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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Left ventricular hypertrophy (LVH) is associated with increased cardiovascular morbidity and mortality and is therefore important for risk stratification. Although the ECG remains a simple, ubiquitous, and inexpensive way to diagnose LVH, the clinical utility of ECG is limited by the impact of lead placement, body habitus, age, lung pathology, conduction abnormalities, or myocardium pathology on voltage. Additionally, with the AHA endorsing more than 30 ECG criteria for diagnosing LVH, there is no consensus among practitioners on which criteria are most appropriate for clinical use. Studies that have compared some of the most commonly used criteria including the Romhilt-Estes Point-Score system, Sokolow-Lyon, Cornell, and Rodríguez Padial found very low diagnostic value outside of appropriate clinical context. They all carry a very low sensitivity (as low as 12%) but moderate specificity for LVH diagnosis when compared to echocardiography or cardiac-MRI. Comparing these criteria head-to-head, Cornell, Romhilt-Estes, and Sokolow-Lyon have been found to have the best accuracy, sensitivity, and specificity, respectively. These criteria can be more clinically relevant when seen in conjunction with left atrial abnormalities, leftward axis, or widening of the QRS.
Lung volume reduction surgery (LVRS) involves wedge resection of emphysematous lung region in order to reduce overinflation and bronchial tension and improve elastic recoil and airflow. It is considered in patients with advanced emphysematous COPD with continued symptoms despite maximal medical therapy and pulmonary rehab. The National Emphysema Treatment Trial (NETT), which included over 1200 patients, is the largest randomized trial to investigate the effectiveness of this procedure. The patients who benefited the most were those with upper lobe predominant emphysema and low exercise capacity – in this group there was a reduction in long-term mortality (risk ratio 0.57, p-value 0.01) as well as improved exercise capacity and quality of life.
Terbinafine has been associated with hepatotoxicity, making a check of hepatic function before, during or after treatment a common practice. A 2018 retrospective study in JAMA Dermatology looked at 4,300 patients who received terbinafine and found that the rate of elevated transaminases after starting treatment was low and comparable to the rate of baseline abnormalities. When abnormalities did occur on interval testing, more than 90% were classified as low-grade, and less than 1% of these cases led to discontinuation of the medication or other action. In patients without baseline hepatic dysfunction, a repeat hepatic function test appears to be of little value, and most patients will be just fine with terbinafine.
References: LFTs for Terbinafine