Top medicine articles for July 2014

A collection of some interesting medical articles published recently:

Migraines Linked to Increased Risk of 'Silent Strokes'

Doctor’s Salaries Are Not the Big Cost - NYTimes -- "There is a startling secret behind America’s health care hierarchy: Physicians, the most highly trained members in the industry’s work force, are on average right in the middle of the compensation pack. That is because the biggest bucks are currently earned not through the delivery of care, but from overseeing the business of medicine.

The base pay of insurance executives, hospital executives and even hospital administrators often far outstrips doctors’ salaries: $584,000 on average for an insurance chief executive officer, $386,000 for a hospital C.E.O. and $237,000 for a hospital administrator, compared with $306,000 for a surgeon and $185,000 for a general doctor.

Among doctors, there is growing frustration over the army of businesspeople around them and the impact of administrative costs, which are reflected in inflated charges for medical services."

25% of US adults consult online physician-rating sites - Doctors Check Online Ratings From Patients and Make Changes. Online ratings "can be pretty brutal. However, part of being a physician now is having to deal with these.” "When we decided to quit ignoring it and embraced it, it totally changed the game" - WSJ

FDA Approves New Drug for Crohn Disease and UC: vedolizumab (Entyvio), an injectable monoclonal antibody. Vedolizumab, an integrin receptor antagonist

Interferon-free regimen with 3 drugs effective in Hep C with Cirrhosis (ABT-450/r–Ombitasvir, Dasabuvir, Ribavirin) -- Combination of nucleotide polymerase inhibitor sofosbuvir and antiviral ribavirin effective in HCV Genotypes 2 and 3

The relative risk reduction of 20% in breast-cancer mortality associated with mammography comes at a price. Abolish Mammography Screening Programs, says the Swiss Medical Board. The report caused an uproar

In obese patients with uncontrolled DM2, intensive medical therapy plus bariatric surgery was better than drugs alone

First dialysis machine was made with aluminium from a bomber that was shot down and bits from an automobile engine

At least 10% of adults and nearly all children who receive renal-replacement therapy have an inherited kidney disease

Kidney disease in farming communities worldwide remains a mystery: heavy metals and pesticides? indigenous herbs? OTC pain killers? chronic dehydration?

Worldwide, chronic kidney disease affects 8—16% of population, number of deaths almost doubled in the past decade

The articles were selected from Twitter and my RSS subscriptions. Please feel free to send suggestions for articles to clinicalcases AT and you will receive acknowledgement in the next edition of this publication.

Pancreatic Cancer - 2014 update from Am Fam Physician

Pancreatic cancer remains the fourth leading cause of cancer-related deaths in the United States.

Risk factors include:

- family history
- smoking
- chronic pancreatitis
- obesity
- diabetes mellitus
- heavy alcohol use
- possible dietary factors


Because more than two-thirds of adenocarcinomas occur in the head of the pancreas, abdominal pain, jaundice, pruritus, dark urine, and acholic stools may be presenting symptoms.


In symptomatic patients, the serum tumor marker cancer antigen 19-9 can be used to confirm the diagnosis and to predict prognosis and recurrence after resection.

Pancreas protocol computed tomography is considered standard for the diagnosis and staging of pancreatic cancer.



Although surgical resection is the only potentially curative treatment for pancreatic ductal adenocarcinomas, less than 20% of surgical candidates survive five years. The decision on resectability requires multidisciplinary consultation. Pancreatic resections should be performed at institutions that complete at least 15 of the surgeries annually.


Postoperatively, use of gemcitabine or fluorouracil/leucovorin as adjuvant chemotherapy improves overall survival by several months. However, more than 80% of patients present with disease that is not surgically resectable. For patients with locally advanced or metastatic disease, chemoradiotherapy with gemcitabine or irinotecan provides clinical benefit and modest survival improvement.

Palliative care

Palliation should address pain control, biliary and gastric outlet obstruction, malnutrition, thromboembolic disease, and depression.

Jon Lord, the keyboardist of the pioneering British hard-rock band Deep Purple, died of pancreatic cancer in 2012 and at age 71. Here is David Coverdale's eulogy for Jon Lord: David Coverdale remembers his first meetings with Jon Lord - supporting Deep Purple, joining Deep Purple and rehearsing for the Burn album:


Diagnosis and Management of Pancreatic Cancer. De La Cruz MS1, Young AP2, Ruffin MT2. Am Fam Physician. 2014 Apr 15;89(8):626-632.

Jon Lord, Keyboardist With Deep Purple, Dies at 71. NYTimes

Image source: Wikipedia, public domain.

Exercise may keep you young - how exactly? (DW video)

How exercise keeps us young | In Good Shape - DW Interview - YouTube -- The sports medicine expert Dr. Fernando Dimeo explains why.

Two years ago, Jon Lord, legendary Deep Purple keyboard player, "passed from Darkness to Light"

Performed in front of a live TV audience, Deep Purple storm through 'Child In Time', featuring the classic Mark II line up of Gillan/Glover/Lord/Paice/Blackmore:

Jon Lord passed away on July 16, 2012 at age 71, from pancreatic cancer and pulmonary embolism.

From Jon Lord's official website:

Jon Lord, the legendary keyboard player with Deep Purple co-wrote many of the bands legendary songs including Smoke On The Water and played with many bands and musicians throughout his career.

Best known for his Orchestral work Concerto for Group & Orchestra first performed at Royal Albert Hall with Deep Purple and the Royal Philharmonic Orchestra in 1969 and conducted by the renowned Malcolm Arnold, a feat repeated in 1999 when it was again performed at the Royal Albert Hall by the London Symphony Orchestra and Deep Purple.

Jon’s solo work was universally acclaimed when he eventually retired from Deep Purple in 2002.

Jon passes from Darkness to Light.

Jon Lord 9 June 1941 – 16 July 2012.

Pictured Within - Music and Lyrics by Jon Lord: "It is certainly no coincidence that Jon chose to reflect Elgar’s paean to the love of friends and family in his own very personal music. This song was among the music heard at Jon’s funeral, played by myself and sung by the incomparable Miller Anderson for whom it was originally written."

Recorded From Deep Purple In Concert With The London Symphony Orchestra Live At Royal Albert Hall.Singer: Miller Anderson, Conductor: Paul Mann.

Here is Roger Glover's reflection:

"A bittersweet year. It was in the studio in Nashville that we heard about Jon. It was a real blow to the body, even though we expected it. Stories and thoughts of him flooded the following weeks as the enormity of the loss sank in. Back in England we said goodbye to Jon with great dignity, the service was sadness made beautiful with music. When Jon first gave me Pictured Within, I wept at the beauty of it. At his funeral I wept again at the sadness of it. Such moving music. Music that has the power to stir emotions that run deep. He changed my life. I am a lucky man."

I had the chance to see Jon Lord at a Deep Purple concert in 2001, and he was truly amazing. Several songs from the latest Deep Purple album Now What?! are devoted to him and they are featured during the live performance. Deep Purple will be touring the US in August. Join me during the last day of the tour on August 31st.

I have written about Deep Purple before: What Musicians Can Teach Doctors, And How Allergists Are Like Rock Stars and did a brief interview for the University of Chicago Science Life blog: Rock Star Doctors: What Physicians Can Learn from Musicians | Science Life

Excerpt from the 2012 blog post: I went to a concert of the British rock legends Deep Purple last summer. Their biggest hit “Smoke on the Water” was recorded more than 40 years ago. The average age of the musicians is 65 nowadays. I looked around. The audience ranged from the 70-year-old parents of 30-year-old fans to their 5-year-old children. When Deep Purple hit the first big riffs everyone jumped to their feet. The rock stars were clearly in their element - smiling, engaging, and seemingly enjoying the experience, sending great vibes to the audience who sang the songs from start to finish with them. What struck me was that the musicians have played the same song tens of thousands of times by now, and yet it was like their first time. Because it was the first time for their audience.

Smoke On The Water video from "Live At Montreux 2006" DVD:

Related reading:

Music Man
Jon Lord obituary | Music | The Guardian -
BBC News - Deep Purple's Jon Lord dies at 71 -
Malc Deakin talks to Jon Lord on Vimeo -
BBC's Last Word: Ritchie Blackmore, Rick Wakeman, Geoff Barton pay tribute to Jon Lord. Also, Jon on how he'd like to be remembered.
Steve Morse on Jon Lord - YouTube

Elbow Pain in Adults - 2014 review from Am Fam Physician

The elbow is a complex joint designed to withstand a wide range of dynamic exertional forces. The location and quality of elbow pain can generally localize the injury to one of the four anatomic regions: anterior, medial, lateral, or posterior.

The history should include questions about the onset of pain, what the patient was doing when the pain started, and the type and frequency of athletic and occupational activities.

What are the common causes?

- Lateral and medial epicondylitis are two of the more common diagnoses and often occur as a result of occupational activities. Patients have pain and tenderness over the affected tendinous insertion that are accentuated with specific movements.

- If lateral and medial epicondylitis treatments are unsuccessful, ulnar neuropathy and radial tunnel syndrome should be considered.

- Ulnar collateral ligament injuries occur in athletes participating in sports that involve overhead throwing.

- Biceps tendinopathy is a relatively common source of pain in the anterior elbow; history often includes repeated elbow flexion with forearm supination and pronation.

- Olecranon bursitis is a common cause of posterior elbow pain and swelling. It can be septic or aseptic, and is diagnosed based on history, physical examination, and bursal fluid analysis if necessary.

What are the recommended tests?

Plain radiography is the initial choice for the evaluation of acute injuries and is best for showing bony injuries, soft tissue swelling, and joint effusions. Magnetic resonance imaging is the preferred imaging modality for chronic elbow pain. Musculoskeletal ultrasonography allows for an inexpensive dynamic evaluation of commonly injured structures.


Evaluation of Elbow Pain in Adults. Kane SF, Lynch JH, Taylor JC. Am Fam Physician. 2014 Apr 15;89(8):649-657.

Image source: Normal radiograph; right picture of the straightened arm shows the carrying angle of the elbow. Wikipedia, Creative Commons Attribution-Share Alike 2.5 Generic license.
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