Chiefs’ Inquiry Corner- 3/14/22

March 14, 2022

Chief residents of the NYU Langone Internal Medicine Residency give quick-and-easy, evidence-based answers to interesting questions posed by house staff, both in their clinics and on the wards.

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There are two validated methods for assessing JVP with POCUS. In one method, patients are placed in the semi-upright position (30-45 degrees), and JVP height is estimated using the location on the neck where the internal jugular vein’s diameter is smaller than the adjacent carotid artery. A second method seeks to determine whether jugular venous distention (JVD) is present by positioning patients upright at 90 degrees and placing the ultrasound probe right above the clavicle: if the internal jugular vein’s diameter is equal to or greater than the adjacent carotid, JVD is considered present. The determination of JVD using this upright POCUS method was 94.6% specific for an elevated right atrial pressure (> 10 mmHg) measured by right heart catheterization. Video demonstrations of these methods can be found at the link below.

References: Accuracy of Ultrasound Jugular Venous Pressure Height in Predicting Central Venous Congestion
 In addition to lifestyle modifications (small frequent meals, adequate sleep, avoiding triggers), consider pyridoxine (vitamin B6). It has been shown to be a safe and effective treatment for nausea during pregnancy since the 1940s, though it does not significantly reduce vomiting. Its mechanism remains unknown, and no link has been found between low pyridoxine blood levels and severity of nausea. Pro-tip: if without adequate relief from pyridoxine, you can also recommend it in combination with the antihistamine doxylamine (combo has been found to be even more effective than either on its own, but be wary of combo pill prices).

References: Nausea and Vomiting of Pregnancy
 Acute phase reactants are markers of inflammation that have significant changes during inflammatory states. They may be positive or negative, depending on how their serum concentrations vary during inflammation. Positive acute phase reactants include procalcitonin, CRP, ferritin, fibrinogen, hepcidin, and serum amyloid A. Negative acute phase reactants include albumin, transferrin, retinol-binding protein, and antithrombin. Mechanisms underlying the changes can vary, but there are a few proposed mechanisms. For transferrin, macrophages internalize transferrin to sequester iron and inhibit iron scavenging by microbes. Albumin production is decreased to conserve amino acids for the positive acute phase reactants – this occurs as a result of decreased hepatic production and proteolysis.

References: Physiology, Acute Phase Reactants