Jun 28, 2019

Sensitivity training

The story

Summertime means sweat and smells in an overcrowded ED. Can high sensitivity troponin help clear the hallways?

The background

While 6 hours in the hospital pass before you can blink, low-risk patients with chest pain have more to do than wait for a repeat blood draw. High sensitivity troponin (hsT) detects troponin at greater sensitivity than traditional tests and can detect clinically significant short-interval changes. The assay, which was FDA-approved in the US in 2017 after years of use in other parts of the world, has been controversial since inception. Critics worry hsT could lead to excessive testing without actually changing outcomes. Supporters say the more precision, the better. 

The study

COMPASS-MI drew upon a trove of available hsT trials – 22,000 patients across 15 studies – to make risk-estimation diagrams for low and high hsT results. For patients presenting to the ED with chest pain, a low hsT that held steady on repeat draw 45 to 120 minutes later could safely rule out myocardial infarction (MI) in over 50% of patients, and such patients had a low risk of MI at 30 days. Intermediate hsT levels were associated with an increased risk of death at 1 and 2 years even when MI was ruled out in the acute setting, suggesting these patients could benefit from closer follow up. 

The takeaway

If the role for hsT has always been a bit unclear, COMPASS-MI offers support for its use as an ED triage tool and as a biomarker for risk of future cardiac disease. Whether the test will gain further acceptance in the US remains unclear. 

Say it on rounds

When someone forgot to put the blood gas on ice

Acidic results can be hard to trust, but not in chronic kidney disease (CKD). Veverimer is a once-daily oral med that binds acid in the gut to promote base absorption. A RCT of 200 patients with CKD and metabolic acidosis found that more patients (63% vs. 38%) saw a meaningful increase in bicarb levels with veverimer than placebo at 1 year with minimal adverse effects. Treatment patients also saw improvements in physical function, though critics question the use of placebo rather than a standard-of-care treatment like sodium bicarb. 

When 'culture' during the work week means waiting for GNRs to speciate

The T2Bacteria (T2B) Panel uses PCR amplification to identify 5 of the 6 ESKAPE bacteria in bloodstream infections. A prospective study comparing a single set of blood cultures to T2B in 1,400 patients found that the panel identified ESKAPE organisms faster than blood cultures (about 3 - 7 hours vs. a mean of 70 hours) with sensitivity and specificity around 90%. Hospitals may seek proof that the FDA-approved panel impacts clinical outcomes before widespread adoption.

When the scrub machine actually has a size medium

A little change works wonders. Old ICU pal Ketamine was recently FDA-approved for refractory depression, and now a small study of ketamine in cocaine abuse found that the drug improved abstinence rates at 2-weeks (48% vs. 11%) compared to midazolam. Participants were drawn from mindfulness-based relapse prevention programs and received a single 40-minute infusion of ketamine or midzaolam during a 5-day inpatient stay. Craving scores were 58% lower in the ketamine group.  
Am J Psychiatry

Brush up


What your grandma calls heatstroke is probably just dehydration or heat exhaustion. Medical heatstroke is the most severe of overheating illnesses and follows the clinical triad of hyperthermia, neurologic abnormalities, and hot weather or physical activity exposure. Classic heatstroke – expected to grow more common with climate change – occurs when individuals (often the elderly) are unable to compensate for excessive heat, while exertional heatstroke is tied to intense physical activity.

Get meta

With rapid cooling in heatstroke. Time is of the essence despite many unfounded myths about the danger of lowering body temperature too quickly. A 2009 systemic review of 7 studies found that ice-water immersion produced the most rapid cooling rate (0.35°C/min with ice at 2°C) among interventions studied. Ice packs, cold packs, wet gauze sheets, and fanning are also effective and can be used in a pinch, especially in classic heatstroke when EDs can be overrun with afflicted patients. 

What your public health friends are talking about

San Francisco is hitting the pause button on sales for all e-cigarettes that have not undergone pre-market review by the FDA. The catch? None have, meaning SF is the first US city to ban e-cigs.


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