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.
Review of topics covered in morning report, M&m, and core conferences with links to supplemental reading material.
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Saturday, July 30, 2011
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.
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