Medication Use in the Elderly

A nice review in JAMA here.  The author touches on what I believe to be a key point -- the use of medications designed to reduce long term mortality in patients with a limited life expectancy.  


"for patients with advanced dementia, poor prognosis, or both, consensus panels do not recommend (and in some cases advocate against) medications such as statins,bisphosphonates, and cholinesterase inhibitors, although these positions are not universally endorsed."  


I must say, in the era of escalating health care costs, partially driven by medication costs -- thinking about the above statement seems to be reasonable from a policy-making point of view.

Mandatory influenza vaccination?

Article on changing policies in the USA here...

If you don't take the temperature, the patient can't have a fever...

This article reminded me of one of the fatman's rules from Shem's novel.  In this study, computer rule generated central line infection rates were significantly higher than those reported by infection control teams --  in the modern era of reporting and pay for performance, one does wonder if, given a case that is grey one may be more inclined to call it black or white.

Blastomycosis

I saw a case of cutaneous blastomycosis in clinic today -- two lesions, one on the face, the other on the buttock in an otherwise healthy male patient.  A nice review is here.

Blastomycosis is a dimorphic (mould at room temperature, yeast at body temperature) fungus which is endemic in certain geographic areas of North America.  Ontario, where I currently live, and in particular northwest Ontario by the Manitoba border is one such geographic hot spot.

The most common sites of infection are:

• Pulmonary (most patients have some pulmonary involvement)
• Presents as acute (including ARDS) or chronic pneumonia, pulmonary nodule, asymptomatic
• Cutaneous (in 40-80% of cases) presenting as verrucous or ulcerative skin lesions (like my patient)
• Osteomyelitis (~25% of extrapulmonary) presenting as painful lesion in bone, which can mimic sarcoma in radiographic appearance.  Occasionally can have concomittant septic arthritis in adjacent bone.
• GU: (10-30%) in men prostate, testicle, epididymis.
• CNS (5-10%), usually chronic meningitis, occasionally space occupying lesions
• Other

Treatment is with amphotericin B for severe disease (or CNS induction) or with azoles (itraconazole or voriconazole) for other forms.  Treatment guidelines from the IDSA are available here.

PE Prognosis -- Click for article

The simplified PESI is useful to select patients at low risk of death from PE who could probably be treated as outpatients (see archives int medicine article linked above).  A score of zero has a negative predictive value of 99% in both derivation and validation cohorts.

New HIV Guidelines

vailable July 21 issue of JAMA (free, please read the full article from there).

Not sure I agree with all recommendations.  This is the curse of 'growing up' in medicine and therefore developing your own opinion.

I think it is too early to consider raltegravir (and maybe even darunavir) as first line therapies in treatment naive patients.  Especially with other options available.  The authors hint at this point but are not explicit enough for the audience of the guideline (in my humble opinion)

Likewise for starting with CD4 greater than 500.  Those patients should be enrolled in properly designed prospective studies (hence the CIII recommendation)

Format revision and Candidemia Line Removal

Since I have left the clinical ID teaching service as a fellow -- hopefully to return as faculty in 2011, I will slightly alter the blog format.  I will highlight interesting cases that I see in my individual practice, and will highlight what I think are interesting/notable articles in the current literature.

This week's post:

Challenging dogma:  Central lines may not need to be removed early in candidemia???

Subgroup analysis of 2 RCTs in treatment of candidemia (mainly echinocandin and lipid ampho B used)
Looked at removal 24-48h vs. later removal vs. retention
842 total, 354 removed early 180 removed late 304 retained

Note that it appears in multivariate analysis that CVC removal was not associated with treatment success or mortality.  But the point estimates are in favor of removal and the CI's are wide.

In the univariate analysis CVC removal within 48h was associated with improved survival.

Why?  Were sicker patients having their lines retained leading to the perception of increased mortality (that was adjusted for in the multivariate analysis). Statistical confounding?

The associated editorial is worth reading.


I also see candidemia reported -- but not other metastatic complications such as endopthamitis, which would be clinically relevant but not noted in surveilance blood cultures.

Bottom line:  An interesting read that challenges dogma, and I think lends itself to further analysis with large enough numbers and robust enough data to exclude a meaningful clinical benefit of earlier removal.

Until then -- please remove my line promptly should I ever have a CVC related candidemia.