Sinus pauses after MI
I have a case of a 58 year old patient was involved in a traffic accident when under the influence of heroin, causing chest trauma including pulmonary contusions and sternal fracture. In the emergency department, he suffered from a ST-elevated myocardial infraction and was treated with emergent cardiac catheterization and started on secondary prevention therapy. The day after, we observed multiple sinus pauses lasting around 5-10 second each, longest was 12 second. After each pause, the patient enters junctional rhythm. Echocardiogram shows left ventricular ejection fraction of 56%, with normal global and regional systolic left ventricular function except a moderate hypokinesis of the apex. Could someone advise on the sinus pauses?
Renal cell carcinoma, recent biopsy and renal calyces
A 67-year-old patient with a medical history of hypertension, type 2 diabetes mellitus (on insulin), dyslipidemia, and permanent atrial fibrillation, anticoagulated with dabigatran. She first presented with cardiac failure, which was stabilized, but also found to have an increased abdominal perimeter of fewer than 5 months of development (constipation).
A CT scan of the thorax, abdomen and pelvis was performed showing a left retroperitoneal mass up to 10 cm in diameter. Follow-up PET-CT scan confirmed a hypermetabolic retroperitoneal pararenal mass of up to 9 cm in maximum diameter, highly suggestive of malignancy, as well as a diffuse increase of glucose metabolism in the bone marrow, of doubtful character. One week after the extension study, a biopsy was done and a histological study reveals renal cell carcinoma.
Now, the patient has presented again, three days after the biopsy, with abdominal pain, nausea, hypotension and tachycardia. Additionally, the patient reports pain in the RIGHT lumbar region. Blood tests show reduced creatinine clearance and reduction of hemoglobin from 11 to 9.5. A renal echo was performed in which a dilatation of the renal collecting system due to an increase in the size of the pelvis and renal calyces was observed.
What acute management options are available for this patient?
Hypotension during dialysis
We have a 55-year-old patient on dialysis three times a week, who recently started experiencing worsening heart failure symptoms. Her most recent echocardiogram shows an LV ejection fraction is 30% with reduced left ventricular wall motion. Chest x-ray also shows a large chest-thoracic ratio. She was started at carvedilol 2.5mg, titrated to 8.75mg three times a day and enalapril 2.5mg. However, since the start of these drugs, she has been suffering from symptomatic hypotension (~86/60) with pre-syncopal symptoms and tachycardia (>100 beats) during her dialysis. How would you alter the management of her heart failure?
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Family Medicine
Spain
La verdad es que es una gran cantidad de dinero, supongo que a pesar de sus gastos también tendrá posibilidad de ahorro. Es cierto que la población no tiene educación financiera en la gran mayoría de los casos, cosa que beneficia a quienes no nos enseñan precisamente cómo invertir ni diversificar el dinero. Dentro de mis conocimientos y limitaciones en este sentido le recomiendo no despilfarrar, sino hacer inversiones "simples" en bienes físicos que sean "reserva de valor", es decir: bienes inmuebles, monedas (nunca lingotes) de oro / plata, antigüedades, relojes e incluso perfumes pueden ser reserva de valor, por lo que estará diversificando su patrimonio en diferentes bienes y no solamente moviendo dinero fiduciario intangible de aquí para allá. Obviamente puede darse más de un capricho, y más con sus ingresos, que en mi país no lo veríamos en nuestra vida. Huya como la peste de invertir en bolsa o criptomonedas, es un mercado manipulado hasta la saciedad. De hecho el mercado del oro está también manipulado, pero invertir en monedas es buena idea, siempre que sea de confianza. Espero que le sirva algo de lo dicho.
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Pediatrics
Australia
Dear John and Louis,
This 'dilemma' has been around of decades but what has become very obvious to me is the way that the very basic fundamental notion of Evidence Based Medicine has been manipulated and perverted to ONLY mean what appears in commercial medical journals under the guise of RCT Trials, Meta analyses etc.
The following comment was published in the BMJ Issue 2022;376 doi with the heading 'The illusion of evidence based medicine'.
"Evidence based medicine has been corrupted by corporate interests, failed regulation, and commercialisation of academia, argue these authors"
The acknowledged Father of EBM was Dr David Sackett (1934-2015) who believed that Clinical Skill and Patient Satisfaction were of equal importance as 'Research' and instituted the 3 Ring model of EBP or EBM. I have attached 2 slides from one of my lecture series which explains this graphically and you will see that what is truly 'Evidence Based' is the small area where Skill, Expertise, Patient Satisfaction and Best Available Research all intersect. ALL carry equal weighting.
It is simply naive to assume that a 'published paper' - where there exists so many opportunities for selection criteria bias, interpretational bias and commercial satisfaction for those funding these trials - can be relied on as a single metric of 'evidence'. Finally - to echo the words of Karl Sagan the Astronomer - 'Absence of Evidence is not Evidence of Absence'.
Add to this the equally sage comment from Albert Einstein 'Not everything that is counted, counts - and not everything that counts, is counted'.
If the slides don't render correctly please feel free to DM directly and I will email them to you. rogerlprice@gmail.com
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General Medicine
United Kingdom
I would check her haemoglobin - above 80 is fine
Duty of candour means you need to tell her the flight is equivalent to an operation so 2 operations 2 times the risk of VTE - LMWH plus no alcohol plus keep hydrated
If she had severe pre eclampsia or heart failure in pregnancy, be aware decompression effectively creates right sided failure so I would do an echo
and finally presume the child is also travelling so check no congenital issues or persistent foetal circulation
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Concerning CT Findings Increase Health Care Utilization With Low-Risk Pulmonary Embolism
TUESDAY, July 18, 2023 (HealthDay News) -- Concerning computed tomography (CT) findings among patients with low-risk pulmonary embolism (PE) are associated with increased hospitalization and resource utilization without short-term adverse clinical outcomes, according to a study recently published in JAMA Network Open.
Connor O’Hare, M.D., from the University of Michigan in Ann Arbor, and colleagues examined whether concerning CT findings among patients seen in the emergency department with acute, low-risk PE are associated with differences in treatment and/or clinical outcome. The analysis included 817 adults with PE characterized as high risk or low risk (bilateral central embolus, right ventricle-to-left ventricle ratio greater than 1.0, right ventricle enlargement, septal abnormality, or pulmonary infarction).
The researchers found that 40.5 percent of PEs were low risk and 59.5 percent were high risk by PE Severity Index score. For all low-risk patients, clinical outcomes were similar, with no 30-day deaths in the low-risk group with concerning CTPE findings (0 of 151 patients) versus four of 180 (2.2 percent) in the low-risk group without concerning CT findings and 18.1 percent in the high-risk group. Compared with those without concerning CTPE findings, low-risk patients with concerning CT findings were less frequently discharged from the emergency department (2.0 versus 7.8 percent). Additionally, low-risk patients with concerning findings had more frequent echocardiography (57.6 versus 27.2 percent without concerning findings) and PE response team activation for consideration of advanced therapies (22.5 versus 6.1 percent).
"These findings suggest that concerning computed tomography imaging findings may be a significant barrier to outpatient treatment among patients with otherwise low-risk acute PE," the authors write.
One author disclosed ties to the pharmaceutical industry.
Copyright © 2020 HealthDay. All rights reserved.
Por qué los médicos en España piden que comas esta fruta con las lentejas
La combinación de determinados alimentos puede paliar las carencias para nuestra salud y multiplicar sus efectos beneficiosos. Las lentejas y los kiwis son dos alimentos complementarios que ofrecen numerosos beneficios para nuestra salud. Por un lado, las lentejas son una excelente fuente de proteínas, fibra y micronutrientes, mientras que los kiwis son ricos en vitaminas, minerales y antioxidantes.
Existen diversos estudios que respaldan los efectos positivos de las lentejas en la salud. Por ejemplo, se ha demostrado que reducen la presión arterial, el colesterol en sangre y la hiperglucemia. También reducen los niveles de colesterol en personas con diabetes y protegen contra el cáncer de mama en mujeres. Los kiwis, una fruta rica en vitamina C que tiene la capacidad de facilitar la absorción del hierro vegetal. Al combinar las lentejas con alimentos ricos en esta vitamina, se protegen las moléculas de hierro y se aumenta así la cantidad que el organismo es capaz de absorber. De hecho, hay estudios que indican que consumir 25 miligramos de ácido ascórbico (vitamina C) en dos comidas al día puede duplicar la absorción del hierro.
De hecho, incluso la Universidad de Harvard se ha hecho eco del efecto potenciador de la vitamina C. "Las lentejas tienen bajos niveles de sodio y grasas saturadas y tienen altos niveles de potasio, fibra, folatos y químicos vegetales conocidos como polifenoles que tienen actividad antioxidante. Estas propiedades nutricionales han llevado a los científicos a investigar sus efectos en enfermedades crónicas", afirma esta prestigiosa universidad en su página web...Leer más
¿Qué opinas de este 'truco'?
Cardiopulmonary exercise limitation is frequent after PE and associated with persisting clinical, ec...
Cardiopulmonary exercise limitation is frequent after PE and associated with persisting clinical, echocardiographic… https://t.co/EgxNkYg8AYJune 12,2023
