Jones & Bartlett Learning Medicine Blog

By James H. O’Keefe, MD FACC, author of The Complete Guide to ECGs: A Comprehensive Study Guide to Improve ECG Interpretation Skills, Fifth Edition

The most common arrhythmia seen in COVID-19 patients is sinus tachycardia, but other pathologic arrhythmias such as atrial flutter and/or fibrillation, ventricular tachycardia, and bradyarrhythmia can occur especially among critically ill patients. However, the vast majority of patients presenting with COVID-19 will not have symptoms or signs of arrhythmias or conduction system disease.

The must-have Physicians’ Cancer Chemotherapy Drug Manual is now available for your iPhone, iPad, and Android. The new app offers busy physicians convenient and affordable access to up-to-date information on standard therapy and recent advances in oncology medication.

New fads and diets are constantly surfacing in our world today, however it’s interesting to note that often a lot of the new fads are actually a resurfacing out of old traditions translated into a modern setting. For example, looking up Kombucha on www.huffingtonpost.com leads to a wealth of articles like “What Kombucha Really is, for those of you who Drink it but Don’t really know,” “Kombucha: A Love Story,” and “7 Ways Fermented Tea Can Give You Better Skin.”  And these are only a few of the headlines surfacing online today.

Cancer is a leading cause of Death in the world today, so whether it’s you, a loved one, friend, or acquaintance, chances are high that cancer will be a part of your life at some point.

U.S. News & World Report has released their ranking of the 100 best jobs for 2015. Beginning with the occupations that the U.S. Department of Labor Bureau of Labor Statistics predicts will grow the most between 2012 and 2022, the list ranks jobs in a variety of industries based on projected openings, rate of growth, job prospects, unemployment rates, salary, and job satisfaction.

Perioperative statin therapy has long been felt to confer cardiac protection during both cardiac surgery and major noncardiac surgery.  Until recently the data have been scarce to definitively make claims in support of this belief.  In 2004, Durazzo et al. conducted the first randomized trial examining the use of Perioperative statins in major noncardiac surgery.  They compared the use of atorvastatin 20 mg daily compared against placebo initiated 2 weeks prior to elective major vascular surgery and continued for 45 days post-operatively.  The investigators found that statins were associated with a 70% relative risk reduction of the combined end-point of death, nonfatal MI, unstable angina, or stroke. [1] Prior to this in 1999, Christenson had demonstrated cardioprotective effects of statins during coronary artery bypass grafting surgery. [2]

Statins are thought to be beneficial for a myriad reasons:

• They lower lipids and have additional pleiotropic effects.
• The cardioprotective effects of statins during the perioperative period is more likely related to their pleiotropic effects than their lipid-lowering effects.
• Statins inhibit the action of HMG-CoA Reductase which is the rate-limiting step in cholesterol synthesis, but effective lipid lowering takes months.
• Perioperative studies have demonstrated that statins confer a cardioprotective benefit when started even 1-2 weeks in advance of major surgery.
• These pleiotropic effects of statins include suppression of endothelial nitric oxide which promotes coronary vasodilation.
• Statins also reduce lipopolysaccharide-induced tissue factor release, decrease plasminogen activator inhibitor levels, and increase tissue plasminogen activator; the combination of which reduces coronary thrombosis.
• Statins also have anti-inflammatory properties which may provide more plaque stability. [3]

Acid suppression has long been associated with an increased risk of developing Clostridium difficile infection (CDI), having recurrent Clostridium difficile infection, and now has been shown to increase the complication rate and mortality from Clostridium difficile infection.  This risk applies to both H2-blockers and proton pump inhibitors (PPI), but the risk appears to be significantly higher for proton pump inhibitors.

Several prior studies and meta-analyses have demonstrated an increased risk of Clostridium difficile infection with proton pump inhibitor therapy.[1,2,3]    Howell et al. performed a case-cohort study investigating over 101,000 patient discharges at a tertiary medical care center over a five-year period.  They discovered a three-fold increased incidence of nosocomial CDI in patients receiving daily PPI therapy compared with controls not receiving any acid suppression therapy.  The risk of CDI was two-fold in patients receiving daily H2-blocker therapy and 4.5-fold increased risk for patients receiving twice daily PPI therapy.[1]  The meta-analysis performed by Deshpande et al. reviewed 30 observational studies between 1990 and 2010 and concluded that PPI therapy is associated with a two-fold increased the risk for CDI.[3]

In addition, we know that PPI use increases the risk of recurrent CDI.  A retrospective, cohort study by Linsky et al. analyzed 1166 inpatients at a single center over a five year period and determined that use of PPI within 14 days of CDI diagnosis increased the rate of recurrent CDI after appropriate treatment by 42% compared with those patients not receiving PPI therapy.[4]

Scientists at the University of Eastern Finland led by Professor Juhu Rouvinen, in cooperation with Professors Kristiina Takkinen and Hans Söderlun from VTT, a technical research center in Finland, discovered unique IgE‐binding structures in allergens. They say these structures can be genetically modified so they do not bind IgE anymore, but they can still induce the production of the immunoglobulin G (IgG).  IgG protects you from allergic symptoms by actually prohibiting the formation of IgE-allergen complexes and could, in theory, prevent the degranulation and histamine release from white blood cells. The modified allergens are produced using modern molecular biology and biotechnology.

Patients will hypothetically develop a natural immunity against each allergy they have been vaccinated for in the same manner immunity is created against infectious diseases with vaccinations.

“Histamines are not the solution because they only inhibit or lesson the allergy so you still have the allergy.  We believe that curing allergies is about changing or modifying the genetic structure of the allergen molecules inside of your body, so we want to eliminate the cause of the allergy, instead of removing symptoms.” said Rouvinen.

According to the National Institute of Health, An allergy is an exaggerated immune response or reaction to substances that are generally not harmful. The immune system normally protects the body against harmful substances, such as bacteria and viruses. It also reacts to foreign substances called allergens, which are generally harmless and in most people do not cause a problem.  But in a person with allergies, the immune response is oversensitive. When it recognizes an allergen, it releases chemicals such as histamines. which fight off the allergen. This causes allergy symptoms.

In the United States, 65 million people have some type of allergy:

• 56% percent are allergic to grasses and pollen
• 39% are allergic to cat and dog dander
• 10% have some type of food allergy

Instances of seasonal allergies are on the up-swing, primarily for environmental reasons.

"The seasons are getting longer—they're starting earlier and pollens are getting released earlier," says Dr. Stanley Fineman, president-elect of the American College of Allergy, Asthma and Immunology and an allergist at the Atlanta Allergy and Asthma Clinic. "And not only is there warmer weather, there tends to be more CO2 in atmosphere."

This is the follow-up blog post from Tarascon Publishing Author, Matthew Dasco, MD, MSc.  Click here to read Part 1 of the Botswana and Human Resources for Health post.

This is the first in a two-part blog series from Tarascon Publishing Author, Matthew Dasco, MD, MSc.

Part 1:

The world’s burden of disease and human resources for health are not well aligned.  While sub-Saharan Africa has 24% of the world’s disease burden, it only has 3% of the world’s healthcare workers.  On the other end, the Americas region has 10% of the world’s disease burden but 37% of its health workers.

The Joint Learning Initiative (JLI) has calculated that the minimum number of health care workers (doctors, nurses, and midwives) in a population to achieve and 80% coverage rate of skilled birth attendance and measles vaccination is 2.5 per 1000 – countries with fewer than this number run a very high risk of not achieving the health-related millennium development goals (JLI, 2004).  57 countries in the world have been designated by the World Health Organization (WHO) as in this state of “crisis” with regards to human resources for health, which translates to a global shortage of roughly 2.4 million health workers (WHO, 2006).

(Chart from Kerry, 2011)

My first contact with the disparity between disease burden and human resources for health occurred while I was attending on the internal medicine wards at Princess Marina Hospital (PMH) in Gaborone, Botswana.  PMH is the largest of two public sector tertiary care referral hospitals in the country.  In our department, there were six general medicine teams, an oncology service, and a nephrology service – each was assigned an internal medicine specialist.  The department consisted of two Cubans (a pulmonologist and a nephrologist), a Chinese generalist, an Indian generalist, a German oncologist, an Egyptian cardiologist, and a smattering of Americans working through university partnerships.  I found it odd that there were only two Batswana internal medicine specialists working there – they were among a very small number that had received specialty training abroad and returned to their home country to practice.