Deepan Dalal

Migraine Headache and Ischemic Stroke Risk: An Updated Meta-analysis

BACKGROUND Observational studies, including recent large cohort studies that were unavailable for prior meta-analysis, have suggested an association between migraine headache and ischemic stroke. We performed an updated meta-analysis to quantitatively summarize the strength of association between migraine and ischemic stroke risk. METHODS We systematically searched electronic databases, including MEDLINE and EMBASE, through February 2009 for studies of human subjects in the English language. Study selection using a priori selection criteria, data extraction, and assessment of study quality were conducted independently by reviewer pairs using standardized forms. RESULTS Twenty-one (60%) of 35 studies met the selection criteria, for a total of 622,381 participants (13 case-control, 8 cohort studies) included in the meta-analysis. The pooled adjusted odds ratio of ischemic stroke comparing migraineurs with nonmigraineurs using a random effects model was 2.30 (95% confidence interval [CI], 1.91-2.76). The pooled adjusted effect estimates for studies that reported relative risks and hazard ratios, respectively, were 2.41 (95% CI, 1.81-3.20) and 1.52 (95% CI, 0.99-2.35). The overall pooled effect estimate was 2.04 (95% CI, 1.72-2.43). Results were robust to sensitivity analyses excluding lower quality studies. CONCLUSIONS Migraine is associated with increased ischemic stroke risk. These findings underscore the importance of identifying high-risk migraineurs with other modifiable stroke risk factors. Future studies of the effect of migraine treatment and modifiable risk factor reduction on stroke risk in migraineurs are warranted.

Relationship Between Metabolic Syndrome and Carotid Intima-Media Thickness: Cross-Sectional Comparison Between Psoriasis and Psoriatic Arthritis

To determine the differences in carotid intima‐media thickness (CIMT) between patients with psoriatic diseases with and without metabolic syndrome.

Internal Medicine Residency Training on Topics in Ambulatory Care: A Status Report

The Association of Professors of Medicine (APM) is the national organization of departments of internal medicine at the US medical schools and numerous affiliated teaching hospitals as represented by chairs and appointed leaders. As the official sponsor of The American Journal of Medicine, the association invites authors to publish commentaries on issues concerning academic internal medicine. For the latest information about departments of internal medicine, please visit APMs website at www.im.org/APM. In the US, medical care for most consists of an ambulatory visit. 1-3 When a new medical concern arises, the general internist is typically the first contact. 4 Over the years, ambulatory care has grown to include postacute care from recently hospitalized patients, as well as increasingly complex chronic disease management for diabetes, hypertension, and other diseases. 1 As a result, the need for general internists is growing. 5 Despite this projected increasing need, our current system of training is not producing more general internists. The number of medical students choosing residencies in primary care-oriented internal medicine programs is decreasing , and the number of internal medicine residents choosing careers as general internists is decreasing. 6 There is a structural disconnect between internal medicine residency training and the primary care needs of the population. 1-3,7,8 Internal medicine residency training is heavily inpatient-based, often at the expense of training in ambulatory care. 1,2,7,8 Training in ambulatory care is valued less by residents than are the general medical wards and intensive care unit rotations, despite the fact that the majority of residents will pursue careers that include a strong ambulatory component. 9 Residents graduate from internal medicine residency training programs without the necessary skills to effectively practice ambulatory care, and report feeling unprepared to provide outpatient care. Societys need for competent ambulatory care is growing. Hospitalization rates and Medicare expenditures are both improved by access to a talented pool of general internists. 4,5 The shrinking number of general internists and the shortcomings of internal medicine residency training may be contributing to suboptimal care of common chronic diseases such as diabetes and hypertension. 2,4,11 Internal medicine residents are receiving inadequate training in chronic disease management , and training should be redesigned to improve teaching in ambulatory care. Many of the suggestions for internal medicine residency redesign have focused on structural aspects of training, including a better balance of the time committed to teaching in ambulatory care. There has been little discussion of …

Impact of pretransplant rifaximin therapy on early post–liver transplant infections

Bacterial and fungal infections are major causes of morbidity and mortality after liver transplantation (LT). The role of intestinal decontamination in the prevention of post‐LT infections is controversial. Rifaximin is widely used for the treatment of hepatic encephalopathy. The effect of rifaximin on post‐LT infections is unknown. The aim of our study was to determine the effect of rifaximin therapy in the pretransplant period on early bacterial infections (EBIs) and fungal infections within the first 30 days after LT. All adult patients who underwent LT at our institution (January 2009 to July 2011) were included in this retrospective cohort study. Patients receiving antibiotics other than pretransplant protocol antibiotics were excluded. Patients were stratified into 2 groups based on the presence or absence of rifaximin therapy for at least 2 days before LT. Infections were defined by the isolation of any bacterial or fungal organisms within 30 days of LT. Multivariate regression analysis, Student t tests, and Pearsons chi‐square tests were used to compare the 2 groups. Two hundred sixty‐eight patients were included, and 71 of these patients (26.5%) were on rifaximin at the time of LT. The 2 groups were comparable with respect to age, sex, race, and Model for End‐Stage Liver Disease score. There were no significant differences in the rates of EBIs (30% for the non‐rifaximin group and 25% for the rifaximin group, P = 0.48) or fungal infections between the 2 groups. There was no increase in antimicrobial resistance among the infecting organisms. There was no difference in survival between the rifaximin and non‐rifaximin groups (98% versus 97%, P = 0.36). In conclusion, the use of rifaximin in the pre‐LT period was not associated with an increased risk of bacterial or fungal infections in the early post‐LT period. Liver Transpl 20:544–551, 2014.

Methotrexate dosage as a source of bias in biological trials in rheumatoid arthritis: a systematic review

Objectives To evaluate if optimal dose of either oral or injectable regimens of methotrexate (MTX) of 25 mg/week was used in the comparator arms of studies comparing biologic drugs with MTX in rheumatoid arthritis (RA). Methods A systematic literature search was carried out in MEDLINE, EMBASE and the Cochrane Library databases for randomised controlled trials comparing biologics with MTX in RA. A systematic review was performed among studies that met predefined criteria focusing on assessment of dose of MTX used in the comparator arm. Study authors were contacted when necessary. Study quality was assessed. Results A total of 3276 references were identified and 13 trials were included. We obtained maximal dose and regimen for all. The maximal dose of MTX used in the comparator arm of the trials was no more than 20 mg/week in any trial and for all but one trial, MTX was given orally and not by injection. The trial that used an injectable form reached a maximum of 15 mg/week. Conclusions A suboptimal dose of MTX was used in biological clinical trials performed in RA, particularly regarding route of administration. This may have biased findings in favour of biological agents.

Quantifying harmful effects of psoriatic diseases on quality of life: Cardio-metabolic outcomes in psoriatic arthritis study (COMPASS).

OBJECTIVE Up to 30% of patients with psoriasis suffer from concurrent psoriatic arthritis, and both the diseases have worse quality-of-life outcomes compared to the general population. There is limited literature comparing quality-of-life outcomes between these diseases. We seek to compare quality-of-life outcomes between both these groups. METHODS The current study is a cross-sectional analysis of a cohort of 252 patients with psoriatic diseases, who were recruited from 2 tertiary-care centers. A self-administered questionnaire was used to collect demographic and validated quality-of-life data using short form-12 (SF 12), health assessment questionnaire (HAQ), and dermatology life quality index (DLQI). Univariate and multivariate analyses were conducted to compare the quality-of-life outcomes. RESULTS We included 107 (42.5%) psoriatic arthritis and 145 (57.5%) psoriasis patients in the cohort. The groups had comparable gender distribution and co-morbid diseases prevalence, but arthritis patients were older and received biologics/DMARDs more frequently than psoriasis patients. The physical indices (identified by HAQ and SF 12 PCS) were worse for psoriatic arthritis, whereas the mental/psychometric indices (identified by DLQI and SF 12 MCS) were comparable between both the groups. CONCLUSIONS Despite aggressive therapy, physical quality of life was worse in psoriatic arthritis patients compared to psoriasis patients. The mental quality-of-life indices were comparable in both the groups and were still below the population norm. These results suggest need for screening for psoriatic arthritis in patients with psoriasis to reduce the burden of physical quality of life and screening for early signs of psychiatric illnesses in both these disease populations.

Factors affecting learner satisfaction with an internet-based curriculum

Objective Online curricula are used increasingly for educating physicians, and evaluating educational outcomes can help improve their effectiveness. It is unknown how specific educational outcomes associate with each other among learners using online curricula. We set out to study how two educational outcomes, learner satisfaction and knowledge, and the learner’s year of training and training hospital, were associated with one another among learners accessing a widely used online curriculum. Methods Using data from the 2006–2007 academic year, learner satisfaction was compared with pretest knowledge, posttest knowledge, changes in knowledge, module topic, year of training, and training hospital among 3229 residents at 73 internal medicine residency training programs. A multivariable model was used to calculate the odds ratio of learner satisfaction relative to changes in knowledge. Results Module topic, year of training, and hospital type were associated with learner satisfaction. Second-year residents were more satisfied with training modules (mean rating 4.01) than first- and third-year residents (mean ratings 3.97 and 3.95, respectively; P < 0.05). Learner satisfaction was greater among community hospital residents than university hospital residents (mean rating 4.0 vs 3.92; P < 0.05). Learner satisfaction was greater in residents with high pretest and high posttest knowledge (P < 0.05). In multivariate analyses, greater gains in knowledge were associated with greater learner satisfaction (P < 0.05). Conclusions Greater learner satisfaction is associated with greater baseline knowledge, greater knowledge after completing a curriculum, and greater improvement in knowledge while enrolled in a curriculum.

Use of non-steroidal anti-inflammatory drugs correlates with the risk of venous thromboembolism in knee osteoarthritis patients: a UK population-based case-control study

OBJECTIVE We aimed to examine whether the current users of specific NSAIDs have an increased risk of venous thromboembolism (VTE) among knee OA patients. METHODS We conducted a population-based case-control study using The Health Improvement Network, a database of patient records from general practices in the UK. For every VTE case, we identified five controls matched on age, sex and calendar year of study enrolment. We used conditional logistic regression to assess the association between current use of specific NSAIDs and risk of VTE relative to remote NSAID users. RESULTS Among knee OA patients with at least one NSAID prescription, we identified 4020 incident cases of VTE and 20 059 matched controls. Adjusted odd ratios (ORs) relative to the remote users were 1.38 (95% CI: 1.32, 1.44) for recent users and 1.43 (95% CI: 1.36, 1.49) for current users. Among the current NSAID users, the risk of VTE was increased with diclofenac [OR 1.63 (95% CI: 1.53, 1.74)], ibuprofen [OR = 1.49 (95% CI: 1.38, 1.62)], meloxicam [OR = 1.29 (95% CI: 1.11, 1.50)] and coxibs [celecoxib, OR = 1.30 (95% CI: 1.11, 1.51); rofecoxib, OR = 1.44 (95% CI: 1.18, 1.76)]; naproxen did not increase VTE risk [OR = 1.00 (95% CI: 0.89, 1.12)]. CONCLUSION Compared with the remote users of NSAIDs, the risk of VTE increased for current users of diclofenac, ibuprofen, meloxicam, and coxibs, but not for naproxen, in the knee OA population. Clinicians should consider the risk profile for specific NSAIDs when recommending their use.

Associations between quality indicators of internal medicine residency training programs

BackgroundSeveral residency program characteristics have been suggested as measures of program quality, but associations between these measures are unknown. We set out to determine associations between these potential measures of program quality.MethodsSurvey of internal medicine residency programs that shared an online ambulatory curriculum on hospital type, faculty size, number of trainees, proportion of international medical graduate (IMG) trainees, Internal Medicine In-Training Examination (IM-ITE) scores, three-year American Board of Internal Medicine Certifying Examination (ABIM-CE) first-try pass rates, Residency Review Committee-Internal Medicine (RRC-IM) certification length, program director clinical duties, and use of pharmaceutical funding to support education. Associations assessed using Chi-square, Spearman rank correlation, univariate and multivariable linear regression.ResultsFifty one of 67 programs responded (response rate 76.1%), including 29 (56.9%) community teaching and 17 (33.3%) university hospitals, with a mean of 68 trainees and 101 faculty. Forty four percent of trainees were IMGs. The average post-graduate year (PGY)-2 IM-ITE raw score was 63.1, which was 66.8 for PGY3s. Average 3-year ABIM-CE pass rate was 95.8%; average RRC-IM certification was 4.3 years. ABIM-CE results, IM-ITE results, and length of RRC-IM certification were strongly associated with each other (p < 0.05). PGY3 IM-ITE scores were higher in programs with more IMGs and in programs that accepted pharmaceutical support (p < 0.05). RRC-IM certification was shorter in programs with higher numbers of IMGs. In multivariable analysis, a higher proportion of IMGs was associated with 1.17 years shorter RRC accreditation.ConclusionsAssociations between quality indicators are complex, but suggest that the presence of IMGs is associated with better performance on standardized tests but decreased duration of RRC-IM certification.

A 60-year-old man with abdominal bruising.

A man with liver cancer developed abdominal ecchymoses resembling the Cullen sign and flank ecchymoses resembling the Grey Turner sign.