Monday, June 18, 2018

Don’t conflate type 2 MI and NSTEMI!

Confusion remains wide spread despite the publication of this distinction years ago. But now, according to this piece in Circulation, the coding world is finally catching up. ICD 10 now has a code for type 2 MI. Here are some of my take home points:

A type 2 MI is not an acute coronary syndrome.

On initial presentation the distinction is based on clinical circumstances and may occasionally be difficult.

Further investigation usually makes the distinction clear by the end of the hospitalization.

Type 2 MI, though a distinct category, is not a primary single entity in that it is always secondary to something else, one or more of many known conditions. For this reason it is heterogeneous and there are no guidelines for type 2 MI per se. Its treatment always consists of management of the underlying conditions that are altering the myocardial oxygen supply demand balance.

Though ICD 10 now recognizes the distinction, type 2 MI has yet to be excluded from certain performance and regulatory categories for MI due to acute coronary syndrome.

Those who conflate NSTEMI and type 2 MI not only expose their ignorance (or disregard) of the classification and pathophysiology of MI but also risk subjecting patients to inappropriate and potentially harmful treatments. An example is provided in the article.

Sunday, June 17, 2018

Metformin monotherapy versus dual therapy with the addition of a sodium glucose co-transporter 2 inhibitor (SGLT-2)


•Type 2 Diabetes Mellitus (T2DM) is a current global threat.
•Sodium-glucose co-transporter 2 inhibitor is a new approach for T2DM management.
•Combined therapy of SGLT2 inhibitor and metformin is more effective.



Type 2 Diabetes Mellitus (T2DM) is a chronic disorder and its treatment with only metformin often does not provide optimum glycemic control. Addition of sodium glucose cotransporter 2 inhibitor (SGLT2) will improve the glycemic control in patients on metformin alone. In this study, an attempt is made to investigate the combined therapy of SGLT-2 with metformin in managing T2DM in terms of lowering HbA1c and body weight and monotherapy using metformin alone in HbA1c and body weight reduction.


To compare the clinical effectiveness of combined therapy using SGLT2 inhibitor and metformin with monotherapy using metformin alone in HbA1c and body weight reduction.


A systematic review of the randomized controlled trials has been carried out and Cochrane risk of bias tool was used for the quality assessment. Patient, Intervention, Comparison and Outcomes (PICO) technique is used to select the relevant articles to meet the objective.


The studies used in this article are multicenter, double-blinded randomized controlled trials on SGLT2 inhibitors with methformin, there were a total of 3897 participants, with a range of 182 to 1186 individual study size were included. Studies showed that combined therapy were more effective in HbA1c and body weight reduction as compared to monotherapy.

Saturday, June 16, 2018

Possible health benefits of dietary magnesium

Friday, June 15, 2018

Methamphetamine related heart failure: rising prevalence, distinct phenotype

Hypothesis: We hypothesized that in a VA population over a 15 year period, we would observe a rising prevalence of MethHF in admitted patients, along with a unique phenotype.

Methods: Among 9588 patients with diagnosis of heart failure treated at San Diego VA Medical Center in between 2005-2015, 480 were identified to have history of methamphetamine abuse as determined by ICD-9 diagnosis code and/or urine toxicology screen as well as a diagnosis code of heart failure. Demographic, diagnostic, and clinical characteristics of MethHF and heart failure patients without methamphetamine use (HF) were compared. ..

Results: From 2005-2015, the prevalence of methamphetamine usage among patients with heart failure increased linearly (Figure 1). A preliminary cohort comparison demonstrated MethHF had similar ejection fraction and BNP levels but trends toward increased troponin levels, more atrial fibrillation, and a higher GFR. MethHF patients had a greater risk of ER visits (2.3 per year vs 0.5 per year, p=0.01) and a trend towards a greater risk of all-cause hospital readmission...

Thursday, June 14, 2018

Metformin use and the risk of B 12 deficiency


Long-term metformin therapy is significantly associated with lower serum vitamin B12 concentration, yet those at risk are often not monitored for B12 deficiency. Because metformin is first line therapy for type 2 diabetes, clinical decision support should be considered to promote serum B12 monitoring among long-term metformin users for timely identification of the potential need for B12 replacement.

Wednesday, June 13, 2018

Metacognition: from study habits to clinical reasoning

This article was published in a pharmaceutical education journal but it has general applicability.

Tuesday, June 12, 2018

High risk medication administration in hospitalized elderly patients preceded falls


Of 328 falls, 62% occurred in individuals administered at least one high-risk medication within the 24 hours before the fall, with 16% of the falls involving individuals receiving two, and another 16% in individuals receiving three or more. High-risk medications were often administered at higher-than-recommended geriatric daily doses, in particular benzodiazepines and BRAs, for which the dose was higher than recommended in 29 of 51 cases (57%). Hospital EMR default doses were higher than recommended for 41% (12/29) of medications examined.


High-risk medications were administered to older fallers. Doses administered and EMR default doses were often higher than recommended. Decreasing EMR default doses for individuals aged 65 and older and warnings about the cumulative numbers of high-risk medications prescribed per person may be simple interventions that could decrease inpatient falls.

It would appear that EMR decision support contributed to the problem.

Monday, June 11, 2018

Medical error lunacy continues unabated

Sunday, June 10, 2018

Loeffler endocarditis

Saturday, June 09, 2018

What are residency programs doing to mitigate the July effect?


The response rate was 16% (65/418 programs); however, a total of 262 respondents from all 50 states where residency programs are located were included. Most respondents (n = 201; 77%) indicated that errors occur more frequently in July compared with other months. The most common identified errors included incorrect or delayed orders (n = 183, 70% and n = 167, 64%, respectively), errors in discharge medications (n = 144, 55%), and inadequate information exchange at handoffs (n = 143, 55%). Limited trainee experience (n = 208, 79%), lack of understanding hospital workflow, and difficulty using electronic medical record systems (n = 194; 74% and n = 188; 72%, respectively) were reported as the most common factors contributing to these errors. Programs reported instituting several efforts to prevent harm in July: for interns, additional electronic medical record training (n = 178; 68%) and education on handoffs and discharge processes (n = 176; 67% and n = 108; 41%, respectively) were introduced. Similarly, for senior residents, teaching sessions on how to lead a team (n = 158; 60%) and preferential placement of certain residents on harder rotations (n = 103; 39%) were also reported. Most respondents (n = 140; 53%) also solicited specific “July attendings” using a volunteer system or highest teaching ratings.

Difficulties with EMRs definitely contribute to the problem.

Friday, June 08, 2018

IU critical care

Thursday, June 07, 2018

Who are the most influential ER docs on Twitter?

Find out here.

We must be careful. Social media, where power and influence often surpass truth, may be contributing to the post-modernization of medicine.

Red flags for in residency candidates for negative outcomes


From a dataset of 260 residents who completed their residency over a 19-year period, 26 (10%) were osteopaths and 33 (13%) were international medical school graduates A leave of absence during medical school (p less than .001), failure to send a thank-you note (p=.008), a failing score on United States Medical Licensing Examination Step I (p=.002), and a prior career in health (p=.034) were factors associated with greater likelihood of a negative outcome. All four residents with a “red flag” during their medicine clerkships experienced a negative outcome (p less than .001).


“Red flags” during EM clerkships, a leave of absence during medical school for any reason and failure to send post-interview thank-you notes may be associated with negative outcomes during an EM residency.

This was a study of emergency medicine residents. The applicability to other specialties is unknown.

The ECG: useful for assessing the prognosis of PE

From a recent paper:


•The prognostic significance of ECG signs of RV strain in patients with acute pulmonary embolism is controversial.
•ECG signs of RV strain at admission were investigated in 1194 patients with acute PE of different severity.
•Qr pattern in lead V1 was the only ECG abnormality associated with in-hospital mortality in high-risk patients.
•In not high-risk patients, the presence of at least one ECG sign of RV strain was associated with RV dysfunction or injury.
•These findings highlight the need for early imaging investigations in stable patients with ECG signs of RV strain.



Several electrocardiographic (ECG) abnormalities have been described in patients with acute pulmonary embolism (PE), with discordant reportings about their prognostic value.


Consecutive patients with echocardiography performed within 48 h from admission and ECG at presentation, were included in this analysis. The primary study outcome was in-hospital death for high-risk patients and in-hospital death or clinical deterioration for intermediate-risk patients. As secondary outcomes, the associations among ECG abnormalities and both right ventricular dysfunction at echocardiography and baseline troponin elevation were considered.


1194 patients were included in this analysis: 13.8% of patients were at high risk of early death, 61.7% were at intermediate risk and 24.5% were at low risk. ECG signs of RV strain showed a continuously decreasing prevalence from high-risk to intermediate-risk and low-risk patients. Differently, the prevalence of T- wave inversion was similar in high and intermediate-risk patients. In high-risk-patients, Qr pattern in lead V1 was the only ECG abnormality associated with in-hospital mortality, but this sign was detected in only 15.9% of this risk category; the presence of at least one ECG abnormality was not associated with the risk of in-hospital death. In not high-risk patients, the presence of at least one ECG abnormality was significantly associated with RVD and this association was confirmed for each individual ECG abnormality. Similar results were obtained as regards the baseline troponin elevation in 816 patients.


Among the electrocardiographic signs of RV strain/ischemia, Qr pattern in lead V1 was the only ECG abnormality associated with in-hospital mortality in high-risk patients. In not high-risk patients the demonstrated association among baseline ECG signs of RV strain/ischemia and RV dysfunction at echocardiography or troponin elevation highlights the need for early further investigations in patients with such ECG abnormalities.

Monday, June 04, 2018

ECG changes in hyperkalemia predict outcomes


We collected records of all adult patients with potassium (K+) greater than or equal to 6.5 mEq/L in the hospital laboratory database from August 15, 2010, through January 30, 2015. A chart review identified patient demographics, concurrent laboratory values, ECG within one hour of K+ measurement, treatments and occurrence of adverse events within six hours of ECG. We defined adverse events as symptomatic bradycardia, ventricular tachycardia, ventricular fibrillation, cardiopulmonary resuscitation (CPR) and/or death. Two emergency physicians blinded to study objective independently examined each ECG for rate, rhythm, peaked T wave, PR interval duration and QRS complex duration. Relative risk was calculated to determine the association between specific hyperkalemic ECG abnormalities and short-term adverse events.


We included a total of 188 patients with severe hyperkalemia in the final study group. Adverse events occurred within six hours in 28 patients (15%): symptomatic bradycardia (n=22), death (n=4), ventricular tachycardia (n=2) and CPR (n=2). All adverse events occurred prior to treatment with calcium and all but one occurred prior to K+-lowering intervention. All patients who had a short-term adverse event had a preceding ECG that demonstrated at least one hyperkalemic abnormality (100%, 95% confidence interval [CI] [85.7–100%]). An increased likelihood of short-term adverse event was found for hyperkalemic patients whose ECG demonstrated QRS prolongation (relative risk [RR] 4.74, 95% CI [2.01–11.15]), bradycardia (HR less than 50) (RR 12.29, 95%CI [6.69–22.57]), and/or junctional rhythm (RR 7.46, 95%CI 5.28–11.13). There was no statistically significant correlation between peaked T waves and short-term adverse events (RR 0.77, 95% CI [0.35–1.70]).

It’s an interesting lesson in the fact that all adverse events occurred before calcium was administered. In addition to the points made here, the ECG may also be beneficial in diagnosing hyperkalemia before the labs are back.

Sunday, June 03, 2018

Distinguishing recurrent DVT from old DVT

It is difficult but there are some things you can look for. From a recent review:


Lower limb deep venous thrombosis (DVT) recurrence represents a diagnostic challenge.

Ultrasound is the first choice examination when DVT is suspected.

This review highlights the validated criteria for DVT recurrence.

An increase in vein diameter between 2 and 4 mm requires further examination.

New diagnostic imaging techniques are currently under evaluation.



Recurrent deep vein thrombosis (DVT) is often suspected in patients after anticoagulant drug withdrawal. The clinical signs can be confused with the onset of post-thrombotic syndrome. For these reasons, diagnosis of DVT recurrence must rely on an accurate method.

Materials and methods

In order to assess this challenging clinical issue, we performed an overview of the literature regarding ultrasound criteria for the diagnosis of recurrent DVT through a Medline search, which included articles published from January 1, 1980 to February 20, 2017.


Eighty-eight publications were found based on the defined keywords, of which nine articles with a relevant abstract were selected. By searching the reference lists of these nine articles, we obtained another 27 relevant articles. A new non-compressible vein or an increase in the diameter of a previously thrombosed vein segment by greater than 4 mm are sufficient to confirm the diagnosis of DVT recurrence. In contrast, an increase in diameter of less than 2 mm enables recurrence to be ruled out. An increase between 2 and 4 mm is deemed equivocal. Criteria based on echogenicity and Doppler venous blood flow are not reproducible. Other diagnostic imaging methods, mainly direct thrombus magnetic resonance imaging, are currently under evaluation.


Ultrasound remains the most useful test for the diagnosis of recurrent DVT. Further imaging tests need to be validated.

Saturday, June 02, 2018

Catheter directed thrombolysis for DVT: what are the current recommendations?

Here’s from the latest review:


•The initial treatment of acute DVT influences late complications.
•Post-thrombotic syndrome affects 40% of patients with symptomatic DVT.
•Catheter-directed thrombolysis (CDT) rapidly eliminates clot but increases bleeding.
•Randomized trials are inconclusive on whether CDT provides long-term benefit.
•A highly individualized approach should be used for patient selection.

That’s exactly the recommendation of the ACCP guidelines.

Friday, June 01, 2018

Is a DOAC appropriate for your post bariatric surgery patient? Maybe not!


•DOAC drug levels were tested in 18 post-BS patients and 18 matched controls.
•Five of 7 post-BS patients using rivaroxaban had subtherapeutic plasma levels.
•Patients using apixaban and dabigatran had blood levels within the expected range.
•After BS, we suggest cautious use, if at all, of DOACs, particularly rivaroxaban.
•Until more data become available, warfarin may be more suitable than DOACs after BS.


To determine direct-acting oral anticoagulant (DOAC) blood levels in post-bariatric surgery (BS) patients treated with long-term anticoagulation therapy.


We identified from medical records patients who underwent BS during 2005–2016 and who were treated with DOACs. We offered testing DOAC blood levels to these patients and to age, sex, body mass index, and serum creatinine-matched individuals treated by DOACs who did not undergo BS.


Overall, 36 individuals were enrolled, 18 post-BS patients and 18 control subjects. Of the post-BS patients, 12 underwent laparoscopic sleeve gastrectomy, 4 laparoscopic adjustable gastric banding and 2 laparoscopic Roux-en-Y gastric bypass surgery. Median time lapsed from surgery until study inclusion was 4.9 years. Five post-BS patients had peak drug levels below expected levels compared to none of the control subjects (P = 0.05). For patients who used apixaban (n = 9) and dabigatran (n = 2), peak drug levels were within the expected range. In contrast, for the 7 patients who used rivaroxaban, levels were below the expected range in 5, including all four who underwent sleeve gastrectomy and one following adjustable gastric banding. Peak rivaroxaban levels were significantly lower in the post-BS than the control group (P = 0.02).


This preliminary study suggests that all DOACs, particularly rivaroxaban, be cautiously used following BS, if used at all. Given that vitamin-K antagonists can be easily monitored, they may be a better choice, until more data on DOAC use in this patient population are available.