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MRI stronger predictor of major adverse cardiovascular events than standard scan

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1. MRI stronger predictor of major adverse cardiovascular events than standard scan

Recommendation: http://www.annals.org/article.aspx?doi=10.7326/M15-1801

Paper URLs go live when the embargo lifts

Cardiovascular magnetic resonance (CMR) is a stronger predictor of risk for major adverse cardiovascular events (MACE) than single-photon emission computed tomography (SPECT) at 5 years follow-up. The findings are published in Annals of Internal Medicine.

CMR is an MRI scan that focuses on the area around the heart. Unlike SPECT, CMR does not involve ionizing radiation and the large CE-MARC (Clinical Evaluation of Magnetic Resonance imaging in Coronary heart disease) study demonstrated that CMR had high diagnostic accuracy, with higher sensitivity and negative predictive value compared with SPECT. However, data on the prognostic value of CMR remain limited. A predefined objective of CE-MARC was to assess the ability of CMR and SPECT to predict MACE at 5-year follow-up. To do so, researchers studied 752 patients from the CE-MARC study who were being investigated for suspected coronary heart disease. The patients were scheduled to undergo CMR and SPECT in random order, followed by X-ray coronary angiography (the reference standard) within 4 weeks. The investigators followed up with patients every year for 5 years to assess for MACE.

The researchers found that at 5-year follow-up, CMR was a stronger predictor of risk for MACE than SPECT, independent of clinical cardiovascular risk factors, angiography result, or initial patient treatment. The researchers conclude that CMR should be considered a robust alternative to SPECT for the diagnosis and management of patients with suspected coronary heart disease.

2. Small, inexpensive device could make colonoscopy more comfortable, but few physicians use it

Abstract: http://www.annals.org/article.aspx?doi=10.7326/M16-0209

URL goes live when the embargo lifts

Several studies have shown that using carbon dioxide (CO2) rather than room air to distend the colon during endoscopy can reduce patient pain and discomfort, yet most colonoscopies performed worldwide still use room air insufflation. The authors of an article published in Annals of Internal Medicine discuss the potential reasons why physicians have been slow to adopt the technology.

Millions of patients undergo colonoscopy every year. During the procedure, air is pumped into the patient's bowel through the endoscope so that the physician can get a clear view of the gastrointestinal tract. Room air is poorly absorbed from the colon, so endoscopists suction air during instrument withdrawal. Still, substantial amounts of air remain in the colon. Natural release takes hours to days with patients frequently experiencing symptoms such as pain, discomfort, and anal leakage.

CO2 is absorbed from the colon 160 times faster than nitrogen and 12 times faster than oxygen. When CO2 is used instead of room air, patients experience reduced pain, less anal leakage, faster recovery, and significantly reduced need for nurse attention post-procedure. So why aren't physicians adopting this technology? For one, standard endoscopy equipment comes with air insufflation pumps and insufflation of CO2 would require an add-on purchase of a small box for the endoscopy rack called a CO2 insufflator. While the device is simple to use and very inexpensive, it does not generate much revenue. In addition, CO2 insufflation is not mentioned in guidelines and does not generate the excitement or interest associated with new "high-tech" endoscopic technology. And finally, since patient pain and discomfort is considered a minor problem associated with colonoscopy, there is little interest in changing the procedure. The authors hope that the current era of patient engagement and shared decision making will motivate change in endoscopy.

3. Review of Ebola response provides context for future infection control recommendations

Abstract: http://www.annals.org/article.aspx?doi=10.7326/M15-2944

URL goes live when the embargo lifts

National recommendations and strategies are needed to help hospitals prepare for potential Ebola cases and other emerging infectious diseases. The authors of a review published in Annals of Internal Medicine describe the infection prevention and control measures implemented in a community hospital in 2014 when it became the first hospital of its kind to care for a patient with Ebola.

Ebola is transmitted through direct contact with an infected person's blood or bodily fluids, which puts health care personnel caring for Ebola patients at particular risk for infection. In September 2014, a Liberian man was diagnosed with Ebola at a Dallas community hospital and two nurses were infected while providing his care. To help prevent further disease transmission, a multidisciplinary team from the Centers for Disease Control and Prevention (CDC) joined the hospital's infection preventionists. Together, they established a system of occupational safety and health controls that included changes to the hospital's physical layout, procedures for handling clinical specimens and waste, and job duties of health care personnel. The authors also describe the complexities associated with implementing appropriate procedures for donning and doffing personal protective equipment. The authors suggest that these prevention and control measures may help to inform national policies for preparedness for Ebola and similarly challenging infectious diseases.

Also new in this issue:

The Internal Medicine Reporting Milestones: Cross-sectional Description of Initial Implementation in U.S. Residency Programs

Karen E. Hauer, MD, PhD; Jerome Clauser, EdD; Rebecca S. Lipner, PhD; Eric S. Holmboe, MD; Kelly Caverzagie, MD; Stanley J. Hamstra, PhD; Sarah Hood, MS; William Iobst, MD; Eric Warm, MD; and Furman S. McDonald, MD, MPH

Academia and the Profession http://www.annals.org/article.aspx?doi=10.7326/M15-2411

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