This past December it was reported in the Harvard Crimson that the median grade at their prestigious University was an A-.1 A flood of articles followed bemoaning grade inflation at educational institutions with a former Harvard President noting cheekily that “the most unique honor you could graduate with was none”.2 This might be alright if well-developed criterion-based instruments are used to grade the students, but given the variability in courses taught at the University and difficulty of developing such tools, it is unlikely. That being the case, if the median is an A-, one wonders how sub-par performance must be to fail.
A 3-year-old male presents to the emergency department (ED) complaining of vomiting and diarrhea that has been occurring for 2 days. The mother states that the child has had fewer wet diapers today but has made tears when crying. On physical examination you note no rebound or guarding of the abdomen and determine that the child is moderately dehydrated. Your initial plan is to administer ondansetron and rehydrate the child orally. This is what you have been taught but is it actually efficacious? A just published 2014 JAMA Pediatrics article attempted to answer this question.
You are evaluating a 45-year-old male who is complaining of calf pain. He has a history of cancer however he has never had a clot in the past. The leg is neither swollen nor warm but he notes a cramping sensation in the posterior portion of his calf. You are concerned for a deep vein thrombosis (DVT) and consider the multiple means to reliable exclude the diagnosis: Wells score, D-dimers, ultrasound? What works?
Most of us would agree that massive PE is treated with fibrinolysis and non-massive PE is treated with anticoagulation. The area of great debate has been the optimal treatment for sub-massive PE. The MOPETT Trial was published in January 2013 and although the patient population was small, it did show a huge benefit in pulmonary pressures at 28 months with fibrinolysis. The next study we have all been waiting for is the Pulmonary Embolism Thrombolysis (PEITHO) trial, which was just published yesterday in the NEJM, evaluating fibrinolysis for patients with intermediate-risk PE.
A 6-month-old male presents to the emergency department with diarrhea and vomiting. Despite antiemetic therapy, the the child is unable to tolerate oral intake in the ED and so you opt to admit him to the hospital for IV fluids. The pediatric hospitalist requests that you write maintenance fluids prior to admission to the floor. Utilizing the 4-2-1 rule you calculate maintenance needs and choose D5 ½NS as your fluid. This is what you had been taught to utilize in children. It seems appropriate… but is it?
A 55 year old woman presents as the driver of a motor vehicle collision. She has moderate abdominal tenderness diffusely and a seat belt sign, but has a negative abdominal/pelvis CT. Her INR, however, was noted to be 2.1. She is not on any vitamin K antagonists. The surgeons admit her to the hospital to observe for a potential hollow viscus injury and requests that you order 2 units of FFP for her. Seems reasonable… or is it? What is the logic?