Recommended Book – Polio: An American Story

With the recent success of the PBS documentary, “The Roosevelts”, we talked about President Franklin D. Rossevelt’s history of polio disease at Parkland Morning Report. Dr. Johnson recommended a book written by David Oshinsky, “Polio: An American Story”, that provides insight to how devastating this disease was to the American public and the efforts to find vaccines. For those that are traveling for fellowship interviews, this may be a great read on the airplane!

Improvement in health care, really?

The New York Times published an op-ed piece titled “A Health Care Success Story” this past week. Written by Bob Kocher and Farzad Mostashari, former advisor to President Obama and national coordinator at Dept. of Human Health and Services respectively, the article comments on the changes in health care costs in the city of McAllen, TX. McAllen was referred to in Dr. Gawande’s article, “The Cost Conundrum”, as it was an example of a city with poor outcomes despite high health care costs and brought national attention to US health care. It seems since Dr. Gawande’s article, McAllen has undergone drastic changes and seems like for the better in regards to costs and patient outcomes. Click on the articles below!

Delta Gap

When evaluating a patient with an anion-gap acidosis, calculate a delta gap to check for there is a concomitant non-gap metabolic acidosis or metabolic alkalosis:
  1. Calculate the delta gap
    • Delta gap = patient’s anion gap – normal anion gap
  2. Add the delta gap to the patient’s bicarbonate
    • if it is < 24, suspect a concomitant non-gap metabolic acidosis
    • if it is > 30, suspect a concomitant metabolic alkalosis

Neuroleptic Malignant Syndrome

Today we had a great case of NMS that lead to discussion about the differential and the causes:

What is NMS?

  • Life threatening neurologic emergency associated with the use of neuroleptic agents and characterized by mental status changes, rigidity, fever and dysautonomia
  • Mostly commonly seen with the “typical” high potency agents (haldol and fluphenazine) but also seen in atypical anti-psychotic class and with anti-emetics (metoclopramide – reglan, promethazine – phenergan and prochlorperazine- compazine)
  • Symptoms:
    • Mental status changes (82%) – often presenting as agitated delirium but may lead to profound encephalopathy and eventual coma
    • Muscular rigidity – generalized increased tone and “lead pipe rigidity”
    • Hyperthermia – defining symptom wtih temperatures > 38 in 87% of cases and >40 in 40% of cases
    • Autonomic instability – tachycardia, labile or elevated BP and tachypnea. Often with dysrhythmias and profuse diaphoresis.
  • Differential diagnosis:
    •  Serotonin Syndrome – similar presentation to NMS
      • More likely to be seen in SS – shivering, hyper-reflexia, myoclonus and ataxia with prodrome of N/V and diarrhea
      • More likely to be seen in NMS – rigidity  and severe hypertheramia
    • Malignant hyperthermia – rare genetic disorder occurring with the use of potent halogenated inhalational anesthetics agents and succinylcholine
      • Clinically similar in that it presents with hyperthermia, muscle rigidity and dysautonomia
    • Also consider anti-cholinergic toxicity, cocaine, ecstasy, PCP or amphetamine intoxication, CNS infection, heat stroke, thyrotoxicosis
  • Treatment: stop offending agent, treat supportively (ICU care, cool patient, tx dehydration and correct electrolyte imbalances) and medically with dantrolene, bromocriptine or amantadine.

The Top 5 Advances in Modern Oncology

To celebrate their 50th anniversary, the American Society of Clinical Oncology polled the cancer community to select the five most pivotal clinical cancer research advances in recent history:

  1. 1965: Chemotherapy Cures Hodgkin Lymphoma

  2. 2006: Vaccine Approved To Prevent Cervical Cancer

  3. 2001: Targeted Drug Transforms Treatment For Rare Leukemia

  4. 1977: New Treatment Cures Men With Testicular Cancer

  5. 1991: Powerful Anti-Nausea Drugs Alleviate Major Side Effect Of Cancer Treatment

Resident’s Work: Screening by Primary Care Providers for HCC in Patients with Cirrhosis.

Eimile Dalton-Fitzgerald (PGY-03) is first author on a recently published article in Clinical Gastroenterology and Hepatology, “Practice Patterns and Attitudes of Primary Care Providers and Barriers to Surveillance of Hepatocellular Carcinoma in Patients With Cirrhosis.” Click on the link below to check out the article!

Clinical Pearls – Adverse Drug Events

Risk Factors for Adverse Drug Events in Older Adults
• ≥5 medications
• 12 doses/day
• Dementia
• Depression
• Female gender
• Low body weight or body mass index <22
• Multiple chronic conditions
• Age ≥85 year old
• CrCl <50 mL/min
• Recent hospitalization
• Multiple prescribers
• Multiple pharmacies
• Prior ADE
• Regular use of alcohol

UTSW Internal Medicine

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