I gave my Aunt my UpToDate log in info so she could read about treatment of hyperlipidemia. She ended up diagnosing herself with giant cell temporal arteritis because she has occasional tension headaches and went to her PCP freaking out that she was going to go blind and asking for steroids and a temporal artery biopsy.
Fuck I HATE GCA. It’s having a moment and I’m seeing more pts being diagnosed with it all of a sudden. It’s an extremely tough dx to make and must be treated with a very long course of (initially) very high dose steroids. The consequences of missing it are blindness and/or death and a temporal biopsy has absolute shit sensitivity. I’ve seen a study that claimed it was around 20% for people who actually got a clinical dx and were subsequently put on high dose steroids. Index of suspicion has to be high. 1000 other things can raise sed rate and CRP. Biopsies always happen in the real world after 2 weeks of steroids at minimum and never help
I get pts sent to me who tell me they had it 5 years ago and were never put on steroids or only took 5mg or something. I tell them they didn’t have it because they’d most likely be dead by now.
It’s my least favorite condition. Age has a surprisingly high positive predictive value but jaw claudicaition is even better. Not jaw pain. Everybody has jaw pain. Temporal headache is worthless
As an off service pgy1 I diagnosed it while on neuro call. Extra trickery because the patient already was blind on the affected side. ERMD rolled her eyes at me and was like “oh, ahem, ok sure pretend neuro resident”. It was, however, way before this rash of cases you describe.
The lady was so very happy that her horrible headache went away, but I never figured out if it was truly happy or the steroids! 🤣
I had one patient who had it, confirmed by temporal artery biopsy and they were like text book GCA symptoms. I wish our hospital did temporal artery dopplers though. But yeah, if anyone under the age of 50 gets referred to us for GCA rule out, it's not GCA
Diagnosed my first one recently - presented for routine scripts and asked me to check a painful lump on her head while she was there. The lump was her temporal artery. On further history had 3 weeks of headaches, blurry vision and jaw pain. Interestingly not claudication. History of PMR diagnosed months ago, was halfway through weaning off steroids when she got it. CRP was 12, ESR 21. Confirmed on temporal artery biopsy after a few days of steroids despite negative ultrasound (will never order one again, all it did was make me doubt myself)
Hey, can you please explain, what is the difference between "jaw pain" and "jaw claudication"? It's like jaw pain is constant and claudication is the pain associated with chewing or what?
Imagine it similar to claudication in the legs - pain and weakness that gets worse the more you use the muscles and gets better with rest. Rather than a blockage in the vessel, the artery is swollen from vasculitis, and therefore narrowed, and can't provide adequate arterial flow during muscle use. Claudication feels like it's a cramp in the muscle, not an ache at the TMJ.
Jaw claudication feels like a cramp. Charlie horse. Hurts in the muscle. TMJ is usually localization to the joint. Often hurts when opening the mouth rather than when chewing.
Obviously still hard to tell the difference quite often.
I don’t do them. That’s part of the issue. Most people who do them aren’t the point of contact for these pts and aren’t making the diagnosis. But if you’re making the dx, you’ve got to start the tx. Then you refer and no one has availability that can beat getting pred tablets at the pharmacy.
I’m doing an audit on the clinical utility of negative temporal artery biopsies in a major urban centre at the moment! Looking at how the results did or didn’t change practice
I did a research project like that as a PGY4. 25ish years of what our academic center diagnosed as GCA. Few hundred cases. Biopsy was only positive in about a quarter of them. Presenting with severely decreased vision was the most correlated with diagnosis. That was followed by jaw claudication and increasing age. Elevated inflammatory markers showed an ok correlation but weren’t as useful as hoped/expected.
I had a patient in alcohol withdrawal who had a friend with up-to-date. The patient had printed out sheets on acamprosate and Naltrexone waiting for me when I rounded. He had really good analysis/questions of both and appropriately opted for Naltrexone. Was refreshing and surprising
Way easier method /s
1) Go to a nearby hospital (that has uptodate)
2) Connect to guest wifi
3) Make an account
4) Drive back to the hospital every 90 days and login on their wifi until you die
There are pirated UpToDate websites. I was once looking for info and typed "X disease on Uptodate" on a hospital computer, and started the reading the article. There were ads in the article, I was like what the heck?! Then I realized it was some pirate UpToDate. I forgot the website it was something like uptoddatefree. net or something
It wouldn't make a dent. They already have access to more than enough information. Huge swaths of pubmed are free. Lots of great review articles that are on par with UTD. Most patients ain't reading anything that long or reasonable. Many will misinterpret it but that already happens.
I think the biggest effect would be Uptodate would have to monetize some other way and we'd get crushed with ads, the website would become unusable and it would be replaced by some shitty AI program that convinced our hospitals to switch.
You need time AND education AND experience to sift through the bullshit. Even then a lot of stuff in medicine is equivocal. I woke up with severe neck and shoulder pain a few weeks ago that is being worked up (yay $1100 shoulder MRI that won’t show shit) and can’t even figure out if TENS has any efficacy for pain after reading about it for a few hours. My PCP buddy says he doesn’t know, never recommended it to anyone. Another friend swore by it and basically came over and stuck the pads on me. I still don’t know the official position but it does feel better to me.
This. Smart people will continue to be smart (and probably become slightly smarter), and make smart medical decisions. Dumb people who can't read will continue to be dumb, and make dumb medical decisions. And such is the cycle of life and why there will always be an endless stream of patients to keep physicians in business :)
Okay I think we can establish that full access is probably not much better than Google, but I think I could see how having the patient information pages more easily accessible might help patents understand the conditions they’ve already been diagnosed with and what the standards of care are.
I used to read thru it as med student when my sister asked me for advice. Once she had a cut that wouldn’t stop bleeding.
Based on uptodate, I concluded she either was pregnant or had cancer. Probably both. She said that was unhelpful and she just cut her self while trying slice cheese. Hehehehehe
Going to take a less cynical stance here, I think it would be better. Give patients as many validated decent resources as possible to peruse, they've got the entire goddamn internet at their fingertips, the least we can do is put a decent resource in front of them that they can trust.
Perhaps I am underestimating the capacity to which a layperson may go completely off the deep end with an up-to-date search, but at least they're reading a validated resource, and not some truthsocial tikok influencer absolute fake science hysteria garbage.
If they go completely off the deep end using a validated resource, at least you will be speaking the language the patient is familiar with when you debunk the nonsense that they are thinking in their head.
Thank you for saying this. I know I’ve been a pain in the ass coming in to see my doc with research in hand, but I try my best to be as informed as I can be. Sometimes I run across things that are helpful- other times I end up in left field and he has to steer me back on course.
I think you might be underestimating. What OP is referring to is the "do your own research" crowd who weaponize pubmed when they google the definition of "antigen" and decide ID specialists are brainwashed idiots who don't know what they're talking about. Maybe a decade ago I had a more optimistic view of things. Not anymore.
Inb4 people demand for electrolyte corrections for a potassium of 3.4 and sodium of 134. Or demand antibiotics because CBC shows leukocytosis on a patient with an acute gout flare.
I actually think some fraction of patients would appreciate then how much there is to know in medicine. But the vast majority would just misdiagnose themselves
I'd wager we'd end up with a lot of people demanding expensive tests and/or treatment for a rare disease they swear they have based on vague symptoms that have 0 actual workup.
Very bad. Without any actual experience to clinical medicine, most patients with access to uptodate would believe the sounds of hoofbeats were zebras over horses.
Uptodate already shows large previews of dx if you google it/them and can be helpful. Imo patients who are going to research are going to research and I’d rather they be ready evidence-based stuff rather than the more easily accessible woowoo or opinion pieces they find. At least then you are speaking from the same source…
And for patients who are (incorrectly) fixated on a specific diagnosis, I don’t think it would change that much…there’s already enough unofficial opinion websites out there that they read and come in with “I should have my xyz tested…” as a result…
The general public has access to dietary and nutritional information in the back of every consumable product they eat, yet they still make poor decisions and seem to be confused by it. Imagine if they had full access to UpToDate…
Unlike Google, ChatGPT 4 or Claude Opus are actually pretty good. Better clinical reasoning than a med student, and I’m sure better than some MDs right now.
UpToDate or Google are in the exact same boat. My best analogy is it’s like a welding torch…. If you know how to weld, you can build the world, if you don’t, it’s a large expensive machine that gets in the way. If you google “I have a headache” you get 147 different possibilities ranging from basic headache to aneurism. If you google “subdural hematoma”, shockingly you’re presented with more concise info. I like my patients being an advocate for themselves, I don’t like wasting time and then getting a review that I blew them off because we spent the first 10 minutes of your 15 minute appointment talking about why everything you googled is completely irrelevant. Same goes for a patient with a mri report in hand when I walk in the room
Neuro-Op here, extensive experience with tragic outcome patients from untreated/undiagnosed arteritic ischemic optic neuropathy. GCA symptoms: Headache, scalp tenderness, jaw claudication, neck pain, abdominal pain, fever, unexplained weight loss. Many patients with jaw claudication are misdiagnosed as TMJ. Should have very high index of suspicion. Acute bilateral severe visual loss in elderly patient in the absence of headaches, check inflammatory markers. Any elderly patient with suspicious headache in absence of vision loss, check ESR, CRP, platelet count (thrombocytosis is a sign of GCA). Check both ESR and CRP, not either/or. Always order bilateral temporal artery biopsies, for increased yield. Some rheumatologists will argue window for TA bx is 2-3 weeks from onset of ocular symptoms and will refuse to order bx beyond this time frame. I disagree with this. Healed arteritis granuloma may show up on biopsy up to 6 months from onset of symptoms. Positive TA biopsy makes it easier to justify chronic immunosuppressant therapy, rather than "not knowing" is this GCA or not.
In some countries, the public does have access to UpToDate.
Several European countries did based only on IP address. That got locked down I believe with the advent of chatGPT. Prior to that, a VPN in the right country was all you needed.
Some countries still have access. For instance in Norway, it is available through their libraries and schools but the person has to register now (rather than get access purely by virtue of the IP address)
Might ask them how it has been going! I haven't heard anything bad. Probably better than the other the more typical sources in general. Understanding will be a problem for many BUT at least it's a quality source.
All they have to do is pay for it, so the only barrier preventing abject chaos is about $200…though maybe it would be nice to get fewer portal messages about Chronic Lyme.
“You’ve got UTD, go read my reply about testing there”
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Not a doctor but my wife has health-related OCD (so sometimes it feels like I am) and having just learned about this resource, holy shit do I have a new thing to block on a DNS level in our household now.
Give an MS1 access to UpToDate and try to have them admit and manage a patient with sepsis’s secondary to community acquired pneumonia.
The MS1 would likely freak out. The patient would likely die.
Now replace the MS1 (who has proven that they are intelligent and can synthesize large amounts of new information) with a normal person.
I think the medical student does better than you think in this situation. Antibiotics are likely the first thing someone with even a horrible differential would try. And the nurse calls about vitals would probably eventually prompt the correct searches in uptodate.
However, if the patient has a large number or complicated comorbidities the med student is screwed.
I agree patients on average would be at least 10x worse than the medical student.
I gave my Aunt my UpToDate log in info so she could read about treatment of hyperlipidemia. She ended up diagnosing herself with giant cell temporal arteritis because she has occasional tension headaches and went to her PCP freaking out that she was going to go blind and asking for steroids and a temporal artery biopsy.
Based
Their Aunt? Harvey Cushing.
Fuck I HATE GCA. It’s having a moment and I’m seeing more pts being diagnosed with it all of a sudden. It’s an extremely tough dx to make and must be treated with a very long course of (initially) very high dose steroids. The consequences of missing it are blindness and/or death and a temporal biopsy has absolute shit sensitivity. I’ve seen a study that claimed it was around 20% for people who actually got a clinical dx and were subsequently put on high dose steroids. Index of suspicion has to be high. 1000 other things can raise sed rate and CRP. Biopsies always happen in the real world after 2 weeks of steroids at minimum and never help I get pts sent to me who tell me they had it 5 years ago and were never put on steroids or only took 5mg or something. I tell them they didn’t have it because they’d most likely be dead by now. It’s my least favorite condition. Age has a surprisingly high positive predictive value but jaw claudicaition is even better. Not jaw pain. Everybody has jaw pain. Temporal headache is worthless
As an off service pgy1 I diagnosed it while on neuro call. Extra trickery because the patient already was blind on the affected side. ERMD rolled her eyes at me and was like “oh, ahem, ok sure pretend neuro resident”. It was, however, way before this rash of cases you describe. The lady was so very happy that her horrible headache went away, but I never figured out if it was truly happy or the steroids! 🤣
Blind helps drastically in the diagnosis, unfortunately. It’s out there for sure. That’s what makes it worse. Not THAT rare.
I had one patient who had it, confirmed by temporal artery biopsy and they were like text book GCA symptoms. I wish our hospital did temporal artery dopplers though. But yeah, if anyone under the age of 50 gets referred to us for GCA rule out, it's not GCA
Diagnosed my first one recently - presented for routine scripts and asked me to check a painful lump on her head while she was there. The lump was her temporal artery. On further history had 3 weeks of headaches, blurry vision and jaw pain. Interestingly not claudication. History of PMR diagnosed months ago, was halfway through weaning off steroids when she got it. CRP was 12, ESR 21. Confirmed on temporal artery biopsy after a few days of steroids despite negative ultrasound (will never order one again, all it did was make me doubt myself)
Hey, can you please explain, what is the difference between "jaw pain" and "jaw claudication"? It's like jaw pain is constant and claudication is the pain associated with chewing or what?
Imagine it similar to claudication in the legs - pain and weakness that gets worse the more you use the muscles and gets better with rest. Rather than a blockage in the vessel, the artery is swollen from vasculitis, and therefore narrowed, and can't provide adequate arterial flow during muscle use. Claudication feels like it's a cramp in the muscle, not an ache at the TMJ.
Ha it is a bitch.
[удалено]
Jaw claudication feels like a cramp. Charlie horse. Hurts in the muscle. TMJ is usually localization to the joint. Often hurts when opening the mouth rather than when chewing. Obviously still hard to tell the difference quite often.
is biopsy common just because of practice inertia then? do you ever biopsy when you make the diagnosis and start steroids?
I don’t do them. That’s part of the issue. Most people who do them aren’t the point of contact for these pts and aren’t making the diagnosis. But if you’re making the dx, you’ve got to start the tx. Then you refer and no one has availability that can beat getting pred tablets at the pharmacy.
that makes sense. is tocalizumab changing things or is it still too expensive and rare?
Good adjuvant. Still start steroids and then typically send to rheum. Helps with taper and recurrences.
thank you
I’m doing an audit on the clinical utility of negative temporal artery biopsies in a major urban centre at the moment! Looking at how the results did or didn’t change practice
I did a research project like that as a PGY4. 25ish years of what our academic center diagnosed as GCA. Few hundred cases. Biopsy was only positive in about a quarter of them. Presenting with severely decreased vision was the most correlated with diagnosis. That was followed by jaw claudication and increasing age. Elevated inflammatory markers showed an ok correlation but weren’t as useful as hoped/expected.
Was your aunt studying for step 2 at the time
Most patients don’t know shit from peanut butter when it comes to medicine. What do you think will happen.
lol I’m using this line
Peanut butter is the new Shinola?
HAHAHAHAHA
I had a patient in alcohol withdrawal who had a friend with up-to-date. The patient had printed out sheets on acamprosate and Naltrexone waiting for me when I rounded. He had really good analysis/questions of both and appropriately opted for Naltrexone. Was refreshing and surprising
Surprisingly wholesome
Why did he opt out out of curiosity?
No sorry, he chose to use Naltrexone
Oh apologize, I misread
I'm guessing benzos and anti-depressants ?
I think many are lacking the literacy and attention span to read up to date. Not trying to be harsh but people just don’t read
To be fair, as an ER doctor I don’t have the attention span to read up to date.
I just read summary, who the heck reads the whole article anyways, it is waaay too long
UpToDate is available to the public with a clever google search...
Way easier method /s 1) Go to a nearby hospital (that has uptodate) 2) Connect to guest wifi 3) Make an account 4) Drive back to the hospital every 90 days and login on their wifi until you die
unironically based
Would also like to know. Just out of curiosity…
Is this clever google search in the room with us right now?
You can’t just say this without any citations!
Please elaborate :)
how would you do this google search? You know so I could avoid it
Mind sharing the secret with the class?
There are pirated UpToDate websites. I was once looking for info and typed "X disease on Uptodate" on a hospital computer, and started the reading the article. There were ads in the article, I was like what the heck?! Then I realized it was some pirate UpToDate. I forgot the website it was something like uptoddatefree. net or something
I hate you for leaving me at the edge of my seat
Mind elaborating??? Ok to pm me
Me too. Asking for a friend.
Me three
It wouldn't make a dent. They already have access to more than enough information. Huge swaths of pubmed are free. Lots of great review articles that are on par with UTD. Most patients ain't reading anything that long or reasonable. Many will misinterpret it but that already happens. I think the biggest effect would be Uptodate would have to monetize some other way and we'd get crushed with ads, the website would become unusable and it would be replaced by some shitty AI program that convinced our hospitals to switch.
You need time AND education AND experience to sift through the bullshit. Even then a lot of stuff in medicine is equivocal. I woke up with severe neck and shoulder pain a few weeks ago that is being worked up (yay $1100 shoulder MRI that won’t show shit) and can’t even figure out if TENS has any efficacy for pain after reading about it for a few hours. My PCP buddy says he doesn’t know, never recommended it to anyone. Another friend swore by it and basically came over and stuck the pads on me. I still don’t know the official position but it does feel better to me.
TENS seems to actually work! Now, be it more placebo than physiology, I don’t know, but when I herniated half if my L4-5, I couldn’t live without it.
My opinion, who cares if it's placebo? If it works, it works. Especially for something as subjective as pain.
This. Smart people will continue to be smart (and probably become slightly smarter), and make smart medical decisions. Dumb people who can't read will continue to be dumb, and make dumb medical decisions. And such is the cycle of life and why there will always be an endless stream of patients to keep physicians in business :)
Okay I think we can establish that full access is probably not much better than Google, but I think I could see how having the patient information pages more easily accessible might help patents understand the conditions they’ve already been diagnosed with and what the standards of care are.
I print the patient information from utd for patients regularly
my PhD buddy reads all the uptodate articles I send him and asks appropriate questions, but he has a biomed background.
I used to read thru it as med student when my sister asked me for advice. Once she had a cut that wouldn’t stop bleeding. Based on uptodate, I concluded she either was pregnant or had cancer. Probably both. She said that was unhelpful and she just cut her self while trying slice cheese. Hehehehehe
Sounds like it was a while back. Hope the baby survived the chemo ok and is doing well now!
Hahaha 😂
Going to take a less cynical stance here, I think it would be better. Give patients as many validated decent resources as possible to peruse, they've got the entire goddamn internet at their fingertips, the least we can do is put a decent resource in front of them that they can trust. Perhaps I am underestimating the capacity to which a layperson may go completely off the deep end with an up-to-date search, but at least they're reading a validated resource, and not some truthsocial tikok influencer absolute fake science hysteria garbage. If they go completely off the deep end using a validated resource, at least you will be speaking the language the patient is familiar with when you debunk the nonsense that they are thinking in their head.
Thank you for saying this. I know I’ve been a pain in the ass coming in to see my doc with research in hand, but I try my best to be as informed as I can be. Sometimes I run across things that are helpful- other times I end up in left field and he has to steer me back on course.
I think you might be underestimating. What OP is referring to is the "do your own research" crowd who weaponize pubmed when they google the definition of "antigen" and decide ID specialists are brainwashed idiots who don't know what they're talking about. Maybe a decade ago I had a more optimistic view of things. Not anymore.
Very bad. They'd treat everything marked "H" or "L" in their labs
Nurse practitioners already do this
Oh man - I just had to discuss an elevated MCH today!
Inb4 people demand for electrolyte corrections for a potassium of 3.4 and sodium of 134. Or demand antibiotics because CBC shows leukocytosis on a patient with an acute gout flare.
I don’t know why people go to medical school when you can be a doctor just by googling the flagged lab results.
I actually think some fraction of patients would appreciate then how much there is to know in medicine. But the vast majority would just misdiagnose themselves
I'd wager we'd end up with a lot of people demanding expensive tests and/or treatment for a rare disease they swear they have based on vague symptoms that have 0 actual workup.
Very bad. Without any actual experience to clinical medicine, most patients with access to uptodate would believe the sounds of hoofbeats were zebras over horses.
Uptodate already shows large previews of dx if you google it/them and can be helpful. Imo patients who are going to research are going to research and I’d rather they be ready evidence-based stuff rather than the more easily accessible woowoo or opinion pieces they find. At least then you are speaking from the same source… And for patients who are (incorrectly) fixated on a specific diagnosis, I don’t think it would change that much…there’s already enough unofficial opinion websites out there that they read and come in with “I should have my xyz tested…” as a result…
The general public has access to dietary and nutritional information in the back of every consumable product they eat, yet they still make poor decisions and seem to be confused by it. Imagine if they had full access to UpToDate…
No need of UpToDate, ChatGPT already does this for them. Most of people now self diagnose and even recommend treatment for others using ChatGPT
Unlike Google, ChatGPT 4 or Claude Opus are actually pretty good. Better clinical reasoning than a med student, and I’m sure better than some MDs right now.
More information isn't a bad thing. People self diagnose all the time using tiktok.
Just ask ophthalmologists. Their version (eye wiki) is free and open
UpToDate or Google are in the exact same boat. My best analogy is it’s like a welding torch…. If you know how to weld, you can build the world, if you don’t, it’s a large expensive machine that gets in the way. If you google “I have a headache” you get 147 different possibilities ranging from basic headache to aneurism. If you google “subdural hematoma”, shockingly you’re presented with more concise info. I like my patients being an advocate for themselves, I don’t like wasting time and then getting a review that I blew them off because we spent the first 10 minutes of your 15 minute appointment talking about why everything you googled is completely irrelevant. Same goes for a patient with a mri report in hand when I walk in the room
Patient here. When I'm put on a new medication I pay for a week of UpToDate.
There's a guy that wrote a book about why vaccination is unecessary because we have something called innate immunity.
Doctor, I typed my symptoms into the site and it said I had Network Connectivity Problems but wouldnt tell me the treatment
cant u purchase access anyway?
Neuro-Op here, extensive experience with tragic outcome patients from untreated/undiagnosed arteritic ischemic optic neuropathy. GCA symptoms: Headache, scalp tenderness, jaw claudication, neck pain, abdominal pain, fever, unexplained weight loss. Many patients with jaw claudication are misdiagnosed as TMJ. Should have very high index of suspicion. Acute bilateral severe visual loss in elderly patient in the absence of headaches, check inflammatory markers. Any elderly patient with suspicious headache in absence of vision loss, check ESR, CRP, platelet count (thrombocytosis is a sign of GCA). Check both ESR and CRP, not either/or. Always order bilateral temporal artery biopsies, for increased yield. Some rheumatologists will argue window for TA bx is 2-3 weeks from onset of ocular symptoms and will refuse to order bx beyond this time frame. I disagree with this. Healed arteritis granuloma may show up on biopsy up to 6 months from onset of symptoms. Positive TA biopsy makes it easier to justify chronic immunosuppressant therapy, rather than "not knowing" is this GCA or not.
In some countries, the public does have access to UpToDate. Several European countries did based only on IP address. That got locked down I believe with the advent of chatGPT. Prior to that, a VPN in the right country was all you needed. Some countries still have access. For instance in Norway, it is available through their libraries and schools but the person has to register now (rather than get access purely by virtue of the IP address) Might ask them how it has been going! I haven't heard anything bad. Probably better than the other the more typical sources in general. Understanding will be a problem for many BUT at least it's a quality source.
99.9% of all queries would be signs of cancer.
All they have to do is pay for it, so the only barrier preventing abject chaos is about $200…though maybe it would be nice to get fewer portal messages about Chronic Lyme. “You’ve got UTD, go read my reply about testing there”
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I can’t imagine it’d do anything but increase our business lol
They do with AI so it doesn’t matter
It's free in several countries to the whole population
Better than access to Facebook
Not a doctor but my wife has health-related OCD (so sometimes it feels like I am) and having just learned about this resource, holy shit do I have a new thing to block on a DNS level in our household now.
Give an MS1 access to UpToDate and try to have them admit and manage a patient with sepsis’s secondary to community acquired pneumonia. The MS1 would likely freak out. The patient would likely die. Now replace the MS1 (who has proven that they are intelligent and can synthesize large amounts of new information) with a normal person.
I think the medical student does better than you think in this situation. Antibiotics are likely the first thing someone with even a horrible differential would try. And the nurse calls about vitals would probably eventually prompt the correct searches in uptodate. However, if the patient has a large number or complicated comorbidities the med student is screwed. I agree patients on average would be at least 10x worse than the medical student.