Acute heavy menstrual bleeding

Blog Post  by Malcolm G. Munro MD, FACOG, FRCS(c), Professor, Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Director of Gynecologic Services, Kaiser Permanante, Los Angeles Medical Center, Los Angeles, CA, USA

Recently a young healthy woman presented with acute heavy menstrual bleeding (HMB) and was placed on a multidose combination estrogen-progestin oral contraceptive (COC) regimen. As the bleeding stopped she developed central neurological symptoms and findings and was diagnosed with internal jugular venous thrombosis that resulted in profound neurological sequellae. Investigation identified the presence of a previously undiagnosed case of von Leiden factor deficiency. This case provides a suitable backdrop for discussion about acute heavy uterine bleeding, the role for medical therapy, and the potential consequences of high dose estrogenic interventions.

The entity of acute HMB has only recently been defined as heavy uterine flow not associated with pregnancy that is of sufficient volume to require urgent or emergent medical intervention.¹  Although research evaluating the causes of this recently defined entity is necessary, it is likely that ovulatory disorders (AUB-O) are the most common cause. However, coagulopathies may also contribute (AUB-C), and, particularly in adolescents with von Willebrand disease, may augment the heavy bleeding associated with perimeharcheal anovulation (AUB-C, -O). Arteriovenous malformations are yet another but admittedly rare entity that can also cause acute HMB.

Treating radiation injuries in US travelers returning from Japan

March 22, 2011 — In response to the crisis in Japan, the US Centers for Disease Control and Prevention (CDC) hosted a conference call for clinicians to answer questions about treating radiation injuries in US travelers returning from Japan.

During the hour-long Clinician Outreach and Communication Activity call yesterday evening, Jeffrey Nemhauser, MD, who is a captain in the US Public Health Service and a medical officer in the CDC’s Radiation Studies Branch, answered questions from healthcare providers about radiation exposure and treatment.

Dr. Nemhauser stressed that the CDC is not aware of any US travelers returning from Japan who have been “contaminated with material at a level of concern.” If a traveler is contaminated, the CDC will recommend decontamination, collect data, and follow-up with the traveler, he said.

Customs officials routinely screen travelers (and their luggage) entering the United States for radiation contamination, he said. Because of the radiation leaks in Japan, however, the CDC is creating extra screening protocols for airports. Dr. Nemhauser said that these protocols should go into effect this week.

Medical Resources Strained in Japan

 March 17, 2011 — The devastating magnitude 9.0 earthquake and tsunami that occurred in Japan’s Miyagi prefecture on March 11 have caused a cascade of health and safety problems for survivors, including possible exposure to radiation from the region’s damaged Fukushima Daiichi nuclear plant. The disaster has strained medical resources on the ground, but it is unclear how many resources will be needed in the future.

“This is a very complex disaster, and it’s an evolving, ongoing situation,” Kristi L. Koenig, MD, director of the Center for Disaster Medical Sciences at the University of California–Irvine, told Medscape Medical News.

“The recovery phase of this disaster is going to be years and years and years,” she said. “They need people over the next many months to years to help, because the whole public health infrastructure is disrupted.”

Japan’s experience has been very different from Haiti, where a magnitude 7.0 earthquake struck in January 2010 and created a vast need for medical help. “In Haiti, the existing healthcare infrastructure was basically nonexistent,” Dr. Koenig said, “and the building codes for earthquakes were not anywhere near what they are in Japan.”

Unlike Haiti, Japan has well-organized civil defense teams that helped victims immediately until outside help was available, Dr. Koenig pointed out. These factors likely mitigated the injuries and deaths from the earthquake in Japan.

“Japan has significant emergency management capacity — one of the best in the world,” Margaret Aguirre, director of global communications for the International Medical Corps, told Medscape Medical News in an email.

Future Clinical Assistance May Be Needed

Abnormal uterine bleeding

Blog Post  by Malcolm G. Munro MD, FACOG, FRCS(c), Professor, Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Director of Gynecologic Services, Kaiser Permanante, Los Angeles Medical Center, Los Angeles, CA, USA

Many medical students, registrars/residents, primary care physicians and even gynecologic specialists struggle when confronted with a patient with abnormal uterine bleeding (AUB) in the reproductive years. This is no surprise as both the investigation and management of abnormal AUB in such women has been hampered by confusing and inconsistently applied nomenclature and the lack of standardized methods for investigation and categorization of the various potential causes of the problem.(1, 2) Terms such as “menorrhagia” and “dysfunctional uterine bleeding” frequently have different meanings in different environments, often resulting in misinterpretation of patients, colleagues, and textbooks or the medical literature. In addition, while many potential causes of AUB are invisible such as endometrial defects or coagulopathies, many uterine entities that are discernable, such as adenomyoais, leiomyomas, and endometrial polyps, are frequently asymptomatic.

Neuroanesthesia and anesthesiology

Blog Post by George A. Mashour MD, PhD, Director, Division of Neuroanesthesiology and Assistant Professor of Anesthesiology and Neurosurgery,  University of Michigan

Neuroanesthesia is a subspecialty of anesthesiology that focuses on the perioperative care of patients undergoing surgery of the brain, spine or peripheral nerves. Because the drugs routinely used for anesthesia have their therapeutic action at all of these sites, anesthesiologists and neurosurgeons must “share” the nervous system during the course of an operation. This becomes particularly important at the end of surgery, when the assessment of neurologic function is a major priority. If, for example, a patient has suffered a stroke or has brain swelling, it needs to be recognized and acted upon rapidly before permanent damage occurs.

CAM-ICU Delirium Test

Blog Post and YouTube video by Valerie Page, UK national clinical lead in ICU delirium

Watch the YouTube video now on CAM-ICU Delirium Test

ICU delirium is associated with adverse outcomes particularly long-term cognitive impairment, effectively at the very least a mild dementia and second that it will usually go undiagnosed unless we screen for it.  To diagnose and manage delirium does not require equipment, money or a great deal of training.  If we can modify the incidence or duration of delirium “delirium dose” there is the potential for improving patient’s outcomes, particularly brain function.

Disaster Medicine Core Competencies for Emergency Physicians, Nurses and EMTs

Blog Post by Carl H. Schultz, MD, Professor of Emergency Medicine

The specialty of disaster medicine continues to grow and mature.  Journals dedicated to this field of study as well as textbooks now exist.  In fact, ACEP has recently endorsed a new reference text published by Cambridge University Press entitled Koenig and Schultz’s Disaster Medicine:  Comprehensive Principles and Practices.  Ideally, this body of scientific data would lead to development of a standard set of clinical competencies for those involved in the initial evaluation and treatment of disaster victims.  This is needed to ensure that effective emergency medical response can be provided efficiently during all types of disaster events.  Creation of broadly-recognized standard core competencies to support development of disaster response education and training for specific healthcare professionals will help to ensure that medical personnel are truly prepared to care for victims of mass casualties.  Nonetheless, a widely supported standardized set of core competencies for emergency physicians, nurses, and pre-hospital EMS personnel is currently lacking. 

What should you read to prepare for MRCOG II Written

Blog Post by Arri Coomarasamy, MBChB, MD, MRCOG, DFFP, lecturer and specialist registrar in obstetrics and gynaecology

As my past course candidates know, I am a great fan of the “Handbook of Gynaecological Oncology” by Shafi, Luesley and Jordan. It summarised all you needed to know about gynae cancers in 277 A5 size pages, with very little padding and fine print, and was as readable and enjoyable as the classic gold standard of Nelson-Piercy’s Handbook of Obstetric Medicine. However, I didn’t recommend this book in 2009; the reason was that it had aged (it was published in 2001). So, imagine my delight when I found a new book “Gynaecological oncology” by Shafi, Earl and Tan! I bought it and have already read half of it, and it is proving to be an absolute pleasure! This book is likely to take  the pain outof your MRCOG oncology revision!  Just like “Mr Muscle” kitchen cleaner, it makes you love the job you hate! I highly recommend it: 205 pages of highly relevant stuff for MRCOG.

Gynaecological Oncology is published by Cambridge University Press

Third National Congress of Health System Readiness: Disaster Medicine and Public Health Preparedness in the 21st Century

Blog Post by Kristi L. Koenig, MD, FACEP, Professor of Emergency Medicine, Director of Public Health Preparedness, Director, International Disaster Medical Sciences Fellowship, http://www.ucihs.uci.edu/emergmed

On December 1st in Washington DC nearly 500 physicians and others involved in public health preparedness gather at a joint session of the American Medical Association and the federal Department of Health and Human Services during the Third National Congress of Health System Readiness:  Disaster Medicine and Public Health Preparedness in the 21^st Century .  The session, delivered by senior government officials and academicians, is entitled “Medical Countermeasures:  From the Bench to the Bloodstream.”  This follows a full day of presentations that focused on using science to inform evidence-based preparedness for disasters of all types.  Highlights included an update on the threat and management of terrorist bombings, current concepts in mass casualty triage, and a fascinating international presentation about terrorist attacks and health system surge capacity with senior health and policy representatives from Israel, London, Madrid and Mumbai.  These provocative presentations were followed by interactive discussions with the audience, several of whom were contributors to the newly published Koenig and Schultz’s Disaster Medicine: Comprehensive Principles and Practices .  I look forward to future discussions with experts on the H1N1 pandemic.  The Congress concluded with several sessions focusing on the future of public health preparedness to include a special panel on education and training. 

Leadership and Management in the operating department

Blog Post by Paul Wicker, Head of Perioperative Studies, Faculty of Health, Edge Hill University, Ormskirk, UK

Ugh! I can hear you now, after all, who on earth would be interested in a droll subject like leadership and management, let alone buy a book about it!

Well, I think that there are three main reasons why you might want to read Operating Department Practice, Leadership and Management. Firstly there are 234 million surgical procedures carried out in the world annually. Somebody has to manage that mess. Secondly, if you work in an operating department, you might be the manager taking the buck for it all. Thirdly, you might be at the receiving end of all of this. Wouldn’t you want your operation to go smoothly?