We are re-booting the UTMCK Internal Medicine Blogspot at a time for increased stress and social distancing

We will get into cases - but let's start with some resources for your wellness...

The meditation app - "Headspace" is free for medical providers during this time.
https://www.headspace.com/health-covid-19

Radio Garden is a free app (works on desktop too) that allows you to plug into 8,000 radio stations around the world.
https://www.npr.org/sections/goatsandsoda/2016/12/16/505829305/radio-garden-lets-you-tune-into-a-world-of-global-broadcasts

Do you have a favorite song or playlist?  One stress reliever for my family is making me a playlist!
Dr. Lubas showed me how to make this into a hand washing poster which really made my family feel like they were helping me!  https://washyourlyrics.com/  Her preferred song is from Trolls "Can't Stop the Feeling" by Justin Timberlake.

Feel free to submit a song (or an app) that gets you through the day.

Dr, Norwood -  I think I will start with Kung Fu Fighting by Carl Douglas
https://www.youtube.com/watch?v=jhUkGIsKvn0

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,

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.

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.

Friday morning report covered management of acute ischemic stroke, as well as measures to prevent recurrences.  Good articles covering the topic are below:

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.

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.

Intern Boot Camp - Chest Pain Workup

Nejm chest pain article

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

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.

Sep 30 MR - Hyperglycemia Potpourri

Hyperglycemic Crises in Diabetes - review article from the ADA with great references and resources, covers the topics discussed today.  Read this and you will know enough for boards and most patient care scenarios.  Read and know the rest and you will be an internist.

Two contrasting cases of significant hyperglycemia - classic DKA and hyperglycemic hyperosmolar nonketotic state (HHNS) also formerly known as hyperglycemic nonketotic coma and many other names.

HHNS is a condition seen in type 2 diabetics with uncontrolled disease that lose access to free water due to debility, restraints, or acute illness.  Things rapidly spiral out of control as they lose fluids from osmotic diuresis and develope more and more concentrated serum.

This AFP article is a good review of the condition and its treatment.  Primary focus should be on volume resuscitation as it is not a pure insulin deficiency state.  Administering insulin before fluid resuscitation could precipitate hypotension.

Also, keep in mind that this syndrome can precipitate central pontine myelinolysis, even in the absence of hyponatremia, as this article and several other reports have demonstrated.


As for DKA this is a condition that some patients have so often it often breeds complacency in physicians caring for them.  It is a life threatening emergency and bad management decisions can make things worse.  Overcorrection of glucose, inadequate volume resuscitation, or mismanagement of electrolyte problems are all potential pitfalls.  It is easy to get lost in the data and a flowchart is essential to ensure good management.  This article from a pediatric diabetes journal summarizes concensus guidelines and includes tons of useful calculations and fomulas for various fluid and insulin regimens.  Most of this generalizes to care of adult DKA patients.

15 Sep - Annual Program Review

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.

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.

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.

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.

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.

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.