Chiefs’ Inquiry Corner – 6/6/22

June 6, 2022

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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 It appears that the sensitivity of low voltage on EKG is not a particularly sensitive or reliable finding – one study investigated the findings of low voltage in patients with known pericardial fluid. The estimated volume of effusion was not related to EKG voltage, and after pericardiocentesis there was only a small increase in voltage. In another group of patients with low voltage findings (36 patients), only 13 had pericardial effusions by echocardiographic findings. It is also worth considering that a decrease in voltage may be observed in any fluid-retention state, such as cirrhosis, nephrotic syndrome, and congestive heart failure.

References:  “Low Voltage ECG” and Pericardial Effusion
 Pressure ulcers are increasing in incidence with our aging population and increased older adults living with disability. Prevention is a mainstay of management for patients with known risk factors (both intrinsic and extrinsic), but once a patient has developed an ulcer there are a number of treatment modalities. The mainstays of treatment include offloading the pressure source, adequately draining any areas of infection, debriding devitalized tissue, and optimizing regular wound care. Controlling contamination is important, as urine and stool can be irritating to the skin causing further breakdown and ulcer extension. Frequent changes of diapers are encouraged to minimize contact with urine and stool. Rectal tubes can be used, though there is little evidence supporting their utility.

References: Review of the Current Management of Pressure Ulcers
 The Hepatitis B vaccines have shown efficacy, safety, and immunogenicity over several decades. The Advisory Committee on Immunization Practices (ACIP) has expanded recommendations for universal adult HepB vaccination from ages 19-59. This was based on a review of current trends, which show that the number of cases of acute hepatitis B have increased among adults ages 40 years or greater, and about 50% of acute cases in 2019 occurred in individuals ages 30-49. Vaccination among individuals >19 is low (estimated 30%). A universal recommendation was made with hopes that we will increase vaccination before onset of chronic liver disease or other comorbidities (such as obesity or diabetes) which may make the vaccine less effective.

References: Universal Hepatitis B Vaccination in Adults Aged 19-59 Years