Friday, July 21, 2017

Babesiosis at Stony Brook University Hospital


Babesiosis is a potentially life-threatening, tick-borne infection endemic in New York. The purpose of this study was to review recent trends in babesiosis management and outcomes focusing on patients, who were treated with combination of azithromycin and atovaquone.


A retrospective chart review of patients seen at Stony Brook University Hospital between 2008 and 2014 with peripheral blood smears positive for Babesia was performed. Clinical and epidemiological information was recorded and analyzed.

62 patients had confirmed babesiosis (presence of parasitemia). Forty six patients (74%) were treated exclusively with combination of azithromycin and atovaquone; 40 (87%) of these patients were hospitalized, 11 (28%) were admitted to Intensive Care Unit (ICU), 1 (2%) died. Majority of patients presented febrile with median temperature 38.5 °C. Median peak parasitemia among all patients was 1.3%, and median parasitemia among patients admitted to ICU was 5.0%. Six patients (15%) required exchange transfusion. Majority of patients (98%) improved and were discharged from hospital or clinic.


Symptomatic babesiosis is still rare even in endemic regions. Recommended treatment regimen is well tolerated and effective. Compared to historical controls we observed a lower overall mortality.

Saturday, July 15, 2017

Management of atrial fibrillation in the elderly

The elderly are under represented in clinical trials. This review summarizes the available evidence for the management of AF in the elderly. The conclusions of this evidence synthesis are in line with current AF recommendations in general:

Stroke prophylaxis

Elderly adults with AF are at greater risk than those without AF of stroke without anticoagulation and greater risk of bleeding with anticoagulation, posing a therapeutic challenge

Studies assessing the net clinical benefit of anticoagulation (which weighs the risk of ischemic stroke against the risk of major bleeding) demonstrate a significant benefit of anticoagulation in most elderly adults

Recently available direct oral anticoagulants may tip the balance further in favor of anticoagulation by reducing the rate of major bleeding, in particular intracranial hemorrhage

Evidence to support antiplatelet therapy for AF stroke prophylaxis is relatively weak, and in general, antiplatelet agents should have a limited role

In elderly adults who are unable to undergo long-term anticoagulation, percutaneous left atrial appendage occlusion devices may provide a reasonable alternative, although data are still emerging in this area

Symptom management

As a routine strategy, there is no benefit of rhythm control (using anti-arrhythmic drugs, cardioversion, or both) over rate control with AV nodal blocking agents

In individuals treated using rate control, a lenient strategy (target resting heart rate less than 110 bpm) is as effective for symptom control as strict rate control (target resting heart rate less than 80)

Individuals who cannot tolerate rate-slowing agents or those with tachycardia–bradycardia syndrome may benefit from pacemaker implantation plus AV nodal blocking drugs or ablation of the AV node

AF catheter ablation may be beneficial in appropriately selected elderly adults with inadequately controlled symptoms on medical therapy, although data on outcomes of ablation in elderly adults are limited

Wednesday, July 12, 2017

Homocysteine, B12 levels, folic acid levels and various categories of CAD

Elevated homocysteine, low B12 and low folate levels are risk factors for CAD. It remains to be seen whether treatment with these vitamins reduces cardiovascular events in patients identified with abnormal levels.

Tuesday, July 11, 2017

Monday, July 10, 2017

What’s the best BP target in non-diabetic patients with CKD to reduce progression?

Best practice advisories in the EMR

Asthma COPD overlap syndrome: clarifying the confusion

Here are key points from a recent article on this subject:

1) A patient with asthma may develop non-fully reversible airflow obstruction but this is not COPD, not even ACO; it is obstructive asthma.

2) A patient with asthma who smokes may also develop non-fully reversible airflow obstruction, which differs from obstructive asthma and from “pure” COPD. This is the most frequent type of patient with ACO.

3) Some patients who smoke and develop COPD may have a genetic Th2 background (even in the absence of a previous history of asthma) and can be identified by high eosinophil counts in peripheral blood. These individuals could be included under the umbrella term of ACO.

4) A patient with COPD and a positive bronchodilator test (greater than 200 mL and >12% FEV1 change) has reversible COPD but is not an asthmatic, or even ACO.

5) A patient with COPD and a very positive bronchodilator test (greater than 400 mL FEV1 change) is more likely to have some features of asthma and could also be classified as ACO.

Sunday, July 09, 2017

Comparative effectiveness research in action: enoxaparin versus fondaparinux for acute coronary syndrome


Seven studies with a total number of 9618 patients (mainly composed of non-ST elevated myocardial infarction/NSTEMI) were included. This analysis showed mortality to be similarly observed between enoxaparin and fondaparinux with OR: 1.05, 95% CI: 0.67–1.63; P = 0.84. Myocardial infarction (MI) and stroke were also not significantly different throughout different follow up periods. However, minor, major and total bleeding were significantly lower with fondaparinux (OR: 0.40, 95% CI: 0.27–0.58; P = 0.00001), (OR: 0.46, 95% CI: 0.32–0.66; P = 0.0001) and (OR: 0.47, 95% CI: 0.37–0.60; P = 0.00001) respectively during the 10-day follow up period. Even during a follow up period of 30 days or a midterm follow up, major and minor bleeding still significantly favored fondaparinux in comparison to enoxaparin.


In patients who were treated for ACS, fondaparinux might be a better choice when compared to enoxaparin in terms of short to midterm bleeding events. This result was mainly applicable to patients with NSTEMI. However, due to a limited number of patients analyzed, further larger randomized trials should be able to confirm this hypothesis.

The reduced bleeding risk likely has to do with dosing, as I once explained here:

It would appear that the improved outcome was driven by a reduction in bleeding with fondaparinux. I think this relates to the fact that for acute coronary syndrome fondaparinux is administered in the same dose as is used for VTE prophylaxis rather than in a full therapeutic anticoagulation dose.

And, depending on the patient’s body weight, that ACS dose could amount to half, one third or even a quarter the VTE treatment dose. This usage for ACS, while validated in clinical trials, remains off label in the US. This indication based difference in dosing for fondaparinux is similar to that with unfractionated heparin where the ACS dose is lower than the VTE treatment dose. Though enoxaparin is used in the same dose for VTE and ACS treatment, for all we know it might be effective for ACS at a lower dose but as far as I know it has not been studied in that manner.

Saturday, July 08, 2017

Babesiosis review

Post marketing withdrawal of weight loss drugs


We identified anti-obesity medications withdrawn since 1950 because of adverse drug reactions after regulatory approval, and examined the evidence used to support such withdrawals, investigated the mechanisms of the adverse reactions, and explored the trends over time.


We conducted searches in PubMed, the World Health Organization database of drugs, the websites of drug regulatory authorities, and selected full texts, and we hand searched references in retrieved documents. We included anti-obesity medications that were withdrawn between 1950 and December 2015 and assessed the levels of evidence used for making withdrawal decisions using the Oxford Centre for Evidence-Based Medicine criteria.


We identified 25 anti-obesity medications withdrawn between 1964 and 2009; 23 of these were centrally acting, via monoamine neurotransmitters. Case reports were cited as evidence for withdrawal in 80% of instances. Psychiatric disturbances, cardiotoxicity (mainly attributable to re-uptake inhibitors), and drug abuse or dependence (mainly attributable to neurotransmitter releasing agents) together accounted for 83% of withdrawals. Deaths were reportedly associated with seven products (28%). In almost half of the cases, the withdrawals occurred within 2 years of the first report of an adverse reaction.


Most of the drugs that affect monoamine neurotransmitters licensed for the treatment of obesity over the past 65 years have been withdrawn because of adverse reactions. The reasons for withdrawal raise concerns about the wisdom of using pharmacological agents that target monoamine neurotransmitters in managing obesity. Greater transparency in the assessment of harms from anti-obesity medications is therefore warranted.