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APT: Antibiotics

This week we will be covering a bread and butter topic every internist needs to know about, antibiotics. In preparation we have pulled two of the IDSA guidelines to review. First is the IDSA skin and soft tissue infection guidelines, which most of you should be familiar with. Please review the material in this article (you don’t need to read it cover to cover). In addition, we have provided the IDSA guidelines on cystitis and pyelonephritis to help you prepare. We look forward to fighting some bugs with you on Friday!

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Ethan Fried Ethan Fried

APT: Liver

This week we will be discussing the Liver and Bile Collecting system. Please review NEJM review articles on cirrhosis, acute liver failure, and ACG clinical guidelines for LFT interpretation/work up to help prepare.


Approach to Liver chemistries:

ALT: 33 (males), 25 (females), ALP: 115 (males), 100 (females)

Hepatocellular: ALT and AST both up

Cholestatic: ALP up and also direct hyperbilirubinemia

Infiltrative: ASLT up without significant bilirubin or AST or ALT elevation

Non-hepatic: Isolated AST elevated, indirect hyperbilirubinemia


Any degree of AST/ALT elevated:

  • meds/toxins (aceteaminophen, certain abx, INH, MTX, NSAIDs, heparin, amiodarone, steroids, augment, sulfa drugs, allopurinol, etc)

  • Alcohol related (alcoholic hepatitis usually >2:1 AST:ALT ratio)

  • viral infections (Hep A-E, EBV, CMV, VZV, HSV)

  • Sepsis /ischemia

  • Biliary obstruction (mixed picture)

  • NAFLD (usually AST and ALT elevated but <4x ULN)

If above: Workup includes, but not limited to:

  • stop offending medications/toxins

  • viral hepatitis serologies

  • RUQ US (steatosis, cirrhosis, fibroscan)

  • ANA, ASMA, LKM-1, IgG, Ceruloplasmin, urinary copper, Fe/TIBC >45%, ferritin >200,

Extreme elevation (AST/ALT >1000s, indicates some acute process)

  • Ischemia (Shock, cardiac arrest, Budd-Chiari, usually AST/ALT goes up first then bilirubin increases)

  • Meds/toxins (acetaminophen toxicity)

  • Acute viral infection (Hep A-E, consider HBV reactivation)

  • autoimmune hepatitis

  • acute biliary obstruction

If above, workup includes, but not limited to

  • INR, assess for hepatic encephalopathy, acute liver injury/failure

  • stop offending meds/toxins, consider activated charcoal, N-acetylcysteine

  • viral serologies

  • RUQ US with dopplers

Cholestatic injury pattern (Increased ALP and biliriubin)

  • Biliary obstruction (Choledocholithiasis, malignancy, primary sclerosis cholangitis, chronic pancreatitis w/ strictures)

  • intrahepatic cholestasis: Medications (penicillin, cephalosporins, anabolic steroids, bactrim, TPN, sepsis, primary biliary cholangitis (PBC)

If above, workup with include, but not limited to

  • RUQ US for obstruction

  • MRCP or ERCP

  • +/- liver biopsy

Infiltrative pattern (primarily ALP elevation)

  • sarcoidosis or other granulomatosis (Tb)

  • Malignancy (lymphoma, mets to liver, HCC)

  • Amyloidosis

  • abscess

If above, workup includes, but not limited to

  • GGT, imaging with RUQ US or CT, MRCP

  • Consider SPEP + IgG4

  • +- liver biopsy

Acute Liver Failure

King’s College Criteria

  • Acetaminophen induced liver failure: pH <7.3, or ALL 3 of INR > 6.5, Cr > 3.4, grades 3-4 Hepatic encephlopathy

  • All other causes of ALF: INR >6.5 OR 3/5 of the following: age <10 or >40, Tbili >17, INR >3.5, time from jaundice to encephalopathy >7d, unfavorable etiology (Seronegative hepatitis, DILI, Wilson’s)

Decompensated Cirrhosis



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APT: COPD

On October 18, we will be focusing on COPD for our Academic Half Day. In preparation there is a review article posted for pulmonary function tests. In addition, please review the GOLD Pocket guide. The guide itself is quite long, please focus on the diagnosis and management sections in the guide.


Indications for Noninvasive mechanical ventilation (at least one of the following)

  1. Respiratory acidosis

  2. Severe dyspnea with clinical signs suggestive of respiratory muscle fatigue, increased work of breathing, or both, accessory muscle use (paradoxical motion of abdomen, retraction of intercostal spaces)

  3. Persistent hypoxemia despite supplemental oxygen therapy

SUMMARY

Classification of Airflow limitation severity in COPD

GOLD 1 (Mild): FEV1 ≥ 80% of predicted

GOLD 2 (Moderate): 50% ≤ FEV1 < 80%

GOLD 3 (Severe): 30% ≤ FEV1 < 50%

GOLD 4 (Very severe): FEV1 <30% of predicted

Triple therapy:

  • IMPACT Trial (Once-Daily Single-Inhaler Triple versus Dual Therapy in Patients with COPD (nejm.org) : phase 3 RCT that compared effects of once daily triple therapy with LABA+LAMA+ICS vs: LABA/ICS or LABA/LAMA on COPD exacerbation

    • in contrast to FLAME trial which showed a benefit of LAMA-LABA over ICS-LABA for prevention of exacerbations

  • triple therapy led to significantly lower rates of moderate or severe COPD exacerbations and better lung function and quality of life

Long term supplemental O2 therapy

  • indicated for stable patients who have SaO2 ≤ 88% or PaO2 ≤ 55mHg

  • also indicated if PaO2 between 55 and 60mmHg if also evidence of pulmonary hypertension, CHF, polycthemia (Hct > 55%)

  • NEJM LOTT trial (A Randomized Trial of Long-Term Oxygen for COPD with Moderate Desaturation | NEJM) - patients with stable COPD and resting or exercise induced moderate desaturation, the prescription of long term O2 did NOT result in longer time to death or 1st hospitalization than no long term O2.

 
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APT: Heart Failure

We will try not to get backed up this week while we discuss heart failure. In preparation, please review the below materials. If you get through that, there is additional reading you may found useful: the EVALUATE-HF and PROVE-HF trials as well as an editorial from JAMA discussing some of the reversibility of remodeling seen with ARNIs.



Additional Reading

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AHD: Pneumonia

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This Friday we will be discussing pneumonia. Please read the articles below prior to AHD to help give a good foundation. You are only responsible for the first 7.5 pages of the VAP/HAP guidelines, which is the executive summary, and the CAP guidelines below (see recommendations). There is another link with updates on CAP guidelines.


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APT: Acute Coronary Syndrome (ACS)

For this week’s Academic Half Day we will review ACS guidelines. In preparation, please review the NEJML Acute MI article and ACS evidence breakdown. Below are some other articles that may help you prepare: The use of TIMI and GRACE scores within risk stratification and an article outlining management from Cleveland Clinic.


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