Happy New Year 2007!

Orange dots on the map represent the readers of ClinicalCases.org and CasesBlog.

Map via Google Analytics. Idea from GigaOM.

One Million Page Views

ClinicalCases.org and Casesblog have reached the milestone of one million page views since their launch in 2005 (see the SiteMeter screenshot on the right). We stand at 1,007,723 page views and 348,425 visits as of today. Most of the visitors came from Google, links from other medical websites and blogs, and from BMJ and Medscape. Just as a short explanation, ClinicalCases.org is an attempt to build an online case-based curriculum of medicine; Casesblog is the blog I use to collect ideas, interesting stories and to post relevant news about the Clinical Cases and Images project.

I, and my colleagues who write for ClinicalCases.org, would like to express our deep appreciation to all our readers. We hope you continue to find our sites interesting, educational and worth-visiting in the future.

In the past year, Joshua Schwimmer and I tried to spread the word about the perceived usefulness of blogs in medical education. Our abstracts about different uses of a medical blog platform were accepted to the Annual Perioperative Summit of the Cleveland Clinic, the Annual Renal Week of the American Society of Nephrology, and the Annual Session of the American College of Cardiology.

Although a significant milestone, one million page views is less than the one million visits that Robert Centor's blog has recently reached. Listen to his interesting reflection of what this number means to him and his readers (mp3 file).

Happy New Year!

References:
American Society of Nephrology (ASN) Renal Week 2006
Cleveland Clinic Perioperative Medicine Summit
British Medical Journal Features Clinical Cases and Images - Blog, Again
1 Million hits - a podcast. DB’s Medical Rants.

My 'Best' Blog Posts of 2006

I am not sure if these are really the "best" posts on this blog for 2006 but I sometimes find them useful for my "Web 2.0 in Medicine" presentations and decided to collect them in one place:

Do We Need a Free Medical Encyclopedia?

How Can a Doctor Use Google Page Creator?

Residency Program Blogs

MDCalc is a Useful Online Clinical Calculator

Cocaine FOR Chest Pain

Medical Blog Closed Down by Request of Employer

Six Tips for Happiness by a Harvard Teacher

Another blogger quits due to "blog fatigue"

Digg for Medicine: Nature Publishing Group Launches Dissect Medicine

Physician Bloggers Talk to a Medical Librarian

Microsoft Blogger Has as Much PR Power as CEO. What Does That Mean for Your Hospital?

How Can Academic Physicians Benefit From "Google Office"?

Make Your Own "Medical Journal" with Google Personalized Page

What I Learned from Making the Website of the Cleveland Clinic Hospitalists

What's New in General Internal Medicine?

Top 5 Medical Podcasts I Listen To

Complete List of Medical Abbreviatons and Acronyms

American Society of Nephrology (ASN) Renal Week 2006

UK Medical School Interview Technique on YouTube

YouTube video: Victoria Wood - University Interview -- A nervous schoolgirl is interviewed as a potential student at a UK medical school. Link via NewMediaMedicine.



Admission committee:
Do you think the National Health Service (NHS) is crumbling or doing very well?

Applicant (with a politically correct answer):
I think part of it is crumbling and part of it is doing very well. You have to look at both sides really...

Translate Your Medical Website Automatically with Google Translate

Casesblog and ClinicalCases.org have had automatic translation via Google Translate for a while now (see the form in the lower right corner of any page). I have noticed through SiteMeter statistics that some international visitors are using the form to translate the blog and ClinicalCases.org into their native language.

Google released a translation algorithm from English to Russian a few weeks ago and I just added this function to the form. The automatic translation is far from perfect grammatically but in most cases it can convey the sense of what is written. The translation works seamlessly from technical point of view though -- if somebody closes the top frame, he/she can browse any English website, translated into his/her native language, without even knowing that the website is originally written in English -- try it with CNN. If you hover the mouse over any text in Firefox, you can see a callout with the English translation. This is neat. It works only in Russian, Arabic and Chinese, as far as I tested it.

Using Google Translate makes your website accessible to medical students and residents from around the world who may not know English well. Callouts could help them learn the language better and faster.

I have included the HTML code of the translation form here (click to open a new page). Feel free to use it for your own website, just replace "casesblog.blogspot.com" with the URL of your site.

References:
Google Russian Translator. Google Operating System.
Embed Google Translate widget in your blog template: Translation Widgets for Your Site. Google Operating System, 11/2007.

Related:
Read Googlified in Multiple Languages. Googlified.
Useful Google Translate Addresses. Google Operating System.
Google Translate Becomes the Best Free Online Translator. Google Operating System, 05/2008.

Updated: 05/09/2008

Interesting Medical Links

Top Five (5) Free Meta-Search Tools in Medicine. UBC Academic Search - Google Scholar Blog.

Converting to an Electronic Medical Record: Advice (and Cookies) From a Doc Who's Been There. The Blog That Ate Manhattan.

Graham's Guide to Boards Prep

Physician Salary Survey

10 ways to guarantee a lawsuit. Medical Economics.
Link via The Patient's Doctor.

Long Hours Up High Blood Pressure Risk. More Time at Work Might Earn You 29% Greater Chance of High BP. WebMD.

2 Out of 3 Americans Don't Wash Hands. Survey Finds Germany Is the Worst at Hand Washing. WebMD.

British Medical Journal Features Clinical Cases and Images - Blog, Again

Dean Giustini was kind to include this blog in his landmark BMJ editorial How Web 2.0 is changing medicine:

One of the best blogs in medicine is Ves Dimov's Clinical Cases and Images - Blog. It contains a rich collection of "presurfed" material for busy clinicians and features interactivity and timely discussion. Dimov is also a supporter of medical librarian bloggers. Why waste time fumbling with search engines when you can consult this blog for timely updates? As well as case discussions, Ves provides links to today's medical headlines from Reuters and clinical images via a dynamic, free photo sharing tool called Flickr. One of his slide presentations "Web 2.0 in medicine" is available on Slideshare (itself a fantastic new 2.0 tool). Clinical Cases and Images is a virtual laboratory for doctors and medical librarians interested in Web 2.0.

Since its launch in 2005, ClinicalCases.org and this blog were featured 3 times in the BMJ and twice in Medscape.

BMJ:
How Web 2.0 is changing medicine. Dean Giustini. BMJ 2006;333:1283-1284 (23 December)
How Google is changing medicine. Dean Giustini. BMJ 2005;331:1487-1488 (24 December)
Reviews, Netlines. Harry Brown. BMJ 2005;331:1345 (3 December)

Medscape:
Popular Case-Based Resource Models Online Medical Training. 2006;8(2), 2006 Medscape.
Clinical Cases Make Blog a Popular Resource. 2006;8(1), 2006 Medscape.

MD Net Guide:
Why they blog: Healthcare providers are embracing blogs; Should you join them?. Fard Johnmar.

As I have commented before, I am happy to think that may be this blog is one of the many good medical blogs out there... It is important to keep the online conversation going and this is probably the most significant thing, not the individual blog of any of us.

ClinicalCases.org and the blog will have one million page views by the end of the year. Currently, we are just 4,000 pages short of a million but with 2,000-3000 page views daily, this number will certainly be reached by the end on 2006. It feels as if you have written a book and somebody reads 3000 pages of it... every day. It is funny to realize that this blog likely has a larger readership than many journals. KevinMD, Medgadget, and DB's Medical Rants (by the current president of the Society of General Internal Medicine) have even larger audiences. It is time to assess the effect of medical blogs on the way doctors receive and share medical information.

Further reading:
1 Million hits - a podcast. DB’s Medical Rants.
Redesign of Clinical Cases and Images - A Case-Based Curriculum of Clinical Medicine
Wikis, blogs and podcasts: a new generation of web-based tools for virtual collaborative clinical practice and education. Boulos MNK, Maramba I, Wheeler S. BMC Med Educ 2006;6:41.

James Brown, 'the Godfather of Soul', Died Early Today

From Wikipedia:

"James Joseph (May 3, 1933 – December 25, 2006), also known as The Godfather of Soul, was an African American entertainer who was recognized as one of the most influential figures in 20th century music.

Brown was admitted to the Emory Crawford Long Hospital in Atlanta, Georgia on December 24, 2006 after a dentist visit where he was found to have severe pneumonia. Brown died the next day on December 25, 2006, around 1:45 a.m. at the age of 73.

Frank Copsidas of Intrigue Music said the cause of death was uncertain. "We really don't know at this point what he died of," he said."

According to eMedicine: "Pneumonia is the 6th leading cause of death in the U.S. and is the most common infectious cause of death. The mortality rate is reported to be 1% in the outpatient setting but may increase to up to 25% in those requiring hospital admission."

James Brown "was renowned for his shouting vocals, feverish dancing and unique rhythmic style." (Wkipedia). Many videos showing memorable James Brown's performances during the years are uploaded to YouTube. There are also several hundreds photos on Flickr. Motocchio described what it felt to be at a James Brown concert:

"Tonight turned to be one of the most special nights in my life.... Marco and i went to JB's concert tonight!

he's 73 years old. but he's still damn good, and the concert was one perfect entertainment show. and, his charisma... when he appeared on the stage, everybody got crazy and screamed.... including us. when he was singing "it's a man's man's man's world," i understood very very well why bruce brothers got enlightened by a church minister played by him... his music really touches people's soul. he's truly the king of soul.


James Brown & Pavarotti

References:
James Brown, from Wikipedia, the free encyclopedia
Pneumonia, Bacterial. eMedicine.
James Brown, the 'Godfather of Soul,' dies at 73. CNN.
James Brown RIP: Jump Back, Jack, See You Later, Alligator. Steve Anderson.
Image source: James Brown performs at the Yunfeng Theater in Shanghai. Licensed under Creative Commons.

Updated: 12/01/2007

There is a Santa Claus

Dr. Charles links to a wonderful editorial response to the letter of a 8-year old girl who doubted that Santa Claus existed. It was published in the New York Sun in 1897. Not much has changed since then.

Dear Editor--

I am 8 years old. Some of my little friends say there is no Santa Claus. Papa says, "If you see it in The Sun, it's so." Please tell me the truth, is there a Santa Claus?
~VIRGINIA O'HANLON

References:
Yes Virginia, There is a Santa Claus. Dr. Charles, 2006.
Yes, Virginia, there is a Santa Claus, from Wikipedia, the free encyclopedia.
Image source: Wikipedia, public domain.

Are Bloggers the Person Or the Fool of the Year?

It depends on what you read. According to the Time magazine, people posting user-created content online are its "Person of the Year." Surprisingly (or not), a Wall Street Journal editorial calls the same people "fools": "The Blog Mob. "Written by fools to be read by imbeciles."

Who is right? I write a blog, so I am biased... Although I cannot speak of my own intelligence, many bloggers I read daily are some of the smartest people you can find. I think the Wall Street Journal got this one wrong. Happy new blogging year 2007!

Do not forget to nominate the Best Medical Blogs of 2006.

References:
Time's Person of the Year: You. Time.
The Blog Mob. WSJ, 2006.
WSJ Bodyslams Bloggers. Micro Persuasion, Steve Rubel, 2006.
Time Magazine's Person of the Year - is You. Dr. Charles.

The 2007 WeblogCartoons.com Calendar

Dave Walker, the author of free (and really funny) cartoons which I have used before, has released a 2007 Cartoon Calendar:

"The 2007 WeblogCartoons.com Calendar

This calendar (pdf file) features 12 of my non-church-themed cartoons, mostly from WeBlogCartoons.com but also some from the Cartoon Blog that I plan to add to We Blog Cartoons when I get around to it. The cartoons in this calendar are:

• This gadget
• Heat
• Save the environment
• Your car
• Waiting for something to blog
• If I had more money
• Depression / elation
• Customer service
• In through one ear and out the other
• How to tie a tie
• Telephone calls
• The spectrum of cartoon quality

These calendars are entirely free and you are welcome to print them off, print copies for other people, print one off for your church office, give them to your friends as Christmas presents etc etc.

The calendars are pdf files of about 1mb and a bit. My advice would be to right click on the link and select ‘ Save Target As…’ or ‘Save link as…’. Choose where you want to store the file on your computer, then click ‘Save’. Each calendar is 14 pages: One title page, twelve individual monthly pages and then one infomational page at the back. You’ll need to staple or clip the pages together in some way and then find a way to hang the calendar if that is what you want to do."

References:
Blog Cartoon: Too Many RSS Feeds to Read
Keep on Blogging...

Radiology Picture of the Day

Radiology Picture of the Day features a new medical image daily, with a brief description. The website is edited and maintained by Dr. Laughlin Dawes who is a Radiology Registrar at Prince of Wales Hospital, Randwick. He lives in Sydney "with his wife Daniella, his sons Max and Alex, and Oscar the dog."

The website was started in 11/2006 and the Category Archives include:
Brain (10)
Cardiovascular (1)
Gastrointestinal (11)
Genitourinary (2)
Head & Neck (5)
Musculoskeletal (3)
Obstetrics (3)
Paediatrics (8)
Spine (2)
Thoracic (7)

There are more and more competitors to the famous NEJM Images in Clinical Medicine series...

References:
Link via Kevin, M.D.
NEJM RSS Feed for Image of the Week
Image source: Radiology Picture of the Day

Related:
More Consequences of IT: The Disappearance of Radiology Rounds. Wachter's World, 01/2008.

Updated: 01/31/2008

Nominate Best Medical Blogs of 2006

The nominations for the Best Medical Blogs of 2006 are currently underway on Medgadget.com.

There is a new voting system this year:

"Please meet the judges: Medgadget editorial staff is joined by Sumer from Sumer's Radiology Site, Josh from Kidney Notes, Enoch from Tech Medicine, Maria from Intueri, Orac from Respectful Insolence, Steven from docinthemachine, Bard from A Chance to Cut is a Chance to Cure, Amy from Diabetes Mine and Allen from GruntDoc. Judges will conduct a review of each blog submitted and will vote to sort out those blogs that don't belong to a particular category, or simply splogs (spam blogs.) Furthermore, judges will vote for blogs. Your votes and judges' votes are counted as 50% to 50%. Such a voting system was held at a recent TV show Dancing with the Stars, and details on how the counting was done can be found here."

Related:
The Best Medical Blogs of 2005 on Medgadget.com
Image sources: Medgadget

Flickr: Spirit of the Tree

Spirit of the Tree by Venticello (?) on Flickr:

"There have been made many sculptures from cut down trees. The trunks are left standing there and an artist comes and scarves on the tree. It always makes my day to see a new one on our walks in the city's parks.

This is in Kaivopuisto, Finland."

Creative Commons License

Edit Wars in Medical Wikipedia

Background

Wikipedia uses the "wisdom of crowds" concept which postulates that scores of non experts do a better job writing an article than a single expert. It is probably true. Most experts are busy people and do not have time to write, edit and protect from vandals more than one million articles.

Any social media website (and Wikipedia is one of them) has a relatively small number of devoted users who keep the project going and do the bulk of contributions. For Wikipedia, these users are about 500 and they are called administrators. They are in charge of keeping the encyclopedia what is supposed to be -- an encyclopedia -- and not a self-promotion tool.

What happens when administrators disagree with regular contributors? Edit war. There are revisions and versions changed back and forth until sometimes users are even locked-out of "Wikipedia land."

How is this related to medicine?

According to a recent Medscape editorial, "Wikipedia is the future of medicine, and it's good." There is a Clinical Medicine project on Wikipedia which one day may become the most comprehensive medical textbook. Dean Guistini of UBC Academic Search - Google Scholar Blog also started a wiki at University of British Columbia.

I was reading the Wikipedia article about Polycythemia and since I had an illustrative typical case of secondary polycythemia on ClinicalCases.org, I decided to add it in the "External Links" section at the bottom of the page. That was a well-intentioned and innocent addition, I thought. One of the administrators, JFW, disagreed, called my little effort "advertisement" and deleted the link. We discussed it at the talk page and since I tremendously respect people who take care of the world's largest encyclopedia (for free), I just moved on.

Some people are tougher to deal with though. One hair-transplant surgeon is having fierce fights on his talk page regarding his contributions to Wikipedia which are dubbed by some administrators "commercial" and "promotional." If you have 4-5 minutes, I would recommend reading the whole page to get a feel of what an edit war looks like:

Administrator:

Welcome to Wikipedia. We invite everyone to contribute constructively to our encyclopedia. Take a look at the welcome page if you would like to learn more about contributing. However, unconstructive edits, such as your changes to the Raymond V. Damadian page, are considered vandalism, and if you continue in this manner you may be blocked from editing without further warning. Please stop, and consider improving rather than damaging the hard work of others. Thank you. Talk: Administrator.

Plastic surgeon:

Unconstructive edits, vandalism? nonsense. The page on Raymon V Damadian contains numerous factual errors and much evident confusion about the technology which I was just attempting to correct. I'm and MD PhD who was there when all this stuff was going on. Even published papers in the field and know many of the princopals. See my comments at. Talk:Raymond V. Damadian.

There is (was?) also a Wikipedia page about one of the medical bloggers, Summer Sethi, which was labeled for deletion as a "vanity page":

Strong delete: Wikipedia is not a resume or publication list. There are perhaps thousands of other medical researchers with similar publications, nothing shows why this person is any more notable than them. --Ragib 23:59, 2 September 2006 (UTC)

The Full-body scan article is another example of a disagreement between contributors and administrators.

A fine line

Administrators like JFW and Samir are the backbone of the Clinical Medicine project in Wikipedia. Their job is to keep the vandals and self-promotion types out of the encyclopedia. If you make contributing too difficult though, "regular guys" may just go somewhere else.


Wikis in Plain English

References:
Who Edits Wikipedia? Philipp Lenssen.
Raw Thought: Who Writes Wikipedia? Aaron Swartz.
Wikipedia:Lamest edit wars, via Yahoo picks.
Make the Largest Encyclopedia in the World Better. I already did (I hope)

Related:
Why Slate is Wrong About “the myth of Web 2.0 democracy” DavidRothman. net, 02/2008.
Wikipedia: A Key Tool for Global Public Health Promotion (review article)

Rule of 3 for Wilderness Survival

Many people followed closely James Kim tragedy. James was a San Francisco man who sought help for his stranded family, got lost in the snowy Oregon wilderness and died of hypothermia.

According to CNN:

You can survive for 3 hours without shelter
You can survive for 3 days without water
You can survive for 3 weeks without food

References:
Wilderness survival: The rule of threes. Anderson Cooper 360 degrees blog.
A Winter Tragedy. Paul Auerbach, MD. Medicine for the Outdoors.
Kim died close to food, shelter, officials say. CNN.com.

A Typical Home Dialysis Day on YouTube

Gustine, a YouTube user who has been on dialysis since 1978, posted a video of his typical home hemodialysis day:

"Each time I do dialysis at home my two small dogs always are on the alert and tend to keep any intruders from getting near. If I fall asleep they'll bark in front my face!! What can I say, I guess having such critters alongside really helps get through the day!"

Gus also uploaded a video of buttonhole cannulation which is definitely not for the faint-hearted:

"For some of you it may all look gruesome, but in reality its not. I'ts a way of life for many of us who lost our kidneys, but now we have the freedom to do it at home self-care without living your whole life in-center."

Gus writes a blog about dialysis.

More videos:

Bill Peckham does self-dialysis & cannulation via buttonhole method. Billpeckham.com.
Bill Peckham answers Travel on dialysis FAQ and describes his own trips around the world while on dialysis.

Living Donor Kidney Transplant. OR-Live.com.

Link via KidneyNotes.com.

Related:
YouTube Feeds. Google Operating System, 01/2008.

Updated: 01/10/2008

Gordon Brown's Son is Diagnosed with Cystic Fibrosis

Gordon Brown is the Chancellor of the Exchequer of the United Kingdom (the British cabinet minister responsible for all economic and financial matters) and is expected to succeed Tony Blair as Prime Minister.

Mr. Brown' four-month old son Fraser was diagnosed with cystic fibrosis (CF) during routine screening test soon after his birth. According to The Times, "Fraser Brown was born on July 17 at the Royal Infirmary, in Edinburgh. He weighed a healthy 7lb 14oz (3.6kg). The condition was picked up in routine blood tests that all babies in Scotland (but not in England) undergo."

I have worked with children and young adults with cystic fibrosis in the past and I have always been impressed by how tough and mentally grown up those little guys are. Currently, they are fighting a loosing battle since there is no treatment for CF and the average life expectancy is 30-35 years. I cannot help but to share my utmost respect for all patients with cystic fibrosis and their families and my hope that one day a cure for this genetic condition will be found.

Cystic fibrosis is the most common autosomal recessive disease among people of European heritage. In the United States, approximately 30,000 individuals have CF. Approximately 1 in every 25 people of European descent is a carrier of a cystic fibrosis mutation. Approximately 1 in every 46 Hispanics, 1 in every 65 Africans and 1 in every 90 Asians carry at least one abnormal CFTR gene (source: Wikipedia, verified).

Newborn screening for cystic fibrosis (CF) has been mandated for the state of Ohio, beginning August 30, 2006.

References:
Brown family faces a new challenge as baby Fraser has cystic fibrosis. The Times.
'Each winter survived is another victory'. The Guardian.
Rainbow Babies & Children's Hospital Prepared for Newborn Screening for Cystic Fibrosis. UHHS.com.
Image source: Cystic fibrosis from Wikipedia, the free encyclopedia.

Pfizer Discontinues Drug Which Increases HDL Due to Higher Death Rate

Torcetrapib, a new medication developed by Pfizer, is very effective in increasing HDL levels ("good" cholesterol). There is a huge marketing niche for such medications since currently we lack a very efective pharmacological therapy for low HDL, apart from Niacin. The first hint of trouble for torcetrapib was the preliminary report that the drug increases blood pressure. The latest results from a trial of about 15000 patients show significantly increased mortality in the group treated with torcetrapib (7500 patients). According to a Pfizer spokesman, 82 patients taking the combination of torcetrapib and Lipitor died, compared to 51 deaths in the arm of the study where patients were taking Lipitor alone.

Pfizer announced today that it will stop future development of the new drug. The company spent around $800 million to develop torcetrapib and the share prices will certainly take a big hit tomorrow. Ultimately though, there is no doubt that Pfizer did the right thing by reporting the disappointing results early.

We are back to square one -- there is no highly effective pharmacological treatment for low HDL apart from Niacin which usefulness is limited by unpleasant side effects (flushing) and poor glucose control in diabetic patients. Fibrates can also be used to raise HDL levels.

Further reading: A 33-year-old man has a low HDL level. Should you treat him?

References:
Pfizer cuts off cholesterol drug trials. USA Today.
Pfizer's Torcetrapib: Rest In Peace. Dr. Wes.
Deaths Halt Development Of Pfizer Cholesterol Drug. WSJ.
Effects of Torcetrapib in Patients at High Risk for Coronary Events. NEJM, Volume 357:2109-2122, November 22, 2007.

Monounsaturated fats found in vegetable oils, nuts and avocados increase "good" HDL cholesterol levels by 12% http://goo.gl/GBQa5
Image source: Cholesterol. Wikipedia (public domain).

Correct Anemia in Chronic Kidney Disease Up To a Point

Moderation in practice of medicine is just as important as it is in life. Too much of a good thing can sometimes kill you.

In this case, the "good thing" are the recombinant erythropoetins -- Epogen, Procrit, and the latest one, Aranesp. They are used to treat anemia in patients with chronic kidney disease (CKD). Anemia is due to decreased production of erythropoetin by the failing kidneys.

According to NYTimes, "dialysis patients should have a target hemoglobin level of 10 to 12 grams per deciliter of blood. In its most recent guideline, the panel of doctors overseen by the kidney foundation said a target of 11 to 13 grams was appropriate.

In practice, almost all dialysis patients receive the drugs, and almost none have hemoglobin levels below 11 grams after treatment. About half have levels of more than 12 grams, almost 20 percent of patients have levels above 13 grams.

The differences may seem small, but one of the studies published in The New England Journal found that patients treated to an average hemoglobin level of 12.6 grams had a 34 percent higher risk of death or serious heart problems than those treated to a level of 11.3 grams."

The first author of the NEJM study was a "star" lecturer at one the lunch symposia at the 2006 ASN Renal Week.

In conclusion, it makes sense to correct anemia in CKD up to a point. Currently, this point seems to be 11 g/dL.

Update 03/09/2007:
FDA will add a black box warning to the label of erythropoiesis-stimulating agents (ESAs) due to increase in serious side effects and greater number of deaths in patients treated with these agents.

Update 3/28/2007:
FDA added a black box warning to the labels of all currently available Erythropoiesis Stimulating Agents (ESAs). Source: ASN.

Targeting higher hemoglobin levels in CKD increases risks for stroke, hypertension, and vascular access thrombosis and probably increases risks for death, serious cardiovascular events, and end-stage renal disease. The mechanisms for harm remain unclear.

References:
Treatment of Anemia Questioned. NYTimes.
Correction of Anemia with Epoetin Alfa in Chronic Kidney Disease. NEJM.
Normalization of Hemoglobin Level in Patients with Chronic Kidney Disease and Anemia. NEJM.
American Society of Nephrology (ASN) Renal Week 2006
Amgen, J&J anemia drugs to carry new warning: FDA. Scientific American, March 09, 2007.
Anemia Drugs: How Much Is Too Much? WSJ Health Blog, 4/17/2007.

Meta-analysis: Erythropoiesis-Stimulating Agents in Patients With Chronic Kidney Disease. Annals, 2010.

Image source: Wikipedia, public domain.

Updated: 07/06/2010

"Grand Rounds" of Medical Blogs Multiply

Grand Rounds was conceived as a weekly hosting event which features the best posts in the medical blogosphere. Several outgrowths of the "original" Grand Rounds have appeared recently, arranged mainly by subspecialty or location. I do not think that they will dilute the Grand Rounds "brand" and they may be interesting to follow. A list is compiled below:

Grand Rounds (original). I have hosted it twice, it was fun and an eye-opening experience.

Radiology Grand Rounds

Change of Shift: A Nursing Blog Carnival

Pediatric Grand Rounds

The BritMeds - this is the latest carnival. Dr Crippen would like "this round-up to be be strictly British. Otherwise, the criteria will be relaxed. British blogs written by anyone working in healthcare or anyone receiving health care in this country."

BlogCarnival.com has a longer list of many health-related carnivals.

American Society of Nephrology (ASN) Renal Week 2006

The American Society of Nephrology (ASN) Renal Week 2006 in San Diego, California was a big event attended by more than 12,000 nephrologists from all over the world. The conference was at the Convention Center at the beautiful bay of downtown San Diego.


Downtown San Diego

Joshua Schwimmer and I submitted the abstract Assessment of a Blog as a Medium for Nephrology Education which was accepted for poster presentation. The abstract was based on the idea behind the ClinicalCases.org project and was met with significant interest (and curiosity) at the conference. My other poster was in the much more traditional format of a case report: Dermatomyositis-induced Rhabdomyolysis as a Rare Cause of Acute Renal Failure.


Our poster Assessment of a Blog as a Medium for Nephrology Education

The art department of the Cleveland Clinic forgot to add the Clinic logo to the posters but that was a minor mishap compared to the poor guy who lost his poster on the plane (click to enlarge the photo below).


"Sorry, original poster missed in the plane"

There is a blog about ASN Renal Week 2006 but it looks like the authors were busier this year than in 2005 and managed to publish just a few posts.

In the long security line at the San Diego airport, a young lady saw my ASN conference bag choke-full with abstract and syllabus books and tried to pronounce: "Neph-ro-lo-gy... What is that?". "Kidney diseases", I answered. "Kidney? Do you carry one there?", quipped her boyfriend. We still have a lot to do in terms of educating the general public ;-)

About ASN:
"The American Society of Nephrology (ASN) was founded in 1967 as a nonprofit corporation to enhance and assist the study and practice of nephrology, to provide a forum for the promulgation of research, and to meet the professional and continuing education needs of its members."

More photos from San Diego:
Seaport Village in Downtown San Diego, California
Balboa Park, San Diego, California
San Diego Zoo in Balboa Park, San Diego, California
Coronado, San Diego County, California

Botox Injections for Treatment of Diabetic Gastroparesis

A 75 year-old female with diabetic gastroparesis is admitted to the hospital with generalized weakness and N/V for 2 days.

She is not able to tolerate metoclopromide (Reglan).

The GI consultant recommends botulinum toxin (Botox) injections of the pylorus.


Figure 1. Stomach filled with food (left); Botulinum toxin was injected in a 4-quadrant fashion in the pylorus (right).

What is the effect of the procedure on the patient's symptoms?

Read more in Botulinum Toxin Injections for Treatment of Diabetic Gastroparesis. ClinicalCases.org

The Lancet Launches a Blog, Critiques Medical Bloggers

The venerable British medical journal The Lancet was founded 1823 but it does not shy away from the latest Web 2.0 tools. It launched a podcast in April and a blog in October 2006.

The journal advertises an impact factor 23.88 on its front page (a measure of how many other journals cite its articles) but it also finds time to critique the "competition" of the medical bloggers by claiming that many of them do not close disclose conflicts of interest. A free registration is required to read Bloggers beware: conflicts of interest and diabetes (link via Notes from Dr. RW).

Figure 1. Mixed content/advertising and blog ethics. Source: Paid Blog Posts? Philipp Lenssen. Creative Commons license.



References:
The Lancet, from Wikipedia, the free encyclopedia.
The Lancet Features Weekly Audio Summary
Bloggers beware: conflicts of interest and diabetes. The Lancet.
Paid Blog Posts? Philipp Lenssen.
Look out bloggers. The medical journalists are on to you. Notes from Dr. RW.

Update 03/27/2010:

The URL of the Lancet blog (http://blogs.thelancet.com) is no longer acive.

Google Finds Correct Diagnosis in 58 % of Cases Published in NEJM

According to a BMJ study, Google searches revealed the correct diagnosis in 58% of cases published in the case records of the New England Journal of Medicine in 2005. In each of the 26 cases studied, researchers selected 3-5 terms from each case and did a Google search without knowing the correct diagnoses.

In conclusion, "the use of web based searching may help doctors to diagnose difficult cases."

Hmm... I use Google multiple times every day but, in its current form at least, I am not sure sure I will let any search engine (which basically relies on "wisdom of crowds") to be my trusted diagnostic adviser.

Dr. Charles ran a few sample searches and was not very convinced either.

The Krafty Librarian points out that, "first, the authors just stated that Google only displayed results to the correct diagnosis 58% of the time, and now the they are ready to use it as a clinical decision tool! Those odds are slightly better than flipping a coin!"

"This is research?", asks one of the rapid responses, "I am amazed by the publication of this article. As a regular reviewer for numerous journals, this article would never have seen the light of day. The results actually show an extremely poor correct diagnostic rate even with trained personnel to filter and process the information. As doctors we would never accept the same level of diagnostic accuracy of a colleague. I am shocked that this has been published by the BMJ."

By the way, by naming their paper "Googling for a diagnosis" the authors violated one of Google "rules" which advises strongly against using the name of the search engine as a verb, e.g. googling.

I have covered the use of Google in medicine at length before -- you can review it here.

References:
Googling for a diagnosis--use of Google as a diagnostic aid: internet based study. BMJ.
Googling For A Diagnosis. The Krafty Librarian.
Is Google The Fastest Diagnostician On the Planet? UBC Academic Search - Google Scholar Blog.
This is research? BMJ. T C Winthrop.
Google 'aids doctors' diagnoses. BBC.
Attention: Paging Dr. Google! Dr. Charles.
Do you "Google?" Google Blog.
Google in Medicine
Adam Bosworth, Vice President of Engineering at Google Inc. covered similar topics in: How do you know you're getting the best care possible?
Google now wants to diagnose your disease, offers differential diagnosis based on 10 sites and Wikipedia http://goo.gl/SD1qM

Image source: Doctors Using Google by Philipp Lenssen, used with permission

Stream Podcasts Without Subscribing via Noisely.com

Noisely is supposedly an "intelligent podcast player". According to Download Squad, if you enter words that describe what you want to listen to, Noisely will find the right podcast for you. "Noisely works solely online in your browser and searches through their database, spitting out results based on matching keywords, and the date the actual podcast took place."

For example, just type "NEJM", and the podcast starts automatically. Noisely worked well with popular feeds like NPR and BBC but did not find JAMA podcast in my test today.

References:
Listen to continuously streamed Podcasts with Noisely. Download Squad.
Image source: Noisely.com

It's Interview Time for IM Residency -- Avoid Top 10 Mistakes

November, December and January are the busiest months of the year for the U.S. medical students and international medical graduates looking to secure a position in internal medicine residency.

LifeHack.org and QuintCareers list top 10 interview blunders - try to avoid them:

1. Poor handshake
2. Talking too much
3. Talking negatively about current or past employers/managers
4. Showing up late or too early
5. Treating the receptionist rudely
6. Asking about benefits, vacation time or salary
7. Not preparing for the interview
8. Verbal ticks
9. Not enough/too much eye contact
10. Failure to match communication styles

Most importantly -- don't try to be somebody else, just be yourself.

References:
10 Interview Bloopers. LifeHack.org.
Avoid These 10 Interview Bloopers. Deborah Walker.
Residency Interview Advice from Fat Doctor
Unsolicited Advice to Residency Applicants. Intueri, 2007.
Image source: Wikipedia, GNU Free Documentation License.

Related reading:
How the Match Works(’Cause everyone’s been asking, “So did you get a job?”). Over My Med Body, 02/2008.
Top 10 interview mistakes. CNN, 05/20008.

How to perform on the residency interview. Conrad Fischer's Blog.

DPP-4 Inhibitors for Treatment of Diabetes

Glucagon-like peptide-1 (GLP-1) is a GI peptide that stimulates insulin secretion (similar to sulfonylureas). GLP-1 also inhibits glucagon release, gastric emptying and food absorption. GLP-1 and another similar peptide are called incretins. As noted above, incretins have a dual action which leads to lowering blood glucose:

1. Stimulate insulin release

2. Inhibit glucagon release


Figure 1. Action of DPP-4 inhibitors. Note that DPP-4 normally inactivates GLP-1. DPP-4 inhibitors block DPP-4 which in turn leaves GLP-1 active. Click to enlarge the figure. Created with Gliffy. The diagram Action of DPP-4 inhibitors is now on Wikipedia.

Exenatide (Byetta) is a GLP-1 receptor agonist approved for adjunctive therapy for patients with DM 2 who are not well controlled on oral agents. It is available only as injections and has to be administered twice daily.

Two new medications increase GLP-1 levels by blocking the enzyme which inactivates GLP-1. The enzymes is called DPP-4 (dipeptidyl peptidase-4) and the new medications are called DPP-4 inhibitors or gliptins.

They act similarly to Byetta (see figure above) but have the big advantage to be available in oral form (pills). These 2 new medications for treatment of DM2 are:

- Sitagliptin (Januvia) is taken once a day and it costs about $ 4.50 per pill

- Vildagliptin (Galvus) is waiting for FDA approval but it is already speculated to be at a competitive disadvantage to Januvia because it has to be taken twice a day

References:
New Medications
Merck Wins U.S. Approval for a New Diabetes Drug. NYTimes.
Sitagliptin: First DPP-4 Inhibitor for Type 2 Diabetes. Resident and Staff Physician, 04/2007.
Merck Diabetes Drug Could Face Competition from Takeda. WSJ Health Blog, 01/2008.

Related:
Lilly, Amylin Disclose More Cases of Byetta-Related Pancreatitis. WSJ Health Blog, 08/2008.
FDA Issues Warning for Diabetes Drug Byetta about possible kidney problems, including renal failure http://bit.ly/1UOjwB

Updated: 11/03/2009

One of the First Journal Articles About Podcasting

Richard Savel is the author of many firsts. In 2005, he made the first podcast for a national medical society -- the official podcast of the Society of Critical Care Medicine. Last month, Dr. Savel published the first paper about medical podcasting in the Journal of the American Medical Informatics Association:

The iCritical Care Podcast: a novel medium for critical care communication and education.
Richard H. Savel MD, Evan B. Goldstein DO, Eli N. Perencevich MD, MS, and Peter B. Angood MD

I am almost certain that this article will be often referenced in the future manuscripts about using portable audio and video for medical education. I have communicated with Richard Savel during the last 2 years, and I look forward to learning more about his future endeavors. He pointed out that his article was technically not the "first" one in a medical journal (this one was published in June 2006) but the first published in the informatics literature.

When Dr. Savel started his work on the podcast for the Society of Critical Care Medicine, few doctors knew what the term meant. We have certainly come a log way since then. Now, Cleveland Clinic has audio and video podcasts for both patients and health professionals. I think it is a safe bet to predict that on-demand technologies will radically change the way we receive both information and entertainment.

References:
How a Critical Care Podcast Was Born
The Critical Care Podcast is Featured on the Official SCCM Website
Free Audio and Video Podcasts for Health Professionals by Cleveland Clinic
Society of Critical Care Medicine Introduces iCriticalCare Podcasts. SCCM.org.
Internet-Based Dissemination of Educational Audiocasts: A Primer in Podcasting—How to Do It. American Roentgen Ray Society.

Custom Google Search Engines to Help Patients Find Reliable Medical Information

Google brings blogs at the top of search results for many medical queries. This is good for bloggers but is it good for patients who search medical information online? Probably not, since many of them do not bother to check how reliable the source of the information is.

Micro Persuasion and The Krafty Librarian write about The Pew Internet and American Life research which shows that 75% of those who search for health information do not check the source or the date of the information they find.

If you are a doctor/physician group/hospital, you would like your patients to get reliable information online but you may not want to limit them to a few selected links listed on your website. The solution could be Google Custom Search Engine (CSE) which lets you include websites reviewed by you and found to be trustworthy. CSE either searches the selected sites exclusively or gives preference to them in the top results.

Philipp Lenssen writes that "CSE was just revealed this week, but there are already second-party directories built around the idea. Both CustomSearchGuide.com and Lurpo.com let you browse through different topics, and then search right on their site using the custom search engines." CSE is part of Google Co-op.

I found just 2 CSE for health information:
- Patient's Medical Info
- Health Professional's Medical Search

Summary:

Google CSE can help patients find dependable medical information online.

You can build your own Google Search Engine of reliable sources. Then just put a simple search box on your website and give a business card with the URL to your patients.

Update 03/28/2007:
Adam Bosworth, Vice President of Engineering at Google Inc. covers similar topics in: How do you know you're getting the best care possible?

Update 06/05/2007:
I use Google Custom Search Engines for the search function of ClinicalCases.org, CasesBlog and the related sites.

References:
Pew: Health Searchers Don't Check Their Sources. Micro Persuasion.
Growing Popularity of the Web to Solve Medical Questions. The Krafty Librarian.
Google Custom Search Directories. Philipp Lenssen.
Eureka! Your own search engine has landed! Official Google Blog.
Creating Your Own Search Engine using Google Custom Search. Google Tutor, 06/2007.
Creating Google Custom Search Engines. O'Reilly Media, 09/2007.

Related:
An easy way to add new features to Google. Matt Cutts: Gadgets, Google, and SEO, 02/2008.

Updated: 02/26/2008

UBC Google Scholar Blog is Going on Hiatus

UBC Academic Search - Google Scholar Blog was the place to go for updates and insights on how medical librarians, physicians and patients are using search engines to sort out the staggering amount of information on the web. Now, Dean Giustini, the blog author is putting the site on hiatus for at least a year:

UBC Google scholar blog is going on hiatus. Well, let's just call it a sabbatical. As of January 2007, a sign will go up saying Gone fishing - see you in 2008. I am going to be immersing myself in learning theory for my 2007 sabbatical, and that means I won't be tracking trends in search. What will happen to GS blog? What about the wiki? All good questions.

I am pondering what to do next. Will I return here? Time will tell.

Last December, Dean wrote an interesting editorial for BMJ: How Google is changing medicine. He also interviewed several physician bloggers (including me) a few months ago.

I am not the only one waiting for Dean to start blogging again and that's why I will stay subscribed in Bloglines.

Update 01/29/2008:

Dean is blogging again.

References:
Physician Bloggers Talk to a Medical Librarian
BMJ: Build Google Medicine
Image source: UBC Academic Search - Google Scholar Blog

Updated: 01/29/2008

Free Audio and Video Podcasts for Health Professionals by Cleveland Clinic

Several months ago, Cleveland Clinic launched a video podcast for patients called HealthEdge. The next logical step was to have a similar service for health professionals.

Cleveland Clinic Center for Continuous Medical Educations now features free audio and video podcasts. The series starts with the Sessions from the 18th Annual Intensive Review of Internal Medicine. You can either listen/view podcasts online or subscribe with iTunes.

References:
Video Podcasts by The Cleveland Clinic
Cleveland Clinic Health Edge on Google Video
Cleveland Clinic Offers New Podcasts
Image source: Cleveland Clinic

RSS "Feeds That Matter"

So many feeds to read, so little time... Which are the good ones? There is a "proof-of-concept" website which helps you quickly browse the feeds which many people have already chosen.

Feeds That Matter is a tag cloud which lists the top 100 most popular RSS feeds by topic, for example, "health", "Google", "business", etc.

The tag cloud combines data from Bloglines users who chose to make their subscription choices public:

"There are about 83,000 publicly listed users on Bloglines and they have a combined 2,786,687 feed subscriptions. Roughly 35% of these publicly listed users organize their feeds into folders. On an average there are about 20 feeds per folder. By analyzing this data and combining merging folders that are very similar, we have come up with an automatic way of creating a taxonomy of popular topics and make it easy to find feeds that are most relevant to that topic."

Established media (Reuters, BBC, NYTimes, ABC) tops the list of the most popular "health" feeds but quite a few blogs are also present: Kevin, MD, Medpundit, The Health Care Blog, etc. Clinical Cases and Images - Blog (barely) makes the top 100 list at number 88. My blog rating jumps to number 15 in the list of medical feeds though. You can check your own blog rating, just for the fun of it.

Link via LifeHacker.com.

Should we use ACEi or ARBs for prevention of renal failure in patients with hypertension or diabetes?

Diabetes mellitus (DM) and hypertension (HTN) increase the risk for development of chronic kidney disease (CKD). Type 2 diabetes (DM 2) is the biggest single cause of ESRD in the United States which is reflected in the mnemonic for differential diagnosis of CKD.

Should we use ACE inhibitors (ACEi) or Angiotensin II Receptor Blockers (ARBs) for prevention of CKD in patients with HTN and/or DM?

According to UpToDate (subscription required):

ARBs have similar antiproteinuric activity as ACEi but it should not be assumed that ARBs are equivalent to ACEi. A medication from either group should be used in proteinuric nondiabetic kidney disease, although the strength of evidence favors the use of an ACEi.

Summary: ACEi is the medication of choice to prevent progression of CKD in HTN.

How about patients with DM?

Again, according to another UpToDate review:

The authors prefer initiating therapy with ACEi inhibitor in DM 1 nephropathy and either ACEi or ARBs in DM2 nephropathy.

Summary: Either ACEi or ARB can be used to prevent progression of CKD in DM 2. I would still prefer ACEi since they have been on the market longer and are generally less expensive due to the fact that generics are available.

References:
Prevention of the Development and Progression of Renal Disease. J Am Soc Nephrol 14:S144-S147, 2003 (free full text).
Antihypertensive therapy and progression of chronic kidney disease. UpToDate (subscription required).
Treatment and prevention of diabetic nephropathy. UpToDate (subscription required).
ACEi and ARBs links and images are from Wikipedia.

Executive Health Physicals. Are They Worth $ 3,000?

According to Forbes: "A sick CEO is bad for the company's health... executives who had a physical exam lost 45% fewer workdays than those who did not... generally executive health physicals cost between $1,000 and $3,000."

Cleveland Clinic, Mayo Clinic, Duke University and Mount Sinai all have executive health programs. I know personally 2 of the physicians who work in the Clinic program and they are excellent.



What you can expect on during your Executive Health Assessment - Cleveland Clinic video.

References:
Not So Routine Physicals. Forbes.com.
Welcome to Executive Health. Cleveland Clinic.com.

Complete List of Medical Abbreviations and Acronyms

"He had CP and SOB, was diagnosed w NSTEMI, had a PCI and is now in MICU."

Whether you like or not, medical jargon is part of health care. Years ago, before I started my clinical rotations, I assembled a comprehensive list of all medical abbreviations I could find and memorized them by heart. It may sound strange but I actually liked using them. Also, for a short while, I was known as the "mnemonics guy" since (due to lack of other ideas how to better spend my time) I had made up about 800 mnemonics. Abbreviations and acronyms are sort of mnemonics, they save time and... create confusion. Pretty much everybody who works in health care knows CHF and COPD but how about AOCD (anemia of chronic disease)?

When I started ClinicalCases.org (an online case-based curriculum of clinical medicine), I deliberately decided to use a lot of abbreviations. Why? Because this is how the real medicine looks like in patient charts. You have to know that "WNL" means within normal limits, otherwise you may never figure out what the note is about. Now, with EHR (electronic health records) and medical coding, the art of medical acronyms may come to an end. Computer-generated notes (with some human input) are infamously verbose, often with amazingly little substance. Who needs to write "WD/WN in NAD" when the computer lavishly puts "well-developed and well-nourished in no apparent distress"?

Every now and then, international readers of ClinicalCases.org ask what the different abbreviations in case descriptions mean. This is a link to a very detailed Wikipedia page which lists almost every medical acronym and abbreviation known to human kind. And the beauty of the wiki system is that if you find one which is not listed there, you can add it yourself.

Don't forget to check the difference between acronyms and abbreviations. For starters, all acronyms are abbreviations, but not all abbreviations are acronyms.... :-)

References:

A Comprehensive List of Medical Abbreviations http://goo.gl/0wW0R and  http://goo.gl/DQvEM
List of medical abbreviations, from Wikipedia, the free encyclopedia.
Translating the medical chart. KevinMD/blog.
Online Resources for Medical Abbreviations. DavidRothman.net.
Medical Mnemonics
100% of Greek philosopher named trials showed reduction in mortality, compared with 12% of trials with other acronyms. Lancet, 2011.
Image source: Openclipart.org

EmergiBlog Advice: So You Want to Host Grand Rounds?

EmergiBlog has some useful advice for future hosts of the venerable and well-respected Grand Rounds, the weekly collection of the best posts in medical blogosphere.

Coincidentally (or not), Kim of Emergiblog is this week's host after a 12-hour ER shift. It's amazing what sleep deprivation and caffeine can do to normally sane people. It can even lead them to assemble a 7-point checklist of things to do when you host Grand Rounds... :-)

Grand Rounds has become the contemporary weekly portrait of medicine through the eyes of the medical bloggers.

Pre-Rounds is an article series about the hosts of Grand Rounds on Medscape.com. Nick Genes of Blogborygmi, who writes the Medscape column, is the founder of GR and the archive host.