January 4, 2021 | RR Baliga, MD, MBA

Circadian clocks help to coordinate physiological processes with the daily cycles of light and dark and periods of feeding, activity, and rest. Being out of sync with such 24-hour cycles can have unhealthy effects. Sancar and Van Gelder review the available evidence regarding circadian disruption and predisposition to cancer and circadian variations in response to cancer chemotherapy.

December 26, 2020 | RR Baliga, MD

Myeloid-epithelial-reproductive tyrosine receptor (MerTK), a receptor on the surface of the cardiac macrophage, is key to phosphatidylserine-triggered activation and was previously shown to be required for cardiac recovery after injury. Nicolás-Ávila et al. showed that in mice lacking MerTK, cardiac macrophages are intact but unable to absorb mitochondria, a finding that implicates MerTK in the removal of mitochondria. The extracellular portion of MerTK can be cleaved and released into the serum, where it can be measured as a biomarker of chemotherapy induced cardiotoxicity?

August 3, 2020 | RR Baliga, MD, MBA

Anthracyclines like doxorubicin are anticancer drugs, used by over 1 million cancer patients annually. However, they cause severe side effects, most notably, cardiotoxicity and therapy-related malignancies. It is unclear whether these side effects are directly linked to their anticancer activity. Doxorubicin exerts two activities: 1) DNA damage and 2) chromatin damage. Here, this paper shows that both activities conspire in the cardiotoxicity, while doxorubicin variants with only chromatin-damaging activity remain active anticancer drugs devoid of side effects. This challenges the concept that doxorubicin works primarily by inducing DNA double-strand breaks and reveals another major anticancer activity, chromatin damage. Translating these observations will yield anticancer drugs for patients that are currently excluded from doxorubicin treatment and improve the quality of life of cancer survivors.

June 16, 2020 | RR Baliga, MD, MBA

Dexamethasone reduced deaths by one-third in ventilated patients (rate ratio 0.65 [95% confidence interval 0.48 to 0.88]; p=0.0003) and by one fifth in other patients receiving oxygen only (0.80 [0.67 to 0.96]; p=0.0021). There was no benefit among those patients who did not require respiratory support (1.22 [0.86 to 1.75; p=0.14). Based on these results, 1 death would be prevented by treatment of around 8 ventilated patients or around 25 patients requiring oxygen alone.

June 14, 2020 | RR Baliga, MD, MBA

Neutrophil extracellular traps (NETs) have recently emerged as a newly recognized contributor to venous and arterial thrombosis. DNA component of NETs (NET-DNA) is associated with cancer metastasis

June 14, 2020 | RR Baliga , MD, MBA

Sodium Glucose Transporter-2 (SGLT2) Inhibition can potentially prevent lung cancers and also have been shown to reduce mortality in systolic heart failure. Given their ability to influence glucose metabolism can these agents prevent chemotherapy induced cardiotoxicity?

June 12, 2020 | RR Baliga, MD, MBA

"The complexity of cardiac metabolism is formidable. New knowledge derived from cancer cell metabolism has exposed two new oncometabolic pathways in the heart. The first is the redirection of cardiac metabolism by a circulating oncomeabolite, and the second is the metabolic rewiring of the stressed heart, just like it occurs in proliferating cells. However, because heart muscle cells do not readily divide, the footprints of cancer cell metabolism may reflect a paradigm for self-renewal of the cardiomyocyte from within. As always, there is more to be known and even more to be understood." Heinrich Taegtmeyer et al

June 10, 2020 | RR Baliga, MD, MBA

Overcoming Racial or Ethnic Distrust Individuals from minority, disadvantaged or marginalized groups may bring a level of suspicion or mistrust to their interactions with health care providers. These feelings may stem from personal experiences, either real or perceived, of bias or mistreatment. They may also reflect wider societal phenomena such as undocumented immigrants who fear deportation; or historical events that contribute to a collective group distrust and suspicion of medicine, an example of which are the suspicions some African-Americans have toward healthcare providers or biomedical research based on the abuses of the Tuskegee Syphilis study. The following are recommendations for navigating those situations where issues of racial or ethnic distrust have become or likely to be part of the patient-provider interaction. First, it is important to not react with anger or defensiveness. Second, don’t ignore the “elephant in the room”. Instead, initiate a nonjudgmental, respectful conversation about the feelings and beliefs of the patient. Sincerity, honesty and a genuine effort to listen and respond to the concerns of the patient can all be helpful in fostering a level of trust that will enable a therapeutic relationship between the provider and the patient. Finally, the physician should emphasize his or her commitment to the well being of the patient, and then diligently and compassionately go about providing the best care possible. Engaging Patients Around Spirituality The spiritual and religious beliefs of patients may be the bases for life style choices, decision-making, approaches for understanding and coping with illness and death,and the rituals of death (Figure 4). There is also evidence that an individual’s level of religiosity may influence health outcomes. It therefore proves helpful in relationships with patients to establish a habit of clinical practice that conveys respect for the spiritual beliefs of patients. Some physicians may not be comfortable doing this because of either the “sensitive” nature of religion in the current socio-political climate, or the physician’s own personal ignorance, indifference, ambivalence or non-belief. Self-awareness of this discomfort is necessary in order to avoid dismissive or aversive behaviors that could undermine communication with the patient.

June 2, 2020 | RR Baliga, MD, MBA

For healthcare providers, cultural competency is understood as involving three elements: self-awareness, development and refinement of cross-cultural communication and negotiation skills and knowledge of cultural norms and health disparities. Further, it is necessary to see the acquisition of cultural competence as an ongoing process rather than an isolated, single event (such as listening to a lecture or taking a course).

June 2, 2020 | RR Baliga, MD, MBA

Cultural competency is best framed as an issue of professionalism. That is, a competent healthcare provider will also be skilled at providing culturally appropriate care across diverse (in its widest sense) patient populations. Cultural competency in health care is about the ability to bridge the cultural differences between the patient and the healthcare provider so as to deliver respectful and effective care that results ultimately in good patient outcomes. Cultural competency is an ongoing process that involves: (i) self-awareness; (ii) cross-cultural communication and negotiation skills; and (iii) knowledge of the cultural norms and health disparities of the populations the healthcare provider services. Eliciting the patient’s explanatory model of illness is an important means of facilitating cross-cultural communication and identifying areas of conflict that will need to be negotiated and resolved. As long as generalizations (cultural norms) are seen as a starting point for understanding patients, rather than fully defining them, stereotyping can be avoided.

May 25, 2020 | RR Baliga, MD, MBA

Venous thromboembolism (VTE) is a major preventable disease that affects hospitalized inpatients. Risk stratification and prophylactic measures have good evidence supporting their use, but multiple reasons exist that prevent full adoption, compliance, and efficacy that may underlie the persistence of VTE over the past several decades. This policy statement provides a focused review of VTE, risk scoring systems, prophylaxis, and tracking methods. From this summary, 5 major areas of policy guidance are presented that the American Heart Association believes will lead to better implementation, tracking, and prevention of VTE events. They include performing VTE risk assessment and reporting the level of VTE risk in all hospitalized patients, integrating preventable VTE as a benchmark for hospital comparison and pay-for-performance programs, supporting appropriations to improve public awareness of VTE, tracking VTE nationwide with the use of standardized definitions, and developing a centralized data steward for data tracking on VTE risk assessment, prophylaxis, and rates.

May 20, 2020 | RR Baliga, MD, MBA

The strengths of Cardiac Magnetic Resonance Imaging for the diagnosis of myocarditis reside in its excellent spatial resolution (rather than temporal resolution)

May 20, 2020 | RR Baliga, MD, MBA

Oral apixaban was noninferior to subcutaneous dalteparin for the treatment of cancer-associated venous thromboembolism without an increased risk of major bleeding.

May 20, 2020 | RR Baliga, MD, MBA

Key Question Is initiation of pulmonary rehabilitation after hospitalization for chronic obstructive pulmonary disease (COPD) associated with better survival? Findings In this retrospective observational study that included 197 376 Medicare beneficiaries discharged after hospitalization for COPD, initiation of pulmonary rehabilitation within 3 months of discharge, compared with later or no initiation of pulmonary rehabilitation, was significantly associated with lower risk of mortality at 1 year (hazard ratio, 0.63). Meaning These findings support current guideline recommendations for pulmonary rehabilitation after hospitalization for COPD, although the potential for residual confounding exists and further research is needed.

May 15, 2020 | RR Baliga, MD, MBA

A significant number of patients receiving high-risk cancer therapies present objective data of myocardial injury or LVD. Nevertheless, the number of patients with severe CTox is comparatively very low but is strongly related with all-cause mortality. Milder forms induced ventricular dysfunction were not found to be related with prognosis but represent an important warning to consider a closer follow-up, initiation of classic HF treatments, or even discontinue chemotherapy on an individual basis in spite of solid evidence-based data.

December 18, 2019 | RR Baliga, MD, MBA

This podcast summarizes recommendations for colorectal cancer screening.

December 15, 2019 | RR Baliga, MD, MBA

Discusses two important papers published the week of Dec 8-14, 2019

October 12, 2019 | RR Baliga, MD

from a chapter titled "Pleural Disease" authored by Jeremy B Richards & Richards MD M Schwartzstein, MD, Harvard Medical School & Beth Israel Deaconess Medical Center, Boston, MA in Baliga's Textbook of Internal Medicine: An Intensive Board Review with 1480 MCQs | www.MasterMedFacts.com

August 28, 2019 | RR Baliga, MD, MBA

Hyponatremia is a state of water excess. Reduced urine output from persistent antidiuretic hormone (ADH) secretion and/or low osmole intake accounts for a vast majority of cases of hyponatremia. Seldom does hyponatremia develop without impairment in water excretion when high water ingestion exceeds the normal renal water excretory capacity. Analysis of serum osmolality, urine osmolality, and urine Na+ along with assessment of extracellular volume status helps elucidate the cause of hyponatremia. The severity of symptoms and the severity of hyponatremia determine the therapeutic choice in hyponatremia. The rapid correction of hyponatremia must be avoided to minimize the risk of osmotic demyelination syndrome.

August 7, 2019 | RR Baliga, MD, MBA

Severe or symptomatic hyperkalemia requires urgent interventions to prevent and to treat potentially life-threatening muscular and cardiac sequelae of hyperkalemia. The treatment involves a three-prong approach aimed at (1) counteracting the detrimental effects of hyperkalemia on the cardiac membranes with intravenous calcium gluconate; (2) sequestering extracellular K+ into cells with insulin/dextrose (and at times β2 agonists and sodium bicarbonate); and (3) eliminating the excess K+ from the body. Until treatment is complete, patients may require repeat doses of these treatments, as the duration of action of calcium gluconate (~30 minutes) and insulin/dextrose (~90 minutes) is relatively short. The use of a K-binding resin (kayexalate) requires an intact colon for its use. There is a risk of colonic necrosis due to kayexalate crystal deposition in the colonic mucosa; therefore, its use should be restricted to patients with significant hyperkalemia (serum K+ above 6 mEq/L). In patients without renal function (acute renal failure or ESRD), dialysis is necessary to correct the hyperkalemia.

August 2, 2019 | RR Baliga, MD, MBA

The extracellular K+ concentration is tightly maintained between 3.5 to 5.0 mEq/L because normokalemia is essential for generation of normal action potentials in cardiac and skeletal muscles, and neurons. Cellular buffering of K+ provides the first, immediate defense against a major fluctuation in the extracellular K+ concentration. The cells contain 98% of the total body K+ (3,000 to 4,000 mEq), and can sequester extracellular K+ in hyperkalemia or release intracellular K+ in hypokalemia. The kidneys provide a long-term K+ homeostasis by adjusting the urinary K+ excretion according to K+ intake and body’s K+ status. The urinary K+ excretion which rises in response to an increased K+ intake and hyperkalemia is so efficient that even a 10-fold increase in the daily K+ intake from 40 to 400 mEq does not produce persistent hyperkalemia. A corollary to this is that persistent hyperkalemia always indicates a defect in the urinary K+ excretion. In contrast, in response to a decreased K+ intake and hypokalemia, the urinary K+ excretion can fall to as low as 15 to 25 mEq/day. Therefore, a diminished K+ intake alone, unless quite severe, does not cause chronic hypokalemia. Except for the cases of the non-renal K+ loss from the GI tract or skin, persistent hypokalemia stems from an excessive urinary K+ excretion.

August 2, 2019 | RR Baliga, MD, MBA

The total body potassium content and plasma potassium level are maintained within narrow limits despite potentially wide variations in dietary potassium intake. Maintaining potassium homeostasis involves two concurrent processes — external and internal. External potassium homeostasis regulates potassium excretion by the kidneys to balance potassium intake, minus extra-renal potassium loss and correction for any potassium deficits. Internal potassium regulation controls the distribution of total body potassium with the greater part (~ 98%) intracellular and only a small fraction (~ 2%) extracellular. Substantial evidence supports the role of the circadian clock in external homeostasis, and some evidence indicates a role in internal homeostasis.

July 31, 2019 | RR Baliga, MD, MBA

🎧 Dr RR Baliga's Internal Medicine MUST KNOW FACTS Podcasts for Physicians

July 19, 2019 | RR Baliga, MD, MBA

Anthracycline chemotherapy causes dose-related cardiomyocyte injury and death leading to left ventricular dysfunction. Clinical heart failure may ensue in up to 5% of high-risk patients. Improved cancer survival together with better awareness of the late effects of cardiotoxicity has led to growing recognition of the need for surveillance of anthracycline-treated cancer survivors with early intervention to treat or prevent heart failure. The main mechanism of anthracycline cardiotoxicity is now thought to be through inhibition of topoisomerase 2β resulting in activation of cell death pathways and inhibition of mitochondrial biogenesis. In addition to cumulative anthracycline dose, age and pre-existing cardiac disease are risk markers for cardiotoxicity. Genetic susceptibility factors will help identify susceptible patients in the future. Cardiac imaging with echocardiographic measurement of global longitudinal strain and cardiac troponin detect early myocardial injury prior to the development of left ventricular dysfunction. There is no consensus on how best to monitor anthracycline cardiotoxicity although guidelines advocate quantification of left ventricular ejection fraction before and after chemotherapy with additional scanning being justified in high-risk patients. Patients developing significant left ventricular dysfunction with or without clinical heart failure should be treated according to established guidelines. Liposomal encapsulation reduces anthracycline cardiotoxicity. Dexrazoxane administration with anthracycline interferes with binding to topoisomerase 2β and reduces both cardiotoxicity and subsequent heart failure in high-risk patients.

July 16, 2019 | RR Baliga, MD, MBA

Among conventional cytotoxic chemotherapies, 5-FU is likely one of the most common chemotherapeutic agents to cause cardiotoxicity, second only to anthracyclines. Reported clinical manifestations have largely been consistent with angina attributed to coronary vasospasm, although myocardial infarction, heart failure, arrhythmias, pericarditis, coronary dissection, QT prolongation, and sudden cardiac death have also been reported in the setting of fluoropyrimidine use.

July 16, 2019 | RR Baliga, MD, MBA

This AHA Scientific Statement is a broad overview of cardio-oncology, discussing various aspects of this newish discipline including cardiotoxicity, structuring a cardio-oncology service, training in cardio-oncology, and directions in research

July 14, 2019 | RR Baliga, MD, MBA

The guideline endorses a heart-healthy lifestyle beginning in childhood to reduce lifetime risk for ASCVD. It contains several new features compared with the 2013 guideline. For secondary prevention, patients at very high risk may be candidates for adding nonstatin medications (ezetimibe or proprotein convertase subtilisin/kexin type 9 [PCSK9] inhibitors) to statin therapy. In primary prevention, a clinician–patient risk discussion is still strongly recommended before a decision is made about statin treatment. The AHA/ACC risk calculator first triages patients into 4 risk categories. Those at intermediate risk deserve a focused clinician–patient discussion before initiation of statin therapy. Among intermediate-risk patients, identification of risk-enhancing factors and coronary artery calcium testing can assist in the decision to use a statin. Compared with the 2013 guideline, the new guideline gives more attention to percentage reduction in low-density lipoprotein cholesterol as a treatment goal and to long-term monitoring of therapeutic efficacy. To simplify monitoring, nonfasting lipid measurements are allowed.

July 12, 2019 | RR Baliga, MD, MBA

Coronary Artery Bypass Grafting 101: "CABG offers significant improvement in survival and quality of life for appropriately selected patients with multivessel coronary artery disease. Those with more advanced coronary artery disease, left ventricular dysfunction, or diabetes are particularly likely to benefit from CABG. Primary care physicians, internists, and cardiologists play a key role in the patient selection and referral process. Many patients, and some physicians, have the misconception that CABG cures coronary artery disease. In fact, CABG does not prevent the progression of native coronary artery disease, and internal-thoracic-artery and saphenous-vein grafts can fail. Although ongoing research may incrementally improve the CABG procedure, the largest improvements in outcomes are likely to be realized by appropriately selecting patients to undergo CABG" N Engl J Med 2016; 374:1954-1964

July 11, 2019 | RR Baliga, MD, MBA

The "assessment" at the close of your presentations is your time to shine, your chance to highlight salient data, show what you know, and display your clinical reasoning. The best assessments guide your listeners, focus your thinking, and point towards effective diagnostic and treatment plans.

July 10, 2019 | RR Baliga, MD, MBA

The presence of jugular venous distension, at rest or inducible, had the best combination of sensitivity (81%), specificity (80%) and predictive accuracy (81%) for elevation of the pulmonary capillary wedge pressure (≥8 mm Hg). (Journal of the American College of Cardiology Volume 22, Issue 4, October 1993)

July 10, 2019 | R.R. Baliga, MD, MBA

This is a series of PodCasts on Statistics for Internal Medicine Residents

April 6, 2019 | R.R. Baliga, , MD, MBA

Vascular Access Key Articles

February 6, 2019 | R.R. Baliga, MD

This guidelines, keeping in mind that blood pressure as a risk factor is a continuum, has reclassified BP into 4 categories ° Normal                                          <120 mm Hg ° Elevated                                        120-129/<80 mm Hg ° Stage 1 Hypertension                   130-139/80-89 mm Hg ° Stage 2 Hypertension                   ≥140/≥90 mm Hg Out-of-office BP measurements (particularly, home BP measurements) are recommended in this guideline, both to diagnose and titrate anti-hypertensive medications According to this definition, about 46% of U.S. adults have hypertension, as compared with about 32% under the previous definition

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