In addition, some general questions about your approach to screening in relation to this paper:
Does anyone have specific differences in the sequence or diseases you screen for?
Do you screen all your patients with abnormal enzymes for celiac sprue?
Do you agree that ANA, smooth muscle and LKA are second line tests after SPEP?
With regards to the approach I would say that the patient characteristics and epidemiology have to be more closely linked to the approach they outline, for example if I had a person with past IDU with a single abnormal elevation I would screen them for at least HIV, HCV, HBV and not repeat the enzymes before doing so. The case has been made for screening all people regardless for HIV and HCV and CDC recommends screening all adults born between 1945 and 1965 for HCV.
Any comments?
Please consider the topic for the next session and recommend any papers you have. Also please comment if you would like to look at the issue of influenza vaccine and/or Tamiflu effectiveness for the next session. This would bring us to the dreaded metanalysis…..
Chester
Hi all,
Thanks for all your input and discussion. Hope we can get all participants to contribute this session.
We will address one of the areas you identified as important in this session, the approach to elevated liver enzymes in asymptomatic patients with a paper from the NEJM in 2000.
Although a bit dated it demonstrates a relevant approach with all major pathologies outlined and it is open access.
Learning Objectives:
ARTICLE:
Pratt D & Kaplan M. Evaluation of Abnormal Liver-Enzyme Results in Asymptomatic Patients. N Engl J Med. 2000. 342:1266-1271. (NEJM Free Full Text) or click the image of the article.
(Posted on behalf of Neil Gibson)
As a related but interesting side note, this discussion could also include the differences seen between single trials and metanalyses.
(Posted on behalf of Chester Morris)
The results also don’t address the question of spironolactone versus eplerenone and whether one is superior/equivalent to the other and whether those with NYHA class II symptoms and higher ejection fractions could benefit. In addition as with any subjective classification NYHA could be seen as bias in stratification.
Can you share your views on the superior/equivalent nature of spironolactone versus eplerenone?
From my experience in our community there is a lack of clarity on the use of these agents especially among family physicians and guidelines are not yet updated so there is a need for education in this area.
(Posted on behalf of Chester Morris)
I have included two points to ponder to start the discussion. Please feel free to add to the discussion.
In terms of the trial there are always problems here getting representative samples as certain ethnicities and female gender are both underrepresented in the sample. Does anyone have anything to add or any strategies that might deal with the issue of representative samples?
Hi all,
Thanks for following us on the specialist journal club.
Hope you all had a nice weekend and are ready for our first journal club session.
We are going to start with a publication on the use of mineralocorticoid antagonists and mild heart failure addressing one of your topic suggestions. This is the report of the EMPHASIS-HF trial in the NEJM last year.
This paper reported on the study of mineralocorticoid antagonists and heart failure in a group of patients who had not been covered in earlier studies such as EPHESUS (eplerenone in acute myocardial infarction complicated by left ventricular
systolic dysfunction and heart failure) and RALES (spironolactone for NYHA functional class III or IV symptoms).
Specifically those with NYHA II functional class and either an LVEF ?30 percent or LVEF >30 and ?35 percent and QRS duration >130 msec.
This paper is interesting as it will change guidelines on the management of this group of patients which we all see in our offices and hospitals.
The learning objectives for this session will involve:
1) Understanding the indications for the use of these agents in heart failure
2) Commenting on the use of these agents in your practice
3) Discussing the validity and applicability of the study
ARTICLE:
Krum H, Pitt B, Pocock S.J, et al. Eplerenone in Patients with Systolic Heart Failure and Mild Symptoms. N Engl J Med. 2011. 364(1): 1-11. (NEJM Free Full Text) or click the image of the article.
Regards,
Chester
Hi all,
Thanks for signing up to the Club. We have gone through the results of the Topics Survey and the 5 sessions of the club will be based on the following topics:
Review of internal medicine issues;
Inflammatory bowel disease;
Cardiovascular disease in the elderly;
Abnormal liver tests; and
New therapies for cardiac diseases
Please let me know if you have specific papers in mind for the sessions. Suggestions are welcome. We would prefer open access papers but any source is fine as long as you think it is relevant.
Look forward to your responses.
Chester
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