Tuesday, August 11, 2020

A case of relapsing polychondritis

From a case report and mini review in the American Journal of Medicine:

McAdam and the Damiani/Levine diagnostic criteria. 12 RPC is diagnosed if 3 of 6 clinical findings are present: 1) auricular chondritis; 2) nonerosive inflammatory arthritis; 3) nasal chondritis; 4) ocular inflammation, including conjunctivitis, keratitis, scleritis, episcleritis, or uveitis; 5) laryngotracheal chondritis; and 6) cochlear or vestibular damage presenting as sensorineural hearing loss, tinnitus, or vertigo. A diagnosis of RPC also can be made if a patient meets one of 6 criteria AND has compatible cartilage biopsy histology or meets 2 of 6 criteria AND improves clinically after receiving corticosteroids or dapsone. 2

RPC is a rare inflammatory disease with a peak age of onset between ages 40 and 50 years and an estimated incidence of 3.5 cases per million people per year. 3 Cases have been diagnosed across all racial groups. Men and women are equally affected. 3 RPC is defined by abrupt-onset inflammation of the cartilaginous ear, nose, joints, laryngotracheobronchial tree, or heart valves. The disease usually follows an indolent, relapsing-remitting course but may also present fulminantly and threaten vision and organ function. 4 …

Up to one-third of cases of RPC present prior to, during, or after another disease. 6 The most commonly associated syndrome is systemic vasculitis, followed by rheumatoid arthritis and systemic lupus erythematosus.

Thyroid acropachy: an unusual complication of Graves disease

From a recent published case report and mini-review:

The pathogenesis of acropachy is unknown, except for the anatomic location, in that it is probably similar to that of pretibial myxedema. It appears that TRAb molecules bind to the TSH receptors of fibroblasts present in the periosteum region and trigger an inflammatory response, producing cell proliferation and glycosaminoglycan deposition (7,8). The musculoskeletal manifestation is almost never seen without the remaining components of the triad of orbitopathy, dermopathy, and acropachy (9,10). Some studies suggest smoking is a predisposing factor for acropachy in GD patients (9).

In most cases, acropachy is asymptomatic, but the main clinical manifestations are digital clubbing, skin tightness with or without digital clubbing and usually with small-joint pain (in severe cases), soft tissue edema, and reactional periosteum, and skin alterations in fingers and nails may also be present (7). The disorder mostly affects the metacarpus phalangeal and proximal interphalangeal regions in the upper and lower limbs, especially the ankles and metatarsal phalangeal joints (11).

Monday, October 21, 2019

What are the risks for bad outcomes in patients admitted with influenza?


A history of OSAS/CSAS, myocardial infarction and BMI greater than 30 are risk factors for ICU admission.

Non-survivors suffer more often from diabetes mellitus and (pre-existent) renal failure.

ICU patients develop renal failure and bacterial/fungal co-infections more often.



While most influenza patients have a self-limited respiratory illness, 5–10% of hospitalized patients develop severe disease requiring ICU admission. The aim of this study was to identify influenza-specific factors associated with ICU admission and mortality. Furthermore, influenza-specific pulmonary bacterial, fungal and viral co-infections were investigated.


199 influenza patients, admitted to two academic hospitals in the Netherlands between 01-10-2015 and 01-04-2016 were investigated of which 45/199 were admitted to the ICU.


A history of Obstructive/Central Sleep Apnea Syndrome, myocardial infarction, dyspnea, influenza type A, BMI greater than 30, the development of renal failure and bacterial and fungal co-infections, were observed more frequently in patients who were admitted to the ICU, compared with patients at the normal ward. Co-infections were evident in 55.6% of ICU-admitted patients, compared with 20.1% of patients at the normal ward, mainly caused by Staphylococcus aureus, Streptococcus pneumoniae, and Aspergillus fumigatus. Non-survivors suffered from diabetes mellitus and (pre-existent) renal failure more often.


The current study indicates that a history of OSAS/CSAS, myocardial infarction and BMI greater than 30 might be related to ICU admission in influenza patients. Second, ICU patients develop more pulmonary co-infections. Last, (pre-existent) renal failure and diabetes mellitus are more often observed in non-survivors.

Saturday, October 19, 2019

Extending VTE prophylaxis post hospitalization for medical patients

This is not currently a recommended practice but it gets revisited from time to time. Here’s the latest systematic review and meta-analysis in PLOS Medicine. From the paper:


The efficacy, safety, and clinical importance of extended-duration thromboprophylaxis (EDT) for prevention of venous thromboembolism (VTE) in medical patients remain unclear. We compared the efficacy and safety of EDT in patients hospitalized for medical illness.


Electronic databases of PubMed/MEDLINE, EMBASE, Cochrane Central, and ClinicalTrials.gov were searched from inception to March 21, 2019. We included randomized clinical trials (RCTs) reporting use of EDT for prevention of VTE. We performed trial sequential and cumulative meta-analyses to evaluate EDT effects on the primary efficacy endpoint of symptomatic VTE or VTE-related death, International Society on Thrombosis and Haemostasis (ISTH) major or fatal bleeding, and all-cause mortality. The pooled number needed to treat (NNT) to prevent one symptomatic or fatal VTE event and the number needed to harm (NNH) to cause one major or fatal bleeding event were calculated. Across 5 RCTs with 40,247 patients (mean age: 67-77 years, proportion of women: 48%-54%, most common reason for admission: heart failure), the duration of EDT ranged from 24-47 days. EDT reduced symptomatic VTE or VTE-related death compared with standard of care (0.8% versus 1.2%; risk ratio [RR]: 0.61, 95% confidence interval [CI]: 0.44-0.83; p = 0.002). EDT increased risk of ISTH major or fatal bleeding (0.6% versus 0.3%; RR: 2.04, 95% CI: 1.42-2.91; p less than 0.001) in both meta-analyses and trial sequential analyses. Pooled NNT to prevent one symptomatic VTE or VTE-related death was 250 (95% CI: 167-500), whereas NNH to cause one major or fatal bleeding event was 333 (95% CI: 200-1,000). Limitations of the study include variation in enrollment criteria, individual therapies, duration of EDT, and VTE detection protocols across included trials.


In this systematic review and meta-analysis of 5 randomized trials, we observed that use of a post-hospital discharge EDT strategy for a 4-to-6-week period reduced symptomatic or fatal VTE events at the expense of increased risk of major or fatal bleeding. Further investigations are still required to define the risks and benefits in discrete medically ill cohorts, evaluate cost-effectiveness, and develop pathways for targeted implementation of this postdischarge EDT strategy.

This analysis does not make a good case for extending pharmacologic VTE prophylaxis beyond the period of hospitalization. Note that the ACCP guidelines recommend against this practice. According to those guidelines, post hospital continuation of pharmacologic VTE prophylaxis is recommended for only two situations: post major orthopedic surgery (10 days total minimum) and post cancer surgery (4 weeks).

Friday, October 18, 2019

ICU or stepdown for your DKA patient?


In some centers, all Diabetic Ketoacidosis (DKA) patients are admitted to ICU.

No difference in in-hospital mortality was found between DKA patients admitted to step-down units or ICU.

DKA patients admitted to step-down units had significantly lower costs than those admitted to ICU.

Hospitals should preferentially consider monitoring of DKA patients in step-down units.



There is wide variation in the utilization of Intensive Care Unit (ICU) beds for treatment and monitoring of adult patients with Diabetic Ketoacidosis (DKA). We sought to compare the outcomes and hospital costs of adult DKA patients admitted to ICUs as compared to those admitted to step-down units.

Materials and methods

We included consecutive adult patients from two hospitals with a diagnosis of DKA. Patients were either admitted to the ICU, or a step-down unit, which has a nurse-to-patient ratio of 2:1, but does not have capability for mechanical ventilation or administration of vasoactive agents. The primary outcome was in-hospital mortality.


We included 872 patients in the analysis. 71 (8.1%) were admitted to ICU, while 801 (91.9%) were admitted to a step-down unit. We found no difference in in-hospital mortality between patients admitted to the ICU and those admitted to the step-down unit (adjusted odds ratio [OR]: 1.14, 95% confidence interval [CI]: 0.87–2.64). Mean total hospital costs were significantly higher for patients admitted to the ICU ($20,428 vs. $6484, P less than 0.001).


Adult DKA patients admitted to a step-down unit had comparable in-hospital mortality and lower hospital costs as compared to those admitted to the ICU.

Delirium in hospitalized patients predicts readmission and other forms of increased post hospital utilization

Report here.

This is not surprising, since delirium in the hospital is often a sign of frailty.

Tuesday, August 06, 2019

The cholesterol hypothesis is alive again!

Key Points

Question Is consuming dietary cholesterol or eggs associated with incident cardiovascular disease (CVD) and all-cause mortality?

Findings Among 29 615 adults pooled from 6 prospective cohort studies in the United States with a median follow-up of 17.5 years, each additional 300 mg of dietary cholesterol consumed per day was significantly associated with higher risk of incident CVD (adjusted hazard ratio [HR], 1.17; adjusted absolute risk difference [ARD], 3.24%) and all-cause mortality (adjusted HR, 1.18; adjusted ARD, 4.43%), and each additional half an egg consumed per day was significantly associated with higher risk of incident CVD (adjusted HR, 1.06; adjusted ARD, 1.11%) and all-cause mortality (adjusted HR, 1.08; adjusted ARD, 1.93%).

Meaning Among US adults, higher consumption of dietary cholesterol or eggs was significantly associated with higher risk of incident CVD and all-cause mortality in a dose-response manner.

This paper has been wildly overhyped. It’s new data but concludes nothing we didn’t already know: cholesterol matters. The real problem is, so do a lot of other things. Those who would hype this finding lack an appreciation of the concept of population attributable risk.

Sunday, August 04, 2019

Check point inhibitor induced colitis

Saturday, August 03, 2019

Which patients post cardiac arrest need to go straight to the cath lab?

CAD is a common substrate, and its severity is a potential trigger for OHCA, especially in the case of shockable rhythms. Patients with VF/pVT OHCA should be considered at the highest severity of a continuum of acute coronary syndromes. Patients with VF/pVT have a significant burden of CAD: acute, chronic, or acute on chronic (Figure 8)…

Current guidelines recommend early CAG and reperfusion for postarrest patients manifesting ST-segment elevation after ROSC is achieved. However, because of a lack of conclusive randomized data and ongoing perceived clinical equipoise, there is no consensus guideline on the use of CAG and coronary revascularization in patients without ST-segment elevation on ECG. Multiple randomized trials addressing this question are underway. Until their completion, there is a significant body of observational studies that address the role of the CCL in this population.

The current evidence suggests that early access to the CCL in patients resuscitated from VF/pVT cardiac arrest is associated with 2- to 3-fold higher functionally favorable survival rates than more conservative approaches of late or no access to the CCL. This body of evidence, with potential for unmeasured selection bias, suggests that patients resuscitated from OHCA, especially those with presenting shockable rhythms, should be considered for early CAG, identification of reversible causes, and revascularization when indicated.

This is in line with the current ACLS guidelines, which say that if there’s ST elevation post ROSC an immediate trip to the cath lab carries a class I recommendation. For patients without STE, the guidelines give a IIa recommendation to go straight to the cath lab if the arrest is of suspected cardiac origin on clinical grounds.