Saturday, April 21, 2018

Atypical presentation of retroperitoneal hematoma 3 weeks after IVC filter insertion

Report here.

Friday, April 20, 2018

Pitfalls in ICU management

This article in Today's Hospitalist, drawn from recent talks at the UCSF hospitalist conference, has a lot of pearls. Most of the admonitions are about avoiding knee jerk care.

The real gem comes in her discussion of the importance of de-escalation of IV fluids:

“Multiple studies have replicated that, even in sepsis,” Dr. Santhosh noted. “After initial resuscitation with early goal-directed therapy, you want a maintenance or stabilization phase and then de-escalation.” That could mean active diuresis in patients to attain a negative fluid balance once they’re off pressors.

And while it can be a challenge to find the maintenance fluids in your EHR to discontinue them…

That’s right. She said, in effect, that the EHR interferes with the clinician’s ability to discontinue potentially harmful IV fluids. The statement rings true and concerns one of those key provisions of meaningful use: CPOE. Meaningful to patients for sure if it interferes with their care with the potential for harm.

Thursday, April 19, 2018

Hypothyroidism and heart disease

Free full text review.

From the review:

Hypothyroidism can result in decreased cardiac output, increased systemic vascular resistance, decreased arterial compliance, and atherosclerosis.

Impaired cardiac muscle relaxation, decreased heart rate, and decreased stroke volume contribute to heart failure in hypothyroidism.

Subclinical hypothyroidism is associated with ischemic heart disease and increased cardiovascular mortality.

Treatment of hypothyroidism may have a beneficial impact on several parameters of cardiac dysfunction, including subclinical hypothyroidism, especially in younger individuals.

Wednesday, April 18, 2018

Cardiac manifestations of hyperthyroidism

Free full text review.

Tuesday, April 17, 2018


This wonderful free full text review has everything you want to know and probably more.

Monday, April 16, 2018

Hyper- and hypokalemia in the ER

From a recent study:


Hyperkalemia or hypokalemia occur in 1 of 11 ED patients and are associated with inpatient admission and mortality. Treatment of hyperkalemia varies greatly suggesting the need for evidence-based treatment guidelines.

Sunday, April 15, 2018

Insulin autoimmune syndrome aka Hirata disease

It’s caused by spontaneous development of insulin antibodies (no prior exposure to insulin). If that’s the case why does it cause hypoglycemia and not just hyperglycemia? From a review:

Although the precise mechanism for hypoglycemia in IAS is unknown, the most widely accepted hypothesis is a mismatch between blood glucose and free insulin concentration, secondary to the binding and release of secreted insulin by autoantibodies.7 Following a meal or oral glucose load, glucose concentration in the bloodstream rises, providing a stimulus for insulin secretion. Autoantibodies bind to these insulin molecules, rendering them unavailable to exert their effects. The resultant hyperglycemia not only promotes further insulin release, but may also explain the increased hemoglobin A1c often seen in IAS patients.6 As glucose concentration eventually falls, insulin secretion also subsides, and the total insulin level decreases. Insulin molecules spontaneously dissociate from the autoantibodies at this time, giving rise to a raised free insulin level inappropriate for the glucose concentration, evoking hypoglycemia.7 Insulin autoantibodies with a high binding capacity and a low affinity are more likely to bring about hypoglycemic symptoms.10 Medications containing a sulfhydryl group have been proposed to induce autoantibody formation by interacting with the disulfide bonds of the insulin molecule and augmenting its immunogenicity;11 however, the true underlying pathophysiology remains unclear at this time. Rarely, the co-existence of both insulin autoantibodies and insulin receptor autoantibodies within the same patient has been described.12