A 34-year-old man visits a primary care clinic because his family says that his voice sounds hoarse and he finds that he needs to clear his throat often. During the initial visit, he tells you that he returned from military service 1 year ago and that his routine physical exam 6 months ago was normal. He is slightly overweight and currently smokes 1 pack of cigarettes a day and has done so since age 20. He denies experiencing any heartburn or regurgitation, although he has upper abdominal discomfort. He has no family history of esophageal cancer. His hoarseness has developed over the last 2 months.
A case study for primary care doctors also for us too.
GERD - Case study
April 30, 2008
An acid base puzzle
| Electrolyte panel | |||||
|---|---|---|---|---|---|
| Na | 141 | Cl | 112 | BUN | 18 |
| K | 4.3 | HCO3 | 15 | creat | 0.7 |
| Blood Sugar | 105 |
| ABG | |
|---|---|
| pH | 7.33 |
| pCO2 | 25 |
| pO2 | 103 |
| calc HCO3 | 13 |
She is 32 and has a long history of Crohn’s disease, with an ileostomy. Consider the differential diagnosis, and recommend tests to prove your hypothesis.
ECG lead misplacement
It’s hard enough to read ECGs. Your job becomes even more challenging when your nurse throws you a print out by misplacing the electrodes. This is the most systematic treatment of the topic I’ve seen.
The Diagnosis and Management of Acute Porphyrias
We don't see any porphyrias. But in exam this topic comes so often and most of the time we only to forget after exams. This Clinical Update provides a comprehensive overview on the diagnosis and management of acute porphyrias.
Contamination of Heparin and anaphylaxix
April 27, 2008
IV bolus Heparin has been noted to be associated with severe hypersenitivity reaction. In this weeks article published in NEJM this has been linked to contaminated heaprin with over sulphated chondroitin sulphate(OSCS). THis has been found in LMWH enxapirin.
The Debate over doctors and drug reps! A proposal
Proposal by Dr. James Alpert, editor of the American Journal of Medicine, is one of the better ones I’ve seen, but I don’t think it’s extreme enough for some.
Near Fatal Asthma
The full text of a review appearing in Current Opinion in Pulmonary Medicine is accessible via Medscape.
Training then and training now
I finished my internal medicine training 30 years ago. I have taught residents continuously since 1980. Most physicians from my cohort will tell you that our training was more difficult.
Training then
I worked every 3rd night as an intern, then averaged every 4th as a resident. The only days I ever got off were Sundays after Friday night call. We had no caps, and occasionally did admit more than 5 patients in a 24 hour period. We were explicitly expected to stay at least until 5 p.m. on our post call day. We averaged over 100 hours each week.
Training now
My interns work every 4th night, but only stay over night on Fridays, Saturdays, and half of the remaining days. They have a cap of 5 admissions. They must leave work at 1 p.m. on their post call day. They get at least 4 days off each month. They have a 80 hour work week cap.
Training then
We had little pressure to discharge patients. We had no utilization review nurses. Length of stay probably averaged a week.
We had many less diagnostic tests and fewer treatments. We had no CT, no MRI and limited ultrasound (really only M-mode echo.) We never had to use vancomycin (no MRSA.) We had no HIV.
We treated MI patients with lidocaine, morphine and nitrates, but talked a lot about how great it would be if we could decrease infarct size. Our major hospital did 3 cardiac caths each day. We had no interventional cardiology.
CHF patients had an average life expectancy of 6 months after their admission. We used digoxin and furosemide. ACE inhibitors became available in 1988. Beta blockers became available during my senior residency year, but they were absolutely contraindicated in CHF.
COPD patients usually developed cor pulmonale, because we had no home oxygen.
We treated hypertension with alpha methyldopa and a thiazide.
We had no histamine 2 blockers, no PPIs, and no 3rd generation cephalosporins.
Training now
Obviously, our residents have the things that we did not have, and much more. Current residents have much greater supervision (and thus too often micromanagement.) Current residents experience a much shorter length of stay, and have great pressure to discharge patients quickly.
We can do much more for each patient, and we make much more accurate diagnoses.
Which is better, more difficult, more appropriate
This comparison is impossible, because the context of the comparison has changed so greatly. In the 70s, our senior attendings puffed out their chests and bragged about how much harder their training was. Now most of my cohort would say the same thing about current trainees.
The older generation always view their history as being more relevant and more stringent.
I believe that internal medicine training has always required hard work, both intellectually and much time. To try to compare then and now is really not possible.
I personally believe that training is more difficult than ever. Our residents are dedicated to learning our difficult specialty. They struggle with the current social context of patient care.
Our field has changed. We have more responsibility because we can do more. Our subspecialists have deeper knowledge of their subspecialty field, but generally narrower knowledge of the breadth of internal medicine.
I hope that those of my generation will chime in. I hope that current and recent trainees will comment also.
Taken from blog site. It almost what i would have said.When to suspect a false-positive cardiac troponin?
A false-positive troponin should be suspected when the cTn elevation does not fit the rise and fall pattern classically observed in cases of acute myonecrosis, especially if the patient's clinical presentation does not suggest an ACS.
If a false-positive cTn is suspected, it si recommended that the cTn assay be repeated with the techniques used to determine whether there is heterophile antibody interference.
Practice points:-
- Tachycardia, myocarditis, and other conditions that lead to myonecrosis are common causes of elevated cTn levels.
- Patients with a myocardial infarction and myonecrotic conditions have fluctuating cTn levels; suspect analytical interference in patients with consistently elevated cTn levels.
- Perform a stress test and enzyme assays to confirm suspected analytical interference.
- Heterophile blocking antibodies can cause falsepositive troponin levels, and adding them to the reagent in confirmed cases of analytical interference may decrease cTn levels
microlabuminuria- what we need to know
April 25, 2008
During the last few years, a subtle increase in urinary albumin excretion (UAE) not detectable by routine methods, so called microalbuminuria, has been identified as a prognostic marker for renal and/or cardiovascular risk in diabetic and non-diabetic subjects . Consequently, assessment of microalbuminuria is now recommended as a risk stratification strategy not only
in diabetic subjects, but also in the management of hypertensive patients . In order to make the best clinical use of UAE, the physician who measures UAE should know several facts:
a. what kind of albumin molecules are present in the
urine, and which methods are most suitable for
assessing each of them;
b. what method of urine sampling is recommended and
how should one interpret the UAE values;
c. how can one reduce the variability of the UAE
estimate
d. how should one evaluate the results and manage the
patient based on the results of UAE determination.
White-Coat Hypertension Is Hypertension
April 23, 2008
White Coat Hypertension(WCH), I strongly believe this name shoud be changed as doctors are not allowed to wear coat any more. The question always arises whether we we have to treat this kind of blood pressure or not. This article published in Hypertension journal nicely deals with this issue.
All the Cs
Many of the words that describe what makes a good doctor begin with the letter C. A cohort of UK doctors that has been tracked by the BMA since they qualified in 1995 has twice been asked to rank a list of core professional values. This page is entittled Core Professional values. Competence scores highest on both occasions, but caring, compassion, and commitment are all up there in the top six.
Why Ignaz Semmelweis Went Mad?
April 22, 2008
Remember Ignaz Semmelweis? Of course you don't. But you're in his debt nonetheless, because it was Dr. Semmelweis who first demonstrated over a hundred years ago that routine handwashing can prevent the spread of disease.
You should read this nicely written post by maggie mahar.
You should read this nicely written post by maggie mahar.
Non Alcoholic Steato Hepatitis (NASH)
We do see many cases of abnormal liver functions and some of them get labeled as having NASH rightly or wrongly. I have a patient who is obese with Metabolic syndrome and abnormal LFT. I concluded it was NASH without considering other options. Realised bit later she also has auto immune Tyroid disease and had to investigate her for Auto immune hepatitis. This is a recent review that discuss pathogenesis and management of NASH.
B12 and skin
April 21, 2008
Cutaneous manifestations of Vitamin B12
defeciency not uncommon. Hyperpigmentation of skin involving hands , feet and oral cavity can be seen. These two cases illustrate few of these skin manifestations.
First is a 54 year old lacto-vegan presented with ploymorphic lesions in her neck and limbs and second case is a 34year old thyrotoxic lady who presented with these lesions.
You can read about these cases in detail in this article.
Barrets's Oesophagus:
April 20, 2008
Barret's esophagus is common and it is the number 1 risk factor for adenocarcinoma of esophagus. New guideline for the management of this condition has been published recently by American College of Gastroentrology.
Cardaic CT Angiography; Radiation doses all over the place!
Numbers of Cardiac CT performed is on the increase and more and more younger patients undergo this procedure. Radiation dose they receive is considerable and also varies with algorithms used. In this abstract authors conclude that cardiologists and radiologists should be educated re excessive radiation. Interesting point in this study is that different makes of machines give different doses. You better find out before getting fried.
Evaluation of Acute Abdominal Pain Reviewed
In the recent edition of AFP guidelines for evaluation of abdominal pain is published. Though this article is meant to be for primary care doctors, i think we should know this too.
Specific clinical recommendations for practice, all of level of evidence rating C, are as follows:
- Appendicitis cannot be ruled out by a normal white blood cell count.
- In patients with epigastric pain, simultaneous amylase and lipase measurements are recommended.
- For evaluation of patients with acute right upper quadrant abdominal pain, ultrasonography is the imaging study of choice.
- For evaluating patients with acute right lower quadrant or left lower quadrant abdominal pain, CT is the imaging study of choice.
Heparin Induced Thrombocytopenia(HIT)
This is my favorite topic though I have not seen many.This can occur with administration of any form of heparin and produces paradox of arterial and venous thrombosis. Unfortunately we are unable to measure HIT antibodies. This review article explains pathogenesis and management in detail.
Models for Managing Anticoagulation
Anticoagulation is potentially dangerous unless used appropriately. Long term care is mandatory to maximise the benefit and reduce the risks i.e Inta cerebral bleed. Three models are described and the one practiced in our hospital is Anticoagulant clinic model. Systematic Anticoagulation management is the best option but in our environment tracking patient is a big hurdle. This is an article published in Medscape is helpful to understand the new concept.
Interpreting CHARISMA study: Dual anti platelet therapy
April 19, 2008
CHARISMA was a prospective, randomized,double-blind, placebo-controlled study of the
efficacy and safety of clopidogrel plus aspirin vs placebo plus aspirin in patients at high risk
of cardiovascular events.
This study has shown that in asymptomatic patients( patients with cardio-cerebro-peripheral vascular disease(CCP- VD) the absolute rask reduction of 1%(RRR 13%) but in asymptomatic patients ( multiple risk factors without CCP-VD) there was no benefit.
Do not waste resources.
Hyponatremia and Brain
Hyponatremia is a common admission diagnosis in our medical wards. Acute hyponatremia can cause cerebral dysfunction due to cerebral edema and rapid correction can give rise to dreaded complication Central Pontine Myelinolysis. In my previous post i have discussed a case of hyponatremia and its management.
This article is a excellent review of hyponatremia and brain.
Perioperative statin use: Continue seamlessly
In my previous post i talked about use of beta blockers in perioperatively.The ACC guideline for perioperative evaluation and management of patients undergoing noncardiac surgery now give statins virtually equal status with beta blockers, recommending that patients already taking statins have them continued throughout the perioperative period.
This study is of interest to us physicians Interruption of statin use was associated with increased early postoperative cardiac events. The problem though is patients undergoing higher risk surgeries such as abdominal aortic procedures had longer interruptions in statin therapy because of NPO for longer periods.They suggest that administration of an extended release statin before surgery may help bridge the gap. Extended release statin can be used before surgery.. Fluvastatin (Lescol XL) is the only extended release statin available.
A recent study is published in annals of Surgery discussing statins and perioperative risk reduction.
Interpreting pleural Fluid
Interpreting Thoracentisis Analysis - Diagnostic Hints from Pleural Fluid
Renal calculators
These are useful renal calculators ;
- A-a gradient
- Anion Gap
- Cockcroft-Gault (GFR)
- Free Water Deficit
- MDRD GFR
- Saline Infusion Calculator
- Sodium Correction for hyperglycemia
- Winter's Formula( Metabolic acidosis compensation)
Vasculitis: all you want to know
April 16, 2008
Rheumatologic processes are often confusing, presenting in a multitude of forms with overlapping symptoms between diseases. Fortunately, Johns Hopkins has a fantasitic guide to the major vasculitities online here.
Cardiac clearance for non cardiac surgery
This topic always comes up when you are on call for medicine or a GP may be faced with this kind of problem.
Case Scenario:
R.J. is a 76-year-old man who is scheduled for a right hip arthroplasty in two weeks. He presents at the request of his orthopedic surgeon for a medical consultation before surgery. He had an inferior MI one year ago for which he received antithrombolytic therapy with complete resolution of his symptoms. He has never smoked, has no history of cerebrovascular disease or diabetes, has a normal ejection fraction, and normal renal function. R.J. usually walks one to two miles in the morning, but his function has been severely limited over the past two months because of hip pain. He is taking hydrochlorothiazide (Esidrix) and simvastatin (Zocor). Although his primary care physician prescribed a beta blocker after his MI, R.J. stopped taking it after a bout of bronchitis two weeks ago. He is asymptomatic from a cardiac and respiratory standpoint. His vital signs are normal except for a blood pressure of 157/92 mm Hg. His physical examination is within normal limits, and electrocardiography demonstrates Q waves inferiorly. Should he undergo cardiovascular stress testing before surgery, and is he a candidate for perioperative beta blockade or other medical therapy?
Answer To comment: Thanks for your help. Suggested site is perioperativebetablockade
How to read Chest X-ray?
How To Read a Chest X-Ray (CXR)
Every physician has their own method of evaluating films. Most will tell you that it doesn't matter so much what method you chose, but rather that you approach an image systematically, the same way every time, in order to ensure the fewest possible omissions and errors. I have found the following method effective, feel free to adapt and post comments.
- Identify your pt: DOB, CC, HPI
- Use the "PIER" mnemonic to assess for adequacy of the film. Ask yourself is the film worth "pier-ing" into? <-- to remember the mnemonic
- Position: Typically, upright PA and lateral. Sick patients will have the fuzzier supine AP (because the film is slid under their chest as they are lying down).
- Inspiration: Count the visible ribs. Lung fields should extend to about the 10th or 11th rib.
- Exposure: If the film is penetrated enough, you should be able to make out the spinous processes "inside" the vertebrae. If the film is underexposed/too white, you won't be able to see them. If the film is overexposed/too black, bony details will be lost.
- Rotation: Evaluate the clavicals. They should appear symmetric and equal in length. Now systematically work through the x-ray.
- Evaluate the film. Here is one popular pneumonic. See the links at the bottom of the post for more CXR guides with images.
- A = Airway: are the trachea and mainstem bronchi patent; is the trachea midline?
- B = Bones: are the clavicles, ribs, and sternum present and are there fractures, lytic lesions?
- C = Cardiac silhouette: is the diameter of the heart > ½ thoracic diameter (enlarged)?
- D = Diaphragm: are the costophrenic and costocardiac margins sharp? is one hemidiaphragm enlarged over another? is free air present beneath the diaphragm?
- E = Effusion/empty space: is either present?
- F = Fields (lungs): are there infiltrates, increased interstitial markings, masses, air bronchograms, increased vascularity, or silhouette signs?
- G = Gastric bubble: is it present and on the correct (left) side?
- H = Hilar region: is there increased hilar lymphadenopathy?
- Now check the places you forgot to look:
- Soft Tissue - Breast shadows, supraclavicular regions, axillae, chest wall. Look for thickness, subcutaneous emphysema (air bubbles-dark spots), calcifications (bright spots).
- Behind the heart
- The apices
- Under the clavicles
- The costophrenic angle and the cardiophrenic angle and interface
- Types of lung densities:
- alveolar: patchy, poorly marginated. Represents material other than air in the airspaces. May see "air bronchograms"-black lines representing air-filled bronchi amidst water-density alveoli. May note "silhouette signs"-organs' margins blurred by dense material in alveoli of nearby lung tissue.
- interstitial: thickening of bronchi, septae. Linear or finely granular patterns of abnormal shadows. "Kerley's B-lines" (not "curly" B-lines) are thickening of interlobular septae and are small, bright, horizontal lines seen esp. towards the bases of the lungs. They are associated with CHF. The interstitial pattern is seen in CHF, interstitial fibrosis, cancer, inflammation.
- atelectasis: loss of volume leads to a shift of interlobar fissures & mediastinum towards the collapsed region.
- nodules: one or more dense, bright, round lesions. Adenoma, granuloma, cancer, cyst, lymph node, etc.
- other: abscess (lucency within density, air-fluid level); pneumatoceles (air-containing spaces seen with some pneumonias); honeycombing (airspaces w/thick septae)
- Also check out:
eGFR and CKD
Traditional way of assessing renal function is by measuring serum creatinine. But Serum creatinine grossly under estimates renal function especially in women and old people. This delays referral to renal physician Our laboratory should calculate eGFR in all our patients. This article talks how eGFR helps to manage patients with CKD.
Carpal Tunnel Syndrome
CTS is one of the commonest Entrapment neuropathies. This is an excellent review article in Ulster Medical Journal.
Effect of ACE plus on albuminuria : GUARD study
April 15, 2008
This GUARD double blind randomised controlled study was recently published in Kidney international. ACE plus diuretic is better than ACE plus Calcium blocker for albuminuria.
Free water calculator
The calculation is important in determining the amount of free water (in liters) needed to treat hypernatremia.
Infuse 1/2 of the deficit over 24 hrs., then the remainder over the next 1-2 days
Simplifying diagnosis of pulmonary embolism
April 14, 2008
The use of history and clinical signs in the diagnosis of pulmonary embolism (PE) is notoriously inaccurate, and clinical judgement alone can rarely confirm or refute the diagnosis of PE with certainty. It is the first clinical assessment will decide whether we need to proceed with imaging to confirm or exclude PE.
The pre-test probability (PTP) of disease represents a formal assessment of the likelihood of disease before a confirmatory test, or investigation, is performed. Post test probability depends on no 1. pre test probability no 2. type of test performed.
The Geneva and Wells scores are clinical pre-test probability scores derived from large trials that sought to determine the clinical signs and symptoms that reliably predict the diagnosis of PE
Transfusion Dependant Thalassemia - a new era
Managing transfusion Thalassemia youngsters is difficult and seeing them die of cardiac failure and infections is heart breaking. Appearance of Oral Chelators have made my life much easier and also patients lefe much easier too. This Editorial comes at the right time
The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity
Endless numbers of SSRI are available and used by lots of patients. So Serotonin toxicity has become an important and common side effect. Serotonin toxicity can be mild, severe or some times life threatening. Hunters Serotonin Toxicity Criteria has been developed and a flow chart to help in assessing severity of such toxicity.
If you want to learn about managing Serotonin toxicity you can read this clinical update published in Medical Journal of Australia.
Management of Adrenal Insufficiecy during medical illness and surgery
A very good clinical update is published in the recent Medical journal of Australia. Useful to remember the guidelines.
Granulomatous Hepatitis: TB or Not?
Cholestatic liver dysfunction with non caseating granuloma can be misdiagnosed to be non tuberculous. In our place TB comes first and some times it is only found only Liver. A lesson from practice is published in Medical Journal of Australia.
Oxygen overdose?
Improper administration of O2 results in CO2 narcosis in COPD admitted with exacerbation. This real case demonstrates dangers and how this can be avoided in our COPD patients
Dual Blockade in Acromegaly?
Medical treatment of Acromegaly has become feasible with long acting somatostatin analogues and GH receptor blockade.
Author concludes:
1) Disease control by medical therapy is now obtainable in almost all patients with acromegaly,
2) Long term data on the effects and side effects of combination therapy are still needed and
3) Should combination therapy be first choice to all patients who do not respond adequately to SA?
Graves Ophthalmopathy(GO): Questions answered
Graves Ophthalmopathy remains most enigmatic presentation of Graves disease. This abstract tells it all.
Clopidogrel Rebound
When clopidogrel ( plavix) is stopped following a course of treatment for acute coronary syndrome, whether medically managed or with stent placement, cardiac events tend to cluster in the first 90 days after discontinuation according to a disturbing report in JAMA.
According to Medscape’s coverage of the study, the lead author commented that:…there were two possibilities as to how to deal with it: keep the patient on clopidogrel for longer periods or taper the dose when stopping. "We need to study each of these possibilities to find out which one is best. But until we know for sure, physicians should discuss with each patient how they want to handle the situation after they have taken clopidogrel for a year after an ACS event. A patient who is doing well on clopidogrel, has no bleeding issues or other side effects, and can afford it may want to stay on the drug long term. If they want to come off the dug, then tapering the dose over a few weeks may be a good idea. Or perhaps the dose of aspirin could be doubled for a while. I can't recommend any of these things as we haven't got the data; they are just suggestions.”
Should I start a patient with stable angina on aspirin. He is already taking warfarin as he previously had an artificial heart valve fitted
April 13, 2008
Are there guidelines for dealing with cellulitis?
I have found this guideline. I hope this will be useful in managing your patients with cellulitis correctly . Another guideline also from 2005 is there but due to be revised soon. A clinical vignette is discussed in NEJM is worth reading.
What is the difference between PCR and ACR and what is the clinical relevance of the difference?
Some times we tend to get confused with ACR and PCR in diabetic patients. I have got a review answering this questions.
Confusion assessment method in Medical ward
Delerium is common in elderly patients admitted in medical ward. This is universally used questionnaire for assessing confused patient in ward or in any acute setting
Pre operative assesment of a Diabetic patient:
April 12, 2008
How often you are asked to see a patient who is being prepared for surgery and you straight away refer to the endocrine unit. This review is very comprehensive and very helpful.
UTI in Pregnant woman
This is a review article describing management of UTI in pregnancy. I talked about UTI in non pregnant women in my previous post.
CCU cheat!
This is all the information you need to manage patients in CCU. This sheet of information is for MO s becoming SMO and have to cover CCU.
How to interpret Pulmonary function tests?
You don't need to be Respirologist to interpet PFT. Here is some help. Hope you will be good at it.
A worksheet for understanding Acid Base disorders
Therapeutic response: Can we give credit to our treatment?
We always think it is our treatment that makes our patients get better! or feel better. Is the therapeutic response that simple. This is an interesting clinical letter titled Dissecting Therapeutic response..
Management of Carotid stenosis: three to choose from
April 10, 2008
We had a long discussion regarding management carotid stenosis yesterday's internal medicine grand rounds. Eventually we recommended medical treatment and i have suggested same for this case vignette published in NEJM.
Carotid stenting or Surgical endarterectomy in high risk patients: Sapphire Study
This is 3 year follow up study report from SAPPHIRE investigators published in NEJM. They conclude in their patients with severe carotid artery stenosis and increased surgical risk, no significant difference could be shown in long-term outcomes between patients who underwent carotid artery stenting with an emboli-protection device and those who underwent endarterectomy.
UTI in Non Pregnant woman
April 9, 2008
The American College of Obstetricians and Gynecologists (ACOG) has issued a practice bulletin to address the diagnosis, treatment, and prevention of uncomplicated acute bacterial cystitis and acute bacterial pyelonephritis in nonpregnant women.
Synovial fluid analysis and interpretation
Examination of synovial fluid is important diagnostic procedure in acute monoarthritis. Results of fluid analysis will help you to manage patients properly
When is tight control too tight! The ACCORD study: what does it mean?
April 8, 2008
A safety analysis and the intensive glycemic control arm of the ACCORD study was halted. This you can read press release from NIH.
we have learned that intensive glycemic control reduces microvascular complications in DM-1 (DCCT) and in DM-2 (UKPDS)there’s been not a shred of evidence that it helps macrovascular disease (heart attacks and strokes) at least in DM-2. A very long follow up DCCTsuggested late macrovascular benefit in DM-1 but that’s a different disease entirely
Further analysis of UKPDS study hinted at macrovascular benefits (stroke only) attributable to drug metformin though not to intensive control, and only in patients with DM-2 who were obese and on metformin as initial monotherapy, not as add on.PROACTIVE study.
Finally with PROACTIVE study we begin to see evidence that treatment with Pioglitazone might offer macrovascular benefits. I believe this was a unique effect of pioglitazone via non-glycemic mechanisms such as favorable lipid effects, improvement in insulin resistance and improvement in endothelial function. Read my previous post.
Don’t forget ECMO in ARDS: CESAR trial
Previous studies suggested no improvement in outcomes for ARDS treated with extracorporeal membrane oxygenation (ECMO). i thought ECMO is not used any more!
CESAR trial presented in the Society of Critical Care Medicine 37th Critical Care Congress suggests it should be considered early in certain patients.
Most patients with ARDS die due to their underlying disease.Those who appear at risk of dying of respiratory failure may be worthy of consideration for ECMO.
The investigators used a Murray score of 3 or more as a criterion for patient selection.
The Murray Score calculator is here. It remains to be seen how it should be incorporated into clinical practice, especially we who dont have ECMO. Should patients be shipped?
When the heart remembers!
Alteration in ventricular repolarization occurs during changes in ventricular activation as may occur with ventricular pacing, bundle branch block and various arrhythmias. This may result in T wave abnormalities which persist following cessation of pacing, resolution of bundle branch block or resolution of arrhythmia. Such changes may be confused with ischemia.
The phenomenon, known as cardiac memory, is reviewed in an article in the American Journal of Emergency Medicine.
How should we manage acute hypertension in stroke? Here comes CHIPPS!
Current guidelines for ischaemic stroke stroke do not recommend emergency anti hypertensive therapy until SB 220 or DB 120 unless TPA is given. The guideline for hemorrhagic stroke allow a moderately more aggressive approach to blood pressure lowering depending on the clinician’s estimate or the actual measurement of intracranial pressure.
Results from a small study called CHIPPS presented at the American Stroke Association's (ASA's) International Stroke Conference 2008 demonstrated that immediate antihypertensive treatment targeted to a systolic blood pressure of 145 to 155 mm Hg or a drop in systolic blood pressure of 15 mm resulted in improved stroke outcomes at 3 months.
This small study should not change clinical practice and should be considered preliminary. Moreover, the study population was a mixture of patients with hemorrhagic stroke and ischemic stroke, limiting its applicability to either subgroup.
VTE prophylaxis should be extended for 4 weeks!
April 7, 2008
Without VTE prophylaxis hospitalised medical patients develop VTE at rate of 5-15%. The EXCLAIM Trial, I think, is a particularly interesting study because it is evaluating the benefits of prophylaxis restricted to the hospital stay, versus extending that prophylaxis beyond hospital stay for acutely ill medical patients. This is a comprehensive article.
Is it safe to give thrombolytics to patients already taking antiplatelets?
April 6, 2008
Prior use of antiplatelet (AP) drugs increases the risk of symptomatic intracerebral hemorrhage (SICH) and influences functional outcome in patients with ischemic stroke treated with intravenous thrombolysis.This is a single center prospective cohort study published in Archives in Neurology.
Conclusion Despite a higher incidence of SICH, the net benefit of intravenous tissue plasminogen activator therapy for acute ischemic stroke was greater in patients using AP drugs.
Managing Anti Coagulants During Surgery
Peri Operative and post operative management of patients taking warfarin can be tricky. I have found a good article to read.
An Acid Base Case
60 yo male with strong alcohol history is admitted for cellulitis. On his second day in the hospital he develops delirium tremens and aspirates. In the ICU he requires sedation for his DTs.
He had the following laboratory values on the 3 rd day:| Electrolyte panel | |||||
|---|---|---|---|---|---|
| Na | 142 | Cl | 110 | BUN | 9.6 |
| K | 4.5 | HCO3 | 17 | creat | 176 |
| Blood Sugar | 25.9 |
| ABG | |
|---|---|
| pH | 7.24 |
| pCO2 | 25 |
| pO2 | 126 |
| calc HCO3 | 10 |
His albumin is 3gram His serum osms are 345. His admission creatinine was 1.4.
Please explain his acid base disorder!Answer:
Purging the colon and Preserving the kidneys!
Clean bowel preparation is essential for proper colonic study. OSP solutions or tablets are better tolerated but recent concern is electrolyte imbalances and worsening renal function especially in elderly.Besides causing acute renal failure in some patients, the high phosphorus content can potentially cause chronic kidney damage to patients undergoing colonoscopy.
This retrospecive study is published in Archives in Internal Medicine. They conclude Oral sodium phosphate solution preparation is associated with decline in GFR in elderly patients with creatinine levels in the normal range. Its routine use for elective and screening procedures should be discouraged in the elderly population.
This retrospecive study is published in Archives in Internal Medicine. They conclude Oral sodium phosphate solution preparation is associated with decline in GFR in elderly patients with creatinine levels in the normal range. Its routine use for elective and screening procedures should be discouraged in the elderly population.
Can Fenofibrate reduce laser treatment in patients with T2DM?
Self Monitoring of skin temperature in Diabetic patients
The primary aim of this study published in Reviews in Endocrinology was to evaluate the effectiveness of self-administered, in-home, infrared, temperature probe monitoring to reduce the incidence of diabetic foot ulcers in high-risk patients with type 2 diabetes.
Self-evaluation of skin temperature appears to offer a mechanism to identify an early sign of injury when there is still time to avert a wound. Our study suggests that a simple, inexpensive temperature device can lead to reduced foot ulceration in high-risk diabetic patients.
Self-evaluation of skin temperature appears to offer a mechanism to identify an early sign of injury when there is still time to avert a wound. Our study suggests that a simple, inexpensive temperature device can lead to reduced foot ulceration in high-risk diabetic patients.
Does PERISCOPE provide a new perspective on diabetic treatment?
PERISCOPE is a double blind randomised multi center study published in recent JAMA.
PERISCOPE results come in the wake of PROACTIVE, which showed a nonsignificant 10% reduction in its primary end point of all macrovascular events and a significant 16% reduction in its secondary end point of death, MI, and stroke with pioglitazone.
What this study now tells us is: we must do a comparator effectiveness trial looking at different diabetes treatment strategies. We can't just focus on pricking the finger, getting the blood sugar down, and saying, that's the goal of therapy. The goal in therapy is to prevent complications of diabetes, and the most feared, most serious complication is heart disease, which will kill 75% of diabetics
Can We predict severity of Community Acquired pneumonia(CAP)?
A prospective study published in AJM recently has an addition to the world of CAP- C- Reactive protein.
I wish this study had tried combining these predictors to find how CRP can complement CURB65 and (Pneumonia Severity Index)PSI.
Currently, I will probably use all three to estimate severity until we have data to help me choose just one.
Something to think: hyponatremia
Case 1
A 70-year-old man with non-small-cell lung cancer presents to the clinic with fatigue and dizziness for 1 month. He also complains of weight loss (5-10 pounds) and anorexia. His wife states that he seems forgetful. His blood pressure is 95/47 without orthostasis or tachycardia. He does not have peripheral edema, and the remainder of the exam is unremarkable.
Laboratory Analyses
Electrolyte panel: Sodium 115 mmol/L; potassium 6.1 mmol/L; chloride 83 mmol/L; bicarbonate 20 mmol/L; blood urea 9.9 mmol/l; creatinine 123umol/L; glucose 3.96mmol/L.
Serum osm 243 mOsm/kg; urine osm 343 mOsm/kg
The Problem
Speculate on the cause of hyponatremia and support your speculation in several ways.(solution)
Case 2
A 58-year-old schizophrenic man was brought to the hospital because of strange behavior. He was disoriented and provided no history.
On the basis of the lab results presented here, your task is to identify the acid-base disturbance and postulate a cause for it.
Metabolic profile:
Sodium 139 mmol/L
Potassium 4.7 mmol/L
Chloride 90 mmol/L
Bicarbonate 14 mmol/L
Blood urea 6.42mmol/L
Creatinine 88.4 umol/L
Glucose 5.6 mmol/L
Arterial blood gas:
pH 7.49
pCO2 15
pO2 169 (2 L nasal O2)
HCO3 (calculated) 11
The Problem
What is the acid-base disturbance?
What is a reasonable cause of the disturbance?(solution)
INTERACT: Reducing BP in ICH
In a multicenter open label pilot study published in Lancet Neurology investigators looked at safety and benefit of Intensive BP lowering in patients with ICH.
Methods:The patients, whose elevated systolic blood pressure ranged from 150 to 220 mm Hg, were randomly assigned to early intensive lowering of systolic BP to a target of 140 mm Hg or standard guideline-based management with a target of 180 mm Hg.
Concluson: Early intensive BP-lowering treatment is clinically feasible, well tolerated, and seems to reduce haematoma growth in ICH.
ONTARGET: ARBs and ACE inhibitors are equal but together they fall
This double blind study published in NEJM compared the ACE inhibitor ramipril, the ARB telmisartan, and the combination of the two drugs in patients with vascular disease or high-risk diabetes.
Conclusions Telmisartan was equivalent to ramipril in patients with vascular disease or high-risk diabetes and was associated with less angioedema. The combination of the two drugs was associated with more adverse events without an increase in benefit.
There are important lessons from this study. firstly ACE inhibitors are unbeatable in reducing
cardio vascular events in high risk patients. Secondly ARB s are as good as ACE inhibitors but it is an expensive options. Thirdly combining ACE to ARB in patients with arterial disease is risky. Thats a surprise to me.
Intensive glycemic control
April 5, 2008
A large cohort study published in the journal Critical Care found no benefit, and a statistically insignificant trend toward increased mortality, associated with intensive glycemic control in ICU patients with a variety of critical illnesses.
Do we correctly diagnose pneumonia?
Archives of Internal Medicine has another important article on pneumonia diagnosis - Antibiotic Timing and Errors in Diagnosing Pneumonia.
Background :The percentage of patients with community-acquired pneumonia (CAP) whose time to first antibiotic dose (TFAD) is less than 4 hours of presentation to the emergency department (ED) has been made a core quality measure, and public reporting has been instituted. This study looks at whether these time pressures might also have negative effects on the accuracy of diagnosis of pneumonia.
Conclusion :Reduction in the required TFAD from 8 to 4 hours seems to reduce the accuracy by which ED physicians diagnose pneumonia, while failing to reduce the actual TFAD achieved for patients.
Pneumonia treatment
In CHEST a retrospective cohort study study published comparing patients with CAP admitted in ICU and admitted in medical ward.
Conclusions: ICU patients present with more severe disease and more comorbidities. ICU patients stay longer in the hospital and have a much higher mortality rate when compared to ward patients. Management strategies should be designed to improve clinical outcomes in ICU patients
Current guidelines for both CAP and healthcare associated pneumonia (HCAP) recognize the need for risk stratification.
There are lessons here. Read the guidelines carefully with particular attention to the risk categories. In every encounter with a pneumonia patient ask yourself what risk category or categories apply.
Obesity and Reduced Testosterone
Should we test all our obese men for testosterone levels? Is low testosterone is the cause or is this only an epiphenomena?
How would you manage your male obese patient with low testosterone?
My Powerpoint presentations
These presentations are very valuable to my learning process. Some I have taken from websites and some are mine. Enjoy.
a) Mushroom Poisoning - History, myths and Medicine
Click on mushroom...
b)Pressure Sores - Prevention and treatment.
Click on pressuresores...
c)Update in Internal Medicine 2007.
Click on internal medicine update...
c)Systemic Sclerosis
Click on systemic sclerosis update...
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