Recent study here.
Saturday, March 25, 2017
Friday, March 24, 2017
---according to this systematic review and meta-analysis. The authors concluded:
Increased AKI with concomitant vancomycin and piperacillin/tazobactam should be considered when determining beta-lactam therapy.
Thursday, March 23, 2017
Background—Whether the pattern of atrial fibrillation (AF) modifies the risk/benefit of anticoagulation is controversial…
Conclusions—In ENGAGE AF-TIMI 48 trial, patients with paroxysmal AF suffered fewer thromboembolic events and deaths compared with those with persistent and permanent AF.
Wednesday, March 22, 2017
From a recent paper published in Critical Care Medicine:
Objectives: We sought to assess the incidence of acetaminophen-induced hypotension. Our secondary objectives were to describe systemic hemodynamic changes and factors associated with this complication.
Design: Prospective observational study.
Setting: Three ICUs.
Patients: Adult patients requiring IV acetaminophen infusion. Arterial pressure was monitored via an arterial catheter for 3 hours. Hypotension was defined as a decrease in the mean arterial pressure of greater than or equal to 15% compared with the baseline…
Conclusions: Half of the patients who received IV injections of acetaminophen developed hypotension, and up to one third of the observed episodes necessitated therapeutic intervention. Adequately powered randomized studies are needed to confirm our findings, provide an accurate estimation of the consequences of acetaminophen-induced hypotension, and assess the pathophysiologic mechanisms involved.
Tuesday, March 21, 2017
Here is a guideline synopsis published in JAMA. From the article:
Major recommendations Whether to initiate immediate antiepileptic drug (AED) treatment after a first seizure should be based on individualized assessments that weigh the risk of recurrence against the adverse effects of AED therapy, a consideration of the preferences of an educated patient, and the advice that immediate treatment will not improve the long-term prognosis for seizure remission but will reduce the risk of seizures over the subsequent 2 years…
The new guideline emphasizes that clinicians should weigh the individualized risk of seizure recurrence against the adverse effects of AEDs and consider the preferences of patients. For instance, the risk of seizure recurrence in a patient with normal electroencephalogram and brain magnetic resonance imaging results is relatively low at approximately 25% over the next 2 years.8 While some patients may accept the 25% risk, others may consider it too high. Regardless, patients should be advised that immediate treatment may not improve the long-term prognosis for seizure remission but will reduce seizure risk over the next 2 years. Despite avoiding explicit “to treat or not to treat” recommendations, most of the guideline recommendations conform to current clinical practices. States vary widely in driver licensing requirements for patients with epilepsy (https://www.epilepsy.com/driving-laws), as do requirements for physicians to notify state authorities, complicating the provision of accurate instructions to patients.
Monday, March 20, 2017
There have been no RCTs looking at induced hypothermia following in hospital arrest. The 2010 ACLS guidelines recommended hypothermia for out of hospital VF/PVT arrest but only recommended that it be considered for other types of arrest. However the 2015 guidelines extended the recommendation to all post arrest comatose patients regardless of the arrest location. A new cohort study published in JAMA, drawing from a very large database, calls this into question. From the paper:
Importance Therapeutic hypothermia is used for patients following both out-of-hospital and in-hospital cardiac arrest. However, randomized trials on its efficacy for the in-hospital setting do not exist, and comparative effectiveness data are limited.
Objective To evaluate the association between therapeutic hypothermia and survival after in-hospital cardiac arrest.
Design, Setting, and Patients In this cohort study, within the national Get With the Guidelines–Resuscitation registry, 26 183 patients successfully resuscitated from an in-hospital cardiac arrest between March 1, 2002, and December 31, 2014, and either treated or not treated with hypothermia at 355 US hospitals were identified. Follow-up ended February 4, 2015.
Exposure Induction of therapeutic hypothermia.
Main Outcomes and Measures The primary outcome was survival to hospital discharge. The secondary outcome was favorable neurological survival, defined as a Cerebral Performance Category score of 1 or 2 (ie, without severe neurological disability). Comparisons were performed using a matched propensity score analysis and examined for all cardiac arrests and separately for nonshockable (asystole and pulseless electrical activity) and shockable (ventricular fibrillation and pulseless ventricular tachycardia) cardiac arrests.
Results Overall, 1568 of 26 183 patients with in-hospital cardiac arrest (6.0%) were treated with therapeutic hypothermia; 1524 of these patients (mean [SD] age, 61.6 [16.2] years; 58.5% male) were matched by propensity score to 3714 non–hypothermia-treated patients (mean [SD] age, 62.2 [17.5] years; 57.1% male). After adjustment, therapeutic hypothermia was associated with lower in-hospital survival (27.4% vs 29.2%; relative risk [RR], 0.88 [95% CI, 0.80 to 0.97]; risk difference, −3.6% [95% CI, −6.3% to −0.9%]; P = .01), and this association was similar (interaction P = .74) for nonshockable cardiac arrest rhythms (22.2% vs 24.5%; RR, 0.87 [95% CI, 0.76 to 0.99]; risk difference, −3.2% [95% CI, −6.2% to −0.3%]) and shockable cardiac arrest rhythms (41.3% vs 44.1%; RR, 0.90 [95% CI, 0.77 to 1.05]; risk difference, −4.6% [95% CI, −10.9% to 1.7%]). Therapeutic hypothermia was also associated with lower rates of favorable neurological survival for the overall cohort (hypothermia-treated group, 17.0% [246 of 1443 patients]; non–hypothermia-treated group, 20.5% [725 of 3529 patients]; RR, 0.79 [95% CI, 0.69 to 0.90]; risk difference, −4.4% [95% CI, −6.8% to −2.0%]; P less than .001) and for both rhythm types (interaction P = .88).
Conclusions and Relevance Among patients with in-hospital cardiac arrest, use of therapeutic hypothermia compared with usual care was associated with a lower likelihood of survival to hospital discharge and a lower likelihood of favorable neurological survival. These observational findings warrant a randomized clinical trial to assess efficacy of therapeutic hypothermia for in-hospital cardiac arrest.
The ACLS guidelines now have a dynamic (continuously updating) web page but this study has yet to be mentioned there.
Sunday, March 19, 2017
According to the authors of a recent viewpoint article in JAMA, although the decade following the Institute of Medicine Report was widely regarded as a failure, progress may have been made from 2000 to 2014. The data are a little soft, though and it is difficult to tell whether the purported improvement is due to systems improvements, secular trends or pervasive chart doctoring which is believed to have increased over the past few years with the recent external pressures.
Saturday, March 18, 2017
Question Does empirical antifungal therapy increase invasive fungal infection–free survival at day 28 in nonneutropenic critically ill patients with sepsis, multiple Candida colonization, and multiple organ failure exposed to broad-spectrum antibacterials?
Findings In this randomized clinical trial of 260 adults, there was no significant difference in the rate of survivors without any fungal infection at day 28 between micafungin-treated (87/128 [68%]) and placebo-treated (74/123 [60.2%]) groups.
Meaning The use of micafungin as a routine empirical treatment in critically ill patients with suspected fungal infection did not improve fungal infection–free survival at 28 days.
These were patients with hospital acquired suspected infections with multiple risk factors for invasive candida infection (apart from neutropenia and certain other forms of severe immunosuppression). The practice of using antifungals in such patients is widespread. This may be practice changing, though some caveats were pointed out in a related editorial:
The study was well powered to assess difference in mortality between groups and the results are largely generalizable to critically ill patients with characteristics similar to the study inclusion criteria. Nonsignificant improvement in survival was noted among patients with high Sequential Organ Failure Assessment scores, which may suggest that certain critically ill subgroups may benefit from empirical therapy. Additionally, there was low participation among patients with postoperative gastrointestinal leakage and acute necrotizing pancreatitis, among which there is a high risk of invasive fungal infection. Previous studies have shown surgical patients may benefit from empirical therapy.
Based on the above, the “empirical” use of antifungal therapy in such patients may need to be more targeted. (The quotation marks point out that the use of antifungal agents such as is described herein is based more on theory and rationale than evidence and so is hardly empirical).
Friday, March 17, 2017
Here is a recently published evidence summary:
Conclusions: Many stress ulcer prophylaxis recommendations are based on older studies at risk of bias, which may not be applicable to modern practice. Stress ulcer prophylaxis should be limited to patients considered to be at high risk for clinically important bleeding. When evaluating only the trials at low risk for bias, the evidence does not clearly support lower bleeding rates with proton pump inhibitors over histamine 2 receptor antagonists; however, proton pump inhibitors appear to be the dominant drug class used worldwide today. The current rate of upper gastrointestinal bleeding and the relative adverse effects of acid suppression on infectious risk may drive not only the effectiveness, but also the cost-effectiveness of stress ulcer prophylaxis today. Research is currently underway to better address these issues.
Thursday, March 16, 2017
Being on a statin was associated with a higher likelihood of survival following in hospital cardiac arrest
Methods: A retrospective analysis of consecutive hospitalized patients that underwent CPR between 4/2012 to 12/2013 at Beaumont Hospital. Patients with CPR perioperatively, in the setting of trauma, during pregnancy and postpartum were excluded, also patients or their surrogates who elected palliative care/hospice were excluded. Univariable and a step-down logistic regression multivariable analysis were performed…
Pre-arrest clinical factors and CPR characteristics associated with survival on univariable analysis were: History of PCI in 36.4% of survivors compared to 16.5% of those who did not survive (p=0.013). Hyperlipidemia was more common in survivors (68.2% versus 32.5%, p=0.001), as well as being on statins (76.7% versus 43%, p=0.0004). Those who did not survive were more likely to have active cancer (16.3% versus 2.3%, p=0.018), less likely to have a shockable rhythm (7.9% versus 27.9%, p=0.003), and more likely to have CPR greater than or equal to 15 minutes (82.4% versus 19.5%, p less than 0.0001). On multivariable analysis, CPR duration and statin therapy were the only factors associated with survival. Those who did not survive were more likely to have CPR greater than or equal to 15 minutes (Adjusted OR 18.08, 95% CI 6.5-50.5, p less than 0.001) and less likely to be on statin therapy before cardiac arrest ( Adjusted OR 0.29, 95% CI : 0.10-0.83 p= 0.021) with C-Statistic of 0.86.
Wednesday, March 15, 2017
Tuesday, March 14, 2017
Here is a scientific statement from AHA. From the abstract:
Sleep is increasingly recognized as an important lifestyle contributor to health. However, this has not always been the case, and an increasing number of Americans choose to curtail sleep in favor of other social, leisure, or work-related activities. This has resulted in a decline in average sleep duration over time. Sleep duration, mostly short sleep, and sleep disorders have emerged as being related to adverse cardiometabolic risk, including obesity, hypertension, type 2 diabetes mellitus, and cardiovascular disease.
Of interest, sleep duration may influence eating behavior. More from the paper (SSD=short sleep duration):
An emerging evidence base suggests that SSD is related to food intake. Among factory workers in Japan, SSD was associated with more snacking between meals, more irregular eating habits, less consumption of vegetables, and a greater preference for strongly flavored food.49 In the United States, a study of 459 postmenopausal women enrolled in the Women’s Health Initiative examined relationships between dietary records and sleep diary and actigraphy variables.50 This study showed that SSD, measured objectively with actigraphy, was strongly associated with higher intakes of many dietary fat–related variables.
Monday, March 13, 2017
A single-center retrospective study including all patients diagnosed with SIADH in a large community hospital and tertiary center between 1.1.2007 and 1.1.2013...
The study cohort included 555 patients. The most common etiologies were malignancies and medication-induced SIADH, followed by idiopathic SIADH, pulmonary infections, pain and nausea, and central nervous system (CNS) disorders. Subgroup analysis according to etiology showed that CNS disorders were associated with more severe episodes of SIADH. Patients with idiopathic SIADH were older than patients with a specific diagnosis, had a lower urine osmolality, and required less treatment with hypertonic saline. Long-term survival was determined primarily by SIADH etiology rather than hyponatremia severity, with hazard ratios for death of up to 7.31 (95% CI 4.93–10.82, p less than 0.001) for patients with malignancy-associated SIADH as compared to patients with idiopathic SIADH. Hyponatremia grade at short-term follow-up was also predictive for long-term survival (HR 1.42 per grade, 95% CI 1.21–1.66, p less than 0.001).
Sunday, March 12, 2017
Investigators recently addressed this question by capturing telemetry recordings from pacemakers and AICDs. From their paper:
Background: The RATE Registry (Registry of Atrial Tachycardia and Atrial Fibrillation Episodes) is a prospective, outcomes-oriented registry designed to document the prevalence of atrial tachycardia and/or fibrillation (AT/AF) of any duration in patients with pacemakers and implantable cardioverter defibrillators (ICDs) and evaluate associations between rigorously adjudicated AT/AF and predefined clinical events, including stroke. The appropriate clinical response to brief episodes of AT/AF remains unclear.
Methods: Rigorously adjudicated electrogram (EGM) data were correlated with adjudicated clinical events with logistic regression and Cox models. Long episodes of AT/AF were defined as episodes in which the onset and/or offset of AT/AF was not present within a single EGM recording. Short episodes of AT/AF were defined as episodes in which both the onset and offset of AT/AF were present within a single EGM recording.
Results: We enrolled 5379 patients with pacemakers (N=3141) or ICDs (N=2238) at 225 US sites (median follow-up 22.9 months). There were 359 deaths. There were 478 hospitalizations among 342 patients for clinical events. We adjudicated 37 531 EGMs; 50% of patients had at least one episode of AT/AF. Patients with clinical events were more likely than those without to have long AT/AF (31.9% vs. 22.1% for pacemaker patients and 28.7% vs. 20.2% for ICD patients; P less than 0.05 for both groups). Only short episodes of AT/AF were documented in 9% of pacemaker patients and 16% of ICD patients. Patients with clinical events were no more likely than those without to have short AT/AF (5.1% vs. 7.9% for pacemaker patients and 11.5% vs. 10.4% for ICD patients; P=0.21 and 0.66, respectively).
Conclusions: In the RATE Registry, rigorously adjudicated short episodes of AT/AF, as defined, were not associated with increased risk of clinical events compared with patients without documented AT/AF.
“Short” episodes lasted 10-12 seconds on average.
More from Clinical Correlations on this study.
Saturday, March 11, 2017
This is a retrospective cohort study of ED patients age 18 years and older with an initial BP greater than or equal to 180/100 mm Hg and no acute TOD, who were discharged with a primary diagnosis of hypertension. Patients were divided based on receipt of antihypertensive therapy and outcomes (ED revisits and mortality) and were compared.
Of 1016 patients, 435 (42.8%) received antihypertensive therapy, primarily (88.5%) oral clonidine. Average age was 49.2 years, and 94.5% were African American. Treated patients more often had a history of hypertension (93.1% vs 84.3%; difference = −8.8; 95% confidence interval [CI], −12.5 to −4.9) and had higher mean initial systolic (202 vs 185 mm Hg; difference = 16.9; 95% CI, −19.7 to −14.1) and diastolic (115 vs 106 mm Hg; difference = −8.6; 95% CI, −10.3 to −6.9) BP. Emergency department revisits at 24 hours (4.4% vs 2.4%; difference = −2.0; 95% CI, −4.5 to 0.3) and 30 days (18.9% vs 15.2%; difference = −3.7; 95% CI, −8.5 to 0.9) and mortality at 30 days (0.2% vs 0.2%; difference = 0; 95% CI, −1.1 to 0.8) and 1 year (2.1% vs 1.6%; difference = −0.5; 95% CI, −2.5 to 1.2) were similar.
Revisits and mortality were similar for ED patients with markedly elevated BP but no acute TOD, whether they were treated with antihypertensive therapy, suggesting relative safety with either approach.
Friday, March 10, 2017
That's what the authors of this paper suggest:
Objective A proposed revision of sepsis definitions has abandoned SIRS, defined organ dysfunction as an increase in total SOFA score of greater than or equal to 2, and conceived “qSOFA” as a bedside indicator of organ dysfunction. We aimed to (1) determine the prognostic impact of SIRS, (2) compare diagnostic accuracy of SIRS and qSOFA for organ dysfunction, and (3) compare standard (Sepsis-2) and revised (Sepsis-3) definitions for organ dysfunction in emergency department patients with infection.
Methods Consecutive ED patients admitted with presumed infection were prospectively enrolled over three years. Observational data were collected sufficient to calculate SIRS, qSOFA, SOFA, comorbidity and mortality.
Results 8871 patients were enrolled, 4176 (47.1%) with SIRS. SIRS was associated with increased risk of organ dysfunction (RR 3.5), and mortality in patients without organ dysfunction (OR 3.2). SIRS and qSOFA showed similar discrimination for organ dysfunction (AUROC 0.72 vs 0.73). qSOFA was specific but poorly sensitive for organ dysfunction (96.1%, 29.7% respectively). Mortality for patients with organ dysfunction was similar for Sepsis-2 and Sepsis-3 (12.5%, 11.4%) although 29% of patients with Sepsis-3 organ dysfunction did not meet Sepsis-2 criteria. Increasing number of Sepsis-2 organ dysfunctions was associated with greater mortality.
Conclusions SIRS was associated with organ dysfunction and mortality, and abandoning the concept appears premature. Although qSOFA greater than or equal to 2 showed high specificity, poor sensitivity may limit utility as a bedside screen. Although mortality for organ dysfunction was comparable between Sepsis-2 and Sepsis-3, more prognostic and clinical information is conveyed using Sepsis-2 regarding number of organ dysfunctions. The SOFA score may require recalibration.
I believe clinicians talking to one another and communicating in the chart should use the most current and agreed upon clinical terminology, which is Sepsis-3. Unfortunately the coding and regulatory world still operates in Sepsis-2. These competing influences pull providers all over the map when they document, such that these days, when I see the word sepsis at the top of the problem list I have no idea what the patient actually has. I always have to go back and examine the raw data.
There were good reasons for transitioning to Sepsis-3 and abandoning SIRS which failed to capture many patients who were infected and had a high risk of death. Moreover, many infected patients with SIRS are not at risk of death.
But, as the article points out, neither definition is perfect. Clinical judgment dictates that patients must be assessed for their risk of mortality and organ failure regardless of what label is applied. Unfortunately the word sepsis has become as much an administrative term as a clinical one.
Thursday, March 09, 2017
This was a global, prospective, observational, quality improvement study of compliance with the SSC bundles in patients with either severe sepsis or septic shock.
A total of 1794 patients from 62 countries were enrolled in the study with either severe sepsis or septic shock. Overall compliance with all the 3-h bundle metrics was 19 %. This was associated with lower hospital mortality than non-compliance (20 vs. 31 %, p less than 0.001). Overall compliance with all the 6-h bundle metrics was 36 %. This was associated with lower hospital mortality than non-compliance (22 vs. 32 %, p less than 0.001). After adjusting the crude mortality differences for ICU admission, sepsis status (severe sepsis or septic shock), location of diagnosis, APACHE II score and country, compliance remained independently associated with improvements in hospital mortality for both the 3-h bundle (OR = 0.64 (95 % CI 0.47−0.87), p = 0.004)) and 6-h bundle (OR = 0.71 (95 % CI 0.56−0.90), p = 0.005)).
Compliance with all of the evidence-based bundle metrics was not high. Patients whose care included compliance with all of these metrics had a 40 % reduction in the odds of dying in hospital with the 3-h bundle and 36 % for the 6-h bundle.
Wednesday, March 08, 2017
Conclusions—Cardiac screening revealed abnormalities in 30% of first-degree relatives of UCA or sudden unexplained death victims, with a clear working diagnosis in 17%. Long-QT, arrhythmogenic right ventricular cardiomyopathy, and catecholaminergic polymorphic ventricular tachycardia were the most common diagnoses. Systematic cascade screening and genetic testing in asymptomatic individuals will lead to preventive lifestyle and medical interventions with potential to prevent sudden cardiac death.
Tuesday, March 07, 2017
Monday, March 06, 2017
The latest from a review:
Recent findings: Administration of intravenous fluids may contribute to the development and sustention of acute kidney injury. In excess, fluids cause kidney interstitial edema and venous congestion, which prevents renal blood flow and glomerular filtration rate. In contrast to balanced crystalloids, chloride-rich solutions impair renal blood flow via autoregulatory mechanisms. Synthetic colloids, such as hydroxyethyl starches, gelatins, and dextrans are potentially nephrotoxic because they can cause osmotic nephrosis, which, in susceptible patients, might precede permanent kidney damage. Albumin solutions appear well tolerated to use in septic patients, although their renal efficacy over balanced crystalloids is not established. In contrast, administration of albumin solutions to patients with decompensated liver failure effectively prevents and ameliorates hepatorenal syndrome.
Summary: Being nephrotoxic, synthetic colloids should be avoided in patients with reduced renal reserve, such as in critically ill patients and in patients with preexisting renal dysfunction. Suggested adverse effects with chloride-rich solutions need confirmation from ongoing trials. Albumin solutions are well tolerated in patients with sepsis and/or liver failure and improve outcomes in the latter.
Sunday, March 05, 2017
Using computerized analysis of electrocardiograms from a large primary care population, we evaluated the association between P-wave duration and the risk of AF. Secondary end-points were death from cardiovascular causes and putative ischemic stroke. Data on drug use, comorbidity, and outcomes were collected from administrative registries.
A total of 285,933 individuals were included. During median follow-up period of 6.7 years, 9550 developed AF, 9371 died of a cardiovascular cause, and 8980 had a stroke. Compared with the reference group (100–105 ms), individuals with very short (less than or equal to 89 ms; hazard ratio [HR] 1.60, 95% confidence interval [CI] 1.41–1.81), intermediate (112–119 ms; HR 1.22, 95% CI 1.13–1.31), long (120–129 ms; HR 1.50, 95% CI 1.39–1.62), and very long P-wave duration (greater than or equal to 130 ms; HR 2.06, 95% CI 1.89–2.23) had an increased risk of incident AF. With respect to death from cardiovascular causes, we found an increased risk for very short (less than or equal to 89 ms; HR 1.20, 95% CI 1.06–1.34), long (120–129 ms; HR 1.11, 95% CI 1.04–1.19), and very long P-wave duration (greater than or equal to 130 ms; HR 1.30, 95% CI 1.21–1.40) compared with the reference group (106–111 ms). Similar but weaker associations were found between P-wave duration and the risk of putative ischemic stroke.
In a large primary care population we found both short and long P-wave duration to be robustly associated with an increased risk of AF.
Saturday, March 04, 2017
The purpose of this study was to test the correlation of various factors to the presence PVCi-CMP in a large multicenter population.Methods
One hundred sixty-eight consecutive patients referred for ablation of frequent premature ventricular contractions (PVCs) were included. Patients were divided into 2 groups: group 1 with suspected PVCi-CMP (96 patients, ejection fraction 38% ± 10%, left ventricular end-diastolic diameter 62 ± 8 mm, with or without additional structural heart disease); and group 2 (control group, 72 patients with normal ejection fraction and left ventricular dimensions). Various clinical and electrophysiologic parameters were compared between groups.Results
In univariate analysis, left ventricular origin of PVC, lack of palpitations, long PVC coupling interval, epicardial origin of the focus, long sinus beat QRS duration, male gender, high PVC burden, presence of polymorphic PVCs, high PVC QRS duration, and older age were significantly related to the presence of PVCi-CMP. In multivariate analysis, only lack of palpitations, PVC burden, and epicardial origin remained significantly and independently correlated with the presence of cardiomyopathy.
Friday, March 03, 2017
Background: The frequency of pulmonary vein stenosis (PVS) after ablation for atrial fibrillation has decreased, but it remains a highly morbid condition. Although treatment strategies including pulmonary vein dilation and stenting have been described, the long-term impacts of these interventions are unknown. We evaluated the presentation of severe PVS, and examined the risk for restenosis after intervention using either balloon angioplasty (BA) alone or BA with stenting.
Methods: This was a prospective, observational study of 124 patients with severe PVS evaluated between 2000 and 2014.
Results: All 124 patients were identified as having severe PVS by computed tomography in 219 veins. One hundred two patients (82%) were symptomatic at diagnosis. The most common symptoms were dyspnea (67%), cough (45%), fatigue (45%), and decreased exercise tolerance (45%). Twenty-seven percent of patients experienced hemoptysis…
Conclusions: The diagnosis of PVS is challenging because of nonspecific symptoms and the need for dedicated pulmonary vein imaging. There is no difference in acute success by type of initial intervention; however, stenting significantly reduces the risk of subsequent pulmonary vein restenosis in comparison with BA.