Preview Mode Links will not work in preview mode

Ridgeview and the Ridgeview Continuing Medical Education Program are proud to present the Ridgeview Podcast: CME Series. Quality, portable and on-demand continuing medical education, featuring a variety of our exceptional physicians, providers and other staff from Ridgeview and it's affiliates. Hosting the program are Fred Demeuse, PA-C and Jason Hicks, PA-C. Thanks for tuning-in, downloading and listening! 

 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview & Ridgeview Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Jan 22, 2021

In this podcast Dr. Chris Solie, an ER physician with EMPAC, and Dr. Abby Elliott, with Lakeview Clinic, cover a variety of topic areas from six journal articles. If you like to skip to the conclusion part of the article, this podcast is for you.

Enjoy the podcast!

Objectives:  
  Upon completion of this podcast, participants should be able to:

  • Differentiate if chest pulmonary CTs are necessary when patients present with suspected venous thromboembolism (VTE).
  • Name at least 2 benefits of nighttime antihypertensive dosing for patients.
  • Assess when cardioversion would be deemed necessary for individuals experiencing A-fib.
  • Identify the risks of short-term steroid use.
  • Identify the relevance of lumbar MRI and its findings.
  • Summarize the findings that IV contrast causing acute kidney injury is a myth.

CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org.

To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.

 CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

  

SHOW NOTES:

Journal Article 1: "Diagnosis of Pulmonary Embolism with d-Dimer Adjusted to Clinical Probability"

PEs and DVTs can be elusive. There are rising numbers of chest pulmonary CTAs being done with lower yields. These can result in increased cost and health risks. In this study, the adjusted d-dimer was looked at to see if the number of CTs being ordered can be reduced.

The Wells criteria was used to place patients into low, moderate or high clinical pretest probability for venous thromboembolism of VTE. In the podcast, "clinical pretest probability" is referred to as risk. Of the entire 2000 patients enrolled, the diagnosis of VTEW was only made in 7%. Participants that qualified as low risk numbered 1742 and 1200 of these had d-dimer less than 1000. No VTWE was found in these patients for the next 90 days. For those with a d-dimer between 500 and 999, none had a VTE at 90 days.

In moderate-risk groups with d-dimer less than 500, none had VTE at 90 days. Combining low-risk patients with a d-dimer less than 1000, non of these patients had evidence of VTE at 90 days. Even in the 467 patients with a d-dimer greater than 1000, only 87 had a VTE.

Moderate- or high-risk patients are not applicable for this study. According to the article, if the d-dimer is greater than 1000, and the patient is low-risk, there was a 20% incidence of VTE. While it is an impressive study, it is one peice of data and should not replace clinical gestalt and decision making when truly concerned about the presence of VTE.

Journal Article 2: "Bedtime Hypertension Treatment Improves Cardiovascular Risk Reduction: The Hygia Chronotherapy Trial"

HTN is difficult to manage in many patients. This was a large study out of Spain of approximately twenty thousand patients. Patients were selected to take their medication either in the AM or nighttime and 48-hour blood pressure monitoring was performed. Patients were followed for 6 years. Night time dosed patients had significantly lower cardiovascular event rates than the daytime group, as well as better blood pressure management. There is little evidence to not advise nighttime antihypertensive dosing for patients, unless there would be compliance concerns. Medications that would not be tolerated, or specific medications, like diuretics, that can disrupt sleep. This was an impressive study that demonstrates a rather simple maneuver to effect a remarkable change in cardiovascular risk. Bear in mind, diet and lifestyle may also contribute to the results, but those were not assessed in this study.

Journal Article 3: "Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation"

A-Fib is a common presentation in primary care practice and in Emergency Departments. In this study of early cardioversion strategy vs delayed, 437 patients, aged 18 and above, were reviewed. Necessary criteria included A-fib bit less than 36-hours and hemodynamic stability. The conclusion was that neither strategy delayed or early cardioversion was an inferior approach.

A large number of patients in this study spontaneously converted to normal sinus rhythm without demonstrating higher rates of stroke. However, this study was not powered to assess risk of long-term stroke, and this remains unknown. Though based on other studies referenced today, it's known that a patient cardioverted after 12-hours of A-fib has an increased risk of stroke.

Psychologically, being in A-fib can be disturbing for the individual, and remaining in A-fib is not always desirable from the patient perspective. There are also potential logistical and cost considerations with delayed approach including numerous repeat clinics and ER visits for a small number of patients.

Journal Article 4: "Short-term Use of Oral Corticosteroids and Related Harms Among Adults in the United States: Population-based Cohort Study"

An impressive review of three hundred thousand patients was performed. Corticosteroids were given for mostly musculoskeletal, respiratory and allergic issues. Sepsis, VTE and fracture were monitored for over a 90-day time period and statistically significant higher rates of all of these were noted.

Bear in mind, this was a study without true placebo, and patients essentially compared their experience on steroids to their experience not on steroids. It should probably be followed up with a prospective trial to help further validate these concerning findings.

Still, this study only looked at 3 different complications and the numbers here are pretty striking, with 205 of adults receiving steroids. There are a number of studies which have shown no evidence of benefit in the use of steroids for a variety of indications, including conditions, such as urticaria and even anaphylaxis.

Journal Article 5: "No Association Between MRI Changes In The Lumbar Sone and Intensity of Pain, Quality of Life, Depressive and Anxiety Symptoms in Patients With Low Back Pain"

In this study, out of Poland, patients were referred for a lumbar spine MRI by neurologists, surgeons or other specialists, but not by primary care. These MRIs were graded in the study based on criteria derived from the reading radiologists. The endpoint of the study was to compare the severity of MRI findings with the patient's self-assessment and scoring of pain, quality of life, etc. The study ultimately showed there was no correlation.

However, age and BMI, and total MRI scores did correlate. Physically active patients had better scores. Learning new ways of coping with pain and helping our patients with this reality can equal a more efficient use of time and money. Per this study, medications or a reassuring MRI, does not correlate to resolution of pain. Of course, MRIs are often indicated in the setting of significant neurologic findings and emergencies, but outside of those settings, some patients may not be convinced that an MRI is not necessary. Using articles like this one can assist to better counsel patients and reduce unnecessary MRIs.

Journal Article 6: "Contrast Associated Acute Kidney Injury Is A Myth: Yes"

IV contract is often blamed for acute kidney injury, or AKI. It turns out, like many time honored beliefs in medicine, this is not likely the case. While attempting to research and write a paper on this subject, the investigators quickly discovered that ample data already exists that shows CIN or contrast induced nephropathy, appears to be more a myth than truth.

One senior author of this paper demonstrated in a pool of thousands of patients in two other separate studies that there's no association between contrast and AKI. Another investigator who is a cardiologist demonstrated actually less incidence of AKI in a cohort of patients. So, while personal clinical experience and Gestalt should not be ignored, we also must maintain a desire to debunk dogma that is unfounded time and again in the scientific literature. With regard to AKI from IV contrast, maybe there will be a prospective randomized trial looking at this, but there seems to be a preponderance of evidence already to suggest it may not be necessary.

Thanks for listening.

  Sources/Links: 

Kearon C, de Wit K, Parpia S, et al.  Diagnosis of Pulmonary Embolism with d-Dimer Adjusted to Clinical Probability. N Engl J Med. 2019;381(22):2125-2134. doi:10.1056/NEJMoa1909159  Available:  https://www.nejm.org/doi/10.1056/NEJMoa1909159?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed

Hermida RC, Crespo JJ, Domínguez-Sardiña M, et al.   Bedtime hypertension treatment improves cardiovascular risk reduction: the Hygia Chronotherapy Trial. Eur Heart J. 2020;41(48):4565-4576. doi:10.1093/eurheartj/ehz754 Available: https://academic.oup.com/eurheartj/article/41/48/4565/5602478

Pluymaekers NAHA, Dudink EAMP, Luermans JGLM, et al.   Early or Delayed Cardioversion in Recent-Onset Atrial Fibrillation. N Engl J Med. 2019;380(16):1499-1508. doi:10.1056/NEJMoa1900353  Available: https://www.nejm.org/doi/full/10.1056/NEJMoa1900353

Airaksinen, K. E., Grönberg, T., Nuotio, I., Nikkinen, M., Ylitalo, A., Biancari, F., & Hartikainen, J. E. (2013).  Thromboembolic Complications After Cardioversion of Acute Atrial Fibrillation. Journal of the American College of Cardiology, 62 (13), 1187-1192. doi:10.1016/j.jacc.2013.04.089

Waljee AK, Rogers MA, Lin P, et al.   Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study. BMJ. 2017;357:j1415. Published 2017 Apr 12. doi:10.1136/bmj.j1415 Available: https://www.bmj.com/content/357/bmj.j1415

Yao, T., Huang, Y., Chang, S., Tsai, S., Wu, A. C., & Tsai, H. (2020). Association Between Oral Corticosteroid Bursts and Severe Adverse Events. Annals of Internal Medicine, 173 (5), 325-330. doi:10.7326/m20-0432

Babińska, A., Wawrzynek, W., Czech, E., Skupiński, J., Szczygieł, J., & Łabuz-Roszak, B. (2018). No association between MRI changes in the lumbar spine and intensity of pain, quality of life, depressive and anxiety symptoms in patients with low back pain. Neurologia I Neurochirurgia Polska . doi:10.5603/pjnns.a2018.0006  Available: file:///C:/Users/E55983/Downloads/No_association_between_MRI_changes_in_the_lumbar_s.pdf

Ehrmann, S., Aronson, D., & Hinson, J. S. (2018). Contrast-associated acute kidney injury is a myth: Yes. Intensive Care Medicine, 44 (1), 104-106. doi:10.1007/s00134-017-4950-6  Available: file:///C:/Users/E55983/Downloads/Ehrmann2018_Article_Contrast-associatedAcuteKidney.pdf

Davenport, M. S., Perazella, M. A., Yee, J., Dillman, J. R., Fine, D., Mcdonald, R. J.,  Weinreb, J. C. (2020).   Use of Intravenous Iodinated Contrast Media in Patients with Kidney Disease: Consensus Statements from the American College of Radiology and the National Kidney Foundation. Radiology, 294 (3), 660-668. doi:10.1148/radiol.2019192094