Can the post resuscitation electrocardiogram distinguish between patients who do or do not need to go to the cath lab post resuscitation?

According to this paper it can help despite recent teaching which says it is unreliable:

ST-segment elevation predicted AMI with 88% sensitivity and 84% specificity. The criterion including ST-segment elevation and/or depression had 95% sensitivity and 62% specificity. The combined criterion including ST-segment elevation and/or depression, and/or non-specific wide QRS complex and/or left bundle branch block provided a sensitivity and negative predictive value of 100%, a specificity of 46% and a positive predictive value of 52%.

So reliance on classic STEMI criteria is not enough because it will miss at least 22% of patients who need to go to the lab. On the other hand the use of combined criteria (meaning the patient's EKG has to be nearly stone-cold normal to avoid a trip to the lab) has very high sensitivity.

Troponin measurement in heart failure

What does it mean when it’s elevated? Does it mean ACS or chronic elevation as a part of the heart failure syndrome? How does one distinguish? If the patient does not have ACS are measurements of value in risk stratification? These questions and more are answered in a review from last year in JACC, available here as free full text.

Hospitalization for adverse medication events in elders

67% in a new study were due to oral hypoglycemics, insulins and antithrombotics, none of which are on the Beers list.

The authors conclude that intensified outpatient vigilance targeting these classes of medications is warranted to reduce hospitalizations in the elderly.

EMRAP TV

Short videos on clinical emergency medicine and the intersection with critical care medicine.

Intraosseous access

---may be catching on in the ER but is still underutilized. It can serve as a bridge to a central line if you can't get a peripheral in in a reasonable amount of time. Study here, Medscape commentary here.

Gram positive bacteremia in hemodialysis patients

A review in the American Journal of Kidney Diseases. Free full text.

Celiac disease

It has a wide clinical spectrum with many atypical variations. A review in the Archives of Pathology and Laboratory Medicine.

Update on animal bite infections

This is a very comprehensive review. Article at journal site. Free full text from Medscape.

Open courseware from Yale

Multiple subjects covered here.

Vaccine news from IDSA

A Medscape video by Dr. William Schaffner.

Managing severe acute valvular regurgitation

Here is a review from the Texas Heart Institute Journal, focusing on left sided valvular regurg:

Although acute, severe valvular regurgitation can be a true surgical emergency, accurate diagnosis and subsequent treatment decisions require clinical acumen, appropriate imaging, and sound judgment. An accurate and timely diagnosis is essential for successful outcomes and requires appropriate expertise and a sufficiently high degree of suspicion in a variety of settings. Whereas cardiovascular collapse is the most obvious and common presentation of acute cardiac valvular regurgitation, findings may be subtle, and the clinical presentation can often be nonspecific.

Cerebral salt wasting vs SIADH

Via The Bottom Line:

Cerebral salt wasting is associated with hypovolemic hyponatremia in patients with intracranial disease, such as subarachnoid hemorrhage, traumatic brain injury, craniotomy, encephalitis, and meningitis. SIADH is a cause of euvolemic hyponatremia due to the excess secretion of vasopressin that may be attributed to malignancy, various CNS or pulmonary disorders or drugs, such as chlorpropamide and carbamazepine.

The treatments differ completely but the distinction between the two can be very difficult. Both conditions have CNS disease in common and are biochemically similar. The diagnosis my hinge on volume assessment and response to treatment.

Donald Berwick to step down as CMS leader

Berwick, who once said evidence based medicine may have to “take a back seat,” has decided to take a back seat himself rather than face confirmation hearings in the Senate as Republicans remain determined to block his nomination. For many of them the problem is their perception of Berwick as a Marxist. For me it was his incoherence---advocating for more central control on the one hand while favoring an agenda of radical consumerism on the other. The Fox News piece gives us a sample of the double talk (my emphasis):

"I abhor rationing. My entire life has been spent fighting rationing. There's no substance whatsoever to the substance of that," Berwick told the House Ways and Means Committee in February 2011…

The decision is not whether or not we will ration care ... the decision is whether we will ration with our eyes open.

Berwick had big and interesting ideas. If there was a unifying thread in them I couldn’t find it.

Bacteremia as a red flag for colon cancer---it’s not just Strep bovis

According to a poster presentation at the 51st Interscience Conference on Antimicrobial Agents and Chemotherapy other species, particularly anaerobic organisms, can be indicitative of increased risk.

Anti-Xa assays---ready for prime time on the wards?

The anti-Xa assay is becoming more readily available in community hospital labs. Its potential value in dosing low molecular weight heparins in special situations such as pregnancy, morbid obesity and renal disease is well known. Less well known is a potential role in monitoring unfractionated heparin. How does it compare with PTT monitoring and what are the practical aspects? These questions are answered in a recent review in Lab Medicine, available as free full text here.

The concluding paragraph of the paper summarizes the current controversy:

Anti-Xa assays represent an attractive alternative to the PTT for UH monitoring; however, minimal outcomes data and greater expense are limiting factors. While the cost of Anti-Xa assays might decrease with higher test volumes, prospective clinical outcomes data are not likely to be forthcoming because of the waning utilization of UH. Nonetheless, laboratories may elect to switch to anti-Xa heparin monitoring based on the outcomes data currently available.

What is HCAHPS?

Ever notice how a new acronym or buzzword gets introduced and no body bothers to tell you what it means? It may be that the people throwing it around don't know what it really means themselves. Such is the case with HCAHPS. At first I thought they were talking about health care associated pneumonia. Later I realized that it was a new survey method that will change the way the patient satisfaction game is played. But when I asked around nobody, it seemed, could tell me what those letters stand for. So I looked it up. It's Hospital Consumer Assessment of Healthcare Providers and Systems. There you are. Information here and here.

Physical fitness and brain aging

Physical fitness may be associated with slowed brain aging according to a presentation at the Society for Neuroscience. Via WSH Health Blog.

Does Up To Date save lives?

Maybe so according to this study in which hospital outcomes were compared based on use or non-use of Up To Date:

We found that patients admitted to hospitals using UpToDate had shorter lengths of stay than patients admitted to non-UpToDate hospitals overall (5.6 days vs 5.7 days; P less than 0.001) and among 6 prespecified conditions (range, −0.1 to −0.3 days; P less than 0.001 for each). Further, patients admitted to UpToDate hospitals had lower risk-adjusted mortality rate for 3 of the 6 conditions (range, −0.1% to −0.6% mortality reduction; P less than 0.05). Finally, hospitals with UpToDate had better quality performance for every condition on the Hospital Quality Alliance metrics. In subgroup analyses, we found that it was the smaller hospitals and the non-teaching hospitals where the benefits of the UpToDate seemed most pronounced, compared to the larger, teaching institutions where the benefits of UpToDate seemed small or nonexistent.

The study, by the way, according to the WSJ Health Blog, was funded by Up To Date. It passes the test of plausibility for me, and supports my long held contention that doctors need “tools not rules.” I hope we see more research in this exciting area.

Managing the patient with electrical storm

Very helpful article from the Texas Heart Institute Journal.

Do you need to interrupt single or dual antiplatelet therapy for dental extractions?

No, but a marked increase in bleeding in patients on uninterrupted dual antiplatelet therapy may require local hemostatic measures according to this study.