Author: FA Manian MD, MPH

How would you answer these 7 most popular clinical questions of 2022 on Pearls4Peers??

FA Manian MD, MPH, , , , , , , , , , , , , , Leave a comment

Peers,

www.Pearls4Peers.com just turned 7 with 2022 poised to become its best year ever in viewership  (>30,000 views so far)!  To mark this “momentous” occasion, I thought I would share with you, loyal viewers and subscribers, the 7 most viewed posts  of 2022 at its midway point.  Imagine rounding on the wards with your team and someone asks you one or more of these questions.  Take a crack at answering them and compare your answers with those of P4P (Ctrl+Click)! Have fun!

  1. What is the significance of teardrop cells(dacrocytes) on the peripheral smear of my patient with newly-discovered pancytopenia?
  2.  My elderly patient developed a flare-up of her gout few days after receiving covid-19 vaccine. Is there a connection between immunization and gout flare? 
  3. What is the clinical relevance of the “SPICE” organisms? 
  4. What does an “indeterminate” result in QuantiFERON Gold in-Tube Test for latent tuberculosis really mean? 
  5. What is the difference between “moderate” and “high complexity” medical decision making under the Centers for Medicare and Medicaid Services (CMS) rule? 
  6. The urine culture of my female patient with urgency is growing Lactobacillus. Should I treat it?
  7. Why is serum AST levels generally higher than ALT in alcohol-induced liver injury?

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Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis, Massachusetts General Hospital, Harvard Catalyst, Harvard University, their affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

How would you answer these 7 most popular clinical questions of 2022 on Pearls4Peers??

“Should I consider cardiac CT angiography in my 76-year-old male patient with chest pain of unclear origin?”  

FA Manian MD, MPH, , , , , , , , , , , , , , Leave a comment

Probably not!1-4 Although the 2021 AHA/ACC Chest Pain Guidelines have generally widened the scope of indications for cardiac CT angiography (CCTA) to patients at low to intermediate risk of coronary artery disease (CAD) presenting with acute coronary syndrome (ACS)1 (with or without known CAD), several caveats should be considered before ordering this test. In general preference is given to patients with the following characteristics: 

  • Age sixty-five years of age or younger.  Elderly are not ideal candidates for CCTA as the calcium burden may be too high, rendering the test non-diagnostic due to the interference with proper coronary artery lumen assessment. Women tend not to accumulate as much calcium and their age threshold may be increased to 70 years. Some studies like the ROMICAT II Trial extended the age up to 74 years.4 
  • BMI <40.2
  • Sinus rhythm. Atrial fibrillation can be circumvented with expanded padding techniques, albeit at higher radiation exposure.2
  • Without coronary stents, unless their stents are > 3.0 mm in diameter (eg, in left main, very proximal left anterior descending, circumflex or right coronary stents).2
  • Without high coronary calcium burden, or without multiple risk factors for CAD (eg, type 2 diabetes, hypertension, hyperlipidemia) in the setting of typical anginal chest pain.1
  • Other technical requirements: must be able to hold breath during procedure, not have contraindications to beta blockers (ideal heart rate <60 bpm), not have an iodinated contrast allergy, and have stable kidney function.2

Despite these caveats, many patients may still be able to undergo CCTA to help exclude coronary causes of their chest pain.  For example, a 49-year-old patient at low to intermediate risk of CAD presenting with atypical chest pain can potentially undergo CCTA and, if negative, be discharged the same day!4  

In our patient, however, given his older age, CCTA is likely to be non-diagnostic and proceeding to an alternative test, such as stress test or invasive coronary angiography (depending on circumstances and pre-test probability), may be a better option.  

Bonus Pearl: Did you know that, as a “bonus”,  CCTA provides a “free” look at the lungs, calcium score (used largely in asymptomatic patients to help weigh pros and cons of starting a statin)3, and other cardiopulmonary structures that may hint at alternative diagnoses for the cause of chest discomfort and/or dyspnea?

Contributed by Eldin Duderija MD, Cardiologist, Mercy Clinic, St. Louis, Missouri

 

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References:

  1. Gulati M, Levy P, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain. J Am Coll Cardiol. 2021;78:e187–e285. https://pubmed.ncbi.nlm.nih.gov/34709879/
  2. Raff GL, Chinnaiyan KM, Cury RC, Garcia MT, Hecht HS, Hollander JE, O’Neil B, Taylor AJ, Hoffmann U; Society of Cardiovascular Computed Tomography Guidelines Committee. SCCT guidelines on the use of coronary computed tomographic angiography for patients presenting with acute chest pain to the emergency department: a report of the Society of Cardiovascular Computed Tomography Guidelines Committee. J Cardiovasc Comput Tomogr 2014;8:254-71. doi: 10.1016/j.jcct.2014.06.002. Epub 2014 Jun 12. PMID: 25151918. https://pubmed.ncbi.nlm.nih.gov/25151918/
  3. Hecht H, Blaha MJ, Berman DS, Nasir K, Budoff M, Leipsic J, Blankstein R, Narula J, Rumberger J, Shaw LJ. Clinical indications for coronary artery calcium scoring in asymptomatic patients: Expert consensus statement from the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr 2017;11:157-168. doi: 10.1016/j.jcct.2017.02.010. Epub 2017 Feb 24. PMID: 28283309. https://pubmed.ncbi.nlm.nih.gov/28283309/
  4. Hoffmann, Udo, et al. “Coronary CT angiography versus standard evaluation in acute chest pain.” N Engl J Med 2012;367:299-308. https://www.nejm.org/doi/full/10.1056/nejmoa1201161

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis, Massachusetts General Hospital, Harvard Catalyst, Harvard University, their affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

 

“Should I consider cardiac CT angiography in my 76-year-old male patient with chest pain of unclear origin?”  

How do I assess the left ventricular (LV) systolic function by bedside point-of-care ultrasound (POCUS)?

FA Manian MD, MPH, , , , , , , , , , , , Leave a comment

You can assess the LV systolic function by POCUS by just zeroing in on the following cardiac parameters: 1. Anterior mitral valve leaflet motion in early diastole; 2. Change in LV chamber diameter; and 3. LV wall thickness during systole.1

First assess the anterior mitral valve leaflet motion towards the interventricular septum in early diastole in the parasternal long axis view (Figure). Estimated or measured distance between anterior mitral valve leaflet and the interventricular septum is called E-point septal separation (EPSS). When LV systolic function is normal, anterior mitral valve leaflet opens fully in early diastole, resulting in a small or minimal separation between it and the interventricular septum. Due to the fixed length of the chordae and the enlarged LV chamber size, anterior mitral valve leaflets are unable to fully open as systolic function worsens. This results in increased separation between the anterior mitral valve leaflet and the interventricular septum. An estimated EPSS greater than 10 mm is considered abnormal and suggests LV dysfunction.1,2

You can also estimate the LV ejection fraction (LVEF) quantitatively  by utilizing the following formula:3

LVEF (%)=75.5 – 2.5xEPSS (mm)

Keep in mind that aortic insufficiency and mitral stenosis can affect the accuracy of this formula.1

As for assessing the LV chamber diameter and wall thickness, recall that these parameters are also dynamic throughout the cardiac cycle. In systole, LV diameter should decrease by 30-40% while LV wall thickness should increase by approximately 40%. Using this as a guide, you can perform qualitative assessment by “eyeballing” the LV systolic function in parasternal long axis, parasternal short axis, apical 4-chamber and subcostal 4-chamber views. Beware that in parasternal long axis, apical 4-chamber and subcostal 4-chamber views, off axis of images can foreshorten the chamber size, resulting in overestimation of systolic function. Also be sure to use the midventricular papillary muscle view when assessing systolic function in the parasternal short axis.1   

Once you have obtained all the necessary images, feel free to categorize the systolic function as either “hyperdynamic”, “normal”, “reduced” or “severely reduced” (watch video below).1

Bonus pearl:  Did you know that qualitative assessment of the LV systolic function  following brief training sessions have been shown to significantly correlate with that obtained by formal echocardiography (k = 0.77, p <0.001).1,4,5 

Contributed by Woo Moon, D.O, Director POCUS Training Program, Mercy-St. Louis Hospital, St. Louis, Missouri

Figure: EPSS in normal vs reduced EF 

Note: EPSS (yellow arrows) is narrow in normal but wide in reduced EF

Video: Four categories of systolic function

 

References

  1. Soni MD MS NJ, Arntfield MD FRCPC R, Kory MD MPA P. Point of Care Ultrasound. 2nd ed. St. Louis, MO: Elsevier; 2019. . https://www.elsevier.com/books/point-of-care-ultrasound/soni/978-0-323-54470-2
  2. Kimura BJ, Yogo N, O’Connell CW, Phan JN, Showalter BK, Wolfson T. Cardiopulmonary limited ultrasound examination for “quick-look” bedside application. Am J Cardiol 2011;108(4):586–90. https://linkinghub.elsevier.com/retrieve/pii/S0002-9149(11)01424-X
  3. Silverstein JR, Laffely NH, Rifkin RD. Quantitative estimation of left ventricular ejection fraction from mitral valve E-point to septal separation and comparison to magnetic resonance imaging. Am J Cardiol 2006;97(1):137–40. https://www.ajconline.org/article/S0002-9149(05)01683-8/fulltext
  4. Melamed R, Sprenkle MD, Ulstad VK, Herzog CA, Leatherman JW. Assessment of left ventricular function by intensivists using hand-held echocardiography. Chest 2009;135(6):1416–20. https://journal.chestnet.org/article/S0012-3692(09)60341-X/fulltext 
  5. Johnson BK, Tierney DM, Rosborough TK, Harris KM, Newell MC. Internal medicine point-of-care ultrasound assessment of left ventricular function correlates with formal echocardiography. J Clin Ultrasound 2016;44(2):92–9. https://onlinelibrary.wiley.com/doi/10.1002/jcu.22272

 

 

 

 

 

 

 

How do I assess the left ventricular (LV) systolic function by bedside point-of-care ultrasound (POCUS)?

My patient with COPD on prednisone with recurrent pneumonia has a low serum IgG level.  Can corticosteroids lower serum immunoglobulin levels?

FA Manian MD, MPH, , , , , , , , , , , , , Leave a comment

Yes! Both exogenous and endogenous hypercortisolism may be associated with a drop in serum immunoglobulin levels, particularly IgG, which may persist even after discontinuation of steroid treatment.1-4 This means that a low serum IgG level in a patient on corticosteroids should be interpreted with caution and may not necessarily suggest primary antibody deficiency.

Although some early studies did not find a significant impact of corticosteroids on immunoglobulin levels, several subsequent studies found otherwise.  A 1978 study involving atopic asthmatic patients (averaging 16.8 mg prednisone daily) found that mean serum IgG significantly decreased (-22%) with milder drop in IgA levels (-10%) and no drop in serum IgM levels.2 Of interest, IgE level increased significantly initially but later dropped as well. More importantly, mean serum IgG levels remained significantly decreased an average of 22 days after corticosteroids were discontinued.

More recently, in a study involving patients with giant cell arteritis and polymyalgia rheumatica on corticosteroids, 58% developed antibody deficiency with the great majority involving IgG, either alone or along with other immunoglobulins.3 The reduction of IgG persisted even after discontinuation of corticosteroids in nearly 50% of patients, and observed in nearly one-quarter of patients for at least 6 months! Whether low serum immunoglobulins due to corticosteroids alone significantly increase susceptibility to infections is unclear, however.

In our patient with COPD on prednisone, if serum IgG level is found to be low and a primary antibody deficiency is still suspected, a functional assessment of the antibody production after active immunization (eg, polysaccharide pneumococcal vaccine, tetanus toxoid) may be necessary. 1 An adequate antibody response to active immunization makes primary immunodeficiency unlikely. 

 

Bonus Pearl: Did you know that corticosteroid-induced hypogammaglobulinemia may be in part related to reduced IgG production as well as an increase in IgG catabolism?1,4

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References

  1. Sarcevic J, Cavelti-Weder C, Berger CT, et al. Case report-secondary antibody deficiency due to endogenous hypercortisolism. Frontiers in Immunology 2020;11:1435. https://www.frontiersin.org/articles/10.3389/fimmu.2020.01435/full
  2. Settipane GA, Pudupakkam RK, McGowan JH. Corticosteroid effect on immunoglobulins. J Allergy Clin Immunol 1978;62: 162-6. https://www.jacionline.org/article/0091-6749(78)90101-X/pdf
  3. Wirsum C, Glaser C, Gutenberger S, et al. Secondary antibody deficiency in glucocorticoid therapy clearly differs from primary antibody deficiency. J Clin Immunol 2016;36:406-12. https://link.springer.com/article/10.1007/s10875-016-0264-7
  4. McMillan R, Longmire R, Yelenosky R. The effect of corticosteroids on human IgG synthesis. J Immunol 1976;116:1592-1595. https://www.jimmunol.org/content/116/6/1592

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis, Massachusetts General Hospital, Harvard Catalyst, Harvard University, their affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

My patient with COPD on prednisone with recurrent pneumonia has a low serum IgG level.  Can corticosteroids lower serum immunoglobulin levels?

Why do we often prescribe ceftriaxone in preference to fluoroquinolones for prophylaxis of infections in patients with cirrhosis and upper GI bleed?

FA Manian MD, MPH, , , , , , , , , , , Leave a comment

Preference of ceftriaxone over fluoroquinolones (FQs) for prophylaxis of infection in patients with cirrhosis and upper GI bleed (UGIB) can often be traced back to a small 2006 Spanish randomized controlled trial (RCT)1 which found a significantly lower rate of proved or possible bacterial infection and lower rate of fermentative Gram-negative bacilli infection in the ceftriaxone group (vs norfloxacin) over a 10-day period (11% vs 33% and 0% vs 11%, respectively). There was no significant difference in the incidence of proved bacterial infection (spontaneous bacterial peritonitis or bacteremia, P=0.07) or 10-day mortality between the 2 groups.   

It’s worth emphasizing that the primary impetus for this study was evaluation of the efficacy of ceftriaxone in patients with cirrhosis and UGIB in a setting where FQ Gram-negative bacilli was thought to be highly prevalent. Parenthetically, a similar RCT performed where the prevalence of FQ resistance was considered low failed to find a significant difference in breakthrough bacterial infection, rebleeding or mortality when ceftriaxone was compared to IV ciprofloxacin.2

Another caveat of the 2006 study was that an IV antibiotic (ceftriaxone) was compared to a oral antibiotic (norfloxacin) which, in the setting of active UGIB, may be problematic.

Despite these limitations, its favorable safety profile compared to FQs coupled with its ease of administration has often made ceftriaxone the drug of choice for prophylaxis of infections in patients with cirrhosis and UGIB. The 2016 Practice Guidance by the American Association for the Study of Liver Diseases considers ceftriaxone as the first choice in patients with advanced cirrhosis, on FQ prophylaxis, and in hospital settings with high prevalence of FQ resistant bacterial infection.3

Bonus Pearl: Did you know that the prevalence of FQ resistant in Enterobacteriaceae may be as high as 30% in certain regions of U.S. and >50% in certain regions of the world? 4

Also see related 2 P4P pearls (1, 2) on the association of UGIB bleed with infections in patients with cirrhosis.

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References

  1. Fernandez J, Del Arbol LR, Gomez C, et al. Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage. Gastroenterol 2006;131:1049-1056. https://pubmed.ncbi.nlm.nih.gov/17030175/
  2. Pittayanon R, Reknimir R, Kullavanijaya P, et al. Intravenous ciprofloxacin vs ceftriaxone for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding:A randomized controlled trial. Thai J Gastroenterol 2016;17:24-30. http://www.thaigastro.com/books.php?act=content&content_id=476&book_id=61
  3. Garcia-Tsao G, Abraldes JG, Berzigotti A, et al. Portal hypertensive bleeding in cirrhosis:risk stratification, diagnosis and management: 2016 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2017;65:310-335. https://pubmed.ncbi.nlm.nih.gov/27786365/
  4. Spellberg B, Doi Y. The rise of fluoroquinolone-resistant Escherichia coli in the community:scarier than we thought. J Infect Dis 2015;212:1853-1855. https://pubmed.ncbi.nlm.nih.gov/25969562/

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis, Massachusetts General Hospital, Harvard Catalyst, Harvard University, their affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

Why do we often prescribe ceftriaxone in preference to fluoroquinolones for prophylaxis of infections in patients with cirrhosis and upper GI bleed?

My 19-year-old patient wishes treatment for his chronic acne while waiting for his dermatology appointment. What treatment should I recommend?

FA Manian MD, MPH, , , , , , , , , , , , , Leave a comment

Irrespective of your patient’s acne severity, a good starting point is over-the-counter topical benzoyl peroxide.1 Benzoyl peroxide not only kills the bacteria that causes acne (Cutibacterium acnes) through the release of free oxygen radicals, but also functions as a comedolytic.2

If your patient’s acne is mild to moderate (defined as non-inflammatory lesions [comedones] or less than 5 inflammatory lesions [papulopustules]), you may consider prescribing a topical retinoid such as tretinoin 0.025%, adapalene 0.1%, or tazarotene 0.05% in combination with the benzoyl peroxide.1,3 These agents have been shown to have both comedolytic and anti-inflammatory effects, and are the cornerstone of topical therapy for all acne cases, save for the most mild.1,4

In moderate to severe acne (defined as multiple inflammatory lesions), you can consider prescribing an oral antibiotic in combination with the retinoid and benzoyl peroxide.1,3 The first-line therapy in this situation is often a tetracycline, such as daily doxycycline in the 1.7 to 2.4 mg/kg dose range.5,6 

As with all medications, please familiarize yourself with contraindications and adverse side effects of these drugs before prescribing (eg, doxycycline-related photosensitivity or adverse impact on GI flora, or avoiding tretinoin in pregnancy).

For extremely severe acne (defined as widespread inflammatory lesions, nodules, and/or scarring), you should consider referral to a dermatologist for Accutane (isotretinoin) treatment.3 However, the aforementioned treatment options should be sufficient to control your patient’s symptoms until seen by a dermatologist!           

Bonus Pearl: Did you know that besides anabolic-androgenic steroids, dietary supplements containing vitamins B6/B12, iodine and whey have also been linked to acne?7

Contributed by Aditya Nellore, Fourth-Year Medical Student, St. Louis University Medical School, St. Louis, Missouri   

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References:

  1. Zaenglein AL, Pathy AL, Schlosser BJ, Alikhan A, Baldwin HE, Berson DS, Bowe WP, Graber EM, Harper JC, Kang S, Keri JE, Leyden JJ, Reynolds RV, Silverberg NB, Stein Gold LF, Tollefson MM, Weiss JS, Dolan NC, Sagan AA, Stern M, Boyer KM, Bhushan R. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016 May;74(5):945-73.e33. doi: 10.1016/j.jaad.2015.12.037. Epub 2016 Feb 17. Erratum in: J Am Acad Dermatol. 2020 Jun;82(6):1576. PMID: 26897386. https://www.jaad.org/article/S0190-9622(15)02614-6/fulltext#tbl6
  2. Cunliffe WJ, Holland KT. The effect of benzoyl peroxide on acne. Acta Derm Venereol. 1981;61(3):267-9. PMID: 6167116. https://pubmed.ncbi.nlm.nih.gov/6167116/
  3. Purdy S, Deberker D. Acne vulgaris. BMJ Clin Evid. 2008 May 15;2008:1714. PMID: 19450306; PMCID: PMC2907987. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907987/
  4. Cunliffe WJ, Caputo R, Dreno B, Förström L, Heenen M, Orfanos CE, Privat Y, Robledo Aguilar A, Meynadier J, Alirezai M, Jablonska S, Shalita A, Weiss JS, Chalker DK, Ellis CN, Greenspan A, Katz HI, Kantor I, Millikan LE, Swinehart JM, Swinyer L, Whitmore C, Czernielewski J, Verschoore M. Clinical efficacy and safety comparison of adapalene gel and tretinoin gel in the treatment of acne vulgaris: Europe and U.S. multicenter trials. J Am Acad Dermatol. 1997 Jun;36(6 Pt 2):S126-34. doi: 10.1016/s0190-9622(97)70056-2. PMID: 9204091. https://pubmed.ncbi.nlm.nih.gov/9204091/
  5. Tan J, Humphrey S, Vender R, Barankin B, Gooderham M, Kerrouche N, Audibert F, Lynde C; POWER study group. A treatment for severe nodular acne: a randomized investigator-blinded, controlled, noninferiority trial comparing fixed-dose adapalene/benzoyl peroxide plus doxycycline vs. oral isotretinoin. Br J Dermatol. 2014 Dec;171(6):1508-16. doi: 10.1111/bjd.13191. Epub 2014 Oct 28. PMID: 24934963. https://pubmed.ncbi.nlm.nih.gov/24934963/
  6. Leyden, James J., et al. “A randomized, phase 2, dose-ranging study in the treatment of moderate to severe inflammatory facial acne vulgaris with doxycycline calcium.” Journal of Drugs in Dermatology: JDD6 (2013): 658-663. https://pubmed.ncbi.nlm.nih.gov/23839182/
  7. Zamil DH, Perez-Sanchez A, Katta R. Acne related to dietary supplements. Dermatol Online J. 2020 Aug 15;26(8):13030/qt9rp7t2p2. PMID: 32941710. https://pubmed.ncbi.nlm.nih.gov/32941710/

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis, Massachusetts General Hospital, Harvard Catalyst, Harvard University, their affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

My 19-year-old patient wishes treatment for his chronic acne while waiting for his dermatology appointment. What treatment should I recommend?

Is there a connection between nocturia and obstructive sleep apnea (OSA)?

FA Manian MD, MPH, , , , , , , , , , , Leave a comment

Absolutely! Although seemingly unrelated medical conditions, nocturia is commonly associated with OSA. [1,2]

A retrospective study [1] (n = 138) reported pathologic nocturia (≥2 urination events per night) in 47.8% of patients with OSA-hypopnea-syndrome. In this study, nocturia was linked to increasing age, 02 desaturation and severity of OSA. In another study (n=30), OSA (defined as apnea-hypopnea index [AHI] ≥5) was diagnosed in 66% of patients with nocturia with increasing nocturia associated with higher AHI.[2]

Recall that repetitive apnea episodes in OSA expose cardiovascular system to cycles of exaggerated negative intrathoracic pressure. [3] This causes myocardial stretching which is likely the reason OSA has been linked to elevated nocturnal atrial natriuretic peptide (ANP) levels. [4] In turn, ANP as an aldosterone inhibitor, increases salt and water excretion causing nocturia. Of interest, use of continuous positive airway pressure (CPAP) has been shown to normalize ANP levels [5] which may explain CPAP’s favorable impact on the frequency of nocturia based on a meta-analysis. [6]

Although the role of screening for OSA in nocturia remains unclear, OSA should be considered in the differential diagnosis of nocturia, especially in men and women younger than 50 years of age. [7,8]

Bonus pearl: Did you know that OSA has been associated with recreational MDMA (“ecstasy”) use, with severity of OSA correlating with lifetime MDMA exposure? [9]

Contributed by Fahad Tahir, MD, Mercy Hospital-St. Louis, St. Louis, Missouri

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References:

  1. Hajduk IA, Strollo PJ Jr, Jasani RR, Atwood CW Jr, Houck PR, Sanders MH. Prevalence and predictors of nocturia in obstructive sleep apnea-hypopnea syndrome–a retrospective study. Sleep. 2003 Feb 1;26(1):61-4. PMID: 12627734. https://pubmed.ncbi.nlm.nih.gov/12627734/
  2. Umlauf MG, Chasens ER, Greevy RA, Arnold J, Burgio KL, Pillion DJ. Obstructive sleep apnea, nocturia and polyuria in older adults. Sleep. 2004 Feb 1;27(1):139-44. doi: 10.1093/sleep/27.1.139. PMID: 14998251.https://pubmed.ncbi.nlm.nih.gov/14998251/
  3. Bradley TD, Floras JS. Obstructive sleep apnoea and its cardiovascular consequences. Lancet. 2009 Jan 3;373(9657):82-93. doi: 10.1016/S0140-6736(08)61622-0. Epub 2008 Dec 26. PMID: 19101028. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61622-0/fulltext
  4. Svatikova A, Shamsuzzaman AS, Wolk R, Phillips BG, Olson LJ, Somers VK. Plasma brain natriuretic peptide in obstructive sleep apnea. Am J Cardiol. 2004 Aug 15;94(4):529-32. doi: 10.1016/j.amjcard.2004.05.010. PMID: 15325948. https://www.ajconline.org/article/S0002-9149(04)00730-1/fulltext/
  5. Krieger J, Laks L, Wilcox I, Grunstein RR, Costas LJ, McDougall JG, Sullivan CE. Atrial natriuretic peptide release during sleep in patients with obstructive sleep apnea before and during treatment with nasal continuous positive airway pressure. Clin Sci (Lond). 1989 Oct;77(4):407-11. doi: 10.1042/cs0770407. PMID: 2530023. https://pubmed.ncbi.nlm.nih.gov/2530023/
  6. Wang T, Huang W, Zong H, Zhang Y. The Efficacy of Continuous Positive Airway Pressure Therapy on Nocturia in Patients With Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis. Int Neurourol J. 2015 Sep;19(3):178-84. doi: 10.5213/inj.2015.19.3.178. Epub 2015 Sep 22. PMID: 26620900; PMCID: PMC4582090. https://pubmed.ncbi.nlm.nih.gov/26620900/
  7. Lowenstein L, Kenton K, Brubaker L, Pillar G, Undevia N, Mueller ER, FitzGerald MP. The relationship between obstructive sleep apnea, nocturia, and daytime overactive bladder syndrome in women. Am J Obstet Gynecol. 2008 May;198(5):598.e1-5. doi: 10.1016/j.ajog.2008.02.024. PMID: 18455544. https://www.ajog.org/article/S0002-9378(08)00168-3/fulltext
  8. Moriyama Y, Miwa K, Tanaka H, Fujihiro S, Nishino Y, Deguchi T. Nocturia in men less than 50 years of age may be associated with obstructive sleep apnea syndrome. Urology. 2008 Jun;71(6):1096-8. doi: 10.1016/j.urology.2008.02.038. Epub 2008 Apr 8. PMID: 18400277.https://pubmed.ncbi.nlm.nih.gov/18400277/
  9. McCann UD, Sgambati FP, Schwartz AR, Ricaurte GA. Sleep apnea in young abstinent recreational MDMA (“ecstasy”) consumers. Neurology. 2009 Dec 8;73(23):2011-7. doi: 10.1212/WNL.0b013e3181c51a62. Epub 2009 Dec 2. PMID: 19955499; PMCID: PMC2790228. https://n.neurology.org/content/73/23/2011.long

 

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis, Massachusetts General Hospital, Harvard Catalyst, Harvard University, their affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

 

 

 

Is there a connection between nocturia and obstructive sleep apnea (OSA)?

What’s the latest on second Covid vaccine boosters and should I recommend them to my adult patients?

FA Manian MD, MPH, , , , , , , , , Leave a comment

On March 29, 2022, the CDC and the FDA approved second booster shots of Pfizer and Moderna Covid vaccines for everyone 50 years of age or older as well as people 12 years of age or older with moderate to severe immune deficiencies to be given at least 4 months following the first booster.1-3  This means a 4th dose of an mRNA vaccine for many adults and a 5th dose for those with moderate to severe immune deficiencies. 

Admittedly, these recommendations are made in the context of many uncertainties, including when the next Covid surge will arrive, what will be the predominant variant, and how will our immunity hold up if a surge occurs. 

Nevertheless, in discussing the merits of a 2nd booster, I would emphasize several “talking points”:

  • Covid hasn’t gone away with new cases still diagnosed daily, some still  requiring hospitalization, albeit at lower frequency than recent past. 
  • Our immunity against Covid wanes in the absence of boosters or natural infection.
  • SARS-CoV-2 has been unpredictable in its surges, as well as emergence of new variants with frequent changes in its virulence and ease of transmission. This means we don’t know when the next surge will hit us (summer, fall or later) and how the predominant variant will behave.
  • But let’s not get too hung up on surges! The fact is that as long as Covid is circulating around, maintaining a robust immunity against infection is the best way to avoid getting infected and the best way to do this is through boosters!
  • As more people go around without masks, the risk of unprotected exposure to SARS-CoV-2 is also likely to increase, particularly in indoor public gatherings.  Boosters may allow us the freedom to go maskless more often!
  • The risk of Long Covid even following mild infection is still real even between surges. This means even if we don’t get very sick from Covid, we are placing ourselves at risk of Long Covid. Remember, no Covid, no Long Covid!
  • Irrespective of whether it’s mild or even asymptomatic, Covid infection  can cause significant disruption in our lives, whether it be isolation at home, not being allowed to return to work or just the anxiety of having it or having passed it to others. This means that, at least currently, it’s premature to consider this virus as “just another respiratory virus.”  It’s impact on our everyday lives is still a lot different than typical respiratory viruses. 
  • mRNA vaccine boosters have been proven to be as safe as primary series. 
  • Last, but not the least, a preprint Israeli study involving volunteers 60 to 100 years old found a 78% reduction in mortality from Covid following a 2nd booster dose of Pfizer mRNA vaccine compared to those who only had 1 booster.4  This study has several limitations including self-selected volunteers who may already be at lower risk of Covid mortality due to their healthier lifestyle. Nevertheless, the data is very encouraging!

Ultimately, the decision to get a second booster, particularly during non-surge periods, will depend a lot on not only available facts but the individual’s threshold for acceptable risk of even mild disease, concern over transmission to others and more recently the cost of the vaccine, among other factors.  

Bonus Pearl: Did you know that each year there are plenty of uncertainties around which influenza A or B subtypes will be the predominant seasonal strain or what month they may surge but these questions never keep us from recommending the annual flu vaccine to the public as a means of reducing influenza cases and saving lives?   

 

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References

  1. D.A. Allows Second Covid Boosters for Everyone 50 and Older – The New York Times (nytimes.com)
  2. Coronavirus (COVID-19) Update: FDA Authorizes Second Booster Dose of Two COVID-19 Vaccines for Older and Immunocompromised Individuals | FDA
  3. CDC Recommends Additional Boosters for Certain Individuals | CDC Online Newsroom | CDC
  4. Arbel R, Sergienko R, Friger M, et al. Second booster vaccine and Covid-19 mortality in adults 60-100 years old. Preprint, posted March 24, 2022. 24514bba-2c9d-4add-9d8f-321f610ed199.pdf (researchsquare.com)

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis, Massachusetts General Hospital, Harvard Catalyst, Harvard University, their affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

 

What’s the latest on second Covid vaccine boosters and should I recommend them to my adult patients?

My patient presents for evaluation of a mole on her arm. What features of the mole should I look for to help me distinguish a benign mole from melanoma?

FA Manian MD, MPHLeave a comment

Great question! Identifying a melanoma is a lot easier than you might think. A good starting point is the ABCDE criteria, which stands for Asymmetry, Border irregularity, Color variation, Diameter > 6 mm/Dark, and Evolution over time (see Fig 1 below). 1 Higher number of these characteristics in a particular lesion increases the probability of it being melanoma. For example, in the presence of just one characteristic, the positive likelihood ratio (LR) is 1.5 with the probability of melanoma of 7.4%. However, if all five characteristics are present, the positive LR rises to 107, while the probability of melanoma increases to 85%. 2,3,4

Another useful trick is looking for the “ugly duckling sign” (UDS), which refers to any pigmented lesion that appears obviously different than others on a patient’s body.5 For example, let’s say you’re seeing a patient with multiple small, circular, equally-sized moles on his forearm. A few inches away, he has a significantly larger mole with an irregular border. This would qualify as a positive UDS.  While the sensitivities of melanoma recognition are similar for the UDS and the ABCDE criteria (100% and 99%, respectively), the UDS has been shown to significantly improve specificity (88.3%) and accuracy (90.9%) when compared to the ABCDE criteria alone (57.4% and 66.7 %, respectively).6 So incorporating both sets of criteria into your approach to melanoma recognition may be prudent.

Once you suspect a melanoma, your should refer your patient to a dermatologist for an excisional biopsy, the gold standard for melanoma diagnosis.  This procedure consists of excising the entire lesion with 1-3 mm margins.7 The resulting sample can then be used to histologically confirm the diagnosis, prognosticate, and guide management.

Primary care providers play a crucial role in the early detection and treatment of melanoma, so keep your eyes open for any “unusual” looking moles, even if you’re seeing a patient for something unrelated!

Bonus Pearl

Did you know that cardiac involvement with melanoma is not uncommon, affecting an estimated 28% to 56% of patients with metastatic melanoma? 8

 

Figure 1: ABCDE criteria to help differentiate benign skin lesions from melanoma

i

 From Pawan Sonawane, Sahel Shardhul, Raju Mendhe, “Cloud based mobile solution for early detection of Skin Cancer using Artificial Intelligence”, International Journal of Scientific Research in Computer Science, Engineering and Information Technology (IJSRCSEIT), ISSN : 2456-3307, Volume 7 Issue 3, pp. 312-324, May-June 2021. Available at doi : https://doi.org/10.32628/CSEIT217327 Journal URL : https://ijsrcseit.com/CSEIT217327 (https://www.researchgate.net/publication/352394140_Cloud_based_mobile_solution_for_early_detection_of_Skin_Cancer_using_Artificial_Intelligence)

Contributed by Aditya Nellore, 4th year Medical Student, St. Louis University Medical School, St. Louis, Missouri

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References:

  1. Goldsmith SM. Why Is Darkness an Essential Feature for Melanoma Recognition? Skinmed. 2021 Oct 1;19(5):334-336. PMID: 34861912. (https://pubmed.ncbi.nlm.nih.gov/34861912/)
  2. Duarte AF, Sousa-Pinto B, Azevedo LF, Barros AM, Puig S, Malvehy J, Haneke E, Correia O. Clinical ABCDE rule for early melanoma detection. Eur J Dermatol. 2021 Dec 1;31(6):771-778. doi: 10.1684/ejd.2021.4171. PMID: 35107069. (https://pubmed.ncbi.nlm.nih.gov/35107069/)
  3. Thomas L, Tranchand P, Berard F, Secchi T, Colin C, Moulin G. Semiological value of ABCDE criteria in the diagnosis of cutaneous pigmented tumors. Dermatology. 1998;197(1):11-7. doi: 10.1159/000017969. PMID: 9693179. (https://pubmed.ncbi.nlm.nih.gov/9693179/)
  4. Ebell M. Clinical diagnosis of melanoma. Am Fam Physician. 2008 Nov 15;78(10):1205, 1208. PMID: 19035070. (https://pubmed.ncbi.nlm.nih.gov/19035070/)
  5. Gaudy-Marqueste C, Wazaefi Y, Bruneu Y, Triller R, Thomas L, Pellacani G, Malvehy J, Avril MF, Monestier S, Richard MA, Fertil B, Grob JJ. Ugly Duckling Sign as a Major Factor of Efficiency in Melanoma Detection. JAMA Dermatol. 2017 Apr 1;153(4):279-284. doi: 10.1001/jamadermatol.2016.5500. PMID: 28196213. (https://pubmed.ncbi.nlm.nih.gov/28196213/)
  6. Ilyas M, Costello CM, Zhang N, Sharma A. The role of the ugly duckling sign in patient education. J Am Acad Dermatol. 2017 Dec;77(6):1088-1095. doi: 10.1016/j.jaad.2017.06.152. Epub 2017 Sep 28. PMID: 28964538. (https://pubmed.ncbi.nlm.nih.gov/28964538/)
  7. Swetter SM, Tsao H, Bichakjian CK, Curiel-Lewandrowski C, Elder DE, Gershenwald JE, Guild V, Grant-Kels JM, Halpern AC, Johnson TM, Sober AJ, Thompson JA, Wisco OJ, Wyatt S, Hu S, Lamina T. Guidelines of care for the management of primary cutaneous melanoma. J Am Acad Dermatol. 2019 Jan;80(1):208-250. doi: 10.1016/j.jaad.2018.08.055. Epub 2018 Nov 1. PMID: 30392755. (https://pubmed.ncbi.nlm.nih.gov/30392755/)
  8. Goldberg AD, Blankstein R, Padera RF. Tumors metastatic to the heart. Circulation. 2013 Oct 15;128(16):1790-4. doi: 10.1161/CIRCULATIONAHA.112.000790. PMID: 24126323. (https://pubmed.ncbi.nlm.nih.gov/24126323/)

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis, Massachusetts General Hospital, Harvard Catalyst, Harvard University, their affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

 

My patient presents for evaluation of a mole on her arm. What features of the mole should I look for to help me distinguish a benign mole from melanoma?

Is it safe to use diltiazem or verapamil for treatment of my hospitalized patient with heart failure with reduced ejection fraction (HFrEF) and atrial fibrillation?

FA Manian MD, MPH, , , , , , , , , , Leave a comment

Short answer, no! It is generally recommended to avoid the use of diltiazem or verapamil, both a non-dihydropyridine calcium channel blocker (CCB), in patients with HFrEF.  Multiple randomized controlled trials involving patients with HFrEF have shown that use of diltiazem [1] or verapamil [2] is associated with increased cardiovascular mortality and morbidity, especially congestive heart failure (CHF) exacerbations.

Although you might argue that most studies [1,2] on HFrEF on CCBs have been based on patients on chronic (weeks to months) therapy, these agents are also sometimes used in the acute inpatient setting for rate control in atrial fibrillation and even blood pressure control. Even in acute settings, avoidance of these agents–or at least using them with great caution— in patients with HFrEF is prudent. Fortunately, for blood pressure control, another CCB, amlodipine [3] has been deemed safe to use in patients with HFrEF.

Adverse effects of diltiazem and verapamil are often attributed to their negative inotropic effects. As a result, patients with preexisting left ventricular dysfunction may be expected to have worse outcomes. In contrast, amlodipine primarily acts on the peripheral vasculature without significant negative inotropic effect. [4]

What about the use of these agents in patients with heart failure and preserved ejection fraction? Studies to date have found that CCBs are safe in this setting, although no mortality benefit has been shown with their use either [1]. 

Bonus Pearl: Did you know that use of another CCB, nifedipine, a close cousin of amlodipine (both 1,4- dihydropyridines), has been associated with increased cardiovascular morbidity (worsening CHF and increased hospitalizations) in patients with HFrEF? [5]

Contributed by Fahad Tahir, MD, Mercy Hospital-St. Louis, St. Louis, Missouri

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References:

  1. Goldstein RE, Boccuzzi SJ, Cruess D, Nattel S. Diltiazem increases late-onset congestive heart failure in postinfarction patients with early reduction in ejection fraction. The Adverse Experience Committee; and the Multicenter Diltiazem Postinfarction Research Group. Circulation. 1991 Jan;83(1):52-60. doi: 10.1161/01.cir.83.1.52. PMID: 1984898.https://www.ahajournals.org/doi/epdf/10.1161/01.CIR.83.1.52
  2. Effect of verapamil on mortality and major events after acute myocardial infarction (the Danish Verapamil Infarction Trial II–DAVIT II). Am J Cardiol. 1990 Oct 1;66(10):779-85. doi: 10.1016/0002-9149(90)90351-z. PMID: 2220572.https://www.ajconline.org/article/0002-9149(90)90351-Z/pdf
  3. Packer M, Carson P, Elkayam U, Konstam MA, Moe G, O’Connor C, Rouleau JL, Schocken D, Anderson SA, DeMets DL; PRAISE-2 Study Group. Effect of amlodipine on the survival of patients with severe chronic heart failure due to a nonischemic cardiomyopathy: results of the PRAISE-2 study (prospective randomized amlodipine survival evaluation 2). JACC Heart Fail. 2013 Aug;1(4):308-314. doi: 10.1016/j.jchf.2013.04.004. Epub 2013 Aug 5. PMID: 24621933.https://reader.elsevier.com/reader/sd/pii/S2213177913001844?token=510153852A5AEBBDF5CA9F8B16C671C4E2F4B511B6F723227BA1D2180CDAA4726EC329D5ABC4118738CB1D8B67A3CF6B&originRegion=us-east-1&originCreation=20220316135803
  4. Zamponi, G. W., Striessnig, J., Koschak, A., & Dolphin, A. C. (2015). The Physiology, Pathology, and Pharmacology of Voltage-Gated Calcium Channels and Their Future Therapeutic Potential. Pharmacological reviews, 67(4), 821–870.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4630564/
  5. Elkayam U, Amin J, Mehra A, Vasquez J, Weber L, Rahimtoola SH. A prospective, randomized, double-blind, crossover study to compare the efficacy and safety of chronic nifedipine therapy with that of isosorbide dinitrate and their combination in the treatment of chronic congestive heart failure. Circulation. 1990 Dec;82(6):1954-61. doi: 10.1161/01.cir.82.6.1954. PMID: 2242521.https://www.ahajournals.org/doi/epdf/10.1161/01.CIR.82.6.1954

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis, Massachusetts General Hospital, Harvard Catalyst, Harvard University, their affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

Is it safe to use diltiazem or verapamil for treatment of my hospitalized patient with heart failure with reduced ejection fraction (HFrEF) and atrial fibrillation?