Saturday, October 13, 2018

The cost of an outbreak of carbapenemase-producing Enterobacteriaceae

Report here.

Friday, October 12, 2018

Fludrocortisone versus midodrine for orthostatic hypotension


Background Orthostatic hypotension causes ≈80 000 hospitalizations per year in the United States. Treatments for orthostatic hypotension include fludrocortisone, a mineralocorticoid analog that promotes sodium reabsorption; and midodrine, an α‐1 adrenergic agonist that is a direct vasoconstrictor. Although both medications are used to treat orthostatic hypotension, few studies have compared their relative safety.

Methods and Results We compared incidence rates of hospitalizations for all causes, and for congestive heart failure between users of fludrocortisone and users of midodrine in a retrospective cohort study of Tennessee Medicaid adult enrollees (1995–2009). Adjusted incidence rate ratios were calculated using negative binomial regression models. Subgroup analyses based on history of congestive heart failure were conducted. We studied 1324 patients initiating fludrocortisone and 797 patients initiating midodrine. Compared with fludrocortisone users, midodrine users had higher prevalence of cardiovascular conditions. Incidence rates of all‐cause hospitalizations for fludrocortisone and midodrine users were 1489 and 1330 per 1000 person‐years, respectively (adjusted incidence‐rate ratio 1.20, 95% confidence interval, 1.02–1.40). The respective rates of heart failure–related hospitalization were 76 and 84 per 1000 person‐years (adjusted incidence‐rate ratio: 1.33, 95% confidence interval, 0.79–2.56). Among patients with a history of congestive heart failure, the rates of all‐cause hospitalization for fludrocortisone and midodrine were 2448 and 1820 per 1000 person‐years (adjusted incidence‐rate ratio: 1.42, 95% confidence interval, 1.07–1.90), and the respective rates of heart failure exacerbation–related hospitalizations were 297 and 263 per 1000 person‐years (adjusted incidence‐rate ratio: 1.48, 95% confidence interval, 0.69–3.16).

Conclusions Compared with users of midodrine, users of fludrocortisone had higher rates of all‐cause hospitalizations, especially among patients with congestive heart failure.

Clinical Perspective

What Is New?

This is the first study to evaluate the comparative safety of fludrocortisone and midodrine, 2 drugs commonly used for the treatment of orthostatic hypotension.

Fludrocortisone use was associated with increased risk of all‐cause hospitalizations, particularly among patients with prevalent history of heart failure and orthostatic hypotension.

What Are the Clinical Implications?

Our findings should help inform healthcare providers about safety of fludrocortisone use in patients with orthostatic hypotension.

Our findings could be used to aid healthcare providers to make treatment decisions for patients with orthostatic hypotension.

In patients with heart failure and orthostatic hypotension, fludrocortisone should not be used.

Thursday, October 11, 2018

Oral agents for type 2 diabetes: ACP guidelines

Recommendation 1:

ACP recommends that clinicians prescribe metformin to patients with type 2 diabetes when pharmacologic therapy is needed to improve glycemic control. (Grade: strong recommendation; moderate-quality evidence)
Recommendation 2:

ACP recommends that clinicians consider adding either a sulfonylurea, a thiazolidinedione, an SGLT-2 inhibitor, or a DPP-4 inhibitor to metformin to improve glycemic control when a second oral therapy is considered. (Grade: weak recommendation; moderate-quality evidence.) ACP recommends that clinicians and patients select among medications after discussing benefits, adverse effects, and costs.

Appendix table 1 has a nice summary on outcomes.

Wednesday, October 10, 2018

Adrenal insufficiency due to chronic opiate use

Available data from small heterogeneous studies suggest that 9% to 29% of patients receiving long-term treatment with opiates have development of adrenal insufficiency. However, predictors and the timing of the OIAI onset are unclear. Given the widespread use of narcotics in every field of medicine, physicians should be aware of the potential for endocrine-related adverse effects, in particular OIAI. We suggest careful consideration of OIAI in any patient receiving long-term opiate therapy who manifests symptoms and signs suggestive of adrenal insufficiency. Prospective large studies need to be designed with the goals of elucidating factors associated with OIAI, developing the best approach to case detection of OIAI, and establishing an appropriate management and monitoring plan.

Tuesday, October 09, 2018

Monday, October 08, 2018

Obfuscation of the language: assisted suicide and euthanasia are now medical assistance in dying (MAID)

Sunday, October 07, 2018

TAVR reverses the acquired Von Willebrand syndrome in severe aortic stenosis



In this study, we sought to analyze the incidence and relevance of von Willebrand factor (VWF) abnormalities in patients undergoing transcatheter aortic valve implantation (TAVI), especially on perioperative bleeding. Furthermore, we hypothesized that, similar to aortic valve surgery, TAVI results in a restoration of VWF abnormalities.

Methods and results

We performed a prospective analysis of periinterventional VWF parameters in 74 patients (80 ± 7 years, female in 37.5%) undergoing transfemoral TAVI for severe symptomatic aortic valve stenosis. At baseline, VWF:Ag was 210 ± 90 IU/dl with a mean VWF activity of 166 ± 106 IU/dl; activity-to-antigen ratio was 0.85 ± 0.45. Heyde's syndrome (severe aortic stenosis plus GI bleeding from angiodyplasia) was observed in 2/74 (2.7%). Whereas preprocedural loss of high-molecular-weight (HMW) VWF multimers was found in thirty-six patients (48.6%), none of the patients fulfilled criteria for possible acquired VW syndrome. After TAVI, an increase of both VWF:Ag and activity compared to baseline was observed (p less than 0.01). In patients with HMW multimer loss, post-interventional recovery of multimers occurred in all cases. In the two patients with Heyde's syndrome, a trend towards reduced VWF:Ag was seen, with loss of HMW multimers in one patient. Of interest, all patients suffering from periprocedural major bleeding (5/74; 6.8%) exhibited activity-to-antigen ratios less than 0.7, indicating subclinical VWF dysfunction.


Whereas clinically relevant VWF dysfunction is rare, loss of HMW VWF multimers is common in TAVI patients. Similar to surgery, TAVI leads to a restoration of this loss. Furthermore, VWF parameters may be useful parameter to evaluate risk of periprocedural bleeding.

PE related cardiac arrest



Pulmonary Embolism (PE) is a relatively common cardiovascular condition, occasionally and tragically manifesting as Sudden Cardiac Arrest (SCA). The natural history of SCA complicating PE has been poorly evaluated.In this study, we described the management and outcome of PE-related SCA.


In this prospective population-­based study, we included all patients admitted at hospital alive after out­ of­ hospital SCA, in Paris and suburbs, France (6.6 million inhabits), from May 2011 to September 2015.


Of 2926 patients hospitalized after SCA, 82 cases were diagnosed as PE-related SCA (2.8%, 95%CI = 2.2–3.4). Systemic thrombolysis was performed in 47 patients (57%), without significant increased risk of major bleeding among patients treated with thrombolysis. 12 patients (15%) were treated with ECLS, 29 patients (36%) had targeted temperature management, and 20 patients (24%) underwent coronary angiography. 94% of PE-related SCA had initial non-shockable rhythm, and were associated with better survival compared with other non-shockable SCA (crude OR = 3.0, 95%CI = 1.7–5.4, P less than 0.001; adjusted OR = 4.1, 95%CI 2.0–8.3, P less than  0.001). Among PE-related SCA, thrombolysis was independently associated with survival (OR = 12.5, 95%CI = 1.8–89.1, P = 0.01). Multiple sensitivity analysis was performed, with consistent results.


PE is responsible of approximately 3% of hospitalizations for SCA. Thrombolysis was associated with an increased survival in this population, reinforcing current guidelines advocating for such treatment in PE-related SCA.

Obesity related digestive diseases

From a free full text review:

Obesity is a growing medical and public health problem worldwide. Many digestive diseases are related to obesity. In this article, the current state of our knowledge of obesity-related digestive diseases, their pathogenesis, and the medical and metabolic consequences of weight reduction are discussed. Obesity-related digestive diseases include gastroesophageal reflux disease, Barrett’s esophagus, esophageal cancer, colon polyp and cancer, nonalcoholic fatty liver disease, hepatitis C-related disease, hepatocellular carcinoma, gallstone, cholangiocarcinoma, and pancreatic cancer. Although obesity-related esophageal diseases are associated with altered mechanical and humoral factors, other obesity-related digestive diseases seem to be associated with obesity-induced altered circulating levels of adipocytokines and insulin resistance. The relationship between functional gastrointestinal disease and obesity has been debated. This review provides a comprehensive evaluation of the obesity-related digestive diseases, including pathophysiology, obesity-related risk, and medical and metabolic effects of weight reduction in obese subjects.