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.

Waste not want not... Ultrasound in AKI

Great editorial here embracing my philosophy.  Ultrasound has a role in patients for whom conservative measures have failed, or in whom there is a significant pre-test probability of obstruction.  A reduction in unneccessary ultrasounds for AKI will free up the ultrasound machine, technologist and radiologist for many other studies which are more clinically urgent.

A rethink to how we manage uncomplicated cellulitis...

See here.

Essentially, in this study of culture negative cellulitis (without abscess), the authors show that Group A streptococcus is responsible for >75% of cases, and based on response to beta-lactams, 95% of cases are probably caused by GAS, GBS, and MSSA meaning that the need for empiric vancomycin in cellulitis is questioned -- even in areas with high MRSA like the USA.

This CID article discusses how physicians often use too broad a spectrum (i.e. gram negative coverage for non-complicated cellulitis) and utilize too many laboratory and imaging resources.

UPDATE FEB 2011:
The IDSA MRSA guidelines incorporate this data saying initial VANCO is not necessary unless septic shock or purulent cellulitis.  VANCO would be added for those not responding (though you should note erysipelas often worsens in the first 24h of therapy, and  non-cellulitis as a cause of red leg is a common reason for non-improvement)

Medication Use in the Elderly

A nice review in JAMA here.  The author touches on what I believe to be a key point -- the use of medications designed to reduce long term mortality in patients with a limited life expectancy.  


"for patients with advanced dementia, poor prognosis, or both, consensus panels do not recommend (and in some cases advocate against) medications such as statins,bisphosphonates, and cholinesterase inhibitors, although these positions are not universally endorsed."  


I must say, in the era of escalating health care costs, partially driven by medication costs -- thinking about the above statement seems to be reasonable from a policy-making point of view.