Rapid Rule-Out of Acute Myocardial Infarction With a Single High-Sensitivity Cardiac Troponin T Measurement

MedicalResearch.com Interview with:
Martin P. Than, MBBS
Emergency Department, Christchurch Hospital and
Dr John W Pickering, PhD
Associate Professor Senior Research Fellow in Acute Care
Emergency Care Foundation, Canterbury Medical Research Foundation, Canterbury District Health Board | Christchurch Hospital
Research Associate Professor | Department of Medicine | University of Otago
Christchurch New Zealand

MedicalResearch.com: What is the background for this study?

Response: Patients being investigated for possible acute coronary syndrome comprise one of the largest groups of patients presenting to emergency rooms. Troponin assays have developed such that they can now measure with greater accuracy much lower concentrations of troponin. A large retrospective registry based study and a couple of smaller prospective studies suggested that patients with a very low concentrations of troponin T (below the current limit of detection of 5 ng/L) measured with Roche Diagnostic’s high-sensitivity troponin T (hsTnT) assay on presentation to the emergency department (ie single blood draw) are very unlikely to be having a myocardial infarction (MI).

Our study gathers the current best evidence for using concentrations below the limit of detection in conjunction with no evidence of new ischaemia on ECG to safely risk stratify patients to a very low-risk group for MI and, therefore, potentially identify patients safe for early discharge.

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Cystic Fibrosis Patients Survive Ten Years Longer in Canada than in US

MedicalResearch.com Interview with:
Dr. Anne L. Stephenson, MD, PhD

St. Michael’s Hospital
Toronto Canada

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Both Canada and the US have maintained national registries on individuals with cystic fibrosis (CF) dating back to the 1970s. Previous reports suggested that survival differed between the two countries however direct comparisons of survival estimates between national registry reports were limited because of differences in methodologies used, data processing techniques and possible differences in the patients captured within each registry.

We aimed to compare survival in  cystic fibrosis between Canada and the US to determine if differences existed when we applied a systematic and standardized approach.

Our analysis showed that between 1990 and 2013, survival for individuals with CF increased in both countries, however, the rate of increase was faster in Canada compared to the USA. The survival gap widened at two distinct time points: 1995 and 2005.

In the contemporary period between 2009 and 2013, the median age of survival for individuals with cystic fibrosis in Canada was found to be 50.9 years compared to 40.6 years in the US. Overall, the risk of death was 34% lower for Canadians compared Americans with CF after adjusting for markers of disease severity. When US CF subjects were classified by insurance status, we found a 77% lower risk of death among Canadians with CF compared to Americans who indicated unknown or no insurance, a 44% lower risk compared to Americans receiving continuous Medicare/Medicaid, and a 36% lower risk in Canadians compared to Americans receiving intermittent Medicare/Medicaid. The risk of death for Americans with private insurance was not statistically different from that of Canadians with cystic fibrosis .

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Physicians, PAs and Nurse Practitioners Provide Similar Amount of Low Value Care

MedicalResearch.com Interview with:

John N. Mafi, MD, MPH Division of General Internal Medicine and Health Services Research Department of Medicine, Ronald Reagan UCLA Medical Center Los Angeles, CA

Dr. John N. Mafi

John N. Mafi, MD, MPH
Division of General Internal Medicine and Health Services Research
Department of Medicine, Ronald Reagan UCLA Medical Center
Los Angeles, CA

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Our country has a primary care physician shortage. Some have advocated that we expand the scope of practice for nurse practitioners and physician assistants to help alleviate this problem and improve access to primary care. But a 2013 study in the New England Journal of Medicine found that a large number of physicians believed that nurse practitioners provided lower value care when compared with physicians. We decided to put that belief to the test. We studied 29,000 U.S. patients who saw either a nurse practitioner, physician assistant, or physician in the primary care setting for common conditions, and we compared the rate of low-value or unnecessary services—for example, unnecessary antibiotics for the common cold, or MRI for low back pain, or a CT scan for headache. Things that don’t help patients and may harm.

We found no difference in the rates of low value services between nurse practitioners, physician assistants, and physicians. In other words, they did equivalent amounts of inappropriate or bad care.

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Tele-Rehabilitation Can Improve Physical Function In Chronic Knee Pain Patients

MedicalResearch.com Interview with:
Rachel Nelligan, BPhysio
Physiotherapist & Research Physiotherapist
Department of Physiotherapy | Centre for Health, Exercise and Sports Medicine
The University of Melbourne
Victoria Australia

MedicalResearch.com: What is the background for this study?

Response: This novel study investigated the efficacy of an internet delivered model of service delivery that combined online education, Skype delivered exercise physiotherapy and an Internet-based interactive pain coping skills training program for people with persistent knee pain.

Osteoarthritis, the leading cause of chronic knee pain and disability globally, has a significant individual, societal and economic burden. On an individual level knee osteoarthritis causes loss of function, reduced quality of life, and psychological distress. Clinical guidelines recommend adoption of a biopsychosocial approach to management which should include nondrug, nonsurgical treatments. Specifically exercise, education and psychological interventions (including pain coping skills training (PCST)) that foster self-management are recommended. Evidence identifies that many knee OA sufferers are not receiving adequate management due in part to challenges of accessing these effective treatments. There is an urgent need for new models of health service delivery to rectify this.

Tele-rehabilitation is growing in acceptance as an effective, time efficient and convenient means for people to access effective health interventions. In knee OA internet delivered interventions specifically remotely delivered physiotherapy exercise using specialised tele-rehabilitation equipment and an Internet-based interactive PCST program (PainCOACH), designed to translate key therapeutic elements of clinician-delivered face-to-face PCST, have shown improved patient outcomes. Prior to this study the combination of these two internet-based treatments has not been investigated.

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Smokers Who Switch Completely To E-Cigs Reduce Their Exposure to Toxins

MedicalResearch.com Interview with:
Dr Lion Shahab
MA (Oxon) MSc MSc PhD CPsychol AFBPsS PGCLTHE
Senior Lecturer in Health Psychology
Department of Behavioural Science and Health
University College London
London 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: To date most studies on e-cigs have either looked at the product itself, i.e. analysed vapour/aerosol or e-liquid, or investigated its effects on animal and cell models. Only very few studies have looked at actual body-level exposure in users of e-cigarettes to evaluate their safety, and this study is the first to explore this in long-term real-life users of e-cigs.

We find that compared with people who continue to smoke conventional cigarettes, those who switch over completely to using e-cigarettes long-term (1.5 years) dramatically reduce their exposure to cancer-causing chemicals to levels observed in users of nicotine replacement products like nicotine patch or gum (which are known to be safe when used long-term).

Our results also suggest that while e-cigarettes are not only safer, the amount of nicotine they provide is not noticeably different to conventional cigarettes. This can help people to stop smoking altogether by dealing with their cravings in a safer way.

MedicalResearch.com: What should readers take away from your report?

Response: The public has been receiving very mixed signals about the safety of e-cigarettes, with some reports claiming to show that they are as harmful as smoking. These reports have been based on studies that bear little relationship to exposure of e-cigarette users in the real world.

We report the first study that has actually measured the intake of potentially harmful chemicals in e-cigarette users, and compared this with people using licensed nicotine products (e.g. nicotine patches), and cigarettes. This study should reassure smokers who are thinking of switching to an e-cigarette that if they manage to cut out cigarettes altogether, they should see a large benefit in terms of their health.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Response: The next step would be would be to follow smokers over a longer period of time who switch over to using e-cigarettes and measure potential harm and risks not only in relation to cancer but also lung function and cardiovascular health.

MedicalResearch.com: Is there anything else you would like to add?

Response: None of the other authors have received funding from an e-cigarette company or any organisation acting for one.

MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.

Citation:

Shahab L, Goniewicz ML, Blount BC, Brown J, McNeill A, Alwis KU, et al. Nicotine, Carcinogen, and Toxin Exposure in Long-Term E-Cigarette and Nicotine Replacement Therapy Users: A Cross-sectional Study. Ann Intern Med. [Epub ahead of print 7 February 2017] doi: 10.7326/M16-1107

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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Exposure to Violence, Psychological Distress, and Gun Carrying Among Male Adolescents

MedicalResearch.com Interview with:
Joan A. Reid, Ph.D., LMHC

Assistant Professor
Criminology Program DAV 266
University of South Florida St. Petersburg

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Firearm-associated homicide and suicide are leading causes of death among American youth (i.e., 10-24 years old), with disproportionately high rates observed among male youth of color. Notably, gun violence and psychological problems are often conflated in public discourse regarding gun violence and prevention. However, few studies have assessed the impact of exposure to violence, either as a witness or a victim, when exploring the association between gun-carrying behavior and psychological distress.

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Medical Residents Spend More Time Working on Electronic Medical Records than With Patients

MedicalResearch.com Interview with:
Dresse Nathalie Wenger

Cheffe de clinique
FMH médecine interne
Département de Médecine Interne
CHUV – Lausanne 

MedicalResearch.com: What is the background for this study?

Response: The structure of a residents’ working day dramatically changed during the last decades (limitation of working hours per week, wide implementation of electronic medical records (EMR), and growing volume of clinical data and administrative tasks), especially in internal medicine with increasing complexity of patients. Electronic Medical Records (EMR) have some positive effects but negative effects have been also described ie more time writing notes, more administrative works, and less time for communication between physicians and patients.

Few time motion studies have been published about the resident’s working day in Internal Medicine: the impact of the computer, and what really do the residents do during their work, especially the time spent with the patient versus the computer, as now the EMRs are widely implemented. Previous studies have been mostly performed in the US, so we decided to conduct one observational and objective study in Europe.

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Breast and Prostate Cancer Screenings Have Similar Potential for OverDiagnosis

MedicalResearch.com Interview with:
Karsten Juhl Jørgensen, MD, Dr. MedSci
The Nordic Cochrane Centre
Rigshospitalet, Copenhagen 

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Our systematic Cochrane review of the original randomised breast screening trials showed substantial conflict between their estimates of the benefit. Some trials showed a large benefit, others none or a small benefit. This difference was related to the design of the trials.

The most optimistic trials were those with suboptimal randomisation.

The main findings of our current study support those of the most rigorously performed randomised trials: breast screening does not fulfill its fundamental premise, which is to reduce the occurrence of late stage disease. This means a mortality reduction is unlikely and that use of less invasive surgery due to breast screening is also unlikely.

However, we did find very substantial increases in early stage breast cancer, which persisted over our 17 year observation period. This means that breast screening likely leads to substantial overdiagnosis of breast cancers that would otherwise not have caused health problems during a woman’s lifetime. We estimate that 1 in 3 breast cancers detected in a screened population is likely overdiagnosed.

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Little Evidence Pay-For-Performance Improves Patient Outcomes

MedicalResearch.com Interview with:

Devan Kansagara MD, MCR Associate Professor of Medicine, Oregon Health and Science University Director, Evidence-based Synthesis Program, Portland VA Medical Center Staff Physician, Portland VA Medical Center

Dr. Devan Kansagara

Devan Kansagara MD, MCR
Associate Professor of Medicine
Oregon Health and Science University
Director, Evidence-based Synthesis Program, Portland VA Medical Center
Staff Physician, Portland VA Medical Center

MedicalResearch.com: What is the background for this study?

Response: Historically, the US health care system has been dominated by a fee-for-service payment structure in which health care providers are paid for discrete procedures and visits regardless of care quality. Pay for performance programs are part of the move towards value-based care. They tie a portion of payments to individual health care providers, institutions, or health care systems to performance on a discrete set of measures of health care quality.

In theory, these programs are meant to encourage the right care at the right time and thereby improve the health of the patient population. Over the last decade, many studies in and outside the US have examined whether or not, in fact, these programs do result in improved care, reduced cost, and improved patient health. Our study is a systematic review of this literature.

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No Association Between Length of Red Blood Cell Storage and Mortality

MedicalResearch.com Interview with:
Märit Halmin, MD, PhD student

Department of Medical Epidemiology and Biostatistics, Karolinska Institutet,  Stockholm, Sweden

MedicalResearch.com: What is the background for this study?

Response: During recent years the possible negative effects among recipients of stored red blood cells have been investigated.  Despite a large number of studies, including four randomized trials, no consensus exists.

We therefore performed the hitherto largest register based cohort study of transfused patients, assessing the association between length of storage of red blood cells and mortality. Our design allowed for detection of small but still clinically significant effect, if such exists.

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How Strong is the Scientific Basis of Sugar Intake Guidelines?

MedicalResearch.com Interview with:

Bradley C. Johnston, PhD Prevention Lab, Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Peter Gilgan Centre for Research and Learning, 686 Bay Street, Room 11.9859 West, Toronto, Ontario

Dr. Bradley Johnston

Bradley C. Johnston, PhD
Prevention Lab, Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute
Peter Gilgan Centre for Research and Learning
Toronto, Ontario

MedicalResearch.com: What is the background for this study?

Response: I am scientist at The Hospital for Sick Children and a professor of clinical epidemiology at the University of Toronto and McMaster University in Canada. I have a particular interest in research methodology and preventive medicine. As a research methodologist I am interested in how researchers get to their conclusions. In particular I am interested in the “uncertainty” in estimated treatment or exposure effects.

Many guidelines have methodological issues but it was suspected that the nutritional guidelines were especially problematic. Our study in Annals of Internal Medicine set out to document the issues systematically with respect to sugar intake recommendations from authoritative guidelines.

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Access To Two Different Health Care Systems Can Lead To Dangerous Presciption Combinations

MedicalResearch.com Interview with:

Dr-Joshua-M-Thorpe.jpg

Dr. Joshua Thorpe

Joshua M. Thorpe, PhD, MPH
From the Center for Health Equity Research and Promotion
Veterans Affairs Pittsburgh Healthcare System
Pittsburgh Pennsylvania, and
Center for Health Services Research in Primary Care
Department of Pharmacy and Therapeutics
University of Pittsburgh School of Pharmacy

MedicalResearch.com: What is the background for this study?

Response: Care coordination for persons with dementia is challenging for health care systems under the best of circumstances. These coordination challenges are exacerbated in Medicare-eligible veterans who receive care through both Medicare and the Department of Veterans Affairs (VA). Recent Medicare and VA policy changes (e.g., Medicare Part D, Veteran’s Choice Act) expand veterans’ access to providers outside the VA. While access to care may be improved, seeking care across multiple health systems may disrupt care coordination and increase the risk of unsafe prescribing – particularly in veterans with dementia. To see how expanded access to care outside the VA might influence medication safety for veterans with dementia, we studied prescribing safety in Veterans who qualified for prescriptions through the VA as well as through the Medicare Part D drug benefit.

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