Presentation: Guidelines for Management of Venous Thromboembolism (DVT and PE) by ACP

A presentation on the 2007 Guidelines for Management of Venous Thromboembolism (DVT and PE) by ACP is embedded below. It is based on an article published in the Annals of Int Med, 6 February 2007. The presentation is one of the Topics Discussed During the Medicine Consult Service Rotation at Cleveland Clinic in March/April 2008.



In the presentation, I used only free public domain images from OpenClipArt.org and Wikipedia.

Google Docs (Word Docs, Spreadsheets and Presentations) is gradually getting better although not yet without some annoying technical glitches. Google Docs will not require an Internet connection in near future and can be used completely offline via Google Gears. When you connect to the Internet, the offline document will be synchronized with the online version. See how it works in the video below.


Offline access to Google Docs

By the way, you can embed videos directly in your Google Docs (Word). How cool is that?

References:
Offline access to Google Docs. Google Blog.
Bringing the cloud with you. Google Docs Blog.
How to Embed YouTube Videos in Google Docs. Labnol.org.

Related:
Using Google Docs Offline. Google Blogoscoped, 04/2008.

Topics Discussed During the Medicine Consult Service Rotation at Cleveland Clinic in March/April 2008

This is a list of the topics discussed during the Medicine Consult Service rotation with residents and medical students at Cleveland Clinic:

Which blood pressure medications to take on the morning of surgery?
Use of blogs in medicine
How to start a medical blog in 2 minutes
Use of RSS feeds in Medicine
Best Web Feeds Reader for Medical and General Information
What is the risk for developing ARF after surgery?
Something you have never seen before -- a rare central line complication in NEJM
Self-plagiarism of a Case Report in NEJM
What to do if you loose a guide wire during central line placement?
Guidelines for treatment of DVT/PE. See the presentation from Google Docs.
Preoperative Care of Patients with Kidney Disease, mnemonics PAST and HIP
New perioperative guidelines for noncardiac surgery (ACC, Medscape)
Podcasts in Medicine:
- Top 5 Medical Podcasts I Listen To
- Annals of Internal Medicine Launches Podcast and Audio Summaries
- Podcasts from Conferences of University of Tennessee IM Residency Program
Text-to-Speech Programs and Continuous Medical Education
Case 2: Does this patient need a beta-blocker? and 4CD mnemonic to remember the risk factors in RCRI
How to Score Well on the Boards?
Chest compressions-only CPR works as well as standard technique in adults
Hyponatremia and Hypernatremia:
Hyponatremia - Na 118 - What is the cause?
Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) due to SSRIs
SIADH due to Lung Cancer and Aspiration Pneumonia
Hypernatremia due to Dehydration in Dementia
Wellbeing practices correlated with the feeling of happiness: MOTORS
Keep residents happy -- it is better for patients
Inventor of Cardiac Bypass (CABG)
A doctor asks which portable computer/PDA/smartphone to choose
Electrocardiogram (ECG, EKG) Learning Tools
A Systematic Approach to Electrocardiogram (EKG) Interpretation by Using 2 Mnemonics: A RARE PQRST/DR III EEE by Dr. Dimov
Atrial fibrillation (AFib) with rapid ventricular response (RVR) due to triple lumen catheter (TLC) placement
Complications of Central Line Placement: Pneumothorax, Arrhythmia, Hematoma
Drum circles at a major Cleveland hospital relieve employee stress
Will "Dr. Nurses" Take Over Primary Care?
Case 3: When to correct hyperkalemia before surgery?
Case 4: When to do hemodialysis before surgery in patients with ESRD?

To be discussed in the future

Acid-base Balance Cases and Calculators by Dr. Dimov
5 Tips to Stay Up-to-Date with Medical Literature
Web 2.0 in Medicine (from Google Presentations) by Dr. Dimov
Aortic Stenosis and Preoperative Evaluation for Noncardiac Surgery
New guidelines for prevention of bacterial endocarditis

Topics from previous rotations

Different IV catheters and related complications
Atelectasis as source of fever by Dr. Dimov
Rates of medication errors among depressed and burnt out residents by Dr. Dimov
How do you define prolonged immobilization?
Hydralazine use in HTN 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
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

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.

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: 04/04/2008

Remembering the ACGME 6 Core Competencies by a SIMPLE mnemonic

The Accreditation Council for Graduate Medical Education (ACGME) is responsible for the accreditation of post-MD medical training programs within the United States. The ACGME developed the so-called 6 "core competencies" that all residents should achieve during their training. When I was a chief resident, the concept was still new and not easy to remember so I made up a SIMPLE mnemonic for the 6 competencies:

SIMPLE

Systems-Based Practice
Interpersonal Skills and Communication
Medical Knowledge
Patient Care
Learning - Practice-Based and Improvement
Etiquette ~ professionalism

References:
General Competencies. The Accreditation Council for Graduate Medical Education (ACGME).
Medical Mnemonics
Image source: OpenClipArt, public domain.

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

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

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

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.

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.

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

"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

Podcasts from Conferences of University of Tennessee IM Residency Program

Online medical education has changed significantly during the last 2-3 years. When I first started lecturing about using Web 2.0 in Medicine in 2005, few members of the audience had ever heard of podcasts and even fewer shared my enthusiasm for them as a medium for continuous medical education. Fast forward 3 years later, and now some doctors wonder if they should even go to a conference if they can just download the podcasts... More and more institutions make their grand rounds and conferences available for free via downloadable audio and video files.

A few examples of useful podcasts for medical education are listed below:

University of Tennessee Internal Medicine Residency Program

Three years of grand rounds and noon conferences of the internal medicine residency program of the University of Tennessee have been recorded and posted as podcasts on this website. You can listen to the podcasts directly or subscribe vai iTunes. The podcasts are searchable by topic. This is probably the most useful and comprehensive podcast resource for residents and medical students. Highly recommended.

The are 268 audio lectures published on the UTHSC website as of January 2008 which cover most of the curriculum in internal medicine. The podcasts are available for free compared to the audio review courses by major institutions such as Johns Hopkins which cost $200-1,200.

The authors of the project use Libsyn (Liberated Syndication) as a host which is a good place to start if you want to produce your own podcast. Libsyn plans start from $5 per month with unlimited downloads and an upload limit of 100 MB per month. The UTHSC podcasts are encoded at 16 kbs, mono, 22 kHz which does not provide the best sound quality but produces very small files (3-5 MB for a 30-60-minute talk). The total size of all 268 podcasts is 1.3 GB. Libsyn supports RSS and the extended Apple iTunes podcasting tags.

Other Medical Podcasts

Texas Tech Medcast

The Texas Tech Medcast is a podcast for medical residents, medical students and practicing physicians. It has several series:
- SOAP Note 101 Series: designed for first-year medical students who are learning how to write an effective patient note for a medical record (SOAP)
- Geriatrics Series
- Continuity Clinic Series
- Diabetes Mellitus Series
- PreMed Forum Series

Boston University General Internal Medicine Rounds

Weekly selection of the General Internal Medicine Grand Rounds from Boston University Medical Center. The project is still in early stages of development and only a few podcasts are available.

Yale Medicine Podcast

Visit itunes.yale.edu or launch iTunes, then select Yale from the offerings under iTunes U. The podcast is included under “Yale Health & Medicine.”

EMS Lecture Series by Albany Medical Center

Online continuing education courses for EMTs and emergency medicine residents.

PeerView Podcasts

Podcasts in different specialties by the supplier of continuing medical education activities PeerView Press.

MedPod101

Podcasts in different specialties by 3 doctors. The project is still in early stages of development.

References:
Medical podcasts: the future of continuing professional development? BMJ Career Focus 2008;336:29-30.
How to Use Web 2.0 in Medicine? Clinical Cases and Images - Blog, 05/2006.
Top 5 Medical Podcasts I Listen To. Clinical Cases and Images - Blog, 08/2006.

Related:
How to Embed MP3 Audio Files In Web Pages With Google or Yahoo! Flash Player. Digital Inspiration, 02/2008.
The iCritical Care Podcast: a novel medium for critical care communication and education. Journal of the American Medical Informatics Association 2007;14(1):94-99.
Joining the Podcast Revolution. J Dent Educ. 72(3): 278-281 2008.

Updated: 03/07/2008

Interesting Medical Websites

I you are interested in using the web for medical education, you can always rely on DavidRothman.net and ScienceRoll to find something useful.

A few examples are listed below:

- GoldMiner is a radiology search engine. I added it to the list of resources on ClinicalCases.org: Imaging: Electrocardiograms, X-rays, CT scans. Link via DavidRothman.net.

- FreeMD is "an electronic doctor that conducts an interview, analyzes symptoms, and provides expert advice — for free.” The website may not be an "electronic doctor" but is simple and easy to use. In my tests, the online diagnostic tool FreeMD worked well, and due to its extensive use of pre-recorded videos, it felt more interactive. Link via DavidRothman.net.

Related:
Performance of a Web-Based Clinical Diagnosis Support System for Internists. Mark L. Graber and Ashlei Mathew. J Gen Intern Med. 2008 January; 23(Suppl 1): 37–40.
Image source: Wikipedia

NEJM is a Journal (Only) No More

It is official. The venerable New England Journal of Medicine (NEJM) is a paper journal no more. Just visit the NEJM website to see what you have been missing if you have limited yourself only to the paper version of the journal. There is a slew of Web 2.0 and interactive features. I have been interested in the way medical journals use RSS (Really Simple Syndication), podcasts, videos, etc. for a while and was recently consulted by The Lancet to comment on their plain to introduce new tools to their website. Looking at the NEJM site, I have to say that there is a reason why they are still the leading authority in the medical publishing world. This is a list of some of the features a visitor encounters when landing on the NEJM homepage (see the screenshot below):

- Audio summary -- streaming audio and podcasts
- Interactive decision making tool using the "wisdom of crowds" concept
- Video of a roundtable discussion
- RSS Feeds
- Image challenge which also uses the "wisdom of crowds"
- Procedure videos
- Lists of Most Viewed, Most E-Mailed, Most Blogged, etc. articles
- "Listen to the full text of this article" feature


The homepage of NEJM is full of Web 2.0 features -- circled in red in the screenshot above. There are even more tools on the beta page of the journal at: http://beta.nejm.org/

In conclusion, the NEJM is using so many interactive features that it is putting even the most advanced blogs to shame. Comments are not available yet but this addition must surely be planned for not too distant future.

In recent years, the leading medical journals have become much more than a print medium for articles. The NEJM has gone beyond the RSS feeds and has created features which compel the reader to visit the website -- the ultimate goal of a portal site. RSS is so useful that if one can read it all in a RSS reader, there is little reason to click through the website. The NEJM seems to have found an elegant solution to this problem.

Try Web 2.0 in Medicine

I have collected RSS feeds and podcasts from the major journals in one-click subscription for iGoogle. Give it a try to see if it works for you:

RSS feeds of the major medical journals -- NEJM, JAMA, BMJ, Lancet and Annals and more

Podcasts of the 4 major journals

References:
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

Interesting Journal Articles

Etanercept Treatment for Children and Adolescents with Plaque Psoriasis. NEJM, 01/2008.

Etanercept is a recombinant human soluble tumor necrosis factor-alpha (TNFα) receptor fusion protein. Etanercept (Enbrel) reduced disease severity in children and adolescents with moderate-to-severe plaque psoriasis.

Biomarkers of Inflammation and Thrombosis as Predictors of Near-Term Mortality in Patients with Peripheral Arterial Disease (PAD): A Cohort Study. Annals of Int Med, 01/2008.

Levels of D-dimer and inflammatory markers (serum amyloid A and CRP) are higher 1-2 years before death in patients with PAD. Increasing levels of those biomarkers are independently associated with higher mortality in PAD. This is a mnemonic for the 3 biomarkers included in the study -- CAD: CRP, Amyloid, D-dimer.

A Risk Score for Predicting Near-Term Incidence of Hypertension (HTN): The Framingham Heart Study. Annals of Int Med, 01/2008.

A HTN risk prediction score can be used to estimate an individual's absolute risk for HTN. The risk score can be used as a simple, office-based tool to help management of high-risk individuals with prehypertension.

Review: Update on Avian Influenza A (H5N1) Virus Infection in Humans. NEJM, 01/2008.

Daily Assessment of Pain in Adults with Sickle Cell Disease. Annals of Int Med, 01/2008.

Pain in adults with sickle cell disease (SCD) seems to be far more prevalent and severe than previous large-scale studies have portrayed.

Review: Update in Palliative Medicine. Annals of Int Med, 01/2008.

A Bridge to Nowhere — The Troubled Trek of Foreign Medical Graduates in Australia. NEJM, 01/2008.

Interactive feature: Management of Type 2 Diabetes. NEJM, 01/2008.

This interactive feature allows readers to decide on the diagnosis or management of a clinical case.

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.

Why Use Web 2.0: An Open Letter to Physicians

Bertalan Meskó explains how academic and private practice physicians can benefit from using Web 2.0 in Open Letter to the Physicians of the World.

He covers what I call the the 6 axes of medical education in Web 2.0 style:

1. Web feeds (RSS)
2. Podcasts
3. Blogs
4. Wikis
5. Custom search engines
6. Second Life virtual world

Bertalan's letter is worth-reading and the University of Debrecen is lucky to have him as a student.

My presentation on Web 2.0 in Medicine from December 2006 is below:



References:
Open Letter to the Physicians of the World. ScienceRoll.com.
Image source: ScienceRoll.com, a Creative Commons license.

What Do You Call a "Medical Library" in 2008? "Information Commons"

John D. Halamka of the blog Life as a Healthcare CIO shares some interesting ideas:

"In my CIO role at Beth Israel Deaconess, I oversee the medical libraries. In the past, Libraries were "clean, well lighted places for books". With the advent of Web 2.0 collaboration tools, blogging, content management portals, lulu.com on demand publishing, and digital journals, it is clear that libraries of paper books are becoming less relevant.

The end result is that the Medical Library has been renamed the Information Commons and the Department of Medical Libraries has been retitled the Department of Knowledge Services. Librarians are now called Information Specialists."

Way of the future.

Google is scanning books in such a fervor that you can see the fingers of the overworked human scanners in quite a lot of digital copies on Google Books. In the 21st century, paper is converted to digital medium via manual labor.


Hand Scanned in Google Book Search. Image source: Google Blogoscoped, a Creative Commons license.


My Interview With Google Discussing Google Book Search. The Efficient MD.

References:
Knowledge Navigators Combat Information Overload. Life as a Healthcare CIO.
Hand Scanned in Google Book Search. Google Blogoscoped.
Google Books Adds Hand Scans. Tech Crunch.

Related:
What Do You Call A Medical Library. The Krafty Librarian.
NPR: “Who Needs Libraries?” (aidio), 01/2008.

Updated: 02/28/2008

Why Do I Blog?

A few answers are below:

I'm a Finalist by Dr. Wes.

Why I blog by Kevin, M.D.

Why do I blog?

This blog is a type of educational portfolio. I also use it during my teaching months to make a list of the topics discussed during the rotation with the residents and get feedback. And last but not least, this is the "blog of ClinicalCases.org with medical, tech and other interesting stories."

Currently, there are more than 2,000 subscribers via RSS and more than 1,000 daily website visitors but even if nobody reads it, I will still keep the blog up. Why? Because I have found that writing a blog can be useful, educational, entertaining and time-efficient. It creates your own section of the web that you own and trust. It also creates a relationship with some of the smartest people around the world that you would probably have never had the chance to meet otherwise. If you do not have a blog yet, may be you should consider starting one. The 2 easiest and free options are Blogger.com by Google and WordPress.com.

There are many downsides of having a blog, of course. But just like with any useful treatment, the benefits outweigh the risks for most people. I am not sure what is the "number needed to treat (NNT)," though...


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

From Twitter:

	AllergyNotes "Blogging keeps your mind sharp, improves your writing, brings you closer to intellectual people" http://tinyurl.com/9tuban 2 minutes ago from web
	AllergyNotes Blogging: A book that you write slowly over time http://tinyurl.com/9tuban 3 minutes ago from web
	AllergyNotes Blogging Is Like Going To The Gym… For Your Brain http://tinyurl.com/9tuban 3 minutes ago from web

Related reading:

"One of the best decisions I’ve made in my career was to start a blog and a wiki, leaving a paper trail of ideas" http://bit.ly/GX7Z6C
How To Use Your Blog To Make 2008 Your Best Year Ever! LifeHack.org.
Using a Blog to Build an Educational Portfolio. Clinical Cases and Images - Blog.
Topics Discussed During the Internal Medicine Rotation at Cleveland Clinic in October/November 2007. Clinical Cases and Images - Blog.
Blogging Is Like Going To The Gym... For Your Brain. Adam Singer, The Future Buzz, 01/2009.
Why Blog? Smartzville, 2009.

Why I blog? Life in the fast lane, 2010.

As A Busy Physician, Why Do I Even Bother Blogging? http://goo.gl/fSF3 - Excellent summary.
Why blog? Notes from Dr. RW. A perfectly reasonable list. All doctors should consider blogging. It's do-it-yourself CME.
Beautiful example of how blogs can disseminate medical information much more efficiently than journals, NEJM included (http://goo.gl/rOvNq).

Interesting Journal Articles

Hydrocortisone Therapy for Patients with Septic Shock. NEJM, 01/2008.

Hydrocortisone did not improve survival in patients with septic shock, either overall or in patients who did not have a response to corticotropin.

Intensive Insulin Therapy and Pentastarch Resuscitation in Severe Sepsis. NEJM, 01/2008.

Intensive insulin therapy placed critically ill patients with sepsis at increased risk for serious adverse events related to hypoglycemia. Use of hydroxyethyl starch in the study was harmful.

Four no more: The ‘PSA cutoff era’ is over (PDF file). CCJM, 01/2008.

Platelet-Activating Factor, PAF Acetylhydrolase, and Severe Anaphylaxis. Peter Vadas et al. NEJM, 01/2008.

Serum PAF levels were directly correlated with the severity of anaphylaxis. It looks like PAF has a good chance of becoming as important in anaphylaxis diagnosis as BNP has become in CHF exacerbation.

Metformin for the Treatment of the Polycystic Ovary Syndrome. NEJM Review. John E. Nestler, M.D. NEJM, 01/2008

Major Depressive Disorder. NEJM Review. R.H. Belmaker, M.D., and Galila Agam, Ph.D. NEJM, 01/2008.

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.