10 Ways to Increase Your Physical Activity

Posted on by

Some helpful tips from one of the PLoS blogs, Obesity Panacea:

1. Take the stairs as often as possible.
2. Drink plenty of water.
3. Park as far from the front door as possible.
4. Clean your home regularly.
5. Gardening and yardwork.
6. Disconnect your cable for the summer.
7. Buy a pedometer.
8. Use active transportation and public transit.
9. Have “walk-meetings”.
10. Go for a family walk after dinner.

"Health Promotion" video: Benefits of exercise:

Telomeres are the chromosome tips which shorten each time a cell divides, making them a possible marker of aging. Exercise delays telomere shortening, and potentially slows the aging process in humans. A study of 2400 twins showed that physically active people had longer telomeres than sedentary people. According to the authors, this provides a powerful message that could be used by clinicians to promote the potentially antiaging effect of regular exercise.


Human chromosomes (grey) capped by telomeres (white). Image source: Wikipedia, public

domain.

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


Gout update: New drugs for an old disease

Posted on by

Febuxostat is a non-purine-analogue inhibitor of xanthine oxidase that opened a new era in the treatment of gout.

Modified uricases

The use of modified uricases to rapidly reduce serum urate concentrations in patients with otherwise untreatable gout is progressing. Pegloticase, a pegylated uricase, is in development.

Drugs in development
Transport of uric acid in the renal proximal tubule and the inflammatory response to monosodium urate crystals (shown above) are targets for potential new treatments.

Several pipeline drugs for gout related to the targets above include:

- selective uricosuric drug RDEA594
- various interleukin-1 inhibitors

References:
Gout therapeutics: new drugs for an old disease. The Lancet, Volume 377, Issue 9760, Pages 165 - 177, 8 January 2011.

Image source: Spiked rods of uric acid (MSU) crystals from a synovial fluid sample photographed under a microscope with polarized light. Wikipedia, public domain.

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


Managing fever of unknown origin in adults – BMJ review

Posted on by

Few clinical problems generate such a wide differential diagnosis as pyrexia (fever) of unknown origin. The initial definition proposed by Petersdorf and Beeson in 1961 was later revised. Essentially the term refers to a prolonged febrile illness without an obvious cause despite reasonable evaluation and diagnostic testing.

Definition

Classic adult fever of unknown origin (FUO) is fever of 38.3°C (101°F) or greater for at least 3 weeks with no identified cause after 3 days of hospital evaluation or 3 outpatient visits
Causes of FUO
Common causes of FUO are infections, neoplasms, and connective tissue disorders.

Investigations almost always include imaging studies. Serological tests may be indicated

Treatment of FUO

Empirical antibiotics are warranted only for individuals who are clinically unstable or neutropenic. In stable patients empirical treatment is discouraged, although NSAIDs may be used after investigations are complete. Empirical corticosteroid therapy is discouraged.

References:

Investigating and managing pyrexia of unknown origin in adults. BMJ 2010; 341:c5470 doi: 10.1136/bmj.c5470 (Published 15 October 2010).
Image source: Wikipedia, public domain.

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


Average time patients spend waiting to see a health-care provider is 22 minutes

Posted on by

The average time patients spend waiting to see a health-care provider is 22 minutes. Orthopedists have the longest waits, at 29 minutes; dermatologists the shortest, at 20.

Patient satisfaction dropped significantly with each 5 minutes of waiting time. Even the term "waiting room" has a bad connotation. Many offices prefer "reception area" instead.

"I live my life in seven-minute intervals," says Laurie Green, a obstetrician-gynecologist in San Francisco who delivers 400 to 500 babies a year and says she needs to bring in $70 every 15 minutes just to meet her office overhead.

Measures the health-care industry is trying to minimize waiting time include:

- "Open-access" scheduling
- Minimize office visits
- Advance preparation
- Huddling up: "Mr. Jones is in a 15-minute slot, but we know he's a 45-minute guy"
- Teamwork
- Cutting "cycle time"
- Keep patients informed
- Survey patients

References:

Image source: OpenClipArt.org, public domain.

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


What to look for when buying sunglasses?

Posted on by

From the NYTimes:

Unprotected exposure to sunlight can cause significant damage to the eyes
Sunlight can burn the surface of the eye, causing a temporary and painful condition known as photokeratitis. Over time, unprotected exposure can contribute to cataracts, as well as cancer of the eyelids and the skin around the eyes.

UV exposure also may increase the risk of macular degeneration, the leading cause of blindness in people over age 65.

What to look for when buying sunglasses?
Look for labels indicating at least “98 percent UV protection” or that it “blocks 98 percent of UVA and UVB rays.” If there is no label, or it says something vague like “UV absorbing” or “blocks most UV light,” don’t buy them.

For the best defense, look for sunglasses that “block all UV radiation up to 400 nanometers,” which is equivalent to blocking 100 percent of UV rays

Sunglasses should cover the sides of your eyes to prevent stray light from entering. Wraparound lenses are best. Look for close-fitting glasses with wide lenses. Avoid models with small lenses, such as "John Lennon-style" sunglasses.

UV protection is not related to how dark the lens is. Sunglasses tinted green, amber, red and gray may offer the same protection as dark lenses.

Polarized lenses block the horizontal light waves that create glare. But remember, polarization in itself will not block UV light.

You should be able to find a pair of drugstore sunglasses for $10 to $20 that provide all the protection you need.

References:
Let the Sunshine in, but Not the Harmful Rays. NYTimes, 2011.

Image source: OpenClipArt.org, public domain.

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


Only 62% of referring PCPs received consultation results from specialists

Posted on by

Communication between primary care physicians (PCPs) and specialists regarding referrals and consultations is often inadequate, with negative consequences for patients.

A study found that perceptions of communication regarding referrals and consultations differed.

For example, 69% of PCPs reported "always" or "most of the time" sending notification of a patient's history and reason for consultation to specialists, but only 34.8% of specialists said they "always" or "most of the time" received such notification.
Similarly, 80.6% of specialists said they "always" or "most of the time" send consultation results to the referring PCP, but only 62% of PCPs said they received such information.
The 3 practice characteristics associated with PCPs and specialists reporting good communication regarding referrals and consultations were:
- "adequate" visit time with patients
- receipt of quality reports regarding patients with chronic conditions
- nurse support for monitoring patients with chronic conditions
Twitter comments:
@westr: Case for EHRs...
@Kind4Kids: but then the inpatient and outpatient EHR need to "communicate".
@GruntDoc: 0% of ED docs... -- Only 62% of referring PCPs received consultation results from specialists
References:
Referral and Consultation Communication Between Primary Care and Specialist Physicians. Arch Intern Med. 2011;171(1):56-65. doi:10.1001/archinternmed.2010.480

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


"How to Conquer Your Fear of Doctors"

Posted on by
The term "content farm" describes a company that employs large numbers of often freelance writers to generate large amounts of textual and/or video content which is specifically designed to satisfy algorithms for maximal retrieval by search engines. Their main goal is to generate advertising revenue through attracting reader page views (source: Wikipedia).
This is what the content farms are producing nowadays:
How to Conquer Your Fear of Doctors (HowCast video). A mix of good and bad advice, don't take it seriously:

"How to Live to Be 100" (HowCast video). Some tips in the video may fall in the category "Do not try this at home":

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


86% of Australian doctors report high rates of job satisfaction – see why

Posted on by

More than 80% of Australian doctors are moderately or very satisfied with their jobs, a national survey has found.

The survey, of 10?498 doctors, 19% of those who were contacted and eligible, found that 86% were moderately or very satisfied with their jobs, with no significant differences between GPs, specialists, and specialists in training. Hospital non-specialists were less satisfied.
The predictors of high professional satisfaction included:
- a good support network
- a household with a high income
- patients with realistic expectations w
- being able to take time off
- being younger or close to retirement
- having good self reported health.
Female GPs earn an average 25% less than their male counterparts and that GPs on average earn 32% less than specialists. The average annual pretax personal earnings of GPs and specialists were $US 180?000 and $US 316?570, respectively.
With Australia in the throes of national health reform, the researchers said that their findings set an important baseline for examining the effects of policy changes on doctors’ job satisfaction.
The survey was conducted between June and November 2008, before the Australian government announced its national health reform agenda.
The survey findings were published in the 3 January edition of the Medical Journal of Australia.
Twitter comments:
@gastromom (Meenakshi Budhraja): What are comparative figures in the US - 80% of Australian doctors report high rates of job satisfaction http://goo.gl/mchQT”
@PMillerMD (Philip Miller): 80% of Australian doctors report high rates of job satisfaction. / What is it in US? And if lower, why? I suspect payment morass.
@cotterj1 80% of Australian doctors report high rates of job satisfaction http://goo.gl/mchQT -> Explains why half the HSE docs are gone!
References:
Australian doctors report high rates of job satisfaction. BMJ 2011; 342:d119 doi: 10.1136/bmj.d119 (Published 10 January 2011)
Image source: Wikipedia, public domain.

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


Microsoft software to "replace" radiologists – recognizes organs and structures in medical images

Posted on by

Microsoft Research, Mar 8, 2011: InnerEye focuses on the analysis of patient scans using machine learning techniques for automatic detection and segmentation of healthy anatomy as well as anomalies:

Antonio Criminisi is the the researcher shown in the video above.

The InnerEye research project focuses on the automatic analysis of patients' scans by using machine learning techniques for:
- Automatic detection and segmentation of healthy anatomy, as well as anomalies
- Semantic navigation and visualization
Microsoft Research methods aim to combine medical expertise and modern machine learning theory in the design of tools for computer-aided diagnosis, personalized medicine, and natural user interfaces for surgical intervention.
The InnerEye project has a host of famous collaborators, including Johns Hopkins Medical Institute, The University of Oxford, Cornell Medical School, Massachusetts General Hospital, the University of Washington, Kings College London, and Cambridge University Hospitals.

High-Performance Cancer Screening: See how a high--performance, 3-D rendering engine can be transformed into a real-world, life-saving medical application:

References:

Comments from Twitter:
@doctorwhitecoat (Vamsi Balakrishnan): Definitely not a replacement... but cool tool in development.
@DrVes: Well, of course it's not a replacement... 🙂 Just as "Watson" supercomputer won't replace PCPs/specialists...
@ILoveOrthopedix (Orthopaedic Resident): MS Radiology! very interesting - the ECG machines recognise patterns & give diagnoses, but all the doctors make their own diagnosis.

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


What drug to add to maximal metformin therapy for diabetes?

Posted on by

Metformin is the recommended initial drug therapy for patients with type 2 diabetes mellitus (DM). However, the optimal second-line drug when metformin monotherapy fails is unclear.

All noninsulin antidiabetic drugs were associated with similar HbA1c reductions but differed in their associations with weight gain and risk of hypoglycemia.

The different classes of drugs were associated with similar HbA1c reductions (range, 0.64%-0.97%) compared with placebo.

Noninsulin antidiabetic drugs and their effect on body weight:
- thiazolidinediones, sulfonylureas, and glinides were associated with weight gain (range, 1.77-2.08 kg)
- glucagon-like peptide-1 analogs, alpha-glucosidase inhibitors, and dipeptidyl peptidase-4 inhibitors were associated with weight loss or no weight change
Sulfonylureas and glinides were associated with higher rates of hypoglycemia than with placebo.
References:
Image source: Metformin. Wikipedia, public domain.

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


When physicians prescribe a new medication… confusion ensues

Posted on by

According to a 2006 study of physician-patient communication during primary care visits, when physicians prescribed a new medication they:

- did not tell the patient the name of the new medication in 26% of the cases (the other way to look at the data is that the physicians stated the specific medication name for 74% of new prescriptions)

- did not explain the purpose of the medication to patients in 13% of cases (explained the purpose of the medication for 87%)
- did not tell patient about adverse side effects of the medication in 65% of cases
- did not describe to patients how long to take the medication in 66% of cases
- did not tell patients the number of pills to take in 45% of cases
- did not tell patients about medication dosing and timing in 42% of cases
References:
Physician Communication When Prescribing New Medications. Arch Intern Med. 2006;166:1855-1862.
Image source: Wikipedia, public domain.

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


Collecting family history predicts cancer risk better than 23andMe genetic testing

Posted on by

Collecting family history predicts cancer risk better than 23andMe genetic testing, according to a recent study from the Cleveland Clinic:

As you're sharing fond family memories, don't forget to bring up family health history -- it's the best gift you can give. Dr. Charis Eng comments on a study she led looking at the important role of family history in predicting future disease risk.
Related reading
Beware the fortune tellers peddling genetic tests - BMJ http://goo.gl/F0DQt
FDA panel: genetic testing should not be available directly to consumers without what amounts to a "prescription". WebMD, 2011.
Comments from Twitter
@23andMe: See our perspective of Cleveland Clinic study - http://bit.ly/c373aj - bottom line is 2 aren't the same, so can't compare h2h. Also, we agree that family history is a very important piece, and believe it complements detailed genetic info.

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


Investigating easy bruising in a child

Posted on by

From BMJ:

In a child, unusual bruising or bleeding out of proportion to the injury sustained should be investigated.

All children under investigation for easy bruising or a bleeding tendency should have:

- full blood count
- blood film (peripheral smear)
- coagulation screen including a thrombin time, in addition to a Von Willebrand factor assay and assays of factors VIII and IX

This is to ensure that mild forms of haemophilia are excluded even if the activated partial thromboplastin time is normal

In 30% of cases of haemophilia, there is no family history: it arises secondary to new genetic mutations


The coagulation cascade. Black arrow - conversion/activation of factor. Red arrows - action of inhibitors. Blue arrows - reactions catalysed by activated factor. Grey arrow - various functions of thrombin. Image source: Wikipedia

References:
Investigating easy bruising in a child. Anderson and Thomas 341, BMJ.

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


Oropharyngeal carcinoma increased by 22% in 6 years, related to rise in HPV

Posted on by

Head and neck cancer is the sixth most common cancer. Despite an overall marginal decline in the incidence of most head and neck cancers in recent years, the incidence of oropharyngeal squamous cell carcinoma has increased greatly, especially in the developed world.

In the United States, the incidence of oropharyngeal squamous cell carcinoma increased by 22% between 1999 and 2006.

The increase in incidence of oropharyngeal squamous cell carcinoma seems to be accounted for by a rise in human papillomavirus (HPV) related oropharyngeal carcinoma.

References:

Oropharyngeal carcinoma related to human papillomavirus. BMJ 2010; 340:c1439 doi: 10.1136/bmj.c1439 (Published 25 March 2010).
Image source: HPV types and associated diseases, Wikipedia, public domain.
Twitter comments:
@travispew (Travis Pew): So get your kids the HPV shot.

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


Electronic medical record (EMR) – review of pros and cons in Cleveland Clinic medical journal

Posted on by

Some negatives regarding the use of EMR:

- So far, electronic systems are not interconnectable
- Do electronic records improve or worsen the quality of care?
- Accuracy vs copying and pasting
- A third party in the examination room
- Devoid of real medical thought

A contrasting view:

- Connectivity will improve
- Staying focused on the patient, even with a computer in the room
- Doctor-doctor communication is enhanced

References:
The electronic medical record: Diving into a shallow pool? CCJM.
The electronic medical record: Learning to swim. CCJM.

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


There are 25,400 scientific journals and their number is increasing by 3.5% a year

Posted on by

More scientific and medical papers are being published now than ever before. Is it possible to be an expert nowadays, asks BMJ.

Every doctor has an ethical duty to keep up to date. Is this just getting more difficult or has it already become impossible? Since Alvin Toffler coined the phrase “information overload” in 1970, the growth of scientific and medical information has been inexorable.

There are now 25?400 journals in science, technology, and medicine, and their number is increasing by 3.5% a year; in 2009, they published 1.5 million articles. PubMed now cites more than 20 million papers.

One response of the medical profession to the increasing scientific basis and clinical capacity of medicine has been to increase subspecialisation. This may restrict the breadth of knowledge of the ultraspecialist, but can such subspecialists still maintain their depth of expertise?

I described my approach in 5 Tips to Stay Up-to-Date with Medical Literature:

1. RSS Feeds for Medical Journals.
2. Podcasts.
3. Persistent Searches on PubMed, Google News and Google.
4. Text-to-speech (TTS) for journal articles.
5. Blogs and Twitter accounts.

If you have a blog or Twitter account, you can try to deal with the information overload from blogs, RSS and Twitter more efficiently by using this:


The circle of online information (click to enlarge).

References:
On the impossibility of being expert. BMJ 2010; 341:c6815 doi: 10.1136/bmj.c6815.

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


Current school system is failing boys – how to re-engage them in learning – TED video

Posted on by

At TEDxPSU, Ali Carr-Chellman pinpoints 3 reasons boys are tuning out of school in droves, and lays out her bold plan to re-engage them: bringing their culture into the classroom, with new rules that let boys be boys. The first part of the talk points to some eye-opening facts about how the current school system is failing boys.

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


Blogs read by 20% of UK medical students, but only 8% write their own

Posted on by

A wide range of social media tools has become readily available in recent years, to the extent that the use of Facebook in particular is perceived as "second nature" by many students. There is increasing interest in the possibilities of using this social media services for medical education - blogs, wikis, Twitter and Facebook.

This UK study included a self-administered questionnaire survey of 212 first year medical students.
Over 90% used instant messaging. Social networking sites were also highly used - by 70%. There was no significant difference between males and females.
Blogs were read by 20% of students and a small number (8%) wrote their own blogs.
20% of males were users of media sharing and contributed to wikis.
Social bookmarking was rarely used by either gender.
Medical educators need to recognise the potential of social software in medical education but it is essential that students maintain the informality and privacy of these sites. The challenge is how to integrate social software into current curricula and institutional Virtual Learning Environments.

References:
Web 2.0 and social software: the medical student way of e-learning. Sandars J, Homer M, Pell G, Crocker T. Med Teach. 2010 Jun 18.

Comments from Twitter:

@DrVes I didn't expect that 8% of med students in the study wrote blogs - this is not my experience from teaching students and residents at Cleveland Clinic, Case Western and Creighton University.

@sandnsurf Medical education blog vs tumblr/posterous blog possibly. My students are at 10% for blog writing but 1% are actually medical.

@DrVes This is way higher than the stats here in the U.S. "Everybody's on Facebook, nobody has a blog"... 🙂

@doctorwhitecoat Not to jump mid convo, but at my school, I can say that most don't have blogs... at most maybe 3-5% and those that do... don't update.

@DrVes 2-5% is high. There was only one blogging student at Cleveland Clinic medical school who stopped after 1-2 years.

Image source: Blogger.com.

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.


Acute bronchitis: Many patients expect to be treated with antibiotics and cough meds but this differs from guidelines

Posted on by


Mind map of differential diagnosis of cough. See more Allergy and Immunology mind maps here.

Cough is the most common symptom bringing patients to the primary care physician's office. The most common diagnosis in these patients is acute bronchitis, according to a recent review in the official journal of AFP, American Family Physician.
Acute bronchitis should be differentiated from other common causes of cough such as pneumonia and asthma - because the therapies are clearly different.
Symptoms of acute bronchitis typically last 3 weeks. As we already know, the presence of colored (e.g., yellow or green) sputum does not reliably differentiate between bacterial and viral lower respiratory tract infections.
Viruses cause more than 90% of acute bronchitis, and therefore, antibiotics are generally not indicated. They should be used only if pertussis is suspected to reduce transmission or if the patient is at increased risk of developing pneumonia (e.g., patients 65 years or older).
The typical therapies that have been traditionally used for managing acute bronchitis symptoms have been shown to be ineffective. The U.S. Food and Drug Administration recommends against using cough and cold preparations in children younger than 6 years.
The supplement pelargonium may help reduce symptom severity in adults.
Many patients expect to be treated with antibiotics and cough medications but this differs from evidence-based recommendations.
The CNN video below tries to decipher what hides behind the names of common cough and cold medications:

References:
Diagnosis and treatment of acute bronchitis. Albert RH. Am Fam Physician. 2010 Dec 1;82(11):1345-50.

Posted at Clinical Cases and Images. Stay updated and subscribe, follow us on Twitter and connect on Facebook.