The abdominal aorta is the section of the aorta located in the abdomen. Abdominal aortic aneurysms (AAAs) occur when this section of the aorta abnormally enlarges due to weakening of the aortic wall. AAAs are usually asymptomatic until rupture, which can cause life-threatening internal bleeding. Ultrasound screening for men over 65 can detect AAAs and help prevent ruptures. Treatment options for AAAs include open surgical repair and endovascular aneurysm repair (EVAR) via catheter deployment of a stent graft. While EVAR has lower risks, open repair may provide longer-term durability in some cases.
DETAILS OF EVIDENCE TAVI FROM ITS EXISTENCE IN INTERVENTIONAL CARDIOLOGY TO THE SURTAVI REGISTRY ..AS AN OPTION FROM HIGH RISK UNOPERABLE PATIENTS TO INTERMEDIATE AND LOW RISK PATIENTS
This document summarizes techniques for endovascular treatment of aorto-iliac occlusive disease. It discusses:
1) Technical success rates are high but complications can occur, especially with chronic total occlusions. Primary stenting is preferred over PTA with provisional stenting for long lesions.
2) Patency rates at 5-10 years range from 46-96% depending on the location and type of lesion. Risk factors for restenosis include occlusion length and poor runoff.
3) Endovascular treatment has advantages over open surgery like shorter hospital stays and lower complications/mortality, though open bypass has higher long term patency. Drug-eluting devices may help address issues of rest
This document discusses avascular necrosis (AVN), including:
- Causes of AVN such as corticosteroid use, alcohol abuse, and trauma
- Management involves early diagnosis via imaging like MRI and treatment based on staging, with options ranging from observation to core decompression and bone grafting for pre-collapse cases or osteotomy for some post-collapse cases
- Surgical techniques are described for core decompression with or without bone grafting to improve blood flow and support the femoral head, as well as various osteotomies to redistribute weight bearing for some collapsed cases
- Case studies demonstrate outcomes of these treatments in preserving femoral heads or delaying total hip replacement
1. Atrial septal defects can be classified into four main types based on their location: ostium secundum, ostium primum, sinus venosus, and coronary sinus defects.
2. Ostium secundum defects, which account for 75-85% of ASDs, involve a defect in the fossa ovalis. Ostium primum defects involve the lower portion of the atrial septum.
3. The likelihood of spontaneous closure of an ASD depends on its size, with defects larger than 8-10 mm being less likely to close compared to smaller defects.
The abdominal aorta is the section of the aorta located in the abdomen. Abdominal aortic aneurysms (AAAs) occur when this section of the aorta abnormally enlarges due to weakening of the aortic wall. AAAs are usually asymptomatic until rupture, which can cause life-threatening internal bleeding. Ultrasound screening for men over 65 can detect AAAs and help prevent ruptures. Treatment options for AAAs include open surgical repair and endovascular aneurysm repair (EVAR) via catheter deployment of a stent graft. While EVAR has lower risks, open repair may provide longer-term durability in some cases.
DETAILS OF EVIDENCE TAVI FROM ITS EXISTENCE IN INTERVENTIONAL CARDIOLOGY TO THE SURTAVI REGISTRY ..AS AN OPTION FROM HIGH RISK UNOPERABLE PATIENTS TO INTERMEDIATE AND LOW RISK PATIENTS
This document summarizes techniques for endovascular treatment of aorto-iliac occlusive disease. It discusses:
1) Technical success rates are high but complications can occur, especially with chronic total occlusions. Primary stenting is preferred over PTA with provisional stenting for long lesions.
2) Patency rates at 5-10 years range from 46-96% depending on the location and type of lesion. Risk factors for restenosis include occlusion length and poor runoff.
3) Endovascular treatment has advantages over open surgery like shorter hospital stays and lower complications/mortality, though open bypass has higher long term patency. Drug-eluting devices may help address issues of rest
This document discusses avascular necrosis (AVN), including:
- Causes of AVN such as corticosteroid use, alcohol abuse, and trauma
- Management involves early diagnosis via imaging like MRI and treatment based on staging, with options ranging from observation to core decompression and bone grafting for pre-collapse cases or osteotomy for some post-collapse cases
- Surgical techniques are described for core decompression with or without bone grafting to improve blood flow and support the femoral head, as well as various osteotomies to redistribute weight bearing for some collapsed cases
- Case studies demonstrate outcomes of these treatments in preserving femoral heads or delaying total hip replacement
1. Atrial septal defects can be classified into four main types based on their location: ostium secundum, ostium primum, sinus venosus, and coronary sinus defects.
2. Ostium secundum defects, which account for 75-85% of ASDs, involve a defect in the fossa ovalis. Ostium primum defects involve the lower portion of the atrial septum.
3. The likelihood of spontaneous closure of an ASD depends on its size, with defects larger than 8-10 mm being less likely to close compared to smaller defects.
Medullary carcinoma of thyroid genene m. bekele, md, faceGofasefer
1) This document describes the case of a patient with metastatic medullary thyroid carcinoma (MTC) who underwent multiple surgeries and treatments over several years as their disease progressed and calcitonin levels increased.
2) Vandetanib, a drug that targets the RET gene mutation often present in MTC, was approved by the FDA in 2011 based on results of the ZETA clinical trial showing it significantly increased progression-free survival compared to placebo.
3) The ZETA trial involved 331 patients randomized to receive either vandetanib 300mg daily or placebo, with the primary endpoint being progression-free survival assessed by independent review. Vandetanib was found to nearly halve the risk of progression or death
This document provides an overview of pediatric bone tumors, focusing on osteosarcoma and Ewing sarcoma. It discusses the epidemiology, clinical presentation, diagnostic workup, treatment, and outcomes of these two malignant bone tumors. Osteosarcoma most commonly affects the long bones of adolescents and is typically treated with neoadjuvant chemotherapy followed by surgery. Ewing sarcoma occurs in younger children and commonly involves the pelvis or long bones. It is treated with chemotherapy and local control with surgery or radiation therapy when possible. Both tumors require a multidisciplinary treatment approach to achieve long-term survival in approximately 60-75% of patients.
CT coronary angiography in ED chest pain patientskellyam18
CTCA shows promise in reducing length of stay and costs for ED chest pain patients, but more research is needed. While CTCA is highly sensitive for detecting CAD, it may overestimate lesion severity and has radiation risks. Current evidence does not clearly support CTCA as a routine test for ED chest pain patients without known CAD who have normal ECG and biomarkers. CTCA may be useful in select subgroups, but how to define these subgroups is unclear.
Contraindications, futility & fraility in liver transplantDr. Rohit Saini
This document discusses contraindications and factors used to assess futility for liver transplantation (LTx). It covers absolute and relative contraindications to LTx. Scores like MELD, SOFT, and UCLA are used to predict post-LTx outcomes and futility. Factors like frailty, age, comorbidities, acute liver failure criteria, and ACLF grade impact survival. The concept of a "transplantation window" in ACLF is discussed. Precipitating events, physical frailty, sarcopenia, cardiovascular disease, and pulmonary hypertension also influence futility decisions for LTx.
This document discusses mitral valve disease and treatment options such as surgical repair/replacement and the MitraClip procedure. Some key points:
- Mitral regurgitation (MR) is the most common valve problem and increases in prevalence with age. Left untreated, MR can lead to heart failure and death.
- Surgical treatment has traditionally been the only option to reliably reduce MR, but many patients are considered too high-risk for surgery.
- The MitraClip procedure is a minimally invasive treatment that fills this gap for inoperable patients by using a clip to repair the mitral valve and reduce MR without open heart surgery.
- Clinical trials show the MitraClip procedure reduces MR
- Several studies have found that older liver transplant recipients (over age 60) have similar short-term outcomes to younger recipients in terms of postoperative morbidity, mortality, and length of hospital stay. However, long-term survival is significantly lower in older recipients, largely due to non-hepatic age-related causes of death.
- While patient survival is lower in older recipients, graft survival is not significantly different between older and younger groups. The increased mortality in older patients is attributed to infections, cardiac events, and neurological causes rather than hepatic causes.
- Careful consideration of medical fitness and life expectancy due to comorbidities is important when evaluating older recipients for liver transplantation. While age alone should not preclude transplantation, risks
Comorbidities and Other Predictors for Severity of Colonic Diverticulitis?semualkaira
Predicting severity of acute colonic diverticulitis (ACD) is important for management, morbidity and mortality. The aim of this study is evaluating the Charlson’s Comorbidity Index (CCI) as severity predictor of ACD.
Management of splenic injuries has evolved over the last 30 years from primarily operative to non-operative management (NOM). NOM is now the standard of care for hemodynamically stable patients with splenic injuries. The success rate of NOM has increased to 85% with the addition of splenic artery embolization (AE) which can treat contrast blush and pseudoaneurysms seen on CT scans that are predictors of NOM failure. AE has reduced NOM failure rates to as low as 2-6% and allowed for non-operative management of even high grade IV-V injuries at rates over 80%. Careful patient selection based on grade of injury, hemoperitoneum, and CT findings remains
The document discusses recent developments in left atrial appendage closure. Key points include:
- Long term results and meta-analyses from randomized trials of warfarin vs. Watchman leading to FDA approval.
- Differences between trial populations and real-world patients.
- Results from studies of patients who cannot take oral anticoagulants.
- Technical advances in devices.
- Role of CT imaging.
Health Surveillance of asbestos-exposed workers at Helsinki Asbestos 2014Työterveyslaitos
This document discusses health surveillance of asbestos-exposed workers. It summarizes various asbestos-related diseases such as asbestosis, pleural plaques, and mesothelioma. It notes that CT scans have found more early-stage lung cancers in asbestos workers but have not reduced mortality. Biomarkers and microRNAs show promise as screening tools but require more research. Lung function tests and smoking cessation also remain important aspects of health surveillance for these workers. Overall, the benefits of screening must be weighed against the risks of repeated radiation exposure and invasive follow-up procedures.
Giant Cell Tumors of Bones: Management & Single Author ExperienceMohamed Abdulla
This document discusses giant cell tumor of bone (GCTB) and the potential role of denosumab in its management. It provides background information on GCTB, including its incidence, presentation, histopathology involving RANKL expression, and standard treatment options. It then describes a pilot study of 17 patients with advanced or metastatic GCTB who were treated with denosumab. The majority of patients experienced pain alleviation and stabilization or improvement of neurological deficits and pulmonary metastases. Denosumab represents a promising targeted therapy for salvage treatment of difficult GCTB cases.
This document provides an overview of pulmonary embolism (PE) including epidemiology, risk factors, clinical presentation, diagnostic evaluation, and treatment recommendations. Some key points:
- PE affects 300,000-600,000 Americans annually, with 30-50% developing long-term complications. Up to 50% of cases are initially missed by clinicians.
- Clinical prediction tools like the Wells Criteria and PERC Rule can assess pre-test probability. D-dimer can help exclude PE in low risk patients. CT pulmonary angiography and ventilation-perfusion scans are used for diagnosis.
- Anticoagulation is standard treatment for PE. For intermediate/high-risk PE, thrombolysis,
This document summarizes key findings from several studies related to acute myeloid leukemia (AML) in elderly patients:
1) A phase 3 trial found that azacitidine extended overall survival compared to conventional care regimens in older patients with newly diagnosed AML, with median OS of 10.4 months for azacitidine vs 6.5 months for conventional care.
2) Subanalyses found azacitidine provided particularly long OS benefits vs conventional care for patients with poor-risk cytogenetics (median OS 6.4 vs 3.2 months) or myelodysplasia-related changes (1-year OS 55.1% vs 31.3% for LDAC preselected
This patient is a 13-year-old girl presenting with right thigh pain and elevated markers. Imaging shows erosion of the tumor through the cortex with no metastases. Biopsy reveals malignant spindle cells producing osteoid. This represents Stage IIb osteosarcoma - a high grade tumor with extra-compartmental growth and no metastases. The next steps are neoadjuvant chemotherapy followed by wide excision and reconstruction with adjuvant chemotherapy to treat micrometastatic disease.
This case series describes 8 patients who presented with acute mesenteric ischemia and bowel gangrene. The most common presenting symptom was abdominal pain. Four patients had pre-existing cardiac conditions that increased their risk. All patients underwent exploratory laparotomy where gangrenous bowel segments were resected. Post-operative complications occurred in 4 patients, and the mortality rate in the series was 37.5%. Acute mesenteric ischemia can be difficult to diagnose due to non-specific symptoms, but prompt surgical treatment is needed to prevent high mortality from bowel necrosis.
Ultrasound assisted thrombolysis for vte turkish experienceuvcd
This document summarizes the key findings from several studies on using ultrasound-accelerated thrombolysis to treat pulmonary embolism and deep vein thrombosis. The ULTIMA trial found that low-dose catheter-directed ultrasound-accelerated thrombolysis was superior to anticoagulation alone in reversing right ventricular dysfunction in pulmonary embolism patients. The SEATTLE II study aimed to evaluate this technique for submassive and massive pulmonary embolism. A single-center retrospective review of 106 patients treated for chronic deep vein thrombosis found that over 90% reported significant symptom improvement and ultrasound follow-up showed high patency rates over time. The mechanism of action is that ultrasound energy exposes plasminogen receptor sites and increases
This document discusses mitral valve disease and treatment options. It provides information on:
- Mitral regurgitation (MR), the most common type of heart valve disease, which occurs when the mitral valve does not close properly.
- Treatment options for MR including open-heart surgery, minimally invasive surgery, robotic surgery, and the MitraClip procedure. MitraClip offers a less invasive alternative for high-risk surgical patients.
- Guidelines for referral for mitral valve repair/replacement, focusing on patients with moderate-severe or severe MR who are at high-risk for open-heart surgery.
- The large population of MR patients who are not surgical candidates, representing an unmet
A 14-year-old girl presented with easy fatigability and gum bleeding. Her CBC showed Hb 4.0, MCV 80, TLC 1500, and platelets 4000/mm3. Her bone marrow aspiration was hypocellular and her biopsy was hypoplastic, consistent with aplastic anemia. Treatment options for aplastic anemia include immunosuppressive therapy with antithymocyte globulin (ATG) and cyclosporine (CSA), which has a 70% response rate. For those who do not respond to ATG+CSA, options include a second course of ATG, eltrombopag, or allogeneic hematopoietic stem cell transplantation from a
- A 12-year-old boy presented with pain and swelling in his left tibia for one month with a history of intermittent fever. Differential diagnoses included osteomyelitis, osteoid osteoma, Ewing's sarcoma, and osteosarcoma.
- Ewing's sarcoma most commonly affects children and young adults between 5-25 years old and presents with pain, swelling, and sometimes pathological fractures. Definitive diagnosis is based on histology, immunohistochemistry, and detection of specific gene fusions.
- Treatment involves chemotherapy with VACA/IE cycles alternating every 2-3 weeks for 17 cycles along with possible surgery and/or radiation therapy based on response and margins. The goal is
Medullary carcinoma of thyroid genene m. bekele, md, faceGofasefer
1) This document describes the case of a patient with metastatic medullary thyroid carcinoma (MTC) who underwent multiple surgeries and treatments over several years as their disease progressed and calcitonin levels increased.
2) Vandetanib, a drug that targets the RET gene mutation often present in MTC, was approved by the FDA in 2011 based on results of the ZETA clinical trial showing it significantly increased progression-free survival compared to placebo.
3) The ZETA trial involved 331 patients randomized to receive either vandetanib 300mg daily or placebo, with the primary endpoint being progression-free survival assessed by independent review. Vandetanib was found to nearly halve the risk of progression or death
This document provides an overview of pediatric bone tumors, focusing on osteosarcoma and Ewing sarcoma. It discusses the epidemiology, clinical presentation, diagnostic workup, treatment, and outcomes of these two malignant bone tumors. Osteosarcoma most commonly affects the long bones of adolescents and is typically treated with neoadjuvant chemotherapy followed by surgery. Ewing sarcoma occurs in younger children and commonly involves the pelvis or long bones. It is treated with chemotherapy and local control with surgery or radiation therapy when possible. Both tumors require a multidisciplinary treatment approach to achieve long-term survival in approximately 60-75% of patients.
CT coronary angiography in ED chest pain patientskellyam18
CTCA shows promise in reducing length of stay and costs for ED chest pain patients, but more research is needed. While CTCA is highly sensitive for detecting CAD, it may overestimate lesion severity and has radiation risks. Current evidence does not clearly support CTCA as a routine test for ED chest pain patients without known CAD who have normal ECG and biomarkers. CTCA may be useful in select subgroups, but how to define these subgroups is unclear.
Contraindications, futility & fraility in liver transplantDr. Rohit Saini
This document discusses contraindications and factors used to assess futility for liver transplantation (LTx). It covers absolute and relative contraindications to LTx. Scores like MELD, SOFT, and UCLA are used to predict post-LTx outcomes and futility. Factors like frailty, age, comorbidities, acute liver failure criteria, and ACLF grade impact survival. The concept of a "transplantation window" in ACLF is discussed. Precipitating events, physical frailty, sarcopenia, cardiovascular disease, and pulmonary hypertension also influence futility decisions for LTx.
This document discusses mitral valve disease and treatment options such as surgical repair/replacement and the MitraClip procedure. Some key points:
- Mitral regurgitation (MR) is the most common valve problem and increases in prevalence with age. Left untreated, MR can lead to heart failure and death.
- Surgical treatment has traditionally been the only option to reliably reduce MR, but many patients are considered too high-risk for surgery.
- The MitraClip procedure is a minimally invasive treatment that fills this gap for inoperable patients by using a clip to repair the mitral valve and reduce MR without open heart surgery.
- Clinical trials show the MitraClip procedure reduces MR
- Several studies have found that older liver transplant recipients (over age 60) have similar short-term outcomes to younger recipients in terms of postoperative morbidity, mortality, and length of hospital stay. However, long-term survival is significantly lower in older recipients, largely due to non-hepatic age-related causes of death.
- While patient survival is lower in older recipients, graft survival is not significantly different between older and younger groups. The increased mortality in older patients is attributed to infections, cardiac events, and neurological causes rather than hepatic causes.
- Careful consideration of medical fitness and life expectancy due to comorbidities is important when evaluating older recipients for liver transplantation. While age alone should not preclude transplantation, risks
Comorbidities and Other Predictors for Severity of Colonic Diverticulitis?semualkaira
Predicting severity of acute colonic diverticulitis (ACD) is important for management, morbidity and mortality. The aim of this study is evaluating the Charlson’s Comorbidity Index (CCI) as severity predictor of ACD.
Management of splenic injuries has evolved over the last 30 years from primarily operative to non-operative management (NOM). NOM is now the standard of care for hemodynamically stable patients with splenic injuries. The success rate of NOM has increased to 85% with the addition of splenic artery embolization (AE) which can treat contrast blush and pseudoaneurysms seen on CT scans that are predictors of NOM failure. AE has reduced NOM failure rates to as low as 2-6% and allowed for non-operative management of even high grade IV-V injuries at rates over 80%. Careful patient selection based on grade of injury, hemoperitoneum, and CT findings remains
The document discusses recent developments in left atrial appendage closure. Key points include:
- Long term results and meta-analyses from randomized trials of warfarin vs. Watchman leading to FDA approval.
- Differences between trial populations and real-world patients.
- Results from studies of patients who cannot take oral anticoagulants.
- Technical advances in devices.
- Role of CT imaging.
Health Surveillance of asbestos-exposed workers at Helsinki Asbestos 2014Työterveyslaitos
This document discusses health surveillance of asbestos-exposed workers. It summarizes various asbestos-related diseases such as asbestosis, pleural plaques, and mesothelioma. It notes that CT scans have found more early-stage lung cancers in asbestos workers but have not reduced mortality. Biomarkers and microRNAs show promise as screening tools but require more research. Lung function tests and smoking cessation also remain important aspects of health surveillance for these workers. Overall, the benefits of screening must be weighed against the risks of repeated radiation exposure and invasive follow-up procedures.
Giant Cell Tumors of Bones: Management & Single Author ExperienceMohamed Abdulla
This document discusses giant cell tumor of bone (GCTB) and the potential role of denosumab in its management. It provides background information on GCTB, including its incidence, presentation, histopathology involving RANKL expression, and standard treatment options. It then describes a pilot study of 17 patients with advanced or metastatic GCTB who were treated with denosumab. The majority of patients experienced pain alleviation and stabilization or improvement of neurological deficits and pulmonary metastases. Denosumab represents a promising targeted therapy for salvage treatment of difficult GCTB cases.
This document provides an overview of pulmonary embolism (PE) including epidemiology, risk factors, clinical presentation, diagnostic evaluation, and treatment recommendations. Some key points:
- PE affects 300,000-600,000 Americans annually, with 30-50% developing long-term complications. Up to 50% of cases are initially missed by clinicians.
- Clinical prediction tools like the Wells Criteria and PERC Rule can assess pre-test probability. D-dimer can help exclude PE in low risk patients. CT pulmonary angiography and ventilation-perfusion scans are used for diagnosis.
- Anticoagulation is standard treatment for PE. For intermediate/high-risk PE, thrombolysis,
This document summarizes key findings from several studies related to acute myeloid leukemia (AML) in elderly patients:
1) A phase 3 trial found that azacitidine extended overall survival compared to conventional care regimens in older patients with newly diagnosed AML, with median OS of 10.4 months for azacitidine vs 6.5 months for conventional care.
2) Subanalyses found azacitidine provided particularly long OS benefits vs conventional care for patients with poor-risk cytogenetics (median OS 6.4 vs 3.2 months) or myelodysplasia-related changes (1-year OS 55.1% vs 31.3% for LDAC preselected
This patient is a 13-year-old girl presenting with right thigh pain and elevated markers. Imaging shows erosion of the tumor through the cortex with no metastases. Biopsy reveals malignant spindle cells producing osteoid. This represents Stage IIb osteosarcoma - a high grade tumor with extra-compartmental growth and no metastases. The next steps are neoadjuvant chemotherapy followed by wide excision and reconstruction with adjuvant chemotherapy to treat micrometastatic disease.
This case series describes 8 patients who presented with acute mesenteric ischemia and bowel gangrene. The most common presenting symptom was abdominal pain. Four patients had pre-existing cardiac conditions that increased their risk. All patients underwent exploratory laparotomy where gangrenous bowel segments were resected. Post-operative complications occurred in 4 patients, and the mortality rate in the series was 37.5%. Acute mesenteric ischemia can be difficult to diagnose due to non-specific symptoms, but prompt surgical treatment is needed to prevent high mortality from bowel necrosis.
Ultrasound assisted thrombolysis for vte turkish experienceuvcd
This document summarizes the key findings from several studies on using ultrasound-accelerated thrombolysis to treat pulmonary embolism and deep vein thrombosis. The ULTIMA trial found that low-dose catheter-directed ultrasound-accelerated thrombolysis was superior to anticoagulation alone in reversing right ventricular dysfunction in pulmonary embolism patients. The SEATTLE II study aimed to evaluate this technique for submassive and massive pulmonary embolism. A single-center retrospective review of 106 patients treated for chronic deep vein thrombosis found that over 90% reported significant symptom improvement and ultrasound follow-up showed high patency rates over time. The mechanism of action is that ultrasound energy exposes plasminogen receptor sites and increases
This document discusses mitral valve disease and treatment options. It provides information on:
- Mitral regurgitation (MR), the most common type of heart valve disease, which occurs when the mitral valve does not close properly.
- Treatment options for MR including open-heart surgery, minimally invasive surgery, robotic surgery, and the MitraClip procedure. MitraClip offers a less invasive alternative for high-risk surgical patients.
- Guidelines for referral for mitral valve repair/replacement, focusing on patients with moderate-severe or severe MR who are at high-risk for open-heart surgery.
- The large population of MR patients who are not surgical candidates, representing an unmet
A 14-year-old girl presented with easy fatigability and gum bleeding. Her CBC showed Hb 4.0, MCV 80, TLC 1500, and platelets 4000/mm3. Her bone marrow aspiration was hypocellular and her biopsy was hypoplastic, consistent with aplastic anemia. Treatment options for aplastic anemia include immunosuppressive therapy with antithymocyte globulin (ATG) and cyclosporine (CSA), which has a 70% response rate. For those who do not respond to ATG+CSA, options include a second course of ATG, eltrombopag, or allogeneic hematopoietic stem cell transplantation from a
- A 12-year-old boy presented with pain and swelling in his left tibia for one month with a history of intermittent fever. Differential diagnoses included osteomyelitis, osteoid osteoma, Ewing's sarcoma, and osteosarcoma.
- Ewing's sarcoma most commonly affects children and young adults between 5-25 years old and presents with pain, swelling, and sometimes pathological fractures. Definitive diagnosis is based on histology, immunohistochemistry, and detection of specific gene fusions.
- Treatment involves chemotherapy with VACA/IE cycles alternating every 2-3 weeks for 17 cycles along with possible surgery and/or radiation therapy based on response and margins. The goal is
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
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Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- 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
1. Endocarditis:
Evaluation and
Management
Rekha Mankad, MD, FACC
Assistant Professor of Medicine
Mayo Clinic College of Medicine
Director, Women’s Heart Clinic
Mayo Clinic, Rochester, MN
mankad.rekha@mayo.edu
@RMankadMD
3. “The different modes of
onset, and the
extraordinary diversity of
symptoms which may arise,
render it very difficult to
present a satisfactory
clinical picture”
- Sir William Osler, 1885
Infective Endocarditis
4. What is the annual incidence of IE in
contemporary Western cohorts?
1. 5-7/100,000 person years
2. 50-70/100,000 person years
3. 5-7/1000 person years
4. 5-7/10,000 person years
4
5. Epidemiology
• Infective endocarditis (IE) is uncommon
– Annual incidence of 5-7/100,000 person years
• Associated with significant morbidity and mortality
– 3rd most life threatening infection after sepsis/ pneumonia &
intra-abdominal abscess
• Male: Female approximately 2:1
• Age of onset > 60 yo (men 6-7 years older than women)
• Uncommon in children (when occurs typically due to
congenital heart disease)
• Mitral valve > aortic valve >> tricuspid valve
5
6. Major Criteria Minor Criteria
Positive blood culture for IE with
typical organism
Predisposition: predisposing heart condition or
IVDU
Persistently positive blood cultures for
any organism
Fever ≥ 380C
Single positive blood culture for
C.burnetti
Vascular phenomena: arterial embolism, septic
pulmonary infarcts, mycotic aneurysm, ICH,
Janeway lesions
Echocardiogram positive for IE Microbiologic evidence that does not meet major
criteria
Positive blood culture not meeting major criteria
Immunologic phenomena 6
Diagnosis of Infective Endocarditis
7. Positive Echocardiogram
Oscillating intracardiac massor
Abscess or
New partial dehiscence of prosthetic
valve or
New Valvular Regurgitation
Diagnosis of Endocarditis
Duke Criteria
Durak et al. Am J Med 1994;96:200.
8. Diagnosis
Diagnostic Clinical Criteria
8
DEFINITE
2 major criteria
1 major & 3 minor criteria
5 minor criteria
POSSIBLE 1 Major AND 1 minor criteria or 3 minor criteria
REJECTED
Firm alternative diagnosis
Resolution of syndrome ≤ 4 days
No pathologic evidence of IE after ABx for ≤ 4 days
11. Echo features of a Vegetation
• Echogenic mobile mass
• Location: atrial side for MV,
ventricular side for AV
• Shaggy, irregular, amorphous
• Intermediate echogenicity: like
the myocardium
• Motion independent of valve
(oscillating)
• Associated tissue deformity,
destruction
12. Risk Factors for Infective Endocarditis
74.6
19.4
13.4
6.7
4.2
1
0 50 100
Adjusted
Odds
Ratio
Dental Treatment
Heart Murmur
Congenital Heart
Disease
Rheumatic Fever
Mitral Valve
Prolapse
Cardiac Valve
Surgery
Adapted from Strom BL et al., Ann Intern Med 1998;129:761-9
13. Endocarditis Prevention
13
Who needs
prophylaxis?
Prior IE
Prosthetic valves
Congenital Heart
Disease
Valvulopathy
after cardiac
transplantation
Unrepaired cyanotic
congenital heart
disease
Completely repaired
CHD with prosthetic
materials placed within
6 months
CHD repair with
residual defects next to
prosthetic materials
Includes TAVR valves
and patients with
prosthetic material
used in valve repair
14. Case
27 year old pregnant woman with cough
• 17 weeks pregnant
• 1-2 weeks of productive cough
–Scant hemoptysis
• ROS: Subjective fevers, dizziness
Courtesy of Dr. Anavekar
15. Case
27 year old pregnant woman with cough
• Vital Signs
• BP 103/67 mmHg, HR 130 bpm, RR 24, Temp 38.90C
• HEENT: JVP mildly elevated
• Resp: Good air intensity bilaterally, scattered areas of
wheeze and crackles
• CV: Tachycardic, regular rhythm, II / VI holosystolic
murmur
• Ext: 1+ pitting edema
16. Case
• Labs: Blood cultures growing S. aureus
–3 of 3 bottles in 8 hours
–Blood work: Hgb 8.0, WBC 17.8, Plt
26K, Sodium 120, Creatinine 0.6
17.
18. What is the most appropriate next
diagnostic step?
1. Cardiac CT
2. Cardiac MRI
3. Transthoracic echocardiogram
4. Transesophageal echocardiogram
5. PET/CT
20. Echocardiography: Sensitivity
• TTE: 54-83%
–30% for prosthetic valves
• TEE: 95-100%
–77-90% for prosthetic valves
• Specificity: good for both (92-100%)
- Mugge et al, J Am Coll Cardiol 1989
- Aragram et al, in Weyman’s Principles and Practice of Echocardiagraphy, 2nd edition
- Shively et al, J Am Coll Cardiol 1991
21. Sources of Error in Echo Interpretation
• Poor image quality
• Valvular degeneration, calcification,
sclerosis
• Other masses
–Papillomas
–Thrombi
–Myxomatous degeneration
–Healed (old) vegetations
• Small size
• Overzealous interpretation
24. S. aureus Bacteremia
• Must exclude IE via TEE
– Highest sensitivity on days 5-7
• If no other metastatic foci the antibiotic course will be
14 days
• TEE should be repeated at the end of the 2 week
course prior to completing antibiotics
– 10-15% of will have developed IE
Sochowski RA, et al. J Am Coll Cardiol. 1993.
25. Staphylococcus aureus
Bacteremia
• 103 pts Staphylococcus aureus Bacteremia
• All patients had fever and > 1 + blood culture
• DUKE Criteria used for diagnosis
• Death due to sepsis:
15%* with I.E. (*p<0.01)
3% without I.E.
Fowler et al. J Am Coll Cardiol 1997;30:1072
26.
27. Right-sided Infective Endocarditis
• Associated with IV drug abuse or Indwelling
catheters/devices
• Septic pulmonary emboli
– Often multifocal and cavitating
• Right heart failure
– Dyspnea on exertion
– JVD + Lower extremity edema
• Perivalvular extension of infection
– Increased mortality (23%)
– Increased embolic risk (64%)
Omari B, et al. Chest. 1989.
Daniel WG, et al. N Engl J Med. 1991.
28. Case continued
• Hospital day 14 – clinical deterioration
–Low grade fevers
–Rising leukocytosis
–TEE performed
• To assess for progression of cardiac disease
29.
30.
31.
32. IE in Pregnancy - Outcomes
• Maternal morbidity/mortality
– Mortality: 11.5%
• Left-sided > Right-sided
– Septic pulmonary emboli ~20-25%
– CNS emboli ~10-15%
• Fetal Outcomes
– Delivery and survival to discharge 80%
– Intrauterine demise 10-15%
Kebed K, et al. Mayo Clin Proc. 2014.
33. Case
• 55 year old female with fever, chills
• Staph aureus bacteremia
• Systolic murmur
• Started on antibiotics, but within 24 hours had
transient left arm weakness
–No CVA on CT
–No residual neurologic symptoms (left arm
weakness resolved)
• TEE performed
35. What do you recommend?
1. Immediate mitral valve surgery
2. Continue antibiotics and close observation
3. Anticoagulation
Can Echo help decide based on
size and mobility?
37. TEE in Infective Endocarditis
Incidence of Embolism
0
20
40
60
80
Aortic valve Mitral Valve Prosth valve
Incidence
of
Embolism
(%)
Veg <10mm
Veg >10mm
n = 45 n = 31 n = 25
16
35
67
4
38
52
p = ns
p <0.001
p = ns
Mugge JACC 14:631(1989)
38.
39. 0
10
20
30
40
50
60
70
80
90
Absent <10 10-15 >15
Vegetation size (mm)
Embolic
events
(%)
0
10
20
30
40
50
60
70
80
90
Absent Low Mod Severe
Vegetation mobility
Importance of Vegetation
Size and Mobility
De Salvo G et al. J Am Coll Cardiol 2001;37: 1077-1079.
n = 178
40. Vegetation Size
• 145 patients with endocarditis
• Aortic: 62 (43%) Mitral valve 83 (57%)
• Strokes occurred more often in mitral valve
endocarditis: 33% vs. 11% with aortic
• Independent Predictor of stroke:
• Mitral Valve Vegetation Length > 7 mm
Cabell et al. Am Heart J. 2001;142:75-80
41. Relation of
embolism to
vegetation size
Relation of
embolism to
vegetation size
Embolic events
Embolic events
Di Salvo et al: Positive 37% 9%
JACC, 2001 (>10 mm)
(178 pt)
Di Salvo et al: Positive 37% 9%
JACC, 2001 (>10 mm)
(178 pt)
Cabell et al: Positive 23% 11%
AHJ, 2001 (>7 mm)
(145 pt)
Cabell et al: Positive 23% 11%
AHJ, 2001 (>7 mm)
(145 pt)
Vilacosta et al: Positive 33% 13%
JACC, 2002 (>10 mm)
(211 pt)
Vilacosta et al: Positive 33% 13%
JACC, 2002 (>10 mm)
(211 pt)
Embolism in Infective Endocarditis
Vegetation Size by TEE and Impact of Therapy
Embolism in Infective Endocarditis
Vegetation Size by TEE and Impact of Therapy
On therapy
On therapy
Total
Total
CP1189948-74
42. One Year Survival According to
Vegetation Length
Thuny F et al. Circulation 2005; 112:69-75
n = 384
43. Predictors of 1-Year Mortality
(Cox Multivariable Analysis)
Adjusted RR 95% CI P
Age 1.02 1.01–1.04 0.007
Female sex 1.6 1.01–2.58 0.048
Comorbidity index >2 1.6 0.92–2.64 0.1
Serum creatinine >2 mg/L 1.9 1.16–3.23 0.01
Prosthetic valve 1.6 0.99–2.68 0.053
S aureus IE 2 1.19–3.24 0.001
Moderate or severe CHF 1.6 1.02–1.54 0.04
Vegetation length >15 mm 1.8 1.10–2.82 0.02
Thuny F et al. Circulation 2005; 112:69-75
45. Early Surgery for Infective Endocarditis
with Large Vegetations (> 10 mm)
N Engl J Med 2012;366:2466-73
Mortality Composite End-Point
8 vs 0 embolic events
46. Risk of Embolism
• Consider early surgical treatment for:
• Larger vegetations
• Highly mobile vegetations
• Mitral valve location
• Controversial
• Risk diminishes significantly over time with
antibiotics
47. Indications for Intervention in Infective Endocarditis
• Class IIA: Early surgery (during initial hospitalization
before completion of a full therapeutic course of
antibiotics) is reasonable in patients with IE who
present with recurrent emboli and persistent
vegetations despite appropriate antibiotic therapy.
(Level of Evidence: B)
• Class IIb: Early surgery (during initial hospitalization
before completion of a full therapeutic course of
antibiotics) may be considered in patients with native
valve endocarditis who exhibit mobile vegetations
greater than 10 mm in length (with or without clinical
evidence of embolic phenomenon). (Level of
Evidence: B)
2014 AHA/ACC Valve Guidelines, Circulation 2014
48. Timing of Surgery in
Endocarditis After Embolic CVA
–Embolic stroke-wait 7-21 days
–Hemorrhagic stroke- wait 4 weeks
–If headache, think mycotic aneurysm
(avoid valves that need anticoagulation)
Hoen B and Duval X. N Engl J Med 2013;368:1425-33
49. 2017 Focused Valve Update: IE
• Operation without delay may be considered in
patients with IE and an indication for surgery who
have suffered a stroke, but have no evidence of
intracranial hemorrhage or extensive neurological
damage (Class IIb, LOE B-NR).
• If hemodynamically stable, delaying valve surgery for
≥4 weeks may be considered among patients with IE
and major ischemic stroke or intracranial hemorrhage
(Class IIb, LOE B-NR).
50. Complications of Endocarditis Identified
by Echocardiography
• Abscess
• Aneurysm of intervalvular fibrosa
• Fistula
• Perforation
• Other Mechanical Complications Secondary to
Leaflet Destruction
• Hemodynamic
– Most common cause of death is a regurgitant lesion with
CHF (Lerner et al, N Engl J Med 1966)
51. 47 Year Old Male with Fever and Heart
Block
TEE: Large Aortic Root Abscess
54. Case: When to operate in a
patient with an Abscess?
• 57 year old male s/p Medtronic-Hall AVR
• Normal coronary arteries 3 years prior
• Transferred to Mayo Clinic on a Friday with
endocarditis, abscess, and heart block
• Temporary pacemaker in place (screw in lead)
• Hemodynamically Stable
• Surgery planned for Monday
60. • Patient being prepped for emergency
surgery
• Suddenly developed hypotension followed
by ventricular fibrillation
• 45 minutes of resuscitation
– Unsuccesful
• Patient died before he could make it to
operating room
When to operate in a
patient with an abscess?
Urgently !
61. Case
• 68 yo male presented at an outside hospital
with 4 weeks of chills, night sweats, and
fatigue.
–PMH: s/p TAVR 1 year prior, hepatitis C and
alcoholic cirrhosis
–Blood cultures drawn at the outside hospital
were positive for Gemella haemolysans
Courtesy of Dr. J. Thaden
67. Case
• Echo-guided pericardiocentesis (575 mL)
• 6 weeks of IV antibiotics
• Plans to undergo liver transplant workup prior to
potential aortic valve replacement
• Repeat TEE at 4 weeks…..