Preoperative Care of Patients with Kidney Disease: A Case-based Curriculum

The 8 clinical cases below illustrate specific teaching points in the preoperative care of patients with chronic kidney disease. We will try to incorporate more case-based modules in the Cleveland Clinic Perioperative Medicine Summit next year. The 2006 Summit starts on September 18.


Case 1: Does this patient need a stress test?

Case 2: Does this patient need a beta-blocker?

Case 3: Do you need to correct the potassium?

Case 4: When to do hemodialysis before surgery?

Case 5: Does this patient need an antibiotic before surgery?

Case 6: Does this patient need a blood transfusion?

Case 7: Which blood pressure medications to take on the morning of surgery?

Case 8: What is the risk for developing ARF after surgery?


Read more on ClinicalCases.org.

Do eye exercises help myopic people?

Wiki eHow shows How to Exercise Your Eyes to "keep them healthy and take away eye strain."

Currently, there is no cure for shortsightedness (myopia) and overcorrection with glasses can make it worse. There are popular books on the market claiming that eye exercises alone can improve myopia but I have not found any evidence about it. On the other hand, Chinese authors claim that acupuncture helps myopic children.

I know that Dr. RW thinks that most alternative medicine is a form of scam but in the absence of effective treatment for myopia, it may be time to conduct studies involving alternative treatment methods.

Alternative medicine seems to be gaining traction recently. There is a PBS documentary featuring several medical directors of alternative treatment centers. One of them is Tanya Edwards who is the director of the Cleveland Clinic Center for Integrative Medicine.


How to Exercise Your Eyes - Howcast | July 23, 2010.

References:

How to Exercise Your Eyes. Wiki eHow.
Myopia. Clinical review. BMJ 2002;324:1195-1199 (18 May)
Shortsightedness: A Review of Causes and Interventions. AFP 9/2002.
What does the science say about acupuncture? Consumer Reports health blog, 12/2007.
Image source: OpenClipArt.org.

Related reading:

Vision Correction Lens Works from the Inside Out. Cleveland Clinic News, 03/2008.
The Recent History of Acupuncture. Edzard Ernst, MD. Am Journal of Medicine, Volume 121, Issue 12, Pages 1027-1028 (December 2008).

Scientists identified a gene that causes short-sightedness - RASGRF1 http://goo.gl/cATk

Acupuncture May Help Lazy Eye - Results as Good as Patching
Does traditional Chinese medicine have a place in the health system? http://goo.gl/RH04o
Impact of Pediatric Vision Disorders in Adulthood - impacts health, self-perception, educational attainment, job choices http://goo.gl/y1EHg

Self adjustable spectacles. Which idea is likely to make the biggest impact on healthcare by 2020? BMJ http://goo.gl/sKnrS
People with low vision can drive with 'bioptics' -  small telescopes mounted on eyeglass frames  http://goo.gl/sUIQh and http://j.mp/qEJZv7
20-20-20 rule: For every 20 minutes of reading a screen take a 20-second eye break, look at something beyond 20 feet. NYTimes, 2012.

A Dictionary of Useful Research Phrases

This is a reportedly "popular tool for reading research papers seen tacked up in offices, labs, and above copying machines everywhere." Do not take it too seriously... :-)


Research Phrase / Translation

It has long been known... / I didn't look up the original reference.

It is clear that much additional work will be required before a complete understanding of the phenomenon occurs... / I don't understand it.

It is hoped that this study will stimulate further investigation in this field... / This is a lousy paper, but so are all the others on this miserable topic.

A careful analysis of obtainable data... / Three pages of notes were obliterated when I knocked over a glass of beer.


Link via LifeHack.org.
Image source: OpenClipart.org, public domain

Top 5 Medical Podcasts I Listen To

A podcast is a downloadable audio file that you can subscribe to and get regular updates when a new episode is released (usually weekly). Almost all podcasts are free and the best way to use them is via Apple's iTunes/iPod.

There is not a single doctor I know who is not busy. Listening to podcasts takes time -- 15-30 minutes per episode for most of them. Obviously, you have to prioritize which one to listen to unless you want to spend the whole day with your iPod on.

I subscribe to about 40-50 podcasts in iTunes but I rarely have time to listen to more than 4-5 per week.

Here is the list of the Top 5 Podcasts I Listen To:

1. ACC Conversations with Experts

American College of Cardiology Conversations with Experts is probably the most useful podcast for medical professionals at the moment. Dr. Hutter has 2-3 guests on each session which makes it lively and refreshing to listen to. In contrast, the NEJM 15-minute podcast, recorded with a single monotonous voice, is a sure recipe for sleep.

2. Johns Hopkins Medicine podcast

Similarly to ACC Conversations, this podcast benefits from having two speakers. One of them is Rick Lange, the Johns Hopkins chief of medicine who looks behind the medical headlines of the week. Cleveland Clinic also has a weekly podcast but it focused primarily on patient education rather than on informing medical professionals.

3. JAMA Audio Commentary

Catherine DeAngelis, Editor-in-Chief of JAMA, summarizes and comments on each issue of the journal. This podcast is easier to listen to than the one by the NEJM because the editor can undoubtedly explain better why she chose a particular article for publication and why we should take the time to read it. Dr. DeAngelis ends every podcast commenting on the windy weather in Chicago and how the patients are their top priority there. I cannot really see the connection between the two but she obviously likes this finale.

4. NEJM This Week podcast

The NEJM podcast is not bad but not great either. As I mentioned before, its biggest drawback is the monotonous voice of a single reader (male or female depending on the episode) and the fact that they often provide just "teases" for the articles rather than telling the listeners what is the story really about. This is especially annoying with the case reports from the Mass General Hospital. ACC Conversations with its in-dept analysis is much better in terms of both education and entertainment. There is nothing wrong if the education is entertaining at the same time, isn't it?

5. Annals of Internal Medicine

The Annals of Internal Medicine was the latest member of the "Big Five" of general medical journals to launch a podcast. The other four -- NEJM, JAMA, BJM and Lancet -- have been experimenting with portable audio for a while now.

NPR podcasts are also great but I just don't have time to listen to them regularly.

Among the video podcasts, the top 5 that I like best are:

1. ABC World News

2. JAMA News Release (available from iTunes)

3. CNN video podcasts

4. National Geographic

5. Rocketboom

The easiest way to subscribe to the podcasts/videocasts above is to download iTunes, then go to the podcast section and search for "JAMA", NEJM", "ACC", etc. Once you find a podcast you like, click the "subscribe" button.

Apple really has a lock on the podcast/videocast market for now with iTunes/iPod. I doubt that Microsoft can make a meaningful move in this arena soon. Google is spread too thin in too many areas and this leaves Apple in the position of a dominant force in the market of portable audio/video for now.

Related:

Podcasts and Videocasts. UBC Health Library Wiki.
Podcasts and vodcasts in medicine. Dean Giustini (PDF)
Medical podcasts: the future of continuing professional development? BMJ Career Focus 2008;336:29-30.
Medical journals that use social media (spreadsheet). Body in Mind, 2011.
Google ranks the top 100 journals and NEJM is no more the "top dog" according to G Scholar Metrics for Publications http://goo.gl/unTjs

A good doctor with a "bad" accent?

Kevin, MD points out to an LA Times article (free registration required) which discusses the trouble some international medical graduates (IMGs) have getting understood by their patients:

"Although foreign-born physicians may have excellent medical training and comprehension of English, patients and co-workers can struggle to understand their speech and are often reluctant to call attention to the problem. This increases the potential for medical errors, Wilner says.

"People are frustrated when they get in this situation," she says. "Others, especially elderly patients, may be intimidated and not want to ask questions."

The comments on Kevin's blog are often very amusing, like this one by Gasman who claims to be a native English speaker:

"Sometimes it is the patient who is heavily accented. Some of these folks are n-th generation Americans but from places with dialect and accent that is quite a bit different from standard American English.

I speak perfect standard English, just like the guy on the news, so it must be the patient's that need to be changed."

Another commenter:

"I work for an HMO that's like the United Nations. I can't pronounce the names of many physicians when I book an appointment for a patient. I usually ask the patient how the doctor pronounces their name, they don't know how to."

Personally, I am not bothered by different accents, and as a patient, I would prefer to see a good doctor no matter what accent he/she has.



Video: "George (Adam Sandler) and Ira (Seth Rogen) make fun of a doctor's accent during an appointment." Courtesy of Universal Pictures. Link via Life in the Fast Lane.

References:

Excuse me, could you repeat that? By Karen Blum, Baltimore Sun, July 24, 2006.
IMGs: Get used to it. Kevin, M.D., 09/2007.
Image source: Openclipart.org, public domain.

Related reading:

Difficult Sign Out. ER Stories - Shocking, Hilarious, Bizarre, and Sad Tales from the Emergency Room, 03/2008.
'Overseas doctors - particularly those from the Far East - speak incredibly fast. Daily Mail.

Where Do Doctors Learn Best? - NYTimes http://goo.gl/Qb5mm - The last letter will surprise many.

Who would you give the job to? Verbatim excerpts from the application letters of overseas doctors seeking a job in Australia. Life in the Fast Lane, 2011.
The One Dozen Most Important Things You May Not Have Known About American Medicine - A Guide for IMGs http://goo.gl/dY6hK
"Medicalese" Glossary - what is the meaning of brady, bronch, neb, soft admission, triple-A, lytes, de-sating?   http://goo.gl/SX83R

Jumping Over the Grand Canyon

A set of 3 photos on Flickr by Hans van de Vorst:

Photo 1: Showtime!
"I was simply stunned seeing this guy standing on this solitary(!!) rock IN the Grand Canyon. The canyon's depth is 900 meters here."

Photo 2: Cliffhanger
"After the sun set behind the canyon's horizon he packed his things (having only one hand available) and prepared himself for the jump. This took about 2 minutes, at that point he had the full attention of the crowd."

Photo 3: Slip Slidin' Away
"We've come to the end of this little story. Look carefully at the photographer. He has a camera, a tripod and also a plastic bag, all on his shoulder or in his left hand. Only his right hand is available to grab the rock and the weight of his stuff is a problem."

Only on Flickr...

What's New in General Internal Medicine?

The latest Update in General Internal Medicine is published in the Annals of Internal Medicine (PDFs free after 6 months). While the whole text is spread over 11 pages, I would like to summarize just a few things I found useful. Recommendations are divided in 3 groups: "start", "consider" and "stop."


Start

Start prescribing a high-dose statin (Lipitor 80 mg po qd) for patients with CAD.
I am not so sure about prescribing the high dose if you can achieve a significant LDL and CRP reduction with a lower statin dose.

Start U/S screening for AAA in male smokers aged 65 to 73.
It took us such a long time to realize that U/S screening saves lives in AAA patients...

Start considering seriously MRSA in skin/soft tissue infections, and consider Vancomycin treatment according to local guidelines.


Consider

Consider referring eligible patients with CHF for AICD.

Consider once-daily Spiriva (tiotropium) in COPD patients.


Stop

Stop prescribing high-dose vitamin E. In a large study of 130,000 patients, vitamin E use was associated with increased mortality.

Stop prescribing cholinesterase inhibitors (Aricept) routinely in dementia. These drug are at best marginally effective and can cause significant adverse effects. Memantine (Namenda) is still considered helpful, at least until newer studies show that it may not be...

Stop prescribing beta-blockers for:
- low-risk patients in the perioperative period. Patients with RCRI > 3, may still benefit from a beta-blocker.
- first-line HTN treatment. Beta-blockers increase the risk for development of DM2 and offer less protection against stroke than CCB and ACEi.


Up-To-Date also publishes regular updates in different medical specailties in the section "What's New" (paid subscription required).


References:
Update in General Internal Medicine. Christopher L. Knight, MD, and Stephan D. Fihn, MD, MPH. Annals of Internal Medicine, 7/2006. Paid subscription required (PDFs free after 6 months).

Perioperative beta blockers may not benefit patients with diabetes (if not used properly)

Norvasc plus ACEi much better than Atenolol plus HCTZ

Images source: Openclipart.org, public domain.

"Blogger Friends Circle" Shows Who Links To Your Blog

TTLB Blogosphere Ecosystem lists the incoming links in a form of a spiral wheel with colored bubbles. The wheel represent websites which link to one's blog most frequently. An example with my blog (ranked # 4695) is shown below. It looks like I get about 60-70 links per month from other websites.



To check the incoming links for you blog, replace the URL of my blog with yours:

http://truthlaidbear.com/showdetails.php?host=http://casesblog.blogspot.com

(remove the final "/" in the URL when you copy and paste)

References:
Link via Digital Inspiration.
Measure Your Blog Popularity on Social Bookmarking Websites with Socialmeter. Digital Inspiration.

Blogger Hacks: Change Your Blog to Fit Your Ideas

Blogger.com is owned by Google and is probably the most popular free blogging services on the web. You can edit the template and this offers almost unlimited options for customization.

This customization or "hacking" just got easier with the launch of BloggerHacks Wiki which "catalogs dozens of "hacks" for Blogger in categories ranging from Navigation to Encryption. The hacks vary in difficulty from easy to advanced, and there's also an area for requesting new hacks." (link via DownloadSquad.com).

Blogger.com a new beta version last week which does not allow you to edit the template yet (it will be fixed later) but if you already have an old blog, you may find BloggerHacks Wiki very useful.

References:
Blogspot URLs That You Should Bookmark. Digital Inspiration.
Image source: Blogger.com.

A Drop in Google Shares Causes Chest Pain

Last week, a computer glitch by Nasdaq lead to a drop of $350 a share in Google stock value in just 10 minutes.

According to The New York Sun:

"At about the $391 price point, an order originated on Instinet-ATS (a Nasdaq company) that triggered trades between 4:10 p.m. and 4:12 p.m. at a price as low as $38 (representing a drop of almost $350 a share from the close). In brief, someone from a Nasdaq member firm punched in an erroneous figure to commence a trade.

An investor whose identity was not revealed, "bought 200 shares earlier last week at around $380, or about $76,000, only to discover from his broker he was suddenly sitting with a fast and damaging paper loss (at the quoted $38 a share) of about $68,400.

The broker told his customer the $38 price was probably a mistake, but he added that he could not guarantee it, given the volatility in Google's shares. Nonetheless, the customer, he said, became hysterical, complaining of chest pains and crying. "The way he sounded, I thought for sure the man was going to have a heart attack," he said."

Luckily, Nasdaq soon corrected the mistake. There was no word if this helped the chest pain of the "poor" investor.

References:
Error Knocks Down Google $350 a Share. The New York Sun.
Image source: Openclipart.org, public domain

BMJ Offers Tips on Dealing with Angry Patients

BMJ Career Focus continues its series of articles with practical advice:

Tips on... Getting more energy

Tips on... Dealing with angry and aggressive patients

Handling aggressive patients

May be you can stay out of trouble by using the The "BEST" Communication Model described in one of the previous issues...

Image source: Openclipart.org, public domain.

Mediterranean Diet Seems to Improve Cardiovascular Risk Factors After Just 3 Months

According to a substudy of PREDIMED published in the Annals of Internal Medicine:

"Compared with a low-fat diet, Mediterranean diets supplemented with olive oil or nuts have beneficial effects on cardiovascular risk factors."

How was the study done?

772 asymptomatic people aged 55 to 80 years were recruited for the study. Participants were assigned to a low-fat diet or to one of 2 types of a Mediterranean diet. Those allocated to Mediterranean diets received either free virgin olive oil (1 liter per week), or free nuts (30 gm/day). The authors evaluated laboratory outcomes at 3 months.

Mediterranean diet improved (decreased) plasma glucose levels, systolic blood pressure, cholesterol, and C-reactive protein levels compared to the low-fat diet. The changes were small and the study was not powered to show any clinical significance, but again, the intervention duration was only 3 months

Further Reading from Wikipedia

Cuisine of the Mediterranean

Mediterranean diet

References:

Effects of a Mediterranean-Style Diet on Cardiovascular Risk Factors.
Ramon Estruch et al., Annals of Internal Medicine, 7/2006.

Why to Eat Like a Greek http://goo.gl/Chpwf - Mediterranean diet improves heart risk factors http://goo.gl/DkPhF
Image source: Olive oil, Wikipedia

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

As some of you probably know, I am a staff physician at the Section of Hospital Medicine at the Cleveland Clinic. Being one of the largest academic hospitalist groups in the country, I found it odd that we did not have a website yet, and with the support of my colleagues (and bosses) I decided to create one.

How It Started

I had a lot of experience tinkering with the Blogger.com templates and the first version of the website was naturally done there at Hospitalists.blogspot.com.

The IT and marketing departments reviewed our provisional website on blogspot.com, they liked it, and gave a green light to relocate it to the Cleveland Clinic servers.

Launching the New Website

Our brand new official website is at: ClevelandClinic.org/Hospitalist

Now you can see the people who work in the section, including their CVs and publications. We modeled this part after the UCSF hospitalist website.

Also, we have listed the main areas where we work: the huge main campus with 1,000 beds, the outpatient preoperative center with 15,000 patient visits per year and the subacute rehabilitation center.

There are also links to our hospitalist fellowship program and the research projects currently underway at the section. As academic hospitalists, we have several projects in different stages at any time.

This is by no means the complete version of the website, it is and will continue to be a work in progress. Our goal is to have it constantly updated to keep pace with the persistent stream of new developments at the Cleveland Clinic. Your input and comments are highly appreciated, please send feedback to clinicalcases@gmail.com.

Things I Learned

I learned several things during my work on the websites for the Section of Hospital Medicine at the Clinic:

1. If you want to start a web project, go ahead and give it a try instead of waiting for somebody else to do it for you.

2. Start your website on Blogger.com. It is much better to show a complete version of the website (although temporary) to the decision makers, so that they can visualize it, rather than to have just a project on paper.

3. Relocating your website from Blogger.com to its permanent place on the company/hospital servers is relatively easy.

4. As I have written before, Blogger.com can be used for much more than blogging. Both your practice, and you personally, should have websites. In a society that sees the world more and more through "Google eyes", if something is not on the web, it does not exist.

The purpose of this post is not only to showcase our new website but also to encourage you to start your own, if you have such plans. After all, if I did it, you can too.

References:
How Can a Doctor Use Google Page Creator?
Image source: Cleveland Clinic

Thanks to John Sharp and his colleagues at the IT and marketing departments of the Cleveland Clinic for all the support.

Taking the Pulse of the Healthcare Blogosphere

Envision Solutions and The Medical Blog Network are conducting a survey of medical bloggers called "Taking the Pulse of the Healthcare Blogosphere." The results will be available by the end of the year and will be presented at the first ever Healthcare Blogging Summit on December 11, 2006 in Washington, D.C. The keynote speaker at the conference will be Steve Rubel who is the author of the very informative blog MicroPersuasion (on my daily reading list). For example, do you know that according to Technorati it looks like most bloggers post while at work?

Click here if you would like to participate in "Taking the Pulse of the Healthcare Blogosphere" survey. It takes about 5-10 minutes to complete.

Image source: The Medical Blog Network, used with permission.

Medical Videos from Loyola University Chicago

I just found this thoracentesis video from the Loyola University Chicago on Yahoo Video. The video complements well our thoracentesis step-by-step procedure guide. It was added to Yahoo Video a month ago and has been viewed only 68 times.

There are also links to many other free medical videos from the Loyola University.

Reference:
Thoracentesis - Procedure Guide
Procedure Guides Step-by-Step
Image source: Yahoo Video

Walk for Life

Joanne Colan of the daily videoblog Rocketboom made a very funny episode about race walking. Take a look at those "peculiar creatures" who walk lightning fast swinging arms and hips. The technique seems to really work, and it did not take long for Joanne to learn it. According to Wikipedia, fitness-wise, race walking exceeds the caloric requirements of running because of stronger arm motion and less efficiency than running.

It's a funny video and hopefully it will encourage more people to walk daily. It does not have to be THAT fast... :-)

As a side note, I just updated the Wikipedia entry on race walking with a link to the Rocketboom episode. Let's see if the link remains there or the "wisdom of crowds" throws it out.

References:
Race walking from Wikipedia, the free encyclopedia
Image source: Rocketboom.com

How to Make Money Blogging?

Forget about AdSense and banner ads. The answer may be in the cartoon below:



Cartoon author: Hugh Macleod, Creative Commons license.
Link via Digital Inspiration.

Useful Free Software for Windows Security and Maintenance

1. Firewall

ZoneAlarm
A free firewall, it works similar to Norton Internet Security. You need a free antivirus programs (see below) for a complete protection. Download and read reviews from C|Net.

2. Antivirus

Avast
A free antivirus program, just as good and up-to-date as Norton. Currently, this is the perfect free addition to ZoneAlarm firewall. Download and read reviews from C|Net.

3. System Cleaner

CCleaner
"CCleaner is a freeware system optimization and privacy tool. It removes unused files from your system - allowing Windows to run faster and freeing up valuable hard disk space." Download and read reviews from C|Net.

I personally use these programs and I find them very useful. They are free and do not contain any spyware/adware.

Update 09/09/2007:
40+ Free Windows Apps For You. Technology Bites, 2007.
The ones that I am trying now are Freemind, a free mind-mapping software, and Truecrypt, a free open-source disk encryption software for my external hard drive.

References:
Scan a File Using the Top Antivirus Software. Google Operating System, April 11, 2007.
The Best Free Software for Windows. Digital Inspiration, 12/2007.
Avoid Viruses, Spyware, Adware and Trojan Horses. Information Technology in Medicine, 2008.

Updated: 12/31/2007

Interactive Health Tutorials from Medline

I was reading Dean Giustini's post about Healia's Search Vortal and decided to check out Healia one more time. While making a sample search for CHF, I noticed in the upper right corner (where Google ads usually are) the link to a MedlinePlus Interactive Tutorial for CHF (screenshot below).



Medline used an external provider to compile a comprehensive list of Flash-based Interactive Health Tutorials:

• Diseases and Conditions
• Tests and Diagnostic Procedures
• Surgery and Treatment Procedures
• Prevention and Wellness

This looks like a valuable resource for patient education. Click to see the Kidney Failure tutorial as an example (screenshot below).



References:
Healia's Search Vortal - does it have a chance? UBC Academic Search - Google Scholar Blog.
Screenshots: Healia, MedlinePlus

Further reading:
Bioscreencast.com. Link via DavidRothman.net.

Updated: 10/02/2007

Iron in Anemic Patients with Chronic Kidney Disease

This is a presentation from Medscape Nephrology. A free registration is required to listen to the presentation and download the PowerPoint file.

The bottom line:

• Iron deficiency is one of the causes of erythropoetin resistance.
• IV iron is superior to oral iron in managing anemia in hemodialysis, peritoneal dialysis, and CKD patients.
• IV iron sucrose is safe and may be given up to 500 mg IV over 4 hours during an outpatient visit.
  

Update 3/28/2007:

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

References:
Iron in patients with chronic kidney disease. From Medscape Nephrology, Posted 07/27/2006.
Image source: Wikipedia