Last week, the American College of Chest Physicians (ACCP) published updated evidence-based guidelines addressing the prevention and management of thrombosis. Developed by an international panel of 90 experts, these guidelines include more than 700 recommendations related to the prevention and management of thrombotic disorders. While I thought it would be fun to go through all 700 recommendations, I decided to choose a few highlights.
For all of our MOs wondering who should get venous thromboembolism (VTE) prophylaxis, the guidelines recommend it for most patients. However, they do not recommend routine use for patient groups with a very low risk of VTE. This includes patients undergoing laparoscopic surgery, knee arthroscopy, or those who take long airplane flights. The guidelines continue to recommend against the use of aspirin alone for VTE prophylaxis in any population. Several specialized populations are addressed in the new guidelines,including those undergoing surgery. A full chapter is dedicated to the perioperative management of patients on long-term antithrombotic therapy who require surgery or other invasive procedures. Most patients must temporarily stop anticoagulation just prior to undergoing surgery in order to minimize bleeding; however, this can increase the risk of a thromboembolic event. To address this challenge, the guidelines recommend that the risk of a thromboembolic event during interruption of therapy be balanced against the risk for bleeding when antithrombotic therapy is discontinued. The guidelines also recommend routine use of VTE prophylaxis for patients undergoing major general, gynecologic, or orthopedic surgeries and have been expanded to include bariatric and coronary artery bypass surgery. Also specifically addressed in the new guidelines are challenging issues facing women who are pregnant or wish to become pregnant while undergoing long-term antithrombotic therapy. Pregnant women taking vitamin K antagonists (VKAs) such as warfarin have an increased risk for birth defects and miscarriage. For most women taking VKAs who become pregnant, the guidelines recommend substituting low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) and suggest frequent pregnancy tests and the substitution of LMWH or UFH once pregnancy is achieved. For women with mechanical valves who become pregnant, the guidelines suggest either adjusted-dosebid LMWH or UFH throughout pregnancy or adjusted-dose bid LMWH or UFH until the thirteenth weekwithVKA substition untilLMWH or UFH are resumedclose to delivery. In pregnant women with high-risk mechanical valves (i.e., older-generation valve in the mitral position or history of thromboembolism), the use of oral anticoagulants over heparin is suggested because of concerns about the effectiveness of alternative anticoagulants in preventing stroke and valve thrombosis. Remember, this is just a teaser. If youre still interested or have a management question about a patient, check out the full set of guidelines. Here is a copy all the abstracts..
Venous thrombo embloism prophylaxis
July 1, 2008
Renal Hydatid
I guess hydatid acn occur any where but i have not seen a renal hydatid.
Click on renal hydatid...
Imaging findings in hydatid disease depend on the stage of cyst growth (ie, whether the cyst is unilocular, contains daughter cysts, or is partially or completely calcified [dead]) . A difference in attenuation and signal intensity between the fluid in the central portion of the cyst and that in the peripheral cysts is a typical finding in echinococcosis due to a difference in content .Daughter vesicles (brood capsules) are small spheres that are formed from rests of the germinal layer and appear as cysts within a cyst. They contain the scolices and hooklets, along with sodium chloride, proteins, glucose, ions, lipids, and polysaccharides . When daughter cysts are separated by the hydatid matrix, they demonstrate a "wheel spoke" pattern . (Syndicated from Sumer's Radiology site)
Resistant Hypertension
June 29, 2008
Read this review published in Hypertension recently...
Chilaiditi’s Syndrome: What you should know?
June 28, 2008
Trachea and Goitre
Estimated Average glucose (eAG)
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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Mitral Regurgitation- Treatment strategy
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..
Radiological Quiz
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)
Foreigners in our body
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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Is it over for ezetimibe?
Ezetimibe selectively inhibits the absorption of cholesterol by blocking the Niemann–Pick C1-like (NPCL)1 protein DNA receptor at the intestinal wall, which decreases cholesterol return to the liver, very similar to bile acid sequestrants. These two drugs, along with statins, all lower intracellular hepatic cholesterol levels and upregulate the LDL-receptor to enhance LDL-C clearance from plasma.
I have to introduce you to ENHANCE study published in NEJM. ENHANCE found that adding ezetimibe to high-dose simvastatin therapy had no significant effect on carotid intima media thickness (CIMT) in 720 subjects with familial hypercholesterolemia. Read more...
If you look at the study 80% patients who entered the study were already taking statins. These patients failed to show any difference from baseline( They have aleady have less CIMT thickness. But what happened to 20% of statin naive patients? read the study fully..
So the answer for my question is NO.
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Related links
Which is the best risk predictor? Apo B or non HDL Cholestrol
June 24, 2008
LDL-cholestrol has been the recognised target in Lipid lowering therapy to prevent further cardiovascular events in high risk patients. Recently other targets like Non-HDL cholestrol , Apo-B lipoprotein have been considered targets in patients already on statin therapy.
Non-HDL cholesterol is already being used as a secondary target in the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP-III) guidelines in patients with elevated triglyceride levels.
A post hoc analysis published in Circulation recently performed that combined data from 2 prospective, randomized clinical trials in which 10 001 ("Treating to New Targets")(TNT) and 8888 ("Incremental Decrease in End Points through Aggressive Lipid Lowering")(IDEAL) patients with established coronary heart disease were assigned to usual-dose or high-dose statin treatment. Read more..
Read the abstract of this study here...
Further discussion on this study and what it means to us in clinical practice is discussed here..
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Cancer Risk and Alcohol - Is there a Link?
June 23, 2008
Boston Globe published an article on How to Nap. Read here..
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Vitamin D and Atheroma
Read article here...
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Health - How many times your patient sees You
THE Japanese make most visits to the doctor of any rich country. Each person goes 13.8 times a year on average according to the OECD. The high rate could be explained in part by Japan's high ratio of older people who require more care. Americans see a doctor less than four times a year, although the high number people without medical insurance may be a factor. Neighbouring Mexicans are the most doctor-shy. See this chart posted in Economist..
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Old and Flexible!
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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Mr Bean!
I like to watch Mr Bean movies and he is irritatingly funny sometime. Click here to see him.. ha ha ha
Clostridium difficile associated disease (CDAD) - an update
Metronidazole should be used for initial treatment of non-severe CDAD. The recommended dose is 500 mg three times daily or 250 mg four times daily. As discussed below, intravenous metronidazole at a dose of 500 mg every eight hours may also be used for treatment of CDAD. Fecal concentrations in the therapeutic range are achievable with this regimen because of the drug's biliary excretion and increased exudation across the intestinal mucosa during CDAD.
If oral vancomycin is used, the recommended dose is 125 mg four times daily. Oral vancomycin is not absorbed systemically and achieves predictably high levels in the colon. Dosing regimens of 125 mg four times daily and 500 mg four times daily are equally effective for the treatment of CDAD. Intravenous vancomycin has no effect on C. difficile colitis since the antibiotic is not excreted appreciably into the colon.
Duration of therapy — The standard duration of initial antibiotic therapy for non-severe C. difficile diarrhea is 10 to 14 days. Patients with an underlying infection requiring prolonged duration of antibiotics should continue CDAD treatment throughout the antibiotic course plus one additional week after its completion.
Repeat stool toxin assays are NOT warranted following treatment. Up to 50 percent of patients have positive stool assays for as long as six weeks after the completion of therapy. Read full article here..
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Maraviroc: The First of a New Class of Antiretroviral Agents
Maraviroc is the first US Food and Drug Administration-approved drug from a new class of antiretroviral agents that targets a host protein, the chemokine receptor CCR5, rather than a viral target. Binding of maraviroc to this cell-surface protein results in blocking human immunodeficiency virus type 1 (HIV-1) attachment to the coreceptor and prevents the virus from entering CD4+ cells. Read this review...
Mushroom Poisoning
Here is a presentation i read from the web. Lot of interesting information.
Click on mushroom...
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