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Medical Sites:
PubMed Medline Plus NEJM   JAMA Up To Date Cardiosource WebMD

EvidenceMedicine.com / GuidelineMedicine.com

Intensive Lipid Lowering with Atorvastatin in Patients with Stable Coronary Disease (nejm 4-05)
“ . . .
an absolute reduction in the rate of major cardiovascular events of 2.2 percent and a 22 percent relative reduction in risk (hazard ratio, 0.78; 95 percent confidence interval, 0.69 to 0.89; P<0.001). There was no difference between the two treatment groups in overall mortality.
This occurred with a greater incidence of elevated aminotransferase levels.
http://content.nejm.org/cgi/content/abstract/352/14/1425

IDSA: “Flu Pandemic
Coming, U.S. Not Prepared” (MARCH 22, 2005)
Infectious Disease Experts Recommend Immediate Action”
http://www.idsociety.org/Template.cfm?Section=Home&Template=/ContentManagement/ContentDisplay.cfm&ContentID =12436

CDC AVIAN (BIRD) FLU INFO PAGE
http://www.cdc.gov/flu/avian/index.htm

CDC PHYSICAL ACTIVITY RECOMMENDATIONS
http://www.cdc.gov/nccdphp/dnpa/physical/recommendations/index.htm

“Ximelagatran
vs Low-Molecular-Weight Heparin and Warfarin for the Treatment of Deep Vein Thrombosis”Conclusions Oral ximelagatran administered in a fixed dose without coagulation monitoring, was as effective as enoxaparin/warfarin for treatment of deep vein thrombosis with or without pulmonary embolism and showed similar, low rates of bleeding. Increased levels of liver enzymes in 9.6% of ximelagatran-treated patients require regular monitoring; the mechanism requires further evaluation. Prospective assessment of coronary events in future studies is warranted.
http://jama.ama-assn.org/cgi/content/abstract/293/6/681

Ximelagatran vs Warfarin for Stroke Prevention in Patients With Nonvalvular Atrial Fibrillation”
Conclusions The results establish the efficacy of fixed-dose oral ximelagatran without coagulation monitoring compared with well-controlled warfarin for prevention of thromboembolism in patients with atrial fibrillation requiring chronic anticoagulant therapy, but the potential for hepatotoxicity requires further investigation”
http://jama.ama-assn.org/cgi/content/abstract/293/6/690

Quantitative Determinants of the Outcome of Asymptomatic Mitral Regurgitation” (NEJM, 3-3-05)
Conclusions Quantitative grading of mitral regurgitation is a powerful predictor of the clinical outcome of asymptomatic mitral regurgitation. Patients with an effective regurgitant orifice of at least 40 mm2 should promptly be considered for cardiac surgery.”
http://content.nejm.org/cgi/content/short/352/9/875

“Does This Patient Have Influenza” (JAMA. 2-2005)
http://jama.ama-assn.org/cgi/content/abstract/293/8/987

Avian Flu Spread Among Humans” (JAMA, 2-2005)
http://jama.ama-assn.org/cgi/content/extract/293/7/790

“Amiodarone or an Implantable Cardioverter– Defibrillator for Congestive Heart Failure
(NEJM, Jan 2005)
“Conclusions In patients with NYHA class II or III CHF and LVEF of 35 percent or less, amiodarone has no favorable effect on survival, whereas single-lead, shock-only ICD therapy reduces overall mortality by 23 percent”
http://content.nejm.org/content/vol352/issue3/index.shtml

C-Reactive Protein Levels and Outcomes after Statin Therapy (NEJM,1-2005)
Conclusions
Patients who have low CRP levels after statin therapy have better clinical outcomes than those with higher CRP levels, regardless of the resultant level of LDL cholesterol. Strategies to lower cardiovascular risk with statins should include monitoring CRP as well as cholesterol”
http://content.nejm.org/cgi/content/short/352/1/20


NEJM (11-04)
“Combination of Isosorbide Dinitrate and Hydralazine in Blacks with Heart Failure
Conclusions
The addition of a fixed dose of isosorbide dinitrate plus hydralazine to standard therapy for heart failure including neurohormonal blockers is efficacious and increases survival among black patients with advanced heart failure”
http://content.nejm.org/cgi/content/short/351/20/2049

Associated Press (9-8) : “Antibiotic may trigger cardiac deaths”
http://dailynews.att.net/cgi-bin/news?e=pri&dt=040908&cat=news&st=newsd84vqu8g0&src=ap

NEJM (9-9-04)
 
“Oral Erythromycin and the Risk of Sudden Death from Cardiac Causes”
http://content.nejm.org/cgi/content/short/351/11/1089  
“The adjusted
rate of sudden death from cardiac causes was five times as high (incidence-rate ratio, 5.35; 95 percent confidence interval, 1.72 to 16.64; P=0.004) among those who concurrently used CYP3A inhibitors and erythromycin as that among those who had used neither CYP3A inhibitors nor any of the study antibiotic medications”

Study on Diet (low/high
carbohydrate) and Breast Cancer gets widespread media coverage (8-6-04) despite being only a “survey” of women in Mexico
http://cebp.aacrjournals.org/cgi/content/abstract/13/8/1283 in August issue of journal Cancer Epidemiology, Biomarkers and Epidemiology
Popular Press coverage (MSNBC 8-6-04):
http://www.msnbc.msn.com/id/5614168/


MEDICAL ETHICS: medical ethicist in  journal LANCET charges US military doctors of complicity in prison abuses (8-2004)

Abu Ghraib: its legacy for military medicine

Steven H. Miles
“The complicity of US military medical personnel during abuses of detainees in Iraq, Afghanistan, and Guantanamo Bay is of great importance to human rights, medical ethics, and military medicine. Government documents show that the US military medical system failed to protect detainees' human rights, sometimes collaborated with interrogators or abusive guards, and failed to properly report injuries or deaths caused by beatings.”
http://www.thelancet.com/journal/vol364/iss9435/full/llan.364.9435.review_and_opinion.30574.1

AHA 2002 Fish Oil Recommendations Still Get Little Attention:
Fish oils in heart cells can block dangerous heart rhythms” (5/03)The first clinical suggestion that n-3 PUFAs significantly benefited the heart came from a 1989 study in which 2,033 men with heart disease were given dietary advice on fat, fiber or fish. After two years the men who were told to eat fish at least twice a week had a 29 percent reduction in death.   SEE LINK BELOW

Mediterranean Diet Revisited: Lyon Diet Heart Study; from AHA:
“Benefits of a Mediterranean-Style, National Cholesterol Education Program/American Heart Association Step I Dietary Pattern on Cardiovascular Disease”
After 46 months of follow-up, 204 control and 219 experimental subjects (93% of the original cohort) participated in the final examination. A total of 302 experimental and 303 control group subjects were randomized into the study; however, the study was stopped early because of significant beneficial effects noted in the original cohort. Despite a similar coronary risk factor profile (plasma lipids and lipoproteins, systolic and diastolic blood pressure, body mass index, and smoking status), subjects following the Mediterranean-style diet had a 50% to 70% lower risk of recurrent heart disease, as measured by 3 different combinations of outcome measures including (1) cardiac death and nonfatal heart attacks; (2) the preceding plus unstable angina, stroke, heart failure, and pulmonary or peripheral embolism; and (3) all of these measures plus events that required hospitalization”.
http://circ.ahajournals.org/cgi/content/full/103/13/1823

Study on Diet (low/high carbohydrate) and Breast Cancer gets widespread media coverage (8-6-04) despite being only a “survey” of women in Mexico
http://cebp.aacrjournals.org/cgi/content/abstract/13/8/1283 in August issue of journal Cancer Epidemiology, Biomarkers and Epidemiology
Popular Press coverage (MSNBC 8-6-04):
http://www.msnbc.msn.com/id/5614168/  

NEW ACC/AHA JULY 21, 2004 ST-ELEVATION MYOCARDIAL INFARCTION GUIDELINES - SUMMARY http://www.americanheart.org/presenter.jhtml?identifier=3023107
full text
http://www.americanheart.org/presenter.jhtml?identifier=3023467

NEW CHOLESTEROL GUIDELINES (UPDATE OF NECEP/ATP 3 2001) RELEASED JULY 12, 2004 IN CIRCULATION: NEW GOAL of LDL<70 in highest risk patients, a consideration
Circulation abstract: 
http://circ.ahajournals.org/cgi/content/abstract/110/2/227
Alternate NIH / NHLBI / NCEP Link to NCEP 3 Update
http://www.nhlbi.nih.gov/ch

Nevirapine plus Zidovudine prevents mother to child transmission of HIV-1 http://content.nejm.org/cgi/content/full/351/3/217 (NEJM 7-04)

NEW ACCP (American College of Chest Physicians) July 2004 Guidelines:  Diagnosis and Management of Pulmonary Arterial Hypertension released in journal CHEST (supplement) www.chestjournal.org/content/vol126/1_suppl/

ADA releases statement to address myths and misconceptions of “low carb” diets http://www.diabetes.org/diabetesnewsarticle.jsp?storyId=5949638&filename=20040706/washingtonpost20040706engwas hingtonpostwpniengwashingtonpostwpni0005104226827859763411333EDIT.xml (ADA, July 2004)

Low carbohydrate vs conventional diet after one year, Cardiosoucre research summary (No difference in small amount of  weight loss, but some potential benefits?) Note: other prior studies have shown similar results at one year - NO statistical difference in weight loss but differences in lipids http://www.cardiosource.com/news/cjr_picks/acc/cjrpicks/CJRPick.asp?cjrID=900

Milk, Calcium may reduce the risk of colon cancer; analysis from Journal of the National Cancer Institute July 7, 2004 http://jncicancerspectrum.oupjournals.org/cgi/content/abstract/jnci;96/13/1015                                                
Popular media article: (WebMD/ATT)
http://dailynews.att.net/cgi-bin/health?e=pri&dt=040715&cat=news&st=news100560&src=webmd

SYNERGY TRIAL results released July 7, 2004 JAMA                                                                                               
Enoxaparin vs Unfractionated Heparin in High-Risk Patients With Non–ST-Segment Elevation Acute Coronary Syndromes Managed With an Intended Early Invasive Strategy                                                                                                                                          
 
Conclusions
Enoxaparin was not superior to unfractionated heparin but was noninferior for the treatment of high-risk patients with non–ST-segment elevation ACS. Enoxaparin is a safe and effective alternative to unfractionated heparin and the advantages of convenience should be balanced with the modest excess of major bleeding. http://jama.ama-assn.org/cgi/content/abstract/292/1/45 (abstract)
http://jama.ama-assn.org/cgi/content/full/292/1/45 (full article)
NOTE 3 TRIALS RELATED TO ENOXAPARIN IN THIS ISSUE OF JAMA

SYNERGY TRIAL results released July 7, 2004 JAMA                                                                                                                                   Enoxaparin vs Unfractionated Heparin in High-Risk Patients With Non–ST-Segment Elevation Acute Coronary Syndromes Managed With an Intended Early Invasive Strategy                                                                                                                               Conclusions Enoxaparin was not superior to unfractionated heparin but was noninferior for the treatment of high-risk patients with non–ST-segment elevation ACS. Enoxaparin is a safe and effective alternative to unfractionated heparin and the advantages of convenience should be balanced with the modest excess of major bleeding.

http://jama.ama-assn.org/cgi/content/abstract/292/1/45   (abstract)
http://jama.ama-assn.org/cgi/content/full/292/1/45 (full article- currently FREE access)
NOTE 3 TRIALS RELATED TO ENOXAPARIN IN THIS ISSUE OF JAMA

VALUE Trial: Valsartan v Amlodipine in HTN, CARDIOSOURCE summary: http://www.cardiosource.com/library/journals/journal/article/abstract?acronym=LANCET&uid=PIIS0140673604164519&kw highligh=

Debate on treatment of Ductal Carcinoma in Situ of breast NYTimes (6-27)http://www.nytimes.com/2004/06/22/health/22brea.html?ex=1089354557&ei=1&en=5bf203b07037efbe                               NEJM Review (April 04): http://content.nejm.org/cgi/content/extract/350/14/1430    

10 million women without cervix get pap smears (contrary to expert advice)                                                                               JAMA study http://jama.ama-assn.org/cgi/content/short/291/24/2990                                                                                       NYTimes article http://www.nytimes.com/2004/06/23/health/23PAP.final.html?ex=1089003182&ei=1&en=829132249fa30719

CARD trial: Atorvastatin (lipitor, 10 mg/day) in Diabetes results presented at ADA 2004 scientific meeting - no print citation, highlights reviewed on www.cardiosource.com   June 9, 2004

Folate, B6 and B12 may increase risk of coronary restenosis (contrary to previous study) NEJM: http://content.nejm.org/cgi/content/short/350/26/2673

Risk of Recurrent Thromboembolism in Men and Women (NEJM)http://content.nejm.org/cgi/content/short/350/25/2558           Conclusions The risk of recurrent venous thromboembolism is higher among men than women.

Med Update 2004.18 June 18, 2004

Risk of Recurrent Thromboembolism in Men and Women (NEJM)http://content.nejm.org/cgi/content/short/350/25/2558         Conclusions The risk of recurrent venous thromboembolism is higher among men than women.

***********************************************************************************************
MED UPDATE 2004.17  ASA and other NSAIDS in the prevention of Breast CA?   May 
26, 2004
 
Highly publicized research looking at the potential benefits of ASA/NSAIDS in 
the prevention of Breast Cancer
 
*** NOTE Data collected from surveys/interviews of 2800+ women  ***
 
May 25, 2004
ABC, NBC an CBS eve news programs all report on findings
only ABC mentions report published in JAMA
only NBC reports ibuprofen also evaluated but incorrectly reports findings 
related to ibuprofen
only ABC and CBS discuss side effect of ASA use
only ABC and CBS clearly indicate data gathered from a SURVEY of women with and 
without Br CA
all networks correctly report this data alone may be insufficient to recommend 
ASA use for 
prevention of Br CA to general public
 
for link to JAMA go to  - the article is currently a FREE access article
 
http://www.evidencemedicine.com
 
for literature searches click "PubMed"
 
*******************************************************************************
 
MED UPDATE 2004.16  Vaccines and Autism - IOM report
 
May 18, 2004 NBC, MSNBC.com and CBS news report findings of  the INSTITUTE OF 
MEDICINE 
disputing prior popular suspicions and claims limking childhood immunizations 
with autism.
MSNBC.com provides no link to the original report or the IOM.  Dan Rather refers 
to "a team of U.S. medical experts" and the story shows an interview of a CDC 
expert but there is no mention of the Institute of Medicine.  The CBS report 
focusses mostly on continued fears among parents and one physician-lawmaker (who 
favors a ban) of mercury containing (thimerosal) vaccines despite the report.  
The news report states thiomerosal has been virtually eliminated from vaccines 
with the exception of certain flu vaccine preparations.
 
Institute of Medicine press release:
http://www.iom.edu/report.asp?id=20155
 
"The committee concludes that the body of epidemiological evidence favors 
rejection of a causal relationship between the MMR vaccine and autism. The 
committee also concludes that the body of epidemiological evidence favors 
rejection of a causal relationship between thimerosal-containing vaccines and 
autism."
 
full report:
http://www.nap.edu/books/030909237X/html/
 
for literature searches click PubMed in left column of
http://www.evidencemedicine.com
search "vaccination and autism"
 
********************************************************************************
 
MED UPDATE 2004.15 High Homocysteine levels as predictors of fractures
 
May 12, 2004
 
NBC Nightly News reports 2 studies supporting the use of "Folic acid", "B-6" and 
"B-12" in the treatment of osteoporosis
CBS Evening news reports the possible benefits of "folic acid" in osteoporosis
 
*** HOWEVER, neither study from the NEJM evaluated the use of any of these 
vitamins in the treatment/prevention of osteoporosis or fractures, they evaluate 
the association between (homocysteine) levels and events (fractures) - prior 
studies have shown the use of these inexpensive and safe vitamins in lowering 
homocysteine levels - this is 
not the same as proof of efficacy in this condition  ***
 
study 1:
 
http://content.nejm.org/cgi/content/short/350/20/2033
 
"Conclusions An increased homocysteine level appears to be a strong and 
independent risk factor for osteoporotic fractures in older men and women. "
 
study 2:
 
http://content.nejm.org/cgi/content/short/350/20/2042
 
"Conclusions These findings suggest that the homocysteine concentration, which 
is easily modifiable by means of dietary intervention, is an important risk 
factor for hip fracture in older persons."
 
http://www.evidencemedicine.com
 
********************************************************************************
MED UPDATES 2004.14: New AAP Guidelines on Otitis Media with Effusion (NOTE 
distinction from Acute Otitis Media - AOM - AOM Guideline link also below)
 
May 11, 2004
 
New Practice Guidelines from
 
American Academy of Pediatrics, the American Academy of Family Physicians and 
the American Academy of Otolaryngology-Head and Neck Surgery 
 
advocates "WATCHFUL WAITING" in the treatment of Otitis Media (OME) in children
 
"Antihistamines and decongestants are not effective treatments for OME. 
Antibiotics and corticosteroids are not recommended for routine management of 
OME"
 
link to 1/2 page press release:
 
http://www.aap.org/advocacy/releases/mayome.htm
 
link to May 2004 Otitis Media with Effusion Guideline in Pediatrics journal:
 
http://pediatrics.aappublications.org/cgi/content/abstract/113/5/1412
 
link to Acute Otitis Media March 2004 Guideline
 
http://pediatrics.aappublications.org/cgi/content/abstract/113/5/1451
 
http://www.evidencemedicine.com
 
********************************************************************************
 
 
MED UPDATE 2004.13.: Updated Pneumonia Guideline and Quiz
 
May 1, 2004
 
Latest IDSA PNEUMONIA Guidelines Nov(web)/Dec(print) 2003 (updates 2000 which 
replaced 
1998)
 
QUIZ
 
A 32 yo M high school teacher is diagnosed with pneumonia in the emergency 
room, HIV neg history
His pneumonia PORT Severity Index score (see p1426) is recorded on the chart as 
"Class I" by the ED resident.
His temperature is 37 C, no fever at home. CXRay shows LLL infiltrate consistent 
with crackles on exam.  He has no recent travel but one of his students just 
returned from Hong 
Kong but is not ill. Resident checks CDC website on ED computer - Hong Kong 
"areas with community transmission of SARS."  no other students ill, no recent 
antibiotic tx, no allergies, no COPD, DM, renal failure, CHF or malignancy 
 
(1) choose one
A) treat as outpatient; since "Hong Kong" reference documented, document why 
SARS still not suspected
B) outpatient but collect sputum first; any reference to SARS in the U.S. in 
2004 could not be an issue
C) inpatient IV antibiotics
D) admit to ICU with respiratory and contact isolation - fits CDC definition of 
"suspected SARS" (p 1416)
 
(2) treatment options
A) doxycycline, erythromycin, azithromycin or clarithromycin po
B) azithromycin, clarithromycin, ciprofloxacin or amoxicillin-clavulanate po
C) azithromycin plus cefotaxime or ceftriaxone (or other selected B-lactams)
D) azithromycin, clarithromycin or levofloxacin (or other resp fluroquinolone 
but not Cipro)
 
(3) same scenario but patient has DM (or CHF or RF or COPD or malignancy)
A) doxycycline, erythromycin, azithromycin or clarithromycin po
B) azithromycin, clarithromycin, ciprofloxacin or amoxicillin-clavulanate po
C) azithromycin plus cefotaxime or ceftriaxone (or other selected B-lactams)
D) azithromycin, clarithromycin or levofloxacin (or other resp fluroquinolone 
but not Cipro)
 
(4) a 53 yo F with DM is being admitted to GMB for com acq pneumonia (CAP), no 
recent antibiotic therapy
a) Moxifloxacin, gatifloxacin, levofloxacin or ciprofloxacin alone
b) Moxifloxacin, gatifloxacin or levofloxacin alone
c) Azithromycin (or clarithromycin) plus cefotaxime (or other select B-lacatam)
d) Moxiflox.,gatiflox or levoflox plus B lactam (ie, cefotaxime)
e) b or c
f) c or d
 
(5) before patient leaves ED or receives antibiotics, admitting physician 
realizes pt should be admitted to ICU, pseudomonous is not a suspected issue
a) Moxifloxacin, gatifloxacin, levofloxacin or ciprofloxacin alone
b) Moxifloxacin, gatifloxacin or levofloxacin alone
c) Azithromycin (or clarithromycin) plus cefotaxime (or other select B-lacatam)
d) Moxiflox.,gatiflox or levoflox pus cefotaxime (or select B-lactam)
e) b or c
f) c or d
 
(6) Which would be LEAST useful test in the 53 yo patient
table 4, p 1412
a) blood culture
b) sputum C&S
c) Legionella  urinary antigen
d) Legionella culture of resp secretions
e) Chlamidophilia pneumoniae single IgM titer or PCR of secretions
f) Influenza a/b antigen
g) RSV antigen
 
 
(7) the 53 yo with DM is being discharged on December 5, the medical student has 
written DAILY on problem list - no hx of pneumococcal vaccine or flu shot (and 
no contraindications)
 
a) pt to receive injected influenza vaccine (preferred over FluMist since not 
age 5-49) upon discharge, repeat every Oct/Nov, the patient is given written 
documentation (ie, a pre-printed wallet card or added to med list) indicating 
this, this is dictated on  discharge summary
b) remind household contacts to receive injected influenza vaccine repeat yearly 
because patient has DM
c) every member of house staff even if no contact with this patient, INJECTED 
influenza vaccine yearly in Oct/Nov ideally but now ok
d) pt to receive Pneumovax and documentation before discharge since she has DM, 
year of vaccination is placed on patient's med list, dictated on disc summary 
and written on all future H&Ps
e) ask patient's 66 yo husband to discuss Pneumovax with his doctor based on his 
age
f) HIV TESTING with consent for the patient during admission since she is 
between 15-54
g) a through e
h) a through f
 
ANSWERS:
 
 
 
1)a, PORT Class I supports outpatient tx without identification of organism
2)a, outpatient treatment without comorbidities, no recent antbx
3)d, outpatient with comorbidity, no recent antbx
4)e, inpatient medical ward
5)f, inpatient ICU, if pseudomonas not an issue
6)g, RSV testing not recommended in adults - insensitive
7)h, p1422-24 for vaccines; see table 4 p1412 lab test-general assessment for 
HIV testing
 
see table 1 p1406 for tx
 
for link TO GUIDELINES
 
go to 
http://wwww.evidencemedicine.com   
 
click Infectious Disease Society of America  in left column (not idsa.org) then 
choose 
GUIDELINES pick 2003 update to cap
 
next CAP guide will be joint IDSA and Amer Thor Soc
********************************************************************************
April 21, 2004
 
MED UPDATES 2004.12  New Virtual Colonoscopy Study - conclusions challenging 
those of previous studies (?)
 
from JAMA April 2004
http://jama.ama-assn.org/cgi/content/abstract/291/14/1713
 
"Conclusions  Computed tomographic colonography by these methods is not yet 
ready for widespread clinical application. Techniques and training need to be 
improved. "
 
from  NEJM Dec 2003
http://content.nejm.org/cgi/content/abstract/349/23/2191
 
Conclusions "CT virtual colonoscopy with the use of a three-dimensional approach 
is an accurate screening method for the detection of colorectal neoplasia in 
asymptomatic average-risk adults and compares favorably with optical colonoscopy 
in terms of the detection of clinically relevant lesions." 
 
from NEJM Nov 1999
http://content.nejm.org/cgi/content/abstract/341/20/1496
 
Conclusions "In patients at high risk for colorectal neoplasia, virtual and 
conventional colonoscopy have similar efficacy for the detection of polyps 6 mm 
or more in diameter"
 
Nov 2003 ACG statement on Virtual Colonscopy
http://www.acg.gi.org/physicianforum/virtualcolonoscopy.html
 
link to American College of Gastroenterology on www.evidencemedicine.com
 
********************************************************************************
 
April 16, 2004  Med Updates 2004.11. : AHA statement on Statins and CVA/TIA
 
AHA and Amer Stroke Assoc release 1/2 page statement on 
 
Statins after Stroke and TIA  (March 2004)
 
http://stroke.ahajournals.org/cgi/content/full/35/4/1023
 
www.evidencemedicine.com
 
*******************************************************************************
 
Subject: MED UPDATES 2004.10.: baby ASA prim prev CVD in DM
 
APRIL 8, 2004    MED UPDATES 2004.10.   baby ASA PRIM PREV CVD IN DM
 
American Diabetes Association 2004: ASA under-utilized for PRIMARY prevention of 
cardiovasc disease in Type 1 and 2 DM (less than 50% of eligible patients)
 
RECOMMENDATION for PRIMARY prevention
 
       Type 1 or 2 DM       +     >40 yo    +  additional cardiac risk factor  =
 
                                   Rx ASA (75-162mg)   NOT 325mg!!!
                                   (i.e, 1-2 baby ASA/day)
 
If prescribed, make sure patient/family clearly understand(s) why ASA being used 
for prevention and not for established CAD - that way other doctors will be able 
to weigh it's necessity in situations of bleeding or it's use perioperatively.
 
"Use aspirin therapy therapy (75–162 mg/day) as a primary prevention strategy in 
men and women with type 2 diabetes at increased cardiovascular risk, including 
those over 40 years of age or who have additional risk factors (family history 
of CVD, hypertension, smoking, dyslipidemia, albuminuria). " (same for type 1)
 
http://care.diabetesjournals.org/cgi/content/full/27/suppl_1/s72
 
ADA home link:
 
www.diabetes.org
 
*******************************************************************************
 
JNC 7 (Hypertension Guidelines) WEBLINK:
 
http://www.nhlbi.nih.gov/guidelines/hypertension/index.htm
 
********************************************************************************
APRIL 6, 2004   MED UPDATES 2004.9  NEWEST ALDOSTERONE ANTAGONISTS AND HEART 
FAILURE
 
www.evidencemedicine.com
 
EPLERENONE (aka Inspra) - POST MI HF/LV DYSFUNCTION  NEJM 2003
http://content.nejm.org/cgi/content/abstract/348/14/1309
 
KEY DIFFERENCES IN STUDY COMPARED TO RALES (Spironolactone) STUDY
-POST ACUTE MI POPULATION
-HIGHER AVE EF
-HIGHER PLACEBO GROUP MORTALITY
-MUCH HIGHER USE OF BETA BLOCKERS
-GYNECOMASTIA NO GREATER THAN PLACEBO
-COSTLIER STUDY MEDICATION
 
Though low incidence reported in study setting, potentially LIFE-THREATENING 
Hyperkalemia possible when using aldosterone antagonists, especially in patients 
on K+ supplements or with renal insufficiency - a contraindication if 
significant
(If K+ not monitored appropriately or reasonable concern in compliance with 
outpatient labs- don't even prescribe)
 
Authors'Conclusions: "The addition of eplerenone to optimal medical therapy 
reduces morbidity and mortality among patients with acute myocardial infarction 
complicated by left ventricular dysfunction and heart failure. "
 
CORRECTION TO ABOVE:
http://content.nejm.org/cgi/content/full/348/22/2271
 
RALES STUDY - SPIRONOLACTONE (aka Aldactone) IN HF  1999
http://content.nejm.org/cgi/content/abstract/341/10/709
 
ACC/AHA HF GUIDELINES REGARDING ALDOST ANTAGONIST - SEE SECTION 3 a UNDER 
Selected Patients
http://www.acc.org/clinical/guidelines/failure/IV_therapy.htm#IV_D2
 
*******************************************************************************
March 31, 2004   MED UPDATES 2004.8   C-Reactive Protein/CVD
 
CRP as Predictor of CAD - this study also includes the latest META-ANALYSIS on 
CRP
 
from NEJM April 1, 2004  p 1387-1397
 
C-RP AND OTHER MARKERS IN THE PREDICTION OF CHD
 
http://content.nejm.org/cgi/content/short/350/14/1387
 
authors note recent CDC/AHA publication (Circ 2003;107:499-511) "concluded that 
it is reasonable to measure C-reactive protein" in establishing CHD risk, 
previous meta-analysis report odds ratio of "about 2.0" 
 
current study:
CRP odds ratio for CHD = 1.92 (CI 1.68-2.18)
comparing CRP of 2.0 and higher with .78 and lower
BUT,
odds ratio = 1.45 when adjusting for established CHD risk factors and socioecon. 
status
 
(CRP)" . . . provided comparitively little additional predictive value over . . 
. established risk factors" (page 1392)
 
they also performed new meta-analysis of prior studies:
odds ratio = 1.49-1.58
 
"Conclusions: C-reactive protein is a relatively moderate predictor of coronary 
heart disease. Recommendations regarding its use in predicting the likelihood of 
coronary heart disease may need to be reviewed."
They base this on their conclusion of CRP odds ratio closer to 1.5 rather than 
2.0 as previously reported. They still conclude it is a "moderate predictor."  
(Note: ESR and vWF were less predictive than CRP in this study).
 
2003 CDC/AHA Guidelines on markers of inflammation
 
http://www.americanheart.org/presenter.jhtml?identifier=3008009
see page 504 for very specific circumstances to measure hs-CRP (Class IIa 
recommendations)
 
though most major Cardio guidelines are available on Cardiosource or ACC sites - 
the above isn't - but it's on AHA site
********************************************************************************
 
for ACC guidelines (many ACC/AHA) go to evidencemedicine.com - intern med - 
consensus
 
http://www.i-medonline.com/consensus.html
 
for AHA guidelines:
 
http://www.americanheart.org/presenter.jhtml?identifier=2158
 
********************************************************************************
 
March 27, 2004    MED UPDATES 2004.7
 
LATEST NIDDK(part of the NIH) HEPATITIS C GUIDELINES from February 2003 
(unlikely you've read this version - replaces all previous NIH/CDC Hepatitis C 
Guidelines)
 
http://www.cdc.gov/ncidod/diseases/hepatitis/c_training/edu/4/default.htm
 
********************************************************************************
IN THE NEWS . . . from AP on ATT.NET                      March 24, 2004
 
"Report Says Medicare to Go Broke by 2019 
 
WASHINGTON (AP) - Medicare will go broke by 2019 without changes, 11 years 
sooner than its trustees projected two years ago _ a deterioration the White 
House blames on rising health care costs, but that Democrats attribute to failed 
economic policies. "
 
for full article - see attachment included in MEDICAL UPDATES 2004.6
 
 
******************************************************************************
March 9, 2004
 
NEW 2004 ADA DIABETES Guidelines (updated yearly)
 
check link for 1 page summary of changes
http://care.diabetesjournals.org/cgi/content/full/27/suppl_1/s3
 
link to entire guidelines:
http://care.diabetesjournals.org/content/vol27/suppl_1/#SUMMARY_OF_REVISIONS
 
DM QUESTIONS per ada 2004
 
(1) goal A1C                   
                              (2) goal BP              (3)Dx of Diabetes
a) <10 %                       a) <140/90              a) fast gluc of 126
b) <8                          b) <135/85              b) random gluc of 200 
                                                       w classic Sxs
c) <7 or even <6 in cases      c) <130/80              c) 2 hr gluc of 200 
                                                       on OGTT
d) <6                          d) <110/70              d) any of above
 
ANSWERS: C,C,D
********************************************************************************
 
STATINS AND ACS:
 
EARLY RELEASE NEJM ARTICLE  MARCH 8, 2004 TO BE PUBLISHED APRIL 2004
MODERATE(PRAVASTATIN 40MG) V INTENSIVE (ATORVASTATIN 80MG) LIPID LOWERING TX 
AFTER ACS
http://content.nejm.org/cgi/content/abstract/NEJMoa040583
"Conclusions Among patients who have recently had an acute coronary syndrome, an 
intensive lipid-lowering statin regimen provides greater protection against 
death or major cardiovascular events than does a standard regimen. These 
findings indicate that such patients benefit from early and continued lowering 
of LDL cholesterol to levels substantially below current target levels."
 
*****************************************************************************
 
NEW CANDIDA GUIDELINES (IDSA DEC 2003)
http://www.journals.uchicago.edu/CID/journal/issues/v38n2/32301/32301.html
 
******************************************************************************                                     
March 3, 2004   WOMEN AND HEART DISEASE
 
(for listing of all ACC guidelines  WWW.EVIDENCEMEDICINE.COM click Internal Med, 
then Consensus buttons)
 
NEW GUIDELINES: ACC/AHA  Prevention of Heart Disease in Women (PDF)             
 
http://www.acc.org/clinical/consensus/CVD_women/women.pdf
 
********************************************************************************
EVIDENCE ON LOW CARBOHYDRATE DIETS:                                             
FEB 12, 2004
 
FROM MAY 2003 NEJM, LOW CARB VS LOW CAL/FAT DIET:  (see same issue for related 
article)
 
http://content.nejm.org/cgi/content/abstract/348/21/2082
 
JAMA REVIEW OF LOW CARB DIET STUDIES, APRIL 2003
 
http://jama.ama-assn.org/cgi/content/abstract/289/14/1837
 
 
OPTIMAL DIET FOR CHD RISK REDUCTION, JAMA  NOV 2002
 
http://jama.ama-assn.org/cgi/content/abstract/288/20/2569
 
WEB MD ARTICLE:
http://my.webmd.com/content/article/82/97129.htm
 
********************************************************************************
 
 
EMERGING INFECTIONS: MAD COW(BSE)/CJD, SARS, MONKEY POX, BIRD FLU
 
MAD COW(BSE) and VARIANT CREUTZFELD-JACOB (vCJD)  from CDC 2004
http://www.cdc.gov/ncidod/diseases/cjd/cjd.htm  (EVERYTHING you need to know)
 
IDSA's BSE and CJD LINKS PAGE
http://www.idsociety.org/Template.cfm?Section=Home&Template=/ContentManagement/C
ontentDisplay.cfm&ContentID=7953
 
CJD   Feb 2003 NEJM review CJD 
http://content.nejm.org/cgi/content/extract/348/8/681
 
CJD   Dec 1998 NEJM Review CJD and related S.E.
http://content.nejm.org/cgi/content/extract/339/27/1994
 
MONKEY POX:  from NEJM Jan 2004
http://content.nejm.org/cgi/content/short/350/4/342
 
SARS: from CDC 2004
http://www.cdc.gov/ncidod/sars/
 
BIRD FLU:  news report from WebMD 2004
http://my.webmd.com/content/article/79/96291.htm?lastselectedguid={5FE84E90-
BC77-4056-A91C-9531713CA348}
 
for INFLUENZA see CDC link below
 
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
 
VASOPRESSIN v. EPI in out of hosp CPR
from NEJM Jan 8, 2004   www.nejm.org
 
***CONSULT THE LATEST ACLS FOR OFFICIAL ACLS RECOMMENDATIONS***
 
"Conclusions The effects of vasopressin were similar to those of epinephrine 
in the management of ventricular fibrillation and pulseless electrical 
activity, but vasopressin was superior to epinephrine in patients with 
asystole. Vasopressin followed by epinephrine may be more effective than 
epinephrine alone in the treatment of refractory cardiac arrest." 
******************************************************************************
CDC update on Influenza 2003-04
 
jama 2004 print citation: JAMA.2004; 291: 34-37
 
www.evidencemedicine.com for links to journals 
 
******************************************************************************
DEFIBRILLATORS:  Review on ICDs   nejm 2003;349:1836-47
 
http://content.nejm.org/cgi/content/extract/349/19/1836
 
******************************************************************************
EARLY RELEASE NEJM on "virtual" colonoscopy
 
(if you can't click on, try cut and paste or re-typing address)
 
http://www.content.nejm.org/cgi/content/abstract/NEJMoa031618v1
 
ACG comments on VIRTUAL COLONOSCOPY  NOV 2003
 
http://www.acg.gi.org/physicianforum/virtualcolonoscopy.html
 
 
***************************************************************************
HEPATITIS A outbreak in Western PA
 
CDC Info on Hepatitis A
 
http://www.cdc.gov/ncidod/diseases/hepatitis/a/index.htm
 
NIH info on Hepatitis A
 
http://www.health.nih.gov/result.asp?disease_id=322
 
*****************************************************************************
 
NEJM study on new therapy after Tamoxifen - Letrozole - for Breast Ca
 
http://www.content.nejm.org/cgi/content/abstract/349/19/1793
 
*****************************************************************************
LOW DOSE ASA (75-100mg) Best for ACS (with or without Clopidogrel)
Circulation Sept 2003
 
http://www.cardiosource.com/news/browse/article?
uid=MDNEWS.20030922clin006&from=home/main
 
*****************************************************************************
COUMADIN ALTERNATIVE:
 
Efficacy and Safety Study of Oral Direct Thrombin Inhibitor Ximelagatran 
 
Compared with Dose-Adjusted Warfarin in the Prevention of Stroke and Systemic 
Embolic Events in Patients with Atrial Fibrillation (SPORTIF V)
 
http://www.cardiosource.com/meetings?page=aha2003tues.htm
 
 
*****************************************************************************
 
Valsartan v. Captopril for MI and LV dysfunction
 
http://www.content.nejm.org/cgi/content/short/349/20/1893
 
*****************************************************************************
 
FDA SEREVENT / ADVAIR warning
 
from WebMD:
 
"Basis of alert: Based on the results of a 28-week study that compared 
effects of salmeterol in asthma patients with asthma patients not taking the 
drug. African Americans, in particular, had a significantly higher risk of 
having a life-threatening asthma attack or asthma-related death when taking 
Serevent. "
 
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
 
FDA warns of lung injury following blood/plasma transfusions - potentially 
fatal
 
link:
 
http://www.dailynews.att.net/cgi-bin/health?
 
e=pri&dt=030805&cat=alerts&st=alerts4048_111&src=webmd
 
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
 
New HYPERTENSION Guidelines  JNC SEVEN:
JAMA:  restricted access unless subscriber - use AGH library computer for 
free access
 
to get to JAMA go to www.evidencemedicine.com 
 
 (not www.jama.com)
 
link:
http://www.nhlbi.nih.gov/guidelines/hypertension/index.htm
 
citation:
 
The Seventh Report of the Joint National Committee on Prevention, Detection, 
Evaluation, and Treatment of High Blood Pressure: The JNC 7 Report
JAMA 2003 289: 2560-2571.  
 
correction printed in next issue (wrong drug name on table)
 
 
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
 
NEW (June 2003) TB Guidelines (ATS-CDC-IDSA)
 
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm
 
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
 
Low dose v. conventional dose Warfarin to prevent recurrent DVT
 
NEJM Aug 2003: http://www.content.nejm.org/cgi/content/abstract/349/7/631
 

 

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