Strudy has shown not surprisingly that there is no worthwhile clinical benefit from opening the vessel.
Saves lots of money
Atherosclerotic Renal Artery Stenosis - ASTRAL Investigators
November 25, 2009
VTE priphylaxis in cancer -guideline
VTE in cancer patients is associated with increased morbidity and mortality. Recent review in JCO.
Consensus:
1)Prolonged prophylaxis for hospitalised high risk surgical patients
2) prophylaxis not recommended for ambulatory cancer patients or fir central lines
3)LMH is preferred for long term treatment of VTE
Extended release Niacin for carotid intima-media thickness
November 20, 2009
When you add extended release niacin to statin therapy the mean HDL cholestrol increased by 18% and significantly reduced LDL cholestrol and triglycerides. Mean carotid intima media wad signifantly reduced.
From NEJM nov 15,2009
Early repolarisation
In a Finnish study ECG showing J point elevation of 0.1mV and 0.2mV in the inferior leads was sugnificantly associated with cardiac death
Neiropathy and Diabetes
November 10, 2009
To diagnose neuropathy in diabetics with mo foot ulcer follwing clinical tests should be done,
check vibration sense with 128 tuning fork, pressure sensation with 10 g monofilament over distal hallus, ankle reflex and tests for pin prick.
Why do people use alternate medicine?
November 5, 2009
Are you not surprised so many people spend loads of money on alternate therapies?
The simple answer according to Rob is people want magic and alternate medicine promises magic
From distractible org
Anabolic steroids cause kidney disease
October 31, 2009
According to a paper published in ASN annual meeting body building supplementd by anabuc steroid usage can lead to focal segmental glomerulisclerosis.
Cardiovascular serious side effects are well known. This includs heart failure, MI, and ventricular tachy arrythmias.
Assessment of Neuropathic pain
Chronic pain falls into 3 categories;
1) pain due to tissue disease or damage( nociceptive pain)
2) pain due to somatosensory disease or damage( neuropathic pain)
3) pain without any somatic background
Chronic neuropathic pain is under recognised and under treated.
Treatment requires identifying type of pain, assessing it's components and determining appropriate treatment.
Am J Med 2009 Oct; 122(10 Suppl):S13-21
Peanut butter for vegetable resistant children
Thus was study presented in recent obesity society meeting .
When peanut butterbwas given to children who are vegetable resistant their vegetable intake incresed substantially.
Conclusion is give your children peanut butter along with vege.
Post exposure prophylaxis in HIV
October 30, 2009
Recommended regimen in combination of tenofovir with emtercitabine with or without boosted ritonovir - lopinovir. Duration of treatment is 28 days.
Resistant hypertension
Defined as blood pressure that remains above the goal despite taking three antihypertensive medications or blood pressure that is controlled but requires four it more medications.
Treatment:
1) life style midificaions such as reduce salt intake, reduce weight, less alcohol
2) identify secondary causes
3) use of long acting diuretics
4) some patient may benefit from mineralicoticoid receptor antagonist(MRA)
Spontaneous Bacterial Peritonitis: what's new?
October 29, 2009
A recent review is published in World Journal of Gastroentrology,March 7 th issue.
This condition seldom occurs with s
Small volume ascites or in those ascites unrelated to liver disease.
13% of patients have no direct symptoms.so diagnostic tap in patients admitted with large volume ascites in cirrhotic setting.
It is important to distinguish between primary and secondary peritonitis due to perforation of gut.
Applying a drop of ascitic fluid to the leucocyte esterase of a urine dip stick may help in rapid detection.
5 days of antibiotic is as effective as longer courses.
Albumin infusion us recommended for most patients, those with renal deterioation and those who undergo large volume paracentesis. Albumin is a volume expanded and binds to inflammatory mediators. 1.5G/kg on day 1 and 1G/kg for 3 days has been recommended.
Revised Criteria for Hepato-Renal syndrome
October 28, 2009
Revised criteria for HRS has been published in Gut, 2007. This is presented here for revision:
1) cirrhosis with ascites
2) serum creatinine > 133 mmol/L
3) no improvement in serum creatinine after atlesst diuretic withdrawal and volume expansion with albumin
4) Absence of shok
6) no current or recent use of nephrotixic drugs
7) absence of renal parenchymal disease
PSA Sceening / do the benefits outweigh risks
To screen or not to do PSA in screening for prostate cancer Is still going on. Two studies have reported recently.
First study from North America reported in NEJM march 2009 looked at PSA and DRE on the rate of death from prostate cancer. Result was after 7 to 10 years if screening did not differ significantly.
Second study was an European Study that looked at PSA and death from prostate cancer. Conclusion was PSA based screening reduced death rate by 20% with considerable over diagnosis .
Ideal and adjusted weight
October 27, 2009
Calculation of ideal and adjusted body weight is essential when treating electrolyte disorders:
Ideal weight: females: 45 kg+2.3 of for every inch over 5 feet (males 50kg)
Adjusted weight: ideal weight +0.4(actual body weight - ideal weight)
When to intervene in NSTE-ACS
ABOARD study results were presented at the ACC scientific Sessions,2009.
Primary endpoint was the rate of MI defined by peak rise in treponin-I levels .
The median time of intervention was 1.1h in immediate group and 20.5h in the delayed group.
The primary outcome was similar tobogg groups
Conclusion;
1) risk stratification in NSTE-ACS is mandatory
2)in real emergency situations - pulmonary edema, ventricular arrhythmias primary PCI I'd indicated
3) in high risk cases PCI can be performed within next 72 hours
Diet modifications to prevent nephrolithiasis
October 25, 2009
Ureteric colic is very painful
And secondary prevention is often overlooked.
There are few dietary measures have been shown to reduce the risk of stones;
1) drink plenty of water(keep urine out put > 2.5L/day
2)eat low animal fat diet
3) eat low sodium diet
4) avoid excess oxalate rich foods like spinach, beets, rhubarb & chocolalate
In a recent study published in JASN : oct;20, 2009:authors report DASH style diet Is associated with reduction in kidney stone risk.
Source : Renal fellow network
Length of time to defer surgery after stents
This Is an important question that's always asked by cardiologists and surgeons . This study published on line in AJC.
This cohort study looked at tick of major peri operative cardiac events in patients undergoing NCS,
Risk of cardiac events after NCS are substantial after stent even on dual anti-platelet therapy. Noncardiac surgery should be delayed as long as possiblein post stent ( atleast 1.5 months in BMS and 1 year in DES).
FOUR Coma Scale
Four stands for Full outline of UnResoinsivrness. It is a new coma scale consists of 4 components( eye reponse, motor response, brain stem reflex and respiratory pattern ).
This score was tested agsianst GCS . Useful score in patients when they are intubated.
The FOUR score is a good predictor of prognosis in critically Ill patients.
Drugs Associated Hyperkalemia
1) drugs that cause movement of K from inteacelular to the extracellular fluid
Succinyl choline
Minoxidil
Betablickers
2)potassium sparing diuretics
3) renin angiotensin inhibitors
4)osmotic diuretics
5)NSAIDs lower renin levels
6)bactrim inhibits ENAC
7)calcineurin inhibitors
8)heparin and ketakonazole
8) digitalisby inhibiting Na-K ATPase
Bed Side Eye Exam more sensitive for Stroke than MRI
Patients who present with dizziness may actually have stroke. This Is an important concern when you see patients on take.
In this prospective study they looked at 3 tests checking vestibulo- ocular reflex on horizontal head impulse, nystagmus, and ocular alignment during prism cross over.
The researcher report a normal head impulse test, direction changing nystagmus or skew deviation was highly predictive if stoke.
CAP and its treatment
September 19, 2009
This study evaluated the guideline concordant therapy on in hospital survival in adults patients treated for CAP. Of 54 619 non–intensive care unit inpatients with CAP hospitalized at 113 community hospitals and tertiary care centers, 35 477 (65%) received initial guideline-concordant therapy. After adjustment for severity of illness and other confounders, guideline-concordant therapy was associated with decreased in-hospital mortality (odds ratio [OR], 0.70; 95% confidence interval [CI], 0.63-0.77), sepsis (OR, 0.83; 95% CI, 0.72-0.96), and renal failure (OR, 0.79; 95% CI, 0.67-0.94), and reduced both length of stay and duration of parenteral therapy by approximately 0.6 days (P < .001 for both comparisons).
Guideline-concordant therapy for CAP is associated with improved health outcomes and diminished resource use in adults. Abstract of study..
ISDA GUIDELINE
score for acute pancreatitis
This study evaluated for bedside index for severity in acute pancreatitis(BISAP) score to predict mortality. BISAP score was calculated from data at 24 hours.
BISAP score consists of 5 variables( Urea >25 age >60, Glasgow coma scale <15, SIRS, Pleural effusion). Score of >3 was associated 1ith 18% mortality and <3 was associated 1ith 1% mortality.
CONCLUSIONS: The BISAP score represents a simple way to identify patients at risk of increased mortality and the development of intermediate markers of severity within 24 h of presentation. This risk stratification capability can be utilized to improve clinical care and facilitate enrollment in clinical trials.
Read abstract here..
Statins- Another indication
In the DECREASE-III trial, 497 statin-naive patients undergoing elective vascular surgery (carotid, aortic, or lower extremity) were randomized to fluvastatin 80mg or placebo (for 1 month before and 1 month after surgery). The statin group experienced less myocardial ischemia (11% vs 19%) and non-fata MI/CV death (5% vs 10%)You would expect most of these patients should have been on statins anyway, so there is no need to start all patients on statins..
Read the abstract here...
Platypnea-orthodeoxia
August 24, 2009
Platypnea-orthodeoxia is a relatively uncommon but striking clinical syndrome characterized by dyspnea and deoxygenation accompanying a change to a sitting or standing from a recumbent position. Since Burchell et al1 described this rare syndrome over half a century ago, no more than 50 cases have been reported in the literature.Platypnea-orthodeoxia has been described to occur in pulmonary arteriovenous shunts, pulmonary parenchymal shunts (as in the hepatopulmonary syndrome), or with intra-cardiac right-to-left shunts.
Two conditions must coexist to cause platypnea-orthodeoxia: an anatomical component in the form of an interatrial communication and a functional component that produces a deformity in the atrial septum and results in a redirection of shunt flow with the assumption of an upright posture. The former may be an atrial septal defect, a patent foramen ovale, or a fenestrated atrial septal aneurysm. The latter may be cardiac, such as pericardial effusion or constrictive pericarditis; pulmonary, such as emphysema, arteriovenous malformation, pneumonectomy, or amiodarone toxicity; abdominal, such as cirrhosis of the liver or ileus; or vascular, such as aortic aneurysm or elongation.2
Under normal conditions an interatrial communication allows blood to shunt from left to right due to a higher pressure in left atrium than right atrium and a greater compliance of the right ventricle than the left ventricle. Right-to-left interatrial shunting is usually associated with spontaneous or induced pulmonary hypertension and, therefore, in the absence of a right-to-left pressure gradient, what is the mechanism for a right-to-left shunt? Or put in another way, what causes water to flow uphill?2 A persistent Eustachian valve can cause interatrial right-to-left shunting with a normal right atrial pressure.3 Platypnea-orthodeoxia could be explained on the basis of positional modification of abnormal shunting. Standing upright could stretch the interatrial communication, be it a patent foramen ovale, an atrial septal defect, or a fenestrated atrial septal aneurysm, thus allowing more streaming of venous blood from inferior vena cava through the defect, whether or not a persistent Eustachian valve coexists.3 This redirection of flow caused by an anatomic distortion of the right atrium or the atrial septum also might occur from a loculated pericardial effusion, an aortic aneurysm, or aortic elongation.2
New breath holding test
this new test is useful in detecting early lung abnormalities in smokers and obese people..Read more...
Travel related VTE
Long distance travel is associated with increased risk of VTE. This meta analysis suggests 3 fold increase in VTE risk. Read More..
Subclinical Brain Embolization in Left-Sided Infective Endocarditis
The rue incidence of infective embolization in bacterial endocarditis is not known. This study looked at these patients using MRI.
Read the abstract of this article...
Drug Induced fibrotic Valve Diesase
Initial association between development of valvular heart disease and drugs based on 1960s use of methysergide and ergotamine for migraine prophylaxis
Currently implicated are the appetite suppressants fenfluramine and dexfenfluramine, the dopamine agonists pergolide and cabergoline, and the recreational drug ecstasy (MDMA)
ANCA of nembranous nephropathy
July 22, 2009
A landmark paper on membranous nephropathy was published by Beck et al in the most recent issue of NEJM. Ultimately we will have to see if the finding is reproducible, but based on the data presented this represents a major breakthrough in understanding the pathogenesis of membranous nephropathy and nephrotic syndrome.
There has long been strong evidence in support of a circulating factor which causes podocyte injury and resultant nephrotic syndrome. Additional evidence from the neutral endopeptidase story further suggested that an autoantibody directed again some podocyte antigen might be the culprit. In this issue, the researchers demonstrate that in 70% of patients with idiopathic membranous nephropathy (but 0% of patients with secondary membranous nephropathy or other forms of proteinuric kidney disease such as FSGS or diabetic nephropathy) contain an autoantibody against the podocyte antigen phospholipase A2 receptor. Furthermore, the autoantibody's presence appears to correlate with disease activity, suggesting a possible pathogenic role.
The work has a number of implications. First, it suggests that membranous nephropathy is indeed a separate disease than FSGS and other distinct forms of nephrotic syndrome. The common final pathway for proteinuria is the same (podocyte injury), but the ways in which to get there is likely different. Second, it suggests that detection of serum antibodies against phospholipase A2 receptor may be a useful part of the diagnostic workup for nephrotic syndrome--perhaps even making biopsies unnecessary--and perhaps could be used to follow disease activity in response to various therapeutic maneuvers. That is, this test may well become the "ANCA" of membranous nephropathy.
The Power of Pee?
Finally, I can sleep at night: scientists have discovered a way to turn urine into hydrogen. And you said I was crazy for collecting it in milk jugs!
From a group led by chemist Gerardine Botte of Ohio University comes a report (just published in the Royal Society of Chemistry's journal Chemical Communications) that hydrogen has been produced from urine.
According to a July 3, 2009 story on PhysOrg.com, "Urine's major constituent is urea, which incorporates four hydrogen atoms per molecule -- importantly, less tightly bonded than the hydrogen atoms in water molecules."
"Botte uses electrolysis to break the molecule apart, developing an inexpensive new nickel-based electrode to selectively and efficiently oxidise the urea. To break the molecule down, a voltage of 0.37V needs to be applied across the cell -- much less than the 1.23V needed to split water.
So, you know what this means, right? Wait for it....wait for it....the P-bomb. Thanks folks, I'll be here all week. Make sure to tip your bartender and maybe steal a bottle for me when they're not looking. *tap tap* Haha, is this still on?
Caveats for Using Renal Ultrasound to Diagnose Post-Renal Failure
Most would agree that the renal ultrasound is an invaluable tool in the workup of acute kidney injury. Although the renal ultrasound can give information regarding kidney echogenicity and presence of renal cysts, by and large its predominant utility is in determining the presence or absence of hydronephrosis, a marker for obstructive renal failure ("post-renal" failure when referring to the Holy Trinity of "pre-renal", "intrinsic renal", and "post-renal" categories of AKI).
However, there are important caveats to the use of the renal ultrasound to effectively rule-in or rule-out obstructive nephropathy. For instance, false-negatives (e.g., the renal ultrasound does not show hydronephrosis, but there actually is) can occur in the following scenarios:
1. very early obstruction: truly acute obstruction (e.g., with a kidney stone, for instance) may take some time to develop enough distension of the collecting system to detect with our current imaging tools.
2. obstruction in the setting of pre-renal failure: volume-depleted kidneys may not demonstrate significant hydronephrosis until after volume resuscitation, which expands the collecting system.
3. large retroperitoneal tumors: tumors which encase the kidneys may cause obstruction but not allow expansion of the collecting system enough to see hydronephrosis.
4. retroperitoneal fibrosis: this can occur in patients with past extensive GU surgery or prior chemotherapy or radiation therapy and can cause mechanical obstruction without allowing expansion of the collecting system.
In addition, false-positives (e.g., the renal ultrasound is read as "hydronephrosis" but this is probably not pathologic) can occur as well, most notably in pregnancy. It is also common that hydronephrosis detected on ultrasound is a chronic, long-standing issue and not the main culprit for the present episode of AKI.
This is taken from handout put up by Precious Body Fluids
Now a new study published in Circulation compared the blood pressure between individuals who ate vegetable protein (specifically glutamic acid along with 4 other amino acids which are relatively higher in vegetable than animal protein) with people who ate non-vegetable protein (read animal meat).
They found a difference of about -2.7/-2.0 mm Hg in blood pressure in people eating more vegetables. Although that may sound small, individual results may be different (and maybe higher for you).
H1N1 Death Rate Holds Steady
The latest update from the World Health Organization reveals the number of swine flu cases worldwide at 77,201—a nearly 50% increase from the June 22nd update. Deaths total 332 (up from 113) for an unchanged mortality rate of 0.43%.
H1N1 cases have now been reported in 120 countries or territories, and related deaths have occurred in 17. Countries disproportionately affected by new cases (where more than 500 cases have occurred) include Thailand, the United Kingdom, Brazil, Peru, and Spain. The number of swine flu deaths in the United States now surpasses those in Mexico.
Another Tool for anticoagulation
Medical management of T2DM
This review is a convenient reference and follows the “mainstream” recommendations. Note that the A1C target of 7%, which the authors advocate, is controversial number..
When will you request TEE in Ischemic Stroke?
June 14, 2009
The main reason for getting a TEE in a patient with ischemic stroke is to find out if that patient has an indication for warfarin anticoagulation. You can begin the selection process by excluding patients who already have an obvious indication for warfarin (e.g. atrial fibrillation) and those who have a contraindication for warfarin.
Among the remaining patients only those with cryptogenic stroke are likely to need a TEE. This is an old paper demonstrating a high yield for TEE in finding an indication for warfarin in such patients. Here is a new study documenting similar findings:
The TOAST classification may be helpful in the determination of cryptogenic stroke.
How well do you treat hypertension?
Not all docs are above average but, according to this study, most of us tend to think we do a better job of treating HT than we actually do. Moreover, when the patient doesn’t reach goal we blame it on “noncompliance.Read more..
The most forgotten Lead= aVR
The most neglected electrocardiographic lead may be the most important in some patients with ACS.Often relegated to the status of placeholder in the electrocardiogram, aVR may contain the critical data for the diagnosis of a number of conditions. A review in the American Journal of Emergency Medicine highlights pericarditis, left main coronary obstruction, orthodromic tachycardia and acute tricyclic antidepressant poisoning. From Medscape Emergency Medicine Viewpoints:
The takeaway point is simple: When patients with ACS, including non-STE ACS, demonstrate STE in lead aVR, the aggressiveness of early management must be
increased. These patients have more complex coronary lesions and will likely benefit from earlier invasive therapy.
Additional references:
ST elevation in aVR as a sign of left main coronary artery obstruction.
Review of electrocardiographic clues obtainable from aVR (JACC).
Classic paper on the electrocardiographic changes of pericarditis.
The electrocardiogram in non cardiac conditions..
The extended time window for IV TPA in acute ischemic stroke
The Best Blood Pressure Medicine
June 12, 2009
A recent meta-analysis published in the British Medical Journal compared the efficacy of different classes of blood pressure medications in preventing coronary artery disease (CAD) and stroke.
The investigators found that all blood pressure medicines are equally effective in preventing CAD and stroke.
Beta Blockers (e.g. metoprolol, carvedilol) were more effective in preventing future episodes of heart attacks in people who already had one. For primary prevention of CAD beta blockers were no more effective than other blood pressure lowering medications.
For 10mm reduction in systolic BP and 5mm diastolic BP:-
Risk reduction in CAD = 22%
Risk reduction in stroke = 41%
Calcium channel blockers (e.g. amlodipine) were slightly more effective in preventing stroke than other classes of medicines.
Read BMJ meta analysis..
Cola and Muscle weakness
Chronic consumption of large amounts of cola soft drinks may cause hypokalemia and muscle weakness.. Watch out for hypokalemia in cola drinkers! Read More..
Tamsulosin and cataract surgery
Tamsulosin use within 14 days of cataract surgery associated with significant postoperative adverse events.. Cataract patients have BPH.. Read this study..
Pneumococcal vaccine fails
Pneumococcal vaccine does not work? oh thats not good news! read this meta analysis..
Prophylactic Revasculrisation and Surgery
Pre operative prophylactic revascularisation is done frequently in high risk cardiac patients. Studies have shown no long term nor short term benefits..Read this article..
Abalation Deaths
Dont think abalation of Atrial Fibrillation is nor risky. Death as an complication happens in 1 in 1000 patients..Read this study.
Aspirin and Primary prevention
Lancet Metanalysis: Using aspirin in the primary prevention of cardiovascular disease is "of uncertain net value.. Read now..
Familial Aortopathy
Relatives f pateints with bicuspid Aortic valve have abnormal aorta and aortic wall.. Read now..
Primary PCI and Bleeding
Pimary PCI has been changed the management of patients with Acute MI with an added cost. Significant bleeding after cardiac cath due to anti-platelet agents are an important predictor of mortality.. Read this article..
PTU and Liver Injury
Propylthiouracil associated with higher risk of liver damage compared to Methimazole in the treatment for hyperthyroidism" FDA warns..Read now..
Stroke After TIA
TIA patients are at high risk of recurrent stroke. Almost half of all strokes that occur during the 7 days after a transient ischemic attack (TIA) happen within 24 hours..ABCD2 score is reliable in the hyperacute phase.. Read this article published in Neurology..
Keep antibiotic Working
Nationwide campaign in France - “Keep Antibiotics Working” successful in reducing unnecessary antibiotic prescriptions.. Read more.......
Beta Blocker in CHF
Use of Beta blocker therapy has improved survival of patients with CHF. Magnitude of heart rate reduction is associated with survival benefit and not dose of beta blocker in heart failure. Read this meta analysis published in Annals of Internal medicine;; more..
PPI and Pneumonia
Most of us have been guilty of prescribing proton pump inhibitors (PPIs) to our hospitalized patients without prudently assessing their need and often disregarding the actual indications for their use. Perhaps the article titled “Acid-Suppressive Medication Use and the Risk for Hospital-Acquired Pneumonia,” published in this week’s JAMA, will motivate us to reconsider prescribing PPIs without giving due consideration to potential adverse events.
According to the study, an estimated 40-70% of medical inpatients are treated with either a PPI or H2-receptor antagonist during hospitalization; approximately 50% of the patients are newly started on these medications, and nearly 50% of these patients are discharged on a PPI. While several outpatient studies suggest an increased risk of community-acquired pneumonia in patients receiving acid-suppressive medications, no large-scale studies exist to determine the association between acid-suppressive medications and hospital-acquired pneumonia. Herzig, et al, conducted a large, prospective cohort study from January 2004 through December 2007, including patients over the age of 18 (median age 54) admitted to the hospital for at least 3 days. Excluded from this study were all patients who spent any time in the ICU. The final cohort consisted of 63,878 admissions, of which 52% received either a PPI (83%) or H2-receptor antagonist (23%) during hospitalization. The primary outcome of hospital-acquired pneumonia occurred in 2219 admissions (3.5%). In the group of patients receiving acid-suppressive medications, there was a higher unadjusted incidence of hospital-acquired pneumonia compared to the unexposed group: 4.9% vs 2.0%, OR 2.6 (95% CI, 2.3-2.8). Additionally, there was a significant association for both aspiration pneumonia and non-aspiration pneumonia, with the diagnoses based on ICD-9 codes used at the time of hospitalization. After adjusting for potential confounders, the adjusted OR for hospital-acquired pneumonia in the group receiving acid-suppressive therapy was 1.3 (95% CI, 1.1-1.4). Interestingly, after adjustment, the association was significant only for PPI’s and not H2-receptor antagonists. Overall, the use of acid-suppressive medications, in particular PPIs, was associated with a 30% increased odds of developing hospital-acquired pneumonia. Given the estimated mortality rate of 18% for hospital-acquired pneumonia, these results are somewhat alarming. Thus, this study clearly emphasizes the need to closely examine our patient’s medication regimen at the time of hospitalization and determine if a PPI is truly warranted.
Hyponaremia - Revisited
May 24, 2009
Hyponatrema is the most common electolyte abnormality is hospitalised patients' This is a good review..
PAN-RESISTANT Gram Negative Bugs!
Here is a helpful review of resistance patterns, focusing on the European experience. Again colistin and tigecycline are discussed as the only alternatives for the most resistant isolates
GOUT- AN OLD DISEASE
April 13, 2009
Gout is being treated by GPs and hospital based doctors. It is still common to find this disease is not properly treated. Read more..
Long QT syndrome
Check out this cool presentation on SlideShare:
Title: "Congenital Long QT Syndrome"
Link: http://www.slideshare.net/medicineandman/congenital-long-qt-syndrome
Risk factors for Severe CDAD
Regression modeling showed the following to be significantly associated with severe CDAD (p≤0.05): age >70 years (odds ratio [OR] 3.35), maximum leukocyte count >20,000 cells/mL (OR 2.77), minimum albumin level <2.5 g/dL (OR 3.44), maximum creatinine level >2 mg/dL (OR 2.47), small bowel obstruction or ileus (OR 3.06), and computed tomography scan showing colorectal inflammation (OR 13.54)
Hepato Pulmonary Syndrome
February 23, 2009
Current Concepts in the diagnosis and treatment of hepato pulmonary syndrome is reviewed in this article..
Drug Induced thrombocytopenia
Drug induced Thrombocytopenia is seen in acute setting and becomes an issue when patient is on lots of medications. Pead this excellent review article..
Yellow Nail Syndrome
February 15, 2009
From a Case series in Chest.
Yellow nail syndrome (YNS) is a rare disorder first described in 1964 by Samman and White, consisting of yellow nails with lymphedema and/or chronic respiratory manifestations. The respiratory manifestations are diverse and include pleural effusion, bronchiectasis, rhinosinusitis, chronic cough, or recurrent lung infections. The pathophysiology of the syndrome remains unclear, but various anatomic or functional lymphatic drainage abnormalities have been proposed as the underlying cause.
NAFLD and Emerging Therapies
This review focuses on current and potential future therapies for NASH.
Presurgical CV Risk Reductionn
A patient’s preoperative cardiovascular assessment should do more than determine
whether a patient is cleared for surgery.Ideally, it also should take measures to reduce a patient’s surgical risk. A major focus is to resolve cardiovascular
disease and cut the patient’s risk for a perioperative or postoperative myocardial infarction. Read This Article..
Beware of QT Prolonging Drugs
From a AHA presentation
Nearly 40% of a large series of patients with a known preexisting long QT interval received an order for a QT-prolonging medication while hospitalized, thereby increasing their risk for sudden cardiac death.
Further, at-risk patients rarely underwent monitoring for further widening of the QT interval. Indeed, 8% had an ECG within 48 hours after starting the new QT-prolonging medication, Dr. Ravi K. Mareedu reported ...
Antiarrhythmic agents accounted for more than half of all prescriptions for QT prolonging medications, with amiodarone leading the way. Another 30% were for haloperidol. There were 115 orders for erythromycin and other QT-prolonging antimicrobials, 82 for methadone, and 97 orders for chlorpromazine and other antinausea drugs
Finger prick Lactate
It’s widely accepted that sepsis treatment should be regarded with the same urgency as trauma or acute STEMI. However early recognition of sepsis is notoriously poor. Is there a solution? How about a fingerstick lactate in the triage area? Better yet, in the ambulance? Here’s a study examining the issue. This is a latest study from critical care..
Thrombotic Events in SLE
Predicting thrombo-embolic events with certainty is most difficult. Especially in patients with SLE. Read this review article in medscape..
Acute interstitial Nephritis and Steroid Therapy
Acute interstitial nephritis (AIN) is a drug induced renal failure.The culprit was usually an antibiotic:
Antibiotic in 34 cases
Cephalosporin in 15 cases
Quinolone in 12 cases
Penicillin in 7 cases
NSAID in 23 cases
Allopurinol in 1 case
Ranitidine in 1 case
Omeprazole in 1 case
Pimozide in 1 case
Only 8 patients (13%) had the classic triad of fever, rash and eosinophilia
Patients classically have fever, rash and eosinophilia. Read the original article here..
Loin pain Hematuria Syndrome
Loin pain Hematuria Syndrome is an interesting group of disorders that we should know about. Read more..
Allergic rhinitis - Newer Drugs
February 7, 2009
Read more on choosing between antihisatamines and antiLeukotrene receptor antagonist..
What's going on with diabetes
January 23, 2009
VADT is yet another negative trial showing a lack of benefit from controlling blood sugars.
That makes three negative trials in the last 12 months.
ADVANCE trial: 11,140 people randomized to gliclazide in order to lower the A1c to 6.5, the control group achieved 7.3%. This lowered combined micro- and macrovascular complications by 10% 18.1% vs 20% after a median of 5 yrs (p=0.01). However the difference was entirely driven by a 21% reduction in nephropathy, with no reduction in retinopathy, macrovascular complications or reduction in CV death or death from any cause.
ACCORD Trial: 10,251 people randomized to usual care (A1c 7.0-7.9) or intensive care (A1c under 6%). There was no difference in the primary composite outcome of non-fatal heart attack and strokes and CV mortality. Unfortunately there was a significant increase in total mortality (p=0.04) with high mortality in the intensive therapy group.
All three of these trials were looking to prove that better glycemic control could reduce strokes and heart attacks. We have known since the early nineties that good glycemic control prevents or delays microvascualr complications (kidney disease, blindness, neuropathy) but the data on cardiovascular disease was lacking. This is important because relatively few diabetics develop ESRD and most patients die of heart disease, a macrovascular complication. For example in type 1 diabetics the 20 year risk of developing ESRD is only 2.2%, while the risk of death is four times that at around 10%.
Unfortunately, this looks like a bust. Not one of the trials have shown any sign that improved glycemic control translates into reduced heart attacks or strokes
Non Visible Hematuria
Many clinicians are not sure what constitutes clinically relevant haematuria; they are also unsure about when patients with haematuria should be referred for
specialist assessment and whether they should be referred to a urologist, nephrologist, or both.This review article deals with this nicely..
MRC Dyspnoea Score
Dyspnoea should be assessed with a validated instrument such as the MRC (Medical Research Council) dyspnoea score. This defines five grades of breathlessness related to normal activities and patients are asked to select the level that best describes how breathlessness affects them. The five levels are:
1 Not troubled by breathlessness except on strenuous exercise
2 Short of breath when hurrying or walking up a slight hill
3 Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace
4 Stops for breath after walking about 100 metres or after a few minutes on level ground
5 Too breathless to leave the house, or breathless when dressing or undressing.
Bisphosphonate nephrotoxicity
Bisphoaphonates are used to treat PMO and nephrotoxicity is a concern. Read this abstract..
Initial drugs for Moderate Hypertension
January 18, 2009
Initial combination therapy with a renin-angiotensin system (RAS) inhibitor and diuretic has the potential to rapidly and effectively reduce BP across a range of baseline BPs, with a comparable adverse event profile to monotherapy.Read this review..
RAS inhibitor/CCB combination therapy
The combination of RAS inhibitors with DHP-CCBs may provide more intensive BP control to currently recommended targets and cardiovascular protective effects that lead to more global risk-factor reduction in patients with hypertension. Given their excellent and complementary tolerability profiles, combination therapy with an ARB or ACEI with a long-acting DHP-CCB is a rational choice for patients requiring two or more antihypertensive agents.Read the review article here..
Oxygen A-a gradient
This is commonly asked question in ward rounds and all juniors need to know this..Read now..
MRSA infected Stethescopes
Doctors Please Clean your Steths. In this Emergency setting, MRSA was found on approximately one in three stethoscopes of emergency professionals. A longer length of time since the last stethoscope cleaning increased the odds of MRSA colonization.Read more...
Bisphosphonates and Osteonecrosis of Jaw
January 8, 2009
This has become a serious concern for dentist.. The association is real, but it was overhyped. Read more..
ITP - Not always Idiopathic
When clinical conditions warrant consider these underlying diseases:
SLE
Antipholpholipid syndrome
H. pylori infection---here the association is controversial, but some studies indicate a high rate of improvement or remission of thrombocytopenia following eradication.
Hepatitis C---screen all patients with chronic thrombocytopenia for hep C. Thrombocytopenia may improve with treatment of the underlying disease.
HIV
From Current Opinion in Hematology
So testing for H Pylori is warranted in ITP Read more..
Alien Hand Syndrome
Alien hand syndrome is a rare condition that can result from neurodegenerative disorders, tumors, or strokes. This is an acute presentation of alien hand syndrome from a right parietal ischemic stroke. The condition was not recognized by the emergency department, delaying diagnosis and appropriate treatment. Early recognition of unusual manifestations of stroke, such as an acute alien hand syndrome, can lead to timely diagnosis and therapy. Read this interesting case report..
Exercise Capacity on Treadmill and CV events
Reduced exercise capacity is associated with an increased risk of myocardial infarction, unstable angina, and coronary revascularization in patients referred for exercise treadmill testing for clinical indications. The prognostic importance of reduced exercise capacity for nonfatal coronary events is independent of demographic factors, clinical factors, and other exercise treadmill testing measures. Reduced exercise capacity may identify patients in whom aggressive risk-factor modification, further diagnostic testing, and close follow-up is warranted. Read the article..
Infective Endocarditis- Surgical Treatment
January 7, 2009
Infection of native and prosthetic valves is still commonly seen and some cases require surgical management. This article concisely deals with this subject.. Read here..
Hyperglycemia management updated-2009
January 6, 2009
The statement, produced jointly by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD), recommends that if target glycemic goals are not met with initial lifestyle interventions and metformin, rapid transition to new regimens should be initiated.Read this PDF article..
Cheese and Hypertensive Crisis
Hypertensive crisis and cheese has been linked to Monoamine Oxidase Inhibitors use.Read now..
Dual Anti Platelet Therapy
Dual anti platelet therapy in Cardiovascular diseases in frequently used sometime with no definite evidence. Also duration of such combination therapy is arguable..Read this article in PDF format..
Once A Day CV drugs
once daily medications have become norm of the lady and it is always becomes a problem when patients asks you when to take a particular once a drug. This article talks about once a day dosing of Cardiovascular drugs..Read more..
Health care Associated Pneumonia
This outcome study published this year looks at heath care associated pneumonia and its increased mortality. Read more..
Nail Disorders - Drug Induced
January 1, 2009
Nail disorders are common in primary care and it is important for us to know the culprit drugs. Read more this article..
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