Atrial Fibrillation

PHILADELPHIA -- Performance measures for hospitals adopted by Medicare and the Joint Commission on Accreditation of Healthcare Organizations may only be loosely related to patient outcomes.

ORLANDO -- Young patients with acute myeloid leukemia are not only surviving into adulthood but thriving well into life, albeit with an increased risk for secondary cancers or heart disease, show data from the Childhood Cancer Survivor Study.

ORLANDO -- For preventing venous thromboembolism following a total knee replacement, the investigational oral anticoagulant dabigatran etexilate was comparable to Lovenox, investigators reported here.

PORTLAND, Ore. -- Gleevec (imatinib) has led to an overall 60-month survival rate of 95% for chronic myeloid leukemia (CML) patients with who took the tyrosine kinase inhibitor daily, found an international study. Yet the drug doesn't cure the disease.

CAPE TOWN, South Africa -- The thiazolidinedione Avandia (rosiglitazone) has a more durable response than two older oral type 2 diabetes agents, but it was more expensive and had more side effects, researchers reported here.

I enjoyed Dr Henry Schneiderman’s “What’s Your Diagnosis?” case of an elderly woman with severe facial ecchymoses from a fall. Would Dr Schneiderman elaborate on several points about that case? This woman did not trip or complain of dizziness before she fell. What caused her to fall?

Idiopathic pulmonary fibrosis (IPF) is a chronic progressive lung disease with unknown etiology and a grim prognosis.1,2 The median survival is about 3 years after diagnosis or 5 years from the onset of symptoms. Its pathologic findings are those of usual interstitial pneumonia.2 Surgical lung biopsy is needed for diagnosis when these findings are not present. Usual interstitial pneumonia is the histopathologic pattern that characterizes IPF (Figure).

A 79-year-old woman with a history of atrial fibrillation was referred to the pulmonary service for preoperative evaluation for hip replacement surgery. She reported that 20 or more years ago she had been told by her physician that she has an "extra blood vessel" in the right lung. It had not caused her any difficulty. Her medical history was also notable for a heart murmur and gastroesophageal reflux disease secondary to a large hiatal hernia. She was a nonsmoker.

A 52-year-old man presented to his primary care physician with shortness of breath for 5 days, right-sided lower thoracic back pain, and dry cough. The patient was a 15-pack-year cigarette smoker who had emigrated from China to the United States in 1989. He had no significant history of occupational exposure or tuberculosis. He had no significant weight loss, and his past medical history was otherwise unremarkable.

ABSTRACT: Age-related changes that affect drug distribution, such as increased total body fat, decreased muscle mass, and decreased total body water, necessitate reduction in the dosage of water- and lipid-soluble agents. Because creatinine clearance declines with age, the dosage of agents that are excreted primarily by the kidney must also be lowered to prevent toxicity. Examples include aminoglycosides, fluoroquinolones, penicillins, procainamide, lithium, angiotensin-converting enzyme inhibitors, and digoxin. A good rule of thumb to follow until creatinine clearance can be calculated is to reduce the total dose by half in frail elderly persons or in those with established renal disease. Anticholinergic agents should be used with caution because they are associated with urinary retention, heart block, constipation, dry mouth, blurred vision, sedation, and acute or chronic confusion in elderly patients.

Amiodarone, a class III antiarrhythmic, has become the drug of choice for the management of supraventricular and ventricular arrhythmias.1,2 Although not an FDA- approved indication, the use of amiodarone to treat atrial fibrillation is supported by practice guidelines from the American College of Cardiology/ American Heart Association (AHA) and the European Society of Cardiology.

DALLAS -- Fetal oxygen saturation monitoring doesn't alter the rate of caesarean deliveries or improve outcomes for newborns, researchers in a large randomized study reported.

DALLAS -- Weight-loss surgery may be too risky for older patients, according to a population-based study of outcomes.

ROCKVILLE, Md., Nov. 17 -- The FDA said today it has expanded approval of Herceptin (trastuzumab) to include its use as adjuvant therapy in the treatment of early stage HER2 positive breast cancer.

CHICAGO -- A noninvasive office-based test can improve the chance that implantable cardioverter defibrillators (ICDs) will go to the patients most likely to benefit from them, researchers reported today.

CHICAGO -- Stenting for an acute myocardial infarction has a better outcome when the reperfusion is followed up with an infusion of carperitide, a human atrial natriuretic peptide, Japanese researchers reported here.

CHICAGO -- A widely available blood test for heart failure should be used more frequently when patients arrive at the emergency department with shortness of breath, researchers said here.

CHICAGO -- Tolvaptan, an investigational selective oral vasopressin V2 -receptor antagonist, restored serum sodium concentrations in heart failure and cirrhosis patients with hyponatremia, researchers reported here.

SAN FRANCISCO -- Older men with limited life expectancies are getting screened much too often for prostate cancer, given the potential harm that may follow a positive test versus the likelihood of benefit, researchers here reported.

NEW YORK -- Uncomplicated diabetes does not affect 10-year heart transplant survival, but patients with diabetes-related renal disease or stroke do not do as well, reported surgeons here.

ROCHESTER, Minn. -- Mortality rates for heart failure patients with preserved left ventricular ejection fraction (non-systolic) are similar to those for patients with a reduced ejection fraction (systolic). However, a higher systolic pressure on admission was a marker of better prognosis.

CHICAGO -- Induction therapy with Taxotere (docetaxel), Platinol (cisplatin), and 5-FU (fluorouracil) leading up to chemoradiation improved complete response in patients with inoperable stage III or IV squamous cell carcinoma of the head and neck, researchers reported here.

CHICAGO -- When treating non-small cell lung cancer, the success of trimodality therapy -- chemoradiation followed by pneumonectomy -- depends upon the experience of the clinical center and the location of the lesion.

LONDON -- For a handful of carefully selected patients, a combination of mechanical and pharmacologic interventions has reversed severe heart failure and restored normal ventricular function, investigators here reported.

OAKLAND, Calif. -- Statins appear to be beneficial in reducing death and hospitalizations in heart failure patients, according to researchers here.

Abstract: Our understanding of the pathobiology of pulmonary arterial hypertension (PAH) has evolved considerably over the past 2 decades, with increasing recognition of the important role that aberrant vasoproliferative responses play in conjunction with disordered vasoconstriction. Classification of the many forms of PAH into categories sharing a similar pathophysiology and clinical presentations help the practicing clinician approach a complex differential diagnosis. Noninvasive tests can be used to narrow this differential but must be applied with an appreciation for their limitations. Transthoracic echocardiography is the screening tool of choice; the workup should also include chest radiography and electrocardiography. However, right heart catheterization is ultimately required to establish the diagnosis. While PAH remains a progressive and generally fatal disease, existing therapies have a significant impact on survival and new therapeutic targets offer great hope for improving the prognosis. (J Respir Dis. 2006;27(11):487-493)

ABSTRACT: Establishing the time of symptom onset is essential to selecting the appropriate therapy. Intravenous tissue-type plasminogen activator (t-PA), administered within 3 hours of symptom onset, is the only FDA-approved treatment for acute ischemic stroke. Intra-arterial and combined intra-arterial-intravenous thrombolytic therapy may be considered for patients whose condition does not improve or who present within 3 to 6 hours of symptom onset. Other options for treating acute ischemic stroke are balloon angioplasty with or without stenting (for symptomatic patients with more than 50% intracranial stenosis in whom medical therapy has failed) and mechanical clot retrieval (for those with an NIH Stroke Scale score greater than 10 who present after the 3-hour window for intravenous t-PA and can be treated within 8 hours of symptom onset or who present within 3 hours of symptom onset but in whom intravenous thrombolysis is contraindicated).

THECASE:An 84-year-old man with a history of stable angina, type 2 diabetes, hyperlipidemia, and hypertension presents to the emergency department with worsening dyspnea and peripheral edema. Congestive heart failure is diagnosed, and the patient is admitted to the care of a hospitalist. A standard therapeutic regimen, including diuretics, angiotensin-converting enzyme inhibitors, and oxygen, is instituted, in addition to the patient's home regimen of isosorbide mononitrate, glipizide, and amlodipine. The hospitalsubstitutes pravastatin for the patient's atorvastatin. A Foley catheter is inserted by a urologist because of the patient's benign prostatic hypertrophy. The patient complains of insomnia and is given diphenhydramine. His hospital course is otherwise uneventful.

If Rip Van Winkle were a primary care physician who fell asleep a generation ago and woke up today, what would he think? He would have missed the arrival of managed care. He wouldn't know what a hospitalist does. He might ask how this evasive concept called quality is measured . . . and then cringe at the idea of "report cards" and "pay for performance."

ABSTRACT: Establishing the time of symptom onset is essential to selecting the appropriate therapy. Intravenous tissue-type plasminogen activator (t-PA), administered within 3 hours of symptom onset, is the only FDA-approved treatment for acute ischemic stroke. Intra-arterial and combined intra-arterial-intravenous thrombolytic therapy may be considered for patients whose condition does not improve or who present within 3 to 6 hours of symptom onset. Other options for treating acute ischemic stroke are balloon angioplasty with or without stenting (for symptomatic patients with more than 50% intracranial stenosis in whom medical therapy has failed) and mechanical clot retrieval (for those with an NIH Stroke Scale score greater than 10 who present after the 3-hour window for intravenous t-PA and can be treated within 8 hours of symptom onset or who present within 3 hours of symptom onset but in whom intravenous thrombolysis is contraindicated).