Recently, The New York Review of Books, published online an article written by Dr. Lara Goitein (pulmonologist/critical care board ceritified physician from New Mexico) who discusses the current state of residency training. She makes several references to the book, Let Me Heal: The Opportunity to Preserve Excellence in American Medicine, written by Dr. Kenneth M. Ludmerer from Washington University. Dr. Goiteini writes of when and where the current model of residency training began with Dr. William Osler and the importance of the mentoring relationship between faculty and the housestaff. Faculty who were held to the highest esteem by peers, residents, and the institution were the ones who were the best teachers. However, with healthcare undergoing major changes and how it’s delivered, Dr. Goitein is concerned about the erosion of this relationship and how residency training is changing. She comments on the recent ACGME guidelines regarding duty hours as well as how the institutions where residents train have changed and its effect on resident education. Check out the article below by clicking on the link! Thanks to several residents who referred to this article for the blog.
Below are some key points in diagnosing and managing milk-alkali-syndrome:
Triad of hypercalcemia, metabolic alkalosis, and acute kidney injury associated with the ingestion of large amounts of calcium and absorbable alkali.
- Excessive amounts of calcium carbonate is considered 4-5 g daily
- Originally described in association with the use of milk and sodium bicarbonate for the treatment of peptic ulcer disease
- There may be a resurgence of this disorder due to increased calcium therapy for presenting/treating osteoporosis, more OTC calcium carbonate preparations, and use of calcium carbonate in patients with CKD to minimize secondary hyperparathyroidism
- Among patients hospitalized with hypercalcemia, milk-alkali syndrome is the 3rd most common cause behind hyperparathyroidism and cancer
- Pathogenesis remains uncertain as studies have shown that some patients given high amounts of alkali and calcium don’t develop milk-alkali syndrome
- Although renal impairment is associated, it’s not a prerequisite to develop milk-alkali syndrome
- Individual variations in the buffering capacity of bone may play role in the susceptibility to development of hypercalcemia
- Patients at higher risk include
- Older individuals
- Those at risk for volume depletion (including patients on thiazide diuretics)
- Medications that reduce GFR (ie ARB’s, ACE-I, NSAIDS)
- Diagnosis is based upon the history of ingestion of calcium-rich medications and the exclusion of other causes of hypercalcemia
- Stop offending agent
- Treat with IV saline and furosemide
- Hypocalcemia can occur transiently with rapid rise of PTH to supranormal levels which is unique to milk-alaki syndrome
(Medarov. Mayo Clin Proc. 2009 Mar; 84(3): 261–267.)
Today on KERA – Dallas affiliate of NPR – Dr. Jade Le from the division of infectious diseases at UT Southwestern talked about West Nile virus and cases already being reported. She provides a quick overview of the infection including individuals who may be at higher risk. Listen to the interview by clicking on the link below!