Oral anticoagulants and reversal/hemostatic strategies.

In the elegant tug-of-war between thrombosis and hemostasis, prescribing an

 anticoagulant is essentially telling the clotting cascade, “Let’s all just relax,” until

 the moment it relaxes a bit too much and starts free styling. At that point, the

 clinician must pivot with theatrical composure, as if this was the plan all along, and

 gently convince the body to reconsider its life choices. Enter Vitamin K, the polite

 memo to the liver that productivity is once again expected; Prothrombin Complex

 Concentrate (PCC), essentially clotting factors arriving like an over prepared

 emergency committee; and the delightfully specific Idarucizumab and Andexanet

 alfa, which function as the rare “ctrl+Z” buttons in medicine. All the while, the

 clinician must maintain a reassuring calm because nothing stabilizes a patient quite

 like someone who looks as though reversing a potentially catastrophic bleed is

 merely a minor administrative correction, rather than an intense, real-time negotiation with a coagulation system that occasionally behaves like it has read the

 textbook and chosen rebellion.

 

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Pulse oximetry and Capnography

Essential tools for monitoring respiratory health, but they serve different purposes:

Pulse Oximetry: 

• Measures blood oxygen saturation (SpO₂) and pulse rate. 
• Normal SpO₂ is 95–100%. 
• It’s useful for tracking oxygenation but may delay detecting ventilation issues.

Capnography: 

• Monitors exhaled CO₂ (EtCO₂) and respiratory rate. 
• Normal EtCO₂ is 35–45 mmHg. 
• It detects ventilation problems faster and provides real-time updates.

While SpO2 monitors oxygenation (often delayed), EtCO2 measures metabolic

 perfusion and ventilation. 

Continuous capnography detects almost 6 times more potential respiratory events

 than SpO2 alone.

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Cervical Artery Dissection (CAD)

Occurs as a result of the interplay among risk factors, minor trauma, anatomic &

congenital abnormalities, & genetic predisposition.

Diagnosis can be challenging both clinically & radiologically.

In those with acute ischemic stroke attributable to CAD, acute treatment

strategies such as thrombolysis & mechanical thrombectomy are reasonable in

otherwise eligible patients.

AHA suggest that the antithrombotic therapy choice be individualized &

continued for at least 3 to 6 months.

Risk of recurrent dissection is low, & preventive measures may be considered

early after the diagnosis & continued in high-risk patients. 

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Perioperative Antithrombotic Management:

The recommended pre-operative workup for patients taking anticoagulants involves

 stratifying both thromboembolic & bleeding risk, determining appropriate timing for

 medication interruption, & deciding whether bridging therapy is needed. The

 specific approach depends on the type of anticoagulant, renal function, and

 procedure-related bleeding risk.

• Direct Oral Anticoagulants (DOACs)

1. For apixaban, rivaroxaban, and Edoxaban, the American College of Chest Physicians recommends stopping these agents 1-2 days before low-to-moderate bleeding risk procedures and 2 days before high bleeding risk procedures.

• For dabigatran, interruption timing depends on renal function. 

1. With normal renal function (CrCl ≥50 mL/min), stop 1-2 days before low-risk procedures and 2 days before high-risk procedures. 
2. With impaired renal function (CrCl <50 mL/min), extend interruption to 3-4 days before high-risk procedures due to predominantly renal clearance.

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Urinary Tract Infections (UTI)

• Women have a lifetime risk of 53% of experiencing UTI. 
• Men prior to age 50, have lifetime risk is 14%.
• Risk of experiencing a UTI increase with age in both sexes.

Classification:

• Uncomplicated UTI

Infection confined to the bladder in afebrile women or men.

• Complicated UTI: 

Infection beyond the bladder in women or men. 

• Pyelonephritis 
• Febrile or bacteremic UTI 
• Catheter-associated (CAUTI)
• Prostatitis.

Catheter- Associated UTI (CA-UTI)

• CAUTIs are one of the most common healthcare-associated infection (HAI).
• 75% of UTIs developed in hospitals are associated with a urinary catheter.
• 15-25% of hospitalized pts receive urinary catheters during their hospital stay.
• CAUTIs are associated with increased morbidity, mortality, healthcare costs & LOS.
• They are preventable.

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Invasive Fungal Infection (IFI

 

Invasive fungal infections are severe infections in which fungal pathogens invade normally sterile body sites. They predominantly affect immunocompromised patients, including those with neutropenia, hematologic malignancies, solid organ or stem cell transplants, and prolonged corticosteroid or broad-spectrum antibiotic use.

Common Pathogens

• Candida species (most frequent cause of bloodstream infections)
• 
  
• Aspergillus species (primarily pulmonary infections)
• 
  
• Cryptococcus species (commonly CNS involvement)
• 
  
• Emerging molds and rare fungi in high-risk populations

Risk Factors

• Immunosuppression (neutropenia, chemotherapy, transplant)
• 
  
• Indwelling catheters or prosthetic devices
• 
  
• Prolonged ICU stay and broad-spectrum antibiotic exposure

Clinical Presentation

• Symptoms vary by site of infection and may include fever, organ dysfunction, respiratory distress, or neurological deficits

Diagnosis

• Culture and microscopy from sterile sites
• 
  
• Antigen/antibody testing (e.g., β-D-glucan, galactomannan, cryptococcal antigen)
• 
  
• Imaging studies (CT, MRI) for organ involvement
• 
  
• Histopathology when feasible

Management Principles

• Early initiation of targeted antifungal therapy
• 
  
• Source control, including removal of infected catheters or drainage of abscesses
• 
  
• Selection of therapy guided by species identification and antifungal susceptibility
• 
  
• Multidisciplinary approach with infectious diseases consultation

Prognosis

• Dependent on timely diagnosis, host immunity, and pathogen virulence
• 
  
• Delays in treatment significantly increase morbidity and mortality

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Ulcerative Colitis

 

The diagnosis of UC is best made with endoscopy and mucosal biopsy for

 histopathology. Laboratory studies are helpful to exclude other diagnoses and assess

 the patient's nutritional status, but serologic markers can assist in the diagnosis of

 inflammatory bowel disease. Radiographic imaging has an important role in the

 workup of patients with suspected inflammatory bowel disease and in the

 differentiation of UC from Crohn disease by demonstrating fistulae or the presence of

 small bowel disease seen only in Crohn disease.

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Orbital Cellulitis

Peri-orbital and orbital cellulitis are distinct clinical diseases, though have overlapping clinical features and therefore can be difficult to differentiate

• Orbital cellulitis: Infection within the orbit, (ie post-septal, the structures posterior to the orbital septum); Surgical emergency with major complications including loss of vision, abscess formation, venous sinus thrombosis and extension to intracranial infection with subdural empyema, and meningitis; & the majority (>80%) of cases relate to local sinus disease.
• Peri-orbital cellulitis: Infection of the eye lids and surrounding skin not involving the orbit (ie pre-septal, the structures anterior to the orbital septum)
• The globe is not involved in either infection.

The causative organisms, commonly bacterial but can also be polymicrobial, often including aerobic and anaerobic bacteria and even fungal or mycobacteria. The most common bacterial organisms causing orbital cellulitis are Staphylococcus aureus and Streptococci species. Rare cases of orbital cellulitis caused by non-spore-forming anaerobes Aeromonas hydrophila, Pseudomonas aeruginosa, and Eikenella corrodens have also been reported. 

 

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