Today we discussed the antiphospolipid antibody syndrome and thromboembolic disease.

A NEJM images in clinical medicine case of phlegmasia cerulea dolens is posted here
Phlegmasia cerulea dolens:

• massive proximal DVT of the leg
  
• complications include severe pain , swelling, cyanosis, edema, venous gangrene, compartment syndrome, and arterial compromise, often followed by circulatory collapse and shock
• one of the few reasons to consider thrombolysis (genearlly catheter directed) or thrombectomy for lower limb DVT

APLA syndrome:

• Recurrent positive testing for an antiphospholipid antibody (>2x >3 months apart)
• Clinical sequlae - usually arterial and/or venous thrombosis or pregnancy loss (either recurrent early loss or single late loss, without other cause)
  

Notes on the lupus anticoagulant:

• causes prolonged aPTT (not always present), the dilute Russell viper venom time (dRVVT), the kaolin clotting time
• prolongation is not reversed during a 50:50 mix test
• patients with this dont always have SLE
  
• the term anticoagulant refers to invitro phenomenon - in vivo these patients are prone to thrombosis
  

Interstitial Lung Disease

A case of interstitial lung disease that covers alot of the issues discussed in morning report can be found here

Another article about exacerbations of IPF can be found here

From a public health point of view, an article about Canada's export of asbestos despite it being classified as a hazardous substance in Canada can be found here

FASTENS
The mnemonic for upper lobe intersitial pattern:
F - farmer's lung (hypersensitivity pneumonitis
A - Ank spond.
S - Sarcoid
T - TB
E - Eosinophilic Granulomatosis
N- Neurofibromatosis
S - silicosis

Sugar, sugar

We started today by discussing an approach to weight loss. A very useful classification is to divide causes with decreased appetite from those with increased appetite. Remember also the big categories: cancer, endocrine, psychological/psychiatric and access to food. CMAJ has a great review of weight loss in the elderly from our local experts.

We also touched on the criteria for Hyperosmolar Hyperglycemic State (calling in HONK is becoming passe). Though decreased level of consciousness is common (seen in over 50%) it is not always seen.

Finally we talked about the evidence for preventing --or delaying-- diabetes in persons with IGT/IFG. Check out the landmark Diabetes Prevention Program (DPP) study to learn more about it. The lifestyle modification arm showed a 60% reduction in progression to diabetes after 3 years, compared to a 30% reducation in those receiving metformin. Now if we could all just find the time to exercise....