After five decades of growth that has included advances in medical education and health care delivery, value cohesion, and integration of diversity, we propose an overarching mission for academic general internal medicine to lead excellence, change, and innovation in clinical care, education, and research. General internal medicine aims to achieve health care delivery that is comprehensive, technologically advanced and individualized; instills trust within a culture of respect; is efficient in the use of time, people, and resources; is organized and financed to achieve optimal health outcomes; maximizes equity; and continually learns and adapts. This mission of health care transformation has implications for the clinical, educational, and research activities of divisions of general internal medicine over the next several decades.
The increased use of social media by physicians, combined with the ease of finding information online, can blur personal and work identities, posing new considerations for physician professionalism in the information age. A professional approach is imperative in this digital age in order to maintain confidentiality, honesty, and trust in the medical profession. Although the ability of physicians to use online social networks, blogs, and media sites for personal and professional reasons should be preserved, a proactive approach is recommended that includes actively managing one's online presence and making informed choices about disclosure. The development of a "dual-citizenship" approach to online social media that separates public and private personae would allow physicians to both leverage networks for professional connections and maintain privacy in other aspects. Although social media posts by physicians enable direct communication with readers, all posts should be considered public and special consideration for patient privacy is necessary.
BACKGROUND:Although patients are commonly using the Internet to find healthcare information, the amount of personal and professional physician information and patient-generated ratings freely accessible online is unknown.OBJECTIVE:To characterize the nature of online professional and personal information available to the average patient searching for physician information through a standardized web search.DESIGN, SETTING, AND PARTICIPANTS:We studied 250 randomly selected internal medicine physicians registered with the Massachusetts Board of Registration in Medicine in 2008. For each physician, standardized searches via the Google search engine were performed using a sequential search strategy. The top 20 search results were analyzed, and websites that referred to the study subject were recorded and categorized. Physician rating sites were further investigated to determine the number of patient-entered reviews.MAIN MEASURES:Number and content of websites attributable to specific physicians.KEY RESULTS:Websites containing personal or professional information were identified for 93.6% of physicians. Among those with any web sites identified, 92.8% had professional information and 32.4% had personal information available online. Female physicians were more likely to have professional information available on the Internet than male physicians (97.5% vs. 91.7%, p=0.03), but had similar rates of available personal information (32.5% vs. 32.5%, p=ns). Among personal sites, the most common categories included social networking sites such as Facebook (10.8% of physicians), hobbies (10.0%), charitable or political donations (9.6%), and family information (8.8%). Physician rating sites were identified for 86.4% of providers, but only three physicians had more than five reviews on any given rating site.CONCLUSIONS:Personal and professional physician information is widely available on the Internet, and often not under direct control of the individual physician. The availability of such information has implications for physician-patient relationships and suggests that physicians should monitor their online information.
AIM:Leptin and adiponectin are two well-studied adipokines in relation to malignancies. In this study, we examined the association between leptin/adiponectin and risk of B-cell chronic lymphocytic leukemia (B-CLL), as well as the relationships between adipokines and several established prognostic factors of B-CLL.METHODS:Ninety-five patients with incident B-CLL and 95 hospital controls matched on age and gender were studied between 2001 and 2007, and blood samples were collected. Leptin, total and high molecular weight adiponectin, and prognostic markers of B-CLL were determined.RESULTS:Cases had a higher body mass index (BMI) than controls (p = 0.01) and lower levels of leptin (p < 0.01). Significantly more cases than controls presented a family history of lymphohematopoietic cancer (LHC) (p = 0.01). Higher serum leptin levels were associated with lower risk of B-CLL adjusting for age, gender, family history of LHC, BMI and serum adiponectin; the multivariate odds ratio comparing highest to lowest tertile was 0.05 (95% CI 0.01-0.29, p trend < 0.001); Adiponectin was not significantly different between cases and controls.CONCLUSION:Leptin was found to be inversely associated with risk of CLL but in contrast to prior studies of CLL and hematologic malignancies, this study found no significant association between CLL and adiponectin.
The purpose of this article is to report the unusual presentation of a 63-year-old patient with Rutherford grade 2, category 5 tissue ischemic changes involving the right foot secondary to an occult popliteal stenosis that was obscured behind a prosthetic knee on diagnostic angiograms. Conventional abdominal angiography with bilateral lower extremity runoff showed no evidence of significant disease and the patient was misdiagnosed with atheroemboli syndrome secondary to ipsilateral common femoral access following recent catheterization. Ultimately, a meticulous physical examination disclosed a bruit in the right popliteal fossa and selective right leg angiography with oblique views confirmed eccentric complex luminal encroachment in the right popliteal artery that was eclipsed by a prosthetic knee on antecedent nonselective angiography. The lesion responded favorably to endovascular treatment with durable clinical improvement. This case illustrates the importance of a meticulous physical examination and noninvasive studies prior to angiography in patients with ischemic tissue changes and emphasizes the importance of oblique views to image any vessel that may be obscured by a metal prosthesis.
BACKGROUND: Finding the optimal image intensifier angle of obliquity during renal intervention is important for accurate stent placement but can require multiple catheter rotations and test injections of contrast. OBJECTIVE: Explore the usefulness of axial magnetic resonance angiography (MRA) as a roadmap for predicting image intensifier position during subsequent renal intervention. METHODS: MRA images were reviewed in 137 consecutive patients (255 renal arteries) undergoing workup for renal artery stenosis. The axial angle of renal artery incidence perpendicular to the spine was estimated by two operators and results averaged. RESULTS: The average angle of incidence for the renal artery ostia was +21.24 degrees +/-2.31 degrees for the right and +8.81 degrees +/-2.0 degrees for the left (P < .0001). The positive numbers correlate with left anterior oblique (LAO) and negative right anterior oblique (RAO). CONCLUSIONS: MRA can be used to define the origin of the renal artery and is most likely to predict an LAO image window for subsequent angiography of the left and right renal arteries displacing the "ipsilateral oblique" axiom. In patients without baseline MRA the 10 to 20 degree LAO "empiric" position will allow coaxial imaging of both renal ostia in 75% of cases. However, there can be extreme variation in the renal origin (53 degrees RAO to 85 degrees LAO) and we advocate using the simple technique reported herein to define the renal origin in patients with pre-procedure MRA.
The purpose of this study is to report the progress of a patient who entered the hospital with symptomatic tracheal compression from a large right subclavian artery aneurysm that was treated with a self-expanding stent graft. The patient was at increased risk for traditional surgery, thus endovascular isolation of the aneurysm was felt to be reasonable. A flexible self-expanding stent graft was placed via a brachial artery cutdown and common femoral access without complication. The symptoms improved and the patient remained asymptomatic at 2-year follow-up with serial CT scan confirmation of aneurysm regression. This unusual case illustrates that endovascular decompression of an aneurysm may have some benefit in alleviating subacute symptoms of extrinsic encroachment into other vital structures. Technical and clinical success was achieved with the stent graft deployment and this seems to be a reasonable alternative to surgery in such patients.
Carotid stent-supported angioplasty is currently under investigation in many medical centers, for use in treating extracanial cerebrovascular disease. The early results of CSSA in selected patients appear promising. While carotid endarterectomy (CEA) remains the current standard of care, we believe that a small subgroup of patients at a high risk for surgery can benefit from CSSA. This case report describes a patient with symptomatic high-grade recurrent stenosis due to critical angulation (kinking) and redundancy of the internal carotid artery following CEA with patch angioplasty who was then treated successfully with CSSA.
BACKGROUND AND PURPOSE:Several studies have reported on the correlation of ultrasonic carotid plaque morphology, cerebrovascular symptoms, and intraplaque hemorrhage. This study correlates ultrasonic carotid plaque morphology with the degree of carotid stenosis.METHODS:Carotid arteries (n=2460) were examined by using color duplex ultrasound during a 1-year period. Carotid stenoses were classified into <50%, 50% to <60%, 60% to <70%, and >70% to 99%. Ultrasonic plaque morphology was characterized as either heterogeneous (mixed hyperechoic, hypoechoic, and isoechoic) or homogeneous.RESULTS:Heterogeneous plaques were noted in 138 of 794 arteries with <50% stenosis, in 191 of 564 arteries with 50% to <60% stenosis, in 301 of 487 arteries with 60% to <70% stenosis, and in 496 of 615 arteries with 70% to 99% stenosis. The higher the degree of stenosis, the more likely it is to be associated with heterogeneous plaques. Heterogeneous plaques were present in 59% of the arteries with > or =50% stenoses versus 17% of the arteries with <50% stenoses, in 72% of the arteries with > or =60% stenoses versus 24% of the arteries with <60% stenosis, and in 80% of the arteries with > or =70% stenoses versus 34% of the arteries with <70% stenoses (P<0.0001 and odds ratios of 6.9, 8.1, and 8.0, respectively). Heterogeneous plaques were associated with an incidence of symptoms that was higher than that for homogeneous plaques for all grades of stenoses; percentages were, respectively, as follows: 68% versus 16% for <50% stenosis; 76% versus 21% for 50% to <60% stenosis; 79% versus 23% for 60% to <70% stenosis, and 86% versus 31% for > or =70% to 99% stenosis (P<0.0001 and odds ratios of 8.9, 11.9, 12.6, and 13.7, respectively). Heterogeneity of plaques was more positively correlated with symptoms than with any degree of stenosis (regardless of plaque structure). Eighty percent of all heterogeneous plaques were symptomatic versus 58% for all stenoses > or =50%, 68% for all stenoses > or =60%, and 75% for all stenoses > or =70% (P<0.0001, P<0.0001, and P=0.02, respectively).CONCLUSIONS:The higher the degree of carotid stenosis, the more likely it is to be associated with ultrasonic heterogeneous plaque and cerebrovascular symptoms. Heterogeneity of the plaque was more positively correlated with symptoms than with any degree of stenosis. These findings suggest that plaque heterogeneity should be considered in selecting patients for carotid endarterectomy.
A 72-year-old woman developed severe flank pain associated with hemodynamic compromise immediately after a J-curve guidewire was inadvertently advanced into the right renal artery during cardiac catheterization. Contrast extravasation consistent with perforation of the main renal artery was seen on abdominal angiography. The perforation was successfully sealed using a premounted coronary stent that was covered with an autologous antecubital vein. Wide stent patency without aneurismal dilatation was confirmed on a 2-year follow-up renal angiogram.