Despite universal agreement that antibiotic overprescribing is a problem, the practice continues to vex us. Antibiotic use--whether appropriate or not--has been linked to rising rates of ...antimicrobial resistance, disruption of the gut microbiome leading to Clostridium difficile infections, allergic reactions, and increased health care costs. And yet, physicians continue to overprescribe this class of medication. A 2016 Centers for Disease Control and Prevention report estimates that at least 30% of antibiotics prescribed in US outpatient settings are unnecessary. Another report cites a slightly higher figure across a variety of health care settings. Pair these findings with the fact that there are currently few new drugs in development to target resistant bacteria, and you have the potential for a post-antibiotic era in which common infections could become lethal. Family practitioners are on the front lines of this battle. Here's what we can do now.
Coronary haemodynamic testing frequently identifies abnormal pathophysiological parameters in patients with angina and non-obstructed coronaries on angiography (NoCAD) but the clinical utility of ...these measures has received limited attention.
This study aims to identify the clinical and coronary haemodynamic determinants of recurrent chest pain at one month in patients with NoCAD.
Patients with angina, NoCAD (<50% stenosis) and normal LV systolic function underwent invasive coronary haemodynamic testing involving: (1) angiographic TIMI frame and opacification rate, (2) microvascular functional measures including coronary flow reserve (CFR) and hyperaemic microvascular resistance (HMR), (3) coronary endothelial function assessment with low dose intracoronary acetylcholine (IC-ACh) infusions (0.18 μg/min & 1.8 μg/min over 2 min), and (4) Provocative spasm testing with high dose IC-ACh boluses (25, 50 and 100 μg). Clinical and health status were assessed at baseline and one month.
In the 49 NoCAD patients (78% female, mean age of 54 ± 11) undergoing comprehensive coronary haemodynamic testing, 33 (67%) continued to experience chest pain at one month. Determinants of recurrent chest pain on univariate analysis included baseline chest pain status or a HMR > 1.9. Multivariate logistic regression analysis identified frequent angina at baseline (OR: 68.9 4.1, 1165.0, p = 0.003), previous unstable angina admission (OR: 43.9 3.5, 547.9, p = 0.003) and a HMR > 1.9 (OR: 15.6 2.1, 114.0, p = 0.007) as independent predictors of recurrent chest pain.
In this small pilot study, an abnormal HMR was the only coronary haemodynamic parameter that was a determinant of ongoing angina at short-term follow-up.
•Many patients with angina but no significant CAD or ischaemia, have abnormal coronary haemodynamic measures.•Hyperaemic Microvascular Resistance index (HMR) is a determinant of ongoing angina at 30 days.
The coronavirus disease 2019 (COVID-19) pandemic impacted the ski industry worldwide by closing or limiting access to ski resorts. Subsequently, anecdotal reports of increased backcountry use emerged ...in the press, with concerns of inexperienced skiers causing or having problems in the backcountry. This study attempted to quantify this and identify motivations for new backcountry skiers.
Self-identified backcountry skiers and snowboarders (aged ≥18 y) in the United States and Canada completed an anonymous 29-question online survey distributed by regional avalanche centers, education providers, and skiing organizations (n=4792). Respondents were stratified by backcountry experience, defining “newcomers” who began backcountry skiing from 2019 to 2021, coincident with the COVID-19 pandemic. Percentages of ski days spent in the backcountry were compared before and during the COVID-19 pandemic using paired t-tests and across cohorts using repeated-measures analysis of variance. Avalanche education was compared using unpaired χ2 tests.
Of established skiers, 81% noticed more people in the backcountry and 27% reported increasing their own use. Participants reported spending 17% (95% CI, 15.8–17.9) more of their days in the backcountry during the COVID-19 pandemic, with newcomers increasing their time spent by 36% and established skiers increasing their time spent by 13% (P<0.0001). Of newcomers, 27% cited the COVID-19 pandemic as motivation to enter the backcountry and 24% lacked formal avalanche education, which is significantly higher than the 14% of established skiers (P<0.0001).
Influenced by factors related to COVID-19, reported backcountry use increased during the pandemic. Newcomers had a lower level of avalanche education and less confidence in evaluating terrain. Because 80% of participants were recruited from avalanche safety or education websites, this likely underestimates skiers lacking avalanche awareness or education and is further limited by the nature of online surveys.
Background A delayed Door-to-Balloon (DTB) time in women with ST-elevation myocardial infarction (STEMI) has been associated with an increased mortality. The objectives of this study were to (a) ...quantify the components of the delayed DTB time in women and (b) assess the independent effect of gender on DTB time in patients undergoing percutaneous coronary intervention (PCI) for STEMI. Methods Clinical parameters were prospectively collected for 735 STEMI patients undergoing primary PCI from 2006 to 2010, with particular attention to the components of DTB time, including the onset of chest pain and the ‘code’ notification of the STEMI team by the Emergency Department. Results Women were significantly older with more co-morbidity. Upon hospital arrival they also experienced delays in Door-to-Code (23 vs. 17 min, P = .012), Code-to-Balloon (63 vs. 57 min, P = .001) and thus DTB time (88 vs. 72 min, P = .001). After multivariate adjustment, independent determinants of DTB time included female gender (ratio of geometric means RGM = 1.13; 95% CI 1.02–1.26; P = .022), hypertension (RGM = 1.12, 95% CI 1.02–1.23, P = .014), maximum ST-elevation (RGM = 0.97, 95% CI 0.94–0.98, P < .001), office hours (RGM = 0.84, 95% CI 0.78–0.92, P < .001) and triage category (RGM = 1.23, 95% CI 1.09–1.40, P = .001). Conclusions Women experience delays in identification of the STEMI diagnosis and also in the PCI process. Thus a multifaceted approach addressing both the diagnosis and management of STEMI in women is required.
Altitude illness affects 25 to 85 percent of travelers to high altitudes, depending on their rate of ascent, home altitude, individual susceptibility, and other risk factors. Acute mountain sickness ...is the most common presentation of altitude illness and typically causes headache and malaise within six to 12 hours of gaining altitude. It may progress to high-altitude cerebral edema in some persons. Onset is heralded by worsening symptoms of acute mountain sickness, progressing to ataxia and eventually to coma and death if not treated. High-altitude pulmonary edema is uncommon, but is the leading cause of altitude illness-related death. It may appear in otherwise healthy persons and may progress rapidly with cough, dyspnea, and frothy sputum. Slow ascent is the most important measure to prevent the onset of altitude illness. If this is not possible, or if symptoms occur despite slow ascent, acetazolamide or dexamethasone may be used for prophylaxis or treatment of acute mountain sickness. Descent is mandatory for all persons with high-altitude cerebral or pulmonary edema. Patients with stable coronary and pulmonary disease may travel to high altitudes but are at risk of exacerbation of these illnesses. Medical management is prudent in these patients.
Approximately 20% of patients undergoing diagnostic angiography for the evaluation of chest pain are found to have a normal coronary angiogram. Although this finding is generally associated with a ...low risk of cardiac events, approximately half will continue to experience chest pain over the next 12 months. Therefore, the finding of normal angiography warrants further evaluation of the potential causes for the presenting chest pain if we are to improve the disability suffered by these patients. In this review, the potential non‐cardiac and cardiac causes for the chest pain in patients with normal angiography are briefly discussed with an in‐depth focus on coronary vasomotor disorders including coronary artery spasm (variant angina) and microvascular disorders such as syndrome X, microvascular angina, the coronary slow flow phenomenon and microvascular spasm.
Nausea and vomiting are common for runners during ultramarathons and often contribute to non-finishes. We aimed to determine the efficacy of ondansetron, a commonly used antiemetic, to treat nausea ...and vomiting in runners during an ultramarathon. Runners who had a previous history of frequent nausea or vomiting during races and entered in 160, 80, and 55 km ultramarathons in 2018 and 2019 were randomized in a double-blind fashion to 4 mg ondansetron or placebo capsules to use if they developed nausea or vomiting during the race with the ability to take three additional doses. Study participants completed a post-race online survey to assess medication use and efficacy. Of 62 study participants, 31 took either ondansetron (20) or placebo (11). In this small study, there were no group differences in those reporting any improvement in nausea and vomiting (
= 0.26) or in the amount of improvement (
= 0.15). We found no evidence that ondansetron capsules improve nausea and vomiting during ultramarathons.
Several biologic and clinical factors contribute to the increased 30-day mortality and re-infarction rate in women with ST-segment elevation myocardial infarction (STEMI). Sex differences in cardiac ...hemodynamic parameters such as pulmonary capillary wedge pressure (PCWP) have not been examined and might play an important role. The objectives of the present study were to examine whether female sex is an independent determinant of PCWP during acute STEMI and whether an elevated PCWP contributes to all-cause 30-day mortality and re-infarction in women. The clinical, angiographic, and hemodynamic features of 470 consecutive patients with STEMI (n = 135 women) undergoing emergency coronary angiography with right-side heart catheterization were evaluated with respect to sex. Women had an elevated PCWP (20 ± 8 vs 16 ± 7 mm Hg, p <0.001) and reduced mixed venous oxygen saturation (67 ± 11% vs 71 ± 9%, p = 0.004). On multivariate analysis, female sex (β = 4.04, 95% confidence interval CI 2.04 to 6.04, p <0.001), hypertension (β = 2.07, 95% CI 0.31 to 3.83, p = 0.021), and creatine kinase-estimated infarct size (β = 0.001, 95% CI 0.001 to 0.002, p ≤0.001) were independent predictors of an elevated PCWP. Female sex exerted a minor independent effect on 30-day mortality and re-infarction (odds ratio 2.36, 95% CI 1.25 to 4.46, p = 0.008). However, once PCWP was entered into the mediation model, sex was no longer significant, suggesting that the effect of sex on the post-STEMI outcomes is potentially mediated through PCWP (odds ratio 1.07, 95% CI 1.02 to 1.12, p = 0.011). In conclusion, during acute STEMI, women have greater left ventricular filling pressures compared with men, independent of age, hypertension, and infarct size. The biologic explanation for this difference requires additional investigation, although it does not appear to contribute to the increased 30-day mortality and re-infarction rate observed in women.
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