Bleeding, antiplatelets and anticoagulants

JAMA Reference here

Pulmonary Embolism

Pulmonary embolism:

Diagnosis
Treatment
Overdiagnosis?
Thrombolysis PE PEITHO Trial
Thrombolysis SMPE and Echo

Meninigitis

- Always think of this diagnosis in patients with Fever + headache or Fever + altered mental status. The ABSENCE of fever+neck stiffness+altered LOC has high sensitivity (ie none of these 3  = no meningitis). Also in this JAMA rational Clinical exam paper much is made of the jolt accentuation (worsening headache when shaking head side to side at 1Hz).  However, the evidence for this comes from only one small study. When considering this serious diagnosis an LP is required to rule out!

- Look at the Tangents TWH Blog for some recommendations on LP!

- Common organisms include Steptococcus pneumoniae, Neisseria meningitidis. In older adults also consider Listeria. Contrary to some sources older adults seem to present quite typically.   Given the epidemiology, in those over 50 y/o with community acquired meningitis we treat empirically with Ceftriaxone 2g iv q12h (for Neisseria and sensitive pneumococci), Vanco 1.5-2g iv q12h (for resistant pneumococci) and Ampicillin 2g iv q4h (for Listeria).  Note the high doses for CSF penetration.

- Adjunctive steroids are recommended, chiefly based on this trial and this metanalysis.  But interestingly a 2010 Cochrane Metanalysis puts this recommendation into question, perhaps more so in developing countries.

- Lastly, with Neisseria meningitis always think of the public health implications.

Cheers

COPD and PE

Hey team:

We admit many cases of AECOPD on GIM, and many of our patients presenting with exacerbations are elderly.  Check this excellent article from JAMA on the care of older patients with COPD. Advance care planning in partnership with the patient and their family is key!

In patients where the etiology of the exacerbation is unclear, looking for PE is very important, as high as 25% of all presentations.  Decision making as to when and how to investigate is complex - many comorbidities are usually present.
 Here is an article discussing different investigations, and a useful decision tree (midway down the page).

Team 2 June 14 Roundup:

Some fascinating stuff I learned or was reminded of this week:

- ITP is a hypercoagulable state

-Valacyclovir may be better than acyclovir for preventing postherpetic neuralgia, but the cochrane metanalysis suggested that no antiviral is effective for PHN.

- PFO closure:  The evidence is lacking for this procedure in preventing recurrent cryptogenic stroke. See also the primary evidence from the Closure and Respect Trials.

Plus here is some of the other evidence I owe the team:

A) Post hoc analysis of the DIG trial suggesting that serum dig concentrations should be lower that our "normal" range:

                  Men with heart failure and a left ventricular ejection fraction of 45% or less may be optimized in the SDC range of 0.5 to 0.8 ng/mL, and likely similar for women, but with no mortality benefit.

B) Constrictive and effusive pericarditis: a good review

And last but not least a GREAT REVIEW on orthostatic hypotension

PRV, thrombosis and AE fistula

Quick links to the relevant articles on:
Italian study PRV and Thrombosis, showing phlebotomy to HCT< 45 is key and its editorial that suggests that ASA and Hydroxyurea may not add much
Aortoenteric fistula image and case from NEJM

Feb 2013 Topics

So we chatted about a bunch of EBM stuff in the last couple of weeks.  I thought I'd try and capture some of it and provide links to the literature. 

First off we discussed the interesting article on the pathophysiology of Heyde's syndrome. I like this because the history highlights the link from clinical observation to understanding of pathophysiology.  This is a crucial step in the advancement of medical knowledge which we don't discuss nearly enough when talking about scholarship in medicine.

We also had good discussions on the Duke criteria for endocarditis, both in its original form and in the 2000 revisions by Li et al. Remember criteria are just an attempt to categorize reality and clinical diagnosis needs to weigh the uncertainties.

Lastly, we chatted about lipodermatosclerosis, an important differential when assessing lower extremity erythema.  Often patients will get treated for "cellulitis" that does not resolve when lipodermatosclerosis is the actual diagnosis.  Think about this condition when the redness starts above the ankle and there is a predisposition to developng edema (e.g. with decompensated hearth failure).