New content quiz May 2014

The Joint Committee on Hypertension (US) recommended in late 2013 that the threshold for treatment of hypertension in patients ≥ 60 years of age should occur when sBP ≥ 150mmHg or dBP ≥ 90mmHg. (link)

The evidence of benefit from treatment of mild hypertension in the absence of other cardiovascular risk factors is reasonably weak, particularly for prevention of ischaemic heart disease. (link)

The sodium-glucose co-transporter 2 (SGLT2) inhibitors dapagliflozin and canagliflozin block renal reabsorption of glucose. They may causes dehydration, but may also facilitate weight loss and help reduce BP. Because of this they are contra-indicated in: patients on dialysis; moderate – severe renal impairment; diabetic ketoacidosis; type 1 diabetes and active bladder cancer. (link)

Icatibant is a synthetic decapeptide that acts as a bradykinin antagonist. It is effective in in hereditary and drug related life threatening angioedema and is indicated in airway obstruction or other persistent severe symptoms. In Australia it is the first line recommended treatment for life threatening angioedema in the non pregnant patient with a dose of 30mg S/Cut, but cannot be used IV. The approximate cost is AUD$2500/dose, however is PBS listed in Australia, hence the cost is not borne by the provider. It has the advantage of not being a blood derived product (unlike C1 esterase inhibitor concentrate), however is contra-indicated in pregnancy and injection causes local pain. (link)

The alternate cover test (also known as the cover-uncover test) tests for ocular skew or strabismus. The patient is asked to fix on an object whilst one eye is covered for several seconds. The cover is then moved quickly to the other eye and if the eye moves when it is uncovered, a strabismus or skew is considered present. A skew deviation of the eyes is approximately 30% sensitive and 98% specific for a central cause of vertigo. In patients without auditory symptoms, the presence of all of the following: a negative vestibulo-ocular reflex (unilateral head impulse test; fixed direction horizontal nystagmus; and absent vertical ocular misalignment (skew), almost completely excludes a stroke as the cause of vertigo (98% sensitive, 85% specific for stroke), and is more sensitive than DWI MRI in the acute phase. (link)

Delaying cholecystectomy until acute inflammation has resolved (often 3 weeks or more) was previously thought to be preferable to early surgery, however recent evidence suggests that early cholecystectomy is associated with fewer patient symptoms, complications, and less resource usage than delayed cholecystectomy. Indications for immediate intervention include: gall bladder perforation; gallstone ileus; empyema of the gall bladder; and acalculus cholecystitis. (link)

Erythema nodosum is a nodular vasculitis that classically occurs over anterior aspect of shins and is usually tender but does not ulcerate. It is associated with: sarcoidosis, Streptococcal infection, idiopathic, ulcerative colitis, Crohn’s disease, Tuberculosis, drugs (antibiotics and oral contraceptives especially), Yersinia infections, EBV, Hep B, Salmonella, Chlamydia, lymphoma, leukaemia and other malignancies, and Takayasu’s disease. (link)

ACE is elevated in 60% of patients with sarcoid disease and is 90% specific. (link)

Seborrhoeic keratosis is the most common pigmented lesion in patients > 50 years of age. They are typically well defined, initially slightly raised but become more warty as they develop. They may have a very slightly undercut edge (with normal skin at the edge) and often pigmented – however colour change is slow. (link)

Ashman phenomenon is a transient bundle branch block involving up to several QRS complexes and more commonly causes RBBB than LBBB. It is caused by an abrupt increase in heart rate as His-Purkinje system refractoriness is increased at slower heart rates, and reduced with faster heart rates. Refractoriness may not adjust immediately with rapid changes in heart rate, causing the transient bundle branch block.

Approximately 99% of patients with AF have detectable levels of high sensitivity troponin I, making mild elevations very poorly specific for ACS. (link)

Features associated with poor outcome in myocarditis include: low ECG voltages (< 5 mm in any precordial lead), ST elevation, and pathological Q waves. T wave changes and long QTc do not appear to have prognostic significance. (link)

Bone, tendon and skin can tolerate up to 8 – 12 hours of warm ischaemia and 24 hours of cold ischaemia with successful digital implantation reported after 94 hours of cold ischaemia. Muscle will necrose after 6 hours of warm ischaemia and 12 hours of cold ischaemia. (link)

The increased risk of thrombo-occlusive disease post partum lasts for 12 weeks, with the relative risk being much higher in the first 6 weeks than the second six weeks. Until recently it was thought that increased risk was only present for 6 weeks post partum. (link)

Valsalva retinopathy is a pre-retinal haemorrhage caused by straining, coughing vomiting and other Valsalva like actions. It is caused by retinal capillary rupture after abrupt rises in intraocular venous pressure. Management is usually expectant as good recovery is expected. It usually causes a sudden onset unilateral central area of reduced visual acuity. Examination demonstrates preretinal haemorrhage that often has an air-fluid level and may be enclosed in a dome shaped membrane. (link)