The goiter: the Botox lip pout of 1622?

Marie de Medici had a goiter, and Rubens painted her with it in 1622. According to Dr. Susan Mandel, who spoke on thryoid nodules at a session today, this painting made goiters all the rage. Other women of the period would actually ask their painters to add goiters to their portraits--even if they didn't have one--in order to be a little bit more like Marie.

Sounds crazy... but is it any worse than injecting yourself with botulinum toxin to get lips as fat as Angelina Jolie?

(Image courtesy of Olga's Gallery at www.abcgallery.com)

Labels: internal medicine 2009, thyroid

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posted by Jessica Berthold at 3:00 PM   1 Comments

This post will not teach you about syncope

I assume that the packed house of internists learned a lot from this morning's session on syncope, but since medical-writer school doesn't include a course on reading electrocardiograms, what I picked up were some jokes about bears.

So here goes: The president wants to decide which law enforcement agency is the best so he releases a rabbit into the woods and sends the CIA, FBI and NYPD to get it. The CIA interviews all the animals, can't find it. The FBI kills everything in the woods, including the rabbit. After the NYPD goes in, a badly beaten bear comes out saying, "Yes, yes, I swear I'm a rabbit." The point was something about how electrophysiology is like the NYPD--you get an answer but it might not be the right one.

Then, presenter Fred Kusumoto, MD, told us about how premature ventricular contractions are like bear poop. If you're hiking in the woods and you see poop, you'd better watch out for a bear. Cleaning up the poop will not make you any less likely to run into a bear. Similarly, studies have found that using medication to get rid of patients' PVCs does not improve mortality.

Labels: cardiology, internal medicine 2009

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posted by Stacey Butterfield at 2:38 PM   0 Comments

Fibromyalgia: Not just for women

Daniel Clauw, ACP Member, has a bone to pick with the American College of Rhematology's criteria for fibromyalgia.

He particularly dislikes the one which says there must be tenderness in at least 11 of 18 tender point sites to diagnose the disease. "When insurance companies come asking me about this, I say I don't know, and I don't care," said Dr. Clauw during a session on fibromyalgia this morning. "It's not even objective."

Indeed, one reason fibromyalgia is commonly--and erroneously--known as a women's disease is because women are more likely to report tender points than men, he said. It's true that the disease is 1.5 to 2 times more common in women, but there are plenty of men who have it, too--and they often go undiagnosed because of the "women only" myth.

"When males have fibromyalgia, the doctor keeps looking (for an alternate reason) until he finds a peripheral cause, like a bulging disc in the back. Then the patient gets surgery, and when that doesn't work, it's said that the patient 'failed back surgery,'....not that the surgeon failed by doing the surgery."

Labels: fibromyalgia, internal medicine 2009

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posted by Jessica Berthold at 4:00 PM   1 Comments

The upside of losing your brain

Neurology is one of those specialties that always has case studies interesting to the layman, and yesterday's "update" was no exception.

Martin A. Samuels, MACP, told the story of a woman whose primary progressive aphasia caused her to become a great painter. As her frontal lobe deteriorated, her talent emerged. The theory is that the inhibitory part of her brain had previously been masking her creativity. Not sure whether it's inspiring or depressing to learn that us overly analytic scientific types might actually have artistic genius buried somewhere in our heads.

Dr. Samuels joked, "I've told my wife, 'If I ever paint anything halfway decent, get some long-term care insurance.'"

Labels: internal medicine 2009, neurology

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posted by Stacey Butterfield at 1:33 PM   0 Comments

Warts and all

General internists must see a lot of crusty, itchy, oozing patients.

Today's "Essential Dermatology for the Practicing Internist" session was packed to the gills, with audience members consuming all available floor and wall space. Speaker Julia Nunley, ACP Member, even encouraged folks to sit down front in the area before the podium, "like little children at church."

Once settled in, we all enjoyed a pre-lunch earful and eyeful of scaly patches, inflamed sores, engorged pustules--and juicy clinical tidbits. Among them:

--Be sure to tell patients you treat for acne that it can take 2-3 months to clear up, and that the acne may not disappear completely. Many will quit treatment after three weeks if they don't see results.

--When female patients come in with acne, always ask about their menstrual cycles. "You don't want to miss PCOS," Dr. Nunley said. "When I'm checking out faces, I tuck my finger under the chin so I can feel to see if she's shaving. Often she won't tell you."

--Ask older patients with acne about flushing and blushing; you don't want to miss a diagnosis of rosacea.

--www.rosacea.org is a good site for patients to learn about things that can cause rosacea flair-ups. "You won't see this in any dermatology textbook, but rosacea flairs with menses," Dr. Nunley said. "For me personally, it flairs when I fly."

--Sun protection is the single most important treatment for rosacea. People are born with rosacea, and it gets worse with age-- but it can be stemmed if one is careful in the sun.

--Treatment for dandruff (Seborrheic Dermatitis) varies with ethnic background. African- Americans typically wash their scalps once per week, so shampoo treatments are of limited benefit. Ointments (fluocinonide) and oils (fluocinolone) should be used instead. For Asians and Caucasians, solutions (clobetasol) and lotions (triamcinolone) work well.

...and finally, the one that caused some gasps and murmurs to ripple through the crowd..

--HPV can actually live in liquid nitrogen. Never, ever double dip when performing back-to-back cryosurgery on warts.

Labels: dermatology, internal medicine 2009

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posted by Jessica Berthold at 4:30 PM   1 Comments

Is it wrong for you to pay patients?

In the "Ethics year in review" session this afternoon, Daniel P. Sulmasy, FACP, and attendees debated the moral and practical merits of paying patients to lose weight or quit smoking. The concept dramatically changes the way physicians would go about encouraging healthy practices, he said. "I think it begins to move us along the continuum from persuasion to manipulation." Financial incentives also may be ineffective, according to some research, because of the way they mess with people's motives. For example, patients can be reluctant to engage in healthy behaviors if they're not being paid, or suspicious of their physicians' motivations for providing compensation.

The discussion naturally led to the financial incentives that shape physicians' behavior, from pay for performance to pharma support. And that led to some hot debate on whether meetings like Internal Medicine 2009 should allow any industry funding--an issue that doesn't seem likely to be resolved any time soon.

Labels: ethics, internal medicine 2009

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posted by Stacey Butterfield at 4:06 PM   0 Comments

Mummers on the Move

If you were in the Philly Convention Center Exhibit Hall today around 10:30 am, you may have seen-- or heard-- some Mummery afoot. (And if you've never heard the word "Mummer" in your life, stop now and read this.)

A small but potent parade of Mummers made a circuit 'round the hall, dressed in full regalia and blaring classics like "Baby Face" on their saxes and banjos. With luck, we may catch them again on Friday-- and they may play the penultimate Mummer tune "O Dem Golden Slippers." If so, I'll bet at least one person won't be able to resist doing a bit of the Mummers strut around the booths. You'll know it when you see it.

(The stock photo is courtesy of gophila.com. Today's Exhibit Hall Mummers were too fleet of foot for an action shot.)

Labels: internal medicine 2009, Mummers

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posted by Jessica Berthold at 1:20 PM   0 Comments

Fat is bad, you know

It was a small feeding of the mind to put you off feeding. The lecture this morning by Louis Arronne, FACP, reviewed all the negative consequences of obesity and offered a few additional tidbits:

• Hoodia, the trendy OTC weight loss supplement, is not a good idea. The extract it comes from could have negative cardiac effects. "The good news is that most compounds that are said to have hoodia actually have no hoodia in them," Dr. Arronne said.
• Exercise is important, particularly for weight maintenance. You're not going to lose weight with just exercise, unless you work out like Michael Phelps. But exercise can compensate for the increased muscle efficiency that follows weight loss, the doctor said.

Labels: internal medicine 2009, weight loss

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posted by Stacey Butterfield at 12:16 PM   0 Comments

A sight no patient should see

I always appreciate it when session presenters try to engage the audience by asking multiple choice questions (especially when I can guess the answer by looking ahead to the next slide). But today's precourse session on hormone use was remarkable for how many of the questions the audience got wrong. On several questions, there were some hands raised for every single option! Guess it goes to show that they were good, tough questions. And to be fair, in some cases there were multiple correct answers. But for those of us on the outside of medicine, it's a little scary to think any randomly selected physician might give you a different randomly selected prescription. Not to worry, though, three more days of CME should fix all that.

Labels: internal medicine 2009

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posted by Stacey Butterfield at 5:44 PM   0 Comments

Some CAM humor

Tired of your patients declining proven medications because they want to take something natural? Douglas S. Paauw, FACP, who led a precourse session on headaches, has a snappy response. "You like tsunamis? They're natural, too."

Seriously, though, there is some evidence that riboflavin can be an effective migraine prophylaxis, Dr. Paauw said. It can't hurt to give it a try, but if it doesn't work after a few months, you might as well stop it. Unless your patients are really into having unusually colored urine, that is. A recent study also found that vitamin E helped with severity and disability from menstrual migraine headaches, Dr. Paauw noted.

In case the "natural" options don't work, and you run into a patient with moderate to severe headaches, Dr. Paauw also offered his basic treatment algorithm. First, try an NSAID with a motility drug like metoclopramide, then an oral triptan, and only if that doesn't work, prescribe oral narcotics. But don't let them take too many narcotics, or they'll get rebound headaches.

Labels: headache, internal medicine 2009

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posted by Stacey Butterfield at 1:57 PM   0 Comments

Not a minute too soon.

Yesterday, news broke about two kids in California contracting swine flu.

Today, ACP's Board of Governors voted for more collaboration between human and veterinary medicine, in order to prevent disease transmission across species.

Are they on the ball or what?

(Ok, so the measure was originally inspired by West Nile virus, which was recognized by vets in animals before anyone noticed it in humans. Still.)

Specifically, the Governors' measure supports cross-species disease surveillance, and joint efforts to develop new diagnostic methods, medicines and vaccines to prevent and control the diseases.

I, for one, am comforted by the fact that this may prevent any of us from ever knowing what hippopotamus flu feels like.

Labels: H1N1, internal medicine 2009, West Nile

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posted by Jessica Berthold at 1:00 PM   0 Comments

A collection of diabetes tidbits

I spent today at an Internal Medicine 2009 precourse on diabetes and picked up a lot of miscellaneous interesting info, particularly during the session by Irl Hirsch, FACP, on monitoring in diabetes.

• Most common reason that patients' finger-sticks are inaccurate? They don't wash their hands beforehand. If you eat an orange, then test blood from one of your sticky fingers, the glucose from the fruit could make the result inaccurately high.
• But should your type 2 patients who aren't on insulin even be bothering to self-monitor? Given that there's no proof that home testing affects outcomes and test strips are expensive, Dr. Hirsch sees the main use being special occasions, like when a patient is eating something new and wants to see how her blood sugar responds.
• A1cs are good, but not perfect. Anemia, in particular, can make their results inaccurate. Also, did you know that half of an A1c result is determined by glucose levels over the previous 30 days?
• The newest big thing in diabetes monitoring--real-time continuous glucose monitors. They work great (i.e., significantly lower A1cs) if patients wear them all the time and pay attention to them, Dr. Hirsch said. Best used by patients and physicians who are tech-savvy and willing to devote some real time and attention.
• The next big thing, however, could turn out to be a very old thing--urine glucose testing. If a currently underway study proves that it's as effective as home blood testing, payers could push for a move back to the older, cheaper option.
• In the afternoon, David Kendall, MD, made a convincing case for incretin-based therapies. In addition to improving insulin secretion and response, the drugs reduce food intake and cause weight loss. So how to decide if exentide and the other on-their-way-to-market options in the class are right for your patients? That was a little fuzzier--you'll know 'em when you see 'em was the gist of his message.

Labels: Diabetes, internal medicine 2009

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posted by Stacey Butterfield at 3:11 PM   0 Comments

Digging for fun in the scientific program

With Internal Medicine 2009 less than a week away, it's time for another edition of "Ill-advised Session Titles." We are disappointed to report that ACP presenters are unusually matter-of-fact in their session-naming. Still, there are some awards to be distributed.

Best pun: Shocking Developments in Resuscitation
Most likely to be a spam email: How to Live (and Want) to Be 100!
Most likely to be a cable show: The V Words
Best session for the whole family: Adventures in Liver Land
Best follow-up to the above: Adults Beware! Children Are in the Building
And finally, the grand prize goes to the session that makes us nervous about wandering the halls here at headquarters: Anorectal Disorders Encountered in the Office Setting

Labels: Ill-advised session titles, internal medicine 2009

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posted by Stacey Butterfield at 4:29 PM   0 Comments