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...