Chiefs’ Inquiry Corner

May 20, 2019

Chiefs' Inquiry Corner 3 min read

Being an outstanding physician and lifelong learner requires stoking the flames of clinical curiosity.  In Chiefs’ Inquiry Corner (CIC) we attempt to succinctly answer actual clinical questions that have been raised on the wards and in the clinics of NYU’s teaching hospitals.  Our answers are not meant to be all encompassing or practice changing but rather to serve as springboards for further exploration.  For those of us with short attention spans, we hope CIC satisfies that craving for a morsel of knowledge in a digestible format.

 

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Brugada Syndrome represents a combination of a characteristic Brugada ECG pattern with clinical manifestations of ventricular arrhythmia in patients with structurally normal hearts. Typical Brugada Patterns include Type 1 – described as a ‘coved’ ST elevation in V1 or V2; and Type 2 –  described as a a ‘saddleback’ ST elevation in V1 or V2, both occurring with some degree of pseudo right bundle branch block features. Type 1, and not Type 2, Brugada pattern is considered the diagnostic pattern. Brugada patterns or resulting ventricular arrhythmias can be unmasked by several provoking factors, including fever, electrolyte abnormalities, and medications with sodium channel blocking properties. Provocative testing of candidates for Brugada Syndrome can be performed with sodium channel blocking ant arrythmics, such as flecanide and procainamide. Candidates for provocative testing are those asymptomatic patients with Type 2 Brugada pattern for whom there is intermediate suspicion of Brugada Syndrome – such as those patients with family history of sudden cardiac death, or family history of Type 1 Brugada pattern.

References: Brugada Syndrome  
Over the last few months, egg consumption has yet again been brought into the limelight as the debate over dietary cholesterol intake rages on. The recent publication of several studies highlighting the potential harms of egg intake has made its way into popular media, leaving many Americans wondering whether they should forgo their daily breakfast sandwiches. One such study published in JAMA attempted to examine the association between egg and dietary cholesterol intake with both cardiovascular as well as all-cause mortality. Self-reported data was obtained from 29,615 participants in 6 prospective cohort studies and pooled over a median follow-up period of 17.5 years. Results of this study suggest a dose-dependent association between dietary cholesterol and specifically egg intake with both cardiovascular disease and all-cause mortality. However, the association between egg consumption and both incident cardiovascular disease and mortality disappeared when adjusting for dietary cholesterol intake, suggesting that the danger of eggs lies in its effect on dietary cholesterol itself. While this study suggests that we should be mindful of the amount of eggs and cholesterol we consume in our diets, the results must be interpreted cautiously given the challenging nature of dietary studies and the use of self-reported data.

References: Eggs and Dietary Cholesterol  
Primary vaccine failure occurs when an individual does not mount a sufficient antibody response after vaccination. This occurs in 2-10% of vaccinated healthy individuals. This is more common in those >50 years old suggesting that an aging immune system contributes to reduced responsiveness to vaccination. Secondary vaccine failure occurs when individuals who previously responded to vaccination lose protective antibodies over time. A study published in Clinical Infectious Diseases evaluated the clinical characteristics of measles infection in vaccinated versus unvaccinated patients. Among cases of confirmed measles, the majority were in unvaccinated subjects, however there were cases of confirmed measles in individuals who received 1 dose or 2+ doses of the measles vaccine. It was unclear, however, if these individuals who had received at least 1 dose of the vaccine represented primary or secondary vaccine failure. Those who received 2 or more doses of the vaccine were noted to have milder clinical courses with lower rates of hospitalization, cough, coryza, conjunctivitis, and fever than those who had 1 dose or were unvaccinated. Overall those who are infected with the measles virus despite vaccination seem to do better than those who contract the virus and are unvaccinated.

References: Primary and Secondary Vaccine Failure