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

Incidental finding of lymphocytosis in an asymptomatic patient -- Grove et al. 338: b2119 -- BMJ

Causes of lymphocytosis

Reactive (secondary) lymphocytosis

Normal morphology

• Chronic smoking
• Acute hypoxia (transient):

  Acute asthma

  Pulmonary embolus

  Myocardial infarction

• Acute stress (transient)
• Bordetella pertussis

Atypical morphology

• Viral infections:

  Most common—Epstein-Barr virus; cytomegalovirus

  Less common—herpes simplex, influenza, mumps, HIV, dengue haemorrhagic fever; hepatitis A or B

• Bacterial infections:
• • Rickettsial infections
• Drug hypersensitivity

Neoplastic (primary) lymphocytosis

• Chronic lymphocytic leukaemia—most common
• Less common neoplasms:

  Hairy cell leukaemia

  Prolymphocytic leukaemia

  Leukaemic phase of non-Hodgkin lymphoma

Summary of the article

• Lymphocyte morphology can often distinguish between reactive and neoplastic causes of lymphocytosis
• If "atypical lymphocytes" are present, an infectious mononucleosis screening test and viral serology are indicated
• If the lymphocytes have normal morphology and the cause of lymphocytosis is uncertain, repeat the blood count and film in 2-4 weeks
• When lymphocytosis is persistent and unexplained, lymphocyte phenotyping may provide insight into the aetiology

Incidental finding of lymphocytosis in an asymptomatic patient -- Grove et al. 338: b2119 -- BMJ

‘ABCDE’ Mnemonic for Secondary Causes of Hypertension (after American Family Physician, 2003)

A
Accuracy
Alcohol
Apnea
Aldosteronism
Are the blood pressure readings accurate? Could chronic alcohol use be playing a role? Does the patient have obstructive sleep apnea? Does the patient have hypokalemia or other suggestions of primary hyperaldosteronism?

B
Bruits
Bad kidneys
Is there an abdominal bruit suggestive of renovascular hypertension? Does the patient have renal parenchymal disease (which can be cause or a consequence of hypertension)?

C
Catecholamines
Coarctation
Cushing's
Is the patient having palpitations, tachycardia, diaphoresis, headaches, and/or paroxysmal hypertension suggestive of pheochromocytoma? Are there decreased or delayed femoral pulses, or rib notching on chest x-ray suggestive of coarctation of the aorta? Any weight gain, hirstuism, amenorrhea, striae, or moon facies suggestive of Cushing's syndrome?

D
Drugs
Diet
Any use of sympathomimetics, corticosteroids, NSAIDs, oral contraceptive pills, MAOIs, or other drugs that can elevate blood pressure? Are excess dietary sodium or obesity contributing?

E
Endocrine
Erythropoietin
Is there untreated thyroid disease or hyperparathyroidism? Is there another disorder (COPD) leading to increased erythropoietin levels?

Abbr.: NSAID, non-steroidal anti-inflammatory drug; MAOI, monoamine oxidase inhibitor; COPD, chronic obstructive pulmonary disease

Primary Aldosteronism—Changing Concepts in Diagnosis and Treatment (2003)

In patients with suspected primary aldosteronism, screening can be accomplished by measuring a morning (preferably 0800 h) ambulatory paired random PAC and PRA. This test may be performed while the patient is taking antihypertensive medications and without posture stimulation. Spironolactone is the only medication that will absolutely interfere with interpretation of the ratio.

Endocrinology -- Young 144 (6): 2208 Figure 1

JAMA -- A Simplified Approach to the Management of Non-ST-Segment Elevation Acute Coronary Syndromes

While outcomes of controlled studies support a comprehensive approach in the management of patients with NSTE-ACS, many physicians perceive existing guidelines as lengthy and complex. After risk stratification to identify those patients most likely to benefit from an early invasive vs early conservative strategy, a comprehensive management plan can be assembled through an "ABCDE" approach. The elements of this include "A" for antiplatelet therapy, anticoagulation, angiotensin-converting enzyme inhibition, and angiotensin receptor blockade; "B" for beta-blockade and blood pressure control; "C" for cholesterol treatment and cigarette smoking cessation; "D" for diabetes management and diet; and "E" for exercise.

JAMA -- A Simplified Approach to the Management of Non-ST-Segment Elevation Acute Coronary Syndromes, January 19, 2005, Gluckman et al. 293 (3): 349