Sources for syncope rules

Evaluation of Guidelines in Syncope Study (EGSYS) syncope score: Calculate by QxMD (app is freely available for Android and Apple devices), EMERG CDRs (app is freely available for Android devices)

Osservatorio Epidemiologico sulla Sincope nel Lazio (OESIL) risk score: American Family Physician (AFP, see Table 1)

Risk Stratification of Syncope in the Emergency Department (ROSE) risk score: AFP (see Table 1)

San Francisco Syncope Rule: AFP (see Table 1), CliniCalc (app is freely available for Apple devices), MDCalc, MediCalc® (app is freely available for Android and Apple devices), Omnio (app is freely available for Android and Apple devices)

Syncope Risk Prediction (similar to OESIL tool): DynaMed (app is freely available to Emory users for Android and Apple devices)

Posted in Applying evidence, EUH, Miscellaneous

The China Antihypertensive Trial in Acute Ischemic Stroke (CATIS) Study

The Bottom Line: The effect of antihypertensive treatment in patients with acute ischemic stroke is uncertain. This RCT concluded that bloodpressure reduction with antihypertensive medications, compared with the absence of hypertensive medication, did not reduce the likelihood of death and major disability at 14 days or hospital discharge.

Reference: He, Jiang, Zhang, Yonghong, Xu, Tan, Zhao, Qi, Wang, Dali, Chen, Chung-Shiuan, Tong, Weijun, Liu, Changjie, Xu, Tian, Ju, Zhong, Peng, Yanbo, Peng, Hao, Li, Qunwei, Geng, Deqin, Zhang, Jintao, Li, Dong, Zhang, Fengshan, Guo, Libing, Sun, Yingxian, Wang, Xuemei, and Cui, Yong. “Effects of Immediate Blood Pressure Reduction on Death and Major Disability in Patients with Acute Ischemic Stroke: The CATIS Randomized Clinical Trial.JAMA the Journal of the American Medical Association. 311.5 (2014): 479-89.

For Additional Reading: Gorelick, Philip B. “Should Blood Pressure be Lowered in Acute Ischemic Stroke? The CATIS Trial.” Journal of American Society of Hypertension 9.5 (2015):331-333.

Ivanov A, Mohamed A, Korniyenko A. “Permissive Hypertension In Acute Ischemic Stroke: Is It a Myth or Reality?Journal of the American College of Cardiology. 65.10S (2015). doi:10.1016/S0735-1097(15)61344-4.

Posted in Applying evidence, Background question, EUH | Tagged ,

Pustular psoriasis: A review

The Bottom Line: Several clinical variants of pustular psoriasis exist: generalized pustular psoriasis (von Zumbusch type), annular pustular psoriasis, impetigo herpetiformis, and two variants of localized pustular psoriasis—(1) pustulosis palmaris et plantaris and (2) acrodermatitis continua of Hallopeau. Treatment of patients with pustular psoriasis depends on the severity of presentation and patient’s underlying risk factors. The literature and data are extremely weak and limited for this type of psoriasis.

Click here for a book chapter on psoriasis, with a section covering pustular psoriasis.

DynaMed Plus provides treatment guidelines recommended by the National Psoriasis Foundation (NPF).


Gudjonsson, Johann E., and James T. Elder.Chapter 18. Psoriasis.Fitzpatrick’s Dermatology in General Medicine, 8e. Eds. Lowell A. Goldsmith, et al. New York, NY: McGraw-Hill, 2012. n. pag. AccessMedicine. Web. 22 Jan. 2016. <;.

DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – . Record No. 116742, Psoriasis; [updated 2015 Dec 21, cited 2016 Jan 22]. Available from Registration and login required.

Summary: Pustular psoriasis involves monomorphic sterile pustules on painful inflamed skin. There is localized pustular variant involving soles and palms occurring with or without plaque-type disease (palmoplantar psoriasis). The acute generalized disease also called von Zumbusch variant consists of widespread pustules on erythematous background and is an uncommon severe form of psoriasis associated with fever and toxicity.

Treatment: Treatment should be governed by the extent of involvement and severity of disease. Acitretin, cyclosporine, methotrexate, and infliximab are considered to be first-line therapies for those with generalized pustular psoriasis. Adalimumab, etanercept, and psoralen plus ultraviolet A are second-line modalities in this setting. Pustular psoriasis in children, in pregnant women, and in localized forms alter which agents are first-line modalities as concerns such as teratogenicity need to be factored into the decisionmaking for the individual patient.



Posted in Background question, EUH | Tagged ,

Sensitivity and specificity of the Nikolsky sign

The Bottom Line: The Nikolsky sign is a moderately sensitive but highly specific tool for the diagnosis of pemphigus.

Reference: Uzun, Soner, and Murat Durdu. “The Specificity and Sensitivity of Nikolskiy Sign in the Diagnosis of Pemphigus.” Journal of the American Academy of Dermatology 54.3 (2006): 411-15

Summary: Presence of the Nikolskiy sign with the modifications of “direct” and “marginal” on 123 consecutive patients with various cutaneous diseases presenting as intact blisters and/or erosions was sought.

A positive Nikolskiy sign was demonstrated in 24 (19.5%) of the 123 patients. Of the positive 24 patients, 18 had pemphigus, 4 had bullous pemphigoid, 1 had linear IgA dermatosis, and 1 had staphylococcal scalded skin syndrome. The sensitivity of “direct” Nikolskiy sign (38%) was less than that of the “marginal” form (69%), but the specificity of “direct” Nikolskiy sign (100%) was higher than that of the “marginal” form (94%) in the diagnosis of pemphigus.

Posted in Background question, Diagnosis, EUH | Tagged ,

Gastric AFB

The Bottom Line: AFB smear of GA is a relatively insensitive but highly specific indicator of pulmonary tuberculosis warranting institution of antituberculosis treatment. Gastric AFB smear positivity appears to reflect a high bacillary burden within the respiratory tract.

Reference: Bahammam A., Choudhri S., Long R. “The validity of acid-fast smears of gastric aspirates as an indicator of pulmonary tuberculosis.” The International Journal of Tuberculosis and Lung Disease 3.1 (1999): 62-67.

Summary:  To establish a definitive diagnosis of pulmonary tuberculosis, Mycobacterium tuberculosis must be isolated from the respiratory tract. This usually involves examination of a sputum sample, but when the patient cannot produce sputum, one must resort to alternative diagnostic procedures such as gastric aspiration (GA) or induced sputum.

From 1994 to 1996 inclusive, 1155 GA were performed in 889 patients at a TB referral hospital in Canada. Mycobacteria were cultured from 109 (9%) GA. Thirteen of these were positive on smear (sensitivity 19%). All GA that were positive on smear were culture positive for Mycobacterium tuberculosis. There were no false positive smears (specificity 100%). The sensitivity and specificity of the sputum smear were 45% and 99%, respectively. Of the 96 culture positive, smear negative GA, 54 grew M. tuberculosis and 42 grew an NTM. Of 13 patients who had sputum and GA studied coincidentally, and in whom the sputum was both smear and culture positive, the GA culture was positive in 13 and the smear was positive in eight (66%).

Posted in Background question, Diagnosis, EUH | Tagged

PCR’s sensitivity in pulmonary tuberculosis

The Bottom Line: Combining CT findings of consolidation and QFT test results may improve clinicians decision-making in patients with TB-PCR-negative BA.

Reference: Kim, CH, et al. “Predictive factors for tuberculosis in patients with a TB-PCR-negative bronchial aspirate.” Infection 41.1 (2013): 187-194.

Summary: A retrospective study was conducted on patients who had undergone a bronchoscopy because of suspected PTB. Clinical, laboratory, and computed tomography (CT) findings were investigated in PTB patients with TB-PCR-negative but positive culture BA results, and non-PTB patients with a radiographic lesion comparable to the former.

Of 250 patients screened, 31 (12 %) were diagnosed with PTB by positive culture results only. Of these 31 patients, 30 (97 %) had a lesion within one-third of the hemithorax as determined by chest radiography. In the final analysis of 30 PTB and 65 non-PTB patients with comparable radiographic lesions, a positive QuantiFERON-TB Gold In-Tube (QFT) result was independently associated with an increased risk of a positive TB culture. CT findings of consolidation were a negative predictor for PTB. Patients with a negative QFT result and consolidation had a negative predictive value of 95 % for PTB, while patients with a positive QFT result and nodular CT abnormalities without consolidation had a positive predictive value of 86 % for PTB.

Posted in Background question, Diagnosis, EUH | Tagged

What is the association of hyperprolactinemia in association with hypothyroidism?

The Bottom Line This study showed prevalence of hyperprolactinemia in subclinical hypothyroidism is notable and this disorder is more common in female subclinical
hypothyroidism than the men.

Bahar, Adele, et al. “Hyperprolactinemia in association with subclinical hypothyroidism.” Caspian journal of internal medicine 2.2 (2011):229-33.

Hyperprolactinemia is the most prevalent endocrine disorder in hypothalamicpituitary axis. Pathologic hyperprolactinemia is generally applied for the situation in which prolactin level increases because of some reasons other than physiologic causes. Prolactin secretion is controlled by prolactin inhibitor factor that is secreted from hypothalamus, other factors like vaso active inhibitory peptide and Thyroid releasing hormone cause to increase prolactin secretion. In fact, TRH in addition to increasing TSH causes to rise prolactin level . In patients with primary hypothyroidism, increased levels of TRH can cause to rise prolactin levels and these patients may have galactorrhea. Different increased level of serum prolactin has been reported in 30% of patients with primary hypothyroidism. Subclinical hypothyroidism is defined by high TSH and normal thyroid hormones.

Posted in Background question, VA | Tagged