Gastrointestinal Bleeding and Anticoagulant or Antiplatelet Drugs

Gastrointestinal (GI) bleeding is a frequently encountered and very serious problem in emergency room patients who are currently being treated with anticoagulant or antiplatelet medications. There is, however, a lack of clinical practice guidelines about how to respond to these situations. The goal of this study was to find published articles that contain specific information about how to safely adjust anticoagulant and antiplatelet therapy when GI bleeding occurs.The investigators initiated a global search on the PubMed and Google websites for published information about GI bleeding in the presence of anticoagulant or antiplatelet therapy. After eliminating duplicate entries, the medical articles that remained were screened to narrow the sets of articles to those that met specific criteria. Articles that most closely matched study criteria were analyzed in detail and compared to determine how many actual guidelines exist and are useful.We could provide only minimal information about appropriate therapeutic strategies because no articles provided sufficient specific advice about how to respond to situations involving acute GI bleeding and concurrent use of anticoagulant or antiplatelet drugs. Only 4 articles provided enough detail to be of any use in an emergency situation.Clinical practice guidelines and also clinical trials for GI hemorrhaging should be expanded to state in which situations the use of anticoagulant or antiplatelet drugs should be suspended and the medications should later be resumed, and they should state the level of risk for any particular action

Cement-augmented dorsal instrumentation of the spine as a safe adjunct to the multimodal management of metastatic pheochromocytoma: a case report

Malignant pheochromocytoma is a neuroendocrine tumor that originates from chromaffin tissue. Although osseous metastases are common, metastatic dissemination to the spine rarely occurs

Cardiac magnetic resonance findings predict increased resource utilization in elective coronary artery bypass grafting

Morbidity following CABG (coronary artery bypass grafting) is difficult to predict and leads to increased healthcare costs. We hypothesized that pre-operative CMR (cardiac magnetic resonance) findings would predict resource utilization in elective CABG. Over a 12-month period, patients requiring elective CABG were invited to undergo CMR 1 day prior to CABG. Gadolinium-enhanced CMR was performed using a trueFISP inversion recovery sequence on a 1.5 tesla scanner (Sonata; Siemens). Clinical data were collected prospectively. Admission costs were quantified based on standardized actual cost/day. Admission cost greater than the median was defined as 'increased'. Of 458 elective CABG cases, 45 (10%) underwent pre-operative CMR. Pre-operative characteristics [mean (S.D.) age, 64 (9) years, mortality (1%) and median (interquartile range) admission duration, 7 (6–8) days] were similar in patients who did or did not undergo CMR. In the patients undergoing CMR, eight (18%) and 11 (24%) patients had reduced LV (left ventricular) systolic function by CMR [LVEF (LV ejection fraction) <55%] and echocardiography respectively. LE (late enhancement) with gadolinium was detected in 17 (38%) patients. The average cost/day was $2723. The median (interquartile range) admission cost was$19059 ($10891–157917). CMR LVEF {OR (odds ratio), 0.93 [95% CI (confidence interval), 0.87–0.99]; P=0.03} and SV (stroke volume) index [OR 1.07 (95% CI, 1.00–1.14); P=0.02] predicted increased admission cost. CMR LVEF (P=0.08) and EuroScore tended to predict actual admission cost (P=0.09), but SV by CMR (P=0.16) and LV function by echocardiography (P=0.95) did not. In conclusion, in this exploratory investigation, pre-operative CMR findings predicted admission duration and increased admission cost in elective CABG surgery. The cost-effectiveness of CMR in risk stratification in elective CABG surgery merits prospective assessment

Open and hidden agendas of "asymptomatic" patients who request check-up exams

BACKGROUND: Current guidelines for a check-up recommend routine screening not triggered by specific symptoms for some known risk factors and diseases in the general population. Patients' perceptions and expectations regarding a check-up exam may differ from these principles. However, quantitative and qualitative data about the discrepancy between patient- and provider expectations for this type of clinic consultation is lacking. METHODS: For a year, we prospectively enrolled 66 patients who explicitly requested a "check-up" at our medical outpatient division. All patients actively denied upon prompting having any symptoms or specific health concerns at the time they made their appointment. All consultations were videotaped and analysed for information about spontaneously mentioned symptoms and reasons for the clinic consultation ("open agendas") and for cues to hidden patient agendas using the Roter interaction analysis system (RIAS). RESULTS: All patients initially declared to be asymptomatic but this was ultimately the case in only 7 out of 66 patients. The remaining 59 patients spontaneously mentioned a mean of 4.2 ± 3.3 symptoms during their first consultation. In 23 patients a total of 31 hidden agendas were revealed. The primary categories for hidden agendas were health concerns, psychosocial concerns and the patient's concept of disease. CONCLUSIONS: The majority of patients requesting a general check-up tend to be motivated by specific symptoms and health concerns and are not "asymptomatic" patients who primarily come for preventive issues. Furthermore, physicians must be alert for possible hidden agendas, as one in three patients have one or more hidden reasons for requesting a check-up

What makes internal medicine attractive for the millennial generation? A survey of residents in internal medicine in Switzerland

AIMS: A new generation of physicians, millennials (also known as Generation Y), are entering residency programmes in internal medicine, and these young men and women learn and work in ways that are different from those of past generations. The aim of the present study was to investigate aspects contributing to the attractiveness to young residents of a career in general internal medicine (GIM) compared with medical subspecialties (SUB). METHODS: In a cross-sectional online survey, we included residents working in residency facilities in GIM in German- speaking Switzerland. A total of 1818 junior residents were eligible. We looked for personal preferences, characteristics, and criteria influencing the choice of a career in GIM or SUB. RESULTS: 392 out of 1818 (22%) residents participated in the survey (66% females); they had been in clinical training for 35.5 months on average. 87% of the respondents aspired to a title in GIM, and 29% of these to a SUB title as well. 71% of the women chose GIM and not a SUB vs 58% of the men (p <0.019). GIM residents gave significantly higher ratings to “broad range of expertise,” “flexible work hours” (p = 0.007), “work-life balance”, and “reconciliation of work, family and private life” than residents aiming at a SUB. SUB residents evaluated career-related criteria as significantly more important (p <0.0001). With regard to career motivation, GIM residents and female residents rated extraprofessional concerns significantly higher than SUB residents did (p = 0.019). In contrast, SUB residents showed significantly higher intrinsic motivation than GIM residents (p = 0.025). Only 28.2% of GIM residents had a mentor, compared to 49.6% of SUB residents (p <0.0005). Concerning personal perceptions of the future within the next 5 years, GIM residents attached significantly more importance to part-time work (p = 0.001), whereas SUB residents attached more importance to getting a leading position as a main goal (p = 0.0001). CONCLUSIONS: There are considerable differences between GIM and SUB residents regarding career motivation and their views on working conditions and work-life balance. It is essential to understand the factors that motivate or deter the next generation in order to ensure the attractiveness of the profession of GIM. Keywords: millennials, generation Y, general internal medicine, medical subspecialty, residents, career, worklife balance, mentorin