RESUMO
2013 was full of significant advances in all areas of medicine, which may have an impact on daily practice in general internal medicine. From salt and water restriction in heart failure to transfusion threshold in upper gastrointestinal bleeding and fecal infusion in Clostridium difficile colitis; from new data in resuscitation and persistent questions in palliative care and intensive care medicine, through pneumology, nephrology and endocrinology, the literature has been rich in new considerations. Each year, the residents of the Department of internal medicine of the University hospital of Vaud (CHUV) meet to share their most interesting readings. Thirteen of them are reviewed and commented here.
Assuntos
Medicina Geral/tendências , Medicina Interna/tendências , Internato e Residência , Hospitais Universitários , Humanos , SuíçaRESUMO
Applying knowledge acquired from recent medical studies to patient care poses a daily challenge to physicians. Chief residents from the Department of Internal Medicine at the University Hospital of Lausanne carried out a review of some of the issues they considered important. The conclusions of these various publications may have a significant impact on the daily practice of hospital-based internal medicine. Modern medicine based on scientific studies is a reminder that in spite of the essential importance of clinical experience, it is crucial to confront it with the results of relevant publications from the medical literature.
Assuntos
Medicina Interna , Internato e Residência , HumanosRESUMO
Internists must regularly adjust their patients care according to recent relevant publications. The chief residents from the Department of Internal Medicine of a university hospital present some major themes of internal medicine treated during the year 2009. Emphasis will be placed primarily on changes in the daily hospital practice induced by these recent studies. This variety of topics illustrates both the broad spectrum of the current internal medicine, and the many uncertainties associated with modern medical practice based on evidence.
Assuntos
Medicina Interna/tendências , Hospitais , Humanos , Internato e ResidênciaRESUMO
OBJECTIVE: Overanticoagulated medical inpatients may be particularly prone to bleeding complications. Among medical inpatients with excessive oral anticoagulation (AC), we sought to identify patient and treatment factors associated with bleeding. METHODS: We prospectively identified consecutive patients receiving oral AC admitted to the medical ward of a university hospital (February-July 2006) who had at least one international normalized ratio (INR) value >3.0 during the hospital stay. We recorded patient characteristics, AC-related factors, and concomitant treatments (e.g., platelet inhibitors) that increase the bleeding risk. The outcome was overall bleeding, defined as the occurrence of major or minor bleeding during the hospital stay. We used logistic regression to explore patient and treatment factors associated with bleeding. RESULTS: Overall, 145 inpatients with excessive oral AC comprised our study sample. Atrial fibrillation (59%) and venous thromboembolism (28%) were the most common indications for AC. Twelve patients (8.3%) experienced a bleeding event. Of these, 8 had major bleeding. Women had a somewhat higher risk of major bleeding than men (12.5% vs 4.1%, p = 0.08). Multivariable analysis demonstrated that female gender was independently associated with bleeding (odds ratio [OR] 4.3, 95% confidence interval [95% C1] 1.1-17.8). Age, history of major bleeding, value of the index INR, and concomitant treatment with platelet inhibitors were not independent predictors of bleeding. CONCLUSIONS: We found that hospitalized women experiencing an episode of excessive oral AC have a 4-fold increased risk of bleeding compared with men. Whether overanticoagulated women require more aggressive measures of AC reversal must be examined in further studies.
Assuntos
Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Hemorragia/induzido quimicamente , Saúde da Mulher , Administração Oral , Idoso , Fibrilação Atrial/tratamento farmacológico , Feminino , Seguimentos , Hemorragia/epidemiologia , Humanos , Coeficiente Internacional Normatizado , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Distribuição por Sexo , Suíça/epidemiologia , Tromboembolia/tratamento farmacológicoRESUMO
Oral anticoagulants are frequently used in clinical practice. The most important complication of oral anticoagulation is major bleeding. The incidence of major bleeding is about 2-3%/year in randomized controlled trials but may be considerably higher under real life conditions. Major bleeding risk in patients receiving oral anticoagulants depends on factors related to anticoagulation itself (intensity and quality), patient-related factors (demographic characteristics and comorbid diseases), and concomitant treatments with antiplatelet or non-steroidal anti-inflammatory drugs. The role of clinical prediction rules for major bleeding is discussed.
Assuntos
Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêutico , Hemorragia/induzido quimicamente , Administração Oral , Quimioterapia Combinada , Hemorragia/epidemiologia , Humanos , Incidência , Fatores de RiscoRESUMO
Salmon calcitonin (SCT) is a well-tolerated peptide drug with a wide therapeutic margin and is administered parenterally for long-term treatments of bone diseases. Its clinical usefulness would be enhanced by the development of an orally active formulation. In this randomized crossover double-blinded phase I trial, controlled by both a placebo and a parenteral verum, we have tested a new oral formulation of SCT associated with a caprylic acid derivative as carrier. Eight healthy volunteers received single doses of 400, 800, and 1200 microg of SCT orally, a placebo, and a 10-microg (50 IU) SCT intravenous infusion. SCT was reliably absorbed from the oral formulation, with an absolute bioavailability of 0.5-1.4%, depending on the dose. It induced a marked, dose-dependent drop in blood and urine C-terminal telopeptide of type I collagen (CTX), a sensitive and specific bone resorption marker, with the effects of 1200 microg exceeding those of 10 microg intravenously. It also decreased blood calcium and phosphate, and increased the circulating levels of parathyroid hormone (PTH) and, transiently, the urinary excretion of calcium. It was well-tolerated, with some subjects presenting mild and transient nausea, abdominal cramps, diarrheic stools, and headaches. This study shows that oral delivery of SCT is feasible with reproducible absorption and systemic biological efficacy. Such an oral formulation could facilitate the use of SCT in the treatment of osteoporosis and other bone diseases.