Annals of Internal Medicine 2015

Treatment


1. Sandhu AT, Dudley RA, Kazi DS. A Cost Analysis of the American Board of Internal Medicine's Maintenance-of-Certification Program. Ann Intern Med. 2015 Sep 15;163(6):401-8. doi: 10.7326/M15-1011.

CONCLUSION: The ABIM MOC program will generate considerable costs, predominantly due to demands on physician time. A rigorous evaluation of its effect on clinical and economic outcomes is warranted to balance potential gains in health care quality and efficiency against the high costs identified in this study. PMID: 26216046

Comments: I am board certified in Internal Medicine, Pediatrics, and Emergency Medicine.  The time it takes to study for these is enormous.  Also, the direct cost is > $2400 each!  And this has occurred at a time where my institution has removed CME funding for such expenses.  Since I am faculty for all three departments, it seems important for job security to maintain all three certifications.  Many share a similar story, even if they have only one board certification.  This study found that a general internist spends almost $24,000 in MOC costs (time and direct) over 10 years.  For many of us, this isn't "funny money" that we can pull from CME funds.  This is cash out of our pockets in time and direct costs.  Is it worth it?  Probably not.  Although I learned a lot studying for IM and Peds recertification 2 years ago, I didn't see much impact on my daily practice from the knowledge gained.  Yes, I can recite colon cancer screening guidelines and what age child can draw a cube, but is this really important?  Certainly the learning for MOC is nothing like the impact curating this website has on my practice and teaching.  For EM, LLSA articles are a mixed bag - some good and some awful.  I guess I could say it is the cost of doing business.  Except the certifying boards have a monopoly and make tons of money on the backs of doctors who must have the board certification to practice.  Small wonder question writing is so expensive when it includes posh flights, hotels, and dinners for question authors.  Is that really necessary in 2015-2016 in the era of instant electronic communication, Skype, and FaceTime?  For now, we are stuck paying whatever they demand.  But just as ABIM backed down when massive numbers of internists put their foot down, maybe other boards will listen to the numbers above and make MOC less onerous on the wallet by reducing time and monetary costs.


2. Siemieniuk RA, Meade MO, Alonso-Coello P et al. Corticosteroid Therapy for Patients Hospitalized With Community-Acquired Pneumonia: A Systematic Review and Meta-analysis. Ann Intern Med. 2015 Oct 6;163(7):519-28. doi: 10.7326/M15-0715.

CONCLUSION: For hospitalized adults with CAP, systemic corticosteroid therapy may reduce mortality by approximately 3%, need for mechanical ventilation by approximately 5%, and hospital stay by approximately 1 day. PMID: 26258555

Comments: Several studies have shown corticosteroids have promise to improve outcome in hospitalized patients with pneumonia.  This SR found that this simple treatment may have an impact on these patients.  I plan to incorporate this into my practice.  There appears to be little down side and many benefits, including possible reduction in mortality (NNT = 36).


3. Raja AS, Greenberg JO, Qaseem A et al for the Clinical Guidelines Committee of the American College of Physicians. Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2015 Nov 3;163(9):701-11. doi: 10.7326/M14-1772. Epub 2015 Sep 29.

Gentle reader, I have included this abstract in its entirety.  It has similarities to the peer reviewed lecture I published in Academic EM. Use password - perls.

DESCRIPTION: Pulmonary embolism (PE) can be a severe disease and is difficult to diagnose, given its nonspecific signs and symptoms. Because of this, testing patients with suspected acute PE has increased dramatically. However, the overuse of some tests, particularly computed tomography (CT) and plasma d-dimer measurement, may not improve care while potentially leading to patient harm and
unnecessary expense.
METHODS: The literature search encompassed studies indexed by MEDLINE (1966-2014; English-language only) and included all clinical trials and meta-analyses on diagnostic strategies, decision rules, laboratory tests, and imaging studies for the diagnosis of PE. This document is not based on a formal systematic review, but instead seeks to provide practical advice based on the best available
evidence and recent guidelines. The target audience for this paper is all clinicians; the target patient population is all adults, both inpatient and outpatient, suspected of having acute PE.
BEST PRACTICE ADVICE 1: Clinicians should use validated clinical prediction rules to estimate pretest probability in patients in whom acute PE is being considered.
BEST PRACTICE ADVICE 2: Clinicians should not obtain d-dimer measurements or imaging studies in patients with a low pretest probability of PE and who meet all Pulmonary Embolism Rule-Out Criteria.
BEST PRACTICE ADVICE 3: Clinicians should obtain a high-sensitivity d-dimer measurement as the initial diagnostic test in patients who have an intermediate pretest probability of PE or in patients with low pretest probability of PE who do not meet all Pulmonary Embolism Rule-Out Criteria. Clinicians should not use imaging studies as the initial test in patients who have a low or intermediate pretest probability of PE.
BEST PRACTICE ADVICE 4: Clinicians should use age-adjusted d-dimer thresholds (age × 10 ng/mL rather than a generic 500 ng/mL) in patients older than 50 years to determine whether imaging is warranted.
BEST PRACTICE ADVICE 5: Clinicians should not obtain any imaging studies in patients with a d-dimer level below the age-adjusted cutoff.
BEST PRACTICE ADVICE 6: Clinicians should obtain imaging with CT pulmonary angiography (CTPA) in patients with high pretest probability of PE. Clinicians should reserve ventilation-perfusion scans for patients who have a contraindication to CTPA or if CTPA is not available. Clinicians should not obtain a d-dimer measurement in patients with a high pretest probability of PE.

PMID: 26414967


4. Pargaonkar VS, Perez MV, Jindal A et al. Long-Term Prognosis of Early Repolarization With J-Wave and QRS Slur Patterns on the Resting Electrocardiogram: A Cohort Study. Ann Intern Med. 2015 Nov 17;163(10):747-55. doi: 10.7326/M15-0598. Epub 2015 Oct 27.

CONCLUSION: J waves and QRS slurs did not exhibit a clinically meaningful increased risk for cardiovascular death in long-term follow-up. PMID: 26501238

Comments: Prior studies have concluded that early repolarization is associated with risk of arrhythmia or sudden cardiac death.  In this study of younger veterans, mostly male, there was no difference in cardiovascular mortality.  They could not say conclusively whether or not CV mortality was arrhythmia related or not.  Here is a picture of what they are referring to in this study cohort.

From Annals of Internal Medicine

From Annals of Internal Medicine

Diagnostic

1. Molloy PJ, Telford SR 3rd, Chowdri HR et al. Borrelia miyamotoi Disease in the Northeastern United States: A Case Series. Ann Intern Med. 2015 Jul 21;163(2):91-8. doi: 10.7326/M15-0333.

CONCLUSION: Patients with BMD presented with nonspecific symptoms, including
fever, headache, chills, myalgia, and arthralgia. Laboratory confirmation of BMD
was possible by PCR on blood from acutely symptomatic patients who were
seronegative at presentation. Borrelia miyamotoi disease may be an emerging
tickborne infection in the northeastern United States. PMID: 26053877

Comments: This tick borne illness presents similarly to others like Rocky Mountain spotted fever, anaplasmosis, and ehrlichiosis.  Cardinal features of illness for most patients included: "high fever, chills, marked headache, and myalgia or arthralgia. Twenty-four percent were hospitalized. Elevated liver enzyme levels, neutropenia, and thrombocytopenia were common."  If someone shows up with this constellation of symptoms, I don't really care nor can I know if it is a new esoteric form of Borrelia.  This patient will leave with a course of doxycycline.  In the case series, patients responded to doxycycline, amoxicillin, or ceftriaxone.

Review

1. Badhiwala JH, Lai CK, Alhazzani W et al. Cervical spine clearance in obtunded patients after blunt traumatic injury: a systematic review. Ann Intern Med. 2015 Mar 17;162(6):429-37. doi: 10.7326/M14-2351.

CONCLUSION: Cervical spine clearance in obtunded adults after blunt traumatic injury with negative results from a well-interpreted, high-quality CT scan is probably a safe and efficient practice. PMID: 25775316

Comments: A similar systematic review was conducted in Journal of Trauma and Acute Care Surgery this year by the EAST group and had similar findings.  This is a strange study to find in an Internal Medicine journal.  The highest quality prospective studies found that no patients with high quality c-spine CT had missed injuries.  This was a group of patients who were obtunded, so they will be admitted from the ED.  But it calls into question if it is necessary to keep awake and alert patients in a collar who have persistent midline c-spine tenderness.  This study was not designed to answer this question, so we will have to wait on the answer.

Clinical Prediction Rules

None