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Annals of Internal Medicine Tip Sheet
September 13, 2016


Below is information about articles being published in Annals of Internal Medicine. The information is not intended to substitute for the full article as a source of information. Annals of Internal Medicine attribution is required for all coverage.


1. These 3 criteria quickly identify cardiac arrest patients with zero chance of survival who could be referred for organ donation

Abstract: http://www.annals.org/article.aspx?doi=10.7326/M16-0402

Three objective criteria can be used to quickly identify patients with out-of-hospital cardiac arrest (OHCA) who have zero chance of survival and can therefore be considered for organ donation. Using data from two registries and one trial in Paris, France, researchers found that there is essentially no chance of survival in patients whose OHCA is not witnessed by emergency medical services personnel, who have nonshockable initial cardiac rhythm, and in whom spontaneous circulation does not return before receipt of a third 1-mg dose of epinephrine. The findings are published in Annals of Internal Medicine.

Medical professionals are ethically required to perform CPR and consider all available technologies to save the life of a person with OHCA. Clinical decision rules known as termination-of-resuscitation rules help to identify cases where further resuscitation is futile, thus avoiding ambulance transport and its associated costs. These rules do not, however, take into consideration the potential utility of transporting dead patients to the hospital for organ donation. For organ donation after cardiac death to be considered, patients must have zero chance of survival, be legally eligible to donate, and be rapidly transported to an appropriate hospital under continuous resuscitative maneuvers. The most important thing is to establish objective criteria for identifying patients with no chance of survival during the first minutes of CPR. Researchers suggest that their findings could inform decision making.

2. Acupuncture safe and effective for severe functional constipation

Abstract: http://www.annals.org/article.aspx?doi=10.7326/M15-3118

Eight weeks of electroacupuncture, a technique where an electrical current is passed between a pair of acupuncture needles, is safe and effective for relieving chronic constipation. Results of a randomized controlled trial are published in Annals of Internal Medicine.

Chronic constipation occurs when a patient has no more than two complete bowel movements per week with hard stools, frequent straining, and the sensation of incomplete evacuation. Most chronic constipation is functional, which means that it is not caused by any physical illness, and is associated with decreased quality of life. Laxatives produce only temporary relief and nearly half of patients are dissatisfied with their traditional therapies. Research has supported the use of acupuncture for chronic constipation and electroacupuncture might have some sustained effects. However, the evidence for the therapeutic effects of acupuncture is limited.

Researchers randomly assigned 1,075 patients to 28 sessions of electroacupuncture at traditional acupoints or sham electroacupuncture at nonacupoints over 8 weeks. They found that the patients in the treatment group had increased complete spontaneous bowel movements during the 8 weeks of treatment and improved quality of life. These effects persisted throughout the 12-week follow-up. The researchers conclude that acupuncture could be a valuable new therapeutic option for patients with chronic severe functional constipation.

3. Considerable discrepancies exist among cardiovascular disease risk assessment guidelines

Abstract: http://www.annals.org/article.aspx?doi=10.7326/M16-1110

A systematic review of current guidelines for screening and risk assessment for primary prevention of cardiovascular disease (CVD) in apparently healthy persons found areas of agreement but no consensus on the optimum screening strategy, recommended target population, screening tests, or treatment thresholds. The findings are published in Annals of Internal Medicine.

The aim of CVD screening is to improve the health of an already healthy population and reduce the risk factors for CVD. Primary care physicians, who play a central role in CVD prevention, cite inconsistency in published recommendations as one of the reasons for not using CVD prevention guidelines or global risk assessment tools.

The reviewers identified 21 guidelines, 17 of which were rigorously developed, on cardiovascular screening interventions that would be done within a cardiovascular health check program. Recommendations from 16 of the 17 rigorous guidelines supported CVD risk assessment. Most guidelines recommended integrating age, sex, smoking, blood pressure, and lipid levels into CVD risk assessment by using prediction models. However, there was no consensus on which prediction model to use. Guidelines on total cardiovascular risk differ about when to initiate statin treatment.

Most guidelines agreed on the need to consider ethnicity as a risk factor for CVD. Other areas of agreement included a consensus on the limited role of novel biomarkers and markers of subclinical atherosclerosis, a conservative approach to aspirin use, and the importance of addressing lifestyle factors.

The diversity in CVD guidelines may partly reflect the uncertainty of the benefits of screening. Physicians should assess the strength of the recommendations and the level of evidence to decide which of the recommendations they should implement, the reviewers write.

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