Chiefs’ Inquiry Corner – 9/23/19

September 23, 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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The point-of-care hemoglobin A1c is a potent lab value that can help clinicians make diabetes management decisions within a single patient visit. A 2017 meta-analysis of studies testing several available point-of-care devices found an overall range of about +/- 1% relative to the gold-standard laboratory-determined value. Most devices tended to provide a lower A1c than the laboratory value. This has left providers feeling more comfortable using point-of-care data for management than for diagnosis. In its guidelines, the American Diabetes Association notes that while some devices may be FDA-approved for diagnosis, they should be used for that purpose only in certain settings.

References: POC a1c  
Brainerd diarrhea is an underrecognized cause of acute-onset, chronic, watery diarrhea, which occurs in both outbreaks and sporadic cases. It was first described in 1983 during a large outbreak in Brainerd, Minnesaota. The diarrhea usually occurs 10-20 times a day and is accompanied by gas and bloating, but rarely upper GI symptoms. The cause of Brainerd diarrhea is unknown, but outbreaks have been linked to contaminated unpasteurized milk and well water, suggesting an infectious or toxic etiology. The incidence of sporadic Brainerd diarrhea is likewise unknown, as it is likely underreported, and there is no established confirmatory test for diagnosis. Sporadic Brainerd diarrhea is often presumptively diagnosed when an extensive efforts have been taken to exclude similar causes of chronic diarrhea. There is no known effective treatment for Brainerd diarrhea and the course is usually prolonged, but patients almost always spontaneously recover within 3 years.  

References: Brainerd  
In a multicenter study looking at 51 patients with dilated cardiomyopathy, 46% of patients randomized to treatment withdrawal developed a relapse of their dilated cardiomyopathy, compared to 0% in the treatment continuation group. This suggests that in this patient population, who largely had idiopathic or familial dilated cardiomyopathy, neurohormonal blockade should be continued. However, it is not clear if this strategy would also apply to patients with other forms of cardiomyopathy. 

References: TRED-HF