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Oct 6, 2017

Call center

The story

You can't just hang up on rounds presentations that take forever, even if in your head you're calling outer space. Policymakers in the UK want to move patients from the waiting room to the dial tone. A new study frames the experience so far. 

The background

Hospital labor is built on passing work down the chain (think fellow to resident to intern and so forth), but clinics are a different story. Primary care docs attend to most matters themselves and in person. With outpatient care growing more complex as clinics are expected to deal with sicker and sicker patients, UK clinics have seen substantial increases in the number and length of patient visits in the past 10 years. It's led the country's National Health Service to look to save time and decrease costs by shipping primary care consults to the phone.

The study

You know when you think to yourself 'does this person really need to be here' during walk-in clinic? Well people study things like that. A look at a telephone first triage strategy in the UK found that about half of primary care complaints could be addressed over the phone. The study implemented a call-before-visiting approach in 150 UK general practices and compared outcomes to traditional face-to-face clinics. Average overall workload for physicians increased in the phone group, while there was no difference in emergency room visits. More organized practices seemed to handle the switch better, but costs, perhaps the key driver in the experiment, remained similar in both groups. 
BMJ

The takeaway

Much of the research that advocates for telemedicine was sponsored by companies and agencies looking to profit. These independent results show that phone consults may not yet be better than face-to-face conversation.

Say it on rounds

When your friend thinks every mosquito bite will make him infertile

Zika just freaks people out. A Phase 1 trial of an anti-Zika DNA vaccine found the 3-injection series to be safe and immunogenic in participants. The novel vaccine places Zika DNA in host human cells which in turn make Zika proteins. These proteins are recognized as foreign by the immune system and provoke an antigenic response. Both 1 mg and 2 mg doses produced immune responses in all participants at 14 weeks, though the 2 mg dose produced higher antibody titers. For those worried about the brain, 95% of serum samples from vaccinated patients neutralized infection in colonies of neuronal cells. A Phase 2 study is underway.
NEJM

When you switch from bacon to bagels

You're about halfway there. A retrospective cohort of dietary questionnaires from over 200,000 participants graded diets based on consumption of healthy plant-based foods (think whole grains, legumes, fruits and vegetables), unhealthy plant-based foods like refined grains and sweetened beverages, and animal-based foods. Adherence to a healthy plant-based diet was associated with a 25% lower incidence of cardiovascular disease, while unhealthy plant-based diets were associated with a 32% increase in cardiovascular disease.
JACC

When your focus shifts from the patient to the movie that's playing in her room

It takes discipline not to get sucked in. And while little as captivating as the surprises on patient TVs, a good video helps. Families randomized to watch a 6-minute video on CPR and code status as part of code status discussions were more than three times as likely to choose DNR / DNI than those assigned to conventional goals of care conversations in a 120-patient trial. Previous studies have used videos tailored to cancer or heart failure patients, but this is among the first trials to evaluate a video designed for the general medicine wards. 
J Hosp Med

Brush up

Pre-eclampsia

Babies are beautiful but pregnancy isn't always pretty. Diagnose pre-eclampsia with new-onset hypertension in pregnancy along with proteinuria or maternal organ dysfunction. Risk factors include pre-existing or gestational hypertension, chronic kidney disease, autoimmune disease, and prior pre-eclampsia. Low-dose aspirin is best studied for prevention, though calcium supplementation may also be helpful. Mom's symptoms can vary widely, but treatment is centered around tight blood pressure control, IV magnesium, and prompt delivery.

What's the evidence

For predicting adverse outcomes in preeclampsia? Given the lethality and clinical heterogeneity of severe disease, appropriate triage is vital in low-resource settings. A 2011 prospective study of the fullPIERS model found that it accurately predicted adverse maternal outcomes in the first 48 hours of admission. Oxygen saturation, chest pain, dyspnea, platelet count, creatinine, liver enzymes, and gestational age were found to be the most useful parameters. The more clinical miniPIERS model can help in situations where laboratory data is inaccesible.

Gun control

We can’t divorce gun violence from healthcare, not when all we hope to do as doctors can be cut down by bump stocks and semiautomatic rifles. Our hearts pour out to all the victims of domestic terror in Las Vegas. We simply can’t wrap our brains around gun lobbies and the financial strength that allows them to dictate gun safety politics in Washington in tragedy after tragedy. Thanks to Jimmy Kimmel for using his platform to cast light on dirty money. Here are Steve Israel’s thoughts on the hurdles of gun politics, even after Las Vegas, Orlando, and Sandy Hook. And here’s a chart plotting popular support for gun control relative to expert-predicted efficacy.

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