Use of novel oral anticoagulant agents in venous thromboembolism.

New oral anticoagulants (NOAC) serve as alternatives for patients currently using warfarin for the prevention and treatment of venous thromboembolic (VTE) disease. This article provides a brief summary of the clinical use of these drugs as well as a review of the landmark clinical trials which evaluated described their safety and efficacy. As more data becomes available, a fundamental understanding of these medications will be vital to cardiovascular practitioners managing patients with VTE.

Noninfiltrating Adenocarcinoma of the Lung Causing ST-Segment Elevation.

ST-segment-elevation myocardial infarction is a leading cause of cardiovascular morbidity and death. We describe the case of a 51-year-old woman with advanced adenocarcinoma of the lung who presented with ST-segment elevation in the presence of an extracardiac lung mass but no objective evidence of myocardial ischemia or pericardial involvement. After the patient died of hypoxic respiratory failure, autopsy findings confirmed normal-appearing pericardium and myocardium, and mild-to-moderate atherosclerosis in the coronary arteries. A 4.5 × 4-cm extracardiac left hilar lung mass was confirmed to be poorly differentiated adenocarcinoma of the lung adjacent to the myocardium. The persistent current of injury that had been detected electrocardiographically was thought to occur from direct myocardial compression. ST-segment elevations secondary to direct mass contact on the myocardium should be considered in patients who have a malignancy and ST-segment elevation.

Use of novel oral anticoagulant agents in atrial fibrillation: current evidence and future perspective.

The increasing availability of novel oral anticoagulants (NOAC) for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation (AF) offers alternatives for patients currently prescribed warfarin. This article provides a brief overview on the mechanism and clinical use of these drugs as well as a review of the pivotal clinical trials providing the basis for each agent's safety and efficacy. While these agents are currently Food and Drug Administration (FDA) approved for anticoagulation of patients with nonvalvular AF, additional studies continually emerge offering further insight into the application of these agents in other areas.

Association between body mass index and quality of split bowel preparation.

BACKGROUND & AIMS: Little is known about the association between obesity and bowel preparation. We investigated whether body mass index (BMI) is an independent risk factor for inadequate bowel preparation in patients who receive split preparation regimens. METHODS: We performed a retrospective study of data from 2163 consecutive patients (mean age, 60.6 ± 10.5 y; 93.8% male) who received outpatient colonoscopies in 2009 at the Veterans Affairs Medical Center in Indianapolis, Indiana. All patients received a split preparation, categorized as adequate (excellent or good, based on the Aronchick scale) or inadequate. We performed a multivariable analysis to identify factors independently associated with inadequate preparation. RESULTS: Bowel preparation quality was inadequate for 44.2% of patients; these patients had significantly higher mean BMIs than patients with adequate preparation (31.2 ± 6.5 vs 29.8 ± 5.9, respectively; P < .0001) and Charlson comorbidity scores (1.5 ± 1.6 vs 1.1 ± 1.4; P < .0001). Independent risk factors for inadequate preparation were a BMI of 30 kg/m(2) or greater (odds ratio [OR], 1.46; 95% confidence interval [CI], 1.21-1.75; P < .0001), use of tobacco (OR, 1.28; 95% CI, 1.07-1.54; P = .0084) or narcotics (OR, 1.28; 95% CI, 1.04-1.57; P = .0179), hypertension (OR, 1.30; 95% CI, 1.07-1.57; P = .0085), diabetes (OR, 1.38; 95% CI, 1.12-1.69; P = .0021), and dementia (OR, 3.02; 95% CI, 1.22-7.49; P = .0169). CONCLUSIONS: BMI is an independent factor associated with inadequate split bowel preparation for colonoscopy. Additional factors associated with quality of bowel preparation include diabetes, hypertension, dementia, and use of tobacco and narcotics. Patients with BMIs of 30 kg/m(2) or greater should be considered for more intensive preparation regimens.

Recurrent septic shock in a 34-year-old woman.

A 34-year-old woman presented to the Emergency Room (ER) with an acute presentation of septic shock that required fluid and pressor support in the Intensive Care Unit. History revealed this was her third episode of such a presentation with asymptomatic periods in between. She responded well to medical interventions but reported persistent joint pain. Immunologic workup revealed her diagnosis.

Physician approaches to beta-lactam use in patients with penicillin hypersensitivity.

Beta-lactam antibiotics are widely used, but hypersensitivity reactions are common and difficult to manage. This study was designed to identify lack of knowledge regarding the safe use of alternative beta-lactams in penicillin-allergic patients and assess management differences between allergists and nonallergists. An electronic physician survey was sent to 623 providers in allergy, internal medicine, pediatrics, and family medicine, querying beta-lactam use in patients with a history of penicillin allergy. A total of 110 (17.7%) surveys were completed. For patients with a prior maculopapular rash to penicillin, most providers were uncomfortable prescribing penicillins again, although they would use other beta-lactams. In patients with an exfoliative dermatitis to penicillin, 46% of responders would not prescribe any beta-lactam again. For patients with a positive skin test to penicillin, only 45.1% of nonallergists were comfortable prescribing monobactams versus 62.5% of allergists; 30.3% of all responders would give a carbapenem. In patients with urticaria to penicillin, pediatricians were the most comfortable prescribing third- or fourth-generation cephalosporins. Providers (both allergists and nonallergists) were unfamiliar with the safety of prescribing penicillin in patients with history of maculopapular rash, the safety of monobactams, and low cross-reactivity with carbapenems in penicillin-allergic individuals. Nonallergists were also unfamiliar with the usefulness of penicillin skin testing. Improved education is needed to address these areas. Additionally, we found variability in responses regarding exfoliative dermatitis and comfort prescribing cephalosporins in patients with suspected IgE-mediated drug allergy to penicillin, highlighting the need for additional research in these areas.