Should we artificially lower temperature in septic patients? It's complicated.

In general the lowering of body temperature in febrile patients via antipyretics or external methods is useless in terms of outcomes and may be harmful. Exceptions include heat stroke and other hyperthermia syndromes, stroke patients and post cardiac arrest patients.

The issue recently became more nuanced when publication of this paper from the blue journal added another possible exception: patients in septic shock treated with external cooling, in whom a decrease in pressor requirements and mortality was observed. On the other hand the use of antipyretics in septic patients across the board was associated with increased mortality in this study.

It is intuitive that external cooling would reduce pressor requirement because it induces vasoconstriction.

Influenza resources

Here's the link for professionals from the CDC and the CCJM annual update.

Asthmatic granulomatosis: a novel phenotype of severe asthma

What has come to be known as severe asthma comprises a number of unique phenotypes, poorly understood. A novel phenotype characterized by granulomatous inflammation is described in this paper from the blue journal.

Apheresis and plasma exchange: what the hospitalist needs to know

How it's done, how it works, when to do it.

Subclinical hyper- and hypothoroidism increase the risk for heart failure events

----according to the findings in this pooled analysis.

Peripartum cardiomyopathy

This topic was nicely reviewed in the Texas Heart Institute Journal and the free full text can be accessed here.

Key points:

Its onset can be in late pregnancy or up to 5 months postpartum.

Diagnosis is by exclusion of other heart disease combined with, in order to avoid overdiagnosis, very specific echocardiographic criteria.

Treatment includes general heart failure therapy (a table in the article summarizes drug precautions during pregnancy and lactation) and disease specific therapies.

Recovery is frequent but not invariable.

Neurogenic pulmonary edema

Some lessons in neuropulmonology from the journal Critical Care:

A common thread among all case descriptions of NPE is the severity and acuity of the precipitating CNS event. Neurologic conditions that cause abrupt, rapid, and extreme elevation in intracranial pressure (ICP) appear to be at greatest risk of being associated with NPE..

The autonomic nervous system and catecholamines play a significant role.

Annoying habits in the medical record

Here are some of Dr. Herb Fred's pet peeves. A couple of my favorites:

Many consultants from various disciplines routinely end their reports with, “Thank you for allowing me to participate in the care of this most interesting patient.” What is the difference between an uninteresting patient, an interesting patient, and a most interesting patient?7 The answer, like beauty, lies in the eyes of the beholder. In my eyes, all patients are interesting, but not all doctors are interested.8 A simple “Thank you” or “Thank you for this consultation” would be sufficient and devoid of insincerity and cliché.

Finally, “The patient is ‘satting’ at 88%.” This expression of the patient's oxygen saturation level crops up frequently, not only in hospital records, but also in Morning Report, teaching rounds, and doctors' lounges. Patients can sit or be sitting, but they can't sat or be satting. To sat is not a verb form. It's a neologism—arguably the most popular neologism in medicine today. House officers are particularly fond of it, uniformly include it in case presentations, and consider it the 5th vital sign.9 Unless teaching faculties consistently prohibit its use by all trainees, “satting” will continue to saturate the medical environment.

I would add that those fond of the term “satting” are not only grammatically incorrect but also tend to be confused about the physiology of oxygen transport.

Dr. Fred opens:

This editorial focuses on selected examples of bad habits that I have found repeatedly in traditional (paper) hospital records.

Well, Dr. Fred, it only gets worse in the electronic medical record.

The EMR and diabetes care: no impact

This study is important because it looked not just at the phony surrogate of performance but also at outcomes. The EMR was no better than paper in either category. HT to Clinical Cases and Images.

Dr. Smith talks about his ECG blog

With the passage of the old generation of electrocardiography masters (Marriott, Hurst) a new generation of ECG masters is arising and it comes from the ranks of emergency medicine. The driving force behind this is the fact that early “STEMI” recognition, both in the ED and in “the field,” is a performance measure. No one wants to miss one and no one wants egg on their face for calling a STEMI false alarm. Emergency medicine types are motivated more than ever to get it right.

Dr. Smith teaches residents in emergency medicine. His blog is on my list of the best ECG resources on the web.

Via Clinical Cases and Images.

Doctors on the receiving end of abuse

Sometimes it's patient against doctor, sometimes it's doctor against doctor. This paper is not quantitative but it has a ring of truth.

Cardiac device associated infections

Here's a nice little article in the Texas Heart Institute Journal.

Key points:

Presenting findings may be nonspecific and subtle. It may show up late after implantation. System explantation is generally recommended.

Drink coffee, cut your nasal MRSA carriage rate in half

Hospital administrators takenote---don't skimp on the coffee machines.

Cellulitis and its mimics

This review deals with several non-infectious mimics. Presentations of cellulitis which harbor more serious conditions such as nec fash, abscess or bad fungal infections were not covered.

Cardiac device therapy: ICD and CRT

A comprehensive review in the Texas Heart Institute Journal covers standard indications (ischemic and non-ischemic cardiomyopathy), unusual indications (infiltrative diseases, channelopathies) and controversies (timing of implantation after MI or onset of HF). Free full text available here.

Yet another CAM promoting article in a mainstream medical journal

The premise of this article seems to be that treatment choices should be based on perception and preference. What ever happened to evidence and scientific plausibility?

A review of acute aortic regurgitation

Free full text from Circulation.

Key points:

Acute severe AR may be difficult to recognize clinically and is often erroneously diagnosed as another acute condition such as sepsis, pneumonia, or nonvalvular heart disease.

Infective endocarditis and aortic dissection are the “big two” causes and their managements are depicted in this figure.

Whither the stethoscope?

Due to the pervasive decline in the basic clinical skills of physicians and trainees the stethoscope has been relegated to the status of an instrument to facilitate CPT coding with the unintended consequence of spreading germs.

Well, after all, the thinking goes, why work to maintain auscultatory skills when you can just get an echo? As this article in CCJM points out, that's dangerous thinking. Echocardiography can mislead. If it doesn't correlate with basic clinical data something's wrong.

As the late J.Willis Hurst was fond of saying, master low technology (basic clinical skills) or you're bound to abuse high technology.

Autoinflammatory syndromes as causes of recurrent fever

Familial Mediterranean fever is the prototype but many new variants are emerging as explained in this review.

Bad science is no respecter of politics

Is it fair to brand the right as anti-science and the left as pro-science? No.

Did you know, for example, that Barack Obama said, concerning vaccines and autism:

"We've seen just a skyrocketing autism rate. Some people are suspicious that it's connected to the vaccines. This person included..."

Well, so did John McCain.

There's much more in this web cast from C-SPAN Book TV including a general discussion of the hazards of opening scientific discussions to the arena of public debate. Discussions of science should inform policy. They should not be mixed with or driven by a policy agenda.

There's plenty of bad science on both sides of the aisle.