Wernicke's makes an appearance

Interesting case of real deal Wernicke's encephalopathy.

I hadn't previously appreciated the controversy around the ideal thiamine dose (ref) and I'm happy to be corrected about the dogmatic but not true "thiamine before glucose" in the comatose patient.

Preventing Hospital Acquired Disability

Part of my further quest to improve the care of elderly patients -- this article is a must read. I particularly believe in the restriction of delerium inducing medications, the ambulate 3-4 times a day prescription (rather than AAT), and the wearing of clothes...

Those of you who have heard my "patients should wear pants unless they have a problem in the pants area" routing will appreciate where I am coming from.

Consult Service - October 18

1) Wow...  Triglycerides of 67mmol/L -- can't say I've seen that before -- and in a patient with mild pancreatitis.  Hence this article on the use of insulin infusion to treat severe hypertriglyceridemia and a review on options in pancreatitis caused by hypertriglyceridemia.  

Consult Service - October 17

We talked about a lot of things today.  Many have previously been blogged about -- I believe the search actually works now.

One topic we discussed, which I haven't touched on before was Warfarin Induced Skin Necrosis (this is a helpful review).

Causing harm through quality improvement...

Primum non nocere

This article discusses developing quality measures to offset the unintended harms that come with more aggressive attempts to reach quality benchmarks for therapy (i.e. hypertension).

Time Limited Trials

Decisions about end of life care is patients with significant comorbid illness is challenging.  This article is worth a read...  Time limited intervention plans. 

From the clinic Oct 5

Though we didn't all talk together about these issues -- here are a few topics related to our individual discussions.

1) Physical exam diagnosis of ascites (and related previous blog on ascites).

2) The famous histoplasmosis (prev blog) outbreak in Montreal in the 1960s during the digging of the subway tunnels .

3) Job's syndrome and Chronic Granulomatous Disease (also here)

4) Alcoholic liver disease (subtypes here).

Clinic Sept 23, 2011

The handout for solitary pulmonary nodule (password required) is here.

A recent review (2008) on the evaluation of said nodules is here:
http://pats.atsjournals.org/cgi/content/full/5/9/900

This algorithm is advocated by the guidelines:

As discussed, the role of CT-PET is still being defined, particulary for nodules less than 8mm but it may be a useful technique in specific circumstances when biopsy or resection would be difficult or have significant morbidity. 

1) We then discussed radiation risk from CT scans -- review here
http://content.nejm.org/cgi/content/full/357/22/2277

Interesting editorial here (written by a mentor and a classmate from my time in Toronto):
http://jama.ama-assn.org/content/304/19/2170.full

2) We had a patient with significant by asymptomatic hypothyroidism with a profoundly elevated TSH.  He also had mild renal failure, normocytic anemia, and mild hepatitis all of which could be due to the hypothroidism.


This older blog post describes the approach to myxedema coma.

We discussed the importance of ruling out other endocrinopathies (in particular Addison's disease) and one astute resident mentioned the impotance of excluding celiac disease.

Dabigatran and bleeding

From Annals Int Med -- the bleeding reduction for dabigatran seems to be for younger and not older patients (with all the caveats of subgroup comparisons).

Question -- why wasn't this data included in the original publication?

From the clinic -- September 14, 2011

Some related articles to our discussion(s):

A) Late onset CVID (common variable immunodeficiency)
https://webvpn.mcgill.ca/http/www.ncbi.nlm.nih.gov/pubmed/19807277

(and late onset congenital immunodeficiencies in general)
https://webvpn.mcgill.ca/http/www.ncbi.nlm.nih.gov/pubmed/20581672

B) On the ever challenging question of use of beta-blockers in COPD
https://webvpn.mcgill.ca/http/www.ncbi.nlm.nih.gov/pubmed/21596228

C) Conn's Syndrome
Diagnosis and Treatment:
https://webvpn.mcgill.ca/http/www.ncbi.nlm.nih.gov/pubmed/21565669

What happens if you remove a functional adenoma?
https://webvpn.mcgill.ca/http/www.ncbi.nlm.nih.gov/pubmed/21882028

What do you do when you find an "incidentaloma" of the adrenal?
http://www.nejm.org/doi/full/10.1056/NEJMcp065470

D) The (possible) association between leukotriene receptor agonist therapy and Churg-Strauss
https://webvpn.mcgill.ca/http/www.ncbi.nlm.nih.gov/pubmed/20147592

Reading about osteomyelitis

See previous blog here. 

There is a good NEJM review of vertebral osteomyelitis here.

The role of CRP and other predictors of clinical failure are discussed here.

Amazing science

If only bone marrow transplant wasn't so toxic and high risk.  The previously reported HIV positive patient who had a CCR5 delta-32 homozygous transplant for AML remains both leukemia and HIV free after 3 years (report here).

Amazing...

Tube feeding at end of life

An interesting study here in Archives of Internal Medicine, which provides more iformation about decision making in patients with severe dementia.  Also, a link to the very powerful NEJM piece which is now in its 11th year.  And yet, patients still receive PEG tubes for severe dementia for reasons which are unclear but are not rooted in the evidence.