Public Release: 

Computer tool quickly identifies which PE patients can be safely treated at home

American College of Physicians

1. Sensitive cardiac injury marker could reduce stress testing for myocardial ischemia

Abstract: http://annals.org/aim/article/doi/10.7326/M18-0670
Editorial: http://annals.org/aim/article/doi/10.7326/M18-2984
URLs go live when the embargo lifts

Measuring for troponin, a protein released by injured heart muscle that indicates whether someone recently experienced a heart attack, can cut down on cardiac stress tests, hence reducing health care costs and radiation exposure. Findings from an observational study are published in Annals of Internal Medicine.

Cardiac stress testing is useful in diagnosing and managing coronary artery disease (CAD), but it is expensive and commonly overused. As such, current guidelines recommend against routine surveillance cardiac stress testing in persons with known, stable ischemic heart disease unless it is done to evaluate new or progressive symptoms. Newly developed high-sensitivity cardiac troponin I (hs-cTnI) assays can measure troponin concentrations substantially lower than those detected by conventional assays and may help to stratify patients with CAD in various clinical settings.

Researchers from Emory University School of examined two groups of patients from research studies in which cardiac stress testing, exercise or pharmacological, was performed via SPECT (Single Photon Emission Computed Tomography) imaging. A first group (589 total, all with stable CAD) was used to determine the best cut-off level for hs-TnI, pointing out which people were unlikely to have inducible ischemia, or problems with blood flow in the heart visible by imaging. Overall, few people in the group had experienced recent chest pain, but stress-inducible ischemia was observable in about a third. Using a cut-off of 2.5 picograms per milliliter for hs-TnI, the researchers could define a smaller sub-group of 101 patients who had a low proportion of inducible ischemia.

According to the authors, these findings are important because the high sensitivity troponin test could be used to triage individuals with stable CAD before performing stress testing. This would likely reduce the numbers of stress tests performed.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Arshed A. Quyyumi, MD, please contact Quinn Eastman at qeastma@emory.edu.

2. Health commissioner recommends 6 elements for addressing the nation's opioid crisis

Abstract: http://annals.org/aim/article/doi/10.7326/M18-1757
URLs go live when the embargo lifts

Mark Levine, MD, the commissioner of Health for the Vermont Department of Health has outlined six essential elements for addressing the nation's opioid crisis using a more coordinated and comprehensive approach than has previously been employed. Recommendations by Dr. Levine and his co-author from the Association of State and Territorial Health Officials (ASTHO) are published in Annals of Internal Medicine.

According to the authors, the complex nature of the opioid epidemic and its broad, pervasive and substantial impact on communities and society at large justify a multi-pronged set of strategies and solutions. They recommend six essential elements to comprise a robust effort. These elements, which are fully explained in their paper, include leadership; partnership and collaboration; epidemiology and surveillance; education and prevention; treatment and recovery; and harm-reduction.

While the six elements are essential, the authors recognize that a seventh element may also play an important role in addressing the opioid crisis - enforcement. Enforcement lies outside of a public health approach, but the authors acknowledge that law enforcement must be engaged to impact the drug supply, trafficking, and criminal activity that is contributing to the crisis. They also acknowledge there is a limited evidence-base for many of the prevention, treatment, and recovery efforts that currently comprise local, state, and federal responses to the opioid crisis and that more evaluation and assessment is needed.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Mark Levine, MD, please contact Nancy Erickson at Nancy.Erickson@vermont.gov or Bennett Truman at Bennett.Truman@vermont.gov.

3. Doctors look to genes to understand patient's extreme vitamin deficiencies

Abstract: http://annals.org/aim/article/doi/10.7326/L18-0358
URLs go live when the embargo lifts

A patient being treated for the effects of severe vitamin deficiencies was found to have two previously unreported DNA mutations in the microsomal triglyceride transfer protein (MTTP). The extreme severity of her case prompted physicians to look to her genes for a better understanding of her condition. A brief case report is published in Annals of Internal Medicine. Physicians from Ghent University Hospital and Ghent University, Ghent, Belgium, report the case of an 18-year-old patient who was being seen for mild vision impairment and an inability to see in dim light. Her ophthalmologic symptoms were consistent with a long-standing vitamin A deficiency. The case was particularly remarkable to her physicians because the patient had a nearly complete absence of triglycerides and non-HDL cholesterol in the blood, and hence, the fat soluble vitamins. Taking her severe symptoms into consideration, the clinicians conducted tests for abetalipoproteinemia, a rare inherited disorder caused by gene mutations, and, to their surprise, found that both parents each had a different mutation in the MTTP gene, both of which were previously undescribed.

Discovering the connection between the gene mutation and her condition helped the physicians to gain a better understanding of the case. The patient's condition was managed with a low-fat diet; intravenous supplementation of essential fatty acids; and large-dose lipophilic vitamins. According to the authors, treating this condition is very important because a deficiency of fat-soluble vitamins can be devastating to the patient's physical health

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Samyah Shadid, MD, PhD, please contact Stephanie Lenoir at persdienst@ugent.be.

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Also in this issue:

Swan, Ganz, and Their Catheter: Its Evolution Over the Past Half Century
Anjali B. Thakkar, MD, MBA; Sukumar P. Desai, MD
History of Medicine

Abstract: http://annals.org/aim/article/doi/10.7326/M17-2145

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