Grady Morning Report: How can you stress dose steroids to treat adrenal insufficiency in patients receiving chronic steroids?

The Bottom Line:

Increase the maintenance dose during periods of stress (e.g., illness, surgery, trauma, GI upset) to satisfy the increased physiologic need for cortisol.

A typical stress dose is three times the daily maintenance dose of glucocorticoid.¹⁶

Hunt Conference: What are historical causes of subclavian artery stenosis?

The Bottom Line:

A history of smoking, higher levels of systolic blood pressure, lower levels of high‐density lipoprotein cholesterol, and the presence of peripheral arterial diseases are associated with an increased risk of subclavian artery stenosis.

EUH Morning Report: What is monkeypox and how do you evaluate, diagnose, and treat it?

The Bottom Line:

• Monkeypox is a virus transmitted from humans to animals with symptoms similar to those seen in smallpox
• It is usually self-limited but severe cases can occur especially in those with underlying immune deficiency.
• It is transmitted person-to-person by close contact with skin lesions, respiratory droplets, and body fluids.
• Initial symptoms include fever, rash, and lymphadenopathy. Skin eruption usually follows after 1-3 days.
• Antiviral agent called Tecovirimat is recommended for people who are likely to get severely ill.
• Contacts can receive vaccine post-exposure prophylaxis
  • Best if given within 4 days from date of exposure but can be given up to 14 days after

EUH Morning Report: Is there an association between elevated alkaline phosphatase levels and diarrhea in patients with HIV/AIDs?

The Bottom Line:

Disseminated M. avium complex infection occurs predominantly in patients with CD4+ T-cell counts of ≤100 cells/mm³ who are not on ART or azithromycin prophylaxis.

Associated symptoms include weight loss, diarrhea, malaise, and anorexia.

Dissemination to the bone marrow, liver, and spleen results in anemia and elevated alkaline phosphatase levels.

NEJM Journal Watch: Physician Attire: Is All Dress Created Equal (in Patients’ Eyes)? / Physicians Attire — Does It Matter to Patients?

Patients prefer formal attire with white coat for their primary care and hospital-based physicians.

Comment: “This is the largest study of U.S. patient preferences for physician attire and the only one that addresses both inpatient and outpatient physicians’ attire. Findings make a statement on how attire might affect patient satisfaction — now measured and reported by healthcare institutions — and could have implications for dress codes or guidelines based on clinical settings and physician practices.”

Dressler DD. Physician Attire: Is All Dress Created Equal (in Patients’ Eyes)? NEJM Journal Watch. (July 3, 2018)

Citation:

Petrilli CM et al. Understanding patient preference for physician attire: A cross-sectional observational study of 10 academic medical centres in the USA. BMJ Open 2018 May 29.

---

In a survey, white coats were rated more highly than other attire; women were rated as less professional than men, regardless of attire.

Scwenk TL. Physicians Attire — Does It Matter to Patients?. NEJM Journal Watch. (Aug 10, 2021).

Comment: “Isolating patient assessments of physicians based solely on pictures of attire obviously does not capture the nature of a physician’s demeanor or communication skills, but this study and another similar one suggest there is something about white coats that has meaning for patients. This study also reinforces the known and unfortunately persistent sex bias that causes patients to discount the role and experience of female physicians.”

Citation:

Xun H et al. Public perceptions of physician attire and professionalism in the US. JAMA Netw Open 2021 Jul 30.

Grady Morning Report: What is the approach to acute weakness in the adult patient?

The Bottom Line:

Weakness is a vague and often incorrectly described symptom without a specific pattern of occurrence that may be part of the initial presentation of broad range of conditions.

This can make diagnosis of an underlying cause difficult as clinicians must distinguish true muscle weakness from subjective fatigue.

Grady Morning Report: How do adenovirus infections present and when should you test for them?

The Bottom Line:

Consider adenovirus infection in patients with upper respiratory infection, lower respiratory infection such as pneumonia, and conjunctivitis.

In patients with immunocompromise, broader spectrum of disease that may be more severe, with more end-organ involvement and dissemination

Grady Morning Report: What are the clinical features of cardiogenic shock?

The Bottom Line:

Cardiogenic shock is characterized by persistent hypotension due to a reduced cardiac index and in the presence of elevated pulmonary capillary wedge pressure (PCWP).

Grady Morning Report: How can you cautiously re-lower the serum sodium concentration when you overcorrect hyponatremia?

In the event of overcorrection, free water, with or without DDAVP, should be infused to re-lower the serum sodium to an acceptable level.

EUH Morning Report: What is the pathophysiology of steroid-induced pancreatitis?

The Bottom Line:

“Steroid-induced pancreatitis is a topic that is generally not well-studied or reported. Steroids have many known side effects through their inhibition of inflammatory mediators and prostaglandins. It has been suggested that steroids can affect the pancreas by increasing the viscosity of pancreatic secretions and delaying the emptying.” (Minpuri et. al, 2020)

“Corticosteroids, for instance, are used in the treatment of IBD which itself increases the risk of AP.” (Hung and Lanfranco, 2014)