Primary Care of the Transplant Patient

 

Summary Recommendations for the Primary Care of Solid Organ Transplant Recipients

Medications

1. Check for possible drug interactions of all new medications prescribed.

2. Check immunosuppressant levels 48 to 72 hours after initiation of any new medication expected to affect levels.

Hypertension

1. Target blood pressure is <130/<80 mm Hg for renal and liver transplant recipients and for other transplant recipients with renal disease or other cardiac risk equivalents.

2. The choice of blood pressure agents should be influenced by comorbid conditions, the pathophysiology of hypertension in transplant recipients, and drug effects on immunosuppressant levels.

Hyperlipidemia

1. The target LDL is <100 mg/dL for renal transplant recipients.

2. In the absence of data, PCPs should consider treating other transplant recipients to a target LDL of <100 mg/dL.

3. Statins should be used as first-line therapy.

4. Special attention should be paid to the increased risk of myopathy associated with statin use in the transplant population.

Diabetes

1. Recommendations of the American Diabetic Association should be applied to the transplant population.

Malignancy

1. Transplant recipients should be considered at high risk for all malignancies.

2. PCPs should consider shorter screening intervals.

3. Annual dermatological examinations should screen for skin malignancies.

4. Sunblock with an SPF of 60 or greater should be applied daily to sun-exposed skin surfaces.

5. Patients with newly diagnosed malignancy should be considered for a reduction in immunosuppressants.

Immunizations

1. All patients preparing for transplantation should receive immunizations against tetanus, diphtheria, pertussis, Streptococcus pneumoniae, hepatitis A and hepatitis B.

2. After transplantation, booster immunization should be provided for influenza, tetanus, diphtheria, Streptococcus pneumoniae, and hepatitis A and B.

Contraception

1. Women of child-bearing age should be counseled about the need for contraception after transplantation.

2. Low-dose oral contraceptive agents should be considered for women who have diabetes, hypertension, or hyperlipidemia and do not have contraindications for their use.

3. Women should be counseled about the decrease in contraceptive efficacy of intrauterine devices after transplantation.

ScienceDirect - The American Journal of Medicine : Primary Care of the Transplant Patient

Doctors on Facebook – dangers of open society networks

 

Clinicians & Facebook: The Boundaries of Professionalism
Anne Meneghetti, MD
Director, Clinical Communications

Imagine a series of photos showing you in progressive stages of drunkenness at a party.  Imagine a quote in which you gripe about a particularly difficult day at work, using robustly colorful language. Imagine the reaction from patients, colleagues, or prospective employers as they view these on Facebook.  A study of medical trainees¹ found that nearly half had a Facebook account; 70% of them had posted photos showing alcohol, some with implied excess. Examples of foul language were present, as well as comments such as, “Physicians looking for trophy wives in training.”

In light of the unprecedented access to personal information on the web, consider the following if you choose to create a digital identity on Facebook:

1.
Scrupulously examine both privacy and profile settings, limiting access only to “friends” you accept; “friends of friends” might be patients.  Limit who can “tag” a photo of you or post on your personal page. Ignore “friend” requests from patients; explain your policy at the next face-to-face visit.

2.
If you choose to create a separate professional identity (Facebook business or group page), consider that page “fans” may perceive it as a direct hotline to you.  Privacy concerns, lack of 24/7 monitoring of messages, medical recordkeeping, and misuse of the page for emergency inquiries are serious issues.

3.
If you come across information about a patient through social networking sites, do not record it in the medical record without the patient’s consent.

Patients understand that clinicians are human beings with lives outside the office, and social media serves to personalize our profession. Maintaining a professional online persona preserves the mutual trust and respect we share with patients.

¹Thompson LA, J Gen Intern Med. 2008 Jul;23(7):954-7.

Epocrates Pulse: Social Media and Medicine

Hoarseness – Take-home points

 

Red flag symptoms are persistent hoarseness for more than three weeks, difficulty or pain on swallowing, haemoptysis, earache with normal otoscopy, weight loss, and heavy smoking or alcohol intake

Urgent chest x ray is needed if hoarseness persists for more than 3 weeks (especially if the patient is a heavy drinker, smoker, or over 50 years old)

If the x ray is positive, refer urgently for suspected lung cancer. If it's negative, refer urgently for suspected head and neck cancer

Routine ENT referral is advised for recurrent but non persistent (<3 weeks) hoarseness with no red flag symptoms

Advise patients to stop smoking, reduce alcohol intake, and improve vocal hygiene

Treat any exacerbating conditions such as oral thrush, asthma, or rhinitis 

5 Minutes of General Practice from BMJ