24 August - Atrial Fibrillation

Here is the article I mentioned on care of patients with atrial fibrillation:

ACP InTheClinic Atrial Fibrillation 2010 update.  Has links to a slideset for use in student teaching as well.

There is also this supplementary toolkit with info on quality measures, guidelines for newly diagnosed a-fib, and patient information material.

You need to be familiar with the findings and limitations of the AFFIRM study, which showed equivalent outcomes between rate and rhythm control strategies, with a potential survival advantage to rate control due to avoidance of antiarrhythmic drug toxicity. 

Also know the results and implications of the RE-LY trial of dabigatran in atrial fibrillation, published in 2009 in NEJM.

23 August - M&m follow up - Critical Thinking

As discussed, this is the book by Groopman titled "How Doctors Think."  There are a couple books with similar/same titles, but this is the one I was talking about.  I will have some curriculum based on this book for Dr Norwood's PGY 1 and 2  courses this year.

Also, this past post from one of my favorite blogs walks through many of the cognitive traps we can fall victim to.  I especially like this gem from his post:

"Ulysses syndrome

Ulysses went from one adventure to another in the odyssey of returning home from the Trojan War. A false positive test can lead to a fruitless odyssey of further investigation: tests lead to more tests, maybe even invasive procedures and harm to the patient. Eventually it is realized that the patient has been healthy all along."

Confirms my adage that imaging begets imaging, tests begets tests, and false positives beget operations.


For additional reading material, this site from Harvard has an extensive bibliography on the topic.  You can not download articles from the site, but paste the titles in google search and you can access most full text articles through the Preston library or on campus.

Acute Renal Failure - RIFLE Criteria

Couple articles to share here to f/u Dr Reddy's MR on renal failure. 

The rifle criteria were established by a concensus conference and are predictive of mortality in acute kidney injury patients:

Risk = 1.5 x increase Cr, GFR down 25%
Injury = 2 x increase Cr, GFR down 50%
Failure = 3 x increase Cr, GFR down 75%
Loss = complete loss for 4 weeks
ESRD = complete loss for 3 months

When managing patients at risk of or in early stages of ARF, this article from AFP has a nice review of the evidence for different interventions.

Back From Vacation - Blog Updates from Recent Topics Week of Aug 1 - 5

Aug 3rd - Evaluation of Cognitive Impairment / Acute Delirium

Hallmark of delirium is fluctuating course with impaired concentration.  My favorite mnemonic to remember causes is I WATCH DEATH, as it also helps remind me what an ominous condition this is.

This site from Vandy has a rundown of that as well as other mnemonics to help with delirium.

Aug 4th - Resuscitation from Lower GI Bleeds.

Sometimes catastrophic bleeding, but usually less immediately life threatening than upper GI bleeds.  Just remember the mantra "two large bore peripheral IVs" when approaching the resiscitation of any hemorrhage.

As far as transfusion triggers goes, generally a lower threshold hemoglobin is better.  There is also some data from Europe that transfusions increase rebleeding risk, at least in upper GI hemorrhages.  Waiting for the hemoglobin to drop ~7 is probably best, barring signs of impaired oxygen delivery.  There is no convincing evidence that transfusing those with cardiac disease up to hemoglobins of 10 is helpdful, and in fact may be harmful.

Aug 5th - End of Life Care

Not directly related to case discussed, but wanted to share this recent JAMA article on elder abuse and self neglect.  Complex situation without good solutions in may cases.