Understanding Cardiomyopathies: Definition, Diagnosis, Treatment, and Prognosis

 

Definition:

Cardiomyopathy refers to diseases of the heart muscle that affect its size, shape, or structure, leading to impaired function. These conditions can lead to heart failure, arrhythmias, and other serious cardiac issues.

Types:

1. Dilated Cardiomyopathy (DCM):

   • The heart's ventricles enlarge and weaken, reducing the heart's ability to pump blood efficiently.
   • Common causes include genetic factors, infections, and toxins such as alcohol.

2. Hypertrophic Cardiomyopathy (HCM):

   • The heart muscle thickens abnormally, often leading to obstructed blood flow.
   • It is usually inherited and can cause sudden cardiac death, especially in young athletes.

3. Restrictive Cardiomyopathy (RCM):

   • The heart muscle becomes rigid and less elastic, preventing proper filling of the heart chambers.
   • It is often associated with conditions like amyloidosis and can result from radiation therapy or connective tissue disorders.

4. Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC):

   • Fat and fibrous tissue replace the muscle of the right ventricle, leading to arrhythmias.
   • This type is typically genetic.

Fig. 1 Cardiomyopathies according to pathophysiologic types a. normal, b. dilated, c. hypertrophic (obstructive), d. hypertrophic (non-obstructive), e. hypertrophic (obliterative), f. restrictive (obliterative), g. restrictive (non-obliterative) (From: Overview of Cardiomyopathies - Cardiovascular Disorders - Merck Manual Professional Edition (merckmanuals.com) )

Diagnosis:

• Medical History and Physical Examination: Key to identifying symptoms and risk factors.
• Electrocardiogram (ECG): Detects electrical activity abnormalities.
• Echocardiogram: Visualizes heart structure and function.
• Cardiac MRI: Provides detailed images of heart tissues.
• Blood Tests: Identify markers of heart damage or underlying conditions.
• Genetic Testing: Important for detecting inherited forms of cardiomyopathy.
• Biopsy: In some cases, a small sample of heart tissue is examined.

Prognosis

The prognosis for patients with cardiomyopathy varies widely depending on several factors, including the type and severity of the cardiomyopathy, the patient's overall health, the presence of other medical conditions, and how well the condition is managed. Here is an overview of the prognosis for different types of cardiomyopathy:

1. Dilated Cardiomyopathy (DCM):

   • Prognosis: The prognosis can vary significantly. Some patients may remain stable for many years with appropriate treatment, while others may experience progressive heart failure.
   • Factors Influencing Prognosis: Severity of symptoms, response to treatment, presence of complications such as arrhythmias, and whether the underlying cause (e.g., alcohol use, viral infection) is reversible.

2. Hypertrophic Cardiomyopathy (HCM):

   • Prognosis: Many people with HCM live normal lifespans with few symptoms. However, there is a risk of sudden cardiac death, particularly in younger individuals and athletes.
   • Factors Influencing Prognosis: Family history of sudden cardiac death, severity of left ventricular hypertrophy, presence of arrhythmias, and adherence to treatment and lifestyle recommendations.

3. Restrictive Cardiomyopathy (RCM):

   • Prognosis: This type generally has a poorer prognosis compared to other forms of cardiomyopathy due to its association with underlying conditions such as amyloidosis or other systemic diseases.
   • Factors Influencing Prognosis: The underlying cause of the restrictive cardiomyopathy, the extent of heart damage, and the patient's response to treatment for the underlying condition.

4. Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC):

   • Prognosis: The prognosis can be quite variable. Some individuals may experience only mild symptoms, while others may develop severe heart failure or life-threatening arrhythmias.
   • Factors Influencing Prognosis: The presence of arrhythmias, the extent of right ventricular involvement, and adherence to treatment including the use of ICDs to prevent sudden cardiac death.

General Factors Influencing Prognosis:

• Early Diagnosis and Treatment: Early detection and management of cardiomyopathy can improve outcomes significantly.
• Adherence to Treatment: Following prescribed medications, lifestyle modifications, and regular follow-ups with a healthcare provider.
• Management of Comorbid Conditions: Controlling conditions such as hypertension, diabetes, and coronary artery disease.
• Access to Advanced Therapies: Availability of advanced treatments such as heart transplantation or gene therapy can impact prognosis.

Here is a table comparing the three main types of cardiomyopathies: Dilated Cardiomyopathy (DCM), Hypertrophic Cardiomyopathy (HCM), and Restrictive Cardiomyopathy (RCM).

Feature	Dilated Cardiomyopathy (DCM)	Hypertrophic Cardiomyopathy (HCM)	Restrictive Cardiomyopathy (RCM)
Definition	Enlarged and weakened ventricles	Abnormally thickened heart muscle	Rigid and less elastic heart muscle
Primary Cause	Genetic, viral infections, toxins	Mostly genetic	Often related to systemic diseases
Symptoms	Fatigue, shortness of breath, edema	Chest pain, shortness of breath, palpitations	Shortness of breath, fatigue, edema
Heart Chamber Affected	Mainly left ventricle	Typically left ventricle	Both ventricles
Heart Function	Reduced ejection fraction	Often preserved ejection fraction but with outflow obstruction	Preserved ejection fraction but impaired filling
Risk of Arrhythmias	High	High	Moderate to high
Common Complications	Heart failure, arrhythmias, thromboembolism	Sudden cardiac death, heart failure	Heart failure, arrhythmias
Diagnostic Tools	Echocardiogram, MRI, ECG, blood tests, genetic testing	Echocardiogram, MRI, ECG, genetic testing	Echocardiogram, MRI, ECG, biopsy
Treatment Options	Medications, lifestyle changes, ICD, heart transplant	Medications, lifestyle changes, ICD, septal myectomy	Medications, lifestyle changes, treat underlying cause, heart transplant
Prognosis	Variable; can be stable or progressive	Generally good with treatment, but risk of sudden death	Poorer prognosis due to underlying conditions
Lifestyle Modifications	Avoid alcohol, low-sodium diet, regular exercise	Avoid intense exercise, maintain healthy diet	Low-sodium diet, regular but moderate exercise

Treatment:

• Medications:
  • Beta-blockers, ACE inhibitors, or ARBs to reduce heart strain.
  • Diuretics to manage fluid retention.
  • Anti-arrhythmic drugs to control irregular heartbeats.
• Lifestyle Changes:
  • Dietary modifications, exercise, and avoiding alcohol.
• Implantable Devices:
  • Pacemakers or Implantable Cardioverter Defibrillators (ICDs) to regulate heartbeat.
• Surgery:
  • Septal myectomy (removal of thickened heart muscle) in severe HCM.
  • Heart transplant in advanced cases.
• Gene Therapy: Emerging treatments aimed at addressing underlying genetic causes.

In summary, while cardiomyopathy can be a serious condition, many patients manage well with appropriate treatment and lifestyle changes. The prognosis is highly individualized and depends on a combination of factors specific to each patient. Early diagnosis and treatment are crucial to managing cardiomyopathy and improving the quality of life and prognosis for affected individuals. Regular follow-up with a cardiologist is crucial for monitoring the condition and adjusting treatment as necessary.

Cholesterol Lowering Drugs

These medications are used for patients with hyperlipidemia, dyslipidemia, and hypercholesterolemia. The first line of treatment for increased cholesterol level is still dietary therapy, lifestyle changes, weight loss, and exercise.

1. Bile acid sequestrants lower LDL cholesterol by binding to bile acids, preventing cholesterol absorption in the small intestine. 

They benefit patients with Type 2 diabetes by reducing blood sugar levels and can quickly lower plasma thyroid hormones, making them useful for refractory thyrotoxicosis. Additionally, they can raise HDL-C levels and are used to manage pruritus in patients with cholestatic disease and incomplete biliary obstruction. 

However, these medications can cause gastrointestinal side effects like nausea, bloating, cramping, and increased liver enzymes. Dyspepsia and bloating can be mitigated if cholestyramine is fully suspended in liquid hours before ingestion. Bile acid sequestrants can also inhibit the absorption of fat-soluble vitamins such as vitamin K, leading to potential clotting issues.

Examples: 

cholestyramine (Questran)

colesevelam (Welchol)

colestipol (Colestid)

2. Fibric Acids- prevent cardiovascular disease in patients with elevated triglycerides and low HDL when diet and lifestyle changes are unsuccessful. Fibrate commonly causes dyspepsia and has also been shown to produce fatigue, vertigo, pancytopenia, and elevation of serum transaminases.

Examples: 

fenofibrate (Tricor)

fenofibric acid (Trilipix)

Gemfibrozil (Lopid)

3. HMG CoA Reductase Inhibitors- inhibit the enzyme in the liver (HMG-CoA reductase) responsible for making cholesterol. 

Examples: 

atorvastatin (Lipitor)

pitavastatin (Livalo)

pravastatin (Pravachol)

osuvastatin (Crestor)

simvastatin (Zocor)

lovastatin (Mevacor)

4. Other

Ezetimibe (Zetia) is a synthetic 2-azetidinone agent that lowers cholesterol by inhibiting its absorption in the intestines, unlike other cholesterol-lowering agents that increase bile acid excretion or inhibit cholesterol synthesis in the liver. It can be taken with meals and safely used with statins or fibrates. When taken with bile acid sequestrants, it should be dosed at least 2 hours before or 4 hours after. Side effects of ezetimibe include fatigue, diarrhea, headache, runny nose, body aches, back pain, chest pain, joint pain, sore throat, and elevated serum transaminases.

ezetimibe & simvastatin (Vytorin)

MORE ON STATINS

Statins, also known as HMG-CoA Reductase Inhibitors, reduce low-density lipoproteins (LDL) or "bad" cholesterol but typically do not affect high-density lipoprotein (HDL) or "good" cholesterol. They work by inhibiting the liver enzyme HMG-CoA reductase, which is responsible for cholesterol production. Statins also stabilize and shrink fatty plaques, prevent their rupture, inhibit clot formation, and reduce inflammation. Statins usually have the suffix "-statin."

When taken correctly, statins can lower the risk of coronary artery disease and the risk and recurrence of stroke. However, they can cause side effects such as nausea, headache, blurred vision, muscle pain, rashes, flushing, and gastrointestinal disturbances. Additionally, some patients may experience elevated liver enzymes, hyperglycemia, and hyperuricemia.

Lab Values to Watch Out for When on Statins

Normal Liver Function Test

ALT 7-55 units per liter (U/L)

AST 8-48 U/L

ALP 45- 115 U/L

Albumin 3.5-5 grams per deciliter (g/dL)

Total protein 6.3-7.9 g/dL

Bilirubin 0.1 to 1 mg/dL

GGT 9-48 U/L

LD 122-222 U/L

PT 9.5-13.8 seconds

Normal random blood glucose: 70-140 mg/dl

BUN 7-20 mg/dL

Nursing Precautions and Recommendations for Statins

1. Advise your client to take this during evening meal. Most cholesterol synthesis occurs at night, reflecting the fasting state. Thus, prompting the statins to be administered at evening or bedtime.

2. Assess and monitor the increase in muscle pain and liver enzyme

3. Annual eye exam should be facilitated so as to monitor for the formation of cataracts

4. Never give to clients with preexisting gallbladder disease

5. Patients should avoid taking grapefruit juice since it may increase drug toxicity and adverse effects

References: 

Bansal AB, Cassagnol M. HMG-CoA Reductase Inhibitors. [Updated 2023 Jul 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542212/

Chhetry M, Jialal I. Lipid-Lowering Drug Therapy. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541128/

Duong H, Bajaj T. Lovastatin. [Updated 2023 Mar 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK540994/

Sizar O, Nassereddin A, Talati R. Ezetimibe. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532879/ 

All About Clostridium Difficile Infection (CDI). Please Read to Prevent Its Spread!

 

Clostridium Difficile Infection (CDI) is the most common healthcare-associated infection, causing half a million infections and an estimated 29,000 deaths. Protect yourself and your family.  

Risk Factors for CDI
Most cases of C. diff occur when you’ve been taking antibiotics.

There are other risk factors: • Being 65 or older • Recent hospitalizations • A weakened immune system • Previous infection with C. diff or known exposure to the germs. 

Symptoms of CDI

Symptoms can vary depending on the degree of inflammation in the colon, ranging from mildly loose stools to over twenty episodes of diarrhea per day. Abdominal pain and fever may also manifest.

In severe instances, a C. difficile infection can lead to potentially life-threatening complications such as dehydration due to excessive fluid loss from diarrhea, low blood pressure, toxic megacolon (markedly distended colon requiring surgical intervention), and colon perforation.

Precautions

Healthcare professionals, including nurses and doctors, need to strictly adhere to isolation protocols to prevent the spread of this infection. These protocols involve contact and enteric precautions:

• Hand Hygiene: Healthcare providers and visitors should thoroughly wash their hands with soap and water before and after entering a patient's room, using the restroom, or moving between patients. Handwashing with soap and water is preferred over hand sanitizer for effectiveness.
• Personal Protective Equipment: Healthcare workers and visitors should wear disposable gowns and gloves when interacting with infected patients. Gloves are necessary when handling potentially contaminated materials, while gowns should be worn if there's a risk of fecal soiling. Proper removal of gowns and gloves followed by hand hygiene is crucial before leaving the patient's room.
• Room Placement: Ideally, patients with C. difficile should be isolated in private rooms with dedicated bathrooms. If private rooms are unavailable, patients can be grouped based on their C. difficile status.
• Environmental Cleaning: All surfaces in healthcare settings should be thoroughly disinfected using chlorine bleach products since C. difficile spores can survive on surfaces even after standard cleaning.

Enhanced Barrier Precautions For Nursing Homes:

Enhanced Barrier Precautions (EBPs) involve using personal protective equipment (PPE) to minimize the transmission of multidrug-resistant organisms (MDROs) in nursing home settings. EBPs are implemented during high-contact resident care activities and entail wearing gowns and gloves for residents known to be infected with or colonized by MDROs or those at a heightened risk of acquiring them. This includes residents with wounds, indwelling medical devices, central lines, urinary catheters, feeding tubes, tracheostomies, or ventilators.

MDRO transmission is common in skilled nursing facilities, and can lead to increased healthcare costs, as well as significant resident morbidity and mortality. 

Sending Specimen for C Diff Testing

• Do NOT send stool for C. difficile testing without diarrhea (≥ 3 loose bowel movements in 24 hours).
• Do not send stool if there has been recent use of laxatives. Discontinue laxatives and consider testing if diarrhea continues beyond 48 hours and there is no alternative explanation for the diarrhea.
• Testing requires approval from the ID attending on-call.
• Do not send repeat specimens to document “test of cure.” The test can remain positive for weeks after treatment
• Do not repeat testing in patients who have undergone recent fecal microbiota transplantation (FMT) for the same reason (Fecal microbiota transplantation 0r FMT, commonly referred to as stool transplant, is a medical procedure wherein beneficial bacteria from a healthy donor are transferred to the colon of a recipient. The aim is to alter the microbial composition of the recipient's gut, offering potential health advantages. FMT is widely accepted as the preferred treatment for recurrent C. diff  infections.)

Antibiotic Therapy for CDI

 The Agency for Healthcare Research & Quality (AHRQ) has launched a fresh online initiative, the Safety Program for Enhancing Antibiotic Use, designed to enhance antibiotic usage across acute, long-term, and ambulatory care settings by strengthening antibiotic stewardship programs. The objective is to discontinue antibiotics whenever feasible. Antibiotic usage stands as the foremost risk element for CDI (Clostridioides difficile infection). Specifically, broad-spectrum antibiotics such as clindamycin eliminate a wide range of gut bacteria, many of which play crucial roles in human health.  

C diff treatment is based on the severity of symptoms. Below are some treatment guidelines followed by hospitals as recommended by Infectious Disease (ID) doctors. Always follow your hospital policy.

Severity	Clinical Manifestations	Treatment
Asymptomatic colonization	Positive C. difficile test without diarrhea, ileus, or colitis	No treatment necessary
Non-severe	Positive C. difficile test with diarrhea and no manifestations of severe disease	Vancomycin 125 mg* every 6 hours PO/NGT for 10 days (pre-approved)
Severe	Positive C. difficile test with diarrhea and ≥ 1 of the following attributable to CDI ·  WBC ≥ 15,000 · Serum Cr > 1.5 mg/dL	Vancomycin 125 mg* every 6 hours PO/NGT for 10 days (10 days are pre-approved) Consider GI consultation for Fecal Microbiota Transplantation (FMT) in patients without improvement on 5 days of therapy
Fulminant*	Criteria as above with ≥ 1 of the following attributable to CDI · Hypotension · Toxic megacolon · Lactate ≥ 4 · ICU admission for severe disease	Vancomycin 500 mg PO/NGT every 6 hours AND Metronidazole 500 mg IV every 8 hours If unable to tolerate oral therapy can consider Vancomycin retention enema (500 mg in 100 mL Normal Saline every 6 hours) Please consult GI for Fecal Microbiota Transplantation (FMT) Please consult ID and Surgery

(Note: There is a difference between infected and colonized by C Diff. Those who are infected are 'symptomatic". While those who are colonized are "asymptomatic" but still carry the organism in their system. Always observe handwashing and barrier precautions in both cases.)

Other treatment recommendations:

 Avoid use of anti-motility agents in patients with CDI.

 Avoid use of binding agents (e.g. cholestyramine) as they can bind oral vancomycin.

 If patient is not improving on vancomycin, other causes should be evaluated and/or FMT considered. Fidaxomicin is not to be used as a rescue medication if patient is not improving on vancomycin.

 Routine prophylactic use of metronidazole or oral vancomycin is not recommended. There may be specific situations where this is warranted and this should be discussed with ID.

 

Recurrent CDI

 Defined as episode of symptom onset and positive assay result following an episode of positive assay result in previous 2-8 weeks

 Resistance to either metronidazole or vancomycin has not been described.

 Recurrence occurs in approximately 25% of patients and can be due to failure to eradicate spores or acquisition of a new strain. The risk for recurrence increases with every bout of CDI.

I hope you learned something from this article and please check out the references below for more information about CDI. Thank you.

Please watch the YouTube videos that covers this topic: 

Clostridium Difficile Infection Lecture Part 1

 

Clostridium Difficile Infection Lecture Part 2

 

References:

https://apic.org/professional-practice/implementation-guides/

https://apic.org/resources/topic-specific-infection-prevention/clostridium-difficile/

https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html#:~:text=1.,wounds%20or%20indwelling%20medical%20devices).

https://cdiff.org/wp-content/uploads/2023/10/seecdiff_factsheet.pdf

https://cdiff.org/c-diff-myths/

https://cdiff.org/clinician-resources/?gad_source=1&gclid=CjwKCAjwmYCzBhA6EiwAxFwfgDkf9tLA-SmZSpF199MUVuYeXFZ6GoFDEwUrzpSGKFlfzARAnRQJgRoCu1oQAvD_BwE

Did You Know That Bruce Lee Died of Heat Stroke? Let's Learn How to Manage Heat Related Illnesses

 How to Manage Heat Related Illnesses

Did you know that martial arts movie icon Bruce Lee died of a heat stroke at the age of 32 on July 20, 1973, the hottest day of the month that year in Hong Kong? 

Several months before his death, Lee underwent surgery to remove the sweat glands from his armpits, believing that sweaty armpits looked unattractive on screen. This surgery reduced his body's ability to cool itself. On May 10, ten weeks before his death, Lee went into a small dubbing room to re-record dialogue for "Enter the Dragon." 

The sound engineers turned off the air conditioner to prevent noise interference with the recording. After about 30 minutes in the stifling room, Lee fainted and began convulsing. He was rushed to the hospital and nearly died from cerebral edema, which the doctors managed to diagnose and treat just in time.

The medical team did not recognize that his collapse was most likely caused by heat stroke, a common cause of death among young athletic men during the summer. In the United States, an average of three high school and college football players die each year from heat stroke. Autopsies of heat stroke victims often reveal cerebral edema. 

According to Dr. Lisa Leon, an expert in hyperthermia at the U.S. Army Research Institute of Environmental Medicine, “A person who has suffered one heat stroke is at increased risk for another. Patients experience multi-organ dysfunction during the hours, days, and weeks of recovery, which increases the risk of long-term disability and death.”

Heat Related Illnesses

Heat-related illnesses vary in severity from mild to life-threatening. Additionally, heat exposure worsens many common health conditions such as heart, respiratory, and kidney diseases. As summer is drawing near, we have to be aware of heat related illnesses and its management.

                 

Heat Syncope: This refers to dizziness or fainting due to standing up too quickly in the heat or pooling of blood in the limbs from vasodilation, especially when no other cause is identified. It is more frequent in individuals with heart conditions or those taking diuretics. Treatment: Remove the patient from the heat and treat with rest in a supine position, passive cooling, and rehydration (either oral or intravenous). If recovery is prolonged or if there are concerns about a cardiac cause, especially in patients with cardiac risk factors, further evaluation is necessary.

Heat Edema: This is a mild swelling in dependent areas of the body, typically seen in people who are not yet acclimated to hot environments.  Treatment: Remove patient from heat and elevate the legs. Diuretic agents are not indicated.

Heat Cramps: Painful muscle spasms in the abdomen, arms, or legs can occur during or after activity in the heat, often due to excessive salt loss from sweating during physical exertion. Treatment: Remove patient from heat, treat with rest, oral electrolytes, and fluid repletion.

Heat Exhaustion (Prostration) - Profound fatigue, weakness, nausea, headache, or dizziness (or a combination of these symptoms) can result from decreased body water content or blood volume due to water or salt depletion from heat exposure. Mild body temperature elevation (below 40°C) may be present, but there is no altered mental status. Treatment: Remove the patient from the heat and treat with rest in a supine position, evaporative cooling, and rehydration (intravenous or oral). Monitor mental status, and if there is a delayed response to treatment, further evaluation is needed.

Heat Stroke

Heat stroke is the least common but most dangerous heat illness, often fatal without immediate treatment. The most frequent victims are the urban elderly poor. It is identified by a body temperature exceeding 40ºC.

    Predisposing Factors: Salt and water depletion, infections, fever post-immunization, lack of acclimatization, obesity, drug use, fatigue, and various medical conditions like cardiovascular disease, diabetes, malnutrition, alcoholism, hyperthyroidism, impaired sweating, and potassium deficiency. 

Heat stroke can be categorized into two forms: classic and exertional.

1. Classic Heat Stroke: Occurs after several days of high temperatures (above 37.0ºC) or lower temperatures with high humidity. Continuous sweating eventually ceases, causing a rapid rise in body temperature. The first symptom may be sudden collapse. In 80% of cases, onset is abrupt with the patient becoming delirious, comatose, or having seizures. In the remaining 20%, symptoms like weakness, dizziness, nausea, fainting, or frontal headache precede collapse. Muscle cramps are rare. Patients typically have hot, dry skin but may continue sweating. Progression to coma is common.

2. Exertional Heat Stroke: Occurs with activities that increase internal heat production. In the U.S., it commonly affects long-distance runners, football players, and military recruits. Intense physical activity usually precedes heat stroke. Overuse of salt supplements with insufficient water can be fatal. Core temperatures might not exceed 40ºC and still be lethal, while in classic cases, patients have survived with temperatures as high as 43.7ºC. Rapid cooling is crucial to prevent extensive tissue necrosis. Common complications include thrombocytopenia, prolonged PT and PTT, marked DIC, hypotension, shock, acute pulmonary edema, and rhabdomyolysis. Severe hypoglycemia and death often result from acute hyperkalemia or renal failure due to extensive muscle breakdown.

Heat Stroke Management: Immediate cooling is critical. Delays in cooling due to misdiagnosis, underestimation of severity, or lack of facilities are major factors leading to death or disability. The ABCs (Airway, Breathing, Circulation) are the first priority. Effective cooling methods include ice water immersion or evaporative cooling with fans and skin wetting. Cooling should cease when core temperature reaches 39º-40ºC, as body temperature will continue to fall. Avoid large initial IV fluid amounts due to the risk of pulmonary edema; use fluid boluses with careful CVP and urine output monitoring. Avoid alpha-adrenergic drugs like norepinephrine. Check glucose levels and administer D50% if needed, especially in exertional heat stroke. Severe rhabdomyolysis may cause hyperkalemia and myoglobinuria, leading to renal failure, shock, and diaphragm necrosis with respiratory failure. Hyperthermia may recur within 3-4 hours, requiring repeated cooling. ICU admission is warranted for management of end-organ sequelae. Monitor patients closely as they may lose the ability to sweat for several weeks.

References:

Treatment and Prevention of Heat-Related Illness | New England Journal of Medicine (nejm.org)

How Did Bruce Lee Die? | HISTORY

Did you know that humans have a second heart?

 Did you know that humans have a second heart? 

The soleus muscle: The body's "second heart"

Did you know that the soleus muscle is often referred to as the "second heart"? 

It serves as an additional pump in the body, complementing the function of the heart. 

While the heart pumps blood outward to the extremities, deep muscles like the soleus aid in pumping blood back towards the heart. 

Positioned at the body's lowest gravitational point when standing upright, the soleus muscle is strategically located to work in harmony with the heart. This muscle, found in the calves, plays a crucial role in facilitating the return of venous blood to the heart from the periphery. 

It is also known as the skeletal-muscle pump, peripheral heart, or the sural (tricipital) pump.

Each time the calf muscle contracts, it triggers the opening of one-way valves within the leg veins, facilitating the upward movement of blood towards the heart. Conversely, when the calf muscle relaxes, these valves close to prevent the backward flow of blood into the legs. 

The dangers of prolonged sitting

Prolonged periods of sitting or standing can elevate pressure in the veins, potentially causing damage to the valves over time, resulting in increased blood pooling in the legs. 

This weakening of the calf muscle pump function can manifest in symptoms characteristic of chronic vein disease, including leg swelling, fatigue, and the development of varicose veins. 

A rare but serious complication of prolonged sitting, such as during a long flight, is the formation of blood clots.

How to keep the soleus pumping

Activate the "second heart" in one simple step: Just walk. Take walking breaks regularly throughout the day, ideally every hour or so, is key. You can get the calf muscle pumping by staying in motion. 

For those with desk jobs or who stand for long periods, prioritizing walking whenever possible is crucial. 

If circumstances prevent getting up, such as during a flight or while stuck at a desk, performing toe raises—flexing the foot up and down—can help replicate the motion of walking to some extent.

The “second heart” only starts pumping when your legs move so keep moving those legs and walk! 

Source: https://www.today.com/health/diet-fitness/what-is-the-second-heart-rcna117576

Pradaxa (dabigatran etexilate mesylate) Capsules Storage Instructions From the FDA

Pradaxa (dabigatran etexilate mesylate) Capsules 

Storage Instructions From the FDA

Pradaxa capsules should only be dispensed and stored in their original bottle or blister package, and patients should follow specific handling requirements.

Facts about Pradaxa

• Pradaxa is an anticoagulant (blood thinner) known as a direct thrombin inhibitor, which prevents the formation of blood clots.
• It is used to help prevent strokes or serious blood clots in people with non-valvular atrial fibrillation (an irregular heartbeat), a condition that increases the risk of clot formation and stroke.
• Between October 2010 and January 2011, around 128,000 Pradaxa prescriptions were dispensed, with approximately 86,000 patients filling these prescriptions at outpatient retail pharmacies in the U.S.
• The Pradaxa label and Medication Guide provide information on special storage and handling requirements, but the FDA is concerned that these guidelines are not widely known or followed by Pradaxa users and pharmacies.

Many consumers use pill boxes or organizers to help them remember to take their medications. 

However, due to the risk of product degradation and potency loss Pradaxa should not be stored in any container other than its original manufacturer packaging. Keeping Pradaxa capsules in pillboxes can cause it to lose potency increasing the risk of stroke for the patients.

Pharmacists should also dispense Pradaxa capsules only in the original packaging to prevent moisture-related breakdown. Pradaxa bottles contain a 30-day supply with a desiccant (drying agent) in the cap to protect the capsules from moisture. Pradaxa capsules are also available in blister packages, which offer similar protection.

Source: FDA Drug Safety Communication: Special storage and handling requirements must be followed for Pradaxa (dabigatran etexilate mesylate) capsules | FDA