dem hungry bones

This week we started off by discussing a case of hypocalcemia, post parathyroidectomy.

We reviewed the symptoms to monitor for (ie symptoms of hypocalcemia) post parathyroidectomy:   

• Symptoms:   numbness, tetany, cramps,  
• Signs: Seizures tetany, parasthesias, Chvostek’s sign- facial (think: CH-->Cheek), Trousseau’s sign, (CHECK OUT VIDEO HERE) arrhythmia, prolonged QT

1Its a good time to think about what PTH does to:  Bone, gut, kidneys; and thus the LACK of PTH has important implications. 

a.     Bone: Resorptionàwith lack of stimulation of osteoclasts with lack of mobilization of calcium from bone, there is persisitant osteoblast activity,  and increased urine calcium loss, and resultant hypocalcemia.  (leading to bone FORMATION)

b.     Kidney: 1α-hydroxylase is downregulated, with a resultant decreased production of 1,25-dihydroxy vitamin D.

c.      GUT: This decreased production  of vit D- impairs the absorption of calcium and phosphorus in the gut.

Hungry bone syndrome is the extreme case and is seen when:

-->hypocalcaemia with varying degrees of hypophosphatemia after parathyroid surgery 

-->occurs as a result of retention of calcium by bones  that were previously demineralized from the effects of PTH excess (similar to refeeding syndrome)

-->hypomagnesaemia (a sequelae) can exacerbate hypocalcaemia by inhibiting parathyroid hormone release 

Treatment:

Calcium Gluconate, IV and PO, then continue PO

Vit D

Mg replacement

Prevention can be acheived with vit d and calcium loading prior to surgery

For more info check out THIS article. 

A night of only GI consults...

Not quite sure how I made it through 3 months without reviewing a GI bleed....

Last at least 4 patients were admitted with GI bleed.

We reviewed a gentleman,  unknown to powerchart, with hematemesis a significant etoh history and signs of portal hypertension on physical exam.

After stabilizing the patients with fluids +/- blood

Some of the specific managements:

1. IV PPi- Pantoprazole infusion: 80 mg IV bolus then 8 mg/hr

àWhat does it do? Suppresses gastric acid secretion by inhibiting the parietal cell H⁺/K⁺ ATP pump to↑ pH may improve platelet function

EVIDENCE: - decreases endoscopic stigmata, à NOT decrease mortality, or rebleeding or need for surgery

à most effective for PUD

--> more evidence post bleed (72 hours) (with a NNT of 7!! according to THIS article)

2. Octreotide: 50mcg then 50 mcg/h

--> WHat does it do? somatostatin analogue that reduces splanchnic blood flow and portal pressure.

 EVIDENCE:  modest reduction in the amount of transfused blood, a possible decrease in the rate of rebleeding, with no overall decrease in mortality

-->only evidence for Variceal bleed

3. Correct INR

4. Antibiotic therapy – Ceftriaxone or ciprofloxacin x 7 days

--> What does it do? proph for infection (SBP and bacteremia)

--> Start if patients have cirrhosis

EVIDENCE: Reduced rate of infection (SBP and bacteremia) and mortality

Here is a new JAMA article: Does this patient have an UGIB?

Pleural effusion...

Yesterday we reviewed a patient with a giant pleural effusion (after bouncing back from a short admission for pneumonia)

For a reminder of Light's criteria see the previous post HERE

notice the shifted trachea AWAY from the whiteout

For the guidelines of see this article

But some of the main points:

Exudative effusion can be divided  into:


Category 1:  Minimal, free-flowing effusion (< 10 mm on lateral decub CXR) and unknown culture/gram stain and unknown pH --> SIMPLE
Category 2: Small to moderate free-flowing effusion (> 10 mm and < 1/2 hemithorax) and negative culture and Gram stain and pH > 7.20 (i.e., an uncomplicated) 
Category 3: Large free-flowing effusion ( > 1/2 hemithorax) or Loculated or thickened parietal pleura or positive culture/Gram stain or pH < 7.20 (i.e., a complicated) 
Category 4: Frank pus  (Empyema)


• Categories 1 and 2 have good outcomes and do not usually require drainage. 

• Categories 3 and 4 have poor outcomes and generally require drainage. The panel reviewed the literature on the management of these effusions. 

Some  fun facts of pH: 
Can be low in infection and malignancy. 

<7.20 in parapneumonic infection is indication for drainage 

<7.20 in malignancy predicts a poor response to pleurodesis ( and a poor prognosis eg. a median survival of only 30 days)

pancreatitis revisited

 Today we discussed a patient from last night who presented with sever pancreatitis, with necrosis on  CT scan.

Here is a LINK to our last discussion of pancreatitis. 

Typically, not everyone gets a CT scan,


Indications for CT scanning include: 

• High fevers or signs of sepsis 
• Severe pancreatitis 
• Failure to improve with conservative therapy 

CT scanning is helpful for several reasons: 

• prognosis (See this article for the CT scoring index)_
• presence or absence of local complications,(eg pseudocyst  that would need for surgical intervention)
• Determining the need for antibiotics 

Speaking of antibiotics...

The use of antibiotics for pancreatitis is controversial. In general  antibiotics should be given if there is necrosis seen on CT scan (especially if > 30% of the pancreas). The first-line antibiotic appears to be a beta-lactam (Imipenem is what is typically used)

Here is a Cochrane review of this dilemma.

tylenol revisited

Welcome new clerks!!!!

Today we revisited a case of tylenol toxicity,

The original post can be found HERE


Here is a good review on acetaminophen toxicity and treatment options.

Special post!! Id rounds

Thank you Dr. Elsayed for forwarding the rounds on Infective endocarditis

The can be found HERE.

Have a great weekend!

A

Thrombocytopenia

Happy last day to the clerks!

Today we spoke  about a case of thrombocytopenia.

The differential includes:


Decreased Production:
Problem with Bone marrow ability to produce platelets  because of toxicity (meds, chemotherapy, alcohol), infection (viral, TB), replacement (cancer, fibrosis, amyloid/ sarcoid), or nutrition (folate and B12 deficiency)

Sequestration:
Secondary to portal hypertension or primary hypersplenism. Note: the counts do not drop below  around 50k if this is the only cause

Destruction/Consumption:
Mechanical (prosthetic valves, malignant HTN), Immune (HIT, ITP), consumptive (TTP, DIC) 

Itp is typically a 'diagnosis of exclusion' but the new guidelines don't require a bone marrow for everyone. A thorough history and physical exam need to be done!


Here is a REVIEW article on ITP.

This is a recent Commentary on ITP with the updates in management.

This is a very easy read of the new guidelines!

Pregnancy and elevated liver enzymes

And we're back....

Today we talked about a case of elevated liver enzymes in a patient who was in her 3rd trimester of pregnancy.


Don't forget about your differential of elevated liver enzymes in a patient who NOT pregnant, since all of those can affect young women as well!

Below is a figure from 'uptodate' which summarizes the differential of "pregnancy associated causes"
Certain features, like Timing (which trimester) or how high the liver enzymes are, can help narrow the differential.

 HERE is a review on liver disease in pregnancy!
Have a good night.