Thursday, December 24, 2009
Improving primary care conditions or increasing the number of physicians, what should be first? the egg or the chicken? - I think both!
Many physicians and analysts have completely opposite points of view; some advocate the increase in the number of residency slots to cover the increased demand of physicians; other disagree considering that this will not resolve the problem but just increase the number of subspecialists.
What does this mean? Why is this discussion relevant?
The way Medicine has evolved in the US, has unfortunately given a dramatic importance to therapeutics and not to prevention. It is fancy to show the dramatic improvement in coronary robotic surgery, the fascinating techniques for laparoscopic bariatric surgery (although this one is moving toward the site of prevention of obesity complications), it is fancy to develop newer and more expensive drugs to treat hypertension, hyperlipidemia, as well as the complications of atherosclerosis. A fascinating story is the development of all the drugs to treat smoking; how much money does a self-destructive habit caused to be spent in an attempt to treat it.
Therapeutic medicine is a necessity, however, I believe that Preventive Medicine with a specific focus on wellness is more important. How many trillions of dollars can be saved if people don’t develop diabetes or hypertension, and myocardial ischemia and strokes could be prevented. How many trillions of dollars could be saved if people would not smoke. If people eat well, exercise, avoid drinking and smoking, and just focus on enjoying our planet with respect for humankind and the environment perhaps a lot of money would be saved, but we are not in the position of having wishful thinkings.
There is concern about spending money in medications the patients need. Unfortunately, once you have developed a chronic disease you won’t really cure it, but you can prevent the complications by means of good control and lifestyle changes. For example, if a hypertensive patient complies with the DASH diet and walks 30 minutes per day, aims to be in the ideal body weight, may need fewer medications as weight loss in addition to increased aerobic capacity and decrease in insulin resistance will be in fact therapeutic as well as prevent further complications; for instance, preventing a single stroke that can be devastating, can save millions in a single person lifetime.
But going back to the beginning of the discussion – we need more emphasis in Primary Care; we need good Family Practitioners, Pediatricians and Internists that will have the aim of educating people to prevent the development of complications of chronic diseases, or even, preventing the development of chronic diseases.
As a hospitalist; in addition to our fascination with acute medicine, we all (at least I do) emphasize in-house in teaching our patients regarding lifestyle changes and encourage the follow up with a good Primary Care Physician.
If you realize that you have spent 8 years to become an MD and 3 or four of training, your least desire is to practice a Medicine that will burn you out and crush any remaining passion for healing and helping others. If you are underpaid, focused on filling a lot of paperwork every day, having a suboptimal timeframe to see patients (10-15 minutes) like a robot, without a real possibility of even having a brief conversation that can enhance the human interaction, and as well you live in uncertainty (due to insurance issues, lack of immediate diagnostic resources, etc.), this is a real uninspiring scenario.
What if the bureaucracy that is so heavily involved in Primary Care would be diluted; what if there would be a more streamlined process to help patients and avoid the doctors filling so much useless paperwork; what if there would be more time to enjoy the interaction with the patients and the opportunity to be more careful and thorough in the patient’s assessment; what if the economic compensation would be substantially improved to enhance the fundamental activity of keeping Americans healthy. What if there would be a real focus on physicians wellness; what if there would be real chances for Primary physicians to update themselves with protected time to study (as this do not exist in a lot of practices); I guess, that would definitely be a very attractive job. But not only we need to change the way it is being done, but we need more physicians – if we’ll see less patients per day as we’ll have more time to see them, then we’ll have need for more docs – we need to increase the source of physicians, and this is done by means of training more internists, pediatricians and family doctors.
Yes, the national healthcare bill is going to go up by increasing residencies, but people don’t realize that residents are in fact extremely underpaid doctors (yes, they are MD's or DO's) and even when working 60 hours, will really work hard. (I was trained in the 120+ hours/week era and regardless, I appreciate that they work very hard nowadays); these residents treat patients; these residents are a cheap source of healthcare providers and will be the future physicians. Paving the road with better work conditions that will be witnessed as an attractive choice for practice, will broaden their perspectives and increase the chances that they remain in Primary Care.
I believe that passion should be the engine behind a decision and not just the money factor. But we need to nurture that passion and changing the conditions for better is part of the process. While improving the current work conditions of Primary Care Providers, their availability should be enhanced so that patients don’t need to wait so long to have the chance of seeing their doctor - we need more docs.
Which will be the best way to improve Primary Care retention? – this is a good question – I advocate decreasing paperwork and improving salaries. Cash only practices, retainer models, are both valid choices that are well explained in Dr. Val and Dr. Centor's blogs. The main thing is to look in the first place for the well being of our patients, as our goal is a stronger America; a better world for our children. Because even in politics, the goal of physicians is always primum non nocere.
Sunday, December 13, 2009
This activity is called the Nocturnal Internal Medicine Triage Officer, which basically is a medical-administrative job as said above. You accept and coordinate transfers from any external medical center, and triage them to the appropriate medical subspecialty. After you accept a patient, and you consider the patient should be admitted, let's say, to Hematology, then you get connected with the Hematologist on call and give report so that the patient can be admitted under their service.
As well, you take all the calls from the Emergency Department (ED) transferring patients to Internal Medicine, where you do the same thing; help the ED staff to triage the patients to the appropriate service; help the ED residents to determine the required acuity of care (regular floor, telemetry, ICU) and as well the appropriate specialty.
You want to ensure that the patient gets the best standard of care; and even if our Internal Medicine staff are tremendously bright, knowledgeable and insightful, if a patient benefits from being on a primary subspecialty service, then that is the best; for example - a lung transplant patient or a patient with a congenital heart disease with Eisenmenger's, etc. What is most important is always to look at the situation this way: "if this patient would be me or my mother, who would I prefer her to be taken care from"....a bright internist with limited subspecialty knowledge, or a bright subspecialist that wrote the "State-of-the-art" on that very particular disease last week (which is the kind of colleagues I'm fortunate enough to interact with)", and if needed can always get an Internal Medicine consult on board.
Appropriate triaging impacts patients in many ways: they can get different standards of care depending the service where they go to; the length of stay is minimized in subspecialty services that have an increased comfort level discharging patients that based on their experience are stable enough to be followed as outpatient; the patient can get procedures done earlier; the subspecialist's experience can as well mandate an earlier work-up. Remember, your eyes can see what your brain knows. That means a lot in Medicine. We as internists know a lot of everything; but a subspecialist knows a lot of a particular thing that generally goes well on top and beyond our knowledge and that is fine; they did an additional 2-3 years of fellowship plus an extra 1-2 years of further fellowship (so in general 3-5 years more than our training). I feel very proud of being an Internist and a Pediatrician. I harbor with pride my FAAP FACP titles (which may seem pompous, selfish and arrogant, but it is not; it is important as the letters are designed to identify my area of expertise); however, I recognize that there are limitations to our knowledge, and I start a work-up, have a perspective of things, but at some point, it is the subspecialist expertise which will help the patient the most.
Of course, most patients will end up in the Internal Medicine service. The difference will be depending on their medical complexity whether will be triaged to a "teaching" service or a "non-teaching" service. This is an academic medical center, so residents will take care of patients supervised by a staff; in the non-teaching service, a hospitalist will take care alone of all the patients.
In addition, you are the staff at night to help the Internal Medicine consult resident on call with questions and see patients that need urgent evaluations, particularly pre-operative assessments. For the pre-operative evaluation we do "assessments" and "determine the medical optimization" of the patients; we "optimize" them as much as we can from the medical standpoint. We do not "clear" patients; this is a common misconception; in our large outpatient preoperative clinic (IMPACT - Internal Medicine Preoperative Assessment, Consult and Treatment) we write at the end of the note..."the patient is optimally prepared for surgery" or " not optimally prepared...".
You track all the admissions and transfers. We have organized and know all the details of each single admission - where it comes from, which service is taking care of the patient, who wrote the history and physical, what floor and bed the patient is at, which service will take care of the patient in the morning, who is the responsible staff.
Essentially, from the medical operations standpoint this is one of the finest and most sophisticated way that patient safety in transitions-of-care has evolved into.
There is variation from night to night. I have been kept awake from 5pm until 8am non-stop. Tonight, it is a quieter night. So quiet, that I decided to write a new post.
I realize that yesterday it was the most sacred day in Mexico, the Day of the Virgin of Guadalupe, or the "dark skinned lady from the Tepeyac" as people refer to her. It was as well the second night of Hannukah; the first one fell on Shabbat - so it is a special celebration. Last night (saturday night), the menorah was lighted after singing Eliyahu anavi. It is a religious weekend. I feel blessed and enlightened as I'm able to work in good health and spirit, and able to help people, both our patients (even if I'm just coordinating their transition of care, are MY patients) and my colleagues. As always....primum non nocere
Thursday, December 10, 2009
I wish I would be able to convince many parents who adamantly refuses the influenza H1N1 vaccine given the extreme misinformation provided by the media "based" on "non-evidence-based" resources. It is frustrating as a physician it is my main interest to enhance and ensure the well being of the human-kind. But for the most part, the majority of parents have been very well compliant with the recommendations. It should be recognized the fact that immunizations are perhaps, the best discovery of the last century, and hopefully the truth will overcome the fear toward immunizations.
Today, I had a 6 months old little boy admitted with URI symptoms, with very prominent clear rinorrhea, nasal congestion, cough and concerns for bronchiolitis. As soon as he had his nose cleared with bulb syringe suctioning, his symptoms improved dramatically and did not require oxygen. As part of the admission we obtained a Respiratory Viral Panel (an example of what it detects is here). The baby had positive Influenza A, and by definition, on this season, you consider it as H1N1. His family got the influenza vaccine; his parents are extremely pleasant, but the fact is that the baby started going to daycare last week.
Fortunately for him his chest roentgenogram is normal and is not requiring oxygen, however, the question brought to the table was: it is safe to start him on antivirals?
The data on safety and dosing of oseltamivir in infants is very limited, and if used, a careful monitoring for adverse events should be pursued. FDA recommends against routine prophylactic use in infants younger that 3 months of age. Recently (October 30, 2009), the FDA released a statement about Emergency use of Tamiflu in Infants less than 1 year of age.
The recommended treatment dose for infants younger than 12 months of age is 3 mg/kg/dose twice a day. However, as it will likely happen, if weight is unknown, a dose based on age can be used: birth to 2 mo, 12 mg (1 mL) BID; 3-5 mo, 20 mg (1.6 mL) BID; 6-11 mo, 25 mg (2 mL) BID.
The recommended prophylactic dose for infants 3 mo to 1 year old is 3 mg/kg/dose once daily. For infants younger than 3 months it is not recommended.
Of note, the FDA makes it very clear that the weight-based dosing recommendations are not intended for premature infants, as given their immature renal function, they can have slower clearance and offer the potential for toxicity.
So, we started him on oseltamivir, and we had as well an immediate concern for the parents. So we gave them a prescription for prophylactic oseltamivir use. Hopefully they won't develop the symptoms. They are immunized and hopefully in the case that the flu shows up, it will be as mild as it can be.
What about the other kids in the daycare? should they receive prophylaxis? what is my role as a hospitalist? - we essentially let the parents inform the daycare about the case and the other children's parents can discuss with their pediatricians; most likely they'll get prophylaxis.
Wednesday, December 9, 2009
Monday, December 7, 2009
Today we had many interesting cases; we had a classic croup case, and I emphasized about the evidence based approach to croup, the demonstrated lack of effectivity of cool mist, and the classic JAMA study comparing low and high humidity with cool mist. The patient did very well with racemic epinephrine alone. We decided not to treat ourselves with cool mist.
We discussed a patient discharged over the weekend that was admitted with low back pain. A toddler with back pain should be approached in a very careful way. Fortunately for the pleasant kid, the pain lasted a few hours and faded away. However, we did asked the parents about all the potential red flags which are nicely summarized in this excellent article from Archives of Diseases in Childhood: Education and Practice:
Pre-pubertal children especially < 5years
Duration > 4 weeks
Recurrent or worsening pain
Early morning stiffness and/or gelling
Fever, weight loss, malaise
Postural changes: kyphosis or scoliosis
Limp or altered gait
Weight loss, bruising, lymphadenopathy or abdominal mass
Altered spine shape or mobility
Vertebral or intervertebral tenderness
Limp or altered gait
Bladder or bowel dysfunction
Fortunately the child essentially didn't met any of the criteria. His personal history was negative for any suggestion of uveitis (red eye, ocular pain, photophobia), inflammatory arthritis, rash, micrognathia, limping; his growth was normal, he was afebrile, his exam was unremarkable with no spinal or paraspinal tenderness and with normal range of motion of all joints.
The patient did well after a single dose of ibuprofen and his acute phase reactants were mildly elevated. Before his admission he had a CT of the lumbosacral spine in the ED which were both unremarkable. A hip X-ray was done to r/o referred hip pain and was normal. An abdominal ultrasound was unrevealing with no nephrolithiasis or hydronephrosis, as well as no psoas abscess. Back pain can be elicited by multiple extraaxial causes such as retrocecal appendix, nephrolithiasis, psoas abscess, hip arthritis, etc.
His lack of cervical spine involvement essentially ruled out a Juvenile Rheumatoid arthritis (JRA), but he as well didn't have the manifestations suggestive of it; the CT scan ruled out spondylosis and spondylolisthesis, bone tumors as well as intervertebral disk pathology such as disk herniation or diskitis (and although an MRI would have been a better image it was not warranted given the rapid improvement of the symptoms). The lack of fever and systemic symptoms was reassuring as well against an inflammatory or infectious process. His gait was normal, with no urinary or fecal incontinence and his neurologic exam was nonfocal.
In addition, the family history was negative for any rheumatologic or autoimmune disease.
The patient was admitted the night before and essentially we arrived to see a healthy appearing child that had a transient low back pain but whom was extensively worked-up in a different institution Emergency room and who was happy, playful and with a complete unremarkable examination.
The parents were satisfied with the questionnaire we asked and the explanation for the rationale of the questions. They were reassured of the lack of any data suggestive of a significant life threatening condition, but as always, encouraged to follow up with their Primary Care Pediatrician.
This case provided an excellent teaching opportunity to review causes of back pain in childhood. I taught the Pediatric residents about the fact that low back pain is a very frequent complaint in adults (perhaps the most frequent in the outpatient setting) and that we are facing a difficult struggle to avoid a lot of unnecessary MRI imaging (that patients demand with the belief that the cause of the pain will be easily found). However, most MRI's are unnecessary as the most common cause of back pain is musculoskeletal. This is an excellent review on back pain at the Cleveland Clinic Journal of Medicine.
The Pediatrics residents became more aware of the interrogation to elicit signs and symptoms of JRA, as well as to think "outside of the box" with all the different extraspinal etiologies. It was fascinating to have the opportunity to revisit this subject once again and to ensure an safe health delivery.
We all see interesting cases every single day. All patients can be as fascinating and interesting as you want them to be. The residents at the Cleveland Clinic, present fantastic morning reports with all the imaging and labwork included, excellent bibliographic search, etc. This is in both Medicine and Pediatrics. As an academic hospitalist, I am invited to the morning reports to help catalize the case's presentation and emphasize high yield teaching points.
What surprises me, is the extemely poor academic outcome that yields from those morning reports in terms of productivity - the residents have already extensively summarized the case, and put it all together - the only thing is to put all the information in an abstract, as the slides can just be copied and pasted in a poster template. Or even the slides can be used to present in a National meeting as case conference. But, most of the residents leave those fantastic cases in the academic oblivion; they met their function - teach whomever was present in the morning report, but these cases deserve more than that; the educational value is superlative, and a lot of physicians can benefit from them; you share knowledge by means of presenting the cases in a national meeting. The work is already done; it is just means of finding submission deadlines for the different meetings and take the advantage of your own effort.
As a hospitalist, I work in teaching services with fantastic residents in both Internal Medicine and Pediatrics, and sometimes in non-teaching services, where I enjoy my loneliness to attempt to master the floors in the most cost-effective and evidence-based way as possible; I look for original references in the literature, and in many occasions, share the publications with my patients, to expand their knowledge and horizons. I don't hide things from my patients; the savvier they become, the more they develop their health literacy, the better outcomes they'll have. But, in addition, I learn an impressive amount of new things on a daily basis; and I find cases that are incredible for teaching purposes; more patients will benefit from the acquired knowledge and experience.
I have two choices; just "do my job", and try to be ready at 5 pm for sign out and prepare for the next day, and enhance the turnover. The other choice is "enjoy my job", learn as much as I can, make a list of all the interesting academic cases, read as much as possible, put them together, and when the time comes, present them in my own Department of Hospital Medicine Grand Rounds or in national meetings such as the Society of Hospital Medicine. Once you are in the meeting, it is pleasurable to see how you enhance other colleagues knowledge, but as well it is fascinating to learn a lot of different new things and overall, appreciate the different perspective and approach to Medicine in other institutions around the country.
Once in the meeting it is very interesting the peculiar questions you get asked which enrich and expands further the insight about the case. It makes you better; you learn from your colleagues experience and return home with novel ideas. These ideas work very well at the time of putting together the case for submission to a medical journal and then enhance the teaching in a global way.
Despite working late, I woke up with a lot of energy and enthusiasm, with the happiness of achievement; I hope that the abstracts will get accepted; it may happen otherwise, and then may think of improving them and perhaps submit to a different meeting or just have them for further teaching purposes, as our own experience and learning make us better every day to help is provide the best medical care and as always...primum non nocere.....
Sunday, December 6, 2009
Admitting a child to the hospital exclusively for observation purposes is a standard of care in order to be able to provide first hand evaluation and assessment of the child. This permits to ensure a safe discharge home and provide reassurance to both physicians and parents; likely, if a child does well during the observation period, will do well at home. The value of parental reassurance and documenting that after a short stay in the hospital the patient is able to safely be discharged home is very important. In Pediatrics, the medical decision making is based on the physical examination and appearance of the baby in the hospital.
Let's see a hypothetical case of an infant with a presumed "apparent life threatening event" or "ALTE"; the parents are distraught when witnessing first hand an unknown phenomenon such as a "staring spell" or "perioral cyanosis", etc. If the infant is well appearing in the Emergency room, with no clinical findings suspicious for a severe infection, the neurologic examination is non-focal, and the cardiopulmonary examination is unrevealing, it is highly likely that the patient will do well; however, safety is the main concern and priority in Pediatrics; obtaining basic studies including bloodwork and perhaps a chest roentgenogram (not necessarily the whole body X-Ray known as "babygram") and an EKG is in general sufficient. The next step is admitting the patient to the Pediatric ward to observe in a cardiopulmonary monitor for disrrhythmias, desaturations, apneas or respiratory changes such as the physiologic "periodic breathing". We can as well observe the patient's reaction to feeding, as well as the elimination pattern (urine output, bowel movements). A frequent cause of "ALTE" is gastroesophageal reflux - if a patient receives reflux precautions and antacids (such as famotidine) permits us observe if the phenomenon corrects; if not, then it is in place to rule-out other life threatening causes - from the CNS standpoint, obtaining an EEG and a head imaging (US or CT-scan); from the cardiovascular standpoint getting and echocardiogram; from the metabolic standpoint, documenting the value of glucose, bicarbonate and ammonium (if all three are normal, the likelihood of an organic acidemia is very low) as well as urinary organic acids; from the GI standpoint a swallow evaluation and an upper GI series (this permits an assessment of intrathoracic vascular anomalies such as a vascular ring as well as assess for reflux and malrotation); generally, the most frequently abnormal test will be the UGI series that reveals significant reflux.
The parents obtains reassurance from the thorough assessment (which apart from the bloodwork and the UGI, is in general safe and non-invasive) and the patient can start being treated in the hospital with observation of the medical intervention's outcome - for instance, changing the breastfeeding pattern, timing the feeds, permitting the baby take a breath between suckling, stimulating eructation, avoiding an immediate horizontal position after eating, having the head of the bed elevated 30 degrees - and if the events resolves, then the patient can be safely discharged home and have an outpatient follow-up.
It seems excessive but it is not. Safety is the most important aspect in medical care, especially in Pediatrics. I emphasize with the Pediatrics residents in always think outside of the box; is there any potential risk of abuse?, is there any need for parental education about feeding?, is there any significant family history we need to be aware of?, and help them organize their thoughts and medical decision making based on each individual case needs; doing studies in a protocolized way should not be advocated unless there is a well planned medical decision making algorithm behind the protocol. I emphasize in a thorough examination and assessment of all variables in order to reach a diagnostic conclusion and pathway. At the very end, the residents appreciate their own ability to approach each patient individually and enhance a safe medical care and transition of care, following always our motto....primum non nocere.
Saturday, December 5, 2009
This past couple days have been interesting. We had two adolescent patients with tonsilopharyngitis; one of them required a drainage of a peritonsilar abscess/phlegmon; the other one responded well to antibiotics alone. Based on Centor's criteria (enlarged tonsils with exudate, tender cervical lymphadenopathy, and exposure to strep throat) alone they met the clinical criteria for a strep pharyngitis and were treated as such. The patient with the most dramatic presentation with a peritonsilar abscess required intravenous steroids once. What was interesting was the choice of antimicrobials based on the physician starting the intervention; the ENT specialist chose clindamycin; the Pediatrician chose Ampicillin/sulbactam. Any of those are actually correct, and I would argue that perhaps, Penicillin would have been the best choice in any case. Regardless of antibiotic choice, both patients did very well; however, what would have been if the outcomes would have been different?
The past week was a very intense week in the academic media as Dr. Centor published a new article in Annals of Internal Medicine focusing on Lemierre's syndrome (secondary to Fusobacterium necrophorum). This is a very important article as it broadens the differential diagnosis of tonsilopharyngitis and reinforces the recognition that it can be a life-threatening disease (as its title implies "expands the paradigm"). I enjoyed pulling the PDF at the middle of the round in one of the multiple computer stations outside the patient's room and showing an Annals of Internal Medicine article to the Pediatrics residents. I need to emphasize that before we even went to the Annals website, I pimped all of them with the differential diagnosis of tonsilopharyngitis in children and then we discussed both common and uncommon causes.
I took my Pediatrics Board in 2007; the ABP has been giving increased importance to a rare bacteria called Arcanobacterium haemolyticum. And in addition to the F. necrophorum, as well as discussing the complications of Streptococcal infections I emphasized my teaching around A. haemolyticum.
The following information was extracted from the 2009 AAP "Red Book". A. haemolyticum is a catalase-negative, facultative anaerobic gram-positive bacillus formerly classified as Corynebacterium haemolyticum. Humans are the primary reservoir and spread is person to person, via droplet respiratory tract secretions and pharyngitis occurs primarily in adolescents and young adults. It is estimated that it causes 0.5% to 3% of all acute pharyngitis. The incubation period is unknown.
Clinically, it causes an acute pharyngitis indistinguishable from that caused by group A streptococci (GAS): fever, pharyngeal exudate, lymphadenopathy, rash, and pruritus are common; in almost half of all reported cases, a maculopapular or scarlatiniform exanthem is present, beginning on the extensor surfaces of the distal extremities, spreading centripetally to the chest and back, and sparing the face, palms, and soles. In comparison with GAS, palatal petechiae and strawberry tongue are absent.
Other clinical manifestations include URI and LRI that mimic diphtheria, including membranous pharyngitis, sinusitis, and pneumonia; and skin and soft tissue infections, including chronic ulceration, cellulitis, paronychia, and wound infection. Invasive infections, including septicemia, peritonsillar abscess, Lemierre syndrome, brain abscess, orbital cellulitis, meningitis, endocarditis, pyogenic arthritis, osteomyelitis, urinary tract infection, pneumonia, and pyothorax have been reported. No nonsuppurative sequelae have been reported.
The treatment of choice is erythromycin. A haemolyticum has in vitro susceptibility to erythromycin, clindamycin, and tetracycline. It is generally resistant to penicillin and trimethoprim-sulfamethoxazole, although penicillin resistance is variable. According to the Red Book, in disseminated infection, parenteral penicillin plus an aminoglycoside may be used initially as empiric treatment.
The residents were very surprised and expressed fascination with the newly acquired knowledge; the fourth year medical student was avidly writing down in her small notebook the name of the bacteria, as well as the references to read afterwards.
I felt well. The residents discovered a new world behind what they thought was a well known subject to them; we discussed the classic complement profile (C3 and C4) in post-streptococcal glomerulonephritis; we discussed about Rheumatic Fever and the Jones' criteria, about Streptococcal Toxic Shock Syndrome (STSS) and the controversial PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections) syndrome. They know more than they did before the rounds; this was teaching provided with only 2 cases of 15 we rounded. Of course a lot of other teaching points came out, but it was very satisfying to witness first-hand the progress of the Pediatric residents converting themselves in "Children's internists".
The other cases were fascinating as well, we had a baby with recurrent MRSA abscesses, which oriented the teaching toward the immune deficiencies that can predispose to recurrent staphylococcal abscesses; we had some epileptic patients using novel antiepileptic drugs such as lacosamide and rufinamide.
I strive, that regardless of how "common and boring" a disease may appear, it can be as fascinating as you want it to be, but this requires the imagination and creativity of the academic hospitalist to ask questions that stimulates his/her own thinking as well as the resident's and medical students. The knowledge can be unlimited, especially if you go to intricate pathophysiologic or biochemical aspects of the disease, or as well into pharmacology.
Pediatrics is fascinating; I can't never end being so grateful for the blessing I received in becoming a Pediatrician. Tomorrow is Sunday and we'll make it an efficient day; have the resident's leave early to comply with duty hours, but I do expect to provide some focused teaching.
As always, primum non nocere...
Sunday, November 8, 2009
There are simple ways of obtaining information as well, such as looking in Wikipedia, Google, medical news such as Medscape, WebMD, Heart.org, etc. or for more sofisticated and resourceful physicians, into UpToDate and MDConsult.
Being able to obtain immediate information from the direct source (not the intermediaries) is a privilege that technology brings to us. Many physicians chose to avoid the hassle and just limit themselves to use Google. This is not bad, as Google will likley direct them to the original source as well. However, knowing or having the links to direct sources of information makes the reader a more careful and selective researcher.
I made a list according to the different medical specialties, linking to the most important medical societies in the United States and Europe that provide Practice Statements and Guidelines. I hope you find it useful.
SUGGESTED GENERAL GUIDELINE SITES:
AGENCY FOR HEALTHCARE RESEARCH
NATIONAL GUIDELINE CLEARINGHOUSE
ALLERGY, IMMUNOLOGY AND ENT
AMERICAN ACADEMY OF ALLERGY, ASTHMA AND IMMUNOLOGY
AMERICAN ACADEMY OF OTOLARYNGOLOGY AND HEAD AND NECK SURGERY
AMERICAN SOCIETY OF ANESTHESIOLOGISTS
AMERICAN COLLEGE OF CARDIOLOGY
AMERICAN HEART ASSOCIATION
EUROPEAN SOCIETY OF CARDIOLOGY
EUROPEAN SOCIETY OF HYPERTENSION
AMERICAN SOCIETY OF HYPERTENSION
HEART FAILURE SOCIETY OF AMERICA
AMERICAN ACADEMY OF DERMATOLOGY
ENDOCRINOLOGY AND DIABETES
AMERICAN DIABETES ASSOCIATION – 2009 RECOMMENDATIONS
THE ENDOCRINE SOCIETY
AMERICAN THYROID ASSOCIATION
AMERICAN COLLEGE OF GASTROENTEROLOGY
AMERICAN GASTROENTEROLOGICAL ASSOCIATION
AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES
AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY
HEMATOLOGY AND ONCOLOGY
AMERICAN SOCIETY OF CLINICAL ONCOLOGY
AMERICAN SOCIETY OF HEMATOLOGY
INFECTIOUS DISEASES SOCIETY OF AMERICA
AMERICAN COLLEGE OF PHYSICIANS
INTERNATIONAL SOCIETY OF NEPHROLOGY (KDOQI GUIDELINES)
AMERICAN ACADEMY OF NEUROLOGY
STROKE GUIDELINES AND RESOURCES
THE BRAIN ATTACK COALITION
AMERICAN ACADEMY OF OPHTHALMOLOGY
AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS
AMERICAN ACADEMY OF PHYSICAL MEDICINE AND REHABILITATION
AMERICAN SPINAL INJURY ASSOCIATION
NORTH AMERICAN SPINE SOCIETY
AMERICAN ACADEMY OF PEDIATRICS
AMERICAN PSYCHIATRIC ASSOCIATION
PULMONARY AND CRITICAL CARE/SLEEP
AMERICAN COLLEGE OF CHEST PHYSICIANS
AMERICAN THORACIC SOCIETY
SOCIETY OF CRITICAL CARE MEDICINE
AMERICAN ACADEMY OF SLEEP MEDICINE
AMERICAN COLLEGE OF RHEUMATOLOGY
EUROPEAN VASCULITIS STUDY GROUP
EUROPEAN LEAGUE AGAINST RHEUMATISM (EULAR)
AMERICAN COLLEGE OF SURGEONS
AMERICAN UROLOGICAL ASSOCIATION
EUROPEAN ASSOCIATION OF UROLOGY
SOCIETY FOR VASCULAR SURGERY
Tuesday, November 3, 2009
The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have just released their 2009 update on perioperative betablockers.
You can access the update in perioperative betablockers here.
The whole 2009 Perioperative Guidelines (2007 guidelines with the update in perioperative betablockers) is here.
I summarized for you the current indications, and strongly invite you to access the new publications.
Class I indication
- Beta blockers should be continued in patients undergoing surgery who are receiving beta blockers for treatment of conditions with ACCF/AHA Class I guideline indications for the drugs. (Level of Evidence: C)
Class IIa indication
- Beta blockers titrated to heart rate and blood pressure are probably recommended for patients undergoing vascular surgery who are at high cardiac risk owing to coronary artery disease or the finding of cardiac ischemia on preoperative testing. (Level of Evidence: B)
- Beta blockers titrated to heart rate and blood pressure are reasonable for patients in whom
preoperative assessment for vascular surgery identifies high cardiac risk, as defined by the
presence of more than 1 clinical risk factor. (Level of Evidence: C)
- Beta blockers titrated to heart rate and blood pressure are reasonable for patients in whom
preoperative assessment identifies coronary artery disease or high cardiac risk, as defined by
the presence of more than 1 clinical risk factor, who are undergoing intermediate-risk surgery.
(Level of Evidence: B)
- The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate risk procedures or vascular surgery in whom preoperative assessment identifies a single clinical risk factor in the absence of coronary artery disease. (Level of Evidence: C)
- The usefulness of beta blockers is uncertain in patients undergoing vascular surgery with noclinical risk factors who are not currently taking beta blockers. (Level of Evidence: B)
- Beta blockers should not be given to patients undergoing surgery who have absolute
contraindications to beta blockade. (Level of Evidence: C)
- Routine administration of high-dose beta blockers in the absence of dose titration is not useful and may be harmful to patients not currently taking beta blockers who are undergoing noncardiac surgery.8 (Level of Evidence: B)
I hope you find this updates useful. At this point it doesn't change a lot of our current practice, but simply emphasize the cautious approach to avoiding elevated doses of betablockers and a well avoiding starting them without careful uptitration.
Saturday, October 24, 2009
(http://www.cardiacengineering.com/bbac/) showed survival benefits of perioperative beta blockers for patients with cardiovascular risk.
He uses a protocol called PCRRT that stands for Perioperative Cardiac Risk Reduction Therapy and can be accessed at http://www.cardiacengineering.com/bbac/PCRRT.pdf.
The protocol uses up-titrating dose of oral atenolol if the HR is >60x' or SBP > 120mmHg. They use iv metoprolol on the day of surgery and until the patient is able to take po, and then resume atenolol postoperatively at a dose of 100 mg once a day for 7 days. They advocate the indefinite use of betablockers in patients with CAD or PAD.
Fascinating is the fact that in the patients that betablockers were contraindicated, they used the alpha 2 agonist agent clonidine at a dose of 0.2 mg the night before surgery, a clonidine patch at a dose of 0.2 mg/24h and an additional oral dose of 0.2 mg in the AM of surgery.
The mortality at 30 days and 1 year was:
- Addition of betablocker:
30 days - O.R. 0.52 (95%CI, 0.33 - 0.83; P =.0055) ---> Reduction of almost 50%
1 year - O.R. 0.64 (95% CI, 0.51 - 0.79; P =.0001) ----> Reduction of almost 40%
- Continuation of previous betablocker:
30 days - 0.68 (95% CI, 0.47 - 0.98; P =.037) ---> Reduction of 32%
1 year - 0.82 (95% CI, 0.67 - 1.0; P =.05) ---> Reduction of almost 20%
- Withdrawal of previous betablocker:
30 days - increase in mortality 4-fold (P < .0001) 1 year - doubled mortality (P > .0001)
This information is very exciting, and supports the value of perioperative betablockers. The POISE trial brought a lot of noise in the perioperative medicine world; they used a very supraphysiologic dose of metoprolol in a very rapid fashion with no titration. This is a major caveat considered by the detractors of its results, mainly Dr. Poldermans.
The recently published European Society of Cardiology guidelines for Perioperative cardiac risk reduction in non-cardiac surgery (which were lead by Dr. Poldermans), advocate the use of perioperative betablockers in patients with 2 or more RCRI factors.
We should continue being careful in identifying this subset of patients. However, patients with stable systolic heart failure and coronary artery disease by themselves, benefit from the use of betablockers, regardless of the presence of other risk factors, although most likely they will in fact, have them given the common pathophysiologic ground - atherosclerosis -. The recent results of DECREASE group showed the benefits of adding fluvastatin perioperatively to patients undergoing vascular surgery (http://content.nejm.org/cgi/content/short/361/10/980).
I liked very much Dr. Wallace webpage (link above) and I think this large VA study will bring a significant backup to the use of betablockers in the perioperative setting. The use of clonidine was very refreshing. The idea is to control the heart rate - I wonder what result will a trial using calcium channel blockers or digoxin could bring . Comparing diltiazem or verapamil versus placebo versus betablockers versus clonidine and have subgroups with and without statins - I think the results will be very interesting. At the very end of the road, we want to decrease heart rate and perioperative oxygen consumption after induction of anesthesia.
I would love to see a discussion between Dr. Wallace, Dr. Devereaux and Dr. Poldermans. It would be very fascinating!
Reference can be accessed here. I look forward for a published article in a strong impact factor journal (JACC, Circulation or Anesthesia and Analgesia).
Sunday, October 18, 2009
What is unique about my presentation is that perioperative medicine as a separate field is way underdeveloped in Pediatrics. In adult medicine, especifically, in Hospital Medicine, the role of the hospitalist as an expert in Perioperative Medicine has been blossoming and growing up year by year, and is now a well established subspecialty field.
Perioperative Medicine is a discipline that provides a well rounded evaluation to the patient undergoing surgery, and has the objective of identifying and stabilizing in a timely fashion all the potential comorbidities, risk factors as well as potential complications that a patient can have during surgery.
In the perioperative evaluation for non-cardiac surgery, there are well developed guidelines for assessment and prevention of postoperative cardiovascular and pulmonary complications. For example, the 2007 AHA guidelines (http://bit.ly/4pzzK3) and the 2009 ESC guidelines (http://bit.ly/HAVZ2) or the ACP perioperative pulmonary guidelines (http://bit.ly/1nwVKL) or AHA guidelines for perioperative assessment of the morbid obese patient (http://bit.ly/26wUUU). Other well established guidelines are about perioperative management of antithrombotic therapy (http://bit.ly/K1Iaz) and prevention of venous thromboembolism (http://bit.ly/1Dfsv7).
However, there are no real guidelines or well delineated consensus or statements for perioerative management in children. There are well written articles that focuses on specific aspects or specific diseases (congenital heart surgery, diabetes, sickle cell anemia, etc.) but there is a lack of a guideline that delineates general rules in perioperative management of the Pediatric Patient.
In the lecture, I provide an outline that focus on the general approach to the perioperative management of the pediatric patient, and then on specific issues focused mostly on the children with complex medical problems.
I hope this effort offers a broad perspective of the important aspects to take into consideration in the perioperative evaluation and management of the pediatric patient.
As always, primum non nocere.
Thursday, October 1, 2009
Multiple resources exist; however it becomes almost impossible to have awareness of every single item out there. What I personally do as a hospitalist (but with an incredibly intense interest for Nephrology -as well as I have for Cardiology and Endocrinology -) is to get in my e-mail the TOC of most of the important journals.
If you see, here in my blog I get the updated RSS feed for the most important Internal Medicine and Pediatrics journals. This facilitates my search for information as I have in my fingertips the latest table of contents for most journals and giving a quick look to them permits me to be aware of new articles that I can recall later on, if not, read them immediately.
Below is a list of articles and links to the different journals as well as resources for Nephrology:
1. Nature Reviews Nephrology - http://www.nature.com/nrneph/index.html - on the left side there is a box that has a little envelope that states "Sign-up for e-alerts" (you need to register, is free, and you can get emails with the Table of contents of only this journal, or all Nature Clinical Journals, including Nature Reviews Urology, which is very good).
2. Nephrology Dialysis Transplantation - http://ndt.oxfordjournals.org/ - on the left lower side there is a section called Alerting Services. Click on "Email table of contents" as well as "email advance access" - you need to register (is free).
3. Kidney International - http://www.nature.com/ki/index.html - this is a Nature publication - you can register to this one by the link from Nature Reviews Nephrology.
4. Current Opinion in Nephrology and Transplantation - http://journals.lww.com/co-nephrolhypertens/pages/default.aspx - they have excellent reviews and concise articles that suggests you further literature. Register at Subscribe to eTocs.
5. Journal of the American Society of Nephrology - http://jasn.asnjournals.org/ - go to http://jasn.asnjournals.org/cgi/alerts - and just type your email.
6. American Journal of Kidney Diseases - http://www.ajkd.org/ - this is published by Elsevier; register for free at http://www.ajkd.org/user/alerts - here you can register as well to get the Table of Contents of: Advances in Chronic Kidney Diseases (http://www.ackdjournal.org/), and Journal of Renal Nutrition (http://www.jrnjournal.org/)
7. Complimentary registration to National Kidney Foundation - http://www.kidney.org/professionals/physicians/ajkd.cfm
- they publish the KDOQI and the KDIGO guidelines.
8. Medscape Nephrology - http://www.medscape.com/nephrology - Excellent source for updated medical information and CME.
9. Medpage Nephrology - http://www.medpagetoday.com/Nephrology/ - Excellent source for updated medical information and CME. Has nice divisions in DM, ESRD, hypertension, Transplant, etc.
10. Ukidney - http://ukidney.com/ - excellent resource for education in Nephrology.
11. Nephrology Now - a blog dedicated to education in Nephrology - http://www.nephrologynow.com/
12. HDCN - Hypertension, Dialysis and Clinical Nephrology - http://www.hdcn.com/ - excellent resource for education in Nephrology.
Here you can access:
- Atlas of diseases of the kidney (http://cnserver0.nkf.med.ualberta.ca/cn/Schrier/Default6.htm) - nice PDF's and Powerpoint - you can use to prepare your lectures.
- Atlas of renal pathology (http://www2.us.elsevierhealth.com/ajkd/atlas/) - useful for preparing lectures.
13. Societies other than ASN - Renal Physician Association - http://www.renalmd.org/
14. British Medical Journal collections - http://www.bmj.com/collections/ - You select the arrow on "Renal Medicine" and it opens you the access to articles on ARF, CRF, Dialysis, Fluid, electrolyte and Acid-Base, Nephrotic Syndrome, Proteinuria, Renal Transplant. You select the arrow on "Cardiovascular Medicine" and you can access the Hypertension articles.
15. Medical Pearls - a nice webpage with links to useful sites - http://www.medicalpearls.com/neph/nephlinks
Feel free to share this information, copy and paste in your own blog and email to other Internal Medicine or Nephrology doctor. Hopefully Dr. Bertalan Mesko will publish this links along with others in his fantastic Webicina 2.0 webpage.
Wednesday, June 3, 2009
Medicine is not an exact science, however, a significant amount of effort is put everyday in research endeavors directed toward minimizing human or system's errors and improve safety. Large randomized trials appear every day in the different journals around the globe and in fact, can change the whole practice of Medicine in one way or the other; a critical review of the data is recommended, but given the impressive amount of literature that appears everyday, people may just go ahead with the conclusions of the studies without further examining the "fine print in the text". Every one percent in mortality or survival is important as it affects a large population.Dogmatic teaching has been replaced by a mixture of experience, evidence and common sense; we become pragmatic in the way we use knowledge as we need to be extremely cautious when examining new data before considering it as the "real truth". Controversy arises when a previously established dogma (not necessarily a mistake of the past) appears to be severly questionned by new evidence, putting in perspective the frailty of our belief system. What is truth today, may be a lie tomorrow. Medicine evolves, so does the methodology in research as well as the amount of knowledge that supports new research endeavors. The main issue is that meanwhile this turmoil of data and knowledge, lie or truth, happens, patients are subjected to medical care based on the current evidence.
Since the last decade, data came up supporting the use of betablockers in the perioperative setting since Dr. Mangano's trial with atenolol, (NEJM 1996). Posteriorly Poldermans (NEJM, 1999) published the initial data using bisoprolol in high risk surgery patients in the DECREASE study. Multiple back and forth discussions occurred after a dramatic increase in perioperative betablocker use and in 2005, Lindenauer (NEJM) demonstrated that only high risk patients (essentially those with RCRI > 2) had a survival benefit from the perioperative use of betablockers. Most recently, the POISE trial (Devereaux, Lancet, 2008) showed an impressive amount of adverse complications in patients using perioperative betablockers, especially increased risk for stroke and sepsis; however its methodology was controversial as at differing from DECREASE in which low dose of betablocker was used initially with careful uptitration over a period of 30 days, at POISE a large dose (200 mg) of metoprolol succinate was used immediately prior to surgery.
Yesterday, Dr. Poldermans and its group published the most recent data on the DECREASE IV trial, and as in their previous publications, showed an impressive effect on survival - this time with an almost 70% decrease in 30 days mortality in patients using bisoprolol.
I have several comments on the study. I am amused by his positive results which he (Dr. Poldermans) has always strongly defended. Here are my thoughts:
1. As already known, DECREASE is an open labeled study (as that was the only way they could titrate up the betablocker), so although it was randomized, it was not blinded and this can yield to treatment bias which they recognize as on of their limitations.
2. They only recruited 1066 patients (from an original goal of 6000 (1500 per group) to detect an the anticipated risk reduction of 30% with a power of 81% and a 2-sided alpha of 5%). - however given the small number of patients in comparison (16% of the original goal) they obtained a dramatic result in 30 days mortality, however although the proportionally smaller sample did not affect negatively the betablocker group, it presumably had an effect on the statins group which had a trend toward decrease in mortality, although not statistically significant.
3. No seconary end-points were included in this article such as stroke, sepsis, etc....which makes POISE stronger methodologically speaking. However the authors make the point that the POISE trial showed a 1% incidence of stroke in the group randomized to metoprolol compared with 0.5% in the control group. In comparison, the incidence of stroke was 0.4% in the DECREASE studies, with no difference between groups.
4. The discussion provided is solid making the arguments against the unfavorable results from POISE. States that the beneficial effect of beta-blockade on coronary plaque stability, related to sustained mechanical and antiinflammatory effects require weeks to develop.
5. DECREASE IV has focused on the INTERMEDIATE risk group of patients, which do not take into account the low risk, however, the Lindenauer paper from NEJM in 2005 showed deleterious effect of betablockers in persons with RCRI score <2.> 3 carefully starting a low dose at the beginning (atenolol or metoprolol succinate 12.5 mg per day) with slow up-titration to a HR of 60 to 70.
In summary, we need to be very careful. Perhaps only patients with RCRI 3 or more really benefit from it and a very low dose should be started. Ideally slow and careful uptitration should be achieved. Realistically, we need to optimize patients almost immediately prior to surgery, therefore, starting a low dose is advised and titrate it up post-operatively.
1. Dunkelgrun M, et al. Bisoprolol and Fluvastatin for the Reduction of Perioperative
Cardiac Mortality and Myocardial Infarction in Intermediate-Risk Patients Undergoing Noncardiovascular Surgery A Randomized Controlled Trial (DECREASE-IV). Ann Surg. 2009;249: 921–926.
2. Auron M. Perioperative Betablockers and the POISE: Evidence revisited. Slideshare, http://bit.ly/hceO6
Tuesday, May 26, 2009
Most likely, although these glucose limits may help some practitioners, it is unlikely that this will be the last word in inpatient glycemic management and an ongoing long term debate will continue.
An interesting point is when the common sense and an expected outcome linked to hypoglycemia is converted into "evidence". It is reasonable to think that although the patients in the hospital and critical care setting need strict glucose control, they still need to have enough substrate to permit an adequate metabolic functioning and therefore low glucose levels may be potentially related to poor outcomes, even death. But now, we have "evidence" that show us that glucose below 110 can be potentially dangerous.
The interest is to increase patients' safety and better outcomes. More than just look into numbers is to determine what is the best practice to do so. Perhaps, the best measure is to individualize our patient glucose management, taking into consideration all the involved factors that can affect the glucose levels (sepsis or infections, steroid use, medications such as beta-agonists or quinolones, etc.) Establishing a basal insulin dose along with preprandial insulin coverage should be advocated, and the use of an insulin sliding-scale as a sole measure for glucose control should be discouraged.
We are aiming into "reasonable" goals of glucose levels for determining the maximum tolerated glucose level (180) mixed with "strictly evidence-based" glucose levels to determine how low we can aim (not less than 110), although the guidelines were not explicit about establishing a lower limit.
As always...primum non nocere.
Thursday, March 5, 2009
When we are in the academic rounds, daily discussion regarding our patients' multiple issues arises. The implications for the diagnostic or therapeutic decisions are discussed in order to support the best way possible the rationale or evidence behind our decision-making: trials, guidelines, task-force recommendations, etc., come to life to bring the truth closer to our eyes...
I suggest the reading of certain articles based on the above; generally I e-mail them to my residents, most of the time with comments that highlight the relevant teaching points. I disagree with providing paper copies as it is a waste of paper, money and of course...we need to go green and paperless!!!. In more than one occassion I have found those lonely and sad copies forgotten in a dark corner of the discussion room if not in the trash can, therefore, if they decide not to read the articles, they can delete the email, but not throwing the articles into the trashcan.
Sometimes, I suggest the residents to do a specific topic search and provide articles with good quality evidence, especially randomized controlled trials, or even good reviews.
But what is the challenge....?.....I presume, and perhaps I may be mistaken, that not all the residents will read the suggested articles....or at least will just read just one or a couple of them.
Once the e-mail is sent, there is no way to quantify the impact of this in medical education.
On the other hand, at long term, all the academic activity developed, the collection of articles, and the teaching points can get lost once the email is erased. In order to establish a portfolio that witness the evolution of academic teaching in the Internal Medicine rotation, which will treasure the material used for teaching, this blog comes on purpose.
The resources provided by the blog will always be accessible; people can always go back and read about already discussed topics. Residents can as well discuss about the value of this blog in their education and patient care.
An additional resource is posting mini-blogs with links to abbreviated URL's in Twitter, as you "immortalize" the information, being available for future reference. This can be linked to other resources such as facebook.
Well, welcome and remember.....primum non nocere......
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