Journal Club

Impact of harmonic imaging on transthoracic echocardiographic identification of infective endocarditis and its complications
Chirillo F, Pedrocco A, De Leo A, Bruni A, Totis O, Meneghetti P, Stritoni P

OBJECTIVE: To evaluate the comparative diagnostic value of harmonic imaging (HI) in the assessment of patients with suspected infective endocarditis (IE).
SETTING: Tertiary referral centre.
DESIGN: 139 consecutive patients were evaluated with three imaging modalities: transthoracic echocardiography with fundamental imaging (FI); HI; and transoesophageal echocardiography (TOE). Image quality was assessed for each modality by semiquantitative scoring (0, poor, to 3, excellent). Presence, dimension, and characteristics of vegetations were assessed separately for each imaging modality, as well as presence of abscesses.
RESULTS: 35 patients had definite IE. TOE was positive in 33 patients, HI in 28, and FI in 12 (p < 0.001 for FI v HI and v TOE). Mean image quality was 1.4 (0.7) for FI, 2.1 (0.6) for HI (p < 0.01 v FI), and 2.6 (0.4) for TOE (p < 0.001 v HI). The association between FI and TOE findings was Phi = 0.35 (chi2 = 17.57, p = 0.0014) and between HI and TOE it was Phi = 0.95 (chi2 = 125.72, p < 0.0001; p < 0.0001 v FI). The global echo score of vegetations was 7.1 (3.3) with FI, 8.5 (3.4) with HI, and 11.3 (3.9) with TOE (p < 0.001 v HI). Compared with TOE, FI identified only one of seven abscesses (sensitivity 14%) and HI identified two of seven abscesses (sensitivity 28%).
CONCLUSIONS: HI provides an accurate assessment of suspected IE. TOE achieves superior definition of IE related abnormalities.

Heart. 2005 Mar;91(3):329-33.

Problem with our medical education system

One of the problems that we face as medical students is difficult working environment and autocratic seniors, the problem here is that the only method that we know of teaching medical students is this and this hinders the overall development of a medical student/resident.

Three unfortunate outcomes are:

Physicians who go into teaching turn around and use the same tactics that were modeled to them because those are the only tactics they know. This is self perpetuating.

Even worse, some physicians use these tactics with great gusto because for a moment, they have the opportunity to feel powerful superior to the student by humiliating him in front of his peers, staff and even patients.

Physicians complete their education trained to keep a low profile and go into self-protection mode when challenged. In my opinion, this is one of the root causes for the great shortage we have in the number of physicians willing to step up to the challenge of leading the change we so desperately need in healthcare.

Do u agree? Read the following post, its really good...
Still Pimping...

Medical News

Federal agency adds x-rays to carcinogen warning list

Ionizing radiation has been listed for the first time as a known human carcinogen in a report prepared by the National Toxicology Program, an interagency group coordinated by the U.S. Department of Health and Human Services. The report has been published every two years for more than two decades.
According to the "Report on Carcinogens, Eleventh Edition" released on Jan. 28, studies show that exposure to x-rays and gamma rays causes many types of cancer. Childhood exposure is linked to an increased risk for leukemia and thyroid cancer, while exposure during reproductive years increases the risk for breast cancer. Exposure later in life increases risk for lung cancer.
The report cites evidence that exposure to ionizing radiation is linked to cancer of the salivary glands, stomach, colon, bladder, ovaries, central nervous system, and skin.
The American College of Radiology will petition the NTP to have ionizing radiation removed from the list. The ACR fears that patients will be inappropriately alarmed.

The U.S. National Toxicology Program has added ionizing radiation to its list of known carcinogens. Do you believe this step will deter patients from getting needed x-ray and CT exams, or that it is a legitimate warning against overuse of radiological procedures?

From-
www.diagnosticimaging.com

Jounal Club

CT virtual endoscopy of the stomach: comparison study with gastric fiberscopy.
Inamoto K, Kouzai K, Ueeda T, Marukawa T.

BACKGROUND: We evaluated the value of computed tomographic (CT) gastric virtual endoscopy (VE) by comparing it with real gastric fiberscopy (GF).
METHODS: Sixty-six VE findings in 63 patients were compared with lesions found with GF. After a GF examination, the examinees were given bubble-making granules for the stomach and placed in a supine position on the CT table. Abdominal CT slices of 1 mm thickness were obtained by multidetector row CT (Siemens Sensation 16) and reconstructed to VE images with volume and surface rendering on the same day.
RESULTS: VE images were successful in showing subtle alterations in the gastric mucosal folds. Gastric cancer, polyps, ulcers, erosions, and gastritis were clearly visualized. Comparison studies between VE and GF (as the gold standard) showed a sensitivity of 92.7% and a specificity of 90.9%. Original CT images were also useful in detecting lesions in other abdominal organs such as the liver, adrenal gland, and kidney.
CONCLUSION: Because VE is a good noninvasive screening method, except for minimal radiation exposure, it is expected to become a new technique for stomach examinations.

Abdom Imaging. 2005 Feb 1; [Epub ahead of print]

Grand Rounds XXI

This weeks' Grand Rounds marks the 21st in the weekly roundup of the best posts of the medical blogosphere. This is the first time that the grandrounds have come toIndia. It was a great and a wonderful experience. I would like to thank all the contributors for their wonderful posts; it was an enlightening experience going through them.

THE MEDICAL DETECTIVE (THE EDITOR'S CHOICE)

Two days ago a slender middle-aged man walked into a local emergency room, complaining of neck pain after taking a spill in his brother's front yard. X-rays of the cervical spine were unremarkable, and the patient was discharged with a standard information sheet for home care of a neck sprain and told to follow-up with his primary care physician. What follows in This Case of the Strange Sprain from The Cheerful Oncologist is a surprise. Sometimes the secrets to a successful outcome in medicine, like clues hidden around the old dark mansion on the night of the crime, require the protagonist to play dual roles - that of doctor and detective.

THE MEDICAL RESEARCH CORNER

This one is for those interested in Genetics-There are basically two kinds of DNA. The DNA everybody knows about, that determines your hair color and skin color is “nuclear DNA.” This is the type of DNA responsible for the inheritance patterns discovered by Mendel. The other kind is called “mitochondrial DNA.” It is inherited completely from the mother, while the Nuclear DNA comes half from each parent.Now the question arises in Cloning while all of the nuclear DNA came from the “nucleus donor” being cloned, the mitochondrial DNA came from the egg cell donor, not the individual being cloned. Could this mismatch cause some trouble?

Now this is interesting-Body-clock dilemma: "My boyfriend is a morning person -- and I'm definitely not." Reset solutions You want to dance till dawn; he can't keep his eyelids open past 9 p.m. You're grumpy in the morning, while he's whistling a tune. Owl-lark couples can have a tough time with everything from socializing to sex, simply because their sleep-wake cycles aren't in harmony. Couples can take steps to work with their mismatched biology. Read on here is Everything You Always Wanted To Know About Sleep (But Were Too Afraid To Ask).

Combining a laboratory research career with a clinical career has always been difficult, but these days it's become a Herculean challenge. This is what is revealed in this post by Orac how difficult it is wear two hats; to be a surgeon and a scientist.

MEDICAL STUDENT'S CORNER

Mad House Madman-This week has a series on Medical student debt. Data compiled over the last twenty years concerning medical education and the debt burden of medical students reveal a troubling trend. For one, the average student debt is rising faster than the consumer price index (CPI) and parallels the rise in medical student tuition which is rising considerably faster than the CPI. This alarming rise in the cost of medical education has lead to a decreasing desire to pursue medicine as a career which in turn would only decelerate the advancement of new treatments and a better future.

A case of histiocytosis-X was presented at Grand Rounds in the University of Michigan (with a vain comment..It certainly is very fortunate that this young lady came to the University of Michigan, where she could get the correct diagnosis, and treatment could be instituted promptly...). At Grand Rounds, nobody told the real story, what was the real story behind this diagnosis?

One would think that having made it to medical school, we would all have enough common sense to act properly and with respect. Sadly, that's not quite the case. Then, the real question is, what role should a medical school have in legislating its students' behavior? A great discussion on Professionalism in Medical Education by Mudfud.

THE PARAMEDICS CORNER

This week from Far From Perfect the paramedic tells us why is he into the job he is, because by doing this job he makes a difference. Isn't this true in as way for all of us!!

THE PATIENT'S CORNER

DrTony who works in a large community hospital Emergency Center just outside Chattanooga, TN, and reviews medical records for disability claims at a nation-wide disability insurer, also serves as a Deputy Sheriff on the SWAT team for a local county, as the medical asset tells us about what is the right way to report a patients disability. And in the end leaves us with with some very useful recommendations to consider before writing any disability report,

THOUGHT PROVOKING CORNER

Dr. Charles brings to us a very insightful post about the relationship between physicians and priests. It brings to mind the differences between those who sought to heal the body and those who seek to treat the soul.

If you are or have ever been a medic, you will at some point become that most feared and disliked item, a medical relative. you will know what I am talking about when you read the whole story. A must read!

THE HEALTH CARE SERVICES' CORNER

This week from The Hospice Blog-An editorial on the fact that the difference between good and bad hospice care has nothing to do with the IRS status of a company. There are good profit and good non-profit hospices, and it's time for non-profit hospices to admit that fact.

Considerable media attention has been paid to a recent study demonstrating a strong link between bankruptcy and medical illness. The media headlines trumpeted one conclusion of the study: that 55% of bankruptcies were related to medical illness or expenses. But should the health care costs alone shoulder the responsibility of over half of all bankruptcies?

Grunt Doc talks of Lifelong Learning and Self Assessment (LLSA) which is the newest certification requirement from American Board of Emergency Medicine.

THE DIAGNOSTIC IMAGING CORNER

Are you a more than 65-year-old and are a smoker? The U.S. Preventive Services Task Force (part of AHRQ) now 'recommends one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65 to 75 who have ever smoked.'

THE DRUG CORNER

Catallarchy-This week covers the controversy regarding Medicare’s decision to cover drugs for erectile dysfunction. What is your opinion on this one??

In JournalClub there is discussion on ximelagatran, an oral thrombin inhibitor whose anticoagulant effect is not significantly influenced by diet, body-weight and drug interactions. A drug that can be given at a fixed dose without monitoring anticoagulant effect. But is hepatotoxicity of this drug a limitation?

Saint Nate talks about the possiblity offered by desmoteplase as a new stroke treatment, especially since it appears to have advantages over tPA, and how health reporters often wrongly presume (just for the novelty value of it) how it's made from something similar to bat saliva despite the fact it's a genetically engineered version of the active agent in bat drool.

From Kevin,MD this week we have a post on discussion on the price of Prilosec.

Thanks to Nick of Blogborygmi for starting the concept of Grand rounds, and check out the Archives.

Next weeks Grandrounds would be held on Catallarchy, so you can send your posts for inclusion to him.And keep Blogging. Happy Valentine's Day to all!! Hope i did a good job!!

Medical grand rounds on 15-2-05 on my site!!

Medical grandrounds will be posted on Sumer's Radiology Site on 15-2-2005 early morning. All medbloggers are invited to post their post at-sumerdoc-at-yahoo-dot-com...

All are cordially invited to this Carnival of the best in medical blogs!!

MAIL HERE

URINARY CALCULI- A NEW APPROACH??

Combined magnetic resonance urography and targeted helical CT in patients with renal colic: a new approach to reduce delivered dose.

Blandino A, Minutoli F, Scribano E, Vinci S, Magno C, Pergolizzi S, Settineri N, Pandolfo I, Gaeta M.Department of Radiologic Sciences, University of Messina, Policlinico G. Martino, Contrada Gazzi, Messina 98125, Italy.



PURPOSE: To determine whether magnetic resonance urography (MRU), obtained before helical computed tomography (CT) in patients with acute renal colic, can help delimit the obstructed area to be subsequently examined by a targeted CT scan, thus reducing the dose of radiation.

MATERIALS AND METHODS: Patients (51) with symptoms of acute renal colic underwent MRU and a total urinary tract helical CT. CT images from the 5 cm below the level of ureteral obstruction as demonstrated by MRU were selected out. Combined interpretation of MRU and selected CT images constituted protocol A. Protocol B consisted of the entire unenhanced helical CT of the urinary tract. The two protocols were compared regarding the following points: 1) sensitivity in diagnosing the presence of obstructing urinary stones, and 2) the delivered radiation dose.

RESULTS: Protocol A and protocol B had, respectively, 98% and 100% sensitivity in demonstrating ureteral stone as a cause of renal colic. Estimated average dose calculated from phantom study was 0.52 mSv for protocol A and 2.83 mSv for protocol B. Therefore, the effective radiation dose was 5.4 times lower in protocol A compared to protocol B.

CONCLUSION: Combined MRU and short helical CT has a high sensitivity in detecting ureteral calculi with a reduced radiation dose.



J Magn Reson Imaging. 2004 Aug;20(2):264-71.

what do you have to say about this fellows??

AIIMS doctor attempts suicide



From-The Times of India

http://timesofindia.indiatimes.com/articleshow/1008169.cms



A 37-year-old neurosurgeon at the prestigious AIIMS attempted suicide in his hostel bathroom by slashing his wrists. He was found soon thereafter by his colleagues who rushed him to the hospital's casualty section.

According to doctors attending to the neurosurgeon, his condition is critical. A spokesperson, however, said that his blood pressure became normal after resuscitation.

The doctor in question is a senior resident with the neurosurgery department at the hospital and had joined about seven months back. He has an Army background. He is married and has two children, one of whom is a five-year-old son.

He had reportedly attempted to commit suicide about 6 pm. "He was immediately resuscitated and has now been shifted to the cardiothoracic vascular (CTVS) department," said a doctor at the casualty.

Interestingly, Dr Rachit Gupta, 29, an M Ch student in the same department, had committed suicide on July 16, 2004 by injecting himself with a muscle relaxant. His diaries had revealed that besides a considerable work, he was also feeling "pressured" by senior faculty members.

Following reports of workplace harassment, a four-member internal inquiry committee had been set up to look into the circumstances that led to his suicide. "Not a single hearing has been held by this committee, nor any person from the RDA involved in it," said Dr Amrish Kamboj, president of the Residents' Doctor Association (RDA) here. "We will not take this lying down. We have called a meeting tomorrow and further caution will be taken," said RDA general secretary Dr Dev Kant.

On Tuesday, however, no suicide note was recovered from the victim's room. He was on duty at the neurosurgery department on Tuesday morning and according to doctors at the ward, made the rounds normally. Fellow doctors in the ward said he was usually "very cool". A doctor did point out that "he is not very talkative and made friends selectively. He is very competitive. But this has come as quite a shock to us."

While no one quite knows what the exact reason for this attempt may have been, speculation is rife. "He was from the Army, so he may have been feeling a bit strange here. Also, it all depends upon your seniors -- whether they give you enough surgeries to conduct, if any," said a post-graduate student.



Sumer Sethi says-this is a second incidence in a year that a doctor from the same dept in aiims has attempted suicide..although this is the main issue lets approach this issue more from the core of the problem.. resident doctors have inhuman work hours, most of the resident doctors all over the city dont get a post duty off after a gruelling 24 hr duty.. usual attitude of the management in various hospitals in the city is pathetic.. beyond that the process to become a doctor is very long it takes around 12-15 years for a doctor to complete superspecialization and during the period of residency he is subjected to gruelling work, inhuman work hours and often autocratic behaviour by the seniors.. also the number of residents in any institution is less than the total reqd so most of the resident doctors end up working day in and day out...



any comments???

Journal Club

Effect of the introduction of helical CT on radiation dose in the investigation of pulmonary embolism.



O'neill J, Murchison JT, Wright L, Williams J.



The aim of this study was to assess the change in patient radiation dose in the radiological investigation of pulmonary embolism since the introduction of helical CT pulmonary angiography (CTPA) in a large teaching hospital. All radiological investigations performed as an integral part of the imaging protocol in the investigation of clinically suspected pulmonary embolism (PE) were retrospectively reviewed. The protocol for the investigation of PE changed in our institution after the introduction of CTPA. Protocols 1 and 2 were the protocols in place before and after the introduction of CTPA, respectively. An in-depth evaluation was made of the imaging records and radiation dose for 30 consecutive patients investigated for clinically suspected PE in 1995 (protocol 1) and 2002 (protocol 2). Radiation doses were then extrapolated for the total number of patients investigated in each year. The number of radiological investigations performed per patient decreased from a mean of 1.17 in protocol 1 to 1.06 in protocol 2. There was a 44% increase in the total number of patients investigated. The effective dose per patient increased from 1.30 mSv to 1.35 mSv with the introduction of CTPA into the imaging protocol, an increase of only 4%. First line investigations showed a significant decrease in indeterminate examinations from 25.7% to 8.5%. Two different imaging protocols are reviewed with respect to type and number of procedures required for the investigation of PE and the resulting patient effective dose incurred. Results demonstrate an increase in the number of patients being investigated for suspected PE and a small increase in effective dose per patient since the introduction of helical CTPA. Although CTPA in itself incurs a higher effective dose, this is offset by the significant decrease in the number of non-diagnostic and total number of investigations per patient. In addition the ventilation component of lung scintigraphy was not required in protocol 2, thus reducing the dose further. We believe this small increase in effective dose is justified by the decrease in non-diagnostic studies and the reduction in total number of investigations per patient. We hope this paper will serve as a stimulus for the radiology community to examine current protocols in all areas of diagnostic imaging. We stress the importance of assessing new and established imaging investigative protocols to maximize the benefit and reduce any risk to patients.



Br J Radiol. 2005 Jan;78(925):46-50.

Both lung fields show multiple small nodular lesions the classical miliary appearance, a case of miliary tuberculosis.
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