Internet addiction and depression

A study out last year from the journal Psychopathology found a relationship between excessive Internet use and depression. It was based on an online questionnaire sent to 1319 respondents. Here are some selected portions of the abstract (my bold):

There is a growing awareness of a psychiatric construct that needs to be better defined and understood: Internet addiction (IA)...

Three scales were included: the IA Test, the Internet Function Questionnaire and the Beck Depression Inventory (BDI). 1,319 respondents completed the questionnaires, with 18 (1.2%) identified as falling in the IA category...

Across the whole data sample, there was a close relationship between IA tendencies and depression, such that IA respondents were more depressed; there were also significant differences between the sexes, with men showing more addictive tendencies than women. In addition, young people were significantly more likely to show addictive symptoms than were older people. There was a significant difference between the IA and the NA group in their levels of depressive symptoms, with the NA group firmly in the non-depressed range, and the IA group in the moderately-to-severely depressed range (F1, 34 = 22.35; p less than 0.001). In terms of the function for which they used the Internet, the IA group engaged significantly more than the NA group in sexually gratifying websites, gaming websites and online community/chat websites...

Related content at Clinical Cases and Images.

Acute respiratory failure complicating obesity hypoventilation syndrome

Review in Current Opinion in Pulmonary Medicine.

What have we learned about fluid therapy in septic shock?

From a review in Current Opinion in Critical Care:


Front load it and titrate it early to hemodynamic goals.


Although starch preparations have been associated with renal harm in some studies the type of fluid didn't matter in this literature review.

What is an internist anyway?

One time years ago, when it came out in conversation that I was a doctor, a lady asked what kind of a doctor I was. “An internist,” I said. “Are you learning a lot?” she asked. From that moment on I never told anyone I was an internist. My usual answer became “I am a specialist in internal medicine.” Clearly internal medicine struggles with its identity.


The other day DB did a little experiment. He asked readers to submit answers to the question “What is an internist?” He got eleven replies, mainly from internists, and nobody seemed to nail it.


In a follow up post he reflected on the difficulty we have in defining our specialty. He had this to say about what an internist is/does:

I like the comment about diagnostician, because in my experience that is the crux of the issue. Our job always involves diagnosing the patient, whether diagnosing a disease, the severity of disease, the response to medication (including unacceptable side effects), the patient's goals of therapy, or the social situation. Internists diagnosis and then appropriately treat adult patients. The location of our practice or the scope of our practice (generalist or subspecialist) does not change with that definition. Excellent internists order diagnostic tests (laboratory tests, observation over time, imaging studies or even referral to a subspecialist) in order to help the patient receive the most desirable outcome. That outcome depends on our diagnosis of the patient's desires.

True enough, but isn't that what every good doc does regardless of specialty? Does it explain the uniqueness of IM? Well, only if it means, at the substantial risk of sounding elitist, that internists are superior to other specialists in diagnosis and appropriate treatment! That may not bother our orthopedic colleagues (“I'm just a dumb bone cruncher”) but how would it sit with others? The true notion of IM is about expertise at a special level of complexity in diagnosis and treatment.


Sapira's Art and Science of Bedside Diagnosis, on page 7, defined it thus:

(1) (Obsolete) That nonsurgical medical specialty concerned with clinical diagnosis and scientific therapy. Previously a secondary-care consultant specialty, it underwent crisis by lysis in the late 1960s; (2) (contemporary) a biopolitical consortium of balkanized tertiary nonsurgical subspecialties, which, oxymoronically, claim it to be a primary care specialty.

Definition 1 gets close to the true notion of IM. It truly is a secondary-care consultant specialty. (Well, yes, it's devolved considerably form that state, but that's the original idea). This is not easy to define and requires elaboration. I attempted to do so in a Medscape Roundtable piece a couple of years ago. I reviewed the history of the specialty, hoping that would add clarity to the true notion of IM.


Rather than elaborate on what I said there, let me recount my own journey. I was profoundly influenced by my dad. He was an old fashioned GP in the suburban fringes of St. Louis. He had great admiration for internists. He had always wanted to be one, but when he started his IM training WW II got in the way. After the war he was ready to come home and hang out the shingle. Though a skilled diagnostician himself, he had a special regard for internists. He held them in awe. Whenever he had a really really tough case he called the internist.


When my mom developed a mysterious illness he called a colleague he considered one of St. Louis's finest internists. When she was finally diagnosed with Graves disease things didn't get any easier. The tests used to monitor thyroid treatment in those days (the BMR and PBI) were crude and required a great deal of clinical skill to use. During the difficult course of her illness there were many encounters with the internist. By the time she recovered I knew that an internist was a specialist.


Fast forward to medical school. Every department had its outstanding mentors, but clearly the master clinicians were in the department of Internal Medicine. The exemplar was Thomas Brittingham. His teaching rounds were awe inspiring. Brittingham didn't promote IM over other specialties but through his teaching I learned that an excellent internist was not only a medical detective, but also the one you called for severe illness and very difficult management situations.


Our professional organizations need to do a better job of defining and promoting the specialty. The American College of Physicians slogan “Doctors for Adults” is unfortunate because it defines Internal Medicine as Family Practice without Pediatrics. This view has led to a proposal, published in the Journal Academic Medicine, that IM and FP be merged. It would mean the dissolution of general IM as a specialty. It's little wonder so few trainees want to go into general IM anymore. Who in their right mind would sign up for a specialty that's slated for dissolution in the next decade?

The provision on reimbursement for end of life counseling

---What does would it add?


As I've explained before, we've always had reimbursement for end of life counseling. I've availed myself of it many times in my career. Before we ponder the inscrutable question of what the measure would add it might be useful to take a closer look at the counseling provisions already in place. First a direct quote from the 1995 and the 1997 Medicare coding guidelines:

D. DOCUMENTATION OF AN ENCOUNTER DOMINATED BY COUNSELING OR COORDINATION OF CARE

In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services.

If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter (face-to-face or floor time, as appropriate) should be documented and the record should describe the counseling and/or activities to coordinate care.

What this means (Happy Hospitalist explains here) is that if you spend enough time counseling, about end of life or other issues relevant to a person's care (and it doesn't have to take very long) you can code a level 3 visit without even taking a history or laying a stethoscope on the patient. No history, no exam, no complexity required. Any time you counsel a patient in any detail at all it makes coding level 3 a breeze.


From discussions I've had with other docs this seems to be a well kept secret, but in the many coding seminars I've attended, whenever I pin the experts down about this they tell me it's true.


So why, then was the new provision felt to be necessary and what would it have added? We were never told. The policy wonks refuse to talk about it. To me that leaves three possible explanations. 1) It was purely symbolic. 2) There was a hidden agenda. 3) The policy makers and politicians were showing their ignorance of the regs already in place.

Obama pulls the plug

---not on Grandma, but on the end of life counseling provision. This is actually the second time the plug was pulled. First time around it was from the House draft of the health care reform bill. This time it's from the “regs” which Obama added via the regulation writing process.


So let's look at the sequence of events in this marvelous example of Obama administration transparency:


A provision regarding reimbursement for end of life counseling was included in a draft of the health care reform bill.


In the debate that followed it was never explained what the provision added to counseling reimbursement already embedded in the CPT codes.


The provision was dropped from the final version of the bill that passed and signed into law.


Boosters of the provision urge implementation via the regulation writing process.


The provision was included in a list of proposed regs.


But the provision was missing from the list when the proposals were submitted for public feedback.


The reg was implemented anyway, more or less in secret.


One of the provision's chief supporters urged it be kept secret for as long as possible, warning in an email “The longer this goes unnoticed, the better our chances of keeping it.”


But the secret didn't last long; it hit the newspapers and the blogs in no time.


The White House failed to respond to a request for comment about why they yanked the provision.


Clearly they want to hide this from public debate. What is concerning is this arrogance on the part of the administration and the obfuscation in the media. Reimbursement for counseling itself, as I explained here, is a non-issue. We've had reimbursement for counseling for a long time, explicitly written into the regs as far back as 1994.

Blogging: “It doesn't matter if anyone reads it.”

This is according to Seth Godin.



As he said, it's the metacognition that matters. Blogging has forced me to think about what I read and how I think.


Via Clinical Cases and Images.

Intraosseous access: when and how

According to this Medscape presentation:

IO access is one of the quickest ways to establish vascular access for the rapid infusion of fluids, drugs, and blood products in an emergency. In adults and pediatrics after 2 peripheral IV attempts, IO is the next-line modality.

Pneumonia in critically ill patients: age matters

From a study in Critical Care Medicine.

Conclusions: Increasing age was independently associated with risk-adjusted short- and long-term mortality in critically ill patients with pneumonia. These findings may help elderly patients, their families, and physicians better understand what intensive care unit admission can offer and help them to make more informed decisions.

Using the EMR to reduce ventilator associated lung injury

The EMR has not lived up to its promise of improving patient safety and quality. Reasons for this might include the fact that the process “improvements” to this point in our experience with the EMR are weak and loaded with unintended consequences. More sophisticated tools will need to be embedded into EMRs before they deliver robust process improvements.

One such idea was recently reported in Critical Care Medicine. The EMR monitored mechanically ventilated patients. Providers were alerted via text page in real time when potentially injurious ventilator settings or measurements were detected. The results:

Findings: The prevalence of acute lung injury was 42% (n = 490) among 1,159 patients receiving greater than 24 hrs of invasive ventilation. The system sent 111 alerts for 80 patients, with a positive predictive value of 59%. The exposure to potentially injurious ventilation decreased after the intervention from 40.6 ± 74.6 hrs to 26.9 ± 77.3 hrs (p = .004).

Interpretations: Electronic medical record surveillance of mechanically ventilated patients accurately detects potentially injurious ventilator settings and is able to influence bedside practice at moderate costs. Its implementation is associated with decreased patient exposure to potentially injurious mechanical ventilation settings.

This is a novel idea and attempts to use the EMR for all it’s worth. We need a good deal more experience with ideas such as this before the EMR will become a real quality and safety tool.

Outcomes after convulsive status epilepticus

---were generally poor and related to the duration of status in this study:

The median time from convulsive status epilepticus onset to anticonvulsant drug initiation was 40 mins (interquartile range, 5–80). Total seizure duration was 85 mins (interquartile range, 46.5–180). Convulsive status epilepticus was refractory in 49 (20%) patients. The most common causes of convulsive status epilepticus were anticonvulsive agent withdrawal (36.4%) in patients with previous epilepsy and stroke (27.7%) in inaugural convulsive status epilepticus. Mechanical ventilation was needed in 210 (85%) patients. On day 90, 42 (18.8%) patients were dead, 87 (38.8%) had marked functional impairments (Glasgow Outcome Scale score, 2–4), and 95 (42.4%) had a good recovery (Glasgow Outcome Scale score, 5). Factors showing independent positive associations with poor outcome (Glasgow Outcome Scale score, less than 5) were older age (odds ratio, 1.04/year; 95% confidence interval, 1.02–1.05; p = .0005), cerebral insult (odds ratio, 2.70; 95% confidence interval, 1.37–5.26; p = .007), longer seizure duration (odds ratio, 1.72/120 min; 95% confidence interval, 1.05–2.86; p = .03), on-scene focal neurologic signs (odds ratio, 2.08; 95% confidence interval, 1.03–4.16; p = .04), and refractory convulsive status epilepticus (odds ratio, 2.70; 95% confidence interval, 1.02–7.14; p = .045).

Conclusions: Ninety days after intensive care unit admission for convulsive status epilepticus, half the survivors had severe functional impairments. Longer seizure duration, cerebral insult, and refractory convulsive status epilepticus were strongly associated with poor outcomes, suggesting a role for early neuroprotective strategies.

Blood pressure measurement in hypotensive critically ill patients

How many intensivists do it non-invasively?

From a survey of SCCM members:

Measurements and Main Results: Use of non-invasive and invasive blood pressure devices. Eight hundred eighty individuals received an invitation to complete the survey and 149 responded. We found that 71% (105 of 149) of intensivists estimated the correct cuff size rather than measuring arm circumference directly. In hypotensive patients, 73% of respondents (108 of 149) reported using noninvasive blood pressure measurement measurements for patient management. In patients on a vasopressor medication, 47% (70 of 149) of respondents reported using noninvasive blood pressure measurement for management.

Conclusions: The use of noninvasive blood pressure measurement measurements in critically ill patients is common despite the paucity of evidence validating its accuracy in critically ill patients.

Pulmonary-critical care slide show

Pulmonary (Read)

View more presentations from changezkn.

This slide show has excellent content and numerous pearls warranting posting here. Note, however, the following cautions:

Some of the content is dated, e.g. referencing the 2004 Surviving Sepsis Guidelines instead of 2008.

The answers to some of the multiple choice questions are confusing because they don’t match the corresponding letters.

Some case studies in this board review could resemble exam content. If you plan to sit for boards please carefully review ABIM’s terms and conditions before accessing this resource.

Results of a community wide campaign to improve cardiac resuscitation

The Take Heart America campaign resulted in process improvements and more than double the rate of cardiac arrest survival as reported in Critical Care Medicine. And guess what? The campaign was supported by (gasp) industry.

VRE urinary tract infections: when and how to treat

Review in Pharmacotherapy. Full text via Medscape.

Physiology lecture notes

From Eastern Kentucky University. Lecture notes enhanced by You Tube videos.

Physiology lectures from LA City College

These are word files and a few MP3s.

Partial DNR orders: always patient centered, often irrational, maybe harmful

In the era of patient centered care it's fashionable during DNR discussions to let people pick and choose from a menu of interventions, often resulting in “partial DNR” decisions. In some cases irrational combinations of interventions are chosen despite efforts to educate patients and family members on the rationale and expectations for various treatment modalities.


A recent paper in Critical Care Medicine reviewed the literature on partial DNR orders. Based on the limited published experience the authors suggested that the practice was “clinically and ethically problematic” and concluded:


Discouraging partial do-not-resuscitate(s) order may help promote more accurate and comprehensive advance care planning.

Osteoporosis treatment after hip fracture: how often done and by whom?

Not nearly often enough, and it depends on the specialty service according to this study.

The 2010 dumb awards for public policy speech

Bright people in high places occasionally say dumb things. In such a politically charged time as 2010 it made for great entertainment. Here are a few that made me laugh, mostly about health care reform. In no particular order.




Democratic Congressman Phil Hare on health care reform.


“I don't worry about the Constitution on this.”



And at 1:00 the Congressman confuses the Constitution with the Declaration of Independence.






Peter Orszag's New York Times column on October 3---


in which he implied (in a smooth way, but still strongly implied) that doctors don't work hard enough, doctors aren't used to having their performance measured, and hospitals shut down for the weekend.






A NEJM writer declared that if the Republican agenda on health care moved forward it would be a recipe for a failed republic.

Well, they won big in November. Better stock up on some survival provisions.






Nancy declared that we had to pass health care reform in order to find out what was in the bill.






Paul Krugman dropped the bomb about death panels.



This was such a bunch of double talk, it's hard to know what he really meant, but the plain point seems to be that we need to soothe the death panel alarmists now, then implement the panels later. Whatever he meant, it was dumb.






The interview with Bill Maher in which he said...


Well, he said a lot of dumb things. The whole clip is stupid. You'll just have to watch.