Recommended Readings

(1). Susanne Wegener. Triggers of Stroke: Anger, Emotional Upset, and Heavy Physical Exertion.

‘Could it be that my stroke was brought on by emotional stress?’ This is a common question of stroke survivors directed to their physicians at follow-up. Stroke is a drastic event. Concerns about recurrent symptoms initiate the search for potential triggers-something one can control and change for good. A typical answer would be that indeed, extreme physical or emotional stress are risk factors for stroke, but their role as immediate triggers of stroke is unclear.

(2). Brian A Bergmark, et al. Acute coronary syndromes. Lancet. 2022;399(10332):P1347-58.

Although substantial progress has been made in the diagnosis and treatment of acute coronary syndromes, cardiovascular disease remains the leading cause of death globally, with nearly half of these deaths due to ischaemic heart disease. The broadening availability of high-sensitivity troponin assays has allowed for rapid rule-out algorithms in patients with suspected non-ST-segment elevated myocardial infarction (NSTEMI). Dual antiplatelet therapy is recommended for 12 months following an acute coronary syndrome in most patients, and additional secondary prevention measures including intensive lipid-lowering therapy (LDL-C <1.4 mmol/L), neurohormonal agents, and lifestyle modification, are crucial. The scientific evidence for diagnosis and management of acute coronary syndromes continues to evolve rapidly, including adapting to the COVID-19 pandemic, which has impacted all aspects of care. This Seminar provides a clinically relevant overview of the pathobiology, diagnosis, and management of acute coronary syndromes, and describes key scientific advances.

(3). Ryan A. Mace, et al. Redefining Brain Health: A Call to Embrace a Biopsychosocial Approach. NEJM. 2022.

Biomedical science, which focuses on identifying and treating neurological and psychiatric illness, has dominated our understanding of the brain over the past 3 decades. This approach has failed to identify causes, cures, or effective prevention strategies. Neurological and psychiatric illnesses have become leading causes of death and disability in the United States. From this perspective, faculty at Massachusetts General Hospital’s Integrated Brain Health Clinical and Research Program urge the field to embrace a biopsychosocial and developmental conceptualization of brain health. This approach would allow us to shift the focus to (1) preventing neurological and psychiatric illness rather than treating symptoms, (2) promoting optimal brain functioning rather than removing disability, and (3) enhancing quality of life across the brain health-illness continuum rather than increasing lifespan. The authors describe scientific initiatives, informed by the proposed biopsychosocial definition, that will lead the next area of brain health research, practice, and training. They encourage health care leaders and multidisciplinary colleagues to adopt a team science approach to investigate and treat the interconnected factors that promote brain health at all ages.

(4). Researchers find cause of irregular heart rhythm in Covid patients.

The SARS-CoV-2, the virus causing Covid-19, can infect cells of the heart’s natural pacemaker that maintain the rhythmic beat, setting off a self-destruction process within the cells, according to a preclinical study.

(5). Changes in airway cells cause genetic risk for asthma: Study.

This work will help us identify targetable pathways to intervene for asthma, to stop mucus hypersecretion or type 2 airway inflammation, an allergic response that can exacerbate asthma,” said Max A. Seibold, PhD, professor of Pediatrics at the National Jewish Health Center for Genes, Environment and Health and senior author of the paper.

(6). Preparing for the next wave

Just when the Omicron wave seems to have died down in the U.S., experts are already warning about the next surge of cases – this time driven by the highly infectious subvariant BA.2.

It’s still early days, but there are signs that the next wave may already be upon us. Researchers have seen an uptick in cases in the U.S., and they’ve detected a rise in the viral particles recovered from nearly 150 wastewater-surveillance sites.

To help us prepare for the next wave, my colleagues Tara Parker-Pope and Knvul Sheikh shared the best ways to prepare for a surge:

Pay attention to Covid indicators in your community.

An easy way to do this is to check the color-coded map from the C.D.C. that shows community levels of Covid. As the map shifts to yellow or orange in your area, it’s time to take extra precautions, including donning masks in public spaces and rethinking large indoor gatherings where you don’t know the vaccination status of others.

Another useful indicator is your community’s positive test rate. Experts advise taking more precautions as you see positivity rates start to rise above 5 percent.

Have high-quality masks on hand.

A limited number of free N95 respirator masks are available at pharmacies and community centers. Enter your ZIP code on the C.D.C.’s mask locator site to find a participating distributor. If you want to buy additional masks, use our guide to avoid counterfeits.

Get home Covid tests sooner rather than later.

Order them now – for free from the government – before the weather turns warm. The tests can be damaged by heat, and you don’t want yours sitting for hours in a mail truck on a hot day. People with health insurance can also be reimbursed for eight free tests a month.

Get a booster (when you’re eligible).

Federal regulators authorized a second booster for everyone 50 and older and people 12 and older with certain immune deficiencies. The protective antibodies from a vaccine or an infection tend to wane in four or five months, and a well-timed booster shot can help the body bump up its antibody defenses.

Get a pulse oximeter.

It’s a small device that clips on your finger and measures your blood oxygen levels. When levels drop to 92 or lower, patients should see a doctor. Low oxygen can be a sign of Covid pneumonia and may raise your risk for serious complications. One warning: The devices can be less reliable for people with darker skin.

Make a plan for antiviral drug treatment.

Two oral antiviral therapies are available for high-risk patients with a prescription: Paxlovid, developed by Pfizer, is available for people 12 and older and Molnupiravir, developed by Merck, is available for adults 18 and older.

Check with your doctor to make sure you can receive the medication should you fall ill. Or, look up qualified health centers near you that have authorized medical providers so you can get tested and, if positive, receive antiviral medication on the spot.

People who are immunocompromised should also talk to their doctors about Evusheld, an antiviral drug from AstraZeneca that can be given by injection to provide an additional layer of protection on top of vaccines.

Have backup plans for social events and travel.

If you’re hosting a large event, have an outdoor backup plan if case numbers spike. Before traveling, do a little research on clinics and pharmacies at your destination so you know whether you can receive antiviral drugs. Make sure you have extra funds or plenty of room on your credit card in case you need to extend your trip to recover from Covid.

(7). Evan W. Neczypor, et al. E-Cigarettes and Cardiopulmonary Health. Circulation. 2022;145(1):219-232.

Electronic cigarettes (e-cigarettes) are battery powered electronic nicotine delivery systems that use a propylene glycol/vegetable glycerin base to deliver vaporized nicotine and flavorings to the body. E-cigarettes became commercially available without evidence regarding their risks, long-term safety, or utility in smoking cessation. Recent clinical trials suggest that e-cigarette use with counseling may be effective in reducing cigarette use but not nicotine dependence. However, meta-analyses of observational studies demonstrate that e-cigarette use is not associated with smoking cessation. Cardiovascular studies reported sympathetic activation, vascular stiffening, and endothelial dysfunction, which are associated with adverse cardiovascular events. The majority of pulmonary clinical trials in e-cigarette users included standard spirometry as the primary outcome measure, reporting no change in lung function. However, studies reported increased biomarkers of pulmonary disease in e-cigarette users. These studies were conducted in adults, but >30% of high school-age adolescents reported e-cigarette use. The effects of e-cigarette use on cardiopulmonary endpoints in adolescents and young adults remain unstudied. Because of adverse clinical findings and associations between e-cigarette use and increased incidence of respiratory diseases in people who have never smoked, large longitudinal studies are needed to understand the risk profile of e-cigarettes. Consistent with the Centers for Disease Control and Prevention recommendations, clinicians should monitor the health risks of e-cigarette use, discourage nonsmokers and adolescents from using e-cigarettes, and discourage smokers from engaging in dual use without cigarette reduction or cessation.

(8). Sylvie Baggett. Doctor Climbing Mt. Everest to Raise $1 Million for Cancer Research.

The Mount Everest base camps, situated on either side of the world’s tallest mountain, are pitched at an altitude of about 17,500 feet – a wise decision, as the human body begins to enter a state of decay somewhere between 18,000 and 19,000 feet. Depending on which route is taken, adventurers may find themselves on the more easily accessible Tibetian side of the mountain or making their way along the southern and much more remote Nepalese route.

(9). Chloe Smith. Living with type 1 diabetes as a medical student. BMJ 2022;377:o920.

I was diagnosed with type 1 diabetes when I was 17, just days after finishing my A level exams. I had lost 5kg in weight and experienced extreme thirst and tiredness over the previous few weeks, but I put that down to exam stress and was looking forward to recovering over the summer. “Luckily,” my very elevated blood glucose levels were picked up on a routine blood test before I went into diabetic ketoacidosis. In one day, I went from a normal 17 year old, preparing to apply to medical school, to someone with a chronic illness, controlled by multiple injections and finger pricks a day.

Although it was initially a huge lifestyle change, the routine of managing diabetes soon became second nature. From an outside perspective, it may even look somewhat easy. Check blood glucose, count the carbohydrates in food, inject insulin, eat food, and repeat. However, multiple factors can affect my blood glucose levels and insulin absorption, including exercise, the fat content of food, illness, stress, or even changes in weather, which all need to be taken into account. Type 1 diabetes is an exhausting, full time job that no one ever wanted.

When you look after someone with type 1 diabetes, what you see is just the tip of the iceberg of all the hours they’ve invested in managing their condition. You may look at a chart listing all the blood glucose levels of your patient at different times of the day, but these numbers, detached from any larger context, don’t give you an insight into the work that patient has put into caring for themselves and the impact it has on their everyday life. Patients are often experts in their own condition and this should not be underestimated.

Getting through medical school with type 1 diabetes was challenging. Long days on placement, variable meal times (with sometimes no time for lunch), and unpredictable activity levels all wreaked havoc on my blood glucose control. This caused physical symptoms that affected my performance and made me feel unwell. The most difficult parts of medical school were during exam time as the stress pushed my glucose levels higher and higher, making me feel fatigued and hindering my ability to think and concentrate. Physically, I felt like I was wading through treacle every time I moved. All of which was very counterproductive to being able to revise effectively and perform well in an exam. However, during these times, I would choose to run my glucose levels a bit higher than normal to avoid having an episode of hypoglycaemia during an exam, which could be catastrophic to my performance.

During medical school, I always dreaded going to lectures about diabetes because I hated listening to all of the things that could happen to me in the future and hearing about all of the diseases I am now at a higher risk for because of my diabetes. The framing of these lectures often made me feel that complications from diabetes were inevitable and that the blame for these outcomes was put upon the person with diabetes. Yet I know from experience that managing diabetes is not an exact science. On two separate days, I can have exactly the same routine, eat the same meals at the same times, do the same amount of exercise, and still have wildly different blood glucose levels.

One of the best lectures that I had during medical school about diabetes was by a paediatrician who demonstrated just how many decisions a person with diabetes makes in a day. Even as someone with type 1 diabetes, it was startling to see just how many there were and how much extra headspace diabetes takes up. I consider myself incredibly lucky that I have such fantastic technology available to me that helps ease the burden of these decisions, providing a bit of a safety net if I don’t get my carbohydrate counting or insulin dosing spot on. It means that diabetes is no longer constantly at the forefront of my mind, allowing me to focus on other things. Type 1 diabetes has never held me back from doing anything that I’ve wanted to do, but it has made my life as a medical student more challenging, giving me valuable insight into the labour involved in managing a chronic condition.

As someone with type 1 diabetes, here are a few pieces of advice for healthcare professionals caring for a patient with the condition:

  • If you see a patient with high blood glucose levels, reserve judgment and try to find out what is happening in their life that could be having an impact on their control. They may be trying their absolute best but are “burnt out” with the constant demands of this disease. Language matters too; try to avoid using the term “non-compliant.”
  • Joking that you’ll get diabetes from a chocolate cake or a doughnut is not funny. It adds to the stigma associated with diabetes, and undermines all the effort and hard work it takes by the patient to keep this disease under control.
  • When a person with type 1 diabetes comes into hospital, it can be a scary time for them if they are too unwell to manage their own blood glucose and have to hand over control of this to the medical team. Although protocols and guidelines exist, it is important to remember that these are a good starting point but are not one size fits all and the administration of insulin and glucose on a sliding scale needs careful monitoring.
  • Every individual with diabetes is unique and what may work for one person may not work for another.
  • Finally, the person with type 1 diabetes lives with their condition 24/7 and is likely to be very knowledgeable about it. Recognise this and work with the person to find a solution, rather than making decisions for them.

(10). Gods in the Operation Theatre.

‘Can I see one surgery?’ my engineer brother queried when he once came visiting me. He had never been inside an operation theatre. Spending time in any profession except our own is always fascinating but nothing beats the experience of an actual surgery for a layperson. I rubbed my hands in glee. I looked forward to impress him so thoroughly that he comes out with a deep sense of respect and awe towards surgeons in general and myself in particular. He should feel guilty of all the bullying he gave his future illustrious younger brother in the growing years…….

(11). Ryan Syrek. Trending Clinical Topic: Alcohol.

Little more than a month after the World Heart Federation issued a policy brief that declared no amount of alcohol can be considered safe for the heart, new studies addressing alcohol’s effect on the brain, cancer risk, and amyotrophic lateral sclerosis (ALS) incidence resulted in this week’s top trending clinical topic. A new study out of the United Kingdom suggests that even a single drink per day is linked to detectable changes in the brain (see Infographic)……

(12). Kelsey Goostrey. Prognostication and shared decision making in neurocritical care. BMJ 2022;377:e060154.

Prognostication is crucial in the neurological intensive care unit (neuroICU). Patients with severe acute brain injury (SABI) are unable to make their own decisions because of the insult itself or sedation needs. Surrogate decision makers, usually family members, must make decisions on the patient’s behalf. However, many are unprepared for their role as surrogates owing to the sudden and unexpected nature of SABI. Surrogates rely on clinicians in the neuroICU to provide them with an outlook (prognosis) with which to make substituted judgments and decide on treatments and goals of care on behalf of the patient. Therefore, how a prognostic estimate is derived, and then communicated, is extremely important. Prognostication in the neuroICU is highly variable between clinicians and institutions, and evidence based guidelines are lacking. Shared decision making (SDM), where surrogates and clinicians arrive together at an individualized decision based on patient values and preferences, has been proposed as an opportunity to improve clinician-family communication and ensure that patients receive treatments they would choose. This review outlines the importance and current challenges of prognostication in the neuroICU and how prognostication and SDM intersect, based on relevant research and expert opinion.