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June 29, 2008
June 28, 2008
Soon we will be talking glucose control as eAG and HBA1C amy be soon forgotten. Should we want to change is not a question here. When this will happen is the question?
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June 26, 2008
You are sure to get a case of mitral regurgitation in your paces and you will asked how to assess severity and indications for surgery. This is an article worth reading..
Can you click on these three images from the same patient and give me a diagnosis?
Click on arterial...
Click on venous...
Click on delayed...
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This is a case of 40 year old female with giant hemangioma of liver with triple phase CT showing classical centripetal fill-in.( Images Courtesy of dr Sethi)
We have moved on to an era of devices and patients are walking around with prosthetic joints, pace makers, Intra cardiac defibrillator and Long term Iv catheters and so on.Infections of these foreign bodies can happen. Diagnosis and management of these infections are really difficult.
Biofilm formation takes place when infection occurs and this provides with safe heaven for these bacteria. Read this review here..
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June 24, 2008
June 23, 2008
How old is old Kan? Some times thats not easy to judge. I am getting on 57 and some days i feel young and other days old. It is interesting to read this post that i have syndicated from hospitalist..
At what point do you draw the line? Look at This old and flexible old lady. People come in many states of health. Clinically, I say it over and over again. Those who don't smoke and who exercise on a regular basis look much younger than their stated age. Those that smoke and don't exercise look much older than their stated age. There is the physiological age and the birth age. 90 year olds look like 60 year olds. 60 year olds look like 90 year olds.
Walking a day in my shoes involves a continuous evaluation of the whole clinical picture. I don't consider myself a specialist per say of any organ system. But I do consider myself a specialist of all organ systems. It's called internal medicine. And I fine tune my practice for hospital based presentations. Every day I must make decisions. Decisions on how to evaluate new abnormalities that present themselves. Decisions on how to manage known chronic medical conditions. But how do I decide? How do I decide what to do and when to do it. What to order. What not to order.
Many non practicing policy bench warmers would like to believe that practicing medicine is nothing more than following a guideline. For example, from the public's point of view, if they came across this website, they may be lead to believe that being a doctor is simply following rules. It couldn't be farther from the truth.
Let me give you an example. What do you do when an independent 95 year old man comes to the hospital with a 3 week history of weakness and found to have anemia. A hemoglobin of 6. What do you do when this same 95 year old man is found to have paroxysmal SVT with bursts of 180 and sinus rhythms of 40? What do you do? What do you do when you find moderate to severe mitral regurgitation with pulmonary pressures of 60 mmHg?
What do you do? Do you follow the guidelines (if they exist) and treat each problem as an independent entity, devoid of a living person? Or do you look at the big picture?
How do you make a decision on how aggressive to be? We all want to sit here and say that age should not be an independent predictor for making medical decisions. I ask why shouldn't it be. Why should we not employ age in the equation of resource allocation. Let me ask you this:
Would you put a $30,000 defibrillator into a 60 year old patient with sudden cardiac arrest due to ventricular tachycardia and concurrent colon cancer with metastatic lung and liver lesions? How about a $5,000 pace maker? If you would, why would you. If not why not? What would be the basis of your decision? These are clinical decisions that are made every day. Judgement calls by medical professionals. You can't write guidelines for this stuff. Some doctors lose site of the big picture and do things to patients because they can. Because they lose sight of the big picture. And sometimes, when you focus on the nail, it's just easier to ignore the house falling apart around you.
Good hospitalists are able to provide a big picture look at patient care and health care utilization in the hospital. You could call it expert medical opinion based rationing. That's what it is. And it's perfectly ok to limit ineffective and costly care with limited expected benefit. In the case of my 95 year old man. Imagine if a cardiologist or a gastroenterologist was primary. The gastro consults the heart. When the kidneys get stunted from the cath dye, the kidney docs come on board. When the temperatures start rising after a vomiting episode, on come the ID docs and the lunginators.
When I admit this patient, this patient is mine. I make the decision when a heart doctor is appropriate. When a lunginator or when the fever beavers are needed. But when a specialist admits this kind of patient, anything outside their organ leads to a cornucopia of specialists with macular degeneration. With out a hospitalist, or internist, or family practice specialist the big picture is often lost in a sea of "check with Dr. Fever Beaver. That's not my area." I see it all the time when we come on board patients who have compartmentalized.
My 95 year old has an actuarial life expectancy of about 2 1/2 years. Not until you hit age 112 is the life expectancy less than one year. Does that mean we should do everything possible because the patient has a life expectancy of over one year? I don't think so. I make decisions not to pursue abnormalities every day. I make decisions not to make patients lives more miserable. I make calculated decisions based on risk and benefit all the time. Sometimes I discuss my thoughts with the patient. Sometimes I don't. Sometimes I don't give them the option of a pace maker. Some times I tell them dialysis is not an option. Sometimes I tell them that their granny would not survive that procedure or surgery. And I feel completely at ease because I know that not doing many things by the guideline is often times cheaper and will have no meaningful change in long term outcomes. In other words, death is natural.
Do I think I need to offer a pacemaker to a 95 year old with colon cancer? How about a 95 year old without colon cancer? Do I even need to offer a colonoscopy to a 95 year old who may have colon cancer? I often don't know the answer to my own questions because I need to be there, in the thick of things to really understand how to answer my own questions. Guidelines are just that, but often worthless when you are dealing with real life situations. A 95 year old is the equivalent of a patient with cancer with a 2 year expected survival. As a nation we have to accept our mortality and start serious discussions about resource utilization across many spectrums of disease. That includes end stage disease. But that also includes end stage age. If we are going to realistically fund future generations, then the talks must begin now.
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I like to watch Mr Bean movies and he is irritatingly funny sometime. Click here to see him.. ha ha ha
Here is a presentation i read from the web. Lot of interesting information.
Click on mushroom...
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June 21, 2008
June 20, 2008
June 19, 2008
A 37 year old fisherman from India presented with these tortuous and serpentine tracts and forks were seen traveling in a bizarre pattern, extending from the dorsum of the feet up to the knees. Similar tracts were present in the left hand also.lesions present in both legs.
Click here to see image...Cutaneous larva migrans (LM) or creeping eruption (CE) is a distinct cutaneous eruption caused by the hookworms or nematodes such as Ankylostoma brasiliensis , A. caninum , A. ceylonicum , Uncinaria stenocephala and Bubostomum phlebotomum . It is rarely caused by Strongyloides stercoralis , Dirofilaria spp., Spirometra spp., Gnathostoma spp. and Loa Loa . These nematodes normally do not parasitize human skin. However, the infective larval forms of the dog or cat hookworm may accidentally penetrate the intact exposed skin and then wander through the epidermis.
June 18, 2008
I have never ever heard of this syndrome and probably not seen one.Did you know that. You will never know you may see one. Did you know Brown Sequard suffered with this syndrome? I knew him for other descriptions.. What is this syndrome? Rumination is a syndrome characterised by repetitive regurgitation of food from the stomach. The food is then partially or completely re chewed, swallowed or expelled..
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PEG provides durable access for enteral nutrition, can generally be performed quickly and usually with only conscious sedation, and continues to be one of the most common procedures referred to gastroenterologists. It represents a dramatic improvement over surgical gastrostomy.However, a large number of PEG tubes continue to be placed in patients for whom the benefit is questionable or limited at best.
These patients are exposed to a procedure with a procedure-related mortality of 0.5% and morbidity of 17% while they are unlikely to derive benefit. It is difficult to think of other medical procedures with as unfavorable risk-benefit ratios that are performed as commonly as PEG. The moral and ethical uncertainty facing patients, surrogates, and physicians when confronted with the choice to withhold artificial nutrition and hydration likely drives the decision to place PEG tubes in many patients who are unlikely to derive benefit. It remains to be seen if interventions such as improved physician education about the limitations of PEG tubes to improve outcome, the increased use of palliative care teams, the increased use of advanced directives, or overall education of physicians and the public about end-of-life issues, will lead to a decrease in the placement of PEG tubes in patients with end-stage illness... I have copied the conclusions of this article but worth reading.
Systolic blood pressure should become the sole defining feature of hypertension and key treatment target for people over age 50 years. The reason is systolic pressure rises with age, diastolic pressure increases until around age 50 and falls thereafter. What about patients below the age of 50, Read more... Among people under age 40 years, as many as 40% of patients with high blood pressure have isolated diastolic hypertension, and between ages 40 and 50 years, such disease accounts for a third of hypertension. So in patients younger than 50 years a continued emphasis on both diastolic and systolic pressures remains appropriate. Read online publication in recent Lancet..
For the past 15 years, hypothermia therapy has been tested for many neurologic emergencies. Studies have provided clear evidence for protective effects; others have yielded mixed or conflicting results. Available evidence suggests that hypothermia therapy is more effective if it is applied soon after injury. This inhibits the complex cascade of processes that occurs at the cellular level after a period of ischemia. Induction of mild hypothermia (32 - 35°C) has been used as treatment of TBI, stroke, hepatic encephalopathy, MI, and other clinical conditions.. Indications are read more...
* Potential indications for hypothermia include cardiac arrest and cardiopulmonary resuscitation, perinatal asphyxia, TBI, ischemic stroke, acute MI, and perioperative hypothermia.
* Cardiac arrest and cardiopulmonary resuscitation:
o Between 1997 and 2001, 6 small clinical trials were conducted and reported improved 21 outcomes vs historical controls. Subsequently, 3 randomized controlled trials were performed and demonstrated a favorable outcome in the hypothermia group.
o Guidelines by the European Resuscitation Council and American Heart Association recommend hypothermia after cardiac arrest if the initial rhythm is ventricular tachycardia or ventricular fibrillation and to consider its use for other rhythms.
o A meta-analysis concluded that the number needed to treat (NNT) to leave the hospital in good neurologic recovery was 6.
o Current evidence suggests that patients should be cooled to 32 to 34°C for 12 to 24 hours, but this is subject to change as more information becomes available.
* Perinatal asphyxia:
o Hypothermia should be considered for newborn babies with perinatal asphyxia, especially those with mild to moderate injuries.
o Adverse effects seem to be minor, and studies support an NNT of 6.
o Target temperature should be 33 to 35°C, with some evidence suggesting that the lower range (33 - 33.5°C) is more effective; duration should be 48 to 72 hours.
* TBI:
o Hypothermia is effective in controlling intracranial hypertension.
o Lower intracranial pressure does not guarantee improved outcome; positive effects on survival and neurologic outcome have been achieved only in large referral centers with experience in hypothermia use, when treatment was applied within a few hours after an injury for more than 48 hours in patients with raised intracranial pressure.
o Management of adverse effects, such as hypotension or hypovolemia, is of key importance.
o Rewarming should be done very slowly for at least 24 hours.
o Patients with TBI with mild hypothermia (33 - 35°C) at admission, who are hemodynamically stable, should be allowed to remain in a hypothermic state.
o Hypothermia can also be used to control intracranial pressure in the later stages after TBI, but no evidence exists that neurologic outcome is improved by such delayed application of hypothermia.
* Ischemic stroke:
o Animal studies and some clinical data suggest that hypothermia could limit neurologic injury in stroke, but insufficient evidence exists to recommend its use outside clinical trials.
o Hypothermia could be used to control intracranial pressure in patients with middle cerebral artery infarction and cerebral edema and could improve their outcome.
* Acute MI:
o No evidence demonstrates that hypothermia is harmful to the injured heart, and rapid induction of hypothermia might reduce infarct size in patients with anterior MI.
* Perioperative hypothermia:
o Although intraoperative hypothermia is widely used, firm evidence from randomized controlled trials is often absent.
o Animal studies and initial clinical trials using hypothermia for spinal protection in major vascular surgery have shown promising results.
o However, a large clinical study in patients undergoing cerebral aneurysmal clipping noted no substantial effect of hypothermia.
o Evidence suggests that rapid rewarming can be harmful and might cancel out potential benefits of preceding hypothermia treatment or even make the neurologic situation worse.
o Fever is a common complication in patients with various types of neurologic injury and is independently associated with increased risk for adverse outcomes.
Read recent review article published in Lancet..
June 17, 2008
Baroreflex failure is rarely recognised syndrome. What is this reflex and its role in maintaining normal blood pressure? Read more.... and more..
This can be confused with Autonomic failure.Baroreflex failure has a range of presentations, varying from the acute onset of a hypertensive crisis to a chronically volatile blood pressure and heart rate with hypertensive surges in response to stress, punctuated by periods of normal or even low blood pressure during rest. Differentiating this syndrome from other causes of labile hypertension ike Pheochromocytoma is essential in devising effective treatment. In the Current issue of Kidney International they present a case of Paroxysmal hypertension due to baroreflex failure.
Further Reading here...
June 16, 2008
Measuring four vital signs( temp, Pulse rate, Blood Pressure, Respiratory rate)is vital in monitoring patients in medical ward. Out of these respiratory rate is usually ignored and not always recorded. Why? Ignorance of its Importance? That it is a marker of serious illness? Read more...
Not only recognizing but responding to the acute problem is mandatory. Please read this NICE recommendation...
![cover_160608[1]](http://img147.imageshack.us/img147/3123/cover1606081aw1.jpg)
How many times we have read that apparently healthy children and young adults die without warning. Even fit atheletes die.
The long-QT syndrome is foremost among responsible causes, and is known to be the consequence of mutations in genes encoding ion channel function. Previously thought to be rare , its prevalence is now estimated as one in 2000.
What are the implications for physicans and general practitioners?
Fainting is common, most often vasovagally mediated, and benign. How do we decide otherwise? The key is to be mindful of possible long-QT syndrome when checking the history; fainting or a seizure during exercise, or when upset or angry, and premature death (including drownings or accidents) in family members should ring alarm bells and trigger detailed exploration of the family history, close scrutiny of ECGs and appropriate referral. In such settings, a corrected QT (QTc) interval > 0.45 seconds in males and > 0.47 seconds in females makes the diagnosis virtually certain. |
The ladder diagram (also called a laddergram) remains a popular visual aid when graphically representing the mechanism of arrhythmia. It disentangles atrial and ventricular electrical activity and gives explicit representation to the sinoatrial and atrioventricular nodes.
More than 100 years after the first published ladder diagrams, this report reviews their origins, development, and limitations. Ladderlike diagrams have existed since 1885, first applied to venous and arterial pulsation timing or waveform tracings and later in 1920 alongside electrocardiograms to explain the generation and propagation of electrical impulses in the heart. Let us look at PAC s.
Premature atrial complexes
Occur as single or repetitive events and have unifocal or multifocal origins.
The ectopic P wave (called P’) is often hidden in the ST-T wave of the preceding beat. (Dr. Marriott, master ECG teacher and author, likes to say: "Cherchez le P on let T" which in French means: "Search for the P on the T wave", but it’s more sexy in French!)
The P’R interval is normal or prolonged because the AV junction is often partially refractory when the premature impulse enters it.
PAC’s can have three different outcomesdegree of prematurity (i.e., coupling interval from previous P wave), and the preceding cycle length. This is illustrated in the "ladder" diagram where normal sinus beats (P) are followed by three possible PACs; in the diagram the refractory periods of the AV node and bundle branches are indicated by the width of the boxes):
Let me show Laddergram:
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June 15, 2008
The Caduceus is a winged staff with two snakes wrapped around it. Originally the Caduceus was considered as a symbol of commerce and associated with the Greek god Hermes. Later in the seventh century it was associated with medicine based on the Hermetic astrological principles of using planets to heal the sick.
In learned circles the Rod of Asclepius is preferred over the Caduceus as a symbol of medicine.
Neutropenia makes whole medical floor to get worried and finding an isolation room is always a problem.
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June 14, 2008
Clubbing remains an amazing clinical sign.This was described Hippocrates 2000 years ago. Its strong association with serious disease is still a clinical enigma. Moreover, the significance of diagnosing clubbing is not well established. But recently the riddle is solved and a new tool has been described. Read here....
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I am some one who has been keen on ward rounds and what we call grand rounds. No doubt by this way lot of decisions are made with improvement in patient care. Abstract taken from European Journal of Medicine.
The ward round has been a central activity of hospital life for hundreds of years. It is hardly mentioned in textbooks. The ward round is a parade through the hospital of professionals where most decision making concerning patient care is made. However the traditional format may be intimidating for patients and inadequate for communication. The round provides an opportunity for the multi-disciplinary team to listen to the patient's narrative and jointly interpret his concerns. From this unfolds diagnosis, management plans, prognosis formation and the opportunity to explore social, psychological, rehabilitation and placement issues. Physical examination of the patient at the bedside still remains important. It has been a tradition to discuss the patient at the bedside but sensitive matters especially of uncertainty may better be discussed elsewhere. The senior doctor as round leader must seek the input of nursing whose observations may be under-appreciated due to traditional professional hierarchy. Reductions in the working hours of junior doctors and shortened length of stay have reduced continuity of patient care. This increases the importance of senior staff in ensuring continuity of care and the need for the joint round as the focus of optimal decision making. The traditional round incorporates teaching but patient's right to privacy and their preferences must be respected. The quality and form of the clinical note is underreported but the electronic record is slow to being accepted. The traditional multi-disciplinary round is disappearing in some centres. This may be regrettable. The anatomy and optimal functioning of the ward round deserves scientific scrutiny and experimentation.
ADA: Intensive Diabetes Treatment to Blame for Excess Mortality Risk
And here is the rest of it.The elevated mortality seen among patients with type 2 diabetes in a major trial of intensive glucose management cannot be pegged to either rosiglitazone (Avandia) or hypoglycemia, researchers said here.
Rather, they suggested, it was the multiple-agent treatment and rapid decrease in glycosylated hemoglobin levels to a target 6.5% that increased mortality 22% (1.41% versus 1.14% per year, P=0.04) compared with a standard approach targeting 7% in the ACCORD trial.
The results of ACCORD and two other large, randomized trials of tight glucose control made waves at the American Diabetes Association meeting. (See: ADA: ACCORD Diabetes Trial a Complete Bust)
I believe it is logical that using more drugs for a problem will likely cause problems. The point of intensive control is to decrease deaths. Thus, physicians must balance errors of commission against errors of omission. In fact we always have to consider the consequences of our treatments on the patient (rather on the disease.)
Now Dr. Mintz reads these data in a different way - AACCORD and ADVANCE: Good News for Type 2 diabetes…really.. He says:
All of the reports (linked to above) point out that these studies failed to prove that aggressive treatment makes any difference in heart attacks or strokes, and in the case of ACCORD seemed to (surprisingly) cause more heart attacks. However, they are missing a majorly important finding of both studies. Treating diabetes aggressively is quite effective!
I must disagree with Dr. Mintz. Death is the ultimate poor outcome, and death rates caused investigators to stop the ACCORD study,.
The real question is summed up with the expression - how hard must we squeeze to get the juice? And the hard squeeze does more than produce the juice.
We must focus on patient outcomes, not disease outcomes. The importance of these studies is that they reinforce that message.
Perhaps we should examine each drug to see if it helps patients. Then we should look at specific 2 drug combinations to see what happens. We should work at treating patients, observing patient and disease related outcomes. We should eschew intermediate outcomes, until and unless they are shown to really matter.
This questions is asked frequently and the answer is yes.
Read more....
June 13, 2008
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Non-steroidal anti-inflammatory drugs and colchicine used to treat acute gout arthritis have gastrointestinal, renal, and cardiovascular adverse effects. Systemic corticosteroids might be a beneficial alternative. I have used prednisolone with great success. This published in Lancet investigated equivalence of naproxen and prednisolone in primary care.
Authors conclude( as expected by me), the present study provides a strong argument to consider prednisolone as a first treatment option in patients with gout
Read full article here.....
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Patients with severe attack of migraine seek help in emergency department and may end up getting admitted in medical wards. In a systemic review published in BMJ authors assess the effectiveness of parenteral corticosteroids for treating acute severe migraine and preventing recurrence. In the same issue this editorial discuss treating severe migraine in emergency department.
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Since these guidelines were last updated in 2002, an explosion in information has expanded the indications for placement of a permanent pacemaker (PPM), cardiac resynchronization therapy (CRT) device, or implantable cardioverter-defibrillator (ICD), particularly for primary prophylaxis of sudden cardiac death and heart failure.
Read more....
This months review discuss Stroke risk reduction, treatment of UTI, Mediterranean diet and Lipid management.
Read More.....
June 12, 2008
We have learned from recent clinical trials that early, aggressive, combination therapy produces superior outcomes in patients with rheumatoid arthritis (RA). Early disease was initially defined as 5 years and more recently 3 years. However, many rheumatologists feel that the best opportunity to halt disease progression and obtain the best clinical response is to initiate an aggressive therapy program within the first 6-12 months of disease.The American College of Rheumatology (ACR) criteria for the diagnosis of RA initially developed in 1987 have come under scrutiny in recent years because of their inability to establish the diagnosis of RA in the early stages of the disease. This criteria was estblished in 1987 nad it has taken so many years to even attempt to change it.
Yuo can read this abstract that has included Anti CCP antibody to the existing ACR criteriae and called this CCP6.
In my last post i talked about the guideline tyranny and how different societies have differing recommendations. Guidelines published by authoritative societies have important influences on clinical practice. Are they changing our practice or confusing our decisions. This is a editorial published in Lancet.
Read more.....
You can read more on this dicrepancies in this report.....
June 11, 2008
When I say colitis we always think of infectious colitis. May be IBD in some cases. You have to remember that there are other types of colitis that can present with chronic diarrhoea.
This is an excellent review published in Nature. Read here.....
To bridge or Not to bridge these patients with LMWH is always the question asked. Although interruption of warfarin is thought to expose patients to a low risk of arterial thromboembolism, such events can have devastating consequences: valve thrombosis is associated with a 15% mortality rate, and an embolic stroke is associated with a 70% rate of major neurologic deficit or death.
Attempting to mitigate this risk by administering a short-acting anticoagulant, typically low-molecular-weight heparin (LMWH), shortly before or after surgery as “bridging anticoagulation” can expose patients to serious bleeding complications.
To walk this fine line between the twin risks of thromboembolism and bleeding requires an approach to perioperative anticoagulation that is sensible and, when possible, based on evidence.
A sensible approach entails first estimating a patient’s risk of thromboembolism, which will help determine whether bridging can be justified on the basis of empiric considerations (as clinical trials addressing this issue have not yet been done). After estimating the patient’s risk, the clinician should next consider the risk of bleeding associated with the surgery and tailor postoperative anticoagulation to minimize this risk. An assessment of postoperative hemostasis is essential, as it can modify reinitiation of postoperative anticoagulation. Finally, after anticoagulant treatment is resumed, ongoing vigilance for bleeding and thromboembolism is needed, especially during the first 1 to 2 weeks after surgery when most of these adverse events occur.
Read the article published in Mayo Clinic Proceedings.......
Obesity among teens is on the rise. This is eb site that helps parents with big children.It talks about te things that parents can do to prevent obesity among kids
Read more...........
Diagnosis of etiology of stroke sub types is not always possible in some patients and this prevents these patients from receiving definitive treatment. In this interesting study authors looked at the diagnostic value of a panel of biochemical markers to differentiate stroke sub types. Is it not wonderful if there is a blood test that will clinch the etiology. Read this article published in Stroke recent issue.
Read Here.
LDL cholesterol is the principal target for lipid lowering treatment.In this recent study published in Circulation authors looked Lipids, apolipoprotein and their ratios in relation to CV events. It is the CV outcome that is important in patient management.
Authors conclude that in patients receiving statin therapy, on-treatment levels of non-HDL cholesterol and apolipoprotein B were more closely associated with cardiovascular outcome than levels of LDL cholesterol. Read more......
BACKGROUND: -Low-density lipoprotein (LDL) cholesterol is the principal target of lipid-lowering therapy, but recent evidence has suggested more appropriate targets. We compared the relationships of on-treatment levels of LDL cholesterol, non-high-density lipoprotein (HDL) cholesterol, and apolipoprotein B, as well as ratios of total/HDL cholesterol, LDL/HDL cholesterol, and apolipoprotein B/A-I, with the occurrence of cardiovascular events in patients receiving statin therapy. Methods and Results-A post hoc analysis was performed that combined data from 2 prospective, randomized clinical trials in which 10 001 ("Treating to New Targets") and 8888 ("Incremental Decrease in End Points through Aggressive Lipid Lowering") patients with established coronary heart disease were assigned to usual-dose or high-dose statin treatment. In models with LDL cholesterol, non-HDL cholesterol and apolipoprotein B were positively associated with cardiovascular outcome, whereas a positive relationship with LDL cholesterol was lost. In a model that contained non-HDL cholesterol and apolipoprotein B, neither was significant owing to collinearity. Total/HDL cholesterol ratio and the apolipoprotein B/A-I ratio in particular were each more closely associated with outcome than any of the individual proatherogenic lipoprotein parameters.
Conclusions-In patients receiving statin therapy, on-treatment levels of non-HDL cholesterol and apolipoprotein B were more closely associated with cardiovascular outcome than levels of LDL cholesterol. Inclusion of measurements of the antiatherogenic lipoprotein fraction further strengthened the relationships. These data support the use of non-HDL cholesterol or apolipoprotein B as novel treatment targets for statin therapy. Given the absence of interventions that have been proven to reduce cardiovascular disease risk through raising plasma levels of HDL cholesterol or apolipoprotein A-I, it seems premature to consider the ratio variables as clinically useful.
Gastroscopy is done without sedation in our hospital. Sedation is always preferred by patients. In this study in Gastrointestinal Endoscopy assesses moderate sedation for routine endoscopic procedures.
Numerous agents are available for moderate sedation in endoscopy.
In this study authors compared efficacy, safety, and efficiency of agents used for moderate sedation in esophagogastroduodenoscopy or colonoscopy.
The team undertook a systematic review of computerized bibliographic databases for randomized trials of moderate sedation.The trials compared 2 active regimens or 1 active regimen with placebo or no sedation.The team assessed unselected adults undergoing esophagogastroduodenoscopy or colonoscopy with a goal of moderate sedation.The team measured sedation-related complications, patient assessments, physician assessments, and procedure-related efficiency outcomes.
The researchers evaluated 36 studies of 3918 patients. Sedation improved patient satisfaction and willingness to repeat esophagogastroduodenoscopy versus no sedation.
Midazolam provided superior patient satisfaction to diazepam, and less frequent memory of esophagogastroduodenoscopy versus diazepam. The researchers found adverse events and patient/physician assessments were not significantly different for midazolam vs propofol.
However, there was slightly less patient satisfaction, and more frequent memory problems with midazolam plus narcotics. Procedure times were similar, but sedation and recovery times were shorter with propofol than midazolam-based regimens.
The team noted marked variability in design, regimens tested, and outcomes; relatively poor methodologic quality.
Authors concluded, "Moderate sedation provides a high level of physician and patient satisfaction and a low risk of serious adverse events with all currently available agents."
"Midazolam-based regimens have longer sedation and recovery times than does propofol."
June 9, 2008
Laughter is a good medicine; it enhances cardiovascular heath and the immune system. But what happens if you laugh too much or out of control? Laughter-induced syncope is rare and likely goes unrecognized by many healthcare providers. It is thought to be another form of valsalva-induced syncope.
Read full article here.
June 8, 2008
A condition in which there is repeated episodes of HEMOGLOBINURIA caused by intravascular HEMOLYSIS. It is of two types.
In cases occurring upon cold exposure (paroxysmal cold hemoglobinuria), usually after infections, there is a circulating antibody which is also a cold hemolysin. In cases occurring during or after sleep (paroxysmal nocturnal hemoglobinuria), the clonal hematopoietic stem cells exhibit a global deficiency of cell membrane proteins.
Procalcitonin (PCT), the precursor of the calcitonin, is synthesized in the parafollicular C-cells of the thyroid. It has been used to detect and to differentiate systemic bacterial infections from flares of systemic lupus erythematosus (SLE).
PCT in serum increases in severe bacterial and fungal infections, but not, or only slightly in viral infections.
In this case controlled study published in Journal of Clinical Rheumatology authors looked at PCT levels in patients with active and withous lupus activity. They conclude that there is no association between activity of SLE and PCT.
I have always wondered why remove whole uterus when fiboids are only benign. This review paper discusses new technology, Magnetic resonance-guided focused ultrasound (MRgFUS) in treating such condition.
Uterine fibroids are common smooth muscle tumors, which can result in substantial symptoms affecting the quality of life of women. Whereas patients have several options available for treatment, focused ultrasound ablation is one of the least invasive treatment options outside medical therapy.
Magnetic resonance-guided focused ultrasound (MRgFUS) ablation combines therapy delivered by an ultrasound transducer with imaging, guidance for therapy, and thermal feedback provided by magnetic resonance imaging. In 2004, the MRgFUS system ExAblate 2000 (InSightec, Haifa, Israel) was approved by the FDA for clinical treatments of uterine fibroids.
This paper published in Ultrasound Quarterly provides an overview of clinical experience with MRgFUS, including a brief description of the treatment system, pertinent features to review on screening magnetic resonance imaging, how the procedure is performed, and risks and benefits of the treatment.
June 7, 2008
In Elderly heart failure is common. Appearance of pulmonary crackles(rales) is an important sign. But the presence of age-related pulmonary crackles might interfere with a physician's clinical management of patients with suspected heart failure
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Got ulcers? Know someone who does? Grab a virgin.
Olive oil, that is.
Yep, the antioxidants found in extra-virgin olive oil (or EVOO ), may put the kibosh to stomach ulcers by squashing the H. pylori bacteria, which is a cause of ulcers.
Says a study in the Journal of Agricultural and Food Chemistry, all you need is a couple teaspoons a day to get the benefits.
Try preparing your chicken or fish with EVOO instead of veggie oil, or add some to your salad dressing for that extra boost.
Long live the virgin!!
Here are some of the presentations from ADA meeting.
1)ESTIMATED AVERAGE GLUCOSE - New Measure for Diabetic control
The International A1c-AG study was conducted at 10 centers in the North America, Europe, and Africa, in an attempt to determine, as accurately as possible, the relationship between average blood glucose levels and HbA1c.
The study has recruited almost 650 of its goal of 700 volunteers (300 patients with type 1, 300 with type 2, and 100 without diabetes).
The patients' HbA1Cs are measured in a central laboratory in Holland using the new reference standard monthly for four months, with patients using a combination of continuous glucose monitoring for two to three days for each of the four months, plus frequent finger sticks equivalent to daily self-monitoring.
The results of the first 250 volunteers who have completed the study showed that there was a close correlation between HbA1c values at three months and average blood glucose during the same period
2) SELF GLUCOSE MONITORING IS UNNEEDED RITUAL IN MANY T2DM
This Oxford study found no significant benefit for frequent self-monitoring of blood glucose for many patients with type 2 diabetes, but self-monitoring remained essential for maintaining good glucose control in type 1 diabetes, and type 2patients who require insulin injections.
June 6, 2008
In chronic autoimmune conditions such as myasthenia gravis (MG), immunosuppression—usually long-term—is often necessary. The mechanisms of action of immunosuppressant drugs in MG fall into three main categories: inhibition of the cell cycle (azathioprine, cyclophosphamide, methotrexate and mycophenolate mofetil), immunosuppression of T cells (steroids, ciclosporin and tacrolimus), and B-cell depletion (rituximab).
This interesting review article is worth reading.
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Keep your teeth clean and you can reduce vascular disease. This is the implication of this study from VA.
The VA Normative Aging and Dental Longitudinal Studies in Boston followed 1200 men for up to 35 years and gave clear evidence of an association between chronic periodontitis and the risk of coronary heart disease independent of classical risk factors. We also know that periodontitis causes endothelial dysfunction together with systemic inflammation and endothelial function can be improved after successful periodontal treatment - however no true causal relation between periodontitis and vascular disease has been evidenced.
Regular dental care with treatment of periodontitis using local dental and antibiotic therapy with maybe even a statin seems advisable in patients at risk for atherosclerotic disease, because poor oral health and the presence of periodontitis may negatively affect the blood vessel wall. Read more...
