Transfusion Strategies for Acute Upper GI Bleeding- NEJM Article link!

Hi everyone,

Here is a link to the summary of the article we discussed on Monday with respect to blood transfusion strategies in Acute Upper GI bleeds. The article is called "Transfusion Strategies for Acute Upper Gastrointestinal Bleeding", out of the NEJM in January 2013.

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1211801

Hope you are having a great week!

-Jade

The art of morning report

As I head off into the sunset I wanted to leave you all with two interesting reads:

The Art of Presenting
The Art of Pimping

Good luck everyone!
Leslie

Vascular dementia

Dementia: A major impairment in memory or learning with one of: agnosia, aphasia, apraxia or executive function impairment

Vascular dementia:
- Often early age onset (50-60s) and patients may have no or little insight early in the disease process. Memory is preserved so the diagnosis of dementia may not be obvious
- The typical 'step-wise' decline may not be present in patients with a strategic infarct (ie. thalamus)
- There may be symptoms of emotional blunting, disinhibition or apathy. Speech can also be affected. These patients may first present to psychiatry, with a change in personality or a question of depression

Here are the official 2012 guidelines on the diagnosis and treatment of dementia

Ethylene glycol poisoning

This week we reviewed an approach to acid-base disorders. The DDx for an anion gap (AG) acidosis includes 
1) lactate - type A and B
2) ketones - DKA, starvation, alcohol
3) uremia
4) toxic ingestions - salicylates, toxic alcohols like methanol and ethylene glycol

- Ethylene glycol is a parent compound that is a measured osmole, and will contribute to an osmolar gap (but not the AG). The toxic metabolite, glycolate, will contribute to the anion gap (but not the osmolar gap). The goal is to prevent end-organ damage from glycolate, the compound that causes renal failure and CNS toxicity

- Treatment of overdoses:
Stability: Always begin with the ABCS! (Consider the universal antidotes for all patients)
Decontamination: Not a big role for activated charcoal here
Excretion: High rates of IV fluid, consider bicarbonate infusion if acidemic
Antidotes: Fomepizole or IV ethanol binds to alcohol dehydrogenase, preventing conversion of EG to glycolate. Thiamine and pyroxidine are co-factors that help metabolize glycolic acid to non-toxic glycine. Similarly, folinic acid is a co-factor given for methanol poisoning
Hemodialysis: Assess on a case-by-case basis, but may be indicated with significant acidemia (pH < 7.3), end-organ damage, or an EG level > 8.1 mmol/L (or methanol > 15.6 mmol/L)

Here is a great NEJM review article on the treatment of ethylene glycol and methanol poisoning

Pancytopenia: the elusive diagnosis of HLH

- We recently talked about a case of pancytopenia. Here's an approach to bone marrow pathology:

Infiltrative - Any hematological malignancy (includes myelofibrosis) 
                - Metastatic solid tumors
                - Inflammatory: sarcoid, amyloid
                - Invasive infections 

Dysplasia - Myelodysplastic syndrome 

Aplasia - Immune 'aplastic anemia' 
            - Toxins, drugs or chemotherapy
            - Radiation 
            - Nutritional - VB12, folate deficiency
            - Viral (HIV, HBV, HCV, EBV, CMV, etc.) or sepsis 

- We reviewed a rare case of pancytopenia, hemophagocytic lymphohistiocytosis, where the immune system becomes overactive because of a lack of functioning NK cells and CD8+ T cells
Diagnostic criteria:
1) Fever
2) Splenomegaly
3) Cytopenia in at least 2 cell lines
4) Hypertriglyceridemia and/or hypofibrinogenemia
5) Tissue demonstration of hemophagocytosis (not specific)
Additional criteria include low/absent NK cell function, very high ferritin levels, or elevated CD25

Febrile neutropenia

- Definition: temperature > 38.3 or 2 readings of >38 (1 hour apart) AND an absolute neutrophil count <0.5 x 10^9/L or <1.0 x 10^9/L with a predicted nadir of <0.5 within 48 hours

- Patients without neutrophils may present with little to no signs of inflammation - a detailed assessment to look for a source is needed

- In addition to the usual culprits check for mucositis, oral thrush or vesicular lesions, GI infection including perianal abscess (no rectal!), and examine the indwelling venous catheter

- While no single antibiotic has been shown to be superior, hospitalized patients should be initiated on IV antibiotics with broad spectrum and anti-pseudomonal coverage (ie.  piperacillin/tazobactam or imipenem). Vancomycin is only added upfront if there is suspicion for a gram positive infection, the patient is high risk for MRSA, or is hemodynamically unstable

- Neutropenic patients are at risk of invasive fungal infections (ie. aspergillus). After day 4-7 of persistent fevers, investigating for and potentially starting treatment for a fungal infection may be warranted 

- Check out a pocketcard summary of the IDSA guidelines for febrile neutropenia in cancer patients