The edition · Internal Medicine
After a clean chest-pain work-up, the anxiety is still there to treat
PACER found online CBT eased anxiety in people discharged with low-risk chest pain, most in those with severe symptoms. Also: systematic cardiovascular care for men starting androgen deprivation, and why one in five medical inpatients is still in a bed a week after they are ready to go.
The edition in brief
Today's internal medicine edition closes on PACER, a three-arm randomised trial of 375 adults discharged from the emergency department with low-risk chest pain and at least moderate anxiety. Over 12 months, peer-supported internet CBT improved anxiety scores by 1.22 points more than a primary care referral (95% CI 0.01 to 2.43), with a larger effect of about 2.8 points in severe anxiety; both CBT arms tripled the odds of patients reporting their anxiety had improved. A trial in 2487 men with prostate cancer starting androgen deprivation found that routine referral to an internist or cardiologist for a blood pressure target and a statin improved a hierarchical outcome (win ratio 1.60), almost entirely through lower cholesterol, with no difference in cardiovascular death, heart attack, stroke or heart failure. An American College of Physicians guideline from October places oestrogen-based hormone therapy first for menopausal hot flushes, with an SNRI second. A one-day census across 21 US veterans' hospitals found 41.9% of 1348 medical inpatients were medically ready for discharge, and 18.1% had been ready for a week or more, mostly awaiting long-term care placement. The pearl covers starting discharge planning at admission.
Men starting androgen deprivation: systematic statin and blood pressure care lowered cholesterol, not events
Review cardiovascular risk factors when a man starts androgen deprivation, but do not expect a specialist referral alone to prevent events.
Menopausal hot flushes: ACP puts hormone therapy first, non-hormonal options in a ladder behind it
For a woman seeking treatment of hot flushes and without contraindications, offer hormone therapy first; use an SNRI as the next step.
One in five medical inpatients had been ready to leave for a week or more
Identify discharge barriers in the first two days of admission, because waiting for placement, not medicine, keeps many patients in hospital.
Start the discharge plan on the day of admission
Ask about home, function and carers at admission, and set an expected discharge date on day one.
Low-risk chest pain with anxiety: online CBT eased symptoms more than a GP referral
After a negative chest pain work-up, screen for anxiety and consider offering CBT, particularly when symptoms are severe.
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