A 41 year old with chest pain and a Nondiagnostic Triage ECG. Thrombolytics prior to transfer for PCI.
Conclusion:Transfer for PCI without thrombolytics is best if PCI at receiving facility can be done in less than 120 minutes from first medical contact, or less than 90 minutes from STEMI diagnosis in first ED.Thrombolytics prior to Transfer to a PCI capable facility, then rescue PCI if no reperfusion for STEMITRANSFER AMI(Cantor et al. 2009).High risk STEMI: BP less than 100, HR greater than 100 Killip class II, III, ST depression of at least 2 mm in precordial leads, ST elevation in right precordial leads (right ventricular MIAll patients get TNK-tPA.80-90% received clopidogrel 300 mg (75 mg for age over 75).Enox...
Source: Dr. Smith's ECG Blog - November 8, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs

Enoxaparin dose for VTE prophylaxis in obese patients
(Source: Notes from Dr. RW)
Source: Notes from Dr. RW - October 6, 2018 Category: Internal Medicine Tags: cardiovascular hematology hospital medicine pharmacology Source Type: blogs

Watch what happens when " pericarditis " and morphine cloud your judgment
Submitted and written by Alex Bracey with edits by Pendell Meyers and Steve SmithCaseA 50ish year old man with a history of CAD w/ prior LAD MI s/p LAD stenting presented to the ED with chest pain “similar to his prior MI, but worse.” The pain initially started the daypriorto presentation. The pain roused him from sleep but subsided without intervention. Around 19 hours later, he experienced the same pain, which prompted his presentation to the ED. By this time, three hours had passed from the onset of the pain but it was no longer present. Here is his initial ECG:00:04What do you think? - Sinus rhythm at ~70 b...
Source: Dr. Smith's ECG Blog - July 3, 2018 Category: Cardiology Authors: Pendell Source Type: blogs

Let's Stop Claiming That Palliative Care Improves Survival
by Drew RosielleHospice and palliative care community, I'm calling for a moratorium on all blanket, unqualified claims that hospice and palliative care improve survival.Let's just stop doing this.There has never been any actual evidence that palliative care (PC) interventions improve survival in patients, but since thelandmark Temel NEJM 2010 RCT of early outpatient palliative care for lung cancer patients showed a clinically and statistically significant improvement in longevity in the PC arm, I have heard and all read all sorts of statements by palliative people and all sorts of others (hospital executives, policy m...
Source: Pallimed: A Hospice and Palliative Medicine Blog - June 30, 2018 Category: Palliative Care Tags: lung cancer palliative palliative care quality of life rosielle temel The profession Source Type: blogs

Let's Stop Claiming That Palliative Care Improves Survival
by Drew RosielleHospice and palliative care community, I'm calling for a moratorium on all blanket, unqualified claims that hospice and palliative care improve survival.Let's just stop doing this.There has never been any actual evidence that palliative care (PC) interventions improve survival in patients, but since thelandmark Temel NEJM 2010 RCT of early outpatient palliative care for lung cancer patients showed a clinically and statistically significant improvement in longevity in the PC arm, I have heard and all read all sorts of statements by palliative people and all sorts of others (hospital executives, policy m...
Source: Pallimed: A Hospice and Palliative Medicine Blog - June 30, 2018 Category: Palliative Care Tags: lung cancer palliative palliative care quality of life rosielle temel The profession Source Type: blogs

How to manage a patient with LA clot and Mitral stenosis ?
Take Our Poll (function(d,c,j){if(!d.getElementById(j)){var pd=d.createElement(c),s;pd.id=j;pd.src='https://s1.wp.com/wp-content/mu-plugins/shortcodes/js/polldaddy-shortcode.js';s=d.getElementsByTagName(c)[0];s.parentNode.insertBefore(pd,s);} else if(typeof jQuery !=='undefined')jQuery(d.body).trigger('pd-script-load');}(document,'script','pd-polldaddy-loader')); Answer  Though PTMC in the presence of LA clot is an option in low risk clots , my strategy would be the last one ,whenever feasible. Intensive, monitored Heparin /Oral anticoagulants ( Heparin 5000 units tds or qid  or Low molecular weight heparin Enox...
Source: Dr.S.Venkatesan MD - February 3, 2018 Category: Cardiology Authors: dr s venkatesan Tags: Uncategorized Source Type: blogs

How doctors add stress to the poor IVF patient's life
Being infertile is bad enough, and an IVF cycle is stressful because you are never sure whether it's going to work or not. Not only is the uncertainty difficult to handle, the fact that it's so expensive just adds to your anxiety. While we can't reduce the uncertainty which plagues IVF , the tragedy is that IVF doctors often add insult to injury , by making the treatment unnecessarily stressful .For one thing, they subject patients to lots of useless tests, which are completely unnecessary , because they don't change the treatment options we can offer to patients. They justify these by doing it under the garb of being &quo...
Source: Dr.Malpani's Blog - January 28, 2018 Category: Reproduction Medicine Source Type: blogs

How doctors add stress to the poor IVF patient's life
IVF treatment is stressful as it is , and many doctors make it even more stressful. Being infertile is bad enough, and an IVF cycle is stressful because you are never sure whether it's going to work or not. Not only is the uncertainty difficult to handle, the fact that it's so expensive just adds to your anxiety.While we can't reduce the uncertainty which plagues IVF , the tragedy is that IVF doctors often add insult to injury , by making the treatment unnecessarily stressful .For one thing, they subject patients to lots of useless tests, which are completely unnecessary , because they don't change the treatment options we...
Source: Dr.Malpani's Blog - January 11, 2018 Category: Reproduction Medicine Source Type: blogs

Palliative Care & CHF: PAL-HF trial
The main results of PAL-HF - a randomized, controlled trial of specialty palliative care team involvement in advanced heart failure patients -  have just been published in the Journal of the American College of Cardiology (DOI: 10.1016/j.jacc.2017.05.030. Clinicaltrials.gov registration here). This is an important, well-done study, with encouraging results - specialty PC improved the quality of life of patients with HF. I'll discuss the results in more details in this post.The study was done by a multi-disciplinary team of palliative& cardiology investigators at Duke. This week's publ...
Source: Pallimed: A Hospice and Palliative Medicine Blog - July 14, 2017 Category: Palliative Care Tags: chf heart failure research research issues rosielle Source Type: blogs

Comparative effectiveness research in action: enoxaparin versus fondaparinux for acute coronary syndrome
(Source: Notes from Dr. RW)
Source: Notes from Dr. RW - July 9, 2017 Category: Internal Medicine Tags: cardiovascular pharmacology Source Type: blogs

In Which I Go Under The Knife And Learn About Medicine In The Real World
I’m not a doctor but I thought I knew something about anticoagulation. Over the course of a career covering cardiology I’ve written countless stories about heparin, warfarin, the low molecular weight heparins, and the new oral anticoagulants. So when I had bilateral total knee replacement a few weeks ago I thought I knew what to...Click here to continue reading... (Source: CardioBrief)
Source: CardioBrief - January 27, 2017 Category: Cardiology Authors: Larry Husten Tags: People, Places & Events Policy & Ethics anticoagulation aspirin Evidence-based medicine Lovenox total knee replacement Xarelto Source Type: blogs

Understanding head injuries
Ski season is here, and I am reminded of the story of Natasha Richardson (Liam Neeson’s wife), who tragically died of a head injury while skiing without a helmet in 2007. Here in the emergency department, we see many patients with concern for head injuries. We factor what may have caused the injury, your age, what we find when we examine you, the timing of the incident, the medicines you take, as well as some other factors, when deciding whether to do a CT scan or admit you to the hospital. When a head injury causes bleeding in the brain Ms. Richardson died of an epidural hematoma, one of several types of brain bleed...
Source: Harvard Health Blog - January 18, 2017 Category: Consumer Health News Authors: Jonathan Nadler, MD Tags: Brain and cognitive health Injuries Prevention Safety Source Type: blogs

Why do IVF doctors write such irrational prescriptions ?
This is a standard prescription from a leading IVF clinic in India.There are 8 medicines described for luteal phase support after the frozen embryo transfer.This is a textbook example of needless polypharmacy and irrational prescribing.The only 2 medicines which are needed for luteal phase support are estrogen and progesterone - which are Susten and Progynova. This much is rational.Duphaston contains progesterone, as does Gestone. Why prescribe 3 different medicines which serve exactly the same purpose and contain the same hormone ?Pregynl contains HCG and has no role to play in a frozen ET because there is no corpus luteu...
Source: Dr.Malpani's Blog - November 21, 2016 Category: Reproduction Medicine Tags: irrational prescribing ivf IVF medications IVF prescription Source Type: blogs

DM / DNB Cardiology Entrance Mock Test 7
Please wait while the activity loads. If this activity does not load, try refreshing your browser. Also, this page requires javascript. Please visit using a browser with javascript enabled. If loading fails, click here to try again Click on the 'Start' button to begin the mock test. After answering all questions, click on the 'Get Results' button to display your score and the explanations. There is no time limit for this mock test. Start Congratulations - you have completed DM / DNB Cardiology Entrance Mock Test 7. You scored %%SCORE%% out of %%TOTAL%%. Your performance has been rate...
Source: Cardiophile MD - January 23, 2016 Category: Cardiology Authors: Prof. Dr. Johnson Francis, MD, DM, FACC, FRCP Edin, FRCP London Tags: Cardiology MCQ DM / DNB Cardiology Entrance Featured Source Type: blogs

DM / DNB Cardiology Entrance Mock Test 4
Please wait while the activity loads. If this activity does not load, try refreshing your browser. Also, this page requires javascript. Please visit using a browser with javascript enabled. If loading fails, click here to try again Click on the 'Start' button to begin the mock test. After answering all questions, click on the 'Get Results' button to display your score and the explanations. There is no time limit for this mock test. Start Congratulations - you have completed DM / DNB Cardiology Entrance Mock Test 4. You scored %%SCORE%% out of %%TOTAL%%. Your performance has been rate...
Source: Cardiophile MD - January 18, 2016 Category: Cardiology Authors: Prof. Dr. Johnson Francis, MD, DM, FACC, FRCP Edin, FRCP London Tags: Cardiology MCQ DM / DNB Cardiology Entrance Featured Source Type: blogs

What Do We Know About Medical Errors Associated With Electronic Medical Records?
By ROSS KOPPEL Recently, the Journal of Patient Safety published a powerful and important article on the role of EHRs in patient harm, errors and malpractice claims. The article is open access. Electronic Health Record–Related Events in Medical Malpractice Claims by Mark L. Graber, Dana Siegal, Heather Riah, Doug Johnston, and Kathy Kenyon.  

The article is remarkable for several reasons: Considerably over 80% of the reported errors involve horrific patient harm: many deaths, strokes, missed and significantly delayed cancer diagnoses, massive hemorrhage, 10-fold overdoses, ignored or los...
Source: The Health Care Blog - January 11, 2016 Category: Consumer Health News Authors: John Irvine Tags: Uncategorized Source Type: blogs

"How could I convince my interventionalist to come do a cath in the middle of the night?"
I just received this email today.  I receive these fairly frequently:Dear Dr. Smith:I am an Emergency physician working in an outlying hospital in _________. We have an interventional hospital to which we refer cath lab patients.  I had a 31 year old with typical chest pain and vomiting and the attached ECG. I was sure he was infarcting but couldn’t convince the interventionalist to take him (after emailing him the ECG).I treated the patient aggressively with medical management and transfered him to the tertiary center.  They did not take him to the cath lab emergently.  When he went to the cath l...
Source: Dr. Smith's ECG Blog - August 27, 2015 Category: Cardiology Authors: Steve Smith Source Type: blogs

Venous thromboembolism in cancer – Cardiology MCQ
Which of the following cancer has the highest relative risk of venous thromboembolism? a) Pancreatic cancer b) Brain cancer c) Multiple myeloma d) Colonic cancer Correct answer: c) Multiple myeloma Multiple myeloma has forty six fold risk of venous thromboembolism than healthy controls while brain cancer has twenty fold and pancreatic cancer sixteen fold relative risk. But by absolute numbers, most episodes occur with lung, colon and prostate  cancer [1]. Chemotherapy confers six fold extra risk though chemotherapy per se is not considered an indication for prophylactic anticoagulation in ambulatory patients, the exce...
Source: Cardiophile MD - June 3, 2015 Category: Cardiology Authors: Prof. Dr. Johnson Francis, MD, DM, FACC, FRCP Edin, FRCP London Tags: Cardiology MCQ DM / DNB Cardiology Entrance Source Type: blogs

Elimination of unfractionated heparin – Cardiology MCQ
Principal route of elimination of unfractionated heparin: a) Renal b) Hepatic c) Reticuloendothelial system d) None of the above Correct answer: c) Reticuloendothelial system Unfractionated heparin being a large molecule, is eliminated mainly by the reticuloendothelial system, like abciximab. Renal excretion plays only a minor role in the elimination of unfractionated heparin from the body and hence it can be used with better safety profile in the presence of renal dysfunction. In contrast, a significant amount of low molecular weight heparin (most commonly used being enoxaparin) is eliminated by renal excretion (about for...
Source: Cardiophile MD - May 31, 2015 Category: Cardiology Authors: Prof. Dr. Johnson Francis, MD, DM, FACC, FRCP Edin, FRCP London Tags: Cardiology MCQ DM / DNB Cardiology Entrance Source Type: blogs

Cardiology MCQ: Catheter thrombosis with Fondaparinux
Catheter thrombosis with Fondaparinux is due to: a) High anti-Factor Xa activity b) Low anti-Factor IIa activity c) High factor VIIIa activity d) Low factor Xa activity Correct answer: b) Low anti-Factor IIa activity Though Fondaparinux is a safe and effective in the management of ST elevation myocardial infarction, it was associated with a higher incidence of guide catheter thrombosis in those who underwent percutaneous coronary intervention. The same concern applies to non ST elevation acute coronary syndromes where fondaparinux is ideal in terms of lower bleeding risk, albeit with a potential risk of guide catheter thro...
Source: Cardiophile MD - November 26, 2014 Category: Cardiology Authors: Prof. Dr. Johnson Francis, MD, DM, FACC, FRCP Edin, FRCP London Tags: Angiography and Interventions Cardiology MCQ Coronary Interventions DM / DNB Cardiology Entrance Source Type: blogs

CPOE Humor Memes. (Laugh Q 1 Hour PRN Scheduled Routine Stat)
If you're looking for a little CPOE humor, look no further.   CPOE stands for Computerized Physician Order Entry.   CPOE provides a perfect opportunity for good humor. Their ain't nothin' funnier in this world than watching emotional breakdowns in middle-aged 1%ers as they try to navigate C-B-C on a standard English keyboard that hasn't changed in centuries.   No matter what your position is on physician order entry, we can all agree on one thing:  If you can't laugh at yourself, the Happy Hospitalist will do it for you. What you'll find here is a fine assortment of original (and not so original)  ...
Source: The Happy Hospitalist - May 5, 2014 Category: Internists and Doctors of Medicine Authors: Tamer Mahrous Source Type: blogs

Critical Care Compendium update
LITFL’s Critical Care Compendium is a comprehensive collection of pages concisely covering the core topics and controversies of critical care. Currently there are almost 1,500 entries with more in the works… Some pages are more developed than others, and all the pages are being constantly revised and improved. Links to new references and online resources are added daily, with an emphasis on those that are free and open access (FOAM!). These pages originated from the FCICM exam study notes created by Dr Jeremy Fernando in 2011, and have been updated, modified and added to since. As such will be partic...
Source: Life in the Fast Lane - November 17, 2013 Category: Emergency Medicine Doctors Authors: Chris Nickson Tags: Critical Care Compendium Education eLearning Emergency Medicine Featured CCC LITFL collection Source Type: blogs

Pharmalot... Pharmalittle... Good Morning
Rise and shine, everyone, another hectic day is on the way. And this may be a soggy one, unfortunately. But we will persevere, nonetheless, as our spirits remain sunny. Once again, let us recall what the Morning Mayor used to say: Every brand new day should be unwrapped like a precious gift. How bad can a little rain and cloudy skies really be? While you ponder, here are some tidbits. As always, have a great day and do stay in touch... Glaxo Sells The Bad With The Good In New Safety Push (Bloomberg News) Bayer Seeks Wider Use For Eylea Eye Drug In Europe (Reuters) Novartis To Boost Boston R&D HQ By 150 Jobs (The Boston...
Source: Pharmalot - November 7, 2013 Category: Pharma Commentators Authors: esilverman Source Type: blogs

Healthcare Update Satellite — 11-04-2013
See more medical news from around the web on my other blog at DrWhiteCoat.com 72 year old Connecticut patient awarded $9.3 million after being hospitalized for UTI, then given overdose of Lovenox. She developed intra-abdominal bleeding and required several surgeries and blood transfusions to correct the problem. She also developed a large abscess at the site of a central line insertion. Attorneys for the patient say that it was “an understatement” to say that the standard of care was violated. One of the ideas behind providing more patients with “insurance” (not with “health care,” mind ...
Source: WhiteCoat's Call Room - November 5, 2013 Category: Emergency Medicine Doctors Authors: WhiteCoat Tags: Healthcare Update Source Type: blogs

Worrier In Chief
Saul couldn't have been a nicer guy. The story behind his arrival to the nursing home was long and sorted. But now we had a black gangrenous foot to deal with. The culprit, not the toe ulcer that brought him in to the hospital in the first place, but small thrombosed blood vessels from heparin induced thrombosis and thrombocytopenia, a reaction to a medication given as a precaution. The vascular surgeon was equivocal, amputation versus watchful waiting. Toes can autonecrose (self amputate), but when the black tide of dead tissue spread towards the ankle our options became limited. As the white count began to rise, I had t...
Source: In My Humble Opinion - September 5, 2013 Category: Family Physicians Authors: Jordan Grumet Source Type: blogs

Think twice before getting an injection for low back pain or sciatica
It’s been a while since I did a Cycling Wednesday topic. As I was skimming thorough the Journal of the American Medical Association last night, I came across this review article on spinal injection therapy for low back pain. It was a shocker. Two factors brought my attention to the article: First, almost all the cyclists or runners I know have been beset with either back pain or sciatica (referred pain or weakness down the leg). In fact, in some cases, back issues have ended their competitive careers. I too have been flattened with low back pain. It was awful. The other reason to pay attention to the review is the hu...
Source: Dr John M - June 19, 2013 Category: Cardiology Authors: Dr John Source Type: blogs

Hazards of using enoxaparin in patients with reduced creatinine clearance but above the threshold for dose adjustment
(Source: Notes from Dr. RW)
Source: Notes from Dr. RW - May 2, 2013 Category: Internists and Doctors of Medicine Tags: pharmacology hematology cardiovascular nephrology Source Type: blogs

MKSAP: 28-year-old man with left calf deep venous thrombosis
Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.A 28-year-old man is evaluated 24 hours after a new diagnosis of a left calf deep venous thrombosis. One week ago, he underwent orthopedic surgery. Two weeks ago, he returned from vacationing in Italy on an 8-hour flight. Current medications are enoxaparin, 80 mg subcutaneously twice daily, and warfarin, 5 mg/d.On physical examination, temperature is normal, blood pressure is 145/85 mm Hg, pulse rate is 72/min, and respiration rate is 18/min. BMI is 25. His lungs are clear. His left calf is erythematous and ed...
Source: Kevin, M.D. - Medical Weblog - February 23, 2013 Category: Family Physicians Tags: Conditions Medications orthopedics Source Type: blogs

Drug Costs In Hospitals & Clinics To Rise 4 Percent
The cost of medications administered by clinics and hospitals are expected to rise by as much as 4 percent this year, which is less than in previous years, thanks to the increasing availabitily of lower-cost generics, according to a study in the American Journal of Health-System Pharmacy. Specifically, medication expenditures are projected to rise between 1 percent and 3 percent across all clinics and hospitals not run by the federal government. But medication costs are forecast to increase between 2 percent and 4 percent in clinics, while there will be a 1.5 percent gain ih hosptials. “In the aggregate, drug expend...
Source: Pharmalot - February 19, 2013 Category: Pharma Commentators Authors: Ed Silverman Tags: Uncategorized Affordable Care Act Contraceptives Epogen Lovenox Procrit Prolia Remiicade Rituxan Xgeva Source Type: blogs

Rivaroxaban Effective In Medically Ill Patients But At High Bleeding Cost
The recent arrival of novel oral anticoagulants has provided important new options for venous thromboembolism (VTE) treatment and prevention. New indications for these drugs have been granted for patients with atrial fibrillation and following orthopedic surgery. But an additional indication, for acutely ill medical patients at risk for VTE, does not appear likely in the near future, as a new trial published in the New England Journal of Medicine shows that one of these novel drugs, though effective at preventing VTE, also resulted in a significant increase in bleeding risk. In the Multicenter, Randomized, Parallel Gr...
Source: CardioBrief - February 7, 2013 Category: Cardiology Authors: Larry Husten Tags: Heart Rhythms Prevention, Epidemiology & Outcomes Anticoagulant atrial fibrillation Enoxaparin sodium rivaroxaban Venous thrombosis VTE Source Type: blogs

Precordial ST depression. What is the diagnosis?
A middle aged male with no h/o CAD presented with one week of crescendo exertional angina, and had chest pain at the time of the first ECG:Here is the patient's previous ECG:NormalHere is the patient's presenting ED ECG:What do you think?There is isolated ST depression in precordial leads, deeper in V2 - V4 than in V5 or V6.  There is no ST elevation.  Precordial ST depression may be subendocardial ischemia or posterior STEMI.  How can we tell the difference?  See the list below.If you thought it might be a posterior STEMI, then you might have ordered a posterior ECG [change leads V4...
Source: Dr. Smith's ECG Blog - January 1, 2013 Category: Cardiology Authors: Steve Smith Source Type: blogs