Rheumination

Arava Induced Dextrocardia

When I started my practice many years ago I had to do internal medicine call.  It was good in some respects, keeping my well-earned internal medicine skills sharp, but after a while I had to question the appropriateness of a rheumatologist handling drug overdoses and pre-eclampsia.  I then restricted my call to rheumatology and allergy since we were in the same department, and finally to rheum call alone.  After a decade with little general internal med I can see that I've now become a bit rusty.  Heart sounds are now limited to  present or not present. I pray infections I stumble upon are treatable with the three antibiotics I know, and hope that they are still being manufactured.  Where's chloramphenicol when you need it?  I actually read the computer generated ecg report,  and I completely ignore, so far without any perceptible  negative consequence, all D-dimer results.

But chest x-rays are still just chest x-rays and even I can see that the film in a recent article of Nature Reviews Rheumatology was a bit off.  The article discusses leflunomide induced lung disease but it would appear that it also causes dextrocardia:

The incidence of ILD in the cohort decreased over time, as fewer patients with pre-existing ILD were prescribed the drug following the issue of a safety notice in January 2004. Although not mentioned in the safety notice, the use of a loading dose also declined.

In a separate study, a UK-based group reviewed the clinical characteristics of 32 published cases (including 6 from Japan) of leflunomide-induced pneumonitis in patients with RA. The investigators were prompted to undertake the retrospective review after finding a dearth of information in the literature and clinical guidelines.

Med School Under the Microscope

When I went through first year of med school some twenty five years ago, one of my least favourite courses was histology.  We had a great teacher and great labs, but the problem was that we had so much of it.  Eight months if I'm not mistaken, and many hours a week. I remember thinking that this was way, way too much.  Apparently somebody was listening.

Our service has only recently become  affiliated with a university, and we now have the pleasure of having students and residents on the consult team.  I am only now becoming aware of the new curriculum and training methods.  While demonstrating crystal microscopy lately I gave our student a quick look at a low power field of white cells to orient her before turning to polarised light.  She looked down the tube for several seconds before asking,  "you mean those spots?"  Okay, not the most technical description but I figured we would move on.  It quickly became obvious though that she was very uncomfortable and excused herself because she had not used a microscope since college.  In three years of med school, never a practical histology lab, blood smear or gram stain.

This might be what we refer to as the pendulum swinging a little too far to the other side.  Now I have no idea if this is of any real consequence in modern clinical medicine, apparently greater academic minds than mine think not, but I have to wonder if it is not the cause of a recent problem, at least in Quebec, with a shortage of pathologists.  I have never actually talked to a pathologist about their career choice but I would guess that most were introduced to the field through their first histology and anatomy courses.  It seems now though, that a student can get through his entire med school training without ever seeing tissue, healthy or diseased, close up.  Where will the pathologists come from.  CSI Miami fans?  

Blog On

Took some time off from blogging.  After two years it was good to take a break but I must admit, after a prolonged lay-off, it's hard to get restarted.  It's not that there isn't stuff to talk about, after all, rheumatology changes every day.  And it's fun.  How often can we talk about hockey chants and rheumatology in normal circles?  In fact, when can we ever put pen to paper, so to speak, outside of our daily practice?  

Unfortunately, many of my favourite blogs have fallen be the wayside.  Aspirations of a Joint Doc sputtered shortly after I started.  Pharmalot, Wait Times and now Dr Wes have seemingly packed it, and there are others.  It's fairly predictable, of course, but reading blogs is part of the process and losing all of these seems to take a bit of wind out of the sails.

But there are a few blog worthy happenings afoot.

I've discovered  All Joints Considered, a rheumatology blog by Dr. Oliveira on Medscape, and hopefully that will rekindle the spirit.

Our practice has recently become affiliated with a university hospital and I think the arrival of residents and students will be worthy of discussion.

We'll see.