نذكر انه ما فيش mortality benefits ل الاستخدام الطويل ل ادويه loop diuretics ولكن قد نعطيها اذا مازال في congestion symptoms او ف حاله رجوع اعراض congestion بعد ايقاف الدواء 😁
#ACCp

✅في دراسه حديثه اسمها GRADE
✅كانت بعنوان After Metformin, Which Medication Should Be Next for Patients with Type 2 Diabetes? (يعني في مريض السكري النوع الثاني بعد استخدام metformin ماهو الدواء المناسب الذي نضيفه )

✅قارنت بين اربع عائلات مختلفه من ادويه السكر
✅insulin(glargine)
✅GLP-1 receptor agonists(liraglutide)
✅sulfonylureas(glimepiride)
✅ DPP-4 inhibitors(sitagliptin)

✅وتابع المرضى خلال خمس سنوات فكانت النتائج كالاتي

✅A minority of patients in all groups had HbA1c values consistently lower than 7.0%. More patients who took liraglutide (32%) or glargine (33%) maintained HbA1c <7.0%, compared with those who took glimepiride (28%) or sitagliptin (23%).
✅يعني المرضى الذين اخذوا glargine insulin و liraglutide كان السكري التراكمي وصل الى اقل من 7%

✅Severe hypoglycemia, although rare, occurred most frequently in patients taking glimepiride (i.e., in 2.2% of glimepiride users vs. ≈1% of other groups).
✅ انخفاض السكري Hypoglycemia نادر في جميع المجموعات لكن كان يحصل بشكل متكرر في المرضى الذين اخذوا glimepiride

I✅ncidences of major adverse cardiovascular events (MACE; i.e., nonfatal myocardial infarction, stroke, or death from cardiac cause), hypertension, dyslipidemia, albuminuria, or peripheral neuropathy were similar among groups.
✅اما حدوث major adverse cardiovascular events كانت متقاربه بين جميع المجموعات

✅Incidence of any adverse cardiovascular event (i.e., MACE, unstable angina or heart failure requiring hospitalization, and revascularization) was less common with liraglutide: 6.6% of liraglutide users, compared with 9% of patients in other groups (number needed to treat with liraglutide for 5 years to prevent 1 event, ≈40).
✅بينما حصول اي any adverse cardiovascular event كانت اقل في المرضى الذين اخذوا دواء liraglutide

✅مختصر الدراسه
✅Liraglutide produced modestly better cardiovascular outcomes and equivalent or better glycemic results, whereas glimepiride was slightly less safe than the other medications*

✅لكن بنفس الوقت يجب اخذ cost بعين الاعتبار عند اختيار دواء نضيفه الى metformin
خاصه في فرق كبير في السعر بين glimepiride و liraglutide
#salah

#تذكر
✅بنسبه لجرعه Amlodipine في معالجة ارتفاع ضغط الدم نبدا غالبا ب 5 ملجم وممكن نرفع الى 10 ملجم مره في اليوم
✅لكن لو كان مريض عنده تليف كبدي او عمره فوق 65 سنه نبدا ب 2.5 ملجم
#martindale
#Lexicomp
#Salah

✅هنا يوضح لنا بان piperacillin-tazobactam افضل من carbapenem اذا كانت العدوى المسببه هي Pseudomonas ,لكن في حالة وجود ESBLs ايضا هنا قد نفضل carbapenem

#IDSA

؛؛
اخر يومين في حياتي الجامعية التي استمرت ست سنوات ،مشاعري الان مختلطة بين الفرح والحزن ،فرح لانة بنجز شي في حياتي وانتقل الى حياة اخرى مرحلة العمل وحزين لأنه ستنتهي اجمل ايامي ،حزين لانه لن اجد وقت كافي للقراءة والاطلاع نفس ايام الجامعة ،احيانا اتمنى ان يرجع بي الزمن لسنة رابعة مثلا لكي اتعلم واطلع اكثر، نصيحة للزملاء في السنوات الأولى استغل هذه الست سنوات بكل ماتستطيع لن تعود هذه الأيام مره اخرى ،نصيحية ايضا لاتظن بانك تعرف الكثير حتى لاتقع في فخ انا فهمان ما احتاج اقراء ،العلم بحر وكلما قراءت اكثر كلما اكتشفت انك تجهل الكثير ،خذ المعلومه من اي شخص ولكن ابحث بنفسك وتاكد منها ،لاتحتقر من هو اصغر منك في السنوات الدراسية ربما هو يقراء اكثر منك ولاتعتقد بانك افضل منه كونك اعلى منه في المستوى الدراسي، في الأخير سر نجاحك هو مشاركة ما تعلمتة مع الآخرين،اسال الله التوفيق للجميع
#Salah

#Remember
Diabetic patients with multivessel CAD involving the left anterior descending artery should undergo CABG instead of PCI.
#salah

Managing Acute Upper Gastrointestinal Bleeding from Ulcers

🛑Strong recommendations, backed by moderate- or high-quality evidence:

1 ✅Endoscopic therapy should be performed for ulcers with active bleeding or a nonbleeding visible vessel.

2 ✅High-dose proton-pump inhibitor (PPI) therapy should be given continuously (intravenously) or intermittently (intravenously or orally) for 3 days after successful endoscopic therapy.

🛑Conditional recommendations, with low- or very low–quality evidence:

1 ✅Early risk stratification should be performed in the emergency department, and patients with low risk (Glasgow-Blatchford score, 0–1) should be discharged for outpatient follow-up.

2 ✅Blood transfusions should be restrictive (i.e., only for patients with hemoglobin levels ≤7 g/dL).

3 ✅Erythromycin infusion should be given before endoscopy.

4 ✅Endoscopy should occur within 24 hours of hospitalization.

5 ✅Endoscopic treatment should be undertaken for high-risk ulcers.

6 ✅Epinephrine injection should not be used alone — only in combination with another hemostatic modality.

7✅Twice-daily oral PPI therapy should be continued for 2 weeks after index endoscopy and parenteral PPI treatment.

8 ✅Patients with recurrent bleeding should undergo another endoscopy procedure, rather than surgery or embolization; however, patients in whom endoscopic therapy fails should proceed to embolization

#ACG clinical guideline
#salah

✅في كلام مهم بخصوص استخدام dexamethasone في منع او معالجة Respiratory distress syndrome في حديثي الولاده ،ذكر مرجع Applied Therapeutic بان استخدام dexamethasone بجرعه 0.5mg/kg/day او اكثر قد تزيد احتماليه الاصابة ب cerebral palsy
✅ايضا جرعه اقل من 0.2mg/kg/day قد تكون غير فعاله في منع او معالجة Respiratory distress syndrome
#Applied_Therapeutic
#salah

Managing Hyperglycemia in Noncritically Ill Hospitalized Adults



✅In patients who experience hyperglycemia (blood glucose, >140 mg/dL) in conjunction with glucocorticoids, an NPH or a basal-bolus insulin regimen is suggested.

✅Inpatient diabetes education should be provided at discharge.

✅In patients with hyperglycemia, with or without type 2 diabetes, insulin therapy is suggested over noninsulin therapies; noninsulin therapies can be used in stable patients with type 2 diabetes, particularly those nearing hospital discharge.

✅In select patients with type 2 diabetes and mild hyperglycemia, dipeptidyl peptidase-4 (DPP-4) inhibitors with correction or scheduled insulin (basal or basal-bolus) is suggested.

✅In patients with no history of diabetes with hyperglycemia, correction insulin is suggested over scheduled insulin.

✅In patients with diabetes who were treated with diet or noninsulin therapies prior to admission, correction or scheduled insulin is recommended, with a glucose target of 100 to 180 mg/dL.

✅In patients with insulin-managed diabetes prior to admission, continuation of home insulin regimens, adjusted for current nutritional intake, is recommended to maintain a glucose target of 100 to 180 mg/


🛑This new Endocrine Society guideline update is comprehensive, but most of the recommendations are based on a low level of evidence

#Endocrine Society

#Salah

🅿️Key Points

Managing Ascites, Spontaneous Bacterial Peritonitis, and Hepatorenal Syndrome
🛑Ascites

✅Diagnostic paracentesis should be performed in all patients with new-onset ascites and in all patients with cirrhosis and pre-existing ascites who are admitted to the hospital.

✅Recommended initial peritoneal fluid tests are cell count and differential total protein, and albumin (to enable calculation of the serum albumin–ascites gradient [SAAG]).

✅Minimal ascites (i.e., detected only by ultrasound) does not require treatment. Moderate ascites should be treated with dietary sodium restriction and diuretics (spironolactone, furosemide, or both), and large or tense ascites often requires large-volume paracentesis (LVP).

✅To prevent postparacentesis circulatory dysfunction (PPCD), a potentially dangerous complication of LVP, administer 6 to 8 g intravenous (IV) albumin per 1 L of fluid removed above 5 L. Risk for PPCD increases with LVP of >8 L in a single session.

🛑Spontaneous Bacterial Peritonitis (SBP):

✅Empirical treatment for SBP is recommended for all patients with ascitic fluid polymorphonuclear leukocytes >250 cells/mm3, even in the absence of symptoms; such treatment consists of an intravenous third-generation cephalosporin plus IV albumin (1.5 g/kg on day 1, followed by 1 g/kg on day 3). Cultures should be obtained prior to starting antibiotics.

✅All patients who recover from SBP should receive daily norfloxacin or ciprofloxacin for prophylaxis.

✅All patients with ascites and upper gastrointestinal hemorrhage should receive prophylaxis for SBP with IV ceftriaxone for as long as 7 days.

🛑Hepatorenal Syndrome (HRS):

✅Vasoconstrictors in combination with IV albumin are the mainstay of treatment for HRS. Terlipressin (a vasopressin analogue, not available in the U.S.) is the preferred first-line agent; norepinephrine is an alternative. Midodrine plus octreotide can be used, but their efficacy is low.

✅If creatinine does not decline after 4 days on maximal doses of vasopressors, further improvement is unlikely and treatment can be stopped.

✅Liver transplantation should be considered for patients with HRS


#AASLD
#salah

The Sanford guide 2022
كتاب يختص في مضادات الميكروبات كتاب جميل جدا
شكرا لدكتور حسن يونس والدكتور اسلام وكل من ساهم في ذالك
👇🏼

🛑patients with AF and hemodynamic instability undergoing urgent cardioversion (electrical or pharmacologic), after successful cardioversion to sinus rhythm,
✅we suggest therapeutic anticoagulation (with VKA or full adherence to NOAC therapy) for at least 4 weeks rather than no anticoagulation, regardless of baseline stroke risk (weak recommendation, low quality evidence).

✅patients with AF and hemodynamic instability undergoing urgent cardioversion (electrical or pharmacologic), we suggest that therapeutic-dose parenteral anticoagulation be started before cardioversion, if possible, but that initiation of anticoagulation must not delay any emergency intervention (weak recommendation, low quality evidence).
#salah