A recent article in Sleep suggests that sleep interruptions are more detrimental on mood than overall reductions in sleep duration. Researchers at John Hopkins University subjected 62 healthy men and women to a randomized trial including 3 arms: three consecutive nights of forced awakenings (8 times per night), delayed bedtimes or uninterrupted sleep. Outcomes included sleep architecture (polysomnography) and a standard mood questionnaire. Participants subjected to forced awakenings had a 31% reduction in positive mood, while the delayed bedtime group had a decline of 12% compared to the first day. Researchers did not find significant differences in negative mood between these two groups. These findings suggest a “putative biologic mechanism (slow wave sleep deficit) that could help explain the strong comorbidity between insomnia and depression.”
This research asks provocative questions regarding the approach to sleep during residency training. Extended call duration (i.e. 24-28 hour in house call) is associated with frequent episodes of sleep interruption and, therefore, may be more detrimental to psychological well being when compared to shift work (only associated with reduced sleep duration). We cannot draw conclusions regarding educational benefit or patient safety, but, with ongoing controversy regarding resident work hour restrictions, this study surely provides food for thought.
Oviea Akpotaire, Jeffrey Okonye (medical students) and Dale Okorodudu (senior pulmonary/critical care fellow) were recently interviewed by KERA on the declining representation of African Americans in Medicine. Despite increasing minority enrollment and matriculation in higher education, fewer African-American men applied to medical school last year compared to 1978. See this link for Akpotaire, Okonye and Okorodudu’s experience as medical trainees and their thoughts on what can be done to reverse this troubling trend. Also see Dr. Okorodudu’s mentoring website Diverse Medicine Inc to read about his outstanding initiative to improve diversity in medicine.
At morning report today, we had an interesting discussion regarding the justification of antibiotic monotherapy for acute appendicitis. The NEJM recently published a comprehensive review examining this “antibiotic first” approach. Urgent appendectomy has been the mainstay of treatment for acute appendicitis since the 1800’s. Traditionally, antibiotics have been reserved for complicated cases of appendicitis (including prolonged inflammation with phlegmon or abscess). However, recent data from the U.S. Navy as well as a series of European clinical trials suggest that antibiotic therapy alone may be appropriate for select patients. Inclusion criteria for these studies included patients that were relatively healthy without evidence of sepsis, diffuse peritonitis, abscess or perforation. Initially patients were treated with IV antibiotics targeting enteric pathogens followed by a 1-2 week course of PO antibiotics on discharge. Cross over to surgical intervention was indicated by progressive fever, intractable pain or evolution of sepsis/shock.
Clinical outcomes among patients randomly assigned to the antibiotics-first strategy were generally favorable. Patients assigned to this group had similar pain scores, required fewer doses of narcotics, and had quicker return to work. Perforation rates were not significantly higher among the antibiotic group. The rate of crossover to surgery within 48 hours after the initiation of antibiotics ranged among trials from 0 to 53%. Eventual appendectomy after initial, successful treatment with antibiotics occurred in 10 to 37% of the patients assigned to the antibiotics-first strategy (mean time to appendectomy, 4.2 to 7 months). In general, these trials viewed the antibiotic first approach as a viable option.
Despite these favorable findings, several areas of uncertainty still exist drawing caution to antibiotic monotherapy. The aforementioned trials fail to confidently assess complications related to delayed surgery, comparative cost, length of hospital stay, anxiety about future episodes of abdominal pain and factors associated with a higher risk of recurrence. Moreover, it remains unclear which patients are most appropriate for an antibiotic approach given the fact up to 50% of patients receiving monotherapy progressed to needing surgery. Furthermore, unlike the U.S. where laparascopic approach is by far most commonly performed, the majority of appendectomies included in the European trials were open. Large scale U.S. trials investigating these issues are certainly in need.
Guidlines from the American College of Surgeons, the Society for Surgery of the Alimentary Tract, and the World Society of Emergency Surgery all describe appendectomy as the treatment of choice for appendicitis. They consider antibiotic monotherapy to be potentially effective but associated with an unacceptably high rate of recurrent disease. Taken together surgical management remains standard of care in the United States. Antibiotic monotherapy can certainly be considered in select patients (those with high risk for surgery, personal aversion to invasive procedures or mild disease), but a detailed conversation regarding risks and benefits should be performed with all in consideration. Most importantly, close outpatient follow-up must be ensured in light of the significant risk for recurrent appendicitis. This topic is fascinating and clinically relevant to all internists engaged in hospital medicine.
During medical school, the RIME framework is used to assess the progression in the educational process as the student moves from the most basic role of gathering and reciting information as the Reporter, to an Interpreter of the information utilizing skills to prioritize problems. Towards the end of medical school and during the intern year, the same student hopefully achieves the status of Manager by synthesizing the problems into a coherent plan for the patient. By the end of residency, the student should have mastered these clinical skills and become an Educator, passing these skills along to others on the team.
This model has been widely accepted yet the clinical reasoning process and the methods by which these skills might be imparted to other students has not been as well defined. Dr. Judith Bowen offers an excellent take on the delivery of this information, methods to assess clinical reasoning, and ways for the educator to facilitate the clinical experience so as to provide excellent patient care and produce an articulate problem-focused presentation. She highlights elements of the Clinical Diagnostic Reasoning Process, use of Illness Scripts, and examples of Diagnostic Hypotheses for various disease processes. Furthermore, she identifies ways to diagnose the learner’s skills and areas of weakness in clinical reasoning while offering strategies to “treat” the deficient skill. The article was published in NEJM in 2006 and is titled, Educational Strategies to Promote Clinical Diagnostic Reasoning. The review is pertinent for all levels of training but especially useful for residents and faculty to use with their team of interns and medical students to facilitate growth during rotations.
Bowen: Educational Strategies to Promote Clinical Diagnostic Reasoning
Watson is an artificially intelligent computer system developed by IBM. In 2011, Watson was made famous by competing on Jeopardy! at which time it defeated prior champions Brad Rutter and Ken Jenning’s. IBM now aims to apply this revolutionary technology to healthcare. Researchers at Memorial Sloan-Kettering are developing Watson as a decision making tool for oncologists. With the capacity for massive data storage and advanced reasoning algorithms, Watson synthesizes up-to-date, comprehensive clinical evidence and patient data to create accurate diagnostic and treatment plans. This function hopes to extend high quality, evidence based practice uniformly around the world. Expanded use in other sub-specialties is planned, as well. The potential applications of this technology are staggering and extend to decision making, clinical research and administration. In the digital age of healthcare, tools like Watson have the potential to improve efficiency and the provision of high quality, patient centered care. Please see the following articles for more information: Article 1, Article 2.
A recently published article in JAMA addressed some updates in sepsis management and diagnosis. The report incorporated numerous randomized clinical trials in order to strengthen the recommendations. Key advances noted in the paper include focused ultrasound for early recognition of underlying contributors to hypoperfusion such as cardiogenic shock or hypovolemia and invasive monitoring in only a select group of patients. Sepsis protocols were found to have little advantage over management without a protocol in a number of studies and albumin/crystalloid solutions remain up for debate. An excellent algorithm is included in the paper.
Read the full article here:
Septic Shock – Advances in Diagnosis & Treatment
A little late, but here is the August edition of our resident-led publication with micro-reviews of recent medical articles. Stay up to date on recent advances with brief but comprehensive analyses by our own residents! Articles highlighted this month:
- Troponin and Cardiac Events in Stable Ischemic Heart Disease and Diabetes (NEJM), reviewed by Dr. Wally Omar
- Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation (NEJM), reviewed by Dr. Wally Omar
- EKG challenge – Jeomi Maduka
- Second-Look Colonoscopies and the Impact on Capacity in FIT-Based Colorectal Cancer Screening (Am J Gastro) – reviewed by Dr. Udayan Shah
- Effect of Amitriptyline and Escitalopram on Functional Dyspepsia: A Multicenter, Randomized Controlled Study (Gastroenterology) – reviewed by Dr. Udayan Shah
- Toward a More Complete Understanding of the Association Between a Hepatitis C Sustained Viral Response and Cause-Specific Outcomes. (Hepatology) – reviewed by Dr. Brian Davis
- The Cholangiopathies (Mayo Clin Proc) – reviewed by Dr. Brian Davis
- Systemic Inflammatory Response Syndrome Criteria in Defining Severe Sepsis (NEJM) – reviewed by Dr. Arjun Gupta
- Screening for Occult Cancer in Unprovoked Venous Thromboembolism (NEJM) – reviewed by Dr. Arjun Gupta
- Chemotherapy Use, Performance Status, and Quality of Life at the End of Life (JAMA Onc) – reviewed by Dr. Tri Le
- Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection (NEJM) – reviewed by Dr. Natalia Rocha
- Systolic BP and Mortality in Older Adults with CKD (Clin J Am Soc Nephrology) – reviewed by Dr. Jeanney Lew
- Implantable Cardioverter-Defibrillators in Patients with CKD: A Propensity-Matched Mortality Analysis (Clin J Am Soc Nephrology) – reviewed by Dr. Jeanney Lew
- Lumacaftor–Ivacaftor in Patients with Cystic Fibrosis Homozygous for Phe508del CFTR (NEJM) – Dr. Fernando Woll Plenge
- Risk of major cardiovascular events in patients with psoriatic arthritis, psoriasis and rheumatoid arthritis: a population-based cohort study (Ann Rheum Dis) – reviewed by Dr. John Matt Hancock
How many times has your attending asked you “What do the guidelines say?” or “Whats the evidence for that?” in regards to a particular clinical question? How many times have you tried to find the guidelines (maybe even Googled it!) and then resorted to an Up-to-date style answer? With the avalanche of medical information available at our fingertips, it is often a daunting task for young physicians to access the right clinical guideline to answer the question at hand. One of our favorite resources is
a website sponsored by the Agency for Healthcare Research and Quality (AHRQ). Here you can find a database of updated clinical guidelines that is searchable by disease, organization or strength of evidence. You can even register an account and have updated guidelines of your choice emailed to you. Continue reading Where do I find those pesky guidelines?
Our own master of electrolytes and kidney specialist, Dr. Biff Palmer, recently published an excellent review article in New England Journal of Medicine titled “Electrolyte and Acid–Base Disturbances in Patients with Diabetes Mellitus.” These frequently encountered clinical scenarios pose problems both in the inpatient and outpatient settings and it is important for physicians of all specialties to become familiar with common presentations and approach to workup and management.
Continue reading Electrolyte & Acid–Base Disturbances in Patients with Diabetes Mellitus
Today, at morning report, Dr. Warshauer presented a fascinating case of suspected metronidazole induced encephalopathy. Metronidazole neurotoxicity is a rare condition and is typically diagnosed by exclusion. The pathophysiology is poorly understood but postulated to involve GABA receptor modulation or neurotoxic free radicals. Presenting signs and symptoms are variable and include cerebellar, cranial nerve and cerebral dysfunction. Characteristic MRI findings include “non-enhancing, hyper-intense lesions on T2-weighted and FLAIR images without evidence of mass effect.” These lesions are typically symmetrical, involve the cerebellum and resolve upon discontinuation of metronidazole. The condition generally reverses days to weeks following cessation of the drug. Although rare, this condition emphasizes the importance of recognizing polypharmacy and drug toxicity as important precipitants of altered mental status. Please see the following article for more information.