Current guidelines for children are logical. Current guidelines for adolescent/adults follow from an assumption that I am happy to argue against.
All guidelines recommend not to test or treat for Centor scores (with or without McIsaac modification) of 0 or 1. The pre-test probabilities are very low and most positive tests are false positives. Unfortunately, many urgent care centers and emergency departments perform a rapid strep test prior to the treating practitioner spending 3-5 minutes doing a quick history and exam. Testing wastes resources in 40-50% of patients presenting with a sore throat complaint and leads to unnecessary antibiotics. This is the biggest mistake that I see!
The controversy for adolescents/adults with pharyngitis and Centor scores of 2-4 involves the concept of lack of proof. Why treat pharyngitis with antibiotics?
There are 5 potential reasons to treat pharyngitis with antibiotics:
Brandon Webb, MD, is an infectious disease physician in the division of epidemiology and infectious diseases at Intermountain Healthcare in Utah. He has also served as an adjunct assistant professor at the University of Utah School of Medicine. Dr. Webb’s research interests include bacterial pneumonia, antimicrobial stewardship, and transplant infectious diseases.
Andrew Shorr, MD, MPH, is an associate director of pulmonary and critical care medicine and the chief of the Pulmonary Clinic at MedStar Washington Hospital Center in Washington, DC. Dr. Shorr’s research interests include resistant pathogens and healthcare-associated bacteremia, and he has published more than 140 original studies.
Why did you develop the BAP-65 Score? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?
I think we were interested in developing the score for two reasons: one, as a purely academic exercises, given that we have risk scores for PE and risk scores for pneumonia, clearly one of the pulmonary disease states where patients are sicker than they look is in COPD. So it was a clear hole in the range of pulmonary-critical care disease states that didn’t have some pulmonary risk stratification tool. And when you tie that together with the fact that COPD is a leading reason for admission in general, you can understand.
Dr. Michael Fine, professor of medicine at the University of Pittsburgh, led the team that developed the Pneumonia Severity Index (PSI) and began studying the prognosis and other clinical aspects of community-acquired pneumonia (CAP) in the early 1990s.
His interest in predicting mortality in CAP started while he served as chief resident in internal medicine at the University of Pittsburgh. His mentor, Dr. Wishwa Kapoor, then hired him after his general internal medicine fellowship in the Harvard Generalist Faculty Development Program. At the time Dr. Fine transitioned from fellowship to faculty at the University of Pittsburgh, the Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality, AHRQ) had a well-funded portfolio of research projects called PORT (Patient Outcome Research Teams) studies. Continue reading “Predicting Mortality in Community Acquired Pneumonia – Dr. Robert Centor Interviews PSI Creator Dr. Michael Fine”→
Counseling patients with diabetes on lifestyle change during primary care office visits is motivated by good intentions. We as primary care doctors are interested in prevention, lifestyle changes can positively affect many patients with diabetes, and patients do best when engaged in managing their disease1. But it’s difficult to show with data that brief physician encounters are effective at producing any of these outcomes. Continue reading “Diabetes Management: Why Can’t We Do This with Lifestyle Alone?”→
Simon J. Griffin, DM, is professor of general practice at the University of Cambridge, Group Leader in the MRC Epidemiology Unit and an assistant general practitioner at Lensfield Medical Practice in Cambridge, UK. He leads the Prevention of Diabetes and Related Metabolic Disorders Programme. Professor Griffin’s research interests include prevention and early detection of chronic conditions such as diabetes.
Haywan Chiu, DPM, is a practicing podiatrist in Albuquerque, New Mexico. He has a special interest in the diabetic foot. Haywan runs Diabetic Foot Guardian, an easily digestible resource for patients regarding feet and diabetes.
Callus Debridement Can Be Diagnostic
Calluses form when shear forces and pressure induce the epidermis to reinforce itself. In patients with diminished pain sensation such as in diabetic neuropathy, continued friction from shear forces and pressure evolves the callus into a blister, then a blood blister (figure 1). When I see a bloody foot callus, I know that at some point, there was a break in the dermis. I don’t know if it has healed on its own or if it has expanded into a full blown ulcer because I can’t see past the callus. In fact, some calluses can be so thick I can’t even see the blood underneath! The only way to find out what’s hiding is to debride the callus.
Patrick S. Kamath, MD, is a professor of gastroenterology and hepatology at the Mayo Clinic in Rochester, Minnesota. His research interests include acute-on-chronic liver failure, nonalcoholic fatty liver disease, polycystic liver disease, Budd-Chiari syndrome and hereditary hemorrhagic telangiectasia. Dr. Kamath is internationally renowned as a leading researcher in hepatology and has also won numerous awards as an educator.
Why did you develop the MELD Score? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?
Following a trans-jugular intrahepatic portosystemic shunt (TIPS) procedure for complications of portal hypertension, some patients do well and others fare poorly. My colleague in statistics, Mike Malinchoc, and I studied laboratory variables prior to the procedure and identified INR, serum creatinine, serum bilirubin and etiology of cirrhosis being predictive of survival. We developed a score based on these variables and demonstrated it predicted survival in a wide variety of patients with cirrhosis not undergoing TIPS. The score was originally called the Mayo End-Stage Liver Disease (MELD) model and was shown to be superior to the Child-Turcotte-Pugh score. Continue reading “Interview with MELD Score Creator Dr. Patrick Kamath”→
Dr. John Bedolla is the assistant director of research education and assistant professor of emergency medicine at the Dell Medical School at the University of Texas at Austin. He is also editor-in-chief of ED CLEAR, an evidence-based medical risk reduction program. Dr. Joe Habboushe is MDCalc’s co-founder and CEO. Earlier this year, the two sat down and talked about MDCalc’s content development process and future plans.