On Being a PatientApril 2023Missed DirectivesGlenn S. Ross, MDGlenn S. Ross, MDSentara Medical Group, Newport News, VirginiaSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M22-3199 Audio Reading - “Missed Directives” Audio. Michael A. Lacombe, MD, Annals Associate Editor, reads “Missed Directives” by Glenn S. Ross, MD Your browser does not support the audio element. Audio player progress bar Step backward in current audio track Play current audio trackPause current audio track Step forward in current audio track Mute current audio trackUnmute current audio track 00:00/ SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail My mother died the day before my 60th birthday, or at least she should have. My mother at age 88 had accumulated an array of chronic medical conditions, including advanced multifocal arthritis, COPD that was oxygen dependent by day and BiPAP dependent by night owing to carbon dioxide retention, hypertension, chronic anxiety, and a smattering of other ailments. Several years ago, she developed acute respiratory failure after a hip replacement and had to be placed on a ventilator and then reintubated when her first extubation was unsuccessful. From that moment forward, she was resolute in her desire never to be ... Author, Article, and Disclosure InformationAuthors: Glenn S. Ross, MDAffiliations: Sentara Medical Group, Newport News, VirginiaCorresponding Author: Glenn S. Ross, MD, Sentara Medical Group, 11803 Jefferson Avenue, Suite 140, Newport News, VA 23606; e-mail, [email protected]com. PreviousarticleNextarticle Advertisement Audio Reading - “Missed Directives” Audio. Michael A. Lacombe, MD, Annals Associate Editor, reads “Missed Directives” by Glenn S. Ross, MD Your browser does not support the audio element. Audio player progress bar Step backward in current audio track Play current audio trackPause current audio track Step forward in current audio track Mute current audio trackUnmute current audio track 00:00/ FiguresReferencesRelatedDetails Metrics Current IssueApril 2023Volume 176, Issue 4Page: 580-581 ePublished: 18 April 2023 Issue Published: April 2023 Copyright & PermissionsCopyright © 2023 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

Colchicine is a standard therapy for the treatment of acute pericarditis. It is metabolized by cytochrome P-450 3A4 (CYP3A4) and is subject to potential drug interactions. Multiple case reports describe accumulation of colchicine with CYP3A4 inhibitors, but limited data exist for increased colchicine clearance with CYP3A4 inducers. We describe a case of idiopathic haemorrhagic pericarditis treated with colchicine but rendered ineffective given potential drug interaction with carbamazepine. A 61-year-old man with a history of seizures presented to the emergency department with severe chest pain radiating to the back and was found to have a large pericardial effusion. The patient underwent pericardiocentesis, which demonstrated a haemorrhagic pericardial effusion. After an extensive workup, he was treated for idiopathic pericarditis with anti-inflammatories and colchicine but failed to improve despite adequate colchicine loading and maintenance dosing. A serum colchicine level was checked given a potential CYP3A4 drug interaction in the setting of chronic carbamazepine use and was found to be sub-therapeutic. Concomitant use of CYP3A4 inducers in the setting of colchicine use can render anti-inflammatory strategies ineffective and may result in treatment failure. Due to its hepatic and intestinal metabolism by CYP3A4 enzymes, colchicine is susceptible to drug-drug interactions resulting in either toxicities or rendering it ineffective with concomitant CYP3A4 inhibitors or inducers, respectively. Carbamazepine, a common anti-epileptic medication and known inducer of the CYP3A4 enzyme, may reduce levels of colchicine in the blood resulting in treatment failure. Further study is required to determine if dose adjustments may overcome this drug interaction.

Left main coronary artery (LMCA) disease is defined as > 50% narrowing of vessel diameter; it is the disease of significant morbidity and mortality because it supplies 75% of the left ventricle, so any insult to the left main can lead to severe LV dysfunction, sudden cardiac arrest and arrhythmia. The incidence of left main disease in patients undergoing coronary angiography is 4-6%. The untreated left main disease has mortality around 20% at 1 year [1,2].Initially, the procedure of choice for the significant left main disease was coronary artery by-pass surgery (CABG), as medical therapy carries a high mortality rate as compared to CABG (36.5% vs 16.0%). Nevertheless, with the advancement in percutaneous intervention (PCI), there is a growing interest and passion in the percutaneous intervention of LMCA [3]. European [4] and American [5] guidelines recommend CABG (class I) as the treatment method of choice for LMCA in patients with all anatomical complexities. Current European treatment guidelines give PCI class I along with CABG if SYNTAX score < 22, class IIa if between 23-32, and class III (Harm) if SYNTAX > 33. Current US guidelines currently gives class IIa recommendation for PCI if syntax score is low, class IIb for a score between 23-32 and similar to European guideline's class III (Harm) for SYNTAX score > 33. We reviewed the major landmark trials that compare PCI vs CBAG as a treatment option for left main disease along with important meta-analysis

Compared to idiopathic pulmonary arterial hypertension (IPAH), patients with portopulmonary hypertension (POPH) have worse survival. Health disparities may contribute to these differences but have not been studied. We sought to compare socioeconomic factors in patients with POPH and IPAH and to determine whether socioeconomic status and/or POPH diagnosis were associated with treatment and health-care utilization. We performed a cross-sectional study of adults enrolled in the Pulmonary Hypertension Association Registry. Patients with IPAH (n = 344) and POPH (n = 57) were compared. Compared with IPAH, patients with POPH were less likely to be college graduates (19.6% vs. 34.9%, p = 0.02) and more likely to be unemployed (54.7% vs. 30.5%, p < 0.001) and have an annual household income below poverty level (45.7% vs. 19.0%, p < 0.001). Patients with POPH had similar functional class, quality of life, 6-min walk distance, and mean pulmonary arterial pressure with a higher cardiac index. Compared with IPAH, patients with POPH were less likely to receive combination therapy (46.4% vs. 62.2%, p = 0.03) and endothelin receptor antagonists (28.6% vs. 55.1%, p < 0.001) at enrollment with similar treatment at follow-up. Patients with POPH had more emergency department visits (1.7 ± 2.1 vs. 0.9 ± 1.2, p = 0.009) and hospitalizations in the six months preceding enrollment (1.5 ± 2.1 vs. 0.8 ± 1.1, p = 0.02). Both POPH diagnosis and lower education level were independently associated with a higher number of emergency department visits. Compared to IPAH, patients with POPH have lower socioeconomic status, are less likely to receive initial combination therapy and endothelin receptor antagonists but have similar treatment at follow-up, and have increased health-care utilization.

Background: The advent of biomarker-driven identification of candidates for acute therapies in the 4.5-24-hour time window has resulted in an increase in the number of telestroke consults with low yield for acute intervention. While the use of the Vision Aphasia Neglect (VAN) score and a National Institutes of Health Stroke Scale (NIHSS) cutoff score of ≥6 may help identify patients with Large Vessel Occlusions (LVO), there are no guideline-based protocols for using these scales as a decision point for telestroke activation. Method: We selected 5 spoke sites from an academic hub-and-spoke model telestroke network for inclusion in our study. In the extended window (4.5-24 hours), telestroke consultants assisted with appropriate selection for hospital transfers for mechanical thrombectomy (MT) with the goals of maximizing retention at the spoke sites. All sites were able to obtain computed tomography angiography (CTA) head and neck onsite. In the extended window, the following protocols were followed at the sites for telestroke activation: Sites A - B: NIHSS ≥6; Site C: NIHSS ≥6 and/or VAN positive; Sites D - E any acute-onset, focal neurological symptoms within 24 hours of symptom onset. Descriptive statistics were used. Results: Between July 2019 and February 2020, there were 1,114 telestroke consults with 351 (32%) extended window activations. In the extended window, the number of activations for NIHSS≥6 was less than a third of the total activations and the rate of transfer for MT was low across the sites regardless of whether the sites had adopted a protocolized activation (Table). However, 80% of all transfers had an NIHSS ≥6. Conclusion: In an academic telestroke network, protocols for selecting “high-yield” consults in the extended thrombectomy window did not lead to less telestroke activation or a higher yield for MT. More studies are needed to determine if this is due to the applied scales or whether targeted educational interventions at the sites would improve selection.

IntroductionShark-related-injuries (SRIs) are not thoroughly evaluated in the medical literature given their rare occurrence. Previous studies involve the utilization of large-independent databases and have demonstrated that shark attacks appear to be increasing, even though mortality of SRIs has decreased from 51% in 1958 to 8.3% in 2001. MethodsWe performed a retrospective chart review on patients presenting to 10 emergency departments (ED) in southeastern Virginia from February 22, 2008 through December 31, 2016. We used a free-text search feature to identify patients documented to have the word “shark” in the record. We reported descriptive statistics for patient demographics, disposition, mortality, time of injury, body injury location, activity during injury, injury severity score (ISS), antibiotic use, and if the patient was in the International Shark Attack File(ISAF) or the Global Shark Attack File(GSAF). ResultsWe identified 11 patients. Most patients were male (81.8%) and Caucasian (90.9%) with a mean age of 35 years old (SD = 13.4, range17–55). Most patients (72.7%) arrived to the ED by private vehicle. Seventy-eight percent of patients were safely discharged from the ED. There were no deaths. There was a bimodal distribution of the time of injury around noon and early evening. Only 1 of our patients was present in the GSAF and 4 were present in the ISAF. ConclusionMost SRIs can be safely evaluated, treated, and discharged from the ED. Utilization of large databases for shark related research may underestimate its prevalence in the US. Further research is needed into the care of SRIs in the ED.

Obesity is one of the most common preventable diseases. It is a major public health concern. Obesity has a multifactorial etiology that includes genetic, environmental, socioeconomic, and behavioral or psychological influences. Obesity results from a chronic positive energy balance regulated by a complex interaction between endocrine tissues and the central nervous system. Obesity measurement can also be used to estimate morbidity and mortality. Body mass index (BMI) has been used to screen overweight and obese individuals. However, waist circumference is the best anthropometric indicator of visceral fat and a better predictor of metabolic disorders such as diabetes, hypertension, and dyslipidemia. People with a normal BMI with a large waist are at higher risk. However, combining BMI and waist circumference adds relatively less risk prediction since they are collinear in nature. Furthermore, hip circumference is inversely related to metabolic syndrome. Large hip circumference is related to lower risks of diabetes and coronary heart disease. This is probably due to having a large muscle mass in the hip region. Compared to the Body Mass Index (BMI), the Visceral Adiposity Index (VAI) is a more specific and sensitive examination tool. The VAI is, therefore, a reliable indicator of increased patient risk for cardiometabolic diseases. There is currently a lack of scientific knowledge regarding the biochemical and physiologic mechanisms associated with this. A possible explanation for the increased specificity and sensitivity of the VAI is that visceral fat has direct access to the portal venous system, whereas subcutaneous white adipose tissue does not.Obesity has inflammatory components, directly and indirectly, related to major chronic diseases such as diabetes, atherosclerosis, hypertension, and several types of cancer. Overweight and obese individuals have altered circulatory levels of inflammatory cytokines, such as IL-6, TNFα, C-reactive protein (CRP), IL-18, resistin, and visfatin. Measures of body fat have a stronger correlation with inflammatory markers than BMI.. Exercise and dietary restrictions have been strongly advocated to reduce weight gain and its related complications. Caloric restriction has been proven effective in reducing inflammation in obesity. However, a few studies showed that dietary weight loss has less impact on a long-term anti-inflammatory intervention. On the other hand, regular exercise significantly affects chronic inflammation related to obesity and obesity-associated conditions such as hypertension, diabetes, dyslipidemia, etc.It is well documented that obesity and its inflammatory markers have significant effects on hypertension, diabetes, and other chronic conditions. This review provides detailed insight into chronic inflammation, immune and hormonal disturbance related to the pathophysiology of obesity and their effects on chronic conditions.

This study examines the impact of plant-based, Mediterranean, Paleolithic, and DASH diets on CVD risk factors. Nondiabetic adults (ages 35-85)with one or more risk factors for CVD selected 1 of the 4 diet plans and then underwent a comprehensive nutrition education program prior to a 60 day diet