Thursday, December 14, 2017

Atrioesophageal fistula following a fib ablation



Methods and Results Electronic searches were conducted in PubMed and Embase for English scientific literature articles. Out of 628 references, 120 cases of AEF were identified using various ablation modalities. Clinical presentation occurred between 0 and 60 days postablation (median 21 days). Fever (73%), neurological (72%), gastrointestinal (41%), and cardiac (40%) symptoms were the commonest presentations. Computed tomography of the chest was the commonest mode of diagnosis (68%), although 7 cases required repeat testing. Overall mortality was 55%, with significantly reduced mortality in patients undergoing surgical repair (33%) compared with endoscopic treatment (65%) and conservative management (97%) (adjusted odds ratio, 24.9; P less than 0.01, compared with surgery). Multivariable predictors of mortality include presentation with neurological symptoms (adjusted odds ratio, 16.0; P less than 0.001) and gastrointestinal bleed (adjusted odds ratio, 4.2; P=0.047).

Wednesday, December 13, 2017

The association between aortic stenosis and ventricular conduction disturbances


The more severe the AS the wider the QRS (roughly) and the more likely the patient is to have RBBB or LBBB. This paper looks at the clinical implications.

Tuesday, December 12, 2017

Influenza activity



Abstract

Influenza activity in the United States was low during October 2017, but has been increasing since the beginning of November. Influenza A viruses have been most commonly identified, with influenza A(H3N2) viruses predominating. Several influenza activity indicators were higher than is typically seen for this time of year. The majority of influenza viruses characterized during this period were genetically or antigenically similar to the 2017-18 Northern Hemisphere cell-grown vaccine reference viruses. These data indicate that currently circulating viruses have not undergone significant antigenic drift; however, circulating A(H3N2) viruses are antigenically less similar to egg-grown A(H3N2) viruses used for producing the majority of influenza vaccines in the United States. It is difficult to predict which influenza viruses will predominate in the 2017-18 influenza season; however, in recent past seasons in which A(H3N2) viruses predominated, hospitalizations and deaths were more common, and the effectiveness of the vaccine was lower. Annual influenza vaccination is recommended for all persons aged greater than or equal to 6 months who do not have contraindications. Multiple influenza vaccines are approved and recommended for use during the 2017-18 season, and vaccination should continue to be offered as long as influenza viruses are circulating and unexpired vaccine is available. This report summarizes U.S. influenza activity* during October 1-November 25, 2017 (surveillance weeks 40-47).

Monday, December 11, 2017

Locums versus non-locums in terms of outcomes


It’s quite the thing nowadays to look at large administrative databases and compare outcomes in various categories of physicians (male versus female, FMG versus domestic, age categories, DO versus MD, and on and on). So it was inevitable that someone would compare locums docs versus non-locums docs. Make whatever you will of this:

Design, Setting, and Participants A random sample of Medicare fee-for-service beneficiaries hospitalized during 2009-2014 was used to compare quality and costs of hospital care delivered by locum tenens and non–locum tenens internal medicine physicians.

Exposures Treatment by locum tenens general internal medicine physicians.

Main Outcomes and Measures The primary outcome was 30-day mortality. Secondary outcomes included inpatient Medicare Part B spending, length of stay, and 30-day readmissions. Differences between locum tenens and non–locum tenens physicians were estimated using multivariable logistic regression models adjusted for beneficiary clinical and demographic characteristics and hospital fixed effects, which enabled comparisons of clinical outcomes between physicians practicing within the same hospital. In prespecified subgroup analyses, outcomes were reevaluated among hospitals with different levels of intensity of locum tenens physician use.

Results Of 1 818 873 Medicare admissions treated by general internists, 38 475 (2.1%) received care from a locum tenens physician; 9.3% (4123/44 520) of general internists were temporarily covered by a locum tenens physician at some point. Differences in patient characteristics, demographics, comorbidities, and reason for admission between locum tenens and non–locum tenens physicians were not clinically relevant. Treatment by locum tenens physicians, compared with treatment by non–locum tenens physicians (n = 44 520 physicians), was not associated with a significant difference in 30-day mortality (8.83% vs 8.70%; adjusted difference, 0.14%; 95% CI, −0.18% to 0.45%). Patients treated by locum tenens physicians had significantly higher Part B spending ($1836 vs $1712; adjusted difference, $124; 95% CI, $93 to $154), significantly longer mean length of stay (5.64 days vs 5.21 days; adjusted difference, 0.43 days; 95% CI, 0.34 to 0.52), and significantly lower 30-day readmissions (22.80% vs 23.83%; adjusted difference, −1.00%; 95% CI −1.57% to −0.54%).

Conclusions and Relevance Among hospitalized Medicare beneficiaries treated by a general internist, there were no significant differences in overall 30-day mortality rates among patients treated by locum tenens compared with non–locum tenens physicians. Additional research may help determine hospital-level factors associated with the quality and costs of care related to locum tenens physicians.

That first sentence is a little misleading. Hospital reimbursement for ordinary Medicare patients is not fee for service and hasn’t been since the Prospective Payment System was implemented in 1884.

A few more observations:

The physicians in both categories were, without a doubt, hospitalists.

Although there was no significant difference in mortality the locums docs had longer LOS. The part B spending referred to above would be their rounding and procedure fees, which may mean locums docs tended to code higher for their visits.

Saturday, December 09, 2017

Inflammatory markers in obese adolescents


Friday, December 08, 2017

Hospitalization with infection as a particular risk factor for VTE



Highlights

•Hospitalized infection appears to trigger VTE events.
•The triggering effect of infection on VTE decreases over time after an infection.
•VTE preventive measures may prevent VTE events in the peri-infection period.
•Hospitalized patients with an infection may be considered for VTE prophylaxis.

Wednesday, December 06, 2017

GIK for myocardial infarction


We refuse to give up on it but haven’t quite found a way to make it work, and it’s been 40 years now. The latest? If you couple it with tight glycemic control in NSTEMI, then maybe.

Tuesday, December 05, 2017

Should drug eluting (as opposed to bare metal) stents be used in patients with atrial fibrillation?


Another way of asking this might be “how long do you want to subject a patient to triple anti-thrombotic therapy?”

There is not a clear evidence based answer. This study looked at practice patterns and there is considerable variation.

Monday, December 04, 2017

Cefepime neurotoxicity


Here’s a systematic review on this increasingly recognized problem.

Sunday, December 03, 2017

Interatrial block aka Bayes syndrome: role in atrial fibrillation and stroke


Free full text review.

Saturday, December 02, 2017

Interatrial block: diagnosis and clinical significance


Free full text review here.

Friday, December 01, 2017

Hypokalemia and supraventricular ectopy: risk factors for stroke


Thursday, November 30, 2017

Hyperammonemic encephalopathy following bariatric surgery


You can add this one to two growing lists: bariatric surgery complications and non hepatic hyperammonemias. [1] [2]

Mechanisms? From the first reference:

The specific mechanisms driving the hyperammonemic state after RYGB may be multifactorial. As it has been almost exclusively observed in women, X-linked partial ornithine transcarbamylase (OTC) deficiency has been implicated (Figure 2). Previously asymptomatic heterozygous OTC-deficient women can present when faced with catabolic stressors, and biochemical profiling is consistent with impaired urea cycle function. Zinc deficiency has also been proposed to interfere with OTC function (5). Nongenetic mechanisms of increased ammoniagenesis have been considered, including portosystemic shunting, severe hepatic dysfunction, and overgrowth of intestinal flora. A profound catabolic state may also play a role, driving protein breakdown and accumulation of nitrogenous waste products.

Wednesday, November 29, 2017

HRCT scanning in the diagnosis of pulmonary diseases


In diffuse or multifocal parenchymal lung disease the HRCT may point to a specific diagnosis or place the disorder in a category, thus shortening the differential. Free full text review.

Tuesday, November 28, 2017

Monday, November 27, 2017

Hospitalists as housekeepers


Hospitalists write medication orders, take calls for “housekeeping” issues and do the discharge paperwork. With us, quality of care and patient satisfaction generally improve, and the surgeon isn’t being called at 2 a.m. with requests for Tylenol or laxatives. What’s not to like?


How did we get into this mess? By failing to set boundaries to limit the mission creep that moved us away from the original notion of hospitalists as clinicians within the original scope of their training, IMHO. Our professional organization didn’t help.

Sunday, November 26, 2017

Saturday, November 25, 2017

The hospital of tommorrow


Hospitalists will be obsolete as the hospital care team continues home care via telemedicine and putting patients to death will be considered patient centered. Read the rest.

Friday, November 24, 2017

Clinical status before and outcomes after admission to hospice



Background

Prior work has shown that symptoms leading to restrictions in daily activities are common at the end of life. Hospice is a Medicare benefit designed to alleviate distressing symptoms in the last 6 months of life. The effect of hospice on the burden of such symptoms is uncertain.

Methods

From an ongoing cohort study of 754 community-dwelling older persons, aged greater than or equal to 70 years, we evaluated 241 participants who were admitted to hospice from March 1998 to December 2013. A set of 15 physical and psychological symptoms leading to restricted activity (ie, cut down on usual activities or spend at least half the day in bed) were ascertained during monthly telephone interviews in the year before and 3 months after hospice admission.

Results

The prevalence and mean number of restricting symptoms increased progressively until about 2 months before hospice admission, before increasing precipitously to a peak around the time of hospice admission. After the start of hospice, both the prevalence and the mean number of restricting symptoms dropped markedly. For several symptoms deemed most amenable to hospice treatment, including depression and anxiety, the prevalence dropped to levels comparable to or lower than those observed 12 months before the start of hospice. The trends observed in symptom prevalence and mean number of symptoms before and after hospice did not differ appreciably according to hospice admission diagnosis or sex. The median duration of hospice (before death) was only 15 days.

Conclusion

The burden of restricting symptoms increases progressively several months before the start of hospice, peaks around the time of hospice admission, and decreases substantially after the start of hospice. These results, coupled with the short duration of hospice, suggest that earlier referral to hospice may help to alleviate the burden of distressing symptoms at the end of life.

Thursday, November 23, 2017

Hospitalists’ enthusiasm for MOC: less than overwhelming


Wednesday, November 22, 2017

Home NPPV



Question Does the addition of home noninvasive ventilation to home oxygen therapy prolong time to readmission or death for patients with chronic obstructive pulmonary disease and persistent hypercapnia following a life-threatening exacerbation?

Findings In this randomized clinical trial of 116 patients, the addition of home noninvasive ventilation significantly prolonged time to readmission or death from 1.4 months to 4.3 months.

Meaning The addition of home noninvasive ventilation to home oxygen therapy may improve outcomes in patients with severe chronic obstructive pulmonary disease and persistent hypercapnia following hospital admission.

Tuesday, November 21, 2017

An attempted classification to encompass the diverse phenotypes of diabetes


The different forms of diabetes no longer lend them selves to two simple categories. Various efforts to refine the classification have been met with controversy and complicated by evolving understanding. Here is my attempt to summarize the current thinking.

Type 1: caused by complete autoimmune destruction of the beta cells. A good practical definition is that patients require exogenous insulin in order to stay alive. That is, they will invariably develop ketoacidosis (DKA) when deprived of insulin, even in the basal state. It is important to specify the basal state, because patients with other forms of diabetes can go into DKA as well, but only in the presence of some stressor such as sepsis, MI, stroke, etc. This designation has changed little in recent decades and remains useful, though it has seen some tweaks as noted below.



Type 1b aka 1.5: These designations are no longer very useful for a variety or reasons. They originally (especially 1b) referred to a group of patients in certain ethnic groups with phenotypic characteristics of both type 1 and type 2 diabetes who seemingly transitioned from type 1 to type 2 and/or back, due to a non autoimmune mechanism: intermittent reversible severe beta cell failure due to an exaggerated form of glucotoxicity. This group has subsequently been found to be more heterogeneous than previously thought, both in terms of ethnicity and pathogenesis. To confuse things further, these terms (especially 1.5) have also been used to denote late autoimmune diabetes of adulthood (LADA), an unrelated condition. The terms were partially replaced in popular usage with ketosis prone type 2 diabetes but that too has been waning in popularity, largely abandoned. The ADA, recognizing that there are patients who develop DKA but lack antibodies, created the category of “idiopathic type 1 diabetes.” A more recently proposed category recognizes the heterogeneity in these patients (and subclassifies them accordingly) and is known as ketosis prone diabetes (see below). To confuse things a bit, KPD also incorporates patients who do not fit this phenotype, in order to encompass all diabetic patients who go into ketoacidosis apart from some severe stress. (Note: a very early designation for patients seemingly transitioning between the phenotypes of DM 1 and 2 was Flatbush diabetes).



Ketosis prone diabetes (KPD): This is a proposed designation to replace the category immediately above and adds some other mechanisms, attempting to encompass all patients who spontaneously develop DKA. It recognizes the heterogeneity of the phenotype above, specifically the fact that some forms have an autoimmune pathogenesis. Its 4 categories are based on the presence or absence of beta cell reserve and the presence or absence of autoimmunity.



Type 2: DM 2 is pretty well defined and I will not spend a great deal of time here other than to caution against defining it as any case of diabetes that does not develop DKA in the basal state. That is to say that some forms of diabetes, that don’t invariably cause DKA in the basal state, are not appropriately classified as DM 2 as will be discussed below. Although DM 2 is itself heterogeneous the patients have in common insulin resistance, gradual beta cell fatigue and the metabolic syndrome.



Type 3: Here’s where it gets even more confusing. While often a wastebasket there are some forms of diabetes that rightfully belong in this category though in current literature they have varied and sometimes quite limited degrees of acceptance. There are numerous subcategories. Here they are.

Type 3, no letter designation: This is a theoretical construct that Alzheimer disease is essentially diabetes (insulin resistance) localized to the brain and might be effectively treated with insulin sensitizing agents.

Additional categories of DM 3, designated by letter, were taken from this site:

Type 3 A refers to genetic defects in beta cells, essentially MODY. Inheritance is monogenic autosomal dominant as opposed to the polygenic inheritance of DM 2.

Type 3 B refers to severe genetically determined insulin resistance as seen in Donohue syndrome and related disorders.

Type 3 C is a more accepted category and denotes diabetes due to damage to the pancreas as a whole, eg pancreatitis, pancreatic cancer or pancreatic trauma. [1] [2]. This is important because it is usually misdiagnosed as DM 2 yet has unique treatment implications.

Type 3 D is DM caused by other endocrinopathies eg Cushing’s.

Type 3 E refers to DM caused by drugs such as corticosteroids.

Type 3 F refers to DM caused by infection. In the cite referenced above congenital rubella was given as the example. Would Hep C fit in here?

Type 3 G refers to diabetes associated with unusual autoimmune diseases, eg stiff person syndrome.

Type 3 H refers to diabetes associated with Down’s syndrome.

Note: Although all the entities mentioned above under type 3 are real I could find little or no independent support in the literature for the nomenclature except for the one with no letter designation (Alzheimer disease) and type 3C.



Type 4 This is a theoretical construct based on an animal model, attempting to explain some instances of apparent DM 2 in lean adults. This may not be an important entity in man if it exists at all and might be confused with LADA.



Miscellaneous forms:

Latent autoimmune diabetes in adults (LADA). It is sometimes been referred to as DM 1.5.

Double diabetes. You could be unlucky and have both 1 & 2. Or, in DM 1, if you treat overeating with more and more and more insulin and thereby gain of sufficient weight the characteristics of DM 2 could develop secondarily.


Monday, November 20, 2017

Sunday, November 19, 2017

Saturday, November 18, 2017

Appropriate and inappropriate use of troponin assays



The article offers a useful perspective on troponin testing but, if I’m not mistaken (correct me if I’m wrong) starts out with an error:

Troponin is a protein in striated muscle that regulates excitation and contraction, and consists of 3 molecules: C, I, and T. Troponin I and T are specific to cardiac tissue…

I’m pretty sure skeletal muscle has troponin I and T.

At any rate, the key point of the article is that in the old days of the early generation troponins, any elevation meant the patient was having an acute MI, usually due to acute coronary syndrome. Several generations (and sensitivity improvements) later that is no longer the case. The problem is, too many of us apparently interpret troponins the way we did in those good old days. This, as the author points out, can lead to problems such as knee jerk anticoagulation.

The remedy for this, according to the author, is to do a history and physical before ordering a troponin. That’s easier said than done in the crazy environment of hospital medicine where time is of the essence and we often have to utilize a shotgun approach to very sick patients. The reality is that troponin positivity has now become much more complex and requires considerable skill in applying the result to the prevailing clinical context.

Friday, November 17, 2017

Antipyretic therapy in septic patients


Thursday, November 16, 2017

Your critically ill patient went into atrial fibrillation. Amiodarone was started. Now what?


Sound familiar? This paper makes the case for cardiology consultation, at least if the drug is going to be continued at discharge.

Wednesday, November 15, 2017

Monday, November 13, 2017

Atrial flutter


This review is mainly about the various mechanisms and electrocardiographic patterns.

Sunday, November 12, 2017

Fluid overload and sepsis and using bioimpedence to monitor it



Guideline-directed therapy for sepsis calls for early fluid resuscitation. Often patients receive large volumes of intravenous fluids. Bioimpedance vector analysis (BIVA) is a noninvasive technique useful for measuring total body water. In this prospective observational study, we enrolled 18 patients admitted to the intensive care unit for the treatment of sepsis syndromes. Laboratory data, clinical parameters, and BIVA were recorded daily. All but one patient experienced volume overload during the course of treatment. Two patients had greater than 20 L of excess volume. Volume overload is clinically represented by tissue edema. Edema is not a benign condition, as it impairs tissue oxygenation, obstructs capillary blood flow, disrupts metabolite clearance, and alters cell-to-cell interactions. Specifically, volume overload has been shown to impair pulmonary, cardiac, and renal function. A positive fluid balance is a predictor of hospital mortality. As septic patients recover, volume excess should be aggressively treated with the use of targeted diuretics and renal replacement therapies if necessary.

Saturday, November 11, 2017

EP testing in bradyarrhythmias


This free full text review deals mainly with the various mechanisms of AV block, clues on the surface ECG and when EP testing is needed.

Friday, November 10, 2017

Arrhythmogenic cardiomyopathy (aka arrhythmogenic right ventricular cardiomyopathy/dysplasia)


The new terminology relates to the increasing recognition of left ventricular involvement. Free full text review.

Thursday, November 09, 2017

Drug therapy to reduce AICD shocks


Wednesday, November 08, 2017

How to take a high yield history


Tuesday, November 07, 2017

High flow nasal canula: a game changer in respiratory medicine


Monday, November 06, 2017

Liberal versus restrictive transfusion strategy: the debate is not quite over


Although a hemoglobin of 7 has become a widely accepted threshold for transfusion in a variety of situations there remain areas of uncertainty. One of these areas is ischemic heart disease. The NIH sponsored MINT is being organized to address this question. (Public Citizen thinks it should not be carried out). One of the questions here is whether there is equipoise for such a trial. Public Citizen, while leveling their principal objections toward trial ethics and the informed consent process, implies that there is no equipoise and a higher hemoglobin threshold should be accepted. The argument that equipoise exists is based on the fact that for ischemic heart disease there are only low level data to guide transfusion practices. High level trials lumped patients together having many different underlying diseases. How might transfusion thresholds apply to various subgroups? That raises nearly endless questions.

What about, for example, oncology patients with septic shock? Check out the results of this single center RCT:



Objective: To assess whether a restrictive strategy of RBC transfusion reduces 28-day mortality when compared with a liberal strategy in cancer patients with septic shock.

Design: Single center, randomized, double-blind controlled trial.

Setting: Teaching hospital.

Patients: Adult cancer patients with septic shock in the first 6 hours of ICU admission.

Interventions: Patients were randomized to the liberal (hemoglobin threshold, less than 9 g/dL) or to the restrictive strategy (hemoglobin threshold, less than 7 g/dL) of RBC transfusion during ICU stay.

Measurements and Main Results: Patients were randomized to the liberal (n = 149) or to the restrictive transfusion strategy (n = 151) group. Patients in the liberal group received more RBC units than patients in the restrictive group (1 [0–3] vs 0 [0–2] unit; p less than 0.001). At 28 days after randomization, mortality rate in the liberal group (primary endpoint of the study) was 45% (67 patients) versus 56% (84 patients) in the restrictive group (hazard ratio, 0.74; 95% CI, 0.53–1.04; p = 0.08) with no differences in ICU and hospital length of stay. At 90 days after randomization, mortality rate in the liberal group was lower (59% vs 70%) than in the restrictive group (hazard ratio, 0.72; 95% CI, 0.53–0.97; p = 0.03).

Conclusions: We observed a survival trend favoring a liberal transfusion strategy in patients with septic shock when compared with the restrictive strategy. These results went in the opposite direction of the a priori hypothesis and of other trials in the field and need to be confirmed.

This contributes to the evidence we have to guide transfusion practices but also serves as a reminder that there is no pat answer. Clinical judgment must surpass slavish adherence to pathways and guidelines, which is what evidence based medicine is all about.



Sunday, November 05, 2017

Saturday, November 04, 2017

Thursday, November 02, 2017

Assessment of fluid responsiveness is associated with improvement in robust outcomes



The big question is how invasive you need to be to accomplish this.

Wednesday, November 01, 2017

Tuesday, October 31, 2017

COPD: another example of the epidemic of misdiagnosis



Background

Guidelines recommend the confirmation of a COPD diagnosis with spirometry. International Classification of Diseases, Ninth Revision, Clinical Modification, diagnostic codes are frequently used to identify patients with COPD for administrative purposes. However, coding the diagnosis of COPD does not require confirmation using spirometry. The purpose of this study was to determine how often the discharge diagnosis of COPD is supported by spirometric measurements in the Veterans Affairs (VA) health system.

Methods

We reviewed records of patients hospitalized for COPD in a VA teaching hospital between 2005 and 2015. Individuals were counted once; rehospitalizations for COPD in the same time frame were excluded. Patient records were assessed for the presence of spirometric measurements and for spirometric evidence of COPD.

Results

There were 1,278 discharges with the principal diagnosis of COPD and allied conditions in the time frame. A total of 826 discharged patients were included. Among them, 21% had no spirometric measurements, 12% were unable to perform the breathing maneuvers correctly, 56% had spirometric evidence of airways obstruction, and 11% had normal prebronchodilator or postbronchodilator FEV1/FVC measurements. Older patients were more likely to fail the spirometry test or have no documented spirometry. Younger patients were more likely to have the first spirometry conducted after their COPD hospitalizations.

Conclusions

Caution must be taken when using the discharge diagnosis database to measure health-care outcomes and determine resource management. Efforts are needed to assure that patients clinically suspected of having COPD are tested with spirometry to improve the accuracy of a COPD diagnosis.

Monday, October 30, 2017

Acute eosinophilic pneumonia


Sunday, October 29, 2017

Early head CT post cardiac arrest



Aim

Neurological emergencies can lead to cardiac arrest, and post-arrest patients can develop life-threatening neurological abnormalities. This study aims to estimate and characterize the use of early head CT (HCT), and its potential impact on post-resuscitation management.

Methods

This retrospective study analyzed 213 adults who suffered an out-of-hospital cardiac arrest (OHCA) and survived for at least 24 h. Demographics were collected and arrest-related variables were documented. Timing of HCT was recorded and if abnormalities were found on HCT within 24 h of resuscitation, any resulting changes in management were recorded. Outcome was measured by cerebral performance category at discharge.

Results

Only 54% of patients who survived OHCA underwent HCT in the first 24 h after resuscitation. Patients who underwent HCT were healthier and had better pre-arrest functional status and shorter duration of arrest. Acute abnormalities were found on 38% of HCT and 34% of these abnormal scans resulted in management changes.

Conclusions

Early HCT is not consistently performed after OHCA and may be heavily influenced by a patient’s premorbid status and duration of arrest. Early HCT can demonstrate acute abnormalities that can result in significant changes in patient management.

Saturday, October 28, 2017

Friday, October 27, 2017

Fosfomycin


Thursday, October 26, 2017

What are the best agents for fever and neutropenia?



Objectives

To compare the effectiveness and safety of antipseudomonal β-lactam empiric monotherapy for febrile neutropenia by network meta-analysis.

Methods

Searches using Pubmed, Cochrane CENTRAL, EMBASE and Web of Science Core Collection were carried out in June 2016. English articles, non-English articles, full-length articles, short articles and conference abstracts were allowed. Eligible trial design was a parallel-group individual randomization. We included febrile neutropenia adult and paediatric patients undergoing chemotherapy for either solid tumours or haematological malignancies and treated with intravenous antipseudomonal β-lactams for initial empiric therapy. Protocol was registered with PROSPERO ID 42016043377.

Results

Of 1275 articles detected by the search, 50 studies with 10 872 patients were finally included. Among the guideline-recommended cefepime, meropenem, imipenem/cilastatin, piperacillin/tazobactam and ceftazidime; imipenem/cilastatin showed the highest odds of treatment success without modification, which was the primary endpoint, based on the random-effect model network analysis. Ceftazidime was related to lower treatment success rate without modification compared with imipenem/cilastatin with OR of 0.71 (95% CI 0.57–0.89, p 0.006). Imipenem/cilastatin showed the lowest odds of all-cause death. Patients treated with cefepime had higher risk for all-cause death compared with those treated with imipenem/cilastatin (OR 2.05, 95% CI 1.11–3.78, p 0.029). Any adverse event was significantly more prevalent in the imipenem/cilastatin arm; however, there was no difference concerning adverse events leading to discontinuation.

Conclusions

Imipenem/cilastatin, piperacillin/tazobactam and meropenem may be reasonable first-choice medications for empiric therapy of febrile neutropenia.

Wednesday, October 25, 2017

Diabetic striatopathy



Highlights

•“Diabetic striatopathy” denotes a clinico-radiologic syndrome of chorea-ballism and striatal hyperintensities on MR imaging.
•It is common in elderly females with hyperglycemic hyperosmolar state but rare in diabetic ketoacidosis.
•Chorea-ballism usually resolves with intensive management of diabetic ketoacidosis.

Abstract

“Diabetic striatopathy” is characterized by dyskinesias with basal ganglia hyperintensities on neuroimaging. It is usually reported in elderly females with hyperglycemic hyperosmolar state and rare in patients with diabetic ketoacidosis. Here, we report two young males with diabetic ketoacidosis presenting as striatopathy, along with review of literature.

Tuesday, October 24, 2017

Type 2 diabetes: it’s about more than “getting the numbers down”


We’ve known this for years now, so why are we still obsessed with it?

This article is spot on:

An important challenge in the management of patients with type 2 diabetes is cardiovascular disease (CVD) prevention. While it is well established that intensive glycemic control prevents the onset and slows the progression of certain microvascular complications, such a strategy utilized in multiple clinical trials over the past few decades has failed to show a similar benefit with regard to cardiovascular events, including mortality. Despite this, a major hope has been the discovery of glucose-lowering medications that simultaneously improve cardiovascular outcomes. Over the past year and a half, four randomized clinical trials (involving empagliflozin, pioglitazone, liraglutide, and semaglutide) have reported important benefits in preventing adverse cardiovascular outcomes in patients with or at risk for type 2 diabetes and established CVD. On the basis of these landmark trials, we propose that a paradigm shift in the management of patients with type 2 diabetes, specifically in those with prior macrovascular disease. A transition from current algorithms based primarily on hemoglobin A1c values to a more comprehensive strategy additionally focused on CVD prevention seems warranted.