Successful percutaneous management of hypothenar hammer syndrome with thrombosuction and catheter-directed intra-arterial thrombolysis.

Hypothenar hammer syndrome (HHS) is a rare vascular disorder leading to ulnar artery thrombosis or aneurysm and causing acute or chronic limb ischemia. The optimal approaches to managing this condition lack a definitive consensus and are essentially empirical, typically necessitating conservative methods for symptomatic relief, with surgical intervention reserved for cases for which conservative measures prove inadequate or when acute limb ischemia ensues. Limited data are available on percutaneous management for this condition. We present the case of a 36-year-old male powerlifter who developed acute digital ischemia due to HHS in the left hand that was managed successfully through an innovative approach using antegrade left brachial artery access and combining percutaneous thrombosuction and intra-arterial thrombolysis. This comprehensive approach resulted in restoration of blood flow and resolution of acute limb ischemia. The patient was subsequently prescribed short-term anticoagulation therapy and remained symptom free at 3 months of follow-up. This innovative strategy challenges traditional surgical approaches in HHS management, underscoring the importance of using minimally invasive techniques as a promising alternative and highlighting potential avenues for further research.

Is hyponatremia associated with mortality in pulmonary arterial hypertension?

Hyponatremia is associated with poor prognosis in left heart failure and liver disease. Its prognostic role in pulmonary arterial hypertension (PAH) is not well defined. We investigated the association between hyponatremia and one-year mortality in two large cohorts of PAH. This study is a secondary analysis evaluating the association between hyponatremia and one-year mortality in patients treated with subcutaneous treprostinil (cohort 1). The results are validated using a PAH registry at a tertiary referral center (cohort 2). Eight-hundred and twenty patients were enrolled in cohort 1 (mean age = 47 ± 14 years) and 791 in cohort 2 (mean age = 55 ± 15 years). Sodium level is negatively correlated with mean right atrial pressure (r = -0.09, P = 0.018; r = -0.089, P = 0.015 in cohorts 1 and 2, respectively). In unadjusted analyses of cohort 1, the sodium level (as a continuous variable) is associated with one-year mortality (hazard ratio = 0.94; P = 0.035). Hyponatremia loses its significance (as a continuous variable and when dichotomized at ≤ 137 mmol/L; P = 0.12) when adjusted for functional class (FC), which is identified as the variable whose presence turns the effect of sodium level into non-significant. Secondary analyses using a cut-off value of < 135 mmol/L showed similar results. These results are validated in cohort 2. Although the sample size for patients with sodium < 130 mmol/L is small (n = 31), severe hyponatremia is associated with higher overall mortality (47% versus 23%; P = 0.01), even when adjusting for age, FC, and baseline 6-min walk distance ( P < 0.001). Although baseline hyponatremia is associated with one-year mortality, it loses its significance when adjusted for FC.

A structured workshop to improve the quality of resident discharge summaries.

BACKGROUND: Poor communication at hospital discharge can increase the risk of adverse events. The hospital discharge summary is the most common tool for detailing events related to hospitalization in preparation for postdischarge follow-up, yet deficiencies in discharge summaries have been widely reported. Resident physicians are expected to dictate discharge summaries but receive little formal training in this arena. We hypothesized that implementation of an educational program on chart documentation skills would result in improvements in the quality of hospital discharge summaries in a community hospital internal medicine residency program. METHODS: A monthly, 1-hour workshop was launched in August 2007 to provide consistent and ongoing instruction on chart documentation. Guided by a faculty moderator, residents reviewed 2 randomly selected peer chart notes per session using instruments developed for that purpose. After the workshop had been in place for 2 years, 4 faculty members reviewed 63 randomly selected discharge summaries from spring 2007, spring 2008, and spring 2009 using a 14-item evaluation tool. RESULTS: Mean scores for 10 of the 14 individual items improved in a stepwise manner during the 3 years of the study. Items related to overall quality of the discharge summary showed statistically significant improvement, as did the portion of the summaries "carbon copied" to the responsible outpatient physician. CONCLUSIONS: The quality of hospital discharge summaries improved following the implementation of a novel, structured program to teach chart documentation skills. Ongoing improvement was seen 1 and 2 years into the program, suggesting that continuing instruction in those skills was beneficial.

Retrospective review of the frequency of ECG changes in hyperkalemia.

BACKGROUND AND OBJECTIVES: Experimentally elevated potassium causes a clear pattern of electrocardiographic changes, but, clinically, the reliability of this pattern is unclear. Case reports suggest patients with renal insufficiency may have no electrocardiographic changes despite markedly elevated serum potassium. In a prospective series, 46% of patients with hyperkalemia were noted to have electrocardiographic changes, but no clear criteria were presented. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Charts were reviewed for patients who were admitted to a community-based hospital with a diagnosis of hyperkalemia. Inclusion criteria were potassium >/=6 with a concurrent electrocardiogram. Data were abstracted regarding comorbid diagnoses, medications, and treatment. Potassium concentrations were documented along with other electrolytes, pH, creatinine, and biomarkers of cardiac injury. Coincident, baseline, and follow-up electrocardiograms were examined for quantitative and qualitative changes in the QRS and T waves as well as the official cardiology readings. RESULTS: Ninety patients met criteria; two thirds were older than 65, and 48% presented with renal failure. Common medications included beta blockers, insulin, and aspirin; 80% had potassium <7.2. The electrocardiogram was insensitive for diagnosing hyperkalemia. Quantitative assessments of T-wave amplitude corroborated subjective assessments of T-wave peaking; however, no diagnostic threshold could be established. The probability of electrocardiographic changes increased with increasing potassium. The correlation between readers was moderate. CONCLUSIONS: Given the poor sensitivity and specificity of electrocardiogram changes, there is no support for their use in guiding treatment of stable patients. Without identifiable electrocardiographic markers of the risk for complications, management of hyperkalemia should be guided by the clinical scenario and serial potassium measurements.

The cardiovascular implications of hypokalemia.

The role of potassium in the progression of cardiovascular disease is complex and controversial. Animal and human data suggest that increases in dietary potassium, decreases in urinary potassium loss, or increases in serum potassium levels through other mechanisms have benefits in several disease states. These include the treatment of hypertension, stroke prevention, arrhythmia prevention, and treatment of congestive heart failure. Recently, the discovery that aldosterone antagonists not only decrease sodium reabsorption and decrease potassium secretion in the nephron, but also decrease pathological injury of such nonepithelial tissues as the myocardium and endothelium, has generated great controversy regarding the actual mechanisms of benefit of these agents. We review the available data and draw conclusions about the relative benefits of modulating potassium balance versus nonrenal effects of aldosterone blockade in patients with cardiovascular disease.