Unusual condition discussed today - spontaneous dissection of the carotid artery resulting in stroke in a young patient. Often precipitated by an innocuous trauma such as turning the head rapidly, painting a ceiling, extending the neck during hair care at a beauty shop, and chriopractic manipulation (risk probably less than 1 in 40,000 encounters).
Collagen vascular disease present in ~ 1/4 as a predisposing cause.
This article from NEJM is a comprehensive review of the topic and covers vertebrobasilar (which has a similar pathogenesis and treatment) dissection as well.
Treatment is anticoagulation with heparin followed by warfarin, and interventions such as stenting is generally reserved for those with unresolving neuro deficits or significant hemodynamic cerebral blood flow impairments.
Review of topics covered in morning report, M&m, and core conferences with links to supplemental reading material.
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Wednesday, October 5, 2011
Tuesday, October 4, 2011
Sep 30 MR - Hyperglycemia Potpourri
Hyperglycemic Crises in Diabetes - review article from the ADA with great references and resources, covers the topics discussed today. Read this and you will know enough for boards and most patient care scenarios. Read and know the rest and you will be an internist.
Two contrasting cases of significant hyperglycemia - classic DKA and hyperglycemic hyperosmolar nonketotic state (HHNS) also formerly known as hyperglycemic nonketotic coma and many other names.
HHNS is a condition seen in type 2 diabetics with uncontrolled disease that lose access to free water due to debility, restraints, or acute illness. Things rapidly spiral out of control as they lose fluids from osmotic diuresis and develope more and more concentrated serum.
This AFP article is a good review of the condition and its treatment. Primary focus should be on volume resuscitation as it is not a pure insulin deficiency state. Administering insulin before fluid resuscitation could precipitate hypotension.
Also, keep in mind that this syndrome can precipitate central pontine myelinolysis, even in the absence of hyponatremia, as this article and several other reports have demonstrated.
As for DKA this is a condition that some patients have so often it often breeds complacency in physicians caring for them. It is a life threatening emergency and bad management decisions can make things worse. Overcorrection of glucose, inadequate volume resuscitation, or mismanagement of electrolyte problems are all potential pitfalls. It is easy to get lost in the data and a flowchart is essential to ensure good management. This article from a pediatric diabetes journal summarizes concensus guidelines and includes tons of useful calculations and fomulas for various fluid and insulin regimens. Most of this generalizes to care of adult DKA patients.
Two contrasting cases of significant hyperglycemia - classic DKA and hyperglycemic hyperosmolar nonketotic state (HHNS) also formerly known as hyperglycemic nonketotic coma and many other names.
HHNS is a condition seen in type 2 diabetics with uncontrolled disease that lose access to free water due to debility, restraints, or acute illness. Things rapidly spiral out of control as they lose fluids from osmotic diuresis and develope more and more concentrated serum.
This AFP article is a good review of the condition and its treatment. Primary focus should be on volume resuscitation as it is not a pure insulin deficiency state. Administering insulin before fluid resuscitation could precipitate hypotension.
Also, keep in mind that this syndrome can precipitate central pontine myelinolysis, even in the absence of hyponatremia, as this article and several other reports have demonstrated.
As for DKA this is a condition that some patients have so often it often breeds complacency in physicians caring for them. It is a life threatening emergency and bad management decisions can make things worse. Overcorrection of glucose, inadequate volume resuscitation, or mismanagement of electrolyte problems are all potential pitfalls. It is easy to get lost in the data and a flowchart is essential to ensure good management. This article from a pediatric diabetes journal summarizes concensus guidelines and includes tons of useful calculations and fomulas for various fluid and insulin regimens. Most of this generalizes to care of adult DKA patients.
Wednesday, September 14, 2011
15 Sep - Annual Program Review
Below are articles mentioned in today's Annual Program Review
Internal Medicine Residency Redesign - AJM 2011
Comprehensive Residency Research Curriculum
Quality of Life, Burnout, and Medical Knowledge among IM Residents
Attractiveness of IM to Medical Students
ACGME Letter GME Funding
Costs of Failing to Fail
APDIM E Learning Links - Also added permanent link on cool sites column to right.
Internal Medicine Residency Redesign - AJM 2011
Comprehensive Residency Research Curriculum
Quality of Life, Burnout, and Medical Knowledge among IM Residents
Attractiveness of IM to Medical Students
ACGME Letter GME Funding
Costs of Failing to Fail
APDIM E Learning Links - Also added permanent link on cool sites column to right.
Thursday, September 8, 2011
8 Sep - Hepatorenal Syndrome
This case was of a gentleman with severe decompensated cirrhosis with refractory ascites. Management of ascites was discussed previously in this post.
A couple key articles to add:
Know the trail test - quick, easy, and evidence based way to monitor cirrhotics for early encephalopathy. This NEJM review from 1997 goes over the use of this test for early detection, as well as most interventions short of the newly used rifaximin.
As for use of TIPS - two traditional uses are to control variceal hemorrhage and to improve refractory ascites. A recent trail suggests that this technique should be used more early in patients at high risk for variceal bleeding, before they have had their first bleed.
Finally - know hepatorenal syndrome. This was well reviewed recently in NEJM. Type 1 hepatorenal is the rapidly progressive, more dramatic version with highest short term mortality. FENA <1 suggests hepatorenal syndrome in cirrhotics with kidney impairment. Accurate estimation of GFR in cirrhotics is difficult, and the CG equation performs more poorly than MDRD, and even that overestimates the actual renal function. The potential role of TIPS in this condition was mentioned, but definitive clinical data is lacking.
The cost of midodrine/octreotide/albumin therapy is ~$2000 per day in drug cost alone, and should primarily be considered a bridge to definitive treatment such as transplant.
A couple key articles to add:
Know the trail test - quick, easy, and evidence based way to monitor cirrhotics for early encephalopathy. This NEJM review from 1997 goes over the use of this test for early detection, as well as most interventions short of the newly used rifaximin.
As for use of TIPS - two traditional uses are to control variceal hemorrhage and to improve refractory ascites. A recent trail suggests that this technique should be used more early in patients at high risk for variceal bleeding, before they have had their first bleed.
Finally - know hepatorenal syndrome. This was well reviewed recently in NEJM. Type 1 hepatorenal is the rapidly progressive, more dramatic version with highest short term mortality. FENA <1 suggests hepatorenal syndrome in cirrhotics with kidney impairment. Accurate estimation of GFR in cirrhotics is difficult, and the CG equation performs more poorly than MDRD, and even that overestimates the actual renal function. The potential role of TIPS in this condition was mentioned, but definitive clinical data is lacking.
The cost of midodrine/octreotide/albumin therapy is ~$2000 per day in drug cost alone, and should primarily be considered a bridge to definitive treatment such as transplant.
7 Sep - Sepsis Guidelines
Discussion today focused primarily on the early management of sepsis. This is a condition for which the mortality has not really decreased much since the advent of antibiotic therapy. A few interventions have been shown to decrease mortality, and there are a core set of interventions that should be considered in all septic patients.
The Surviving Sepsis Campaign has papers and pocket cards that review the current interventions shown to improve mortality in septic shock. They focus their measures on two phases of care - the first 6 hours (primarily ED interventions) and the following 24 hours (primarily ICU interventions).
This Nov 2001 trial on early goal directed therapy for sepsis formed the basis for much of the recommendations in this guideline. The only part that gives me pause is the recommendation to transfuse above a HCT of 30 if patients have low SVO2 despite volume resuscitation. This somewhat conflicts with other studies that show trends for worse outcomes with higher transfusion targets.
As for steroid therapy in sepsis, the clinical trial data follows a roughly 11 year cycle that I think correlates with sunspot activity cycles. The most recent data from recent JAMA and NEJM trials is pessimistic, and argues that any benefit from steroids, if truly present, is likely small. This benefit comes with the clearly documened risks of steroid therapy, to include worsening immunosuppression and hyperglycemia. If you so choose to use them, current dogma is to not base the decision on a ACTH stim test and only use low doses of hydrocortisone.
One side discussion revolved around the impact of severe sepsis on cognitive decline in elderly survivors of sepsis. A recent trial published in Mayo Clinic Proceedings demonstrated significant persistent cognitive decline in elderly patients post-surgery. This corresponds with previous studies that have shown similar persistent declines in elderly patients after severe sepsis. The rate of significant permanent cognitive impairment in elderly sepsis survivors is high, and fundamentally alters independent living for many patients. These studies should help you set realistic expectations for families when dealing with elderly family members facing major surgeries or critical illness.
The Surviving Sepsis Campaign has papers and pocket cards that review the current interventions shown to improve mortality in septic shock. They focus their measures on two phases of care - the first 6 hours (primarily ED interventions) and the following 24 hours (primarily ICU interventions).
This Nov 2001 trial on early goal directed therapy for sepsis formed the basis for much of the recommendations in this guideline. The only part that gives me pause is the recommendation to transfuse above a HCT of 30 if patients have low SVO2 despite volume resuscitation. This somewhat conflicts with other studies that show trends for worse outcomes with higher transfusion targets.
As for steroid therapy in sepsis, the clinical trial data follows a roughly 11 year cycle that I think correlates with sunspot activity cycles. The most recent data from recent JAMA and NEJM trials is pessimistic, and argues that any benefit from steroids, if truly present, is likely small. This benefit comes with the clearly documened risks of steroid therapy, to include worsening immunosuppression and hyperglycemia. If you so choose to use them, current dogma is to not base the decision on a ACTH stim test and only use low doses of hydrocortisone.
One side discussion revolved around the impact of severe sepsis on cognitive decline in elderly survivors of sepsis. A recent trial published in Mayo Clinic Proceedings demonstrated significant persistent cognitive decline in elderly patients post-surgery. This corresponds with previous studies that have shown similar persistent declines in elderly patients after severe sepsis. The rate of significant permanent cognitive impairment in elderly sepsis survivors is high, and fundamentally alters independent living for many patients. These studies should help you set realistic expectations for families when dealing with elderly family members facing major surgeries or critical illness.
Friday, September 2, 2011
2 Sep Cavitary Lung Disease
This AM covered a case of long-standing progressive cavitary lung disease, due in this case to Mycobacterium avium. Cavitary diseases of the lung cover a broad range of infectious and non-infectious causes. Chronicity of the process, associated findings, and epidemiologic history are all necessary to narrow down the possibilities. If spontaneous sputum does not reveal the offending pathogen invasive diagnostics are often needed, usually starting with bronchoscopy, followed by CT guided needle biopsy, and ultimately VATS / open lung biopsy.
When you see cavitary lesions on XRay always consider TB, and err on the side of placing the patient in respiratory isolation precautions if you are ordering AFB smears. Don't wait until they are positive.
Further reading:
Clin Micro Review April 2008 - best review of the differential of cavitary lung lesions with many good images of representative radiographs for many possible causes.
This image from that article shows a MAI cavity very similar to that seen in our patient.
Treatment of non-TB mycobacterial lung disease is actually more complicated than treating TB itself, and takes longer to achieve cure. These guidelines from the ATS and IDSA cover the topic in depth.
When you see cavitary lesions on XRay always consider TB, and err on the side of placing the patient in respiratory isolation precautions if you are ordering AFB smears. Don't wait until they are positive.
Further reading:
Clin Micro Review April 2008 - best review of the differential of cavitary lung lesions with many good images of representative radiographs for many possible causes.
Treatment of non-TB mycobacterial lung disease is actually more complicated than treating TB itself, and takes longer to achieve cure. These guidelines from the ATS and IDSA cover the topic in depth.
Thursday, September 1, 2011
31 Aug - Obstructive Jaundice
Evaluation of elevated LFTs discussed in a recent MR, but topic today was a slightly different scenario. Obstructive jaundice is often the first sign of a biliary tract malignancy such as cholangiocarcinoma. Evaluation is aimed at locating the site of the obstruction and the potential resectability of the lesion.
Remember Courvoisier sign - though in the modern era of easily accessed imaging studies and lab tests the diagnosis is often made before this sign develops.
This section from the eMedicine article on obstructive jaundice gives a nice rundown of the strengths and weaknesses of different imaging modalities for evaluating obstructive jaundice.
Remember Courvoisier sign - though in the modern era of easily accessed imaging studies and lab tests the diagnosis is often made before this sign develops.
This section from the eMedicine article on obstructive jaundice gives a nice rundown of the strengths and weaknesses of different imaging modalities for evaluating obstructive jaundice.
Wednesday, August 24, 2011
24 August - Atrial Fibrillation
Here is the article I mentioned on care of patients with atrial fibrillation:
ACP InTheClinic Atrial Fibrillation 2010 update. Has links to a slideset for use in student teaching as well.
There is also this supplementary toolkit with info on quality measures, guidelines for newly diagnosed a-fib, and patient information material.
You need to be familiar with the findings and limitations of the AFFIRM study, which showed equivalent outcomes between rate and rhythm control strategies, with a potential survival advantage to rate control due to avoidance of antiarrhythmic drug toxicity.
Also know the results and implications of the RE-LY trial of dabigatran in atrial fibrillation, published in 2009 in NEJM.
ACP InTheClinic Atrial Fibrillation 2010 update. Has links to a slideset for use in student teaching as well.
There is also this supplementary toolkit with info on quality measures, guidelines for newly diagnosed a-fib, and patient information material.
You need to be familiar with the findings and limitations of the AFFIRM study, which showed equivalent outcomes between rate and rhythm control strategies, with a potential survival advantage to rate control due to avoidance of antiarrhythmic drug toxicity.
Also know the results and implications of the RE-LY trial of dabigatran in atrial fibrillation, published in 2009 in NEJM.
Tuesday, August 23, 2011
23 August - M&m follow up - Critical Thinking
As discussed, this is the book by Groopman titled "How Doctors Think." There are a couple books with similar/same titles, but this is the one I was talking about. I will have some curriculum based on this book for Dr Norwood's PGY 1 and 2 courses this year.
Also, this past post from one of my favorite blogs walks through many of the cognitive traps we can fall victim to. I especially like this gem from his post:
"Ulysses syndrome
Ulysses went from one adventure to another in the odyssey of returning home from the Trojan War. A false positive test can lead to a fruitless odyssey of further investigation: tests lead to more tests, maybe even invasive procedures and harm to the patient. Eventually it is realized that the patient has been healthy all along."
Confirms my adage that imaging begets imaging, tests begets tests, and false positives beget operations.
For additional reading material, this site from Harvard has an extensive bibliography on the topic. You can not download articles from the site, but paste the titles in google search and you can access most full text articles through the Preston library or on campus.
Also, this past post from one of my favorite blogs walks through many of the cognitive traps we can fall victim to. I especially like this gem from his post:
"Ulysses syndrome
Ulysses went from one adventure to another in the odyssey of returning home from the Trojan War. A false positive test can lead to a fruitless odyssey of further investigation: tests lead to more tests, maybe even invasive procedures and harm to the patient. Eventually it is realized that the patient has been healthy all along."
Confirms my adage that imaging begets imaging, tests begets tests, and false positives beget operations.
For additional reading material, this site from Harvard has an extensive bibliography on the topic. You can not download articles from the site, but paste the titles in google search and you can access most full text articles through the Preston library or on campus.
Sunday, August 21, 2011
Acute Renal Failure - RIFLE Criteria
Couple articles to share here to f/u Dr Reddy's MR on renal failure.
The rifle criteria were established by a concensus conference and are predictive of mortality in acute kidney injury patients:
Risk = 1.5 x increase Cr, GFR down 25%
Injury = 2 x increase Cr, GFR down 50%
Failure = 3 x increase Cr, GFR down 75%
Loss = complete loss for 4 weeks
ESRD = complete loss for 3 months
When managing patients at risk of or in early stages of ARF, this article from AFP has a nice review of the evidence for different interventions.
The rifle criteria were established by a concensus conference and are predictive of mortality in acute kidney injury patients:
Risk = 1.5 x increase Cr, GFR down 25%
Injury = 2 x increase Cr, GFR down 50%
Failure = 3 x increase Cr, GFR down 75%
Loss = complete loss for 4 weeks
ESRD = complete loss for 3 months
When managing patients at risk of or in early stages of ARF, this article from AFP has a nice review of the evidence for different interventions.
Tuesday, August 16, 2011
Back From Vacation - Blog Updates from Recent Topics Week of Aug 1 - 5
Aug 3rd - Evaluation of Cognitive Impairment / Acute Delirium
Hallmark of delirium is fluctuating course with impaired concentration. My favorite mnemonic to remember causes is I WATCH DEATH, as it also helps remind me what an ominous condition this is.
This site from Vandy has a rundown of that as well as other mnemonics to help with delirium.
Aug 4th - Resuscitation from Lower GI Bleeds.
Sometimes catastrophic bleeding, but usually less immediately life threatening than upper GI bleeds. Just remember the mantra "two large bore peripheral IVs" when approaching the resiscitation of any hemorrhage.
As far as transfusion triggers goes, generally a lower threshold hemoglobin is better. There is also some data from Europe that transfusions increase rebleeding risk, at least in upper GI hemorrhages. Waiting for the hemoglobin to drop ~7 is probably best, barring signs of impaired oxygen delivery. There is no convincing evidence that transfusing those with cardiac disease up to hemoglobins of 10 is helpdful, and in fact may be harmful.
Aug 5th - End of Life Care
Not directly related to case discussed, but wanted to share this recent JAMA article on elder abuse and self neglect. Complex situation without good solutions in may cases.
Hallmark of delirium is fluctuating course with impaired concentration. My favorite mnemonic to remember causes is I WATCH DEATH, as it also helps remind me what an ominous condition this is.
This site from Vandy has a rundown of that as well as other mnemonics to help with delirium.
Aug 4th - Resuscitation from Lower GI Bleeds.
Sometimes catastrophic bleeding, but usually less immediately life threatening than upper GI bleeds. Just remember the mantra "two large bore peripheral IVs" when approaching the resiscitation of any hemorrhage.
As far as transfusion triggers goes, generally a lower threshold hemoglobin is better. There is also some data from Europe that transfusions increase rebleeding risk, at least in upper GI hemorrhages. Waiting for the hemoglobin to drop ~7 is probably best, barring signs of impaired oxygen delivery. There is no convincing evidence that transfusing those with cardiac disease up to hemoglobins of 10 is helpdful, and in fact may be harmful.
Aug 5th - End of Life Care
Not directly related to case discussed, but wanted to share this recent JAMA article on elder abuse and self neglect. Complex situation without good solutions in may cases.
Saturday, July 30, 2011
F/U from my CAM rant
Those of you who got to hear me ranting about the encroachment of complementary medicine into "respectable" academic internal medicine departments might want to check out this post that just popped up from one of my favorite ID docs on the web - the venerable (or cantankerous) Mark Crislip. His puscast and quackcast podcasts are essential downloads. Ties in with our prior week journal club discussion on the placebo effect.
A snippett:
"Placebo effects can be clinically meaningful. You are receiving a SCAM based/placebo based therapy. You think you are better. Your tumor, your HIV, your rheumatoid arthritis, your asthma is unchanged and the basic pathophysiology, with its physiological consequences, metastasis, immune destruction, joint damage, lung inflammation, continues unabated and unchecked. That is good?"
The full post here.
A snippett:
"Placebo effects can be clinically meaningful. You are receiving a SCAM based/placebo based therapy. You think you are better. Your tumor, your HIV, your rheumatoid arthritis, your asthma is unchanged and the basic pathophysiology, with its physiological consequences, metastasis, immune destruction, joint damage, lung inflammation, continues unabated and unchecked. That is good?"
The full post here.
MR wrap up week - Jul 28&29
On Thursday Dr Schneider presented an unusual case of anemia with both macrocytic and hemolytic features. It sounded suspiciously like this case.
Blood smears are an indispensable tool in evaluating obscure anemias. The article I mentioned is a comprehensive review with great pics and is linked here: N Engl J Med 2005; 353:498-507 August 4, 2005
Frida y's "mystery case" was severe symptomatic hyponatremia pecipitated by excessive intranasal ddavp usage in a pt with DI. I have found this article very helpful for learning/teaching about the workup of hyponatremia: CMAJ February 3, 2004 vol. 170 no. 3
The article walks through the workups of different causes and offers some pointers for correction rates with hypertonic saline. Just remember that normal saline will worsen SIADH.
Also be aware of the risk of central pontine myelinolysis with too rapid correction.
Blood smears are an indispensable tool in evaluating obscure anemias. The article I mentioned is a comprehensive review with great pics and is linked here: N Engl J Med 2005; 353:498-507 August 4, 2005
Frida y's "mystery case" was severe symptomatic hyponatremia pecipitated by excessive intranasal ddavp usage in a pt with DI. I have found this article very helpful for learning/teaching about the workup of hyponatremia: CMAJ February 3, 2004 vol. 170 no. 3
The article walks through the workups of different causes and offers some pointers for correction rates with hypertonic saline. Just remember that normal saline will worsen SIADH.
Also be aware of the risk of central pontine myelinolysis with too rapid correction.
Wednesday, July 20, 2011
Jul 20 - Evaluation of Syncope
Good July topic for discussion. See this blog post from last July for an in-depth review with article links - not much new research in this area since then so no new links of note. I will link again to this article describing the cost effectiveness of a variety of tests for sycope. Basically it costs $17 per correct diagnosis for postural BP checks, $1000 for an ECG, and ~$20,000 for a carotid ultrasound.
Monday, July 18, 2011
Jul 18 - Journal Club F/U
Thanks to Dr Anderson for being the guest discussant at today's journal club. Below are links to the articles reviewed:
Continuation of Low-Dose Aspirin Therapy in Peptic Ulcer Bleeding from Annals of Internal Medicine, Jan 5, 2010. Though small in size, this study offered compelling evidence that patients taking low dose aspirin for secondary prevention of cardiovascular events should be continued on aspirin even when they are treated for GI bleeding. The clinical event rate with aspirin withdrawal was quite high, even in the brief 30 day follow up period.
The major methodological issue I had with this trial was the use of a "non-inferiority" design. I do not think it was the appropriate way to look at this clinical question, as there was no well-established clinically proven baseline to compare it to. A randomized controlled trial would have sufficed. Also - beware of non-inferiority trials in general. In up to 12% of publications reviewed by one group it was found that conclusions drawn by the authors were incorrect and missed by the editors. Another concern in general with non-inferiority trials is that they may lead to "biocreep" where drugs of decreasing effectiveness are deemed non-inferior to a prior drug that was non-inferior to a prior drug that actually was superior to placebo. After a few generations of non-inferiority the actual effectiveness compared to placebo may actually be nil.
The second article: Rifaximin Therapy for Patients with Irritable Bowel Syndrome without Constipation from the Jan 6, 2011 NEJM brough up several interesting points. One was the difference between statistical and clinical significance. In this trial, most people that took rifaximin experienced no relief. Additionally, 1/3 of patients experienced relief with placebo. The overall proportion of patients who's improvement could be attributed to an expensive medication was quite small. At >$900 per treatment course it would be best to start with some cheap innocuous meds like amitriptyline which improved nearly 70% of patients (compared to 30% placebo) and costs pennies a day.
It also brought to mind another recent NEJM (Jul 15, 2011) trial that shed quite a bit of light on the placebo effect in general, especially for clinical conditions with subjective clinical endpoints. In this trial of asthma therapy they compared albuterol to three other treatments - placebo inhaler, pretend quackery (AKA sham accupuncture), and no treatment. Interestingly, the symptomatic improvement was equal with real or fake albuterol as well as fake accupuncture. All three of those arms experienced better relief of symptoms compared with no treatment. Tellingly - the only intervention that improved the objective outcome of an increase in FEV1 was real albuterol. The only issue I had with their methods is that the phrase "sham accupuncture" is a tautology.
Continuation of Low-Dose Aspirin Therapy in Peptic Ulcer Bleeding from Annals of Internal Medicine, Jan 5, 2010. Though small in size, this study offered compelling evidence that patients taking low dose aspirin for secondary prevention of cardiovascular events should be continued on aspirin even when they are treated for GI bleeding. The clinical event rate with aspirin withdrawal was quite high, even in the brief 30 day follow up period.
The major methodological issue I had with this trial was the use of a "non-inferiority" design. I do not think it was the appropriate way to look at this clinical question, as there was no well-established clinically proven baseline to compare it to. A randomized controlled trial would have sufficed. Also - beware of non-inferiority trials in general. In up to 12% of publications reviewed by one group it was found that conclusions drawn by the authors were incorrect and missed by the editors. Another concern in general with non-inferiority trials is that they may lead to "biocreep" where drugs of decreasing effectiveness are deemed non-inferior to a prior drug that was non-inferior to a prior drug that actually was superior to placebo. After a few generations of non-inferiority the actual effectiveness compared to placebo may actually be nil.
The second article: Rifaximin Therapy for Patients with Irritable Bowel Syndrome without Constipation from the Jan 6, 2011 NEJM brough up several interesting points. One was the difference between statistical and clinical significance. In this trial, most people that took rifaximin experienced no relief. Additionally, 1/3 of patients experienced relief with placebo. The overall proportion of patients who's improvement could be attributed to an expensive medication was quite small. At >$900 per treatment course it would be best to start with some cheap innocuous meds like amitriptyline which improved nearly 70% of patients (compared to 30% placebo) and costs pennies a day.
It also brought to mind another recent NEJM (Jul 15, 2011) trial that shed quite a bit of light on the placebo effect in general, especially for clinical conditions with subjective clinical endpoints. In this trial of asthma therapy they compared albuterol to three other treatments - placebo inhaler, pretend quackery (AKA sham accupuncture), and no treatment. Interestingly, the symptomatic improvement was equal with real or fake albuterol as well as fake accupuncture. All three of those arms experienced better relief of symptoms compared with no treatment. Tellingly - the only intervention that improved the objective outcome of an increase in FEV1 was real albuterol. The only issue I had with their methods is that the phrase "sham accupuncture" is a tautology.
Thursday, July 14, 2011
One More Post - Social Media Rules for Residents
Blogs, Facebook, Twitter, and Professional Behavior - all well covered in this site from Mayo. For the new interns, current residents, etc who have developed in an era when private lives are on display as never before, best to review the rules of the road for social media in the medical world.
http://socialmedia.mayoclinic.org/2011/06/30/network-video-project-to-prod-discussion-on-physician-social-media-use/
http://socialmedia.mayoclinic.org/2011/06/30/network-video-project-to-prod-discussion-on-physician-social-media-use/
Jul 14 - Diagnostic Criteria for Acute Myocardial Infarction
Dr Khan presented a talk today on an important topic to learn early in the year, particularly since ~ 1 in 50 will be missed and misdiagnosis of MI is a major source of malpractice suits for primary care docs.
The best way to learn ECG diagnosis is to practice, and the Beth Israel Deaconess Medical Center has an ECG learning site that is free to access and has tons of ECGs that can be viewed in either a quiz or learning mode - http://ecg.bidmc.harvard.edu/maven/mavenmain.asp
In addition to reviewing the UpToDate chapter, I highly recommend this NEJM review article on the topic from March 6, 2003, which covers basic diagnosis as well as diagnosis in the setting of left bundle branch block and RV MI.
And if you want to read deeper, this article from 1996 is the best study on ECG criteria that support a specific diagnosis of MI in the setting of LBBB.
The best way to learn ECG diagnosis is to practice, and the Beth Israel Deaconess Medical Center has an ECG learning site that is free to access and has tons of ECGs that can be viewed in either a quiz or learning mode - http://ecg.bidmc.harvard.edu/maven/mavenmain.asp
In addition to reviewing the UpToDate chapter, I highly recommend this NEJM review article on the topic from March 6, 2003, which covers basic diagnosis as well as diagnosis in the setting of left bundle branch block and RV MI.
And if you want to read deeper, this article from 1996 is the best study on ECG criteria that support a specific diagnosis of MI in the setting of LBBB.
Wednesday, July 13, 2011
13 July - Alcohol withdrawal
Dr Reddy presented a CPC today on treatment of alcohol withdrawal. The May 1, 2003 NEJM has a review of drug and ETOH withdrawal. It summarizes the data in support of symptom triggered (CIWA)rather than scheduled therapy and als runs through other withdrawal scenarios such as stimulants and opioids.
If you care for patients later in the course who already have alcohol withdrawal delirium (DTs) higher doses of benzos for treatment (rather than prevention) and closer monitoring are required. This article from Archives of Internal Medicine Jul 12, 2004 summarizes the clinical trail data as of 2004. Basically high dose benzos and frequent monitoring until symptoms are controlled are the key interventions. Neuroleptics are adjuncts, and beta blockers should be used infrequently, if at all, and only for persistent hypertension when other medical therapy has been tried.
The following links show all the good studies that support the use of oral or IV ethanol to treat/prevent alcohol withdrawal symptoms:
Get my point?
If you care for patients later in the course who already have alcohol withdrawal delirium (DTs) higher doses of benzos for treatment (rather than prevention) and closer monitoring are required. This article from Archives of Internal Medicine Jul 12, 2004 summarizes the clinical trail data as of 2004. Basically high dose benzos and frequent monitoring until symptoms are controlled are the key interventions. Neuroleptics are adjuncts, and beta blockers should be used infrequently, if at all, and only for persistent hypertension when other medical therapy has been tried.
The following links show all the good studies that support the use of oral or IV ethanol to treat/prevent alcohol withdrawal symptoms:
Get my point?
Friday, July 8, 2011
8 July - How to be a resident and measure progress
Today we discussed some basic skills for intern survival in internal medicine. I alluded to some milestones that are expected at different points in time. This paper from the American Board of Internal Medicine has the individual items with the timeline for acquisition of skills. Useful to know these as elements will start being reflected in evaluationss of resident performance in the coming years.
For those of you interested in the future of academic medicine, this paper details one centers synthesis of the ABIM milestones with the basic RIME framework we discussed today. Expect to see something similar in use here in the future.
For those of you interested in the future of academic medicine, this paper details one centers synthesis of the ABIM milestones with the basic RIME framework we discussed today. Expect to see something similar in use here in the future.
Thursday, July 7, 2011
Jul 7 - Evaluation of Elevated LFTs
Discussion of a case of acute alcoholic liver disease with underlying cirrhosis. Some links to things discussed this AM:
Comprehensive NEJM review on Cirrhosis and Ascites - Excellent review of cirrhosis management.
This NEJM article on evaluation of abnormal LFTs is a nice complement to the uptodate article on the reading list.
Finally - this article walks you through how and when to do a paracentesis and how to interpret the results. Part of the outstanding "Rational Clinical Exam" series in JAMA.
Comprehensive NEJM review on Cirrhosis and Ascites - Excellent review of cirrhosis management.
This NEJM article on evaluation of abnormal LFTs is a nice complement to the uptodate article on the reading list.
Finally - this article walks you through how and when to do a paracentesis and how to interpret the results. Part of the outstanding "Rational Clinical Exam" series in JAMA.
July 6 - COPD Exacerbation
First MR of the year covered diagnosis, staging, and management of COPD.
This was covered in a previous post from last year
Also, there is this updated Annals In the Clinic from April 2011 on COPD diagnosis and management that covers pretty much everything you need to know.
This was covered in a previous post from last year
Also, there is this updated Annals In the Clinic from April 2011 on COPD diagnosis and management that covers pretty much everything you need to know.
Friday, May 20, 2011
Thursday, March 3, 2011
3 March - Anemia in the elderly
After finding out this morning that morning report is illegal in Tennessee, we discussed a hypothetical case of anemia in elderly patients. One of the features that suggests MDS is an isolated normo or macrocytic anemia. Other features include poikolocytosis, dacrocytosis, and anisocytosis. Pseudo Pelger-Huet cells are an indicator of MDS. Teardrop shaped cells, as I have been told in the past, mean "the bone marrow is crying." Below is an image of a pseudo Pelger-Huet cell.
Also, our own Dr Lands has published this article on anemia in elderly patients. Appropriate to today's discussion, anemia has been strongly and independently linked to cognitive decline in the elderly. I have a PDF which is easier to read if anyone wants a copy.
Also, our own Dr Lands has published this article on anemia in elderly patients. Appropriate to today's discussion, anemia has been strongly and independently linked to cognitive decline in the elderly. I have a PDF which is easier to read if anyone wants a copy.
Pseudo - Pelger-Huet cell - link to ASH image database
Dacrocytes, or tear drop poikilocytes, links to ASH image bank
In contrast to pseudo-Pelger-Huet cells which generally signify internal disease, true Pelger-Huet anomaly is an essentially benign condition that comes to attention whem automated WBC counts suggest bandemia or immature WBC forms / left shift. This emedicine article discusses this condition in more detail.
Monday, February 21, 2011
21 Feb Long Overdue Blog Update
Links to recent articles of interest:
Dr Emmet's recent discussion of CAD in women mentioned this AHA guideline - published in the Feb 14, 2011 issue of Circulation (Appropriately timed for valentine's day I suppose). Some important points:
- Do Not use aspirin in healthy women <65 y/o for the purpose of coronary event prevention
- Do not use estrogens or SERMs to prevent CAD.
- Otherwise treat with same guidelines you would use for men.
Dr Emmet's recent discussion of CAD in women mentioned this AHA guideline - published in the Feb 14, 2011 issue of Circulation (Appropriately timed for valentine's day I suppose). Some important points:
- Do Not use aspirin in healthy women <65 y/o for the purpose of coronary event prevention
- Do not use estrogens or SERMs to prevent CAD.
- Otherwise treat with same guidelines you would use for men.
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