Vincent van Gogh: "I'd like to show by my work what such an eccentric, such a nobody, has in his heart"


How a genius feels: "I'm a nonentity, an eccentric, an unpleasant person"

March 30th is the birthday of Vincent van Gogh, born in Holland in 1853, a famous painter and also great letter-writer. His letters were lively, engaging, and passionate; they also frequently reflect his struggles with bipolar disorder.

He wrote: "What am I in the eyes of most people — a nonentity, an eccentric, or an unpleasant person — somebody who has no position in society and will never have; in short, the lowest of the low. All right, then — even if that were absolutely true, then I should one day like to show by my work what such an eccentric, such a nobody, has in his heart."

He wrote thousands of letters to his brother Theo over the course of his life. Theo's widow published the van Gogh's letters to her husband in 1913.

Doctors' Day in a high-risk profession: suicide rate of U.S. doctors is one per day

This quote serves as a good reminder how people with depression may have an altered perception of themselves. March 30 is also National Doctors' Day in the U.S. Other countries celebrate Doctors' Day on different dates.

More than a quarter of primary care doctors reported being "burnt out." The United States loses the equivalent of at least one entire medical school class (approximately 400 physicians) each year to suicide.

In other words, 300-400 doctors in the United States kill themselves every year, or roughly 1 per day. Male doctors have suicide rates 1.4 times that of the general population, while female doctors have twice the rate of depression and 2.3 times the suicide rate when compared with women who are not physicians.

A conversation could save a life: "Are you OK?" Day

Hugh Jackman shows his support for R U OK?Day, a national day of action in Australia that aims to prevent suicide by encouraging people to connect with colleagues, friends and loved ones and ask simply: "Are you OK?" This may help your medical colleagues too:



References

Writer's Almanac. NPR, 2012.
High-risk profession: Suicide rate of U.S. doctors is one per day
Help for Today's Tense, Frustrated Doctors. Medscape, 2009.
http://www.medscape.com/viewarticle/710904
Doctors have higher rates of suicide than the general population: 40% higher for male doctors, 130% for female doctors http://goo.gl/ckTm
R U OK? Day
Image source: Vincent van Gogh's 1890 painting At Eternity's Gate. Wikipedia, public domain.

Crohn's disease - 2011 review

Crohn's disease is a chronic inflammatory condition affecting the GI tract at any point from the mouth to the rectum.

Symptoms and signs may consist of:

- diarrhea
- abdominal pain
- fever
- weight loss
- abdominal masses
- anemia

Extraintestinal manifestations of Crohn's disease include:

- osteoporosis
- inflammatory arthropathies
- scleritis
- nephrolithiasis
- cholelithiasis
- erythema nodosum

Laboratory findings

Acute phase reactants, such as CRP and ESR, are often increased with inflammation and may correlate with disease activity.

Levels of vitamin B12, folate, albumin, prealbumin, and vitamin D can help assess nutritional status.

Procedures often used to diagnose Crohn's disease:

- colonoscopy with ileoscopy
- capsule endoscopy
- computed tomography (CT) enterography
- small bowel follow-through

Diagnostic tools for extraintestinal manifestations or complications (e.g., abscess, perforation):

- ultrasonography
- computed axial tomography (CT)
- scintigraphy
- MRI

Medical management

Mesalamine products are used for mild to moderate colonic disease. Antibiotics (e.g., metronidazole, fluoroquinolones) are often used for treatment.

Patients with moderate to severe Crohn's disease are treated with:

- corticosteroids
- azathioprine
- 6-mercaptopurine
- anti-tumor necrosis factor agents (e.g., infliximab, adalimumab)

References

Diagnosis and management of Crohn's disease. Wilkins T, Jarvis K, Patel J. Am Fam Physician. 2011 Dec 15;84(12):1365-75.

Image source: Colon (anatomy), Wikipedia, public domain.

"Lifestyle 180": Cleveland Clinic 1-year program promises to reverse chronic disease through lifestyle modification

During the past 5 years, the Cleveland Clinic has moved aggressively to expand from illness management to wellness management. They even have a Wellness Institute. One example of its programs is Lifestyle 180 (R) which is "designed to reverse" the effects of chronic disease through lifestyle modification.

Here is a 5-minute video about the program from the Clinic YouTube channel:



The program focuses on nutrition, exercise, and stress management. The yearlong program is available at the Cleveland Clinic Wellness Institute campus located in Lyndhurst, Ohio.

References:

Lifestyle medicine

Interactive wellness guide by Cleveland Clinic

Lifestyle 180 (PDF)

Disclaimer: I was on faculty at Cleveland Clinic and Case Western Reserve University as Assistant Professor of Medicine until 2008.

Comments from Twitter:

Meenakshi Budhraja @gastromom: Like>>

Linda Pourmassina,MD @LindaP_MD: "the $3,000 fee for this program represents a fraction of the increasingly high co-pays for doctor visits and medications."

Cirrhosis - 2011 update from Am Fam Physician

Cirrhosis is the 12th leading cause of death in the United States. The mortality rate is 9.7 per 100,000 persons.

The most common causes of cirrhosis are:

- alcohol abuse
- viral hepatitis
- nonalcoholic fatty liver disease is emerging as an increasingly important cause

Patients with cirrhosis should be screened for hepatocellular carcinoma with imaging studies every 6-12 months.

Causes of hepatic encephalopathy include:

- constipation
- infection
- gastrointestinal bleeding
- some medications
- electrolyte imbalances
- noncompliance with medical therapy

Treatment

Lactulose and rifaximin are aimed at reducing serum ammonia levels.

Ascites should be treated initially with salt restriction and diuresis. Physicians should be vigilant for spontaneous bacterial peritonitis.

Patients with acute GI bleeding should be monitored in an intensive care unit, and should have endoscopy performed within 24 hours.

Prevention

Mechanisms to reduce the incidence of cirrhosis:

- treat alcohol abuse
- screen for viral hepatitis
- control risk factors for nonalcoholic fatty liver disease

Cirrhosis: Phil's story (video):



From NHSChoices: Many people enjoy a drink in the pub after work without realising how social drinking can damage health. Phil didn't realise the harm his alcohol intake was doing until he was diagnosed with cirrhosis of the liver. He talks about his experience and the shock he felt at being diagnosed.

References

Cirrhosis: diagnosis, management, and prevention. Starr SP, Raines D. Am Fam Physician. 2011 Dec 15;84(12):1353-9.

Cirrhosis - JAMA Patient Page, 2012.

The Number of Tweets Predicts Future Citations of a Specific Journal Article

Citations of journal articles and the impact factor are widely used measures of scientific impact. Web 2.0 tools such as Twitter, Facebook, blogs and social bookmarking tools provide the possibility to construct article-level or journal-level metrics to gauge impact and influence.

Between 2008 and 2011, all tweets containing links to articles in the Journal of Medical Internet Research (JMIR) were data mined.The tweets were compared to subsequent citation data 17-29 months later.

4,000 tweets cited 280 JMIR articles. The distribution of tweets followed a power law, with most tweets sent on the day when an article was published (44% of all tweets in a 60-day period) or on the following day (16%), followed by a rapid decay.

The Pearson correlations between "tweetations" and regular citations were moderate and statistically significant (0.42 to 0.72).

Highly tweeted articles were 11 times more likely to be highly cited than less-tweeted articles.

Top-cited articles could be predicted from top-tweeted articles with 93% specificity and 75% sensitivity.

Tweets can predict highly cited articles within the first 3 days of article publication.

Social media activity may:

- increase citations
- reflect the underlying qualities of the article

Social impact measures based on tweets are proposed to complement traditional citation metrics. The study author proposed a "twimpact" factor that measures uptake and filters research resonating with the public in real time.

After the initial publication, some science blogs have pointed out potential issues and conflicts of interests in relation to the topic and the single author who is also the founder, owner, and Editor-in-Chief of the journal. You can find more by performing a Google search for "twimpact" factor or checking the references section at the end of this post. Overall, I think this is an interesting concept and Gunther Eysenbach did a great job focusing the attention of the journal publishers on Twitter and Facebook as distribution channels that can also guide in measuring the impact of their articles.

References:

Can Tweets Predict Citations? Metrics of Social Impact Based on Twitter and Correlation with Traditional Metrics of Scientific Impact. Gunther Eysenbach. J Med Internet Res 2011;13(4):e123.

New research plus twitter. Does it make a difference in the clinic. Heidi Allen Digital Strategy in Health.

'Highly Tweeted Articles Were 11 Times More Likely to Be Highly Cited'. The Atlantic.

Twimpact factors: can tweets really predict citations? BMJ.

Tweets, and Our Obsession with Alt Metrics

Image source: Twitter.com.

Comments from Twitter:

@paediatrix:  Interesting. Makes sense

Harris Lygidakis @lygidakis: And Twimpact Factor is a good sign of what's ahead!

Internal medicine residents spent little time reading, and prefer electronic resources, specifically UpToDate

This study from the Mayo Clinic assessed residents' reading habits and preferred educational resources at 5 internal medicine training programs via a survey.

78% of residents reported reading less than 7 hours a week.

81% of residents read in response to patient care encounters.

The preferred educational format was electronic, and UpToDate was the big winner among the surveyed group:

- 95% of residents cited UpToDate as the most effective resource for knowledge acquisition
- 89% of residents reported that UpToDate was their first choice for answering clinical questions

The study authors concluded that residents spent little time reading and sought knowledge primarily from electronic resources. Most residents read in the context of patient care.

The abstract does not mention anything about social media sources such as Wikipedia, blogs, and Twitter, but the residents encounter a lot of those through Google searches.

References:

A multi-institutional survey of internal medicine residents' learning habits. Edson RS, Beckman TJ, West CP, Aronowitz PB, Badgett RG, Feldstein DA, Henderson MC, Kolars JC, McDonald FS. Med Teach. 2010;32(9):773-5. Image source: UpToDate.

Motion sickness - what to do?

From a 2011 BMJ review:

Travel by car, train, or other transport is part of everyday life for most people, and therefore motion sickness is a quite common problem. It was recognized in the early days of sea travel and the word for sickness, “nausea,” derives from the Greek word νανς, meaning “ship.”

Motion sickness is also a potentially disabling problem, thought to be due to sensory conflict or “mismatch” involving the vestibular system.

Symptoms can be provoked by:

- externally imposed motion
- implied self motion from a moving visual field, such as in a cinema

Symptoms

Motion sickness manifests with:

- nausea, vomiting, and stomach awareness
- increased salivation
- belching
- pallor
- sweating
- headache
- dizziness
- apathy, drowsiness, and malaise
- hyperventilation

Habituation

Behavioral treatments such as habituation can be effective but at the same time they can be unpleasant and time consuming

Hyoscine

Hyoscine is an effective preventive medication. There are oral forms and transdermal patches. Hyoscine nasal spray is also effective in preventing motion sickness

Evidence to support the use of other drugs is weaker, especially taking into account the trade off between efficacy and adverse effects. Traditional remedies such as ginger and acupressure bands have not been effective.

References:

Managing motion sickness. BMJ Review 2011; 343 doi: 10.1136/bmj.d7430
Image source: OpenClipArt.org, public domain.

Symptomatic knee osteoarthritis (OA) increased during the past 20 years but radiographic OA did not

A recent surge in knee replacements is assumed to be due to aging and increased obesity of the U.S. population.

This cross-sectional study used data from 6 NHANES (National Health and Nutrition Examination Survey) surveys between 1971 and 2004 and from 3 examination periods in the FOA (Framingham Osteoarthritis) Study between 1983 through 2005 of the U.S. population.

Prevalence of knee pain increased by 65% in NHANES from 1974 to 1994.

In the FOA Study, prevalence of knee pain and symptomatic knee osteoarthritis doubled in women and tripled in men over 20 years.

However, no such trend was observed in the prevalence of radiographic knee osteoarthritis.

Prevalence of knee pain has increased substantially over 20 years. Obesity accounted for only part of this increase.

Symptomatic knee osteoarthritis increased but radiographic knee osteoarthritis did not. Why the patients are more symptomatic now than 20 years ago?

Research Finds Exercise is Good for Arthritis (a Cleveland Clinic video):



What is Boomeritis?

In 2006, the NYTimes described the health problems of aging baby boomers who continue to exercise: osteoarthritis which needs "knee and hip replacements, surgery for cartilage and ligament damage, and treatment for tendinitis, arthritis, bursitis and stress fractures." Some doctors call this phenomenon "boomeritis" or "Generation Ouch."

References:

Increasing Prevalence of Knee Pain and Symptomatic Knee Osteoarthritis: Survey and Cohort Data. ANN INTERN MED, December 6, 2011, vol. 155 no. 11 725-732.

What is Boomeritis?

Image source: OpenClipart.org, public domain.

What are Yips? (Mayo Clinic video)

Yips are involuntary wrist spasms that occur most commonly when golfers are trying to putt. However, the yips can also affect people who play other sports - such as cricket, darts and baseball.

It was once thought that the yips were always associated with performance anxiety. However, it now appears that some people have yips that are caused by a focal dystonia, which is a neurological dysfunction affecting specific muscles.



Charles H. Adler, M.D., neurologist at Mayo Clinic in Arizona, discusses study findings related to the yips, a condition affecting a significant number of already anxious golfers during putting or chipping.

References:

Yips. Mayo Clinic.

Best Tweets - Selection of Twitter Favorites













The inclusion of a Twitter update (tweet) in Best Tweets - Selection of Twitter Favorites does not represent endorsement or agreement of any kind. If you are included in this post but you would like to have your tweet removed for any reason, please email me and will comply with your request the same day.

March Madness Vasectomies: Postop period is "a perfect situation for television", says Cleveland Clinic urologist

Vasectomy is a surgical procedure for male sterilization, and consequently, birth control. During the procedure, the vasa deferentia of a man are severed, and then tied/sealed. This prevents sperm from entering into the seminal stream (ejaculate). You can watch a video how the procedure is done here.



From Cleveland Clinic YouTube channel: A urologist talks about the increase in the number of vasectomies he does this time of year. "Guys get it done, then watch the NCAA Basketball tournament all weekend long." The procedure takes 5-10 minutes. Patients need to ice the area for 2-3 days.

The NCAA Men's Division I Basketball Championship is a single-elimination tournament held each spring in the United States, featuring 68 college basketball teams, to determine the national championship in the top tier of college basketball. The tournament, organized by the National Collegiate Athletic Association (NCAA), was created in 1939 by the National Association of Basketball Coaches, is held mostly in March, and it is known informally as March Madness (source: Wikipedia).



Private urology practices advertise on TV their "Vasectomy Madness" campaigns:



CNN RidicuList with Anderson Cooper: Vasectomy and free pizza (video):

Essential tremor: what are the treatment options?

Essential tremor is a common neurologic problem. It should be differentiated from secondary causes of tremor and Parkinson disease.

Impact of essential tremor

Essential tremor causes motor dysfunction (e.g. a dentist may have to quit his/her job). However, more importantly, the tremor can have a psychological impact on the patient, especially since it usually gets worse in social situations.

Diagnosis

Essential tremor is a clinical diagnosis. A thorough review of the medical history and medication exposures is a good start. Laboratory and imaging tests may be ordered to rule out a secondary cause.

Treatment

The two first-line agents in drug therapy for essential tremor are:

- nonselective beta-blocker propranolol (Inderal)
- antiepileptic primidone (Mysoline)

They can be used alone or in combination.

Severe, resistant, or atypical cases should be referred to a specialist. Botulinum toxin injection and deep brain stimulation are reserved for resistant tremor or for patients who do not tolerate drug therapy.

Dr. Young from Swedish Medical Center discusses some of the new treatments for essential tremor in this video:



References:

Essential tremor: Choosing the right management plan for your patient. CCJM, 2011.

3 million Americans are living with celiac disease

Celiac disease is the most common genetically based food intolerance (1% prevalence among general population) (JAMA 2014, http://buff.ly/1cJWgFy).

Celiac disease, an immune system reaction to gluten in the diet, is four times as common today as it was 50 years ago. Lack of awareness of celiac could be contributing to a delay of up to 11 years in diagnosis of adults in North America (http://goo.gl/sy778).

This is a very informative and beautifully designed video by the University of Chicago Celiac Disease Center. It looks like an infographic made into video - have a look:



New classification is being proposed for gluten-related disorders: celiac disease; dermatitis herpetiformis; gluten ataxia; wheat allergy; gluten sensitivity. WSJ, 2012.

Recent studies support the existence of the new condition nonceliac gluten sensitivity which is defined as symptoms with negative celiac antibodies and biopsy (http://goo.gl/57IlB).

Key figures:

New nomenclature and classification of gluten-related disorders

Algorithm for the differential diagnosis of gluten-related disorders, including celiac disease, gluten sensitivity and wheat allergy. BMC Medicine 2012.

References:

Celiac disease is different from wheat allergy

Disclaimer: I am an Assistant Professor of Medicine and Pediatrics at University of Chicago.

Pathogenesis of idiopathic pulmonary fibrosis - 2011 Lancet review

Idiopathic pulmonary fibrosis (IPF) is a devastating, age-related lung disease of unknown cause that has few treatment options.

IPF was once thought to be a chronic inflammatory process, but current evidence indicates that the fibrotic response is driven by abnormally activated alveolar epithelial cells (AECs).


Interstitial Lung Diseases (ILD) (click to enlarge the image).

Alveolar epithelial cells (AECs) produce mediators that induce the formation of fibroblast and myofibroblast foci through:

- proliferation of mesenchymal cells
- attraction of circulating fibrocytes
- stimulation of the epithelial to mesenchymal transition

The fibroblast and myofibroblast foci secrete excessive amounts of extracellular matrix (collagen), resulting in scarring and destruction of the lung architecture.


Mechanisms of IPF (click to enlarge the image). Image source: PLoS Medicine, Creative Commons license.

References:

Idiopathic pulmonary fibrosis. The Lancet, Volume 378, Issue 9807, Pages 1949 - 1961, 3 December 2011.

Interstitial Lung Diseases (ILD)

Antibiotics prescribed during 21% of pediatric ambulatory visits; 50% were broad-spectrum

Antibiotics are commonly prescribed for children with conditions for which they provide no benefit, including viral respiratory infections.

The researchers used the National Ambulatory and National Hospital Ambulatory Medical Care surveys from 2006 to 2008, which are representative of ambulatory care visits in the United States.

Antibiotics were prescribed during 21% of pediatric ambulatory visits; 50% were broad-spectrum, most commonly macrolides. Respiratory conditions accounted for >70% of visits in which antibiotics were prescribed.

The authors concluded that broad-spectrum antibiotic prescribing in ambulatory pediatrics is extremely common and frequently inappropriate.

Cough is one of the common reasons for unnecessary antibiotic prescription. As you can see from the diagram below, the differential diagnosis of chronic cough is broad and includes asthma and other conditions in which antibiotics are ineffective:



Differential diagnosis of cough, a simple mnemonic is GREAT BAD CAT TOM. Click here to enlarge the image: (GERD (reflux), Laryngopharyngeal Reflux (LPR), Rhinitis (both allergic and non-allergic) with post-nasal drip (upper airway cough syndrome), Embolism, e.g. PE in adults, Asthma, TB (tuberculosis), Bronchitis, pneumonia, pertussis, Aspiration, e.g foreign body in children, Drugs, e.g. ACE inhibitor, CF in children, Cardiogenic, e.g. mitral stenosis in adults, Achalasia in adults, Thyroid enlargement, e.g. goiter, "Thoughts" (psychogenic), Other causes, Malignancy, e.g. lung cancer in adults).

References:

Antibiotic Prescribing in Ambulatory Pediatrics in the United States. Adam L. Hersh, MD, PhDa, Daniel J. Shapiro, BAb, Andrew T. Pavia, MDa, Samir S. Shah, MD, MSCE. Pediatrics Vol. 128 No. 6 December 1, 2011, pp. 1053 -1061, (doi: 10.1542/peds.2011-1337).

Image source: Wikipedia, GNU Free Documentation License.