A clinical image collection

From Life in the Fast Lane.

A clinical prediction rule may obviate the need for TEE in patients with nosocomial Staph aureus bacteremia

Here is the abstract of the recent paper. The complete rule is not covered in the abstract but is outlined in this post from Hospital Medicine Quick Hits.

Note that the rule applies only to nosocomial Staph aureus bacteremia.

Delirium guidelines from NICE

Available here. HT to Hospital Medicine Quick Hits.

Clot Connect MD

A resource on thrombosis and thrombophilia.

Dealing with bleeding in patients on Pradaxa

Very little has been published on this, but some folks have worked it out. Here's a very helpful post on the topic from the EMCrit blog.

The anticoagulation forum

This is an educational resource on topics related to antithrombotic therapy. Archived webcasts of the 11th National Conference on Anticoagulant Therapy are posted.

Pure quackery invades a critical care nursing journal

You've got to see it to believe it. Via Respectful Insolence.

Appreciating hospitalists for (gasp!) their clinical skills

Since its origins the hospitalist movement has been redefined. According to our founding documents a hospitalist was a generalist physician, usually an internist, who brought exceptional clinical skills to the care of hospitalized patients. Emphasis on the word clinical. Things devolved considerably since then. Clinical expertise gradually took a back seat to clerical skills, coding and performance measures. Today our thought leaders, or many of them, seem to devalue clinical expertise.

I'm not generally impressed by promotional items about hospitalists, but a recent post by Dr. John M got my attention because it focused on hospitalists as excellent clinicians:

But for good patient care, the details are important too. Hospitalists are good at details. In fact, an internists’ area of expertise is in using, considering and synthesizing such specifics. They mesh together a patient’s history, exam, laboratory values, X-rays, and other specialists’ opinions. I feel strongly that having thinkers on the case is a good thing.

What's wrong with performance measures?

In large part they are substitutes for thought. That's why they are so faulty and so many docs resist them.

CT angiography is not the diagnostic modality of choice for PE

A recent study published in Chest evaluated the sequence of clinical scoring, D-dimer testing, compression ultrasonography, V/Q scanning and CT (MDCT) in that order for the diagnosis and rule-out of PE. CT was only needed in 11% of the patients:

Results: Detection of DVT by ultrasonography established the diagnosis of PE in 43 (13%). Lung scan associated with clinical probability was diagnostic in 243 (76%) of the remaining patients. MDCT scan was required in only 35 (11%) of the patients. The 3-month thromboembolic risk in patients not given anticoagulants, based on the results of the diagnostic protocol, was 0.53% (95% CI, 0.09-2.94).

Conclusions: A diagnostic strategy combining clinical assessment, d-dimer, ultrasonography, and lung scan gave a noninvasive diagnosis in the majority of outpatients with suspected PE and appeared to be safe.

A related editorial was titled Retro Is the Rage!: Ventilation-Perfusion Scanning Is Alive and Well in the Diagnosis of Pulmonary Embolism.

Well, I'm going to savor this moment for a little self aggrandizement. I told you so. I've been hammering this point for the last six years on this blog. The evidence has never favored CT over V/Q for PE. Minimizing the use of CT in the evaluation of patients for PE will save costs, radiation risk and kidneys.

Review of therapeutic hypothermia after cardiac arrest

Here's a nice update from CCJM with free full text and CME available.

Points of interest:

For neurologically appropriate patients (GCS less than 8) the intervention carries a class I recommendation in the 2010 ACLS guidelines when the cardiac arrest was out of hospital and the initial rhythm was VF or pulseless VT and spontaneous circulation was restored in less than 60 minutes.

For all other rhythms and for in hospital arrest of any rhythm the intervention is given a class IIb recommendation.

Patients without obvious extracardiac cause for their arrest need prompt coronary angiography. Therapeutic hypothermia can be implemented in parallel with cardiac catheterization, with the protocol started before or during the procedure.

All bets are off for estimating neurologic prognosis until 72 hours after rewarming.

Trends in elective PCI post-COURAGE

It looks like cardiologists are following the evidence according to this new study:

Conclusions—Publication of results from the COURAGE trial was temporally associated with a significant and sustained decline in the use of PCI to treat patients with stable angina. The long-term impact of this change in practice on patient outcomes remains to be determined.

Unexplained AV block in younger patients: think beyond the pacemaker!

In this recent paper investigators found a surprisingly high prevalence of cardiac sarcoidosis and giant cell myocarditis among patients aged 18-55 with unexplained AV block requiring pacing:

Conclusions—CS and GCM explain greater than or equal to 25% of initially unexplained AVB in young and middle-aged adults. These patients are at high risk for adverse cardiac events.

A high rate of adverse events was noted in follow up of the CS and GCM patients. In contrast, those patients whose heart block remained idiopathic after investigation had a benign course.

The Clinical Perspective piece related to this article stated:

These data suggest that CS and GCM are not uncommon causes of AVB in young and middle-aged adults and that the prognosis of CS and GCM is poor even when the first manifestation is AVB. We encourage a policy of active and systematic screening for CS and GCM in all adults aged less than 55 presenting with unexplained high-degree AVB.

Benign versus malignant early repolarization---can they be distinguished?

The early repolarization pattern on the electrocardiogram was long considered a benign variant. Recent evidence suggests a subset of patients in whom it signifies an increased risk of sudden cardiac death. I blogged on that topic here and here.

A recent study addressed electrocardiographic distinctions:

Conclusions—ST-segment morphology variants associated with ER separates subjects with and without an increased risk of arrhythmic death in middle-aged subjects. Rapidly ascending ST segments after the J-point, the dominant ST pattern in healthy athletes, seems to be a benign variant of ER.

On the other hand, horizontal or descending ST segments signify an increased risk of death.

Quick reference card, asthma classification

The asthma classification is important to an understanding of the treatment guidelines. I’ve always found it difficult to keep straight, so this quick reference from the Paucis Verbis series at the Academic Life in Emergency Medicine blog should be useful.

CT pulmonary angiography and overdiagnosis of PE

A new study published in Archives of Internal Medicine looked at changing trends in diagnosis and outcomes for pulmonary embolism since introduction of CT pulmonary angiography:

We compared age-adjusted incidence, mortality, and treatment complications (in-hospital gastrointestinal tract or intracranial hemorrhage or secondary thrombocytopenia) of PE among US adults before (1993-1998) and after (1998-2006) CTPA was introduced. 

Results Pulmonary embolism incidence was unchanged before CTPA (P = .64) but increased substantially after CTPA (81% increase, from 62.1 to 112.3 per 100 000; P less than .001). Pulmonary embolism mortality decreased during both periods: more so before CTPA (8% reduction, from 13.4 to 12.3 per 100 000; P less than .001) than after (3% reduction, from 12.3 to 11.9 per 100 000; P = .02). Case fatality improved slightly before (8% decrease, from 13.2% to 12.1%; P = .02) and substantially after CTPA (36% decrease, from 12.1% to 7.8%; P less than .001). Meanwhile, CTPA was associated with an increase in presumed complications of anticoagulation for PE: before CTPA, the complication rate was stable (P = .24), but after it increased by 71% (from 3.1 to 5.3 per 100 000; P less than .001).

The authors note that these findings suggest overdiagnosis attributable to CTPA due to detection of isolated inconsequential filling defects. As the data show, this has significant clinical consequences. In that sense CTPA may be considered by some to be more sensitive than V/Q scanning. However, when long term clinical outcomes are used as the standard V/Q scanning has demonstrated superior sensitivity so long as a normal perfusion scan (note that’s normal, not “low prob”) is used to rule out PE.

The changing profile of bacterial meningitis

From an NEJM study:

The incidence of meningitis changed by −31% (95% confidence interval [CI], −33 to −29) during the surveillance period, from 2.00 cases per 100,000 population (95% CI, 1.85 to 2.15) in 1998–1999 to 1.38 cases per 100,000 population (95% CI 1.27 to 1.50) in 2006–2007. The median age of patients increased from 30.3 years in 1998–1999 to 41.9 years in 2006–2007..

Of the 1670 cases reported during 2003–2007, S. pneumoniae was the predominant infective species (58.0%), followed by GBS (18.1%), N. meningitidis (13.9%), H. influenzae (6.7%), and L. monocytogenes (3.4%). An estimated 4100 cases and 500 deaths from bacterial meningitis occurred annually in the United States during 2003–2007.

Parenteral iron therapy

---is enjoying expanded use. Newer products are safer and no longer carry black box warnings.

Brugada pattern quick reference card

From the Paucis Verbis series at the Academic Life in Emergency Medicine blog.

ACLS and the use of antiarrhythmic agents

Here's a new systematic review published in the journal Resuscitation. The conclusions were in line with the current recommendations:

Amiodarone may be considered for those who have refractory VT/VF, defined as VT/VF not terminated by defibrillation, or VT/VF recurrence in out of hospital cardiac arrest or in-hospital cardiac arrest. There is inadequate evidence to support or refute the use of lidocaine and other antiarrythmic agents in the same settings.