Saturday, September 23, 2017

Risk of thrombosis in patients with essential thrombocythemia


To assess the role of platelet (PLT) count for thrombotic complications in Essential Thrombocythemia (ET), 1201 patients followed in 11 Hematological centers in the Latium region were retrospectively evaluated. At multivariate analysis, the following factors at diagnosis were predictive for a worse Thrombosis-free Survival (TFS): the occurrence of previous thrombotic events (p = 0.0004), age greater than  60 years (p = 0.0044), spleen enlargement (p = 0.042) and a lower PLT count (p = 0.03). Receiver Operating Characteristic (ROC) analyses based on thrombotic events during follow-up identified a baseline platelet count of 944 × 109/l as the best predictive threshold: thrombotic events were 40/384 (10.4%) in patients with PLT count greater than 944 × 109/l and 109/817 (13.3%) in patients with PLT count less than 944 × 109/l, respectively (p = 0.04). Patients with PLT count less than 944 × 109/l were older (median age 60.4 years. vs 57.1 years., p = 0.016), had a lower median WBC count (8.8 × 109/l vs 10.6 × 109/l, p less than 0.0001), a higher median Hb level (14.1 g/dl vs 13.6 g/dl, p less than 0.0001) and a higher rate of JAK-2-V617F positivity (67.2% vs 41.6%, p less than 0.0001); no difference was observed as to thrombotic events before diagnosis, spleen enlargement and concomitant Cardiovascular Risk Factors. In conclusion, our results confirm the protective role for thrombosis of an high PLT count at diagnosis. The older age and the higher rate of JAK-2 V617F positivity in the group of patients with a baseline lower PLT count could in part be responsible of this counterintuitive finding.

The last sentence helps explain the paradox.

Friday, September 22, 2017

Adult onset Still’s disease

Thursday, September 21, 2017

Epinephrine in cardiac arrest: how strongly is it supported by the evidence?


Sudden cardiac arrest accounts for approximately 15% of deaths in developed nations, with poor survival rate. The American Heart Association states that epinephrine is reasonable for patients with cardiac arrest, though the literature behind its use is not strong.


To review the evidence behind epinephrine for cardiac arrest.


Sudden cardiac arrest causes over 450,000 deaths annually in the United States. The American Heart Association recommends epinephrine may be reasonable in patients with cardiac arrest, as part of Advanced Cardiac Life Support. This recommendation is partly based on studies conducted on dogs in the 1960s. High-dose epinephrine is harmful and is not recommended. Epinephrine may improve return of spontaneous circulation, but does not improve survival to discharge or neurologic outcome. Literature suggests that three phases of resuscitation are present: electrical, circulatory, and metabolic. Epinephrine may improve outcomes in the circulatory phase prior to 10 min post arrest, though further study is needed. Basic Life Support measures including adequate chest compressions and early defibrillation provide the greatest benefit.


Epinephrine may improve return of spontaneous circulation, but it does not improve survival to discharge or neurologic outcome. Timing of epinephrine may affect patient outcome, but Basic Life Support measures are the most important aspect of resuscitation and patient survival.

Wednesday, September 20, 2017

EMRs slow physicians down and distract from real clinical care

Tuesday, September 19, 2017

An automated warning system for deteriorating ward patients modestly improved outcomes


Delayed response to clinical deterioration of ward patients is common.


We performed a prospective before-and-after study in all patients admitted to two clinical ward areas in a district general hospital in the UK. We examined the effect on clinical outcomes of deploying an electronic automated advisory vital signs monitoring and notification system, which relayed abnormal vital signs to a rapid response team (RRT).


We studied 2139 patients before (control) and 2263 after the intervention. During the intervention the number of RRT notifications increased from 405 to 524 (p = 0.001) with more notifications triggering fluid therapy, bronchodilators and antibiotics. Moreover, despite an increase in the number of patients with “do not attempt resuscitation” orders (from 99 to 135; p = 0.047), mortality decreased from 173 to 147 (p = 0.042) patients and cardiac arrests decreased from 14 to 2 events (p = 0.002). Finally, the severity of illness in patients admitted to the ICU was reduced (mean Acute Physiology and Chronic Health Evaluation II score: 26 (SD 9) vs. 18 (SD 8)), as was their mortality (from 45% to 24%; p = 0.04).


Deployment of an electronic automated advisory vital signs monitoring and notification system to signal clinical deterioration in ward patients was associated with significant improvements in key patient-centered clinical outcomes.

This sort of thing has great potential if usage is optimized. Unfortunately, RRT usage has gone far beyond the original intent and unintended consequences abound.

Monday, September 18, 2017

Risk factors for atrial fibrillation in the elderly

Comprehensive free full text review.

Sunday, September 17, 2017

A pleural effusion may have more than one etiology

---especially given recent trends toward increasingly frequent complex comorbidities. From a recent review:


Purpose of review: Historically, pleural effusions have been attributed to a single cause. There is growing recognition that a substantial proportion of pleural effusions may have more than one underlying cause. The purpose of this review is to summarise recent findings regarding the diagnosis and treatment of effusions secondary to more than one aetiology.

Recent findings: A recent prospective study identified that 30% of pleural effusions had more than one underlying aetiology. With a rising prevalence of cardiovascular and malignant disease, the incidence of the complex pleural patient is increasing. The use of biomarkers, including pro-B-type natriuretic peptide, have been suggested as a way of identifying contributing disease process.

Summary: Understanding that there are potentially concurrent causes to a pleural effusion is vital in establishing the diagnoses of multiple underlying aetiologies. New diagnostic pathways, with increasing use of biomarkers, will be required to identify the complex pleural effusion. Further studies on whether the targeting of separate aetiologies improves outcomes will help develop future management strategies.