Medliorate

Improving medical students

Archive for September, 2009

Choosing a Specialty – A Straightforward Approach for the Uncertain

Posted by medliorator on September 21, 2009

from Anne Vinsel, MS, MFA (Project Administrator, Graduate Medical Education, University of Utah Medical Center)

Research those specialties in your institution. Go to the departments and make friends with the residency program coordinators. If you haven’t already done so and haven’t rotated in the program, arrange to shadow a faculty member for a day. Talk with 1 or 2 residents and check out the pros and cons of the specialty. Finally, ask the program coordinator if your board scores would be in a competitive range. Most program coordinators won’t share their board score cut-off, but they likely would tell you if your scores are within range.

Twelve Steps for Choosing a Specialty [Medscape]

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Generic Versus Branded Drugs: Concerns Amidst Limited Evidence

Posted by medliorator on September 18, 2009

Many physicians have found [the switch to generic drugs] particularly problematic in classes of drugs with a narrow therapeutic range, including antiepileptics, psychotropics, antiarrhythmics, and anticoagulants.

although the generic’s mean maximal concentration and area under the concentration-time curve are typically within a few percentage points of the original’s — typically about 4% — the 90% confidence interval for those means can be 20% below or 25% above the branded drug’s mean.

much of the current evidence of problems with generic antiepileptics is anecdotal, or comes from retrospective or case-control studies — not randomized controlled trials.  But all of those studies have come to similar conclusions.

Two retrospective studies published last year in Neurology found that patients who had events like break-through seizures were much more likely to have been switched from a branded product to a generic… “Brand-to-generic seems to be the biggest issue,” Meador said. “But generic-to-generic seems to confer some risk as well.”

some non-SSRI antidepressants aren’t so forgiving, said Jeffrey Lieberman, MD, a psychiatrist at Columbia University in New York City.  He mentioned the tricyclic drug nortriptyline and bupropion (Wellbutrin) as more susceptible than most antidepressants to dosage variations.

Generics versus Brands: How It Plays Out in Practice [Medpage Today]

Posted in Neuro, Pharmacology | Comments Off on Generic Versus Branded Drugs: Concerns Amidst Limited Evidence

SYNTAX Trial: PCI vs CABG for Severe CAD

Posted by medliorator on September 16, 2009

dph_taxexp_01_cl_us_large

Rationale: Several trials comparing PCI involving bare-metal stents with CABG in patients with multivessel disease [ARTS I Trial, MASS II Trial, ERACI-II Trial & AWESOME Trial] showed similar survival rates but higher revascularization rates among patients with bare-metal stents at 5 years. Others have shown a significant long-term survival advantage with surgery [SOS Trial]. Studies comparing PCI involving drug-eluting stents with CABG have generally been smaller and nonrandomized.

Funding: Boston Scientific (manufacturer of TAXUS Express Coronary Stent System). The sponsor’s biostatisticians performed the analyses; however, data analyses were verified independently by a statistician on a “data and safety monitoring committee”

Endpoints: major adverse cardiac and cerebrovascular events (i.e., death from any cause, stroke, myocardial infarction, or repeat revascularization) throughout the 12-month period after randomization

Methods: 1800 patients with three-vessel or left main coronary artery disease were randomized to undergo CABG or PCI.

Results: Rates of adverse cardiac/cerebrovascular events at 12 months were significantly higher in the PCI group (17.8%, vs. 12.4% for CABG; P = 0.002), in large part because of an increased rate of repeat revascularization (13.5% vs. 5.9%, P<0.001). At 12 months, the rates of death and myocardial infarction were similar between the two groups; stroke was significantly more likely to occur with CABG (2.2%, vs. 0.6% with PCI; P = 0.003).

Percutaneous Coronary Intervention versus Coronary-Artery Bypass Grafting for Severe Coronary Artery Disease [N Engl J Med. 2009 Mar 5;360(10):961-72]

Posted in Cardiology | Comments Off on SYNTAX Trial: PCI vs CABG for Severe CAD

Crash Course: Applying for Grant Money

Posted by medliorator on September 14, 2009

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A crash course in US Federal Government grants, grants of the European Union, Carnegie Corporation grants, and Federal Pell Grant for students in the US presented on wikiHow.

How to Apply for a Grant [WikiHow]

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Serotonin Receptor Antagonists

Posted by medliorator on September 11, 2009

ondansetron

All 5-HT3 antagonists are identified by the suffix -setron

The following are  5-HT3  antagonists serum half- lives:

  • Dolasetron (Anzemet): 7-9 hours.
  • Granisetron (Kytril, generic) 9-11 hours.
  • Ondansetron (Zofran, generic): 3.9 hours.
  • Palonosetron (Aloxi): 40 hours.

At equivalent doses for the prevention of acute emesis, 5-HT3 serotonin receptor antagonists have equivalent safety and efficacy and can be used interchangeably… their clinical use is limited to situations that produce vagal stimulation (eg. surgery) and chemotherapy

5-HT activates 5-HT3 receptors on extrinsic intestinal vagal and spinal afferent nerves. These afferent fibers have projections to the  nucleus tractus solitarius (NTS) and the area postrema (AP).

5HT3 antagonists are superior to metoclopramide, droperidol, and dimenhydrinate in the pharmacologic prophylaxis of postoperative nausea and vomiting. Recently, the FDA added a boxed warning to metoclopramide because of an increased risk of tardive dyskinesia

According to experimental data, these agents have shown to induce minor electrocardiographic changes. It is recommended not to administer dolasetron to patients with prolonged QT or with drugs that may prolong the QT interval.

Serotonin 5-HT3-receptor antagonists: pharmacokinetics, MOA, indications and adverse effects [Pharmamotion]

Posted in Pharmacology | Comments Off on Serotonin Receptor Antagonists

Resident Work-Hour Reform & Patient Safety

Posted by medliorator on September 9, 2009

Reductions in resident physician work-hours at teaching hospitals in 2003 were associated with an increase in complications related to surgery to repair hip fractures, a new study found.

“Our investigation identified that the rate of change of perioperative morbidity in patients with a hip fracture increased significantly in teaching hospitals following resident duty-hour reform.”

Browne and colleagues compared the surgical outcomes from before (2001 to 2002) and after (2004 to 2005) the reform was implemented by reviewing records from the Nationwide Inpatient Sample for 48,430 patients treated for hip fractures at teaching and non-teaching hospitals across the United States.

“It is our anecdotal experience that continuity of care has become more challenging in the orthopaedic teaching environment following duty-hour limitations,” the authors wrote. “Handoffs, particularly problematic in patient care and known to increase the risk of adverse events, appear to occur relatively more frequently in the surgical services after reform.”

Resident Duty-Hour Reform Associated with Increased Morbidity Following Hip Fracture (The Journal of Bone and Joint Surgery)

via Resident Hours Cut, Hip Surgery Complaints Rise [Medpage Today]

Correlate: On the 80-hour Workweek Cap – Part 2

Correlate: Residency: 56 Hour Work Week?

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Influenza Review

Posted by medliorator on September 8, 2009

A plain language review of the influenza virus by Joseph Albietz:

The influenza season in the Northern hemisphere usually runs from October through May, with a peak mid-February.  Every season in the US between 5-20% of the US population is infected by influenza, and while the majority of people recover well from an influenza infection, not everyone will.  Annually 200,000 people are hospitalized, and on average 36,000 will die either from influenza or its complications.

Influenza is an RNA virus encoded by just 11 genes on 8 separate RNA segments  …One in every 1000-10,000 nucleotides is mis-transcribed by influenza, giving it one of the highest mutation rates known… Two genes encode influenza’s characteristic surface proteins hemagglutinin (HA) and neuraminidase (NA).  There are 16 types of HA, 9 of NA, and respectively these two proteins serve to bind the virus to a target cell and to release new viral particles from a host cell, and they also happen to be the parts of influenza the immune system recognizes.  Every so often a transcription error will change the conformation of either HA or NA just enough so that it cannot be recognized by the immune system.

the 2009 (H1N1) is distinct from the seasonal A (H1N1).  It appears to be a “triple recombination,” with characteristics derived from human, bird, and swine influenzas.  When our population was tested for antibodies against 2009 (H1N1) nearly no children, and less than 10% of those under the age of 65 had reactive antibodies, and of those over 65 only 33% showed any response.  It seems no one has seen a similar influenza in half a century.  This means that the vast majority of our population is susceptible to infection this season

An Influenza Primer [Science-Based Medicine]

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