Learning is an everyday process, and I learned this after attending my clinical postings in the general medicine department of our college. I never thought general medicine was something I would start dreaming to pursue as my residency in the future, hopefully. I was always an average student, comparing to many students in my class, and I was pretty underconfident.
However, my experience with my first patient with Diabetic nephropathy progressed to Chronic kidney disease was a turning point in my life. As I was answering questions related to diabetic nephropathy and Chronic kidney disease, our respected HOD sir asked me if I checked JVP and showed me elevated JVP which astonished me as a medical student who never attended clinical postings before. He even said, "heart failure and renal failure are like twins, always go hand in hand," which has been stuck in my mind till now and has helped me assess many patients. We later discussed the case among students and residents and talked about how Chronic kidney disease may cause the manifestations we see in the patient,such as pedal edema due to disruption of two main driving forces in our body(low oncotic pressure due to loss of proteins) and pallor(anemia due to decreased Erythropoietin).During the case discussion,I also learned how important a persons daily routine and his complete history can be in de-coding the disease,what lifestyle changes might have prevented this or improved the outcomes,what lifestyle changes can be adopted to improve the prognosis and how the events of disease have progressed owing to his life style and co-morbidities.
Like this, I have seen and discussed many patients with different commonly occurring medical conditions such as acute pancreatitis, Diabetic ketoacidosis, ascites and portal hypertension due to cirrhosis, CVA, and many more and learned about them without even referring to a textbook through discussing online portfolios. It's amazing how much you can learn from interacting with patients and discussing cases with your colleagues.
I realized it's normal to feel overwhelmed or underconfident when starting out, but interacting with patients and learning from your experiences can help you improve your skills. It's great to hear that I am passionate about learning and medicine! My clinical experience has helped me develop my skills as a clinician, and I am grateful for the opportunities I have had to learn and grow.
Contributing to online learning portfolios and discussing cases with other students and residents has been an excellent way to learn and share knowledge. I have discovered that discussing cases with colleagues and learning from their experiences can help me become a better clinician.
I have a relationship with neurological cases starting right from my personal experience as someone close to me had suffered from a CVA in last June,I can relate to the patients and their attenders in a more empathetic way.He had just severe back pain on 4th June last year,and when he woke up on 5th June,he had hemiplegia of left side along with bowel irregularity.
He has an atherosclerotic plaque and calcifications in his carotid artery which might’ve lodged off and caused the stroke, His 2D echo was normal,which made us rule out atrial fibrillation as causing the stroke.His lifestyle preference such as non adherence to his medications for his chronic health conditions such as Diabetes Mellitus type 2 and Hypertension leading to poor control of the diseases might’ve caused the stroke.
A patient I came across in our hospital,57 year old male came to OPD with chief complaints of difficulty in walking since 7 days and giddiness since 7 days.He had a history of hypertension since 1 year.He had truncal ataxia or gait ataxia swaying to the right side and on investigations-Brain MRI revealed that he had a Acute lateral medullary infaret on right side extending into inferior cerebellar peduncle.Old hemorrhage in left paramedian aspect of pons.Wallerian degeneration of bilateral middle cerebellar peduncles.
https://manogynab87.blogspot.com/2022/09/57-year-old-male-with-lower-limb.html?m=1
Wallerian degeneration is an active process of anterograde degeneration of the distal end of an axon that is a result of a nerve lesion. It occurs between 7 to 21 days after the lesion occurs.
Ischemic stroke can lead to neurophysiological and structural brain tissue changes, distant from the acute, primary focal lesion. These changes can be seen as post-stroke phenomena, known as Wallerian degeneration and diaschisis.(1)
Another patient(50 year old male) I recently came across came with complaints of Weakness of left upper and lower limb since 2days,Slurring of speech since 2days and Deviation of the mouth towards the right side since 2 days.He was Diagnosed with Acute ischemic CVA with left UL and LL hemiparesis(Late hyperacute infarct in Right PONS, chronic infarct in Right and Left Frontal and Right occipital).He had a history of hypertension since 3 years.
A 50yrs old who is a resident of cheruvugattu came with c/o weakness in left UL and LL.No h/o loss of consciousness, involuntary movements, drooling of saliva, involuntary micturation and defeacation.K/C/O Acute CVA (Rt.hemiparesis) 2yrs back.
-1yr back came to OPD with c/o urinary incontinence ,drooling of saliva.
Took medication and left.
K/C/O HTN and DM since 2yrs and on regular medication.MRI brain revealed-Acute infarct in right superior parietal lobule, superior frontal gyrus, centrum semiovale, periventricular white matter - external watershed
territory infaret.
Encephalomalacia with gliotic changes in left frontal lobe extending to
periventricular white matter.
Discussion:
How is a short period from diagnosis of hypertension causing a long term complication such as CVA?
Is hypertension going undiagnosed for many years in these patients?
What are some factors that may cause recurrent stroke as in the patient above? How do his co-morbidities such as hypertension and diabetes affect the recurrence of his stroke?
[08/05/23, 6:35:30 PM] Ankit 18: https://karger.com/ned/article/55/6/427/828639/Diabetes-As-an-Independent-Risk-Factor-for-Stroke(2)
[08/05/23, 6:36:12 PM] Ankit 18: Apart from the strong associations observed between diagnosed diabetes and vascular outcomes, a meta-analysis conducted in 2010 involving 102 cohorts in 25 countries showed a much more moderate relationship of impaired fasting glucose status with coronary heart disease and stroke [9]. Therefore, it is reasonable to think that impaired fasting glucose may also be associated with stroke recurrence. However, large-scale RCTs or epidemiological studies are still needed to confirm this association. In addition to diabetic populations, we should also include patients with prediabetes or impaired fasting glucose in the monitoring and management to avoid worse outcomes.
[08/05/23, 6:38:06 PM] Ankit 18: Sir in this patient we can say that recurrence of stroke could be linked to his diabetes
[08/05/23, 6:38:26 PM] Ankit 18: But there are also several limitations to assuming this as we discussed in the morning
[08/05/23, 6:38:45 PM] Ankit 18: First, most of the included studies were retrospective analyses. Large-scale prospective studies are needed
[08/05/23, 6:39:19 PM] Ankit 18: Second, there is genetic heterogeneity between the patients considered in the trial
[08/05/23, 6:39:42 PM] Ankit 18: The onset of diabetes and progression also varied greatly
[08/05/23, 6:40:12 PM] Ankit 18: Third, diabetes often co-occurs with other cardiovascular risk factors, particularly hypertension and hypercholesterolemia, which are also associated with a higher risk of recurrence. Therefore, it is not entirely clear whether the increased risk of recurrence in people with diabetes reflects a direct effect of their diabetes
[08/05/23, 6:44:18 PM] Ankit 18: We could prevent any further recurrence of stroke by giving GLP-1 agonists which have a role in both reducing sugar levels as well as vascular benefits as evidenced by this study
[08/05/23, 6:44:33 PM] Ankit 18: https://www.sciencedirect.com/science/article/pii/S2173580821000250
[08/05/23, 6:44:47 PM] Manogyna: There are several possible mechanisms wherein diabetes leads to stroke.
These include vascular endothelial dysfunction, increased early-age arterial stiffness, systemic inflammation and thickening of the capillary basal membrane. Abnormalities in early left ventricular diastolic filling are commonly seen in type II diabetes. The proposed mechanisms of congestive heart failure in type II diabetes include microvascular disease, metabolic derangements, interstitial fibrosis, hypertension and autonomic dysfunction (Figure 1). Vascular endothelial function is critical for maintaining structural and functional integrity of the vessel walls as well as the vasomotor control. Nitric oxide (NO) mediates vasodilation, and its decreased availability can cause endothelial dysfunction and trigger a cascade of atherosclerosis. For example, NO-mediated vasodilation is impaired in individuals with diabetes, possibly due to increased inactivation of NO or decreased reactivity of the smooth muscle to NO. Individuals with type II diabetes have stiffer arteries and decreased elasticity compared with subjects having normal glucose level. Type I diabetes is more often associated with an early structural impairment of the common carotid artery, commonly reflected as increased intima-medial thickness, and is considered as early sign of atherosclerosis. An increased inflammatory response is frequently seen in individuals with diabetes, inflammation plays an important role in the development of the atherosclerotic plaque.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5298897/
[08/05/23, 6:46:35 PM] Ankit 18: patients with DM2 and established vascular disease or high vascular risk, we recommend adding GLP-1 receptor agonists to standard antidiabetic treatment for fatal and non-fatal stroke prevention (class I recommendation, level of evidence B).
In patients with DM2 and established vascular disease or high vascular risk, adding pioglitazone or SGLT2 inhibitors to standard antidiabetic treatment is not recommended for stroke prevention (class III recommendation, level of evidence B).
[08/05/23, 11:00:07 PM] Rakesh Biswas Sir: Share the RCT evidence in the PICO format
[08/05/23, 11:17:34 PM] Ankit 18: P - DM2 and recent history of ischaemic heart disease ( mean age 62 and women make up 38%)
I- Weekly subcutaneous semaglutide along with standard diabetic therapy
C- standard diabetic therapy without GLP-1 receptor agonists
O- Treatment with GLP-1 receptor agonists was associated with a 14% decrease in the Recurrence of fatal or non-fatal stroke
[08/05/23, 11:18:19 PM] Ankit 18: SUSTAIN-6 trial
[09/05/23, 7:41:29 AM] Rakesh Biswas Sir: You have to tell the absolute numbers
How many patients in P and C
In O How many out of total how many in GLP 1 group had Stroke vs how many in placebo group?
[09/05/23, 7:44:05 AM] Ankit 18: Ok sir
[09/05/23, 8:50:56 AM] Ankit 18: P- 3297
C-
with intervention 1648
Control -1649
O-
GLP-1 group : 27
Control:44
[09/05/23, 9:29:49 AM] Ankit 18: 27 patients had recurrence of non fatal stroke in GLP -1 group
[09/05/23, 9:30:13 AM] Ankit 18: 44 patients had recurrence of non-fatal stroke in control group
[09/05/23, 9:35:14 AM] Rakesh Biswas Sir: Both the groups were properly matched?
Can you share the patient characteristics table?
[09/05/23, 9:35:32 AM] Ankit 18: Ok sir
[09/05/23, 9:39:45 AM] Ankit 18: Patients with type 2 diabetes and a glycated hemoglobin level of 7% or more were eligible if they had not been treated with an antihyperglycemic drug or had been treated with no more than two oral antihyperglycemic agents, with or without basal or premixed insulin. Key inclusion criteria were an age of 50 years or more with established cardiovascular disease (previous cardiovascular, cerebrovascular, or peripheral vascular disease), chronic heart failure (New York Heart Association class II or III), or chronic kidney disease of stage 3 or higher or an age of 60 years or more with at least one cardiovascular risk factor
[09/05/23, 9:59:47 AM] Manogyna: Population of interest-
patients were required to have had a hemispheric transient ischemic attack (TIA), transient monocular blindness, or a nondisabling stroke associated with a stenosis of 30% to 99% in the ipsilateral carotid artery based on linear diameter reduction.
Intervention-
Accredited NASCET surgeons were not constrained to follow any standardized surgical technique, other than their normal practice.(Carotid endarterectomy)
Control-
All the 1415 patients participating were randomised under 278 surgeons with no control group.
Outcome-
results from NASCET demonstrate that in experienced surgical hands CE is safe and effective in the near term and remarkably effective in the longer term in preventing recurrence of ipsilateral carotid ischemia and, in particular, in preventing disabling ipsilateral stroke. The challenge for those investigating the usefulness of carotid angioplasty and stenting as an alternative to CE will be to demonstrate that not only is it as safe and effective as CE in the near term but that it is as effective in preventing disabling stroke in the long term.
In 1415 patients there were 92 perioperative outcome events, for an overall rate of 6.5%. At 30 days the results were as follows: death, 1.1%; disabling stroke, 1.8%; and nondisabling stroke, 3.7%. At 90 days, because of improvement in the neurological status of patients judged to have been disabled at 30 days, the results were as follows: death, 1.1%; disabling stroke, 0.9%; and nondisabling stroke, 4.5%. Thirty events occurred intraoperatively; 62 were delayed. Most strokes resulted from thromboembolism. Five baseline variables were predictive of increased surgical risk: hemispheric versus retinal transient ischemic attack as the qualifying event, left-sided procedure, contralateral carotid occlusion, ipsilateral ischemic lesion on CT scan, and irregular or ulcerated ipsilateral plaque. History of coronary artery disease with prior cardiac procedure was associated with reduced risk. The risk of perioperative wound complications was 9.3%, and that of cranial nerve injuries was 8.6%; most were of mild severity. At 8 years, the risk of disabling ipsilateral stroke was 5.7%, and that of any ipsilateral stroke was 17.1%.
Study Design-Regression modeling was used to identify variables that increased or decreased perioperative risk. Nonoutcome surgical complications were summarized. The durability of carotid endarterectomy was examined.
https://www.ahajournals.org/doi/10.1161/01.str.30.9.1751
References-
Comments
Post a Comment