Friday, March 29, 2019

Low vitamin D levels associated with increased mortality


To determine the relationship between 25-hydroxyvitamin D (25[OH]D) values and all-cause and cause-specific mortality.

Patients and Methods

We identified all serum 25(OH)D measurements in adults residing in Olmsted County, Minnesota, between January 1, 2005, and December 31, 2011, through the Rochester Epidemiology Project. All-cause mortality was the primary outcome. Patients were followed up until their last clinical visit as an Olmsted County resident, December 31, 2014, or death. Multivariate analyses were adjusted for age, sex, race/ethnicity, month of measurement, and Charlson comorbidity index score.


A total of 11,022 individuals had a 25(OH)D measurement between January 1, 2005, and December 31, 2011, with a mean ± SD value of 30.0±12.9 ng/mL. Mean age was 54.3±17.2 years, and most were female (77.1%) and white (87.6%). There were 723 deaths after a median follow-up of 4.8 years (interquartile range, 3.4-6.2 years). Unadjusted all-cause mortality hazard ratios (HRs) and 95% CIs for 25(OH)D values of less than 12, 12 to 19, and more than 50 ng/mL were 2.6 (95% CI, 2.0-3.2), 1.3 (95% CI, 1.0-1.6), and 1.0 (95% CI, 0.72-1.5), respectively, compared with the reference value of 20 to 50 ng/mL. In a multivariate model, the interaction between the effect of 25(OH)D and race/ethnicity on mortality was significant (P<.001). In white patients, adjusted HRs for 25(OH)D values of less than 12, 12 to 19, 20 to 50, and greater than 50 ng/mL were 2.5 (95% CI, 2.2-2.9), 1.4 (95% CI, 1.2-1.6), 1.0 (referent), and 1.0 (95% CI, 0.81-1.3), respectively. In patients of other race/ethnicity, adjusted HRs were 1.9 (95% CI, 1.5-2.3), 1.7 (95% CI, 1.1-2.6), 1.5 (95% CI, 1.0-2.0), and 2.1 (95% CI, 0.77-5.5).


White patients with 25(OH)D values of less than 20 ng/mL had greater all-cause mortality than those with values of 20 to 50 ng/mL, and white patients had greater mortality associated with low 25(OH)D values than patients of other race/ethnicity. Values of 25(OH)D greater than 50 ng/mL were not associated with all-cause mortality.

Testosterone replacement associated with better cardiovascular outcomes

Troponin elevation in stroke may point to a cardioembolic etiology


Background Our aim was to determine whether patients with embolic strokes of undetermined source (ESUS) have higher rates of elevated troponin than patients with noncardioembolic strokes.

Methods and Results CAESAR (The Cornell Acute Stroke Academic Registry) prospectively enrolled all adults with acute stroke from 2011 to 2014. Two neurologists used standard definitions to retrospectively ascertain the etiology of stroke, with a third resolving disagreements. In this analysis we included patients with ESUS and, as controls, patients with small‐ and large‐artery strokes; only patients with a troponin measured within 24 hours of stroke onset were included. A troponin elevation was defined as a value exceeding our laboratory's upper limit (0.04 ng/mL) without a clinically recognized acute ST‐segment elevation myocardial infarction. Multiple logistic regression was used to evaluate the association between troponin elevation and ESUS after adjustment for demographics, stroke severity, insular infarction, and vascular risk factors. In a sensitivity analysis we excluded patients diagnosed with atrial fibrillation after discharge. Among 512 patients, 243 (47.5%) had ESUS, and 269 (52.5%) had small‐ or large‐artery stroke. In multivariable analysis an elevated troponin was independently associated with ESUS (odds ratio 3.3; 95% confidence interval 1.2, 8.8). This result was unchanged after excluding patients diagnosed with atrial fibrillation after discharge (odds ratio 3.4; 95% confidence interval 1.3, 9.1), and the association remained significant when troponin was considered a continuous variable (odds ratio for log[troponin], 1.4; 95% confidence interval 1.1, 1.7).

Conclusions Elevations in cardiac troponin are more common in patients with ESUS than in those with noncardioembolic strokes.

Unfortunately the test characteristics for determining cardioembolic stroke are poor. Most patients with cardioembolic stroke do not have elevated troponins and some with other types of stroke have elevations.

Thursday, March 28, 2019

Appropriateness of troponin ordering in the hospital

Troponin assays are integral to the diagnosis of acute myocardial infarction (AMI), but there is concern that testing is over utilized and may not conform to published guidelines. We reviewed all testing performed at 14 hospitals over 12 months and associated troponin values with the primary and secondary diagnoses for each visit. Troponin was determined to be negative, indeterminate or elevated based on reference ranges. The majority of troponin measurements were single, not serial (64%). The rate of AMI was low, with only 3.5% of tested patients having a primary or secondary diagnosis of AMI. Sensitivity, specificity and negative predictive value were excellent, exceeding 90%. However, positive predictive value was low, suggesting testing of populations with diseases known to be associated with elevated troponin levels in the absence of AMI. The majority (79%) of elevated troponin values were associated with primary diagnoses other than AMI. Only 28% of elevated troponins were associated with a primary or secondary diagnosis of AMI. These data suggest possible overuse of troponin testing in our healthcare system. Journal of Hospital Medicine 2017;12:329-331. © 2017 Society of Hospital Medicine

This conclusion is premised on the idea that the only reason to order a troponin is to diagnose or exclude MI.

Triple antibiotic therapy against carbapenemase producing bacteria

Here is a review on the topic. These regimens have been our go-to for a while now and are effective although the crude mortality for these infections remains high, in the 30+% range. Newer antibiotics either approved or in the pipeline have brightened the outlook. From the article:

A few emerging treatment options for CPKP infections appear promising. The most prominent new agent is ceftazidime–avibactam, a cephalosporin combined with a novel β-lactamase inhibitor approved by the US Food and Drug Administration (FDA) in February 2015 [60]. Ceftazidime–avibactam has shown potent in vitro activity against CRE isolates [61–63]. and there have also been reports that ceftazidime–avibactam is effective for CPKP infections after other combination regimens have failed [19, 64, 65]. Other β-lactam/β-lactamase inhibitor combinations are also being investigated including ceftolozane–tazobactam and aztreonam–avibactam [12, 66]. Plazomicin, a novel aminoglycoside that has shown in vitro activity against CRE, is currently undergoing a Phase 3 clinical trial (NCT01970371) as part of a combination therapy [67]. Another agent showing potential is eravacycline, a tetracycline derivative, which has shown in vitro efficacy against CRE as well as for complicated intra-abdominal infections and complicated urinary tract infections in clinical trials [68, 69].

Targeted temperature management post arrest: how long?

Question Does targeted temperature management at 33°C for 48 hours result in better neurologic outcome compared with standard 24-hour targeted temperature management in unconscious patients with out-of-hospital cardiac arrest?

Findings In this randomized clinical trial enrolling 355 adults with out-of-hospital cardiac arrest, there was no significant difference in favorable neurologic outcome at 6 months for those treated for 48 hours (69%) vs 24 hours (64%) (difference, 5%).

Meaning Prolonged targeted temperature management at 33°C did not result in better neurologic outcome; however, the study may have had limited power to detect clinically important differences, and further research may be warranted.

Wednesday, March 27, 2019

Vitamin C deficiency as a cause of pulmonary hypertension

Hospitalization rates and lengths of stay for VTE in Alberta Canada


Acute venous thromboembolism leads to significant morbidity and mortality. Advances in pharmacotherapy facilitate outpatient care in low-risk acute venous thromboembolism. The proportion of hospitalized acute venous thromboembolism cases and the average length of stay are not known. We sought to identify predictors of hospitalization, changes in hospitalization rates and length of stay of acute venous thromboembolism over a decade in Alberta, Canada.


Using linked administrative health databases, we identified adult patients diagnosed primarily with acute venous thromboembolism between April 2002 and March 2012. We measured trends using Poisson regression, adjusted length of stay using analysis of covariance. We identified predictors of hospitalization using multivariate logistic regression.


8198 out of 31,656 acute venous thromboembolism cases were hospitalized. The overall venous thromboembolism admission rates ranged between 23.7% and 27.8% with no evident temporal trend (P = 0.10). The average admission rate was 51.9% for pulmonary embolism and 16.1% for deep vein thrombosis. The mean length of stay for deep vein thrombosis and pulmonary embolism remained unchanged with an adjusted mean for venous thromboembolism of 6.9 ± 1.0 days. Higher Charlson index, older age, male gender, pulmonary embolism at presentation and multiple comorbidities were associated with hospitalization. Hospitalization was associated with 30-day mortality (odds ratio:2.8, 95% CI: 2.2–3.5) whereas the length of stay was not (odds ratio:1.0, 95% CI: 0.99–1.0).


Hospitalization rates and mean length of stay for acute venous thromboembolism did not change significantly between 2002 and 2012. Advances in pharmacotherapy have not yet reduced hospitalization rates or length of stay for venous thromboembolism.

In non malignant pleural effusions transudates may have a worse prognosis than exudates

Tuesday, March 26, 2019

Adjuvant metolazone (zaroxalin) in loop diuretic refractory patients

Resist the temptation to add the “big Z” according to this study.

Hepatic encephalopathy update

Hepatic encephalopathy is a state of brain dysfunction resulting from decompensation of cirrhosis. The mortality and morbidity associated with the overt form of hepatic encephalopathy are high, and even the covert form associates with poor outcomes and poor quality of life. We know that the dysfunction is not just an acute insult to the brain but rather results in long-standing cognitive issues that get worse with each episode of HE. Hence, there is an urgency to accurately diagnose these conditions, start appropriate therapy, and to maintain remission. Currently, we have two mainstay pharmacological treatment options (lactulose and rifaximin), but the narrative is evolving with new therapies under trial. Microbiome manipulation resulting in a favorable change to the gut microbiota seems to be a promising new area of therapy.

The adverse effects of CPOE on ER throughput

Can voice patterns give away your risk of CAD?

Is thrombophilia testing helpful?

Monday, March 25, 2019

Checking urine eosinophils to evaluate for acute interstitial nephritis

I agree this is one we should probably just stop doing. Not that it’s costing a lot of money or harming patients, but, despite popularity for years, the test characteristics according to recent data are so poor it’s probably just not worth doing.

Growing evidence challenges conservative transfusion dogma

The last few years have seen quite a push toward restrictive transfusion strategies with conservative hemoglobin (less than seven) triggers.  Not only did numerous research publications support such an approach but there are important theoretical concerns. For example banked blood is relatively ineffective in terms of oxygen delivery due to depletion of 2, 3 DPG levels. There's also a concern based on indirect evidence that blood transfusions may be immunosuppressive by poorly understand mechanisms. Guidelines support a conservative (hemoglobin seven) trigger in almost all situations (though allowing room for clinical judgment which might favor a trigger of 8 in some circumstances).
In recent years the discussion around transfusion restriction has morphed into a campaign of sorts with conservative triggers embedded into electronic medical records and institutional policies taking the form of dogma with little regard for clinical judgment or the unique attributes of certain patients.

A paper in Critical Care Medicine challenges this dogma in certain patients:

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 9g/dL) or to the restrictive strategy (hemoglobin threshold, less than 7g/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.
Although the survival advantage for more aggressive transfusion did not reach statistical significance 28 days it did at 90 days.

Thrombocytopenia developing in hospitalized patients

What the hospitalist needs to know about the TTP-HUS spectrum

This is the best review I’ve ever seen on this. Free full text.

Saturday, March 23, 2019

Be careful using a restrictive transfusion strategy in patients with cardiovascular disease

There is biological plausibility that patients with CVD may benefit from higher transfusion thresholds than patients without CVD. Evidence from a systematic review and meta‐analysis in this population suggest that there is no difference in 30‐day mortality, but there is an increased risk of ACS in patients with CVD who were randomized to a restrictive transfusion threshold compared with a more liberal threshold. We suggest that a more liberal transfusion threshold (greater than 80 g/l) in this population should be used until a high‐quality trial including endpoints for longer term mortality, ACS, quality of life and cost effectiveness has been performed.

Visceral fat (android obesity) and oxidative stress

At 1 year, the change in android but not gynoid fat mass or body mass index negatively correlated with the change in the plasma glutathione level after adjustment for cardiovascular risk factors. Increased body fat, specifically android fat mass, is an independent determinant of systemic OS, and its change is associated with a simultaneous change in OS, measured as plasma glutathione. In conclusion, our findings suggest that excess android or visceral fat contributes to the development of cardiovascular disease through modulating OS.

Unintended consequences of patient safety interventions

On the whole there is little evidence that patient safety initiatives at the system level have been beneficial. Here is a systematic review unintended consequences. From the review:

Abstract: This is a systematic review of the literature on unintended consequences of clinical interventions to reduce falls, catheter-related urinary tract infection, and vascular catheter-related infections in hospitalized patients. A systematic search of the literature was conducted in CINAHL and PubMed. We developed a screening tool and a two-stage screening process to identify relevant articles. Nine articles met inclusion criteria, and of those, 8 reported on interventions to reduce patient falls. Four studies reported a positive, unexpected benefit; 3 studies reported a negative, unexpected detriment; and 4 reported a perverse effect (different from what was expected). Three studies reported both positive and perverse effects arising from the intervention. In 4 of the studies, despite fall prevention interventions, patients fell while trying to get to the bathroom, suggesting that interventions to reduce one adverse outcome (i.e., CAUTI) may be associated with another outcome (i.e., patient falls). In some cases, there were positive outcomes for those who implemented and/or evaluated interventions. We encourage colleagues to collect and report data on possible unintended consequences of their interventions to allow a fuller picture of the relationship between intervention and all outcomes to emerge.

These represent the safety areas where Medicare has focused its “no pay for errors” policy.

Unraveling the mystery of thrombotic storm

Friday, March 22, 2019

Is less really more? Under treatment with antithrombotic therapy still a huge problem

–---at least in a fib. Study here.

A virtual museum of mechanical ventilators

Interesting stuff here.

Using ventilator graphics

Medical decision making for unbefriended older adults: an AGS position statement

Policy Recommendations

1.National stakeholders should work together to create legal standards regarding unbefriended older adults that could be considered for adoption by all states.
2.Clinicians, health care organizations, and other stakeholders should work proactively to prevent older adults without potential surrogates from becoming unbefriended.
3.Clinicians, health care organizations, communities, and other stakeholders should develop innovative, efficient and accessible approaches to promote adequate protections and procedural fairness in decision making for unbefriended older adults.

Clinical Practice Recommendations

4.Medical decision making for unbefriended older adults should include adequate safeguards against ad hoc approaches and ensure procedural fairness.
5.Clinicians should consider non-traditional surrogate decision makers for unbefriended older adults.
6.Clinicians should assess medical decision-making capacity in a systematic fashion.
7.Clinicians and healthcare institutions should develop and standardize/systematize methods to make decisions for unbefriended older adults in urgent, life-threatening situations.
8.Clinicians and healthcare institutions should ensure that patients with long-term incapacity have longitudinal access to a decision-making surrogate who is familiar with the patient's medical condition and specific circumstances.
9.When applying the best interest standard to unbefriended older adults, institutional committees (such as an ethics committee) should synthesize all available evidence, including cultural and ethnic factors, during deliberations about treatment decisions.

Thursday, March 21, 2019

Diagnosis of upper extremity DVT


•The evidence on the diagnostic management of upper extremity deep vein thrombosis is scarce.
•Only one study evaluated the use of a diagnostic algorithm, similar to the one used for deep vein thrombosis of the lower extremities.
•Further studies are needed to validate the algorithm, especially in high-risk subgroups.


Upper extremity deep vein thrombosis (UEDVT) accounts for 4% to 10% of all cases of deep vein thrombosis. UEDVT may present with localized pain, erythema, and swelling of the arm, but may also be detected incidentally by diagnostic imaging tests performed for other reasons. Prompt and accurate diagnosis is crucial to prevent pulmonary embolism and long-term complications as the post-thrombotic syndrome of the arm. Unlike the diagnostic management of deep vein thrombosis (DVT) of the lower extremities, which is well established, the work-up of patients with clinically suspected UEDVT remains uncertain with limited evidence from studies of small size and poor methodological quality. Currently, only one prospective study evaluated the use of an algorithm, similar to the one used for DVT of the lower extremities, for the diagnostic workup of clinically suspected UEDVT. The algorithm combined clinical probability assessment, D-dimer testing and ultrasonography and appeared to safely and effectively exclude UEDVT. However, before recommending its use in routine clinical practice, external validation of this strategy and improvements of the efficiency are needed, especially in high-risk subgroups in whom the performance of the algorithm appeared to be suboptimal, such as hospitalized or cancer patients.

In this review, we critically assess the accuracy and efficacy of current diagnostic tools and provide clinical guidance for the diagnostic management of clinically suspected UEDVT.

Systematic review and meta-analysis of tygecycline in bloodstream infections

This paper is complex but seems to show that tygecycline is best in combination therapy .

Topiramate renal toxicity

Troponin elevation in stroke: what does it mean?

Background and Purpose—Acute ischemic stroke (AIS) patients may have raised serum cardiac troponin levels on admission, although it is unclear what prognostic implications this has, and whether elevated levels are associated with cardiac causes of stroke or structural cardiac disease as seen on echocardiogram. We investigated the positivity of cardiac troponin and echocardiogram testing within a large biracial AIS population and any association with poststroke mortality.

Methods—Within a catchment area of 1.3 million, we screened emergency department admissions from 2010 using International Classification of Diseases, Ninth Edition, discharge codes 430 to 436 and ascertained all physician-confirmed AIS cases by retrospective chart review. Hypertroponinemia was defined as elevation in cardiac troponin above the standard 99th percentile. Multiple logistic regression was performed, controlling for stroke severity, history of cardiac disease, and all other stroke risk factors.

Results—Of 1999 AIS cases, 1706 (85.3%) had a cardiac troponin drawn and 1590 (79.5%) had echocardiograms. Hypertroponinemia occurred in 353 of 1706 (20.7%) and 160 of 1590 (10.1%) had echocardiogram findings of interest. Among 1377 who had both tests performed, hypertroponinemia was independently associated with echocardiogram findings (odds ratio, 2.9; 95% confidence interval, 2–4.2). When concurrent myocardial infarctions (3.5%) were excluded, hypertroponinemia was also associated with increased mortality at 1 year (35%; odds ratio, 3.45; 95% confidence interval, 2.1–5.6) and 3 years (60%; odds ratio, 2.91; 95% confidence interval, 2.06–4.11).

Conclusions—Hypertroponinemia in the context of AIS without concurrent myocardial infarction was associated with structural cardiac disease and long-term mortality. Prospective studies are needed to determine whether further cardiac evaluation might improve the long-term mortality rates seen in this group.

Thrombolytic versus conventional therapy for submassive PE

Wednesday, March 20, 2019

Syncope review

What to do with subclinical hyperthyroidism

From a recent concise review:

Subclinical hyperthyroidism is defined by a low or undetectable serum thyroid-stimulating hormone level, with normal free thyroxine and total or free triiodothyronine levels. It can be caused by increased endogenous production of thyroid hormone (e.g., in Graves disease, toxic nodular goiter, or transient thyroiditis), by administration of thyroid hormone to treat malignant thyroid disease, or by unintentional excessive replacement therapy. The prevalence of subclinical hyperthyroidism in the general population is about 1% to 2%; however, it may be higher in iodine-deficient areas. The rate of progression to overt hyperthyroidism is higher in persons with thyroid-stimulating hormone levels less than 0.1 mIU per L than in persons with low but detectable thyroid-stimulating hormone levels. Subclinical hyperthyroidism is associated with an increased risk of atrial fibrillation and heart failure in older adults, increased cardiovascular and all-cause mortality, and decreased bone mineral density and increased bone fracture risk in postmenopausal women. However, the effectiveness of treatment in preventing these conditions is unclear. A possible association between subclinical hyperthyroidism and quality-of-life parameters and cognition is controversial. The U.S. Preventive Services Task Force found insufficient evidence to assess the balance of benefits and harms of screening for thyroid dysfunction in asymptomatic persons. The American Thyroid Association and the American Association of Clinical Endocrinologists recommend treating patients with thyroid-stimulating hormone levels less than 0.1 mIU per L if they are older than 65 years or have comorbidities such as heart disease or osteoporosis.

Increased risk of stroke after an episode of sepsis

Background and Purpose—Infections have been found to increase the risk of stroke over the short term. We hypothesized that stroke risk would be highest shortly after a sepsis hospitalization, but that the risk would decrease, yet remain up to 1 year after sepsis.

Methods—This case-crossover analysis utilized data obtained from the California State Inpatient Database of the Healthcare Cost and Utilization Project. All stroke admissions were included. Exposure was defined as hospitalization for sepsis or septicemia 180, 90, 30, or 15 days before stroke (risk period) or similar time intervals exactly 1 or 2 years before stroke (control period). Conditional logistic regression was used to calculate the odds ratio (OR) and 95% confidence interval (95% CI) for the association between sepsis/septicemia and ischemic or hemorrhagic stroke.

Results—Ischemic (n=37 377) and hemorrhagic (n=12 817) strokes that occurred in 2009 were extracted where 3188 (8.5%) ischemic and 1101 (8.6%) hemorrhagic stroke patients had sepsis. Sepsis within 15 days before the stroke placed patients at the highest risk of ischemic (OR, 28.36; 95% CI, 20.02–40.10) and hemorrhagic stroke (OR, 12.10; 95% CI, 7.54–19.42); however, although the risk decreased, it remained elevated 181 to 365 days after sepsis for ischemic (OR, 2.59; 95% CI, 2.20–3.06) and hemorrhagic (OR, 3.92; 95% CI 3.29–4.69) strokes. There was an interaction with age (P=0.0006); risk of developing an ischemic stroke within 180 days of hospitalization for sepsis increased 18% with each 10-year decrease in age.

Conclusions—Risk of stroke is high after sepsis, and this risk persists for up to a year. Younger sepsis patients have a particularly increased risk of stroke after sepsis.

Stressed volume in critical care

Tuesday, March 19, 2019

Get those discharge summaries out. Faster please.

Single dose dexamethasone almost as affective as a five day prednisone regimen in acute asthma

A single dose of 12-mg dexamethasone, which has a longer duration of action than prednisone, is almost as effective as five days of 60-mg prednisone for the prevention of relapse in adults with acute asthma treated in an emergency department. It is a reasonable option for treatment in the emergency department, given its fewer adverse effects. In this study, patients who received the single dose also took placebo for four days. Further research is needed to determine whether patients are comfortable with taking just a single dose. (Level of Evidence = 2b)

The strong ion difference in predicting the severity of acute pancreatitis


In a cohort of patients with AP, SIG was a strong independent predictor of severity and mortality. Besides, SIG might also be an early marker for acute kidney injury in AP patients. Additional research is needed to identify the nature of the unmeasured anions responsible for such findings.

Monday, March 18, 2019

Chronic tachycardia induced cardiomyopathy

An update on this topic recently appeared in JACC.

First a little background. This was the topic of one of my very first blog posts almost 12 years ago.

Decades ago this entity was described in patients with incessant forms of SVT (eg long RP or “fast-slow reentry” tachycardias. Some of these were also ectopic atrial tachycardias). These patients had heart failure with low ejection fractions and some were cured after ablation. (See here). It wasn’t until much later when it was recognized that this entity could result from longstanding uncontrolled atrial fibrillation. Prior to that time many patients were labeled as “idiopathic” DCM with atrial fibrillation as a result. It is now recognized that the reverse is often true. That is, a DCM might evolve in a patient who started with “lone” AF. It is a chronic process. Many affected patients seem to lack cardiac awareness, thus allowing them to go for long periods with high rate atrial fibrillation.

Over time it was recognized that this was more common and occurred with varying severity. There has been some evidence, for example, that the most aggressive rate control strategy, AVN ablation and pacing, may modestly improve EF (counterbalanced, of course, by the adverse effects of RV pacing unless biV pacing is part of the management strategy).

Now on the the paper, which reported distinct inflammatory and ultrastructural patterns. From the abstract:

Results Patients with TCM, on the basis of clinical criteria, had stronger myocardial expression of major histocompatibility complex class II molecule and enhanced infiltration of CD68+ macrophages compared with patients with DCM. Furthermore, when compared with patients with ICM, the presence of T cells and macrophages was significantly reduced in TCM. Myocardial fibrosis was detected to a significantly lower degree in patients with TCM compared with patients with DCM and ICM. Electron microscopic examination revealed severe structural changes in patients with TCM. A disturbed distribution pattern of mitochondria was predominantly present in TCM. Quantitative assessment of myocyte morphology revealed significantly enhanced myocyte size compared with patients with ICM. Ribonucleic acid expression analysis identified changes in metabolic pathways among the patient groups.

Conclusions TCM is characterized by changes in cardiomyocyte and mitochondrial morphology accompanied by a macrophage-dominated cardiac inflammation. Thus, further prospective studies are warranted to characterize patients with TCM by endomyocardial biopsy more clearly.

The accompanying audio file, available as open access on the abstract page, discusses a related editorial in the same issue.

An evidence summary on severe asymptomatic hypertension

Hypertension affects one-third of Americans and is a significant modifiable risk factor for cardiovascular disease, stroke, renal disease, and death. Severe asymptomatic hypertension is defined as severely elevated blood pressure (180 mm Hg or more systolic, or 110 mm Hg or more diastolic) without symptoms of acute target organ injury. The short-term risks of acute target organ injury and major adverse cardiovascular events are low in this population, whereas hypertensive emergencies manifest as acute target organ injury requiring immediate hospitalization. Individuals with severe asymptomatic hypertension often have preexisting poorly controlled hypertension and usually can be managed in the outpatient setting. Immediate diagnostic testing rarely alters short-term management, and blood pressure control is best achieved with initiation or adjustment of antihypertensive therapy. Aggressive lowering of blood pressure should be avoided, and the use of parenteral medications is not indicated. Current recommendations are to gradually reduce blood pressure over several days to weeks. Patients with escalating blood pressure, manifestation of acute target organ injury, or lack of compliance with treatment should be considered for hospital admission.

Testosterone and cardiovascular health

From a recent review:

Testosterone (T) has a number of important effects on the cardiovascular system. In men, T levels begin to decrease after age 40, and this decrease has been associated with an increase in all-cause mortality and cardiovascular (CV) risk. Low T levels in men may increase their risk of developing coronary artery disease (CAD), metabolic syndrome, and type 2 diabetes. Reduced T levels in men with congestive heart failure (CHF) portends a poor prognosis and is associated with increased mortality. Studies have reported a reduced CV risk with higher endogenous T concentration, improvement of known CV risk factors with T therapy, and reduced mortality in T-deficient men who underwent T replacement therapy versus untreated men. Testosterone replacement therapy (TRT) has been shown to improve myocardial ischemia in men with CAD, improve exercise capacity in patients with CHF, and improve serum glucose levels, HbA1c, and insulin resistance in men with diabetes and prediabetes. There are no large long-term, placebo-controlled, randomized clinical trials to provide definitive conclusions about TRT and CV risk. However, there currently is no credible evidence that T therapy increases CV risk and substantial evidence that it does not. In fact, existing data suggests that T therapy may offer CV benefits to men.

Septic encephalopathy

Should we reinvent the physical exam?

Saturday, March 16, 2019

A single ectopic beat on a 12 lead ECG is an important predictor

Clinical Perspective
What Is New?

Among participants in 2 large, community‐based cohort studies, the presence of a premature atrial contraction detected from a single, standard 12‐lead ECG predicted a statistically significant elevated risk of both incident atrial fibrillation and death.

Similarly, a premature ventricular contraction from a single, standard ECG predicted statistically significant increased risks of incident heart failure, decline in left ventricular ejection fraction, and death.

What Are the Clinical Implications?

In combination with other risk markers, ectopy on a single, standard 12‐lead ECG may provide valuable information regarding an individual's cardiovascular risk and serve as a broadly available tool for the prediction and prevention of atrial fibrillation, heart failure, and death.

Reducing blood culture contamination with a special collection device


Blood culture contamination is a clinically significant problem that results in patient harm and excess cost.


In a prospective, controlled trial at an academic center Emergency Department, a device that diverts and sequesters the initial 1.5–2 mL portion of blood (which presumably carries contaminating skin cells and microbes) was tested against standard phlebotomy procedures in patients requiring blood cultures due to clinical suspicion of serious infection.


In sum, 971 subjects granted informed consent and were enrolled resulting in 904 nonduplicative subjects with 1808 blood cultures. Blood culture contamination was significantly reduced through use of the initial specimen diversion device™ (ISDD) compared to standard procedure: (2/904 [0.22%] ISDD vs 16/904 [1.78%] standard practice, P = .001). Sensitivity was not compromised: true bacteremia was noted in 65/904 (7.2%) ISDD vs 69/904 (7.6%) standard procedure, P = .41. No needlestick injuries or potential bloodborne pathogen exposures were reported. The monthly rate of blood culture contamination for all nurse-drawn and phlebotomist-drawn blood cultures was modeled using Poisson regression to compare the 12-month intervention period to the 6 month before and after periods. Phlebotomists (used the ISDD) experienced a significant decrease in blood culture contamination while the nurses (did not use the ISDD) did not. In sum, 73% of phlebotomists completed a post-study anonymous survey and widespread user satisfaction was noted.


Use of the ISDD was associated with a significant decrease in blood culture contamination in patients undergoing blood cultures in an Emergency Department setting.