CPAP for sleep apnea - BMJ video

BMJ: Sleep apnoea (apnea, in its American spelling) is a condition that causes a patient to stop breathing for short periods during their sleep. In this video researchers Joaquín Durán-Cantolla and Jose María Montserrat discuss their work into the use of CPAP (continuous positive airway pressure) to treat the condition.

People with OSA may be twice as likely to develop a stroke.

Did you know that obstructive sleep apnea (OSA) can reduce a child’s IQ by as many as 10 points, while treatment in children with OSA can improve school grades?

Related:

Mavs Fan at the Finals - Photos - SI.com http://goo.gl/tIdL3

Managing fever of unknown origin in adults - BMJ review

Few clinical problems generate such a wide differential diagnosis as pyrexia (fever) of unknown origin. The initial definition proposed by Petersdorf and Beeson in 1961 was later revised. Essentially the term refers to a prolonged febrile illness without an obvious cause despite reasonable evaluation and diagnostic testing.

Definition

Classic adult fever of unknown origin (FUO) is fever of 38.3°C (101°F) or greater for at least 3 weeks with no identified cause after 3 days of hospital evaluation or 3 outpatient visits

Causes of FUO

Common causes of FUO are infections, neoplasms, and connective tissue disorders.

Investigations almost always include imaging studies. Serological tests may be indicated

Treatment of FUO

Empirical antibiotics are warranted only for individuals who are clinically unstable or neutropenic. In stable patients empirical treatment is discouraged, although NSAIDs may be used after investigations are complete. Empirical corticosteroid therapy is discouraged.

References:

Investigating and managing pyrexia of unknown origin in adults. BMJ 2010; 341:c5470 doi: 10.1136/bmj.c5470 (Published 15 October 2010).

Image source: Wikipedia, public domain.

Oropharyngeal carcinoma increased by 22% in 6 years, related to rise in HPV

Head and neck cancer is the sixth most common cancer. Despite an overall marginal decline in the incidence of most head and neck cancers in recent years, the incidence of oropharyngeal squamous cell carcinoma has increased greatly, especially in the developed world.

In the United States, the incidence of oropharyngeal squamous cell carcinoma increased by 22% between 1999 and 2006.

The increase in incidence of oropharyngeal squamous cell carcinoma seems to be accounted for by a rise in human papillomavirus (HPV) related oropharyngeal carcinoma.

References:

Oropharyngeal carcinoma related to human papillomavirus. BMJ 2010; 340:c1439 doi: 10.1136/bmj.c1439 (Published 25 March 2010).

Image source: HPV types and associated diseases, Wikipedia, public domain.

Twitter comments:

@travispew (Travis Pew): So get your kids the HPV shot.

Investigating easy bruising in a child

From BMJ:

In a child, unusual bruising or bleeding out of proportion to the injury sustained should be investigated.

All children under investigation for easy bruising or a bleeding tendency should have:

- full blood count
- blood film (peripheral smear)
- coagulation screen including a thrombin time, in addition to a Von Willebrand factor assay and assays of factors VIII and IX

This is to ensure that mild forms of haemophilia are excluded even if the activated partial thromboplastin time is normal

In 30% of cases of haemophilia, there is no family history: it arises secondary to new genetic mutations


The coagulation cascade. Black arrow - conversion/activation of factor. Red arrows - action of inhibitors. Blue arrows - reactions catalysed by activated factor. Grey arrow - various functions of thrombin. Image source: Wikipedia

References:
Investigating easy bruising in a child. Anderson and Thomas 341, BMJ.

There are 25,400 scientific journals and their number is increasing by 3.5% a year

More scientific and medical papers are being published now than ever before. Is it possible to be an expert nowadays, asks BMJ.

Every doctor has an ethical duty to keep up to date. Is this just getting more difficult or has it already become impossible? Since Alvin Toffler coined the phrase “information overload” in 1970, the growth of scientific and medical information has been inexorable.

There are now 25 400 journals in science, technology, and medicine, and their number is increasing by 3.5% a year; in 2009, they published 1.5 million articles. PubMed now cites more than 20 million papers.

One response of the medical profession to the increasing scientific basis and clinical capacity of medicine has been to increase subspecialisation. This may restrict the breadth of knowledge of the ultraspecialist, but can such subspecialists still maintain their depth of expertise?

I described my approach in 5 Tips to Stay Up-to-Date with Medical Literature:

1. RSS Feeds for Medical Journals.

2. Podcasts.

3. Persistent Searches on PubMed, Google News and Google.

4. Text-to-speech (TTS) for journal articles.
5. Blogs and Twitter accounts.

If you have a blog or Twitter account, you can try to deal with the information overload from blogs, RSS and Twitter more efficiently by using this:

The circle of online information (click to enlarge).

References:
On the impossibility of being expert. BMJ 2010; 341:c6815 doi: 10.1136/bmj.c6815.

How to deal with the information overload from blogs, RSS and Twitter?

5 Tips to Stay Up-to-Date with Medical Literature

Low risk of transmission of influenza on the plane: 3.5% if sitting within 2 rows of infected passengers

This BMJ study assessed the risk of transmission of pandemic A/H1N1 2009 influenza (pandemic A/H1N1) from an infected high school group to other passengers on an airline flight and the effectiveness of screening and follow-up of exposed passengers.

The design was a retrospective cohort investigation using a questionnaire administered to passengers and laboratory investigation of those with symptoms.

The setting was in Auckland, New Zealand, with national and international follow-up of passengers. The participants were passengers seated in the rear section of a Boeing 747-400 long haul flight that arrived on 25 April 2009, including a group of 24 students and teachers and 97 (out of 102) other passengers in the same section of the plane who agreed to be interviewed.

9 members of the school group were laboratory confirmed cases of pandemic A/H1N1 infection and had symptoms during the flight. Two other passengers developed confirmed pandemic A/H1N1 infection. Their seating was within two rows of infected passengers, implying a risk of infection of about 3.5% for the 57 passengers in those rows.

A low but measurable risk of transmission of pandemic A/H1N1 exists during modern commercial air travel. This risk is concentrated close to infected passengers with symptoms.

Video: "How to Sneeze" Demonstrated by the U.S. Health and Human Services Secretary Kathleen Sebelius. She shows NBC’s Chuck Todd the “Elmo way” to sneeze.

Don't forget to get your influenza immunization (flu shot or spray) this season. The CDC video embedded below clearly explains why this is extremely important.


CDC video: Why Flu Vaccination Matters: Personal Stories from Families Affected by Flu.

References:

Transmission of pandemic A/H1N1 2009 influenza on passenger aircraft: retrospective cohort study. BMJ 2010; 340:c2424 doi: 10.1136/bmj.c2424 (Published 21 May 2010).

Diagram of influenza virus nomenclature. Image source: Wikipedia, GNU Free Documentation License.

Stereotypes in medical photographs

From BMJ:

If you search "medicine" on Google Images, you get a hundred million photographs.

The most common image is a stethoscope. The next is a bottle of pills (or, sometimes, red and black capsules). The next is a surgeon, masked and gowned, slicing skin with a scalpel.

Try "patient" and you will find lots of people in stripy pyjamas, lying obediently in bed, often with a spotty rash or a leg strung up in an orthopaedic hoist.

New images are needed to break the century-old stereotypes in medical photographs.

References:
New images needed: stereotypes in medical photographs. BMJ 2010;340:c1524.

How to identify medical students at risk of subsequent misconduct?

This small BMJ study suggests the following risk factors for subsequent professional misconduct:

- male sex
- lower socioeconomic background
- early academic difficulties at medical school

59 doctors who had graduated from 8 medical schools in the United Kingdom in 1958-97 and had a proved finding of serious professional misconduct in 1999-2004 (cases) and 236 controls (four for each case) were included in the study.

The findings are preliminary and should be interpreted with caution. Most doctors with risk factors will not come before disciplinary panels.

References:

Risk factors at medical school for subsequent professional misconduct: multicentre retrospective case-control study. BMJ 2010; 340:c2040.

Image source: OpenClipArt.org (public domain).

Takotsubo cardiomyopathy (broken-heart syndrome) in differential diagnosis of chest pain

Takotsubo cardiomyopathy (also called stress induced cardiomyopathy, apical ballooning, or broken heart syndrome) was first described in Japan 20 years ago. It is typically precipitated by acute emotional stress, hence the names “stress cardiomyopathy” or “broken-heart syndrome.”

Takotsubo cardiomyopathy is characterised by acute, reversible left ventricular dysfunction in a distribution,which does not correlate with the coronary artery blood supply. The left ventricular dysfunction occurs without obstructive coronary artery disease (CAD) and usually resolves spontaneously over a period of weeks.

The characteristic appearances on contrast angiography include:

- ballooned apical segment

- hypercontractile basal portion of the left ventricle

The appearances are reminiscent of the design of the traditional fishing pot used in Japan to trap octopus, hence the descriptive term "tako-tsubo" cardiomyopathy (octopus trap, tako tsubo). Such a trap, no more than simple ceramic jar, take advantage of the octopus’ preference for small, enclosed spaces and the security they seem to promise. They are simply left on the seabed and gathered later after octopi have had time to occupy them.

Although Takotsubo cardiomyopathy was initially considered rare, it could possibly be responsible for 1-2% of admissions for acute coronary syndrome in industrialised countries.

References:
Takotsubo cardiomyopathy. Banning et al. 340: c1272, BMJ.

Takotsubo Cardiomyopathy, or Broken-Heart Syndrome. SS Virani et al, Tex Heart Inst J. 2007; 34(1): 76–79.

Morikami museum.

Image source: Octopus trap, tako tsubo, Morikami museum.

Approach to evaluation and management of syncope in adults - BMJ Review

Syncope is common in all age groups, and it affects 40% of people during their lifetime, usually described as a "faint" or "blackout".

Neurally mediated syncope, which is benign, is the most common cause

Cardiac syncope as a result of arrhythmias or structural cardiopulmonary disease is more common with increasing age. Cardiac syncope is associated with increased mortality and must be excluded.

Brain imaging, carotid Doppler ultrasound, electroencephalography, and chest radiography are often not needed in patients with syncope.

References:

An approach to the evaluation and management of syncope in adults. BMJ 2010;340:c880.
http://www.bmj.com/cgi/content/short/340/feb19_1/c880

Image source: Illustration of the human brain and skull. Wikipedia, Patrick J. Lynch, medical illustrator, Creative Commons Attribution 2.5 License 2006.

The false idea that only the “top journals” publish the important stuff

From the former Editor-in-Chief of BMJ:

The naïve concept that the “top journals” publish the important stuff and the lesser journals the unimportant is simply false. People who do systematic reviews know this well. Anybody reading only the “top journals” receives a distorted view of the world. Unfortunately many people, including most journalists, do pay most attention to the “top journals.”

References:

Richard Smith: Scrap peer review and beware of “top journals”. BMJ Blogs.

Comments from Google Buzz (March 22, 2010):

Heidi Allen - Love the fact that the BMJ have put out so bold a statement

Neil Mehta - Very provocative. Agree that Peer review is mostly a joke and a lottery. Unfortunately we still live in a world of publish or perish. We need to have something like a YouTube of papers. As more people read these and rate them, the cream will rise to the top. The raters should also be rated and that should also count towards academic promotion.

Lakshman Swamy - Neil-- I agree, but it should be a closed system. Anyone can read, but not anyone can rate-- have to have credentials of some sort. Can't risk creating another place for opinions to become stronger than data.

Ves Dimov, M.D. - On a more basic level, this is also a simple appeal to all physicians to read more than the top 5 journals. Wait... Most physician don't even read the top 5 journals.. :)

Social networks help in some way though - I tend to have a closer look at articles linked by the people I follow.

Vamsi Balakrishnan - @Neil Mehta A friend and myself actually shared that same idea about science, about publishing and its current state. We had a grandiose goal of starting a publishing site that would be more about sharing ideas than anything else (www.sciencetrader.com/).

When I think about publishing in famous journals being important, I think about the famous "cloner" who published in Nature (http://en.wikipedia.org/wiki/Hwang_Woo-Suk); if peer-review was successful, I doubt that he'd have been published his fabricated data. But, once you're successful and thus renowned, no one would have the courage to question you.

Kind of a similar situation is found with Einstein back in the day. When he was working on TOE (theory of everything; a unified grand scheme for how the universe works) he denied the possibility that quantum mechanics could rule the microcosm simply because of his belief that regardless of the evidence, "God does not play dice with the universe" (or something close to that). The macrocosm followed his rules exactly as he predicted, so the microcosm should do the same. No one questioned him since...it's Einstein. He's probably right. (He wasn't); I think Dr. Feynman said in his book (Surely You're Joking Dr. Feynman) it took another ~10 years before Einstein admitted he might be wrong...

Anyway, I diverge.

A last example that's more healthcare-related would be the scientist who developed valproic acid as a treatment for seizures. This scientist, Eymarde, made 30-40 drugs...every drug he made was GOLD, meaning they ALL worked. No one had as much success as he did in creating seizure medications. He could have said anything he wanted about seizures medications since he was the expert, and it was taken as the truth. Unlike most scientists out there though, he knew he was willing to admit that he's not perfect and that no one could make this many drugs work so well. So, he developed controlled studies...testing every component of the medication, only to find that the vector he used to dissolve his "drugs" in was the actual active component with anti-convulsive properties. A modern scientist...would not do anything. Publish or perish. If you just retracted every paper you've written for the last x amount of years...it'd be pretty hard to get future funding, even if you were being honest. This Eymarde did however respect his trade and his peers, so he retracted every one of his papers. After this bit of honest science, he was forgotten to the world and ridiculed.

In a completely circuitous way through three different example, I'm trying to say that I agree with you that peer review, and generally the scientific process now due to peer review is broken. Changes are needed.

Neil Mehta - Vamsi,
thanks for those examples. I was not familiar with the Einstein or the Eymarde examples - I want to publish my case series that suggests famous scientists with last names starting with E tend to make errors that they own up to several years later. Do you think that I should submit to top tier journals? Suggest Vamsi for peer review? Just kidding. Enjoyed reading your comments.
Look forward to more conversations

Vamsi Balakrishnan - Oh, wow, I didn't even notice the common endings. I went searching for a third "E" named person...but couldn't find one that is...on par with the Woo-Suk one.

If I write a book, it's going to be a collection of stories about famous scientists and the things that they...endured and the follies they've made.

It will be entitles, "Famous Scientists: The Things They Endured, and the Follies They've Made."

Aidan Finley - http://www.nature.com/nature/history/timeline_1950s.html The Krebs Cycle paper was rejected by Nature for not being impactful.

http://www2.uah.es/jmc/ai56.pdf (article reviewing other major rejected discoveries, including the MRI). Nature editorial: http://www2.uah.es/jmc/

Ves Dimov, M.D. - "The Krebs Cycle paper was rejected by Nature for not being impactful."

Isn't this just amazing? Reality is truly stranger than fiction.... :)

Aidan Finley - To be fair, I think everyone recognizes it was a mistake.

Related reading:

Nature rejected/declined Krebs cycle paper in 1937 - there were too many submissions - but few remember them now... http://goo.gl/mcxPd

The grossest failures of peer review (PDF) http://goo.gl/3ovkn

Image source: 2009 cover of the journal BMJ, low resolution, fair use.

Video: Why submit your research to the BMJ?

The BMJ has produced a short video to help you find out about getting research published there. It includes interviews with published authors and clips from some of the short films that accompany important research articles.