beyond margins, fluctuance, hemorrhagic bullae, and skin necrosis all significantly increased the likelihood of NF. Three or more of the above factors effectively rules in NF.

What your tech friends are talking about

If you thought Storm Troopers were clunky, take a look at these thumb-shaped robots policing the streets of San Francisco. The 'bots have come under fire for breaking up homeless encampments.

Spread the word

We're taking a two-week break to relax for the holidays. Thanks for all of your support in 2017. Have a wonderful holiday season and New Year. 


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