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Jun 30, 2017

Thin skin

The story

There are few pals you trust more than Vanc and Zosyn when you have a febrile admission at 3 am. And while everyone has their favorite alternative combo regimen for penicillin-allergic patients, a new point-of-care test could help sort out which of those allergies are real.

The background

Like a comparison of Grey's Anatomy to your day-to-day hospital life, penicillin allergies are exaggerated in a way that's, like, frustrating. More than 10% of patients say they've had a reaction to penicillin in the past, when in truth <1% of patients are genuinely allergic. Factor in low cross-reactivity rates for cephalosporins and piperacillin-tazobactam, and the subset of at-risk patients dwindles. Since withholding beta-lactam therapy when it's the preferred first choice can prolong hospital stays and increase risk of re-infection, antimicrobial stewardship guidelines recommend beta-lactam allergy skin testing (BLAST) to dismiss false allergies.

The study

Point-of-care (POC) BLAST increased the odds of receiving preferred beta-lactam therapy by 4.5 times in patients who reported beta-lactam allergy in a prospective study of 830 patients in 3 hospitals. As a new concept, POC BLAST was instituted after specialized training from allergists and proved to be labor-intensive, as tests could take up to one hour to perform at bedside. The intervention allowed for preferred beta-lactam therapy use in 80% of patients without any increase in adverse drug reactions.
Clin Infect Dis

The takeaway

POC BLAST isn't a simple task, and the above study was not powered to detect a difference in clinical outcomes following testing. But with some refinement, point-of-care skin testing could have you falling in love with Vanc-Zosyn all over again.

Say it on rounds

When your pager makes your blood boil

Better than clonal proliferation, though maybe not by much. A nested case-control analysis found that patients with clonal hematopoiesis of indeterminate significance (CHIP), a type of mutant blood cell proliferation seen in 10% of people over age 70, were almost twice as likely to have coronary heart disease compared to controls. Young CHIP carriers were at 4 times greater risk for early-onset MI, and all carriers had significantly higher coronary artery calcification scores. Since CHIP increases with age, it may help explain why age remains the number one risk factor for atherosclerosis.
NEJM

When you're 5 lbs heavier after your MICU month

Some deal with stress better than others, and the bladder is no different. A Chinese RCT of 500 patients with stress urinary incontinence found that treatment with electroacupuncture significantly reduced urinary leakage compared to sham acupuncture. Two-thirds of the patients in the electroacupuncture group reported a > 50% decrease in leakage episodes. The results, including patient-reported satisfaction rates of 85%, are similar to those found in patients who adhere to pelvic-floor strengthening exercises. 
JAMA

When your patient asks if you're a high school volunteer

Don't listen to the haters. An observational study of over 700,000 admissions found that patients treated by older physicians had higher 30-day mortality rates than those cared for by younger physicians, though the findings did not hold for 'high-volume' older physicians who admitted more than 200 patients per year. Physicians aged less than 40 produced the lowest 30-day patient mortality rate. Readmissions did not vary with age, but costs of care were higher among older physicians.
BMJ

Brush up

ICDs in heart failure

Sudden cardiac death accounts for one third of mortality in heart failure. Place an implantable cardiac defibrillator (ICD) in patients with symptomatic heart failure and an ejection fraction ≤ 35% despite optimal medical therapy. Traditional transvenous ICDs remain a mainstay of treatment, but think of cardiac resynchronization therapy (CRT) for patients with wide-complex QRS or subcutaneous ICDs for patients at high risk for transvenous lead complications. 

What's the evidence

For ICDs in systolic heart failure? 2002's MADIT-II and 2005's SCD-HeFT found a mortality benefit for ICD placement in ischemic cardiomyopathy (ICM) with reduced ejection fraction and New York Heart Association class II or III symptoms. But be careful not to generalize to non-ischemic cardiomyopathy (NICM): 2016's DANISH trial found that ICD placement decreased sudden cardiac death by 50%, but failed to improve overall mortality when compared to optimal medical therapy in NICM patients.

A fresh look

Step outside your own shoes to see the senate healthcare debate through the eyes of a rural physician in Georgia, or peer into an inmate's health crisis through the eyes of a correctional physician.

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Congratulations to all on the completion of another academic year! We've transitioned to a new group of writers (pictures will be up soon on our website), and you'll continue to hear from our fellowship-bound PGY-3s in new roles. Thanks to Rachel Arakawa, Ahmad Bazarbashi, Laura Cohen, and Neelima Navuluri for all of their wonderful weekly writing, for their indelible contributions to this project, and for the great work that's yet to come.

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