I am current at the ACP annual meeting, and this morning heard a brilliant grand rounds on hyponatremia - given by Juan Carlos Ayus. I have found an excellent article in the Southern Medical Journal that he co-authored on treatment of dysnatremias and also provide this Medscape link - Hospital-Acquired Hyponatremia — Why Are Hypotonic [...]
Activated Vitamin D Associated with Mortality Drop in Chronic Kidney Disease
For patients with moderate-to-severe chronic kidney disease and hyperparathyroidism, activated vitamin D appears to lower the risk of death over two years, an observational study found.
The 429 patients with stage 3 or 4 disease who took oral calcitriol had a 26% reduced risk of death [...]
This interesting article describes a current Archives of Internal Medicine - Reasons Documented for Heart Failure Admissions
At least one identifiable precipitating factor was found in 61.3% of patients, the researchers said. In order of frequency, they were:
Pneumonia or respiratory processes at 15.3%.
Ischemia or acute coronary syndromes at 14.7%.
Arrhythmia at 13.5%.
Uncontrolled hypertension at 10.7%.
Nonadherence to medications [...]
Please create a differential diagnosis for the following liver tests in an 80 year old woman:
Liver tests
Total protein
4.8
Albumin
2.2
Total Bili
6.5
Direct Bili
4.3
Indirect Bili
2.2
Alk Phos
973
AST
170
ALT
100
Yesterday’s numbers:
Electrolyte panel
Na
141
Cl
112
BUN
18
K
4.3
HCO3
15
creat
0.7
Blood Sugar
105
ABG
pH
7.33
pCO2
25
pO2
103
calc HCO3
13
Additional information:
1. She had increased ileal output.
2. Serum albumin was 5.7
3. Urine Na 10, urine K 47 and urine Cl 72
Her anion gap is 14, which is normal given her elevated albumin
Her urine anion gap is negative, consistent with sufficient ammonium (NH4+) in her urine
The urine anion gap results supports increased [...]
A clinical pharmacology colleague has this wonderful interview published in Medscape this week - Drug Dosing in CKD — Comparing GFR Equations and the Role of the Pharmacist: An Expert Interview With Kurt A. Wargo, PharmD, BCPS
I like this interview and link it for my own future use.
The new issue of the American Journal of Medicine has an addition to the world of CAP severity prediction - C-Reactive Protein Is an Independent Predictor of Severity in Community-acquired Pneumonia
CRP does a better job of predicting complicated pneumonia than the two standard models - CURB65 and Pneumonia Severity Index .
Both indices are better [...]
I have written before about my concerns over a HgbA1c goal of 7.0. Others have questioned this goal even more strenuously then me. This study may lead to a new evaluation of this ill-conceived performance indicator.Diabetes Study Partially Halted After Deaths
For decades, researchers believed that if people with diabetes lowered their blood [...]
Statin Therapy for Coronary Prevention Shows Extended Benefit Life
The coronary prevention benefits of five years of statin therapy in a pioneering trial proved to have enduring power as long as a decade after the original study ended, researchers here found.
The rate of coronary events was reduced by 27% over the entire 15 years of [...]
Walking into the room, one could immediately noticed that Mr. Sutherland had severe dyspnea. He sat bolt upright (clearly a clue), but more remarkable was the look of apprehension on his face. One could imagine the fear that he had with every breath.
I went over to the bedside, shook his hand and introduced [...]
This article caught my eye as an interesting fact to remember (internists like to collect facts which they may need one day). Then I noticed that the first author was a friend with whom I have previously written an article!
Wernicke encephalopathy is a serious disorder caused by thiamine (vitamin B-1) deficiency. Dr Carl [...]
Another acid-base and electrolyte case - not too difficult, but good teaching points -
A 42 year old man with HIV
My search for a reference on this phenomenon found this great story - A Medical Mystery, and How Physicians Solved It
The patient was a woman in her 80’s who complained of weakness and muscle spasms in her back. She appeared healthy and ate properly, but she had high blood pressure and, most strikingly, a [...]
My students and residents know that I love acid-base and electrolyte problems. Since hyponatremia is the most common electrolyte abnormality in the hospital, I often discuss it on rounds and in morning report.
Most hyponatremia is transient, and easily treated. However, sometimes we have a patient with chronic hyponatremia. Three major situations cause [...]
Our classical method for identifying CKD uses serum creatinine. As serum creatinine increases, GFR decreases. We now have formalas to estimate GFR from serum creatinine, age, race and sex (eGFR). However, while eGFR works well for populations, it has great variation for individuals. A growing body of data supports cystatin C [...]
Earlier this week, I rounded on a patient who had just had a myocardial infarction. He is 48 years old, and has an increased waist circumference. His cardiologist noted an elevated blood glucose (around 170) and asked us to care for his diabetes.
He has a normal HgbA1c, but we clearly believe that he [...]
Risk of Steroid-Induced Osteoporosis Often Ignored
I picked this article from the title alone. This problem occurs frequently in the COPD patients who I see at the VA hospital. On reading the article, I was delighted to see that the first author is a colleague at my institution.
Despite international guidelines, the prescribing of anti-osteoporotic [...]
The data continue to accumulate that Cystatin C identifies CKD earlier (and perhaps more accurately) than serum creatinine - Cystatin C May Identify “Pre-CKD” in Elderly With Normal eGFR
A new report shows that cystatin C, a still-novel marker of kidney function, identifies increased risk for death and cardiovascular (CV) and chronic kidney disease (CKD) in [...]
Physicians May Miss Signs of Chronic Kidney Disease
A lot of primary care physicians need to bone up on the signs of chronic kidney disease, according to investigators here.
When randomly selected family practitioners and internists, were asked which diagnostic tests they would order for a hypothetical patient with symptoms and lab values consistent with chronic kidney [...]
Thromboembolic disease represents a major dilemma for clinicians. We know how to treat the patient acutely, but we never really know how long to continue anticoagulation.
This is an important question, because the treatment is not benign. A recent article suggests a way to distinguish those who will not have recurrent thromboembolism. Test [...]
Can That Strange Rash Really Be Scarlet Fever?
As my wife and I left a movie theater one night, my cellphone rang. Our baby sitter was calling to inform us about a strange, rough rash racing across the chest of our 5-year-old daughter, Bess. This succinct announcement set my mind running.
Whenever doctors hear of an interesting [...]
I have a saying that I use when teaching about heart failure: “The goal of diuretic therapy in heart failure is to keep the patient not wet, it is not to make the patient dry.” The concept that I try to bring forward is that we need diuretic therapy to reduce symptoms, but [...]
Today I have a puzzle from a recent admission to my VA service. The patient is a 60 year old man with stable cirrhosis (presumed secondary to alcohol), chronic pancreatitis, hypertension, hepatitis C, and chronic kidney disease (creatinine 1.5). He currently takes bicitra, B12, hydralazine, hctz, Insulin, lactulose, lisinopril, magnesium, and pancreatic enzymes.
At [...]
Tomorrow’s Archives of Internal Medicine continues an important article written by Jeffrey Linder. This article documents how physicians over treat mild pharyngitis.
Results
The 4-point Centor criteria recommended by the American College of Physicians and Infectious Diseases Society of America were not predictive of streptococcal testing (results for 0, 1, 2, 3, and 4 criteria were [...]
Panel Unanimously Recommends Cervical Cancer Vaccine for Girls 11 and Up
I have blogged about this previously. In my mind this is a classic “no brainer”. Of course, there is someone dissenting:
Because Gardasil prevents a sexually transmitted disease, some religious groups have sounded reservations about vaccinating young girls.
“You can’t catch the virus, you have [...]
I first blogged on this story in 2002 - I repeat the story today because I am working on a sore throat article and want to easily find the data.
My original post - Some sore throats are VERY serious
The citation for the report that includes the following two paragraphs - UK Chief Medical Officer Update [...]
A resident asked me the other day whether to put someone on a statin. The patient had an LDL of 136, but was not high risk. My instinctive answer was to recommend against taking a statin, but the resident argued that the patient had a Framingham risk of 10%. We did not [...]
Pneumonia ‘needs less treatment’
Doctors can safely treat community acquired pneumonia with fewer antibiotics, say Dutch researchers.
Current guidance recommends antibiotic treatment for seven to 10 days but little evidence supports this strategy.
A study published in the British Medical Journal found that three days of antibiotic treatment were just as good as an eight-day course.
Shorter courses of [...]
Drug for Bones Is Newly Linked to Jaw Disease
In the last 10 years, millions of patients have taken a class of drugs that can prevent agonizing broken and deteriorating bones. The drugs once seemed perfectly safe and have transformed life for patients with cancer or osteoporosis.
But recently there have been reports of a serious side [...]
This article suggests that low grade prostate cancer patients do not benefit from radical therapy - Prostate therapy benefits doubted
The Institute of Cancer Research team found that radical treatment was only effective for men with high-grade disease.
In those cases they calculated that, without treatment, up to 68% could die from prostate cancer.
Difficult decision
Researcher Dr Chris [...]
Dr. RW has summarized this issue beautifully - Just the FACTTs (Fluid and Catheter Treatment Trial)
db’s bottomline - pulmonary artery catheters do not improve patient outcomes in ARDS. The editorialist holds out the possibility that an unstudied subset of patients might benefit from this invasive procedure.
Technology is wonderful, but too often we accept [...]
