Evidence-based Medicine Podcasts from Cochrane Library

The Cochrane Collaboration produces systematic reviews of healthcare interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. It is a key resource in evidence-based medicine.

The Cochrane Collaboration has a podcast page with audio summaries of selected reviews from The Cochrane Library.

Click here to subscribe to the feed.


Video: Cochrane Library Tutorial from Lake-Sumter Community College Libraries.

References:
(Greatly improved) Cochrane and CINAHL Tutorial Videos. DavidRothman.net.
Image source: The Cochrane Collaboration.

Attending rounds: How to use acetazolamide to correct hypercapnia in OSA and COPD?

A 68 yo CF with morbid obesity, OSA and hypercapnia is admitted to the hospital. ABG is shown below:


ABG

What is the abnormality on ABG?

ABG shows chronic (compensated) primary respiratory acidosis, with metabolic alkalosis. Click here for MedCalc: Acid-Base Calculator.

The patient refuses to wear her BiPAP at home and in the hospital. She has episodes of confusion with elevation of PaCO2 which resolve when PaCO2 is decreased with BiPAP.

Will she benefit from acetazolamide (Diamox)?

A therapeutic trial of acetazolamide is probably indicated in attempt to control hypercapnia in this patient.

Acetazolamide, an inhibitor of carbonic anhydrase, stimulates the ventilatory drive by inducing metabolic acidosis.

Patients receiving who are able to increase their ventilation will decrease their PaCO2 because their increased ventilatory drive will surpass their impaired excretion PCO2. In contrast, patients who are unable to augment their ventilation (eg, those with severe COPD) may develop a severe acidosis on acetazolamide.

Acetazolamide reduced the AHI and destaturation index but the effect is modest. It can not be recommended for the routine care of patients with OSA.

Acetazolamide may play a role in the treatment of acute metabolic alkalosis caused by diuresis or steroids in patients with hypercapnic COPD. A short course may correct the underlying metabolic alkalosis that may be the cause of worsening hypercapnia. Acetazolamide has not been demonstrated in large controlled trials to have significant benefit for the long-term management of hypercapnia in COPD patients.

When used used as respiratory stimulant in COPD and OSA (unlabeled use), acetazolamide dose is 250 mg twice daily. It may induce agranulocytosis and monitoring of CBC is needed with prolonged use.

References:
Acid-base Balance Cases and Calculators. Clinical Cases and Images - Blog.
Use of Acetazolamide in COPD Patients. Medscape.
Disorders of ventilatory control. UpToDate, 15.3.
Carbonic anhydrase inhibitors for hypercapnic ventilatory failure in chronic obstructive pulmonary disease. Cochrane Reviews.
Google Books: 1 and 2.

Related:
A challenging ABG: question and answer. DB’s Medical Rants, 02/2008.

Updated: 03/07/2008

RSS Feeds and Podcasts from American Academy of Family Physicians

American Family Physician (AFP) is the official journal of the American Academy of Family Physicians and although it does not publish any original research, the journal is a good source of review articles and practical advice.

I had used a Pubmed workaround to get RSS feeds for the new articles from AFP but recently noted that the academy website has started offering RSS and podcast feeds:

RSS Feeds from AAFP News Now

Available Podcasts from the AAFP

The Continuing Medical Education (CME) podcast seems the most useful one among the 3 podcasts offered currently.

References:
Make Your Own "Medical Journal" with iGoogle Personalized Page
Share iGoogle Tabs with Medical Journals, Podcasts and Gadgets
Get RSS Feeds for Any Medical Journal from Pubmed

Erythropoiesis-stimulating agents increase risk of death and blood clots in cancer patients

Widely used erythropoiesis-stimulating agents (ESA) for anemia treatment raise the risk of death among cancer patients by about 10%, according to a new meta-analysis published in JAMA. The study also found a 57% increase in the risk of venous thromboembolism, a known side effect of ESAs.

The findings raise concern about the safety of ESA administration to patients with cancer in addition to the concerns we already have about ESA use in CKD and ESRD patients.

In 2007, the FDA added a black box warning to the labels of all currently available ESA due to increase in serious side effects and greater number of deaths in patients treated with these agents.

References:
Correct Anemia in Chronic Kidney Disease Up To a Point
Death Risk Found From Anemia Drugs. NYTimes.
Venous Thromboembolism and Mortality Associated With Recombinant Erythropoietin and Darbepoetin Administration for the Treatment of Cancer-Associated Anemia. Charles L. Bennett at al. JAMA. 2008;299(8):914-924.
Image source: Wikipedia, public domain.

Clinical Case: Diabetic Myonecrosis

A 42 yo male with poorly controlled DM type 2 came was admitted with a one-month history of worsening pain in his left thigh and calf associated with inability to walk. There was no history of trauma or intramuscular injections.

There was swelling and tenderness in the left distal quadriceps area and calf with limited range of motion of the knee. Peripheral pulses and sensation were normal.

MRI of the left knee is shown below. What are the changes?



Read more in Diabetic Myonecrosis: An Unusual Suspect on ClinicalCases.org.

The author of this case is Moises Auron, M.D. from the Department of Hospital Medicine, Cleveland Clinic.

Fibromyalgia is not a rheumatological disease but a central pain syndrome

According to a Medscape video editorial:

In 1990, The American College of Rheumatology established diagnostic criteria for fibromyalgia based on the scoring of 18 potential tender points (pain on palpation with a 4-kg force, pain at 11 of 18 sites is necessary to meet the criteria). "It turns out, however, that these tender points have nothing to do with fibromyalgia. Biopsy of the tender points shows no pathologic changes, and numerous studies have not shown any abnormalities in the musculoskeletal tissues that are painful.

Current evidence points to a neurologic disorder of central pain processing. We will no longer need to refer our fibromyalgia patients to the rheumatologist."

Some doctors doubt if fibromyalgia truly exists but the patient symptoms are real and should be addressed. Duloxetine (Cymbalta) and pregabalin (Lyrica) have been used with some success to treat this disorder. Lyrica is the first and only FDA-approved medication for fibromyalgia therapy.

References:

Fibromyalgia Is Not a Rheumatologic Disease Anymore. George T. Griffing, MD. The Medscape Journal of Medicine. Webcast Video Editorials.
Pharmacotherapy of Fibromyalgia - Medscape review, 2011.
Treating Fibromyalgia. AFP, 2000.
Fibromyalgia. eMedicine, Aug 15, 2007.

Fibromyalgia: Slideshow. Medscape.

Tai chi may be a useful treatment for fibromyalgia - NEJM, 2010.

Sexual dysfunction is common in patients with fibromyalgia - reported by 87% of females and 76% of males http://goo.gl/EsVTx
Image source: Wikipedia, Gray's Anatomy, public domain.

Sea Lion at Cleveland Zoo Dies of Pancreatitis

Huck, one of the Cleveland Zoo two sea lions, enjoyed interacting with visitors, as you can see from the video below at minute 2:01:


Sea Lion at Northern Trek, Cleveland Zoo. See another video here.

The 5-year-old California sea lion, died of of pancreatitis and acute enteritis, according to the zoo press release: "Huck had shown no clinical signs of illness or abnormal behavior until the day he died.

Huck arrived at Cleveland Metroparks Zoo in 2003 from Omaha's Henry Doorly Zoo in Nebraska. He was one of two sea lions residing with five harbor seals in the Northern Trek area of the Zoo."

This post ads to the list of animals with very "human" diseases like:
- Gorillas with CHF
- A tortoise with CAD

References:
Cleveland Metroparks Zoo sea lion dies. The Plain Dealer.
Northern Trek in the Spring at Cleveland Zoo. Hit the Road - See America and the World.

IT Advice: The Ultimate Student Resource List

The Ultimate Student Resource List from LifeHack.org. The list includes:

10 Free Applications Every Student Needs
11 Online Tools Students Should Check Out
15 Websites for Students
30 Pieces of Advice for Students
7 Online Research Resource

Related:
How to Study. Clinical Cases and Images - Blog, 05/2007.
Image source: Wikipedia

Too many feeds to read? Time to trim down RSS subscriptions

Web feeds readers have truly become an "inbox for the web." Until recently, I was subscribed to about 600 web sites, blogs, medical journals, podcasts and persistent searches. With so many feeds to read, information overload became a real issue, and I trimmed down the number of RSS subscriptions significantly this month.


Image is licensed under Creative Commons.


Video: RSS in Plain English

Related:
Dealing with Information Overload. LifeHack.org
Best Web Feeds Reader for Medical and General Information
How to Read Blog Articles Written Only By Your Favorite Bloggers. Digital Inspiration, 02/2008.
Troubleshooting RSS addiction: a blogger finds freedom in a world without feeds. Download Squad, 04/2008.

Check the series "What I Read" by different people in The Atlantic (scroll to the bottom of the page to see other links) http://goo.gl/xWUb

Updated: 04/23/2008

Attending rounds: How many "organ"-renal syndromes are recognized?

There are 3 "organ"-renal syndromes:

- Hepatorenal Syndrome (HRS) - development of renal failure in patients with advanced chronic liver disease, occasionally fulminant hepatitis, who have portal hypertension and ascites; 40% of patients with cirrhosis and ascites will develop HRS.

- Cardiorenal Syndrome - presentation of combined cardiac and renal dysfunction.

- Pulmonary-Renal Syndrome (PRS) - presentation of combined alveolar hemorrhage and glomerulonephritis.

Pulmonary-Renal Syndrome is the least well-recognized among the 3 syndromes. For example, it is not even listed under this name in the current edition of the "universal textbook of medicine" UpToDate (version 15.3). There is an old proverb: beware the man of a single book (homo unius libri).

Pulmonary-renal syndrome (PRS) is diffuse alveolar hemorrhage and glomerulonephritis occurring simultaneously. It sound like Goodpasture's syndrome which is logical since Goodpasture's is the prototype cause of PRS. Pulmonary-renal syndrome can can also be caused by SLE, Wegener's granulomatosis, microscopic polyangiitis, and other connective tissue diseases -- see the Merck Manual for a full list of causes of PRS.

References:

Acute decompensated heart failure: The cardiorenal syndrome. CCJM (PDF).
The Clinical Challenge of Cardiorenal Syndrome. Circulation, 2004.
Are You Dependent on UpToDate for Your Clinical Practice?
Cirrhosis - JAMA Patient Page, 2012.
Image source: Wikipedia, GNU Free Documentation License.

Attending rounds: How to start insulin therapy in diabetes mellitus type 2?

See Figure 3. Algorithm for the management of type 2 diabetes from AFP (http://www.aafp.org/afp/20040801/489.html).

For patients who have been inadequately controlled on oral antidiabetic medications , the initial dose is typically 10 units/day or 0.1 to 0.2 units/kg/day. Initially, basal therapies are usually administered as a single dose in the evening. Where necessary, NPH insulin also may be given in 2 doses: 1 dose in the morning and 1 dose in the evening. The dose can be titrated in 1-, 2-, or 3-unit increments until target FPG levels are achieved. When initiating insulin, it is best to start low and increase the dose gradually until the target is reached (http://www.ispub.com).

If intermediate insulin is chosen, the amount can be calculated by dividing a patient's body weight in kilograms by four and using that number to determine the starting dose (resulting in one fourth of the regular dose) or by figuring the dose according to a ratio of 0.5 U/kg and using 25% to 30% of that amount as the initial dose. Patients who have insulin resistance often need between 0.75 and 1 U/kg and tend to tolerate the larger increases (http://www.postgradmed.com/issues/2003/06_03/3cooppan.htm)

In subjects with type 2 diabetes who are poorly controlled on oral antidiabetic medications, initiating insulin therapy with twice-daily BIAsp 70/30 was more effective in achieving HbA1c targets than once-daily glargine (Lantus), especially in subjects with HbA1c >8.5% (http://care.diabetesjournals.org/cgi/content/abstract/28/2/260).

The INITIATE (INITiation of Insulin to reach A1c TargEt) study provides guidelines for twice-daily initiation of insulin (aspart premix 70/30). Begin with 6 units twice a day if the FPG is 180 mg/dL or greater, and 5 units twice a day if the FPG is less than 180 mg/dL (http://www.medscape.com/viewarticle/567952).

References listed in the text above.
Image source: Wikipedia, public domain.

Interesting Articles: A Weekly Review of the "Big Five" Medical Journals

This is a collection of articles I have found interesting in the weekly editions of the "big five" medical journals: NEJM, JAMA, Annals, Lancet and BMJ (a few more journals are included occasionally). The review is a weekly feature of Clinical Cases and Images - Blog. Please see the end of the post for a suggested time-efficient way to stay up-to-date with the medical literature.

Surgical versus Nonsurgical Therapy for Lumbar Spinal Stenosis. NEJM, 02/2008.

Surgery led to significantly more improvement in all primary outcomes than nonsurgical treatments. NEJM also published a review article in the same issue.

Aprotinin during Coronary-Artery Bypass Grafting and Risk of Death. NEJM, 02/2008.

Aprotinin use on the day of CABG surgery was associated with a higher mortality and a larger increases in serum creatinine compared to aminocaproic acid use. Aprotinin (Trasylol) is used to control bleeding during CABG but accumulating evidence suggests that this practice increases mortality. Trasylol was withdrawn from the U.S. Market in November 2007.

Survival From In-Hospital Cardiac Arrest During Nights and Weekends. JAMA. 2008;299(7):785-792.

Survival from in-hospital cardiac arrest was lower during nights and weekends. See Dr. Wes' comments on the study.

Effect of Glucosamine Sulfate on Hip Osteoarthritis. Annals of Int Med, 02/2008.

Glucosamine sulfate was no better than placebo in reducing symptoms and progression of hip osteoarthritis during the 2-year study period.

Meta-analysis: Effectiveness of Drugs for Preventing Contrast-Induced Nephropathy. Annals of Int Med, 02/2008.

The good: N-Acetylcysteine is more renoprotective than hydration with saline alone. Theophylline may also reduce risk for contrast-induced nephropathy but the association was not statistically significant. The bad: Furosemide increased the risk for contrast-induced nephropathy (relative risk, 3.27). And the indifferent: The remaining agents in the study -- fenoldopam, dopamine, iloprost, statin, mannitol -- did not significantly affect risk.

An audio summary on the topic is also available from the journal.

Perspectives, The art of medicine: History as a medical tool. The Lancet 2008; 371:552-553.

A new generation of medical historians argues that an applied history of medicine can serve as an important tool in medical research.

Body-mass index and incidence of cancer: a systematic review and meta-analysis of prospective observational studies. The Lancet 2008; 371:569-578.

According to this meta-analysis, increased BMI was associated with increased risk of malignancies.

Reviews from American Family Physician

The AFP has a history of publishing review articles that are practical, simple and useful. I like most of them.

Chronic Shoulder Pain: Part I. Evaluation and Diagnosis
Chronic Shoulder Pain: Part II. Treatment
Diagnosis and Treatment of Testicular Cancer
Reducing Tobacco Use in Adolescents
AHA Releases Updated Guidelines on the Prevention of Infective Endocarditis

A time efficient way to stay up-to-date with medical literature

"How do you eat in elephant? In small bites." The same rule probably applies to staying current with the ever expanding avalanche of medical literature. One can try the following approach:

1. Subscribe the to the RSS feeds of the 5 major medical journals (NEJM, JAMA, BMJ, Lancet and Annals) plus 2-3 subpecialty journals in your field of interest.


Medical Journals tab: A screenshot of iGoogle with RSS feeds from the major medical journals.

2. Read the journal on the day it is published online, for example, NEJM on Wednesdays.

3. Use text-to-speech to listen to articles you do not have time to read.

4. Listen to journal podcasts. Click here to subscribe the podcasts of the 4 major journals in iGoogle.

Related:
Make Your Own "Medical Journal" with iGoogle Personalized Page
Share iGoogle Tabs with Medical Journals, Podcasts and Gadgets
Annals of Internal Medicine Launches Podcast and Audio Summaries
Text-to-Speech Programs and Continuous Medical Education
Image source: OpenClipArt, public domain.

How to respond to angry emails: save as draft

Some useful advice from the blog Life as a Healthcare CIO:

"Every time I have responded to angry email with emotion I have regretted it. Although it may feel good to respond to a negative email with a venomous answer, emotion is never appropriate. I tell my staff that if they ever feel emotion while writing an email, "save as draft". Get someone else to review the response first. Send it after a day of rest.

Thus, keep a stiff upper lip, have a thick skin, and run each day based on your trajectory not the position of your ego. "

The same advice applies to writing blog posts and commenting.

References:
Always Look on the Bright Side. Life as a Healthcare CIO.
Image source: Openclipart.org, public domain.

A medical student's letters from Zimbabwe: the home of the 10 million bill

Open Medicine Blog is planning to publish a series of letters from Zimbabwe. The author is a medical student from the University of Zimbabwe, College of Health Sciences.

The country has been in economic free fall in recent years and started printing $10 million bills - one of those won't even buy you a hamburger in Harare according to The Daily Mail.

References:
Zimbabwe bank issues $10 million bill - but it won't even buy you a hamburger in Harare. The Daily Mail.
Letters from Zimbabwe - #1. Open Medicine Blog.

Keep residents happy -- it is better for patients

A study in BMJ showed that depressed pediatric residents made 6.2 times as many medication errors as residents who were not depressed. The setting was in 3 urban children’s hospitals in the United States, 20% of the participating residents met the criteria for depression and 74% met the criteria for burnout. Burnout did not correlate with an increased rate of medical errors.

According to Newsweek, every year, between 300 and 400 doctors take their own lives—roughly one a day. No other profession has a higher suicide rate.

I have always suspected that happier doctors make for happier patients and a few years ago came up with a mnemonic for a set of well-being practices correlated with the feeling of happiness -- MOTORS -- because the pursuit of happiness, in its altruistic sense, can be the motor of your life.

“MOTORS” stands for:

Meaning --> find a meaning in what you do for a living but don't forget to set limits around it
Outlook --> have a positive outlook on life, be philosophical but also focused on success
Time --> spend quality time with F&F (Family & Friends)
Out of yuppie values --> don't focus on chasing money or prestige
Religious / spiritual practices
Self care practices, like sports or meditation

References:
Rates of medication errors among depressed and burnt out residents: prospective cohort study. Amy M Fahrenkopf et al. BMJ, doi:10.1136/bmj.39469.763218.BE (published 7 February 2008)
Image source: OpenClipArt.org

Related:
Physicians wellbeing - WJM theme issue, volume 174(1); January 2001.
Six Tips for Happiness by a Harvard Teacher. Clinical Cases and Images - Blog.
Why are doctors so unhappy? Edwin Leap.
Happiness. DB’s Medical Rants, 03/2008.
Doctors Who Kill Themselves. Newsweek, 04/2008.

Updated: 04/21/2008

Gorillas at Cleveland Zoo have heart disease along with many others at U.S. zoos

Cleveland Zoo's gorillas Mokolo, 20, and Bebac, 23, were examined at the zoo's veterinary hospital by echocardiogram and were found to have left ventricular hypertrophy and congestive heart failure (CHF), respectively.

According to the Cleveland Zoo press release:

"The zoo is participating in a national study of gorilla health, after previous research found that gorillas in captivity are prone to heart disease.

Mokolo's left side of his heart is enlarged. Bebac's heart is more enlarged, shows impairment and doesn't pump as efficiently as it should, he said.

The gorillas will be placed on beta blockers or ACE inhibitors, drugs familiar to people with high blood pressure and heart disease."

Animals die of heart disease juts like humans do. A 176-year-old tortoise, believed to had been owned by Charles Darwin, died MI and CHF in 2006.

I have a video of Mokolo below and, as you can see, he is the silverback (the boss) in the group of the 2 gorillas at the zoo.


Silverback Gorilla at Cleveland Zoo

Some studies show that depression may lead to worse outcomes in CHF and CAD. If we assume that the older Bebac was somewhat depressed by his inferior status, this could explain his worse cardiovascular condition (past MI?).

References:
Gorillas Undergo Cardiac Exams at Cleveland Metroparks Zoo. Cleveland Zoo.
Cleveland zoo's gorillas have heart disease. The Plain Dealer.
Local and National Coverage of Gorilla Project. The Roar Report.

Related:
Do Gorillas have Personalities? Cleveland Zoo Blog, 08/2008.
176-year-old turtle once owned by Darwin dies of MI and CHF
Image source: Winter Visit to the Cleveland Zoo
Has anyone ever seen a photo of a happy captive gorilla? Flickr.

Updated: 09/22/2008

Cell phones do not cause brain tumors but may decrease male fertility

A study of 361 men seen at Cleveland Clinic found an association between heavy cell phone use and sperm quality: the more hours the men spent on their cell phones each day, the lower their sperm count and the greater the percentage of abnormal sperm.

The study was observational and did not mention if decreasing the cell phones use led to improvement in the sperm parameters.

According to the authors, the research shows a strong association of cell phone use with decreased semen quality but does not prove a cause-and- effect relationship. A larger follow-up study is currently underway.

References:
Effect of cell phone usage on semen analysis in men attending infertility clinic: an observational study. Agarwal A, Deepinder F, Sharma RK, Ranga G, Li J. Fertil Steril. 2008 Jan;89(1):124-8. Epub 2007 May 4.
Heavy cell phone use tied to poorer sperm quality. Reuters.
Japanese study clears mobiles of brain cancer risk. Reuters.
Image source: OpenClipArt.org, public domain.

Related:
'Cancer link' to heavy mobile use. BBC, 02/2008.
Cancer and cell phones. Paging Dr. Gupta, 06/2008.

Updated: 06/14/2008

Does atelectasis cause postoperative fever?

Postoperative fever is very common and occurs in 14-90% of surgical patients depending on how fever was defined in different studies and patient population. The incidence of infection in patients with postoperative fever is less than 10%. Fever on postoperative day 1 is most often a nonspecific response to the injury at the surgical site. Trauma leads to release pyrogenic cytokines, such as interleukins, tumor necrosis factor, and interferon-γ.

Atelectasis is defined as a state in which the lung, in whole or in part, is collapsed or without air (see the CXR below). Etymology: from Greek atelēs, incomplete, defective (telos, end) and ektasis, extension, from ekteinein to stretch out.


Right lung atelectasis with mediastinal shift. ETT ends at the level of clavicles. The optimal position is in the middle between the clavicles and the carina. This ETT needs to be advanced 2 cm. Image source: Atelectasis due to Hypoventilation and Mucus Plug. Clinical Cases and Images.

Does atelectasis cause postoperative fever?

Atelectasis does not cause fever, despite common misconception to the contrary. A study of 100 cardiac surgery patients evaluated them for 2 days after surgery with daily portable CXRs and continuous temperature measurements. During the study period, the incidence of fever progressively decreased while that of atelectasis increased, showing a negative correlation between them. Atelectasis and fever occur frequently after surgery, but their concurrence is probably coincidental rather than causal.

Incentive spirometry is used to prevent or treat atelectasis after surgery.

When evaluating postoperative fever, a helpful mnemonic is the “5 Ws”:

• Wind (pulmonary causes: pneumonia, aspiration, and pulmonary embolism, but not atelectasis)
• Water (urinary tract infection)
• Wound (surgical site infection)
• Walking limited (deep vein thrombosis or pulmonary embolism)
• “What did we do?” (iatrogenic causes: drug fever, blood product reaction, infections related to intravenous lines)

References:
1. Evaluating postoperative fever: A focused approach. J. Pile. Clev Clin J Med. Vol. 73, Suppl. 1, Mar 2006.
2. Postoperative fever. H. Weed, L. Baddour. UpToDate 2006, Version 14.2, Sep 15, 2005.

Topics Discussed During the Internal Medicine Rotation at Cleveland Clinic in February/March 2008

This is a list of the topics discussed (or to be discussed) during the internal medicine rotation with residents and medical students at Cleveland Clinic:

Treatment of AIDS-related Neutropenia by Dr. Dimov
DKA management by Dr. Zysek. See a typical case
Atelectasis as source of fever by Dr. Dimov
Pre-renal ARF, HCTZ and FENa. See a case discussion by Dr. Dimov
Indications for DVT prophylaxis in inpatients by Dr. Dimov
Progressive multifocal leukoencephalopathy (PML) in HIV/AIDS - prognosis and treatment by Dr. Mekuria
Use of IV Flagyl in patients with C. diff. by Dr. Mekuria
Value of repeating stool test in resolving C. diff. infection by Dr. Mekuria
Workup of thyroid nodule by Dr. Chooljian
Rates of medication errors among depressed and burnt out residents by Dr. Dimov
How do you define prolonged immobilization?
How Do You Treat VIP Patients?
Diagnosis and treatment of PE by A. Brady
Hampton Hump in Pulmonary Embolism
Discussion of JNC 7, physician card (PDF) by Dr. Dimov
Treatment of hypertension in African Americans (UpToDate link) by Dr. Dimov
ABCD of Hypertension Treatment in Different Ethnic Groups by Dr. Dimov
Hydralazine use in HTN by Dr. Dimov
How to start insulin therapy in diabetes mellitus type 2? by Dr. Dimov
How many "organ"-renal syndromes are recognized? by Dr. Dimov
GLP-1 receptor agonist (Byetta) and DPP-4 Inhibitors for Treatment of Diabetes by Dr. Batal/Dr. Dimov
Nicotine patch use in patients with AFib with RVR by Dr. Chooljian
Perioperative evaluation: mnemonic PASS/HIP and 8 short cases. New perioperative guidelines for noncardiac surgery (ACC, Medscape) by Dr. Dimov
Upper extremity DVT -- causes and treatment by P. Blake
What percentage of patients with a PICC line develop upper extremity DVT? by P. Blake
Choice of antihypertensive medications in aortic stenosis by Dr. Zysak
A Systematic Approach to Electrocardiogram (EKG) Interpretation by Using 2 Mnemonics: A RARE PQRST/DR III EEE by Dr. Dimov
How to stay up-to-date with the medical literature: a suggested approach by Dr. Dimov
Acid-base Balance Cases and Calculators by Dr. Dimov
ATN pathology and diagnosis by A. Brady
AIN diagnosis and treatment by Dr. Batal
Difficult to control asthma - what to do after ICS/LABA/LTRA have failed by Dr. Dimov
When to Use Xolair (Omalizumab) in Asthma? by Dr. Dimov
Mind maps for asthma treatment by Dr. Dimov
Guidelines for treatment of DVT/PE by Dr. Dimov
Podcasts in medicine and residency noon conferences by Dr. Dimov

To be discussed in the future

New treatments for primary pulmonary hypertension by A. Brady
Which patient population would benefit from hydralazine? by Dr. Mekuria
What is SAPHO syndrome? by Dr. Mekuria
How to use acetazolamide to correct hypercapnia in OSA and COPD? by Dr. Dimov
CHADS2 Score Determines Who Needs Anticoagulation in Atrial Fibrillation by Dr. Dimov
Web 2.0 in Medicine (from Google Presentations) by Dr. Dimov
Treatment of hypernatemia by Dr. Dimov

Topics from previous rotations

Different IV catheters and related complications
RTA type 1, 2, 4 by Dr. Dimov
SIADH - causes and diagnostic criteria, click for cases 1, 2
Aortic Stenosis and Preoperative Evaluation for Noncardiac Surgery
New guidelines for prevention of bacterial endocarditis
Treatment of hyperkalemia and hypokalemia - what questions to ask nurses when called about high or low K+, when to to give IV K+ instead of PO K+, etc.
Contrast-induced nephropathy
Indications for LP in patients with dementia
Difference between temporary and permanent IVC filters. Source: UpToDate 15.3
Hyponatremia

The list will be updated periodically as new topics are added by the end of the month. As you can see from the links above, a blog can be used as an educational portfolio for both personal learning and teaching.

Click here to submit suggestions for future topics.

Further reading:
Topics Discussed During the Internal Medicine Rotation at Cleveland Clinic in October/November 2007. CasesBlog, 10/2007.
Topics Discussed During the Internal Medicine Rotation at Cleveland Clinic in September 2007
Using a Blog to Build an Educational Portfolio. CasesBlog, 1/2007.
DB’s thoughts on being a clinical educator. DB’s Medical Rants, 11/2007.
Attending Rounds. DB’s Medical Rants, 02/2008.
Happiness. DB’s Medical Rants, 03/2008.

Updated: 03/06/2008

How-to Advice: Writing a Book in Google Docs

Google Blogoscoped is a blog which often features original tips and ideas and this is one of them: Writing a Book in Google Docs.

"Currently, my editor Brian Jepson and I are collaboratively writing the book (tentatively titled) Google Office Hacks by O'Reilly using Google Docs. I wanted to outline the process we came up with, and maybe it's helpful for you too for certain needs."

I have mentioned before that Google Docs has replaced MS Word for most of the word-processing work I do, for example, writing research proposals, study abstracts and manuscripts. There are many advantages to online storage and collaboration and benefits outweigh the risks in most cases.

References:
Writing a Book in Google Docs. Google Blogoscoped, 01/2008.
Google Docs & Spreadsheets Could Replace Word & Excel for the Average User. Clinical Cases and Images - Blog, 10/2006.
Will Google Apps be a Game-changer for Doctor Practices? Clinical Cases and Images - Blog, 02/2007.

UK closes its doors to foreign doctors

According to the The Times, the National Health System (NHS) is closing its doors to foreign doctors in an attempt to preserve jobs for British graduates.

What is the reason?

Since 1997, the number of medical schools in Britain has doubled. There are now enough home-grown graduates, thus reducing the need to import doctors.

Currently, half of Britain's 277,000 registered doctors were trained overseas. Last year, 10,000 foreign doctors applied for 20,000 posts.

What will happen to the foreign doctors currently in the UK or planning to relocate there?

Many international medical graduates (IMGs) will plan to continue their training in the U.S. or Australia. According to anecdotal evidence, it is much more difficult for the IMGs to find residency positions in the U.S. nowadays due to the influx of competition from Britain. The situation is worse in Australia where IMGs have to wait months just to take the board exams required to start training -- see this recent NEJM article.

References:
NHS closes its doors to foreign doctors
Foreign doctors face competence inquiry
Comment: prejudice against overseas doctors
A Bridge to Nowhere — The Troubled Trek of Foreign Medical Graduates in Australia. NEJM, 01/2008.

Related:
A Guide for Doctors Planning to Relocate Abroad. Clinical Cases and Images - Blog.
A good doctor with a "bad" accent? Clinical Cases and Images - Blog.
Image source: Openclipart.org, public domain.

Interesting Journal Articles

Why not try publishing a case report?
BMJ Career Focus 2008;336:31.
Tips on getting a case report published.

Jane: Suggesting Journals, Finding Experts.
Martijn J. Schuemie and Jan A. Kors, Bioinformatics, January 28, 2008.
"Have you recently written a paper, but you’re not sure to which journal you should submit it? Jane can help! Just enter the title and/or abstract of the paper in the box, and click on ‘Find journals’ or ‘Find authors’. Jane will then compare your document to millions of documents in Medline to find the best matching journals or authors."

"Jane" is an abbreviation for Journal / Author Name Estimator. Link via DavidRothman.net.

Medical podcasts: the future of continuing professional development?
BMJ Career Focus 2008;336:29-30
The exciting potential of podcasts as a new educational medium.

Clinical hospital medicine fellowships: Perspectives of employers, hospitalists, and medicine residents.
Philip H. Goodman, MD, MS, Andrius Januska, BS. Journal of Hospital Medicine, 02/2008.

Mastery learning of thoracentesis skills by internal medicine residents using simulation technology and deliberate practice.
Diane B. Wayne, MD et al. Journal of Hospital Medicine, 02/2008.

Rates of medication errors among depressed and burnt out residents: prospective cohort study. Amy M Fahrenkopf et al. BMJ, doi:10.1136/bmj.39469.763218.BE (published 7 February 2008)

The setting was in 3 urban children’s hospitals in the United States, 20% of the participating residents met the criteria for depression and 74% met the criteria for burnout. Depressed residents made 6.2 times as many medication errors as residents who were not depressed. Burnout did not correlate with an increased rate of medical errors.

Conflicting views:

Are condoms the answer to rising rates of non-HIV sexually transmitted infections? Yes.
BMJ 2008;336:184 (26 January)

Are condoms the answer to rising rates of non-HIV sexually transmitted infection? No.
BMJ 2008;336:185 (26 January)
The article features "A to Z" of prevention strategies for HIV and other sexually transmitted infections, if somebody can remember them all.

A time efficient way to stay up-to-date with medical literature

"How do you eat in elephant? In small bites." The same rule probably applies to staying current with the ever expanding avalanche of medical literature. One can try the following approach:

1. Subscribe the to the RSS feeds of the 5 major medical journals (NEJM, JAMA, BMJ, Lancet and Annals) plus 2-3 subpecialty journals in your field of interest.


Medical Journals tab: A screenshot of iGoogle with RSS feeds from the major medical journals.

2. Read the journal on the day it is published online, for example, NEJM on Wednesdays.

3. Use text-to-speech to listen to articles you do not have time to read.

4. Listen to journal podcasts. Click here to subscribe the podcasts of the 4 major journals in iGoogle.

Related:
Make Your Own "Medical Journal" with iGoogle Personalized Page
Share iGoogle Tabs with Medical Journals, Podcasts and Gadgets
Annals of Internal Medicine Launches Podcast and Audio Summaries
Text-to-Speech Programs and Continuous Medical Education
Image source: OpenClipArt, public domain.

How to write a medical blog and not get fired

I have covered the topic before but there is a new example of a sensible approach to medical blogging.

Kevin, MD linked to the blog Boston EMT which was the subject of an article in Boston Globe. Kevin wondered if the Boston EMT's employer was aware of the blog and the question was answered in the comments by the blog author himself:

"Yes, my employer, Boston EMS, has seen the blog. The Chief of Department has seen it, and, in fact, he has given reporters permission to interview me and write about the blog. In fact, two high-ranking members of the department have participated in it, by telling stories of their own in the form of comments left on the site.

Consent to write the blog was given on two conditions: (1) That I make clear that my views do not necessarily reflect those of the city or of Boston EMS, and (2) that I adhere to the privacy requirements of HIPAA.

I've been careful to do both."

This is one of the "right ways" to do medical blogging.

Tips for Medical Bloggers

- Write as if your boss and your patients are reading your blog every day
- Comply with HIPAA
- Anonymous blogging  may not last long. Consider using your name and credentials on your blog and other social media accounts
- If your blog is work-related, it is probably better to let your employer know.
- Inquire if there are any blogging guidelines. If there are, comply with them strictly.
- Use a disclaimer, e.g. " All opinions expressed here are those of their authors and not of their employer. Information provided here is for medical education only. It is not intended as and does not substitute for medical advice."
- Get your blog accredited by the Heath on the Net Foundation


This Google video shows that it takes about 2 minutes to start a blog on Blogger.com. Creating a web site has never been easier.

References:
Simply Fired - How NOT to Blog About Your Job. Especially If You Are a Doctor. Clinical Cases and Images - Blog, 08/2005.
Dr Flea Blogged His Malpractice Trial, Settles When Outed. Clinical Cases and Images - Blog, 05/2007.
Anonymous Medical Blogger? Not Anymore. Clinical Cases and Images - Blog, 02/2007.

Related:
How to blog - and keep your job. BBC, 2006.
Twitter, HIPAA, Privacy and Freedom of Speech. Phil Baumann, 07/2008.
When Blogging Gets You Fired. David Bradley, 2009.
On blogging. DB’s Medical Rants, 2009.

As A Busy Physician, Why Do I Even Bother Blogging? http://goo.gl/fSF3 - Excellent summary.

When Doctors Become Patients

It never rains but it pours. Two of the medical bloggers that I read and another popular blogger became patients seemingly overnight. I join Kevin, M.D. in wishing them a speedy and complete recovery:

Part I: Metamorphosis. Dr. Wes.
Part II: Access. Dr. Wes.
Part III: The Opportunity. Dr. Wes.

From the other side of the sheets. Notes from Dr. RW.

A Few Thoughts on Diverticulitis. WhiteCoat Rants.

I had been a patient myself in the past and still remember vividly how helpless I felt. This experience reinforced my firm belief that, in general sense at least, the patient is always right. Consequently, I often remind the residents and students during attending rounds: "No matter how bad or tired we may feel, the situation is almost always worse on the colder side of the stethoscope" (where the patient is).

Related:
When Doctors Become Patients. NYTimes, 02/2008.
Image source: sxc.hu

Updated: 02/18/2008

Research Tip: Create Surveys and Databases with Online Forms via Google Spreadsheets

What is Old?

SurveyMonkey.com has been my choice for collecting information via online surveys for the last several years. Its basic version is free, easy to use and automatically calculates the response percentages for each question. See a sample survey here.

What is New?

Google Spreadsheets is part of the online office suite called Google Docs. It recently launched a new feature which lets you create a form to accept data. The blog Google Operating System explains how the online forms work:

"When you go to the Share tab, there's a new option to "invite people to fill out a form". The form is very simple and can be customized by changing the order of entries, their labels and the type of answers. It's also a nice way to get feedback people who wouldn't normally collaborate on a spreadsheet. You can create forms from spreadsheets or using this URL. To keep track of your forms, add this gadget to iGoogle."

How to Use the Online Form?

This is an example: I created a simple form evaluating the exercise habits of the readers of Clinical Cases and Images - Blog. Click to see the form here and the resulting spreadsheet here. One drawback is that you have to re-publish the spreadsheet so that the responders can see the updated information via the public URL. The author of the spreadsheet who is logged in his/her Google account can see the updates in real time.

The form is embedded at the end of this blog post. See the instructions how to embed a form in your own page or website.

Summary

Overall, the online forms by Google Spreadsheet can be quite useful. Each form has a public URL which means that people entering information do not have to log-in to Google Spreadsheets to add data. It can be a simple way to collaborate on data collection from several research locations as long as the collected information is not private or confidential.

References:
Add Data to Google Spreadsheets Using Forms. Google Operating System.
Stop sharing spreadsheets, start collecting information. Google Docs Blog.
Image source: Google Docs Blog.

Related:
Online Form Builder Powered by Google Docs & Spreadsheet. Go2Web2.0, 03/2008.
Video presentations: Novel concepts and easy-to-use web tools for researchers. European Molecular Biology Laboratory, 2006.

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Updated: 03/21/2008

Overdose of prescription drugs caused Heath Ledger's death

The Academy Award-nominated actor Heath Ledger, 22, died as the result of acute intoxication by the combined effects of the prescription medications oxycodone, hydrocodone, diazepam, temazepam, alprazolam, and doxylamine, according to the NYC chief medical examiner.

The blog KidneyNotes illustrates why he died by listing the many potential drug interactions from Epocrates, an online drug database.

The fact that the medications are obtained by prescription does not make them safer in any way. Overdose or abuse of painkillers, sleeping pills and anti-anxiety drugs is just as life-threating as the abuse of street drugs.

In 1977, Elvis Presley's personal physician prescribed 10,000 doses of amphetamines, barbiturates, narcotics, tranquilizers, sleeping pills, and laxatives for Presley. Blood tests showed traces of 14 different drugs in Elvis's body at the time of his death.

"The untimely death of Heath Ledger raises an important question for anyone taking multiple medications: Do you know what you're taking and how much?," writes MarketWatch.

USA Today reiterates that "Ledger's death actually highlights two related problems, say Wick and other pharmacy researchers. One is prescription drug abuse, while the other is something called polypharmacy, or the taking of multiple drugs at one time."

References:
Heath Ledger’s Death Is Ruled an Accident. NYTimes.
When Icons Die Young. NYTimes.
Accidental poisonings on the rise among adults. MarketWatch.
Elvis Presley's personal physician. Clinical Cases and Images - Blog.
Heath Ledger's Drug Interactions. KidneyNotes.

Updated: 02/07/2008

What makes a well-rounded teacher in 21st century?

The same features as in the 20th century plus one new: technology.




Jeff Utecht from the blog Thinking Stick may have a point. I am a teaching attending at Cleveland Clinic and residents generally respond very positively when we incorporate Web 2.0 tools during the teachings sessions -- see an example here. Actually, I prefer the term "learning session" rather than "teaching session" since this is a two-way process. Both the teacher and the students often learn from each other.

Bob Centor, SGIM President-Elect, has covered similar topics in detail on his blog DB’s Medical Rants.

References:
What makes a well rounded teacher? Jeff Utecht
Topics Discussed During the Internal Medicine Rotation at Cleveland Clinic in October/November 2007. Clinical Cases and Images - Blog.
Using a Blog to Build an Educational Portfolio. Clinical Cases and Images - Blog.
In my day… Scoble, 01/2008.
Beautiful example of how blogs can disseminate medical information much more efficiently than journals, NEJM included (http://goo.gl/rOvNq).
Image source: Thinking Stick

Cleveland Clinic building a global brand "like the Louvre or Guggenheim Museum", 50 countries want Clinic to open branches

According to the main Cleveland newspaper, The Plain Dealer:

"Toby Cosgrove, the Cleveland Clinic CEO, said he hopes the new hospital in Abu Dabi will help the Clinic become the first American health care enterprise to emerge as a worldwide "brand" on a par with the Solomon R. Guggenheim Museum in New York and the Louvre in Paris, both of which are building branches in Abu Dhabi.

Cosgrove said the Clinic has had inquiries from 50 countries to open branches or provide other services. "They want our intellectual capital," Cosgrove said. "They want to know how to build a hospital, how to staff a hospital, how to measure quality."

One of the Clinic main competitors, Johns Hopkins Medicine, has partnerships in more than 12 countries but has not built an overseas hospital yet.

References:
Cleveland Clinic has its eyes on a global brand. Cleveland, The Plain Dealer.
Image source: Cleveland Clinic logo.

Related:
Cleveland Clinic Has a New Logo (and a Shorter Name)
U.S. Universities Rush to Set Up Outposts Abroad. NYTimes, 02/2008.

"MedWorm Associates" Promote RSS Use Among Physicians and Researchers

What is a MedWorm Associate?

From their website: "MedWorm Associates have one uniting objective - to promote the use of RSS amongst physicians and those in medical research."

Currently, there are associates in:

Pathology
Orthopaedics
Psychology
Pediatrics
Health, Medicine and and Bioethics Commentators
Medical Databases and Libraries
Genetics

You can become a MedWorm Associate too if you are interested in the following:

"1. Keeping an eye on their specialty in MedWorm, by looking through the feeds that are listed in that specialty, asking for feeds to be removed from that specialty when they are not appropriate and making suggestions for new feeds (eg. any major publications that are missing or medical associations).

2. Commenting on items in their specialty, thus stimulating MedWorm discussions. Associates should aim to make one comment per month.

3. Making suggestions on ways to further develop MedWorm and work in partnership with other sites, in particular their own site(s)."

Two of the bloggers I follow are associates: Berci Mesko and David Rothman.

Image source: MedWorm

Clinical Case: Accessory Renal Artery Stenosis

A 78 yo female with long standing HTN, HLP, PVD, CKD came to the hospital with uncontrolled BP and deterioration of renal function over a 12 months period.

Despite aggressive medical therapy, there was no improvement in her kidney function and blood pressure control.

What was the reason?


Accessory Renal Artery Stenosis

Read more in Accessory Renal Artery Stenosis – A Cause For Drug Refractory Hypertension on ClinicalCases.org.

The author of this case is Moises Auron, M.D. from Department of Hospital Medicine, Cleveland Clinic.

Lions at African Savanna, Cleveland Zoo

Close-up of the Lions at African Savanna, Cleveland Zoo


Click here to see the larger photos in the album.

7 Creative Uses for RSS

Six Creative Uses for RSS. eMarketing & New Media.

1. Subscribe to a custom News RSS feed
2. Develop an RSS Feed for your non-blog site
3. Use eBay’s RSS option
4. Watch for new music on iTunes
5. Keep an eye on your personal brand- your name
6. Subscribe to others’ del.icio.us bookmarks

Here is one more creative use of RSS (for a total of 7):

YouTube Feeds. Google Operating System.

YouTube has never offered too many feeds and they were usually difficult to find. The new YouTube API changed that, but the feeds are still inaccessible from the interface. Google Operating System compiled a list of the most useful YouTube feeds you may want to add in your favorite feed reader.

Related:
Make Your Own "Medical Journal" with iGoogle Personalized Page
Share iGoogle Tabs with Medical Journals, Podcasts and Gadgets
Best Web Feeds Reader for Medical and General Information
It's Brilliant: Continuous search engine queries for public health
Get RSS Feeds for Any Medical Journal from Pubmed
RSS Feeds for the Cleveland Clinic