May 6, 2019

Background: Management and workup of fever in the neonate has been a long-standing challenge. This unique age group is particularly susceptible to serious bacterial infections (SBI’s) despite their clinical “well” appearance. Newborns, specifically those < 60 days of age are considered high risk for SBI’s (urinary tract infections, bacteremia, bacterial meningitis) primarily due to an underdeveloped immune system. As fragile hosts, simple bacterial infections are easily communicated via hematogenous spread, from one system to another. Once bacteremic, spread of infection through their permeable blood-brain barriers is relatively easy. Through a cascade of cellular events, bacteria are able to easily penetrate the CNS, leading to overwhelming meningitis &/or death.[1] Confounding their vulnerability, is the lack of immunizations in the first month of life. If you recall, at birth, newborns are given just their first hepatitis B vaccine. The remainder of baseline immunizations (Pneumococcal, Haemophilus influenzae type b [Hib], Rotavirus, Diphtheria, tetanus & acellular Pertussis [DTap], and Polio) are traditionally not given until 6 weeks - 2 months of age.[2] Thus infants in the < 60 day age range are dependent on their mothers’ antibodies for protection. Lastly as any clinician who has taken care of a sick newborn can attest, babies at this age rarely manifest an “ill-appearance” until they are critically ill, making their exam in the early stages of bacteremia falsely reassuring. Collectively this makes the workup of fever (38 ℃/100.4 ℉) in this age group particularly challenging.

May 1, 2019

Take Home Points on Blunt Cardiac Injury

  • No single test can be used to exclude BCI. However a thorough physical exam combined with a 12-lead EKG, troponin measurement, and echocardiography can be used to characterize BCI and direct care
  • Obtain a 12-lead EKG in all thoracic trauma patients 
  • A chest x-ray may help to identify associated injuries. However, isolated musculoskeletal injuries such as sternal fractures do not correlate with a risk of BCI
  • Bedside TTE can quickly evaluate for life-threats such as cardiac tamponade; A TEE is both sensitive and specific across the spectrum of BCI pathology and is part of a comprehensive evaluation
  • BCI can be excluded in a patient without EKG abnormalities and a negative troponin I

April 3, 2019

Take Home Points on Non-Inferiority Studies

  • Non-inferiority studies should be done when a new treatment (or diagnostic modality) requires less resources (cost or time), is easier for the patient or has a lower side-effect profile.
  • Non-inferiority study design largely negates the protections against bias added by blinding and randomization.
  • Non-inferiority studies can be used to manipulate clinicians when a superiority study would be more appropriate.

March 20, 2019

Take Home Points on Oncologic Emergencies:

  1. Hyperviscosity Syndrome happens when elevated WBCs or severe hyperproteinemia cause high serum viscosity and micro-circulatory problems in patients with Waldenstrom’s macroglobulinemia, multiple myeloma or acute leukemia. Be suspicious of this syndrome in these patient’s when they present with the classic triad of mucosal bleeding, visual disturbances, and neurological symptoms or with any end organ failure.
  2. Tumor Lysis Syndrome results from high turnover of malignant cells resulting in severe metabolic derangements including hypocalcemia, hyperkalemia, hyperphosphatemia, hyperuricemia, AKI, metabolic acidosis. Be suspicious of this in patients presenting with edema, hematuria, fatigue, weakness, altered mental status or symptoms that go along with specific metabolic derangement, particularly if they recently received chemotherapy, radiation or high dose steroids.