Target specific oral anticoagulants

Here is another of the many reviews on this topic. Free full text.  

TIA review

Here is a free full text review in CCJM.

TIA may be going the way of unstable angina in that its numbers are diminishing. That does not mean the true incidence is decreasing. Today's testing is more sensitive in detecting tissue damage. This reclassifies many cases of unstable angina to MI. Likewise many cases formerly called TIA are now known to be strokes. New diagnostic techniques bring new definitions.

Traditional definition of TIA: The sudden onset of a focal neurologic deficit in a vascular territory resolving within 24 hours.

New definition: Same as above but with no evidence of acute infarction on diffusion weighted MRI.

The review covers imaging and stroke prevention strategies.

Statin myopathy

This review emphasizes that statin myopathy is heterogeneous, and discussed the newly appreciated necrotizing autoimmune variant which may persist after statin removal.

The prognosis of heart failure patients with recovered ejection fraction after beta blocker treatment

From a recent paper:

Methods and Results—We included in this analysis 174 consecutive patients with LVSD who had a LVEF greater than or equal to 45% after betablockade. We performed a long-term echocardiographic follow-up (median 7.6 [4 - 9.9] years) and clinical follow-up (median 9.2 [7.2 - 10.8] years). LVEF improved from 33±8% to 54±6% after beta-blockade (p less than 0.0001). At the last echocardiographic evaluation, 26% of the patients had a LVEF less than 45% (mean±SD: 34±6%), while 74% still had a LVEF greater than or equal to 45% (mean±SD: 54±6%). Independent predictors of LVEF deterioration were a post beta-blockade low LVEF, a high left ventricular end-diastolic diameter and a low heart rate after beta-blockade, and the presence of a complete left bundle branch block. In the overall study population, survival rates were 90% at 5 years and 75% at 10 years. Cardio-vascular death rate was 9%, non cardio-vascular death rate was 11%, and unknown death rate was 3%. Patients with subsequent LVEF deterioration had a higher cardiovascular mortality compared to patients with sustained recovered LVEF (22% vs 4%).

Got milk?

What's the first thing you reach for on the crash cart when you glance at this?

ECG findings in RVH and pulmonary hypertension

Great discussions on the topic at Dr. Smith's ECG blog and EMS 12-Lead.

SSRIs for stroke recovery

A Cochrane review suggests they may be helpful even in patients who are not depressed.

Target specific (novel) oral anticoagulants: antidotes are in the pipeline

Here is a summary of where things are.

Severe aortic stenosis and the risk of non-cardiac surgery

Much of the research on this topic was done a decade or so ago. Based on this report it looks like the outcome has improved since then. Severe aortic stenosis patients had an increased of MACE but not 30 day mortality.

Via Hospital Medicine Virtual Journal Club.

Point of care lung ultrasound in the critically ill

Here’s a nice review in the Annals of Intensive Care.

Review of IVC filters

This topic was recently reviewed in Current Opinion in Cardiology.

From the abstract:

In the past 18 months, the American College of Chest Physicians released the 9th edition of their guideline for the prevention and treatment of venous thromboembolism. There have also been a number of studies reviewing the use of IVC filters in select populations for the prophylactic prevention of pulmonary embolism. Trauma continues to be the leading indication for prophylactic filters in a number of series, but further studies have demonstrated some benefit of prophylactic filters in the bariatric and spine surgery populations. The IVC filter complication rate remains low; however, so does the retrieval rate for potentially removable filters. These retrieval rates are increased with use of dedicated patient tracking mechanisms. Finally, there have been a number of technology updates in the hardware itself, focusing on strut design.

Summary: Despite little change in the society guidelines, the use of vena cava filters (VCFs) continues to rise. Overall, the use of IVC filters, especially in prophylactic situations, will remain controversial until randomized, controlled trials are performed within each specific patient population.

The use of IVC filters remains non-evidence based with the exception of the indication for acute proximal DVT in a patient with contraindication to anticoagulation. Complications of filters are well appreciated. It was hoped that the introduction of retrieval filters several years ago would help enable wider and safer use of the devices. However, as pointed out in the review retrieval rates are low. Decisions for filter placement are often made in haste during critical situations and explicit discussion of future retrieval is put aside.

Underappreciated causes of splenic rupture

Surprising findings from a review in BMC Emergency Medicine.

Lemierre’s syndrome review

This review is available as free full text. Though rare in the antibiotic era it seems to be occurring with increasing frequency for unclear reasons, due perhaps to increasing awareness or more restrictive use of antibiotics in recent years.

Idiopathic pulmonary fibrosis: is there a viral link?

From a fascinating paper in Modern Pathology:

21 paraffin-embedded lung biopsies from patients diagnosed with idiopathic pulmonary fibrosis and 21 lung biopsies from age-matched controls with pulmonary fibrosis of known etiology were examined for a series of γ−herpesviruses’ DNA/RNA and related proteins using in situ hybridization and reverse transcriptase-polymerase chain reaction (RT-PCR)-based methods. We detected four proteins known to be in the genome of several γ−herpesviruses (cyclin D, thymidylate synthase, dihydrofolate reductase, and interleukin-17) that were strongly co-expressed in the regenerating epithelial cells of each of the 21 idiopathic pulmonary fibrosis cases and not in the benign epithelia of the controls. Among the γ−herpesviruses, only herpesvirus saimiri expresses all four of these ‘pirated’ mammalian proteins. We found herpesvirus saimiri DNA in the regenerating epithelial cells of 21/21 idiopathic pulmonary fibrosis cases using four separate probe sets but not in the 21 controls. RT-PCR showed that the source of the cyclin D RNA in active idiopathic pulmonary fibrosis was herpesvirus saimiri and not human. We cloned and sequenced part of genome corresponding to the DNA polymerase herpesvirus saimiri gene from an idiopathic pulmonary fibrosis sample and it matched 100% with the published viral sequence. These data are consistent with idiopathic pulmonary fibrosis representing herpesvirus saimiri-induced pulmonary fibrosis.

Via PulmCCM.

Inflammation associated with instability of carotid atherosclerotic plaques

Via Archives of Medical Science.

Ejection fraction is dynamic. What are the predictors of change?

From a recent study:

Background—Patients with heart failure (HF) are typically designated as having reduced or preserved ejection fraction (HFREF, HFPEF) because of the importance of left ventricular ejection fraction (LVEF) on therapeutic decisions and prognosis. Such designations are not necessarily static, yet few data exist to describe the natural history of LVEF over time.

Methods and Results—We identified 2413 patients from Kaiser Permanente Colorado with a primary discharge diagnosis of HF between January 1, 2001, and December 31, 2008, who had greater than or equal to 2 LVEF measurements separated by greater than or equal to 30 days. We used multi-state Markov modeling to examine transitions among HFREF, HFPEF, and death. We observed a total of 8183 transitions. Women were more likely than men to transition from HFREF to HFPEF (hazard ratio, 1.85; 95% confidence interval, 1.38–2.47). Patients who were adherent to β-blockers were more likely to transition from HFREF to HFPEF (hazard ratio, 1.53; 95% confidence interval, 1.10–2.13) compared with patients who were nonadherent to β-blockers, whereas angiotensin-converting enzyme or angiotensin II receptor blocker adherence was not associated with LVEF transitions. Patients who had a previous myocardial infarction were more likely to transition from HFPEF to HFREF (hazard ratio, 1.75; 95% confidence interval, 1.26–2.42).

Conclusions—In this cohort of patients with HF, LVEF is a dynamic factor related to sex, coexisting conditions, and drug therapy. These findings have implications for left ventricular systolic function ascertainment in patients with HF and support evidence-based therapy use, especially β-blockers.

Again, it bears repeating that beta blocker use is associated with improvement in EF whereas ACEI and ARB use are not.  Note that ACEIs and ARBs, but not beta blockers, are part of the heart failure performance measures.

Ischemic preconditioning to reduce contrast induced nephropathy

It proved effective in this study of patients at renal risk undergoing coronary angiography:

Contrast medium–induced acute kidney injury occurred in 26 patients (26%), 20 (40%) in the control group and 6 (12%) in the remote ischemic preconditioning group (odds ratio, 0.21; 95% confidence interval, 0.07–0.57; P=0.002). No major adverse events were related to remote ischemic preconditioning.

Despite the fact that this was published a year and a half ago it hasn't made prime time as far as I can tell. Imagine doing this to a patient:

IPC was accomplished by performing 4 cycles of alternating 5-minute inflation and 5-minute deflation of a standard upper-arm blood pressure cuff to the individual's systolic blood pressure plus 50 mm Hg to induce transient and repetitive arm ischemia and reperfusion. IPC was started immediately before CA.

Impact of ertapenem on resistance patterns of higher generation carbapenems

From a recent paper:

Methods A retrospective time-series segmented regression analysis was conducted in a tertiary centre from January 2001 to December 2011. Ertapenem was introduced in January 2005...

Results Mean monthly use of imipenem was 2.9 ± 0.9 DDDs/100 PDs, as compared with 1.2 ± 0.7 DDDs/100 PDs for meropenem and 1.0 ± 0.7 DDDs/100 PDs for ertapenem (after its introduction). After ertapenem adoption, a downward trend was seen in the use of imipenem (P = 0.016) and ciprofloxacin (P = 0.004). A total of 6272 Pseudomonas aeruginosa and 1093 A. baumannii isolates were evaluated. Susceptibility of P. aeruginosa to imipenem improved after ertapenem introduction, both according to the proportion of susceptible isolates (P = 0.002) and to the incidence density of resistance (P less than or equal to 0.001). No significant change was seen in A. baumannii susceptibility to imipenem (P = 0.772). By multiple linear regression analysis, the incidence density of imipenem-resistant P. aeruginosa increased with the use of imipenem (P = 0.003) and ciprofloxacin (P = 0.008). Occurrence of outbreaks (P less than or equal to 0.001) and use of gentamicin (P = 0.007) were associated with A. baumannii resistance to imipenem.

Conclusions Use of ertapenem was directly associated with a downward trend in the use of imipenem and ciprofloxacin, which may have contributed to improve the susceptibility of P. aeruginosa to imipenem. Ertapenem use had no impact on the susceptibility of A. baumannii to imipenem.

Via Hospital Medicine Virtual Journal Club.

Octreotide: what the hospitalist needs to know

A review of octreotide recently appeared in Chest.

Octreotide is a synthetic analogue of somatostatin. An understanding of the biologic and pharmacologic principles surrounding this agent is important, as it has recently seen increasing use for a diversity of indications in hospitalized patients. Following are a few points of interest from the review.

Somatostatin (SST) is a hypothalamic hormone best known for its inhibition of growth hormone secretion. However, it has other actions less well appreciated. For example, from the review:

SST is synthesized not only in the hypothalamus but also by δ cells of the pancreatic islets, the myenteric neural plexi, and the epithelial lining of the stomach and intestines. Based on the sites where it is found, it is not surprising that SST can influence numerous endocrine and exocrine functions of the GI tract and pancreas, including inhibition of the secretion of insulin, glucagon, cholecystokinin, gastrin, secretin, serotonin, vasoactive intestinal peptide, motilin, and pancreatic polypeptide.3,4 Thus, SST and its synthetic analogs are able to inhibit gastric acid production, gastric emptying, and GI motility, pancreatic exocrine and endocrine secretion, nutrient absorption (eg, glucose, fats, amino acids), and biliary flow and contractility. These functional effects of SST provide the rationale for the use of SST analogs in various GI and non-GI endocrine disorders such as carcinoid syndrome, islet cell tumors, β-islet cell hyperplasia (nesidioblastosis), and acromegaly.4,5 In addition, SST and octreotide can induce vasoconstriction of the splanchnic vessels, thereby reducing blood flow in the splanchnic and portal venous systems.3,4

Clinical uses in hospitalized patients:

Variceal bleeding
Octreotide induces splanchnic vasoconstriction which reduces splanchnic flow thereby reducing portal venous pressure.

Hepatorenal syndrome
The splanchnic vasodilation characteristic of cirrhosis reduces effective blood volume in turn activating a neurohumoral response. These factors are adverse to renal perfusion. By inducing splanchnic vasoconstriction octreotide may help reverse these effects. However, it is not effective as monotherapy and for treatment of HRS is combined with another vasoconstrictor, typically midodrine. The level of supporting evidence is low.

Hypoglycemia from sulfonylureas
The hypoglycemia associated with sulfonylurea therapy can be profound and prolonged. Glucose therapy is necessary as part of the treatment but when used alone may associated with rebound hypoglycemia since sulfonylurea agents are insulin secretagogues and a glucose load stimulates insulin release. Octreotide is a useful adjunct and is now favored over glucagon for sulfonylurea induced hypoglycemia.

Chylous pleural effusion
Octreotide reduces intestinal chyle production thus improving the chances for resolution.

ICU brain (long term cognitive defects after critical illness)

It can be as bad as Alzheimer's according to this study by Vanderbilt researchers.

There's an interesting discussion of the paper at PulmCCM.