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Sincerely,

Joshua Schwimmer, MD, FACP, FASN; The Efficient MD Blog (in association with the American College of Physicians); Clinical Instructor in Medicine, Columbia University College of Physicians & Surgeons and Clinical Assistant Professor of Medicine, New York University School of Medicine

Ves Dimov, MD; Clinical Cases and Images; Clinical Assistant Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University

(Also posted on The Efficient MD Blog.)

Currently Reading: Little Brother

"Lipitor titration is a failed step."

Lipitor Image via WikipediaThree Vytotin/Zetia reps just came to me and said, "When do you feel comfortable using Zetia? After all, Lipitor titration is a failed step. It only reduces LDL by 6%."

I gently referred them to the PROVE IT trial, asked them to come back when they had positive mortality data, and walked away.

Has anyone else encountered this strategy by the Zetia reps?

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• Cardiologists Question Delay of Data on 2 Cholesterol Drugs
  

You'd Never Confuse Diabetes Mellitus With Diabetes Insipidus. The New York Yimes Has It Wrong.

Image via WikipediaI'm still puzzling over this article in the New York Times, "Some Diabetics Don't Have What They Thought They Had." The article seems to imply -- and some other news outlets have picked up -- that some children diagnosed with type 1 diabetes mellitus (DM) actually have diabetes insipidus (DI). What the article means to imply, I think, is that some children with type 1 DM actually have maturity onset diabetes of the young (MODY). (I've looked, but I could not find a situation in which you'd ever confuse type 1 DM and DI. In DI, for example, you wouldn't have glucose in the urine.)

Why is this important? Because if the myth propagates through the media that you can easily confuse DI and DM, countless younger adult patients with DM will approach their doctors demanding that they be tested for DI, which will require a lengthy explanation of how the two could not be confused...

On the other hand, I've seen patients with MODY misdiagnosed as having type 1 DM -- and they eventually are able to stop insulin and switch to oral therapy. This is the real message of the NYT article, I think, and it's great when it happens.

Acute Renal Failure Associated with Cosmetic Soft-Tissue Filler Injections of Silicone in the Buttocks

The moral of the story? Do not get injections of silicone in the buttocks by an unlicensed practitioner. Via the MMWR:

Soft-tissue fillers are substances injected to augment or enhance the appearance of lips, breasts, buttocks, or other soft tissues. Previous reports have linked the administration of soft-tissue fillers, usually liquid silicone, by unlicensed practitioners to severe adverse events, including death On December 27, 2007, the North Carolina Division of Public Health (NCDPH) was notified of three cases of renal failure occurring among women who had received cosmetic soft-tissue filler injections at a facility in North Carolina (facility A). This report summarizes the clinical findings for these cases and describes the subsequent public health investigation. All injections were administered by a practitioner with no medical training or supervision (practitioner A). Investigators were not able to identify the substances injected. Although records indicated that the injections contained liquid silicone, this substance has not been associated previously with renal failure. These findings underscore the risks posed by cosmetic injections administered by unlicensed practitioners. Public health officials should be alert for adverse events associated with these injections and take all necessary actions to prevent additional injuries.

Case Reports

Case 1. On December 8, 2007, a District of Columbia woman aged 42 years, who was previously healthy except for a history of anemia, received cosmetic soft-tissue filler injections in her buttocks at facility A. Records specifying the substance injected were unavailable. On December 22, the woman received additional injections at facility A. According to facility records, 300 mL of "dermal silicone/saline solution" were injected into each buttock (600 mL total) during the December 22 visit. The woman experienced headache and vomiting within 30 minutes of these injections and noted that her urine looked like purple blood. She went to an emergency department (ED) in Maryland on December 24 with fatigue, vomiting, and headache and was found to be in acute renal failure, with a serum creatinine level of 4.2 mg/dL (normal: 0.8--1.4 mg/dL). Laboratory investigations, including urine testing for heavy metals, did not reveal a specific etiology. Her serum creatine phosphokinase (CPK) level was 411 U/L on the day of admission (normal: 25--200 U/L). She remained hospitalized for 10 days. Hemodialysis was not required, and her serum creatinine level subsequently returned to normal.

Case 2. On December 8, 2007, a previously healthy Illinois woman aged 26 years received cosmetic soft-tissue filler injections in her buttocks at facility A. Records indicated that she received 500 mL of "25% silicone dermal filler and 75% saline solution" in each buttock (1,000 mL total). She received additional injections at facility A on December 22. Records from December 22 indicate that 400 mL of a "50% concentration of silicone oil dermal filler and saline solution" were injected into each buttock (800 mL total). Within 1 hour of these injections, she experienced headache and nausea and noted that her urine had a burgundy color. She went to an Illinois ED on December 23 with nausea, headache, and fatigue and was found to be in acute renal failure, with a serum creatinine level of 4.0 mg/dL. Serum CPK was 517 U/L on the day of admission. The patient's renal function worsened, and hemodialysis was initiated. A renal biopsy on December 27 revealed severe acute tubular necrosis with cast formation. The casts were not myoglobin or hemoglobin; pathologists were unable to determine their composition, despite the use of specialized stains. No heavy metals were identified in urine specimens, and no other specific etiology was identified. The woman remained in the hospital for 13 days. Hemodialysis was discontinued after 5 weeks, and the woman subsequently regained normal kidney function.

Case 3. A previously healthy Maryland woman aged 26 years received soft-tissue filler injections in her buttocks at facility A on December 8, 2007, and again on December 22. No records were available from either date. The woman developed abdominal pain, lightheadedness, and nausea within 1 hour after the second procedure. She went to an ED on December 26 with fatigue and vomiting and was found to have a serum creatinine level of 11 mg/dL. Hemodialysis was initiated. A renal biopsy on January 11, 2008, demonstrated acute interstitial nephritis with substantial numbers of eosinophils, consistent with a toxic or allergic etiology. Eosinophilia was not found on peripheral blood smears. No heavy metals were identified in urine specimens. She remained in the hospital for 14 days; hemodialysis was discontinued within 1 week after discharge, and her serum creatinine level subsequently returned to normal.

Image: Wikipedia

Kidney Dissection

Photo: William B. Gruber

"This dissection of the kidneys was done after red latex was injected into the arteries and blue latex into the veins."

See The Body in Depth from The New York Times.

Russian Starbucks, Brighton Beach, Brooklyn

Russian Starbucks, Brighton Beach, Brooklyn, originally uploaded by KidneyNotes.

Hilarious Journal Articles #98: In Jazz, Brain Takes Five

Image via WikipediaNeural Substrates of Spontaneous Musical Performance: An fMRI Study of Jazz Improvisation:

To investigate the neural substrates that underlie spontaneous musical performance, we examined improvisation in professional jazz pianists using functional MRI. By employing two paradigms that differed widely in musical complexity, we found that improvisation (compared to production of over-learned musical sequences) was consistently characterized by a dissociated pattern of activity in the prefrontal cortex: extensive deactivation of dorsolateral prefrontal and lateral orbital regions with focal activation of the medial prefrontal (frontal polar) cortex. Such a pattern may reflect a combination of psychological processes required for spontaneous improvisation, in which internally motivated, stimulus-independent behaviors unfold in the absence of central processes that typically mediate self-monitoring and conscious volitional control of ongoing performance. Changes in prefrontal activity during improvisation were accompanied by widespread activation of neocortical sensorimotor areas (that mediate the organization and execution of musical performance) as well as deactivation of limbic structures (that regulate motivation and emotional tone). This distributed neural pattern may provide a cognitive context that enables the emergence of spontaneous creative activity.

The collection of Hilarious Journal Articles is here.

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Hilarious Journal Articles #97: People Who Wear Glasses Aren't Geeks

Image via WikipediaThe Genes in Myopia (GEM) Twin Study: “We have literally busted the myth that people who wear glasses are introverted or have particular personality characteristics. They are more likely to be agreeable and open, rather than closed and introverted,” said Prof Paul Baird of the University of Melbourne’s Centre for Eye Research Australia.

The collection of Hilarious Journal Articles is here.

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Drug Advertising Has Gone Viral: Anti-Claritin Pro-Zyrtec Ad in NYC

"Missing: 2 hours. Last seen: while waiting for Claritin to start working. If found please call: 1-800-4-ZYRTEC." Apparently, drug advertising has gone viral.

Hilarious Journal Articles #96: Chocolate Milk Better Than No Milk at All

Image via WikipediaFrom The Journal of the American Dietetic Association, "Drinking Flavored or Plain Milk Is Positively Associated with Nutrient Intake and Is Not Associated with Adverse Effects on Weight Status in US Children and Adolescents":

Children and adolescents who included flavored milk in their diets reported higher total milk intakes than consumers of exclusively plain milk. Intakes of vitamin A, calcium, phosphorus, magnesium, potassium, and saturated fat (adjusted for energy intake and age) were generally comparable among milk drinking groups, whereas intakes by milk nondrinkers were significantly lower. Among females aged 12 to 18 years, calcium intakes by flavored and exclusively plain milk drinkers were 992+/-41.5 and 1,038+/-22.5 mg/day, respectively, whereas intake by nondrinkers was 576+/-11.7 mg/day. Intake of added sugars did not differ between flavored milk drinkers and milk nondrinkers. BMI measures of milk drinkers were comparable to or lower than measures of nondrinkers.

The collection of Hilarious Journal Articles is here.

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Hilarious Journal Articles #95: Other People Slow You Down

Seeing vs. believing: Is believing sufficient to activate the processes of response co-representation?:

It has been suggested that the observation of another person's action affects the behavior of the observer because the observation of action leads to the excitation of similar response codes in the observer. It is unknown, however, if one must witness the action or if it is sufficient for one to believe that the other agent is responding for response co-representation to occur. To this end, participants in the present study performed a joint spatial-compatibility task with a confederate when: (1) the confederate sat beside the participant; and, (2) the confederate left the room and told the participant that they would continue to perform their component of the task on a networked computer in another room. Even though participants believed that the confederate performed the task in another room, joint spatial-compatibility was only observed when the confederate was present. These results reveal that the actions of another person may only be represented by the observer when the observer is able to witness a portion of the action.

Hilarious Journal Articles #94: Roads Not Taken Disappear More Quickly Than We Realize

Image via WikipediaWhy People Misimagine the Future: The Problem of Attentional Collapse:

Gilbert presents the results of four experiments, all involving predicted versus actual enjoyment of a very simple experience—eating potato chips. In three of the experiments, participants predicted how much they would like eating potato chips before, after, or instead of eating a much better food (chocolate) or a much worse food (sardines). They then ate the chips and reported how much they liked them. The results showed that the chocolate and the sardines had a large impact on participants’ predictions, but no impact whatsoever on their actual experiences. Those participants who compared the chips to sardines overestimated how much they’d enjoy eating the chips, and those who compared them to chocolate underestimated how much they’d enjoy eating the chips.

The collection of hilarious journal articles is here.

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Bruce Sterling on the Future of Things

Bruce Sterling from Innovationsforum on Vimeo.

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Tactical Internet Pants from merlinmann on Vimeo.

Hilarious Journal Articles #93: Gossip Boosts Cognitive Functioning

Image from WikipediaVia the Personal and Social Psychology Bulletin:

Social interaction is a central feature of people's life and engages a variety of cognitive resources. Thus, social interaction should facilitate general cognitive functioning. Previous studies suggest such a link, but they used special populations (e.g., elderly with cognitive impairment), measured social interaction indirectly (e.g., via marital status), and only assessed effects of extended interaction in correlational designs. Here the relation between mental functioning and direct indicators of social interaction was examined in a younger and healthier population. Study 1 using survey methodology found a positive relationship between social interaction, assessed via amount of actual social contact, and cognitive functioning in people from three age groups including younger adults. Study 2 using an experimental design found that a small amount of social interaction (10 min) can facilitate cognitive performance. The findings are discussed in the context of the benefits social relationships have for so many aspects of people's lives.

The collection of Hilarious Journal Articles is here.

Thanks to Joe.

Stroke of insight: Jill Bolte Taylor on TED.com

"Neuroanatomist Jill Bolte Taylor had an opportunity few brain scientists would wish for: One morning, she realized she was having a massive stroke. As it happened -- as she felt her brain functions slip away one by one, speech, movement, understanding -- she studied and remembered every moment. This is a powerful story of recovery and awareness -- of how our brains define us and connect us to the world and to one another."

Hilarious Journal Articles #92: Happy Hours in the Lab are OVER

Image from WikipediaSent to me by a cardiologist friend with the subject, "Happy Hours in the lab are OVER." Thanks, Huck.

"A possible role of social activity to explain differences in publication output among ecologists:"

Publication output is the standard by which scientific productivity is evaluated. Despite a plethora of papers on the issue of publication and citation biases, no study has so far considered a possible effect of social activities on publication output. One of the most frequent social activities in the world is drinking alcohol. In Europe, most alcohol is consumed as beer and, based on well known negative effects of alcohol consumption on cognitive performance, I predicted negative correlations between beer consumption and several measures of scientific performance. Using a survey from the Czech Republic, that has the highest per capita beer consumption rate in the world, I show that increasing per capita beer consumption is associated with lower numbers of papers, total citations, and citations per paper (a surrogate measure of paper quality). In addition I found the same predicted trends in comparison of two separate geographic areas within the Czech Republic that are also known to differ in beer consumption rates. These correlations are consistent with the possibility that leisure time social activities might influence the quality and quantity of scientific work and may be potential sources of publication and citation biases.

The collection of Hilarious Journal Articles is here.

New Articles of Note from the New England Journal of Medicine

Image from WikipediaTelmisartan, Ramipril, or Both in Patients at High Risk for Vascular Events

ACE Inhibitors in Cardiovascular Disease — Unbeatable?

Treatment of Hypertension in Patients 80 Years of Age or Older

Questionable Choice for Doctor's Lobby Decor

Questionable Choice for Doctor's Lobby Decor, originally uploaded by KidneyNotes.