H Pylori

Recently we discussed PUD and its association with H. Pylori.  The history behind this is quite fascinating, includes intrigue and self infection by one of the proponents of the theory.  If you don't know it read about it here under 'history'.

The question came up regarding timing of triple therapy treatment for prevention of re-bleeding.  This study suggests that if you do it after 180 days the risk is increased compared to under 180 days.  I could not find data on whether shorter is better.  For reasons of GI tolerance I would not do it during the GIB admission.

Rebleeding risk scores such as the Glasgow-Blatchford can be useful in admissions for UGIB.  If only we did ureas.

Aortic stenosis

Hey team,

I owe you guys some info on aortic stenosis, but I doubt I could do better than the post that David Frost made as CMR.  Be sure to check out the two articles at the end of the entry.

Here are the UofT pubmed links to the two articles just in case you are outside the hospital:
Etchells et al JGIM 1998
JAMA RCE on Systolic murmur

Hypokalemia

Low potassium is a frequent occurrence among in-patients.  Common causes include low intake compounded by GI losses through diarrhea and renal losses from thiazides, loop-diuretics, and other medications. A favorite rare cause would be hypokalemic periodic paralysis.  When managing hypokalemia always check for hypomagnesemia, as they frequently go together and adequate K repletion requires Mg (remember ATP - check the image).

Low K may manifest as muscle weakness and mental status changes.  The ECG may show U waves, flat or inverted T waves and QT prolongation.  Be careful with patients on digoxin as dig cardiac toxicity is potentiated by hypokalemia.

Serum hypokalemia will usually only manifest once significant total body losses have occurred, as K+ is mainly an intracellular cation.  The ICU book  has an interesting chart showing that by the time serum K is 2.0 the total body K deficit is 600-900 mEq and may be more if there is acidosis.  Of course we don't replace all of the deficit at once, but remember to supplement enough over a few days (preferably orally or if you must via a central line iv in severe hypokalemia).

 To complement this quick overview I highly recommend this article by Drs Kamel and Halperin.

Short course treatment of Community Acquired Pneumonia (CAP)

Today we discussed short course treatments for CAP.  In the last decade there have been trials looking and five day treatments with levofloxacin in adults and even five day treatments of severe pneumonia with high dose amoxicillin in kids.  Azithromycin is usually used for short courses (3-5 days) for CAP, mainly because of its unique long half-life, different from almost all other antibiotics.  A special formulation of azithromycin has even been used to treat CAP with a single 2g dose!!

Remember to always consider severity of CAP, using  either the PSI/PORT score or the CURB 65 score. These are useful for prognosis and to decide on inpatient vs outpatient treatment.

Overall, there is still a lack of evidence for all approaches to treating CAP.  Check out this recent review for more discussion of the issues of: lenghth of therapy, use of procalcitonin and choice of abx.

Welcome to the Team 4 Blog!

Hey Team 4 members,
I am trying out the blog as a new method of discussing topics with links to electronic resources, including journal articles. Feel free to add comments and other links!

Beta Blockers and COPD

Last week we discussed the use of beta blockers in COPD, and the fact that despite being 'relatively contraindicated' they should not be denied to those with COPD who might benefit from them.  Conditions for which beta blockade has a mortality benefit include heart  failure, and previous MI.  They also provide good anti anginal control in patients with CAD.  Their use in treating hypertension control is more nuanced, I will talk about it at a later post.

 This cochrane meta-analysis from 2005 summarized twenty studies on the use of cardioselective betablockers in COPD.  Note the attention to look at beta1 or cardioselective betablockers that have less effects on the bronchial beta 2 receptors.  The authors concluded that : "Cardioselective beta-blockers, given to patients with COPD in the identified studies did not produce adverse respiratory effects. Given their demonstrated benefit in conditions such as heart failure, coronary artery disease and hypertension, cardioselective beta-blockers should not be routinely withheld from patients with COPD."
For a more recent look at the interplay between COPD and Heart Failure treatment check out this review in JACC.