Should beta blockers be held or reduced when patients are hospitalized with acute decompensated heart failure?

No, according to this study:

Conclusion: In conclusion, during ADHF, continuation of beta-blocker therapy is not associated with delayed or lesser improvement, but with a higher rate of chronic prescription of beta-blocker therapy after 3 months, the benefit of which is well established.

In the vast majority of subjects the beta blocker dose was not changed. Patients requiring drugs like dobutamine were excluded.

According to this Medscape commentary the OPTIMIZE-HF registry also supports beta blocker continuation:

B-CONVINCED is consistent with an analysis from the OPTIMIZE-HF registry [3], in which maintenance of beta-blocker therapy in systolic ADHF dramatically cut mortality at two to three months (p=0.044), as did starting the drugs at discharge in such patients who hadn't previously been on them (p=0.006). Also as reported by heartwire when the study was published, taking patients off beta blockers at hospitalization more than doubled all-cause mortality (p=0.013).

Neutropenic enterocolitis

AKA typhilitis. Another review.

Autoimmune pancreatitis

It mimics pancreatic carcinoma but there are differentiating clues.

Cardiac CT

Here I will try and put together the essentials of this sometimes confusing and ever changing topic. Most of this information is from a lecture by Stephen Frohwein, M.D., delivered at the 2009 Tutorials in the Tetons Update in Cardiovascular Diseases.

The use and indications for cardiac CT are more complex than many people appreciate. Although appropriate use of the various types of cardiac CT is becoming better understood, confusion abounds. Dr. Frohwein did such a good job of reducing it down to the nuts and bolts while maintaining the important distinctions that I thought it useful to summarize a few key points here. I will amplify this post with reference to the ACC Appropriateness Criteria.

The notion of “cardiac CT” is meaningless unless distinctions are made. Three types of scans, with completely different indications, could be referred to: calcium scoring, CT coronary angiography or CT angiography of related structures (pulmonary arteries or aorta).

Calcium scoring

Coronary calcifications detected by CT begin with subintimal plaque rupture. Since these ruptured plaques do not encroach on the lumen, calcium scoring is not a way to evaluate chest pain. What calcification does mean in an asymptomatic patient is that the subclinical atherosclerotic process is underway.

Possible appropriate use: always do a Framingham risk score first. Calcium scoring may be reasonable in asymptomatic patients with intermediate Framingham risk (defined as 2 or more risk factors but with a less than 10% score). It not appropriate for any other category, or in any symptomatic patient. It’s a risk screening tool, but is always ancillary to ordinary clinical risk screening tools. So, think of its role as similar to that of hsCRP or KIF6 testing. It involves no contrast and, while not covered by insurance, is cheap at around $150.

Note: in the ACC appropriateness criteria calcium scoring is NOT rated as appropriate for ANY indication! The highest rating it is given is “undetermined!”

A high score does not indicate hemodynamically significant CAD but does increase the probability of such. So what do you do with a high score? You target the patient for a full court press of preventive efforts.

CT coronary angiography

This test involves iodinated contrast and much more radiation than calcium scoring. It is used to evaluate patients with chest pain (never for screening) with intermediate probability ACS. It is not reliable in evaluating stent patency. The ACC appropriateness criteria deal with nuanced indications and problems evaluating patients who have had CABG.

CTA of aorta and pulmonary arteries

I have dealt with this topic in other posts, and it is beyond the scope of this post, except to say that CTA of the aorta and pulmonary arteries can be combined with CT coronary angiography as the “triple rule out.” The ACC has, in its appropriateness criteria, given “triple rule out” an “undetermined” rating.

Six Sigma and Lean

---are process improvement methodologies originated by industry (Motorola and Toyota, respectively) increasingly employed by health care systems. They are coming to be viewed as more robust than the traditional quality improvement methods used by hospitals. Joint Commission is getting interested. Expect to hear more about this. Here is a paper describing the experience of four hospital emergency departments using Lean to improve throughput and patient satisfaction.

Renal injury after sodium phosphate bowel prep

Phosphate nephropathy, which can lead to not only AKI but also CKD, is an emerging concern as more and more case reports appear. Here is an in depth review.

Influenza update

Recent coverage of influenza in the professional media has consisted of a dizzying flurry of disjointed sound bites. I have set out to put together the essentials here.

We continue to struggle to find an appropriate name for the pandemic strain. The latest is “2009 H1N1” (formerly novel influenza A H1N1, to be distinguished from any ordinary seasonal H1N1 strains).

Who should receive antiviral treatment? This Medscape Medical News piece summarizes the latest revision (October 16) of the CDC recommendations. In short, the treatment is recommended for individuals with suspected influenza considered to be at high risk. This will include 70% of hospitalized patients. From the news piece:

High-risk groups include children younger than 2 years, adults 65 years or older, and pregnant women and those up to 2 weeks after delivery or miscarriage. In addition, persons at high-risk include those with immunosuppression; disorders compromising respiratory tract function or handling of respiratory secretions or increasing risk for aspiration; or chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematologic (including sickle cell disease), or metabolic diseases (including diabetes mellitus).

Severity of illness may trump host factors in clinical decision making (my emphasis):

Treatment or prophylaxis with antiviral medications is not necessary for most healthy individuals with an illness consistent with uncomplicated influenza or for those who appear to be recovering from influenza. Severe symptoms, including evidence of lower respiratory tract infection or clinical deterioration, in persons of any age or previous health status presenting with suspected influenza should mandate prompt empiric antiviral therapy.

And, because so many hospitalized patients fall under the high risk definition:

All persons hospitalized for suspected or confirmed influenza should be treated with oseltamivir or zanamivir.

The above principles apply to both treatment and prophylaxis.

What about the IV preparation?

Peramivir, an IV neuraminidase inhibitor, although lacking full approval, has been made available under an FDA emergency use authorization for hospitalized patients with proven or suspected pandemic flu in whom oral or inhalation therapy is not feasible or appropriate according to their criteria. Usage criteria, procedures for obtaining the drug and full prescribing information are contained in this FDA fact sheet.

How reliable is point of care testing? According to the Medscape news piece the sensitivity for pandemic flu is poor, ranging from 10-70%.

When influenza is diagnosed, either by point of care testing or clinical assessment, what's the likelihood it's pandemic flu as opposed to ordinary flu? From the Medscape news piece:

"As of October 3, 2009, 99% of circulating influenza viruses in the United States were 2009 H1N1 influenza (previously referred to as novel influenza A [H1N1])," the guidelines authors write.

So, it appears, if your point of care test is positive for influenza A it's almost certainly pandemic. If your diagnosis is on clinical grounds alone it's less certain, as many other respiratory pathogens prevail during flu season. (But many cases will need to be diagnosed and treated on clinical grounds given the relatively poor sensitivity of point of care testing).

Since initial diagnosis must often be clinical, what is the case definition which would trigger appropriate isolation procedures and antiviral treatment of high risk patients? Strangely, the CDC has taken down their link to the case definitions page. This Medscape article by John G. Bartlett, MD has the information:

The CDC defines cases as influenza-like illness (ILI) if there is fever of ≥100° F (37.8° C) plus cough and/or sore throat in the absence of a known cause other than influenza.

That last phrase is important. In my career I’ve seen a case of gram negative sepsis and diabetic foot infection (yeah, somebody didn’t look down there) diagnosed as influenza. Raised public awareness and the advice to patients to stay home if symptoms are mild will, I’m sure, lead to cases of sepsis attributed to the flu, and with bad outcomes. As pointed out in the Medscape article, more cases of pandemic flu seem to have GI symptoms than cases of seasonal flu.

Since the sensitivity of commonly used rapid tests for influenza is low, what is the definitive test? The recommended definitive test is the real-time reverse transcriptase PCR (rRT-PCR).

Which patients should be tested with rRT-PCR? Here the recommendations are inconsistent. The CDC recommends such testing in:

Hospitalized patients with suspected influenza

Patients for whom a diagnosis of influenza will inform decisions regarding clinical care, infection control, or management of close contacts.

Patients who died of an acute illness in which influenza was suspected.

However, other recommendations, such as those contained in this Medscape article, seem more vague, and recommend testing for anyone with an acute febrile respiratory infection or sepsis syndrome. It’s difficult, for me anyway, to know how to reconcile these testing recommendations, so I’ll tend to err on the side of over testing. All patients with pneumonia, all COPD exacerbations with fever and all respiratory and undifferentiated sepsis syndromes might be included for definitive testing, isolation and treatment. That seems like a pretty broad net. Testing recommendations and procedures might vary from state to state, and one should follow local health department procedures. The infection control nurses in your hospital should be able to provide guidance.

Since flu is believed to be transmitted by large droplets, propelled no more than six feet, are N-95 masks really necessary? Although the CDC has gone along with the recommendation of the Institute of Medicine that N-95 masks be used, the data are not convincing that they are better than surgical masks. Studies have been inconsistent. The latest, published in JAMA, reached this conclusion:

Among nurses in Ontario tertiary care hospitals, use of a surgical mask compared with an N95 respirator resulted in noninferior rates of laboratory-confirmed influenza.

I’m gonna be team player and use the N-95.

Much more clinically useful information is available in John Bartlett’s “Just the Facts” series of articles in Medscape’s alert center.

Is the American Medical Student Association contributing to the infiltration of non-evidence based woo in academic medicine?

Multiple factors have contributed to the rising promotion and teaching of quackery in mainstream academic medical centers, something I've called quackademic medicine. Financial incentives, such as funding from the National Center for Complementary and Alternative Medicine (NCCAM) and the Bravewell Collaborative, are well known. Add to this the fact that more and more consumers demand quackery and are willing to pay for it out of pocket. Yes, it is to a large extent about money. Medical educators and health system administrators have sold out.

But it's not all about money. There's a deeper cultural change at work at the medical student level, driven by the American Medical Student Association (AMSA). As the largest and most influential organization of medical students, AMSA is not only grooming the next generation of academic leaders but also contributing directly to the development of complementary and alternative medicine curricula in many medical schools. Despite the fact that that effort, as I noted here, got a scathing review recently in the journal Academic Medicine, and despite many previous postings by myself and others exposing the promotions of AMSA, their role in the alarming growth if academic woo remains under appreciated. It's time for some additional exposure and to that end I plan a new series of posts which will drill down on some of the specific promotions.

Will the copyright treaty take us back to Web 1.0?

Here's some of what's leaked from secret negotiations to hammer out the treaty, according to Boing Boing:

That ISPs have to proactively police copyright on user-contributed material. This means that it will be impossible to run a service like Flickr or YouTube or Blogger, since hiring enough lawyers to ensure that the mountain of material uploaded every second isn't infringing will exceed any hope of profitability.

I have no idea what this really means. Read the rest of the post and the large comment thread.

Tygecycline for refractory C diff?

This is not something worthy of a change in practice yet. File it away in the “stay tuned” category.

Natriuretic peptide levels to guide heart failure therapy

Although this has been a swinging pendulum the latest meta-analysis suggests that using BNP or proBNP to guide treatment improves mortality.

Prescription benefit plans in Canada

Prescription benefit plans vary from province to province in Canada. How does this affect patient use of medication?

From a study in Circulation: Cardiovascular Quality and Outcomes:

Conclusion— Among HF patients, residing in a province with a more restrictive prescription plan may be associated with lower use of restricted HF medications over and above the expected regional differences in HF drug use across provinces.

Aortic valve calcification

---(calcific aortic sclerosis or stenosis) is an atherosclerotic process and predicts atherosclerosis elsewhere.

What drug is best for initial treatment of rapid atrial fib?

According to the results of this study it's good old, tried-and-true diltiazem:

Measurements and Main Results: The primary end point was sustained VR control (less than 90 bpm) within 24 hours; the secondary end points included AF symptom improvement and length of hospitalization. At 24 hours, VR control was achieved in 119 of 150 patients (79%). The time to VR control was significantly shorter among patients in the diltiazem group (log-rank test, p less than 0.0001) with the percentage of patients who achieved VR control being higher in the diltiazem group (90%) than the digoxin group (74%) and the amiodarone group (74%). The median time to VR control was significantly shorter in the diltiazem group (3 hours, 1-21 hours) compared with the digoxin (6 hours, 3-15 hours, p less than 0.001) and amiodarone groups (7 hours, 1-18 hours, p = 0.003). Furthermore, patients in the diltiazem group persistently had the lowest mean VR after the first hour of drug administration compared with the other two groups (p less than 0.05). The diltiazem group had the largest reduction in AF symptom frequency score and severity score (p less than 0.0001). In addition, length of hospital stay was significantly shorter in the diltiazem group (3.9 ± 1.6 days) compared with digoxin (4.7 ± 2.1 days, p = 0.023) and amiodarone groups (4.7 ± 2.2 days, p = 0.038).

There was no difference in adverse hemodynamic effects. A surprising finding in the study was that there was no difference in conversion to sinus rhythm. From an electrophysiologic perspective amiodarone would be expected to have some efficacy in achieving sinus rhythm whereas diltiazem and digoxin would not. The authors point out, though, that this was a rate control study and amiodarone was not used in doses optimized for conversion to sinus rhythm. A significant caveat is these were low risk patients:

The main exclusion criteria were VR greater than 200 bpm; pre-excitation syndrome; hypotension (systolic blood pressure less than 90 mm Hg); congestive heart failure; presence of implanted pacemaker and/or implantable cardioverter defibrillator; recent myocardial infarction; unstable angina; stroke or thromboembolism within the past 6 months; allergy or contraindication to the study medications; use of antiarrhythmic and/or atrioventricular nodal blocking drug within last 7 days (in case of amiodarone, within past 3 months); or other major medical conditions including renal failure, respiratory failure, and bleeding disorders.

H/T to The Hospitalist.

Factors in hospitalist retention

Compensation is the obvious one according to this article in ACP Hospitalist, but there are intangibles:

Professional development activities can also give hospitalists a chance to bond with their colleagues and build loyalty to a program. “Whether it’s journal clubs or in-service training by specialists, those are all part,” said Dr. Sheff.
These activities can also contribute to hospitalists’ sense of identification with their field, which may currently be lacking. “Some physicians are seeing a [hospitalist] career path as being nothing more than a glorified resident,” Dr. Sheff said.

Blogging about hospital medicine is one of my remedies for that. It keeps me engaged and interested in the field.

How hospital medicine groups have thrived in troubled economic times

Two new themes emerge from this article in The Hospitalist:

Hospitalist groups need to align their incentives with hospitals.

Hospitals with hospitalists have an easier time recruiting subspecialists.

Easy rule out test for aortic dissection?

I've posted about this before. The latest is this study from Circulation:

Methods and Results— In this prospective multicenter study, 220 patients with initial suspicion of having acute aortic dissection were enrolled, of whom 87 were diagnosed with acute aortic dissection and 133 with other final diagnoses, including myocardial infarction, angina, pulmonary embolism, and other uncertain diagnoses. D-dimer was markedly elevated in patients with acute aortic dissection. Analysis according to control disease, type of dissection, and time course showed that the widely used cutoff level of 500 ng/mL for ruling out pulmonary embolism also can reliably rule out aortic dissection, with a negative likelihood ratio of 0.07 throughout the first 24 hours.

Conclusion— D-dimer levels may be useful in risk stratifying patients with suspected aortic dissection to rule out aortic dissection if used within the first 24 hours after symptom onset.

As with VTE, although the negative predictive power is good, the positive predictive power is poor.

Overuse of CTPAgrams for diagnosis of PE

According to a poster presentation at a recent conference of the American Thoracic Society:

The total number of CTPAs performed for suspected PE stood at 87 in 2000 but jumped to 1,115 in 2005 and to 1,883 in 2008, reported Dr. Chandra, a second-year fellow in the division of pulmonary and critical care at the medical center. In contrast, the percentage of CTPAs that were positive for PE declined during the same period, from 30% in 2000 to 20% in 2005 to 15% in 2008.

According to the survey results docs are not applying pretest probability assessment to guide use of CTs.

Even more importantly, why not just order a good old fashioned V/Q scan? Test performance in appropriately selected patients is as good as CT.

I bet this is keeping the nephrologists busy.

Via Hospitalist News.

Hospitalists at your beck and call

Hospitalists and comanagement---the debate continues

But the debate, as illustrated by a point-counterpoint piece in the October issue of The Hospitalist, is not about whether collaboration among hospitalists, surgeons and subspecialists is good for patient care. It's about the importance of dealing with unintended consequences and defining the relationships.

There are strong arguments in favor of comanagement as a model which benefits patients. It it's not done carefully, though, the adverse consequences for patient care are many and it is a driver of career dissatisfaction. Eric Siegal, M.D., a co-author of the piece, described a situation all too familiar:

In the wee hours of a recent busy call night, the ED called me to admit a patient whose automatic implantable cardioverter cefibrillator (AICD) had fired repeatedly. The patient had no other active medical issues. When called, the electrophysiologist, who was on staff, demanded that I admit the patient for “medical comanagement.” The specialist agreed that I probably would have little to add to the care, but his firm expectation was that hospitalists admit his patients and he “consults” … especially at 2 a.m.