Internal medicine residents spent little time reading, and prefer electronic resources, specifically UpToDate

This study from the Mayo Clinic assessed residents' reading habits and preferred educational resources at 5 internal medicine training programs via a survey.

78% of residents reported reading less than 7 hours a week.

81% of residents read in response to patient care encounters.

The preferred educational format was electronic, and UpToDate was the big winner among the surveyed group:

- 95% of residents cited UpToDate as the most effective resource for knowledge acquisition
- 89% of residents reported that UpToDate was their first choice for answering clinical questions

The study authors concluded that residents spent little time reading and sought knowledge primarily from electronic resources. Most residents read in the context of patient care.

The abstract does not mention anything about social media sources such as Wikipedia, blogs, and Twitter, but the residents encounter a lot of those through Google searches.

References:

A multi-institutional survey of internal medicine residents' learning habits. Edson RS, Beckman TJ, West CP, Aronowitz PB, Badgett RG, Feldstein DA, Henderson MC, Kolars JC, McDonald FS. Med Teach. 2010;32(9):773-5. Image source: UpToDate.

UpToDate is the most read medical reference tool - how did Harrison's, Cecil's, etc. manage to lose that war?

This the summary of my Twitter discussion with an academic nephrologist (by the way, the founding editor of UpToDate is also a nephrologist):

@DrVes: UpToDate is likely the most read medical reference tool, at least in the U.S. - how did Harrison's, Cecil's, etc. manage to lose that war?

@kidney_boy (Joel Topf): Reasons for UpToDate winning: Harrison's had no search, and an editorial style that told you about disease but not how to treat it

@DrVes: Exactly. It's amazing that those publishing companies didn't realize that they shipped "malfunctioning" product for years, and never fixed it.

@kidney_boy (Joel Topf): Harrison's is the great preclinical prof teaching pathophysiology, UpToDate is the smart clinician teaching you how to care for the patient with EBM.

@DrVes: UpToDate now has sections on pathophysiology, some of them quite good, check T-cells types, for example. Unfortunately, a lot of medical students get their basic pathology knowledge from Wikipedia nowadays. Just go to the library section where medical students are and have a look at the monitor screens during study time.

@kidney_boy (Joel Topf): Remember Harrison's is the youngest of the medical texts, it won by having regional approach (headache rather than CNS) to organization.

@DrVes: Classic-style textbooks (e.g. Harrisson's) feel like "half-book" nowadays. The doctors in training often find themselves asking "Where is the second part with treatment, updates, etc.?"

Related reading:

Review of the much anticipated UpToDate iPhone app, arguably the most read medical reference tool. iMedicalApps.com.
Are You Dependent on UpToDate for Your Clinical Practice?
"With UpToDate, students and interns may be as capable of teaching the resident (or attending) as visa versa"
Study: UpToDate More Likely than PubMed to Answer Patient Care Questions

Comments from Google Plus:

Neil Mehta - Ves one of the most useful aspects of Harrison's is/was the approach to symptoms. This is the first 100 or so pages of Harrison's. Understanding this can be a huge help in becoming a good clinician. It is pretty dense reading but internal medicine residents can benefit from spending time on this. Agree UpToDate is a tremendous resource. One thing to remember about U2D is that sections can be written by one author and this does run a risk of bias creeping in (no different than textbooks) but readers should learn to look at other sources/primary literature when necessary.

Ves Dimov - Right. UpToDate is far from perfect but it is very time efficient. It provides quick actionable info within 5-10 minutes of conducting a search. The depth of the content is limited by the person who wrote that particular article, of course.

Robert Silge - Yes, but by and large the people writing that content are qualified to do so. It is to medical textbooks what Wikipedia is to general reference books. Updates faster, to the point, and has info on (almost) everything. Its depth may be lacking, but for clinical practice I doubt the benefits of reading through primary literature is worth the time spent doing it for most endeavors.

And frankly for your first foray into a field, as a med student for example, Wikipedia is a darned useful place to start.

Ves Dimov - And that's why UpToDate is most users' favorite resource. One of the few drawbacks is the price though, $495 per year.

Robert Silge - Wonder how many people pay for it out of pocket vs use an institutional login?

Gary Levin - Up to date is like rounding with your attending or professor with instantaneous gratification. Harrison belongs in the library or for a second year med student to learn the language.

What's new in nephrology and hypertension

35% of UpToDate topics are updated every four months. The editors select a small number of the most important updates and share them via "What's new" page. I selected the brief excerpts below from What's new in nephrology and hypertension:

Glomerulonephritis

In idiopathic membranous nephropathy, among patients with protein excretion less than 8 grams/day, treatment with an ACE inhibitor or ARB increased the probability of remission.

Hypertension

There was no difference in the rate of myocardial infarction, stroke or death from cardiovascular causes between the intensive versus standard hypertension therapy groups, nor in the all-cause mortality rate. ('ACCORD BP trial'). Intensive therapy included goal systolic blood pressure less than 120 mmHg, standard therapy included goal systolic blood pressure less than 140 mmHg.

Hyponatremia

Tolvaptan is a vasopressin receptor antagonists. The long-term administration of tolvaptan appears to be safe and effective among patients with chronic hyponatremia. Responses were similar in heart failure and SIADH, and more modest in cirrhosis.

Transplantation

An increased incidence of angioedema has been noted in patients administered angiotensin-converting enzyme (ACE) inhibitors plus either sirolimus or everolimus.

Autosomal dominant polycystic kidney disease (ADPKD)

Activation of the mammalian target of rapamycin (mTOR) protein may contribute to cyst growth in autosomal dominant polycystic kidney disease (ADPKD). The inhibition of mTOR with rapamycin preserved renal function and inhibits epithelial cell proliferation and fibrosis in a mouse model of ADPKD. In a human trial, cyst volume was stable on rapamycin.

The long-acting somatostatin octreotide decreased liver volume by 5% in patients with autosomal dominant polycystic liver disease.

References:
What's new in nephrology and hypertension. UpToDate.

Twitter comments:

@kidney_boy (Joel Topf): UpToDate seems to be misrepresenting the ADPKD mTOR data. See my interpretation here: More ADPKD and sirolimus data: More definitive; less encouraging

What's new in gastroenterology and hepatology from UpToDate

35% of UpToDate topics are updated every four months. The editors select a small number of the most important updates and share them via "What's new" page. I selected the brief excerpts below from What's new in gastroenterology and hepatology:

Hepatitis C virus (HCV) infection

Peginterferon alfa-2a was superior to peginterferon alfa-2b with regard to virologic response rates in patients with chronic hepatitis C virus infection, genotypes 1, 2, 3, or 4. Patients being treated for chronic hepatitis C virus infection should receive peginterferon alfa-2a rather than peginterferon alfa-2b.

72 weeks of therapy with peginterferon alfa-2a plus ribavirin in patients with HCV genotype 1 or 4 was not better than 48 weeks.

Chronic use of proton pump inhibitors (PPIs)

Chronic use of proton pump inhibitors (PPIs) may lead to an increased risk of fractures. FDA recommends that healthcare professionals who prescribe proton pump inhibitors should consider whether a lower dose or shorter duration of therapy would adequately treat the patient's condition.

Ulcerative colitis

Once daily dosing of delayed-release mesalamine (Asacol 400 mg tablets) 1.6 to 2.4 g/day was as effective as twice daily dosing for maintenance of clinical remission in patients with ulcerative colitis. Remission rates were 85% in both groups.

Crohn's disease

Capsule endoscopy was not a cost-effective third test for establishing the diagnosis of Crohn's disease after a negative ileocolonoscopy and either a CT enterography or small bowel follow-through x-ray.

Azathioprine in combination with infliximab or infliximab alone had a higher rate of glucocorticoid-free clinical remission than those treated with azathioprine alone. Combination therapy and infliximab monotherapy led to significantly more complete bowel healing than azathioprine alone.

Obscure gastrointestinal bleeding

Double balloon enteroscopy (DBE) detected bleeding sources in 78% of patients with obscure gastrointestinal bleeding. Small intestinal ulcers and erosions were the most common findings.

References:
What's new in gastroenterology and hepatology. UpToDate.

What's new in obstetrics and gynecology from UpToDate

35% of UpToDate topics are updated every four months. The editors select a small number of the most important updates and share them via "What's new" page. I selected the brief excerpts below from What's new in obstetrics and gynecology:

Obstetrics

Influenza vaccination with inactivated vaccine is recommended for pregnant women, regardless of the stage of pregnancy. The 2010-2011 influenza vaccine is trivalent and includes antigens from both the 2009 pandemic H1N1 influenza virus and seasonal influenza viruses.

Use of acetaminophen during pregnancy was associated with a reduction in neural tube defects, as well as cleft lip/palate and gastroschisis. These data support the safety of acetaminophen for relief of fever and pain.

Gynecology

Like CA 125, human epididymal secretory protein E4 (HE4) is a promising biomarker for ovarian cancer. In contrast to CA 125, HE4 levels do not appear to be elevated in women with endometriosis, and thus can be useful to rule out ovarian cancer in patients with endometriosis and a pelvic mass suspected to be an endometrioma.

Sterilization does not impact sexual function. Sexual function appears to be unchanged or improved in women following tubal sterilization.

Botulinum toxin may be useful for overactive bladder syndrome (onabotulinumtoxinA, Botox®). Detrusor injection of botulinum toxin (BoNT) had a transient effect. The average time between injections was 8 to 12 months.

References:
What's new in obstetrics and gynecology. UpToDate.

Image source: Wikipedia, GNU Free Documentation License.

What's new in endocrinology from UpToDate

35% of UpToDate topics are updated every four months. The editors select a small number of the most important updates and share them via "What's new" page. I selected the brief excerpts below from What's new in endocrinology:

Osteoporosis

Denosumab (Prolia)

Denosumab is a fully human monoclonal antibody that specifically targets a ligand known as RANKL (that binds to a receptor known as RANK) which is a key mediator of osteoclast formation, function, and survival. Denosumab was approved for the treatment of postmenopausal women with osteoporosis at high risk for fracture (history of osteoporotic fracture, multiple risk factors for fracture) or patients who have failed or are intolerant of other available osteoporosis therapies. Denosumab inhibits the formation, function, and survival of osteoclasts. It decreases bone resorption, increases bone mineral density (BMD), and reduces the risk of fracture.

Teriparatide (Forteo)

Teriparatide (parathyroid hormone) did not accelerate fracture healing in postmenopausal women with distal radial fractures.

Transdermal teriparatide patch worked as well as teriparatide injection in postmenopausal women with osteoporosis.

Orlistat (Xenical, Alli) in obesity

Severe liver injury has been reported rarely with the use of orlistat (13 reports). Over the ten year period of the review, an estimated 40 million people worldwide used orlistat.

References:
What's new in endocrinology and diabetes mellitus. UpToDate.

Image source: Flickr, Creative Commons license.

What's new in rheumatology from UpToDate

35% of UpToDate topics are updated every four months. The editors select a small number of the most important updates and share them via "What's new" page. I selected the brief excerpts below from What's new in rheumatology:

Lower dose colchicine for treatment of acute gout

A lower dose colchicine may have similar efficacy and fewer side effects than a traditional, higher dose regimen for patients with acute gouty arthritis. Colchicine given as 1.2 mg followed by one additional dose of 0.6 mg an hour later (total dose 1.8 mg) worked similarly to 1.2 mg followed by 0.6 mg every hour for up to six hours.

Nocturnal leg cramps

Quinine is no longer recommended due to the potential for serious side effects, drug interactions, and only modest benefit. Calcium channel blockers and vitamin B complex have limited effect.

Anti-CCP antibody testing in RA

Testing for anti-citrullinated peptide/protein antibodies (ACPA) has become common in the evaluation of patients for rheumatoid arthritis (RA). Second generation anti-cyclic citrullinated peptide (anti-CCP) antibodies had the highest utility, with higher specificity and similar sensitivity to rheumatoid factor (RF). Both RF and anti-CCP testing should be performed in patients suspected of having RA. Should I order an anti-CCP antibody test to diagnose rheumatoid arthritis?  http://goo.gl/L3abc - Yes. Cost of RF is $43, anti-CCP $102

Golimumab for RA

Golimumab, a neutralizing human anti-tumor necrosis factor alpha monoclonal antibody, is administered subcutaneously once monthly for the treatment of rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis.

Rituximab for primary Sjogren's syndrome

Rituximab, which is used for the treatment of B cell lymphomas, rheumatoid arthritis, and other autoimmune and lymphoproliferative disorders, is a chimeric monoclonal antibody directed against the B cell antigen CD20. One course of rituximab treatment resulted in significant improvement in patients with Sjogren's syndrome (SS).

References:
What's new in rheumatology. UpToDate.

What's new in pulmonary, critical care, and sleep medicine from UpToDate

35% of UpToDate topics are updated every four months. The editors select a small number of the most important updates and share them via "What's new" page. I selected the brief excerpts below from What's new in hematology:

Asthma

When evaluating patients for occupational asthma, sputum eosinophil counts at 7 and 24 hours after specific inhalation challenge have a greater sensitivity and positive predictive value than exhaled nitric oxide (eNO).

Critical care

Proton pump inhibitors (PPIs) may be slightly more effective than histamine-2 (H2) blockers at preventing gastrointestinal (GI) bleeding in critically ill patients. However, the difference is small if real.

Idiopathic pulmonary fibrosis

Sildenafil, tyrosine kinase inhibitor imatinib, and pirfenidone, an anti-fibrotic agent, were each no more effective than placebo for treatment of idiopathic pulmonary fibrosis.

Pleural effusion

Using ultrasonography to identify a site for diagnostic thoracentesis is associated with significantly lower risk of pneumothorax, than using the physical exam for site selection.

Pulmonary embolism

PE is frequently asymptomatic. Among 5233 patients with a DVT, 32 percent had asymptomatic PE.

References:
What's new in pulmonary, critical care, and sleep medicine. UpToDate.

What's new in hematology from UpToDate

35% of UpToDate topics are updated every four months. The editors select a small number of the most important updates and share them via "What's new" page. I selected the brief excerpts below from What's new in hematology:

Transplantation in aplastic anemia

In patients with severe aplastic anemia over the age of 40 who received allogeneic hematopoietic cell transplantation from an HLA-identical sibling, overall survival was 65 percent.

Improved survival when rituximab is added to fludarabine plus cyclophosphamide in CLL

There were higher response rates and survival with six courses of FCR (fludarabine, cyclophosphamide, and rituximab) when compared with six courses of FC (fludarabine, cyclophosphamide).

Second generation tyrosine kinase inhibitors (TKIs) for CML

Trials comparing dasatinib or nilotinib to imatinib for chronic myeloid leukemia (CML) demonstrated faster and deeper responses with these second generation tyrosine kinase inhibitors.

Improved understanding of pathobiology of multiple myeloma

Virtually all multiple myeloma (MM) cases are preceded by a premalignant plasma cell proliferative disorder known as monoclonal gammopathy of undetermined significance (MGUS). The pathobiology of myeloma as a two-step process - first there is the establishment of a limited stage of clonal proliferation (MGUS); then there is progression of MGUS to MM.

Denileukin diftitox superior to placebo for relapsed mycosis fungoides

There were better response rates with the recombinant interleukin-2-diphtheria toxin fusion protein denileukin diftitox used for therapy of mycosis fungoides and Sezary syndrome.

Survival in sickle cell disease

The estimated survival at 18 years is now 94 percent for those with HbSS or HbS/beta(0) thalassemia and 98 percent for those with HbSC or HbS/beta(+) thalassemia.

References:
What's new in hematology. UpToDate.

What's new in infectious diseases from UpToDate

35% of UpToDate topics are updated every four months. The editors select a small number of the most important updates and share them via "What's new" page. I selected the brief excerpts below from What's new in infectious diseases:

Antibiotics and warfarin
Among patients taking warfarin who require antimicrobial therapy for treatment of urinary tract infection, trimethoprim-sulfamethoxazole and ciprofloxacin werer associated with increased risk of upper gastrointestinal tract bleeding.

C. difficile

Symptomatic patients may play a role in airborne dispersal of C. difficile. In a study including 50 patients with confirmed C. difficile infection, air sampling for one hour demonstrated C. difficile organisms in 12 percent of cases.

Community-acquired pneumonia and antipsychotics

Use of atypical or typical antipsychotics was associated with a dose-dependent increased risk for community-acquired pneumonia (CAP).

High-dose flu vaccine

The FDA approved a high-dose inactivated influenza vaccine for individuals older than 65 years of age. Data showed increased immunogenicity of the high-dose vaccine in older adults.

Measles mumps rubella (MMR)

Monovalent vaccines are no longer available in the United States for measles, mumps or rubella.

Meningococcal vaccine

A new quadrivalent meningococcal conjugate vaccine (Menveo) was approved for individuals from 11 to 55 years of age as an alternative to the older quadrivalent conjugate vaccine (Menactra, MCV4). Both formulations protect against the same serogroups (A, C, Y, and W135).

Herpes zoster vaccine

Uptake of herpes zoster vaccine has been 2 to 7 percent in the United States. The reasons are often financial - only 45 percent of PCPs knew that herpes zoster vaccine is reimbursed through Medicare Part D.

How to Subscribe to "What's New" Specialty Page of UpToDate? No Feed, No Problem for Google Reader

35% of UpToDate topics are updated every four months. The editors select a small number of the most important updates and share them via "What's new" page.

The page does not provide RSS feed for the different specialties. One solution is to copy/paste the URL address of each subspecialty page you are interested in the Google Reader "Add a subscription" field (top left corner). Google Reader will automatically create a RSS feed from this "feedless" page.



References:
What's new in infectious diseases. UpToDate.

UTD Contents: What's New

Are You Dependent on UpToDate for Your Clinical Practice?
5 Tips to Stay Up-to-Date with Medical Literature

Updates in Pediatrics

You can find this information on PubMed but this is a nice summary from UpToDate (only brief highlights are posted below, check the source link for full text):

Sexually transmitted infections

25% of urban adolescent females (14-17 years of age) were diagnosed with a sexually transmitted infection (STI) within one year of first intercourse.

Attention deficit hyperactivity disorder (ADHD)

ECG screening should not be required before initiating stimulant therapy for patients with ADHD.

Autism prevalence

The prevalence of autism spectrum disorders (ASD) among eight-year-old children in the United States increased from 1 in 150 children in 2000 to 2002 to approximately 1 in 111 in 2006. No clear reason for increase has been found.

The choking game

5.7% of eighth-graders had participated in the self-strangulation activity known as "the choking game". Recognize signs of these activities: bruising or red marks on the neck; wearing high-necked shirts, even in warm weather; bloodshot eyes or pinpoint bruising around the eyes; petechiae on the face, especially the eyelids or conjunctiva.

HPV vaccine

The US Food and Drug Administration (FDA) approved the use of quadrivalent human papillomavirus vaccine in males aged 9 through 26 years to reduce their likelihood of acquiring genital warts.

13-valent PCV

The FDA approved a 13-valentpneumococcal conjugate vaccine (PCV13). PCV13 adds serotypes 1, 3, 5, 6A, 7F, and 19A to those contained in the PCV7, the 7-valent vaccine (4, 6B, 9V, 14, 18C, 19F, and 23F). The six additional serotypes accounted for 63% of invasive pneumococcal disease among children younger than five years of age.

References:
What's new in pediatrics. UpToDate.
Pediatrics and Medicine

Image source: OpenClipArt.org, public domain.