Medical News Weekly

Pelvic floor muscle training helps urinary incontinence in women  link

Vitamin D does not prevent fractures or falls in community dwelling adults   link

Canadian Medical Association quits World Medical Association over plagiarism by new president  link

Physical therapy as effective as the still commonly performed surgery for knee non-obstructive  menisceal tears  link

Antibiotics a reasonable option for uncomplicated appendicitis – 5 year figures  link

While Vitamin D keeps falling short in evidence, Zoledronate is shown to reduce fractures in older women  link

Delayed pushing in the second stage of labor has no impact on delivery  link

American Academy of Family Physicians breaks from AMA with “engaged neutrality” policy, and no longer opposes physician-assisted suicide, also preferring the term medical aid in dying  link

Inadequate sleep in adolescents linked to numerous risky behaviours for mental health, accidents, self harm and substance misuse link

Global Cesarean rate alarmingly high (or too low in some countries)  link

If you’re one of the 1-in-2 adults taking dietary ‘supplements’, some 800 supplements contain unapproved ingredients, often powerful and potentially dangerous prescription medicines  link

 

 

 

Timing of Renal Replacement in AKI amd Sepsis

Kidney failure in sepsis (meeting failure criteria in RIFLE classification) has no difference in 90 day mortality if renal replacement is delayed for 48 hours compared to initiation in 12 hours. A delayed strategy may allow renal recovery also, but this group had more metabolic abnormalities including hyperkalemia which may necessitate earlier dialysis.

“The failure stage of the RIFLE classification system is characterized by a serum creatinine level 3 times the baseline level (or ≥4 mg per deciliter with a rapid increase of ≥0.5 mg per deciliter), urine output less than 0.3 ml per kilogram of body weight per hour for 24 hours or longer, or anuria for at least 12 hours”.

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Post-Operative Anemia Management

An international consensus on the management of post-operative anemia encourages a more proactive strategy to complement more restrictive blood transfusion practices.

All patients having major surgery with pre-operative anemia or significant blood loss need Hemoglobin assessment for 1-3 days along with Ferritin measurement. “iron deficiency should be defined by ferritin concentration < 100 μg.l−1, ferritin < 100–300 μg.l−1 and transferrin saturation < 20%, or reticulocyte haemoglobin content < 28 pg”.

Intravenous Iron is favoured as more effective, and off-label Erythropoiesis stimulating agents should be considered. A full exposition of the subject is at the link.

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Resuming Beta Blockers Post-op

For those taking chronic beta-blockers in non-cardiothoracic, non-vascular surgery, resumption on post op day 1 reduces the risk of Atrial Fibrillation (although no evidence supported resuming earlier, on surgery day).

Chronic medications frequently fall through the cracks in the peri-operative setting and efforts to resume these agents in the absence of contraindications should be encouraged. Thromboembolic events could occur even in the brief peri-operative setting.

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Antiplatelet Duration for Stent after MI

Current recommendations specify 6 months dual antiplatelet therapy (DAPT) after PCI in stable ischemic heart disease and 12 months after acute coronary syndromes. This new study looked at DAPT after STEMI and found: “Limiting DAPT duration to six months in patients with STEMI that are event-free results in a non-inferior clinical outcome, as assessed by a patient-oriented composite clinical endpoint versus 12 months of DAPT”. Aspirin was continued after this 6 month period.

While the guidelines remain, these findings are reassuring in that a shorter duration of DAPT may be reasonable especially insofar as surgical procedures are impacted often by delaying for 12 months.

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Prediction of Disability Free Survival

This sub-study sought to evaluate the 6 Minute Walk Test prediction of disability free survival. Of the risk assessment tools analysed, the Duke Activity Status Index was the most predictive of  disability free survival. “The 6MWT was safe and comparable with cardiopulmonary exercise testing for all predictive assessments. Future research should aim to determine the optimal 6MWT distance thresholds for risk prediction”.

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See previous study also: link

 

Preoperative geriatric assessment increases 90 day survival

Preoperative geriatric assessment was performed in only 2.8% of elective non-cardiac surgeries in adults over 65 years of age in this study but was associated with a higher 90 day survival. Given the increasing importance of managing multiple comorbidities, polypharnacy and in particular evaluating frailty and functional status, further randomized studies are needed to verify these findings.

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PEEP, but how much?

An animal study on PEEP showed that while lower levels (below 7cm) have the well known long protective effects, higher levels along with tidal volume, respiratory rate and gas flow  contribute to the mechanical power needed to ventilate the lung, leading to both severe lung damage and hemodynamic impairment.

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Another study on intra-operative patients found that optimal PEEP varies widely. They used electrical impedance tomography to minimize atelectasis and clearly this is not widely available so strategies for PEEP usage remain a topic for study and debate.

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Systemic Inflammation and myocardial injury

Inflammation is thought to be central in the pathogenesis of cardiovascular disease and this study found that one indicator, the Neutrophil-Lymphocyte Ratio > 4 is associated with perioperative myocardial injury, independent of conventional risk factors. The role of inflammation and its possible modification to reduce myocardial injury is an interesting area for future study.

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