Inflammatory myopathies

Review in Mayo Clinic Proceedings.  

What transfusion threshold for UGI bleeds?

Conservative was better in this study.

Writing as therapy and a tool for enhanced professional growth

Maybe this is why we blog.

Troubleshooting high ventilator pressures

Via Academic Life in Emergency Medicine.

Problems with EHR templates and other documentation tools

EHRs were touted early on as time savers while facilitating documentation in support of better reimbursement. The real world truth, as has since been discovered, is that it doesn't work that way if you want to be in compliance. And the regulatory compliance people are getting wise to that fact according to a recent article in Today's Hospitalist. If you want to be in compliance, say the authors, you either need to dictate, free text or spend a significant amount of time deleting and editing. Sorry, that's just the way it is.

From the article:

Hospitalists would never order an MRI scan unless it was medically necessary. Ditto for laboratory studies. But that can all change at the bedside where physicians may not think as much about medical necessity and instead go with their standard scripts for review of systems and physical exam.

Asking a patient with a femoral neck fracture about polydipsia? Probably a stretch. Cranial nerve examination on a patient with a diverticular abscess? Abuse, for sure, and potentially fraud.

That last one doesn't compute for most hospitalists. MRI scans cost thousands of dollars, but cranial nerve examination is just words on paper. What's the big deal?

My favorite is “pupils equal and reactive to light and accommodation.” I don't know about you but I have not checked accommodation in years.

What to do with troponin elevations when the clinical picture is uncertain

The ACCF 2012 Expert Consensus Document is helpful.

Points of interest:

MI type designations 1-5, respectively, denote unstable coronary artery obstruction, demand ischemia (supply/demand imbalance), sudden unexpected cardiac death, association with PCI and association with CABG. Though all are considered MI only type 1 is considered ACS.

In other situations troponin elevations signify myocardial involvement but not MI such as stroke, PE, sepsis, heart failure (see here) and chest trauma.

Some cases are non cardiac and due to lab artifacts or interfering substances (e.g. heterophile antibodies).

Consider the pretest probability and apply bayesian reasoning in unclear cases.

A CKMb is useful for confirmation in some cases.

Stroke after cardiac catheterization

It doesn't happen very often but it happens. Nowadays regional thrombolysis or clot retrieval may be options.

Octreotide for non-variceal UGI bleeds: state of the controversy

An update at the Emergency Medicine PharmD blog.

Mesenteric vein thrombosis

A free full text review is available from Mayo Clinic Proceedings.

Just a few points of interest:

Think of it when the patient's pain “seems real” and is out of proportion to physical findings.

Pain reaches maximum intensity relatively slowly whereas in acute mesenteric arterial occlusion maximum intensity occurs within minutes or even seconds.

Risk factors for arterial occlusion are cardiovascular---atrial fibrillation and atherosclerosis, whereas for MVT a structural or inflammatory abdominal process is often the underlying cause. Absent that, and in many cases, MVT is a disease of thrombophilia, We are taught to think thrombophilia when clots occur in unusual places. In MVT myeloproliferative disorders, with JAK2 mutation as a marker, stand out.

More about the JAK2 mutation can be found here.

Early anticoagulation improves outcomes. The degree of GI bleeding typically associated with MVT is seldom a contraindication.

Indications for surgical intervention are discussed.

Whither sedation interruption?

A lot of folks are no doubt rethinking the notion of daily sedation interruption in view of last November's JAMA paper which at first glance goes against the teaching of the past few years:

Intervention Continuous opioid and/or benzodiazepine infusions and random allocation to protocolized sedation (n = 209) (control) or to protocolized sedation plus daily sedation interruption (n = 214). Using validated scales, nurses titrated infusions to achieve light sedation...

Results Median time to successful extubation was 7 days in both the interruption and control groups...

Conclusion For mechanically ventilated adults managed with protocolized sedation, the addition of daily sedation interruption did not reduce the duration of mechanical ventilation or ICU stay.

So what does it mean and how might it change practice? To put the study in perspective it's helpful to listen to the interview with one of the authors available at the link above.

Can we say now that sedation interruption is of dubious benefit? No. Can we say that the evidence in support of sedation interruption is mixed? No. Prior research has established the benefits of sedation interruption. What is important to understand about this study is the comparison group which was treated with a protocol designed to sedate as lightly as possible. This is in contrast to conventional sedation in which patients definitely benefit from daily interruption.

If there is a practice changing message form this study it is that sedation, protocol driven to be as light as possible is better than conventional continuous sedation and so is sedation interruption and you need to do one or the other but not necessarily both. The study is not a license to ignore the need to use protocols to limit sedation and it is my suspicion that both approaches are about equally onerous to the ICU staff.

Don't forget procainamide---it's still around

Though all but forgotten among emergency medicine and hospitalist types it has a prominent place in several guideline recommendations. These are summarized in a recent post at Emergency Medicine PharmD. The relevant guideline documents are linked in the post. Of note:

The Canadian guidelines give it a class I recommendation for conversion of acute onset a fib to sinus rhythm. The a fib duration needs to be known with certainty to be less than 48 hours. (And by the way, enough of this nonsense about diltiazem converting patients to sinus rhythm. This misconception seems to be pervasive. It is driven by the fact that many patients with acute a fib convert spontaneously while on dilt for rate control. True, true and unrelated. Dilt's mechanism is in the AF node and there's nothing there that drives a fib).

The ACCF/AHA/HRS guidelines give it a class I recommendation for pre-excited a fib (WPW) provided the patient is hemodynamically stable.

The ACLS 2010 guidelines give it a class IIa recommendation for hemodynamically stable monomorphic VT (favored over amiodarone).

Keep in mind that procainamide can cause Torsades so watch the QT and be mindful of the K+ and Mg++.

Post-marketing experience with dabigatran

---is reassuring according to a recent JACC paper:

Conclusions In this ‘everyday clinical practice’ post-approval nationwide clinical cohort, there were similar stroke/systemic embolism, and major bleeding rates with dabigatran (both doses) compared to warfarin. Mortality, intracranial bleeding, pulmonary embolism, and myocardial infarction were lower with dabigatran, compared to warfarin. We found no evidence of an excess of bleeding events or myocardial infarction amongst dabigatran treated patients in this propensity-matched comparison against warfarin..

Mayo Clinic review of new oral anticoagulants

I've blogged a lot on the novel anticoagulants already but this review is important to bookmark because it's free full text and brings everything together including hard to find information on questions such as use in HIT (theoretically appealing but not yet verified) and the treatment of VTE in cancer.

Your patient on Plavix breaks a hip. Now what?

According to this small study from Mayo you don't have to wait to get it fixed.

Opioid deaths

I ranted so much about this I got tired of it a couple of years ago. But then I noticed, via the Emergency Medicine PharmD blog, this little item in JAMA. It seems 2011 marked the eleventh consecutive year of increase in drug overdose deaths, and this was driven primarily by opiates. Do the math and it dates back to when the “pain as the fifth vital sign” campaign was getting into high gear. As concern for patient perceptions continues to trump clinical judgment don't expect the trend to reverse anytime soon, warns the blogger.

Critical care drug doses at a glance

I have a few quibbles and might consider a couple of these to be suggested doses. Useful overall nevertheless. Via Emergency Medicine PharmD.

Calcium contraindication in dig mediated hyperkalemia: fact or myth?

That question is examined in a recent post at the Emergency Medicine PharmD blog, with no pat answer.

Palliative care

Here's a review containing another one of those top ten lists specialists wished others knew about their specialty. Palliative care is widely misunderstood by health care workers, patients and their families. The review makes several points to dispel misconceptions:

Palliative care is not hospice care. It's not even necessarily end of life care. In fact, it is better applied early in the course of a long illness than toward the end. Contrary to intuition, it may prolong rather than shorten survival. Its application is not confined to cancer but extends across a wide spectrum of severe and complex illnesses. Its focus is not just disease management but also detailed communication with patients and their families, aligning care with the patient's goals and unique attributes and coordination of complex care across the continuum. And, according to the authors, specialty level expertise applied to all the above.

So lots of helpful information there. But the authors fail in one aspect. They fail to define palliative care. They talk around it but don't define it. As I've become comfortable with the idea of palliative care in recent years I've come to know what it is. Despite that, no one has precisely articulated a definition that I know of.

If palliative care is a specialty as the authors claim, what are the distinctives? Again, we need a definition. A definition has two steps. First it places the thing under discussion in a general category. Then it lists attributes that distinguish that particular thing from other members of the same category. For example, step 1: Palliative care is a medical discipline.. Step 2: characterized by ?????. There's the hard part. What are the distinguishing characteristics of palliative care? The authors list quite a few characteristics. The problem is those characteristics don't distinguish palliative care from other disciplines of medicine: Palliative care focuses on severe illness in patients with multiple and complex problems. It applies expertise to the management of a variety of symptoms. It educates patients and their families on diagnosis, prognosis and the goals of treatment. It coordinates complex care across multiple disciplines and settings.

Do you begin to see the problem here? Palliative care is nothing more than good primary care. Or what an excellent internist or hospitalist should be doing. So yes, there is a definition for palliative care but it goes unspoken because the profession is, or should be, embarrassed by the fact that we need a “specialty” whose focus is to offload the rest of us from doing all those things that make for excellence in comprehensive care because we don't have the time.

Carbapenem-resistant gram negative infections: treatment update

Here's another review, available as free full text via Medscape.

High level data are lacking but what studies we have suggest the following take home points:

Candidate antibiotics include aminoglycosides, tygecycline, colistin and, yes, carbapenems.

Two or three drug combination therapy is advised over monotherapy.

Despite the fact that these are carbapenemase producing infections outcomes are better when a carbapenem (meropenem is the best studied) is included in the regimen.

Some promising gram negative agents are in the pipeline. Finally.

Cardiac sarcoidosis

A review and a report of it presenting with electrical storm.