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May 17, 2019

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The story

With all the junk mail you receive from hospitals in South Dakota, we’re guessing it's been a while since envelopes caught your eye. Here’s how they’re being put to good use in cardiac devices.

The background

You know how central line kits have that gooey antibiotic seal? Imagine similar protection for cardiac implantable electronic devices (CIED). Though rare, device infections are associated with increased mortality and risky extraction procedures, not to mention big dollars. So while sterile procedure and prophylactic antibiotics go a long way, there's room to go a step further – in this case through the use of an absorbable antibiotic-eluting envelope with minocycline and rifampin – to protect CIEDs and surrounding tissues.

The study

WRAP-IT randomized 7,000 patients undergoing CIED pocket revision or initial implantation to receive their device in an envelope or via standard of care. Over mean follow-up of 21 months, the envelope cut the rate of device infections by 40% (0.7% in the intervention group vs. 1.2% in controls) without an increase in procedural complications. And while envelopes are fully absorbed within 2 months, benefits were evident up to 3 years after device placement.
NEJM

The takeaway

Whether through use of envelopes or other local therapies, taking extra caution with pacemakers seems to pay off down the line. Expect to see similar strategies in your EP lab soon.

Say it on rounds

When your favorite character perished in season 8

Not surprising. But you'll be alarmed to know that pregnancy-related mortality rose in the US between 2011 - 2015 despite falling throughout the rest of the world. CDC surveillance data classified 60% of pregnancy-related deaths as preventable and identified a large racial disparity in maternal mortality. Black women had the highest pregnancy-related mortality ratio (43 / 100,000 live births), more than 3x non-Hispanic white women (13 / 100,000 live births). Cardiovascular causes, including cardiomyopathy, were implicated in over 33% of deaths.
MMWR

When your patient one-liner is half a page

Comorbidities galore. A population cohort study comparing Swedish patients with type 2 diabetes (T2D) to matched controls found that those with T2D were more than twice as likely to develop non-alcoholic fatty liver disease (NAFLD) over 8-year follow up. Risk factors associated with severe liver disease and T2D include advanced age, male sex, and usual suspects smoking, hypertension, kidney disease and BMI.
Clin Gastroenterol Hepatol

When you reach for scrubs on your day off

Change can be hard. A registry analysis of over 2,500 US outpatients with heart failure with reduced ejection fraction (HFrEF) found that over 80% of patients did not have their meds titrated over 12-month follow up. Investigators focused on meds with proven mortality benefit – ACE/ARBs, beta blockers, spironolactone – and found that less than 1% of patients received the target dose of all medications. Those with lower EF and / or recent hospitalization were more likely to have their meds adjusted.
JACC
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Fewer errands, more sleep

Like the rest of your to-do list, you’d figure out disability insurance if you only had the time. Get acclimated to the basics with LeverageRx’s Ultimate Guide to Physician Disability Insurance, then schedule a call with experts to dive into your specific needs. It takes < 5 minutes to check rates from all major providers. LeverageRx focuses exclusively on docs and knows how to work around your schedule.

Brush up

Acute encephalitis

Focal neurologic deficits, seizures, neurologic disability, and, well, encephalopathy are all symptoms of acute encephalitis. Viral infection is the most common etiology followed by autoimmune disorders. Take a careful history that includes recent illness, sick contacts, travel, ingestions, and reasons for immunocompromise, then start your workup with lumbar puncture, MRI and EEG. Focus on stabilizing seizures and elevated intracranial pressure before aiming treatments at suspected causes.

What's the evidence

For prompt treatment with empiric acyclovir in acute encephalitis? Even with empiric acyclovir patients with herpes simplex virus (HSV) encephalitis face a ~50% chance of severe neurological or neuropsychiatric sequelae. A 2015 analysis of 440 patients with molecular confirmation of HSV encephalitis found that duration of symptoms prior to treatment strongly correlated with unfavorable outcomes. Symptomatic periods for > 7 days before treatment were especially hazardous. 

What your nutrition friends are talking about

Onward with omelettes, but time to rethink the vending machine? Volunteers ate about 500 extra calories per day when given ultra-processed food (tortilla chips, bagels) vs. unprocessed foods (scrambled eggs, salads) as part of a strictly monitored diet.

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