Christopher J. Wong

Serious group a streptococcal infections.

The spectrum of illnesses caused by group A streptococcus (GAS) includes invasive infections, noninvasive infections, and noninfectious complications. Increasingly virulent infections associated with high morbidity and mortality have been observed since the late 1980s and continue to be prevalent in North America and worldwide. Penicillin remains the therapy of choice, with the addition of clindamycin recommended in high risk cases. Early recognition of GAS as the cause of these serious clinical syndromes is critical for timely administration of appropriate therapy. In this review, the pathophysiology, clinical manifestations, and treatment of invasive GAS infections are discussed.

Involuntary Weight Loss

Involuntary weight loss remains an important and challenging clinical problem, with a high degree of morbidity and mortality. Because of the frequency of finding a serious underlying diagnosis, clinicians must be thorough in assessment, keeping in mind a broad range of possible causes. Although prediction scores exist, they have not been broadly validated; therefore, clinical judgment remains ever essential.

Primary Care of the Solid Organ Transplant Recipient

Solid organ transplantation (SOT) is one of the major advances in medicine. Care of the SOT recipient is complex and continued partnership with the transplant specialist is essential to manage and treat complications and maintain health. The increased longevity of SOT recipients will lead to their being an evolving part of primary care practice, with ever more opportunities for care, education, and research of this rewarding patient population. This review discusses the overall primary care management of adult SOT recipients.

Office-Based Screening of Common Psychiatric Conditions

Depression and anxiety disorders are common conditions with significant morbidity. Many screening tools of varying length have been well validated for these conditions in the office-based setting. Novel instruments, including Internet-based and computerized adaptive testing, may be promising tools in the future. The best evidence for cost-effectiveness currently is for screening of major depression linked with the collaborative care model for treatment. Data are not conclusive regarding comparative cost-effectiveness of screening for multiple conditions at once or for other conditions. This article reviews screening tools for depression and anxiety disorders in the ambulatory setting.

The Perioperative Medicine Consult Handbook

The perioperative medicine consult handbook / , The perioperative medicine consult handbook / , کتابخانه دیجیتال جندی شاپور اهواز

Epilepsy and Seizure Disorders

DESCRIPTION AND FACTS: The word “epilepsy” comes from the Greek word for “seizure.” It is a disorder of the central nervous system. Brain cells (neurons) create abnormal electrical discharges that cause seizures, which is the temporary loss of awareness and/or control over certain body functions. The many types of epilepsy are often called seizure disorders. Epilepsy is not: • A disease • Contagious • A mental illness • A sign of low intelligence

The ambulatory morbidity and mortality conference meets the morning report

the outcomes in ARMD patients. However, these therapeutic options are relatively new and are unknown to many general practitioners (GPs), although earlier recognition of the problem is expected to reduce associated disability and burden of care. What was tried? A mail survey was used to identify the gaps in GPs’ knowledge of ARMD. The entire GP population in the Spanish region of Castilla and Leon (n = 2365) was surveyed, giving a response rate of 31%. There were no significant differences between responders and non-responders with respect to their demographic or patient portfolio characteristics. The results of the survey were used to inform the design of courses to remediate these gaps in knowledge. An Internet-based course was offered within the health regional government e-learning platform. This platform allows the student’s progress to be tracked. Interaction among teachers and learners was provided through an open forum and student commitment in return for access to subsequent online materials was required. A hybrid course was offered to doctors attending a Spanish GP congress. The objectives and contents of the online materials were identical to those of the materials given to the previous group. Materials were fully accessible for 4 months and were provided within the e-learning platform of the congress, which did not allow any interactive activity. Organisers included a face-to-face course component that consisted of a 2-hour lecture delivered during the conference. There were no differences in sex, age and number of years in practice between the GPs participating in the Internet-based and conferencedelivered courses. The proportion of change in knowledge of ARMD after the courses was calculated as a summation of all off-diagonal proportions in contingence tables. The study was approved by the local ethics committees. What lessons were learned? Serious deficiencies in knowledge of ARMD were detected in the survey, which highlights this as a high-priority teaching topic. In a similar study, doctors demonstrated favourable attitudes towards eye health management, but only 52% of respondents indicated they had adequate knowledge to manage eye diseases. The initial evaluation of information provided by the preliminary survey in this study contributed to the design of specific training programmes. The Internet-based course was undertaken by 205 GPs, 80% of whom passed the final examination. The number of responses using the ‘not known’ option reduced to almost zero and the probability that ARMD would be suspected was higher after the course. The partial in-class course was undertaken by 150 GPs, of whom only 33% passed the examination and 52% admitted to not having read the online materials. Statistically significant differences in results emerged between the two study groups, demonstrating that the effectiveness of learning was worse in the in-class group. The mean ± standard deviation age of course participants was 49.7 ± 9.4 years (range: 29–65 years). This study adds evidence of the effectiveness of continuing medical education programmes to improve care in ARMD. The use of information and communication technologies did not discourage older practitioners from participating. We recommend that teachers and organisers of e-learning courses select platforms that allow interaction to improve the effectiveness of learning.

An Unusual Case of Acute Foot Drop Caused by a Pseudoaneurysm

Lower extremity neurologic symptoms are a common presenting problem. Here we report the case of a 73-year-old man who developed acute right foot pain and foot drop. History, physical examination, and electrodiagnostic studies were consistent with a lumbosacral plexopathy. Imaging studies revealed an internal iliac artery pseudoaneurysm, a rare cause of acute foot drop.

A Cross-Sectional Analysis of Publication Types in Quality Improvement Journals.

Despite widespread engagement in quality improvement activities, little is known about the designs of studies currently published in quality improvement journals. This study’s goal is to establish the prevalence of the types of research conducted in articles published in journals dedicated to quality improvement. A cross-sectional analysis was performed of 145 research articles published in 11 quality improvement journals in 2011. The majority of study designs were considered pre-experimental (95%), with a small percentage of quasi-experimental and experimental designs. Of the studies that reported the results of an intervention (n = 60), the most common research designs were pre–post studies (33%) and case studies (25%). There were few randomized controlled trials or quasi-experimental study designs (12% of intervention studies). These results suggest that there are opportunities for increased use of quasi-experimental study designs.

What’s in a Number? Risk Thresholds in Different Statin Guidelines

W hen exactly should we recommend statin therapy to our patients for primary prevention? Clinical practice guidelines published since the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend quite a range of different treatment thresholds. Imagine the veteran who starts in a private practice, is recommended a 7.5% 10-year risk threshold to start statin therapy, then transfers to the VA system, where the threshold changes to 12%, and then moves to Canada, where the threshold goes back to 10%. While the itinerant patient example above may seem absurd, it highlights that there is more than just evidence-based medicine at play: guideline creation is as much art as it is cold hard evidence. At first glance, the evidence is that statins reduce cardiovascular outcomes in primary prevention across a wide range of baseline risk. On closer inspection, the art comes when we have to decide when and for whom to apply this risk reduction. The modern guidelines shown in Table 1 have some common features, as they attempt to transform evidence into primary prevention recommendations. The majority of guidelines recommend statin therapy based on risk rather than treating to LDL targets. They all advocate the use of risk thresholds divided into discrete categories based on the 10year risk of cardiovascular events as estimated by various risk calculators. Some of the guidelines use a Blow/moderate/highrisk^model: a low-risk category for which no statin therapy is recommended, an intermediate category with either a weakerstrength recommendation (e.g. Bconsider^ treating) or a recommendation for a lower drug dose, and a high-risk category for which treatment is more strongly recommended. In contrast, other guidelines use a dichotomous Blow/high-risk^ model (Bdo not treat/treat^). If we look at the thresholds at which these guidelines recommend statin therapy for primary prevention, we find that they vary from 7.5% to 12%. So why have these guidelines come up with different numbers? It is not because there are new clinical trials that have evaluated the outcomes of treatment based on different risk thresholds. The different clinical practice guidelines, by and large, were based on the same pool of studies: primary prevention trials of statin therapy that typically enrolled subjects based on cardiovascular risk factors and randomized them to a fixed dose of statin versus placebo. Instead, the reason for the difference in threshold recommendations is more likely that the concept of providing appropriate treatment based on risk, however sound, is challenging to translate into thresholds at which the benefits sufficiently outweigh the risks. In particular, the benefits and risks are hard to quantify. How much cardiovascular disease is worth preventing, and how many unnecessary or harmful treatments are we willing to accept to achieve a given level of prevention? The randomized controlled trials cannot answer these questions for us. We do not yet have a consensus framework on how best to set a treatment threshold. Cost–benefit analysis is a common method, and although it has since been applied to statin treatment thresholds, most guidelines did not incorporate this type of analysis in formulating their recommendations. Furthermore, cost–benefit analysis using quality-adjusted life years as an outcome is but one means of balancing benefit and harm, is itself controversial, and does not fully incorporate patient values, ethics, and implementation. Without a commonly agreed-upon framework beyond the dollar values of cost-effectiveness analyses, it is unlikely any guideline committee could come up with a number that everyone would—or should—agree with. Even if we could agree on how to establish a risk threshold, having treatment boil down to a single estimated number can feel uncomfortable, and for good reason. Is a patient estimated as having a 6% risk really so different from another who checks in at 8%? Furthermore, risk calculators vary widely in their ability to include racially diverse populations and those with other medical conditions. A review of recent data found that risk calculators often overestimate risk in real-world populations. Still, we commend these clinical guidelines for providing some kind of barometer for statin therapy. Guidelines should not just restate existing data—on some level there must always be value and judgment in a recommendation that simplifies our decision-making. How then should we approach the use of statin therapy in primary prevention with our patients, in the face of so many guidelines, each with distinct recommendations? Received March 20, 2016 Revised May 19, 2017 Accepted June 14, 2017 Published online June 29, 2017