Stay Still's for POCUS: using bedside ultrasound to screen for cardiac complications.

Adult Still's disease (ASD) is a rare systemic inflammatory disorder of unknown etiology most commonly characterized by daily spiking fevers, an evanescent, 'salmon-colored' rash, and arthralgia. Cardiac complications such as pericarditis, myocarditis, heart failure, and pericardial effusion progressing to tamponade have been reported. Because of the severe and potentially lethal complications associated with these processes, the clinician's index of suspicion must remain high and the threshold for cardiac imaging low. Here, we present a case of ASD-associated myocarditis identified quickly by point-of-care ultrasound, allowing for prompt workup and treatment.

A near miss: subclinical saddle pulmonary embolism diagnosed by handheld ultrasound.

INTRODUCTION: Pulmonary embolism (PE) is a life-threatening condition characterized by occlusive disease of the pulmonary vasculature. Point-of-care ultrasound (POCUS) of right ventricular strain patterns have high specificity and low sensitivity for diagnosis. Here, we describe a patient with a saddle PE and low pre-test probability who was diagnosed primarily by handheld POCUS. CASE REPORT: An 80-year old female was admitted to the intensive care unit with hypotension and lactic acidosis. She also had mild leukocytosis and troponinemia. No other clinical or metabolic abnormalities were present. After transfer to the floor, handheld POCUS demonstrated D-sign and McConnell's sign. Computed tomography angiography showed a saddle PE involving both main pulmonary arteries. The patient was immediately initiated on anticoagulation without further complications. CONCLUSION: Handheld POCUS is inexpensive, carries a low risk of harm and is an invaluable extension of the physical exam when interpreted in the appropriate context.

Hyperinsulinemic syndrome: the metabolic syndrome is broader than you think.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is characterized by hyperinsulinemia. In 2011 we showed that gastric bypass (RYGB) corrects these high levels even though insulin resistance remains high, ie, the operation "dissociates" hyperinsulinemia from insulin resistance. RYGB produces reversal of T2DM along with other diseases associated with the metabolic syndrome. This observation led us to examine whether these illnesses also were characterized by hyperinsulinemia. METHODS: A systematic review was performed to determine whether hyperinsulinemia was present in disorders associated with the metabolic syndrome. We reviewed 423 publications. 58 were selected because of appropriate documentation of insulin measurements. Comparisons were based on whether the studies reported patients as having increased versus normal insulin levels for each metabolic disorder. RESULTS: The presence (+) or absence (-) of hyperinsulinemia was documented in these articles as follows: central obesity (4+ vs 0-), diabetes (5+ vs 0-), hypertension (9+ vs 1-), dyslipidemia (2+ vs 0-), renal failure (4+ vs 0-), nonalcoholic fatty liver disease (5+ vs 0-), polycystic ovary syndrome (7+ vs 1-), sleep apnea (7+ vs 0-), certain cancers (4+ vs 1-), atherosclerosis (4+ vs 0-), and cardiovascular disease (8+ vs 0-). Four articles examined insulin levels in the metabolic syndrome as a whole (4+ vs 0-). CONCLUSION: These data document that disorders linked to the metabolic syndrome are associated with high levels of insulin, suggesting that these diseases share a common etiology that is expressed by high levels of insulin. This leads us to propose the concept of a "hyperinsulinemic syndrome" and question the safety of insulin as a chronic therapy for patients with T2DM.

Effects of respiratory exchange ratio on the prognostic value of peak oxygen consumption and ventilatory efficiency in patients with systolic heart failure.

OBJECTIVES: The purpose of this analysis was to evaluate the prognostic characteristics of peak oxygen consumption (Vo2) and the minute ventilation/carbon dioxide (VE/Vco2) slope of different peak respiratory exchange ratios (RERs) obtained from cardiopulmonary exercise testing in patients with heart failure (HF). BACKGROUND: For patients with HF, peak Vo2 and the VE/Vco2 slope are used for assessing prognosis. Peak Vo2 is assessed in association with peak RER ≥1.10, indicating maximal effort and prognostic sensitivity. Conversely, the VE/Vco2 slope provides effort-independent prognostic discrimination. METHODS: Patients with HF scheduled to undergo cardiopulmonary exercise testing were enrolled. Patients were subclassified by peak RER (RER <1.00, RER 1.00 to 1.04, RER 1.05 to 1.09, RER ≥1.10) and followed for up to 3 years for major cardiac-related events (death, left ventricular assist device implantation, or cardiac transplantation). RESULTS: Included were 1,728 patients with HF (75% males; 40% ischemic etiology; age: 55 ± 14 years; left ventricular ejection fraction: 28 ± 10%). Two hundred seventy major events occurred, with no proportional differences across the RER subgroups. Multivariate Cox regression analysis indicated that the VE/Vco2 slope and peak Vo2 remained prognostic within each subgroup; the VE/Vco2 slope remained the strongest predictor. Receiver-operating characteristic analysis demonstrated equitable prognostic cutoffs for the VE/Vco2 slope (range: 34.9 to 35.7; area under the curve [AUC] range: 0.69 to 0.75) and peak Vo2 (range: 13.8 to 14.0 ml·kg(-1)·min(-1); AUC range: 0.68 to 0.75). CONCLUSIONS: Peak Vo2 provided a sensitive assessment of prognosis in patients with HF in all RER subgroups. The VE/Vco2 slope provided greater prognostic discrimination in all RER subgroups. Clinical consideration may be warranted for patients with low RER, low peak Vo2, and an elevated VE/Vco2 slope.