Saturday, September 30, 2017

Systemic anticoagulation for stroke prevention: should the indications be expanded?

A recent review suggests considering systemic anticoagulation in elderly patients in sinus rhythm but with frequent atrial ectopy, interatrial block and high CHADSVASC score. (What about these same patients who have cryptogenic stroke?).

Friday, September 29, 2017

Exercise improves cognitive function

Conclusions Physical exercise improved cognitive function in the over 50s, regardless of the cognitive status of participants. To improve cognitive function, this meta-analysis provides clinicians with evidence to recommend that patients obtain both aerobic and resistance exercise of at least moderate intensity on as many days of the week as feasible, in line with current exercise guidelines.

Thursday, September 28, 2017

Hospitalist mission creep: feeling dumped on

Alcohol and stroke risk


Whether light-to-moderate alcohol consumption is protective against stroke, and whether any association differs by stroke type, is controversial. We conducted a meta-analysis to summarize the evidence from prospective studies on alcohol drinking and stroke types.


Studies were identified by searching PubMed to September 1, 2016, and reference lists of retrieved articles. Additional data from 73,587 Swedish adults in two prospective studies were included. Study-specific results were combined in a random-effects model.


The meta-analysis included 27 prospective studies with data on ischemic stroke (25 studies), intracerebral hemorrhage (11 studies), and/or subarachnoid hemorrhage (11 studies). Light and moderate alcohol consumption was associated with a lower risk of ischemic stroke, whereas high and heavy drinking was associated with an increased risk; the overall RRs were 0.90 (95 % CI, 0.85–0.95) for less than 1 drink/day, 0.92 (95 % CI, 0.87–0.97) for 1–2 drinks/day, 1.08 (95 % CI, 1.01–1.15) for more than 2–4 drinks/day, and 1.14 (95 % CI, 1.02–1.28) for more than 4 drinks/day. Light and moderate alcohol drinking was not associated with any hemorrhagic stroke subtype. High alcohol consumption (greater than 2–4 drinks/day) was associated with a non-significant increased risk of both hemorrhagic stroke subtypes, and the relative risk for heavy drinking (greater than 4 drinks/day) were 1.67 (95 % CI, 1.25–2.23) for intracerebral hemorrhage and 1.82 (95 % CI, 1.18–2.82) for subarachnoid hemorrhage.


Light and moderate alcohol consumption was inversely associated only with ischemic stroke, whereas heavy drinking was associated with increased risk of all stroke types with a stronger association for hemorrhagic strokes.

Saturday, September 23, 2017

Risk of thrombosis in patients with essential thrombocythemia


To assess the role of platelet (PLT) count for thrombotic complications in Essential Thrombocythemia (ET), 1201 patients followed in 11 Hematological centers in the Latium region were retrospectively evaluated. At multivariate analysis, the following factors at diagnosis were predictive for a worse Thrombosis-free Survival (TFS): the occurrence of previous thrombotic events (p = 0.0004), age greater than  60 years (p = 0.0044), spleen enlargement (p = 0.042) and a lower PLT count (p = 0.03). Receiver Operating Characteristic (ROC) analyses based on thrombotic events during follow-up identified a baseline platelet count of 944 × 109/l as the best predictive threshold: thrombotic events were 40/384 (10.4%) in patients with PLT count greater than 944 × 109/l and 109/817 (13.3%) in patients with PLT count less than 944 × 109/l, respectively (p = 0.04). Patients with PLT count less than 944 × 109/l were older (median age 60.4 years. vs 57.1 years., p = 0.016), had a lower median WBC count (8.8 × 109/l vs 10.6 × 109/l, p less than 0.0001), a higher median Hb level (14.1 g/dl vs 13.6 g/dl, p less than 0.0001) and a higher rate of JAK-2-V617F positivity (67.2% vs 41.6%, p less than 0.0001); no difference was observed as to thrombotic events before diagnosis, spleen enlargement and concomitant Cardiovascular Risk Factors. In conclusion, our results confirm the protective role for thrombosis of an high PLT count at diagnosis. The older age and the higher rate of JAK-2 V617F positivity in the group of patients with a baseline lower PLT count could in part be responsible of this counterintuitive finding.

The last sentence helps explain the paradox.

Friday, September 22, 2017

Adult onset Still’s disease

Thursday, September 21, 2017

Epinephrine in cardiac arrest: how strongly is it supported by the evidence?


Sudden cardiac arrest accounts for approximately 15% of deaths in developed nations, with poor survival rate. The American Heart Association states that epinephrine is reasonable for patients with cardiac arrest, though the literature behind its use is not strong.


To review the evidence behind epinephrine for cardiac arrest.


Sudden cardiac arrest causes over 450,000 deaths annually in the United States. The American Heart Association recommends epinephrine may be reasonable in patients with cardiac arrest, as part of Advanced Cardiac Life Support. This recommendation is partly based on studies conducted on dogs in the 1960s. High-dose epinephrine is harmful and is not recommended. Epinephrine may improve return of spontaneous circulation, but does not improve survival to discharge or neurologic outcome. Literature suggests that three phases of resuscitation are present: electrical, circulatory, and metabolic. Epinephrine may improve outcomes in the circulatory phase prior to 10 min post arrest, though further study is needed. Basic Life Support measures including adequate chest compressions and early defibrillation provide the greatest benefit.


Epinephrine may improve return of spontaneous circulation, but it does not improve survival to discharge or neurologic outcome. Timing of epinephrine may affect patient outcome, but Basic Life Support measures are the most important aspect of resuscitation and patient survival.

Wednesday, September 20, 2017

EMRs slow physicians down and distract from real clinical care

Tuesday, September 19, 2017

An automated warning system for deteriorating ward patients modestly improved outcomes


Delayed response to clinical deterioration of ward patients is common.


We performed a prospective before-and-after study in all patients admitted to two clinical ward areas in a district general hospital in the UK. We examined the effect on clinical outcomes of deploying an electronic automated advisory vital signs monitoring and notification system, which relayed abnormal vital signs to a rapid response team (RRT).


We studied 2139 patients before (control) and 2263 after the intervention. During the intervention the number of RRT notifications increased from 405 to 524 (p = 0.001) with more notifications triggering fluid therapy, bronchodilators and antibiotics. Moreover, despite an increase in the number of patients with “do not attempt resuscitation” orders (from 99 to 135; p = 0.047), mortality decreased from 173 to 147 (p = 0.042) patients and cardiac arrests decreased from 14 to 2 events (p = 0.002). Finally, the severity of illness in patients admitted to the ICU was reduced (mean Acute Physiology and Chronic Health Evaluation II score: 26 (SD 9) vs. 18 (SD 8)), as was their mortality (from 45% to 24%; p = 0.04).


Deployment of an electronic automated advisory vital signs monitoring and notification system to signal clinical deterioration in ward patients was associated with significant improvements in key patient-centered clinical outcomes.

This sort of thing has great potential if usage is optimized. Unfortunately, RRT usage has gone far beyond the original intent and unintended consequences abound.

Monday, September 18, 2017

Risk factors for atrial fibrillation in the elderly

Comprehensive free full text review.

Sunday, September 17, 2017

A pleural effusion may have more than one etiology

---especially given recent trends toward increasingly frequent complex comorbidities. From a recent review:


Purpose of review: Historically, pleural effusions have been attributed to a single cause. There is growing recognition that a substantial proportion of pleural effusions may have more than one underlying cause. The purpose of this review is to summarise recent findings regarding the diagnosis and treatment of effusions secondary to more than one aetiology.

Recent findings: A recent prospective study identified that 30% of pleural effusions had more than one underlying aetiology. With a rising prevalence of cardiovascular and malignant disease, the incidence of the complex pleural patient is increasing. The use of biomarkers, including pro-B-type natriuretic peptide, have been suggested as a way of identifying contributing disease process.

Summary: Understanding that there are potentially concurrent causes to a pleural effusion is vital in establishing the diagnoses of multiple underlying aetiologies. New diagnostic pathways, with increasing use of biomarkers, will be required to identify the complex pleural effusion. Further studies on whether the targeting of separate aetiologies improves outcomes will help develop future management strategies.

Saturday, September 16, 2017

DOAC dosing errors

Three points to be made here:

DOAC dosing is much more “indication based” than warfarin.

DOAC may be less forgiving of dosing errors than warfarin.

Unlike warfarin, DOACs have no monitoring safety net.

Friday, September 15, 2017

Thursday, September 14, 2017

Are blood ammonia levels helpful?

Here are their recommendations:

HE is a diagnosis of exclusion and is made on clinical grounds.

Do not check serum ammonia levels in patients with CLD to diagnose HE, to assess the severity of HE, or to determine whether HE is resolving.

Use your clinical evaluation to determine the severity and course of HE.

Treatment should be tailored according to clinical findings, not ammonia levels.

I get a little nervous about absolute recommendations to stop a widely accepted, physiologically rational, low tech, low harm practice just because there’s a lack of “high level” supporting evidence. An unfounded assumption here is that a lack of high level evidence equates to evidence against.

Another questionable assumption is that the test inherently is bad. Certainly at the cutoff of 55, as cited in the article, the test characteristics are poor. At extreme values, however, it may be more helpful. In a comatose patient presenting to ER whose baseline level is known to be 40, for example, a triple digit ammonia may add greatly to the diagnostic confidence and obviate an MRI and LP pending a therapeutic trial directed at HE. In such a case it might even save resources. This article strikes me as a case of black and white thinking. How about a more nuanced approach in which the ordering threshold is proportional to the cost and potential harm of the test?

Wednesday, September 13, 2017

Benzos and opiates given to ward patients increase the risk of deterioration (ICU transfer or arrest)


Opioids and benzodiazepines are frequently used in hospitals, but little is known about outcomes among ward patients receiving these medications.


To determine the association between opioid and benzodiazepine administration and clinical deterioration.


Observational cohort study.


500-bed academic urban tertiary-care hospital.


All adults hospitalized on the wards from November 2008 to January 2016 were included. Patients who were “comfort care” status, had tracheostomies, sickle-cell disease, and patients at risk for alcohol withdrawal or seizures were excluded.


The primary outcome was the composite of intensive care unit transfer or ward cardiac arrest. Discrete-time survival analysis was used to calculate the odds of this outcome during exposed time periods compared to unexposed time periods with respect to the medications of interest, with adjustment for patient demographics, comorbidities, severity of illness, and pain score.


In total, 120,518 admissions from 67,097 patients were included, with 67% of admissions involving opioids, and 21% involving benzodiazepines. After adjustment, each equivalent of 15 mg oral morphine was associated with a 1.9% increase in the odds of the primary outcome within 6 hours (odds ratio [OR], 1.019; 95% confidence interval [CI], 1.013-1.026; P less than 0.001), and each 1 mg oral lorazepam equivalent was associated with a 29% increase in the odds of the composite outcome within 6 hours (OR, 1.29; CI, 1.16-1.45; P less than 0.001).


Among ward patients, opioids were associated with increased risk for clinical deterioration in the 6 hours after administration. Benzodiazepines were associated with even higher risk. These results have implications for ward-monitoring strategies. Journal of Hospital Medicine 2017;12:428-434. © 2017 Society of Hospital Medicine

Tuesday, September 12, 2017

Review of the ECG findings in WPW

Monday, September 11, 2017

The ER ECG in drug overdose

Sunday, September 10, 2017

Biomarker guided heart failure treatment versus usual (guideline based) care: take your pick!

Question Does a strategy of titrating therapy to a specific amino-terminal pro–B-type natriuretic peptide (NT-proBNP) target improve clinical outcomes in high-risk patients with heart failure and reduced ejection fraction?

Findings In this randomized clinical trial including 894 adults, a strategy of NT-proBNP–guided therapy compared with usual care did not significantly improve time to first hospitalization or cardiovascular mortality (hazard ratio, 0.98).

Meaning These findings do not support NT-proBNP–guided therapy for management of heart failure with reduced ejection fraction.

From table 2 in the paper we learn that both groups got the same treatment. That is, whether you tended to ignore proBNP levels and just do your best to adhere to guidelines or individualized therapy based on proBNP levels, you ended up with the same regimen. These, or course, were trial participants. What would happen in the real world where guideline goal achievement is horrible?

An accompanying editorial summarized what we knew before:

Assays for natriuretic peptide biomarkers, B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP), have become well established for assisting with the diagnosis and assessment of the severity of heart failure and for providing prognostic information in both the setting of acute care of decompensated heart failure and outpatient care of chronic heart failure...

..several randomized clinical trials have evaluated whether the application of serial measurement of natriuretic peptide to guide the titration of medical therapy in chronic heart failure could improve outcomes.4,6 Those trials have yielded mixed results.

Saturday, September 09, 2017

The ECG and future heart failure risk

Background Several markers detected on the routine 12‐lead ECG are associated with future heart failure events. We examined whether these markers are able to separate the risk of heart failure with reduced ejection fraction (HFrEF) from heart failure with preserved ejection fraction (HFpEF).

Methods and Results We analyzed data of 6664 participants (53% female; mean age 62±10 years) from MESA (Multi‐Ethnic Study of Atherosclerosis) who were free of cardiovascular disease at baseline (2000–2002). A competing risks analysis was used to compare the association of several baseline ECG predictors with HFrEF and HFpEF detected during a median follow‐up of 12.1 years. A total of 127 HFrEF and 117 HFpEF events were detected during follow‐up. In a multivariable adjusted model, prolonged QRS duration, delayed intrinsicoid deflection, left‐axis deviation, right‐axis deviation, prolonged QT interval, abnormal QRS‐T axis, left ventricular hypertrophy, ST/T‐wave abnormalities, and left bundle‐branch block were associated with HFrEF. In contrast, higher resting heart rate, abnormal P‐wave axis, and abnormal QRS‐T axis were associated with HFpEF. The risk of HFrEF versus HFpEF was significantly differently for delayed intrinsicoid deflection (hazard ratio: 4.90 [95% confidence interval (CI), 2.77–8.68] versus 0.94 [95% CI, 0.29–2.97]; comparison P=0.013), prolonged QT interval (hazard ratio: 2.39 [95% CI, 1.55–3.68] versus 0.52 [95% CI, 0.23–1.19]; comparison P less than 0.001), and ST/T‐wave abnormalities (hazard ratio: 2.47 [95% CI, 1.69–3.62] versus 1.13 [95% CI, 0.72–1.77]; comparison P=0.0093).

Conclusions Markers of ventricular repolarization and delayed ventricular activation are able to distinguish between the future risk of HFrEF and HFpEF. These findings suggest a role for ECG markers in the personalized risk assessment of heart failure subtypes.

Friday, September 08, 2017

Glossary of critical appraisal

This piece has some helpful information. However it’s a bit imprecise, offering descriptions that “talk around” the various terms rather than actual definitions.

Wednesday, September 06, 2017

Ace inhibitor use in patients with Duchenne and Becker muscular dystrophy slows progression of myocardial fibrosis

Importance In Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD), interventions reducing the progression of myocardial disease could affect survival.

Objective To assess the effect of early angiotensin-converting enzyme (ACE) inhibitor therapy in patients with normal left ventricular function on the progression of myocardial fibrosis (MF) identified on cardiovascular magnetic resonance (CMR).

Design, Setting, and Participants A randomized clinical trial conducted in 2 centers included 76 male patients with DMD or BMD undergoing 2 CMR studies with a 2-year interval for ventricular function and MF assessment. In a non–intent-to-treat trial, 42 patients with MF and normal left ventricular ejection fraction (LVEF) were randomized (1:1) to receive or not receive ACE inhibitor therapy. The study was conducted from June 26, 2009, to June 30, 2012. Data analysis was performed from June 30, 2013, to October 3, 2016.

Interventions Randomization (1:1) to receive or not receive ACE inhibitor therapy.

Main Outcomes and Measures Primary outcome was MF progression from baseline to the 2-year CMR study.

Results Of the 76 male patients included in the study, 70 had DMD (92%) and 6 had BMD (8%); mean (SD) age at baseline was 13.1 (4.4) years. Myocardial fibrosis was present in 55 patients (72%) and LV systolic dysfunction was identified in 13 patients (24%). Myocardial fibrosis at baseline was an independent indicator of lower LVEF at follow-up (coefficient [SE], −0.16 [0.07]; P = .03). Among patients with MF and preserved LVEF (42 [55%]), those randomized (21 patients in each arm) to receive ACE inhibitors demonstrated slower MF progression compared with the untreated group (mean [SD] increase of 3.1% [7.4%] vs 10.0% [6.2%] as a percentage of LV mass; P = .001). In multivariate analysis, ACE inhibitor therapy was an independent indicator of decreased MF progression (coefficient [SE], −4.51 [2.11]; P = .04). Patients with MF noted on CMR had a higher probability of cardiovascular events (event rate, 10 of 55 [18.2%] vs 0 of 21 [0%]; log-rank P = .04).

Conclusions and Relevance In this 2-year, follow-up, randomized clinical trial of patients with Duchenne or Becker muscular dystrophy whose LVEF was preserved and MF was present as determined on CMR, ACE inhibitor therapy was associated with significantly slower progression of MF. The presence of MF was associated with worse patient prognosis.

Tuesday, September 05, 2017

Sunday, September 03, 2017

DM 2 as a part of post intensive care syndrome

Here’s a paradox from the text of the paper that caught my notice:

Teleologically, IR is considered an evolutionary preserved mechanism designed to supply higher amounts of glucose to insulin-independent tissues than to insulin-dependent tissues [2].

Friday, September 01, 2017

What should you do with distal DVT?

From a recent review:

Distal (or calf) DVT is a very common medical condition, representing half of all diagnosed DVTs.

The diagnostic performances of venous compression ultrasound are lower for the diagnosis of distal DVT compared to proximal DVT.

All patients with distal DVT do not necessarily require anticoagulant treatment.

Low-risk outpatients may benefit from ultrasound surveillance alone, without any anticoagulation.

In high-risk patients, such as inpatients, patients with cancer or previous DVT, therapeutic anticoagulation is recommended.