MTX +dual DMARD compared to MTX + etarnecept

My original comments published in http://www.nejm.org/doi/full/10.1056/NEJMoa1303006#t=comments


The study showed a very promising results for triple therapy (methotrexate plus sulphasalazine plus hydroxychloroquine) with no difference significantly compared to methotrexate and etarnecept. The study potentially will give impact to management of rheumatoid arthritis as conventional triple therapy is much cheaper than methotrexate and etarnecept . Firstly combination conventional triple therapy potentially cheaper than methotrexate plus biologics. Secondly the initiating of triple therapy with relatively higher dose as starter therapy compared with normal treatment of DMARD with tapering dose according to response to therapy. NICE guideline only suggest initiate methotrexate with at least one other DMARD. I find this study commencing the aggressive therapy with the results of severe adverse events been observed ( 1mortality in biologics arm and severe infection in both arm). There is not mentioned folate in addition of methotrexate to prevent side effect of methotrexate . I personally suggest and conduct a routine chest radiograph before initiate biologics as pulmonary tuberculosis is relatively common in Malaysia.

Dental procedure during warfarin

From :http://www.neurology.org/content/80/22/2065/reply#neurology_el;58083
Published comments

This guideline is especially helpful in my daily management of patients. [1] Patients taking warfarin come to my clinic to obtain referrals for dental extraction because most dental surgeons in Malaysia refuse to perform dental procedures without clearance. I agree with the continuation of warfarin during dental procedures but certain precautions should be taken. Oral surgery may be completed safely at INR of 1.5-2.5 [2] and up to INR 4 for a small procedure. [3] The INR should be checked prior to surgery. For simple extractions, bleeding should be controlled by minimizing surgery to only one site and post-operative packs or firm sutures should cover the wound. Local anesthetic should be given cautiously to avoid venepunctures. [4] I hope a future guideline will address novel anticoagulant therapy for use during dental procedures.

1. Melissa J. Armstrong, Gary Gronseth, David C. Anderson Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease: Report of the Guideline Development Subcommittee of the American Academy of Neurology

2.Little JW, Falace DA, Miller CS et al. Dental management of medically compromised patient. 5th ed. St. Louis: Mosby; 1997

3.Devani P, Lavary KM, Howell CJ. Dental extraction in patient on warfarin: is alteration of anticoagulant necessary? Br J Oral Maxillofac Surg 1998; 36:107-111

4.Savage N. Managing dental patients receiving warfarin therapy. Aust Prescr 2002; 25:69

Dabigatran post-AF ablation may be riskier than warfarin

Periprocedural anticoagulation in patients undergoing radiofrequency ablation for atrial fibrillation may entail a small but statistically increased risk of stroke or transient ischemic attack, according to a meta-analysis of 10 observational cohort studies.
The meta-analysis, which included 1,501 patients on periprocedural dabigatran (Pradaxa) and 2,356 on warfarin, had dual primary end points.
 One was stroke or TIA, which occurred in 0.7% of the dabigatran group, compared with 0.2% of those on warfarin – a statistically significant difference (P = .0007), Dr. Benjamin A. Steinberg reported at theannual meeting of the Heart Rhythm Society.

Major bleeding, was recorded in 1.6% of the dabigatran group, with a closely similar 1.7% incidence in the warfarin group.

Rates of cardiac tamponade, a secondary end point, were also similar: 1.1% with dabigatran and 0.9% with warfarin.
Conclusion: Dabigatran posted higher risk of stroke periprocedural anticoagulation with equal risk of bleeding and tamponade comparing to warfarin

Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease

Reference neurology journal 2013
Stroke patients undergoing dental procedures should routinely continue aspirin (Level A).
 Stroke patients undergoing invasive ocular anesthesia, cataract surgery, dermatologic procedures, transrectal ultrasound–guided prostate biopsy, spinal/epidural procedures, and carpal tunnel surgery should probably continue aspirin (Level B).
 Some stroke patients undergoing vitreoretinal surgery, EMG, transbronchial lung biopsy, colonoscopic polypectomy, upper endoscopy and biopsy/sphincterotomy, and abdominal ultrasound–guided biopsies should possibly continue aspirin (Level C).
 Stroke patients requiring warfarin should routinely continue it when undergoing dental procedures (Level A) and probably continue it for dermatologic procedures (Level B).
Some patients undergoing EMG, prostate procedures, inguinal herniorrhaphy, and endothermal ablation of the great saphenous vein should possibly continue warfarin (Level C).
Whereas neurologists should counsel that warfarin probably does not increase clinically important bleeding with ocular anesthesia (Level B), other ophthalmologic studies lack the statistical precision to make recommendations (Level U).
Neurologists should counsel that warfarin might increase bleeding with colonoscopic polypectomy (Level C). There is insufficient evidence to support or refute periprocedural heparin bridging therapy to reduce thromboembolic events in chronically anticoagulated patients (Level U). Neurologists should counsel that bridging therapy is probably associated with increased bleeding risks as compared with warfarin cessation (Level B). The risk difference as compared with continuing warfarin is unknown (Level U).

Ceftaroline (Zinforo) a new toy for MRSA skin infection ?

Ceftaroline- a new generation of cephalosporin

Bactericidal

Block PBP

Addictive to other antibiotic, least interaction

Professor Lipman

CANVAS study showed effective against MRSA  complicated soft tissue infection compared to vancomycin  and aztreonem. Study showed non inferiority to Vancomycin and aztreonem

Treatment 5-14 days

FOCUS I and II – study showed effective towards CAP. No clinical data regarding MRSA CAP.

New combination produce –ceftaroline + avibactem –enhanced gram –ve cover.

Causes of short stature

Short stature is a diagnosis which will give you clue during clinical examination especially during inspection.
added with other sign . It will help on your diagnosis.

Short stature can be divided into proportional and disproportional
proportional
Growth hormone deficiency
systemic disease
constitutional delay
familial

disproportional
Turner syndrome
Achondroplasia
Osteogenesis imperfecta
Congenital hypothyroidism (normally low IQ)


Achondroplasia  is a common cause of dwarfism. It occurs as a sporadic mutation in approximately 75% of cases (associated with advanced paternal age) or may be inherited as an autosomal dominant genetic disorder.

Osteogenesis imperfecta is a congenital bone disorder.It happened  because of a deficiency of Type-I collagen

books for sale

The above books is one of my precious books collection. I wish to sell it for better usage of the books rather  than keeping them in my book rack. The first books is essential paediatrics (third edition) sold at RM70. second books is scott an aid to surgery sold at RM40 and last books is paediatric problem in tropical countries sold at RM 40. If buying both paediatric books I will sold at total of 100.If buy 3 books sold at RM140. Additional photocopy books for paeds and O and G will be given with each purchased.

Interested please e mail me at fangpenang@gmail.com. I accept cash on delivery on Penang Island. thanks.

Osteoporosis general management and myth

A talk by enocrinologist from netherland named prof Socrates papapoulas regarding osteoporosis. He outlined biphosphonates and Hrt (forfemale) is the option for osteoporosis. Bisphosphonates better in the sense of risk of breast ca for Hrt. He outlined the risk factor for osteoporosis such as smoking, alcoholic , low BMI, low calcium intake, advancing age, race and etc. he stress the important of vit D (800micro grame) per day. Regarding the myth of atypical fracture and slower healing of hip fracture by biphosphonates, evidence proves that it is unrelated for biphosphonates vs placebo. Regarding the long term uses of biphosphonates for osteoporosis, he stated that for 5years treatment with biphosphonates, it will remain for the next 5 year. Evidence proves that no increased fracture risk compared 5 year biphospphonates and 5 year placebo and 10 year biphosphonates in FLEX study for alendronates.another study for Iv zoledronic acid annually showed similar results. It also critised orthopods not using biphosphonates for hip fracture pt. It stated a old people with fracture needs treatment for osteoporosis without checking Bone mineral density as it is proven by fracture.

Intensive Talk with Prof Falagas

Summary:
Bacteria develop multiple resistance to antibiotic
By:
1)producing B-lactamase
2)overexpression efflux pump to release extra antibiotic
3)antibiotic modify enzyme
4)ribosomal mutation
Thus appear all superbug such as ESBL, carbapenemase producing klebsiella etc
Pt infected with ESBL +ve had relative risk 1.85 of mortality compared to normal bugs
Treatment of commonest bugs in ICU –Acinetobacter spp.
Recommended to do C+S with MIC
Therapy promptly early
Start therapy right at beginning
Modification therapy as nessasary (de-escalation) early
Tigercycline- a new agt
It evades tetracycline efflux pump and ribosomal protective mechanism
Bacteriostatic
That is limitation no good blood level for therapeutic
Varied response to acinetobacter
Imipenem –launch with 4g/day
Recommend 2g/d as reduce seizure
Not enough as moderate susceptible organism need 1g qid .
Recommended for high MIC acinetobacter to give prolong infusion meropenem 1 g tds as long as 3 hr compared with 30min normally given.
Study proved similar dose with prolong infusion better outcome
Colistin monotherapy
Got 52% isolates for acinetobacter were polymycin only susceptible
The rest need colistin and one other antibiotic (rec add carbapenem)
As highest % of survival
Benault et al. showed Obesity highest rate septic shock
Partly related with leptin def
DM
FOsfamycin-good for Klebsiella spp and pseudomonas spp.
Another talk by gastro
If NDM1 may give fosfamycin + carbapenem.
UGIB
Commonest cause H. pylori followed by NSAID, Antiplatelet
Risk of UGIB-age, multiple co-morbidity and H/O peptic ulcer
If pt got cardiovascular problem, may restart antipltelet after 4-5 days of peptic ulcer