In today's lecture on Chronic Kidney Disease, nephrologist Dr. Allen Nissenson said he no longer orders 24-hour urines to measure protein. He uses the albumin/creatinine ratio. I had used this to screen for microalbumin. But Dr. Nissenson uses this ratio exclusively, and no longer orders 24-hour collection.
Albumin-to-Creatinine Ratio
Men
< 17 mg/g (Normal)
17-250 mg/g (Microalbumin)
> 250 mg/g (Clinical Proteinuria)
Women
< 25 mg/g (Normal)
25-355 mg/g (Microalbumin)
>355 mg/g (Clinical Proteinuria)
Others have compared the ratio to results on the standard dipstick.
Saturday. More activity on the beach path this morning.
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Boxer skims low over the shore like a cormorant. He chases pipers and plovers.
Cluster of joggers.
Gliders, walkers, swimmers, (no surfers), kid diggers, baby strollers.
Even the pelican out of bed...late sleeper.
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Easy to forget the work of local organizations to maintain this beautiful San Diego coastal ecology. It is ongoing work.
Enjoyable reception last night, thanks to Paul Epstein (Pennsylvania) and Evelyn Hess (Ohio). Fun also to meet Linda Lemaster and Alissa Wennard.
Missed this morning's run in San Diego for the St. Vincent DePaul Health Services.
Dr. Sankey Williams outlined the American College of Cardiology's new guidelines on chronic stable angina.
Stratification into low, intermediate and high risk groups to determine best testing (type of stress testing, imaging, or angiogram) seems ripe for a handheld calculator. The ACC website suggests this is in the works. (Past versions that I could find have not been interactive.)
A man with a history of remote Hashimoto's thyroiditis and long-standing hypothyroidism presents with progressive swelling in his neck, a diffuse enlargement of his thyroid. Considerations?
Dr. Maria Collazo-Clavell in her Clinical Pearls session reminds us to consider thyroid lymphoma in the setting of rapid thyroid enlargement, especially with past Hashimoto's thyroiditis. ...A special consideration when evaluating throid enlargement or nodule.
Lower doses of estrogen can still relieve vasomotor menopausal symptoms. Dr. Wendy Simons Klein points to a randomized, double-blind, placebo-controlled multi-center HOPE trial showed symptoms (vasomotor and vaginal atrophy) can be controlled with 0.45 or 0.3 mg of estrogen.
Normal T4, but elevated TSH, and no perceived symptoms. When do you supplement with thyroxine?
Dr. David Gardner suggested that vague symptoms, lipid abnormalities, or TSH greater than 10 microunits/ml push him towards treatment. A review article, or this summary cited by Dr. Gardner supplement his discussion. Opinions vary on best practices.
Dr. Gardner mentioned the possibility of tinkering with the "normal" range of TSH--lowering it to 0.5-2.5. This is based on the Whickham survey. From 1975 to 1995 people in this town with initial TSH over 2.0 had higher risk of developing hypothyroidism over the next 20 years.
Over-treatment?
There are risks to heart and bone of over-treatment. (Target post-treatment TSH is 0.5-2.5.)
When evaluating dementia, testing for syphilis is not recommended according to a recent evidence-based review from the American Academy of Neurology. (Cited by Dr. Scherokman at ACP Annual Session Friday.)
Today OSCAR was introduced to the Annual Session by Dr. David Chan. This open source electronic medical record stems from Ontario's Primary Care Reform effort.
In a separate effort, the American Academy of Family Practice (AAFP) has asked for partners to create an open source electronic medical record. Hope we all benefit.
Not open source, but am intrigued by Sevocity who had a booth at ACP. A web-based medical record.
Technical note: OSCAR uses linux, Zope and MySQL. Dr. Chan was uncertain of compatibility with available Mac OS web browsers and with HIPAA compliance.
Random walk in Exhibition Hall leads to celiac disease, to access to care, and to Miralax (polyethylene glycol).
Celiac sprue pops up in two posters (one discusses symptoms at presentation, similar to the recent review of prevalence), at the Celiac Foundation booth (sponsored in part by manufacturer of diagnostic tests), and in Theresa Kehoe's osteoporosis talk where she mentiooned sprue as an overlooked association. (Jacob Reider had earlier commented on his experience.)
Physicians for National Health Care (PNHP) alert us to Himmelstien and Woolhandlers second look at administrative costs of health care, due out in New England Journal of Medicine in May or so.
Miralax, polyethylene glycol or "PEG," looks like water and has no taste (as served at their booth). Oddly, just read that PEG has the rheological properties of lava. It is distinct from antifreeze, which is ethylene glycol.
When they come in to see us, 20% of patients are ready to change (quit smoking, etc). For patients not yet ready to change, listening and empathy are helpful. This can help patient's move from "pre-contemplation" to "action." The stages of change (the transtheoretical model) are best summarized at the Cancer Prevention Research Center website.
The ACP session dealt with how doctors can use DiClemente's stages of change (pre-contemplation, contemplation, determination-action, maintenance, relapse and so on) to help a patient quit smoking, start exercising, or lose weight.
The role of empathy was emphasized--reminders to help us actively listen, respecting patient autonomy. But in the determination stage, active presentation of options and development of a clear plan are helpful.
Other aids mentioned included: patient journals to monitor behavior, a 2x2 decision balance, scales to point out conviction and confidence ("on a scale of 1 to 10 how confident are you in your desire to change?"), and identification of supportive people & role models.
Relapse can be an opportunity to learn. The patient can move back to determination and action.
Also the role of community resources was emphasized (AA, weight watchers, YMCA, etc).
The audience raised doubt about the usefulness in weight control. Speakers felt this model can apply, more certainly for the less-than-morbidly obese. Although one speaker felt that even with the morbidly obese, evidence may be accumulating that reasonable goal-setting (five to ten percent initial loss), and more vigorous help with maintenance, can make a difference.
Excellent hands on session about digital photography, led by Dr. Steven Labkoff. Covered image resolutions, informed consent, macro-imaging (use of a ring flash), and camera features (speed between shots, battery types, storage cards, and use of filters)...Unanswered is the resolution of the human retina.
Coincidentally in San Diego, the inventor of photography Fox Talbot is featured at Balboa Park's Museum of Photographic Arts.
ACP is promoting its online case histories. I walked through an example on breast cancer screening. ...Thoughtfully designed. Particular example included links to a breast cancer risk calculator, and a Mammacare website teaching proper examination technique.
Dr. John M. Luce reviewed recent key papers from goal directed therapy of sepsis, to hyperbaric oxygen, to dexamethasone in meningitis, to hydrocortisone in sepsis.
Among them was a 2001 article on Goal Directed Therapy of Sepsis. More aggressive fluid replacement and transfusions in first six hours reduced mortality from 47% in usual therapy group, to 31% in experimental group (where central venous oxygen was monitored). Dr. Luce feels that for a practical take home message from this study, the central venous oximetry may be less of a key than simply more aggressive early fluid replacement.
He also chose to point out a study confirming that hyperbaric oxygen cut in half the sequelae of carbon monoxide toxicity.
Another study found early dexamethasone can reduce unfavorable outcome in meningitis in adults (especially with pneumoccal meningitis).
Most controverisal was a study suggesting that for people with sepsis, a cortrosyn (ACTH) test can reveal adrenal insufficiency. In these cotrosyn "non-responders" low-dose hydrocortison (50 mg every six hours for seven days) can reduce mortality from 63% in the control group to 53% in the experimental group. (He noted this to be a high mortality in the control group). Another review is recently published.
When usual treatment is not working or not tolerated, PTH may have a role--and works well. Cost is limiting ($515.00 per month). Increased incidence of rat osteosarcoma led to a label warning.
After the lecture I did find an association between osteosarcoma and hyperparathyroidism in humans.
When talking with patients, Dr. Theresa Kehoe (now with the FDA) breaks down the absolute risks of estrogen like this:
"For 10,000 women (age 50-79) taking estrogen and progestin for a year one would expect to see the following diseases increased by the following amounts: 7 heart attacks, 8 strokes, 8 pulmonary emboli, 8 breast cancers. These other disease would be reduced by the following amounts: 6 fewer colon cancers and 5 fewer hip fractures." (Makes more sense as 1,000 women over 10 years?)
Expect to be swamped with information about two new metformin combination pills--one with rosiglitazone (Avandamet), the other with glipizide (Metaglip). Dr. Jolene Johnson also discussed another rapid-acting insulin, Aspart, and the Novolog Mix 70/30.
Dr. Kurt Kroenke reviewed the SPACE DIGS mnemonic which has been discussed here earlier.
Depression related websites were mentioned: Darmouth, guidelines, and depression after delivery.
(Incidentally the use of nortriptyline as an alternative for smoking cessation was mentioned.)
Dr. Richard Simons mentioned that a head-to-head comparision of metoprolol versus carvedilol in CHF will be published this fall, the COMET study.
Morning path is from this cove (which is near these seals) to this pier...past cormorants, pelicans, pipers, gulls, and waves.
Then to Convention Center downtown for American College of Physicians (ACP) Annual Session. (Bill Patterson and Barbara Licht from the ACP have granted permission for these ACP-related posts).
Fish and calamari tacos at Tin Fish are ready at lunch (Mel Firestone's suggestion).
At next break, back to rest and restoration at Balboa Park.