There was an interesting article about rapid assessment of chest pain in the ER. If a process like this was implemented there is a potential to avoid unnecessary observations / stress testing. I'll include a link to the Journal Watch Summary and will also include a link to the Journal of the American College of Cardiology. This may be something to bring to the ER doctors' attentions.

http://emergency-medicine.jwatch.org/cgi/content/full/2012/629/1?q=pfw-featured

http://content.onlinejacc.org/article.aspx?volume=59&issueno=23&page=2091

The First Journal Topic: Anticoagulation

I wanted to mention a podcast I thought was particularly interesting.  It was the ACP pocast from 4/5/11 on anticoagulation.  It is referencing the heme/onc update published in that issue - but the podcast actually has quite a bit more information.  It is a conversation with Mark Crowther - one of the editors of that update. I did print the update itself and will leave it in the call room.

Use this link to the Annals Podcast page: ACP podcast on anticoagulation, April 5, 2011.

You can scroll down and listen to the April 5, 2011 podcast on your internet browser. You can also save the podcast to your computer from that page. 

He discusses the new agents coming out and does reference a few recent studies. He also mentions a few cautions about the new agents I think are worth repeating as we have started seeing dabigatran used here.  

    -  the obvious caution that these are new agents and don't have the years of experience behind them that we have with heparin and coumadin.

     -  the newer agents are renally excreted - so in renal failure pts  - coumadin/heparin are still preferred

     -  there are no reversal strategies for these meds - so you can have a catastrophe if there is major bleeding

     -  it is hard to monitor compliance as you aren't monitoring the INR - and if you miss a dose, the effect is gone so to remind people they have to take them as prescribed  - which is an issue when they get to the pharmacy and dabigitran costs $350 . 

     -  the only approved use of dabigitran in the US right now is prevention of CVA in atrial fibrillation

     -  and lastly a reminder from the podcast that dabigatran is degraded with exposure to moisture - so it needs to stay in its original pill bottle with a special lid - shouldn't be moved to a pill box or different pill bottle.

He also quickly reviews recommendtions for prevention and treatment of thrombosis:

     -  He recommends using the ACCP guidelines of course - and there are apparently new guidelines coming out in 2012.

     -  He indicates there has never been anything proven better than heparin 5000 bid for prevention of DVT  - except in a recent study they did  in ICU patients: lovenox was much better overall. The rate of DVT was the same . The rate of PE was much lower with LMWH.

     -  For treatment of DVT - lovenox/coumadin still the best.

     -  For PE - in Canada and the rest of the world - it is apparently standard of care to tx most PE's on an outpatient basis.  He indicates there is good support for this in the literature.  I am wondering about our practice here. We certainly don't send people home from the ER -but with 24 hours of monitoring - if they are stable, I have been more aggressive lately about sending them home.

     -  Lastly - there is an article in the update the supports treating some patients with superficial thrombophlebitis with anticoagulation for 45 days.  See the details about endpoints in that article.

This posting is a bit longer than I would expect many of ours would be.  I would envison just reviewing a single article and offering a little discussion on it.  But - I think basically anything goes (other than information about specific patients of course).  So please respond to the above and looking forward to seeing how this goes!!

An Introduction From Beth Zaiser

Welcome to the MIM blog/ journal club!  I am opening things with somewhat of a general topic and then a mini review of a podcast I think is worth listening to. 

First - I wanted to open a discussion regarding where people obtain their updates

in the latest research and general medical information.  I thought it might be an interesting topic and easy for people to comment on - to get us used to posting.  

Lately I have been enamored of podcasts because I can kill 2 birds with one stone, ie walking the dog and reviewing journals at the same time. The three I subscribe to are the ACP Annals podcast, NEJM and Clinical Conversations. The ACP and NEJM are both basically summaries of the articles published in the most recent issues of those journals. The ACP  podcast also has some update podcasts around the time of the annual meeting. Updates are  also published in the journals - but the podcast discussion adds some extra information.  Clinical Conversations is generated by Journal Watch. They pick a recently published article and discuss it with one of the authors of the study. So it is an in depth discussion of a particular topic - and I find it generally a bit more interesting than just the podcasts that give     a straight synopsis of the recent issue of a journal (the sound quality is sometimes a bit sketchy though).  

In terms of journals - I basically receive the above 2 journals and use the podcast to screen and then look at an article if something sounds particularly relevant. In regards to CME's, I have never been disappointed with the Mayo CME courses - they are extremely well run, they try to keep things pertinent for practicing physicians and their speakers are polished.  I am attending one of theirs in January and hopefully will have some good stuff to post after that.  I haven't been to a UCSF conference in awhile - but I was always impressed with their courses too - it is another institution that has made a business of CME courses and takes it pretty seriously.  I have been to a few American Medical Seminars in Sarasota.  Those courses are a little different in that they have one or two speakers for a whole week. So, for example, 2 reputable heme/onc professors will lecture on heme/onc topics the entire week.  Generally I thought those were good - you aren't getting people as specialized - but still some good general information and you can't beat the location.

I am interested in other podcasts people listen to, Web services or good CME's you have attended...

Welcome to Midwest Internal Medicine

Welcome to Midwest Internal Medicine. More to come.