Chiefs’ Inquiry Corner – 8/19/2019

August 19, 2019

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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Atropine and transcutaneous pacing are first line treatments for unstable bradycardia. In patients who do not respond to three doses of at least 0.5mg of atropine, additional pharmacologic measures can be taken while attempting to electrically pace the heart. Specifically, patients with infranodal block may not respond atropine’s cholinergic blockade, and may respond better to beta adrenergic stimulation. Both dopamine and epinephrine carry class IIb, level of evidence B guideline based recommendations as atropine alternatives in unstable bradyarrhythmias. 

References: ACLS Bradycardia  
The PIOPED-II study prospectively evaluated 824 patients and calculated the sensitivity and specificity of CT angiography in detecting acute pulmonary embolism to be 83% and 96% respectively. Of note, the study used a composite standard that included results of VQ scan showing high probability PE, abnormal findings on lower extremity ultrasound, and findings on pulmonary digital-subtraction angiography. Also of note, 51 patients were excluded because of poor image quality. 

References: PIOPED-II Study  
For immunocompetent adults, the Advisory Committee on Immunization Practices (ACIP) currently recommends one-time vaccination with PPSV23 (Pneumovax) at age 65 or after. Antibody titers wane 3-5 years after vaccination, therefore revaccinating at-risk older adults has been proposed. However repeat vaccine exposure may paradoxically decrease antibody responses. A 2016 systematic review summarized the results of several studies that tracked titers in patients given a primary vaccine versus those who were revaccinated. Results were mixed, but suggested that although titers transiently decrease after revaccination, there were no long term differences in titers between the two groups. Adverse reactions were a concern in those revaccinated within 5 years of the original dose, so a 5-year interval before revaccination seems appropriate. Regardless, the impact of such a strategy is unclear, with no large-scale studies yet on clinical outcomes. Also, as the ACIP currently doesn’t recommend revaccination, insurance coverage may be lacking.

References: Pneumovax