tag:blogger.com,1999:blog-147430012024-03-13T07:18:13.493-05:00Notes from Dr. RWHospitalist resources and more.Robert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comBlogger6098125tag:blogger.com,1999:blog-14743001.post-31176747565610500102024-01-20T22:17:00.003-06:002024-01-20T22:17:20.854-06:00Special circumstances where warfarin is favored over DOACs When is warfarin favored over DOACs? Valvular atrial fibrillation. This term is becoming obsolete. For anticoagulation for stroke prevention in atrial fibrillation DOACs are contraindicated and warfarin favored in severe rheumatic mitral stenosis and mechanical prosthetic valves.Liver disease. If Child Pugh is C DOACs are not recommended. If B, apixaban and rivaroxaban Robert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-91945791735728703262024-01-20T14:22:00.003-06:002024-01-20T14:22:21.966-06:00ACC atrial fibrillation guidelines 2023 A few key points from the 2023 atrial fibrillation guidelines American College of CardiologyNew classification: The old classification is maintained but it is encompassed in a broader classification outlining the stages of risk and /or the occurrence of atrial fibrillation. Stage 1: at risk. This refers to the presence of risk factors such as obesity and hypertension. Robert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-41485088272280376882023-02-02T12:13:00.005-06:002023-02-02T12:13:38.373-06:00Autonomic dysfunction as a cause of cardiovascular disease
This free full text review focuses on neurodegenerative
synucleinopathies and briefly, in addition, touches on other
disorders such as POTS, vasovagal syncope and inappropriate sinus
tachycardia.
Synucleinopathies
result from misfolded protein aggregates of α-synuclein. The normal
function of α-synuclein in the nervous system is not well
understood.
The
synucleinopathiesRobert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-59526638987969556072023-02-02T12:07:00.004-06:002023-02-02T12:07:22.560-06:00Nucleic acid testing for viral pathogens in community-acquired pneumonia
The
American thoracic Society has published a guideline for this
in the American Journal of Respiratory and Critical Care Medicine.
These are soft recommendations based on low-level evidence.
The
guideline does not address influenza or covid. For influenza,
the IDSA community-acquired pneumonia guidelines recommend influenza
PCR testing during flu season (in preference Robert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-22685537222993954892023-02-02T12:00:00.001-06:002023-02-02T12:00:05.998-06:00Could aspergillus be hiding out in your critically ill patient?
An
issue from the American Journal of respiratory and Critical Care
Medicine contains two articles and a related an editorial addressing
this subject.
This
study looked for evidence of aspergillus infection in
patients diagnosed with VAP:
Rationale: Aspergillus infection
in patients with suspected ventilator-associated pneumonia remains
Robert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-70790933807779715662023-02-02T11:50:00.001-06:002023-02-02T12:01:26.833-06:00Antimicrobial resistance in critically ill patients
This review focuses mainly on gram-negative bacteria. Although
it approaches the problem in light of the covid-19 pandemic it has
general applicability.
First a few
definitions.
ESKAPE
microorganisms : Klebsiella pneumoniae, Acinetobacter baumannii,
Pseudomonas aeruginosa and Enterobacter spp
Enterobacterales:
new term for enterobacteriaceae
MDR: resistant to atRobert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-64966231316386300512023-02-02T11:15:00.004-06:002023-02-02T11:51:38.818-06:00ANCA testing in eosinophilic granulomatosis with polyangiitis (EGPA)
The
American Journal of Respiratory and Critical Care Medicine published
a consensus statement on the use of ANCA testing in patients
with eosinophilic granulomatosis with polyangiitis
(EGPA,formerly Churg Strauss syndrome). The article serves is a
helpful update and review on some aspects of EGPA.
First
some Basics about the ANCA test. The two main types have twoRobert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-25727933308671200102022-07-08T22:10:00.000-05:002022-07-08T22:10:26.365-05:00Myths and facts in antibiotic stewardshipThe current issue of the American Journal of Medicine (the Green
Journal) has an article titled Top Myths of Diagnosis andManagement of Infectious Diseases in Hospital Medicine. This is
one of the better articles pertaining to antibiotic stewardship that
I have seen. Ten myths are listed. They are not complete myths
(exceptions apply to just about all of these principles); rather,
they are Robert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-44659785960352151872022-06-15T13:55:00.000-05:002022-06-15T13:55:07.433-05:00Diagnostic time outWhat is a diagnostic time out? Succinctly defined, it’s a
deliberate exercise in differential diagnosis and systematic clinical
reasoning in the care of an individual patient. But wait, I hear
someone say… isn’t that what we do already? Well, no. We’re
all familiar with the traditional model for clinical reasoning that
we’re taught in medical school but those of us in the real world of
practiceRobert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-1227470881147605332022-06-11T23:51:00.001-05:002022-06-11T23:51:34.889-05:00A little more on metacognitionThis article from Academic Emergency Medicine, published in
2002, remains applicable today. It makes the point that heuristics in
medicine are valuable even though they can lead to error. The article
also makes the statement:
The increasing use
of clinical decision rules, as well as other aids that reduce
uncertainty and cognitive load, e.g., computerized clinical
decision support,will Robert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-61086610385388064162022-06-11T23:37:00.005-05:002022-06-19T23:06:09.725-05:00Indulge me in a little metacognitionI found an interesting post about
cognitive shortcuts in medicine. I have a minor objection to the
title of the post which is Cognitive Errors.
Cognitive shortcuts, known as heuristics, which are examples of fast
instinctive thinking (system one), often lead to error. In
some cases, however, they can be useful because they are efficient
and time saving. There is an up side as well as a down Robert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-28256455803062170362022-05-04T00:02:00.002-05:002022-05-04T00:06:39.128-05:00Stepford doctorsEver since variation was declared to be an enemy of medicine there
has been a multifaceted unrelenting effort to constrain the autonomy
of clinicians.
In an article in the
Medical Humanities journal titled “Stepford doctors”: an allegory GM Sayers described this trend creeping
towards the ultimate creation of a workforce of Stepford doctors. From the paper:
The Stepford Wives,
a novel by Robert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-67067440941224302022-05-02T14:46:00.004-05:002022-12-08T16:20:23.415-06:00Are internal medicine’s core values effectively applied in today’s hospitalist practice?Hospital medicine
has changed. The change has been brought by business and regulatory
pressures rather than the core values of internal medicine. Internal
medicine’s core values are timeless.
Phillip Tumulty
was famous as one of internal medicine’s great teachers. He was a
lead faculty member in the department of internal medicine at Johns
Hopkins for over 20 years. He published an article in Robert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-48438775801663469062021-08-11T12:24:00.002-05:002021-08-11T12:24:06.301-05:00Update on management of the acute abdomen in critically ill patients
From a recent review in Current Opinion in Critical Care Medicine:
Purpose of review
The aim of this
study was to describe important features of clinical examination for
the surgical abdomen, relevant investigations, and acute management
of common surgical problems in the critically ill.
Recent findings
Lactate remains a
relatively nonspecific marker of gut Robert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-62554965743867019142021-08-11T11:43:00.001-05:002021-08-11T11:43:09.304-05:00The fight to curb antimicrobial resistance: how are we doing?
From a recent NEJM review on this topic:
In November 2019,
the CDC released an updated version of its antibiotic-resistance
report…
The new report
reveals reductions in the incidence of infections caused by
carbapenem-resistant acinetobacter species, multidrug-resistant
Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus,
vancomycin-resistant enterococcus,Robert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-68889293921503545262021-06-11T00:25:00.007-05:002021-06-11T11:36:10.796-05:00Primary aldosteronism: an update
Here's an update on this topic recently published in
Cardiology in Review.
The original Conn
syndrome was described in 1956 as a case report of a young woman with
hypertension and severe hypokalemia who was found to have an adrenal
adenoma and was cured after adrenalectomy. Subsequently we've found
that primary aldosteronism is much more common than previously
thought. It's Robert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-12516204226848843662021-06-03T06:45:00.002-05:002021-06-03T06:47:53.704-05:00Procalcitonin guided antibiotic treatment is beneficial in a variety of infectionsFrom a recent report in the American Journal of Respiratory and Critical Care Medicine :
Rationale: Although
early antimicrobial discontinuation guided by procalcitonin (PCT) has
shown decreased antibiotic consumption in lower respiratory tract
infections, the outcomes in long-term sepsis sequelae remain unclear.
Objectives: To
investigate if PCT guidance may reduce the incidence of Robert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-45079665042144365742021-05-02T10:21:00.003-05:002021-05-02T10:21:30.674-05:00Is evidence based medicine the same as science based medicine? In its original notion, yes. In its widespread popular distortion, no. Harriet Hall explains. Robert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-2631825621601381152021-04-16T14:20:00.001-05:002021-04-16T14:20:11.340-05:00Widespread misunderstanding of hypoxemia, hypoxia and pulse oximetry
A recent article in the American
Journal of Respiratory and Critical Care Medicine about hypoxemia
and covid-19 concludes with this:
In conclusion, COVID-19 has engendered
many surprises, but features that baffle physicians are less strange
when contemplated through the lens of long-established principles of
respiratory physiology.
Read this paper when you're Robert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-60569863262719836762020-08-20T10:30:00.001-05:002020-08-20T10:30:31.824-05:00Anticoagulation for atrial fibrillation in stages 4 and 5 of CKDFrom a recently published study:
Purpose
The aim of this
study was to investigate whether oral anticoagulants can provide
efficacy and safety profiles better than no anticoagulant in patients
with stages 4 or 5 chronic kidney disease and atrial fibrillation.
Methods
From 2001 to 2017, a
cohort of patients with stages 4 or 5 chronic kidney disease and
atrial fibrillation based on Robert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com1tag:blogger.com,1999:blog-14743001.post-75749094577090165532020-08-12T12:05:00.001-05:002020-08-12T12:05:12.170-05:00Elevated BP in hospitalized patients: what to do?From a recently
published review:
Elevated blood
pressure is common in patients who are hospitalized. There are no
guidelines and few recommendations to help inpatient providers manage
patients with elevated blood pressure. There are no normal reported
values for blood pressure in the inpatient and recording
circumstances often widely vary. Many factors may influence blood
pressure such as Robert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-35881126893940272422020-08-12T12:01:00.004-05:002020-08-12T12:01:20.926-05:00Cardiac complications of psoriasisLook at the
epicardial fat. From a recent paper in the green journal:
Psoriasis is a
systemic inflammatory disorder that can target adipose tissue; the
resulting adipocyte dysfunction is manifest clinically as the
metabolic syndrome, which is present in ≈20%-40% of patients.
Epicardial adipose tissue inflammation is likely responsible for a
distinctive pattern of cardiovascular disorders Robert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-70732981488726761082020-08-12T11:49:00.001-05:002020-08-12T11:49:31.318-05:00Updated atrial fib guidelines: the essentials
From Joseph S.Alpert.
p { margin-bottom: 0.1in; line-height: 115% }
a:link { so-language: zxx }Robert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-9480863290838174962020-08-11T22:23:00.000-05:002020-08-11T22:23:57.320-05:00A case of relapsing polychondritisFrom a case report and mini review in the American Journal of Medicine:
McAdam and the
Damiani/Levine diagnostic criteria. 12 RPC is diagnosed if 3 of 6
clinical findings are present: 1) auricular chondritis; 2) nonerosive
inflammatory arthritis; 3) nasal chondritis; 4) ocular inflammation,
including conjunctivitis, keratitis, scleritis, episcleritis, or
uveitis; 5) laryngotracheal chondritis;Robert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-87280246385934588222020-08-11T22:06:00.004-05:002020-08-11T22:22:03.518-05:00Thyroid acropachy: an unusual complication of Graves diseaseFrom a recent published case report and mini-review:
The pathogenesis of
acropachy is unknown, except for the anatomic location, in that it is
probably similar to that of pretibial myxedema. It appears that TRAb
molecules bind to the TSH receptors of fibroblasts present in the
periosteum region and trigger an inflammatory response, producing
cell proliferation and glycosaminoglycan deposition Robert W Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0