Renin-angiotensin blockade in heart failure with preserved EF? Mixed results.

From a recent review:

Studies with angiotensin‐converting enzyme inhibitors (ACE‐Is) and angiotensin receptor blockers (ARBs) in patients with heart failure with preserved ejection fraction (HFpEF) have yielded inconsistent results. To conduct a systematic review and meta‐analysis of all evidence for ACE‐I and ARBs in patients with HFpEF, we searched PubMed, Ovid SP, Embase, and Cochrane database to identify randomized trials and observational studies that compared ACE‐I or ARBs against placebo or standard therapy in HFpEF patients. Random‐effect models were used to pool the data, and I 2 testing was performed to assess the heterogeneity of the included studies. A total of 13 studies (treatment arm = 8676 and control arm = 8608) were analysed. Pooled analysis of randomized trials for ACE‐I and ARBs (n = 6) did not show any effect on all‐cause mortality [relative risk (RR) = 1.02, 95% confidence interval (CI) = 0.93–1.11, P = 0.68, I 2 = 0%], while results from observational studies showed a significant improvement (RR = 0.91, 95% CI = 0.87–0.95, P = 0.005, I 2 = 81.5%). In pooled analyses of all studies, ACE‐I showed a reduction of all‐cause mortality (RR = 0.91, 95% CI = 0.87–0.95, P = 0.01). There was no reduction in cardiovascular mortality seen, but in pooled analysis of randomized trials, there was a trend towards reduced HF hospitalization risk (RR = 0.91, 95% CI = 0.83–1.01, I 2 = 0%, P = 0.074). These data suggest that ACE‐I and ARBs may have a role in improving outcomes of patients with HFpEF, underscoring the need for future research with careful patient selection, and trial design and conduct.

Not challenging science is anti-science??

But I thought science was inherently self-challenging. To Dr. John’s credit, though, he does make some good points about the thought police. They’re everywhere in medicine.

Doctors in the US make too much money

---according to a policy wonk at one progressive think tank. So, says he, we must apply pressure from all sides to break up the cartel and reduce doctors’ pay. The fact that patients generally like their doctors doesn’t help.

Valproic acid overdose

Case report and literature review.

Blood letting for the common cold?

This is the kind of thing I would expect to find in BMJ, maybe, but not in the journal Medicine. I hear it didn’t go well for George Washington.

Cardiovascular disease in acromegaly

Free review.

New trends in GERD

Severe adverse effects of PPIs are increasingly recognized so now what?

Inappropriate antibiotic prescribing for patients sent home from the ER

An opportunity for education:

Results

Of 1579 ED antibiotic prescriptions in 2015, we reviewed a total of 159 (10.1%) prescription records. The most frequently prescribed antimicrobial classes included penicillins (22.6%), macrolides (20.8%), cephalosporins (17.6%), and fluoroquinolones (17.0%). The most common indications for antibiotics were bronchitis or upper respiratory tract infection (URTI) (35.1%), followed by skin and soft tissue infection (SSTI) (25.0%), both of which were the most common reason for unnecessary prescribing (28.9% of bronchitis/URTIs, 25.6% of SSTIs). Of the antimicrobial prescriptions reviewed, 39% met criteria for inappropriateness. Among 78 prescriptions with a consensus on appropriate indications, 13.8% had inappropriate dosing, duration, or expense.

Conclusion

Consistent with national outpatient prescribing, inappropriate antibiotic prescribing in the ED occurred in 39% of cases with the highest rates observed among patients with bronchitis, URTI, and SSTI. Antimicrobial stewardship programs may benefit by focusing on initiatives for these conditions among ED patients. Moreover, creation of local guideline pocketbooks for these and other conditions may serve to improve prescribing practices and meet the Core Elements of Outpatient Stewardship recommended by the Centers for Disease Control and Prevention.

Gastroparesis

Free full text review.

Familial hypocalciuric hypercalcemia

Linked here are some reviews on this topic. [1] [2] [3] [4]

Why is it important? Because it looks a lot like primary hyperparathyroidism. A significant number of cases per year get confused with hyperparathyroidism and as a result undergo inappropriate (and failed) surgery. It’s very tricky. There are ways to make the distinction, as outlined in the articles. If you are about to diagnose primary hyperparathyroidism and refer a patient for surgery pause and ask yourself: am I missing familial hypocalciuric hypercalcemia?

How can we end the HIV pandemic? Detect and treat everyone we can!

The topic is reviewed here.

Here’s what’s key, according to the article:

Together, these studies demonstrate that when ART effectively suppresses a person’s viral load to undetectable levels, the risk for sexual transmission of HIV to an uninfected sexual partner is essentially zero.

Conflict of interest concerns misdirected: JAMA report

Another of the articles in JAMA’s theme issue on COI makes a case that the focus of concern has been wrong:

Much current research and debate involving conflicts of interest in medicine focus on the appropriate level of physician interaction with firms in industries related to health care, such as pharmaceutical and medical device companies. The influential article by Brennan et al1 that led academic medical centers to take the lead in tackling problems caused by conflicts of interest focused almost exclusively on interactions between physicians and pharmaceutical companies. The 2009 Institute of Medicine report Conflict of Interest in Medical Research, Education, and Practice also limited its coverage of conflicts to interactions between physicians and pharmaceutical, medical device, and biotechnology companies. The American Medical Student Association “scorecard” grades conflict of interest policies at medical schools purely on the basis of how they regulate physician-industry relations.

Although these interactions may influence physicians in ways unrelated or even detrimental to patient care, only a small percentage of physicians have substantial financial relationships with pharmaceutical or device companies.2 In contrast, every physician is paid for providing patient-directed services via a system set by the physician’s practice group and supported by insurers, government, individuals, and others who reimburse for care. While a minority of physicians receive direct payments from industry, the average primary care physician sees roughly 2000 patients per year who are, directly and via insurance, billed an average of $5000…

The nearly singular emphasis on physician-industry relationships has been way out of proportion, a point I have been making for years on this blog and in other forums.

Exogenous insulin antibody syndrome

Though reduced, it didn’t completely go away when we went from animal to human insulins.

Early cath post out of hospital cardiac arrest improves survival

Read here.

Review of the pathogenesis of DM 1

From the review:

Type 1 diabetes mellitus (T1DM) results from the autoimmune destruction of β cells of the endocrine pancreas. Pathogenesis of T1DM is different from that of type 2 diabetes mellitus, where both insulin resistance and reduced secretion of insulin by the β cells play a synergistic role. We will present genetic, environmental and immunologic factors that destroy β cells of the endocrine pancreas and lead to insulin deficiency. The process of autoimmune destruction takes place in genetically susceptible individuals under the triggering effect of one or more environmental factors and usually progresses over a period of many months to years, during which period patients are asymptomatic and euglycemic, but positive for relevant autoantibodies. Symptomatic hyperglycemia and frank diabetes occur after a long latency period, which reflects the large percentage of β cells that need to be destroyed before overt diabetes become evident.

Dieulafoy’s lesions: free full text review

Read it here.

Drug induced eosinophilic pneumonia

This Medicine paper, available as free full text, is a review of case reports. It provides not only a review of drug induced EP (daptomycin is the most important drug) but also a nice overview of the eosinophilic pneumonias in general.

Mechanisms of sudden cardiac death related to cigarette smoking

This study focuses on repolarization abnormalities, particularly prolongation of the Tp-e.

Animations in cell biology

Free educational resources here.

Should patients admitted with inflammatory bowel disease exacerbation be tested for C diff?

The American College of Gastroenterology guidelines (which as of a few weeks ago are no longer the newest ones) recommend testing. More recently there was this study:

To evaluate the frequency, possible risk factors, and outcome of Clostridium difficile infection (CDI) in inflammatory bowel disease (IBD) patients.

There has been an upsurge of CDI in patients with IBD who has been associated with increased morbidity and mortality. Various risk factors have been found to predispose IBD patients to CDI.

A retrospective case–control study on IBD patients admitted with exacerbation and tested for CDI at the Tel Aviv Medical Center in 2008 to 2013. Epidemiologic, laboratory, and prognostic data were retrieved from electronic files and compared between patients who tested positive (CDI+) or negative (CDI−) for CDI.

CDI was identified in 28 of 311 (7.31%) IBD patients hospitalized with diarrhea. IBD-specific risk factors (univariate analysis) for CDI included: use of systemic steroids therapy (odds ratio [OR] = 3.6, 95% confidence interval [CI] 1.2–10.6) and combinations of ≥2 immunomodulator medications (OR = 2.6, 95% CI 1.1–6.3). Additional risk factors for CDI that are common in the general population were hospitalization in the preceding 2 months (OR = 6.0, 95% CI 2.6–14.1), use of antacids (OR = 3.8, 95% CI 1.7–8.4), and high Charlson comorbidity score (OR = 2.5, 95% CI 1.1–5.7). A multivariate analysis confirmed that only hospitalization within the preceding 2 months and use of antacids were significant risk factors for CDI. The prognosis of CDI+ patients was similar to that of CDI− patients.

Hospitalized IBD patients with exacerbation treated with antacids or recently hospitalized are at increased risk for CDI and should be tested and empirically treated until confirmation or exclusion of the infection.