Sunday, January 25, 2015

Palliative care in the ICU

Palliative care is increasingly being recognized as a part of definitive critical care regardless of prognosis. Review here.

Via Hospital Medicine Virtual Journal Club.

Are corticosteroids beneficial for cardiac sarcoidosis?

From a recent systematic review:

Background
There are no published clinical consensus guidelines or systematic evaluation supporting the use of corticosteroids for the treatment of cardiac sarcoidosis. The purpose of this study was to systematically review the published data...

Results
A total of 1491 references were retrieved and 10 publications met the inclusion criteria. There were no randomized trials and all publications were of poor to fair quality. In the 10 reports, 257 patients received corticosteroids and 42 patients did not. There were 57 patients with AV conduction disease treated with corticosteroids, with 27/57 (47.4%) improving. In contrast, 16 patients were not treated with corticosteroids and 0/16 improved. Four publications reported on left ventricular function recovery, 2 reported on ventricular arrhythmia burden, and 9 reported on mortality. However, the data quality were too limited to draw conclusions for any of these outcomes.


Conclusions
Our systematic review identified 10 publications reporting outcomes after corticosteroid therapy. The best data relates to AV conduction recovery and corticosteroids appeared to be beneficial. It is not possible to draw clear conclusions about the utility of corticosteroids for the other outcomes. There is a clear need for large multicentre prospective registries and trials in this patient population.

Friday, January 23, 2015

The ECG in stress cardiomyopathy versus acute coronary syndrome

I've blogged this topic a couple of times before. Though the two conditions are superficially similar clinically and electrocardiographically they are completely different pathologically. It makes sense that there would be distinctions evident on close examination. Here is another paper on the electrocariographic differences. From the paper:
T inversion and ST elevation mainly appear in precordial leads and more rarely in limb leads. The duration of ST elevation is short, whereas that of T inversion is long. In some cases, T inversion appears for a while after ST elevation begins, disappears, and then begins to appear again. Differences between these two forms require prospective studies with more patients.

It was also pointed out in the paper that patients with stress cardiomyopathy did not exhibit reciprocal ST depressions whereas sinus tachycardia was common. Note that sinus tachycardia is not generally a manifestation of ACS per se and when present is an ominous sign, signifying acute heart failure or cardiogenic shock.

Thursday, January 22, 2015

The use of ultrasound in the diagnosis of vasculitis

It can be a powerful tool in large vessel vasculitis, particularly GCA:
Colour Doppler ultrasound displays a pathognomonic circumferential wall thickening in large-vessel vasculitis. Even rather small arteries like the temporal arteries can be easily examined with modern ultrasound equipment. In addition, ultrasound can detect stenoses and acute arterial occlusions. In large-vessel giant cell arteritis, the axillary arteries are most commonly involved. Takayasu arteritis affects particularly the left subclavian and the left common carotid arteries. As ultrasound diagnosis at the temporal arteries becomes more difficult already after a few days of glucocorticoid treatment in some patients, institutions are implementing fast-track clinics for which patients receive an appointment within 24 hours. An experienced rheumatologist is able to establish a definite diagnosis in most cases with standardised history, clinical examination and ultrasound of temporal and axillary arteries. Furthermore, early diagnosis and treatment may prevent blindness.

Via Hospital Medicine Virtual Journal Club.

Wednesday, January 21, 2015

Fusarium infections

From a recent review:

Fusarium species is a ubiquitous fungus that causes opportunistic infections. We present 26 cases of invasive fusariosis categorized according to the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) criteria of fungal infections. All cases (20 proven and 6 probable) were treated from January 2000 until January 2010. We also review 97 cases reported since 2000. The most important risk factors for invasive fusariosis in our patients were compromised immune system, specifically lung transplantation (n = 6) and hematologic malignancies (n = 5), and burns (n = 7 patients with skin fusariosis), while the most commonly infected site was the skin in 11 of 26 patients. The mortality rates among our patients with disseminated, skin, and pulmonary fusariosis were 50%, 40%, and 37.5%, respectively. Fusarium solani was the most frequent species, isolated from 49% of literature cases. Blood cultures were positive in 82% of both current study and literature patients with disseminated fusariosis, while the remaining 16% had 2 noncontiguous sites of infection but negative blood cultures. Surgical removal of focal lesions was effective in both current study and literature cases.
Skin lesions in immunocompromised patients should raise the suspicion for skin or disseminated fusariosis. The combination of medical monotherapy with voriconazole or amphotericin B and surgery in such cases is highly suggested.

Tuesday, January 20, 2015

Trends in physical activity and obesity

From the green journal:

Methods

Univariate and multivariate analyses were performed using National Health and Nutrition Examination Survey data.

Results

Average body mass index (BMI) increased by 0.37% (95% confidence interval [CI], 0.30-0.44) per year in both women and men. Average waist circumference increased by 0.37% (95% CI, 0.30-0.43) and 0.27% (95% CI, 0.22-0.32) per year in women and men, respectively. The prevalence of obesity and abdominal obesity increased substantially, as did the prevalence of abdominal obesity among overweight adults. Younger women experienced the greatest increases. The proportion of adults who reported no leisure-time physical activity increased from 19.1% (95% CI, 17.3-21.0) to 51.7% (95% CI, 48.9-54.5) in women, and from 11.4% (95% CI, 10.0-12.8) to 43.5% (95% CI, 40.7-46.3) in men. Average daily caloric intake did not change significantly. BMI and waist circumference trends were associated with physical activity level but not caloric intake. The associated changes in adjusted BMIs were 8.3% (95% CI, 6.9-9.6) higher among women and 1.7% (95% CI, 0.68-2.8) higher among men with no leisure-time physical activity compared with those with an ideal level of leisure-time physical activity.

Which interventions are most effective in reducing heart failure admissions and mortality?

From a recent systematic review:

Data Synthesis: Forty-seven trials were included. Most enrolled adults with moderate to severe HF and a mean age of 70 years. Few trials reported 30-day readmission rates. At 30 days, a high-intensity home-visiting program reduced all-cause readmission and the composite end point (all-cause readmission or death; low SOE). Over 3 to 6 months, home-visiting programs and multidisciplinary heart failure (MDS-HF) clinic interventions reduced all-cause readmission (high SOE). Home-visiting programs reduced HF-specific readmission and the composite end point (moderate SOE). Structured telephone support (STS) interventions reduced HF-specific readmission (high SOE) but not all-cause readmissions (moderate SOE). Home-visiting programs, MDS-HF clinics, and STS interventions produced a mortality benefit. Neither telemonitoring nor primarily educational interventions reduced readmission or mortality rates.
Limitations: Few trials reported 30-day readmission rates. Usual care was heterogeneous and sometimes not adequately described.
Conclusion: Home-visiting programs and MDS-HF clinics reduced all-cause readmission and mortality; STS reduced HF-specific readmission and mortality. These interventions should receive the greatest consideration by systems or providers seeking to implement transitional care interventions for persons with HF.