August 29 WeeklyUpdate

Not as much content this week due to quiz bowl and ethics case rounds, but the following articles are very good reading:

From Monday's noon conference on endocarditis, I recommend this condensed article from NEJM that covers what you need to know about endocarditis for board purposes.

Friday morning report covered management of acute ischemic stroke, as well as measures to prevent recurrences.  Good articles covering the topic are below:

Acute Ischemic Stroke (NEJM Clinical Practice)

Secondary Prevention After Ischemic Stroke (NEJM Clinical Practice)

On a related note, the question often arises - should we heparin bridge A-fib patients on warfarin therapy when their medication is held for surgical procedures.  The answer, according to a study in this week's NEJM, is no.  Stroke events are not reduced, and bleeding is increased if heparin is used during the time warfarin is held.  Always pay attention to exclusion criteria, as this trial excluded anyone who had experienced stroke or TIA symptoms within 12 weeks.

Resuscitated

After a long hiatus, the IM blog is back in action.  I will make weekly posts with links for additional reading to follow up discussions form conferences.

On the topic of resuscitation:  The AHA has specific guidelines for resuscitation in certain unique situations, such as severe asthma, pregnancy, etc.  I will develop a simulation center scenario for one of these for use in a future SimMan session.  The material in this article goes far beyond the material covered in standard ACLS provider courses, and should be reviewed before taking on code team leader responsibilities.  There are separate articles that describe ACLS in the setting of recent cardiac surgery.  These are not currently part of official AHA ACLS guidelines but have been adopted by some institutions.

On the topic of appropriate use of the thrombophilia panel - the BJH has a nice summary of the topic.  In general, these workups are most appropriate for the outpatient follow up setting in select cases only.  Their utility in guiding the inpatient management of most patients is questionable.

Intern Boot Camp - Chest Pain Workup

Nejm chest pain article

PAP Smear Screening Update 2012

New cervical cancer screening guidelines by American College of Obstetrics and Gynecology, US Preventive Health Task Force, American Cancer Society and American Society for Clinical Pathology were published yesterday March 15, 2012 and reviewed on noon conference today. Many web sites (including some pages on CDC) are not updated yet to reflect this.

The take home?

Screening starts at age 21 regardless of age of sexual initiation.

Screening ends at age 65 in patients for those who have had appropriate screening and who do not have cancer history even if new sexual partner.

Generally speaking, PAP screening is every 3 years NOT annually if no abnormality.

Given prevalence and latency, do not do HPV co-testing in women under 30.

For women 30-65, Pap screening may be reduced to every 5 years if paired with HPV co-testing. If HPV co-test is positive, any abnormality is sent to colposcopy. If the HPV co-test is negative then ASCUS may be followed up in a year by the PCP.

Studies show that half of women with cervical cancer never had a PAP, but many women are having too many Paps! So do enough, not too many.

Screening for women

ACOG/ ACS/ USPSTF Guidelines:
http://www.acog.org/About_ACOG/Announcements/New_Cervical_Cancer_Screening_Recommendations

What to do with HPV co-test results
http://www.cdc.gov/std/hpv/pap/#table2

ACOG STD Screening Recommendations 2009
Sexually active women aged 25 years or younger should be screened for chlamydia, and all sexually active adolescents should be screened for gonorrhea. Urine-based screening without a speculum examination is sufficient for such screening, according to ACOG. However, pelvic exam may be used to look for STD's, if appropriate. ACOG also says that all adolescents and women aged 19 to 64 years who are sexually active should be screened for HIV, although frequency is not specified.

USPSTF STD Screening Recommendations
http://www.uspreventiveservicestaskforce.org/uspstf08/methods/stinfections.htm

Data do not support pelvic exams for vulvar, vaginal, uterine or ovarian cancers.
A visible or palpable abnormality OR specific complaint initiates a diagnostic test not screening although appearance of condylomata alone do not indicate deviation from cervical cancer screening guidelines.

MODIFIABLE RISKS: About 100 women die in TN each year due to cervical cancer. Here is our state specific facts about cervical cancer and risk factors (diet, smoking, condom use etc):
http://hit.state.tn.us/Reports/SurveyReports/BRFSS_Factsheet/PAPsmear%20BRFSS%20FactSheets%20TN%202005.pdf

PREVENTION: Don't smoke, limit number of sexual contacts, use condoms. HPV vaccination.
Usual vaccination is around age 12, but catch up is outlined in this CDC document. Vaccination status does not alter screening guidelines.
http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-hpv-gardasil.pdf


ACCESS:For individuals you encounter who do not have access to breast and cervical cancer screening (due to insurance, SES), there is a been a federally funded program in place to help. Ours is at the Knox County Dept of Health. To search for sites throughout the country:
http://www.cdc.gov/cancer/nbccedp/screenings.htm

PATIENT INFORMATION ABOUT HPV AND CERVICAL CANCER, INCLUDING IMMUNIZATION AND MODIFIABLE RISK FACTORS:
http://www.cdc.gov/cancer/cervical/pdf/cervical_facts.pdf

Oct 5 - Carotid Dissection

Unusual condition discussed today - spontaneous dissection of the carotid artery resulting in stroke in a young patient.  Often precipitated by an innocuous trauma such as turning the head rapidly, painting a ceiling, extending the neck during hair care at a beauty shop, and chriopractic manipulation (risk probably less than 1 in 40,000 encounters).

Collagen vascular disease present in ~ 1/4 as a predisposing cause.

This article from NEJM is a comprehensive review of the topic and covers vertebrobasilar (which has a similar pathogenesis and treatment) dissection as well.

Treatment is anticoagulation with heparin followed by warfarin, and interventions such as stenting is generally reserved for those with unresolving neuro deficits or significant hemodynamic cerebral blood flow impairments.

Sep 30 MR - Hyperglycemia Potpourri

Hyperglycemic Crises in Diabetes - review article from the ADA with great references and resources, covers the topics discussed today.  Read this and you will know enough for boards and most patient care scenarios.  Read and know the rest and you will be an internist.

Two contrasting cases of significant hyperglycemia - classic DKA and hyperglycemic hyperosmolar nonketotic state (HHNS) also formerly known as hyperglycemic nonketotic coma and many other names.

HHNS is a condition seen in type 2 diabetics with uncontrolled disease that lose access to free water due to debility, restraints, or acute illness.  Things rapidly spiral out of control as they lose fluids from osmotic diuresis and develope more and more concentrated serum.

This AFP article is a good review of the condition and its treatment.  Primary focus should be on volume resuscitation as it is not a pure insulin deficiency state.  Administering insulin before fluid resuscitation could precipitate hypotension.

Also, keep in mind that this syndrome can precipitate central pontine myelinolysis, even in the absence of hyponatremia, as this article and several other reports have demonstrated.


As for DKA this is a condition that some patients have so often it often breeds complacency in physicians caring for them.  It is a life threatening emergency and bad management decisions can make things worse.  Overcorrection of glucose, inadequate volume resuscitation, or mismanagement of electrolyte problems are all potential pitfalls.  It is easy to get lost in the data and a flowchart is essential to ensure good management.  This article from a pediatric diabetes journal summarizes concensus guidelines and includes tons of useful calculations and fomulas for various fluid and insulin regimens.  Most of this generalizes to care of adult DKA patients.

15 Sep - Annual Program Review

Below are articles mentioned in today's Annual Program Review

Internal Medicine Residency Redesign - AJM 2011

Comprehensive Residency Research Curriculum

Quality of Life, Burnout, and Medical Knowledge among IM Residents

Attractiveness of IM to Medical Students

ACGME Letter GME Funding

Costs of Failing to Fail

APDIM E Learning Links - Also added permanent link on cool sites column to right.