2010 AHA Guidelines: The ABCs of CPR Rearranged to "CAB"

October 20, 2010 — Chest compressions should be the first step in addressing cardiac arrest. Therefore, the American Heart Association (AHA) now recommends that the A-B-Cs (Airway-Breathing-Compressions) of cardiopulmonary resuscitation (CPR) be changed to C-A-B (Compressions-Airway-Breathing).

The changes were documented in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, published in the November 2 supplemental issue of Circulation: Journal of the American Heart Association, and represent an update to previous guidelines issued in 2005.

"The 2010 AHA Guidelines for CPR and ECC [Emergency Cardiovascular Care] are based on the most current and comprehensive review of resuscitation literature ever published," note the authors in the executive summary. The new research includes information from "356 resuscitation experts from 29 countries who reviewed, analyzed, evaluated, debated, and discussed research and hypotheses through in-person meetings, teleconferences, and online sessions ('webinars') during the 36-month period before the 2010 Consensus Conference."

Mood Food? Depressed People Eat More Chocolate

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May 3, 2010 — A new cross-sectional study suggests individuals with depressive symptoms eat more chocolate, but it does not explain why.

"There is a lot of lore about chocolate and depression and precious little in the way of scientific evidence, which is what motivated us to do this study," Beatrice A. Golomb, MD, PhD, of the Department of Family and Preventive Medicine, University of California, San Diego, told Medscape Psychiatry.

The study, published in the April 26 issue of the Archives of Internal Medicine, included 931 adults not using antidepressants. The mean age of study subjects was 57.6 years and mean body mass index was 27.8 kg/m² or less; 70.1% were male, 80.4% were white, and 58.8% were college educated. Subjects provided information on chocolate consumption (frequency and amount) and completed the Center for Epidemiological Studies-Depression (CES-D) scale.

How Bizarre

Kendra Campbell, MD, Psychiatry/Mental Health, 08:05PM Dec 22, 2010

One of the more intriguing concepts in psychiatry is that of “bizarre delusions.” Delusions are fixed, false belief, and psychiatrists are taught to categorize these delusions as being either bizarre, or non-bizarre, as this can help with diagnosis.

Bizarre delusion is one that is simply 100% impossible. An example of a non-bizarre delusion would be that one is pregnant with President Obama’s child. This is certainly not likely, but it’s not 100% impossible, either. A bizarre delusion would be that one is an alien from another planet and can shoot laser beams out of one’s eyes. Perhaps this is still only 99% impossible. And therein lies the problem with defining a bizarre delusion.

It's All in the Family (History)

When talking with salespersons, you expect each one to push his or her own product. Sometimes it's just hype. But often the opinions seem to reflect a sincere belief in the value of a product or service.

So it's reasonable that geneticists would extol genomic testing as the best way to understand personal health risks and susceptibilities, right? Odd as it may seem, many genetics experts are convinced that, given our current understanding, family health history, not genetic testing, provides the best insight into personal disease risk and possibly even disease prevention.

Pathology Practice Test

1. The cardinal feature of atypical pneumonia secondary to Legionella pneumophila is:

A. clinical presentation incompatible with chest X-ray
B. rust colored sputum
C. stepwise fever pattern
D. hyponatremia
E. bloody diarrhea


2. A 4yo/m develops an infection with Chlamydia trachomatis. How does infection with this organism cause blindness?


A. Cataract formation
B. Hemorrhage into the anterior chamber
C. Hemorrahge into the posterior chamber
D. Retinal detachment
E. Scarring of the cornea

3. Paroxysmal pattern of hacking coughs, accompanied by production of copious amounts of mucus, that end with an inspiratory gasp is the characteristic clinical manifestationof infection with which of the following organism?

A. Haemophilus influenzae
B. Staphylococcus aureus
C. Parainfluenza virus type I
D. Bordetella pertussis
E. Corynebacterium diphtheriae

Self-Starter on Clerkships

Question

Halfway through my third year, I realized that my biggest weakness is that I'm not enough of a self-starter. I am somewhat anxious and shy, and if I'm not asked to do something, I tend to stand around watching. How can I get over my shyness and take initiative without getting in the way or being really obnoxious?

Response from Alisa R. Gutman, MD, PhD Psychiatry Resident, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania

You’ve hit on a common concern for rotating medical students: how to be active and interested without coming off as annoying. Being naturally shy can make it even more challenging to take the initiative.

First, your team knows that medical students have different dispositions. You're not expected to be bubbly if you're reserved or outgoing if you have social anxiety. But one lesson you should learn during your inpatient months is that your home personality should not necessarily match your work personality. Being a professional means knowing how to leave your personal life at home. Likewise, shyness has no place in the hospital as it pertains to interacting with your residents and attendings. To your team, shyness can look like disinterest or even boredom.

2010 New Cardiopulmonary Resuscitation Guidelines

New Food Allergy Guidelines

Dr. Fenton: Hello. My name is Dr. Matthew Fenton. I'm Chief of the Asthma, Allergy, and Inflammation Branch at NIAID. I led the Institute's effort to create clinical guidelines for the diagnosis and management of food allergy.

Here with me today is my colleague Dr. Hugh Sampson, Professor of Pediatrics and Dean for Translational Biomedical Sciences at the Mount Sinai School of Medicine in New York City where he serves as the Director of the Jaffe Food Allergy Institute. Dr. Sampson is past president of AAAAI. Dr. Sampson made the food allergy guidelines one of his presidential initiatives, and he chaired an expert panel writing group and served on the guidelines coordinating committee.

The food allergy guidelines were released in December 2010; with their release how should they now guide clinical practice? That's the topic we're going to discuss today for Medscape Allergy & Clinical Immunology.

Although the exact prevalence of food allergy in the United States is not known, it's estimated that 10-12 million Americans are affected. A number of different diseases with similar symptoms are shared with food allergy, so there is a real potential for overdiagnosis of food allergy. Current increases in the prevalence of food allergy match the increases in prevalence that we see with other allergic diseases such as asthma. Hugh?

Tonsillectomy in Children

Medscape: One of the most relevant recommendations in the guideline for primary care providers is the first statement, which recommends watchful waiting for recurrent throat infections if there have been fewer than 7 episodes in the previous 12 months or fewer than 5 episodes per year in the previous 2 years or fewer than 3 episodes per year in the past 3 years. So bottom line, children should be observed for at least 1 year before a referral to a surgeon to consider tonsillectomy. Is this number of episodes irrespective of the severity of the episodes? Is the intent that these episodes will have all been of sufficient intensity to warrant a visit to a healthcare provider?

Dr. Wald: To put this in perspective, and this is stated clearly in the document, the purpose of the guideline is to avoid unnecessary intervention in children who have recurrent throat infection who are very likely to have a favorable natural history and improve on their own and therefore will be benefited by avoiding surgery. There may be exceptions occasionally on the basis of either very severe or very complicated infections. But in general, I think this is a good outline and the idea is that, yes, these episodes would have been seen by a clinician and the infection would be adequately documented. A lot of this work dates back to a study that was done by Jack Paradise in the late 1970s.^[2] His research used very stringent criteria that described what were termed "counting episodes." A child was considered to have had a counting episode that contributed to the number of episodes if they had, in addition to their sore throat, at least 1 of the following 4 criteria:

• A fever > 38.3° Celsius;
• Cervical adenopathy, which was defined as a lymph node in the neck that measured > 1 cm and was tender;
• Tonsillar exudates; or
• A positive test for group A streptococci.

"Worst Drug in History"

February 2, 2011 — An estimated 10 million patients have used the pain reliever propoxyphene and were sent scrambling to doctors' offices when it was recently pulled from the market. Many physicians are still dealing with the aftermath of the product, first approved by the US Food and Drug Administration (FDA) in 1957.

"Propoxyphene is the worst drug in history," Ulf Jonasson, doctor of public health, from the Nordic School in Gothenburg, Sweden, told Medscape Medical News. The researcher played a role in the decision to stop the pain reliever in the United Kingdom, Sweden, and later in the entire European Union.

"No single drug has ever caused so many deaths," Dr. Jonasson said.

Clinicians are now prescribing analgesic alternatives to propoxyphene.

Propoxyphene was banned in the United Kingdom 5 years ago because of its risk for suicide. It was taken off the market in Europe in 2009 over concerns about fatal overdoses and now in the United States for arrhythmias.

"I agree that propoxyphene is among the worst drugs in history," Eduardo Fraifeld, MD, president of the American Academy of Pain Medicine, said in an interview. "I'm surprised it stayed on the market so long. It's addictive, in my experience not very effective, and toxic."

Surviving Medical School

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Remember when you were a premedical student in college? It seems like a century ago for many of us who have just completed the first year of medical school. It feels that way because our lives have changed dramatically. Normal life seems to have vanished, and suddenly, 24 hours in a day are not enough to get through the enormous volumes of information that we are expected to learn for every exam. It seems virtually impossible. We barely have time to eat or sleep.

Medical school is not the end of the world. Take it from us, 2 students who have been there, when we say that medical school is what you make of it. Do not let medicine define you; instead, you should tailor medicine to your lifestyle. Otherwise, you might become overwhelmed by the demands of your new life and lose the sense of why you chose medicine in the first place.

Studying Tips

"I hate studying," admits Carl Streed Jr., a student at Johns Hopkins University School of Medicine in Baltimore, Maryland. "I don't know how to do it well," he continues. "And apparently it's required in medical school."

Streed lamented his difficulties with studying on The Differential, a popular Medscape blog for medical students. He asked other students how they master the large volume of material that begins to accumulate on the first day of medical school, and he invited them to share their thoughts on the discussion board. Over 220 readers responded.


Many students offered their own secrets to studying. Of course, studying efficiently is partly a matter of getting motivated, as many hinted. There is no single best technique to study: rather, the method you choose will depend on what sort of learner you are, what type of material is presented in class, and how interested you are in the topic. The main challenge is to figure out what works best for you.

That said, you may find some of their specific advice very helpful:

Job Satisfaction in Geriatrics

I am often asked by my patients, medical students, residents, and even my colleagues, "Why did you choose to go into geriatrics?" The answer is not simple. Much like the patients I care for, my reasons for practicing geriatrics are complex and nuanced. They have a great deal to do with my underlying values as a physician. That said, I will do my best to describe why I chose Geriatrics and why medical trainees should consider it as a career path.

The oldest of the US "baby boomers" generation turned 65 on January 1, 2010. Every day for the next 19 years thereafter, another 10,000 baby boomers will turn 65. To put this in perspective, this is the equivalent of a Boeing 747 airplane full of baby boomers turning 65 every hour. By 2030, the country's population of "senior boomers" will double to an estimated 71 million individuals.

Making Most of Surgery Rotations

Question

When rotating on a busy surgical service, how can I be helpful and show that I am interested without getting in the way?

Response from Sarah N. Bernstein, MD Resident, Department of Obstetrics and Gynecology, St. Luke's-Roosevelt Hospital, New York, NY

In the surgical subspecialties, physicians are usually busy from dawn until dusk, and you may find it difficult to find your place and understand the expectations of the rotation. Just remember that your primary goal is to learn and get as much exposure to the subject as possible. If it is not an area of interest, remember that this may be the only time in your career when you observe particular aspects of this area of medicine. Therefore, you should still try to see as much as possible. If you plan to pursue surgery as your specialty, this is your time to learn the basics and show your enthusiasm. I'm sure each teaching hospital is a little different, but here are some general pointers:

Scheduling Your 3rd Year Clerkship

Question

In what order should I schedule my rotations? What are the best strategies?

Response from Megan L. Fix, MD Assistant Professor, Tufts University School of Medicine; Director, Medical Student Education, Maine Medical Center, Portland, Maine

Your third year of medical school can be exciting and also daunting. Many students ask what the "best" schedule is for their third-year clerkships. Although there is no right answer, there are a few guidelines that can be helpful.

The Forsaken Specialty

PhotoCredit: guardian.co.uk

Abstract and Introduction
Introduction

As a medical student I found that most other students thought that psychiatry was not a true profession—the consultants sit and sip tea, talk nonsense, and nobody ever seems to gets better. No blood test confirms what is wrong. No imaging shows the diagnosis. Simply put, ward rounds that consist of sitting in a room and chatting just didn't seem like "real medicine" to most of my peers. Psychiatric patients were people to be mocked, feared ("you were left alone with them?"), or ignored. Revision for objective structured clinical exams and written papers was left to the last minute because it was "only psych."

I don't know why I thought this would be different when I qualified. Perhaps the "doctor" title would equate to being surrounded by those who understand, appreciate, and respect psychiatry? Goes to show that a label does not define how you act.

How Can I Get Enough Sleep During Med School?

Question:

Sometimes I can't sleep, and other times I'm afraid to sleep because of the amount of work that I have to do. How do I fit in quality sleep during medical school?

Response from Graham Walker, MD Resident, Emergency Medicine, St. Luke's-Roosevelt Hospital Center, New York, NY

Sleeping well -- or at least enough -- is a challenge for medical students and even for physicians long after they've finished a grueling residency. If it's not the long hours, it's a late call in the middle of the night or the tossing and turning while you worry about a patient you saw on the previous day. At the same time, not sleeping well sets you up for a rotten next day filled with brain fog and the mistitration of caffeine. One of the most frustrating things is knowing that you need to sleep but feeling wide awake. What are we to do?

OverCompetitive Medical Students

PhotoCredit: medicalschooladmissionrequirements.com

Introduction
Most medical students are well accustomed to competition. During bedside teaching, it's almost inevitable that one keen student will blurt out the answers to questions directed at others. But what happens when friendly competition turns nasty?

WHO Laboratory Manual for the Examination and Processing of Human Semen 5th Edition

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Forensic Medicine

I have recently attended a National Medical Student's Conference in UP Manila and among the top speaker is Dr. Raquel Fortun. She talked about Forensic Medicine and being only one of the two Forensic Pathologists in the country. The topic and the specialty is only emerging as the practice is not formally recognized and institutionalized in the Philippines. I have learned a lot from her and was inspired to share the tidbits and facts about this road less travelled.

PhotoCredit: Wikimedia

Forensic pathology is a sub-specialty of histopathology, and is concerned with the application of pathological principles to the investigation of the medico-legal aspects of death.

Forensic pathologists are medically trained, specialized, qualified doctors who perform autopsies (postmortem examinations) on those who have died suddenly, unexpectedly, or as a result of trauma or poisoning.

The forensic investigation of death is a multi-disciplinary activity, involving the collaboration between pathologists, crime scene investigators (CSIs), forensic scientists, and other specialists, such as anthropologists, entomologists, odontologists (dentists) and many other experts.

Typhoid Fever

Typhoid fever, also known as enteric fever, is a potentially fatal multisystemic illness caused primarily by Salmonella typhi. The protean manifestations of typhoid fever make this disease a true diagnostic challenge. The classic presentation includes fever, malaise, diffuse abdominal pain, and constipation. Untreated, typhoid fever is a grueling illness that may progress to delirium, obtundation, intestinal hemorrhage, bowel perforation, and death within one month of onset. Survivors may be left with long-term or permanent neuropsychiatric complications.

GI Tuberculosis

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Each year, tuberculosis (TB) results in the death of 3 million people globally. In 2000-2020, an estimated 1 billion people will be infected, 200 million people will become sick, and 35 million will die from TB, if control is not strengthened.

Overall, one third of the world's population is infected with the TB bacillus, but not all infected individuals have clinical disease. The bacteria cause the disease when the immune system is weakened, as in older patients and in patients who are HIV positive. The control of TB has been challenging because of the natural history of the disease and the varying pattern in which it manifests in different groups.

Syphilis

Syphilis is an infectious venereal disease caused by the spirocheteTreponema pallidum. Syphilis is transmissible by sexual contact with infectious lesions, from mother to fetus in utero, via blood product transfusion, and occasionally through breaks in the skin that come into contact with infectious lesions. If untreated, it progresses through 4 stages: primary, secondary, latent, and tertiary.

Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease of unknown cause. The hallmark feature of this condition is persistent symmetric polyarthritis (synovitis) that affects the hands and feet, although any joint lined by a synovial membrane may be involved. Extra-articular involvement of organs such as the skin, heart, lungs, and eyes can be significant.

Juvenile Rheumatoid Arthritis

Juvenile rheumatoid arthritis (JRA) is the most common rheumatological disease in children and is one of the most common chronic diseases of childhood. It represents a group of disorders that all share the clinical manifestation of chronic joint inflammation. The etiology is largely unknown, and the genetic component is complex, making clear distinctions between the various subtypes difficult. As a result, various classification criteria are recognized, with different benefits and limitations. A new nomenclature, juvenile idiopathic arthritis (JIA), is increasingly used and is replacing the term juvenile rheumatoid arthritis.

The American College of Rheumatology classifies juvenile rheumatoid arthritis into 3 distinct subtypes: pauciarticular juvenile rheumatoid arthritis, polyarticular juvenile rheumatoid arthritis, and systemic JRA. Other childhood arthritis such as juvenile ankylosing spondylitis and psoriatic arthritis are classified under spondyloarthropathies.

In 1997, the International League of Associations for Rheumatology (ILAR) conducted a consensus conference during which they proposed the nomenclature juvenile idiopathic arthritis. The classification criteria include psoriatic arthritis and enthesitis-related arthritis, which encompasses juvenile ankylosing spondylitis, arthritis associated with inflammatory bowel disease,reactive arthritis, and spondyloarthropathies. This has resulted in some confusion in the literature; when reviewing existing literature, consider whether authors are referring to the juvenile rheumatoid arthritis or juvenile idiopathic arthritis nomenclature because this affects the population being discussed and thus the generalizability of the results.

This article focuses on oligoarticular juvenile idiopathic arthritis (pauciarticular juvenile rheumatoid arthritis), polyarticular juvenile idiopathic arthritis, both rheumatoid factor positive and negative (polyarticular JRA), and systemic juvenile idiopathic arthritis (systemic JRA).

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Acute Rheumatic Fever

The incidence of acute rheumatic fever (ARF) has declined in most developed countries, and many physicians have little or no practical experience with the diagnosis and management of this condition. Occasional outbreaks in the United States make complacency a threat to public health.

Diagnosis rests on a combination of clinical manifestations that can develop in relation to group A streptococcal pharyngitis. These include chorea, carditis, subcutaneous nodules, erythema marginatum, and migratory polyarthritis. Because the inciting infection is completely treatable, attention has been refocused on prevention.

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