Journal: Cleveland Clinic journal of medicine
Our understanding of the pathophysiology and treatment of sepsis has advanced over the last decade, and evidence-based protocols have improved its outcomes. Here, we review its management in the first hours and afterward, including topics of ongoing study and debate.
In recent years, antisynthetase syndrome has been recognized as an important cause of autoimmune inflammatory myopathy in a subset of patients with polymyositis and dermatomyositis. It is associated with serum antibodies to aminoacyl-transfer RNA synthetases and is characterized by a constellation of manifestations, including fever, myositis, interstitial lung disease, “mechanic’s hands,” Raynaud phenomenon, and polyarthritis. Physicians should be familiar with its variety of clinical presentations and should include it in the differential diagnosis in patients presenting with unexplained interstitial lung disease.
The protein-sparing modified fast (PSMF) is a very-low-calorie diet containing mostly protein and little carbohydrate. This article reviews the principles of the PSMF and its potential benefits in terms of weight loss, glycemic control, insulin resistance, cardiovascular risk factors, and related complications for patients with type 2 diabetes.
Aspirin has a well-established role in preventing adverse events in patients with known cardiovascular disease. However, its benefit in patients without a history of cardiovascular disease is not as clear, particularly in people with diabetes, in women, and in the elderly. Recent studies have provided insight into the risks of aspirin use, particularly bleeding, compared with its benefits in these subgroups.
The new oral anticoagulants dabigatran etexilate (Pradaxa), rivaroxaban (Xarelto), and apixaban (Eliquis) have predictable pharmacokinetic and pharmacodynamic profiles and are alternatives to warfarin. However, many physicians are wary of these drugs, since there is limited evidence on how to manage bleeding in patients taking them, and since no specific antidote is known to reverse their anticoagulant effect. Management requires careful adherence to first principles of bleeding care. Unapproved and untested reversal strategies may be required in patients with life-threatening bleeding.
Vaccination against human papillomavirus (HPV) is safe and effective. It is recommended for females age 9 to 26 and for males age 11 to 26, yet vaccination rates are low. We review the host immune response, the data behind the recommendations for HPV vaccination, and the challenges of implementing the vaccination program.
Surveys are being used increasingly in health-care research to answer questions that may be difficult to answer using other methods. While surveys depend on data that may be influenced by self-report bias, they can be powerful tools as physicians seek to enhance the quality of care delivered or the health care systems they work in. The purpose of this article is to provide readers with a basic framework for understanding survey research, with a goal of creating well-informed consumers. The importance of validation, including pretesting surveys before launch, will be discussed. Highlights from published surveys are offered as supplementary material.
Cardiac tamponade shares symptoms and signs such as dyspnea, edema, and low urine output with other, more-common diseases. Consider it when there is chest trauma or when the patient has a chronic medical illness that can involve the pericardium. Successfully treating it can be rewarding for both the patient and the physician.
Penicillin allergy is the most commonly reported drug allergy in the United States. However, after undergoing a complete evaluation by a board-certified allergist, including skin testing, 90% of patients labeled as ‘penicillin-allergic’ are able to tolerate penicillin. Clinical presentation is key in classifying reactions as either mediated by or not mediated by immunoglobulin E (IgE), and in determining which patients may benefit from penicillin skin testing, graded-dose challenge, or desensitization. Cross-reactivity between penicillin and other beta-lactams is less common than previously thought.
The number of obese older adults is on the rise, although we lack a proper definition of obesity in this age group. The ambiguity is primarily related to sarcopenia, the progressive loss of muscle and gain in fat that come with aging. Whether to treat and how to treat obesity in the elderly is controversial because of a paucity of established guidelines, but also because of the obesity paradox-ie, the apparently protective effect of obesity in this age group.