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Procalcitonin- what are we waiting for?

July 31, 2008

Procalcitonin can be measured in blood and also found in saliva. Procalcitonin measurements in blood can be used to differentiate between high and low risk pneumonia patients. This study that was published in European Journal of Respirology concluded that procalcitonin predicts risks in all CURB-65 classes. It also can help us to differentiate between typical and atypical pneumonia. This study concluded that Determination of the procalcitonin level may provide useful additional diagnostic information on the etiology of pneumonia and could have a crucial influence on the initial antimicrobial therapy. It has been studied in neonatal sepsis and also in patients with SLE.There has been controversy in using procalcitonin in sepsis but a recent article published in American Journal of Respiratory Critical Care concludes that serial measurement of PCT may help in deciding on duration of antibiotics in septic patients.This what i am talking about..
In future point of care measurements will be available to us hospitalist and this will enormously help us to manage our pneumonia patients properly.

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Outpatient Parentral Antibiotic Therapy- Are we Ready?

Diabetic foot infections continue to come to us and we end up giving these patients long courses of IV antibiotics. This requires prolonged hospital stay and beds that we badly need remains occupied. If only these patients can receive antibiotics as out patients , this will be lot of convenience to patients and less expensive to hospital.
A review on diabetic foot infections and other soft tissue infections with emphasis on outpatient infusion therapy is presented here as a Medscape CME activity. It contains a world of information on the practical and administrative aspects of outpatient parenteral antibiotic therapy.

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Clinical Pathology Conference 07/08

This is monthly posting of our NYU Department of Medicine’s Clinical Pathology Conference. Use the link below to review the case, followed by a slide presentation of the radiological findings. Feel free to make your diagnosis by clicking the comment field. We will reveal the answer next week.

Review CPC case here:Click on cpc...
When you’re ready you can download the CPC Answer:Click on cpcanswer...

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Respiratory quiz

A 49 year old undomiciled male with a history of hepatitis C, mycobacterium avium complex colonization of the lungs, and active alcohol abuse presented with fevers, cough productive of green sputum, and an elevated white blood cell count. His symptoms were persistent despite broad spectrum antibiotics, including vancomycin and piperacillin/tazobactam. He had the following radiographic findings:(syndicated from clinical correlations.

Click on cxr...
Click on ctthorax...

What is your favorite diagnosis?

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A case of Central Pontine Myelinolysis

Hypoglemia can result in Central Pontine Myelinolysis. I did not know this. Authors report a case of severe hypoglycemia induced by use of Levofloxacin that resulted in quadriplegia due to CPM.

Read this case repor t in recent Diabetic Medicine..

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Prehypertension is Nasty too!

Pre hypertension in young adults in thought to be not harmful but this study shows otherwise. Blood pressures of 121 to 139 during young age results in increased calcium scores in later life.. To late for me but i hope i can better with my pre -hypertension patients. It will be a hard job convincing them to take medications for life..

Read abstract of this article published in Annals of Internal Medicine..

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Heart and Soul Study?

Current guidelines do not recommend routine stress testing for patients with stable CHD who are asymptomatic.This interesting study looked at recurrent Coronary events in patients who reported angina and who had inducible ischemia.

Read abstract of this article published in Archives of Internal Medicine. I guess regular assessment for inducible ischemia is indicated .

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Dont ask for antibiotics- Guideline says so

Antibiotics usage for common upper respiratory infections is on the rise. This guideline comes at the right time.

Read this practice guideline for primary care doctors published in the wake of new NICE publication.

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Hypothyroidism -An Review

Hypothyroidism in adults is common and treatment practices have not changed much. This review article published in BMJ confirms most of the thinking of recent times. Read more..

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Topiramate in Pregnancy

Most of anti epileptic drugs are associated with increased numbers of birth defects and not surprising this drug drug does too.

Read this abstract..

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More exercise for women

As reported in the July 28 issue of Archives of Internal Medicine, overweight and obese women may need to exercise 55 minutes a day for five days per week to sustain a weight loss of 10 percent over two years - on top of limiting calories. Read more...

Thereby suggesting that the current exercise recommendations is not sufficient in sustaining weight loss in obese women.

"Among obese adults, long-term weight loss and prevention of weight regain have been less than desired. Therefore, there is a need for more effective interventions.

Current recommendations prescribe 30 minutes of moderate physical activity on most days of the week, for a total of 150 minutes per week. However, a growing consensus suggests that more exercise may be needed to enhance long-term weight loss.

Okay...am getting this right? Less calories and a LOT more exercise is necessary. Otherwise more effective interventions are necessary. Maybe the study authors meant lap-band surgery?

Sometimes this is like a 'dead end'. The fact remains that being overweight and obese is like a health hazard to women. The condition just makes all at higher risk of far more serious conditions.

However, if dietary changes, lifestyle changes and exercise combined still isn't enough? I'm just at a loss where that puts us all. I honestly think that more invasive procedures (such as lap-band surgery) doesn't come without a price.

Anyways, read more about this report from JAMA and Archives Journals.

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A Good Death- Can you offer this to your patients?

Death is a certainty in life. Yet for an event that affects us all, the care of people nearing death is neglected in many countries. We are not doing any better. Many of our patients don't even know why they are dying. We have never been taught how to approach patients near end of life and we have all learned by trial and error. This situation now looks set to change in England with the publication of the government's end-of-life care strategy last week. Read this editorial in Lancet..

Click on endoflife...

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Syncope- What you should do!

July 24, 2008

This is a short summary of diagnosis and management of syncope. Read more..

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Waht you need to know about Activated protein C

July 23, 2008

Activation of the coagulation system and inflammatory cytokines are universal in sepsis and are interrelated. Although activated protein C works on both pathways its actions on the inflammatory cascade are less well understood.

Activation of coagulation occurs along a spectrum ranging through asymptomatic laboratory abnormalities, micro thrombosis and overt DIC with diffuse bleeding. In general the more severe the coagulation disturbance the more the patient benefits from activated protein C up to the point where the coagulopathy increases bleeding risk. That point is difficult to define, contributing to difficulty in patient selection. These issues are discussed in a review of the mechanisms of activated protein C, part of a supplement in the journal Critical Care.

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MRI spine- Teaching case

July 22, 2008

This is a neuro image teaching case taken from neurology today. Read more..

A 79-year-old man with ulcerative colitis on chronic prednisone therapy developed severe midcervical pain and progressive weakness of the left arm and leg over several days. This was associated with left forearm paresthesias and urinary hesitancy and incontinence. He had no cranial or bulbar symptoms. On general examination, he was afebrile but there was midcervical spine tenderness. Neurologic examination revealed normal mental status and cranial nerves; strength was 2/5 on the left, and 4/5 on the right; there was a sensory level to pain and temperature on the right to C4, with reduced proprioception in the left foot and hand; there was a left Babinski sign and a mute right plantar response. White blood cell count was 18.2 x 109/L. Blood cultures were negative. Chest CT demonstrated multiple lung nodules.
Click on spinemri...
Open spinal cord biopsy revealed Nocardia farcinica abscess.

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Casa Batllo

Antoni Gaudi's masterpiece of modern architecture is like something from a fairytale.
I have to put this picture. This is an amazing work of art i have ever seen.

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Congenital Scoliosis

July 21, 2008

Diastematomyelia is a common association with congenital scoliosis. Images courtesy of Sumers Radiology.

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Apolipoprotein ratio- INTERHEART study

Which is the better marker for predicting CVD has been changing from one to another. TC/HDL ratio, LDL/HDL ratio and now ApoB/ApoA1 ratio. Authors conclude boldly that the non-fasting ApoB/ApoA1 ratio was superior to any of the cholesterol ratios for estimation of the risk of acute myocardial infarction in all ethnic groups, in both sexes, and at all ages, and it should be introduced into worldwide clinical practice.

Read abstract published in LANCET here..

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Sepsis

July 20, 2008

Management of severe sepsis has always been difficult. Treatment of sepsis has gone round in circles from giving steroids and activated protein C. This is review article of diagnosis and management of sepsis published recently.

Read here the full article..
If you have time to read the full supplement published in critical care click here..

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HRCT for COPD and Bronchectasis

July 18, 2008

HRCT is used extensively to delineate the type and extend of bronchectasis, and COPD. Scoring HRCT and correlating the image characteristics with functional defects is not new. In this very interesting study authors have compared cystic and cylindrical bronchectasis. and their effects on pulmonary function studies. Also in the same journal another study that looked at quantitative and qualitative changes HRCT and trying correlate with extend and severity of COPD.

Read full article(1) and full article (2) published in Annals of Thoracic medicine..
Further reading on HRCT and scoring read here.. This is from radiology journal..

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NSAIDs and CVDs

July 17, 2008

We know selective COX-2 inhibitor usage is associated with increased MIs and sudden cardiac deaths. Not much is known about Non Selective NSAIDs usage and myocardial events though FDA warning is out. This study looked at this association.

Read this interesting study published recently.

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Acetylcysteine- Oral or IV

Number of cases admitted with paracetamol Overdose has not changed but mortality due to ingestion has definitely decreased. Acetylcysteine administration has made off the difference. There are many guidelines that you can follow and this article in NEJM discusses a clinical case followed by benefits of this form of therapy.

Read more..

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Warfarin for stroke- When and How?

July 16, 2008

With ever increasing number of patients with Atrial Fibrillation we do see patients presenting with cardioembolic stroke. One of the frequent questions that gets asked when to start anticoagulation and how? I have always practiced starting warfarin after 10 days and always bridge with Low molecular weight heparin. After reading this study i should change my practice..
Conclusions:- Anticoagulation of patients with cardioembolic stroke can be safely started with warfarin shortly after stroke. Heparin bridging and enoxaparin bridging increase the risk for serious bleeding.

Read More...

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ECG Quiz

July 14, 2008

Click on ecg1...

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Ominus T waves-Wellens Syndrome!

ECG diagnosis in patient presenting with critical LAD stenosis is utmost importance.
T wave changes in acute ischemia is well described.

WELLENS SYNDROME
A. Definition EKG pattern of T waves in the precordial leads that are associated with a critical stenosis of the proximal left anterior descending coronary artery

B. Simplified criteria for Wellens Syndrome

Prior history of chest pain
Little or no cardiac enzyme elevation.
No pathologic precordial Q waves.
Little or no ST-segment elevation.
No loss of precordial R waves.
Biphasic T waves in leads V2 and V3 (Type 1) or symmetric, often deeply inverted T waves in leads V2 and V3 (Type 2).
NOTE: these EKG changes usually occur during a pain-free interval when other evidence of ischemia or unstable angina may be absent.
C. What is important about Wellens Syndrome?
It is highly specific for left anterior descending coronary artery lesions.
These patients are at risk for an extensive anterior wall myocardial infarction and/or sudden death.
Early cardiac catheterization with subsequent angioplasty or CABG is now recommended for these patients.
D. Pitfalls
Diagnosing the biphasic T-wave pattern as "nonspecific" EKG changes, which they are not.
Diagnosing the EKG changes as nontransmural or subendocardial ischemia/infarction and treating them with conservative therapy.
In AE s with chest pain centers, placing these patients in the "nonspecific" EKG protocol and doing an exercise stress test on them. Exercise stress tests are contraindicated in the presence of suspected left main lesions.

Reference: Wellens Syndrome, Annals of Emergency Medicine, March 1999, Vol.33, No. 3, pp347-351.
Read more Myocardial Ischemia...

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An overlooked cause of adbominal pain- ACNES

I have not heard of this syndrome till toady and to my surprise this was described as early as 1792. One more Entrapment Neuropathy..Read more

Abdominal Cutaneous Nerve Entrapment Syndrome.

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Clinical QuiZ

July 13, 2008

Two questions for you guys to answer.

What is the diagnosis?
Which nerves are involved?
Few causes please?

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End of Life and Chemotherapy: when is enough? Part 2

I recently wrote a post on this topic quoting article published in JAMA. I thought i was the only one who cared about these patients. Please read this post just came out recently..

Palliative chemo vs hospice posted by The hospitalist.
Link to my previous post:
End of Life and Chemotherpy: when is enough? part 1
Team Disputes at End of Life

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Concept of "Long Tail"

"The phrase The Long Tail was first coined by Chris Anderson in an October 2004 Wired magazine article to describe the niche strategy of businesses, such as Amazon.com or Netflix, that sell a large number of unique items in relatively small quantities. However, the concept of a frequency distribution with a long tail — the concept at the root of Anderson's coinage — has been studied by statisticians since at least 1946."I think “long tail” concept is very illustrative and informative. As physicians we often provide great value to individual patients when we keep the long tail in mind. We all can acknowledge this. There are serious system downsides, though. I would argue, as a profession, we tend to operate on the long tail excessively for patients who are “short tail” patients. The amount of medical testing and treatment we do dwarfs the expected benefit for many patients. Every renal consult gets a renal US, almost every cardiology consult gets an echo, every ED evaluation of delirium gets a head CT, and most chest pain gets an admission and rule out MI. Certainly we should expect some negative testing to rule out disease, but it is a matter of degree. Coming up with a long differential diagnosis is a valuable skill. Testing each of those hypotheses indiscriminately with expensive medical imaging and blood testing is a failure of judgement. We are way out of step with regional and international spending without any major differences in outcomes. We have problems restricting our workups on many patients who are overwhelming likely to be short tail patients, in an attempt to either a)find a long tail disease or b) avoid a missing something. The balance is the key, but without incentive and/or legal protection to perform judicious testing, we are contributing to the bankrupting of our society. And I think the emphasis in our teaching institutions has not been on judicious application of testing, but on thoroughness (with an emphasis on ruling out long tail diseases). When many physicians see routine problems they revert to robotic thinking. Many non-physician experts think that we can just develop algorithms for episodic care. That works most of the time. However, most of the time is not good enough. That is the point of long tail thinking. I have to be better than 85% when I care for you. Robotic thinking covers around 85%. Our value comes not in robotic attention to details but rather in recognizing the long tail. Sometimes we can make the long tail diagnosis ourselves; sometimes we need to find the right consultant. Either strategy works well. The key is knowing that the patient needs cortical attention rather than brain stem reflexes.

Entering the long tail zone by over at DB's Medical Rants

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guidelines for encephalitis

Management guideline for Encephalitis is just published by IDSA. Worth reading for neuro residents..

Click on encephalitis...

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Does patient have osteomyelitis ? Bone of Contention

Diabetic foot ulcers are common reason for diabetic patients get admitted to medical wards. 20% of foot ulcers are complicated with osteomyelitis. Diagnosis of ostetomyelitis is always challenging. we always find ourselves discussing what is the best way to confirm osteomyelitis. Clinical examination is good enough or what would be the best diagnostic modality. This is a meta analysis that looked at accuracy of tests used to diagnose osetomyelitis. Read more ....

Click on osteomyelitis...

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Update on Aortic Dissection

This is s short power point update on aortic dissection.

Click on dissection...

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Unusual cause for ascites

Hepatic veno occlusive disease is described in well describe in stem cell transplantation. This case report describes such a condition due to adverse reaction to bevacizumab..Read case report here.. You can read more on veno occlusive disease below..

Click on VOD...

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KF RING

Image courtesy of commons wikepedia
All you need to know about KF ring. Read more..

Click on kf ring...

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PCI or CABG?

July 11, 2008

Cardiologist wants to do PCI and patients agree because patients are scared of surgery. stents are put in right left and center till no more place left. Read more..

Ever since coronary stenting became widespread, the rates of CABG worldwide, have plummeted. Looks like by-pass surgeons must re-invent themselves. Obviously given a choice, a patient would rather have a less invasive procedure, with a lesser risk, than a rather invasive CABG, off pump or not. Well, the cardiac surgeons are not keeping still.
The July 7th online edition of Circulation, carries a 6 years followup of the original SoS ( Surgery or Stent ) trial of about 1000 patients who were randomised to either CABG or PCI with coronary stenting ( at that time-2001, it was bare metal stents ). At 6 years, just as it was at 5 years, CABG patients had a better survival ( lesser mortality ). To be fair, the mortality rates in both were low ( 6.8% Vs 10.9% ) at 6 years. Of course, this trial was not blinded. It was randomised, and the operators had some choice in case selection. I suppose the biggest problem with doing these kind of clinical trial is that the moment the trial is completed, it is somewhat outdated. Now, the cardiologist will argue that we have the Drug-Eluting Stents which are better, although DES has not been shown, consistently to improve survival, when compared with bare metal stents. What to do? No clinical trial is perfect. But I think the biggest problem with falling case loads with cardiac surgeons, is the fact that, it is the cardiologist who first sees the patient ( he is in-charge ), who clerks and workup the patient, including doing the angiogram, and on completing the angiogram, he decides on angioplasty or bypass surgery. Therein lies the biaseness., and conflict of interest.
There is another PCI Vs CABG trial ( called the SYNTAX trial ) whose results are about to be released at the coming ESC meeting in September. I wonder what the results will show. But I doubt if another 10 trials supporting CABG will change the current practice patterns, because it is inherently bias for the cardiologist. Maybe insurance re-imbursement will. For the moment, I think, the interventional cardiologist will happily continue ballooning, always claiming that patient prefer angioplasty, until it can no longer be done ( usually for financial reasons ), and that refers him to the cardiac surgeon, who obviously sees the patient but cannot operate, because by then, the patient has run out of money. For your information, currently there is a large interventional meeting, costing millions of ringgit, going on in KL, propounding the merits of angioplasty, attended by GPs and technologist, and some interventionist. Now you know why angioplasty devices are so expensive. Well we must all have our hobby horses.

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CT angio - Life time of xrays

The 29th June 2008 issue of the New York Times, carried a stinging article on the misuse of the 64MSCT angio. A Berenson and R Abelson, did a great piece of investigative journalism, quoting patients, third party payers and also numerous physicians on both sides of the MSCT divide. Sometimes we forget to consider the long term consequences of such procedures. Basically, it states ( as we have always maintained ) that MSCT angios area overused and often, in situations where their usefulness have never been proven. What with the very real radiation risk. Each 64MSCT angio with the present scans that we have carries a radiation exposure of about 500-1000 CXRs. This danger is seldom told to the patient. Of course there is always the danger that these scans may be routinely done as a checkup for CAD ( although there is no evidence of that it helps ), because cardiologist reading the scans get a hefty fee for reporting. The fact that many cardiologist have become shareholders of companies owning these scan machines, further fuel these impressions. Many assymptomatic, healthy males or females, go for a checkup, and were advised to undergo a 64MSCT cardiac angio. stenosis are seen and they end up having a formal coronary angiogram. These often result in angioplasty and stent implantation, including DES. All on the premise that treating assymptomatic stenosis prevents heart attacks and cardiac death, although there is no evidence for that premise. In fact, there is much evidence that assymptomatic stenosis may do better with intensive medical therapy. Well, therein lies the danger of physician owning healthcare facilities, and the resulting severe conflict of interest. Each of us should get the 29th June issue of the NY Times, and appreciate this article for yourselves.

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Dermatology Quiz-2

July 10, 2008

Here is another interesting one.

Click on Dermcase1...
Click on Dermcase2...

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ER pateints dont understand Doctors orders!

What did you say was wrong with me?
Must Read

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PHARMACODYNAMICS

Here is interactive model to learn about pharmacodynamics..
Click on pharmacodynamics...

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Dermatology Quiz

July 9, 2008

My surgical colleague is seen this skin lesion and wondering what this can be. If you have comments or suggestions that will be welcome.

This is an otherwise well 16 year old boy with a painful lesion on the medial aspect of his right thigh. This lesion has been there for the last 13 years and there's evidence that it was initially excised when he was young.

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Tendon Rupture with Cipro- FDA warning

I have used drugs like Cipro for so many and yet to see any tendon rupture. Fluroquinolones get black box waring by FDA. Did FDA cave in to external pressure? Read more.

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Foreign accent after Stroke

Losing speech after a stroke is not uncommon. But acquiring a foreign accent is after stroke is amazing. Brain is known to re wire itself after a stroke but speaking in foreign accent is unheard of. I have not any way..

Foreign accent syndrome (FAS) is a neurological condition that is acquired following a stroke or some other form of brain injury. It occurs as a result of damage to the brain's speech motor centres, so that syllables are mispronounced, making one sound as if they are speaking their native language in a foreign accent.

FAS is extremely rare, with only around 50 reported cases since 1941. Two of these were reported in stroke victims in recent years: Linda Walker, a 62-year-old woman from Newcastle, began speaking in an accent that was described as a mixture of Jamaican, Canadian and Slovakian, whereas Tiffany Roberts, a 63-year-old American, began speaking in what sounds like a British accent.

Neurologists from Toronto now report the first Canadian case study of the condition. Writing in this month's issue of the Canadian Journal of Neurological Sciences, Naidoo et al describe the case of a stroke patient named Rosemary Dore, who previously had a native Southern Ontario accent, but is now speaking with an East Coast Canadian accent, despite never having lived in that part of the country.
This is out in news paper too.

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HUS-TTP syndromes

One of my favorite topics is HUS and TTP. Long time since i have seen a review article on this subject. Worth reading this article..

If you want to learn more you browse through these articles.
Click on adam...
Click on platlet...

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Uric Acid Stones and Diabetes

At the recent meeting of the National Kidney Foundation in Dallas, Dr. Orson Moe reviewed the links between diabetes and uric acid stones .

Uric acid stones are most often caused by low urine pH. With a low urine pH, even relatively little uric acid can precipate, as it forms the protonated form, which is poorly soluble. At higher pH values, uric acid dissociates to the urate anion and the proton is titrated by the base. This dissociated form is quite soluble. With urine pH values of 6.5, even high amounts of urinary uric acid will not be associated with stones. Hyperuricosuria is a less important risk factor. So while patients with hyperuricosuria may have stones, urinary alkalinization is usually a preferred treatment as compared with allopurinol. If uric acid excretion is reduced by this xanthine oxidase inhibitor but urine pH is not raised, uric acid stones may still form. Allopurinol is best indicated in patients who have trouble alkalinizing the urine or continue to have stones despite alkalinization. Hyperuricosuria is seen with some myeloproliferative disorders such as polycythemia vera, high animal protein intake (equivalent to high purine intake). Low pH is seen in states of chronic diarrhea (ileostomy, colitis, Crohns) and diabetes.

The links between diabetes and low pH are being studied. Higher body mass intake is associated with lower urine pH, and this might be explained by higher BMI being associated with insulin resistance. In fact, the more features of metabolic syndrome become evident in an individual patient, the lower the urine pH. Insulin is important in ammoniagenesis, and recent data from U. Texas Southwestern indicate that insulin resistance is associated with impaired ammoniagenesis. In this case, there is less urine ammonia available to accept protons and with less urine buffer, and pH is lower. Some studies suggest that patients with uric acid stones also have increased net acid excretion, suggesting a dietary component of greater acid ingestion. Although research suggests that insulin directly impairs ammoniagenesis, new data from Southwestern are exploring the possibility that the effect is mediated by renal fat. In this hypothesis, increased BMI is associated with deposition of fat in the kidney. MR spectroscopy techniques developed at UT Southwestern are measuring renal fat deposition and attempting to correlate the imaging studies with fat stained in kidney biopsies. This lipotoxicity in the kidney may correlate with impaired insulin effect and impaired ammoniagenesis.

The treatment of recurrent uric acid stones is alkalinization of the urine. This is best accomplished with potassium citrate. Sodium citrate (e.g. Shohls solution or Bicitra) should be reserved for patients with hyperkalemia or GI intolerance as the sodium load, though often tolerated, may increase urine calcium excretion. Potassium citrate (20-30 meq) can be given with liquids or food to minimize GI intolerance. It is usually given 2-3 times per day to achieve round-the-clock alkalinization for patients with stones in place. It can be given once a day (at night) or even every other day for prevention in patients who do not currently have stones.

1: Bobulescu IA, Dubree M, Zhang J, McLeroy P, Moe OW. Effect of renal lipid accumulation on proximal tubule Na+/H+ exchange andammonium secretion.Am J Physiol Renal Physiol. 2008 Apr 16; [Epub ahead of print]PMID: 18417539

2: Sakhaee K, Maalouf NM. Metabolic syndrome and uric Acid nephrolithiasis.Semin Nephrol. 2008 Mar;28(2):174-80.PMID: 18359398

3: Maalouf NM, Cameron MA, Moe OW, Adams-Huet B, Sakhaee K. Low urine pH: a novel feature of the metabolic syndrome.Clin J Am Soc Nephrol. 2007 Sep;2(5):883-8. Epub 2007 Aug 16.PMID: 17702734

4: Cameron MA, Baker LA, Maalouf NM, Moe OW, Sakhaee K. Circadian variation in urine pH and uric acid nephrolithiasis risk.Nephrol Dial Transplant. 2007 Aug;22(8):2375-8. Epub 2007 May 3. No abstractavailable.PMID: 17478488

5: Cameron MA, Maalouf NM, Adams-Huet B, Moe OW, Sakhaee K. Urine composition in type 2 diabetes: predisposition to uric acidnephrolithiasis.J Am Soc Nephrol. 2006 May;17(5):1422-8. Epub 2006 Apr 5.PMID: 16597681

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Honey for Wound Care? Dont Laugh!

This article is funny but interesting. I see all my MRSA patients having bath in various antiseptics and cannot get rid of their bugs. Honey has been used in wound healing and body care for more than centuries. Dating back as far as 6,000 BC references have been found on the use of honey in wound healing. During World War I Russian soldiers used honey to prevent infections and to accelerate healing. The healing properties of honey can be ascribed towards:

- Anti-bacterial activity
- Anti-inflammatory activity
- Stimulation of healing
Our fore fathers knew and practiced natural remedies and of course we have forgotten..

An article featured in this week’s Clinical Infectious Disease was titled “Medical-Grade Honey Kills Antibiotic-Resistant Bacteria In Vitro and Eradicates Skin Colonization.
The investigators studied Revamil, a medical-grade honey, to assess the in vitro bactericidal activity against S. aureus, S. Epidermidis, E. Faecium, E. coli, P. Aeruginosa, Enterobaceter cloacae and Klebsiella oxytoca in forearm colonization. After 2 days of application of honey, the extent of colonization was reduced 100-fold. Apparently, honey has other uses too and has been reported to successfully treat chronic wound infections that were unresponsive to antibiotics. Who would have thought?

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Is coronary disease different in women?

Is coronary disease different in women? Why are they behaving differently as for treatemnt is concerned?

JAMA this week featured a meta-analysis adding to the growing literature supporting an underlying difference in coronary disease in men vs. women. The review included 10,000 patients, 3000 of whom were women, and looked at outcomes for NSTEMI when using an early invasive approach (catheterization) versus a more conservative approach (medical management with catheterization if necessary). Among women who were specifically identified as “biomarker positive” or “high risk” (positive CPK or troponins), an invasive strategy was associated with a 33% lower risk of combined death, MI or re-hospitalization for ACS (odds ratio 0.67, CI 0.50-0.88). Among those women who were not biomarker positive, there was no significant decrease found in this end point when comparing an invasive versus conservative management, and, in fact, a non-significant trend toward increase in death or MI was seen. Among men, the benefit of the invasive approach to NSTEMI was comparable to the “high risk” or “biomarker positive” women. Though there was also more of a benefit seen among those biomarker positive, (44% lower odds of death, MI or re-hospitalization in the biomarker positive group) unlike women, those in the biomarker negative group were not potentially harmed by early catheterization.

To summarize the findings, for a man with a NSTEMI, an early invasive approach is rational. For a woman, early catheterization may only be beneficial if they fall into a high risk group. The postulated explanation for these findings is that CAD in men is different from CAD in women, with women less likely than men to demonstrate obstructive epicardial lesions when they present. An invasive strategy is more beneficial to those with obstructive CAD. Biomarkers are one of the tools we have to help to identify a subset more likely to have obstructive CAD and thus, more likely to benefit from invasive management.
The authors state that these findings provide evidence supporting the ACC guideline that only in high-risk women (biomarker positive) should an early invasive strategy be offered.

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Hearing and Diabetes- Is there a link?

The Annals lead article reports on a newly identified association between diabetes and hearing impairment. We know that hearing loss is common, and we also know that diabetes is common. The question is whether there is an association. Only one previous study addressed a potential association and notably excluded patients younger than 48.

The current study, a cross-sectional analysis, used data from NHANES (National Health and Nutrition Examination Survey) from 1999-2004. In all, 11, 405 people aged 20-69 (which becomes an important point) were studied and about half of them were randomized to audiometric testing. As pointed out in the accompanying editorial, the degree of hearing loss measured in clinical terms is that which would be difficult to detect without formal testing, but which would likely affect an individual’s ability to communicate. Both low-mid frequency and high frequency losses were looked at and in both subsets, diabetes was associated with a greater likelihood of hearing loss. The odds ratio in the low-mid frequency loss was 1.82 and the odds ratio in the high frequency category was 2.16. Age of the population included in this study is important because it may be that diabetes contributes most heavily to younger people. Once the usual risks for developing hearing loss (male sex, lower education, industrial or military occupation, leisure time noise and smoking) were accounted for, diabetes became less of a risk factor. Though controversial, the suggested pathophysiologic mecahanism for hearing loss in diabetes is microvascular damage to the cochlea. Since hearing loss is so difficult to avoid or treat, maybe someday soon we will we be adding audiometric screening to our health maintenance recommendations for our diabetics.

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End of Life and Chemotherapy: when is enough? Part1

July 8, 2008

I see patients get admitted time and time again on chemotherapy near end of life. These treatments may prong life and offer some hope but at a very high cost and adverse events. AS this artcle says prevents patients from meaningful review of life, preparing for death prevent them from entering into hospice..

Read here the full article..

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High Alitude and its problems

July 7, 2008

This article is for mountain climbers and who deal with such patients..

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Tension Pneumothorax

Immediate recognition and prompt treatment of tension pneumothorax can be life saving.
Read this review article..

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New Drugs for Crohn's Disease

July 5, 2008

In the past few years, antagonists of tumour necrosis factor have resulted in unforetold therapeutic benefits in Crohn's disease, but the magnitude and duration of responses are variable. Newer drugs are coming soon.With increasing evidence of an implication of the innate immune system and the intestinal epithelium, the therapeutic paradigm is also shifting from mere immunosuppression to the reinforcement of the intestinal barrier.

Read article in Lancet..

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Treatment Spinal Metastasis

July 4, 2008

As we get more and more cancer patients living longer we will see patients presenting with back pain and lower limb weakness. We will ask for a neuro consult and a MRI will show spinal metastasis. How many times we have wondered what to do with these patients. This is an review article that is a must read for all internal medicine and neuro residents. After discussing treatment options an algorithm is given.

Click on spinal mets...

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New Tool to assess fracture Risk

July 3, 2008

Bone minreal density measurement and calculating T score has been used to classify osteoporosis and assess fracture risk. This has never been a perfect tool as other variables were involved too. WHO has come out with this tool called FRAX tool to evaluate fracture risk.

Click on frax...FRAX integrates the future osteoporotic fracture risk associated with clinical risk factors with that associated with femoral neck BMD. BMD of the femoral neck (although less data is available, the total hip may also be used in women) tracks in parallel to BMI except at very low BMI, so that BMI may be used when BMD is unavailable. BMI and BMD would not be used in the same individual. The incident rates of fractures are country specific and provide the clinician the 10 year probability of hip fracture and the 10 year probability of major osteoporotic fracture (clinical vertebral, forearm, hip and shoulder).

The New National Osteoporosis Federation guideline Guidelines-2008

Role of physicians who evaluate, prevent and treat osteoporosis in postmenopausal women and men age 50 and older:

* Counsel on the risk of osteoporosis and related fractures
* Check for secondary causes
* Advise on adequate calcium and vitamin D intake
* Recommend regular weight bearing and muscle strengthening exercise to reduce risk of falls and fractures
* Advise avoidance of tobacco smoking and excessive alcohol intake

BMD testing is advised for:

* Women age 65 and older
* Men age 70 and older
* In younger postmenopausal women and men age 50 and older based on risk factor profile
* Those with a fracture to determine degree of disease severity

Treatment is recommended for:

* Patients with hip or vertebral fracture (clinical or morphometric)
* Patients with osteoporosis as defined by T score <=-2.5 * Postmenopausal women or men age 50 and older with low bone mass (T score -1 to -2.5, osteopenia) at the femoral neck, total hip, or spine and 10 year hip fracture risk probability >3% or a 10 year all major osteoporosis related fracture probability of >20% based on the U.S. adapted WHO absolute fracture risk model

BMD should be monitored two years after initiating therapy and at two-year intervals thereafter.

Bottom Line:

* BMD measurement alone fails to identify a high number of subjects who subsequently develop fractures. The addition of clinical risk factors may indeed be an improvement in risk factor assessment.
* While FRAX provides a method to evaluate fracture risk with and without BMD to use for global health, understanding exactly what level of fracture risk is appropriate for therapeutic intervention probably requires additional research.

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NSAIDs use and Strokes

In clinical trials involving COX-2 selective NDAIDS is asoociated with increased incidence of strokes. In this European study published in JAMA authors propectively looked at incidence of strokes in over 7000 patients over 10 years. They conclude that Currentusers of nonselective (HR, 1.72; 95% confidence interval [CI],1.22-2.44) and COX-2–selective (HR, 2.75; 95% CI, 1.28-5.95)NSAIDs had a greater risk of stroke, but not users of COX-1–selectiveNSAIDs (HR, 1.10; 95% CI, 0.41-2.97). Hazard ratios (95% CIs)for ischemic stroke were 1.68 (1.05-2.69) for nonselective and4.54 (2.06-9.98) for COX-2–selective NSAIDs. For individual NSAIDs, current use of the nonselective naproxen (HR, 2.63; 95% CI, 1.47-4.72) and the COX-2–selective rofecoxib (HR, 3.38; 95% CI, 1.48-7.74) was associated with a greater risk of stroke. Hazard ratios (95% CIs) for diclofenac (1.60 [1.00-2.57]), ibuprofen (1.47 [0.73-3.00]), and celecoxib (1.79 [0.52-2.76]) were greater than 1.00 but were not statistically significant.

Here is the study report..

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Contrast-induced acute kidney injury

July 2, 2008

IV contrast is frequently used in high risk patients and the measures to prevent CIAKL is not always undertaken. in this propective cohort study authors looked at incidence, preventive measures and eventual out come in these patients..

Read Here..( sorry only abstract)

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Refeeding Syndrome

This is my favorite topic and forgotten often in medical wards.

Read this fine review...

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Can we bypass Blood Brain Barrier?

Blood brain is a nuisance when we come to deliver medications to the brain tissue. Obliviously BBB is there to protect brain from noxious agents. This is review article that talks about how to enhance drug delivery to brain..

Read More..

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Will you give aspirin?

July 1, 2008

Case #1: A 47 year old man with no significant medical history, nonsmoker, and no family history of CAD. Blood pressure 124/72 Cholesterol 5.20, LDL 3.3, HDL 0.8, Triglycerides 2.4.

Case #2: A 36 year old man history of hypertension controlled with hydrochlorothiazide, smoker, with no family history of CAD. Blood pressure 134/72 Cholesterol 4.2, LDL 2.3, HDL 1.1, Triglycerides 1.4.

What is their Framingham risk score and would you prescribe daily Aspirin to either of these individuals in clinic?

Numerous trials have demonstrated the benefits of aspirin including decreasing risk of myocardial infarction, stroke, and vascular mortality in acute coronary syndromes, acute occlusive stroke, and secondary prevention post MI, stroke, TIA, stable angina, or CABG. However, in patients without known cardiovascular disease, when should primary care physicians prescribe daily aspirin? To help answer this question there are 5 major randomized clinical trials that are the basis of the current guidelines.

The first 2 major randomized trials were the Physician’s Health Study (PHS) and British Doctor’s Trial (BDT) from the late 1980’s. The BDT had conflicting results with the PHS. The PHS, which was terminated early due to “extreme benefit,” showed significant reduction in MI but no difference in CVD mortality or stroke. However, the BDT showed no difference in any end point. Interpreting these results was difficult as both were affected by selection bias given that subjects were physicians, undermining the applicability of the results. The BDT specifically had no placebo control (“placebo” group instructed to avoid aspirin), no blinding, and roughly 30% in the aspirin group withdrew secondary to GI side effects. One could also question whether this study was powered to detect a significant difference given a much lower subject population.

The other 3 major randomized trials, published 10-15 years later, included the Thrombosis Prevention Trial (TPT), the Hypertension Optimal Treatment Trial (HOT), and the Primary Prevention Project (PPP). These trials assessed the effects of aspirin in higher risk patients without known CVD and consistently demonstrated a significant reduction in major CVD events, specifically nonfatal ischemic heart disease. However, the TPT and HOT showed no difference in CVD mortality or total mortality. The PPP trial did demonstrate a difference in CVD mortality but no difference in total mortality. Unfortunately, the PPP trial was open label, making it less likely to affect an end point such as mortality. In addition, it was terminated early when the TPT and HOT results were published which may have biased the results, especially since it has been the only major trial to conclude a mortality benefit. The HOT trial showed a significant relative risk increase in hemorrhagic strokes while the other two trials did not demonstrate this difference but did show an increase in major bleeds.

In 2003, a meta-analysis of these five major trials was presented in the Archives of Internal Medicine which compiled the data and demonstrated a significant 32% RRR in first MI and a 15% RRR of any important vascular event. Clearly daily aspirin has some benefit, but what threshold should be used to initiate primary prevention? One of the most widely used risk assessment tools for cardiovascular disease is the Framingham Risk Score. ( BMJ has published Validation of QRISK2 CV risk algorithm. Please read the editorial that disusses CV risk Tables)
The American Heart Association suggests initiating daily aspirin when a patient’s 10-year risk score predicts at least 10% risk of cardiovascular disease while the United States Preventive Services Task Force (USPSTF) recommends using a cut-off of at least 6% because this is the threshold when the benefits (i.e. reduction in mainly nonfatal MI) outweighed the risks (i.e. increase major GI or CNS bleed) according to their own meta-analysis.

If we were to apply these guidelines, we would find that both cases #1 and #2 from the beginning of this post have 10-year CVD risk ≥ 6% (case #1: Framingham score 10 = 6% risk, Case #2: Framingham score 11 = 8% risk) so based upon the USPSTF cut-off we could initiate treatment with 81mg of aspirin daily. This all sounds easy and simple but if one were to take a step back there are few points to consider. 1) Most of the data from the trials used to determine these guidelines were not done in the era of statins, and one could question how much impact aspirin might have in this setting. 2) In calculating the benefit-risk analysis, the USPSTF assumed that risk of bleeding was constant across varying CVD risks, but if CVD risk goes up with age, doesn’t the risk of bleeding? 3) Several of the trials had been terminated early based upon prior results suggesting an overwhelming benefit from aspirin. However, it has been noted that many trials that are terminated early often have an overestimation of the benefit of an intervention especially when not enough data points are collected. This bias is perpetuated in the meta-analyses that use these trials in their calculations. 4) Is using the Framingham Risk Score an ideal risk assessment tool? The risk score actually attempts to predict risk of angina, MI, or coronary disease death. If we were using this risk assessment tool to assess high risk we may be considering many patients that simply develop angina as high risk. Should those patient receive aspirin daily and reduce the risk of a nonfatal symptom while putting them at risk for hemorrhage? Furthermore, is the Framingham Risk Score able to predict patients at high lifetime risk if that risk will not manifest in the next 10 years and more importantly, if we could identify those patients should they be considered for primary prevention with aspirin?

Despite these shortcomings the best model we currently have is the Framingham Risk Score as an adjunct to assess those at highest risk for CVD, but it should not replace clinical judgment. The current guidelines ultimately recommend daily aspirin for primary prevention be entertained in men or women at higher risk for CVD and that the benefits and risks be discussed on an individual basis. For example, those at risk for hemorrhage, whether cerebral or gastrointestinal, would clearly fall into the group of patients that one might not consider aspirin for primary prevention regardless of CVD risk.

But that’s not the end of the story. Most of the data used to synthesize these guidelines did not address whether they would apply to women or diabetics. The HOT and PPP trials were the only 2 of the previously mentioned trials that included women while the Women’s Health Study was a large randomized, double-blind, placebo controlled trial of 39,876 females, >45 years old, followed for about 10 years, that attempted to address this issue. The results demonstrated a significant reduction in total stroke and ischemic stroke but no difference in first major CVD event, hemorrhagic stroke, total MI, or CVD mortality. There was a significant increase risk of GI bleeding (RR 1.4). Similar to all the previously mentioned trials there was no significant change in mortality. However, instead of a reduction in nonfatal MI, there was a reduction in rates of stroke. The current guidelines intend to treat women the same as men and similarly use the Framingham Risk Score to assess CVD risk, but is this appropriate?

Diabetic patients are sometimes referred to as “CAD equivalent” and as such considered high risk (i.e. >20% 10-year CVD risk). With that in mind should 25 year old diabetics automatically be considered high risk and be given daily aspirin for primary prevention? The current guideline by the American Diabetic Association suggests daily aspirin for diabetics at higher risk for CVD, such as >40 years old, family history, hypertension, smoking, dyslipidemia, albuminuria. Between the age of 30-40 there is no clear answer, and those under 30 years of age have never been studied. More specifically the ADA does not recommended aspirin in patients <30 href="http://www.dtu.ox.ac.uk/index.php?maindoc=/riskengine/" target="_blank">UKPDS Risk Engine.

Take-Home Points:
In patients without known cardiovascular disease, aspirin provides a statistically significant reduction in nonfatal MI but there is not enough evidence to conclude any effects on stroke and mortality. The benefits seem to outweigh risks with 10-year CVD risk of ≥ 6%, however, the initiation of daily aspirin and benefit-risk assessment should be discussed with every individual.

REFERENCES:
Physicians’ Health Study. New England Journal of Medicine. 1988; 318: 262-264.
Peto R., et al. British Medical journal. 1988; 296: 313-316.
Meade T.W., et al. Lancet. 1998; 351: 233-241.
Hansson L., et al. Lancet. 1998; 351: 1755-1762.
De Gaetano., et al. Lancet. 2001; 357(9250):89-95.
Eidelman R. S., et al. Archives of Internal Medicine. 2003; 163: 2006-2010.
USPSTF. Annals of Internal Medicine. 2002; 136: 157-172.
Ridker P. M., et al.. New England Journal of Medicine. 2005; 352: 1293-1304.
American Diabetes Association. Diabetes Care. 2007; 30(Suppl 1): S4-S41.
Mueller P.S., et al. Annals of Internal Medicine. 2007; 146: 878-881.

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New Oral Xa inhibitor- warfarin can go now?

Keeping with my last post this weeks NEJM gives us 2 randomized, double-blind, placebo-controlled trials comparing the efficacy and safety of rivaroxaban, an oral factor Xa inhibitor, versus enoxaparin, a LMWH, in preventing VTE after 2 orthopedic surgeries. Rivar-oxapan is direct Factor Xa inhibitor. You see a cartoon of its target of action here..Click on rivaroxaban...

Current options for extended VTE prophylaxis are limited to LMWH, which must be administered subcutaneously, and VKAs such as warfarin, which have unpredictable pharmacologic effects,numerous food and drug interactions andrequire frequent laboratory monitoring. One can begin to see the possible advantages, both for the doctor as well as patient, of giving a once daily, oral medication that does not need lab monitoring. The first study, by Eriksson and Borris et al, compared rivaroxaban with enoxaparin for extended VTE prophylaxis in patients undergoing total hip arthroplasty. About 4500 patients were assigned to receive either 10 mg of oral rivaroxaban once daily, beginning after surgery, or 40 mg of enoxaparin subcutaneously once daily, beginning the evening before surgery. The primary efficacy outcome was the composite of DVT (either symptomatic or detected by bilateral venography), nonfatal pulmonary embolism, or death from any cause at 36 days. This outcome occurred in 1.1% in the rivaroxaban group and 3.7% in the enoxaparin group, a significant difference with an absolute risk reduction (ARR) of 2.6% and a number needed to treat (NNT) of approximately 38. The secondary outcome, major VTE, occurred in 0.2% in the rivaroxaban group and 2.0% in the enoxaparin group, also a significant difference with an ARR of 1.7% and a NNT of approximately 59. The primary safety outcome, major bleeding, was rare and similar in both groups. The second trial, authored by Lassen and Ageno et al, compared rivaroxaban with enoxaparin in preventing VTE after total knee arthroplasty. This study assigned approximately 2500 patients to receive either 10mg of oral rivaroxaban once daily, beginning 6 to 8 hours after surgery, or subcutaneous enoxaparin, 40 mg once daily, beginning 12 hours before surgery. The primary outcome was again the composite of any DVT, nonfatal pulmonary embolism, or death from any cause within 13 to 17 days after surgery. This outcome occurred in 9.6% who received rivaroxaban and 18.9% who received enoxaparin, a significant difference with an ARR of 9.2% and NNT of around 11. Major VTE, a secondary outcome, occurred much less often: 1.0% of patients given rivaroxaban and 2.6% of patients given enoxaparin. This difference remained significant with an ARR of 1.6% and NNT of around 63. Safety profiles were again similar. While longer follow-up data will likely be needed to assess efficacy and safety, this new drug shows promise for VTE prophylaxis following these orthopedic procedures that are frequently complicated by post-operative thrombotic events.
Links to
paper 1
paper 2

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