According to this article in the September 25th edition of the New England Journal of Medicine, alteplase improves the outcomes in stroke patients up to 4.5 hours after symptom onset. Previously, the “window” of effectiveness was only three hours. The clinical trial criteria are here.
The percentage of patients having a favorable outcome at 90 days in this study wasn’t huge, but was statistically significant - 52% of patients receiving alteplase had good outcomes compared with 45% of patients who received placebo. At the same time 27% of patients had some type of bleeding after receiving thrombolytics compared with only 17% of patients who had bleeding after receiving placebo. The rate of symptomatic bleeding in the brain was 2.4% for thrombolytics versus 0.2% for placebo.
So while you may have an overall improvement in your outcome at 90 days if you get the medication, more than 1 in 4 patients who receive the medication will have bleeding and 1 in 40 patients will have symptomatic bleeding.
Is it worth the risk?
In the editorial article accompanying the study, one of the study authors states that “one cannot help wondering why thrombolytic therapy has traveled such a long, difficult path to wider clinical use.”
I can help wondering.
Thrombolytics are one of the few things that physicians can give that will have an immediate and significant harm on patients. Sure, patients may occasionally have bad outcomes from allergic events or they may have undesirable side effects from some medications. But 2.4% of patients will have symptomatic bleeding in their brains when they get thrombolytics. Some of those patients will die.
I like to pose this scenario to my trainees: a patient presents to you 30 minutes after the onset of a left hemispheric stroke; how long do you have to initiate thrombolytic therapy?
The correct answer is 1 minute, not 2.5 hours, and ECASS III does not now justify an answer of 4 hours. From the moment the patient arrives at the door, every minute counts, and the only justifiable delays would be for performing brain imaging studies to exclude hemorrhage and for obtaining the results of a few simple laboratory tests. In fact, the very real peril of the ECASS III data is that some may take an even more leisurely approach to treating acute stroke. Nothing could be more wrong, for as we look back on the past decade of thrombolytic therapy for stroke, it is very clear that our focus must remain on the door-to-needle time. Every minute matters during a stroke.
So the choice is …
1. Let patient continue with the stroke symptoms they have already presented with and follow the doctrine of “primum non nocere.” After all, even this study shows that if doctors do nothing, 45% of the patients will get better on their own.
-or-
2. Give a medication that may improve clinical outcome in 7% more of the patients … at the risk of getting a bad outcome from the medication.
What would you choose?
Want a simple way to immediately expand the use of thrombolytic therapy?
If an On Call physician gets a CT report from a radiologist that says “no bleed,” the patient meets the criteria for thrombolytic therapy and doesn’t have any exclusion criteria, then the Physician cannot be held liable for any bad outcomes for giving thrombolytics.
There will still be some that philosophically disagree with giving patients a medication that could kill them. Nevertheless, there would be an instant spike in thrombolytic use. I guarantee it.
Thrombolytics in Acute Stroke? Time is brain
September 28, 2008
New Diabetic guideline for Canada
September 26, 2008
The Canadian Diabetes Association has released new clinical practice guidelines to emphasise the importance of early identification of risk factors in the prediabetes stage in order to prevent the onset of diabetes and the aggressive management of those risk factors in order to prevent the serious complications associated with the disease.
Select Recommendations
· Early identification and treatment of risk factors for diabetes-related complications such as cardiovascular disease, kidney, and eye disease is essential through proper disease management to avoid serious complications.
· The Guidelines are now recommending that people with diabetes who are at risk for developing heart disease be aggressively treated to lower low-density lipoprotein (LDL) cholesterol to <=2 mmol/L. This lower level, in combination with strict blood pressure control, is proven to help substantially reduce heart disease and stroke. · People with diabetes are encouraged to perform resistance exercises in addition to moderate to vigorous aerobic exercises, such as brisk walking. · Adults with diabetes should consume no more than 7% of total daily energy from saturated fat and should limit intake of trans fatty acids to a minimum..
Full guideline is avialble as PDF format at CDA site..
Hypertension Mega Trials
September 25, 2008
Hypertension mega trials are still being under taken. There is convincing evidence that treating blood pressure is beneficial in reducing CV end points. Does it matter which drug or drugs to be used as initiation therapy? because finally it is better control that translates to such CV benefits. I enjoyed this review article published in SMC recently..
HIT again!
September 23, 2008
Heparin Induced Thromocytopenia has emerged as an auto immune disease and understanding and treatment of this serious condition has evolved recently. This is an timely article published in BLOOD.
DRUMSTICKS
A 62-year-old man was diagnosed with breast cancer by a fine needle biopsy. The family history was negative for breast cancer. He and his wife had no children. When they were evaluated years earlier, he was noted to be infertile. Currently, the physical examination showed a lanky individual with mildly prominent hips, gynecomastia, and pea-sized firm testicles. The peripheral blood smear showed a small nodule of chromatin separated from the main nuclear lobe by a strand of chromatin ("drumsticks") in approximately 3% of the polymorphonuclear leukocytes.
Drumsticks usually appear when two XX chromosomes are present. Women have drumsticks in 3% or more of the polymorphonuclear leukocytes. The active X chromosome is randomly distributed within nuclear lobes, but the inactive X preferentially appears in drumsticks. Typical drumsticks are rarely seen in normal men. Drumsticks should be differentiated from other nuclear appendages (sessile nodules, small clubs, small lobe, rackets) that may occasionally be seen in both sexes.
This patient was infertile, had small testicles, and drumsticks that suggested Klinefelter syndrome (XXY chromosomes). The chromosome analysis confirmed XXY. Patients with Klinefelter syndrome often have gynecomastia, low testosterone levels, and elevated FSH and LH. Studies also suggest that patients with Klinefelter syndrome have an increased tendency to develop breast cancer, the frequency of which is greater than that seen in normal (XY) males, but less frequency than in true females.
Syndicated from BLOOD
Metabolic Syndromes and CV mortality
Definition of Metabolic syndrome has evolved over period of ten years or so. Old NCEP, and revised NCEP and IDF guidelines are available now. This is an interesting French study that looked at All cause mortality comparison using different defintions of metabolic syndrome..Read more this abstract..
September 22, 2008
This study is a meta-analyses of RCTs in hypertension using thiazide diuretics and thiazide-potassium sparing(ENaC-Inhibitor) combination drugs were conducted. The findings:
Significant reductions in both coronary mortality and SCD were observed in the overview of trials in which elderly patients received an ENaC inhibitor/HCTZ combination. The odds ratio (OR) for coronary mortality was 0.59 (95% confidence
interval [CI], 0.44 to 0.78) and for SCD was 0.60 (95% CI, 0.38 to 0.94). In contrast, an overview of the trials using thiazide diuretics alone showed no significant reductions of either coronary mortality (OR, 0.94; 95% CI, 0.81 to 1.09) or SCD (OR, 1.27; 95% CI, 0.93 to 1.75).
Use of an ENaC inhibitor combined with HCTZ for treatment of hypertension in the elderly results in favorable effects on coronary mortality and SCD.
ALLHAT study was first to show that Diuretics are the first choice hypertensive drug especially in elderly. Diuretics are cheap and works well.Current US guidelines recommend using diuretics as initial choice.But Diuretics usage is associated with elecrolyte abnormalities that can be dangerous. This paper discusses this issue clearly. This is an old editorial that is titled Does Thiazides Kill? Will the guidelines change after this study? You want to read what the author of this study had to say in this report? Read more.
Statins Can do Everything?
The <>UCSD Statin study yielded further evidence that statin treatment reduces blood pressure (although not by much) The RCT enrolled over 900 subjects without known CVD or diabetes. The idea was to independently assess the effect on BP. There was no inclusion / exclusion criteria regarding baseline BP. Subjects were randomized to pravastatin, simvastatin, or placebo.
Treatment with a statin resulted in about a 2-2.5 point drop in SBP and DBP. The treatment was stopped at 6 months, and the blood pressures returned to baseline by month 8 - further suggesting that this was a true effect.
Beatrice A. Golomb; Joel E. Dimsdale; Halbert L. White; Janis B. Ritchie; Michael H. Criqui
Reduction in Blood Pressure With Statins: Results From the UCSD Statin Study, a Randomized Trial
Arch Intern Med. 2008;168(7):721-727.
Treatment with a statin resulted in about a 2-2.5 point drop in SBP and DBP. The treatment was stopped at 6 months, and the blood pressures returned to baseline by month 8 - further suggesting that this was a true effect.
Beatrice A. Golomb; Joel E. Dimsdale; Halbert L. White; Janis B. Ritchie; Michael H. Criqui
Reduction in Blood Pressure With Statins: Results From the UCSD Statin Study, a Randomized Trial
Arch Intern Med. 2008;168(7):721-727.
Another Cause for Intermittent Jaundice
Elderly lady comes in with recurrent RUQ pain and jaundice. US shows gallstones and a dilated common bile duct. No stones seen in the CBD on MRCP. The GI consultant attempts an ERCP but the common duct cannot be cannulated secondary to a peri-ampullary diverticulum, noted to be full of food matter. I obtain the Upper GI barium study shown above.
Intermittent jaundice has been <>described in association with peri-ampullary duodenal diverticula, although it's quite rare. Options include formally excising the diverticulum versus simply bypassing the distal segment of the CBD with a biliary-enteric anastomosis.
Syndicated from Buckeye surgeon
New Hep B Recommendations
- <>The CDC just issued new testing recommendations for chronic Hep B virus infection.
Serologic testing for hepatitis B surface antigen (HBsAg) is the primary way to identify persons with chronic hepatitis B virus (HBV) infection. Testing has been recommended previously for pregnant women, infants born to HBsAg-positive mothers, household contacts and sex partners of HBV-infected persons, persons born in countries with HBsAg prevalence of >8%, persons who are the source of blood or body fluid exposures that might warrant postexposure prophylaxis (e.g., needlestick injury to a health-care worker or sexual assault), and persons infected with human immunodeficiency virus.- This report updates and expands previous CDC guidelines for HBsAg testing and includes new recommendations for public health evaluation and management for chronically infected persons and their contacts. Routine testing for HBsAg now is recommended for additional populations with HBsAg prevalence of >2%: persons born in geographic regions with HBsAg prevalence of >2%, men who have sex with men, and injection-drug users.
- Implementation of these recommendations will require expertise and resources to integrate HBsAg screening in prevention and care settings serving populations recommended for HBsAg testing. This report is intended to serve as a resource for public health officials, organizations, and health-care professionals involved in the development, delivery, and evaluation of prevention and clinical services.
Endo Barrier for T2DM
This interesting device that can be inserted through an endoscope has been devised. No need for bariatric surgery..<>READ THIS STUDY REPORT..
Home Blood pressure Monitoring
September 19, 2008
You always find patients in your clinic telling you that their blood pressure at home is normal. There has been definite recommendations regarding home monitoring of blood pressure and guideline in this practice is long awaited.European Society of Cardiology has come with such guideline and you should read this <>abstract.
A new pneumonia severity assessment tool? SMART-COP
Existing severity assessment tools, such as the pneumonia severity index (PSI) and CURB-65 (tool based on confusion, urea level, respiratory rate, blood pressure, and age >or=65 years), predict 30-day mortality in community-acquired pneumonia (CAP) and have limited ability to predict which patients will require intensive respiratory or vasopressor support (IRVS).
Researchers developed a new stratification tool, called SMART-COP, to determine which patients are likely to require intensive respiratory or vasopressor support (IRVS).
Using data from a prospective, multicenter, observational study, researchers of the Australian CAP Study (ACAPS) performed multivariate analysis of clinical features from 882 episodes of CAP in 862 patients to identify features that were significantly associated with receipt of IRVS.
In this ACAPS, 10.3% of patients received IRVS, and the 30-day mortality rate was 5.7%.
The features statistically significantly associated with receipt of IRVS were
(SMART-COP)
S = low systolic blood pressure (2 points)
M = multilobar chest radiography involvement (1 point)
A = low albumin level (1 point)
R = high respiratory rate (1 point)
T = Tachycardia (1 point)
C = confusion (1 point)
O = poor oxygenation (2 points), and
P = low arterial pH (2 points)
A SMART-COP score of >or=3 points identified 92% of patients who received IRVS, including 84% of the 38 patients (42%) who received IRVS and were initially admitted to general wards and later transferred to the intensive care unit
Sensitivities of PSI and CURB-65 for identifying the need for IRVS were 74% and 39%, respectively.
The Infectious Diseases Society of America’s CAP treatment guidelines recommend using the PSI to risk-stratify patients. The simple-to-use SMART-COP score seems to be more sensitive than the PSI for identifying patients who might need intensive care. With further validation, SMART-COP could prove to be better than the PSI.
Click here for the pneumonia severity index calculator.
Click here for a pdf copy of the CURB-65 chart.
Reference:
Charles PGP et al. SMART-COP: A tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia. Clin Infect Dis 2008 Aug 1; 47:
Anemia of chronic disease
All you need to know about anemia of chronic disease. This is second only cause of anemia next to Iron defeciency. Read more..
Ocular associations of DM
September 17, 2008
Diabetic Retinopathy is the most well known ocular complication of Diabetes mellitus. Associations other than retinopathy are known and <>read more to learn about them..
Does ‘ENHANCE’ Diminish Confidence in Ezetimibe?
September 15, 2008
Ezetemibi use has increased tremendously but adverse effects are being reported. ENHANCE study failed to show any benefit in its usage. Read this nice Editorial.
Treat Glucose Early
September 13, 2008
Ten-year posttrial monitoring from the landmark United Kingdom Prospective Diabetes Study (UKPDS) indicates that a strategy of early intensive glucose lowering, either with a sulfonylurea or metformin, has lasting, significant effects not only on major diabetes end points but also on risk of myocardial infarction (MI) or all-cause mortality. One of the "most plausible" theories as to why the recent Action to Control Cardiovascular Risk in Diabetes (ACCORD), Action in Diabetes and Vascular disease (ADVANCE), and Veterans Administration Diabetes (VADT) trials showed no benefit of glucose control on cardiovascular outcomes was that the glucose control was too late and could not "stop the moving train."By contrast, blood-pressure benefits seen with "tighter" blood-pressure lowering in 1997, when the trial first concluded, were not maintained over time.
Read more of this original article published in NEJM..
How to survive a nuclear attack!!
September 12, 2008
Hope we never need this on!!
The face of nuclear terror has changed since the Cold War, but disaster-medicine expert Irwin Redlener reminds us the threat is still real. He looks at some of history’s farcical countermeasures and offers practical advice on how to survive an attack.
Elderly and Hypertension- HYVET study
Elderly patients are at very high risk of Cardiovascular events and recently published HYVET looked at this issue.. Read this summary from Prof Zanchetti.
LCAT activity and Sub Clinical Atherosclerosis
This is an interesting study that looked at relationship between LCAT activity and Carotid IMT. May be this will become marker of sub clinical atheromatous disease.Read the abstract of this study.
How To Read Chest X-Ray?
I have already posted on How to read Ches X-ray. This is a very nice presentation that i have syndicated. Enjoy the presentation and learn how to look at Chest X-rays.
Click on cxr...
My previous post on the same topic..
B12 deficiency - Dont miss this!
Eosinopenia and Sepsis
September 11, 2008
The present study is the first report testing the value of eosinopenia in the diagnosis of sepsis on admission to the ICU.
• Eosinopenia is a good diagnostic marker in distinguishing between noninfection and infection in newly admitted critically ill patients.
• Eosinopenia is a moderate marker in discriminating between SIRS and infection in newly admitted critically ill patients.
• Eosinopenia showed a higher sensitivity and specificity compared with CRP in the diagnosis of sepsis on admission to the ICU
• Eosinopenia may become a helpful clinical tool in ICU practices.
Read this article in critical care..
• Eosinopenia is a good diagnostic marker in distinguishing between noninfection and infection in newly admitted critically ill patients.
• Eosinopenia is a moderate marker in discriminating between SIRS and infection in newly admitted critically ill patients.
• Eosinopenia showed a higher sensitivity and specificity compared with CRP in the diagnosis of sepsis on admission to the ICU
• Eosinopenia may become a helpful clinical tool in ICU practices.
Read this article in critical care..
Leave That Ear Wax Alone
Under the headline "Leave that Ear Wax Alone," the Washington Post reports that the American Academy of Otolaryngology--Head and Neck Surgery Foundation has issued the following not-so-surprising advice:
Ear wax is good. ("Cerumen is a beneficial, self-cleaning agent, with protective, lubricating (emollient), and antibacterial properties.")
Q-tips are bad. ("Inappropriate or harmful interventions are cotton-tipped swabs, oral jet irrigators, and ear candling.")
Ear wax is good. ("Cerumen is a beneficial, self-cleaning agent, with protective, lubricating (emollient), and antibacterial properties.")
Q-tips are bad. ("Inappropriate or harmful interventions are cotton-tipped swabs, oral jet irrigators, and ear candling.")
Obesity is on the increase and this statue is a stark reminder that it is going to stay. I am not sure where this image is found. May be you can find for me..
TIPS For Everyday Complaints
Some tips for primary care doctors managing common problems like cough, headache,fatigue and dizziness.
Statin use and Cancer
Statins are not associated with a higher incidence of cancer, according to a meta-analysis of randomized controlled trials involving more than 97,000 patients.
Previous research reported an association between on-treatment low-density lipoprotein cholesterol (LDL-C) levels and cancer in patients on statins. Authors reviewed data from 15 trials of 51,797 patients given statins and 45,043 given placebo. The patients were followed for an average of about 4.5 years, or 437,017 patient years of follow-up. There were 5,752 cancer cases. Researchers reported their findings in the Journal of the American College of Cardiology.
Meta-regression analysis of the treatment arms of the studies showed an inverse association between treating LDL-C levels with statins and cancer, with 2.2 (95% CI, 0.7 to 3.6) fewer cancers per 1,000 person-years for every 10 mg/dL decrease in treating LDL (P= 0.006). The difference among control arms was 1.2 (95% CI, –0.2 to 2.7; P= 0.09). Meta-regression analysis showed that statins did not affect cancer risk for any levels of treatment.
The study also found a relationship between on-treatment LDL-C levels and cancer in patients not treated with statins.
Researchers concluded that statin-treated patients lower their LDL-C with no extra cancer risk.
Previous research reported an association between on-treatment low-density lipoprotein cholesterol (LDL-C) levels and cancer in patients on statins. Authors reviewed data from 15 trials of 51,797 patients given statins and 45,043 given placebo. The patients were followed for an average of about 4.5 years, or 437,017 patient years of follow-up. There were 5,752 cancer cases. Researchers reported their findings in the Journal of the American College of Cardiology.
Meta-regression analysis of the treatment arms of the studies showed an inverse association between treating LDL-C levels with statins and cancer, with 2.2 (95% CI, 0.7 to 3.6) fewer cancers per 1,000 person-years for every 10 mg/dL decrease in treating LDL (P= 0.006). The difference among control arms was 1.2 (95% CI, –0.2 to 2.7; P= 0.09). Meta-regression analysis showed that statins did not affect cancer risk for any levels of treatment.
The study also found a relationship between on-treatment LDL-C levels and cancer in patients not treated with statins.
Researchers concluded that statin-treated patients lower their LDL-C with no extra cancer risk.
Cancer Scare and Vytorin
September 5, 2008
Within three years of Treatment with Vytorin there is some increase in cancer reported in SEAS trial. I doubt this is true and if so this drug should be labeled a carcinogen..Read this special article reported in NEJM>>
Seafood Allergy and radiologist!
Recent surveys have indicated that the misconception that seafood allergy confers a disproportionately increased risk of adverse reactions to radiocontrast media remains pervasive among physicians and patients. One possible explanation for the persistence of this notion is that physicians responsible for radiocontrast administration are inadvertently contributing to its propagation. Reported in American Journal of Medicine..
Antifungals in ICU
In critically ill adults with risk factors for invasive candidiasis, empirical fluconazole did not clearly improve a composite outcome more than placebo. Study reported in Annals of Internal Medicine..
eAverage Glucose
Next, another straight forward report, this time on diabetes. David Nathan et al from the Joslin Diabetes Center reported in the August 31st issue of Diabetes Care, their study “Translating the A1C Assay into Estimated Average Glucose Values.” Their study essentially defines the mathematical relationship between A1C and average glucose. The obvious and practical need for this is obvious: patients understand “average glucose” much better than a number that tells them the “amount of hemoglobin that is glycosylated.” How many times have you found yourself explaining exactly what HgA1C means only to have a patient respond by telling you that their sugar never goes above 120? With Dr. Nathan’s study, you might realistically be able to tell a patient what their “AG” or “average glucose” is. The other pressing importance of this study is that a new, more stable and specific method for standardization of the A1C assay has been developed. Values are lower and units are different than our current A1C assays. Thus, rather than learn a new system for reporting a non-so-helpful number, why not convert it? In the study, approximately 500 patients had their glucose monitored by two methods: continuous glucose monitoring and sever-point daily self monitoring. Many, many glucoses were obtained on these 500 patients and a linear regression analysis was conducted. The table below is the result:
A1C % AG* mg/dl
5 97 (76-120)
6 126 (100-152)
7 154 (123-185)
8 183 (147-217)
9 212 (170-249)
*AG=average glucose
The limitations of the study include the relative lack of representation of minorities, including Asian and African Americans. Nonetheless, it’s thought that the mathematical relationship is sound regardless of ethnicity and age. The importance of this is underscored by its inclusion in the most recent consensus statement on hemoglobin A1C measurement.
Treatment-failure gout: A moving target
September 3, 2008
The incidence and prevalence of gout have been increasing steadily over the past 40 years. Gout is now the most common inflammatory arthritis in men. Many explanations have been offered for this epidemic of gout, including the alarming rise in obesity , the aging of the population, the increasing prevalence of kidney failure and hypertension , the widespread use of thiazide diuretics and mini-dose aspirin , and a rising consumption of beer. Read the article..
Stalagmite Hips
The patient, a 61-year-old woman with a 25-year history of systemic sclerosis, presented to our clinic with chronic bilateral hip pain and severe restriction of movement. Three-dimensional computed tomographic angiography, performed to assess joint replacement as a treatment approach, provided a vivid illustration of ectopic calcifications that had developed in the course of the disease. The posteroanterior view of the pelvis presented here reveals entrapment of both hip joints within massive calcific tissue. Calcifications developed in the periarticular space and within adjacent muscles (quadriceps, gluteal muscles, obturators). Bilateral loss of cartilage space and erosion of the external side of the acetabulum were also documented, especially on the right side. Ileac arteries and deep and superficial femoral arteries were unaffected, although smaller branches appeared to be trapped within these enormous calcific masses. The morphology of ectopic calcifications in this patient resembled the formation of stalagmites.
From Aerthritis and Rheumatism
From Aerthritis and Rheumatism
Zebra Lines
The patient, a 10-year-old boy, had a history of osteogenesis imperfecta with multiple prior fractures. He had undergone a 2-year series of treatments with intravenous pamidronate every 3-4 months, for a total of 7 treatments. Radiography of the knees revealed 7 metaphyseal bands of increased density paralleling the contours of the physis in the distal femur, proximal tibia, and proximal fibula, corresponding to the number of treatment cycles he had undergone. Pamidronate, a bisphosphonate, is an osteoclast inhibitor that has been used in adults to increase bone mineral density. Radiographic changes in children receiving cyclic bisphosphonate therapy have been described, and include increased bone mineral density and the presence of multiple thin, sclerotic metaphyseal bands corresponding to the number of treatments. The term zebra lines has been proposed to describe this characteristic banding pattern.
From Arthritis and Rheumatism
From Arthritis and Rheumatism
Cancer and Clot
"A nickel's worth of cancer can give a dollar's worth of clot." Dr. Leo Zacharski, is fond of using this expression to describe the phenomenon of clinically overt venous thromboembolism (VTE) triggered by clinically occult cases of cancer. Although Armand Trousseau first described the association between cancer and thrombosis and later developed cancer-associated thrombosis himself, it was Illtyd James and Matheson who in 1935 first promulgated the idea that clinically inapparent cancer could trigger thrombosis. They reported on a seemingly cancer-free patient who developed symptomatic cancer 2 months after presentation with thrombosis and made the conjecture that cancer was already present and that the tumor cells activated the thrombotic process. We now recognize that it takes only a small number of cancer cells with a procoagulant phenotype to initiate coagulation reactions that host coagulation proteins then amplify to produce massive clots . Indeed, compared with the general population, patients with VTE are at substantially increased risk for harboring or subsequently developing cancer.
Whether to undertake an arduous search for concealed cancer in patients with idiopathic VTE is a question that has never been more relevant. We have modern screening tests that detect with great regularity asymptomatic malignant conditions in otherwise healthy individuals, and we commonly cure early-stage cancer. However, screening for cancer has downsides: expense, potential for psychological and physical harm due to false-positive results, and complications of procedures instigated by true- and false-positive test results. Two questions are therefore pertinent: How often do we find cancer if we look hard enough in patients with VTE, and is the search worthwhile? The study by Carrier and colleagues nicely addresses the first question but does not answer the second.
Editorial in the same issue is worth reading.
Whether to undertake an arduous search for concealed cancer in patients with idiopathic VTE is a question that has never been more relevant. We have modern screening tests that detect with great regularity asymptomatic malignant conditions in otherwise healthy individuals, and we commonly cure early-stage cancer. However, screening for cancer has downsides: expense, potential for psychological and physical harm due to false-positive results, and complications of procedures instigated by true- and false-positive test results. Two questions are therefore pertinent: How often do we find cancer if we look hard enough in patients with VTE, and is the search worthwhile? The study by Carrier and colleagues nicely addresses the first question but does not answer the second.
Editorial in the same issue is worth reading.
Hypercholestrolemia and management
September 2, 2008
Hypercholestrolemia and its management has continued to evolve. Statins have changed the face of lipid practice and more than 26 large studies have been done so far. Read this review article published in BMJ.
Summary of NICE guideline for Hypercholestrolemia..Tight Control Is Not Necessary in ICU
September 1, 2008
Risks of Tight Glucose Control in ICU May Outweigh Benefits
Against conventional wisdom, tight glucose control in critically ill patients has not reduced in-hospital death rates. Instead, according to a meta-analysis here, it increases the risk of hypoglycemic episodes.
With data pooled from 27 randomized trials involving 8,315 patients, the relative risk of hospital mortality was 0.93 (95% CI 0.85 to 1.03) for tight glucose control versus usual care, reported Renda Soylemez Wiener, M.D., M.P.H., of the VA Medical Center here, and colleagues in the Aug. 27 issue of the Journal of the American Medical Association.
The American Diabetes Association and several other medical societies have recommended tight glucose control for all critically ill patients, mainly on the basis of a 2001 study that found it reduced hospital mortality among critically ill surgical patients by one-third, said Dr. Wiener and colleagues.
"Subsequent large randomized controlled trials of tight glucose control in medical and mixed medical-surgical ICU settings, however, have failed to replicate this mortality benefit," the researchers said, prompting them to undertake the systematic review.
In an interview, Dr. Wiener said the meta-analysis results warrant a re-evaluation of recommendations of tight glucose control for all ICU patients.
Tight glucose control generally means seeking to keep blood glucose below 150 mg/dL with an insulin infusion during some or all of the ICU stay. Some guidelines, including those endorsed by the ADA, call for glucose levels of 80 to 110 mg/dL.
This study does not surprise me. Achieving tight control while providing intensive care does not have an obvious biologic theory. Of course, if glucose is your focus of attention, then you would be attracted to a glucose theory.
Generally patients in an ICU have so many different problems, that achieving balance seems more important than focusing too deeply on one factor.
Against conventional wisdom, tight glucose control in critically ill patients has not reduced in-hospital death rates. Instead, according to a meta-analysis here, it increases the risk of hypoglycemic episodes.
With data pooled from 27 randomized trials involving 8,315 patients, the relative risk of hospital mortality was 0.93 (95% CI 0.85 to 1.03) for tight glucose control versus usual care, reported Renda Soylemez Wiener, M.D., M.P.H., of the VA Medical Center here, and colleagues in the Aug. 27 issue of the Journal of the American Medical Association.
The American Diabetes Association and several other medical societies have recommended tight glucose control for all critically ill patients, mainly on the basis of a 2001 study that found it reduced hospital mortality among critically ill surgical patients by one-third, said Dr. Wiener and colleagues.
"Subsequent large randomized controlled trials of tight glucose control in medical and mixed medical-surgical ICU settings, however, have failed to replicate this mortality benefit," the researchers said, prompting them to undertake the systematic review.
In an interview, Dr. Wiener said the meta-analysis results warrant a re-evaluation of recommendations of tight glucose control for all ICU patients.
Tight glucose control generally means seeking to keep blood glucose below 150 mg/dL with an insulin infusion during some or all of the ICU stay. Some guidelines, including those endorsed by the ADA, call for glucose levels of 80 to 110 mg/dL.
This study does not surprise me. Achieving tight control while providing intensive care does not have an obvious biologic theory. Of course, if glucose is your focus of attention, then you would be attracted to a glucose theory.
Generally patients in an ICU have so many different problems, that achieving balance seems more important than focusing too deeply on one factor.
HB A1c - Chaos to Harmony!
Haemoglobin A1c (HbA1c) is due to celebrate its 40th birthday. Many people would argue that the clinical studies relating the test to diabetes complications while in its late 20s are likely to be its finest ever achievement. However, this article looks at how HbA1c has matured since then and discusses in detail how its many strengths and idiosyncrasies as a marker of glycaemic risk have, as a 30-something, become more clearly understood.
As HbA1c approaches middle age, this paper also describes how the test appears to be developing a mid-life crisis, as debate over how its results should be expressed seems likely to divide opinion among clinicians for some time to come.
As HbA1c approaches middle age, this paper also describes how the test appears to be developing a mid-life crisis, as debate over how its results should be expressed seems likely to divide opinion among clinicians for some time to come.
Antibiotic Allergy
I pulled out this bit out dated article that talks about antibiotic allergy. A must read for very one..
Backache
How many do we see patients present with back pain and we do nothing except to wait for it to go away. Or give NSAIDS, refer to physio. Distinguishing serious from benign causes for backache is very important. This article deals with this topic..
The Serotonin Syndrome
Sternbach's diagnostic criteria for serotonin syndrome include at least three of the following features: mental status changes (confusion, hypomania), agitation, myoclonus, hyperreflexia, diaphoresis, shivering, tremor, diarrhea, incoordination, and fever. Hunter,s criteria is also used. Recently this condition has been reported in patients taking triptans monotherapy..
Read more
Current concepts in Serotonin Syndrome....
Read more
Current concepts in Serotonin Syndrome....
Upper GI bleeding Review
This is a review article published in NEJM on management of acute GI bleeding.. Worth reading through.
Subscribe to:
Posts (Atom)
