The American journal of medicine
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When primary care physicians are presented with a patient with atrial fibrillation (AFib), there are two concerns. (online video available at: http://education.amjmed.com/video.php?event_id=445&stage_id=5&vcs=1). One is the choice of strategy to treat the AFib, ie, whether to use rate control or a rhythm control strategy (to keep patients in sinus rhythm). The second concern is preventing the principal risk associated with AFib: stroke and systemic embolism. ⋯ Again, the evidence reveals that the patients at highest risk of bleeding are also at highest risk of stroke, and the benefits of preventing stroke with anticoagulation therapy almost always outweigh the risk of bleeding. This is discussed in the context of the new NOACs (discussed in the next review), including addressing what physicians should do if patients move from warfarin to one of the NOACs or vice versa. A final challenge for physicians treating patients with AFib has been the often mistaken belief that patients are at a low-risk status, and this review concludes with an overview of the use of the CHADS2 versus the CHA2DS2-VASc risk scoring systems, including why CHA2DS2-VASc provides a better assessment of which patients are or are not at low risk.
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D-dimer levels are often elevated in renal insufficiency. The diagnostic accuracy of D-dimer to rule out pulmonary embolism in patients with renal insufficiency is unclear. ⋯ D-dimer levels were elevated in patients with an eGFR <60 mL/min, but proved to be highly sensitive for the exclusion of pulmonary embolism. However, because almost all patients with impaired renal function had elevated D-dimer irrespective of the presence of pulmonary embolism, studies should be performed to determine renal function-adjusted D-dimer cutoffs.
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Parkinson's disease is the second most common neurodegenerative disease worldwide, leading to a wide range of disability and medical complications. Managing patients with Parkinson's disease in the perioperative hospital setting can be particularly challenging. Suboptimal management can lead to medical complications, prolonged hospital stays, and delayed recovery. ⋯ These issues lead to higher rates of pneumonia, urinary tract infections, deconditioning, and falls compared with patients without Parkinson's disease, as well as prolonged hospital stays and a greater need for post-hospitalization rehabilitation. Steps can be taken to decrease these complications, including minimizing nothing by mouth status duration, using alternative routes of drugs administration when unable to give medications orally, avoiding drug interactions and medications that can worsen parkinsonism, assessing swallowing ability frequently, encouraging incentive spirometry, performing bladder scans, avoiding Foley catheters, and providing aggressive physical therapy. Knowing and anticipating these potential complications allow hospital physicians to mitigate nosocomial morbidity and shorten recovery times and hospital stays.
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Alcohol quantity and type on risk of recurrent gout attacks: an internet-based case-crossover study.
Although beer and liquor have been associated with risk of incident gout, wine has not. Yet anecdotally, wine is thought to trigger gout attacks. Further, how much alcohol intake is needed to increase the risk of gout attack is not known. We examined the quantity and type of alcohol consumed on risk of recurrent gout attacks. ⋯ Episodic alcohol consumption, regardless of type of alcoholic beverage, was associated with an increased risk of recurrent gout attacks, including potentially with moderate amounts. Individuals with gout should limit alcohol intake of all types to reduce the risk of recurrent gout attacks.