Interesting article from JAMA Internal Medicine.  Not surprisingly, physicians that own CT scans or radiation therapy machines are more likely to deploy these services on their patients, even when the clinical utility of these high cost modalities is in doubt.

Full text here

MR wrap-up from week of Aug 8

Interesting case of Werneckie's encephalopathy - there is an images in clinical medicine from a few years back that demonstrates the characteristic lesions of this disease, which were noted on the patient discussed in morning report.  Keep in mind the clinical triad of Werneckies - encephalopathy, ataxia, and oculomotor dysfunction.

The cost of intravenous vitamins and folate for prevention of Werneckies is excessive - $100 per "banana bag" vs a few cents for oral vitamin supplementation.  Treatment of established Werneckies is more complicated, and there is some literature that full course intravenous repletion in symptomatic cases may be cost saving in the long run due to concerns of patient compliance with oral thiamine replacement after discharge.

Another case this week was a patient with acute monocular vision loss - in this case suspected to be optic neuritis.  Great NEJM review on the topic here.




Also - for this week's ECG of the week, from a diabetic presenting with subacute dyspnea, shows inferior Q waves consistent with prior MI, which in this case was "silent" and came to clinical attention after the heart failure admission.  Up to 20% of MI's resulting in Q waves on ECG may be silent, and up to 8% of a high risk population can have myocardial scars from previous MIs without clinical or ECG evidence.

Evaluation of mixed LFT abnormalities

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,