MTX in RA

"Ten recommendations for the use of MTX in daily clinical practice focussed on RA were developed, which are evidence-based and supported by a large panel of rheumatologists, enhancing their validity and practical use.

1. For patients starting MTX therapy, work-up should include clinical evaluation of risk factors for MTX toxicity, including alcohol intake; patient education; levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), albumin, complete blood count (CBC), creatinine; and chest radiographic examination obtained within the previous year. Serology for HIV, hepatitis B and hepatitis C, blood fasting glucose levels, lipid profile, and pregnancy test should also be considered.
   
2. Oral MTX should be initiated at 10 to 15 mg/week. Depending on clinical response and tolerability, the dose should be escalated by 5 mg every 2 to 4 weeks up to 20 to 30 mg/week. For patients with inadequate clinical response or intolerance, parenteral administration should be considered.
   
3. Prescription of at least 5 mg/week of folic acid given with MTX treatment is strongly recommended.
   
4. When MTX is started or the dose is increased, ALT levels with or without AST, creatinine, and CBC should be checked every 1 to 1.5 months until a stable dose is reached, and every 1 to 3 months thereafter. At each visit, clinical evaluation should determine adverse effects and risk factors.
   
5. If there is a confirmed increase in ALT/AST levels at more than 3 times the upper limit of normal (ULN), MTX should be stopped. After normalization, MTX may be reinstituted at a lower dose. If the ALT/AST levels are persistently elevated up to 3 times the ULN, the MTX dose should be adjusted. If ALT/AST levels are persistently elevated more than 3 times the ULN after discontinuation of MTX, diagnostic procedures should be considered.
   
6. MTX is appropriate for long-term use because of its acceptable safety profile.
   
7. In DMARD-naive patients, the balance of efficacy or toxicity favors MTX monotherapy vs combination with other conventional DMARDs. When MTX monotherapy does not control the disease, MTX should be considered as the foundation for combination therapy.
   
8. MTX is a steroid-sparing agent that is recommended in giant-cell arteritis and polymyalgia rheumatica. It may also be considered for treatment of patients with systemic lupus erythematosus or (juvenile) dermatomyositis.
   
9. In patients with RA who are undergoing elective orthopaedic surgery, MTX can be safely continued in the perioperative period.
   
10. For at least 3 months before planned pregnancy, MTX should not be used for both men and women. MTX should not be used during pregnancy or breast-feeding.
    

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Hypertension , stroke and AF

Hypertension that is poorly controlled will lead on to LVH and then to LV diastolic Dysfunction. LV dysfunction is a predictor of development of AF. Read more..

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Thiazides and Diabetes

Thiazides use in treating hypertension is on the increase. Dibetogenic potential of thiqazides is well known over 25 years. Read this article that discuses the recent changes in guidelines. Read More..

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Blood Quiz

A 66 y/o female with a hx of myelodysplasia, refractory anemia subtype, presents with a Hemoglobin of 9.3 g/dl with a newly reduced MCV of 59 fL . Her iron studies are significant for a ferritin of 425ng/ml, with an iron level of 245 ug/dl . a bone marrow aspirate shows increased erythroid precursors , Hemoglobin H inclusions are seen on her peripheral smear after staining with brilliant cresyl blue . Pt has no family hx of anemia & has previous hemograms that have been unremarkable. her peripheral smear stained with wright giemsa is shown above.
What is her most likely diagnosis?

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The SVT - UTI Connection

I’m still trying to figure this one out. This is what happens in our hospital too!

We had a patient who was in supraventricular tachycardia with a rate of 180 and who was having substernal chest pressure. Her EKG showed that she was starting to get a little ST depression in the lateral leads.

We chemically converted her back into a normal sinus rhythm. Then her chest pain went away and her EKG normalized.

To me, that’s a positive stress test, but I digress.

So we get all the labs back and I call the admitting doctor. I run through what happened, what meds the patient received, and the lab results.

“What’s the urine show?”

“Ummm. We didn’t get a urine.”

“Why not?”

“The patient was having chest pain and a cardiac arrhythmia. What’s a urine going to tell you?”

“I’m not accepting the admit until you call me back with urine results.”

Fine. I played the game and got the STAT urinalysis.

I was hoping that the patient had a whopping UTI so I could publish a case study on the correlation between UTIs and cardiac arrhythmias.

As fate would have it, the urine came back normal.

Dang it.

I did have fun trying to think of a graphic to add to this post that related to urine infections and heart racing, though. Couldn’t do it.

Posted by WhiteCoat on November 25, 2008

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Stop Smoking Now

Amazing response by the human body to return to normal if you quit smoking right now. On the other hand, this also shows how much harm cigarettes do to you.

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Calcinosis Cutis

An 18 year old girl with systemic lupus erythematosus and dermatomyositis overlap presented with multiple, non tender subcutaneous swellings over the back, buttocks, thighs, axillae and elbows. Misinterpreted as multiple subcutaneous abscesses, she had undergone multiple incision and drainage procedures elsewhere. On palpation, the nodules were non tender and firm with chalky, white material oozing from incision sites. The radiographs of pelvis and chest revealed extensive non homogenous subcutaneous calcific densities suggestive of calcinosis cutis.

Virchow described calcinosis cutis in 1855. It has been classified into four types: metastatic, dystrophic, iatrogenic and idiopathic types. Dermatomyositis, systemic lupus erythematosus and systemic sclerosis (CREST) classically manifest with the dystrophic calcification. It is characterized by deposition of hydroxyapatite crystals and amorphous calcium phosphates deposited in soft tissues namely intracutaneous, subcutaneous, fascial, or intramuscular planes. Calcinosis cutis in this setting is not due to an imbalance in calcium homeostasis. The exact nature of its origin is still unclear. It is hypothesized that local inflammation may have a role in its pathogenesis. Calcinosis cutis is usually seen in juvenile dermatomyositis. Presentation of calcinosis cutis varies from asymptomatic nodules to severe, painful, disfiguring disease with ulcerative, infective, and mechanical complications. Established cases of calcinosis cutis in this setting have few treatment options with marginal benefit. Diltiazem and aluminum hydroxide antacids have been used. Surgery may be deleterious as it may stimulated further calcium deposition. Early, effective treatment reduces occurance of this complication.

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Acanthosis Nigricans

A hyperpigmented rash on the neck of an overweight man is likely to be acanthosis nigricans, D. Insulin resistance is often present in obese persons with this rash. There is no specific treatment; however, weight reduction and correction of hyperinsulinemia may help resolve the rash.

Eight types of AN have been described. 

Obesity-associated AN, once labeled pseudo-AN, is the most common type of AN.

Lesions may appear at any age but are more common in adulthood.

The dermatosis is weight dependent, and lesions may completely regress with weight reduction.

Insulin resistance is often present in these patients; however, it is not universal.

Syndromic AN is the name given to AN that is associated with a syndrome. In addition to the widely recognized association of AN with insulin resistance, AN has been associated with numerous syndromes . The type A syndrome and type B syndrome are special examples.

The type A syndrome also is termed the hyperandrogenemia, insulin resistance, and AN syndrome (HAIR-AN syndrome). This syndrome is often familial, affecting primarily young women (especially black women). It is associated with polycystic ovaries or signs of virilization (eg, hirsutism, clitoral hypertrophy). High plasma testosterone levels are common. The lesions of AN may arise during infancy and progress rapidly during puberty.

The type B syndrome generally occurs in women who have uncontrolled diabetes mellitus, ovarian hyperandrogenism, or an autoimmune disease such as systemic lupus erythematosus, scleroderma, Sjögren syndrome, or Hashimoto thyroiditis. Circulating antibodies to the insulin receptor may be present. In these patients, the lesions of AN are of varying severity.

Acral AN (acral acanthotic anomaly) occurs in patients who are in otherwise good health.

Acral AN is most common in dark-skinned individuals, especially those of African American descent.

The hyperkeratotic velvety lesions are most prominent over the dorsal aspects of the hands and feet.

Unilateral AN, sometimes referred to as nevoid AN, is believed to be inherited as an autosomal dominant trait.

Lesions are unilateral in distribution and may become evident during infancy, childhood, or adulthood.

Lesions tend to enlarge gradually before stabilizing or regressing.

Familial AN is a rare genodermatosis that seems to be transmitted in an autosomal dominant fashion with variable phenotypic penetrance.

The lesions typically begin during early childhood but may manifest at any age.

The condition often progresses until puberty, at which time it stabilizes or regresses.

Drug-induced AN, although uncommon, may be induced by several medications, including nicotinic acid, insulin, pituitary extract, systemic corticosteroids, and diethylstilbestrol.

Rarely, triazinate, oral contraceptives, fusidic acid, and methyltestosterone also have been associated with AN.

The lesions of AN may regress following the discontinuation of the offending medication.

Malignant AN, which is associated with internal malignancy, is the most worrisome of the variants of AN because the underlying neoplasm is often an aggressive cancer.

AN has been reported with many kinds of cancer , but, by far, the most common underlying malignancy is an adenocarcinoma of gastrointestinal origin, usually a gastric adenocarcinoma. In an early study of 191 patients with malignant AN, 92% had an underlying abdominal cancer, of which 69% were gastric. Another study reported 94 cases of malignant AN, of which 61% were secondary to a gastric neoplasm.

In 25-50% of cases of malignant AN, the oral cavity is involved. The tongue and the lips most commonly are affected with elongation of the filiform papillae on the dorsal and lateral surfaces of the tongue and multiple papillary lesions appearing on the commissures of the lips. Oral lesions of AN seldom are pigmented.

Malignant AN is clinically indistinguishable from the benign forms; however, one must be more suspicious if the lesions arise rapidly, are more extensive, are symptomatic, or are in atypical locations.

Regression of AN has been seen with treatment of the underlying malignancy, and reappearance may suggest recurrence or metastasis of the primary tumor.

Mixed-type AN refers to those situations in which a patient with one of the above types of AN develops new lesions of a different etiology. An example of this would be an overweight patient with obesity-associated AN who subsequently develops malignant AN.

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NAFLD

NAFLD is on the rise and the increase is due to increase in the number new cases of Diabetes. This is gives a list of secondary causes of NAFLD>

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COPD - Evidence Based Approach

COPD is on the increase and recent figures show that women are catching up with men. Early diagnosis and treatment can delay progression of further airway obstruction and reduction in lung function. Read here for Evidence Based Approach to its management..

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NAP BEFORE WORK

New York Times has an excellent article on the importance of sleep. A quote from the article:

Steven P. Jobs, the chief executive of Apple Computers, once defined creativity as “just connecting things.” Sleep assists the brain in flagging unrelated ideas and memories, forging connections among them that increase the odds that a creative idea or insight will surface.

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Malaria self treatment

Self-Treatment of Presumptive Malaria in a Traveler

Recommended self treatment regimens 

Chloroquine-sensitive regions

(A) Patients not receiving chloroquine prophylaxis

Chloroquine base 600 mg followed by 300 mg base after 6 hours, then 300 mg base daily x 2 days. Children: 10 mg base/kg followed by 5 mg base/kg after 6 hours, then 5 mg base/kg daily x 2 days (maximum are the adult doses).

Start chloroquine prophylaxis.

(B) Patients already receiving chloroquine prophylaxis

Atovaquone/proguanil 1000/400 mg (4 tablets) once daily x 3 days. Children: Atovaquone 20 mg/kg and proguanil 8 mg/kg daily x 3 days (maximum is the adult dose).

Resume chloroquine prophylaxis.

Chloroquine- or chloroquine + mefloquine-resistant P. falciparum regions

(A) Patients not receiving atovaquone/proguanil prophylaxis

Atovaquone/proguanil 1000/400 mg (4 tablets) once daily x 3 days. Children: Atovaquone 20 mg/kg and proguanil 8 mg/kg daily x 3 days (maximum is the adult dose), OR

Quinine/doxycycline: Quinine 250 mg base, 2 tablets three times daily x 7 days, and doxycyline 100 mg twice daily x 7 days.

Start/resume atovaquone/proguanil, doxycycline, or mefloquine.

(B) Patients receiving atovaquone/proguanil prophylaxis

Quinine/doxycycline: Quinine 250 mg base, 2 tablets three times daily x 7 days, and doxycyline 100 mg twice daily x 7 days.

Resume atovaquone/proguanil.

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Banjo center of brain

Bluegrass legend Eddie Adcock recently underwent brain surgery to treat a hand tremor. During this procedure, his surgeons placed electrodes deep into his brain to stimulate the thalamus at just the right spot to inhibit his tremor.

Alas, the banjo center of the brain is not an area well-known to neuroanatomists. To pick the optimal location for the electrodes, the surgery was performed under local anesthesia while Eddie played his banjo. He was thus able to update the surgeons in real-time as to whether the tremor was better or worse, letting them get the lead placement just right.

The BBC has posted some remarkable video and audio clips recorded during this surgery. The audio beginning at the 3:49 marker moved me the most. In this bit, the BBC interviewer asks Mr. Adcock to play the banjo with his stimulator on and off. The difference is pretty clear, even to the non-bluegrass ear.

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Weird Body Quiz

In a desperate attempt to take my mind off the "E" word today, I stumbled across The Weird Body Quiz at the New York Times site. It's probably a good thing I went into medicine instead of specializing in weird body facts -- I scored a paltry 3.

This quiz is taken from a list of unusual medical questions compiled by a surgeon and her teenage daughters called "Why Don't Your Eyelashes Grow? Curious Questions Kids Ask About the Human Body". Sounds like just the place to get some just-in-time CME on boogers, hiccups, pee and farts.

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Septic Shock

Abstract of Current management of Septic Shock. Read here...

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Mounier-Kuhn syndrome

A case of Tracheobronchomegaly.. (Mounier-Kuhn syndrome). I have never seen a case like this!

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Stroke and Imaging

Early diagnosis of stroke is essential to intervene before irreversible damage happens to brain tissue. Imaging is an important tool before even thrombolytic therapy can be considered. Read more..

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Inflammatory AAA

Inflammatory abdominal aortic aneurysm (AA) accounts for 5 % to 10 % of all cases of AAA and is characterised pathologically by marked thickening of the aneurysm wall, fibrosis of the adjacent retroperitoneum, and adherence of the adjacent structures. The abdominal or back pain, weight loss, and elevated systemic inflammatory markers triad in patients with abdominal aortic aneurysms suggests inflammatory aneurysm. Surgical treatment of AA is prudent once the diameter of the aneurysm exceeds 5.5 cm. Even though it is related to a three-time higher perioperative morbidity and mortality rate than in noninflammatory aneurysm, most authors agree that corticosteroids do not alter the long-term development of inflammatory aneurysms and that operative repair of the aneurysm is the treatment of choice.

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Glycemic Burden

In order to develop strategies that optimally address the glycemic burden in type 2 diabetes, it is informative to understand the relative contributions of FPG and PPG. Monnier et al did just that in a study published in 2003.
They enrolled 290 non-insulin- and non-acarbose-using patients with type 2 diabetes. Their plasma glucose concentrations were determined at fasting and during postprandial and postabsorptive periods. The areas under the curve above fasting glucose concentrations and above 6.1 mmol/L were calculated for further evaluation of the relative contributions of postprandial and fasting glucose increments to the overall glycemic burden.. The data were analyzed by quintiles of A1c.As shown in the Figure, the relative contribution of PPG decreased progressively from the lowest (69.7%) to the highest quintile of A1c

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Alpha1 Antitrypsin defeciency- A Review

An open access full text review is available in the Orphanet Journal of Rare Diseases. The most underappreciated point in the article: all patients with COPD and asthma should be screened. Read full article..

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Contrast Induced Nephropathy

Contrast Induced Nephropathy can be disastrous in already ill patient and this condition can be prevented by hydration. This study published in JAMA concludes saline is as good as bicarb. Read more..

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JUPITER on Target

JUPITER is a primary CVD prevention study that has shown benefits in healthy people with raised CRP.

"Ideally, if a patient comes to me with normal LDL-cholesterol levels—in JUPITER, the median LDL-cholesterol level was 2.5 mmol/L—I tell him to keep doing what he's doing and to go about his business," said Nissen. "Now, what happens when that same patient arrives in my office and I know his CRP is elevated? I know that treating him with intensive statin therapy, despite what the guidelines state, is going to cut his risk of cardiovascular morbidity and mortality in half."

Read JUPITER study..

Caution: The rosuvastatin group did not have a significant increase in myopathy or cancer but did have a higher incidence of physician-reported diabetes.

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SMART-COP for CAP

Predicting severity of Community Acquired pneumonia can be difficult even when we use severity indexes like CURB-65 and Pneumonia severity Index. SMART-COP ss eems to a better option concludes this brief report.
The UK Department of Health has published concerns that pneumonia severity scores determined at hospital admission may underestimate the severity of pneumonia in young adults. SMART-COP (systolic blood pressure, multilobar chest radiography involvement, albumin level, respiratory rate, tachycardia, confusion, oxygenation, and arterial pH) was superior to both the CURB65 (confusion, urea, respiratory rate, systolic or diastolic blood pressure, and age 65 years) score and the Pneumonia Severity Index in predicting the need for mechanical ventilation and/or inotropic support, but SMART-COP would still incorrectly stratify 15% of patients..

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ACCF/ACG/AHA 2008 Expert Consensus Document on Reducing the Gastrointestinal Risks of Antiplatelet Therapy and NSAID Use

The following are 12 points to remember about this expert consensus document:

1. Nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin (ASA), are the most widely used class of medications in the United States. 
2. As the use of any NSAID—including COX-2-;selective agents and over-the-counter doses of traditional NSAIDs, in conjunction with cardiac-dose ASA—substantially increases the risk of ulcer complications, a gastroprotective therapy should be prescribed for at-risk patients.
3. The use of low-dose ASA for cardioprophylaxis is associated with a two- to fourfold increase in upper gastrointestinal event (UGIE) risk. Enteric-coated or buffered preparations do not reduce the risk of bleeding. For patients at risk of adverse events, gastroprotection should be prescribed. The risk of UGIE increases with ASA dose escalation; thus, for the chronic phase of therapy, doses greater than 81 mg should not be routinely prescribed.
4. The combination of aspirin and anticoagulant therapy (including unfractionated heparin, low molecular weight heparin, and warfarin) is associated with a clinically meaningful and significantly increased risk of major extracranial bleeding events, a large proportion from the upper GI tract. This combination should be used with established vascular, arrhythmic, or valvular indication; patients should receive concomitant proton pump inhibitors (PPIs) as well. When warfarin is added to aspirin plus clopidogrel, an international normalized ratio (INR) of 2.0-2.5 is recommended.
5. Substitution of clopidogrel for ASA is not a recommended strategy to reduce the risk of recurrent ulcer bleeding in high-risk patients and is inferior to the combination of ASA + PPI.
6. The combination of clopidogrel and warfarin therapy is associated with an increased incidence of major bleeding when compared with monotherapy alone. Use of combination antiplatelet and anticoagulant therapy should be considered only in cases in which the benefits are likely to outweigh the risks. When warfarin is added to aspirin plus clopidogrel, an INR of 2.0-2.5 is recommended.
7. PPIs are the preferred agents for the therapy and prophylaxis of NSAID- and ASA-associated GI injury.
8. Testing for and eradicating H. pylori in patients with a history of ulcer disease is recommended before starting chronic antiplatelet therapy.
9. Decision for discontinuation of ASA in the setting of acute ulcer bleeding must be made on an individual basis, based on cardiac risk and GI risk assessments, to discern potential thrombotic and hemorrhagic complication
10. Endoscopic therapy may be performed in high-risk cardiovascular patients on dual antiplatelet therapy, and collaboration between the cardiologist and endoscopist should balance the risks of bleeding with thrombosis with regard to the timing of cessation of antiplatelet therapy.
11. Overall, in appropriate patients, oral antiplatelet therapy decreases ischemic risks, but this therapy may increase bleeding complications
12. Communication between cardiologists, gastroenterologists, and primary care physicians is important to weigh the ischemic and bleeding risks in an individual patient who needs antiplatelet therapy, but who is also at risk for or develops significant GI bleeding. Debabrata Mukherjee, M.D., F.A.C.C.

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Metformin And fatty Liver

In a small Norweigian Study that compared histological proven fatty liver Metformin did not show any response in reversing fatty changes, This was presented in AASLD meeting this week. It produced weight loss while patients taking drug that was regained soon after. Hepatologists have been borrowing diabetic drugs and hoping these drugs will work in fatty liver. It is time we look at other newer options line dual PPAR inhibitors.

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Hypertension and CKD

Drug therapy in the presence of CKD can be tricky. Read more on HT treatment in CKD.

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Doll's Eye

Oculocephalic reflex

Excellent flash animation showing the oculocephalic reflex doll’s eye sign.

You can see the animation here>>>.

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Phobias

I have phobia of heights. You may have other phobias. This gives extensive list of Phobias..

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