Journal Feed Weekly Wrap-Up

We always work hard, but we may not have time to read through a bunch of journals. It’s time to learn smarter. 

Originally published at JournalFeed, a site that provides daily or weekly literature updates. 

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#1: Ultralow-Dose CT Chest = CXR Radiation Dose?

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Ultralow-dose chest CT (ULCT) had perfect diagnostic accuracy for minor traumatic injury to the chest. It was superior to plain CXR and delivered the same, or in several cases, a lower radiation dose.

Why does this matter?
We often obtain a CXR in patients with blunt thoracic trauma as a screening tool. But as CT technology improves, lower-dose techniques may more accurately detect injuries with the same or lower radiation dose than an x-ray. Is that the case here?

CT vs. x-ray = same radiation dose? Yup…
This was a comparison of patients with chest trauma that were hemodynamically stable and had traditional CXR +/- rib series and ULCT. CT was done with a 64 slice scanner without contrast, with iterative reconstruction (which reduces the “noise” from a lower dose scan). A reference CT, with a 1-2 mSv dose, was also done and read by the radiologists in real time as the gold standard. ULCT performed perfectly, with sensitivity 100%, specificity 100% for detecting all patients with at least one finding on reference CT, with no false positives. Plain x-ray had sensitivity 79%, specificity 89%. The radiation dose of ULCT was the same or lower than plain x-ray. ULCT is more expensive than x-ray. It also may or may not change management to find a small pneumothorax, hemothorax, or a couple rib fractures, but it depends. Might it be best to use ULCT instead of CXR in patients for whom we want to screen but not do a full trauma CT chest?

Here are two example images from the supplemental material.

Source
Minor Blunt Thoracic Trauma in the Emergency Department: Sensitivity and Specificity of Chest Ultralow-Dose Computed Tomography Compared With Conventional Radiography. Ann Emerg Med. 2019 Jun;73(6):665-670. doi: 10.1016/j.annemergmed.2018.11.012. Epub 2019 Jan 18.

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#2: Gabapentinoids – Not Only Ineffective But Harmful

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Gabapentinoids were associated with increased risk of suicidal behavior, overdose, injuries, and car crashes.

Why does this matter?
Gabapentinoids, like gabapentin or pregabalin, are often used as adjuncts for pain, especially neuropathic pain. The efficacy of these agents has been called into question for most painful conditions. But are these agents harmful?

Gabapentinoids – not only ineffective but harmful
This was a large population database study of 191,973 people in Sweden who were prescribed gabapentinoids. They found an increased risk for: “suicidal behaviour and deaths from suicide (age adjusted hazard ratio 1.26, 95% confidence interval 1.20 to 1.32), unintentional overdoses (1.24, 1.19 to 1.28), head/body injuries (1.22, 1.19 to 1.25), and road traffic incidents and offences (1.13, 1.06 to 1.20).” There was no association with violent crime. When stratified by drug, gabapentin was not associated with any of the above and was, in some cases protective; pregabalin was associated with all of the above. Younger patients had a stronger association with adverse outcomes. In particular, patients aged 15-24 years were at increased risk for all of the above outcomes. The strength of this study is that each patient acted as his or her own control, as periods in which they were on the drugs were compared to those in which they were not. This helps reduce confounding. They also found a dose-response with the outcomes of interest, which strengthens the case. The major weakness is it is a large registry, and misclassification may have occurred. It also does not prove causality. However, given that these drugs are largely ineffective and now associated with harm, it’s hard to give a rousing recommendation for their use. If you choose to use them, it seems gabapentin may be a safer choice than pregabalin, and using them in patients over 24 years might be best.

Source
Associations between gabapentinoids and suicidal behaviour, unintentional overdoses, injuries, road traffic incidents, and violent crime: population based cohort study in Sweden. BMJ. 2019 Jun 12;365:l2147. doi: 10.1136/bmj.l2147.

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#3: How Your Compassion Helps Patients Heal

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Showing compassion to patients in the ED with a life threatening emergency reduced the odds of PTSD at one month.

Why does this matter?
It is hard to help and support our patients when we are hurting as physicians. Aspects of burnout include emotional exhaustion and feelings of cynicism and detachment from work. Physician (clinician) wellness is important not only for ourselves; it’s important for patient care. Here is yet another way that taking care of ourselves emotionally can help our patients in their own healing process.

To Do List: 1) Do not give my patients PTSD…
This was a prospective observational study of adult patients in the ED with a life threatening emergency. They assessed whether the provider’s compassion, assessed on a validated CARE scale, was associated with subsequent PTSD in patients a month after discharge. They enrolled 113 patients, 25% of which had PTSD a month out. After adjusting for confounders, they found a statistically significant decrease in PTSD in patients who perceived their healthcare provider to be compassionate, aOR 0.93 (95% CI, 0.89-0.98). I am going to state this a different way: the way you treat people touches them deeply. Your compassion has a quantifiable impact on how your patients recover from the emotional trauma of a life threatening emergency. They won’t forget how you made them feel, how you cared about them as a person, and how you helped them feel less afraid. Granted, the effect size wasn’t huge. But this is something that costs us nothing and is the right way to treat people anyway. And it shows, yet again, the importance of investing in physician/clinician wellness.

Another Spoonful
Sound Physicians did a podcast on this article with co-author and “compassionomics” expert Dr. Stephen Trzeciak.

Source
Healthcare provider compassion is associated with lower PTSD symptoms among patients with life-threatening medical emergencies: a prospective cohort study. Intensive Care Med. 2019 Jun;45(6):815-822. doi: 10.1007/s00134-019-05601-5. Epub 2019 Mar 25.

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