The patient, a 73-year-old man with atrial fibrillation, hypertension, and diabetes, presented with symptoms of a transient ischemic attack (TIA). Tests ruled out bleeding and the patient was diagnosed with a TIA. He was prescribed warfarin and had his international normalized ratio monitored and maintained between 2-3 to prevent further strokes, and did not experience another TIA in the following year.
COMPARES OPTIMAL MEDICAL THERAPY WITH INVASIVE THERAPY IN A PATIENT WITH STABLE ISCHEMIC HEART DISEASE WITH MODERATE TO SEVERE MYOCARDIAL ISCHEMIA ON NON INVASIVE STRESS TESTING
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COMPARES OPTIMAL MEDICAL THERAPY WITH INVASIVE THERAPY IN A PATIENT WITH STABLE ISCHEMIC HEART DISEASE WITH MODERATE TO SEVERE MYOCARDIAL ISCHEMIA ON NON INVASIVE STRESS TESTING
Heart failure Update as per, 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the
Management of Heart Failure and 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
Presentation about heart failure with preserved ejection fraction. Current epidemiology, pathophysiology, diagnostic approac and evidence-based treatment are presented.
differentiating between supraventicular tachycardia and ventricular tachycardia in wide complex rhythm is always confusing and management is totally different. correct diagnosis will make dramatic difference in patient management.
A comprehensive approach to Atrial Fibrillation. Everything you need to know about Atrial fibrillation. Including recent 2014 AHA guidelines of management.
Presentation about heart failure with preserved ejection fraction. Current epidemiology, pathophysiology, diagnostic approac and evidence-based treatment are presented.
differentiating between supraventicular tachycardia and ventricular tachycardia in wide complex rhythm is always confusing and management is totally different. correct diagnosis will make dramatic difference in patient management.
A comprehensive approach to Atrial Fibrillation. Everything you need to know about Atrial fibrillation. Including recent 2014 AHA guidelines of management.
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Audit of Appropriateness for Brain Scan Use for Paediatric Headache at the Em...Lyndon Woytuck
The purpose is to evaluate practice variation at the emergency department in comparison with best practice for brain imaging in children presenting with headache. The results of the study might be used to inform a clinical prediction rule in order to better stratify risk according to the American College of Radiology Appropriateness Criteria.
I created a poster for presentation and am currently working on a paper for publication in a scholarly journal.
In the NOACs era , how to deal with liver cirrhosis needing anticoagulation?magdy elmasry
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A review of mesenteric ischemia: investigations, treatment, surgical approach, medical therapy, and resolution. Flow charts are courtesy of UpToDate.com (all rights reserved 2017).
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Mr. AMF 62 years presented with central chest pain on exertion for last 4 monthsHypertension(BP-220/120 mmHg) for last 4 years, taking 4 anti hypertensives.Diabetes for last 5 years (HbA1c-9.3%).Smoking for 8 years.Dyslipedemic for 3 years. H/o 5 times hospital admissions due to heart failure in last 3 years.ECG-Anterior wall ischemiaEF-58%During careful clinical exam- renal bruit on left side.Coronary angiogram done and revealed DVD. Renal angiogram showed significant left renal artery stenosis. Coronary angioplasty and left renal artery angioplasty done.
Mr AMF now have no chest pain on exertion after 3 months of coronary angioplasty.
Now BP is controlled (130/85 mm Hg), taking B blockers and ARB due to intolerance of ACE inhibitors.
No hospital admission during this period.
Diabetes and serum lipids are controlled.
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How is mental illness defined? Why is the philosophy of psychiatry the way it is today? Is there hope for improvement in the societal context of ill persons?
Poster: Audit of Appropriateness for Brain Scan Use for Paediatric Headache a...Lyndon Woytuck
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I created a poster for presentation and am currently working on a paper for publication in a scholarly journal.
The aetiology, epidemiology, and investigative management of herpes zoster (shingles). The patient details have been changed and anonymised to protect the identity of the individual.
A review of the investigation and management of diabetic ketoacidosis in newly diagnosed type I diabetes. Patient details have been changed and anonymised to protect the identity of the individual.
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Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
2. PRESENTATION TO PRIMARY CARE CLINIC
• A 73-year-old man presents with a history of atrial fibrillation (AF), hypertension, and
diabetes. His daughter, who accompanied the patient, states that yesterday the
patient had a period when he could not speak or understand words, and that
approximately 4 weeks prior he staggered against a wall and was unable to stand
unaided because of weakness in his legs. She states that both instances lasted
approximately a half-hour. She was unable to persuade her father to go to the
emergency room either time.
What is the probable diagnosis of this
episode?
3. FURTHER NOTES
• Past medical history: Hypertension for 15 years, well controlled; diabetes for the past 10 years.
• Medications: Diltiazem CD 300 mg daily; lisinopril 40 mg daily; metformin 500 mg twice daily; aspirin 81
mg daily.
• Allergies: No known drug allergies (NKDA).
• Drug history: Smoked 2 packs a day; quit when he was diagnosed with hypertension. Drinks 1 beer a
day.
• Family history: Mother deceased (age 79, stroke); father deceased (age 64, colon cancer); 1 brother (age
70, diabetes, prostate cancer); 1 sister (age 65, hyperlipidemia).
• Social history: Lives with wife, aged 69; has 2 children; worked for 40 years as a welder.
• Review of systems: Denies dyspnea, dizziness, or syncope; denies focal motor weakness or loss of
sensation, except for the reported incident.
• Physical exam: Vitals: height = 70 inches; weight = 185 pounds; body mass index = 26.5; BP = 134/82 mm
Hg; heart rate = 88 bpm at rest, irregularly irregular pattern.
Was his anticoagulant therapy
adequate?
4. ATRIAL FIBRILLATION
• What is it?
• The most common arrhythmia in adults and increasing in prevalence (lifetime risk 1 in 4)
• Chaotic and irregular atrial arrhythmia; prevalence increases progressively with age
• What does it mean for circulation?
• Significantly increased stroke risk (affect large area of brain fatality or bedridden)
• Framingham study 17x in rheumatic AF, 5x in non
• Thromboembolic events are a large cause of morbidity and mortality
• High prevalence of left atrial appendage thrombus due to relative stasis during fibrillation
• Relative hypercoagulable state found in vitro
5. ATRIAL FIBRILLATION
• Generally >70 years with cardiac or non-cardiac problems, such as hypertension, coronary artery
disease, valvular disease, heart failure, obesity, and sleep apnoea or pulmonary disease
• Significant morbidity and mortality, including palpitations, dyspnoea, angina, dizziness or syncope,
and features of CHF, tachycardia-induced cardiomyopathy, stroke, and death. Many are
asymptomatic or have less specific symptoms, such as mild dementia or silent strokes.
• ECG: absent P waves, fibrillatory waves, and irregularly irregular QRS complexes
• Treatment depends on severity of symptoms, duration of AF, and comorbidities. Rate correction, or
rate plus rhythm, along with anticoagulation in high-risk patients.
• beta-blockers, calcium blockers, digoxin, anti-arrhythmic agents, ablation for pulmonary vein
isolation and left atrial substrate modification, pacemakers, and ablation of the atrioventricular node
• Risks and benefits of therapy need to be weighed based on multiple clinical factors to optimise
outcome.
6. DIAGNOSIS AND EARLY MANAGEMENT OF
ATRIAL FIBRILLATION
• Most patients present with chronic AF, however most with acute AF do not require
immediate intervention, but require medical therapy to control ventricular rate (Beta
blockers, calcium channel blockers, and digoxin)
• Patients who develop haemodynamic compromise should have immediate direct
current cardioversion.
• If the precise timing of the onset of AF is unclear, a transoesophageal
echocardiogram must be performed to exclude left atrial clots before cardioversion.
The tracing demonstrates the absence of P
waves (long arrow), as well as the presence of
the fine f waves of atrial fibrillation (short
arrows). Note the irregularity of the
ventricular response, as seen from the
variable R-R interval (brackets).
7. ANTICOAGULATION
• The preventative benefit in AF is for reduction of embolization leading to stroke
• Indicated for moderate to severe risk group where benefit > risks of bleeding
• Anticoagulation is universally recommended for patients with valvular atrial
fibrillation or those with mechanical heart valves (without contraindication)
• Oral Coumadin (Warfarin) or NOACs (direct thrombin inhibitors and factor Xa
inhibitors) have shown superior efficacy and safety in RCTs (non-valvular AF)
• In low-risk patients, or in patients with contraindications to oral anticoagulation,
aspirin 81–325 mg daily is recommended as an alternative
8. RISK STRATIFICATION
• Stroke risk estimation in non-valvular AF:
• CHADS2
• 1 - congestive heart failure; 1 – hypertension; 1 - age
>75 years; 1 - diabetes mellitus; 2 - history of stroke or
transient ischemic attack
• CHA2DS2-VASc score further stratifies
• 1 for age 65-74 years,
• 2 points for age ≥75 years
• 1 for female sex
• 1 for presence of vascular disease (coronary,
peripheral, or aortic plaque on imaging)
• 1 CHADS factor classifies moderate risk
• Highest risk: prior thromboembolism (stroke,TIA, or
systemic embolism) and rheumatic mitral stenosis
• Bleeding Risk: ATRIA (Anemia (3), Severe renal disease
(3), Age ≥75 (2), Previous bleeding (1), Hypertension
(1)),
HAS-BLED (Hypertension (1), Abnormal liver or renal
function (1x), Stroke (1), Bleeding (1), Labile INR (1), >65
years (1), Drugs or alcohol (1x)), and HEMORR2HAGES
scores
• In practice these parameters are hardly used, no
benefit has been shown for withholding anticoagulation
on high bleeding score
• Guidelines cite bleeding scores should reduce
subjectivity in decision, but emphasize these scores
should not solely exclude treatment
• Current evidence suggests net clinical benefit for all
except those with the highest risk of bleeding
9. • Event rates, according to scores on the
various risk stratification algorithms, for
(A) stroke and (B) bleeding
• BMJ 2014;348:g2116
10. ANTICOAGULATION
• Vit K antagonist Warfarin 64% (95%CI 49-74%) RR reduction for stroke VS placebo
39% (22% to 52%) RR reduction VS antiplatelet drugs
• Intracranial haemorrhage risk with Warfarin, GI bleed risk with direct thrombin
inhibitor Dabigatran (lower overall bleed risk) and Xa inhibitors Rivaroxaban &
Apixaban
• Novel anticoagulants (dabigatran, rivaroxaban, apixaban, and edoxaban) are
collectively safer (avoiding intracerebral hemorrhage) and more effective than
warfarin
• NOACs have much shorter time to onset and offset and each exhibits some level of renal
clearance
• No easy monitoring using readily available commercial assays for anticoagulation
11. MONITORING ANTICOAGULATION
• Adherence is a major problem esp.Warfarin: + drug-drug, drug-food interactions
• Bridging required in high risk patients, but can be stopped otherwise <5 day periods
• Recommended in a dose adjusted to achieve the target intensity international
normalized ratio (INR) of 2.0 to 3.0
• Regular monitoring by phlebotomy is required in warfarin therapy
• NOACs do not require monitoring and interact less, but specific assays are not widely
available so adherence subjective
• PT and PTT can be evaluated, but are not drug or dose specific
12. BLEEDING EVENTS
• Reversal of Coumadin effects by blood products (acutely and temporarily) or
replacing vitamin K (gradually and permanently)
• NOACs have no effective reversal strategy, but recombinant hemostatic factor
concentrates and developmental small molecules have been tried (no increased
mortality or morbidity compared to warfarin related events)
• Plasma not useful w/out primary coagulopathy; factor concentrates have thrombotic risk
• Supportive care (including volume resuscitation, hemodynamic support, and primary
intervention)
13. CASE CONTINUED
• You order a CT scan, complete blood count with platelet count, prothrombin time
(PT), activated partial thromboplastin time (aPTT), blood urea nitrogen (BUN),
creatinine, glucose level, and erythrocyte sedimentation rate (ESR). Results indicate
no hemorrhaging, and you make a diagnosis of a TIA.
• You prescribe warfarin for the patient and titrate to INR 2.5.With continued
monitoring to maintain the therapeutic range, the patient does not experience a
stroke or TIA in the following year.
What therapy should be prescribed?
14. REFERENCES
• Anticoagulation in atrial fibrillation BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g2116 (Published 14 April 2014)
BMJ 2014;348:g2116 Accessed from:
http://www.bmj.com/content/348/bmj.g2116?hwshib2=authn%3A1457547541%3A20160308%253Aa462ca89-531f-418c-
8315-688b98a76a72%3A0%3A0%3A0%3AXQvXtuVMTQWnOc9RYC5q5Q%3D%3D
• Acute Atrial Fibrillation. Chronic Atrial Fibrillation. Accessed from: http://bestpractice.bmj.com/best-
practice/monograph/3.html
• Case Study 2: Patient With Atrial Fibrillation and Prior Transient Ischemic Attack (TIA): Anticoagulant Therapy,
Uncontrolled Hypertension,Dyslipidemia Robert J. Adams, MD, Chair; Jan N. Basile, MD; Philip B. Gorelick, MD. CME
Released: 07/27/2011;Valid for credit through 07/27/2012 Accessed from: http://www.medscape.org/viewarticle/744735
• Acute Management of Atrial Fibrillation: Part I. Rate and Rhythm Control. DANA E. KING, M.D., LORI M. DICKERSON,
PHARM.D., and JONATHAN L. SACK, M.D. Medical University of South Carolina, Charleston,South Carolina. Am Fam
Physician. 2002 Jul 15;66(2):249-257. Accessed from: http://www.aafp.org/afp/2002/0715/p249.html