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Www.bmj
3
132

Anticoagulation in atrial fibrillation

Atrial fibrillation increases the risk of stroke, which is a leading cause of death and disability worldwide. The use of oral anticoagulation in patients with atrial fibrillation at moderate or high risk of stroke, estimated by established criteria, improves outcomes. However, to ensure that the benefits exceed the risks of bleeding, appropriate patient selection is essential. Vitamin K antagonism has been the mainstay of treatment; however, newer drugs with novel mechanisms are also available. These novel oral anticoagulants (direct thrombin inhibitors and factor Xa inhibitors) obviate many of warfarin’s shortcomings, and they have demonstrated safety and efficacy in large randomized trials of patients with non-valvular atrial fibrillation. However, the management of patients taking warfarin or novel agents remains a clinical challenge. There are several important considerations when selecting anticoagulant therapy for patients with atrial fibrillation. This review will discuss the rationale for anticoagulation in patients with atrial fibrillation; risk stratification for treatment; available agents; the appropriate implementation of these agents; and additional, specific clinical considerations for treatment.  
bmj.com
about 6 years ago
Foo20151013 2023 e7fpn8?1444774293
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339

The Importance Of Clinical Skills

In the USA the issue of indiscriminate use of expensive, sophisticated, and time consuming test in lieu of, rather than in addition to, the clinical exam is being much discussed. The cause of this problem is of course multifactorial. One of the factors is the decline of the teaching of clinical skills to our medical students and trainees. Such problems seem to have taken hold in developing countries as well. Two personal anecdotes will illustrate this. In the early nineties I worked for two years as a faculty member in the department of ob & gyn at the Aga Khan University Medical School in Karachi, Pakistan. One day, I received a call from the resident in the emergency room about a woman who had come in because of some abdominal pain and vaginal bleeding. While the resident told me these two symptoms her next sentence was: “… and the pelvic ultrasound showed…” I stopped her right in her tracks before she could tell me the result of the ultrasound scan. I told her: “First tell me more about this patient. Does she look ill? Is she bleeding heavily? Is she in a lot of pain and where is the pain? What are her blood pressure and pulse rate? How long has she been having these symptoms? When was her last menstrual period? What are your findings when you examined her ? What is the result of the pregnancy test?”. The resident could not answer most of these basic clinical questions and findings. She had proceeded straight to a test which might or might not have been necessary or even indicated and she was not using her clinical skills or judgment. In another example, the resident, also in Karachi, called me to the emergency room about a patient with a ruptured ectopic pregnancy. He told me that the patient was pale, and obviously bleeding inside her abdomen and on the verge of going into shock. The resident had accurately made the diagnosis, based on the patient’s history, examination, and a few basic laboratory tests. But when I ran down to see the patient, he was wheeling the patient into the radiology department for an ultrasound. "Why an ultrasound?" I asked. “You already have made the correct diagnosis and she needs an urgent operation not another diagnostic procedure that will take up precious time before we can stop the internal bleeding.” Instead of having the needless ultrasound, the patient was wheeled into the operating room. What I am trying to emphasize is that advances in technology are great but they need to be used judiciously and young medical students and trainees need to be taught to use their clinical skills first and then apply new technologies, if needed, to help them to come to the right diagnosis and treatment. And of course we, practicing physicians need to set the example. Or am I old fashioned and not with it? Medico legal and other issues may come to play here and I am fully aware of these. However the basic issue of clinical exam is still important. Those wanting to read more similar stories can download a free e book from Smashwords. The title is: "CROSSCULTURAL DOCTORING. ON AND OFF THE BEATEN PATH." You can access the e book here.  
DR William LeMaire
almost 6 years ago
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93

Abnormal Uterine Bleeding - ACOG

Abnormal uterine bleeding can have many causes: fibroids, endometrial hyperplasia, contraceptives such as IUDs, or infection. Find out more in this patient FAQ.<br/>  
acog.org
over 4 years ago
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193

Evaluation of Hematuria

This podcast addresses the topic of hematuria in children. The podcast helps students develop an approach to the evaluation of hematuria. There is a brief overview of common causes of hematuria in children. This podcast was written by Peter Gill and Dr. Verna Yiu. Peter is a medical student at the University of Alberta. Dr. Yiu is a pediatric nephrologist at the Stollery Children’s Hospital in Edmonton, Alberta, Canada. These podcasts are designed to give medical students an overview of key topics in pediatrics. The audio versions are accessible on iTunes. You can find more great pediatrics content at www.pedscases.com.  
Pedscases.Com
over 9 years ago
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66

Epistaxis

An overview of the anatomy, aetiology and management of epistaxis  
Jason Fleming
about 9 years ago
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42

Henoch Schonlein Purpura (HSP)

This is a vasculitis that most commonly occurs in children. It tends to only affect the small vessels, and typically presents with: Palpable purpura – red/purple discolorations in the skin, often on the extensor surfaces of the feet, legs, arms, or sometimes on the buttocks. The rash may initially resemble urtricaria, but later becomes palpable. GI disturbance – may include colicky abdominal pain, abdominal tenderness, melena – occurs in 50% of patients  
almostadoctor.com - free medical student revision notes
about 6 years ago
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56

Anaemia of Chronic Disease

This is common, particularly in the hospital setting. It occurs as a result of: Chronic infection Chronic inflammation Neoplasia The anaemia is not related to bone marrow, bleeding or haemolysis, and is generally mild (Hb of 8.5-11.5g/dl).  
almostadoctor.com - free medical student revision notes
about 6 years ago
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31

Hormonal Implants

Implant – aka Implanon Lasts 3 years 12% will have heavier bleeding, particularly in the first 6-12 months. This can be alleviated with: Tranexamic acid – 1g/6-8h for up to 4 days – an antifibrinolytic, can reduce menorrhagia by 50%  
almostadoctor.com - free medical student revision notes
about 6 years ago
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48

Color Atlas and Text of Pulmonary Pathology

Thoroughly updated for its Second Edition, this comprehensive, profusely illustrated text/atlas covers the full range of pulmonary pathology, including common, rare and newly described diseases, both neoplastic and non-neoplastic. The book presents a multimodality approach to diagnosis, integrating cytologic, radiologic, surgical, and clinical pathologic features of each disease. By combining carefully chosen color illustrations with lists of distinguishing features of each entity, this text/atlas provides a quick path to accurate diagnosis. This edition features updated sections on pulmonary hypertension, pulmonary hemorrhage, lung transplantation, and pediatric pulmonary pathology, including new classification and grading systems. Throughout the book, new entities and new images have been added. An online image bank provides instant access to all the book's illustrations.  
Google Books
over 5 years ago
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129

A Modest Man

The registrar's face was taking on a testy look. So enduring was the silence our furtive glances had developed a nystagmic quality. “Galactosaemia” came her peremptory reply. Right on queue the disjointed chorus of ahs and head nods did little to hide our mental whiteboard of differentials being wiped clean. At the time conjugated bilirubinaemia in children only meant one thing: biliary atresia. A fair assumption; we were sitting in one of three specialist centres in the country equipped to treat these patients. Ironically the condition has become the unwieldy yardstick I now measure the incidence of paediatric disease. Biliary atresia is the most common surgical cause of neonatal jaundice with a reported incidence of 1 in 14-16ooo live births in the West. It is described as a progressive inflammatory obliteration of the extrahapatic bile duct. And Dr Charles West, the founder of Great Ormond Street Hospital, offers an eloquent description of the presenting triad of prolonged jaundice, pale acholic stools and dark yellow urine: ‘Case 18...It was born at full term, though small, apparently healthy. At 3 days however, it began to get yellow and at the end of 3 weeks was very yellow. Her motions at no time after the second day appeared natural on examination, but were white, like cream, and her urine was very high coloured.’ 1855 was the year of Dr West's hospital note. An almost universally fatal diagnosis and it would remain so for the next 100 years. The time's primordial classification of biliary atresia afforded children with the 'noncorrectable' type, a complete absence of patent extrahepatic bile duct, an unfortunate label; they were beyond saving. Having discovered the extent of disease at laparatomy, the surgeons would normally close the wound. The venerable Harvardian surgeon, Robert E. Gross saved an enigmatic observation: “In most instances death followed a downhill course…” K-A-S-A-I read the ward’s board. It was scrawled under half the children's names. I dismissed it as just another devilishly hard acronym to forget. The thought of an eponymous procedure had escaped me and in biliary atresia circles, it's the name everyone should know: Dr Morio Kasai. Originating from Aomori prefecture, Honshu, Japan, Dr Kasai graduated from the National Tohoku University School of Medicine in 1947. His ascension was rapid, having joined the 2nd department of Surgery as a general surgeon, he would assume the role of Assistant Professor in 1953. The department, under the tenure of Professor Shigetsugu Katsura, shared a healthy interest in research. 1955 was the landmark year. Katsura and Kasai operated on their first case: a 72 day old infant. Due to bleeding at the incised porta hepatis, Katsura is said to have 'placed' the duodenum over the site in order to staunch the flow. She made a spectacular postoperative recovery, the jaundice had faded and there was bile pigment in her stool. During the second case, Katsura elected to join the unopened duodenum to the porta hepatis. Sadly the patient's jaundice did not recover, but the post-mortem conducted by Kasai confirmed the development of a spontaneous internal biliary fistula connecting the internal hepatic ducts to the duodenum. Histological inspection of removed extrahepatic duct showed the existence of microscopic biliary channels, hundreds of microns in diameter. Kasai made a pivotal assertion: the transection of the fibrous cord of the obliterated duct must contain these channels before anastomosis with the jejunal limb Roux-en-Y loop. This would ensure communication between the porta hepatis and the intrahepatic biliary system. The operation, entitled hepatic portoenterostomy, was first performed as a planned procedure for the third case at Tohoku. Bile flow was restored and Kasai published the details of the new technique in the Japanese journal Shujutsu in 1959. However, news of this development did not dawn on the West until 1968 in the Journal of Pediatric Surgery. The success of the operation and its refined iterations were eventually recognized and adopted in the 1970s. The operation was and is not without its dangers. Cholangitis, portal hypertension, malnutrition and hepatopulmonary syndrome are the cardinal complications. While diagnosing and operating early (<8 weeks) are essential to the outcome, antibiotic prophylaxis and nutritional support are invaluable prognostic factors. Post operatively, the early clearance of jaundice (within 3 months) and absence of liver cirrhosis on biopsy, are promising signs. At UK centres the survival after a successful procedure is 80%. The concurrent development of liver transplantation boosts this percentage to 90%. Among children, biliary atresia is the commonest indication for transplantation; by five years post-Kasai, 45% will have undergone the procedure. On the 6th December 2008, Dr Kasai passed away. He was 86 years old and had been battling the complications of a stroke he suffered in 1999. His contemporaries and disciples paint a humble and colourful character. A keen skier and mountaineer, Dr Kasai lead the Tohoku University mountain-climbing team to the top of the Nyainquntanglha Mountains, the highest peaks of the Tibetan highlands. It was the first successful expedition of its kind in the world. He carried through this pioneering spirit into his professional life. Paediatric surgery was not a recognized specialty in Japan. By founding and chairing multiple associations including the Japanese Society of Pediatric Surgeons, Dr Kasai gave his specialty and biliary atresia, the attention it deserved. Despite numerous accolades of international acclaim for his contributions to paediatric surgery, Dr Kasai insisted his department refer to his operation as the hepatic portoenterostomy; the rest of the world paid its originator the respect of calling it the ‘Kasia’. Upon completion of their training, he would give each of his surgeons a hand-written form of the word ‘Soshin’ [simple mind], as he believed a modest surgeon was a good one. At 5 foot 2, Kasai cut a more diminutive figure one might expect for an Emeritus Professor and Hospital Director of a university hospital. During the course of his lifetime he had developed the procedure and lived to see its fruition. The Kasia remains the gold standard treatment for biliary atresia; it has been the shinning light for what Willis J. Potts called the darkest chapter in paediatric surgery. It earned Dr Kasai an affectionate but apt name among his peers, the small giant. References Miyano T. Morio Kasai, MD, 1922–2008. Pediatr Surg Int. 2009;25(4):307–308. Garcia A V, Cowles RA, Kato T, Hardy MA. Morio Kasai: a remarkable impact beyond the Kasai procedure. J Pediatr Surg. 2012;47(5):1023–1027. Mowat AP. Biliary atresia into the 21st century: A historical perspective. Hepatology. 1996;23(6):1693–1695. Ohi R. A history of the Kasai operation: Hepatic portoenterostomy for biliary atresia. World J Surg. 1988;12(6):871–874. Ohi R. Morio Kasai, MD 1922-2008. J Pediatr Surg. 2009;44(3):481–482. Lewis N, Millar A. Biliary atresia. Surg. 2007;25(7):291–294. This blog post is a reproduction of an article published in the Medical Student Newspaper, April 2014 issue.  
James Wong
about 6 years ago
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40

Risk of GI bleeding associated with oral anticoagulants

Determining the real world safety of dabigatran or rivaroxaban compared with warfarin in terms of GI bleeding.  
bmj.com
about 5 years ago
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51

Intracranial Hemorrhage Vs Subarachnoid Hemorrhage

A useful illustration of causes of Intracranial Hemorrhage versus causes of Subarachnoid Hemorrhage.  
Sarosh Kamal
about 5 years ago
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2
90

Bedside Obstetrics & Gynecology

The second edition of Bedside Obstetrics & Gynecology brings postgraduate trainees fully up to date with the most recent advances in the field. The first section covers obstetrics, discussing normal and abnormal presentations (such as normal labour versus breech presentation), complications in pregnancy (including early pregnancy bleeding and ante- and postpartum haemorrhage), and medical disorders related to pregnancy (such as preeclampsia and gestational diabetes). Section two covers numerous gynaecological abnormalities. This new edition has been fully revised but continues to emphasise the importance of history taking and clinical examination. New chapters have been added to cover topics such as preterm pregnancy, post-dated pregnancy and intrauterine death, bleeding due to miscarriage, menopause and contraception. Nearly 1100 images, illustrations and tables enhance learning, and each chapter includes questions and answers related to case studies. Key points Fully revised, new edition providing recent advances in obstetrics and gynaecology Many new chapters added Includes 1100 images, illustrations and tables Previous edition published in 2010  
books.google.co.uk
almost 5 years ago
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2
16

Atrial fibrillation: management | Guidance and guidelines | NICE

This guideline covers diagnosing and managing atrial fibrillation in adults. It aims to ensure that people receive the best management to help prevent harmful complications, in particular stroke and bleeding.  
nice.org.uk
over 4 years ago
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43

Preterm Premature Rupture of Membranes: Diagnosis and Management - American Family Physician

Preterm premature rupture of membranes is the rupture of membranes during pregnancy before 37 weeks' gestation. It occurs in 3 percent of pregnancies and is the cause of approximately one third of preterm deliveries. It can lead to significant perinatal morbidity, including respiratory distress syndrome, neonatal sepsis, umbilical cord prolapse, placental abruption, and fetal death. Appropriate evaluation and management are important for improving neonatal outcomes. Speculum examination to determine cervical dilation is preferred because digital examination is associated with a decreased latent period and with the potential for adverse sequelae. Treatment varies depending on gestational age and includes consideration of delivery when rupture of membranes occurs at or after 34 weeks' gestation. Corticosteroids can reduce many neonatal complications, particularly intraventricular hemorrhage and respiratory distress syndrome, and antibiotics are effective for increasing the latency period.  
aafp.org
over 4 years ago
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78

Focus On: Treatment of Epistaxis

Epistaxis is one of the most common ear, nose, and throat emergencies, with an estimated 60% lifetime incidence rate for an individual person.  
American College Of Emergency Medicine
over 9 years ago
2
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34

MTPB3 2007 | Case 08 presented by Michael A Schwartz, MD

www.MeetTheProfessors.com – Case from the practice of Michael A Schwartz, MD; postmenopausal 57-year-old reporting a 2y history of gradual right breast hardening w/ulcerating and bleeding lesion spanning both breasts presented to Drs Schwartzberg, Seidman  
Dr Neil Love
over 9 years ago
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29

Haemophilia A

X-linked recessive condition, deficiency of factor VIII, prevalence 1 in 10,000 Range of possible mutations, 30% of cases due to sporadic mutation Low factor VIII levels predispose to bleeding – risk proportional to factor VIII level Mild disease (11-30 units/dl) risk after significant trauma/surgery Moderate disease (2-10 units) - minor trauma  
almostadoctor.com - free medical student revision notes
about 6 years ago
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48

von Willebrand's Disease

Most common inherited bleeding disorder (asymptomatic deficiencies 1%, symptomatic disease 100 per million) von Willeband factor (vWF) important in platelet adhesion and factor VIII transport Types of vWDType 1: decreased concentration of vWF, 80%, often autosomal dominantType 2: qualitative deficiency – AD or AR inheritance  
almostadoctor.com - free medical student revision notes
about 6 years ago
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23

Myelofibrosis

Marrow fibrosis and splenomegaly, de novo or following transformation of PV or ET Usually >50 years old Abnormal megkaryocytes produced in increased numbers. PDGF and TGFβ are released by megakaryocytes, stimulating fibrosis. Haematopoietic stem cells move to the spleen and liver Presentation: fatigue, weight loss, splenomegaly, splenic pain, portal hypertension, bleeding varices, ascites and hepatomegaly  
almostadoctor.com - free medical student revision notes
about 6 years ago