Sunday, August 28, 2016

Sulfonylurea use and myocardial infarct size

The adverse effects of sulfonylureas on macrovascular disease have been known for decades. Now we have this:

Consecutive STEMI patients admitted in Edmonton, Canada between 2006 and 2011 were enrolled in a regional prospective registry program. Patients with type 2 diabetes were identified from this group and the maximum recorded troponin I (max cTnI) within the first 48 h of chest pain onset was used as the primary outcome to quantify infarct size. The relationship between preadmission sulfonylurea use and max cTnI was assessed using multivariable linear regression to adjust for patient demographics, cardiovascular risk factors, clinical data on admission, ischemia time, reperfusion therapy and preadmission drugs.

There were 560 STEMI patients with type 2 diabetes; mean (standard deviation; SD) age was 63.3 (12.8) years, 395 (70.5%) were male, 216 (38.6%) received primary percutaneous intervention, and 211 (37.7%) received thrombolysis. The max cTnI was higher in 146 sulfonylurea users compared to 414 non-sulfonylurea users (mean (SD): 49.8 (74.3) ng/mL versus 39.9 (50.4) ng/mL, respectively; adjusted between-group difference: 12.9 ng/mL; 95% CI 0.3–25.5; p = 0.044).

This study adds further evidence to the proposed causal relationship between sulfonylureas and adverse cardiovascular events by observing a significant difference in infarct size among type 2 diabetes patients presenting with STEMI. Clinicians should consider this association when prescribing sulfonylureas to manage patients with type 2 diabetes.

Saturday, August 27, 2016

Unexplained symptoms

Sometimes it is better for the patient and more intellectually honest to not force a diagnostic label and just acknowledge unexplained symptoms.

Tuesday, August 23, 2016

ER care in VA hospitals

I found this interesting report from the American Journal of Emergency Medicine:


Veterans Health Administration emergency physicians have primarily clinical responsibilities, and less than half have formal emergency medicine board certification. Despite most VHA EDs having university affiliations, traditional academic activities (eg, teaching and research) are performed in only 1 in 3 VHA EDs. Less than half of VHA EDs have availability of consulting services, including advanced stroke care and women's health.

Monday, August 22, 2016

Checklists, daily goal assessments, and clinician prompts

Here's another “systems improvement” initiative that didn't work. From a recent paper:

Importance The effectiveness of checklists, daily goal assessments, and clinician prompts as quality improvement interventions in intensive care units (ICUs) is uncertain.

Objective To determine whether a multifaceted quality improvement intervention reduces the mortality of critically ill adults.

Design, Setting, and Participants This study had 2 phases. Phase 1 was an observational study to assess baseline data on work climate, care processes, and clinical outcomes, conducted between August 2013 and March 2014 in 118 Brazilian ICUs. Phase 2 was a cluster randomized trial conducted between April and November 2014 with the same ICUs. The first 60 admissions of longer than 48 hours per ICU were enrolled in each phase.

Interventions Intensive care units were randomized to a quality improvement intervention, including a daily checklist and goal setting during multidisciplinary rounds with follow-up clinician prompting for 11 care processes, or to routine care.

Main Outcomes and Measures In-hospital mortality truncated at 60 days (primary outcome) was analyzed using a random-effects logistic regression model, adjusted for patients’ severity and the ICU’s baseline standardized mortality ratio. Exploratory secondary outcomes included adherence to care processes, safety climate, and clinical events.

Results A total of 6877 patients (mean age, 59.7 years; 3218 [46.8%] women) were enrolled in the baseline (observational) phase and 6761 (mean age, 59.6 years; 3098 [45.8%] women) in the randomized phase, with 3327 patients enrolled in ICUs (n = 59) assigned to the intervention group and 3434 patients in ICUs (n = 59) assigned to routine care. There was no significant difference in in-hospital mortality between the intervention group and the usual care group, with 1096 deaths (32.9%) and 1196 deaths (34.8%), respectively (odds ratio, 1.02; 95% CI, 0.82-1.26; P = .88). Among 20 prespecified secondary outcomes not adjusted for multiple comparisons, 6 were significantly improved in the intervention group (use of low tidal volumes, avoidance of heavy sedation, use of central venous catheters, use of urinary catheters, perception of team work, and perception of patient safety climate), whereas there were no significant differences between the intervention group and the control group for 14 outcomes (ICU mortality, central line–associated bloodstream infection, ventilator-associated pneumonia, urinary tract infection, mean ventilator-free days, mean ICU length of stay, mean hospital length of stay, bed elevation to ≥30°, venous thromboembolism prophylaxis, diet administration, job satisfaction, stress reduction, perception of management, and perception of working conditions).

Conclusions and Relevance Among critically ill patients treated in ICUs in Brazil, implementation of a multifaceted quality improvement intervention with daily checklists, goal setting, and clinician prompting did not reduce in-hospital mortality.

Sunday, August 21, 2016

Hypoxic hepatitis

An article on this topic recently appeared in The American Journal of Emergency Medicine. The paper focused on the post cardiac arrest situation but it is seen in other types of circulatory collapse. This entity has also been called ischemic hepatitis and shock liver. From the introduction of the paper:

Hypoxic hepatitis (HH) is frequently observed in critically ill patients and is associated with poor outcomes [1] . In HH, hypoperfusion with subsequent ischemia and passive congestion of the liver, severe systemic arterial hypoxemia, and/or impaired hepatic oxygen extraction induces centrilobular liver cell necrosis 2 3 4 5 . According to Henrion et al [2 6] , a diagnosis of HH could be clinically assumed if the following 3 conditions are met: (1) an appropriate clinical setting of cardiac, respiratory or circulatory failure; (2) a sharp increase in serum aminotransferase levels that reach at least 20 times the upper limit of normal; (3) the exclusion of other causes of acute liver cell necrosis, particularly viral or drug-induced hepatitis.

The complex relationships between obesity, hypertension and CKD

Review here.

Autoimmune hemolytic anemia

Linked here are two great review articles. This one addresses such questions as “What are the differences between warm and cold antibody hemolytic anemias?” “What is the difference between primary and secondary AIHA and what are some of the secondary causes?” “How can the ratio of conjugated to total bilirubin help differentiate between biliary disease and hemolysis as the cause of hyperbilirubinemia?”

This one discusses the pathophysiology of AIHA, explains the roles of antibody and complement, and explains why spherocytes are present in peripheral blood in AIHA.