Monthly Archives: July 2019

Hypoglycemia Work-up

Glucose <55 and symptomatic?

  • insulin and pro-insulin
  • C-peptide
  • beta hydroxybutyrate
  • glucose after glucagon
  • circulating OHA
  • Insulin Ab

 

Capture

Hypoglycemia diagnostic work-up

REFERENCE:

Uptodate.

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False Procalcitonin Values

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False Positive:

  • Severe trauma
  • Surgery
  • Cardiac shock
  • Burns
  • Malaria
  • Systemic vasculitis (Granulomatosis with Polyangiitis, Kawasaki disease, Adult Onset Stills Disease and Goodpasture’s syndrome)
  • End-Stage Renal Disease
  • Post ATG, alemtuzumab

 

False Negative:

  • Localized infections (osteomyelitis, abscess, subacute endocarditis)
  • Procalcitonin checked too early

 

PCT powerpoint file

Procalcitonin FAQ 4.2 website

 

REFERENCE:

http://med.stanford.edu/bugsanddrugs/guidebook/_jcr_content/main/panel_builder_1454513702/panel_0/download_170777144/file.res/Procalcitonin%20FAQ%204.2%20website.pdf

MRI Cavernous Malformation

Imaging of Cavernous Malformation

  • – CT – nonspecific, ill-defined calcification
  • – MRI – typical “popcorn appearance”

Popcorn = larger caverns, mixed signals of blood at different stages of organization and calcification, surrounding hemosiderin

“Hemosiderin ring” best seen on T2-weighted sequences

Acute hemorrhage may mask underlying cavernomas on MRI

Gradient recalled echo acquired (T2*/GRE) sequences reveal “blooming” effect of hemosiderin, increasing sensitivity of detection of CAs.

Susceptibility-weighted imaging (SWI/VenBold) sequences, can reveal a number of multifocal lesions in familial cases which do not appear on more conventional and T2*/GRE images.

MRI also allows functional imaging of primary sensorimotor, speech, and visual cortical areas, and their white matter connectome by DTI which has enhanced surgical planning.

MRI FEATURES OF CAVERNOUS ANGIOMA

A. Solitary CA at the floor of the 4th ventricle, around DVA traversing pons

B. AD familial, multifocal CAs (note: punctate lesions on SWI not seen on T2 images)

C. Pontine CA with hemorrhage; acute blood expanding lesion with surrounding FLAIR signal of edema

CAVERNOUS ANGIOMA IMAGES:

A. Artist rendition (mulberry-like CA)

B. 3D MRI (popcorn appearance with hemosiderin ring)

C. Confocal immunofluorescence photomicrogram with staining of endothelium (CD31, green) – lines the vascular spaces or caverns.

D. Normal brain capillaries (with normal endothelium)

Reference:

Awad, I. and Polster, S. (2019). Cavernous angiomas: deconstructing a neurosurgical disease. Journal of Neurosurgery, 131(1), pp.1-13.

Four Principles of Gender-Affirming Care

The 4 principles of gender-affirming care:

1. Ask rather than assume.

    • Ask patients about their sexual orientation, gender identity, and preferred name and pronouns.
    • Example: “Hi, I’m Dr. Goldstein. I use ‘he’ and ‘him’ for pronouns. What’s your name and what pronouns do you use?”

2. Validate the patient’s gender identity.

    • Mirror the language that the patient uses.

3. See mistakes as opportunities to learn.

    • If you make a mistake with a patient, acknowledge it, apologize, and try to move on together.
    • Example: “I’m sorry that I used ‘he’ instead of’they.’ I’ll try my best to use the correct pronouns, and please let me know if I make a mistake.”
  • 4. Remember that anatomy does not define the patient.
      • Provide care related to the anatomy that is present but still validate the patient’s gender identity.
      • Example: Only 25% oftransgender people have had a gender-affirming procedure. For transgender men who retain breast tissue and a cervix, mammography and cervical Papanicolaou (Pap) testing remain important cancer-screening methods.

    Reference:

    Freeman, M., Singh, A., Guidon, A., Arvikar, S., Goldstein, R. and Clement, N. (2019). Case 22-2019: A 65-Year-Old Woman with Weakness, Dark Urine, and Dysphagia. New England Journal of Medicine, 381(3), pp.275-283.

    Recommendations Re: Cavernous Angioma Surgery / Radiosurgery

    Consensus recommendations re: CA surgery proposed based on current evidence:

    SURGERY

    1. Asymptomatic CA, esp in eloquent, deep, BS or spinal. location – surgery not recommended (Class III, Level B)

    2. Multiple asymptomatic lesions – surgery not recommended (Class III, Level B)

    3. Solitary asymptomatic CA that is easily accessible in non eloquent area – may consider surgical resection to prevent future hemorrhage because of psychological burden, expensive / time-consuming follow-ups, facilitate lifestyle or career decisions or inpatients who need to be on anticoagulation (Class IIb, Level C)

    4. CA causing epilepsy, esp medically refractory, no uncertainty about epileptogenicity – should consider early surgical resection (Class IIa, Level B)

    5. Symptomatic, easily accessible lesions – consider surgery; M&M = living with lesion x 2 years (Class IIb, Level B)

    6. Symptomatic deep CA or previous bleed – may consider surgical resection; M&M = living with lesion x 5-10 years (Class IIb, Level B)

    7. Brainstem CA after a second symptomatic bleed– may be reasonable to offer complete resection, after reviewing high risks of early post-op M&M and impact on QOL, these lesions have a more aggressive course (Class IIb, Level B)

    8. Brainstem CA or spinal CA after single disabling bleed – indications are weaker (Class IIb, Level C)

    RADIOSURGERY

    9. Solitary CA lesions with previous symptomatic bleed, in eloquent areas with unacceptable high surgical risks – may consider radiosurgery (Class IIb, Level B)

    10. Asymptomatic CAs, if surgically accessible and in familial disease with concern about de novo lesion genesis – radiosurgery not recommended (Class III, Level C)

    (from the Angioma Alliance from Akers A, et al: Neurosurgery 80:665–680, 2017)

    Reference:

    Awad, I. and Polster, S. (2019). Cavernous angiomas: deconstructing a neurosurgical disease. Journal of Neurosurgery, 131(1), pp.1-13.