Being an outstanding physician and lifelong learner requires stoking the flames of clinical curiosity. In Chiefs’ Inquiry Corner (CIC) we attempt to succinctly answer actual clinical questions that have been raised on the wards and in the clinics of NYU’s teaching hospitals. Our answers are not meant to be all encompassing or practice changing but rather to serve as springboards for further exploration. For those of us with short attention spans, we hope CIC satisfies that craving for a morsel of knowledge in a digestible format.
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AHA/ACC/HRS Guidelines recommend against using dabigatran and rivaroxaban in patients on dialysis requiring anticoagulation, as studies have shown increased risk of hospitalization and death from bleeding in patients treated with these agents compared with those treated with warfarin. Although apixaban is FDA approved for patients with ESRD, actual clinical outcomes are unknown as patients on dialysis were excluded from the original trials. A more recent retrospective cohort study comparing apixaban and warfarin in this population showed no difference in stroke, and apixaban had a better bleeding risk profile. Keep an eye out for the RENAL-AF Trial
, an ongoing prospective randomized control trial comparing apixaban to warfarin in this group of patients.
Well established modifiable cardiovascular risk factors such as exercise, weight loss, and smoking cessation have also been shown to improve sexual function in males. A small randomized control trial published in JAMA in 2004 showed that a weight loss intervention in obese men resulted in significant improvement in self-reported erectile function. In this trial, body mass index reduction from a mean of 36.9 to 31.2 in the intervention group over 2 years resulted in approximately 1/3 of participants no longer meeting criteria for erectile dysfunction based on a self-reported erectile function scale.
References: Weight loss for ED
Children with sickle cell disease or sickle-beta thalassemia are routinely screened with transcranial dopplers to assess their risk of stroke. In children 2-16 years of age with high risk features, prophylactic chronic simple transfusions are indicated to maintain HbSS<30%. In this group, the benefits of primary stroke prevention outweigh the risks of alloimmunization and delayed hemolytic reactions. Unfortunately, there is a paucity of evidence to guide transfusion decisions as these children grow to adulthood. Whether or not to continue chronic prophylactic transfusions in adults must be made on a case by case basis.
References: Transfusion Guidelines