"لعلي أفيدك" Clinical discussion

2022-12-04 00:35:56 باز کردن / نظر دهید

2022-12-04 00:35:48 #ESC Summary of PE Diagnosis criteria & Recommendation باز کردن / نظر دهید

2022-12-04 00:22:59 باز کردن / نظر دهید

2022-12-04 00:22:52 #تابع
Echocardiography in PE Diagnosis :

RV dilation is found in at least 25% of patients with PE Echocardiographic findings used to risk stratify patients with PE include RV dilation, an increased RV-LV diameter ratio, hypokinesia of the free RV wall,
increased velocity of the jet of tricuspid regurgitation, decreased tricuspid annulus plane systolic excursion, or combinations of the above.

A negative result cannot exclude PE.
On the other hand, signs of RV overload or dysfunction may also be found in the absence of acute PE and be due to concomitant cardiac or respiratory disease.

In suspected high-risk PE, the absence of echocardiographic signs of RV overload or dysfunction practically excludes PE as the cause of haemodynamic instability.
In the latter case, echocardiography may be of further help in the differential diagnosis of the cause of shock, by detecting pericardial tamponade, acute valvular dysfunction, severe global or regional LV dysfunction, aortic dissection, or hypovolaemia

Conversely, in a haemodynamically compromised patient with suspected PE, unequivocal signs of RV pressure overload and dysfunction justify emergency reperfusion treatment for PE if immediate CT angiography is not feasible.

Mobile right heart thrombi are detected by transthoracic or transoesophageal echocardiography (or by CT angiography) in less than 4% of unselected patients with PE

Increased RV wall thickness and/or tricuspid insufficiency jet velocity beyond values compatible with acute RV pressure overload.
In these cases, chronic pulmonary hypertension, and CTEPH in particular, should be included in the differential diagnosis. باز کردن / نظر دهید

2022-12-04 00:22:46 باز کردن / نظر دهید

2022-09-25 18:28:31 باز کردن / نظر دهید

2022-09-25 18:28:07 #Hematology_21 #Anemia #Macrocytic_anemia_6
Treatment of VitB12 deficiency

لو المريض اتشخص ك B12 deficiency سواء كان b12 level اقل من 200pg/ml او كانت قيمته borderline من 200-300 وعملنا تحليل لل MMA وال homocysteine وكانو elevated
بهلحاله هنعطيه replacement therapy by B12
بروتوكول العلاج هيكون على حسب هل في Sever anemia او neurological symptom او لأ

واشهر Formulation هنستخدمها لل replacement

Hydroxycoblamin
موجود ك I.M

Cyanocoblamin
موجود ك I.M و SC و orally و Intranasal

الفرق الجوهري بينهم ان ال Cyano لو هيتاخد ك maintenance بيتاخد مرة شهريا
أما ال Hydroxy فإله frequency اقل وبينعطى مره كل 2-3 شهور ك maintenance

السيناريو الأول هو مريض بدون neuro symptoms :
patient without significant Neurologic symptoms

حسب ال BCSH
British Committee for Standards in Haematology (BCSH)
ال recommendation كانت اعطاء 1000mcg of vitB12
ويكون I.M ثلاث مرات في الاسبوع لمدة أسبوعين

اما حسب ال British Columbia (Canada) Medical Association فبيفضلو ال oral method
cyanocobalamin orally as treatment of choice

1,000 mcg/day in patients with pernicious anemia or food-bound cobalamin malabsorption

250 mcg/day in patients with vitamin B12 deficiency due to other causes
في برتوكول تالت
cyanocobalamin or hydroxocobalamin 1,000 mcg intramuscularly per day or every other day for 1 week, followed by weekly injections up to 8 weeks, followed by every 3-4 weeks

وبعدها يكمل Maintenance وال duration هتعتمد على حسب هل المسبب لل b12 deficiency اتصلح
ولا irreversible
duration of treatment depends on underlying cause

for temporary causes (for example, pregnancy), review need for continued treatment once patient is fully replete and causative agent removed

suggested maintenance therapy in patients without neurologic involvement

if caused by dietary deficiency, consider high-dose oral vitamin B12 (50-150 mcg/day) over 3-4 months to replace stores, followed by ≥ 6 mcg/day orally (life-long treatment for vegans or vegetarians where diet is unlikely to change

if caused by food-bound vitamin B12 malabsorption, consider a lower minimum dose of daily oral cyanocobalamin and increasing dose as necessary (BCSH Grade 2C);
suggested dose 500-1,000 mcg/day.

for irreversible cases (such as pernicious anemia, or after gastric surgery), continue treatment for life typically with vitamin B12 1,000-2,000 mcg/day orally or monthly parenteral cyanocobalamin 1,000 mcg (or hydroxocobalamin 1,000 mcg every 3 months)


السيناريو التاني :

Patient with Significant neurologic symptom
حسب ال BCSH
(BCSH) suggest hydroxocobalamin 1,000 mcg intramuscularly on alternate days until no further improvement (review need to continue treatment after 3 weeks)
وبعدها يكمل maintenance بال Hydroxy بجرعة 1000mcg كل شهرين

British Columbia (Canada) Medical Association guidelines suggest crystalline cyanocobalamin 1,000 mcg intramuscularly or subcutaneously daily for 1-5 days, then switch to 1,000-2,000 mcg/day orally

وفي بروتوكول تالت
هياخد 1000mcg كل يوم لمدة 2week
ثم مرة واحدة في الأسبوع لحد ما ال Hb يصير نورمال
وبعدها يمشي maintenance كل اسبوعين ياخد 1000mcg لمدة 6 شهور
وبعدها يكمل monthly لمدى الحياة

or cyanocobalamin is administered at 1,000 mcg/day intramuscularly or subcutaneously for the first week, then twice a week for the next two weeks, followed by 1,000 mcg every month for life
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2022-09-23 09:46:00 جاءتْ امرأةً من الأنصار إلى النبيِّ صلَّى اللهُ عليه وسلَّمَ فقالَتْ:
«يا رَسولَ اللَّهِ، ألَا أجْعَلُ لكَ شيئًا تَقْعُدُ عليه،فإنَّ لي غُلامًا نَجَّارًا»
قال صلى الله عليه وسلم في حياء :إن شئت.
فأسرعت المرأة في فرحة وعملت له المنبر ،فلما كان يوم الجمعة قعد النبي صلى الله عليه وسلم على المنبر الذي صنع،فصاح جذع النخلة التي كان يخطب عنده شوقاً لفراق النبي صلى الله عليه وسلم حتى كاد ينشق.
فنزل النبي صلى الله عليه وسلم حتى أخذه فضمه إليه فجعل يئن أنين الصبي،فلما لامس الجذع فؤاد النبي صلى الله عليه وسلم هدأ وسكت عن البكاء.
اللهم صل وسلم على سيدنا محمد باز کردن / نظر دهید

2022-09-22 17:53:41 باز کردن / نظر دهید

2022-09-22 17:53:27 #Hematology_20 #Anemia #Macrocytic_anemia_5

في حالات ال folate deficiency اول شي بيقل هو ال serum folate يتبعه ال RBCs folate وبعدها ببدأ يصير Macrocytosis و anemia
حسب ال BCSH قالك لو ال Serum folate كانت اقل من 3mcg/l
فهاد Indication لل Folate deficiency
اما البراكتس فبيستخدمو Cutoff value كالتالي :
Deficient: <2 ng/mL

Borderline: 2 to 4 ng/mL

Normal: >4 ng/mL

لو طلع المريضborderline زي ما شفنا مبارح بحالات ال B12
هنشوف قيمة ال MMA وال Homocysteine
لو كان ال MMA نورمال وال homocysteine عالي
معناها في Folate deficiency
لو ال MMA وال Homocysteine عاليين كلاهماا يبقى ال B12 هو اللي فيه نقص
because folate and vitamin B12 are metabolically interdependent, it is important to also evaluate for underlying or coexistent vitamin B12 deficiency (BCSH Grade 1A), which can lead to irreversible neurological damage if left untreated
مهم جدااا في حالات نقص ال folate وهنعطي المريض
Folic acid supplement
نقيسله ال B12 ولو كان ناقص نعوضه
ولو ما عوضناه واخد folate فقط هيدخل ب Neural Damage

for patients with macrocytic anemia, consider folate supplementation rather than serum folate testing ; response to therapeutic doses of folate is indicative of folate deficiency

additional testing used in specific situations

red blood cell (RBC) folate conflicting recommendations

British Committee for Standards in Haematology (BCSH) states routine testing is not recommended, since serum folate is often sufficient for diagnosis (BCSH Grade 1A)

• consider RBC folate if there is strong clinical suspicion of folate deficiency in patients with normal serum folate level and vitamin B12 deficiency ruled out (BCSH Grade 2B)

American Society for Clinical Pathology recommends against testing RBC folate

plasma homocysteine is elevated in both folate and vitamin B12 and should only be used to confirm suspected folate deficiency;
plasma levels > 15 mcmol/L may indicate folate deficiency but should be assessed relative to local ranges

if there is suspicion of coexistent vitamin B12 deficiency serum folate is preferred marker of folate deficiency over RBC

ال serum folate احيانا بيطلع False positive
"false-positive" results for folate deficiency based on serum folate can result when serum folate levels are reduced despite adequate supply to tissues, and may occur in cases of
low dietary folate intake
anorexia
acute alcohol consumption
pregnancy
use of anticonvulsant drugs

واحيانا ال Serum folate بيطلع false negative

"false-negative" results (falsely normal or high levels of serum folate) may occur

in patients with hemolysis or vitamin B12 deficiency

as a result of impaired methionine synthase and accumulation of methyltetrahydrofolate
OR
folate concentration in red blood cells are 30 time higher compared to plasma; even small amount of intravascular hemolysis can lead to elevated folate levels, potentially masking cellular folate deficiency

if testing for serum folate occurs immediately after ingesting a meal with dietary folate or an oral supplement of folic acid
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