Guideline on Cholesterol Management: 2018 Update

Key Recommendations

• For patients with established ASCVD, high-intensity statins should be used to obtain ≥50% reduction in LDL. If this is not achieved, ezetimibe could be added and then a proprotein convertase subtilisin–kexin type 9 (PCSK9) inhibitor.
• For patients with very high risk (history of major ASCVD events, older age, diabetes, hypertension, smoking, familial hypercholesterolemia [FH], kidney disease, or heart failure) and LDL levels >70 mg/dL, adding ezetimibe is reasonable, followed by a PCSK9 inhibitor.
• For patients with severe hypercholesterolemia (LDL levels, >190 mg/dL), maximally tolerated statin therapy is recommended without risk calculations. If LDL is not reduced by 50%, clinicians can reasonably add ezetimibe.
• For patients with diabetes and LDL >70 mg/dL, a moderate-intensity statin is recommended; with elevated ASCVD risk, a high-intensity statin is reasonable.
• For primary prevention, adherence to a healthy lifestyle is the cornerstone of treatment across the lifespan. Clinician-patient discussions about risk assessment and treatment should consider “ASCVD risk enhancers,” such as family history, metabolic history, preeclampsia, inflammatory disease, ethnicity, and abnormal biomarkers.
• 10-year ASCVD risk scores between 7.5% and 19.9% are now considered “intermediate risk.” This broad category acknowledges uncertainty in risk-calculator estimates and is intended to encourage decision-making guided by patient preferences. For patients who elect drug treatment, a moderate-intensity statin is generally recommended.
• Coronary artery calcium (CAC) measurement is helpful when decisions about statin initiation are uncertain. Withholding or postponing statin initiation is reasonable if CAC=0 and the patient lacks other high-risk features. If CAC score is ≥100, statins should be initiated.
• To monitor adherence to therapy and reduction in LDL, clinicians should check lipids 1 to 3 months after a treatment change.

Kegel exercises for men: Understand the benefits

Kegel exercises for men can help improve bladder control and possibly improve sexual performance. Here's a guide to doing Kegel exercises correctly.

By Mayo Clinic Staff

Think Kegel exercises are just for women? Think again.

Kegel exercises for men can strengthen the pelvic floor muscles, which support the bladder and bowel and affect sexual function. With practice, Kegel exercises for men can be done just about anytime.

Before you start doing Kegel exercises, find out how to locate the correct muscles and understand the proper technique.

Hydrocolpos due to imperforated hymen

Case report

A 30-year-old (G3P1) was referred at 35 weeks of gestation for sonographic evaluation due to a suspicion of anorectal malformation with normal second trimester anomaly scan. 

Ultrasound examination in our center revealed the following findings:

A central tubular cystic structure contains internal echo which was located posterior to bladder and anterior to the normal appearing rectum. The fetal sex was female and the target sign of anus seems to be normal. 

Both kidneys had normal location. Our preliminary diagnosis based on the US findings was hydrocolpos due to imperforated hymen which was confirmed by postnatal evaluation.

A Cancer “Vaccine” That Wipes out Tumors is Ready for Human Trial

A Cancer “Vaccine” That Wipes out Tumors is Ready for Human Trial

Cancer is one of those diseases that still manages to strike absolute fear in anyone that hears it, whether that diagnosis is reserved for the person in question or for someone close to them. It is easy to understand why. After all, it wasn’t all that many years ago that virtually any cancer diagnosis was practically a guaranteed death sentence. Even today, there are still a lot of types of cancer that can’t be effectively treated with the kinds of medical treatment that are currently utilized. For individuals suffering from the more aggressive types of the disease, there is still relatively little hope for a cure. Even in those individuals that are considered cancer-free, there is always a chance that it can come back again and again. As a result, very few people that have heard this word ever feel totally cured.

Diagnosis of Fetal Structural Anomalies at 11 to 14 Weeks

Diagnosis of Fetal Structural Anomalies at 11 to 14 Weeks

Abstract

Objectives

To assess the performance of first‐trimester ultrasound (US) in identifying major fetal structural abnormalities in an unselected population.

Methods

We conducted a retrospective analysis of all pregnancies that underwent the 11‐ to 14‐week scan in the Fetal Medicine Department of Filantropia Hospital in Bucharest, which were prospectively examined within our screening program. The purpose of the first‐trimester US was to evaluate the risk for chromosomal abnormalities and to conduct fetal anatomic examination using a detailed protocol.

Results

Our population consisted of 7480 pregnant patients (7576 fetuses). The follow‐up was completed for 6045 patients (6114 fetuses). The prevalence of major structural anomalies was 1.89%. In the first trimester, we identified 79% of all major structural anomalies. The highest detection rates were achieved for abdominal wall defects (100%), major central nervous system anomalies (88%), cardiac defects (74%), and skeletal anomalies (71%). The nuchal translucency was increased in 35% of the cases with structural anomalies, and 95% of these were diagnosed in the first trimester. Seventy percent of the patients who presented with structural anomalies and a normal nuchal translucency were diagnosed in the first trimester.

Conclusions

Our results emphasize the importance of performing a detailed US examination at 11 to 14 weeks' gestation in identification of fetal structural defects.

'Really Good' New Guidelines for T2 Diabetes

'Really Good' New Guidelines for T2 Diabetes

"Editor's Note: The diabetes guidelines discussed below are a draft version of a consensus statement to be issued in October at the annual meeting of the European Association for the Study of Diabetes in Berlin, Germany."

Irritable Bowel Syndrome: A Review of Treatment Options

Irritable Bowel Syndrome: A Review of Treatment Options

Abstract and Introduction

Abstract

Irritable bowel syndrome (IBS) is a complex gastrointestinal condition whose pathophysiology is not well understood. Nonpharmacologic treatment options are the mainstay of therapy, and interventions should focus on dietary alterations and physical activity initially and throughout treatment. Drug therapy is rather limited but is focused on the predominant symptoms of IBS—constipation or diarrhea—as well as on improving abdominal pain. Pharmacists have a vital role in patient education and in drug-therapy management for IBS, and they can help ensure that treatment is safe and efficacious.

Introduction

Irritable bowel syndrome (IBS) encompasses a group of gastrointestinal (GI) conditions that are characterized by pain and abnormal bowel habits that have no identifiable root cause. The pathophysiology of IBS is not completely understood, but a wide variety of factors are believed to be involved. Data are conflicting and have not revealed a specific abnormality that can elucidate why IBS occurs or point to a particular mode of therapy. Many currently used treatments for IBS have addressed GI motility, visceral and dietary sensitivities, inflammation, and alterations in GI flora. One of the more recent etiologies studied is the role of serotonin in the peristaltic reflex of the gut, where an abnormality could lead to increased or decreased motility.^[1] A 2014 study estimated that 5% to 15% of people worldwide experience IBS symptomatology, making this a disorder that will be encountered often in practice.^[2]

Practice-Changing Highlights From DDW 2018

Practice-Changing Highlights From DDW 2018

Hello. I am Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

I recently returned from attending Digestive Disease Week (DDW) in Washington, DC, and would like to share my takeaway messages from this year's meeting, some of which will affect our practice in the short term and others in the long term.

New Clinical Practice Guidelines, May 2018 Edition

New Clinical Practice Guidelines, May 2018 Edition

Are You Missing Subtle MI Clues on ECGs? Test Your Skills

Are You Missing Subtle MI Clues on ECGs? Test Your Skills

Are You Missing Subtle MI Clues on ECGs? Test Your Skills

Are You Missing Subtle MI Clues on ECGs? Test Your Skills

Acute Pyelonephritis in Adults | NEJM

Acute Pyelonephritis in Adults | NEJM

KEY CLINICAL POINTS

Acute Pyelonephritis

• Acute pyelonephritis has the potential to cause sepsis, septic shock, and death.
• Urine culture is the cardinal confirmatory diagnostic test.
• Imaging is recommended at the time of presentation for patients with sepsis or septic shock, known or suspected urolithiasis, a urine pH of 7.0 or higher, or a new decrease in the glomerular filtration rate to 40 ml per minute or lower. Subsequent imaging is indicated in patients whose condition worsens or does not improve after 24 to 48 hours of therapy.
• The rising prevalence of Escherichia coli resistant to fluoroquinolones and trimethoprim–sulfamethoxazole complicates empirical oral therapy. In patients who receive oral treatment from the outset, depending on the likelihood of resistance, an initial dose of a supplemental, long-acting, parenteral antimicrobial agent (e.g., an aminoglycoside, ceftriaxone, or ertapenem) may be appropriate, and close follow-up is warranted.
• Assessment of illness severity, underlying host status, and the patient’s psychosocial situation and estimation of the likelihood of pathogen resistance to relevant antimicrobial agents are critical in decisions regarding patient disposition and treatment.

Toxic Alcohols | NEJM

Toxic Alcohols | NEJM

Poisonings by the toxic alcohols (methanol, ethylene glycol, isopropanol, diethylene glycol, and propylene glycol) can cause cellular dysfunction and death,1 but symptoms may be nonspecific. Delays in diagnosis increase the risk of irreversible organ damage and death.2 In this review, we discuss the mechanisms of toxicity, methods available for diagnosis, and current recommendations for therapy.