1/11. Applying evidence-based medicine to current practice: a round table panel discussion.Over the past decade, an expanding body of epidemiological and clinical trial data has been collated, culminating in the development of guidelines designed to help physicians make decisions about intervention and the intensity of treatment, based on objective assessments of the overall level of risk for cardiovascular disease. However, guidelines are not prescriptive and allow physicians leeway in interpretation. Thus, it is of clinical interest to explore some of the issues that may influence the use of these guidelines in clinical practice. This paper summarises a round table panel discussion that highlighted the usefulness of current guidelines, but also demonstrated that these guidelines, and the evaluation of cardiovascular risk, need to be used with care and always interpreted in the light of sound clinical judgement.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/11. Toxicity of over-the-counter cough and cold medications.Over-the-counter (OTC) cough and cold medications are marketed widely for relief of common cold symptoms, and yet studies have failed to demonstrate a benefit of these medications for young children. In addition, OTC medications can be associated with significant morbidity and even mortality in both acute overdoses and when administered in correct doses for chronic periods of time. physicians often do not inquire about OTC medication use, and parents (or other caregivers) often do not perceive OTCs as medications. We present 3 cases of adverse outcomes over a 13-month period-including 1 death-as a result of OTC cough and cold medication use. We explore the toxicities of OTC cough and cold medications, discuss mechanisms of dosing errors, and suggest why physicians should be more vigilant in specifically inquiring about OTCs when evaluating an ill child.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
3/11. Adverse metabolic and cardiovascular risk following treatment of acute lymphoblastic leukaemia in childhood; two case reports and a literature review.We report two patients who survived childhood acute lymphoblastic leukaemia (ALL) following treatment with chemotherapy, total body irradiation (TBI) and bone marrow transplantation (BMT). The first case presented with an acute cerebral infarction at 23 years of age and was found to have non-ketotic diabetes and gross mixed hyperlipidaemia; the second presented with non-ketotic diabetes, hypertension, proteinuria and dyslipidaemia at age 16 years. The association of glucose intolerance with other vascular risk factors in young adult survivors of BMT was recently highlighted in a follow-up study of 23 survivors of BMT [1], but none presented with such gross mixed hyperlipidaemia. The improving survival rates of childhood malignancy over the last two decades will present adult physicians with patients who have accelerated vascular risk at a young age who will require early treatment to modify it.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
4/11. beta-Blockers and reduction of cardiac events in noncardiac surgery: clinical applications.Recent studies suggest that beta-blockers administered perioperatively may reduce the risk of adverse cardiac events and mortality in patients who have cardiac risk factors and undergo major noncardiac surgery. The objective of this article is to provide practicing physicians with examples of perioperative beta-blocker use in practice by using several hypothetical cases. Although current evidence describing the effectiveness of perioperative beta-blockade may not address all possible clinical situations, it is possible to formulate an evidence-based approach that will maximize benefit to patients. We describe how information from several sources can be used to guide management of patients with limited exercise tolerance, those at highest risk for perioperative cardiac events, patients who are taking beta-blockers long-term, and those with relative contraindications to beta-blockade. Even though fine points of their use remain to be elucidated, perioperative beta-blocker use is important and can be easily applied in practice by any physician involved with the care of patients perioperatively.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/11. Keeping an eye on cardiovascular risk. A practical, case-study approach to assessment in office practice.Primary care physicians typically encounter patients who are not at obvious risk for CAD but who nonetheless need and can benefit from lipid-lowering therapy. Applying algorithms or scoring systems can be helpful in estimating an individual patient's risk, but the basic tools available in everyday clinical practice can be used to alert physicians to elevated CAD risk in their patients. Those patients whose LDL-C level is at or above 220 mg/dL (5.69 mmol/L) should routinely and deservedly get clinical attention, but they account for only 2.5% to 5% of the population. Those with an "average" LDL-C level number in the millions, and from this patient pool come the coronary events that fill clinics and hospitals. Aggressive treatment approaches are required to meet NCEP objectives, and every indication suggests that these goals are just the minimum. The third report of the NCEP Expert Panel on Detection, Evaluation, and Treatment of High Blood cholesterol in Adults (Adult Treatment Panel III) has broadened the indications for drug therapy, reclarifying diabetes and peripheral vascular or cardiovascular disease equivalents and using a global evaluation concept, which will identify 30 million Americans in need of drug treatment. The statins safely and effectively lower LDL-C levels, which is the basis for instituting drug therapy, according to NCEP guidelines. Using these drugs also raises HDL-C levels, which is somewhat protective, and decreases triglyceride levels. The efficacy of statin therapy in both primary and secondary prevention of CAD is now well established. If used more often when dietary therapy fails, which happens quite often, and in doses sufficient to work effectively, statins have the power to turn the corner on the prevention and treatment of atherosclerotic coronary disease in the united states.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/11. depression as a mediator between spousal bereavement and mortality from cardiovascular disease: appreciating and managing the adverse health consequences of depression in an elderly surviving spouse.bereavement in the elderly is becoming a more frequent phenomenon as a result of the aging of the population. The death of an elderly spouse increases psychologic morbidity, particularly depressive symptoms, as well as mortality. depression increases the risk of death independent of age or bereavement, and can thus exacerbate the health effects of losing a spouse. This magnifier effect is especially pernicious because bereavement and depression both tend to increase cardiovascular mortality rates. Primary care physicians should be alert for signs of mood disorders in elderly persons who have recently lost a spouse. Potential therapies for depression in an elderly bereaved individual include pharmacologic agents, psychotherapy, and psychosocial support. Data also support the value of encouraging religious patients to continue with spiritual observances. Although these approaches decrease mood disorders, it is not yet clear whether they also reduce the risk of death or cardiovascular disease.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
7/11. Laser surgery in the medically compromised patient.dermatology has entered a new dimension with the introduction of the laser. There are expanding clinical indications for laser excision. The CO2 laser in the cutting mode can incise tissue as sharply as finely honed steel, yet its photocoagulative properties allow rapid sealing of blood vessels and lymphatics. The physician can thereby perform in a relatively bloodless surgical field. Minimal adjacent normal tissue is injured, there is less local postoperative edema, and fewer postoperative analgesics are required. Since there is no need to use epinephrine as a local vasoconstrictive agent and there is no need to use electrocoagulation for control of hemorrhage, CO2 laser excision presents less risk to the medically compromised patient. The CO2 laser may also diminish the risk of seeding or spreading neoplastic cells in the perioperative field.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
8/11. Evaluation of a new method for cardiovascular reasoning.OBJECTIVE: Evaluate the accuracy of the detailed diagnostic reasoning of the heart failure Program incorporating a new mechanism to handle temporal relationships and severity constraints. DESIGN: Tools were developed to summarize diagnoses and automatically generate evaluation forms. Five expert cardiologists were asked to review the reasoning of the program, with two analyzing each case. Cases were gathered retrospectively for diversity and difficulty and 26 randomly selected cases were evaluated. The underlying issues were identified and classified. RESULTS: Both reviewers rated the first diagnosis correct in 25% of the cases and at least one rated it wrong in 10%. Analyzing the detailed reasoning, 137 issues were raised, about 5.3 per case. Of these, 53% were possible concerns raised by one reviewer. Of the 5.3 issues per case, 2.5 were attributable to controversies, misunderstandings, or mistakes; 1 was due to the overly simplistic representation of the summaries; and 1.8 were issues related to the program. CONCLUSION: overall, the program is capable of providing high-quality detailed diagnostic hypotheses for complex cardiovascular cases. The results highlight several issues: 1) the difficulty of effectively summarizing hypotheses, 2) the nature of a physician's causal explanation, and 3) some problems in evaluating detailed diagnostic reasoning. The mistakes the program made imply that some additional refinement is needed but that the reasoning mechanisms developed can support the appropriate reasoning. The appropriate next step is a prospective evaluation addressing the program's usefulness.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
9/11. Unexplained syncope: diagnostic value of tilt-table testing.Vasovagal syncope is a common syncope in patients who have no structural heart disease and occurs more often in young adults. It typically occurs in the erect posture, either standing or sitting. Upon recognition of the prodrome associated with NCS, subjects may avert syncope by lying down or putting the head between the knees. Use of head-up tilting is a recognized diagnostic tool and widely used for the evaluation of vasovagal syncope. However, cardiac diagnostic tests are not 100% accurate. This fact was recently underscored by what occurred in the recent tragic loss, due to ventricular fibrillation, of basketball star Reggie Lewis of the boston Celtics. It is alleged that the tilt-table test was positive but that he also had structural heart disease. The most important diagnostic tool is the physician's clinical judgment.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
10/11. Serious cardiovascular side effects of large doses of anabolic steroids in weight lifters.Pathological cardiovascular manifestations are reported in four male patients, who had taken massive amounts of anabolic steroids while undergoing many years of strength training. One patient was referred because of ventricular fibrillation during exercise, one because of clinically manifest heart failure, and one because of arterial thrombus in his lower left leg. The fourth patient was persuaded to attend for a check-up because of a long history of massive use of anabolic steroids. All four patients had cardiac hypertrophy. Two of the patients had symptoms and signs of heart failure, and one of these two had a massive thrombosis in both right and left ventricles of his heart. After cessation of the use of anabolic steroids in the other patient with heart failure, left ventricular wall thickness reduced quickly from 12 to 10.5 mm, and fractional shortening increased from 14% to 27%. Endomyocardial biopsy revealed increased fibrosis in the myocardium in two of the three cases. HDL-cholesterol was 0.58 mmol.l-1 and 0.35 mmol.l-1 in the two patients still using multiple anabolic steroids at the time of investigation. The cardiovascular findings described in the present paper should warn all physicians and athletes about the possible serious acute and long-term side effects of the massive use of anabolic steroids.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
| | Next -> |