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ACP’s Internal Medicine 2013 Highlights Julie Crawford, MD Brenda Shinar, MD Jayne Peterson, MD Cheryl W. O’Malley, MD.

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Presentation on theme: "ACP’s Internal Medicine 2013 Highlights Julie Crawford, MD Brenda Shinar, MD Jayne Peterson, MD Cheryl W. O’Malley, MD."— Presentation transcript:

1 ACP’s Internal Medicine 2013 Highlights Julie Crawford, MD Brenda Shinar, MD Jayne Peterson, MD Cheryl W. O’Malley, MD

2 Update in Hospital Medicine Clinical Pearls Update in Hospital Medicine Julie Crawford, MD Hospitalist Phoenix VA Healthcare System May

3 Mrs. P is an 82yo female with a PMH sig for HF (EF 35%), HTN, DM, h/o remote CVA and atrial fibrillation (on AC) who is admitted for management of a left femoral neck fracture that occurred when the patient tripped on a rug in her house and fell. INR was 2.2 on admission. She was given FFP just prior to undergoing an uncomplicated Left Total Hip Arthoplasty. Postoperative INR = 1.6 CHADS2 score is 6. When should you start heparin bridging in this patient? A: Immediately after surgery B: 12 hours after surgery C: 48 hours after surgery D: At least one week after surgery Clinical Pearl #1 3

4 ANSWER: C. 48 hours after surgery Clinical Pearl #1 4

5 Why? C. 48 hours after surgery Current clinical guidelines for peri-procedural anticoagulation management  Based on expert opinion  Place a relatively high value on preventing VTE and a relatively lower value on preventing bleeding  Based on limited data regarding the risks of bleeding Clinical Pearl #1 5

6 OBJECTIVE: “to determine the 3 month cumulative incidence and independent predictors of peri-procedural bleeding in chronically anticoagulated patients requiring temporary warfarin interruption for an invasive procedure” Evidence Predictors of major bleeding in peri-procedural anticoagulation management. Tafur A.J., McBane R, Wysokinski E, Litin S, Daniels P, Slusser J, Hodge D, Beckman MG, Heit JA Journal of Thrombosis and Haemostasis. 2012: 10: Clinical Pearl #1 6

7 Protocol Driven, Cohort study Mayo Clinic N=2182 Used protocols to determine management of perioperative anticoagulation Patients were followed forward for 3 months Predictors of major bleeding in peri-procedural anticoagulation management. Tafur A.J., McBane R, Wysokinski E, Litin S, Daniels P, Slusser J, Hodge D, Beckman MG, Heit JA Journal of Thrombosis and Haemostasis. 2012: 10: Study Details Clinical Pearl #1 7

8 Overall bleeding 5.1%, Major bleeding 2.1% Major bleeding was more frequent in patients receiving heparin bridging (3% vs. 1%); There was no difference in thrombosis rates. INDEPENDENT PREDICTORS OF MAJOR BLEEDING:  Mitral mechanical valves  Active Cancer  Prior bleeding history  Restarting heparin within 24 hours of surgery – ALL of the major bleeding events occurred in patients who resumed full dose heparin within 24 hours of the procedure – NO events in full dose heparin starting >48 hours following the procedure. Predictors of major bleeding in peri-procedural anticoagulation management. Tafur A.J., McBane R, Wysokinski E, Litin S, Daniels P, Slusser J, Hodge D, Beckman MG, Heit JA Journal of Thrombosis and Haemostasis. 2012: 10: Findings Clinical Pearl #1 8

9 Authors’ practice has changed to err on the side of reducing bleeding risk  Wait 48h post-procedure prior to initiating therapeutic heparin  Therapeutic heparin bridging recommended only in those who are at high risk of TE – h/o VTE in past 3 mo – Afib w/ prior CVA, TE, or intracardiac thrombus – Prosthetic heart valves (other than aortic bileavlet valves) – Mechanical heart valves with a h/o coexistent afib, prior CVA, TE, or known intracardiac thrombus Predictors of major bleeding in peri-procedural anticoagulation management. Tafur A.J., McBane R, Wysokinski E, Litin S, Daniels P, Slusser J, Hodge D, Beckman MG, Heit JA Journal of Thrombosis and Haemostasis. 2012: 10: Recommendations Clinical Pearl #1 9

10 CLINICAL PEARL #1 Initiation of bridging heparin within 24 hours of surgery is associated with major bleeding. Better guidelines are needed to determine the optimal timing of postoperative heparin bridging. 10

11 Johns Hopkins Consultative Medicine Essential for Hospitalists Module on Perioperative Management of Anticoagulation 11

12 After surgery, Mrs. P is feeling well. She denies any symptoms of chest pain or shortness of breath. Should you check a troponin level to assess her for possible postoperative acute MI? A: Yes B: No C: Maybe Clinical Pearl #2 12

13 ANSWER: C. Maybe Clinical Pearl #2 13

14 Why? C. Maybe Hip fracture surgery is the most common non- cardiac surgical procedure in the elderly Current Perioperative guidelines suggest that risk of cardiac complications from orthopedic procedures is 1-5%  NOT specific for hip fracture Clinical Pearl #2 14

15 OBJECTIVE: “To define the clinical presentation of PMI and its outcomes among elderly patients admitted for hip fracture surgery” Evidence Clinical Presentation and Outcome of Perioperative Myocardial Infarction in the Very Elderly Following Hip Fracture Surgery. Gupta B, Huddleston J, Kirkland, L, Huddleston P, Larson D, Gullerud R, Burton MC, Rihal C, Wright RS. Journal of Hospital Medicine Nov/Dec (9); pg Clinical Pearl #2 15

16 Population-based, retrospective, case control study ; Residents of Olmsted County, Minnesota; age >65 (average age 85.3yrs) Clinical Presentation and Outcome of Perioperative Myocardial Infarction in the Very Elderly Following Hip Fracture Surgery. Gupta B, Huddleston J, Kirkland, L, Huddleston P, Larson D, Gullerud R, Burton MC, Rihal C, Wright RS. Journal of Hospital Medicine Nov/Dec (9); pg Study Details Clinical Pearl #2 16

17 In 1212 patients with hip fracture surgeries  13.8% of cases suffered PMI in the first 7 days after surgery – 92% PMI occurred within the first 48 hours – 75% of patients were ASYMPTOMATIC – 22.8% had ECG changes consistent with ischemia  PMI was associated with higher mortality – In hospital deaths (14.4% of PMI group vs. 1.2% of non-PMI group – 30 d mortality (17.4% PMI vs. 4.2% non-PMI) – 1y mortality (29% PMI vs. 23% non PMI)  Most of the PMI patients in this study were identified w/ cardiac biomarkers Findings Clinical Presentation and Outcome of Perioperative Myocardial Infarction in the Very Elderly Following Hip Fracture Surgery. Gupta B, Huddleston J, Kirkland, L, Huddleston P, Larson D, Gullerud R, Burton MC, Rihal C, Wright RS. Journal of Hospital Medicine Nov/Dec (9); pg Clinical Pearl #2 17

18 CONCLUSIONS:  “ Elderly patients have a higher incidence of PMI and mortality after hip fracture than what current guidelines indicate”  “Results support the measurement of troponin in postoperative elderly patients for diagnosis of PMI to implement in-hospital preventive strategies to reduce PMI- associated mortality “ Findings Cont. Clinical Presentation and Outcome of Perioperative Myocardial Infarction in the Very Elderly Following Hip Fracture Surgery. Gupta B, Huddleston J, Kirkland, L, Huddleston P, Larson D, Gullerud R, Burton MC, Rihal C, Wright RS. Journal of Hospital Medicine Nov/Dec (9); pg Clinical Pearl #2 18

19 Does postoperative troponin level predict mortality? Clinical Pearl #2 19

20 OBJECTIVE: “To determine the relationship between the peak fourth- generation troponin T (TnT) measurement in the first 3 days after noncardiac surgery and 30-day mortality” Evidence Association Between Postoperative Troponin Levels and 30-day Mortality Among Patients Undergoing Noncardiac Surgery JAMA 2012; 307(21): Clinical Pearl #2 20

21 VISION study: a prospective cohort study designed to evaluate major complications after noncardiac surgery N. and S. America, Africa, Asia, Australia, and Europe 15,133 patients; age >=45yo Measured Troponin T level 6-12 hours after surgery and on postop days 1, 2, and 3 Study Details Association Between Postoperative Troponin Levels and 30-day Mortality Among Patients Undergoing Noncardiac Surgery JAMA 2012; 307(21): Clinical Pearl #2 21

22 30 day mortality rate was 1.9% (282 deaths) Peak TnT values >=0.02ng/mL were independently associated with a higher 30-day mortality compared with the reference group *note; most labs consider <0.04ng/mL to be WNL The higher the peak TnT value, the shorter the median time to death 74.2% of patients with elevated TnT had elevation within 24 hours of surgery Findings Association Between Postoperative Troponin Levels and 30-day Mortality Among Patients Undergoing Noncardiac Surgery JAMA 2012; 307(21): Clinical Pearl #2 22

23 Association Between Postoperative Troponin Levels and 30-day Mortality Among Patients Undergoing Noncardiac Surgery JAMA 2012; 307(21): Clinical Pearl #2 23

24 The peak fourth-generation TnT measurement in the first 3 days after noncardiac surgery is strongly associated with 30 day mortality. Monitoring Troponin levels for first 3 days after surgery improves the 30d mortality RISK STRATIFICATION compared with assessing patients based on preoperative risk factors alone “Clinical trials are needed to establish whether intervention taken in patients with elevated troponin subsequent to noncardiac surgery would result in lower risk of death.” Conclusions Association Between Postoperative Troponin Levels and 30-day Mortality Among Patients Undergoing Noncardiac Surgery JAMA 2012; 307(21): Clinical Pearl #2 24

25 CLINICAL PEARL #2 Elderly patients undergoing hip repair have a higher rate of post-op AMI than previously thought; and they are often asymptomatic. Troponin levels predict mortality after noncardiac surgery but more clinical trials are needed to determine if routine monitoring is indicated. 25

26 Mr. D is a 78 yo male with PMH sig for HTN, DM, HF and Afib (anticoagulated with warfarin) who was admitted for management of hematemesis and abdominal pain. Tachycardic and hypotensive Emergent EGD revealed a bleeding peptic ulcer. Hemostasis was successfully achieved during the EGD. When would you restart warfarin in this patient? A: Immediately B: Within one week C: In one month D: Never Clinical Pearl #3 26

27 Clinical Pearl #3 ANSWER: B. Within one week 27

28 Currently, there is a lack of high quality evidence to help answer this question Why? B. Within one week Clinical Pearl #3 28

29 OBJECTIVE: to determine the incidence of subsequent thrombosis, recurrent GIB, and death in warfarin-treated patients who experienced GIB to determine the time to resumption of warfarin therapy Evidence Risk of Thromboembolism, Recurrent Hemorrhage, and Death After Warfarin Therapy Interruption for Gastrointestinal Tract Bleeding Witt D, Delate T, Garcia D, Clark N, Hylek E, Ageno W, Dentali F, Crowther M. Archives of Internal Medicine 2012; 172(19): Clinical Pearl #3 29

30 Retrospective, Cohort study using databases from Kaiser Permanente Colorado 442 patients with warfarin-associated GIB were followed for 90days  260 patients (58.8%) resumed warfarin therapy Study Details Risk of Thromboembolism, Recurrent Hemorrhage, and Death After Warfarin Therapy Interruption for Gastrointestinal Tract Bleeding Witt D, Delate T, Garcia D, Clark N, Hylek E, Ageno W, Dentali F, Crowther M. Archives of Internal Medicine 2012; 172(19): Clinical Pearl #3 30

31 Multivariate analysis performed on findings to account for confounding factors  THROMBOSIS: Warfarin therapy resumption was associated with a lower risk for thrombosis (0.4% vs. 5.5%) – No thrombosis seen in patients who resumed warfarin within 14 days of the GIB  RECURRENT GIB: – 8.4% (36) had a recurrent GIB  10% of those who resumed warfarin  5.5% of those who did not resume warfarin  This difference was not statistically significant (lacks power due to low number) – No recurrent GIB resulted in death Findings Risk of Thromboembolism, Recurrent Hemorrhage, and Death After Warfarin Therapy Interruption for Gastrointestinal Tract Bleeding Witt D, Delate T, Garcia D, Clark N, Hylek E, Ageno W, Dentali F, Crowther M. Archives of Internal Medicine 2012; 172(19): Clinical Pearl #3 31

32 Multivariate analysis performed on findings to account for confounding factors  DEATH: 11.8% (52) of patients died within 90d – NO deaths were attributable to recurrent GIB – Most common causes of death:  Malignancy  Infection  Cardiac disease – Warfarin therapy resumption was associated with a lower risk for death  Median time to resumption of warfarin was 4 days following index GIB (2-9d) Findings Cont. Risk of Thromboembolism, Recurrent Hemorrhage, and Death After Warfarin Therapy Interruption for Gastrointestinal Tract Bleeding Witt D, Delate T, Garcia D, Clark N, Hylek E, Ageno W, Dentali F, Crowther M. Archives of Internal Medicine 2012; 172(19): Clinical Pearl #3 32

33 “The decision NOT to resume warfarin therapy within the 90d following a GIB is associated with increased risk for thrombosis and death.” “Resumption of warfarin therapy between 1-7days following a GIB was associated with a higher risk if recurrent GIB but lower risk of thrombosis.”  “Clinical judgment remains a critical factor in deciding exactly when to restart warfarin”  Further research is needed to determine the optimal duration of interruption after a GIB event Conclusions Risk of Thromboembolism, Recurrent Hemorrhage, and Death After Warfarin Therapy Interruption for Gastrointestinal Tract Bleeding Witt D, Delate T, Garcia D, Clark N, Hylek E, Ageno W, Dentali F, Crowther M. Archives of Internal Medicine 2012; 172(19): Clinical Pearl #3 33

34 “most patients with warfarin-associated GI bleeding and indications for continued long-term antithrombotic therapy should resume anticoagulation within the first week following the hemorrhage, approximately 4 days afterward.” Commentary Resuming Anticoagulation in the First Week Following Gatrointestinal Tract Hemorrhage. Brotman D, Jaffer A. Arch Intern Med 2012; 172 (19) Clinical Pearl #3 34

35 Not resuming warfarin within 90 days of GI bleed is associated with increased thrombosis and death. Restarting warfarin is not associated with significantly increased bleeding. Further research is needed to identify the optimal duration of warfarin interruption but many suggest resuming anticoagulation within the first week after a GI bleed, usually about 4 days after the bleed. CLINICAL PEARL #3 35

36 CLINICAL PEARL #1  Initiation of bridging heparin within 24 hours of surgery is associated with major bleeding. Better guidelines are needed to determine the optimal timing of postoperative heparin bridging. CLINICAL PEARL #2  Elderly patients undergoing hip repair have a higher rate of post-op AMI than previously thought; and they are often asymptomatic. Troponin levels predict mortality after noncardiac surgery but more clinical trials are needed to determine if routine monitoring is indicated. CLINICAL PEARL #3  Not resuming warfarin within 90 days of GI bleed is associated with increased thrombosis and death.  Restarting warfarin is not associated with significantly increased bleeding.  Further research is needed to identify the optimal duration of warfarin interruption but many suggest resuming anticoagulation within the first week after a GI bleed, usually about 4 days after the bleed. Summary 36

37 Things I learned at ACP 2013 Brenda Shinar, MD

38 Case ID and CC: A 52 year-old Hispanic man with history of NASH cirrhosis presents to the ED with 2 days of melena and one episode of coffee- ground emesis PMH: – Type 2 diabetes – HTN – Cirrhosis due to NASH with small varices 2/2013 Exam: VS: 109/67 HR 78 RR 18 T 98.6 F 99% RA Rectal: black stool guaiac + Labs: Hgb 7.7 g/dL (2/ ) MCV 77 RDW 18.1 Platelets 72,000 INR 1.2

39 Three Questions 1. What are the risks of blood transfusion in 2013? 2. At what hemoglobin should I consider transfusion in a hemodynamically stable patient with anemia? 3. Is the laboratory evaluation of nutritional deficiencies contributing to anemia accurate after blood transfusion?

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43 Risk of Transfusion Extremely low risk of infections that we know about, but still inherently dangerous and risk of unknown pathogens Patients can die from transfusions: – TRALI is most common cause – Hemolytic transfusion reaction: second – Transfusion associated circulatory overload : third Two reasons for malpractice regarding transfusions: – Did not ask for patient permission – Gave unnecessarily

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55 LESSONS LEARNED AT ACP JAYNE PETERSON, MD

56 Diabetes: Expanding my view and trying something new Patient Centered Care: Putting it into practice Lessons Learned From: Anne L. Peters, MD, FACP

57 PATIENT PRESENTATION 46 year old woman with Hypertension, Hyperlipidemia & Diabetes diagnosed 8 years ago presents for follow up. Current Medications: Metformin 1000mg bid Lisinopril 5mg daily, Simvastatin 10mg each evening HPI: She checks her blood sugar 3 times per week and the last several months noticed that her fasting blood sugars are running high – 240. She has tried to modify her diet more – smaller portions. ROS unremarkable except occasional polydipsia, no hypoglycemia PE: 130/82 72 weight : 220lbs with BMI 30.7 What is the treatment goal ? What other information do you need to know?

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73 BACK TO OUR PATIENT HbA1c 3 months ago was 7.5 and now is 8.8 Normal Cr and LFT’s Weight up 8 pounds from 3 months ago Do you have enough information to adjust medication management?

74 PATIENT-CENTERED APPROACH “Providing care that is respectful of and responsive to individual patient preferences, needs and values. Ensuring that patient’s values guide all clinical decisions. “ Gauge patient’s preferred level of involvement Shared decision making: final decision making regarding lifestyle choices ultimately lies with the patient Explore therapeutic choices with patient when available

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77 MY LESSONS LEARNED Utilize all medication options – good evidence to support GLP-1 Agonists as 2 nd line therapy in selected patients: Need to overcome my personal barriers – expectations of patient resistance to injections, insurance authorization, inexperience with the medication When instituting insulin therapy – ok to start with just one meal time coverage to help patient adjust to the therapy. Involve patient early on in the shared decision making by learning about their lifestyle and values. “Know your person before attempting to do them good” - Nathanial Hawthorn

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81 A FEW OF MY FAVORITE THINGS…

82 A 35 year old woman with a BMI of 31 has a 3 year history of RUQ pain. The pain is characterized as 3/10 dull ache in the RUQ and is present most of the time but is aggravated by eating. It has not progressed. It is associated with occasional nausea but no vomiting. She has a tendency toward constipation. She is tender in the RUQ. Her AST, ALT, and alkaline phosphatase are normal. RUQ ultrasound is normal with no stones and a HIDA scan shows an ejection fraction of 18% (normal > 35%). During the HIDA she develops abdominal discomfort similar to her pain. You recommend: A. Proton pump inhibitor (PPI) B. Cholecystectomy C. Colonoscopy D. Abdominal CT E. Symptomatic treatment with dicyclomine

83 Biliary Dyskinesia EPISODIC RUQ pain/epigastrium >30 min Severe enough to interrupt normal daily activities Low EF with CCK stimulation

84 CLINICAL PEARL: Decisions for cholecystectomy should not be based on HIDA alone. A clinical history is the best discriminator of biliary dyskinesia and can be confirmed by a HIDA scan. References: 1. Hansel SL and DiBaise JK. Functional Gallbladder Disorder: Gallbladder Dyskinesia. Gastroenterol Clin N Am 2010;39: Francis G and Baillie J. Gallbladder dyskinesia: Fact or Fiction? Curr Gastroenterol Rep 2011; 13: From: Clinical Pearls Gastroenterology- John A. Schaffner, MD

85 A 58 year old woman has right sided upper abdominal pain for the last 2 years. The pain is present 24/7 at a level that fluctuates between 3-7/10. She cannot pinpoint a cause when it started and it has not changed over the 2 years. It is aggravated by eating on occasion, by constipation, and by sitting for long periods. A CT scan, RUQ ultrasound, EGD, and colonoscopy are normal. On exam she can point to the location of a tender area with one finger in the MCL in the RUQ. Which of the following would you recommend? A. Repeat EGD B. Surgical consultation C. Trigger point injection D. MRI of the abdomen E. Hydrocodone

86 CLINICAL PEARL: Increased tenderness at the symptomatic spot when the abdominal muscles are tensed either by raising the head or legs (A positive Carnett’s sign) can be confirmatory for abdominal wall pain. Abdominal wall pain is often overlooked and the diagnosis is made by history and physical exam. References: 1. Lindsetmo RO, and Stulberg J. Chronic abdominal wall pain-a diagnostic challenge for the surgeon. Am J Surg 2009; 198: Peery AF, Dellon ES, Lund J, et al. Burden of Gastrointestinal Disease in the United States: 2012 Update. Gastroenterology 2012; 143: From: Clinical Pearls Gastroenterology- John A. Schaffner, MD

87 A 54 year old man has long standing heartburn that is well controlled by taking a PPI once a day. He is currently asymptomatic. You recommend an EGD, his first, which demonstrates 3 cm. of Barrett’s esophagus with no dysplasia on biopsy. Which of the following would be the next step? A. Repeat endoscopy in 3 years B. Endoscopic ablation of Barrett’s epithelium C. Increase his PPI dose D. Fundoplication E. No further surveillance

88 Endoscopy in GERD 1) in anyone with alarm symptoms that include dysphagia, bleeding, anemia, weight loss, and recurrent vomiting; 2) in patients with typical symptoms who do not improve on twice daily PPI therapy; 3) in patients with severe or stricturing disease; 4) in men over the age of 50 with a more than 5 year history of GERD and other risk factors that include nocturnal reflux, hiatal hernia, elevated BMI and smoking. Shaheen NJ, Weinberg DS, Denberg TD, et al. Upper endoscopy for gastroesophageal reflux disese: best practice advice from the clinical guidelines committee of the American College of Physicians. Ann Intern Med 2012; 157:

89 CLINICAL PEARL: In the absence of dysplasia in intestinal metaplasia, a surveillance interval of 3 years is recommended. There is growing controversy about treatment of Barrett’s esophagus. References: 1. Wani S, Falk G, Hall M, et al. Patients With Nondysplastic Barrett's Esophagus Have Low Risks for Developing Dysplasia or Esophageal Adenocarcinoma; Clinical Gastroenterology and Hepatology : American Gastroenterological Association Medical Position Statement on the Management of Barrett’s Esophagus. Gastroenterology 2011;140:1084 –1091. From: Clinical Pearls Gastroenterology- John A. Schaffner, MD

90 A 28-year-old female is concerned about a worsening facial rash, thought to be dermatitis. She originally placed over-the-counter hydrocortisone on the rash twice a day without improvement. She then borrowed her daughter’s triamcinolone prescription for twice daily use. The rash continues to progress. The patient is otherwise healthy and has normal menstrual cycles. What is the best treatment for this condition? A. Institute topical clobetasol BID B. Discontinue cosmetics and patch test for allergic contact dermatitis C. Discontinue topical steroids and institute judicious sunscreen use D. Discontinue topical steroids and institute topical metronidazole BID E. Discontinue topical steroids and institute topical tretinoin QHS

91 dermatitis/source/11.html Clinical Pearl: Topical steroids worsen perioral dermatitis. Topical metronidazole is the preferred treatment.

92 Multiple Small Feedings of the Mind For patients with atrial fibrillation, what are the best evidence-based risk stratification models to estimate bleeding risk?

93 69 year female with paroxysmal atrial fibrillation. History of controlled HTN and MI on metoprolol, normal LV function No diabetes, no prior TIA or CVA. Normal kidney and liver function. No history of bleeding, no EtOH. Mild-moderate SOB when she goes intoAfib, HR about 115bpm What is the best treatment for this condition?

94 Complex Issues in anticoagulation: Tracy A. Minichiello, MD- UCSF Minimum effective duration oftherapy for VTE is 3 months. If event is unprovoked consider indefinite anticoagulation if bleeding risk is low Assess individual risk benefit of extended therapy using d-dimer and clinical risk scores In general, avoid expense of comprehensive testing for laboratory thrombophilia given limited role in determining duration of anticoagulation in VTE Consider ASA for secondary prevention of recurrent VTE in patients with unprovoked events who are not candidates for ongoing anticoagulation

95 Summary Clinical Pearls Decisions for cholecystectomy should not be based on HIDA alone. A clinical history is the best discriminator of biliary dyskinesia. Abdominal wall pain is often overlooked and the diagnosis is made by history and physical exam. –Carnett’s sign In the absence of dysplasia in intestinal metaplasia (Barrett’s), a surveillance interval of 3 years is recommended. Topical steroids worsen perioral dermatitis. Topical metronidazole is the preferred treatment. Use the decision calculators to help with anticoagulation decisions in a fib For DVT/PE- individualize the duration of rx based on what the event was, follow up d dimer and consider ASA as a potential continued rx if don’t continue full anticoagulation.

96 But wait there is more!- ”Recruit a Resident Rewards”Recruit a Resident Rewards

97 Questions?


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