Non-transient “self-sustaining” heparin-induced thrombocytopenia: 4-year persistence of a platelet-activating PF4/heparin–antibody status without heparin exposure

Abstract

The more we come to understand the pathophysiology of heparin-induced thrombocytopenia (HIT) syndrome, the more we realize that HIT is a rather unusual immune response. One peculiar feature of HIT is the transient character of the antibodies. After cessation of exposure to heparins, the antibodies tend to disappear after 40–100 days. If re-immunization occurs, it generally takes at least 4 days to redevelop antibodies (if they are formed at all). We report about a patient who most likely developed platelet-activating IgG-specific platelet factor 4 (PF4)/heparin antibodies after knee surgery, experienced a transient ischemic attack years later [when HIT was diagnosed by using PF4/heparin ELISA] and presented a high number of these antibodies even 4 years after this first diagnosis of HIT without further re-exposure to heparin.     

How satisfying is the practice of internal medicine? A national survey

OBJECTIVE: To survey members of the American College of Physicians about their level of satisfaction and sources of dissatisfaction with practice, the extent to which their satisfaction is reflected in their counseling of students about careers in internal medicine, the prevalence of their concerns about patients' access to care, and their attitudes toward changes in the health care system. DESIGN: A questionnaire survey of a random sample of members of the College. PARTICIPANTS: Members (2254) of the College were surveyed; 1446 (64%) responded and 1290 (57%) of the responses were usable. MEASUREMENTS AND MAIN RESULTS: More than 80% of respondents were satisfied with their relationships with patients, professional challenges, and opportunities to interact with colleagues. Only about half were satisfied with their potential income, and most were dissatisfied with their autonomy or loss of control over clinical decision making. Major sources of concern were administrative burdens, the threat of malpractice litigation, loss of income, and loss of clinical autonomy. Forty percent of internists say that they discourage students from careers in internal medicine, and only 39% would once again pursue such a career. "Pain in the practice" seems generalized among internists: logistic regression analysis failed to show any specific groups who were most dissatisfied or concerned. With regard to access, 18% of internists had many patients without health care insurance; 69% had some patients without coverage; and the majority (61%) had some patients who lost their insurance because of changing jobs or location. Assuring universal access to care received the highest priority rating of a set of criteria for health care reform. CONCLUSIONS: There is growing dissatisfaction with the practice of internal medicine, primarily related to concerns over loss of clinical autonomy, the increase in administrative burdens, the potential loss of income, and the threat of malpractice litigation. Although physicians are concerned about patients' access to care, proposals to improve access should be examined for their effects on the major sources of physicians' dissatisfaction with practice.     

Preparing the next generation: is internal medicine in trouble?

Without some immediate changes in graduate medical education programs, general internal medicine could be on the road to disappearing during the next decade, according to this internist and educator.     

What is the role of internal medicine in the collective of a general hospital?

General internal medicine tends to decrease in many Belgian hospitals. On the opposite, United States are now clearly engaged in a reform of their health system, with a drastic augmentation of the number of general internists. This reflection recognizes the specificities of general internal medicine: the first contact, the longitudinal follow-up, the comprehensive approach and the coordination with other medical participants. The need for subspecialists would be reduced and the need for primary comprehensive care physicians would be increased. The development of a performent sector of general internal medicine is able to respond to the demand of the patients and also of the general family practitioners. This model has positive impacts for the whole hospital community. We are all weary of discussions of state medicine, of the high cost of medical care, of the adequacy of medical care for the indigent, of the shortage of hospital beds for those who can pay, of the shortage of nurses, and so on. But these are, in part our problems; if their solution is to be to our liking, we must be active in them. The spector of state medicine is continually raised before us. Greater participation, by the federal, state and local governments in matters of health seems inevitable although most of us think it is important to retain in some manner or other the principle of private enterprise. Change of some sort will come; it is evident that unless we ourselves reorganize the practice of medicine, it will be reorganized for us.     

How confident are internal medicine residents in rheumatology versus other common internal medicine clinical skills: an issue of training time or exposure?

The objective of this study was to determine self-confidence of internal medicine (IM) residents regarding rheumatology clinical skills and factors that may affect their confidence. Permission was sought to e-mail a web-based survey to IM residents at all 13 English language Canadian internal medicine programs. Residents were asked to rank self-confidence in rheumatology, cardiology, respirology, and gastroenterology skills. Further questions included site and year of training, career interests, rheumatology experiences, learning opportunities, and assessment frequency. These factors were analyzed by univariate and multivariate analyses. Two hundred sixteen residents (21.8%) from all 13 sites responded to the survey. Resident self-confidence in rheumatology diagnoses was 5.24/10, lower than all three comparator subspecialties. Increasing teaching exposure had a more significant impact on confidence in rheumatology than on comparator subspecialties. Increasing year of training had no association with higher self-confidence for rheumatology, in contrast to the increase in confidence seen with increased year of training for each comparator subspecialty. Further analysis demonstrated that the completion of a rheumatology rotation, increasing learning opportunities, annual assessment, and career interest were associated with greater resident self-confidence. Resident self-confidence for rheumatology skills is cautious at best and is lower than other common subspecialties. Self confidence improves with targeted rheumatology clinical experience and teaching, but does not improve solely with higher year of IM training. Furthermore, the impact of rheumatology teaching is greater than that of other common IM subspecialties. This information is critical to the planning and implementation of effective rheumatology curricula within internal medicine residency programs.     

Complementary and alternative medicine in inflammatory bowel diseases: what is the future in the field of herbal medicine?

The use of complementary and alternative medicine is wide-spread not only in Eastern countries, but also in the Western world. Despite the increasing evidence on the harmful effects induced by several naturopathic/homeopathic products, patients seem to appreciate these remedies, in particular because they consider them to be absolutely safe. This same phenomenon is common among inflammatory bowel disease (IBD) patients. As a result there is a significant request for scientific data to evaluate both the efficacy and safety of these remedies, and to support the use of such medications as adjuvant treatments to biological and synthetic drugs. We aimed to review the current evidence on efficacy and safety of some natural products that are believed to be effective in inflammatory bowel disease. Further perspectives for the clinical use of herbal products and strategies for improving knowledge about herbal products in IBD are also discussed.