12/12/08
Review of alpha-1 antitrypsin deficiency and hepatopulmonary syndrome
Review articles:
Gary Rachelefsky, D. Kyle Hogarth. Issues in the diagnosis of [alpha]1-antitrypsin deficiency, J Allergy Clin Immun. April 2008;121:833-838.
Kohnlein T, Welte T. Alpha-1 antitrypsin deficiency: pathogenesis, clinical presentation, diagnosis, and treatment. American J Med. 2008;121: 3-9.
Article on hepatic involvement in pulmonary diseases (AT deficiency, sarcoidosis):
Layden TJ, et al. Hepatic manifestations of pulmonary diseases. Clinics in Liver Disease. 2002;6:969-979.
Review on hepatopulmonary syndrome and related letter on platypnea:
Hepatopulmonary syndrome--a liver-induced lung vascular disorder. N Engl J Med. 2008 May 29;358:2378-87.
The hepatopulmonary syndrome. N Engl J Med. 2008 Aug 21;359:866-867.
Gary Rachelefsky, D. Kyle Hogarth. Issues in the diagnosis of [alpha]1-antitrypsin deficiency, J Allergy Clin Immun. April 2008;121:833-838.
Kohnlein T, Welte T. Alpha-1 antitrypsin deficiency: pathogenesis, clinical presentation, diagnosis, and treatment. American J Med. 2008;121: 3-9.
Article on hepatic involvement in pulmonary diseases (AT deficiency, sarcoidosis):
Layden TJ, et al. Hepatic manifestations of pulmonary diseases. Clinics in Liver Disease. 2002;6:969-979.
Review on hepatopulmonary syndrome and related letter on platypnea:
Hepatopulmonary syndrome--a liver-induced lung vascular disorder. N Engl J Med. 2008 May 29;358:2378-87.
The hepatopulmonary syndrome. N Engl J Med. 2008 Aug 21;359:866-867.
12/11/08
What are the clinical features of Legionnaires' disease?
Review article on Legionella infection (includes discussion of sensitivity of urine antigen test)
Diederen BMW. Legionella spp. and Legionnaires' disease. J Infect Dis. 2008;56 (1):1-12
Diederen BMW. Legionella spp. and Legionnaires' disease. J Infect Dis. 2008;56 (1):1-12
12/4/08
When did blood banks begin testing donated blood for hepatitis C?
Excerpt from Mandell, Douglas, and Bennett's: Principles and Practice of Infectious Diseases,6th ed., Chapter 112, states that donors were screened for risk of
blood-borne viral infections in the 1980s and blood was tested for
HCV-specific antibodies beginning in May 1990
See also Donahue JG, et al: The declining risk of post-transfusion hepatitis C virus infection. N Engl J Med 1992; 327:369-373.
blood-borne viral infections in the 1980s and blood was tested for
HCV-specific antibodies beginning in May 1990
See also Donahue JG, et al: The declining risk of post-transfusion hepatitis C virus infection. N Engl J Med 1992; 327:369-373.
11/20/08
11/10/08
11/6/08
10/10/08
9/19/08
Is prophylaxis for PCP effective in an immunocompromised non-HIV patient?
meta-analysis in
Green H, Paul M, Vidal L, Leibovici L. Prophylaxis of Pneumocystis pneumonia in immunocompromised non-HIV-infected patients: systematic review and meta-analysis of randomized controlled trials. Mayo Clin Proc. 2007 Sep;82(9):1052-9.
Green H, Paul M, Vidal L, Leibovici L. Prophylaxis of Pneumocystis pneumonia in immunocompromised non-HIV-infected patients: systematic review and meta-analysis of randomized controlled trials. Mayo Clin Proc. 2007 Sep;82(9):1052-9.
What is the precision and accuracy of clinical examination for clubbing?
Rational Clinical Exam from JAMA contains meta-analysis
8/22/08
8/18/08
8/11/08
What is the incidence of surgical interventions for bicuspid aortic valve by age?
Roberts WC, Ko JM. Frequency by decades of unicuspid, bicuspid, and tricuspid aortic valves in adults having isolated aortic valve replacement for aortic stenosis, with or without associated aortic regurgitation. Circulation. 2005 Feb 22;111(7):920-5. PMID: 15710758
Full text
Table 1 (p. 921) breaks down surgical procedures by gender and age at time of operation.
Full text
Table 1 (p. 921) breaks down surgical procedures by gender and age at time of operation.
8/5/08
7/17/08
What is the criteria for diagnosing scleroderma and what are the recommendations for managing scleroderma renal crisis?
From Current Rheumatology (McGraw-Hill, 2007)
Most frequent symptoms in (descending order):
Raynaud phenomenon
gastroesophageal reflux with or without dysmotility
skin changes
swollen fingers
arthralgias
Other factors:
* A negative antinuclear antibody test makes the diagnosis of scleroderma very unlikely.
* The degree of skin involvement is highly variable. Many patients with limited scleroderma have only subtle cutaneous findings (eg, mild sclerodactyly).
* The available diagnostic criteria do not include many patients with milder forms of scleroderma.
* Some patients may have overlapping clinical features with other systemic autoimmune rheumatic disorders such as polymyositis/dermatomyositis, Sjögren syndrome, systemic lupus erythematosus, and rheumatoid arthritis.
From Uptodate (On campus access only):
See article entitled "Diagnosis and differential diagnosis of systemic sclerosis (scleroderma) in adults"
For management of renal crisis, see article on "Scleroderma renal crisis"
Most frequent symptoms in (descending order):
Raynaud phenomenon
gastroesophageal reflux with or without dysmotility
skin changes
swollen fingers
arthralgias
Other factors:
* A negative antinuclear antibody test makes the diagnosis of scleroderma very unlikely.
* The degree of skin involvement is highly variable. Many patients with limited scleroderma have only subtle cutaneous findings (eg, mild sclerodactyly).
* The available diagnostic criteria do not include many patients with milder forms of scleroderma.
* Some patients may have overlapping clinical features with other systemic autoimmune rheumatic disorders such as polymyositis/dermatomyositis, Sjögren syndrome, systemic lupus erythematosus, and rheumatoid arthritis.
From Uptodate (On campus access only):
See article entitled "Diagnosis and differential diagnosis of systemic sclerosis (scleroderma) in adults"
For management of renal crisis, see article on "Scleroderma renal crisis"
7/10/08
Is aspirin effective for prevention of CVAs?
Cochrane Library
Aguilar M, Hart R. Antiplatelet therapy for preventing stroke in patients with non-valvular atrial fibrillation and no previous history of stroke or transient ischemic attacks. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD001925. PMID: 16235290
Under Graphics, go to Comparison 01 (Antiplatelet versus control...)
Aguilar M, Hart R. Antiplatelet therapy for preventing stroke in patients with non-valvular atrial fibrillation and no previous history of stroke or transient ischemic attacks. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD001925. PMID: 16235290
Under Graphics, go to Comparison 01 (Antiplatelet versus control...)
7/7/08
Is BNP useful in diagnosing heart failure?
Cochrane Library and EBM Reviews
No completed systematic reviews or meta-analyses
PubMed
1. Maisel AS, et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med. 2002 Jul 18;347(3):161-7.
Objective: "to validate and characterize the use of B-type natriuretic peptide levels in the diagnosis of congestive heart failure in a broad population of patients with dyspnea"
Gold standard: ED physician assessment (blinded to the BNP results); 2 independent cardiologists (also blinded) confirmed clinical dx based on
* Framingham congestive-heart-failure score
* National Health and Nutrition Examination Survey (NHANES) congestive heart failure score
* Other information from the ED (chest x-ray, echo, pt history, etc.)
Population: 1,586 pts (of 1,666 presenting) at 7 sites; seen in ED for dyspnea
Characteristics
Results include ROC curve for various cutoffs of BNP
2. Anwaruddin S, et al. Renal function, congestive heart failure, and amino-terminal pro-brain natriuretic peptide measurement: results from the ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) Study. J Am Coll Cardiol. 2006 Jan 3;47(1):91-7.
Objective: "to examine the interaction between renal function and amino-terminal pro-brain natriuretic peptide (NT-proBNP) levels"
Gold standard: Dx by cardiologist blinded to BNP & NT-proBNP; based on ED & hospital records, diagnostic imaging, lab tests, etc.
Population: 599 pts who presented at the ED of an urban hospital and who met criteria for inclusion
Results: Include ROC curve comparing NT-proBNP concentrations in patients with different GFR measures
No completed systematic reviews or meta-analyses
PubMed
1. Maisel AS, et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med. 2002 Jul 18;347(3):161-7.
Objective: "to validate and characterize the use of B-type natriuretic peptide levels in the diagnosis of congestive heart failure in a broad population of patients with dyspnea"
Gold standard: ED physician assessment (blinded to the BNP results); 2 independent cardiologists (also blinded) confirmed clinical dx based on
* Framingham congestive-heart-failure score
* National Health and Nutrition Examination Survey (NHANES) congestive heart failure score
* Other information from the ED (chest x-ray, echo, pt history, etc.)
Population: 1,586 pts (of 1,666 presenting) at 7 sites; seen in ED for dyspnea
Characteristics
Results include ROC curve for various cutoffs of BNP
2. Anwaruddin S, et al. Renal function, congestive heart failure, and amino-terminal pro-brain natriuretic peptide measurement: results from the ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) Study. J Am Coll Cardiol. 2006 Jan 3;47(1):91-7.
Objective: "to examine the interaction between renal function and amino-terminal pro-brain natriuretic peptide (NT-proBNP) levels"
Gold standard: Dx by cardiologist blinded to BNP & NT-proBNP; based on ED & hospital records, diagnostic imaging, lab tests, etc.
Population: 599 pts who presented at the ED of an urban hospital and who met criteria for inclusion
Results: Include ROC curve comparing NT-proBNP concentrations in patients with different GFR measures
7/1/08
6/27/08
What is the prognosis for primary amyloidosis (AL) and what is the evidence for management?
PROGNOSIS:
Kyle RA, et al. Long-term survival (10 years or more) in 30 patients with primary amyloidosis.
Blood. 1999 Feb 1;93(3):1062-6. PMID: 9920856
Highlights:
Fig. 1 Survival curve for 810 patients with systemic amyloidosis
Table 2 Comparison of patients survival
Br J Haematol. 2004 Jun;125(6):681-700. Guidelines on the diagnosis and management of AL amyloidosis.
Highlights:
These guidelines include prognostic factors at the bottom of p. 686.
THERAPY:
Br J Haematol. 2004 Jun;125(6):681-700. Guidelines on the diagnosis and management of AL amyloidosis.
Recommendations and evidence for chemotherapy and stem cell transplantation, pp. 687-693
Summary of treatment recommendations, pp.693 and following.
Recent trials
Jaccard A, et al. High-dose melphalan versus melphalan plus dexamethasone for AL amyloidosis. N Engl J Med. 2007 Sep 13;357(11):1083-93.
Highlights:
RCT 100 pts in two groups
Fig. 2, Survival curves by hematologic responses and treatment group
Fig. 3, Survival according to risk group and according to treatment group among patients with low-risk disease
Kyle RA, et al. Long-term survival (10 years or more) in 30 patients with primary amyloidosis.
Blood. 1999 Feb 1;93(3):1062-6. PMID: 9920856
Highlights:
Fig. 1 Survival curve for 810 patients with systemic amyloidosis
Table 2 Comparison of patients survival
Br J Haematol. 2004 Jun;125(6):681-700. Guidelines on the diagnosis and management of AL amyloidosis.
Highlights:
These guidelines include prognostic factors at the bottom of p. 686.
THERAPY:
Br J Haematol. 2004 Jun;125(6):681-700. Guidelines on the diagnosis and management of AL amyloidosis.
Recommendations and evidence for chemotherapy and stem cell transplantation, pp. 687-693
Summary of treatment recommendations, pp.693 and following.
Recent trials
Jaccard A, et al. High-dose melphalan versus melphalan plus dexamethasone for AL amyloidosis. N Engl J Med. 2007 Sep 13;357(11):1083-93.
Highlights:
RCT 100 pts in two groups
Fig. 2, Survival curves by hematologic responses and treatment group
Fig. 3, Survival according to risk group and according to treatment group among patients with low-risk disease
6/19/08
Does early endoscopic intervention affect mortality in patients with obstructive gallstones
Here is the link to RCT of 120 patients randomized to receive conservative management or endocscopic procedures within the first 72 hours of presentation.
OrÃa A, et al. Early endoscopic intervention versus early conservative management in patients with acute gallstone pancreatitis and biliopancreatic obstruction: a randomized clinical trial. Ann Surg. 2007 Jan;245(1):10-7.
PubMed Central fulltext
ATTN: Here is the systematic review I identified when I recently reran the search in PubMed clinical queries and changed the term "gall bladder" to "gallstones" in the search box (gallstones AND surgery AND mortality)
Ayub K, Imada R, Slavin J. Endoscopic retrograde cholangiopancreatography in gallstone-associated acute pancreatitis. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD003630.
PMID: 15495060
Search terms are important!
OrÃa A, et al. Early endoscopic intervention versus early conservative management in patients with acute gallstone pancreatitis and biliopancreatic obstruction: a randomized clinical trial. Ann Surg. 2007 Jan;245(1):10-7.
PubMed Central fulltext
ATTN: Here is the systematic review I identified when I recently reran the search in PubMed clinical queries and changed the term "gall bladder" to "gallstones" in the search box (gallstones AND surgery AND mortality)
Ayub K, Imada R, Slavin J. Endoscopic retrograde cholangiopancreatography in gallstone-associated acute pancreatitis. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD003630.
PMID: 15495060
Search terms are important!
6/16/08
What is the PPV of the CA-125 for ovarian malignancy in patients presenting with an ovarian mass?
Benjapibal M, Neungton C. Pre-operative prediction of serum CA125 level in women with ovarian masses. J Med Assoc Thai. 2007 Oct;90(10):1986-91.
PMID: 18041413
Prospective study of 120 women with ovarian masses, gold standard=histopathology, PPV=57.0%
How I found it...
In Pubmed Clinical Query-Diagnosis, Narrow:
CA-125 AND positive predictive value AND cohort studies
PMID: 18041413
Prospective study of 120 women with ovarian masses, gold standard=histopathology, PPV=57.0%
How I found it...
In Pubmed Clinical Query-Diagnosis, Narrow:
CA-125 AND positive predictive value AND cohort studies
6/13/08
What are the diagnostic and management considerations for patients with hyponatremia?
Adrogué HJ, Madias NE. Hyponatremia. N Engl J Med. 2000 May 25;342(21):1581-9.
PMID 10824078
Review of diagnosis and management of hyponatremia in hypovolemic patients.
Douglas I. Hyponatremia: why it matters, how it presents, how we can manage it. Cleve Clin J Med. 2006 Sep;73 Suppl 3:S4-12. PMID: 16970147
Review article that includes an illustration of an algorithm for classifying hyponatremia.
PMID 10824078
Review of diagnosis and management of hyponatremia in hypovolemic patients.
Douglas I. Hyponatremia: why it matters, how it presents, how we can manage it. Cleve Clin J Med. 2006 Sep;73 Suppl 3:S4-12. PMID: 16970147
Review article that includes an illustration of an algorithm for classifying hyponatremia.
6/9/08
For patients with neutopenic fever, how does oral administration of antibiotics compare to IV administration at preventing death?
Vidal L, et al. Oral versus intravenous antibiotic treatment for febrile neutropenia in cancer patients. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD003992.
PMID: 15495074
Systematic review and meta-analysis of studies comparing oral and IV delivery of antibiotics.
From the Pubmed record, use Find it @ Emory to go to the fulltext at Wiley Interscience. At the Wiley site, you'll have to paste the title of the review to pull it up.
Check out the Analyses section of the review to see tables comparing the data related to various clinical outcomes, including mortality.
PMID: 15495074
Systematic review and meta-analysis of studies comparing oral and IV delivery of antibiotics.
From the Pubmed record, use Find it @ Emory to go to the fulltext at Wiley Interscience. At the Wiley site, you'll have to paste the title of the review to pull it up.
Check out the Analyses section of the review to see tables comparing the data related to various clinical outcomes, including mortality.
5/19/08
For patients with heart failure, does omission of 1 or more of the 6 core discharge instructions impact readmission to the hospital?
VanSuch M, et al. Effect of discharge instructions on readmission of hospitalised patients with heart failure: do all of the Joint Commission on Accreditation of Healthcare Organizations heart failure core measures reflect better care? Qual Saf Health Care. 2006;15(6):414-17.
Retrospective study of 1121 randomly selected patients admitted to a hospital for heart failure. See Figures 1 and 2 for data on hospital readmission. See Figure 3 for survival data.
Retrospective study of 1121 randomly selected patients admitted to a hospital for heart failure. See Figures 1 and 2 for data on hospital readmission. See Figure 3 for survival data.
5/16/08
What is the incidence of hepatocellular carcinoma metastasizing to the lungs?
PMID: 10966697
Retrospective study of 403 patients diagnosed with HCC. 148 identified (by CT scans) as having extra-hepatic metastases, with 39% (58) of the first detectable metastases being in the lung and 55% (81) of the patients having metastases to the lung. It was the most common metastatic site.
Retrospective study of 403 patients diagnosed with HCC. 148 identified (by CT scans) as having extra-hepatic metastases, with 39% (58) of the first detectable metastases being in the lung and 55% (81) of the patients having metastases to the lung. It was the most common metastatic site.
5/15/08
How well does the fact that nitroglycerin relieves a patient's chest pain predict coronary artery disease?
These studies indicate that relief of chest pain by nitroglycerin is not a predictor of coronary artery disease.
Study (N): Henrikson; PMID 14678917 (459 pts given nitroglycerin in ED because of chest pain)
Measures: Pain relief by increase/decrease of self-reported pain 5 min. after admin. of nitroglycerin; CAD by elevated serum enzyme levels, coronary angiography demonstrating a 70% or greater stenosis, or a positive exercise test result
Results: nitroglycerin relieved pain of 35% of pts w/CAD and 41% of pts without CAD
Study: Diercks; PMID 15940087 (664 pts given nitroglycerin in ED because of chest pain)
Measures: Pain relief by 11-point numeric descriptive scale for chest pain recorded before & after initial dose ; Cardiac-related pain by discharge diagnosis of myocardial infarction or the diagnosis of coronary artery disease based on a positive diagnostic study
Results: Relief of pain following nitroglycerin administration was not significantly different between the cardiac diagnosis group and the non-cardiac diagnosis group.
Study (N): Henrikson; PMID 14678917 (459 pts given nitroglycerin in ED because of chest pain)
Measures: Pain relief by increase/decrease of self-reported pain 5 min. after admin. of nitroglycerin; CAD by elevated serum enzyme levels, coronary angiography demonstrating a 70% or greater stenosis, or a positive exercise test result
Results: nitroglycerin relieved pain of 35% of pts w/CAD and 41% of pts without CAD
Study: Diercks; PMID 15940087 (664 pts given nitroglycerin in ED because of chest pain)
Measures: Pain relief by 11-point numeric descriptive scale for chest pain recorded before & after initial dose ; Cardiac-related pain by discharge diagnosis of myocardial infarction or the diagnosis of coronary artery disease based on a positive diagnostic study
Results: Relief of pain following nitroglycerin administration was not significantly different between the cardiac diagnosis group and the non-cardiac diagnosis group.
5/14/08
What is the evidence concerning GCSF prophylaxis for cancer patients receiving chemotherapy?
From UptoDate:
2006 guidelines from both the American Society of Clinical Oncology (ASCO) and the European Organization for Research and Treatment of Cancer (EORTC) recommend prophylaxis when "the anticipated incidence of febrile neutropenia is approximately 20 percent or more."
UptoDate recommends GCSF prophylaxis for
-patients who are receiving therapies where there is a likelihood of dose-limiting neutropenia
-certain high-risk patients
-patients receiving radiation therapy involving large fields
For more read "Prophylaxis of infection during chemotherapy-induced neutropenia" in UptoDate (on campus only)
2006 guidelines from both the American Society of Clinical Oncology (ASCO) and the European Organization for Research and Treatment of Cancer (EORTC) recommend prophylaxis when "the anticipated incidence of febrile neutropenia is approximately 20 percent or more."
UptoDate recommends GCSF prophylaxis for
-patients who are receiving therapies where there is a likelihood of dose-limiting neutropenia
-certain high-risk patients
-patients receiving radiation therapy involving large fields
For more read "Prophylaxis of infection during chemotherapy-induced neutropenia" in UptoDate (on campus only)
What is the prognosis for erythema nodosum?
According to "Erythema nodosum" in UptoDate (on campus only) and Current Medical Diagnosis and Treatment 2008, the lesions usually disappear in about 6 weeks, but may recur unless any underlying causes are treated.
What is the incidence of PCP in patients with cancer?
Sepkowitz KA. Opportunistic infections in patients with and patients without Acquired Immunodeficiency Syndrome. Clin Infect Dis. 2002 Apr 15;34(8):1098-107. Epub 2002 Mar 21.
Table 1 summarizes incidence of PCP in cancer patients - data taken from 3 studies
1.3% of patients with solid tumors while receiving glucocorticosteroids
Also, a Cochrane Review, Prophylaxis for Pneumocystis pneumonia (PCP) in non-HIV immunocompromised patients (2007), states that the incidence of PCP in non-HIV patients is increasing, naming cancer patients treated with corticosteroids as one of the at risk groups. (See Background section of the review)
Table 1 summarizes incidence of PCP in cancer patients - data taken from 3 studies
1.3% of patients with solid tumors while receiving glucocorticosteroids
Also, a Cochrane Review, Prophylaxis for Pneumocystis pneumonia (PCP) in non-HIV immunocompromised patients (2007), states that the incidence of PCP in non-HIV patients is increasing, naming cancer patients treated with corticosteroids as one of the at risk groups. (See Background section of the review)
5/12/08
Is rifaximin effective for prophylaxis against spontaneous bacterial peritonitis?
No RCTs identified in Pubmed or EMBASE
How do rifaximin & lactulose compare for hepatic encephalopathy
3 RCTs identified in Pubmed - Rifaximin & lactulose appear to be similar in efficacy
Comparison of rifaximin and lactulose for the treatment of hepatic encephalopathy: a prospective randomized study.
Comparison of rifaximin and lactitol in the treatment of acute hepatic encephalopathy: results of a randomized, double-blind, double-dummy, controlled clinical trial.
Double-blind, double-dummy comparison between treatment with rifaximin and lactulose in patients with medium to severe degree hepatic encephalopathy
Comparison of rifaximin and lactulose for the treatment of hepatic encephalopathy: a prospective randomized study.
Comparison of rifaximin and lactitol in the treatment of acute hepatic encephalopathy: results of a randomized, double-blind, double-dummy, controlled clinical trial.
Double-blind, double-dummy comparison between treatment with rifaximin and lactulose in patients with medium to severe degree hepatic encephalopathy
5/9/08
What is the prognosis for tick-borne diseases common to the southeastern US?
Ehrlichiosis
Bakken JS, Dumler JS. Human granulocytic ehrlichiosis. Clin Infect Dis. 2000 Aug;31(2):554-60. Epub 2000 Sep 14.
Review article puts mortality at <1%; style="color: rgb(204, 0, 0);">
Rocky Mountain spotted fever
Kirkland KB, Wilkinson WE, Sexton DJ. Therapeutic delay and mortality in cases of Rocky Mountain spotted fever. Clin Infect Dis. 1995 May;20(5):1118-21.
Retrospective study of patients at a university hospital with RMSF. Patients who received therapy within 5 days of the onset of symptoms were significantly less likely to die than were those who received treatment after the 5th day of illness (6.5% vs. 22.9%, respectively; P < .03) [from Pubmed abstract]
Tularemia
UptoDate: Overall mortality associated with tularemia is 2 to 4 percent
Bakken JS, Dumler JS. Human granulocytic ehrlichiosis. Clin Infect Dis. 2000 Aug;31(2):554-60. Epub 2000 Sep 14.
Review article puts mortality at <1%; style="color: rgb(204, 0, 0);">
Rocky Mountain spotted fever
Kirkland KB, Wilkinson WE, Sexton DJ. Therapeutic delay and mortality in cases of Rocky Mountain spotted fever. Clin Infect Dis. 1995 May;20(5):1118-21.
Retrospective study of patients at a university hospital with RMSF. Patients who received therapy within 5 days of the onset of symptoms were significantly less likely to die than were those who received treatment after the 5th day of illness (6.5% vs. 22.9%, respectively; P < .03) [from Pubmed abstract]
Tularemia
UptoDate: Overall mortality associated with tularemia is 2 to 4 percent
What is the comparative value of the various tests for cytomegalvirus?
Pubmed search
(cytomegalovirus infection) AND specificity AND (cohort studies OR meta-analysis) AND predictive value
LIMITS: human, English
Ø cohort studies of immunocompetent patients comparing methods
UptoDate
Led to this review article, which summarizes diagnostic methods:
Gandhi MK, Khanna R. Human cytomegalovirus: clinical aspects, immune regulation,and emerging treatments. Lancet Infect Dis. 2004 Dec;4(12):725-38.
(cytomegalovirus infection) AND specificity AND (cohort studies OR meta-analysis) AND predictive value
LIMITS: human, English
Ø cohort studies of immunocompetent patients comparing methods
UptoDate
Led to this review article, which summarizes diagnostic methods:
Gandhi MK, Khanna R. Human cytomegalovirus: clinical aspects, immune regulation,and emerging treatments. Lancet Infect Dis. 2004 Dec;4(12):725-38.
5/5/08
Why is methamphetamine use associated with poor oral health?
Donaldson M, Goodchild JH. Oral health of the methamphetamine abuser.
Am J Health Syst Pharm. 2006 Nov 1;63(21):2078-82. Erratum in: Am J Health Syst
Pharm. 2006 Nov 15;63(22):2180.
This review in the American Journal of Health-System Pharmacy identifies 3 conditions associated with methamphetamine use that can contribute to poor oral health:
1. xerostomia
2. grinding of teeth from drug-induced hyperactivity
3. acids used in manufacturing the methamphetamine
Read more...
Am J Health Syst Pharm. 2006 Nov 1;63(21):2078-82. Erratum in: Am J Health Syst
Pharm. 2006 Nov 15;63(22):2180.
This review in the American Journal of Health-System Pharmacy identifies 3 conditions associated with methamphetamine use that can contribute to poor oral health:
1. xerostomia
2. grinding of teeth from drug-induced hyperactivity
3. acids used in manufacturing the methamphetamine
Read more...
4/23/08
Prognosis for patients with stage III melanoma and use of immunotherapy
Balch CM, et al.
Prognostic factors analysis of 17,600 melanoma patients: validation of the
American Joint Committee on Cancer melanoma staging system.
J Clin Oncol. 2001 Aug 15;19(16):3622-34.
PMID: 11504744
"Factors predicting melanoma-specific survival rates were analyzed using the Cox proportional hazards regression model. Follow-up survival data for 5 years or longer were available for 73% of the patients." (from the abstract). Includes analysis of prognosis for stage III by tumor burden, ulceration, and nodal involvement.
Sasse AD, Sasse EC, Clark LG, Ulloa L, Clark OA.
Chemoimmunotherapy versus chemotherapy for metastatic malignant melanoma.
Cochrane Database Syst Rev. 2007 Jan 24;(1):CD005413. Review.
PMID: 17253556
Sytematic review of 18 (out of 28 identified) studies on the use of chemotherapy v. chemotherapy plus immunotherapy in the treatment of metastatic melanoma.
The Atzpodien and Danson studies were the only ones to include patients with brain metastases.
To see summary of results for each study, go to the Analyses Section. Clicking on the links under Outcome Title for each table will show statistics for each study regarding that outcome.
Prognostic factors analysis of 17,600 melanoma patients: validation of the
American Joint Committee on Cancer melanoma staging system.
J Clin Oncol. 2001 Aug 15;19(16):3622-34.
PMID: 11504744
"Factors predicting melanoma-specific survival rates were analyzed using the Cox proportional hazards regression model. Follow-up survival data for 5 years or longer were available for 73% of the patients." (from the abstract). Includes analysis of prognosis for stage III by tumor burden, ulceration, and nodal involvement.
Sasse AD, Sasse EC, Clark LG, Ulloa L, Clark OA.
Chemoimmunotherapy versus chemotherapy for metastatic malignant melanoma.
Cochrane Database Syst Rev. 2007 Jan 24;(1):CD005413. Review.
PMID: 17253556
Sytematic review of 18 (out of 28 identified) studies on the use of chemotherapy v. chemotherapy plus immunotherapy in the treatment of metastatic melanoma.
The Atzpodien and Danson studies were the only ones to include patients with brain metastases.
To see summary of results for each study, go to the Analyses Section. Clicking on the links under Outcome Title for each table will show statistics for each study regarding that outcome.
4/21/08
Which test for iron deficiency anemia has the most diagnostic value?
Guyatt GH, Patterson C, Ali M, Singer J, Levine M, Turpie I, Meyer R.
Diagnosis of iron-deficiency anemia in the elderly.
Am J Med. 1990 Mar;88(3):205-9.
PMID: 2178409
Prospective study of 259 patients aged 65+ diagnosed with iron deficiency anemia. Two hematologists interpreted the results. Since data was generated from the same cohort of patients, the authors used correction factor in generating the ROC curves. Serum ferritin was shown to be the most valuable test for confirming or negating iron deficiency anemia.
Diagnosis of iron-deficiency anemia in the elderly.
Am J Med. 1990 Mar;88(3):205-9.
PMID: 2178409
Prospective study of 259 patients aged 65+ diagnosed with iron deficiency anemia. Two hematologists interpreted the results. Since data was generated from the same cohort of patients, the authors used correction factor in generating the ROC curves. Serum ferritin was shown to be the most valuable test for confirming or negating iron deficiency anemia.
4/18/08
What is the diagnostic value of various tests for pheochromocytoma?
Summary of selected likelihood ratios & sensitivity/specificity from the 2 studies
Lenders JW, et al. Biochemical diagnosis of pheochromocytoma: which test is best? JAMA. 2002 Mar 20;287(11):1427-34.
PMID: 11903030
Cohort study of patients referred for testing -- 214 confirmed pheochomocytoma & 644 confirmed negative -- Compared plasma free metanephrines, plasma catecholamines, urinary catecholamines, urinary total and fractionated metanephrines, and urinary vanillylmandelic acid.
Unger N, et al. Diagnostic value of various biochemical parameters for the diagnosis of pheochromocytoma in patients with adrenal mass. Eur J Endocrinol. 2006 Mar;154(3):409-17.
PMID: 16498054
Prospective study -- 24 confirmed pheochromocytoma, 68 w/other types of adrenal masses, 16 w/essential hypertension & 42 healthy, normotensive volunteers --Compared plasma and urine epinephrine and norepinephrine levels as well as plasma and urinary metanephrine and normetanephrine levels
Lenders JW, et al. Biochemical diagnosis of pheochromocytoma: which test is best? JAMA. 2002 Mar 20;287(11):1427-34.
PMID: 11903030
Cohort study of patients referred for testing -- 214 confirmed pheochomocytoma & 644 confirmed negative -- Compared plasma free metanephrines, plasma catecholamines, urinary catecholamines, urinary total and fractionated metanephrines, and urinary vanillylmandelic acid.
Unger N, et al. Diagnostic value of various biochemical parameters for the diagnosis of pheochromocytoma in patients with adrenal mass. Eur J Endocrinol. 2006 Mar;154(3):409-17.
PMID: 16498054
Prospective study -- 24 confirmed pheochromocytoma, 68 w/other types of adrenal masses, 16 w/essential hypertension & 42 healthy, normotensive volunteers --Compared plasma and urine epinephrine and norepinephrine levels as well as plasma and urinary metanephrine and normetanephrine levels
4/15/08
Tips for exporting images from Netter Presenter
Netter Presenter is Emory's newest online resource for images. First, you'll have to register
How to access
Download the program
User's Guide The program is not all that user friendly for first time users. Instead of wasting a lot of time trying to figure out how to export an image you have edited, check the user's guide.
How to access
Download the program
User's Guide The program is not all that user friendly for first time users. Instead of wasting a lot of time trying to figure out how to export an image you have edited, check the user's guide.
4/14/08
What is the diagnostic value of the ADAMTS 13 for TTP?
ADAMTS13 activity in thrombotic thrombocytopenic purpura-hemolytic uremic syndrome: relation to presenting features and clinical outcomes in a prospective cohort of 142 patients. Blood. 2003 Jul 1;102(1):60-8. Epub 2003 Mar 13.
PMID: 12637323
Prospective study of 255 patients (w/no family history of TTP or HUS) diagnosed with TTP-HUS in 11 hospitals in one region of the US
PMID: 12637323
Prospective study of 255 patients (w/no family history of TTP or HUS) diagnosed with TTP-HUS in 11 hospitals in one region of the US
What is the sensitivity of the tumor marker CA27.29 for detecting recurrence of breast cancer?
CA 27.29 - Breast Cancer
A search of UptoDate provided a reference to "American Society of Clinical Oncology 2007 Update of Recommendations for the Use of Tumor Markers in Breast Cancer" (PMID: 17954709.)
There is not much in the way of prospective studies on CA27.29, probably because it measures the same antigen as CA15-3 (MUC-1). At any rate, as a result of a systematic review of the literature, the ASCO 2007 Update concludes that although some of the studies show some value of these markers in detecting recurrence, there is no data to show "clinical benefit in terms of disease-free survival, overall survival, quality of life, toxicity, or cost-effectiveness."
Nicolini A, Tartarelli G, Carpi A, et al: Intensive post-operative follow-up of breast cancer patients with tumour markers: CEA, TPA or CA15.3 vs MCA and MCA-CA15.3 vs CEA-TPA-CA15.3 panel in the early detection of distant metastases. BMC Cancer 6:269, 2006.
PMID: 17116247
Follow-up study of 268 breast cancer patients in clinical remission at the beginning of the study.
A search of UptoDate provided a reference to "American Society of Clinical Oncology 2007 Update of Recommendations for the Use of Tumor Markers in Breast Cancer" (PMID: 17954709.)
There is not much in the way of prospective studies on CA27.29, probably because it measures the same antigen as CA15-3 (MUC-1). At any rate, as a result of a systematic review of the literature, the ASCO 2007 Update concludes that although some of the studies show some value of these markers in detecting recurrence, there is no data to show "clinical benefit in terms of disease-free survival, overall survival, quality of life, toxicity, or cost-effectiveness."
Nicolini A, Tartarelli G, Carpi A, et al: Intensive post-operative follow-up of breast cancer patients with tumour markers: CEA, TPA or CA15.3 vs MCA and MCA-CA15.3 vs CEA-TPA-CA15.3 panel in the early detection of distant metastases. BMC Cancer 6:269, 2006.
PMID: 17116247
Follow-up study of 268 breast cancer patients in clinical remission at the beginning of the study.
4/12/08
What is the sensitivity and specificity of electrocardiography findings in diagnosis of pericarditis.
Searched UptoDate, Cochrane Library, EBM Reviews, Pubmed Clinical Queries
Spodick D. Diagnostic electrocardiographic sequences in acute pericarditis. Significance of PR segment and PR vector changes. Circulation. 1973 Sep;48(3):575-80.
Retrospective study, n=50
Surawicz B. Electrocardiogram in pericarditis. Am J Cardiol. 1970 Nov;26(5):471-4.
Retrospective study, n=31
Ginzton LE. The differential diagnosis of acute pericarditis from the normal variant: new electrocardiographic criteria. Circulation. 1982 May;65(5):1004-9.
Retrospective study, n=39 (19 acute pericarditis, 20 normal)
Spodick D. Diagnostic electrocardiographic sequences in acute pericarditis. Significance of PR segment and PR vector changes. Circulation. 1973 Sep;48(3):575-80.
Retrospective study, n=50
Surawicz B. Electrocardiogram in pericarditis. Am J Cardiol. 1970 Nov;26(5):471-4.
Retrospective study, n=31
Ginzton LE. The differential diagnosis of acute pericarditis from the normal variant: new electrocardiographic criteria. Circulation. 1982 May;65(5):1004-9.
Retrospective study, n=39 (19 acute pericarditis, 20 normal)
4/10/08
Diagnostic tools for cirrhosis and hemachromatosis
1. In patients with suspected cirrhosis, which imaging tool is more sensitive and/or specific--CT or MRI?
***Source: Pubmed
Identified two systematic reviews of studies comparing imaging tools - both reviews focused on studies evaluating efficacy in diagnosing hepatocellular carcinoma.
Accuracy of ultrasonography, spiral CT, magnetic resonance, and alpha-fetoprotein in diagnosing hepatocellular carcinoma: a systematic review. Am J Gastroenterol. 2006 Mar;101(3):513-23
Review: MRI is more sensitive but less specific than ultrasonography or spiral CT for diagnosis of hepatocellular carcinoma.ACP J Club. 2006 Jul-Aug;145(1):21.
2. In diagnosing hemachromatosis, how do the various tests (ferritin, % saturation, genetics test) compare in terms of sensitivity and specificity. Is there a gold standard?
***Source: UptoDate - searched hemochromatosis
Clinical Guideline for diagnosing hereditary hemochromatosis - from the American Association for the Study of Liver Diseases. Tavill, AS, Hepatology 2001; 33:1321.
***Source: Pubmed
Study/Review - Type of assessment - Sensitivity - Specifity
Baynes (1988) - UIBC - 77% - 95%
Bryant (2008, pooled data from 11 studies) - genetic - 91.8% - NA
Adams (2006, validation study) - serum ferriten and transerrin saturation - means for both were statistically significantly higher in homozygotes than in other genotypes
Liver biopsy is considered the definitive tool for measuring extent of iron overload; however may not be necessary in all cases as documented in the AASLD guideline cited above.
***Source: Pubmed
Identified two systematic reviews of studies comparing imaging tools - both reviews focused on studies evaluating efficacy in diagnosing hepatocellular carcinoma.
Accuracy of ultrasonography, spiral CT, magnetic resonance, and alpha-fetoprotein in diagnosing hepatocellular carcinoma: a systematic review. Am J Gastroenterol. 2006 Mar;101(3):513-23
Review: MRI is more sensitive but less specific than ultrasonography or spiral CT for diagnosis of hepatocellular carcinoma.ACP J Club. 2006 Jul-Aug;145(1):21.
2. In diagnosing hemachromatosis, how do the various tests (ferritin, % saturation, genetics test) compare in terms of sensitivity and specificity. Is there a gold standard?
***Source: UptoDate - searched hemochromatosis
Clinical Guideline for diagnosing hereditary hemochromatosis - from the American Association for the Study of Liver Diseases. Tavill, AS, Hepatology 2001; 33:1321.
***Source: Pubmed
Study/Review - Type of assessment - Sensitivity - Specifity
Baynes (1988) - UIBC - 77% - 95%
Bryant (2008, pooled data from 11 studies) - genetic - 91.8% - NA
Adams (2006, validation study) - serum ferriten and transerrin saturation - means for both were statistically significantly higher in homozygotes than in other genotypes
Liver biopsy is considered the definitive tool for measuring extent of iron overload; however may not be necessary in all cases as documented in the AASLD guideline cited above.
4/7/08
Whole brain radiation therapy (WBRT) for a patient with breast cancer that has metastasized to the brain
Two questions were generated on this topic:
1. What is the survival rate for breast cancer patients with brain metastases versus breast cancer patients with no metastases?
Source: MD Anderson Manual of Medical Oncology. McGraw-Hill. 2006:Chapter 20.
5-year survival rate for metastatic breast cancer is 23%
versus 70% up to > 90% for local disease w/no evidence of axillary involvement
Source: UpToDate
5-year survival rate for metastatic breast cancer is 5-10%
citing older study (1996)
Source: Pubmed Clinical Query
-----------------------
2. What is the functional and/or survival benefit of treating a patient with breast cancer that has metastasized to the brain with WBRT plus chemotherapy versus treating with only chemotherapy?
1. What is the survival rate for breast cancer patients with brain metastases versus breast cancer patients with no metastases?
Source: MD Anderson Manual of Medical Oncology. McGraw-Hill. 2006:Chapter 20.
5-year survival rate for metastatic breast cancer is 23%
versus 70% up to > 90% for local disease w/no evidence of axillary involvement
Source: UpToDate
5-year survival rate for metastatic breast cancer is 5-10%
citing older study (1996)
Source: Pubmed Clinical Query
-----------------------
2. What is the functional and/or survival benefit of treating a patient with breast cancer that has metastasized to the brain with WBRT plus chemotherapy versus treating with only chemotherapy?
Searched Cochrane, EBM Reviews, Pubmed, Embase
Found a few RCTs comparing efficacy of WBRT+chemotherapy v. chemotherapy only. They are discussed in the Cochrane article below. Most RCTs compared WBRT alone or in combination w/systemic chemotherapy, radiosensitizing agents, or radiosurgery
***Source: Cochrane Library (searched: brain metasta* radi* )
Whole brain radiotherapy for the treatment of multiple brain metastases. Cochrane Database of Systematic Reviews 2006, Issue 3. (Should be able to see fulltext on campus)
Reviews RCTs comparing WBRT either alone or w/other treatments in adults with multiple metastases to the brain from any primary cancer. Some trials measured survival, while others also measured cognitive function and quality of life. Check out Authors' Conclusions and Discussion sections.
***Source: Pubmed Clinical Query (therapy, breast cancer AND brain metast* AND (radia* OR radio*))
Found a few RCTs comparing efficacy of WBRT+chemotherapy v. chemotherapy only. They are discussed in the Cochrane article below. Most RCTs compared WBRT alone or in combination w/systemic chemotherapy, radiosensitizing agents, or radiosurgery
***Source: Cochrane Library (searched: brain metasta* radi* )
Whole brain radiotherapy for the treatment of multiple brain metastases. Cochrane Database of Systematic Reviews 2006, Issue 3. (Should be able to see fulltext on campus)
Reviews RCTs comparing WBRT either alone or w/other treatments in adults with multiple metastases to the brain from any primary cancer. Some trials measured survival, while others also measured cognitive function and quality of life. Check out Authors' Conclusions and Discussion sections.
***Source: Pubmed Clinical Query (therapy, breast cancer AND brain metast* AND (radia* OR radio*))
Improved survival, quality of life, and quality-adjusted survival in breast cancer patients treated with efaproxiral (Efaproxyn) plus whole-brain radiation therapy for brain metastases. (This is further work from authors of earlier RCT reviewed in Cochrane Review above. )
This RCT includes only patients with breast cancer that has metastasized to the brain. One group received WBRT and the other received WBRT plus efaproxiral. It does show a statistically significant improvement in median survival time for the group receiving WBRT+efaproxiral, but the difference in the two measures is less than 5 months. Also, the drug can be very toxic. There is a table of hazard ratios for various subgroups in the article (Table
This RCT includes only patients with breast cancer that has metastasized to the brain. One group received WBRT and the other received WBRT plus efaproxiral. It does show a statistically significant improvement in median survival time for the group receiving WBRT+efaproxiral, but the difference in the two measures is less than 5 months. Also, the drug can be very toxic. There is a table of hazard ratios for various subgroups in the article (Table
This RCT explores differences in response to WBRT based on various prognostic factors. Shows useful criteria to consider in contemplating WBRT.
***Source: EMBASE, no information that was different from above
4/4/08
What is the sensitivity of the straight leg raise test in diagnosing disc problems
From PubMed Clinical Queries:
1. Diagnostic value of history and physical examination in patients suspected of lumbosacral nerve root compression. J Neurol Neurosurg Psychiatry. 2002 May;72(5):630-4
Cross-sectional study of 274 patients with pain radiating into the leg. Analysis showed that the straight leg raise was not predictive.
2. Diagnostic value of history and physical examination in patients suspected of sciatica due to disc herniation: a systematic review. J Neurol. 1999 Oct;246(10):899-906.
Systematic review of 37 studies which found that of the various tests used during the physical examination of lower back pain, the straight leg raise was the only test that was reported consistently to be sensitive. However, the sensitivity values varied greatly and the review identified several types of methodological problems with the studies that probably led to overestimating the sensitivity.
Full results from PubMed Clinical Queries
1. Diagnostic value of history and physical examination in patients suspected of lumbosacral nerve root compression. J Neurol Neurosurg Psychiatry. 2002 May;72(5):630-4
Cross-sectional study of 274 patients with pain radiating into the leg. Analysis showed that the straight leg raise was not predictive.
2. Diagnostic value of history and physical examination in patients suspected of sciatica due to disc herniation: a systematic review. J Neurol. 1999 Oct;246(10):899-906.
Systematic review of 37 studies which found that of the various tests used during the physical examination of lower back pain, the straight leg raise was the only test that was reported consistently to be sensitive. However, the sensitivity values varied greatly and the review identified several types of methodological problems with the studies that probably led to overestimating the sensitivity.
Full results from PubMed Clinical Queries
3/14/08
Quick Access to Clinical Resources
This page is designed to give you quick access to the clinical resources frequently used at the hospital.
1/1/08
What pathological findings are generally associated with bilateral mastectomy?
This summary from cancer.gov cites the one study cited in textbooks and uptodate:
http://www.cancer.gov/cancertopics/pdq/treatment/breast/HealthProfessional/page6
The study...
Fisher ER, Redmond C, Fisher B, et al.: Pathologic findings from the National Surgical Adjuvant Breast and Bowel Projects (NSABP). Prognostic discriminants for 8-year survival for node-negative invasive breast cancer patients. Cancer 65 (9 Suppl): 2121-8, 1990.
PubMed citation
...showed that in a 5-year follow-up of 182 women with LCIS, who received only an excisional biopsy, 8 developed tumors in the ipsilateral breast and 3 developed tumors in the contralateral breast. According to the NCI, one of the current treatment options is bilateral total mastectomy w/out axillary node dissection.
Also, a cursory review of the literature from 20 years ago shows that bilateral mastectomy was identified as the most appropriate treatment for LCIS.
http://www.cancer.gov/cancertopics/pdq/treatment/breast/HealthProfessional/page6
The study...
Fisher ER, Redmond C, Fisher B, et al.: Pathologic findings from the National Surgical Adjuvant Breast and Bowel Projects (NSABP). Prognostic discriminants for 8-year survival for node-negative invasive breast cancer patients. Cancer 65 (9 Suppl): 2121-8, 1990.
PubMed citation
...showed that in a 5-year follow-up of 182 women with LCIS, who received only an excisional biopsy, 8 developed tumors in the ipsilateral breast and 3 developed tumors in the contralateral breast. According to the NCI, one of the current treatment options is bilateral total mastectomy w/out axillary node dissection.
Also, a cursory review of the literature from 20 years ago shows that bilateral mastectomy was identified as the most appropriate treatment for LCIS.
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