Chiefs’ Inquiry Corner – 8/26/19

August 26, 2019

Being an outstanding physician and lifelong learner requires stoking the flames of clinical curiosity.  In Chiefs’ Inquiry Corner (CIC) we attempt to succinctly answer actual clinical questions that have been raised on the wards and in the clinics of NYU’s teaching hospitals.  Our answers are not meant to be all encompassing or practice changing but rather to serve as springboards for further exploration. For those of us with short attention spans, we hope CIC satisfies that craving for a morsel of knowledge in a digestible format.


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 The classic teaching that beta blockers should be avoided in patients who actively use cocaine is a subject of debate. There is the theoretical risk of “unopposed alpha effect” which is based on very small human studies, case reports, and some small animal studies. For example, there are only two prospective trials that evaluated a total of 19 participants and showed conflicting results. Studies that support the safe use of beta blockers in people who use cocaine are based on several retrospective studies that are not without its flaws. As such, the use of beta blockers in people who actively use cocaine remains controversial, and dependent on local practice preferences.

References: Beta Blockers and Cocaine
Pulmonary edema is one of several processes that widen intralobular septa and create a B-line pattern on lung ultrasound. In a dyspneic patient with diffuse B-lines and lung sliding in upper lung fields bilaterally, the sensitivity and specificity for detecting cardiogenic pulmonary edema is 97% and 95% respectively. If B-lines are focal, dependent, associated with a ragged pleural line or absent lung sliding, broaden your differential diagnosis to include other interstitial processes such as fibrosis, ILD, ARDs and pneumonia. 

References: Lung POCUS
While society guidelines differ between Europe, Asia and the US, the AASLD (American Association for the Study of Liver Diseases) only recommends routine screening for HBV patients in which it would be cost-effective, i.e., those with a higher than 0.2% annual risk of HCC. This includes everyone with HBV and cirrhosis, but only a subset of patients without cirrhosis. Noncirrhotic HBV carriers qualifying for screening include men of Asian descent over 40, women of Asian descent over 50, patients of African descent over 20, anyone with a family history of HCC, and anyone with evidence of active hepatic inflammation or high HBV RNA concentrations. Biennial ultrasound screening is the modality of choice; pairing this with serum AFP testing is largely considered optional, as it only marginally improves detection rates at the expense of increased false positives. 

References: HCC Screening