Emedinews: Dr Good Dr Bad:A patient with diabetic nephropathy was found to have a high homocysteine levels.

Situation: A patient with diabetic nephropathy was found to have a high homocysteine levels.
Dr Bad: Homocysteine has no correlation with nephropathy.
Dr Good: You should control your homocysteine levels.
Lesson: Results of a nested case–control study suggest that hyperhomocysteinemia has an etiologic role in the pathogenesis of diabetic nephropathy. In the study, baseline plasma homocysteine concentrations and mean HbA1c levels during follow–up were significantly higher in patients who developed microalbuminuria than in those who remained normoalbuminuric. Multivariate logistic regression analysis showed that baseline plasma homocysteine level and mean HbA1c were independent predictors of microalbuminuria in type 2 diabetes (Korean Diabetes J 2010 June; 34(3): 200–206).

Emedinews: Dr Good Dr Bad: A patient with painful diabetic neuropathy came with postural hypotension.

Situation: A patient with painful diabetic neuropathy came with postural hypotension.
Dr Bad: The two are unrelated conditions.
Dr Good: It is due to autonomic dysfunction.
Lesson: Painful diabetic neuropathy is associated with significantly greater autonomic dysfunction than painless diabetic neuropathy. The greater autonomic dysfunction seen in painful diabetic peripheral neuropathy (DPN) may reflect more predominant small fiber involvement and also adds to the growing evidence of its role in the pathophysiology of painful DPN 
(Diabetes Care 2010;33(7):1585-90).

Emedinews: Dr Good Dr Bad:A patient of CAD developed dengue.

Situation: A patient of CAD developed dengue.
Dr Bad: Start paracetamol.
Dr Good: Start paracetamol and stop low-dose aspirin.
Lesson: In dengue, lose-dose aspirin needs to be stopped.

Emedinews: Dr Good Dr Bad: In how many patient of DVT does embolization occur? (JR to SR)

Situation: In how many patient of DVT does embolization occur? (JR to SR)
Dr Bad: Rare!
Dr Good: Common!
Lesson: Embolization occurs in about 50% of patients having proximal vein DVT.

Emedinews: Dr Good Dr Bad: A diabetic patient was diagnosed with sarcopenia.

Situation: A diabetic patient was diagnosed with sarcopenia.
Dr. Bad: It is related to diabetes.
Dr. Good: It is not related to diabetes
Lesson: In the Korean Sarcopenic Obesity Study (KSOS), type 2 diabetes was associated with increased risk of sarcopenia. These characteristics may contribute to physical disability and metabolic disorders in older adults with diabetes
Source: Diabetes Care 2010 July; 33(7): 1497-9.

Emedinews: Dr Good Dr Bad: An asymptomatic patient with no obvious underlying cardiac disease shows ventricular premature contractions (VPCs).

Situation: An asymptomatic patient with no obvious underlying cardiac disease shows ventricular premature contractions (VPCs).
Dr Bad: Anti-arrhythmics should be given.
Dr Good: No treatment is needed.
Lesson: In the absence of cardiac disease, isolated asymptomatic VPCs regardless of configuration and frequency need no treatment.

Emedinews: Dr Good Dr Bad: A diabetic HIV patient came with A1c of 6.5.

Situation: A diabetic HIV patient came with A1c of 6.5.
Dr Bad: It’s perfect.
Dr Good: It is not 100% reliable for your situation.
Lesson: A1c may not be accurate for assessing glycemia among HIV-infected patients on NRTI–based therapy, especially those with macrocytosis or those on abacavir. In a prospective study evaluating the accuracy of A1c in HIV–infected patients with diabetes, glucose levels were significantly higher than anticipated by A1c levels when compared with HIV–uninfected control subjects and established reference values. Relative to the control subjects, A1C underestimated glucose by 29 ± 4 in the HIV–infected subjects (Diabetes Care 2009;32(9):1591–3).

Emedinews:Dr Good Dr Bad: A patient developed tetany after he was given metoclopramide.

Situation: A patient developed tetany after he was given metoclopramide.
Dr Good: Stop metoclopramide. Give inj promethazine.
Dr Bad: Give calcium.
Lesson: Metoclopramide can cause extrapyramidal symptoms

Emedinews: Dr Good Dr Bad: A patient with migraine was put on the herb, Butterbur.

Situation: A patient with migraine was put on the herb, Butterbur.
Dr. Bad: It is a drug of choice for preventing migraine.
Dr. Good: It benefits still remain unproven
Lesson: Herbal therapies like the Butterbur and Feverfew have been evaluated for the treatment of migraine headaches. Of these, Feverfew has been the most widely studied. Some studies have found it to be effective for migraine prevention, although most experts agree that the benefits are still unproven. Neither treatment is recommended.

Emedinews:Dr Good Dr Bad:A female with rheumatoid arthritis became pregnant while taking leflunomide.

Situation: A female with rheumatoid arthritis became pregnant while taking leflunomide.
Dr. Bad: Continue it.
Dr. Good: Stop it immediately
Lesson: In women with rheumatoid arthritis who become pregnant while taking leflunomide, healthy pregnancy outcomes usually occur, if the drug is discontinued at the earliest and a cholestyramine drug elimination procedure is done. (Arthritis Rheum 2010;62:1494)

Emedinews: Dr Good Dr Bad: A female with past history of DVT needed an OC prescription.

Situation: A female with past history of DVT needed an OC prescription.
Dr Bad: Start OC patch (transdermal).
Dr Good: You cannot be on OCs.
Lesson: There is a possibility of an increased risk of venous thromboembolism in oral contraceptive patch users.

Emedinews: Dr Good Dr Bad: A patient with metabolic syndrome was found to have impaired kidney functions.

Situation: A patient with metabolic syndrome was found to have impaired kidney functions.
Dr Bad: They are not related.
Dr Good: They are related.
Lesson: People with metabolic syndrome are at 55% increased risk for kidney disease (reduced kidney functions), according to a study to appear in the Clinical Journal of the American Society of Nephrology.

(Ref: Thomas G, et al. Metabolic syndrome and kidney disease: a systematic review and meta-analysis. Clin J Am Soc Nephrol 2011 Aug 18. Epub ahead of print)

Emedinews: Dr Good Dr Bad: A woman between the ages of 30 and 60 years of age with a current normal Pap test

Situation: A woman between the ages of 30 and 60 years of age with a current normal Pap test came with a current negative HPV test result and a history of 2 consecutive normal Pap test results
Dr Bad: Go for annual pap smear test
Dr Good: get the pap smear every three years
Lesson: Low-risk women be tested every three years as per a report in American Journal of Obstetrics and Gynecology on Aug. 18.

Emedinews: Dr Good Dr Bad: A patient in insulin pump was taking a flight.

Situation: A patient in insulin pump was taking a flight.

Dr Bad: Its ok to use the pump.

Dr Good: Disconnect the pump at landing and taking off.

Lesson: According to a study published online Aug. 4 in the journal Diabetes Care, changes in airliner cabin pressurization during take-off and landing may affect how much insulin is delivered by an insulin pump. Pumps should be disconnected during take-off and landing and during any flight situations in which a loss of cabin pressure results.

Emedinews: Dr Good Dr Bad: A woman between the ages of 30 and 60 years of age with a current normal Pap test

Situation: A woman between the ages of 30 and 60 years of age with a current normal Pap test came with no current human papillomavirus (HPV) test results and history of 2 consecutive normal Pap test results.

Dr Bad: Go for annual pap smear test

Dr Good: get the pap smear every three years

Lesson: Low-risk women be tested every three years as per a report in American Journal of Obstetrics and Gynecology on Aug. 18.

Emedinews: Dr Good Dr Bad: A patient in insulin pump was taking a flight

Situation: A patient in insulin pump was taking a flight

Dr Bad: Its ok to sue the pump

Dr Good: Off the pump at landing an taking off.

 Lesson: According to a study published online Aug. 4 in the journal Diabetes Care, changes in airliner cabin pressurization during take-off and landing may affect how much insulin is delivered by an insulin pump.  Pumps should be disconnected during take-off and landing and during any flight situations in which a loss of cabin pressure results.

Emedinews: Dr Good Dr Bad: A dialysis patient was getting recurrent catheter related infections

Situation: A dialysis patient was getting recurrent catheter related infections
Dr Bad: Try heparin lock
Dr Good: Try minocycline-EDTA lock 

Lesson:  Dialysis patients had significantly fewer catheter-related infections when minocycline - EDTA was used as a catheter-lock solution instead of heparin," according to a study  in the Journal of the American Society of Nephrology. The catheter-related bacteremia rate was one per 1,000 catheter days, a three-fold decrease compared with use of a heparin lock.

Emedinews: Dr Good Dr Bad: A patient with metabolic syndrome was found to have low kidney functions

Situation: A patient with metabolic syndrome was found to have low kidney functions

Dr Bad: They are not related

Dr Good: They are related

 Lesson: People with metabolic syndrome are at 55% increased risk for kidney disease (reduced kidney functions), according to a study to appear in the Clinical Journal of the American Society of Nephrology.

Emedinews: Dr Good Dr Bad: A patient with normal LDL and high CRP wanted to know his risk of CAD.

Situation: A patient with normal LDL and high CRP wanted to know his risk of CAD.
Dr Bad: You are not at risk.
Dr Good: Get cardiac 64 CT test done
Lesson: Among asymptomatic individuals with normal LDL cholesterol levels and elevated high-sensitivity C-reactive protein measuring the burden of calcium in the coronary arteries with cardiac CT appears to stratify the risk of cardiovascular disease

 (Ref: Blaha M, et al. Associations between C-reactive protein, coronary artery calcium, and cardiovascular events: implications for the JUPITER population from MESA, a population-based cohort study. Lancet 2011;378:684-92).

Emedinews: Dr Good Dr Bad : An obese patient came with BMI of more than 40.

Situation: An obese patient came with BMI of more than 40.
Dr Bad: Go for surgery.
Dr Good: First try diet, exercise and drug therapy.
Lesson: Obesity surgery is indicated in patient with BMI more than 40 who have failed diet and exercise with or without drugs.