16 Dec - TTP

Here are the links to articles mentioned in todays CPC about a case of TTP:

NEJM Case Records Dec 9, 2010 - 16 y/o F with lupus nephritis and ADAMTS-13 antibody mediated TTP.

How I Treat TTP - Blood, Nov 18, 2010

Blood Smear Review fron  NEJM - Aug 4, 2005

8 Dec - Endocarditis

This AM - patient with a bioprosthetic valve in the aortic position presented with a few weeks of "flu like illness" and neck pain and muscle spasms.  Imaging of the neck was unremarkable but abdominal imaging revealed splenomegaly and probable splenic infarcts.  This constellation of findings is very worrisome for prosthetic valve endocarditis.  Cultures were noted to be positive for GPCs later in the day.

Prosthetic valve endocarditis is a challenging disease to treat, and difficult to cure without surgery.  PCN susceptible strains of streptococci respond better and may be treated without gentamicin with good cure rates,  Staphylococcal endocarditis requires the addition of gentamicin and rifampin and is more likely to require surgery. 

Culture negative endocarditis is a special case.  Most commonly, prior outpatient antibiotics are the culprit.  Always check blood cultures in patients who are at risk for endocarditis when they present with undifferentiated febrile illness.  This table helps narrow the choices in patients with culture negative endocarditis based on thier comorbid illness or other risk factors.

3 Dec - Dysphagia

Friday's case was a 60ish male who presented with insidious onset of dysphagia without odynophagia.  Swallowing solids but not liquids produced the symptoms.  The problem had been slowly pregressive over a couple months.  He had a history of CAD, atrial fibrillation and prior tobacco use.  CXR revealed an enlarged heart but no masses.  Barium swallow revealed slow transit and delayed passage of a capsule at the distal esophagus. 

The proper evaluation of dysphagia is important both to relive symptoms and to diagnose potentially lethal conditions like malignancy.  Oropharyngeal dysphagia is usually due to motor dysfunction and esophageal has a more even distribution of motor and structural causes.  In general, dysphagia to solids and liquids suggests motor causes and solids only suggests a structural lesion.

This article from Gastroenterology Clinics - Volume 32, Issue 2 (June 2003) is available through MD consult and reviews the common causes as well as a suggested diagnostic approach.  In general the first test is a barium swallow, followed by endoscopy if structural lesions or esophagitis are suggested.  If motor processes such as achalasia or esophageal spasm are suspected then manometry is the next test.

Questions about achalasia have a habit of showing up on boards.  This NEJM image case shows a fairly dramatic example.  Treatment is either surgical (heller myotomy) or medical (botox) in poor surgical candidates.  Botox does not have as durable of effect as surgery. 

2 Dec - Hypercalcemia

This AMs case was a 62 y/o female who presented with progressive muscle weakness of several weeks duration.  There was also some complaints of numbness.  She had lost a significant amount of weight and was not eating well due to some abdominal pain.  She was brought to the hospital when she was no longer able to stand.  Her past history was remarkable for MS, but this was significantly different from any of her prior flares.  She did report a 40 pack year history of smoking.

On initial lab evaluation she was found to have an elevated calcium at ~ 17.  Phosphorus was elevated as well.  Her PTH was 20, and PTHrP is pending at this time.  Her CXR revealed a large perihilar lung mass and follow up CT of the chest revealed the mass and assocaited mediastinal adenopathy.

She recieved IV fluids, furosemide, dexamethasone, calcitonin, and pamidronate.  Her muscle weakness improved as her calcium levels fell.

Hypercalcemia is one of the most common oncologic emergencies.  It is either humoral in origin from ectopic PTHrP secretion by the tumor, due to overexpression of 1,25 vit D by lymphomas, or due to direct bony destruction such as in myeloma.  It usually occurs in patients with known cancer but can be a presenting symptom of the disease.  Patients are often quite volume depleted and require significant amounts of IV fluids in the first few hours.  If calcitonin is given, it must be IM or IV, as the intranasal formulation is not active. 

This article from Mayo Clinic Proceedings summarizes hypercalcemia and other common oncologic emergencies and should be reviewed.

Contrast this presentation with an earlier discussion of hyperparathyroidism.  Remember that in general calcium levels over 12 are almost always due to malignancy. 

Dec 1 - ECG Review

No case today due to team transitions, focused on ECG review with Dr Hirsh.  Below is the wave maven site from Harvard med school.  Great to review.  We will do this from time to time at Wednesday morning report.

ECG Wave Maven - Beth Israel Deconess Med Center.

Nov 29 - Patient Safety Conference

Todays conference further reviewed data regarding a recent Medicare inspector general report on medical errors and harm events in US hospitals.  Their study identified serious harm events in ~14% of patients, with another 14% suffering some type of temporary harm.  Overall the physician reviewers found ~44% of these events to be preventable.  The most common causes of harm were medication related - with high risk drugs such as anticoagulants, insulin, narcotics, and sedatives accounting for the largest numbers of medication related harm events.  Substandard care and failure to monitor accounted for most of the other significant harm events.  The cost of these harm events was estimated at over $300 million in October 2008 alone for an annual cost of $4.4 billion annually. 

We will focus the next few months of patient safety conferences working improving high risk medication safety - starting with insulin.

There are a variety of patietn safety organizations that we will use in upcoming patient safety conferences.  Some of the best are linked below.  As you can see - a lot of folks are paying attention.

Institute for Health Care Improvement (IHI)
Agency for Healthcare Research and Quality
National Patient Safety Foundation
Society of Hospital Medicine Quality Initiatives
National Quality Forum
Leapfrog
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