Concierge medicine: it’s totally a thing now

From the American Journal of Medicine.

Electrocardiographic patterns of circumflex occlusion

About a third failed to meet STEMI criteria.

Appropriate and inappropriate use of troponin assays

This was the topic of a recent article in the American Journal of Medicine.

The article offers a useful perspective on troponin testing but, if I’m not mistaken (correct me if I’m wrong) starts out with an error:

Troponin is a protein in striated muscle that regulates excitation and contraction, and consists of 3 molecules: C, I, and T. Troponin I and T are specific to cardiac tissue…

I’m pretty sure skeletal muscle has troponin I and T.

At any rate, the key point of the article is that in the old days of the early generation troponins, any elevation meant the patient was having an acute MI, usually due to acute coronary syndrome. Several generations (and sensitivity improvements) later that is no longer the case. The problem is, too many of us apparently interpret troponins the way we did in those good old days. This, as the author points out, can lead to problems such as knee jerk anticoagulation.

The remedy for this, according to the author, is to do a history and physical before ordering a troponin. That’s easier said than done in the crazy environment of hospital medicine where time is of the essence and we often have to utilize a shotgun approach to very sick patients. The reality is that troponin positivity has now become much more complex and requires considerable skill in applying the result to the prevailing clinical context.

Antipyretic therapy in septic patients

No improvement in mortality.

Your critically ill patient went into atrial fibrillation. Amiodarone was started. Now what?

Sound familiar? This paper makes the case for cardiology consultation, at least if the drug is going to be continued at discharge.

The American College of Physicians does not support assisted suicide

Here’s their position paper.

Is elevation of the head of the bed beneficial in mechanically ventilated patients?

The evidence is somewhere in the range of slim to none.

Atrial flutter

This review is mainly about the various mechanisms and electrocardiographic patterns.

Fluid overload and sepsis and using bioimpedence to monitor it

From a recent study:

Guideline-directed therapy for sepsis calls for early fluid resuscitation. Often patients receive large volumes of intravenous fluids. Bioimpedance vector analysis (BIVA) is a noninvasive technique useful for measuring total body water. In this prospective observational study, we enrolled 18 patients admitted to the intensive care unit for the treatment of sepsis syndromes. Laboratory data, clinical parameters, and BIVA were recorded daily. All but one patient experienced volume overload during the course of treatment. Two patients had greater than 20 L of excess volume. Volume overload is clinically represented by tissue edema. Edema is not a benign condition, as it impairs tissue oxygenation, obstructs capillary blood flow, disrupts metabolite clearance, and alters cell-to-cell interactions. Specifically, volume overload has been shown to impair pulmonary, cardiac, and renal function. A positive fluid balance is a predictor of hospital mortality. As septic patients recover, volume excess should be aggressively treated with the use of targeted diuretics and renal replacement therapies if necessary.

EP testing in bradyarrhythmias

This free full text review deals mainly with the various mechanisms of AV block, clues on the surface ECG and when EP testing is needed.

Arrhythmogenic cardiomyopathy (aka arrhythmogenic right ventricular cardiomyopathy/dysplasia)

The new terminology relates to the increasing recognition of left ventricular involvement. Free full text review.

Drug therapy to reduce AICD shocks

Many discharges are inappropriate.

How to take a high yield history

Be non directive and don’t interrupt.

High flow nasal canula: a game changer in respiratory medicine

Free review.

Liberal versus restrictive transfusion strategy: the debate is not quite over

Although a hemoglobin of 7 has become a widely accepted threshold for transfusion in a variety of situations there remain areas of uncertainty. One of these areas is ischemic heart disease. The NIH sponsored MINT is being organized to address this question. (Public Citizen thinks it should not be carried out). One of the questions here is whether there is equipoise for such a trial. Public Citizen, while leveling their principal objections toward trial ethics and the informed consent process, implies that there is no equipoise and a higher hemoglobin threshold should be accepted. The argument that equipoise exists is based on the fact that for ischemic heart disease there are only low level data to guide transfusion practices. High level trials lumped patients together having many different underlying diseases. How might transfusion thresholds apply to various subgroups? That raises nearly endless questions.

What about, for example, oncology patients with septic shock? Check out the results of this single center RCT:

Objective: To assess whether a restrictive strategy of RBC transfusion reduces 28-day mortality when compared with a liberal strategy in cancer patients with septic shock.

Design: Single center, randomized, double-blind controlled trial.

Setting: Teaching hospital.

Patients: Adult cancer patients with septic shock in the first 6 hours of ICU admission.

Interventions: Patients were randomized to the liberal (hemoglobin threshold, less than 9 g/dL) or to the restrictive strategy (hemoglobin threshold, less than 7 g/dL) of RBC transfusion during ICU stay.

Measurements and Main Results: Patients were randomized to the liberal (n = 149) or to the restrictive transfusion strategy (n = 151) group. Patients in the liberal group received more RBC units than patients in the restrictive group (1 [0–3] vs 0 [0–2] unit; p less than 0.001). At 28 days after randomization, mortality rate in the liberal group (primary endpoint of the study) was 45% (67 patients) versus 56% (84 patients) in the restrictive group (hazard ratio, 0.74; 95% CI, 0.53–1.04; p = 0.08) with no differences in ICU and hospital length of stay. At 90 days after randomization, mortality rate in the liberal group was lower (59% vs 70%) than in the restrictive group (hazard ratio, 0.72; 95% CI, 0.53–0.97; p = 0.03).

Conclusions: We observed a survival trend favoring a liberal transfusion strategy in patients with septic shock when compared with the restrictive strategy. These results went in the opposite direction of the a priori hypothesis and of other trials in the field and need to be confirmed.

This contributes to the evidence we have to guide transfusion practices but also serves as a reminder that there is no pat answer. Clinical judgment must surpass slavish adherence to pathways and guidelines, which is what evidence based medicine is all about.

Heart failure readmissions

Better outcomes are associated with readmission to the original hospital.

High flow nasal cannula in hypoxemic respiratory failure

Favorable effects on lung mechanics.

Can FOAM be incorporated into medical student and resident education?

It matches the educational needs of millennials according to this article.

Assessment of fluid responsiveness is associated with improvement in robust outcomes

Here is a new systematic review and meta-analysis.

The big question is how invasive you need to be to accomplish this.

ECMO for hospitalists

A free full text review of a few things you need to know.