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.
Review of topics covered in morning report, M&m, and core conferences with links to supplemental reading material.
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Wednesday, September 14, 2011
Thursday, September 8, 2011
8 Sep - Hepatorenal Syndrome
This case was of a gentleman with severe decompensated cirrhosis with refractory ascites. Management of ascites was discussed previously in this post.
A couple key articles to add:
Know the trail test - quick, easy, and evidence based way to monitor cirrhotics for early encephalopathy. This NEJM review from 1997 goes over the use of this test for early detection, as well as most interventions short of the newly used rifaximin.
As for use of TIPS - two traditional uses are to control variceal hemorrhage and to improve refractory ascites. A recent trail suggests that this technique should be used more early in patients at high risk for variceal bleeding, before they have had their first bleed.
Finally - know hepatorenal syndrome. This was well reviewed recently in NEJM. Type 1 hepatorenal is the rapidly progressive, more dramatic version with highest short term mortality. FENA <1 suggests hepatorenal syndrome in cirrhotics with kidney impairment. Accurate estimation of GFR in cirrhotics is difficult, and the CG equation performs more poorly than MDRD, and even that overestimates the actual renal function. The potential role of TIPS in this condition was mentioned, but definitive clinical data is lacking.
The cost of midodrine/octreotide/albumin therapy is ~$2000 per day in drug cost alone, and should primarily be considered a bridge to definitive treatment such as transplant.
A couple key articles to add:
Know the trail test - quick, easy, and evidence based way to monitor cirrhotics for early encephalopathy. This NEJM review from 1997 goes over the use of this test for early detection, as well as most interventions short of the newly used rifaximin.
As for use of TIPS - two traditional uses are to control variceal hemorrhage and to improve refractory ascites. A recent trail suggests that this technique should be used more early in patients at high risk for variceal bleeding, before they have had their first bleed.
Finally - know hepatorenal syndrome. This was well reviewed recently in NEJM. Type 1 hepatorenal is the rapidly progressive, more dramatic version with highest short term mortality. FENA <1 suggests hepatorenal syndrome in cirrhotics with kidney impairment. Accurate estimation of GFR in cirrhotics is difficult, and the CG equation performs more poorly than MDRD, and even that overestimates the actual renal function. The potential role of TIPS in this condition was mentioned, but definitive clinical data is lacking.
The cost of midodrine/octreotide/albumin therapy is ~$2000 per day in drug cost alone, and should primarily be considered a bridge to definitive treatment such as transplant.
7 Sep - Sepsis Guidelines
Discussion today focused primarily on the early management of sepsis. This is a condition for which the mortality has not really decreased much since the advent of antibiotic therapy. A few interventions have been shown to decrease mortality, and there are a core set of interventions that should be considered in all septic patients.
The Surviving Sepsis Campaign has papers and pocket cards that review the current interventions shown to improve mortality in septic shock. They focus their measures on two phases of care - the first 6 hours (primarily ED interventions) and the following 24 hours (primarily ICU interventions).
This Nov 2001 trial on early goal directed therapy for sepsis formed the basis for much of the recommendations in this guideline. The only part that gives me pause is the recommendation to transfuse above a HCT of 30 if patients have low SVO2 despite volume resuscitation. This somewhat conflicts with other studies that show trends for worse outcomes with higher transfusion targets.
As for steroid therapy in sepsis, the clinical trial data follows a roughly 11 year cycle that I think correlates with sunspot activity cycles. The most recent data from recent JAMA and NEJM trials is pessimistic, and argues that any benefit from steroids, if truly present, is likely small. This benefit comes with the clearly documened risks of steroid therapy, to include worsening immunosuppression and hyperglycemia. If you so choose to use them, current dogma is to not base the decision on a ACTH stim test and only use low doses of hydrocortisone.
One side discussion revolved around the impact of severe sepsis on cognitive decline in elderly survivors of sepsis. A recent trial published in Mayo Clinic Proceedings demonstrated significant persistent cognitive decline in elderly patients post-surgery. This corresponds with previous studies that have shown similar persistent declines in elderly patients after severe sepsis. The rate of significant permanent cognitive impairment in elderly sepsis survivors is high, and fundamentally alters independent living for many patients. These studies should help you set realistic expectations for families when dealing with elderly family members facing major surgeries or critical illness.
The Surviving Sepsis Campaign has papers and pocket cards that review the current interventions shown to improve mortality in septic shock. They focus their measures on two phases of care - the first 6 hours (primarily ED interventions) and the following 24 hours (primarily ICU interventions).
This Nov 2001 trial on early goal directed therapy for sepsis formed the basis for much of the recommendations in this guideline. The only part that gives me pause is the recommendation to transfuse above a HCT of 30 if patients have low SVO2 despite volume resuscitation. This somewhat conflicts with other studies that show trends for worse outcomes with higher transfusion targets.
As for steroid therapy in sepsis, the clinical trial data follows a roughly 11 year cycle that I think correlates with sunspot activity cycles. The most recent data from recent JAMA and NEJM trials is pessimistic, and argues that any benefit from steroids, if truly present, is likely small. This benefit comes with the clearly documened risks of steroid therapy, to include worsening immunosuppression and hyperglycemia. If you so choose to use them, current dogma is to not base the decision on a ACTH stim test and only use low doses of hydrocortisone.
One side discussion revolved around the impact of severe sepsis on cognitive decline in elderly survivors of sepsis. A recent trial published in Mayo Clinic Proceedings demonstrated significant persistent cognitive decline in elderly patients post-surgery. This corresponds with previous studies that have shown similar persistent declines in elderly patients after severe sepsis. The rate of significant permanent cognitive impairment in elderly sepsis survivors is high, and fundamentally alters independent living for many patients. These studies should help you set realistic expectations for families when dealing with elderly family members facing major surgeries or critical illness.
Friday, September 2, 2011
2 Sep Cavitary Lung Disease
This AM covered a case of long-standing progressive cavitary lung disease, due in this case to Mycobacterium avium. Cavitary diseases of the lung cover a broad range of infectious and non-infectious causes. Chronicity of the process, associated findings, and epidemiologic history are all necessary to narrow down the possibilities. If spontaneous sputum does not reveal the offending pathogen invasive diagnostics are often needed, usually starting with bronchoscopy, followed by CT guided needle biopsy, and ultimately VATS / open lung biopsy.
When you see cavitary lesions on XRay always consider TB, and err on the side of placing the patient in respiratory isolation precautions if you are ordering AFB smears. Don't wait until they are positive.
Further reading:
Clin Micro Review April 2008 - best review of the differential of cavitary lung lesions with many good images of representative radiographs for many possible causes.
This image from that article shows a MAI cavity very similar to that seen in our patient.
Treatment of non-TB mycobacterial lung disease is actually more complicated than treating TB itself, and takes longer to achieve cure. These guidelines from the ATS and IDSA cover the topic in depth.
When you see cavitary lesions on XRay always consider TB, and err on the side of placing the patient in respiratory isolation precautions if you are ordering AFB smears. Don't wait until they are positive.
Further reading:
Clin Micro Review April 2008 - best review of the differential of cavitary lung lesions with many good images of representative radiographs for many possible causes.
Treatment of non-TB mycobacterial lung disease is actually more complicated than treating TB itself, and takes longer to achieve cure. These guidelines from the ATS and IDSA cover the topic in depth.
Thursday, September 1, 2011
31 Aug - Obstructive Jaundice
Evaluation of elevated LFTs discussed in a recent MR, but topic today was a slightly different scenario. Obstructive jaundice is often the first sign of a biliary tract malignancy such as cholangiocarcinoma. Evaluation is aimed at locating the site of the obstruction and the potential resectability of the lesion.
Remember Courvoisier sign - though in the modern era of easily accessed imaging studies and lab tests the diagnosis is often made before this sign develops.
This section from the eMedicine article on obstructive jaundice gives a nice rundown of the strengths and weaknesses of different imaging modalities for evaluating obstructive jaundice.
Remember Courvoisier sign - though in the modern era of easily accessed imaging studies and lab tests the diagnosis is often made before this sign develops.
This section from the eMedicine article on obstructive jaundice gives a nice rundown of the strengths and weaknesses of different imaging modalities for evaluating obstructive jaundice.
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