News Release 

Embargoed news from Annals of Internal Medicine: Electric fans not safe for relieving the heat when temperatures are high and humidity is low

American College of Physicians

Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information.

1. Electric fans not safe for relieving the heat when temperatures are high and humidity is low

Abstract: http://annals.org/aim/article/doi/10.7326/M19-0512

URLs go live when the embargo lifts

In hot, arid conditions with a relatively low heat index, electric fans may be detrimental to health and are not advisable. However, in hot, but very humid weather conditions with a much higher heat index, fans lowered core temperature and cardiovascular strain and improved comfort. Findings from a brief research report are published in Annals of Internal Medicine.

Researchers from the University of Sydney recruited volunteers on campus to examine the effect of electric fan use on thermal strain (rectal temperature), cardiovascular strain (heart rate and blood pressure), risk for dehydration (whole-body sweat rate), and thermal comfort (assessed using 120-mm visual analogue scale). Volunteers were monitored during a 2-hour exposure to simulated peak conditions of two types of heat waves: One that was very hot and dry (mimicking the peak conditions of the California heatwave in July 2018, and the Ahmedabad heatwave in May 2018) and one that was cooler but more humid and with a higher heat index (representing the peak conditions reported during the Chicago heatwave in July 1995, and the Shanghai heatwave in July 2017). The researchers found that in a hot, humid condition with a heat index of 56 °C, fans lowered core temperature and cardiovascular strain, and improved thermal comfort. However, fans were detrimental for all measures in the very hot, dry condition, despite a lower heat index of 46 °C.

According to the researchers, these findings highlight the issues that may arise when heat index values are used to recommend fan use during heat waves - as presently done by the US Environmental Protection Agency (EPA). The effectiveness of fans depends on the climate, but climate dependency is not adequately captured by heat index values. Fans may be a cheaper and more accessible alternative to air conditioning for some people, such as those living in parts of the United States that have higher humidity, or Southeast Asia, South America, and Europe, where temperatures rarely exceed 40 °C but are also accompanied by moderately high humidity.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the senior author, Ollie Jay, PhD, please contact Michelle Blowers at michelle.blowes@sydney.edu.au.

2. Adults with cerebral palsy at increased risk for mental health disorders

Abstract: http://annals.org/aim/article/doi/10.7326/M18-3420

Editorial: http://annals.org/aim/article/doi/10.7326/M19-1951

Patient Summary: http://annals.org/aim/article/doi/10.7326/P19-0010

URLs go live when the embargo lifts

Compared with adults without cerebral palsy (CP), adults with CP have an elevated prevalence of mental health disorders, some of which may be more pronounced in patients with comorbid neurodevelopmental disorders, such as intellectual disabilities, autism spectrum disorders, or epilepsy. Findings from a cross-sectional analysis are published in Annals of Internal Medicine.

Persons with CP have an increased risk for secondary chronic conditions during childhood, including mental health disorders. However, little is known about how these disorders affect adults with CP.

Researchers from the University of Michigan studied a patient database to determine the prevalence of mental health disorders among adults with CP compared with those without CP. They found that men and women with CP alone had higher age-standardized prevalence than men and women without CP for schizophrenic disorders, mood affective disorders, anxiety disorders, and disorders of adult personality and behavior. Men with CP also had higher rates of alcohol- and/or opioid-related disorders, whereas women with CP did not. According to the researchers, these findings suggest that increasing clinical awareness of the mental health disorders and risks among adults with CP, improving clinical screening strategies, and developing efficient referral resources for mental health care services may help reduce the burden of mental health disorders in this population.

According to the authors of an accompanying editorial from Oregon State University, this research is important because it shines a light on an important issue facing a vulnerable population. The editorialists suggest that physicians may require additional training to care for adults with developmental disabilities so that these patients can get the care they need. It is also important to recognize the stressors faced by this population that can contribute to their mental health, such as trauma from abuse, neglect, intrusive therapeutic procedures, poverty, and social isolation.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Daniel G. Whitney, PhD, please contact Kylie Uban at kylieo@med.umich.edu. To reach the editorialist, Gloria Krahn, PhD, PMH, please contact her directly at Gloria.Krahn@oregonstate.edu or 503-423-7186 (cell).

3. Focused cardiac ultrasonography limited by low specificity

Abstract: http://annals.org/aim/article/doi/10.7326/M19-1337

Editorial: http://annals.org/aim/article/doi/10.7326/M19-1918

URLs go live when the embargo lifts

Focused cardiac ultrasonography (FoCUS) may be more useful for ruling out significant cardiovascular pathology in patients at low suspicion of disease, than for confirming cardiovascular disease strongly suspected on clinical examination. Clinicians should understand the inherent limitations of FoCUS to best utilize it in clinical practice. Findings from a systematic review and meta-analysis are published in Annals of Internal Medicine.

The inaccuracy of physical examination is a long-recognized issue in the clinical setting. Incorporating ultrasonography units, such as FoCUS, could improve the diagnostic yield of bedside patient evaluation for cardiovascular disease.

Researchers from the University of Ottaway Heart Institute reviewed 9 published studies to compare the accuracy of FoCUS-assisted clinical assessment versus clinical assessment alone for diagnosing left ventricular dysfunction or valvular disease in adults having cardiovascular evaluation. They found that FoCUS enabled significantly greater sensitivity, but not greater specificity, than clinical assessment alone. As such, they concluded that FoCUS may be better for ruling out clinically significant cardiovascular pathology in patients at low suspicion of disease rather than for confirming suspected cardiovascular disease. Based on these findings, the researchers suggest that clinicians must understand the situations where formal echocardiography should be pursued and the inherent limitations of FoCUS in terms of both image acquisition and interpretation, before adopting its use in practice.

The authors of an accompanying editorial from Cedars-Sinai Medical Center say that hand-held ultrasonography could be the fifth pillar of the physical examination and improve the accuracy of bedside diagnosis, but caution that its effectiveness is limited by the skills and expertise of the clinician. They suggest that incorporating hand-held ultrasonography in the primary care setting, where the majority of echocardiograms are ordered, could greatly improve downstream work-up and cost-effectiveness.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Benjamin Hibbert, MD, PhD, please contact the Ottawa Heart communications office at communications@ottawaheart.ca. To reach the editorialist Robert J. Siegel, MD, please contact Sally Stewart at Sally.Stewart@cshs.org.

4. Hepatologists debate screening and management of nonalcoholic fatty liver disease

Annals 'Beyond the Guidelines' discussions are based on real Beth Israel Deaconess Medical Center Grand Rounds

Abstract: http://annals.org/aim/article/doi/10.7326/M19-1125

URLs go live when the embargo lifts

Current guidelines from the American Association for the Study of Liver Disease make specific recommendations for the screening and management of patients with nonalcoholic fatty liver disease (NAFLD). However, not all patients fit neatly within the parameters of expert recommendations, making it necessary for clinicians to make decisions based on individual patient characteristics. Hepatologists from Beth Israel Deaconess Medical Center (BIDMC) and University of Michigan Medical Center debate care for a patient with suspected NAFLD in a multicomponent educational article being published in Annals of Internal Medicine.

NAFLD is defined by hepatic fat accumulation that is not attributable to other causes, such as excessive alcohol use. About one-third of the U.S. adult population has nonalcoholic fatty liver disease, and the obesity epidemic is the suspected culprit. The condition has no symptoms, but if left untreated, it may lead to cirrhosis or hepatocellular carcinoma. NAFLD is reversible with lifestyle changes, such as weight loss and improved diet.

Two hepatologists offer differing opinions on how to manage an at-risk patient. Z. Gordon Jiang, MD, PhD recommends that high-risk patients, including those with type 2 diabetes, morbid obesity, or a family history of cryptogenic cirrhosis, be screened for fibrosis in the primary care setting with a non-invasive modality. In addition to recommending lifestyle changes, he would monitor the patient for fibrosis regularly. Elliot Tapper, MD recommends screening only patients with type 2 diabetes who are at the highest risk for advanced fibrosis from NAFLD. He advises a one-time assessment for patients with NAFLD to determine whether advanced fibrosis is present and hepatology consultation is needed. He also recommends lifestyle changes for the patient.

All 'Beyond the Guidelines' papers are based on the Department of Medicine Grand Rounds at BIDMC in Boston and include print, video, and educational components. A list of topics is available at http://www.annals.org/grandrounds.

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Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Howard Libman, MD, please contact Jennifer Kritz at jkritz@bidmc.harvard.edu.

Also new in this issue:

In the Clinic: Stable Ischemic Heart Disease Update

Daniel Katz, MD; Michael C. Gavin, MD, MPH

In The Clinic

Abstract: https://annals.org/aim/article/doi/10.7326/AITC201908060

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