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WHO Announces ICD-11, Coming Next Year

Key point: New set will reflect current terminologies and classifications, integrate more smoothly with new technologies.

Citation: World Health Organization. WHO Releases New International Classification of Diseases (ICD 11). June 18, 2018. Available at: Accessed August 14, 2018.

ICD-10 was released in 2015, but according to the World Health Organization (WHO) we can already expect the next revision, ICD-11, sometime early in the next decade. ICD-11 is supposed to contain updates to key clinical elements and allow the coding process to integrate more smoothly with new electronic records technology. The hope is that it will allow for better interoperability and coding consistency across different platforms. ICD-11 will be presented for adoption at the World Health Assembly in May 2019 and will become effective in 2022. According to the WHO, the new ICD includes several new chapters, including one on traditional medicine and another one on sexual health that brings together conditions that were previously categorized in other ways (eg, gender incongruence was listed under mental health conditions) or described differently. Gaming disorder was added to the section on addictive disorders. The WHO has promised significant improvements over ICD-10, stating that for the first time, it will be completely electronic and also claiming that ICD-11 will be more user-friendly than ICD-10. It took 23 years for the U.S. to agree to ICD-10, but healthcare experts expect ICD-11 to be adopted much quicker this time around.


It’s Official: Boxers Over Briefs for Optimal Male Fertility

Key Point: Boxers are better than briefs when it comes to sperm counts and mobility.

Citation: Mínguez-Alarcón L, Gaskins AJ, Chiu YH, et al. Type of underwear worn and markers of testicular function among men attending a fertility center. Hum Reprod. August 8, 2018. [Epub ahead of print]

A recently published study in Human Reproduction confirmed earlier research regarding underwear types and their potential effects on male fertility. Researchers questioned almost 650 men attending an infertility clinic to determine what kind of underwear they customarily wore. Answer choices included boxers, jockeys, bikinis, briefs, or “other” (a category that included boxer-briefs or mixtures of underwear types). Semen and blood samples were collected from each participant. The men were then divided into two groups according to their underwear type: those primarily wearing looser-fitting boxers and those mainly wearing tighter-fit underwear. The results revealed that a preference for boxers was associated with higher sperm counts and concentrations, and higher numbers of motile sperm. It was also associated with lower serum levels of follicle-stimulating hormone. Sperm counts were, on average, 17% lower in those who wore briefs than in men who wear boxers. The authors postulated that tight underwear elevates scrotal temperatures, thus leading to lower sperm production. They also noted that even though the average sperm count was lower in men who wore tight-fitting underwear instead of boxers, this value was still well within healthy levels, suggesting the difference between underwear types shouldn’t be exaggerated. Skeptics noted that the type of pants typically worn by each patient, such as tight-fitting jeans, could outweigh any benefits derived from wearing loose boxers, and may have confounded results.


FDA Calls for Fluoroquinolones Label Changes

Key point: Warnings regarding hypoglycemia, mental health will be stronger.

Citation: U.S. Food and Drug Administration. FDA updates warnings for fluoroquinolone antibiotics on risks of mental health and low blood sugar adverse reactions. July 10, 2018. Available at: Accessed August 14, 2018.

The FDA called for even more label changes to fluoroquinolones to strengthen warnings that the antibiotics could cause severe hypoglycemia or mental health issues. The first label change requires that all fluoroquinolone labels must now explicitly warn of the potential risk for coma due to hypoglycemia. The second label change regards mental health side effects, which include agitation, attention disturbances, delirium, disorientation, memory impairment, and nervousness. These mental health side effects must now be listed separately from adverse reactions to the central nervous system. The FDA noted that mental health side effects have been reported after just one dose of a flouroquinolone. These new warnings are in addition to numerous other prior fluoroquinolone warnings, including boxed warnings about risks for tendinitis and tendon rupture, as well as worsening muscle weakness in patients with myasthenia gravis. The changes are in response to an agency review of adverse event and case reports.


Speech Recognition Software Needs More Work

Key point: Speech recognition software leads to higher error rates in patient documentation.

Citation: Zhou L, Blackley SV, Kowalski L. Analysis of errors in dictated clinical documents assisted by speech recognition software and professional transcriptionists. JAMA Network Open. Available at: Accessed August 14, 2018.

Speech recognition software (for dictation) is being increasingly used to document clinical encounters in electronic health records. Proponents of the software note that the software decreases the time providers spend on documenting patient notes and procedures. However, a study published in JAMA Network Open suggests that it yields errors in up to 7% of dictated words. The author’s analysis included about 220 documents (office notes) that were dictated using one speech recognition system at two U.S. healthcare organizations. Researchers had human transcriptionists transcribe each original recording to use as the reference standard. They then compared the error rate in the note solely created by the speech recognition software, then compared it to the error rate after the transcriptionist review and physician sign-off. The error rate was 7 per 100 words in the notes created by the speech recognition software, falling to below 1 per 100 after transcriptionist review and physician sign-off. They also noted that when it came to clinically significant errors, 64% of the speech-recognition notes had such errors, which fell to 8% after review and sign-off. The researchers concluded that their study “highlights the crucial role of manual editing and review” when using speech recognition software.


Are Anticonvulsants a Suitable Alternative for Low Back Pain?

Key point: Studied anticonvulsant drugs are ineffective for treating low back pain, and may even be harmful.

Citation: Enke O, New HA, New CH, et al. Gabapentinoids ineffective in treatment of low back pain or lumbar radicular pain. CMAJ. 2018;190(3):E786-E793.

Prescriptions for anticonvulsant drugs have increased sharply in recent years, presumably as alternatives to opioid pain medication. Lyrica (pregabalin) and Neurontin (gabapentin) are primarily used for treating nerve pain and fibromyalgia, but are increasingly being prescribed off-label to treat lower back and neck pain. In a meta-analysis published in the Canadian Medical Association Journal, researchers examined nine studies of chronic low back pain or lumbar radicular pain that included 859 unique patients and compared topiramate, gabapentin, or pregabalin to placebo.  Results revealed that these medications do not appear to improve low back pain. In fact, the gabapentinoids did not have any effect on low back pain or disability and topiramate appeared to have only a small effect on pain, and then only in the short term. Neither treatment had any effect on lumbar radicular pain. Researches also pointed out that gabapentinoids were associated with significantly increased risk for adverse events relative to placebo, including drowsiness, dizziness, and nausea. The authors concluded that the evidence does not support the use of anticonvulsants for treatment of either chronic low back pain or lumbar radicular pain. This was based on the high quality of evidence suggesting no treatment benefit for pain and disability, and high-level evidence supporting the risk of harms.


Stick with Needles for the Upcoming Flu Season

Key point: AAP recommends against nasal spray for upcoming flu season.

Citation: American Academy of Pediatrics. American Academy of Pediatrics advises parents to choose the flu shot for 2018-2019 flu season. Available at: Accessed August 14, 2018.

The American Academy of Pediatrics will advise families to choose the inactivated influenza vaccine (the flu shot) when they vaccinate their children this fall. The decision was made by the AAP Board of Directors after reviewing data on the effectiveness of this season’s flu shot compared with the nasal spray flu vaccine, which has not worked as well in recent flu seasons. Even though the CDC’s Advisory Committee on Immunization Practices gave a weak endorsement of the live attenuated nasal flu vaccine (Flumist) for the 2018–2019 flu season, AAP clearly recommends the injectable influenza vaccine over the nasal spray for youth this year. They will publish their formal policy statement on flu prevention in September. In the previous 2 years, neither the AAP nor the CDC recommended the live attenuated vaccine (nasal spray) because evidence showed it had poor efficacy against H1N1 and other strains. The AAP did not endorse this season’s influenza nasal spray vaccine (still citing poor efficacy), stating that the nasal spray should only be used in children who would otherwise go unvaccinated. In an AAP press release, a member of the AAP Committee on Infectious Diseases said, “If you get the nasal spray vaccine, just be aware that there might be a chance you will not be fully protected against H1N1 strains of flu.” In summary, the AAP does not recommend the nasal spray for routine influenza vaccination in children (they instead recommend the injectable version) and state that the spray should be a last resort for children who would not otherwise receive a flu vaccine.




Abstracts in Urgent Care – September 2018