Update on chronic thromboembolic pulmonary hypertension

From Current Opinion in Pulmonary Medicine:

Recent findings The pathobiology of CTEPH development remains incompletely understood; however, evidence supports both large and small vessel disorder in patients with the disease. Surgical thromboendarterectomy is an increasingly well tolerated and often curative procedure and is the management strategy of choice for most patients. Although excellent outcomes in surgical management have been noted, the role of medical management in selected patients with inoperable or recurrent or persistent disease after surgery is increasing. A recent large, randomized controlled clinical trial of riociguat in CTEPH demonstrated improvements in exercise capacity, functional class, and hemodynamics. A safe, effective angioplasty approach to CTEPH is being pursued in addition.

Summary The approach to CTEPH management in the operable patient remains surgical, without clear benefit to preoperative pulmonary arterial hypertension-specific therapy at this time. Patients with inoperable disease or pulmonary hypertension following thromboendarterectomy, however, should be considered for medical management, with riociguat currently having the strongest evidence specific to CTEPH.

Antibiotic and steroid regimens for COPD

From a recently published update:

Recent findings: Macrolides should be considered the antibiotic of choice for prevention of AECOPD in patients who qualify for therapy. Macrolides, fluoroquinolones, and beta-lactams are all reasonable treatment options for severe AECOPD and the decision to use one over the other should be based upon patient characteristics and institutional or regional antimicrobial susceptibility patterns. The best available evidence now suggests that higher-dose corticosteroids are not superior to treatment with lower-dose corticosteroids in patients with severe AECOPD. Additionally, longer durations of systemic corticosteroid therapy do not improve clinical outcomes.

Summary: Several antibiotic options are efficacious in the management of severe AECOPD and drug selection should be patient-specific. Recent studies suggest that lower dosages and shorter durations of corticosteroid treatment may be prudent.

Cognitive function three months post cardiac arrest

From a recent study:

Aim

To describe cognitive functioning with neuropsychological tests and examine predictors of cognitive outcome in adult survivors of out-of-hospital cardiac arrest (OHCA) of cardiac cause...

Results

45 survivors (4 women) completed the assessment. Neuropsychological tests of fine motor functioning, memory, attention and executive functions were significantly below normative means. Depending on the test, impairment ranged from 9 to 31%. For twenty-five survivors (56%), all cognitive tests were within the normal range. Shorter coma duration and induced hypothermia treatment were associated with favourable cognitive outcomes and explained 45% of the variability in the cognitive composite score. Coma duration was predictive across all cognitive tests, hypothermia treatment of specific tests of memory, attention and executive functioning.

Conclusions

Cognitive outcome was normal in more than half of the survivors. Shorter coma duration and induced hypothermia were associated with favourable cognitive outcomes in the participating survivors three months after OHCA.

Chronic kidney disease is a cause of acquired long QT

From a recent study:

Methods

This was a retrospective, chart-review study of admissions or clinic visits to a university hospital between 2005 and 2010 by patients with a diagnosis of CKD. Inclusion criteria selected patients who had 12-lead surface electrocardiography (ECG), renal function tests within 24 hours, and transthoracic echocardiography within 6 months. Cases with a documented etiology for the corrected Qt (Qtc) interval prolongation including structural heart disease, QT prolonging drugs, or relevant disease conditions, were excluded.

Results

Our sample size was 154 ECGs. Two-thirds of patients with CKD had QTc interval prolongation, and about 20% had a QTc interval greater than 500 ms. QTc interval was significantly different and increased with each successive stage of CKD using the Bazett (P less than 0.006) or Fridericia (P = 0.03) formula. QTc interval correlated significantly with serum creatinine (P = 0.01). These finding were independent of age, gender, potassium, and calcium concentrations.

Conclusions

The progression of CKD resulted in a significant delay of cardiac repolarization, independent of other risk factors. This effect may potentially increase the risk of sudden cardiac death, and may also increase the susceptibility of drug-induced arrhythmia.

The Choosing Wisely recommendations: tools or rules?

This post by Retired Doc is from a few months ago but it it is important and especially timely now in light of all the questions swirling around what the ABIM Foundation is up to. 

The Choosing Wisely (hereafter CW) recommendations were compiled from submissions by leaders of various specialties and are, hence, suggestion based as opposed to evidence based. They were initially promulgated as tools to help clinicians deliver high value care.   But, as Retired Doc pointed out, another agenda is at play:

However in the two years since the launching of CW ( at the time of this writing) several policy experts and wonks have envisioned a much more full bodied, authoritative and coercive role  for the pronouncements announced under the CW brand.  It is this expanded role for CW that I refer to as the medical law of the land...

So based on some of these experts' recommendations, what would the medical landscape look in the era in which the decisions of Choosing Wisely would be much more than the suggestions or recommendations,which is how they are sometimes presented  and  instead be  determinative in regard to the reimbursements of third party payers, private and public as well being used in decisions regarding medical specialty certification  and maintenance of certification and other mechanisms to decrease medical costs.

He quoted these proposed uses of CW from the ABIMF blog:

ABIM could require candidates to achieve a perfect score on questions related to costs and redundant care as a requirement for admission to secure exams for initial certification or MOC.

ACP could grade use of resources through MKSAP questions.

CMS, which has the ultimate negotiating position in the form of reimbursement for Medicare services, could only accept negotiated bundled charges. It could also refuse payment for non-compliance with the Choosing Wisely recommendations.

He quoted other policy leaders proposing a similar agenda and then went on:

Physicians would have to follow the CW guidance or risk loosing certification let alone payment for services. As bound as physicians would be to the  dictates of the CW authority how much trust could a patient have that his physician is acting in his ( the patient's) best interests .Making CW the medical law of the land would be a giant step toward the collectivization of medicine and destruction of the traditional physician patient relationship.

As such it would also mean the destruction of evidence based medicine as I once noted in a post in which I outlined EBM's history, intended purpose and definition:

Two of the interviews are with David Sackett, widely known as one of EBM's main apologists. He talked about the beginnings of the movement and emphasized that it is not merely a collection and critical appraisal (a term the EBM founders coined) of evidence. Rather, it goes beyond that to encompass the judgment of the individual clinician and the preferences and values of the individual patient. Those two elements often get left out of the discussion. Because the individual patient is a key element of EBM, proponents of medicine done by central planning can never claim to advocate for evidence based medicine. Along the same lines Dr. Gordon Guyatt remarked that there is no clinical decision that doesn't have the individual patient's preferences and values attached to it. As a corollary, evidence alone cannot inform a clinical decision.

Clearly those who would leverage central authority to impose CW dogma on medical care are opposed to EBM whether they admit it or not. 

More on the American Board of Internal Medicine and maintenance of certification

Yesterday I linked to the latest Newsweek piece on the ABIM and MOC.  It was a follow up to an earlier Newsweek piece which you can access here for a little background.  Though like much written on this subject it makes some simplistic assumptions about how doctors keep up in their specialties it is generally spot on.  Though not new to this discussion I found the article added clarity.  It is an important read. 

I found this of particular interest:

Then, something strange happened, doctors say. The tests started including questions about problems that had nothing to do with how doctors did their jobs. For example, endocrinologists who worked exclusively with adults said they were forced to answer questions about endocrinology for children, even though the pediatric information was irrelevant to their practices. Heart specialists who do not perform transplants – and even those at hospitals with no heart transplant programs – said they had to study techniques for reading transplant tissue slides and how best to evaluate these patients so they could answer questions on the tests. But that knowledge was unrelated to the care they provide to their real patients, they said, and took time that they could have spent learning the latest medical findings about the cardiology work they actually perform.Videos and study sessions sold to help doctors prepare for re-certification exams often featured instructors saying physicians would never see a particular condition or use a certain diagnostic technique, but they needed to review it because it would be on the test.

This rings true to my own experience in attending board review courses sponsored by academic institutions.  Speakers would say "you may never see this but it always seems to show up on boards.". Although this brand of teaching for the test is pervasive even among the most reputable board prep resources, the ABIM called it "cheating", took legal action and drove at least one board review company out of business --- one which, it appeared to me, was in competition with board prep activities ABIM had "partnered" with.  Curiously, this particular ethical question has received scant attention in the discussion though I blogged it extensively a while back. 

And citing the progressive decline in board exam pass rates the author asks these questions:

Wow. Was it Obamacare? Ebola? A sign of the end times? What was turning so many American doctors so stupid all of sudden? Not to worry, the ABIM declares—the board could help doctors keep their certification. All they had to do was pay to take the tests again. Making doctors appear ignorant became big business, worth millions of dollars, and the ABIM went from being a genial organization celebrated by the medical profession to something more akin to a protection racket.

The ABIM disputes that characterization. Lorie B. Slass, a spokesperson for the ABIM, says “there have been and always will be” fluctuations in test results, since different groups of doctors are taking the exam each year. But in each of the categories cited above, there are no statistically significant fluctuations—the passing rate keeps going down. So the point remains: Either doctors are getting dumber each year, or the test that helps determine who gets to practice medicine has less and less to do with the actual practice of  medicine.

Indeed. 

It goes on to describe the lavish salaries of ABIM's leaders.  By contrast, according to the piece, the leaders of Teirstein's newly formed National Board of Physicians and Surgeons will work for free. 

CKD and hypoglycemia

CKD is emerging as a risk factor for hypoglycemia in diabetic patients. Here's a nice discussion at Mayo Clinic Proceedings.  

Another Newsweek story on maintenance of certification

This one is shocking. Worse than even I thought.  

More from Dr. Wes. 

A big part of this whole discussion has been whether doctors, once certified, should even have to "maintain" this certification by jumping through more hoops in the first place.   One of Dr. Wes's commenters effectively ridicules the notion by extending it to its logical conclusion:

Just got a letter from my alma mater saying that my BS in engineering would be revoked if I didn't come back to college and prove proficiency in calculus and heat transfer. They are charging me a large sum for this remediation and claim that it is best for society. The dean said that my diploma was 'rented' and not granted unconditionally.

Funny, my medical school said the same thing. I need to enroll in a weekend course to brush up on anatomy and biochemistry. The dean said that the Krebs cycle is making a come back.

Finally, if this wasn't bad enough. My residency program and fellowship directors left messages on my phone saying that I will have to round one weekend every six months or I will no longer be certified by their programs.

I am very thankful, though. It could always be worse with the elementary school, junior high and high school requiring proficiency. Wait, the phone is ringing...

Calcium channel blockers given to patients with heart failure and preserved EF

---were not associated with harms in this study.

Cardiorenal syndrome and decongestion in acute decompensated heart failure (ADHF)

A recent review on this topic is available as free full text here.

Here are some key points that emerge from this review:


With a few notable exceptions aggressive decongestion in ADHF improves rather than degrades renal function.

There are several mechanisms for this, described in the review.

Aggressive use of loop diuretics, traditionally considered non-evidence based, has recently been shown to be associated with improvement in important outcomes.

These outcomes include readmissions, progression of chronic heart failure and mortality. Once considered necessary for symptom relief but non-evidence based, loop diuretics are joining the ranks of the neurohumeral antagonists as evidence based for important clinical outcomes.


Some cases of “cardiorenal syndrome” may instead be due to unrecognized other causes.

Examples include ATN, interstitial nephritis, obstruction and intra-abdominal hypertension.


A diminishing role of inotropes for diuretic resistance and cardiorenal syndrome, even in the short term.

From the review:

.. inotropic agents may worsen survival over the long term, even when used temporarily; therefore, they should be avoided if possible.[37] In the OPTIME-CHF (Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure) trial, the short-term use of milrinone increased in-hospital death and the 60-day risk of death or rehospitalization in ischemic HF, and increased arrhythmias in all HF.[38-40] Exogenous cardiac stimulation, at a time when the myocardium is significantly energy depleted, may result in further ischemic and apoptotic damage, and lead to the poor outcomes associated with these agents despite immediate short-term hemodynamic improvement. An inotrope, typically dobutamine, is still indicated temporarily in: (1) wet and cold HF with systolic blood pressure less than 85 to 90 mm Hg, or (2) wet and cold HF not responding to diuretic therapy.[41]

Carbapenem-resistant Enterobacteriaceae: treatment options

The treatment approach to this problem continues to evolve. This is from a recent update:

Recent findings: Retrospective and prospective (nonrandomized noncontrolled) studies provide data regarding the management of infections due to carbapenem-resistant Enterobacteriaceae. The combination of a carbapenem with colistin or high-dose tigecycline or aminoglycoside or even triple carbapenem-containing combinations if the minimum inhibitory concentration (MIC) range of carbapenem (meropenem and imipenem) resistance is 8 mg/l or less seems to have an advantage over monotherapy with either colistin or tigecycline or fosfomycin. For Enterobacteriaceae with MIC for carbapenems over 8 mg/l, combination regimens involve colistin, tigecycline usually administered in a double dose than that suggested by its manufacturer, fosfomycin and aminoglycosides in various combinations.

Summary: Suggestions based on the limited literature cannot be made safely. Combination regimens involving carbapenems for Enterobacteriaceae with MICs 8 mg/l or less for carbapenems (in dual combination with colistin or high-dose tigecycline or aminoglycoside or even triple combinations) seem to confer some therapeutic advantage over monotherapy. For Enterobacteriaceae with higher than the above-mentioned MICs, a combination of two or even three antibiotics among colistin, high-dose tigecycline, aminoglycoside and fosfomycin seems to confer decreased mortality.

Elevated blood pressure in hospitalized patients

Conclusions from a recent article in ACP Hospitalist:

Hypertension has not been clearly defined in the hospital setting. The current definition of hypertension pertains to patients with chronic hypertension in an ambulatory setting.

Hypertensive emergencies should initially be treated with parenteral antihypertensive medications.

There is no benefit to acutely decreasing BP in patients who have elevated BP but no hypertension-related target organ damage.

Reflexive treatment of hypertension based only on BP readings should be avoided, and potential harms of an acute drop in BP should be considered.

Recognition of new or undertreated hypertension might be an opportunity to educate patients about the risks of hypertension and to introduce strategies to achieve better control.

Hypertensive emergencies are defined by the presence of target organ damage, not a number.

A new proposed mechanism for how obesity drives hypertension and other cardiovascular complications: the lowered natriuretic peptide setpoint

It's been known for quite a while that BNP and proBNP levels tend to be low in obese patients, even in heart failure. It is also well known that the natriuretic peptides help maintain sodium balance by facilitating excretion in response to a sodium load and that their activities are antagonistic to the renin angiotensin system.

This all leads to the notion that reduced BNP is a mechanism by which obesity drives hypertension and other cardiovascular events. In an elegant piece of clinical research investigators at Vanderbilt University marshaled evidence in support of that mechanism and also demonstrated reversal of the abnormal BNP setpoint after weight loss surgery.

Bare metal versus drug eluting stents and hospital outcomes

The American Journal of Cardiology recently published these findings from a large database:

A total of 665,804 procedures were analyzed, which were representative of 3,277,884 procedures in the United States. Use of bare-metal stents (BMS) was associated with greater occurrence of in-hospital mortality compared with that of drug-eluting stents (DES; 1.4% vs 0.5%, p less than 0.001). The association stayed significant after adjustment of various possible confounding factors (odds ratio for DES versus BMS 0.59 [0.54 to 0.64, p less than 0.001]) and also in propensity matched cohorts (1.2% vs 0.7%, p less than 0.001). The results continued to be similar in the following high-risk subgroups: diabetes (0.57 [0.50 to 0.64, less than 0.001]), acute myocardial infarction and/or shock (0.53 [0.49 to 0.57, less than 0.001]), age greater than 80 (0.66 [0.58 to 0.74, less than 0.001]), and multivessel PCI (0.55 [0.46 to 0.66, less than 0.001]). In conclusion, DES use was associated with lesser in-hospital mortality compared with BMS. This outcome benefit was seen across subgroups in various subgroups including elderly, diabetics, and acute myocardial infarction as well as multivessel interventions.

This study suffers from the weakness of using an administrative database but was very large. Though it was previously known that the use of DES was associated with less lumen loss and restenosis over weeks it is not intuitive that it would reduce immediate term mortality. The authors do not offer a mechanism.

Early criticism of DES concerned costs compared with BMS, with hospitals under prospective payment wondering if they could afford to offer them. In this database the cost excess of DES, though statistically significant, was minimal and would be of questionable impact.

Pulmonary manifestations of Behçet's syndrome

From a recent update in Current Opinion in Rheumatology:

Purpose of review Pulmonary artery involvement (PAI) due to Behçet's syndrome, although rare, has always been a focus of interest not only in endemic areas but also in many parts of the world. This interest is shared by many disciplines other than internal medicine, such as radiology, cardiothoracic surgery, cardiology and respiratory medicine. Most importantly, our understanding of PAI has significantly changed in recent years.

Recent findings Recent work found the following: pulmonary artery aneurysms are not the only form of PAI. Solo ‘in-situ’ pulmonary artery thrombosis (PAT) can be found in up to one-third of the patients at presentation. Both pulmonary artery aneurysms and PAT present with similar clinical symptoms, whereas abundant hemoptysis is less frequent in PAT. PAI is strongly associated with thrombosis in the lower-extremity deep veins and right side of the heart. Varying and multiple pulmonary parenchymal lesions such as nodules, consolidations and cavities are part of this involvement as well. While either aneurysms or thrombosis could disappear successfully with immunosuppressives in up to 70% of the patients, the condition can be fatal still in one-fourth. Large aneurysms and high pulmonary artery pressures are associated with a poor prognosis.

Beta blockers: what is their role in the management of stable coronary disease today?

From a review in the American Journal of Cardiology:

Considerable progress has been made over the last few decades in the management of clinically stable coronary heart disease (SCHD), including improvements in interventions (e.g., percutaneous revascularization), pharmacological management, and risk factor control (e.g., smoking, diet, activity level, hypercholesterolemia, hypertension). Although β blockers have long been used for the treatment of SCHD, their efficacy was established in the era before widespread use of reperfusion interventions, modern medical therapy (e.g., angiotensin-converting enzyme inhibitors, angiotensin receptor blockers), or preventive treatments (e.g., aspirin, statins). On the basis of these older data, β blockers are assumed beneficial, and their use has been extrapolated beyond patients with heart failure and previous myocardial infarction, which provided the best evidence for efficacy. However, there are no randomized clinical trials demonstrating that β blockers decrease clinical events in patients with SCHD in the modern era. Furthermore, these agents are associated with weight gain, problems with glycemic control, fatigue, and bronchospasm, underscoring the fact that their use is not without risk. In conclusion, data are currently lacking to support the widespread use of β blockers for all SCHD patients, but contemporary data suggest that they be reserved for a well-defined high-risk group of patients with evidence of ongoing ischemia, left ventricular dysfunction, heart failure, and perhaps some arrhythmias.

Imaging the asymptomatic limb in evaluation for DVT

---was rarely helpful in this study.

Via Hospital Medicine Virtual Journal Club.

Asthma management

Here's a great summary form S.O.A.P.

Obesity and asthma: a unique phenotype

From Current Opinion in Pulmonary Medicine:

Recent findings

Clinical and epidemiological studies indicate that obese patients with asthma may represent a unique phenotype, which is more difficult to control, less responsive to asthma medications and by that may have higher healthcare utilization. A number of common comorbidities have been linked to both obesity and asthma, and may, therefore, contribute to the obese–asthma phenotype. Furthermore, recently published studies indicate that even a modest weight reduction can improve clinical manifestations and outcome of asthma.

Summary

Compared with normal-weight patients, obese and overweight patients with asthma have poorer asthma control and respond less to corticosteroid therapy.

Via Hospital Medicine Virtual Journal Club.

Risk factors for aortic disease

From a recently published analysis:

Background Community screening to guide preventive interventions for acute aortic disease has been recommended in high‐risk individuals. We sought to prospectively assess risk factors in the general population for aortic dissection (AD) and severe aneurysmal disease in the thoracic and abdominal aorta.

Methods and Results We studied the incidence of AD and ruptured or surgically treated aneurysms in the abdominal (AAA) or thoracic aorta (TAA) in 30 412 individuals without diagnosis of aortic disease at baseline from a contemporary, prospective cohort of middle‐aged individuals, the Malmö Diet and Cancer study. During up to 20 years of follow‐up (median 16 years), the incidence rate per 100 000 patient‐years at risk was 15 (95% CI 11.7 to 18.9) for AD, 27 (95% CI 22.5 to 32.1) for AAA, and 9 (95% CI 6.8 to 12.6) for TAA. The acute and in‐hospital mortality was 39% for AD, 34% for ruptured AAA, and 41% for ruptured TAA. Hypertension was present in 86% of individuals who subsequently developed AD, was strongly associated with incident AD (hazard ratio [HR] 2.64, 95% CI 1.33 to 5.25), and conferred a population‐attributable risk of 54%. Hypertension was also a risk factor for AAA with a smaller effect. Smoking (HR 5.07, 95% CI 3.52 to 7.29) and high apolipoprotein B/A1 ratio (HR 2.48, 95% CI 1.73 to 3.54) were strongly associated with AAA and conferred a population‐attributable risk of 47% and 25%, respectively. Smoking was also a risk factor for AD and TAA with smaller effects.

Unpacking the benefits of almonds

From a recent study:

Methods and Results In a randomized, 2‐period (6 week/period), crossover, controlled‐feeding study of 48 individuals with elevated LDL‐C (149±3 mg/dL), a cholesterol‐lowering diet with almonds (1.5 oz. of almonds/day) was compared to an identical diet with an isocaloric muffin substitution (no almonds/day). Differences in the nutrient profiles of the control (58% CHO, 15% PRO, 26% total fat) and almond (51% CHO, 16% PRO, 32% total fat) diets were due to nutrients inherent to each snack; diets did not differ in saturated fat or cholesterol. The almond diet, compared with the control diet, decreased non‐HDL‐C (−6.9±2.4 mg/dL; P=0.01) and LDL‐C (−5.3±1.9 mg/dL; P=0.01); furthermore, the control diet decreased HDL‐C (−1.7±0.6 mg/dL; P less than 0.01). Almond consumption also reduced abdominal fat (−0.07±0.03 kg; P=0.02) and leg fat (−0.12±0.05 kg; P=0.02), despite no differences in total body weight.

Conclusions Almonds reduced non‐HDL‐C, LDL‐C, and central adiposity, important risk factors for cardiometabolic dysfunction, while maintaining HDL‐C concentrations.

Left atrial appendage closure

This article in CCJM reviews the evidence, with a focus on the transcutaneous devices. The evidence from clinical trials is somewhat mixed and preliminary. As with any device, improvements in the technology far outpace clinical trials. The bottom line for now is that it is an emerging option for certain patients unable to take oral anticoagulants.

The electrocardiographic findings in massive or submassive PE: it's not just S1Q3T3!

The pattern and timing of T wave inversion can also be helpful as discussed here and here at the EMS 12 Lead blog.

As Henry J. L. (Barney) Marriott used to say, when you see T wave abnormality suggestive of simultaneous anterior AND inferior ischemia think acute cor pulmonale, as in massive or submassive PE.

ECMO: what the hospitalist needs to know

Why would a hospitalist need to know about ECMO? The applications are expanding rapidly. Hospitalists are increasingly likely to be involved in the care of patients who need the procedure and may be involved, at least indirectly, in determining a patient's candidacy. Here is a very helpful free full text review.

Arterial lines: evidence based or not?

In this large propensity-matched cohort analysis no mortality benefit was seen.

Early post resuscitation cardiac catheterization

---is associated with improved survival, overall and neurologically intact, in this meta-analysis. The analysis was based on low level data. There were no randomized trials. The data were not restricted to patients who met STEMI criteria although, as one would expect, “STEMI patients” were subjected to early invasive treatment more often than others. The analysis led the authors to conclude that early cardiac catheterization is reasonable in post arrest patients in whom a cardiac cause is even suspected, and that the decision should not be based solely on the presence or absence of ECG STEMI findings.

Autoimmune pancreatitis

Review here. It is now recognized that there are two types of AIP and only type I is associated with IgG-4.

Why public reporting is meaningless

Recently I've been working through some required learning modules for clinical documentation and coding. Most physicians know that the wording used in progress notes and discharge summaries can modify the DRG payment and greatly impact the hospital's reimbursement. What may be less well appreciated is that these little documentation tweaks can also impact severity adjustment which in turn affects the physician's rating in public reporting sites. I was recently reminded that with a little creative writing just changing a word here and there, the provider can radically impact how a patient encounter looks to outsiders. For example, the same patient could be portrayed as a stable medical patient on the ward, or, with a few little tweaks and the help of your clinical documentation specialist, a critically ill patient in the ICU. The language you use in your chart documentation makes all the difference in your public reporting profile regardless of how good a doctor you are. Physicians, particularly hospitalists, are encouraged to develop this skill because the hospital's livelihood depends on it. Enhancement of the doctor's public reporting profile is a side benefit and has nothing to with his or her skill or effectiveness as a clinician. A physician who is well versed in this creative chart documentation may even push the envelope of fraud but the regulating authorities will likely never know. Having observed these things over the last few years I've become increasingly skeptical of the value of public reporting, yet many of our hospitalist leaders who have a strong focus on health care policy continue to drink this Kool-Aid and serve it up to others.  

From experienced clinician to master clinician

Dr. Gurpreet Dhaliwal, known by his colleagues as Goop, is regarded as one of the master clinicians in the department of Internal Medicine at UCSF. If you've attended very many SHM conferences you've probably been bedazzled watching him discuss a mystery case in CPC fashion.

How do you get to be a master clinician? Are some people just born that way? Goop has pondered this question and decided it's a matter of attitude and motivation as much as anything else. It's the subject of a talk he gave, which I was fortunate enough to attend, at the Society of Hospital Medicine national meeting last spring. That same talk, given as a guest medical grand rounds speaker at the University of Washington, is available for viewing here.

Goop tries to be evidence based in his talk but encounters a problem: there has been next to no research on this question in clinical medicine. In attempting to work around the problem Goop has to look to non medical fields, in which there is a fair body of research on what makes an expert. But such research tends to be unconvincing, as comparison of the art and science of medicine with the mechanics of industry falls short time after time. Fortunately though Goop sprinkles in plenty of personal insights he has gained on his journey to becoming a master clinician. I'll unpack a few things here that rang true to me although I recommend everyone watch the video in its entirety at the link above.

It's a lot about attitude.
Complacency is the enemy. The slide appearing about six minutes into the talk reflects the typical career learning curve. Early on the curve is steep. Everything is new and it's a struggle. After a while, though, things get easier. As experience accumulates we become comfortable and the curve flattens. This, according to Goop, is a zone of complacency where professional stagnation and eventual decline may ensue. The key to staying out of this rut is to keep the curve steep but it takes deliberate effort. If you're comfortable in a particular content area make it harder by inventing new challenges and go after them. Curiosity and humility, the realization of how little you know, are important drivers.

Practice must be deliberate.
Passive practice, the kind we get from seeing a lot of patients, is an inefficient learning method. Deliberate practice might mean, for example, making it a point to carefully review as many electrocardiograms (or rashes or images, etc) as possible during a given month along with related material in textbooks or review articles.

Make the most of case reports.
Though relegated to “low impact” status in medical journals, case reports can be powerful learning tools when read with deliberate learning objectives (not just casually). Case records and clinical problem solving exercises in the New England Journal of Medicine are but two examples.

Is this the next version of MOC? It's a lot of work but there is a key difference. Unlike MOC this is self motivated and self directed. And it's a much more robust form of learning than that which is imposed by some outsider who knows nothing of your educational needs.

Deployment related lung disease---recent insights

Here is an update from Current Opinion in Pulmonary Medicine.

Background from previous posts on this topic can be found here.

Atrial fibrillation and silent cerebral infarction (SCI)

There is a two fold increase in the odds for SCI attributable to atrial fibrillation in this systematic review and meta-analysis.

Hypertensive emergencies and severe asymptomatic hypertension

This post from S.O.A.P. nicely covers true hypertensive emergencies and their distinction from severe asymptomatic hypertension.

D 10 versus D 50 for treatment of severe hypoglycemia

D 10 may be as good or better. Via Academic Life in Emergency Medicine.

A systematic review of four popular weight loss diets

Recent findings:

Background—We conducted a systematic review to examine the efficacy of the Atkins, South Beach, Weight Watchers (WW), and Zone diets...

Conclusions—Head-to-head RCTs, providing the most robust evidence available, demonstrated that Atkins, WW, and Zone achieved modest and similar long-term weight loss. Despite millions of dollars spent on popular commercial diets, data are conflicting and insufficient to identify one popular diet as being more beneficial than the others.

Inpatient diabetes management

Resources and tools from the American Association of Clinical Endocrinologists.

Follow up appointment with a pulmonologist

---reduced readmission for COPD exacerbation in this study.

Via Hospital Medicine Virtual Journal Club.

Diagnosis takes a back seat under administrative pressures

A pithy little note over at DB's Medical Rants got me thinking. From the post:

Diagnosis generally dominates the first few admission days. We cannot really develop a good treatment plan until we solve the diagnostic dilemma.

I agree. But given typical lengths of stay of three or four days that means the majority time spent in the hospital should be devoted to just getting the right diagnosis for many patients. Worse, a significant number will leave the hospital without being correctly diagnosed at all.

But today's external pressures drive us in another direction, which is to force a diagnostic label on the patient too early. First the emergency physician is pressured to label the patient in order to convince the hospitalist to accept the patient for admission. Then the hospitalist has to assign a “principle problem.” If the problem statement is vague (such as a symptom), as is often appropriate, pressure comes from the coding and quality people to make the diagnosis more specific and get the patient on a care pathway. The performance incentives that follow are meaningless if the resulting diagnosis is incorrect.

Dr. Lawrence Weed, originator of the problem oriented medical record, appreciated this fact decades ago when he gave us this rule: in stating the patient's problem do not go beyond the level or resolution you have at the time. If that means listing the problem as “funny looking EKG” so state it until further data and expertise become available.

More tweaks proposed for the hospitalist model of care

The hospitalist model came into being with the hope that it would result in improved quality and cost efficiency. That hope did not withstand scientific scrutiny despite the persistent claims of some. While many hospitalists ascend a long and steep learning curve, thereby becoming quite skilled in the management of inpatients, that advantage may be outweighed by the discontinuity that is built into the system.

Concerns about this discontinuity prompted some leaders to propose modifications which would in effect dismantle the model. Some, for example, have suggested that hospitalists spend part of their time in the clinic. A few years ago AAFP promulgated guidelines calling for PCPs to collaborate with ER doctors before their patients are admitted to hospitalists, and to be involved in their patients' hospital stays. None of these ideas were widely adopted.

Now a Perspective piece in the New England Journal of Medicine proposes taking things a step further:

Under this voluntary system, PCPs would visit their hospitalized patients within 12 to 18 hours after admission to provide support and counseling to them and their families and consultation to the hospitalist team. The consultation would focus on the direction and scope of the patient's workup and care. The PCP would write a succinct consultation note, highlighting key elements of the patient's history (including pertinent family and psychosocial components), physical exam, and recent testing, and conclude with a prioritized differential diagnosis and recommendations for personalized inpatient evaluation and management. The hospitalist team would still retain full attending-physician responsibilities.

The initial consultation — contributing insights from an established doctor–patient relationship — would be designed to complement and help inform the hospitalist's admission workup and care plan, aiming to reduce hospitalist workload while increasing personalization of care. Subsequent to the admission consultative visit, the PCP would be available to meet with the patient, family, and hospitalist team on an as-needed basis, returning just before discharge to consult on the design of a coordinated posthospital program.

This means the PCP would round at least twice during the patient's hospital stay. Given a typical length of stay of about 4 days that means he or she would be rounding at least half the time. Although most hospitalists I know would be delighted to see the PCPs reaching inside the walls of hospitals this proposal would dismantle the hospitalist model as we now know it. It would take a radical payment shift to create enough incentive to bring something like this about and, despite the optimism in today's reform climate I don't see it happening any time soon.

Guidelines for intravascular catheter related infections

These guidelines from the IDSA were released in 2009. Though they may seem dated they are the most current guidelines form IDSA on the topic. No new version is expected anytime soon.

There are almost endless clinical scenarios (suspected versus established infection, type of organism, patient characteristics, type of catheter) and treatment options (duration and type of antibiotic, lock therapy, removal versus retention). The guidelines, accordingly, are quite complicated, a bit more than you could be expected to remember. This is a reference the hospitalist needs to have handy.

Weight loss drugs: risks versus benefits

Throughout their history weight loss drugs have taken off pounds but ultimately proved harmful. Here is a free full text review which traces the multiple generations of these agents and evaluates the latest offerings. Even these purportedly safer drugs have concerns and have yet to be adequately tested for long term cardiovascular outcomes.

The Affordable Care Act

Here is a plain language summary of the ACA and some of its failings in a recent issue of CCJM.

More on Takotsubo cardiomyopathy

Here is yet another of many reviews.

Via Hospital Medicine Virtual Journal Club.

Hemicraniectomy for catastrophic MCA stroke

From NEJM:

BACKGROUND:

Early decompressive hemicraniectomy reduces mortality without increasing the risk of very severe disability among patients 60 years of age or younger with complete or subtotal space-occupying middle-cerebral-artery infarction. Its benefit in older patients is uncertain.

METHODS:

We randomly assigned 112 patients 61 years of age or older (median, 70 years; range, 61 to 82) with malignant middle-cerebral-artery infarction to either conservative treatment in the intensive care unit (the control group) or hemicraniectomy (the hemicraniectomy group); assignments were made within 48 hours after the onset of symptoms. The primary end point was survival without severe disability (defined by a score of 0 to 4 on the modified Rankin scale, which ranges from 0 [no symptoms] to 6 [death]) 6 months after randomization.

RESULTS:

Hemicraniectomy improved the primary outcome; the proportion of patients who survived without severe disability was 38% in the hemicraniectomy group, as compared with 18% in the control group (odds ratio, 2.91; 95% confidence interval, 1.06 to 7.49; P=0.04). This difference resulted from lower mortality in the surgery group (33% vs. 70%). No patients had a modified Rankin scale score of 0 to 2 (survival with no disability or slight disability); 7% of patients in the surgery group and 3% of patients in the control group had a score of 3 (moderate disability); 32% and 15%, respectively, had a score of 4 (moderately severe disability [requirement for assistance with most bodily needs]); and 28% and 13%, respectively, had a score of 5 (severe disability). Infections were more frequent in the hemicraniectomy group, and herniation was more frequent in the control group.

CONCLUSIONS:

Hemicraniectomy increased survival without severe disability among patients 61 years of age or older with a malignant middle-cerebral-artery infarction. The majority of survivors required assistance with most bodily needs.

Via Intensivecare medicine worth knowing.

Extracorporeal life support in severe ARDS

Despite recent advances and rapidly accumulating experience, high level evidence is lacking. Here is an update.

Time limited versus grandfathered board certified internists

This study compared the two groups along various performance metrics:

Main Outcomes and Measures Ten primary care performance measures: colorectal screening rates; diabetes with glycated hemoglobin (HbA1c level) less than 9.0%; diabetes with blood pressure less than 140/90 mm Hg; diabetes with low-density lipoprotein cholesterol (LDL-C) level less than 100 mg/dL; hypertension with blood pressure less than 140/90 mm Hg; thiazide diuretics used in multidrug hypertensive regimen; atherosclerotic coronary artery disease and LDL-C level less than 100 mg/dL; post–myocardial infarction use of aspirin; post–myocardial infarction use of β-blockers; congestive heart failure (CHF) with use of angiotensin-converting enzyme (ACE) inhibitor.

Results After adjustment for practice site, panel size, years since certification, and clustering by physician, there were no differences in outcomes for patients cared for by internists with time-limited or time-unlimited certification for any performance measure...

These results must be viewed in terms of the limitations of using performance metrics as a surrogate.

Evidence summary on high risk PE

From a recent update:

Purpose of review: Although early pulmonary revascularization is the treatment of choice for patients with high-risk (massive) pulmonary embolism, it remains controversial in patients with intermediate-risk (submassive) pulmonary embolism until recently. Recent published data on the management of high-risk and intermediate-risk pulmonary embolism patients will be the main focus of this review.

Recent findings: The PEITHO trial supports the rationale of risk stratification in normotensive patients with pulmonary embolism. Patients with right ventricular dilation on echocardiography and positive cardiac troponin test have a high intermediate risk of complication and death. Thrombolysis prevents hemodynamic collapse in these patients but with an increased risk of major bleeding particularly in older patients (>75 years). Reduced dose of thrombolysis and catheter-based reperfusion with or without fibrinolysis have shown promising results.

Costs and outcomes for MOC-required versus MOC-grandfathered internists

Here's an interesting paper that recently appeared in JAMA:

Importance In 1990, the American Board of Internal Medicine (ABIM) ended lifelong certification by initiating a 10-year Maintenance of Certification (MOC) program that first took effect in 2000. Despite the importance of this change, there has been limited research examining associations between the MOC requirement and patient outcomes.

Objective To measure associations between the original ABIM MOC requirement and outcomes of care....

One group (n = 956), initially certified in 1991, was required to fulfill the MOC program in 2001 (MOC-required) and treated 84 215 beneficiaries in the sample; the other group (n = 974), initially certified in 1989, was grandfathered out of the MOC requirement (MOC-grandfathered) and treated 69 830 similar beneficiaries in the sample. We compared differences in outcomes for the beneficiary cohort treated by the MOC-required general internists before (1999-2000) and after (2002-2005) they were required to complete MOC, using the beneficiary cohort treated by the MOC-grandfathered general internists as the control.

Main Outcomes and Measures Quality measures were ambulatory care–sensitive hospitalizations (ACSHs), measured using prevention quality indicators. Ambulatory care–sensitive hospitalizations are hospitalizations triggered by conditions thought to be potentially preventable through better access to and quality of outpatient care...

Results Annual incidence of ACSHs (per 1000 beneficiaries) increased from the pre-MOC period (37.9 for MOC-required beneficiaries vs 37.0 for MOC-grandfathered beneficiaries) to the post-MOC period (61.8 for MOC-required beneficiaries vs 61.4 for MOC-grandfathered beneficiaries) for both cohorts, as did annual per-beneficiary health care costs (pre-MOC period, $5157 for MOC-required beneficiaries vs $5133 for MOC-grandfathered beneficiaries; post-MOC period, $7633 for MOC-required beneficiaries vs $7793 for MOC-grandfathered beneficiaries). The MOC requirement was not statistically associated with cohort differences in the growth of the annual ACSH rate (per 1000 beneficiaries, 0.1 [95% CI, −1.7 to 1.9]; P = .92), but was associated with a cohort difference in the annual, per-beneficiary cost growth of −$167 (95% CI, −$270.5 to −$63.5; P = .002; 2.5% of overall mean cost).

Conclusion and Relevance Imposition of the MOC requirement was not associated with a difference in the increase in ACSHs but was associated with a small reduction in the growth differences of costs for a cohort of Medicare beneficiaries.

My take on this very busy abstract is that requiring MOC was not associated with improved outcomes but was associated with a very modest cost reduction in this study.

Chest CT findings in acute pericarditis

From a recent study:

Material and Methods: Using the electronic medical record, we retrospectively identified 46 cases of acute pericarditis and 46 control patients with pericardial effusions due to volume overload, all of whom underwent CT examination. Cases were reviewed by two blinded academic thoracic radiologists.

Results: The majority, 67%, of the pericarditis cases were evaluated with PE-protocol CTs. Pericardial thickening/enhancement was the most accurate single parameter for pericarditis, with sensitivity of 54–59% and specificity of 91–96%.

Conclusion: CT findings, while not sensitive for pericarditis, are diagnostic, with few false-positives.

Via Hospital Medicine Virtual Journal Club.

Broken ribs and other injuries from CPR---how often?

Here’s a study of patients undergoing CT scanning post resuscitation, both successful and unsuccessful:

During the study period, 309 patients who suffered out-of hospital cardiac arrest were transported to our emergency room and received CPR; 223 were enrolled in the study.

The CT images showed that 156 patients (70.0%) had rib fractures, and 18 patients (8.1%) had sternal fractures. Rib fractures were associated with older age (78.0 years vs. 66.0 years, p less than 0.01), longer duration of CPR (41 min vs. 33 min, p less than 0.01), and lower rate of ROSC (26.3% vs. 55.3%, p less than 0.01). All sternal fractures occurred with rib fractures and were associated with a greater number of rib fractures, higher age, and a lower rate of ROSC than rib fractures only cases. Bilateral pneumothorax was observed in two patients with rib fractures.

Via Hospital Medicine Virtual Journal Club.

Bedside diagnosis of dysphagia---is it adequate?

From a systematic review:

We conducted a comprehensive search of 7 databases, including MEDLINE, Embase, and Scopus, from each database's earliest inception through June 9, 2014. Studies reporting diagnostic performance of a bedside examination maneuver compared to a reference gold standard (videofluoroscopic swallow study or flexible endoscopic evaluation of swallowing with sensory testing) were included for analysis. From each study, data were abstracted based on the type of diagnostic method and reference standard study population and inclusion/exclusion characteristics, design, and prediction of aspiration. The search strategy identified 38 articles meeting inclusion criteria. Overall, most bedside examinations lacked sufficient sensitivity to be used for screening purposes across all patient populations examined. Individual studies found dysphonia assessments, abnormal pharyngeal sensation assessments, dual axis accelerometry, and 1 description of water swallow testing to be sensitive tools, but none were reported as consistently sensitive. A preponderance of identified studies was in poststroke adults, limiting the generalizability of results. No bedside screening protocol has been shown to provide adequate predictive value for presence of aspiration. Several individual exam maneuvers demonstrated reasonable sensitivity, but reproducibility and consistency of these protocols was not established. More research is needed to design an optimal protocol for dysphagia detection.

The problem with this paper is the choice of gold standard. Bedside evaluation will not pick up as many abnormalities as will video fluoroscopy, but how many positive video studies are really clinically significant?

Via Hospital Medicine Virtual Journal Club.

Celiac disease guidelines

From the American College of Gastroenterology. Free full text.

Systematic review on treatment of calcium blocker overdose

Free full text here.

Academic Life in Emergency Medicine summarizes the review:

A few findings from the systematic review:

The majority of literature on calcium channel blocker overdose management is heterogenous, biased, and low-quality evidence.

Interventions with the strongest evidence are high-dose insulin and extracorporeal life support.

Interventions with less evidence, but still possibly beneficial, include calcium, dopamine, norepinephrine, 4-aminopyridine (where available), and lipid emulsion therapy.

Stay tuned for the international guideline coming out soon. One treatment recommendation from the new guideline, reported at the 8th European Congress on Emergency Medicine September 2014, is not to use glucagon.

Beta blockers in heart failure with preserved ejection fraction

From a recent paper in JAMA:

Objective To test the hypothesis that β-blockers are associated with reduced all-cause mortality in HFPEF.

Design Propensity score–matched cohort study using the Swedish Heart Failure Registry. Propensity scores for β-blocker use were derived from 52 baseline clinical and socioeconomic variables.

Setting Nationwide registry of 67 hospitals with inpatient and outpatient units and 95 outpatient primary care clinics in Sweden...

Participants From a consecutive sample of 41 976 patients, 19 083 patients with HFPEF (mean [SD] age, 76 [12] years; 46% women). Of these, 8244 were matched 2:1 based on age and propensity score for β-blocker use, yielding 5496 treated and 2748 untreated patients with HFPEF. Also we conducted a positive-control consistency analysis involving 22 893 patients with HFREF, of whom 6081 were matched yielding 4054 treated and 2027 untreated patients.

Exposures β-Blockers prescribed at discharge from the hospital or during an outpatient visit...

In the matched HFPEF cohort, 1-year survival was 80% vs 79% for treated vs untreated patients, and 5-year survival was 45% vs 42%, with 2279 (41%) vs 1244 (45%) total deaths and 177 vs 191 deaths per 1000 patient-years (hazard ratio [HR], 0.93; 95% CI, 0.86-0.996; P = .04). β-Blockers were not associated with reduced combined mortality or heart failure hospitalizations: 3368 (61%) vs 1753 (64%) total for first events, with 371 vs 378 first events per 1000 patient-years (HR, 0.98; 95% CI, 0.92-1.04; P = .46)...

Conclusions and Relevance In patients with HFPEF, use of β-blockers was associated with lower all-cause mortality but not with combined all-cause mortality or heart failure hospitalization. β-Blockers in HFPEF should be examined in a large randomized clinical trial.

Bariatric surgery

---seemed to improve long term survival in this study.

Is “atypical coverage” really important in community acquired pneumonia?

In this study the inclusion of atypical coverage was not associated with reduced mortality but did result in shortened time to clinical stability.

Occult bacteremia

These are the people who get sent home from the ER then have to be called back because their blood cultures turn positive. In this study from a single institution it appeared to be a benign entity:

Methods

This is a retrospective cohort study (September 2010 to September 2012), in adult patients discharged from the ED in whom blood cultures turned positive. Patients were evaluated according to a preestablished protocol.

Results

We recorded 4025 cases of significant BSI in the ED and 113 patients with adult occult BSI. In other words, the incidence of occult BSI in the ED was 2.8 per 100 episodes. The predominant microorganisms were gram-negative bacteria (57%); Escherichia coli was the most common (41%), followed by gram-positive bacteria (29%), anaerobes (6.9%), polymicrobial (6.1%), and yeasts (0.8%). The most frequent suspected origin was urinary tract infection (53%), and most infections were community acquired (63.7%). Of the 105 patients that we were able to trace, 54 (42.5%) were asymptomatic and were receiving adequate antibiotic treatment at the time of the call, and 65 (51.2%) had persistent fever or were not receiving adequate antibiotic treatment.

Conclusions

Occult BSI is relatively common in patients in the adult ED. Despite the need for readmission of a fairly high proportion of patients, occult BSI behaves as a relatively benign entity.

Alveolar proteinosis

Case description and brief review.

When is permanent pacing indicated for AV block?

I'm working through MKSAP 16's section on cardiovascular disease. As much as I hate to be immodest, it's a content area I think I know just a little something about, particularly in the area of electrophysiology. I was drawn to their statement on permanent pacing after acute MI (AMI). Sprinkled throughout MKSAP are sets of high value care recommendations for various specialties, apparently their own version of Choosing Wisely.

The pacing recommendation, which is to wait several days after the occurrence of AV block (AVB) before inserting a permanent pacemaker (PPM) in order to see if the block persisted, struck me as awfully simplistic. Pacing recommendations for AVB have strong underpinnings in physiology which have withstood evidence based scrutiny. The relevant electrophysiology, far more often than not, can be assessed at the bedside via simple electrocardiography. Well, maybe I should qualify that by saying it's true provided adequate skill in interpretation of the ECG is brought to the bedside.

Things have changed through the years. Clinical skills in this area have deteriorated, in part because AVB complicating AMI is much less common in today's reperfusion era than it once was. The question of what to do with AVB after AMI seldom comes up anymore. Before the reperfusion era it was routine. The guiding principle back then was that, at least in acute anterior MI, when the block was subjunctional, that is true type II block, permanent pacing was indicated no matter how transient the block. (Caveat: the atypical situation of block arising in the common bundle of His is a nuanced topic, beyond the scope of this post).

So what about the current guidelines? The STEMI guidelines refer this topic to the device therapy guidelines which say in part:

CLASS I

1. Permanent ventricular pacing is indicated for persistent second-degree AV block in the His-Purkinje system with alternating bundle-branch block or third-degree AV block within or below the His Purkinje system after ST-segment elevation MI. (Level of Evidence: B) (79,126 –129,131)

2. Permanent ventricular pacing is indicated for transient advanced second- or third-degree infranodal AV block and associated bundle-branch block. If the site of block is uncertain, an electrophysiological study may be necessary. (Level of Evidence: B) (126,127) 

For patients in general with acquired AVB the guidelines include the following, listed under the class IIa category:

4. Permanent pacemaker implantation is reasonable for asymptomatic type II second-degree AV block with a narrow QRS.

When type II second-degree AV block occurs with a wide QRS, including isolated right bundle-branch block, pacing becomes a Class I recommendation. (See Section 2.1.3, “Chronic Bifascicular Block.”) (Level of Evidence: B) (70,76,80,85)

The recommendation summary is much more extensive but this small sample illustrates the complexity of decision making and the reliance on assessment of the anatomic site of block via electrocardiography (bedside electrophysiology). When it comes to pacing decisions post MI there's considerably more to it than the MKSAP recommendations would indicate.

Opiate withdrawal: usually benign but not always

The main problem is when opiate withdrawal is precipitated (such as with naloxone) in a narcotic tolerant patient. Here is a case report and review.

PVCs can help in the diagnosis of myocardial ischemic syndromes

Here is a case presented at Dr. Smith's ECG blog and a link to several more. As Barney Marriott was fond of saying, PVCs pay diagnostic dividends. Know them!

Admission HgbA1C to help determine discharge diabetes regimen

From a study in Diabetes Care:

RESEARCH DESIGN AND METHODS This was a prospective, multicenter open-label study aimed to determine the safety and efficacy of a hospital discharge algorithm based on admission HbA1c. Patients with HbA1c less than 7% (53.0 mmol/mol) were discharged on their preadmission diabetes therapy, HbA1c between 7 and 9% (53.0–74.9 mmol/mol) were discharged on a preadmission regimen plus glargine at 50% of hospital daily dose, and HbA1c greater than 9% were discharged on oral antidiabetes agents (OADs) plus glargine or basal bolus regimen at 80% of inpatient dose. The primary outcome was HbA1c concentration at 12 weeks after hospital discharge.

RESULTS A total of 224 patients were discharged on OAD (36%), combination of OAD and glargine (27%), basal bolus (24%), glargine alone (9%), and diet (4%). The admission HbA1c was 8.7 ± 2.5% (71.6 mmol/mol) and decreased to 7.3 ± 1.5% (56 mmol/mol) at 12 weeks of follow-up (P less than 0.001). The change of HbA1c from baseline at 12 weeks after discharge was −0.1 ± 0.6, −0.8 ± 1.0, and −3.2 ± 2.4 in patients with HbA1c less than 7%, 7–9%, and greater than 9%, respectively (P less than 0.001). Hypoglycemia (less than 70 mg/dL) was reported in 22% of patients discharged on OAD only, 30% on OAD plus glargine, 44% on basal bolus, and 25% on glargine alone and was similar in patients with admission HbA1c less than or equal to 7% (26%) compared with those with HbA1c greater than

CONCLUSIONS Measurement of HbA1c on admission is beneficial in tailoring treatment regimens at discharge in general medicine and surgery patients with type 2 diabetes.

From commentary in the ACP Hospitalist Weekly:

Measuring HbA1c at admission can help with tailoring a postdischarge treatment regimen for type 2 diabetes patients, the study authors concluded. The observed rate of hypoglycemia was acceptable, which should reassure any hospital clinicians who avoid intensifying outpatient regimens out of fear of hypoglycemia, the authors noted. The findings also support recent guidelines recommending insulin treatment during hospitalization, but resumption of oral medications at discharge for patients with acceptable control. Improving postdischarge glucose control could potentially reduce revisits to the emergency department or hospital, the authors suggested.

Measuring HbA1c at admission can help with tailoring a postdischarge treatment regimen for type 2 diabetes patients, the study authors concluded. The observed rate of hypoglycemia was acceptable, which should reassure any hospital clinicians who avoid intensifying outpatient regimens out of fear of hypoglycemia, the authors noted. The findings also support recent guidelines recommending insulin treatment during hospitalization, but resumption of oral medications at discharge for patients with acceptable control. Improving postdischarge glucose control could potentially reduce revisits to the emergency department or hospital, the authors suggested.

It's important to note that patients in the study had telephone contacts every 2 weeks in the 2 months after discharge and follow-up visits at 1 and 3 months, which could have contributed to their improved glycemic control.

It's important to note that patients in the study had telephone contacts every 2 weeks in the 2 months after discharge and follow-up visits at 1 and 3 months, which could have contributed to their improved glycemic control.

Metabolic syndrome and atrial fibrillation

Here's a free full text review about this emerging association.

A catastrophic late complication of PEG tube placement

Here's a case report and mini-review.

Monitoring the limb lead voltage may help track improvement in acute decompensated heart failure

Especially lead aVR. It performed better than proBNP in this study. Small numbers, but interesting.