Via AACE from J Davidson, P Jellinger, L Blonde, H Lebovitz, C Parkin (2005):
The new position statement is this: Even if the initial A1C is from 6 to 7%, you should start pharmacotherapy.
This aggressive treatment has proved that mortality diminishes considerably.
Regards,
Jon Mikel Iñarritu, M.D.
technorati tags: diabetes, diabetes mellitus, A1C, AACE guidelines, guidelines, pharmacotherapy, medicina, unbounded medicine, medicine
Boston Scientific ENTERYX Procedure Kits and Injector Single Packs .
via FDA Safety I nformation Alerts:
For those who haven’t consider endoscopic procdedures for the treatment of GERD, well, at least, you shouldn’t think in Enteryx treatment.
FDA and Boston Scientific notified healthcare professionals and patients about serious adverse events, including death, occurring in patients treated with ENTERYX, a liquid chemical polymer which is intended to be injected into the lower esophageal sphincter for treatment of gastroesophageal reflux disease. The serious adverse events involve unrecognized transmural injections of ENTERYX into structures surrounding the esophagus. On September 23, 2005, Boston Scientific issued a recall of all ENTERYX Procedure Kits and ENTERYX Injector Single Packs from commercial distribution. Physicians should stop injecting ENTERYX immediately and follow the manufacturer’s procedures for returning unused product. FDA also provided recommendations on avoiding future occurrences and advice for patients.
Last month, Aggravated Doc Surg has made an excellent review of this treatments and recalls.
Regards,
Jon Mikel Iñarritu, M.D.
This week’s Grand Rounds is hosted by Doc Shazam, she starts with a nice gruop categorization, the conclusion of this roundup is to let us know that in medicine’s blogsphere there is not all about medicine. Here we have the categories.
So please, be sure to visit her site and stay up-to-date in all the medical blogs.
Next week’s Grand Rounds, will be hosted by CodeBlog, tales from a nurse. Please, submit your stories.
Regards,
Jon Mikel Iñarritu, M.D.
technorati tags: grand rounds, medicalblogsphere, medical blogs, medicine, medblogs, medicina, unbounded medicine
via Reuters Health and Headache 2005;45:973-982:
National Headache Foundation guidelines for abortive treatment of migraine aren’t right?
This study states that the combination of acetaminophen, aspirin, and caffeine (AAC) is superior to sumatriptan in migraine’s early treatment.
Goldstein et al, compared the combination treatment with 50mg sumatriptan in 171 subjects treated when the first symptoms ofmigraine occurred. Patients taking AAC experienced significantly greater pain intensityreduction than did those taking sumatriptan beginning 2 hours afterdosing and continuing throughout the 4-hour treatment period.
More patients in the AAC group experienced a sustained response and fewer patients in the AAC group required rescuemedication by 4 hours postdose.
This results suggests that migraine sufferers can use AACto treat their migraine episodes at the first sign of an attack.
In my very own personal experience i’ll rather preffer to use Sumatriptan. What do you think?
Regards,
Jon Mikel Iñarritu, M.D.
technorati tags: migraine, acetaminophen, paracetamol, aspirin, aspirina, caffeine, cafeina, headache, clinical trial, unbounded medicine, medicine, medicina, sumatriptan
We all know those evidence linking OSA to systemic hypertension (even if your patient is not obese), because the vasoconstriction and activation of renin-angiotensin-aldosterone axis. But now there is new evidence that OSA is an important risk factor for stroke.
A new observational cohort study of NEJM by Yaggi et al, states that OSA increases significantly the risk of stroke, TIA or sudden death.
REFERENCES:
Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V.Obstructive sleep apnea as a risk factor for stroke and death. N Engl JMed 2005;353:2034-2041.
Regards,
Jon Mikel Iñarritu, M.D.
technorati tags: sleep obstructive apnea, stroke, death, OSA, NEJM, medical articles, Yaggi, medicine, unbounded medicine, sleep disorders
Here is another chest x-ray that shouldn’t have been taken:
As reference, you can trackback this earlier post.
Regards,
Jon Mikel Iñarritu, M.D.
technorati tags: tension type pneumothorax, medical images, CXR, chest x-ray, x-ray, medical emergency, clinical images, medicine, unbounded medicine, medicina, pneumothorax
This week, Grand Rounds 2.07 is hosted by MSSP Nexus Blog.
Rita is the creator and she is a natural born story teller. Now she comes with a StarTrek story very funny and so complete.
Next week’s GR will be hosted by Doc Shazam, be shure to update him her.
Regards,
Jon Mikel Iñarritu, M.D.
technorati tags: Grand Rounds, grandrounds, medblogsphere, medical blogsphere, medicine, medical blogs, medblogs, unbounded medicine
Open fractures are surgical emergencies because of its complications (soft tissue damage, infection, hemorrhage).
We at emergency department need a classification system that it is intented to determine the degree of that damage.
We have to make a rapid (also a good) interrogation of lession mechanisms (what, when, where, who, associated lessions). REMEMBER: If a low-grade open fracture has 6hrs from the begining, it’s considered infected.
On 1984, Gustilo and Anderson made a classification system, wich is the following:
Type I open fracture. Wound less than 1 cm, without contamination and minimal injury of soft tissue.
Type II open fracture. Wound between 1 and 10 cm, mild contamination, extensive soft tissue damage and minimal to moderate crushing component.
Type III-A open fracture. Wound larger than 10 cm, severe contamination and severe crushing component.
Type III-B open fracture. Wound larger than 10 cm, severe contamination and severe loss of tissues.
Type III-C open fracture. Wound larger than 10 cm, severe contamination and neurovascular injury.
REFERENCES:
Gustilo, R.; Mendoza, R.; Williams, D. Problemsin the management of type III (severe) open fractures: A new classification of typeIII open fractures. J Trauma 24:742, 1984.
Regards,
Jon Mikel Iñarritu, M.D.
technorati tags: open fractures, open fracture, fracturas abiertas, fracturas expuestas, fracture, Gustilo, medicine, unbounded medicine, orthopedics, trauma, emergency, surgical emergency, medicina, medical images
• Severeconstant pleuritic pain that localizes over the anterior chest and may radiateto arms and back; it is differentiated from myocardial ischemia, becausethe pain intensifies with inspiration and is relieved by sittingup and leaning forward.
• Pericardial friction rub is best heard with patientupright and leaningforward and by pressing the stethoscope firmly against the chest; itconsists of three short, scratchy sounds:
• Signs and symptoms:
Treatment:
Immediatepericardiocentesispreferably by needle paracentesis with the use of echocardiography, fluoroscopy,orCT Aspirated fluidshould be sent for analysis (protein, LDH, cytology, CBC, Gram stain, AFBstain) and cultures for AFB, fungi, and bacterial C&S.
Cardiac Tamponade
Cardiac Tamponade
Regards,
Jon Mikel Iñarritu, M.D.
technorati tags: cardiac tamponade, CXR, x-ray, xray, medical images, clinical cases, emergency procedures, pericardiocentesis, ecocardiography, unbounded medicine, medicine
A 64 years old politraumatized male, arrive to ER department directly to trauma room. He was on shock.
technorati tags: CXR, mediastinal hematoma, CT scan, Clinical cases, medicine, mediastinum, unbounded medicine, chest x-ray, x-ray, xray
22 year old female with painless slowly progressive, ophtalmoplegia with diplopia and ataxia.
On physical examination we found this:
Bilateral fundoscopy examination:
A characteristic bilateral pigmentary retinosis.
An EKG was performed:
A first degree AV block was found on this patient.
Then we ordered a lumbar punction to chemical and cytologic analysis.
The cerebrospinal fluid was cloudy with no other anormalities except elevated proteins (>100mg/dL).
With this data now we can think about a chronic progressive external ophtalmoplegia.
Differential diagnosis should include:
The next step in the diagnosis of this case is to perform an electromyography (myophatyc pattern), electrorretinography (slow transmission) and a muscle biopsy.
The diagnosis is:
Kearns-Sayre syndrome wich is a mitochondrial cytopathy that is characterized by CPEO, retinal pigmentary changes, and heart block. Patients are typically normal at birth. Progressive ophthalmoplegia usually develops between 5 and 20 years of age, although it may occur earlier. Most cases are sporadic.
The ocular findings include bilateral and symmetric involvement of the horizontal and vertical muscles, bilateral ptosis, and normal pupils. An atypical pigmentary retinopathy (”salt and pepper”) may be present; some patients have a corneal opacity. The ophthalmoplegia progresses slowly over many years and is often asymptomatic because it is insidious and bilaterally symmetric. As the extraocular myopathy progresses, generalized muscle weakness and other systemic manifestations may occur.
Nonocular manifestations include:
Images and clinical case information provided by: Dr. Arturo Ramírez M. from Mexico City.
Thank you for your support, Arturo.
Regards,
Jon Mikel Iñarritu, M.D.
technorati tags: unbounded medicine, ptosis, ophtalmoplegia, diplopia, ophtalmology, medicine, CPEO, Kearns syndrome, Kearns-Sayre syndrome, clinical cases
A 76 years old female comes to the emergency department because shortness of breath. She has been postrated since 2 months ago, when she wasn’t able to move her legs anymore. Shortness of breath since 1 week ago (NYHA IV). She states that she has “rheumas”. She gives no other information. She has been taking methotrexate since 4 years ago, in interval periods of time, she doesn’t know which doses. On physical examination you note a postrated elder woman with severe physical deformities. You also found this:
This is an extremely advanced case of rheumatoid arthritis. But, what associations with pulmonary disease does RA have? What kind(s) of pulmonary disease(s) does this patient have (or could have)?