Reminder about two helpful sites...
No advertisements. National Institute of Health presents reviews of topics and links to resources (clinical trials, etc).
Ten-year heart risk calculator
Clarifies risks when considering lipid management. Also links to other ATP III (Adult Treatment Panel III) Guidelines.
Thursday, August 8, 2002
Glee back? Imatinib and hair color.
Peter Ruehlman points out that in France nine people with grey hair had "re-pigmentation" within five months on imatinib (Gleevec). No word on how often this happens, or the color you get.
NEJM 2002;347:446 (August 8) Correspondence.
Wednesday, August 7, 2002
Truck Tire Blow Out & Accidents
Yesterday morning I was first car behind an 18-wheel flatbed truck. Seems to me I was thinking about safe distance. All I can tell you was the explosion was a bomb. Debris flying towards my windshield. I pulled to the right, and down the magically provided exit ramp. No other cars. No collision.
Got back on I-75. The truck was pulled over. Could see no flat tires. My guess is a tire exploded. (No police report). Amazing sound; instant storm of debris. Not a unique scenario. Many serious accidents over the years? Beautiful day for me. Lucky.
Talking World Health
In the office a woman from Dakar, Senegal did her best with English. I did my best with French. Taking the medical history, when we lost each other Google translator came in handy. Law requires access to translation. Unclear to me how often this is fulfilled.
Sunday, August 4, 2002
Imatinib (Gleevec)--Why do cells die?
Peter Ruehlman treated a man with CML (Chronic Myelogenous Leukemia). After years of elevated counts, fatigue, depression and containment with interferon, imatinib was tried. Counts normalized. (The gentleman subsequently has died of a myocardial infarction.)
Dr. Ruehlman describes another CML patient who has been cleared of chromosomal evidence of disease with imatinib. How does a drug that blocks tyrosine kinase eliminate malignant cells? Does it have other effects beyond inhibition of the phosphorylation?
Answer?...Interfering with glucose metabolism may lead to cell death.
Aortic Root Abscess
Back to this unfortunate problem confronted earlier last month. For helpful review, see Brecker SJ, Pepper JR, Eykyn SJ. Aortic root abscess. Heart 1999 Sep;82(3):260-2. [Image Copyright 2002, WebPath]
Man in the office claimed to drink ten 2-liter bottles of soda per day. (Wife confirmed this. I am still skeptical). He rarely comes to the office, but he drops by this week, a year later. His weight a year ago was 385. Now it is 340 pounds. "You remember our conversation?" he asked. He had stopped drinking sugar drinks...that's all.
Another recent example, same deal, this time a cab driver. Hot days. Lots of sweetened soda. By avoiding soda over six months he had lost 20 pounds. He reminded me of our talk. (In both cases there could, of course, be another cause of weight loss, we will see. I will confirm exact weight loss in each case.)
These are adults. Last year a Lancet article drew attention to the problem in children. Now people and groups with contrary concerns cite personal liberty (right to personal beverage choice) and shoddy evidence. Drink up.
Wednesday, July 31, 2002
Drug Shortages "No lasix?"
Next week: "Where's the solumedrol?"
...Medication shortages happen. To keep up on which and why, the FDA helps.
Can monofilament testing help us (patient & doctor) prevent foot injury and ulceration in diabetes?
Tuesday, July 30, 2002
Weblogs in Medicine
Jacob Rieder uses Family Medicine Notes to help teach. His weblog serves as an example; he provided a jump start for me. Kind recognition appreciated.
Medical Ethics & Radiation Research
US District Court Judge Sandra Beckwith summarizes the history & ethics of Defense Department whole body radiation research in Cincinnati, 1959-1972. Her 1995 decision eloquently discusses autonomy, liberty, and informed consent.
GI Blood and BUN
Does a rise in BUN rise distinguish upper from lower GI bleeding? (Physiologically is the rise in BUN due to catabolism of blood in the gut or simply under perfused kidneys?) This study found a specificity of only 27% and sensitivity of 90%. (Even less reliable in older patients, or with renal & liver diseases.)
Drugs, Neighborhoods and People
To follow-up on our Friday Clinton Hills conversation, the Physician Leadership on National Drug Policy (PLNDP) teaches about substance abuse, public health, and policy.
The book we talked about is Crack in America--essays by physicians, pharmacologists, sociologists and others. Gives sense of recurrent binges and prevalent patterns of use. Has clear opinions on policy.
Friday, July 26, 2002
Our July 2002 Internal Medicine Team at Good Samaritan Hospital moves on. A good team of people.
Backrow...Chris Bode, Jeff Schlaudecker, Rob Stevens, Lisha Fieler, Chuck Herfel
Front...May Mbah, Marco Callirgos, Carl Gandola
Thursday, July 25, 2002
One Painful Shoulder and Edema in PMR
The review article that Jeff brought in says that while shoulder pain is usually symmetric in polymyalgia rheumatica (PMR), it can begin as unilateral (as in our patient).
We also had talked about edema and its causes in our patient, uncertain if this could be associated with PMR. Yes, edema "of the dorsum of the hands and wrists, as well as of the ankles and tops of the feet" can be a distal manifestation of PMR.
Wednesday, July 24, 2002
A Physician's Personal Experience
...A letter to the editor reflecting on the concept of condolence letters.
Antibiotics and COPD?
Antibiotics can help in exacerbations--discussed in this excellent review. (Doxycycline effective).
But antibiotics for cough in an otherwise healthy person in your office is a different story. Same for chickens. (This link asks for a password to register for free access).
Tuesday, July 23, 2002
Tonight Hemlock Society, Assisted Suicide
Tonight (Tuesday July 23) 7:00 at the Vernon Manor Hotel Cindy Kerkoff, President of Hemlock Society of Ohio will speak. "The mission of Hemlock of Ohio is to maximize the options for a dignified death, including voluntary physician aid in dying for mentally competent, terminally ill adults who request it, in the context of legal safeguards."
Rhabdomyolysis, CPK and cuff test
Good review article raises several metabolic conditions that might explain our gentleman's heat/exercise intolerance. Still need information on forearm cuff test and on range of CPK's found in rhabdomyolysis.
How Long Prednisone in Polymyalgia Rheumatica (PMR)?
This review suggests "between one third and one half of patients can stop steroids after two years."
Friday at Clinton Hills Here are directions.
Saturday, July 20, 2002
To Find Quiz
To find the quiz on management of non-pain symptoms click Quiz in the Navigator (the list of items to the left). ...Might help us this coming week.
Friday, July 19, 2002
SOAP notes. BATHE people.
We know about SOAP notes. But do we BATHE the patient?
Thursday, July 18, 2002
Institute of Medicine is looking into it.
NEJM Full Text?
NEJM original articles are released on the web, full text, after six months. Test this out. Try this link. Should take you to a paper on the risk of stroke in asymptomatic internal carotid stenosis.
When you get to the NEJM site you may be asked for a password. Scroll down and register for free access to papers older than six month. (Let me know how this works...leave a comment here.)
Wednesday, July 17, 2002
Lacunes & Carotid Stenosis
Some opinions on whether carotid endarterectomy reduces stroke risk after lacunar infarct. And ideas about management of asymptomatic carotid stenosis.
More on coumadin & acute coronary syndromes
Coumadin for three months after fibrinolysis for acute myocardial infarction reduced reocclusion and re-infarction. APRICOT-2 adds to ASPECT-2 mentioned earlier. ...Chris?
Tuesday, July 16, 2002
Tech Note: Searching?
Looking for something you read here earlier? To find archived posts use the search engine (it searches just this site). Or click on any date in the calendar. To get back to this home page use your browser's "Back" button, or click "Home" on the left of this page.
Letter of Condolence
The NEJM Sounding Board article is not available for free access online. (Unfortunately only original articles are released after six months, not reviews such as this). So I will bring in paper copies. (N Engl J Med 2001;344:1162-1164). Expressing condolence humanizes a part of our work.
Symptoms resolved on second day of therapy. Noted sweats & chills with fourth (final) dose of thiabendazole. Some numbness in fingertips.
...Also see comments on eosinophilia from Rob and me attached to earlier post about "Worms." (July 13).
Aspirin, coumadin and second MI?
Jeff had reported on aspirin use after acute coronary syndromes. Lancet this week reports the ASPECT-2 study, a randomized controlled study of 999 people after myocardial infarction (MI). It shows after 26 months a 9% incidence of MI in the aspirin group, 5% incidence in the coumadin group (target INR 3-4), and 5% incidence in the moderate intensity coumadin + aspirin group (target INR 2-2.5). Administration of drug was open, not blinded. (Look forward to comments of Chris & Tom especially on bleeding and mortality). Lancet 2002;360:109-112.
Noontime Conference today
Hospice introduction by Pam McCabe from Hospice of Cincinnati. Introduction to hospice services, how to refer, and what your rotation will be like.
Saturday, July 13, 2002
How do we best manage dyspnea, nausea, vomiting, constipation, anorexia, fatigue, and insomnia? Common non-pain symptoms seen every day. Here is a clinical quiz put together by Dr. Sydney Morss Dy, modified for the web. (Under construction, but ready for testing).
Here is our culprit. Take a look at strongyloides actually residing in the intestinal mucosa (in situ). Line 'em all up--a parasite collection from the Oregon Health Department.
Thursday, July 11, 2002
"Any advice on Do Not Resuscitate?"
Here are some thoughts. You can read specific sample conversations from Drs. Lo, Quill and Tulskey (deals with palliative care, but applies to DNR). Or see the process broken down to helpful steps by Drs. Weissman and VonGunten. Even pocket cards with phrases have been tried.
...will be up at the hospital around 8:00. May ask for a minute of your time, to bounce off you an idea for rounds on Friday.
If there are pre-tests in the future, all questions and answers will be posted here before rounds.
Quit Smoking Nortriptyline works according to this paper. (Study starts at 25 mg nightly, progressing to 75 mg nightly as tolerated.). Cochrane collaborative also concluded it is effective.
Tuesday, July 9, 2002
When you are using the 14th floor computers, at the hallway ends, you can get back here easily by using Favorites. Open Favorites, then Links. At the bottom of that folder you will see iPosted It...Medicine. Click that and you will come here.
Man with diarrhea and abdominal pain
You may have heard part of this story. More on Wednesday.
Menopause, Estrogen and Progesterone
Here is the NIH discussion on the stopping of a component of the Womens Health Initiative trial due to increased risk of breast cancer, heart disease, stroke and pulmonary embolism.
"Absolute excess risks per 10,000 person-years attributable to estrogen plus progestin were 7 more CHD events, 8 more strokes, 8 more PEs, and 8 more invasive breast cancers, while absolute risk reductions per 10,000 person-years were 6 fewer colorectal cancers and 5 fewer hip fractures. The absolute excess risk of events included in the global index was 19 per 10,000 person-years."
Monday, July 8, 2002
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Platelets and COX-2
I could not find clinical reports of celecoxib associated thrombocytopenia. But did find a basic science in vitro report on a related question: Do COX-2 inhibitors interfere with platelet production or function in states of high turnover (ITP or stem cell transplant)? Not sure what it means for our patient. Tom? Chris?...
Saturday, July 6, 2002
Have improved the Comments feature. Feel free to build on ideas you find here. Click "Comment" to read existing comments or to fill in the pop-up form to add one.
Friday, July 5, 2002
Scurvy--The brave 2nd-year resident (John Crandon)
1939 and the guy goes six months without Vitamin C. Read what happens. (Among many discomforts were "perifollicular hemorrhages" on lower legs...dependent areas as pointed out by Dr. Imhoff.)
Petechiae, Purpura, Ecchymoses
Size seems to be the criteria. Petechiae (1-2 mm), Purpura (>3 mm), Ecchymoses (>1-2 cm).
The NEJM immune thrombocytopenia review from March (PubMed) has some pictures of more explicit petechiae. (Authors of same review do bone marrow on patients over forty years old.) Below 10,000 platelets risk of serious hemorrhage rises.
Thursday, July 4, 2002
Does hydrochlorthiazide (HCTZ) daily lead to increased volume of urination when used to treat hypertension?
Should acetyl cysteine (Mucomyst) routinely be used to prepare patients with renal insufficiency for radiographic dye?
Are morbid obesity and extreme obesity distinguishable terms? (Sense is they both refer to Body Mass Index more than 40.)
Amaurosis fugax. What are the eye findings? What is the treatment?
ACE-Inhibitors in diabetes. Do we wait for microalbuminuria or hypertension to start renal protection?
Cut Diabetes Onset by 60%
Moderate weight loss (7%) and exercise reduced diabetes onset by 60% in first degree non-diabetic relatives over three years. See the Diabetes Prevention Project (DPP).
"Was is it a heart attack?"
McKenna and Forfar answer this question in the British Medical Journal (BMJ). Troponin is key to European and American new definitions.
Even with renal insufficiency troponin can be prognostic. (See NEJM paper and editorial of June 27).
Here are acute myocardial infarction enzymes graphed over time. (Copyright 2001 WB Saunders Co, from Braunwald "Heart Disease" 6th ed)
How do we want to work these? As much as we can let's try most of our teaching with the patient, at the bedside.We can see and hear the individual's concerns--with their full consent. As discussed in the reference by Dr. LaCombe we will work to respect and support the patient as well as each other.
First day will be mostly introductions among the team, planning for the month, then individual time with patients.
It's July. Welcome to Cincinnati!
First, some life support, non-medical variety. Try Findlay Market for food. Rich atmosphere of a public market. Open Saturdays chiefly.
Take Central Parkway south towards downtown about three miles. At Findlay Street turn left. In the second block turn right into Findlay parking lot. (Dean's Mediterranean Market has all things from spice to nuts and is open all week).