VA Report: What is the relationship between uremia and altered mental status?

Measurement of the defects in mental function caused by uremia is also made difficult by the confounding effects of age, personal background, and other illnesses.  Not knowing which uremic solutes are toxic limits our ability to improve therapy. The contribution of retained solutes to the illness experienced by dialysis patients is difficult to dissect, but we believe it is large. We know that if dialysis is withheld, accumulation of waste solutes will cause confusion, coma, and then death.

Meyer TW, Hostetter TH. Approaches to Uremia. Journal of the American Society of Nephrology : JASN. 2014;25(10):2151-2158.

In studying the effects of uremia on mental function, we must also consider how much function will be improved by the reductions in solute levels we are able to achieve. It is worth considering what would be the effect on mental function of reducing levels of a known neuroactive compound, such as ethanol. Reducing very high ethanol levels by half could restore orientation in a stuporous person, analogous to the effect of initiating dialysis in a severely uremic patient.

Table 1.

Common features of uremia

Neural and Muscular                                         Endocrine and Metabolic
Loss of energy                                                            Amenorrhea and sexual dysfunction
Decreased mental acuity                                         Insulin resistancea
Anorexia and nausea                                                Reduced resting energy expenditure
Restless legs                                                               Increased protein/muscle catabolism
Defective taste and smell                                         Other
Peripheral neuropathy                                          Pruritus
Sleep disturbances                                                    Decreased red cell survivala
Reduced muscle membrane potential               Platelet dysfunctiona
Oxidant stressa


VA Report: Why do some patients with heart failure experience severe sweating?

In Morgan and Nadas’s seminal study they reported that sweating was greater at rest in HF patients compared with controls. Moreover, recent studies suggest that HF patients have similar sweating responses to controls when exposed to passive wholebody heating (Table 1).

Table 1. A Summary of Findings From Key Studies to Date Examining Thermoregulation in the Context of HF

Balmain, B., Sabapathy, S., Jay, O., Adsett, J., Stewart, G., Jayasinghe, R., & Morris, N. (n.d.). Heart Failure and Thermoregulatory Control: Can Patients With Heart Failure Handle the Heat? Journal of Cardiac Failure., 23(8), 621-627.

A common finding among studies examining thermoregulation in the context of HF to date is that HF patients appear to demonstrate impaired heat-induced increases in SkBF compared with controls. Although the mechanisms responsible for impaired SkBF in HF are not yet well understood, it may be argued that the compensatory activation of neurohumoral mechanisms that increase with severity of the condition at least partially contribute to the blunted heat-induced rise in SkBF in HF patients

VA Report: Dysphagia in the setting of myocardial infarction

Examples for extrinsic esophageal compression are found in inflammatory, postoperative and neoplastic mediastinal diseases, but also in substernal strumae, cervical spondylitis and vertebral osteophytes. Vascular esophageal compression syndromes are typically caused by an aberrant origin of the right subclavian artery far left in the aortic branch and course of this “A. lusoria” anterior or posterior of the esophagus. In addition, similar forms of esophageal compression can result from a congenital right-sided aorta, aortic aneurysms and conditions of left atrial enlargement.

Werner, C., Rbah, R., & Böhm, M. (n.d.). Cardiovascular dysphagia. Clinical Research in Cardiology : Official Journal of the German Cardiac Society., 95(1), 54-56.

Radiological imaging revealed an extrinsic esophageal compression as the cause of the patient’s complaints, for example, due to a mediastinal tumor. However, computed tomography of the chest showed a rare case of cardiovascular compression as the cause of dysphagia in this case. The patient turned down the option of endoscopic examination at the time.

VA Report: What is the etiology and treatment options for Rapidly progressive crescentic glomerulonephritis?

The Bottom Line:  Early treatment is of paramount importance for patients with crescentic GN. The current approach is based on a combination of corticosteroids and cytotoxic drugs with the aims of quenching the active inflammation and abating the cellular response and the antibody production

The etiology and the initial pathogenetic factors are different in the three types, but the final mechanisms leading to crescent formation and the renal symptoms and signs are similar.

Moroni, G., & Ponticelli, C. (n.d.). Rapidly progressive crescentic glomerulonephritis: Early treatment is a must. Autoimmunity Reviews, 13(7), 723-729.

The term crescentic glomerulonephritis (GN) refers to a pathologic condition characterized by extracapillary proliferation in > 50% of glomeruli. Clinically crescentic GN is characterized by a nephritic syndrome rapidly progressing to end stage renal disease (ESRD).

VA Resident Report: Elevated lactic acid in ischemic hepatitis

The Bottom Line: Ischemic Hepatitis usually occurs in elderly individuals with right-side congestive heart failure and low cardiac output. It usually occurs after periods of haemodynamic instability or hypoxia such as haemorrhage, sepsis, pulmonary embolus, cardiac failure, arrhythmias, acute myocardial infarction and other causes of respiratory distress.

Khan, F., & Baagar, K. (2013). Ischaemic hepatitis precipitated by recurrent episodes of atrial fibrillation. Arab Journal of Gastroenterology., 14(4), 176-179.

Ischaemic hepatitis (IH), also called shock liver or hypoxic hepatitis, is defined as a diffuse hepatic injury that occurs as a result of acute hypoperfusion [1]. It is characterised by a transient and often marked elevation of serum hepatic transaminase levels in association with centrilobular hepatic necrosis. Serum hepatic transaminases usually increase to 10–300 times the upper limit of normal and most often resolve over 5–25 days

VA Resident Report: What is the distribution of arthritis associated with systemic infection?

The Bottom Line: Staphylococcus aureus is the main cause of septic arthritis involving native joints, although many other organisms are encountered also. In our center, neither the distribution nor the antibiotic susceptibility profiles of the causative organisms changed significantly over the last 30 years.

Table 1 Organisms responsible for septic arthritis.  Page 439

Dubost, J., Couderc, M., Tatar, Z., Tournadre, A., Lopez, J., Mathieu, S., & Soubrier, M. (2014). Three-decade trends in the distribution of organisms causing septic arthritis in native joints: Single-center study of 374 cases. Joint, Bone, Spine, 81(5), 438-440.

In this study, the distribution and antibiotic susceptibility profile of the organisms responsible for septic arthritis showed little change over the 30-year study period. Importantly, no significant increase in MRSA was noted, in keeping with a previous study. These findings do not support the use in our center of broader-spectrum antibiotics in patients for whom empirical antibiotic therapy is deemed necessary.

VA Resident Report: How to properly remove a tick

How to remove a tick

Centers for Disease Control and Prevention June 1, 2015

Use fine-tipped tweezers to grasp the tick as close to the skin’s surface as possible.

Pull upward with steady, even pressure. Don’t twist or jerk the tick; this can cause the mouth-parts to break off and remain in the skin. If this happens, remove the mouth-parts with tweezers. If you are unable to remove the mouth easily with clean tweezers, leave it alone and let the skin heal.

After removing the tick, thoroughly clean the bite area and your hands with rubbing alcohol, an iodine scrub, or soap and water.


Dispose of a live tick by submersing it in alcohol, placing it in a sealed bag/container, wrapping it tightly in tape, or flushing it down the toilet. Never crush a tick with your fingers.

Posted in VA

VA Resident Report: What is the management strategy of Kaposi Sarcoma and pneumocystis pneumonia in a HIV positive patient?

The Bottom Line:

The management of pulmonary KS is challenging. There is a risk of precipitating IRIS upon initiating cART. Chemotherapy can also cause further immunosuppression and increase the risk of further infections. In many of these patients, initiation of cART with careful monitoring for IRIS and empiric treatment of suspected infections may be the best therapeutic option. In some patients, there was a hesitancy to start cART if there was a history of poor medication adherence. Many of these patients required prolonged hospitalization, where their adherence could have been carefully monitored and encouraged.

Kasturia, S., Gunthel, C., Zeng, C., & Nguyen, M. (n.d.). Severe Kaposi Sarcoma in an Urban Public Hospital. AIDS Research and Human Retroviruses, 33(6), 583-589.

The majority of patients were highly immunosuppressed when KS was diagnosed (median CD4 count: 11), and 68% had multiple organ involvement with KS. Comorbidities at diagnosis included hepatitis B (26%) and pneumocystis pneumonia (33%). Frequent reasons for admission included skin and soft tissue complaints (28.4%) and respiratory complaints (27.2%). The estimated median survival after KS diagnosis was 3.0 years. Lung involvement, liver involvement, poor performance status, and low CD4 T cell count (<50) were associated with lower survival.

VA Resident Report: What is the effectiveness of POEM for achalasia?

Available data suggests POEM is very effective in the relief of symptoms in patients with achalasia. However, POEM is associated with a very high incidence of pathologic reflux. The clinical sequalae of the increase in pathologic reflux are currently incompletely understood, but it is plausible that longer-term outcomes associated with POEM may demonstrate GERD complications such as stricture and/or Barrett esophagus

Shlottmann, F., Luckett, D., Fine, J., Shaheen, N., & Patti, M. (n.d.). Laparoscopic Heller Myotomy Versus Peroral Endoscopic Myotomy (POEM) for Achalasia: A Systematic Review and Meta-analysis. Annals of Surgery., Annals of surgery. , 2017.

Esophageal achalasia is characterized by lack of peristalsis and by a lower esophageal sphincter (LES) which fails to relax appropriately in response to swallowing. Treatment is not curative, but aims to eliminate the outflow resistance caused by the nonrelaxing LES.  In 2010, Inoue et al54 described the results of a new endoscopic technique called per oral endoscopic myotomy (POEM) in 17 patients with esophageal achalasia. They described the endoscopic creation of a submucosal tunnel, which allowed a myotomy by the transection of the circular fibers of the distal esophagus.

VA Resident Report: Review of Fournier’s gangrene

The Bottom Line: Fournier’s gangrene is a progressive necrotizing soft-tissue infection (NSTI) of the external genitalia and/or perineum. It is a urological emergency requiring prompt diagnosis and treatment — even with administration of parenteral broad-spectrum antibiotics and expedited aggressive surgical debridement, the disease can be fatal.

References: Hagedorn, J., & Wessells, H. (n.d.). A contemporary update on Fournier’s gangrene. Nature Reviews., 14(4), 205-214.

Summary: A high level of suspicion with prompt resuscitation and surgical intervention are the key for optimizing patient outcomes. For equivocal cases, several diagnostic tools, including laboratory tests and imaging, have been developed to be used in conjunction with physical examination findings. Most infections are polymicrobial, requiring broad-spectrum antibiotics and wide surgical debridement. Wound preparation with dressing changes and further debridements are essential for successful reconstruction once the local necrotic process and systemic infection has been treated.