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May 5, 2017

Nocebo

The story

Just like you feel worse when your friends remind you that you're working Friday night, patients feel worse when they're reminded that they're taking meds. New research explores the nocebo effect in statins.

The basics

The placebo effect, where patients feel better after treatment with an inactive substance, is old news. But the nocebo effect, where patients pin unrelated symptoms on a prescribed therapy, is less well-studied. Statins have been a poster child: despite proven efficacy, over 200,000 patients in the United Kingdom stopped taking their meds after media reports surfaced of increased rates of myalgias in statin users. Multiple blinded RCTs have found no difference in myalgias between those taking statins and placebo.

The study

ASCOT, a double-blinded RCT that evaluated the use of atorvastatin in over 10,000 hypertensive patients, was stopped early after demonstrating that statins decreased heart attacks compared to placebo. Investigators then followed patients for a 3-year non-randomized, unblinded trial extension. Though there was no difference in adverse events while the study was blinded, once patients knew they were on statin therapy they suffered increased rates of myalgias, connective tissue-related issues, and hematologic complaints compared to placebo, even after adjusting for baseline differences between groups.
Lancet

The takeaway

We've all seen our patients decline therapies with real but rare side effects (the flu shot in particular comes to mind). This study is among the first to formally demonstrate a nocebo effect, something that may increase with the rapid spread of sensational news.

Say it on rounds

When your Tinder date looks nothing like his or her pictures

Shocks are rarely good outside of medicine, but they work wonders in cardiac arrests. A look into Danish arrest registries found that bystander defibrillator use in out-of-hospital cardiac arrests increased from 2% to 16% from 2001 – 2012, while bystander CPR increased from 67% to 80%. Both interventions were associated with decreases in anoxic brain injury and nursing home admission at one year when compared to arrests where bystanders did not assist. A 2-minute video has more.
NEJM

When rent is due but payday is a week away

As a resident, you can't throw money at problems, and you can't throw steroids at patients. A retrospective study of 300,000 adults who were prescribed low-dose steroids for short time periods found that the steroid users faced significantly higher rates of fracture, venous thromboembolism, and sepsis compared to nonusers within 30 days of their prescription. Adverse events persisted at doses as low as 20 mg of prednisone a day. 
BMJ

When the flight attendant asks if there's a doctor onboard

Try not to panic. While some are better than others when taken out of their comfort zone, tofacitinib (Xeljanz), an oral janus kinase (JAK) inhibitor used in rheumatoid arthritis, has shown it can hang in a few different environments. Three phase 3 RCTs of patients who had failed previous conventional or biologic therapy for ulcerative colitis (UC) found that the drug increased induction and maintenance of remission compared to placebo in patients with moderate to severe disease. The trials confirm the JAK pathway as a promising target in UC-related inflammation.
NEJM

Brush up

ECMO

Use venovenous extracorporeal membrane oxygenation (VV ECMO) as a salvage therapy for patients with refractory acute respiratory distress syndrome (ARDS). Venous blood is pumped through an external membrane oxygenator which, like native lungs, oxygenates blood and removes carbon dioxide. Blood is then reinfused through large catheters in the femoral and jugular veins. Patients must be anticoagulated, and complications include infection, bleeding, hemolysis, thrombocytopenia and DIC. 

What's the evidence

For ECMO in ARDS? The 2009 CESAR trial randomized 180 patients with refractory ARDS to ECMO versus conventional treatment and found significantly lower 6-month mortality or severe disability (47% vs. 63%) in the ECMO group. Many patients in the conventional group did not receive lung protective ventilation, causing some to cast doubt on CESAR's findings. A clinical trial comparing ECMO to lung-protective ARDS management is underway.

What your gender-equity friends are talking about

Leave it to medicine to consistently underwhelm when it comes to equal pay for equal work. New surveys suggest that pay gaps between men and women are present in all medical specialties, and none favor women. The good news? Gaps may be declining among younger physicians.

Spread the word

Send your interns something to look forward to.

  

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