Podcasts from the American Thoracic Society

Lots of good stuff here.

New alcoholic liver disease guidelines from the American College of Gastroenterology

Free full text available.

The document is worth reading in its entirety, but there were a few points I found particularly noteworthy:

Patients who are obese should not consume any ethanol at all!

Definitions, from the paper:

Alcoholic fatty liver disease is diagnosed in a patient with AUD with hepatic steatosis on ultrasound and/or elevation in liver enzymes (aspartate aminotransferase (AST) greater than alanine aminotransferase (ALT)), serum bilirubin less than 3 mg/dL, and the absence of other causes of liver disease.

Clinical diagnosis of AH is determined in a patient with rapid development or worsening of jaundice and liver-related complications, with serum total bilirubin greater than 3 mg/dL; ALT and AST elevated greater than 1.5 times the upper limit of normal but less than 400 U/L with the AST/ALT ratio greater than 1.5; documentation of persistent heavy alcohol use until 8 weeks before onset of symptoms; and exclusion of other liver diseases

Baclofen to help patients stop drinking has a conditional recommendation:

In patients with ALD, baclofen is effective in preventing alcohol relapse (Conditional recommendation, low level of evidence).

Pentoxifylline is no longer recommended for severe alcoholic hepatitis. Steroids still are.

At 7 days into steroid therapy the Lille score should be used to determine if the steroids should be continued:

Response to treatment with corticosteroids should be determined at 7 days using the Lille score. Treatment should be discontinued among non-responders to therapy, defined as those with a Lille score greater than 0.45.

The guideline authors acknowledge evidence that N-acetylcysteine infusion in combination with steroids may be associated with improved outcomes in AH. However, they do not feel the evidence is sufficiently strong to justify a guideline recommendation.

Antibiotic therapy is still recommended as part of the overall treatment regimen for variceal bleeding:

Management of the acute variceal bleeding episode involves pharmacological therapy with available vasoactive agents (terlipressin or octreotide), antibiotics, and endoscopic therapy. Endoscopy should ideally be carried out at least 30 min after initiation of vasoactive therapy (54).

As for the optimal timing of endoscopy, that last sentence is confusing to me.

Have a low threshold for starting broad spectrum antibiotics in AH patients who become critical.  

Concerning the gram negative component of the regimen, the guideline recommends merropenem or zosyn, acknowledging that the clinician should pay attention to local sensitivity patterns:

The choice of antibiotics depends on prevailing local antimicrobial resistance patterns. Piperacillin-tazobactam is generally the preferred drug used for sepsis, although vancomycin and meropenem may be considered in patients with penicillin hypersensitivity.

There’s much more.

Autoimmune hemolytic anemia

Case report and review.

Medical cannabis laws related to increased illicit use and use disorders

From JAMA Psychiatry.

Measles information for hospitalists

It’s a shame that a review like this even needed to be written in 2017.

What is a master clinician-teacher?

Via Nephron Power.

A case illustrating the differential diagnosis of long RP tachycardia

Read here.

Idiopathic paroxysmal AV block due to low baseline adenosine levels and heightened receptor sensitivity

This is a fairly recently described entity:

Idiopathic paroxysmal AV block poses a true diagnostic challenge. Although it is true that the clinical presentation does not differ from that of another cardiogenic syncope, the diagnosis of this block requires the lack of a structural cardiac pathology that justifies the observed manifestations and an absence of electrocardiographic disorders prior to an episode. For diagnosis, it is useful the implantable loop recorder to substantiate AV block paroxysms and assess their clinical correlations.

The mechanism associated with idiopathic paroxysmal AV block is unknown. It has been postulated that patients with low basal adenosine levels exhibit hyperaffinity of the adenosine receptors of the AV node. No relevant data have been reported, so it´s necessary that more studies are needed to confirm this hypothesis.

The prognosis of idiopathic paroxysmal AV block is favorable, given the paroxysmal profile of the AV block and the low probability of degeneration into permanent forms of AV block. Permanent stimulation devices can be employed to prevent and avoid the recurrence of syncopal episodes in patients with idiopathic paroxysmal AV block.

Atypical presentation of retroperitoneal hematoma 3 weeks after IVC filter insertion

Report here.

Pitfalls in ICU management

This article in Today's Hospitalist, drawn from recent talks at the UCSF hospitalist conference, has a lot of pearls. Most of the admonitions are about avoiding knee jerk care.

The real gem comes in her discussion of the importance of de-escalation of IV fluids:

“Multiple studies have replicated that, even in sepsis,” Dr. Santhosh noted. “After initial resuscitation with early goal-directed therapy, you want a maintenance or stabilization phase and then de-escalation.” That could mean active diuresis in patients to attain a negative fluid balance once they’re off pressors.

And while it can be a challenge to find the maintenance fluids in your EHR to discontinue them…

That’s right. She said, in effect, that the EHR interferes with the clinician’s ability to discontinue potentially harmful IV fluids. The statement rings true and concerns one of those key provisions of meaningful use: CPOE. Meaningful to patients for sure if it interferes with their care with the potential for harm.

Hypothyroidism and heart disease

Free full text review.

From the review:

Hypothyroidism can result in decreased cardiac output, increased systemic vascular resistance, decreased arterial compliance, and atherosclerosis.

Impaired cardiac muscle relaxation, decreased heart rate, and decreased stroke volume contribute to heart failure in hypothyroidism.

Subclinical hypothyroidism is associated with ischemic heart disease and increased cardiovascular mortality.

Treatment of hypothyroidism may have a beneficial impact on several parameters of cardiac dysfunction, including subclinical hypothyroidism, especially in younger individuals.

Cardiac manifestations of hyperthyroidism

Free full text review.

Hyperparathyroidism

This wonderful free full text review has everything you want to know and probably more.

Hyper- and hypokalemia in the ER

From a recent study:

Conclusion

Hyperkalemia or hypokalemia occur in 1 of 11 ED patients and are associated with inpatient admission and mortality. Treatment of hyperkalemia varies greatly suggesting the need for evidence-based treatment guidelines.

Insulin autoimmune syndrome aka Hirata disease

It’s caused by spontaneous development of insulin antibodies (no prior exposure to insulin). If that’s the case why does it cause hypoglycemia and not just hyperglycemia? From a review:

Although the precise mechanism for hypoglycemia in IAS is unknown, the most widely accepted hypothesis is a mismatch between blood glucose and free insulin concentration, secondary to the binding and release of secreted insulin by autoantibodies.7 Following a meal or oral glucose load, glucose concentration in the bloodstream rises, providing a stimulus for insulin secretion. Autoantibodies bind to these insulin molecules, rendering them unavailable to exert their effects. The resultant hyperglycemia not only promotes further insulin release, but may also explain the increased hemoglobin A1c often seen in IAS patients.6 As glucose concentration eventually falls, insulin secretion also subsides, and the total insulin level decreases. Insulin molecules spontaneously dissociate from the autoantibodies at this time, giving rise to a raised free insulin level inappropriate for the glucose concentration, evoking hypoglycemia.7 Insulin autoantibodies with a high binding capacity and a low affinity are more likely to bring about hypoglycemic symptoms.10 Medications containing a sulfhydryl group have been proposed to induce autoantibody formation by interacting with the disulfide bonds of the insulin molecule and augmenting its immunogenicity;11 however, the true underlying pathophysiology remains unclear at this time. Rarely, the co-existence of both insulin autoantibodies and insulin receptor autoantibodies within the same patient has been described.12

Physician burnout: a public health crisis

An article looks at how it affects hospitalists.

Burn out drivers for hospitalists: being employees; being robbed of their autonomy as clinicians (after all they just want to be doctors); being given another job (ward secretary, aka CPOE) without additional compensation. One could go on and on.

Ramping up the inhaled steroids at the first sign asthma of exacerbation

---reduced progression to severe exacerbation in adults and adolescents.

A similar trial conducted in children, published in the same issue of NEJM, no benefit and a risk of stunted growth.

Apps you can use

I found some good ones I had not heard about in this list.

Can someone explain to me why I need AHRQ?

According to this Kevin MD post we'll all suffer if it becomes marginalized anymore than it already is. I've never used it. What am I missing?

Hereditary hemorrhagic telangectasia

Free full text review.

Renin-angiotensin blockade in heart failure with preserved EF? Mixed results.

From a recent review:

Studies with angiotensin‐converting enzyme inhibitors (ACE‐Is) and angiotensin receptor blockers (ARBs) in patients with heart failure with preserved ejection fraction (HFpEF) have yielded inconsistent results. To conduct a systematic review and meta‐analysis of all evidence for ACE‐I and ARBs in patients with HFpEF, we searched PubMed, Ovid SP, Embase, and Cochrane database to identify randomized trials and observational studies that compared ACE‐I or ARBs against placebo or standard therapy in HFpEF patients. Random‐effect models were used to pool the data, and I 2 testing was performed to assess the heterogeneity of the included studies. A total of 13 studies (treatment arm = 8676 and control arm = 8608) were analysed. Pooled analysis of randomized trials for ACE‐I and ARBs (n = 6) did not show any effect on all‐cause mortality [relative risk (RR) = 1.02, 95% confidence interval (CI) = 0.93–1.11, P = 0.68, I 2 = 0%], while results from observational studies showed a significant improvement (RR = 0.91, 95% CI = 0.87–0.95, P = 0.005, I 2 = 81.5%). In pooled analyses of all studies, ACE‐I showed a reduction of all‐cause mortality (RR = 0.91, 95% CI = 0.87–0.95, P = 0.01). There was no reduction in cardiovascular mortality seen, but in pooled analysis of randomized trials, there was a trend towards reduced HF hospitalization risk (RR = 0.91, 95% CI = 0.83–1.01, I 2 = 0%, P = 0.074). These data suggest that ACE‐I and ARBs may have a role in improving outcomes of patients with HFpEF, underscoring the need for future research with careful patient selection, and trial design and conduct.

Not challenging science is anti-science??

But I thought science was inherently self-challenging. To Dr. John’s credit, though, he does make some good points about the thought police. They’re everywhere in medicine.

Doctors in the US make too much money

---according to a policy wonk at one progressive think tank. So, says he, we must apply pressure from all sides to break up the cartel and reduce doctors’ pay. The fact that patients generally like their doctors doesn’t help.

Valproic acid overdose

Case report and literature review.

Blood letting for the common cold?

This is the kind of thing I would expect to find in BMJ, maybe, but not in the journal Medicine. I hear it didn’t go well for George Washington.

Cardiovascular disease in acromegaly

Free review.

New trends in GERD

Severe adverse effects of PPIs are increasingly recognized so now what?

Inappropriate antibiotic prescribing for patients sent home from the ER

An opportunity for education:

Results

Of 1579 ED antibiotic prescriptions in 2015, we reviewed a total of 159 (10.1%) prescription records. The most frequently prescribed antimicrobial classes included penicillins (22.6%), macrolides (20.8%), cephalosporins (17.6%), and fluoroquinolones (17.0%). The most common indications for antibiotics were bronchitis or upper respiratory tract infection (URTI) (35.1%), followed by skin and soft tissue infection (SSTI) (25.0%), both of which were the most common reason for unnecessary prescribing (28.9% of bronchitis/URTIs, 25.6% of SSTIs). Of the antimicrobial prescriptions reviewed, 39% met criteria for inappropriateness. Among 78 prescriptions with a consensus on appropriate indications, 13.8% had inappropriate dosing, duration, or expense.

Conclusion

Consistent with national outpatient prescribing, inappropriate antibiotic prescribing in the ED occurred in 39% of cases with the highest rates observed among patients with bronchitis, URTI, and SSTI. Antimicrobial stewardship programs may benefit by focusing on initiatives for these conditions among ED patients. Moreover, creation of local guideline pocketbooks for these and other conditions may serve to improve prescribing practices and meet the Core Elements of Outpatient Stewardship recommended by the Centers for Disease Control and Prevention.

Gastroparesis

Free full text review.