Possibility - chronic alcoholic -> vitamin deficient -> withdrawal symptoms + diarrhea + fever + excessive diaphoresis -> shock
So probably not a case of septic shock. Above hypothesis based on 1) no microbiology test results given 2) two case reports one having diarrhea and hence shock in malnourished alcoholic withdrawl case and another having shock just because of fever and excessive diaphoresis
27/02/22, 12:33 am - Avinash Kumar Gupta: Importance of echo in case of shock https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4992302/#!po=3.62319
27/02/22, 12:34 am - You added Saptarshi Bmj Electives
27/02/22, 12:35 am - Avinash Kumar Gupta: https://04kavyasreekaluvala.blogspot.com/2021/08/general-medicine-e-log-aug-07082021.html
Erythropoetin may not be of any use here. A blog on critical appraisal of erythropoetin in ckd may be good (though we had done earlier but it's not documented)..
I will try for it in coming days.
27/02/22, 12:44 am - Avinash Kumar Gupta: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7917873/
https://pubmed.ncbi.nlm.nih.gov/34348698/
27/02/22, 1:28 am - aditya sir: All of these symptoms suggest Cholinergic / Parasympathetic excess?
27/02/22, 1:30 am - aditya sir: Should be very useful. Adding much value to our teaching programme
https://adityasamitinjay.blogspot.com/2022/02/teaching-programme-case-based-blended.html
27/02/22, 1:31 am - Avinash Kumar Gupta: Yes, (just checked list of Cholinergic symptoms to revise)
Matching to that but not happening all together
27/02/22, 1:31 am - aditya sir: Remember reading AWS and associated Cholinergic excess. Can you verify please?
27/02/22, 1:33 am - Avinash Kumar Gupta: Thanks for sharing this! Interesting work going on..
Completed archiving all blogs- https://classworkdecjan.blogspot.com/2022/02/udhc-cases-mirror-2.html
Total count is 1939 cases.. Some may be repeats.
Bmj case reports..
The case mirror doesn't have full discussion and journey of patient but its still great because shows the history and examination very beautifully (best ever) and hence ignite thoughts, exploration and good *explorative* SDL (self directed learning)
27/02/22, 1:33 am - Avinash Kumar Gupta: <Media omitted>
27/02/22, 1:34 am - Avinash Kumar Gupta: I have started exploring one by one.
Studied 1 case today
- alcohol withdrawl syndrome
Studied from
- case link
- (had seen a case in ward for a few moments with some discussion from Prof. )
- psych. Book
- harrison
- echo case discussion (YouTube)
- grand rounds (YouTube)
- A video specifically on management.
Took alot of time but it was good experience.
Key value addition came from -
1) starting with a case link 2) having seen a case 3) one read from any course book 4) Any good quality video (out of thousands) discussing management.
27/02/22, 1:36 am - aditya sir: Wow wow!! We must publish our reflections in Student BMJ!!
27/02/22, 1:36 am - Avinash Kumar Gupta: 🤟🏻
27/02/22, 1:36 am - aditya sir: I hope you will. Will definitely assist you and add inputs if u can.
27/02/22, 1:36 am - aditya sir: I*
27/02/22, 1:37 am - Avinash Kumar Gupta: 🙏
I plan to discuss here and then move to the topics to global group, hopefully we will have great interaction with some significant documentation too🙏
27/02/22, 1:38 am - aditya sir: Amazing work Avinash. I will surely take some time out and go through your links. Any separate section for rheumatology?
27/02/22, 1:38 am - aditya sir: Yes. You will have my support
27/02/22, 1:39 am - Avinash Kumar Gupta: <Media omitted>
27/02/22, 1:39 am - Avinash Kumar Gupta: 🤟🏻
27/02/22, 1:41 am - aditya sir: Thanks. I will try to go through these and subject them to our Quality Improvement programme designed here
https://adityasamitinjay.blogspot.com/2022/02/quality-improvement-cycle-1-of-teaching.html
27/02/22, 1:41 am - Avinash Kumar Gupta: Alcohol affects GABA (opposite of ach) , probably excess ach like effect is by mechanism via GABA
27/02/22, 1:42 am - aditya sir: I also think benzos may have a role.
27/02/22, 1:47 am - Avinash Kumar Gupta: <Media omitted>
27/02/22, 1:48 am - aditya sir: A peer reviewed study would be better I suppose.
27/02/22, 1:48 am - Avinash Kumar Gupta: <Media omitted>
27/02/22, 1:56 am - aditya sir: https://twitter.com/VelezNephHepato/status/1497651952964022273?t=sFsLUopaz4Z2lQiGCx9oxw&s=08
AKI NASH could be a common entity we may miss often
27/02/22, 1:57 am - Avinash Kumar Gupta: From the 2nd article - diaphoresis and fever
"Mechanisms underlying these conditions involve a state of central nervous system arousal and increased adrenergic activity due to high NMDA (N-methyl-D-aspartate) level and low GABA (gamma aminobutyric acid) activity during alcohol withdrawal [5], for which the symptoms also include diaphoresis, hyperthermia, tremor, nausea, hallucinations or illusions, psychomotor agitation, insomnia, and anxiety [3]. In particular, both diaphoresis and fever increase the water intake requirement [6–8], which, in some cases, might lead to hypovolemia and its medical consequences [9]."
27/02/22, 1:58 am - aditya sir: Ah excellent!
27/02/22, 1:58 am - Avinash Kumar Gupta: Thanks!!
27/02/22, 2:00 am - aditya sir: But what explains the diarrhea?
27/02/22, 2:02 am - Avinash Kumar Gupta: From article 1 (paper from year 2021)
"There is a lack of systematic studies on the pathophysiology of alcohol abuse; thus, the mechanism underlying diarrhea during alcohol withdrawal is still not well understood. Because alcoholics are already at higher risk for diarrhea owing to malnutrition, vitamin deficiency, and impaired gastrointestinal function, careful monitoring of defecation is necessary, even during hospitalization."
27/02/22, 2:05 am - Avinash Kumar Gupta: Not finding any other good explanation.
27/02/22, 2:07 am - Avinash Kumar Gupta: Found full form - NASH = Non-alcoholic steatohepatitis
27/02/22, 2:10 am - Avinash Kumar Gupta: Hepato renal syndrom - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1904420/#!po=19.2308
27/02/22, 2:21 am - Avinash Kumar Gupta: https://onlinelibrary.wiley.com/doi/10.1111/tme.12715
"Conclusion
ESA resulted in a small reduction in the proportion of patients transfused and a trivial increase in haemoglobin concentration, both of questionable clinical relevance, without impacting adverse events or mortality. These results do not support the routine use of ESA to treat anaemia in critically ill adults."
It's for icu patients. Ckd patients on Dialysis are also similarly critically ill or not critically ill? I guess they are not. So, Useful info but should be better to look for more specific evidence too, in ckd context.
27/02/22, 2:23 am - Avinash Kumar Gupta: Interesting
"A new class of drugs, prolyl hydroxylase domain (PHD) inhibitors (PHD inhibitors) is becoming available for the treatment of anemia in CKD patients. Theoretically, these agents have a number of advantages, the main ones being that of stimulating the synthesis of endogenous erythropoietin and increasing iron availability. The impact of their future use in clinical practice is still to be defined. Another possible strategy could be targeting serum hepcidin and its related pathways. This possibility is fascinating from the scientific point of view, but at present its development phase is still far from clinical application."
https://pubmed.ncbi.nlm.nih.gov/33670704/
27/02/22, 8:07 am - Dr. Rakesh Biswas sir: Will be looking forward to it 👍
27/02/22, 9:22 am - Dr. Rakesh Biswas sir: https://pubmed.ncbi.nlm.nih.gov/2108751/
The association between recombinant human erythropoeitin and qualify of life and excercise capacity of patients receiving hemodialysis
A double blind, randomised, placebo controlled study.
Patients- 118 Patients receiving
haemodialysis
Interventions- 40 patients were randomised to receive erythropoeitin to achieve a haemoglobin concentration of 95-110g/l or 38 patients received erythropoietin to achieve a haemoglobin concentration of 115-130g/l.
Results-The mean haemoglobin concentration at six months was 74(12)g/l in patients given placebo, 102(10)g/l in those in the low erythropoietin group, and 117(17)g/l in those in the high erythropoietin group. Compared with the placebo group, patients treated with erythropoietin had a significant improvement in their scores for fatigue , physical symptoms, relationships, and depression on the kidney disease questionnaire and in the global and physical scores on the sickness impact profile.The distance walked in the stress test increased in the group treated with erythropoietin, but there was no improvement in the six minute walk test ,psychosocial scores on the sickness impact profile, or there was no significant difference in the improvement in quality of life or exercise capacity between the two groups taking erythropoietin. Patients taking erythropoietin had a significantly increased diastolic blood pressure despite an increase in either the dose or number of antihypertensive drugs used.Eleven of 78 patients treated with erythropoietin had their sites of access clotted compared with only one of 40 patients given placebo.
27/02/22, 2:58 pm - aditya sir: Correction of anemia by any means in critically I'll patients hasn't shown any benefit for hard outcomes, let alone for ESA.
27/02/22, 3:01 pm - aditya sir: Touch and go this. May need some heuristical thinking too before making a decision.
27/02/22, 3:01 pm - aditya sir: All is well and good sir but do the same data apply to generic ESAs too. I don't think so.
That's a whole different ball game.