Chiefs’ Inquiry Corner – 11/11/19

November 11, 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.


Click to toggle the answers!

Many patients with anemia of chronic disease will also be iron deficient. However, diagnosing underlying iron deficiency is challenging in the setting of inflammation because cytokines and inflammatory mediators reduce duodenal iron absorption and sequester iron in macrophages and ferritin. Thus ferritin does not accurately reflect iron stores in patients with chronic disease. A newer blood test called a “soluble transferrin receptor” (sTfR) is an indirect measure of erythropoiesis that is less affected by an inflammatory state. There is growing evidence that this test, alone or divided by log ferritin values (ferritin index) can help detect underlying iron deficiency in patients with anemia of chronic disease.

It is critical to determine if patients with NAFLD have advanced fibrosis or cirrhosis to determine their need for screening for esophageal varices and hepatocellular carcinoma. Liver biopsy remains a problematic gold standard due to significant sampling error related to the heterogeneity of pathology within the liver parenchyma, not to mention risk of procedural complications, cost and patient preference. Ultrasound elastography is a useful, non-invasive test, but is not widely available. The NAFLD Fibrosis Score is a validated tool that incorporates age, BMI, presence or absence of diabetes, AST, ALT, platelet count, and albumin to predict likelihood of advanced fibrosis or cirrhosis. Using a low cutoff score of -1.455 and a high cutoff score of 0.676, the negative predictive value is 93% and the positive predictive value is 90%. In the initial validation study, over 75% of liver biopsies could have been avoided by using the NAFLD Fibrosis Score to evaluate for advanced fibrosis or cirrhosis.

The Surgical Infection Society Guidelines on the Management of Intra-abdominal Infections categorize patients based on community-acquired (CA-IAI) versus hospital-associated (HA-IAI) intra-abdominal infections. Data regarding empiric antifungal coverage data is limited/contradictory, but the society recommends against the use of empiric antifungals in all CA-IAI patients, with the exception of patients with upper GI sources. For HA-IAI patients, they suggest empiric antifungal for patients who have upper GI perforations, recurrent bowel perforations, surgically treated pancreatitis, those who have received prolonged broad-spectrum antibiotics, and those known to be colonized with Candida.

References: Surgical Guidelines