In this small cohort of patients with confirmed temporal arteritis who underwent bilateral temporal artery biopsies (n=51), 13 of them had pathologic confirmation on only 1 of the 2 biopsies. This indicates that 13% of unilateral biopsies will miss the pathologic diagnosis, and that bilateral biopsies may be worth performing for the increased diagnostic yield (abstract)
In patients with foley or condom catheters, many have asymptomatic bacteriuria. In this retrospective cohort of 280 hospitalized patients with a urinary catheter and positive urine culture (>10,000 cfu), 164 (59%) had no symptoms (fever, urgency, frequency, dysuria, suprapubic tenderness, mental status change, or low BP). Of these, 32% were inappropriately treated with antibiotics. Many inpatients with catheter-associated bacteriuria are asymptomatic, and are being over-treated with antibiotics (abstract).
In this validation cohort of 89 patients with Cdiff, 3 clinical factorswere used to predict recurrence, including age >65, need for antibiotics after Cdiff treatment, or severe/fulminant illness (based on the 4 point Horn Index, which is a clinical judgement of severity of illness; mild, moderate, severe or fulminant). Those with 0-1 risk factors had recurrence risk of 13%, and those with 2-4 risk factors had recurrence risk of 37% (with an AUC of 0.80, CI 0.67-0.92). This simple clinical prediction rule can help facilitate prompt recognition, diagnosis, and treatment of patients at risk for recurrent (abstract).
In this phase 2 trial, patients with acute CHF, HTN (SBP >125) and mild-to-moderate renal insufficiency (GFR 30-75) were randomized to placebo or several doses of relaxin (human peptide that increases vasodilation and renal function). The relaxin group had improved dyspnea scores, shorter length of stay, and reduced CV death/CHF readmissions. Serious adverse events were similar between the groups. If confirmed in phase 3 studies, this will likely be a valuable addition to inpatient management of acute CHF (abstract).
In this retrospective cohort of patients in the ICD registry, researchers evaluated outcomes of patients with an ICD implanted as a function of the specialty of physician that performed the procedure (71% by EP, 22% by non-EP cardiology, 2% by thoracic surgery, and 6% by other specialties). Compared to EP, adjusted in-hospital procedural complication rates were higher for non-EP cardiologists (RR 1.11, RR 1.01-1.21) and thoracic surgeons (RR 1.44, CI 1.15-1.79). Patients eligible for cardiac resynchronization therapy were also less likely to receive such a device if implanted by non-EP specialists. If your patient needs an ICD, seems best to call EP if available (abstract).
In this prospective cohort of over 400 non-diabetic patients undergoing vascular surgery, they all underwent fasting and oral glucose tolerance (OGTT) before surgery, and followed for up to 3 years after surgery. Of the 404 patients, 26% were found to have impaired glucose tolerance (fasting blood sugar 100-125 or OGTT 140-199) and another 11% were found to have diabetes (fasting >126 or OGTT > 200). Those with impaired tolerance had a much greater risk of long term cardiovascular events than normal controls (HR 2.77, CI 1.83-4.2). The authors call for routine fasting and OGTT testing on all vascular surgery patients, although this likely needs to be validated and assessed for cost-effectiveness across other institutions before routine use (abstract).
The Journal of the American College of Cardiology has issued a White Paper outlining the indications for cardiac MRI in patients with suspected myocarditis. Indications include: symptoms (CP, SOB, palpitations, etc), signs of myocardial injury (ventricular dysfunction, ECG changes, or elevated biomarkers), and suspected viral etiology (recent viral illness, previous myocarditis, no evidence of CAD) (article). Cardiac MRI is rapidly becoming the imaging test of choice in patients with suspected myocarditis.
| Dyspnea ororthopnea or palpitations or effort intolerance/malaise or chest pain | Ventricular dysfunction or new or persisting ECG abnormalities orelevated troponin | History of recent systemic viral disease or previous myocarditis or absence of risk factors for coronary artery disease or age <35 yrs orsymptoms not explained by coronary stenosis on coronary angiogram orrecent negative ischemic stress test |
There are now 20 lab-confirmed cases of swine influenza A (H1N1) in 5 states in the US, hundreds of confirmed cases in Mexico, 6 in Canada, and suspected cases in Spain and New Zealand. The CDC is recommending anyone with an influenza-like illness be tested (according to CDC recommendations, see website), and treated with zanamivir or a combination of oseltamivir + amantadine or rimantadine. Stay tuned.
Higher body temperature has been associated with poor functional outcomes in patients with CVA. This multicenter trial randomized CVA patients (temp 36-39 C) to paracetamol (1gram q4 for 3 days) or placebo within 12 hours. Although there was no overall difference in the primary outcome (improvement beyond expectation), subgroup analysis did show improvement in those with temp 37-39 C, and no difference in serious adverse events between the 2 groups. An editorialist agrees that this seemingly innocuous intervention is likely highly valuable in CVA patients with elevated body temperatures (abstract)
As the literature swells with studies re-evaluating the risks and benefits of tight glucose control, this new study adds more caution to tight control. In this longitudinal cohort of over 16,000 patients age >65 with diabetes, the number of hypoglycemic episodes linearly increased their risk of incident dementia. This study and others dampen our enthusiasm for overly tight glucose control in diabetics (abstract).