Internal Medicine News
Orthostatic Syndromes Differ in Syncope Frequency
There are conflicting opinions on whether postural tachycardia syndrome predisposes to syncope. We investigated this relationship by comparing the frequency of syncope in postural tachycardia syndrome and orthostatic hypotension. Of 810 patients referred for postural tachycardia syndrome, 185 met criteria while another 328 patients had orthostatic hypotension. Of the postural tachycardia syndrome patients, 38% had syncope on head-up tilt, compared with only 22% of those with orthostatic hypotension (P<.0001). In the postural tachycardia group, syncope on head-up tilt was associated with a clinical history of syncope in 90%, whereas absence of syncope on head-up tilt was associated with a clinical history of syncope in 30% (P
<.0001). In contrast, syncope on head-up tilt did not bear any relationship to clinical history of syncope in the orthostatic hypotension group (41% vs 36%; P=.49). results demonstrate that syncope (both tilt table and clinical) occurs far more commonly in patients who have postural tachycardia syndrome than in patients with orthostatic hypotension. More Information on Postural Tachycardia Syndrome, also from the National Institute of Health
No Significant Difference in the Rate of Death Between Patients with Shock Treated with Dopamine or Norepinephrine
Both dopamine and norepinephrine are recommended as first-line vasopressor agents in the treatment of shock. There is a continuing controversy about whether one agent is superior to the other. A multicenter, randomized trial was conducted and assigned 1679 patients with shock to receive either dopamine or norepinephrine as first-line vasopressor therapy to restore and maintain blood pressure. There was no significant between-group difference in the rate of death at 28 days (52.5% in the dopamine group and 48.5% in the norepinephrine group; odds ratio with dopamine, 1.17; 95% confidence interval, 0.97 to 1.42; P=0.10). However, there were more arrhythmic events among the patients treated with dopamine than among those treated with norepinephrine (207 events [24.1%] vs. 102 events [12.4%], P<0.001). A subgroup analysis showed that dopamine, as compared with norepinephrine, was associated with an increased rate of death at 28 days among the 280 patients with cardiogenic shock but not among the 1044 patients with septic shock or the 263 with hypovolemic shock.
An Algorithm for Tuberculosis Screening and Diagnosis in People with HIV
Tuberculosis screening is recommended for people with human immunodeficiency virus (HIV) infection to facilitate early diagnosis and safe initiation of antiretroviral therapy and isoniazid preventive therapy. No internationally accepted, evidence-based guideline addresses the optimal means of conducting such screening, although screening for chronic cough is common. A study in the New England Journal of Medicine consecutively enrolled people with HIV infection from eight outpatient clinics. The presence of cough of any duration, fever of any duration, or night sweats lasting 3 or more weeks in the preceding 4 weeks was 93% sensitive and 36% specific for tuberculosis.In persons with HIV infection, screening for tuberculosis should include asking questions about a combination of symptoms rather than only about chronic cough. It is likely that antiretroviral therapy and isoniazid preventive therapy can be started safely in people whose screening for all three symptoms is negative, whereas diagnosis in most others will require mycobacterial culture.
Lactate Clearance vs Central Venous Oxygen Saturation as Goals of Early Sepsis Therapy
A study published in JAMA tested the hypothesis of noninferiority between lactate clearance and central venous oxygen saturation (ScvO2) as goals of early sepsis resuscitation. randomly assigned patients to 1 of 2 resuscitation protocols. The ScvO2 group was resuscitated to normalize central venous pressure, mean arterial pressure, and ScvO2 of at least 70%; and the lactate clearance group was resuscitated to normalize central venous pressure, mean arterial pressure, and lactate clearance of at least 10%. The study protocol was continued until all goals were achieved or for up to 6 hours.Thirty-four patients (23%) in the ScvO2 group died while in the hospital (95% confidence interval [CI], 17%-30%) compared with 25 (17%; 95% CI, 11%-24%) in the lactate clearance group. This observed difference between mortality rates did not reach the predefined –10% threshold concluding additional management to normalize lactate clearance compared with management to normalize ScvO2 did not result in significantly different in-hospital mortality.
Hyponatremia associated with in-hospital mortality and heightened resource consumption
A study out the Archives of Internal Medicine evaluated whether hospital-associated hyponatremia has an independent effect on all-cause mortality, hospital length of stay (LOS), and patient disposition. This cohort study included all adult hospitalizations at an academic medical center occurring between 2000-2007 for which an admission serum sodium concentration ([Na+]) was available. Community-acquired hyponatremia occurred in 37.9% of hospitalizations and was associated with adjusted odds ratios (ORs) of 1.52 for in-hospital mortality and 1.12 for discharge to a short- or long-term care facility and a 14% adjusted increase in LOS. Hospital-acquired hyponatremia developed in 38.2% of hospitalizations longer than 1 day in which initial serum [Na+] was 138 to 142 mEq/L. Hospital-acquired hyponatremia was associated with adjusted ORs of 1.66 for in-hospital mortality and 1.64 (95% CI, 1.55-1.74) for discharge to a facility and a 64% adjusted increase in LOS. The strength of these associations tended to increase with hyponatremia severity.
ICU Catheter Infections Can Be Virtually Eliminated
Catheter-related infections aren't inevitable in the ICU, according to a quality initiative that maintained rates at nearly zero for three years in Michigan hospitals.
The maintenance phase, after initial implementation of low-tech measures such as handwashing and removal of unneeded catheters, saw no rebound in catheter-related infections, Peter J. Pronovost, MD, PhD, of Johns Hopkins, and colleagues reported online in BMJ. Full Text
Single Ultrasound for DVT May Suffice
For patients with suspected deep vein thrombosis, the risk of symptomatic venous thromboembolism after a single, negative whole-leg compression ultrasound examination is low, a meta-analysis showed. Pooled results from seven studies showed the risk to be just 0.57% (95% CI 0.25% to 0.89%) through three months of follow-up in patients who were not given anticoagulants, Scott Stevens, MD, of Intermountain Medical Center in Murray, Utah, and colleagues reported in the Feb. 3 issue of the Journal of the American Medical Association.
Hypocoaguability predicts 30-day ICU survival
Intensive care unit (ICU) patients with hypocoaguability on admission have an increased short-term risk for death, demonstrate the results of a thromboelastography (TEG) study. In addition, patients with hypocoaguability required more ventilator treatment, a higher rate of renal replacement therapy, and more blood products than patients with normal TEG results on admission to the ICU, the Danish team reports in the journal Blood Coagulation and Fibrinolysis.
Adding Fish Oil to IV May Speed Sepsis Recovery
Adding fish oil to intravenous solutions proved beneficial for intensive care patients with the potentially lethal blood infection known as sepsis, a new study finds. The study, published Jan. 19 in the journal Critical Care, compared 13 patients who received fish oil in the normal IV nutrient solution given to patients with sepsis, and 10 patients who received traditional solutions. The patients who received the fish oil had lower levels of inflammatory chemicals in their blood, achieved better lung function, and had a shorter hospital stay.
Insulin pumps may be better than shots
Pumps that deliver insulin to the body as needed may be more effective than insulin injections for helping people with type 1 diabetes keep their blood sugar under control, according to a new review of 23 studies comparing the two approaches.
Chlorhexidine–Alcohol versus Povidone–Iodine for Surgical-Site Antisepsis
A new study from the New England Journal of Medicine hypothesized that preoperative skin cleansing with chlorhexidine–alcohol is more protective against infection than is povidone–iodine. The primary outcome was any surgical-site infection within 30 days after surgery. Secondary outcomes included individual types of surgical-site infections. The overall rate of surgical-site infection was significantly lower in the chlorhexidine–alcohol group than in the povidone–iodine group. Chlorhexidine–alcohol was significantly more protective than povidone–iodine against both superficial incisional infections and deep incisional infections
Continuation of Low-Dose Aspirin Therapy in Peptic Ulcer Bleeding
It is uncertain whether aspirin therapy should be continued after endoscopic hemostatic therapy in patients who develop peptic ulcer bleeding while receiving low-dose aspirin. In a parallel randomized, placebo-controlled noninferiority trial, in which both patients and clinicians were blinded to treatment assignment. It was shown that among low-dose aspirin recipients who had peptic ulcer bleeding, continuous aspirin therapy may increase the risk for recurrent bleeding but potentially reduces mortality rates. Larger trials are needed to confirm these findings.
Statins Decrease the Occurrence of Venous Thromboembolism in Patients with Cancer
Recent data suggest a reduction in the occurrence of venous thromboembolism in select groups of patients who use statins. The objective of this study is to evaluate the impact of statin use on the occurrence of venous thromboembolism in patients with solid organ tumor. The occurrence of venous thromboembolism was 18% (N=132), and 26% (N=194) were receiving statins. Among patients receiving statins, 8% (N=16) developed a venous thromboembolism compared with 21% (N=116) in the control group (odds ratio 0.33; 95% confidence interval, 0.19-0.57). American Journal of Medicine Abstract
