Brit J Hosp Med
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Clinical reasoning is fundamental for effective clinical practice. Traditional consultation models for teaching clinical reasoning or conventional approaches for teaching students how to make a diagnosis or management plan that rely on learning through observation only, are increasingly recognised as insufficient. There are also many challenges to supporting learners in developing clinical reasoning over time as well as across different clinical presentations and contexts. ⋯ Diagnostic errors may be due to cognitive biases but also, in a majority of cases, due to a lack of clinical knowledge. Therefore, effective educational strategies to develop clinical reasoning include identifying learners' knowledge gaps, using worked examples to prevent cognitive overload, promoting the use of key features and practising the construction of accurate problem representations. Deliberate reflection on diagnostic justification is also recommended, and overall, contributes to a growing number of evidence-based and theory-driven educational interventions for reducing diagnostic errors and improving patient care.
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Vasopressor medications for circulatory shock have historically been administered through central venous catheters due to concern for extravasation injury when given peripherally. However, recent studies have demonstrated the safety of peripheral administration of vasopressor medications at lower doses and for a limited duration. Peripheral use of vasopressors is appealing to both patients and providers, as obtaining central access is an invasive procedure associated with the risk of pneumothorax, bleeding, and infection. ⋯ We discuss the guidelines and data for optimal dose, duration, intravenous line (IV) size, IV location, and nursing IV site monitoring for peripheral vasopressors. We then explore adverse events associated with peripheral vasopressors. Finally, we describe how this practice change may impact hospital medicine providers.
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Editorial Review
Should surgical inpatients still wear compression stockings?
Surgical inpatients are at increased risk of venous thromboembolism (VTE). Current national guidelines recommend a combination of pharmacological (chemoprophylaxis) and mechanical thromboprophylaxis to reduce VTE risk. For most patients, mechanical thromboprophylaxis is provided via application of graduated compression stockings (GCS). This editorial reviews the evidence surrounding the efficacy and safety of GCS in VTE prevention, and makes a recommendation regarding their continued use in surgical inpatients.
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Review Case Reports
The impact of an anomalous third segment of the vertebral artery on bypass surgery: a case report and literature review.
The horizontal part of the third segment (V3) of the vertebral artery (VA) is a critical anastomotic site for bypass procedures involving either donor or recipient vessels. It is rare for the V3 segment to deviate from its typical course of passing through the atlanto-transverse foramen. V3 anomaly encountered in occipital artery (OA)-V3 bypass surgery has not been previously reported. ⋯ During the operation, it was noted that the V3 horizontal segment could not be identified within the left VA groove, leading to initial suspicion of left V3 disuse atrophy attributed to prolonged chronic ischaemia. Consequently, there was a need to modify the operative method and to transition from an OA-V3 bypass to an OA-posterior inferior cerebellar artery bypass. Post-operative computed tomography angiography confirmed that indeed, the left V3 did not traverse through the transverse foramen of the atlas and instead entered the dural membrane between the first cervical vertebra (C1) and the second cervical vertebra (C2).
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Primary glomerulonephritis comprises several renal-limited diseases that can cause haematoproteinuria, chronic kidney disease, nephrosis and end stage kidney disease. The most common of these are IgA nephropathy (IgAN), primary membranous nephropathy (PMN), Focal Segmental Glomerulosclerosis (FSGS) and Minimal Change Disease (MCD). Although rare, these diseases cause a significant burden to health care systems, given the high cost of treating End Stage Kidney Disease (ESKD) with dialysis or transplantation. ⋯ However, recent advances in understanding of how these diseases evolve has led to the introduction of novel therapeutic agents. Trials are underway or have recently completed that have huge implications for the standard of care for the primary glomerulonephritidies, and should dramatically reduce the number of patients who progress onto end stage kidney disease. This article reviews the international Kidney Disease Improving Global Outcomes (KDIGO) guidelines for the treatment of IgAN, PMN, FSGS and MCD, as well as recent research on pathogenesis and treatment.