This is short summary of metabolism of chylomicrons.
ARBs or ACEI?
ARBs are expensive but evidence suggests they are as good as ACEI and may be beter if you want to prevent strokes. Read more..
Stroke Prevention- Still Confusion?
Recurrence of stroke is disabling event and prevention of such event is important. S MATCH trial showed increased bleeding in patients taking combination of aspirin with Clopidogrel . This study looked at combination of aspirin plus extended release Dipyridamole compared to clopidogel. Study concludes that there is no difference in using either drugs. Aspirin dose used is only 50 mg daily. What do we do with our stroke patient?"For stroke prevention,/ use an antiplatelet drug./ Treat hypertension" Read more.
Read what the editorial has to say..
Migraine with Aura and Stroke in Women
In women, migraine with aura is a risk factor for several ischaemic outcomes including all cause cardiovascular death, stroke, myocardial infarction, angina, coronary revascularisation procedures, and claudication. Read this editorial in BMJ..
Migraine, vascular risk, and cardiovascular events in women: prospective cohort study
Migraine, vascular risk, and cardiovascular events in women: prospective cohort study
5 minute of medicine
This is interesting collection of mterial from BMJ, 5 minute of International medicine. Read now..
(MRSA): “missing the wood for the trees”
August 28, 2008
MRSA is found very where in health care environment including neck ties, steths nad ID badges. While it is helpful to know all the places we may find MRSA, these types of studies really just confirm what should be blindingly obvious — that MRSA readily disseminates within our health care environment. Thus, the hands of health care workers will frequently come into contact with MRSA.
The real issue with the control of MRSA is not the need for more information on environmental contamination, but the need to use the abundant information we already have to curtail the principal way that MRSA spreads in hospitals — via the hands of health care workers, that's us. Read this editorial and there is an interesting comment too...
The real issue with the control of MRSA is not the need for more information on environmental contamination, but the need to use the abundant information we already have to curtail the principal way that MRSA spreads in hospitals — via the hands of health care workers, that's us. Read this editorial and there is an interesting comment too...
Cardiac repolarisation: the long and short of it
August 27, 2008
A summary of all you need to know about Long and short QT syndrome..
ABCD2 Tool for TIA
- ABCD2 tool for assessment of patients with transient ischaemic attack
- A. Age ≥ 60 years = 1 point.
- B. Blood pressure ≥ 140/90 mmHg = 1 point.
- C. Clinical features: unilateral weakness = 2 points, speech impairment alone = 1 point.
- D. Duration > 60 minutes = 2 points, 10–59 minutes = 1 point.
- D. Diabetes = 1 point.
- Total. 0–3 = low risk of stroke, 4–7 = high risk of stroke.
VTE prophylaxis
Current data suggest that VTE prophylaxis is grossly underused in hospitals.
The ENDORSE study (which enrolled over 68 000 medical and surgical patients in 32 countries,) showed that 51.8% of hospital inpatients were at risk of VTE, but only 58.5% of at-risk surgical patients and 39.5% of at-risk medical patients received VTE prophylaxis. Read more article published in Lancet..
The ENDORSE study (which enrolled over 68 000 medical and surgical patients in 32 countries,) showed that 51.8% of hospital inpatients were at risk of VTE, but only 58.5% of at-risk surgical patients and 39.5% of at-risk medical patients received VTE prophylaxis. Read more article published in Lancet..
Addison,s and Stress
Steroid replacement therapy in Addison,s syndrome has gone through various levels. It has been common practice to give higher doses of steroid during medical stress and surgical procedures. Most f the time patient excessive doses and this can lead to various steroid related complications. This review article published in MJA deals with this topic..
CPC 08/08 - Answer
The answer for last CPC case is posted here..
CPC case presentation..
Click on cpcanswer...
THE MOTHER-IN-LAW EFFECT
August 26, 2008
Derek Harwood Nash, one of the pioneers of neuroradiology, wanted to find an easy way to describe the DSA (digital subtraction angiography) behaviour of meningioma. He noticed that the tumour blush in a meningioma comes very early (early wash-in); normally it is very dense and persistent with a delayed wash-out. This reminded him the behaviour of an unwanted guest who comes early and stays late, and the guest that classically do this is actually the mother-in-law. Meningioma has both a dural and a pial blood supply and a sunburst or radial appearance of the feeding arteries. Depending on the location you may have to perform internal carotid, external carotid, ab vertebral injections. In the typical sphenoid wing meninigioma, the middle menigneal artery is enlarged.
Here is link to see mother-in-law effect.
syndicated from NeuroRAZiology..
When can you stop warafarin in unprovoked DVT
Stopping warfarin in unproved DVT is not easy decision. Identifying patients who are low risk has been a difficult task andi find this study published in Canadian Medical Journal very useful.
It concludes that it may be safe for women who have taken oral anticoagulants for 5–7 months after an unprovoked venous thromboembolism to discontinue therapy if they have 0 or 1 of the following signs or symptoms: hyperpigmentation, edema or redness of either leg; a D-dimer level of 250 µg/L or more while taking warfarin; BMI 30 kg/m2 or more; and age 65 years or more.. What about men?it appears that all men are at high risk of recurrence, particularly men with hyperpigmentation, edema or redness in either leg.They found that men had more than twice the risk of recurrence compared with women and that no subgroup of men with a low risk of recurrence could be identified. Read more..
It concludes that it may be safe for women who have taken oral anticoagulants for 5–7 months after an unprovoked venous thromboembolism to discontinue therapy if they have 0 or 1 of the following signs or symptoms: hyperpigmentation, edema or redness of either leg; a D-dimer level of 250 µg/L or more while taking warfarin; BMI 30 kg/m2 or more; and age 65 years or more.. What about men?it appears that all men are at high risk of recurrence, particularly men with hyperpigmentation, edema or redness in either leg.They found that men had more than twice the risk of recurrence compared with women and that no subgroup of men with a low risk of recurrence could be identified. Read more..
Stopping anticoagulant therapy after an unprovoked venous thromboembolism
ACP guidelines
Thyroid Eye Disease
August 25, 2008
Graves Eye disease can be a serious vision threatening condition. There are still unresolved issues in this condition. This is a recent abstract of lecture presentation.
Low LDL and Cancer Risk: Vytorin?
FDA has rejected cancer scare associated with Vyotorin.Meanwhile, the WSJ reports, the House Energy and Commerce Committee sent more letters to Merck and Schering yesterday. The committee wants to see the analysis of the SEAS trial conducted by an outside expert who concluded that the trial’s cancer findings were an anomaly, and the drug doesn’t increase cancer risk. Association of Low LDL with increasing incidence of cancer has been reported.This study says previously reported association of low levels of on-treatment LDL-C and incident cancer, confirmed here, is not driven by statins, and statin therapy, despite producing marked reductions in LDL-C, is not associated with an increased risk of cancer. Further studies are needed to validate these findings, particularly with longer durations of follow-up. Read more..
Lady with purple Hands
August 19, 2008
A 79-year-old woman with recurrent urinary tract infections presented with complaints of “purple” hands.
Bluish-purple discoloration of skin involved her earlobes and hands. The pulse oximeter read 80% to 84% saturation while 100% oxygen was administered at a flow of 15 L/min. Her urine was deep orange, and arterial blood appeared dark brown. Arterial blood oximetry showed a PO2 of 200 mm Hg, with 87.5% oxyhemoglobin and 11.8% methemoglobin. She had normal glucose-6-phosphate dehydrogenase levels, and intravenous methylene blue improved her cyanosis; her methemoglobin levels decreased to 0.3%. Apparently, acquired methemoglobinemia and urine discoloration had been induced by 10 days of phenazopyridine use (200 mg 3 times daily) for urinary tract infection. Urine returned to normal color within 3 days of discontinuing phenazopyridine. This azo dye, often used as a topical urinary tract analgesic, should not be administered for more than 2 days because of potential adverse effects (cytopenias, methemoglobinemia, nephrotoxicity, orange urine discoloration, and transaminitis).1
Methemoglobinemia is caused by excess methemoglobin (normal ≤1% of total hemoglobin) that is formed by oxidation of the iron moiety of hemoglobin from ferrous (normal) to ferric state. Drugs or chemicals, hemoglobin M variants, and congenital diminished activity of erythrocytic NADH-cytochrome-b5 reductase are associated with methemoglobinemia.2 Avoidance or discontinuation of offending drugs and use of methylene blue (once normal glucose-6-phosphate dehydrogenase levels have been confirmed) constitute the main management options.
The role of carbapenems in initial therapy for serious Gram-negative infections
The treatment of patients with serious Gram-negative infections must be both prompt and correct. Numerous studies have demonstrated that mortality risk is significantly increased when the initial antibiotic regimen does not adequately cover the infecting pathogen.
Furthermore, changing to an appropriate regimen once culture results are available does not reduce this risk. Therefore, one must empirically treat serious infections with a regimen that covers likely pathogens. Selecting such a regimen is complicated by the increasing prevalence of resistance to commonly used antibiotics. Moreover, multidrug-resistant pathogens, once limited to hospital-acquired infections, are increasingly being detected in community-acquired infections, especially those involving the urinary and gastrointestinal tracts or in immunocompromised patients. Consequently, the initial antibiotic regimen must have a broad spectrum of activity that includes potential resistant pathogens, as indicated by the local antibiogram. Many multidrug-resistant pathogens remain susceptible to carbapenems despite increasing worldwide antibiotic resistance. This article reviews the role played by carbapenems in the initial treatment of serious Gram-negative infections and the potential effect of emerging resistance on this role. A review in Critical Care examines this role. A future concern is the emergence of more resistance to carbapenems. What will we do when they begin to wear out their welcome? There’s not much else to turn to and the dry antibiotic development pipeline limits future prospects. (And do you think hospitals are safe now!).
Furthermore, changing to an appropriate regimen once culture results are available does not reduce this risk. Therefore, one must empirically treat serious infections with a regimen that covers likely pathogens. Selecting such a regimen is complicated by the increasing prevalence of resistance to commonly used antibiotics. Moreover, multidrug-resistant pathogens, once limited to hospital-acquired infections, are increasingly being detected in community-acquired infections, especially those involving the urinary and gastrointestinal tracts or in immunocompromised patients. Consequently, the initial antibiotic regimen must have a broad spectrum of activity that includes potential resistant pathogens, as indicated by the local antibiogram. Many multidrug-resistant pathogens remain susceptible to carbapenems despite increasing worldwide antibiotic resistance. This article reviews the role played by carbapenems in the initial treatment of serious Gram-negative infections and the potential effect of emerging resistance on this role. A review in Critical Care examines this role. A future concern is the emergence of more resistance to carbapenems. What will we do when they begin to wear out their welcome? There’s not much else to turn to and the dry antibiotic development pipeline limits future prospects. (And do you think hospitals are safe now!).
Obese and Healthy?
Better to Be Fat and Fit Than Skinny and Unfit, New York Times reports. This is in line with my previous post on Metabolically obese with normal weight.
ARB plus ACE: ON TARGET
Okay, moving on to the next common question, “should I add an ARB to the ACE inhibitor?” Read more..
It’s been shown that angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARB) reduce both proteinuria as well as renal risk (loss of GFR and need for dialysis). What remains unclear, however, is whether a combination of these classes of drugs has an additive effect on renal risk reduction, and whether the effects of ARB and ACE inhibitors are equivalent. Several previous studies have shown that combination therapy reduces proteinuria; however, these trials were limited by their small sample size, short duration of therapy, and did not report on major renal outcomes. The current investigation, the ONTARGET study, published in this week’s Lancet, is a large multi-center, randomized controlled trial that took place over 6 years. Participants were 55 years or older and had established atherosclerotic vascular disease or diabetes with end-organ damage (the baseline mean creatinine was about 83mmol/l). Over 25,000 patients were assigned to ramipril 10 mg daily, telmisartan 80 mg daily, or to a combination of both drugs. The primary outcome was a composite of dialysis, doubling of serum creatinine and death; the secondary outcome was a composite of dialysis and doubling of serum creatinine. The results of this trial may surprise you. Combination therapy reduced proteinuria to a greater degree than either therapy alone. However, both the primary outcome as well as secondary outcome were similar for telmisartan and ramipril but were increased with combination therapy. The study raises interesting questions regarding the relationship between proteinuria and kidney damage and asks if the reduction in proteinuria by itself can be taken as a definitive marker of improved renal function; these questions will no doubt require further investigation. Study limitations include a population that, at baseline, was well-treated with regards to standard cardiovascular therapy and only included a small subgroup with overt diabetic nephropathy. So this population may not represent the majority of patients we treat in our clinic. Overall, this trial suggests that while monotherapy with either an ARB or ACE inhibitor confers similar beneficial effects on major renal outcomes, combination blockade of the renin-angiotensin system may not be the way to go.
It’s been shown that angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARB) reduce both proteinuria as well as renal risk (loss of GFR and need for dialysis). What remains unclear, however, is whether a combination of these classes of drugs has an additive effect on renal risk reduction, and whether the effects of ARB and ACE inhibitors are equivalent. Several previous studies have shown that combination therapy reduces proteinuria; however, these trials were limited by their small sample size, short duration of therapy, and did not report on major renal outcomes. The current investigation, the ONTARGET study, published in this week’s Lancet, is a large multi-center, randomized controlled trial that took place over 6 years. Participants were 55 years or older and had established atherosclerotic vascular disease or diabetes with end-organ damage (the baseline mean creatinine was about 83mmol/l). Over 25,000 patients were assigned to ramipril 10 mg daily, telmisartan 80 mg daily, or to a combination of both drugs. The primary outcome was a composite of dialysis, doubling of serum creatinine and death; the secondary outcome was a composite of dialysis and doubling of serum creatinine. The results of this trial may surprise you. Combination therapy reduced proteinuria to a greater degree than either therapy alone. However, both the primary outcome as well as secondary outcome were similar for telmisartan and ramipril but were increased with combination therapy. The study raises interesting questions regarding the relationship between proteinuria and kidney damage and asks if the reduction in proteinuria by itself can be taken as a definitive marker of improved renal function; these questions will no doubt require further investigation. Study limitations include a population that, at baseline, was well-treated with regards to standard cardiovascular therapy and only included a small subgroup with overt diabetic nephropathy. So this population may not represent the majority of patients we treat in our clinic. Overall, this trial suggests that while monotherapy with either an ARB or ACE inhibitor confers similar beneficial effects on major renal outcomes, combination blockade of the renin-angiotensin system may not be the way to go.
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