2012 June 29

Why are myelodysplastic syndromes unrecognized and underdiagnosed?: a primary care perspective.

Jun 292012

Why are myelodysplastic syndromes unrecognized and underdiagnosed?: a primary care perspective.

Am J Med. 2012 Jul;125(7 Suppl):S15-7

Authors: Khan AM

Abstract

Primary care physicians (PCPs) may lack a basic understanding of myelodysplastic syndromes (MDS). Two case studies, presented to 44 internal medicine residents and outpatient attending internists, highlighted a potential knowledge gap. A differential diagnosis of MDS was overlooked in a 72-year-old man with several comorbidities and a hemoglobin level of 9.2 g/dL (historical levels, 10.8 to 11.2 g/dL). Despite the acute change in hemoglobin levels, and the presence of comorbid lung and heart disease, there was no immediate recommendation from the PCPs for specialist referral. In contrast, in the second case study a 76-year-old man with a 6-month history of recurrent infections, fatigue, a hemoglobin level of 7.2 g/dL, and multilineage cytopenias typifying the clinical presentation of MDS did receive further attention and workup. With these cases as background, this article examines the potential reasons for the failure of many PCPs to identify MDS, and suggests steps to be taken to improve its diagnosis, early referral, and treatment.

PMID: 22735746 [PubMed - in process]

Link to Article at PubMed

Clinical presentation, diagnosis, and prognosis of myelodysplastic syndromes.

Am J Med Start a Discussion »

Jun 292012

Clinical presentation, diagnosis, and prognosis of myelodysplastic syndromes.

Am J Med. 2012 Jul;125(7 Suppl):S6-S13

Authors: Foran JM, Shammo JM

Abstract

Myelodysplastic syndromes (MDS) comprise a group of underrecognized hematologic clonal malignancies with variable propensity for leukemic transformation that can present a diagnostic challenge because they lack hallmark symptoms. MDS can present with varying degrees of anemia, neutropenia, and thrombocytopenia, and at presentation can range from indolent to life threatening. The clinician should have a heightened level of suspicion when treating elderly patients and those with prior exposure to chemotherapy, radiation, and environmental toxins in the presence of unexplained cytopenias. Chronic anemia should not be considered a natural consequence of aging. Approximately 1 in 6 patients with unexplained anemia may have findings compatible with MDS, suggesting that MDS should be considered higher in the differential diagnosis. Primary care physicians are encouraged to conduct comprehensive evaluations to exclude non-MDS-related causes for persistent cytopenias. Patients with pancytopenia, bicytopenia, or any persistent and unexplained isolated cytopenia (and particularly unexplained macrocytic anemia) should be referred to a specialist to establish a diagnosis.

PMID: 22735753 [PubMed - in process]

Link to Article at PubMed

Procalcitonin and C-reactive protein levels as diagnostic tools in febrile patients admitted to a General Internal Medicine ward.

Clin Biochem Start a Discussion »

Jun 292012

Procalcitonin and C-reactive protein levels as diagnostic tools in febrile patients admitted to a General Internal Medicine ward.

Clin Biochem. 2012 Jan;45(1-2):22-5

Authors: Ruiz-Esteban R, Sarabia PR, Delgado EG, Aguado CB, Cuervo-Arango JA, Varela M

Abstract

OBJECTIVE: We study the extent to which procalcitonin (Pro-CT) and/or C-reactive protein (CRP) may be helpful in the early triage of febrile patients admitted to a general internal medicine ward.

METHODS: This is a prospective, observational study on 62 admitted patients in whom a temperature >38ÃÂ°C had been observed the day before inclusion.

RESULTS: Neither Pro-CT nor CRP was able to discriminate infectious (or bacterial) diseases from the other etiologies as a group, with an area under the ROC curve of 0.63 (95% CI 0.47-0.79, p=0.15) for Pro-CT and 0.61, (95CI 0.44-0.78, p=0.23) for CRP. Sensitivity and specificity for Pro-CT varied between 0.59 and 0.67 for a cut-off point of 0.2 ng/mL and 0.03 and 1 for a cut-off point of 10.0 ng/mL. However, in subgroup analysis, Pro-CT was able to discriminate between infectious and inflammatory diseases (Welch two sample t-test t=2.39, df=44.3, p=0.021).

PMID: 22019953 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Management of the post-cardiac arrest syndrome.

J Emerg Med Start a Discussion »

Jun 292012

Management of the post-cardiac arrest syndrome.

J Emerg Med. 2012 Apr;42(4):440-9

Authors: Reynolds JC, Lawner BJ

Abstract

BACKGROUND: Recent advances in resuscitation science have revolutionized care of the cardiac arrest patient. Dramatic departures from time-honored advanced cardiac life support therapies, such as cardiocerebral resuscitation and bundled post-arrest care, have given rise to a new paradigm of resuscitation practices, which has boosted the rate of neurologically intact survival.

OBJECTIVES: This article reviews the pathophysiology of the post-cardiac arrest syndrome, the collective pathophysiology after return of spontaneous circulation, and presents management pearls specifically for the emergency physician. This growing area of scientific inquiry must be managed appropriately to sustain improved outcomes.

DISCUSSION: The emergency physician must understand this pathophysiology, manage resuscitated patients according to the latest evidence, and coordinate with appropriate inpatient resources.

CONCLUSION: The new approach to cardiac arrest care is predicated on a chain of survival that spans the spectrum of care from the prehospital arena through the emergency, intensive, and inpatient settings. The emergency physician is a crucial link in this chain.

PMID: 22281034 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Electrocardiographic Criteria for ST-Elevation Myocardial Infarction in Patients With Left Ventricular Hypertrophy.

Am J Cardiol Start a Discussion »

Jun 292012

Electrocardiographic Criteria for ST-Elevation Myocardial Infarction in Patients With Left Ventricular Hypertrophy.

Am J Cardiol. 2012 Jun 25;

Authors: Armstrong EJ, Kulkarni AR, Bhave PD, Hoffmayer KS, Macgregor JS, Stein JC, Kinlay S, Ganz P, McCabe JM

Abstract

Patients with electrocardiographic (ECG) left ventricular hypertrophy (LVH) have repolarization abnormalities of the ST segment that may be confused with an ischemic current of injury. We analyzed the ACTIVATE-SF database, a registry of consecutive emergency department ST-segment elevation (STE) myocardial infarction diagnoses from 2 medical centers. Univariate analysis was performed to identify ECG variables associated with presence of an angiographic culprit lesion. Recursive partitioning was then applied to identify a clinical decision-making rule that maximizes sensitivity and specificity for presence of an angiographic culprit lesion. Seventy-nine patients with ECG LVH underwent emergency cardiac catheterization for primary angioplasty. Patients with a culprit lesion had greater magnitude of STE (3.0 ÃÂ± 1.8 vs 1.9 ÃÂ± 1.0 mm, p = 0.005), more leads with STE (3.1 ÃÂ± 1.6 vs 2.0 ÃÂ± 1.8 leads, p = 0.002), and a greater ratio of STE to R-S-wave magnitude (median 25% vs 9.2%, p = 0.003). Univariate application of ECG criteria had limited sensitivity and a high false-positive rate for identifying patients with an angiographic culprit lesion. In patients with anterior territory STE, using a ratio of ST segment to R-S-wave magnitude Ã¢ÂÂ¥25% as a diagnostic criteria for STE myocardial infarction significantly improved specificity for an angiographic culprit lesion without decreasing sensitivity (c-statistic 0.82), with a net reclassification improvement of 37%. In conclusion, application of an ST segment to R-S-wave magnitude Ã¢ÂÂ¥25% rule may augment current criteria for determining which patients with ECG LVH should undergo primary angioplasty.

PMID: 22738872 [PubMed - as supplied by publisher]

Link to Article at PubMed

Thirty-Day and 1-Year Outcomes of Emergency Department Patients With Atrial Fibrillation and No Acute Underlying Medical Cause.

Ann Emerg Med Start a Discussion »

Jun 292012

Thirty-Day and 1-Year Outcomes of Emergency Department Patients With Atrial Fibrillation and No Acute Underlying Medical Cause.

Ann Emerg Med. 2012 Jun 25;

Authors: Scheuermeyer FX, Grafstein E, Stenstrom R, Innes G, Heslop C, Macphee J, Pourvali R, Heilbron B, McGrath L, Christenson J

Abstract

STUDY OBJECTIVE: Atrial fibrillation is the most common dysrhythmia observed in the emergency department (ED), yet there is little research describing long-term outcomes after ED management. Our objective is to describe ED treatment approach, conversion success rates, ED adverse events, and 30-day and 1-year outcomes for a cohort of ED patients with atrial fibrillation and no acute underlying medical cause. METHODS: This retrospective cohort study used a database from 2 urban EDs to identify consecutive patients with an ED discharge diagnosis of atrial fibrillation from April 1, 2006, to March 31, 2010. Comorbidities, rhythms, management, and immediate outcomes were obtained by manual chart review, and patients with an acute underlying medical condition were excluded by predefined criteria. Patients were stratified into 5 groups according to ED management: electrocardioversion, chemical cardioversion, spontaneous cardioversion, rate control only, and no arrhythmia-specific treatment. To identify deaths, strokes, and ED revisits within 1 year, each patient's unique provincial health number was linked to the provincial vital statistics registry and the regional ED database. Primary outcome was the number of patients having either stroke or death of any cause at 30 days, stratified by treatment group. RESULTS: Of 927 consecutive eligible patients, 121 (13.1%) converted to sinus rhythm before ED intervention, 357 (38.5%) received ED rhythm control, and 449 (48.4%) did not receive rhythm control. Overall, 142 of 927 patients (15.3%) were admitted to the hospital at the index ED visit. At 30 days, 2 patients had a stroke and 5 died (combined outcome rate 0.8%; 95% confidence interval 0.3% to 1.6%). All 7 of these patients were admitted at the index ED visit. CONCLUSION: In this large cohort of ED patients with atrial fibrillation and no acute underlying medical cause, the 30-day rate for stroke or death was less than 1%. Nearly 85% of patients-regardless of treatment approach or conversion to sinus rhythm-were discharged at the index ED visit, and none of these patients had a stroke or died at 30 days.

PMID: 22738681 [PubMed - as supplied by publisher]

Link to Article at PubMed

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