Schnitzler syndrome

Considered rare, but probably under diagnosed.

Platelet transfusions in critically ill patients: a review

A systematic review in the journal Blood concluded:

Recommendation: For critically ill adults with severe thrombocytopenia and no evidence of bleeding, there is insufficient evidence to make a recommendation for or against platelet transfusion.

However, the authors cite the Surviving Sepsis guidelines which made a weak recommendation for prophylactic platelet transfusion in patients with platelet counts below 20,000 who have significant bleeding risk.

Sideroblastic anemia induced by linezolid

This report makes a pretty convincing case that it's a real entity. I was a bit surprised the article didn't mention vitamin B6, which has a connection. Rare cases of B6 responsive sideroblastic anemia (of a variety of causes) were reported in the 1950s and 60s but soon fell off the radar screen. In more recent years reports have surfaced of B6 responsive anemia (but not other cytopenias) in patients taking linezolid. Those reports, at least the ones I have seen, do not mention sideroblasts.  

ProfRoofs lectures

Videos for students in the medical sciences.

Elevated troponin and abnormal ECG: is it ACS or could it be PE?

Clinical circumstances and the electrocardiogram can provide powerful clues but they are widely ignored. Mistaking PE for ACS or heart failure are well known examples of misdiagnosis. Today's environment of core measures, care pathways and rapid throughput pressures physicians more than ever before to jump to the most superficially apparent cause (troponin positive, thinking stops).

When PE presents with an abnormal ECG and an elevated troponin it is massive or submassive. Nevertheless it tends to be missed. Here is a great post from Dr. Smith which discusses some of the nuances.

AV block occurring when it shouldn't: the paradoxical critical rate phenomenon

When we think of rate related AV block we almost always assume it occurs at faster supraventricular rates, especially type 2 AV block and bundle branch block. Occasionally, rarely in fact, it's the reverse: block occurs only during bradycardia or following a longer RR interval. If a vagal mechanism is excluded (which can usually be done by careful examination of the strips and clinical circumstances) the best known mechanism is phase 4 block which is the topic of the linked article.

Other causes of related electrocardiographic curiosities are supernormal conduction and the Wedensky effect.

Hospital Medicine 2014, Las Vegas

I'm here attending the national meeting of the Society of Hospital Medicine. The clinical sessions have charged my batteries and the organizational/political ones have stoked the fire. I'll have much to say about all that later---maybe in a week or two (there's no way I could do the meeting justice by live blogging or tweeting). In the meantime auto-posting will keep the blog alive until I get home.

Relative hyperlactatemia

---meaning elevated lactate levels within the reference range, was associated with increased mortality in this study of ICU patients. A value of 1.35 mmol/L was found to be the best cutoff.  

Which patients admitted with pneumonia should get blood cultures?

This topic has been a little controversial. Core measures have just now caught up with the more selective culture recommendations from guidelines. A nice topic update is posted at Academic Life in Emergency Medicine.

What are the factors that determine professional satisfaction among physicians?

A recent RAND corporation study addressing this question came up with several interesting findings. As expected, time pressures, externally imposed regulations and threats to the stability of income were negatives. No definitive patterns emerged about the impact of the Affordable Care Act (ACA) perhaps, according to the authors, because it's too early in the game. Intrusive regulation has been increasing steadily for decades and the ACA may prove to be just another point along that continuum. But concerning the impact of proposed new models of health care organization (e.g. the ACO) in the ACA the authors were able to draw upon data from analogous models brought by the wave of managed care in the 1990s. Findings from that era pointed to a negative impact on professional satisfaction.

The report did cite a lot of frustration among physicians about the meaningful use requirements for EMRs (not a part of Obamacare). In general, data from the report indicate that physicians like the idea of the EMR in the abstract (think it has promise) but perceive many aspects of present day use to be impediments to professional satisfaction. Chief among these are poor communication of clinical information (downsides of templates and other automated EMR functions) and the loading on of clerical duties out of the scope of physician training inherent in the way the EMR is used. As such the EMR is perceived as a time consumer rather than a time saver.

For more on the negative impact of the EMR on professional satisfaction see this post at Health Care Renewal.

Patient harm during nursing home stay

From a BMJ news report:

A third of Medicare patients who are discharged to a skilled nursing facility for post-acute care are harmed during their stay at the nursing home, says a new report.1

In the study by the Office of Inspector General at the US Department of Health and Human Services, investigators reviewed the records of 653 randomly selected Medicare beneficiaries whose stay at a skilled nursing facility had lasted a maximum of 35 days and had ended in August 2011.

Here is the link to the original report. According to the report 22% of patients experienced serious harm and 59% of the episodes were preventable.

A close look at the methods of the study suggests several cautions in interpreting the findings. The 59% figure is open to question. The determination of preventability was often based on weak circumstantial evidence and unwarranted assumptions. Many of the events that were truly preventable reflected a need for greater vigilance but not error.

Pharmacy involvement in patient education and discharge medication instructions

---reduced 30 day all cause readmissions in heart failure patients in this study. Via Hospital Medicine Virtual Journal Club.

Unrecognized pheochromocytoma

A case report and mini review.

Phaeochromocytoma is a rare catecholamine-producing tumour with an annual incidence rate of 2 cases per 1 million per year in the general population [1]. The incidence of phaeochromocytoma in autopsy studies is under 0.1% and autopsy studies have also shown that up to 50% of phaeochromocytomas are unrecognized [2]. The tumour has protean manifestations, mimicking a variety of conditions, earning the title “great mimic” and often resulting in erroneous and delayed diagnosis, which if missed or not properly treated, will almost invariably prove fatal [3]

Early discharge planning and outcomes

Here's an interesting systematic review finding that while early discharge planning didn't affect outcomes of the index (current) admission it did extend the readmission interval and reduced the LOS of the readmission. From the paper:

The findings suggest that by implementing early discharge planning focused on functional needs’ assessment for discharge home, patient and caregiver education and follow-up, medication review and information transmittal, clinicians may anticipate reductions in older adults’ hospital readmissions by 22% and readmission lengths of hospital stay by almost two and a half days, compared with usual care.

MedCram

Brief videos on various medical topics.

The hospital pharmacist as part of the multidisciplinary ICU team

From an article in Chest:

Critical care pharmacy services in the ICU have expanded from traditional dispensing responsibilities to being recognized as an essential component of multidisciplinary care for critically ill patients. Augmented by technology and resource utilization, this shift in roles has allowed pharmacists to provide valuable services in the form of assisting physicians and clinicians with pharmacotherapy decision-making, reducing medication errors, and improving medication safety systems to optimize patient outcomes. Documented improvements in the management of infections, anticoagulation therapy, sedation, and analgesia for patients receiving mechanical ventilation and in emergency response help to justify the need for clinical pharmacy services for critically ill patients. Contributions to quality improvement initiatives, scholarly and research activities, and the education and training of interdisciplinary personnel are also valued services offered by clinical pharmacists.

Minute Physics

Physics concepts explained in seconds.

Aerosolized colistin as an adjunct to IV colistin

It appeared to be helpful in this study of patients with VAP due to colistin-only sensitive organisms.

Stethoscope contamination after patient contact

This study looked at stethoscope bacterial contamination and compared it with hand contamination after a single patient contact.

Stethoscope diaphragm contamination was found to exceed contamination of all parts of the hand except for the fingertips.

The authors recommend cleaning the stethoscope after every patient exam. This should be common sense, but system improvements (like hand washing, as important as that is) tend to become substitutes for common sense. As a result we've all but ignored stethoscope cleaning.

I have another suggestion. By all means use the stethoscope (and clean it after you use it) if you intend, and have the skill, to use it as a meaningful clinical tool. Do not use it merely as a coding enhancer.

Via Hospital Medicine Virtual Journal Club.

Preventing hypokalemia in hospitalized patients

From a recent study:

Objectives To determine if administering potassium preemptively in maintenance intravenous fluid would prevent episodes of hypokalemia and reduce the need for potassium boluses.

Methods Medical records of 267 patients with normal potassium and creatinine levels at admission who did not receive total parenteral nutrition were reviewed. The 156 patients who met the study criteria were categorized by group: those who received potassium via maintenance intravenous fluid (treatment; n = 76) and those who did not (control; n = 80). The treatment group had potassium chloride or acetate added to intravenous fluid delivered at 36 to 72 mmol/d...

The patients given maintenance potassium preemptively received significantly fewer (P less than .001) potassium boluses (0.8) than did the control group (2.73), for a mean savings of $231 per patient for the treatment group.

Conclusions Patients with normal potassium and creatinine levels at admission benefitted from a maintenance intravenous dose of potassium of 72 to 144 mmol/L per day. Compared with control patients, patients receiving this dose avoided detrimental hypokalemic events, had fewer invasive procedures and lower costs, and required less nursing care.

Hang normal saline as the maintenance IV fluid on patients with good kidneys and no potassium supplement or potassium sparing drugs on board and they are likely to be hypokalmemic the next morning. If straight normal saline with no additives is the default IV fluid these days it may be driven by CPOE. Customizing IV fluids is more difficult if you don't have a unit secretary to enter it for you.

Via Hospital Medicine Virtual Journal Club.