“That Alkaline Phosphatase Seems Really High…”

Today at Morning Report we talked about how to approach a patient with an elevated alkaline phosphatase. There’s a fantastic review article from Clinical Liver Disease by Dr. Siddique and Dr. Kowdley from Virginia Mason Medical Center about how to evaluate and work up a patient who presents with an abnormally high alkaline phosphatase. Key points, tables, charts below from the article:

  • Highest concentration of AP is in liver and bone. But also found in intestine, kidney, and placenta.
  • It can vary with age, gender, and blood type.
  • Try to find the source of the elevated AP – fractionation of isoenzymes by electrophoresis or obtaining 5’nucleotidase and gamma glutamyl transpeptidase (GGT) levels, both of which are elevated in hepatobiliary disease
  • Determine whether cholestasis is secondary to intrahepatic or extrahepatic disease process keeping in mind some diseases can cause both such as primary sclerosing cholangitis

Figure 1. Algorithm in evaluating elevated AP


Figure 2. Categories based on liver tests


Check out the full article below by clicking the link:

Approach to the Patient with Elevated Alkaline Phosphatase 

(Figure 1 and 2 from Siddique, Kowdley. Clin Liver Dis. 2012.)

A New Approach in Reducing Risk of Peanut Allergy? Promising Study Released!

This week’s NEJM released a study (LEAP Trial) from King’s College in London looking at reducing the risk of developing peanut allergies in infants by having them consume peanuts. The authors observed decreased frequency of peanut allergies in the group that consumed peanuts versus the group that avoided. Dr. Rebecca Gruchalla, Professor and Director of the UT Southwestern Allergy and Immunology Division, co-wrote an editorial in the NEJM describing the trial and its potential effect on future studies and management of food-based allergies. Check out the original study and Dr. Gruchalla’s editorial below!

Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy

Preventing Peanut Allergy through Early Consumption – Ready for Prime Time? 

Rewarming in Accidental Hypothermia



  1. Remove clothing
  2. Dry patient
  3. Cover with blankets / space blanket
  4. Provide warm sugary drinks

Active External:

  1. Forced Air Rewarmer (eg: Bair Hugger) ‐ to trunk only to reduce core temperature afterdrop.
  2. Arctic Sun (for moderate / severe).

Active Internal:

  1. Warmed fluids (D5 NS @ 40-42 C) – Initially 250-500mL bolus, repeat based on clinical
  2. Warm, humidified oxygen. By facemask or consider CPAP – by ETT if intubated.
  3. Peritoneal Lavage – 2 liters of diasylate @ 40 – 45 C, remove after 20-30 minutes. Rewarming rate of 1-3 C / hr.
  4. Body cavity lavage – Through Foley or NGT / OGT. 500mL boluses or continuous Consider risk of fluid / electrolyte shifts.
  5. Closed Thoracic Lavage – 2 large bore (38-40 fr) chest tubes in each hemithorax (one at mid clavicular line @ 2nd / 3rd interspace, second at post. axillary line @ 5th / 6th interspace). Infuse warmed (40-42 C) saline and drain though posterior tube.
  6. Thoracotomy with Mediastinal Lavage – 1-2 liters of warmed NS to mediastinum, remove after 1-2 minutes. May utilize cardiac massage and internal defibrillation. Highly Invasive, requires disposition to OR.


  1. Continuous Venovenous Rewarming (CVVR) – 2-3 C / hr.
  2. Continuous Arteriovenous Rewarming (CAVR) – 3-4 C / hr. Requires adequate MAP. Can be performed in ED with proper equipment.
  3. Hemodialysis – 3-4 C / hr. Requires adequate MAP. Possible to correct electrolyte and toxic abnormalities. Requires dialysis staff.
  4. Cardiopulmonary Bypass – Most rapid rewarming (8-10 C / hr). Provides full cardiopulmonary support for hemodynamically unstable patients.

Created by Jack Gervais MD, Matt Sholl, MD, and Jeff Holmes MD at Maine Medical Center

Internal Medicine Journal Watch – February 2015

STRAIGHT FROM THE HOUSESTAFF – the February 2015 Internal Medicine Journal Watch! They have summarized important issues in clinical practice, from Metformin in CKD to pre-exposure prophylaxis for HIV. There is even an EKG challenge at the end, if you are up for it! You will have to view this post on our website to access the PDF.  There is a quick run down of the topics below:


  • American Diabetes Association’s Standards of Medical Care in Diabetes – 2015.
    • Dr. Jeremy Warshauer reviewing Grant RW, et al. Diabetes Care 2015 Jan;38 Supplement 1
  • Metformin in Patients With Type 2 Diabetes and Kidney Disease: A Systematic Review
    • Dr. Nicolas Barros reviewing Inzucchi, SE, et al. JAMA 2014; 312(24):2668-2675


  • Preliminary analysis of the Very Early Diagnosis of Systemic Sclerosis (VEDOSS) EUSTAR multicentre study: evidence for puffy fingers as a pivotal sign for suspicion of systemic sclerosis
    • Dr. Brian Skaug reviewing Minier T, et al. Ann Rheum Dis 2014;73: 2087–2093

Healthcare Policy

  • Using drugs to discriminate – adverse selection in the insurance marketplace
    • Dr. Ashish Gupta reviewing Jacobs DB and Sommers BD. N Engl J Med. 2015 Jan 29;372(5):399-402

General Internal Medicine

  • Disorders of Plasma Sodium — Causes, Consequences, and Correction
    • Dr. Nicolas Barros reviewing Sterns, R, et al. NEJM 2015; 372:55-65
  • Acid–Base Problems in Diabetic Ketoacidosis
    • Dr. Nicolas Barros reviewing Kamel K, et al. NEJM 2015 ; 372:546-554

Platelet Transfusion

  • A Clinical Practice Guideline From the AABB
    • Dr. Nicolas Barros reviewing Kaufman RN, et al. Ann Intern Med. 2015 Feb 3;162(3):205-13


  • Association of Albumin-Creatinine Ratio and Cystatin C With Change in Ankle-Brachial Index: The Multi-Ethnic Study of Atherosclerosis (MESA)
    • Dr. Ben Jenny reviewing Garimella P, et al. Am J Kidney Dis. 2015;65(1):33-40

Infectious Disease

  • Tenofovir-Based Preexposure Prophylaxis for HIV Infection Among African Women
    • Dr. Brad Cutrell and Dr. Nicolas Barros reviewing Marrazzo J, et al. 2015; 372:509-518
  • Infectious Diseases Diagnosis and Treatment of C. difficile in Adults: Systematic Review
    • Dr. Brad Cutrell and Dr. Nicolas Barros reviewing Bagdasarian N, et al. JAMA 2015; 313(4):398-408


  • An interferon-free antiviral regimen for HCV after liver transplantation
    • Dr. Jan Petrasek reviewing Kwo et al., NEJM. 2014; Dec 18;371(25):2375-82
  • Decreasing Mortality Among Patients Hospitalized with Cirrhosis in the United States From 2002 through 2010
    • Dr. Jan Petrasek reviewing Schmidt et al., Gastroenterology. 2015 Jan 23.


  • Twelve or 30 Months of Dual Antiplatelet Therapy after Drug-Eluting Stents (DAPT trial)
    • Dr. Ben Jenny reviewing Mauri L, et al. N Engl J Med. 2014 Dec 4;371(23):2155-66.

EKG Challenge

  • Dr. Ben Jenny
  • Untitled
All of the work above comes from the IMJW Editorial Board (with Dr. Brad Cuttrell): Jan Petrasek, Purav Mody, Nicolas Barros, Ragisha Gopalakrishnan, Jeremy Warshauer, Shetal Patel,  Ben Jenny (not Jennings), Vishwanatha Lanka, Brian Skaug, Ashish Gupta, and Roma Mehta!