Chiefs’ Inquiry Corner- 9/13/2021

September 14, 2021

Chief residents of the NYU Langone Internal Medicine Residency give quick-and-easy, evidence-based answers to interesting questions posed by house staff, both in their clinics and on the wards.

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 Diabetes is the leading cause of kidney failure and new cases of blindness in the US, and is also associated with increased risks of cardiovascular disease and nonalcoholic fatty liver disease, prompting calls for earlier detection, diagnosis, and treatment of prediabetes and type 2 diabetes. As a result, the USPSTF has updated their 2015 guidelines on screening asymptomatic adults for prediabetes and type 2 diabetes. The recommendation is now to screen for prediabetes and type 2 diabetes in adults aged 35-70 year who are considered overweight (BM >25) or to have obesity (BMI <30); the starting age of 35 has been lowered from the prior recommendation of 40 years. Clinicians can consider screening patients at an even earlier age if they are from a population with a disproportionately high prevalence of diabetes (American Indian/Alaska Native, Black, Hawaiian/Pacific Islander, Hispanic/ Latino) and at a lower BMI (≥23) if a patient is Asian/Asian-American. Recommended screening tests of prediabetes and type 2 diabetes remain the same: measurement of fasting plasma glucose, measurement of HgbA1c, or an oral glucose tolerance test. For adults with an initial normal glucose test result, optimal screening interval is uncertain but every 3 years is considered reasonable.

References: Screening for Prediabetes and Type 2 Diabetes: US Preventive Services Task Force Recommendation Statement.
  Echocardiography is typically the method of detecting right heart strain in patients with confirmed or suspected pulmonary embolism (PE), but CT pulmonary angiography is often the first imaging study performed when there is concern for PE, and thus assessment of RV strain or dysfunction now also occurs on CTA, given the association of such strain and dysfunction with mortality or other adverse events. CT pulmonary angiography findings of RV stain or dysfunction include elevated RV/LV diameter ratio, leftward septal bowing, and reflux of contrast medium into the IVCA (which can be due to tricuspid valve insufficiency as a result of RV dilatation). Consistent with prior studies examining the impact of right ventricular dysfunction on patient outcomes, RV enlargement on CTA (defined as RV/LV diameter ratio > 0.9) predicted adverse clinical events including 30-day mortality or need for cardiopulmonary resuscitation, mechanical ventilation, vasopressors, thrombolysis, or embolectomy (sensitivity 83%, specificity 49%). One study found RV/LV diameter ratio > 1 and leftward septal bowing and a sensitivity 78-92% and a specificity 100% for RV dysfunction when compared with traditional echocardiography, suggesting that while traditional echocardiography remains the standard, CTA as the initial testing modality can also provide important and useful information about right ventricular function in the presence of pulmonary embolism.

References: Can CT pulmonary angiography allow assessment of severity and prognosis in patients presenting with pulmonary embolism? What the radiologist needs to know.
 Some prior studies had suggested an increased risk of community-acquired pneumonia (CAP) in people using proton pump inhibitors (PPIs), although there was limited data to adequately define said risk. A recent meta-analysis of 13 studies (N=2098804 patients; study types included case-control studies, cohort studies, and observational studies) examined the association between PPI use and CAP and found that indeed, the incidence of CAP was higher in PPI users than in people who did not use PPIs [OR= 1.37 (95% CI= 1.22-1.53)], particularly when the PPI had been used for less than 30 days. The risk of CAP was slightly higher in PPI users who also had a history of stroke [OR =1.52 (95% CI=1.33-1.75)], although the underlying mechanism predisposing this population to higher rates of CAP is not clear. Granted, a major limitation of this meta-analysis is the absence of randomized control trials; conceivably, the relationship between CAP and PPI administration could be an association, as patients who are sicker in general are more likely to experience pneumonia as well as be prescribed a PPI. Other limitations of the study included possible misclassification of gastroesophageal reflux disease (GERD)-related aspiration pneumonitis as pneumonia, and lack of adjustment for confounding factors, such as smoking and concurrent medication use. Still, these findings invite further inquiry and suggest clinicians should be mindful of prescribing/recommending PPIs as indicated after weighing potential risks and benefits of this very common class of medications.

References: Proton Pump Inhibitors and the Risk of Community-Acquired Pneumonia: An Updated Meta-analysis.