Rheumination

PubMed

Using google as a medline tool does not make one feel on top of his /her field. Even google scholar which somewhat narrows the search to academia still gives you the sense that People Magazine or The National Enquirer might just pop up in the search results. But it is easy, real easy. Unlike PubMed that is. Probably because I never took the time to find out how the thing really works, I gave up on PubMed after many hours trying to get the "limitations" tool to help me rather than screw up my search.
Recently, however, while browsing the Mayo Clinic Proceedings, I came across an article about the new services at PubMed. It gives detail by example and if possible it's best to read through it while at your computer. (The article is restricted to subscribers on the net until 6 months after publication, so it won't be available on line until Oct. 07) After a short course with this article I am a re-born PubMedian.
In brief;
Go to PubMed. Right away you can enter your search terms and get thousands of results, but if you are looking for clinical information, there are better ways. At the left, in the blue margin, select "clinical queries". You will then get a choice between clinical categories or systematic reviews. Once chosen you can quickly choose limits in the same box, such as etiology, diagnosis and therapy. Press go and you already have a much more manageable selection. To further shorten the list, select the limits tag and narrow it down further by choosing human, language, time frame etc.
As an example, I searched rheumatoid arthritis and prednisone. With the normal search I received 1517 results. Clinical queries reduced it to 66 and reviews to 7.
And there's more. PubMed has over 200 free full-text journals available by selecting PubMed Central, again in the blue margin. Unfortunately, rheumatology is not that well represented, but you never know when you might be in the mood to browse through the Orphanet Journal of Rare Diseases. Arthritis Research and Therapy privides six month old articles and Annals of the Rheumatic Diseases is three years behind. There are two open access journals, BMC and PLoS, but I haven't had time to look into them in any great detail.
The Gateway section, again in the blue margin is a great patient information site but only in English and Spanish. (Will America never forgive France).
And lastly, for the real search collectors, there is myNCBI. Kind of cute don't you think? Makes me feel like I'm back at google. At myNCBI you can create and save up to 100 searches. With a little work you can even arrange regular updates that will be e-mailed to you. The myNCBI does require registration but it is a minor procedure and I believe anyone can sign up with no charge.
So there you are. A comprehensive, user friendly service provided free of charge by the United States of America. Can't complain about that.

Myalgia with Unexplained elevation of CK

Myalgia with unexplained elevation of CK (M.U.C.K.?) ranks right up there with my least favoured diagnoses. All the fun of treating what generally mimics fibromyalgia, but forever cursed by the lingering suspicion that there may well be something more sinister lurking in the background. Without a firm diagnosis the patient is never really relinquished back to the care of the primary physician and so we worry together for years, neither very happy.
In my early years these patients would inevitably have an EMG followed by biopsy, but the results, nearly always abnormal but nonspecific, would worsen the situation. The patient now has biopsy proof that the muscle is abnormal, but we are no closer to a diagnosis nor treatment.
After many repititions of this scenario I gradually altered my game-plan. Now these patients have an EMG and only get a biopsy if something shows up, which is not that often. It seems to be working out, but is it good practice?
Last year two events cast some doubt on my protocol. At a rheumatology conference an invited speaker and muscle pathology specialist was asked exactly this question and responded that all these patients should be biopsied, just in case. Not exactly evidence based medicine, but still, this was his area of expertise. About the same time a paper came out in Neurology, by Fernandez et al., claiming that a diagnosis was possible in over 50% of patients who presented with an elevated CK, even if asymptomatic. This would have been worrisome but further inspection showed some rather odd details. Of the 104 patients there were 13 children and 33 patients under 30. 50 of the patients were completely asymptomatic, only half had an EMG, and 18 ended up having McArdle's disease. Who is doing CK's on asymptomatic children, let alone biopsies? I came to the conclusion that this must be a referral centre for congenital myopathies and that half of these patients were asymptomatic relatives of afflicted patients. Not exactly my clientele.
This year, what appears to be a more representative population was studied by M Filosto et al., also reported in the journal Neurology. This study also had it's quirks; part retrospective, part prospective, myalgias plus cramping, only two fibromyalgia patients excluded out of 254 biopsies. However, the patients were referred by neurologists, rheumatologists and GP's. The results were divided into five pathological patterns as follows:
1) Heterogenous myopathic changes, 52%. Of these, 80% were minimal nonspecific changes.
2) Mitochandrial pattern 20%- but only 1 definite diagnosis.
3) Normal 20%
4) Neurogenic pattern 7% - but no specific disease.
5) Metabolic myopathy- 6 definite cases

By the author's calculation, a patient presenting with myalgia, elevated CK, and normal neurological exam has a 2% probability of having a definite myopathy by muscle biopsy.
Other interesting tidbits:
CK of 2-4X normal did not increase probability of myopathy
EMG abnormalities did not correlate with biopsy abnormalities
Only the metabolic myopathy group had very high CK

Despite that rather low probability of finding anything useful, both the authors and the editorial in the same issue suggest that biopsy is still warranted after "rigorous selection". But with what criteria do we select? It appears both CK levels and EMG are of limited use.
Well, these studies, like the biopsies themselves, add more info than they do clarity. I'm still not convinced that these patients should all be biopsied. I'll still ask for an EMG, primarily to get a neurological second opinion, but can no longer justify passing on the biopsy based on a normal result. My justification, for the moment, will have to rest on "clinical experience".

Boldly blogging

Boldy going where about 75,000,000 have gone before.

Okay, so it's not a new idea but it's still a great idea. For years I have been complaining, largely to myself, that there is no real forum for discussion of rheumatology for the clinician. Quick chatter between patients or at best, discussion of the most weird and wonderful cases at service rounds is almost as good as it gets. Although interesting, the experience around the table is usually limited to less than a dozen seasoned clinicians. Not much when we consider the rarity of some of the conditions under consideration. Journals and conferences are great for the broader picture, but the details are sorely missing.But blogging, the potential is limitless.

Or so I thought.

Then I tried to find such blogs. You would think that with 75,000,000 blogs there would be hundreds of rheumatologists blogging away. There may well be, but how to find them? I googled through innumerable sites and found only personal diaries, group blogs, and natural cures. I finally discovered technorati but a search for "rheumatology" produced a meagre five or six, and none actually about rheumatology except for the ACR site. But wait, over on the left under "bloggers using this tag" I see an X-ray of a hand. Is that AVN of the lunate? I'll take a closer look another day, but sure enough it's someone calling himself carpus at Aspirations of a Joint Doc, a true rheumatologist blogging about rheumatology. From what I can tell, he's young, academically inclined, into epidemiology and computer savvy. All of which I am not. All the better.
It'll take more than two, maybe tens or hundreds of bloggers and commentors to make it a go, but for now I'll take a gang of two. It makes for a tidy blogroll.