Todays case presented a patient with mixed LFT abnormalities and painless jaundice without evidence of extrahepatic biliary obstruction. AST/ALT elevated >400, AlkPhos >500, bili >18.
Differentials discussed included drug induced liver disease, ? recent antibiotic exposure,
This page from NIH has a good breakdown of the varying patterns of drug induced liver disease, including the predominantly cholestatic pattern and the mixed pattern.
The clinical/pathological syndrome of "granulomatous hepatitis" - expanded upon in this presentation - was also discussed, though does not usually lead to the degree of bilirubin elevations noted in this case. The linked presentation walks through a good differential of this condition based on pathological or epidemiological risk factors present in the case.
Lastly, acute hepatitis C is a possibility to be considered. Interestingly - a robust immune response is generally required to trigger symptomatic disease and jaundice, and this subset of patients (presenting with jaundice) have a lower rate of development of chronic hepatitis C infection.
And from noon conference - the noon conference on Sjogren's syndrom brought to mind this image from NEJM, which made an appearance in a prior Quiz Bowl and is likely to make an appearance at a future showing,
Review of topics covered in morning report, M&m, and core conferences with links to supplemental reading material.
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Friday, July 22, 2016
Wednesday, September 30, 2015
Sep 30 Update
Batch of updates today - MR back on schedule after month of CPC, inservice, etc.
Today's topic: gastrointestinal hemorrhage in an anticoagulated patient.
First: guidelines for management of peptic ulcer bleeds from the American College of Gastroenterology: Their 30 key recommendations available here, also has link to full text of their guideline for additional reading.
Contrast those recommendations with the ones provided for management of variceal hemorrhage. Key differences in variceal hemorrhage:
- Octreotide and prophylactic antibiotics indicated for variceal bleed
- All variceal bleeds require ICU admission, whereas only the high risk subset of ulcer bleeds even require hospitalization.
As for reversal of anticoagulants, this handy pocket card from the American Society of Hematology covers dosing as well as reversal of multiple anticoagulant and antiplatelet medications. Their guidelines are available as an app as well.
Cardiogenic Shock
Also from noon conference - make sure you know your mechanical complications of acute myocardial infarction well. This topic is all over the boards and in training examinations.
Also, remember that right ventricular infarction is something of a unique clinical syndrome. Nitrates can do great harm, and large amounts of volume resuscitation are often required to overcome RV dysfunction, Diagnosis in the setting of IWMI requires a R sided ECG, with lead V4r being the highest yield lead for diagnosis.
Today's topic: gastrointestinal hemorrhage in an anticoagulated patient.
First: guidelines for management of peptic ulcer bleeds from the American College of Gastroenterology: Their 30 key recommendations available here, also has link to full text of their guideline for additional reading.
Contrast those recommendations with the ones provided for management of variceal hemorrhage. Key differences in variceal hemorrhage:
- Octreotide and prophylactic antibiotics indicated for variceal bleed
- All variceal bleeds require ICU admission, whereas only the high risk subset of ulcer bleeds even require hospitalization.
As for reversal of anticoagulants, this handy pocket card from the American Society of Hematology covers dosing as well as reversal of multiple anticoagulant and antiplatelet medications. Their guidelines are available as an app as well.
Cardiogenic Shock
Also from noon conference - make sure you know your mechanical complications of acute myocardial infarction well. This topic is all over the boards and in training examinations.
Also, remember that right ventricular infarction is something of a unique clinical syndrome. Nitrates can do great harm, and large amounts of volume resuscitation are often required to overcome RV dysfunction, Diagnosis in the setting of IWMI requires a R sided ECG, with lead V4r being the highest yield lead for diagnosis.
Saturday, August 29, 2015
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.
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.
Wednesday, August 19, 2015
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.
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.
Wednesday, July 3, 2013
Thursday, March 15, 2012
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
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
Wednesday, October 5, 2011
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.
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.
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