Spironolactone in diastolic heart failure

Pathophysiologic rationale and surrogate endpoints look promising but that's as far as we've come so far.  A long journey awaits.  The latest study in JAMA.

RW's Tweets

OK, so I've stepped into the 21st century and am finally tweeting.  But I need some followers.

Medical education resources on YouTube

Here are some I've found recently:

COMLEX USMLE review.

Medical Sciences Animated Videos.

Eric's Medical Lectures.

MedCram.

The Southern diet as a risk factor for stroke

Presented at the International Stroke Conference.

Via Medpage Today.

Initial sedation intensity in mechanically ventilated patients: go easy

From this study recently published in the blue journal:

Measurements and Main Results: We studied 251 patients (mean age, 61.7 ± 15.9 yr; mean Acute Physiology and Chronic Health Evaluation [APACHE] II score, 20.8 ± 7.8), with 21.1% (53) hospital and 25.8% (64) 180-day mortality. Over 2,678 study days, we completed 14,736 RASS assessments. Deep sedation occurred in 191 (76.1%) patients within 4 hours of commencing ventilation and in 171 (68%) patients at 48 hours. Delirium occurred in 111 (50.7%) patients with median (interquartile range) duration of 2 (1–4) days. After adjusting for diagnosis, age, sex, APACHE II, operative, elective, hospital type, early use of vasopressors, and dialysis, early deep sedation was an independent predictor of time to extubation (hazard ratio [HR], 0.90; 95% confidence interval [CI], 0.87–0.94; P less than 0.001), hospital death (HR, 1.11; 95% CI, 1.02–1.20; P = 0.01), and 180-day mortality (HR, 1.08; 95% CI, 1.01–1.16; P = 0.026) but not delirium occurring after 48 hours (P = 0.19).

Conclusions: Early sedation depth independently predicts delayed extubation and increased mortality, making it a potential target for interventional studies.

Which antidepressants prolong the QT interval?

According to a BMJ study:

Results Dose-response association with QTc prolongation was identified for citalopram (adjusted beta 0.10 (SE 0.04), P less than 0.01), escitalopram (adjusted beta 0.58 (0.15), P less than 0.001), and amitriptyline (adjusted beta 0.11 (0.03), P less than 0.001), but not for other antidepressants examined. An association with QTc shortening was identified for bupropion (adjusted beta 0.02 (0.01) P less than 0.05). Within-subject paired observations supported the QTc prolonging effect of citalopram (10 mg to 20 mg, mean QTc increase 7.8 (SE 3.6) ms, adjusted P less than 0.05; and 20 mg to 40 mg, mean QTc increase 10.3 (4.0) ms, adjusted P less than 0.01).

Obesity associated severe asthma

Obesity may be associated with a distinct phenotype of severe asthma according to this paper.

Prehospital advanced airway management associated with more than double the risk of bad neurological outcome

----in this analysis.

This adds support for the arguments Gordon Ewy and his group at Arizona have been making for years, as I have posted here many times.

In which I ponder the antecedents of quackademic medicine

For some time now bloggers who share a concern about quackademic medicine (a term referring to the pervasive infiltration of quackery into the curricula of American medical schools which I coined here) have pondered the reasons. Indeed the reasons are multiple and complex. But I believe there is a causal chain and if you trace back far enough along the chain you land here: the American Medical Student Association (AMSA).

In the past I’ve blogged a great deal about their woo promoting agenda. Moreover, in considering this agenda alongside AMSA’s PharmFree initiative I have previously noted, in less PC terms, a certain lack of internal consistency.

But over time my enthusiasm for calling out the quack promoting activities of the AMSA waned; despite multiple attempts of myself and others in the blogosphere to raise awareness the problem continued unabated. Among the many folks in high places in the world of medical education few people seemed concerned enough to do anything to try and stem the tide.

I recently ran across two wonderful blog posts (here and here) that rekindled my interest. These bloggers have succeeded in probing the extensive AMSA site and unpacking the woo promoting content better than I ever did. Both posts are worth the read. Great exposure!

Denver cluster of carbapenem resistant Klebsiella

Via Medpage Today.

The isolates produced the New Delhi metallo-beta-lactamase (NDM) gene...

Breath acetone as a biomarker in heart failure

It performed comparably to BNP/proBNP in this study, both in diagnosis and severity assessment.

The incredible and never adequately explored potential of breath acetone (BA) analysis for clinical application has long been a pet interest of mine. As a medical student I got to spend my summers playing with the gas chromatograph machine in Oscar B. Crofford's lab. Although the focus of that research was diabetes and obesity BA has potential application as a biomarker in a variety of disease states. This is best appreciated by understanding that BA reflects lipolytic activity; it is, as Dr. Crofford was fond of saying, the “smoke of burning fat.” That in turn reflects the balance between insulin and counter regulatory hormone activity on hormone sensitive lipase located in adipose tissue cells. The counter regulatory hormones are the stress hormones: epinephrine, norepinephrine, growth hormone, glucagon and cortisol. So elevated BA reflects the catabolic state and/or the ratio of activities of stress hormones to insulin.

The methodology is simple, specimen collection is easy (the patient can exhale into a syringe) and turn around is instantaneous. BA analysis deserves further study in a variety of clinical situations.

HIV disease as a powerful risk factor for lung cancer

A recent commentary in Chest notes a marked increased risk. Age of onset and tobacco burden are much lower than in the general population and presentation with advanced disease is common. Histologic type is similar to the general population.

ICU delirium

Here's a nice review and it's free full text.

Nonpharmacologic modalities are preferred by far over drugs though the latter are popular and sometimes necessary when the delirium is agitated. Data to support the use of drugs are sparse. Antipsychotics tend to be preferred over benzos except for alcohol withdrawal delirium, in which benzo therapy is the treatment of choice and antipsychotics are avoided. There is little to recommend second generation over older (e.g. haldol) agents. Dexmedetomidine has promise and is popular, but evidence in favor of its use is weak.

Extreme hypertriglyceridemia

Extreme hypertriglyceridemia can cause acute pancreatitis. It can also wreak havoc on the management of hospitalized patients by interfering with their lab tests. Management is a challenge, as it often responds inadequately to conventional measures. This article discusses two under appreciated (and off label) tricks of the trade: insulin infusion and heparin infusion. These treatments rapidly clear triglycerides and work about as well as plasmapheresis. They work by facilitating lipoprotein lipase. In the case of insulin, hark back to basic biochem and note an important distinction which is an apparent paradox: while insulin facilitates the action of lipoprotein lipase to clear triglycerides from the circulation it also inhibits hormone sensitive lipase in adipose tissue, the rate limiting enzyme for lipolysis and one of the two on-off switches for ketosis.

Obstructive sleep apnea, stroke and dementia

Under appreciated associations.

Lactate clearance predicts mortality

In severe sepsis.

Cardiac amyloidosis

The best review of cardiac amyloidosis this blogger has seen.

ACEI/ARB plus diuretic plus NSAID: the renal triple threat

----for AKI, as reported in BMJ and summarized here. Then again I worry about the renal risk from NSAIDs whether or not they are combined with other drugs.

Endovascular repair of abdominal aortic aneurysm: where we've come in 20 years

Now, more endo repairs have been done than open repairs. Over 70% of repairs now are endo repairs. The history and current status of the procedure are discussed in this review.

Continuous beta lactam infusion

It seems to work better. This harks back to the old days of using continuous infusion IV PEN G to treat meningitis.