This morning we talked about a variety of different cases. One of them, involved a patient with a presentation of swollen warm painful knee. Here is a previous morning repot blog post on approach to monoarthritis.

*The Gout by James Gillray. Published May 14th 1799.

Hormone Replacement Therapy

This morning we briefly talked about the Women’s Health Initiative (WHI)and hormone replacement therapy. WHI was a set clinical trials including two hormone trials in healthy postmenopausal woman 50-70. The hormone trials were stopped early due to increased risk of cardiac events, VTE, stroke and breast cancer. The study did show benefits in reducing fracture and colorectal cancer risk.

Subsequent analysis of the WHI noted that the increased risk of CHD tended to depend on the timing of exposure, with no excess risk observed in younger menopausal women.

Current recommendations are as follows:

Moderate to severe menopausal symptoms can be treated with short term HRT in peri- or postmenopausal women (and no contraindications to estrogen). HRT should be stopped before five years. HRT should not be used as primary or secondary prevention of CAD.


Here is Endocrine Society’s statement on HRT.

Lets SIGN OUT? at TWH!

Handing over. We do it often. And the information we transfer is critical to patient safety. This morning we talked about SIGN OUT? as a template for our signovers.

S: Is the patient sick? Code status!!!
I: Identifying data
G: General hospital course
N: New events
O: Overall health status right now
U: Upcoming possibilities (if and then statements)
T: Tasks to complete overnight
?: Questions

Every team will function differenly, but sticking to consisten hand over template an style keeps communication flowing, and patients safe.

* it's 5pm...have you Singed Out yet?!

VTE and Malignancy

The questions of screening for an occult malignancy comes up often when a patient presents with unprovoked VTE. There are multiple observational studies that have confirmed the increased incidence of malignancy among those with VTE, however, none has shown improved survival with aggressive diagnostic testing. None of these studies are prospective.

As a result, the current recommendations is that all patients with idiopathic DVT should be evaluated with careful history. A past history of cancer should be a red flag. Other symptoms such as loss of appetite, weight loss, fatigue, pain, hematochezia, hemoptysis, and hematuria should also raise suspicion about cancer.

A complete physical examination (including digital rectal examination and testing for fecal occult blood, pelvic examination in women), and routine laboratory testing (complete blood count, chemistry panel including electrolytes, calcium, creatinine, and liver function tests), urinalysis and CXR should also be performed. Furthermore, age-appropriate cancer screening (PSA, FOB and C-scope, mammogram) should be offered.

Any abnormality observed on initial testing should then be investigated aggressively.

HCV-associated Cryoglobulinemia

Cryoglobulins are immunoglobulins that precipitate in cold and dissolve with warming.

HCV infections is associated with Type II or essential mixed cryoglobulinemia (polyclonal IgG and a monoclonal IgM rheumatoid factor directed against the IgG) and Type III or mixed cryoglobulin (polyclonal IgG and rheumatoid factor IgM).

Deposition of antigen-antibody complexes in small and medium-sized arteries leads to the clinical findings of cyroglobulinemia. It is unclear, however, why cryoglobulins are produced and which antigen triggers this process. HCV RNA itself may serve as the inciting agent.

Clinical features include palpable purpura, nonspecific systemic symptoms, arthralgias, lymphadenopathy, hepatosplenomegaly, peripheral neuropathy, and hypocomplementemia (low C4).

Here is a review on the topic.

*image is papable purpura (non-blanching erythematosus papules) found in a patient with chronic HCV infection with mixed cryoglobulinemia.

"Did the green onion make me yellow"?

Hep A is an RNA virus that spreads by the fecal-oral route. HAV is more prevalent in low socioeconomic areas with lack of adequate sanitation and poor hygienic practices. International travel is the most common risk factor in USA (and Canada).

HAV infection usually results in an acute, self-limited illness and only rarely leads to fulminant hepatic failure in those with underlying liver disease, especially chronic hepatits C infection.

The manifestations also vary with age: HAV is usually silent or subclinical in children. In contrast, infection in adults can vary in severity from a mild flu-like illness to fulminant hepatitis. The incubation period averages 30 days (range 15 to 49 days). Symptoms include fatigue, malaise, nausea, vomiting, anorexia, fever, and right upper quadrant pain followed by dark urine, light stools, jaundice, and pruritus. Lab investigations show marked elevations of serum aminotransferases (usually >1000 IU/dL), bilirubin, and alkaline phosphatase.

Acute HAV infection is diagnosed by the detection IgM anti-HAV in serum.

The treatment is supportive care.

* image: the most widespread hepatitis A outbreak in USA affected 640 people (killing 4) ,in late 2003, was blamed on tainted green onions at a restaurant.

Statin-induced muscle injury

Muscle injury with statin therapy can range from myalgias to myositis to rhabdomyolysis. Muscle symptoms usually begin within weeks to months after starting statins and usually return to normal over days to weeks after drug discontinuation.

You should warn your patients about new onset muscle pain and weakness when you start a statin. A CK level should be obtained at baseline, but routine monitoring of serum CK levels is not recommended.

Patients with acute or chronic renal failure, liver disease, and hypothyroidism are at higher risk of developing muscle injury. Clinical symptoms or a CK level >10X the upper limit of normal should prompt a drug discontinuation.

Pravastatin and fluvastatin appear to have much less intrinsic muscle toxicity than other statins. After the CK has returned to baseline, patients may be tried on a statin less likely to cause muscle toxicity with careful monitoring.

Here is review on the topic.

An assessment of statin safety by muscle experts. Thompson PD, Clarkson PM, Rosenson RS, National Lipid Association Statin Safety Task Force Muscle Safety Expert Panel. Am J Cardiol. 2006;97(8A):69C.