Fariba raised questions about Lyme disease in our patient with cranial nerve and peripheral sensory findings.
Most of Ohio is in a minimal or no risk zone. (This CDC map is helpful [1]). More narrowly, Cincinnati is in a “low risk” zone. The CDC site [2] has good pictures of Lyme-related ticks [3]. New to me was the fact that deer do not become infected, but are tick transporters. Small animals like squirrels and mice get infected.
For a good recent review try this American Family Physician article [4]. (It led me to these other links. Its contradictions revolve around the significance of non-specific symptoms and when to test.)
When talking about patients as individuals we touched on the principle of autonomy. Judge Sandra Beckwith discusses autonomy and informed consent in her 1995 decision on the University of Cincinnati's radiation research [1].
Physicians had asked that charges be dropped as brought by family members of research subjects. The research was ongoing from 1960 to 1972. The names of individual subjects became known around 1994. In her decision Judge Beckwith rules against the physician defendents.
Here are key pages in her decision...
Page 4: Factual Allegations
Page 13: Discussion of autonomy and liberty
Page 20: Nuremberg Code
From 1960 to 1972 experiments were conducted
at the University of Cincinnati College of Medicine
and Cincinnati General Hospital on at least 87 people.
(Complaint at P20). The subjects of the experiments were
exposed to total or partial body irradiation. The primary
purpose of the experiments was to test the psychological
and physical effects of radiation on humans.
(Complaint at P21). Indeed, a report prepared for the
Department of Defense by the individual Defendants who
conducted the Human Radiation Experiments during the
period 1960 to 1966 indicated that the goal was "to develop
a baseline for determining how much radiation exposure
was too much, and to determine how shielding
could decrease the deleterious effect of the radiation,"
and to determine what a single dose of whole or partial
radiation could do to "cognitive or other functions mediated
through the central nervous system."
Our patient had hip pads on when she fell. She broke her hip. Do hip pads reduce hip fracture?
This Canadian community-based trial found that many people discontinue hip pad use, but that they did reduce fracture risk with a number needed to treat of 41 (to prevent one fracture) [1]. But a Cochrane Database review of existing literature doubted the protective benefit [2].
Summaries on reducing fall risk can be found in an earlier posting [3], and at this legal site [4].
"Accumulating evidence casts some doubt on the effectiveness of the provision of hip protectors in reducing the incidence of hip in older people. Acceptance and adherence by users of the protectors remain poor due to discomfort and practicality." [2].
A living will is brief. We have seen patients for whom filling one out was no problem--just a part of life. But we also have seen, or felt, how tough it can be when each of us tries to initial a line with our own preference about our own terminal food & hydration.
What about thirst or a sense of starvation due to withholding of hydration or nutrition at the end of life? This 2003 Cleveland Clinic article reviews some evidence [1], as does this 2001 article from a British nursing journal [2]
Again, here is a link to US Living Will Registry [3].
Steve's patient raised the question of reversing anticoagulation before surgery. A 1997 review article is helpful [1], and can be accessed free online (just register with NEJM).
A more recent review by the Cleveland Clinic discusses the lack of randomized trials to guide recommendations in this area [2]. Bridging with heparin may be less necessary than previously thought.
Curiously, other research found warfarin therapy could be safely continued before heart transplant surgery with no excess bleeding [3]
"...We offer a number of recommendations for the perioperative management of anticoagulation in patients who are taking oral anticoagulants. If a patient's INR is between 2.0 and 3.0, four scheduled doses of warfarin should be withheld to allow the INR to fall spontaneously to 1.5 or less before surgery. Warfarin should be withheld for a longer period if the INR is normally maintained above 3.0 or if it is necessary to keep it at a lower level (i.e., <1.3). The INR should be measured a day before surgery to ensure adequate progress in the reversal of anticoagulation; the physician then has the option of administering a small dose (1 mg, subcutaneously) of vitamin K, if required (that is, if the INR is 1.8 or higher). Alternative preoperative or postoperative prophylaxis, or both, against thromboembolism should be considered for the period during which the INR is less than 2.0. " [1]
Here is one way (from UC area) [1].
When you enter, one of the first pieces you will see will be the Museum's oldest representation of a human figure (4500 years-old) [2].
Another way (from Good Sam)
...Take a right onto Clifton
...(0.2 miles then) Left on Martin Luther King
...(1 mile then) Right on Burnet Ave
...(1.5 miles or so) At the bottom of the hill, at the traffic light take a left (onto Eden Ave, also called Dorchester)
...(0.25 miles) Enter straight into Eden Park (curve to the right up the hill)
...(0.25 miles) The Museum is on the right
...Follow signs to parking and main entrance
...Admission is free. Head for the Terrace Cafe.
We talked about writing short-acting opioids, such as oxycodone, as "q 4h" rather every six hours. For more about how to increase an opioid dose, see this FastFact [1]. We have also dealt with managing pain in the setting of substance abuse [2]. And we have talked about propoxyphene (Darvocet) as a less than optimal analgesic choice [3].
For a rich resource of quick tips on pain and palliative care, try this University of Wisconsin end of life care site [4]. It is the home of FastFacts--a concept started by Dr. Warm at the University of Cincinnati. These are a series of quick tips on palliative care. Locally Dr.Manish Srivastava and Sandy Webb, RN lead a Good Samaritan palliative care team.
For a copy of Ohio's living will and durable power of attorney for healthcare forms try this link [1].
US Living Will Registry was mentioned as an online repository [2].
The idea of building empathy into brief interactions with patients came up early in the month in discussion with Rebecca, Steve and Mark.
The algorithm, B.A.T.H.E, helps me as I approach each concern of the patient, no matter how minor or major and regardless of age [1].
The anticoagulation guidelines in the journal, Chest, can be found in their September 2004 supplement. When doing an MDconsult search they will return full text.
In considering after hospital care for Rebecca's patient the subject of PACE came up. This is a federally sponsored program for all-inclusive care of the elderly. The intention is to extend time for folks at home rather than immediate nursing home placement [1, 2].
We have seen lots of people with liver disease and pain. The group's consensus is that in therapeutic doses it is safe even in the setting of liver disease. This abstract provides some evidence to that effect [1]. (...Will try to track down the full text.)
While reviewing the drug list on Mudassir's patient the possible increased mortality of inhaled long-acting beta-agonists came up. The SMART study was terminated early after finding increased mortality in asthmatic patients using salmeterol (Serevent) without inhaled corticosteroids [1]. Our pharmacists are looking into the original research and subsequent interpretation.
We have met Steve's patient that Dr. Zadikoff diagnosed with the C Miller Fisher variant of Guillain Barre Syndrome. Dr. Charles Miller Fisher (born 1913), originally from Montral, was a revered neurologist who helped define TIA's among many other things [1, 2]
This case from Baylor is a concise summary of the Miller variant of Guillain Barre [3].
Wikipedia, a people's online encyclopedia, has more to say about the lives of Guillain [4] and Barre [5]. (Barre is credited with developing a test we all use to diagnose stroke, the arm drift.)
Rebecca's patient serves to remind us that benzodiazepines can overly sedate, lead to behavioral changes and can increase the risk of falls [1]. SSRI's have been reported to have such risks as well [2].
As mentioned by Tom, the FDA has warned of increased mortality when atypical anti-psychotics are used to manage behavioral problems in elderly demented patients [3].
An online review of falls can be found in the American Family Practice Journal [3].
John's patient told of of his use of music as analgesia. Others have investigated this. A European study found music relieved post-op pain and lowered a stress parameter, serum cortisol [1].
A more profound side of sickle cell is presented in this recent case from NEJM. A 22-year old woman with sickle cell and develops acute chest syndrome, bone infarction, embolisms to the lungs, and respiratory failure [2]. (The article will be shared with the group via email.)
Today's bedside exam was tricky because of the extensive size of our patient's liver.
Scratch Test
One small 1997 study found it unhelpful [1]. Many others have been guided by "experience" that has led them to believe the scratch test gets them "in the ball park" of the liver's size.
Shifting dullness--shifting technique
This online textbook reviews the abdominal exam in general. The section on ascites suggests rolling the patient opposite to the direction that I demonstrated [2].