Cream of the Crop 22/Cream of the Crop 22.iso/faq/medmail1.zip/GRFBOOK.DOC

Text File | 1996-11-11 | 23KB | 418 lines

                           INTRODUCTION TO MEDMAIL

MedMail is a subscription to medical news that is sent to you via E-mail                */INTRO,1/COST,1/E-MAIL,1/
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Each E-mail issue will contain clinical reviews, practical tips, new drugs,
and Medical Grand Rounds section that will review a medical topic.

The volume of medical literature appearing in the literature daily is
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                           *** CLINICAL REVIEWS ***

 PERIMENSTRUAL ASTHMA
Apparently, there is a greater likelihood of asthma exacerbating in the
perimenstrual period which is defined as days 26 to day 4 of the menstrual cycle.
The exacerbation is attributed to a decline in the estradiol level. If this
is the case, an increase of inhaled steroids during this period may avert the
attacks. A diary of their asthmatic attacks may be beneficial.

 DEMENTIA AND STROKE IN THE ELDERLY
Patients that are cognitively impaired can have twice the incidence of stroke
as compared to those who are not cognitively impaired. This means that risk
factors must be addressed more closely in those with cognitive disorders.


 CORONARY STENTING AND LONG TERM RESULTS
There now is impressive data that restenosis is fairly uncommon in patients
that have had coronary stents placed. Studies have shown they can last at
least for 5 years. Most cases of late coronary stenosis have occurred due
to progression of the coronary disease at nonstented sites.

 STAPH NASAL CARRIAGE AND BACTEREMIA
25-50% of patients admitted to the ICU can develop nasal carraige for Staph
aureus. Those that are methicillin sensitive can develop bacteremia in only
9.5%, while those that are methicillin resistant can develop bacteremia in
38%. If the nasal carriage can be eliminated, the incidence of bactermia in
nosocomial infections may be reduced.

 NSAIDS AND FAMOTIDINE
Patients that require long term NSAIDs may be able to reduce mucosal damage
by using high dose famotidine at 40 mg BID. It is important to stress that
ulcers will not be totally eliminated at this dose.

 CHLAMYDIA AND CORONARY ARTERY DISEASE
Chlamydial infections may predispose to the development of coronary artery
disease as these organisms have been found in atherosclerotic lesions, but
not normal arteries. Further study is needed.

 BACK PAIN AND ACTIVITY
In most cases a definite back pain diagnosis is unnessary as most patients
have mechanical back pain. In these patients 90% will recover with or
without therapy. Activity rather than rest may be the best treatment.
Activity during the first 2 weeks of back pain can include swimming,
bicycling or walking. Exercises may also be prescribed.

 AMLODIPINE AND CHRONIC HEART FAILURE
Patients that had severe chronic heart failure and were given amlodipine
(Norvasc) were 16% less likely to die than those given a placebo. Patients
with nonischemic cardiomyopathy who were given amlodipine had a 31%
reduction of fatal and nonfatal events.

 DHEA AND THE HEART IN MEN
A decrease of DHEA (dehydroepiandrosterone) in men carries an increased risk
for coronary artery disease. Aging causes a decrease of DHEA. Thus, the
administration of DHEA to patients with decreased DHEA may be protective
to the heart. This may be the equivalent of given estrogen to post-menopausal
women. Further study is needed for the risks and benefits of DHEA.

 RISK FACTORS AND NONCARDIAC SURGERY
Using a simple history can predict with 96% accuracy which patients may need
to undergo coronary diagnostic procedures prior to peripheral vascular
surgery. These markers include a history of myocardial infarction, angina,
diabetes mellitus, and congestive heart failure. If these are all negative,
there is a 17% risk for having a possible life threatening coronary artery
disease. However, if 1 or 2 of these markers are positive, the risk is 37%,
while more than 2 postive markers has a 79% risk.

 THROMBOLYTIC AGENTS AND MYOCARDIAL INFARCTION IN THE ELDERLY
Thrombolytic agents should not be withheld in the elderly as the benefits
outweigh the risks. Patients under the age of 65 treated with t-PA or
streptokinase have a risk for stroke of 0.8%, while those older than 85 have
a risk of 2.9%. t-PA may give the best results in patients less than 85,
while streptokinase may be of more benefit in patients > 85.

 FOODS WITH SALICYLATES AND HEART MORTALITY
The decrease in cardiovasculary mortality may be partly due to the presence
of salicylates in foods such as oranges, raspberries tomatoes and spices
such as curry, dill, paprika, oregano and cinnamon. Americans typically
consume from 10-200 mg of natural salicylates daily. Salicylates in the range
of 40-80 mg daily are needed to thwart heart disease.

 NON MILK-DRINKING WOMEN AND OSTEOPOROSIS
Calcium carbonate can effectively be used in patients that do not drink milk.
Calcium carbonate given as three tablets containing 1000 mg calcium carbonate
was found to significantly increase intestinal calcium uptake, and was just
as good as drinking .333 L milk at breakfast, dinner and bedtime.

 THROMBOLYSIS TREATMENT FOR CHRONIC ANGINA
Do you have a patient that is not a surgical candidate for surgery? If so,
they may benefit from low dose bolus injections of urokinase three times a
weeks for 12 weeks. In this study exercise capacity increased by 60%,
fibrinogen levels dropped by 33%, and plasma viscosity and red blood cell
aggregation dropped. Other studies have found that using other thrombolytic
agents in the treatment of unstable angina have resulted in an increased
incidence of myocardial infarction and death.

                          *** PRACTICAL TIPS ***

 URINARY INCONTINENCE AND NONSURGICAL TREATMENT
Urinary incontinence affects 10-35% of American adults, most of which are
elderly females. Risk factors for urinary incontinence include smoking, low
fluid intake, medications, pregnancy, reduced mobility, diminished cognition,
estrogen deprivation, and stroke. Anticholinergic agents and over the counter
cold medications can cause overflow incontinence in males with an enlarged
prostate or in women with genital prolapse. Diuretics can cause urge
incontinence. Women taking alpha antagonists are susceptible to stress
incontinence. Incontinence can also be caused by caffeine, alcohol and
narcotics. Urge incontinence is treated with oxybutynin, propantheline,
dicyclomine, imipramine, desipramine, nortriptyline, and doxepin. Stress
incontinence is treated with pseudoephedrine. Menopausal patients can use
oral or vaginal estrogen. Kegal exercises, scheduled voiding, and biofeedback
are also useful.

 SCABIES
Scabies has a predilection for the hands, wrist, fingerwebs, subungual areas,
cleft of the buttocks, breasts, umbilicus, elbows, penis and outer borders of
the feet. In infants the scalp, palms and soles of the feet are also
affected. To enhance the burrows, color the area of involvement with a felt
tipped marker. After this has dried, clean off with an alcohol pad. The
burrow will retain the ink, enhancing your diagnosis.

 INTERSTITIAL LUNG DISEASE
Did you know that 30-50% of interstitial lung disease is caused by idiopathic
pulmonary fibrosis (IPF)? Idiopathic pulmonary fibrosis is divided into
usual interstitial fibrosis (UIF), desquamative interstitial fibrosis (DIF),
bronchiolitis obliterans, and lymphoid intersitital fibrosis. Even though
UIF is the most common form, it  will respond to prednisone, imuran or
cytoxan in only about 20% of cases. Desquamative interstitial fibrosis is
the second most common form of IPF and will respond to high dose steroids
in 80% of patients. Bronchiolitis obliterans has a poor prognosis. It
responds poorly to steroids and can be idiopathic, or secondary to nitrogen
dioxide, rheumatoid arthritis, penicillamine, cocaine, gold, ulcerative
colitis, autologous bone marrow transplantation and heart and lung
transplantation. Lymphoid interstitial fibrosis is uncommon, and
may be seen with AIDs and Sjogren's syndrome. It may evolve into a low grade
lymphoma. Treatment is poor and most patients will die.

 PROTEINURIA AS A PREDICTOR OF HEART DISEASE
Any patient that is over the age of 40 may benefit from a routine urine, as
it has been found that proteinuria is a predictor of risk for heart disease.
Patients with hypertension and diabetes and proteinuria are at particular
high risk not only for renal disease but heart disease. If proteinuria is
found, risk factors for coronary artey disease should be addressed, as well
as a tight control of hypertension, weight control and cessation of smoking.

 DIABETICS AND CORONARY ARTERY INTERVENTION
It has been found that diabetics have a better 5 year survival with bypass
than with angioplasty. Patients that had angioplasty had almost twice the
mortality as compared with patients that had bypass surgery. For nondiabetics
patients do equally well whether they have bypass or angioplasty. The
question is whether coronary stenting will be even better.

                        *** MEDICAL GRAND ROUNDS ***

 ABDOMINAL AORTIC ANEURYSM

 OVERVIEW
Most abdominal aortic aneurysms are located below the renal
arteries and above the iliac artery bifurcation. An aneurysm is defined
as an increase in the diameter greater than 1.5 times the diameter of the
normal adjacent arterial portion. The mean age of patients with aneurysm is
67 years of age, and males are affected more often than women in a ratio of
4:1. Abdominal aortic aneurysms may also be associated with other aneurysms
at sites such as the popliteal, femoral and internal iliac arteries. The
majority of abdominal aortic aneurysms are atherosclerotic due to risk
factors such as hypercholesterolemia, cigarette smoking and hypertension.
These aneurysms are clinicall silent until they reach a critical size at
which time they suddenly rupture.

 STATISTICS
About 1 in 250 individuals greater than 50 years of age will
die of a ruptured abdominal aortic aneurysm. About 15,000 will die
suddenly from untreated abdominal aortic aneurysms annually. The 1 year
survival rate for patients with abdominal aortic aneurysm is 60%, and at
5 years only 19%. About 50% of patients with ruptured abdominal aortic
aneurysms will die before they reach the hospital. Of those that do make it
to the hospital with free intraperitoneal ruptures, only 10% will survive.

 SIZE OF ANEURYSM AND RISK FOR RUPTURE
The 5 year risk for rupture of a 4 cm aneurysm is less than 15%. However,
the risk for an aneurysm that is 8 cm in diameter is 75%. Furthermore, once
the aneurysm has reached 5 cm, the risk for rupture increases substantially,
and an aneurysm that grows at a rate in excess of 0.5 cm/year is also at risk
for rupture and sudden death.

 SCREENING FOR ANEURYSM
Screening may be cost effective if one selects out those patients that are
susceptible to aneuyrysm. This would include patients between the ages of
55-80, hypertension, those that have associated aneurysms of the popliteal or
femoral area, and families that have a history of aneurysm.

 CLINICAL
Most infrarenal abdominal aortic aneurysms are asymptomatic (75%), and are
discovered during a routine physical examination as a pulsatile abdominal
mass in the epigastric area. It may be difficult to distinguish an aneurysm
from generalized ectasia and tortuosity. A strong impulse in thin patients
may be normal, while any pulsation in obese patients may be secondary to
aneurysm. About 50% of aneurysms are associated with a bruit. When symptoms
do occur they are usually due to expansion and/or rupture, producing back,
flank, abdominal, testicular or hip pain. The sudden onset of the pain
associated with hypotension is characteristic of expansion or rupture. The
rupture may initially be contained. Leaks in the posterior or postero-lateral
aspect may be contained by the spine or paraspinal muscles, but will be
followed by a massive uncontrolled hemorrhage. Most aneurysms rupture into
the left retroperitoneum. However, rupture can occur into the bowel,
peritoneal cavity and the vena cava. Patients may rarely present to the
physician because of mural thrombi embolizing to the legs.

 LABORATORY
ULTRASOUND. Ultrasonography is 100% sensitive in the hands of an expert
technician. Advantages of US include the following. It requires no contrast
material, longitudinal and transverse sections are available and
reproducibility of size is fairly good. If the patient is obese or has
inordinate gas, the test will be compromised. Disadvantages include the fact
that the exam does not give accurate data for the surgeon, it cannot evaluate
the proximal and distal aortic extent of the aneurysm, and the visceral
vessels cannot be evaluated.
CT. CT has a high sensitivity and specificity, and may be more precise in
estimating the size of the aneurysm. It also give data on the shape of the
aneurysm and the relation of visceral and renal vessels. Disadvantages
include the fact that radiation and contrast has to be used, is more costly
than US, and is not as readily available as US. CT is not recommended as a
screening tool.
X-RAY. An aneurysm may be picked up when an abdominal film is done for
another reason. This may reveal a curvilinear aortic calcification near the
midline in the AP view. The lateral view may outline the aneurysm's
calcified anterior and posterior walls.
AORTOGRAPHY. The use of arteriography has diminished over the years because
it tends to underestimate the size of the aneurysm due to thrombus lining
the walls, and is expensive and invasive. However, if a suprarenal aneurysm
is suspected, and there is mesenteric stenosis, associated iliofemoral
arterial occlusive disease,, renal artery stenosis and hypertension, then
aortography may be indicated.

 TREATMENT
The decision to treat an unruptured aneurysm is based on the size of the
aneurysm. THe risk for rupture of a 5 cm aneurysm is 5-7.5% per year which
increases exponentially with increasing size of the aneurysm. Aneurysms 5 cm
or larger in diameter will require treatment. Although the 5 year risk of
rupture for 4-4.5 cm is only 15%, some would elect to repair these aneurysms
because of the high mortality associated with rupture. A ruptured aortic
abdominal aneurysm has a mortality of 78-90%, while an elective repair
carries a mortality of only 1-3%. Aneurysms less than 5 cm can usually be
followed with serial ultrasound or CT scans every 3 months.

 PREOPERATIVE PREPARATION
CORONARY ARTERY DISEASE. The early and late mortality following elective
repair of an abdominal aortic aneurysm is due to coronary artery disease in
about 50-60% of patients. It is therefore prudent to screen these high risk
patients for coronary artery disease with exercise stress testing, stress
echocardiogram, or dipyridamole/thallium scanning prior to aortic repair.
Patients with known prior coronary artery bypass grafting, positive screening
tests and those that will require thoracic aortic clamping need to have
coronary angiography.
CAROTID ARTERY DISEASE. To prevent strokes postoperatively, carotid
duplex ultrasound scans should be done prior to elective repair ofthe aorta.
LUNG DISEASE. If the patient has less than 50% of predicted FEV1 and vital
capacity, aortic reconstruction may be interdicted.
RENAL DISEAE. Renal artery occlusive disease and creatinine elevations
above 3 mg/dL must be addressed and corrected.
CONTRAINDICATIONS FOR REPAIR. Absolute contraindications to elective aortic
reconstruction include intractable CHF and angina, myocardial infarction
within the last 6 months, severe renal and pulmonary disease with dyspnea
at rest, stroke patients that are severely impaired, and a life expectancy of
only aboyut 2 years.
SURGERY FOR THE ANEURYSM. It has been shown that resuscitating the patient
with fluids and raising the blood pressure before definitive surgery can
result in loss of the retroperitoneal tamponade in patients with rupture.
Therefore, these measures should be deferred until the rupture is controlled.
The repair, itself, is usually accomplished by placing a prosthetic straight
or bifurcated Dacron or polytetrafluoroethylene graft in situ. An alternative
method is placing an endovascular stented graft into the site. This latter
method can result in lower operative morbidity and mortality rates as well
as a shorter hospital stay which will result in a reduction of the total
cost.

 COMPLICATIONS OF AORTIC REPAIR
EARLY. Early compliations following elective surgery include cardiac
arrhythmia, ischemia and CHF (15%), pulmonary insufficiency (8%), renal
damage (6%), distal thromboembolism (3%), bleeding (4%), and wound infection
(2%). The most disastrous compliation is infection ofthe graft. This is
usually due to salmonella. About 2% will develop ischemic colitis which is
heralded by early postoperative diarrhea, prolonged hypotension, oliguria,
and acidemia. The last rare complication is paraplegia due to spinal cord
ischemia. This occurs in only 0.2% of patients, but is increased by 10 fold
in patients with ruptured aneurysm.
LATE. Late complications usually occur 3-5 years after surgery, and include
graft occlusion, infection, and aortic-enteric fistulae.

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Knoxville, Tn 37919

My E-Mail address: [e-mail]