tbuckley/cabot-search huggingface dataset:
The Association Between Residency Training and Internists’ Ability to Practice Conservatively
Authors: Brenda E. Sirovich, Rebecca S. Lipner, Mary Johnston, Eric S. Holmboe
Journal: JAMA Internal Medicine (2014)

<h3>Importance</h3> Growing concern about rising costs and potential harms of medical care has stimulated interest in assessing physicians' ability to minimize the provision of unnecessary care. <h3>Objective</h3> To assess whether graduates of residency programs characterized by low-intensity practice patterns are more capable of managing patients' care conservatively, when appropriate, and whether graduates of these programs are less capable of providing appropriately aggressive care. <h3>Design, Setting, and Participants</h3> Cross-sectional comparison of 6639 first-time takers of the 2007 American Board of Internal Medicine certifying examination, aggregated by residency program (n = 357). <h3>Exposures</h3> Intensity of practice, measured using the End-of-Life Visit Index, which is the mean number of physician visits within the last 6 months of life among Medicare beneficiaries 65 years and older in the residency program's hospital referral region. <h3>Main Outcomes and Measures</h3> The mean score by program on the Appropriately Conservative Management (ACM) (and Appropriately Aggressive Management [AAM]) subscales, comprising all American Board of Internal Medicine certifying examination questions for which the correct response represented the least (or most, respectively) aggressive management strategy. Mean scores on the remainder of the examination were used to stratify programs into 4 knowledge tiers. Data were analyzed by linear regression of ACM (or AAM) scores on the End-of-Life Visit Index, stratified by knowledge tier. <h3>Results</h3> Within each knowledge tier, the lower the intensity of health care practice in the hospital referral region, the better residency program graduates scored on the ACM subscale (<i>P</i> &lt; .001 for the linear trend in each tier). In knowledge tier 4 (poorest), for example, graduates of programs in the lowest-intensity regions had a mean ACM score in the 38th percentile compared with the 22nd percentile for programs in the highest-intensity regions; in tier 2, ACM scores ranged from the 75th to the 48th percentile in regions from lowest to highest intensity. Graduates of programs in low-intensity regions tended, more weakly, to score better on the AAM subscale (in 3 of 4 knowledge tiers). <h3>Conclusions and Relevance</h3> Regardless of overall medical knowledge, internists trained at programs in hospital referral regions with lower-intensity medical practice are more likely to recognize when conservative management is appropriate. These internists remain capable of choosing an aggressive approach when indicated.
An abnormal chest radiograph
Authors: A. Aujayeb, M. Weatherhead
Journal: BMJ (2014)

A 55 year old man presented to the emergency department with syncope after laughing. His full examination was documented as normal, and no abnormalities were seen in his electrocardiograph or routine blood tests. Blood pressure when lying and standing was normal. However, his chest radiograph and the results of computed tomography were abnormal (figs 1⇓ and 2⇓).



Fig 1 Chest radiograph





Fig 2 Computed tomogram of the chest 



He had never smoked, had no occupational dust exposure, and had no pets such as birds or cats. He had noticed some exertional dyspnoea and a mild cough over the past few months, but no haemoptysis. In addition, he had no weight loss or night sweats.



### 1. What does the chest radiograph show?

#### Short answer

There is marked deviation of the trachea to the right, with a homogeneous opacity in the upper mediastinum.

#### Long answer

The radiograph shows marked …
What is the risk of intracranial bleeding during anti-VEGF therapy?
Authors: Craig P. Carden, James M.G. Larkin, Mark A. Rosenthal
Journal: Neuro-Oncology (2008)

Vascular endothelial growth factor (VEGF) is a key mediator of physiological and pathological angiogenesis. All solid tumors are dependent on pathological angiogenesis, and anti-VEGF therapy has demonstrated clinical benefit in breast, colorectal, non-small-cell lung, and renal carcinomas. Central nervous system metastases are common in many of these tumor types. An increased risk of bleeding has been reported with anti-VEGF therapy, but the risk of intracranial bleeding is unknown with this type of therapy. We reviewed the available data to investigate the risk of intracranial bleeding with anti-VEGF therapy in the presence and absence of CNS metastases. The PubMed and Medline databases and the Proceedings of the American Society of Clinical Oncology (ASCO) annual meetings were searched for articles, abstracts, and presentations of clinical trials. We identified 57 trials examining the safety and efficacy of anti-VEGF therapy in a total of 10,598 patients. Four trials examined the use of anti-VEGF therapy in treating patients with brain metastases. The presence of CNS metastases was a stated exclusion criterion in 76% of trials. The rate of intracranial bleeding was negligible. We conclude that there is no trial evidence that anti-VEGF therapy confers an increased risk of intracranial bleeding, even in the presence of CNS metastases. Future trials of anti-VEGF therapy should not exclude patients with controlled CNS metastases at enrollment.
Ciclesonide, a novel “on site activated” inhaled corticosteroid with potent anti-inflammatory actions in the airways
Authors: Maria Belvisi, Daniela Bundschuh, Michael Stoeck, Sharon Wicks, Stephen Underwood, Clifford Battram, Stephen Webber, El-Bdaoui Haddad, Martyn Foster
Journal: Journal of Allergy and Clinical Immunology (2002)
Market penetration of new drugs. Increased prescribing may be appropriate.
Authors: A H Watt
Journal: BMJ (1993)

Coupled with the editorial by Tony Noble arguing against the routine postnatal examination at six weeks,5 this concern about initiating contra- ception before the earliest likely ovulation suggests that the optimum time for a routine postnatal appointment is at or just before four weeks.This should be seen as a safety net for contraception, since the subject is much better raised during the third trimester, at around 30 weeks' gestation, and discussed again with the woman during the post- partum home visit at around 10 days.I have suggested to both the Royal College of Obstetri- cians and Gynaecologists and the Royal College of General Practitioners that these recommendations should be discussed with a view to becoming the colleges' official policy.
Reversal by Liver Transplantation of the Complications of Primary Hyperoxaluria as Well as the Metabolic Defect
Authors: John C. McDonald, Michael D. Landreneau, Michael S. Rohr, George A. DeVault
Journal: New England Journal of Medicine (1989)

LIVER transplantation reverses a number of inborn errors of metabolism that result from the genetically determined absence of an enzyme.1 The earliest enzyme-deficiency disorders to be treated by liver transplantation were those that caused the anatomical destruction of the host liver. The replacement of a grossly normal liver to correct a defect that had caused the destruction of another organ was first performed to treat homozygous familial hypercholesterolemia.2 Although homozygous familial hypercholesterolemia is not the result of an enzyme defect, this experience undoubtedly encouraged others to attempt to correct primary hyperoxaluria in the same way.3 4 5 Three patients with primary hyperoxaluria . . .
On the environmental stress that reshapes our vessels
Authors: E. Thorin
Journal: Cardiovascular Research (2012)

This editorial refers to ‘Pregnane X receptor regulates drug metabolism and transport in the vasculature and protects from oxidative stress’ by K.E. Swales et al. , pp. 674–681, this issue. 

Adaptation to environmental stress is key to animal survival. Humans, however, are temporarily above some of the consequences of the environmental stress by the use of vaccines, antibiotics, and organ transplantation; they are, however, not totally immune to their environment. The fundamental questions are (i) how do we detect the environmental stress and (ii) how do we adapt to it?

Stress comes in a multitude of flavours. The classical risk factors for cardiovascular diseases are by definition deleterious, but the vessels certainly tentatively adapt to them.1 An intermittent low level of ischaemia generated by exercise2 and during ischaemic preconditioning3 is another type of stress that activates defence and repair pathways and that is beneficial to the cardiovascular system. While our lifestyle shapes our metabolism and overall biology, most cell types express receptors that sense chemicals, natural or not, contained in what we ingest and what we breathe. The ensuing signals modify the cells, making certain that they are able to appropriately use these chemicals as well as to resist to their toxicity if needed. Overall, these responses, also known as hormetic responses, are mid- …
Progress Against Osteoporosis
Authors: HUNTER HEATH
Journal: Annals of Internal Medicine (1983)

ExcerptMost internists are aware of the postmenopausal osteoporosis syndrome, and deal at one time or another with the resulting problems of pain, disability, and death caused by fractures, especially those of the spine and hip. However, many of the recent advances in understanding the pathogenesis and treatment of postmenopausal osteoporosis are described in a widely scattered literature that is difficult to assimilate. I do not intend to give a clinical review of osteoporosis, but to highlight new information in noninvasive measurement of bone mineral density, the elucidation of risk factors for osteoporosis, and updated concepts in the treatment and prevention...
Educational Value of the Free Clinic
Authors: Ronald M. Lawrence
Journal: JAMA (1972)

To the Editor.—  An interesting point not emphasized in the recent special communication  Free Medical  (219:603, 1972) is that of the educational possibilities of the Free Clinic, particularly in the field of venereal disease and drug education. The Free Clinic can act to educate the local physicians in the proper treatment of venereal disease and drug abuse. This type of opportunity is not available elsewhere, for the most part, to the interested physician. This is due mainly to the fact that the volume of cases seen in the average general practitioner's office or even in the average specialist's office relating to venereal disease or drug abuse is extremely limited, while the case load in these categories at the Free Clinics is considerably greater. A physician can learn all about venereal disease and learn all about these conditions at a Free Clinic within a few days, while it would
Evolving Strategies for Treatment of Acute Aortic Dissection Type A
Authors: Klaus Kallenbach, Timm Oelze, Rolf Salcher, Christian Hagl, Matthias Karck, Rainer G. Leyh, Axel Haverich
Journal: Circulation (2004)

To assess the outcome of 3 different surgical approaches for treatment of acute aortic dissection type A (AADA).Between October 1990 and October 2003, we operated on 295 patients (pts) for AADA. Follow-up was complete for 257 pts (87%). Supracommissural replacement (SCR) of the ascending aorta was applied to 145 pts, 64 pts received a composite replacement (comp), and 48 pts were treated with the aorta valve-sparing (AVS) reimplantation technique. Pts in SCR were older compared with AVS and comp (P=0.002), gender (overall 65% male, P=0.143) and presence of Marfan syndrome (overall 5%, P=0.109) were comparable. Cannulation of the aorta was performed more often in AVS (58%) than in comp (19%) or SCR (22%; P<0.001). Mean operation time, extracorporeal circulation time, and aortic cross-clamp time differ significantly between groups (P<0.001, respectively). Stay in the intensive care unit (P=0.12) and time of hospitalization (P=0.32) were comparable. Overall perioperative mortality was 24% and did not show significant differences between groups (AVS 10.4% versus comp 28% versus SCR 26%; P=0.053). Incidence of neurological complications was similar between groups (P=0.95). Mean time of follow-up was shorter for AVS (19+/-20 months) compared with comp (48+/-48 months) and SCR (46+/-45 months). Survival at 5 years was comparable with 89% for AVS, 85% for comp, and 80% for SCR (P=0.61). Two patients from AVS (4.1%) required reoperation for failure of the reconstructed valve. Pts in comp required less aortic reoperations than pts in SCR (comp 6.3% versus SCR 22%; P=0.005).In acute aortic dissection type A, the reimplantation technique leads to results comparable to established techniques. Complete removal of diseased tissue, low incidence of reoperation, and lack of anticoagulation may favor this approach in selected patients.
Enzymatic indices of myocardial necrosis: influence on short- and long-term prognosis after myocardial infarction.
Authors: P L Thompson, E E Fletcher, V Katavatis
Journal: Circulation (1979)

The prognostic effect of the peak level of serum creatine kinase (CK) and aspartate transaminase (AST), estimated daily for 3--5 days after acute myocardial infarction, was studied in 560 patients who survived the first day in hospital. In a subgroup of 54 patients, peak enzyme levels correlated well with the cumulated CK release (r = 0.90 with peak CK, r = 0.74 with peak AST), thus reflecting the extent of myocardial necrosis. Total mortality within a year after infarction was not significantly different in the lower three quintiles of peak serum enzyme level, but increased from 15.5% to 27.9% (p less than 0.001) when peak CK level exceeded eight times the upper limit of normal (8 X N) and form 13.1% to 34.8% (p less than 0.001) when peak AST level exceeded five time the upper limit of normal (5 X N). The effect of high enzyme levels was more marked in patients with a prior history of myocardial infarction; mortality increased from 14.7% for first infarctions to 18.2% for recurrent infarctions, with peak CK greater than 8 X N, and from 27.0% for first infarctions to 38.0% for recurrent infarctions with peak CK greater than 8 X N. Early mortality was more significantly affected (p less than 0.0001) than late mortality (p less than 0.05). In hospital survivors, late deaths from cardiac decompensation were three times (p less than 0.05) more frequent in the high enzyme group as in the low enzyme group, but the number of sudden deaths was unaffected. These findings have important implications for studies of reduction of myocardial infarct size.
Designing Medical and Educational Intervention Studies: A review of some alternatives to conventional randomized controlled trials
Authors: Clare Bradley
Journal: Diabetes Care (1993)

The advantages and limitations of RCT designs are discussed, and a range of alternative designs for medical and educational intervention studies considered. Designs selected are those that address the much neglected psychological issues involved in the recruitment of patients and allocation of patients to treatments within trials. Designs include Zelen's (18) randomized consent design, Brewin and Bradley's (20) partially randomized patient-centered design, and Korn and Baumrind's (21) partially randomized clinician-centered design. The possibilities of combining features from each of the last two designs are illustrated, and the advantages of adopting a more flexible and clinically relevant approach to the design of clinical trials are discussed.
Red cell distribution width has incremental prognostic value to B‐type natriuretic peptide in acute heart failure
Authors: Colette E. Jackson, Jonathan R. Dalzell, Vladimir Bezlyak, Ioannis K. Tsorlalis, Rachel C. Myles, Richard Spooner, Ian Ford, Mark C. Petrie, Stuart M. Cobbe, John J.V. McMurray
Journal: European Journal of Heart Failure (2009)
Speech that irritates
Authors: G. Dunea
Journal: BMJ (2003)

Professors of medicine exposed to case presentations by generations of house officers might be forgiven if they eventually develop an aversion to certain overused expressions. Perhaps most annoying among these is the constant use of “multiple,” which has completely replaced the older English adjectives “few,” “several,” and “many.” In the context of a skimped medical history, “multiple operations” means more than one, less than 20, nobody knows, nobody bothered to ask, and …
Early Improvement of Unstable Diabetic Retinopathy After Solitary Pancreas Transplantation
Authors: Rosa Giannarelli, Alberto Coppelli, Maria S. Sartini, Michele Aragona, Ugo Boggi, Franco Mosca, Michele Nardi, Stefano Del Prato, Piero Marchetti
Journal: Diabetes Care (2002)

Solitary pancreas transplantation (SPT) can significantly improve the quality of life of diabetic patients by eliminating the need for exogenous insulin, frequent home glucose monitoring, and many of the dietary restrictions imposed by the disease. In addition, successful SPT is able to eliminate acute diabetes complications, such as hypoglycemic and/or hyperglycemic episodes (1).

The effects of SPT on long-term complications of diabetes is less clear, but restoration of long-lasting normoglycemia seems to have several beneficial actions, including improvement of neuropathy and nephropathy (2). Little information is currently available on the role of SPT on the evolution of diabetic retinopathy. Ramsay et al. (3) studied the progression of retinopathy in solitary pancreas recipients and found some beneficial effect at 3 years after transplant.

An SPT program in type 1 diabetic patients has recently started in …
Cancer risk among atomic bomb survivors. The RERF Life Span Study. Radiation Effects Research Foundation
Authors: Y. Shimizu
Journal: JAMA (1990)

This article summarizes the risk of cancer among the survivors of the atomic bombing of Hiroshima and Nagasaki. We focus primarily on the risk of death from cancer among individuals in the Life Span Study sample of the Radiation Effects Research Foundation from 1950 through 1985 based on recently revised dosimetry procedures. We report the risk of cancer other than leukemia among the atomic bomb survivors. We note that the number of excess deaths of radiation-induced malignant tumors other than leukemia increases with age. Survivors who were exposed in the first or second decade of life have just entered the cancer-prone age and have so far exhibited a high relative risk in association with radiation dose. Whether the elevated risk will continue or will fall with time is not yet clear, although some evidence suggests that the risk may be declining. It is important to continue long-term follow-up of this cohort to document the changes with time since exposure and to provide direct rather than projected risks over the lifetime of an exposed individual.
Abstract 3567: Interaction of pralatrexate with the EGFR/MAPK pathway leads to synergistic activity with EGFR inhibitors
Authors: Maria Serova, Ivan Bieche, Michel Vidaud, Gijsbertus J. Pronk, Esteban Cvitkovic, Sandrine Faivre, Eric Raymond
Journal: Cancer Research (2011)

Abstract Background: Pralatrexate (FOLOTYN®), an antifolate targeting dihydrofolate reductase, has high affinity for reduced folate carrier-1 and is an efficient substrate for polyglutamation by folypolyglutamyl synthetase. Combinations of cytotoxics and small molecule EGFR inhibitors (EGFRi's) have had little clinical success. Recent demonstration that intracellular folates may modulate survival signaling pathways, including EGFR/MAPK, suggests a potential for rational combinations of antifolates and EGFRi's. This study investigated potential roles of the EGFR/MAPK pathway in pralatrexate sensitivity and explored combinations of pralatrexate with EGFRi's. Materials and Methods: Anti-proliferative effects of pralatrexate were evaluated in a panel of human cancer cell lines. mRNA expression was analyzed by qRT-PCR and protein was evaluated by Western blot. Effects of drug combinations were evaluated using the Chou &amp; Talalay method. Results: Pralatrexate displayed potent anti-proliferative effects in 9 of 15 human cancer cell lines, with HEP2 (head &amp; neck [H&amp;N]) and DU145 (prostate) cell lines showing IC50s of 50 nM and 15 nM, respectively. Sensitivity to pralatrexate correlated with higher pre-treatment mRNA expression of EGFR. After 5 hrs of exposure to 10 nM pralatrexate, increased phosphorylation of ERK1/2, MEK1/2, and the downstream target c-JUN was seen in HEP2 and DU145 cells. In addition, early activation of EGFR and EGFR protein degradation was observed. To further explore possible interactions between pralatrexate and the EGFR pathway, combination studies with EGFRi's were performed. Synergistic activity was observed in the MTT assay when pralatrexate was used in combination with erlotinib, gefitinib, and lapatinib in DU145, PC3, and LNCaP prostate and HEP2 H&amp;N cancer cells. Synergistic activity was most pronounced when pralatrexate was given prior to the EGFRi's. Conclusions: Higher expression of EGFR was associated with pralatrexate sensitivity in a panel of human cancer cell lines. Pralatrexate treatment resulted in activation of the EGFR/MAPK pathway. Sequential administration of pralatrexate followed by EGFRi's resulted in synergistic anti-tumor activity. These findings provide rationale for clinical evaluation of pralatrexate in combination with EGFRi's, in particular in tumors sensitive to antifolates and EGFRi's such as NSCLC and H&amp;N cancer. In addition, evaluation of pralatrexate in combination with inhibitors of downstream EGFR targets is warranted. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 3567. doi:10.1158/1538-7445.AM2011-3567
Media, patient confidentiality: compatible?
Authors: Virginia S. Cowart
Journal: JAMA (1985)

When William C. DeVries, MD, first proposed putting an artificial heart in a human in 1981, he was—in his own words—"stunned" when a surgeon he greatly admired called it (in print) a ridiculous idea that should never be done. Four years and four patients later, DeVries has been simultaneously hailed as a medical pioneer and castigated for conducting research in a "circuslike" atmosphere. In a recent interview with<i>JAMA</i>MEDICAL NEWS, DeVries talked about his views on the release of medical information through the nonmedical press, how widespread publicity may affect the outcome of a medical experiment, and whether such publicity breaches the traditional confidentiality of the patient-physician relationship. In a recent speech to newspaper editors in Washington, DC, DeVries had said: "Many doctors maintain a steadfast refusal to talk with the [news] media about individual cases because they are convinced it invades the sanctity of the doctor-patient relationship. They