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Cockcroft-Gault versus modification of diet in renal disease: importance of glomerular filtration rate formula for classification of chronic kidney disease in patients with non-ST-segment elevation acute coronary syndromes.

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Cockcroft-Gault versus modification of diet in renal disease: importance of glomerular filtration rate formula for classification of chronic kidney disease in patients with non-ST-segment elevation acute coronary syndromes.

J Am Coll Cardiol. 2008 Mar 11;51(10):991-6

Authors: Melloni C, Peterson ED, Chen AY, Szczech LA, Newby LK, Harrington RA, Gibler WB, Ohman EM, Spinler SA, Roe MT, Alexander KP

OBJECTIVES: Our purpose was to compare formulae for estimating glomerular filtration rate (GFR) in non-ST-segment elevation acute coronary syndromes (NSTE ACS) patients. BACKGROUND: Assessment of GFR is important for antithrombotic dose adjustment in NSTE ACS patients. METHODS: We assessed estimated glomerular filtration rate (eGFR) with Cockcroft-Gault (C-G) and Modification of Diet in Renal Disease (MDRD) formulae in 46,942 NSTE ACS patients from 408 CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines) hospitals. Formula agreement was shown continuously and by chronic kidney disease (CKD) stages. We determined in-hospital outcomes and the association between antithrombotic dose adjustment and bleeding for moderate CKD as determined by each formula. RESULTS: The median (interquartile range [IQR]) eGFR was 53.2 ml/min (34.7, 75.1 ml/min) by C-G and 65.8 ml/min (47.6, 83.5 ml/min) by MDRD. The mean eGFR was higher with MDRD (approximately 9.1 ml/min), but this difference was greater in age, weight, and gender subgroups. Chronic kidney disease classification differed in 20% of the population and altered when antithrombotic dose adjustment was required by C-G versus MDRD (eptifibatide: 45.7% vs. 27.3%; enoxaparin: 19.0% vs. 9.6%). CONCLUSIONS: Important CKD disagreements occur in approximately 20% of acute coronary syndrome patients, affecting dosing adjustments in those already susceptible to bleeding. Dosing based on C-G formula is preferable, particularly in the small, female, or elderly patient.

PMID: 18325437 [PubMed – indexed for MEDLINE]

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An internist’s role in perioperative medicine: a survey of surgeons’ opinions.

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An internist’s role in perioperative medicine: a survey of surgeons’ opinions.

BMC Fam Pract. 2008;9:4

Authors: Pausjenssen L, Ward HA, Card SE

BACKGROUND: Literature exists regarding the perioperative role of internists. Internists rely on this literature assuming it meets the needs of surgeons without actually knowing their perspective. We sought to understand why surgeons ask for preoperative consultations and their view on the internist’s role in perioperative medicine. METHODS: Survey of surgeons in Saskatoon, Saskatchewan, Canada regarding an internist’s potential role in perioperative care. RESULTS: Fifty-nine percent responded. The majority request a preoperative consultation for a difficult case (83%) or specific problem (81%). While almost half feel that a preoperative consultation is to “clear” a patient for surgery, 33% disagree with this statement. The majority believe the internist should discuss risk with the patient. Aspects of the preoperative consultation deemed most important are cardiac medication optimization (93%), cardiac risk stratification (83%), addition of beta-blockers (76%), and diabetes management (74%). CONCLUSION: Surgeons perceive the most important roles for the internist as cardiac risk stratification and medication management. Areas of controversy identified amongst the surgeons included who should inform the patient of their operative risk, and whether the internist should follow the patient daily postoperatively. Unclear expectations have the potential to impact on patient safety and informed consent unless acknowledged and acted on by all. We recommend that internists performing perioperative consults communicate directly with the consulting physician to ensure that all parties are in accordance as to each others duties. We also recommend that the teaching of perioperative consults emphasizes the interdisciplinary communication needed to ensure that patient needs are not neglected when one specialty assumes the other will perform a function.

PMID: 18208614 [PubMed – indexed for MEDLINE]

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Unexpected mortality in patients discharged from the emergency department following an episode of nontraumatic chest pain.

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Unexpected mortality in patients discharged from the emergency department following an episode of nontraumatic chest pain.

Eur J Emerg Med. 2008 Feb;15(1):3-8

Authors: Geraldine McMahon C, Yates DW, Hollis S

BACKGROUND: Chest pain is the second most common presenting complaint seen in the emergency department. Following evaluation in the emergency department, many of these patients are discharged with a diagnosis of nonspecific chest pain. Our hypothesis is that this group of patients has a high prevalence of ischaemic heart disease. METHODS: This was a prospective follow-up study of mortality in 786 patients who presented to an emergency department in the UK with an episode of nontraumatic chest pain and were discharged without further inpatient assessment. Observed mortality was compared with expected mortality in age-matched and sex-matched local population. RESULTS: The observed mortality of the study group was consistently higher than expected throughout the study period. The 5-year mortality rates for men and women under the age of 65 years were more than double the expected rates for the local population [relative risk of 2.1 (95% confidence interval: 1.4-2.8) and 2.6 (1.4-3.8), respectively]. This increase was less marked in male and female patients aged 65 years or more [relative risk of 1.2 (0.9-1.5) and 1.5 (1.2-1.8), respectively]. Ischaemic heart disease accounted for almost 50% of male deaths in the study group. This compared with an expected rate of less than 30% of male deaths in the local population. An excess of cardiac deaths was not seen in women. INTERPRETATION: Patients discharged from the emergency department following an episode of acute chest pain have significantly reduced 5-year survival. We conclude that further evaluation of this group to establish the prevalence of risk factors is important to support the strategic implementation of appropriate prevention programmes.

PMID: 18180659 [PubMed – indexed for MEDLINE]

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Rhabdomyolysis.

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Rhabdomyolysis.

Intern Emerg Med. 2007 Oct;2(3):210-8

Authors: Bagley WH, Yang H, Shah KH

Rhabdomyolysis is a syndrome involving the breakdown of skeletal muscle causing myoglobin and other intracellular proteins and electrolytes to leak into the circulation. The development of rhabdomyolysis is associated with a wide variety of diseases, injuries, medications and toxins. While the exact mechanisms responsible for all the causes are not fully understood, it is clear that muscle damage can occur from direct injury or by metabolic inequalities between energy consumption and energy production. Rhabdomyolysis is diagnosed by elevations in serum creatine phosphokinase (CPK), and while there is no established serum level cut-off, many clinicians use five times the upper limit of normal ( approximately 1000 U/l). Rhabdomyolysis can be complicated by acute renal failure (occurring in 4%-33% of patients), compartment syndrome, cardiac dysrhythmias via electrolyte abnormalities, and disseminated intravascular coagulopathy. The mainstay of treatment is hospitalisation with aggressive intravenous fluid (IVF) resuscitation with the correction/prevention of electrolyte abnormalities. There are additional adjunctive therapies to IVF, such as alkalinisation of the urine with sodium bicarbonate, diuretic therapy or combinations of both; however the lack of large randomised control studies concerning the benefits of these treatments makes it difficult to make strong recommendations for or against their use in the treatment of rhabdomyolysis. Regardless of these controversies, the overall prognosis for rhabdomyolysis is favourable when treated with early and aggressive IVF resuscitation, and full recovery of renal function is common. Irrespective of the cause of rhabdomyolysis the mortality rate may still be as high as 8%. This is a comprehensive review of the pathophysiology, diagnosis, complications and treatment options for rhabdomyolysis.

PMID: 17909702 [PubMed – indexed for MEDLINE]

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Allergic bronchopulmonary aspergillosis complicating chronic obstructive pulmonary disease.

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Allergic bronchopulmonary aspergillosis complicating chronic obstructive pulmonary disease.

Mycoses. 2008 Jan;51(1):83-5

Authors: Agarwal R, Srinivas R, Jindal SK

Allergic bronchopulmonary aspergillosis (ABPA) is a well recognised entity which complicates the course of 1-2% of patients with asthma and 2-15% of cystic fibrosis. Also, current criteria generally require the presence of asthma or cystic fibrosis for recognition of ABPA. The occurrence of ABPA in conditions other than cystic fibrosis or bronchial asthma is rare. Patients with chronic obstructive pulmonary disease (COPD) have mucus hypersecretion and impaired mucociliary clearance but are not reported to develop ABPA. Herein, we report a 50-year-old male who presented with an exacerbation of COPD due to co-existent ABPA. To our knowledge, this is the first report of such an association. We also speculate on mechanisms of causality and impact of ABPA on disease progression in COPD.

PMID: 18076603 [PubMed – indexed for MEDLINE]