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Nov 18, 2016

Percentage play

The story

For you, lifestyle improvement means doing something – anything – before going to sleep when you get home from work. But for patients at risk for coronary artery disease (CAD), new data shows a better lifestyle can cut the risk of heart disease in half, even in those with bad genes. 

The basics

We love telling patients things they already know, like eat well and stop smoking. The AHA emphasized the contribution of lifestyle to CAD in 2010, when they estimated that a set of healthy lifestyle goals could reduce major adverse cardiovascular events (MACE) by 20% by the year 2020. Yet genes also influence CAD, and the development of genomic risk scores that can predict risk of MACE better than traditional risk factors has left the relative contributions of genes and lifestyle unclear.

Nature meets nurture

Researchers applied genomic risk scores to 55,000 patients from four large CAD studies to determine how genes and lifestyle interact. In large cohort studies, the worst gene scores doubled the risk of MACE compared to the best, but living a favorable lifestyle – defined as 3 of 4 of not-smoking, maintaining a healthy weight, eating fruits, vegetables and lean protein, and exercising once per week – lowered the risk of heart disease by almost 50%.
NEJM

The takeaway

Patients with the worst CAD genes can gain huge benefits from a healthy lifestyle. So while there may be an emerging role for genetic testing in CAD risk evaluation, there's definitely a role for all of your patients to get on the treadmill and start eating salads.

Say it on rounds

When your pager beeps on your day off

So much for the health benefits of off-duty relaxation. A global survey of 19 million adults found no difference in worldwide blood pressure prevalence between 1975 and 2015 despite an increase in treatment options. But a closer look at the data shows that the burden of hypertension has shifted from high-income countries to low income countries in South Asia and sub-Saharan Africa, where the incidence of hypertension is rising. 
Lancet

When your EMR technology leaves you unimpressed

Look elsewhere for inspiration. Specifically the Netherlands, where researchers used a brain-computer interface to help an amyotrophic lateral sclerosis (ALS) patient communicate. Through electrodes implanted in her motor cortex, the patient spelled messages by imagining that she was moving her hand. With ongoing use, the machine achieved a correct task performance rate of 91% and an average time of 33 seconds per letter at 28-week follow-up.
NEJM

When you just can't tell if your patient can breathe on her own

You're probably going to be at the bedside every 15 minutes anyway, but a new scoring metric can cut some of the suspense. A study of 449 patients on non-invasive ventilation (NIV) found that a scale based on heart rate, acidosis, consciousness, oxygenation and respiratory rate (HACOR) can estimate failure of non-invasive ventilation and the need for intubation with a predictive power exceeding 80%. The authors note that each of the HACOR values can be obtained at bedside.
Intensive Care Med

Brush up

Hypercalcemia 

Primary hyperparathyroidism and malignancy are the most common etiologies of hypercalcemia. Make sure to correct serum calcium lab values for albumin. In the outpatient setting, follow mild hypercalcemia and investigate for underlying etiologies, and consider adding a loop diuretic in those with heart failure or renal insufficiency. Treat severe hypercalcemia with aggressive hydration and bisphosphonates.

What's the evidence

For bisphosphonates in hypercalcemia? Both zoledronic acid and pamidronate are FDA approved for the treatment of hypercalcemia of malignancy. A 275 patient paired RCT found that zoledronic acid normalized calcium levels in 88% of patients, while pamidronate was successful in 70% of patients. For patients who fail bisphosphonate therapy, denosumab, an antibody that inhibits osteoclast-mediated bone resorption, lowered serum calcium levels by 64% in a single arm trial. 

Predict the future

A Swedish private-sector trade union set up a hotline for 'mansplaining' to allow their workers to vent about how the issue affects their professional lives. Calling a hospital near you?

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We're off next week to carve turkey and eat cranberries. Wishing the best to you and yours this Thanksgiving. We'll see you back in your inbox on December 2nd.

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