Tintinalli: What I’m reading now

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With an abundance of news and reviews for us to sift through, it’s hard to keep up, especially with general medicine topics that could affect us personally or professionally. Here’s what’s on my mind this month.

l have a file simply named ‘Key Articles.’ In this file I keep articles that explain statistical concepts like ‘propensity analysis’ (in case I ever need that – like hardly ever) and ‘how to calculate the NNT’ (I need that a lot), but also articles that I don’t want to forget because they affect my practice. Given the overabundance of trivial EM and medical research, this sometimes boils down to none or a few each month. But, as they come up, I’ll pass them on to you – see if they make you think or help your practice.

Pseudotumor: How much CSF should be removed?
So, sometimes we see pseudotumor, or its new name: idiopathic intracerebral hypertension (IIH). How do we know how much CSF should one remove? I just had a case last week. It’s an emergency medicine question often treated by “best guess.” However, with a lot of digging, I found the answer. You remove 1 c for every desired cm of H2O reduction. The goal in IIH is to reduce to 15-20 cm H2O, but don’t take off too much [1].


A new perspective on ovarian cancer treatment
In the past few months, I’ve diagnosed ovarian cancer (CA) in the ED in two patients, both being treated for “IBS.” BUT – new and important research conducted in the UK, has changed my perspective.

The UK Collaborative Trial of Ovarian Cancer Screening (UKCTOS) followed more than 200,000 women aged 50-74 in the National Health Service Trusts with three screening methods for ovarian cancer in women without obvious risk factors. To give you the abbreviated results, those with monitoring using routine CA 125 and transvag US, had an overall average mortality reduction of 20%!

Ovarian cancer is a killer. Treatment prolongs life a bit. And treatment can be as bad as the disease. We don’t want to see our wives, mothers, sisters, friends and daughters get this disease before it can be well treated. So we know further follow-up is needed before firm conclusions can be reached on the efficacy and cost-effectiveness of ovarian cancer screening. But the authors of the UKCTOS point out that the relative mortality reductions from breast cancer screening trials and observational studies are of the same magnitude as the UKCTOS. Read the paper and see what you think [2].


Also, don’t miss the online commentary [3], which reviews the pathology (epithelial fallopian tube serous carcinoma), why it is so hard to find and why it masquerades as IBS. The authors point out that the pathophysiology needs to be understood by general medical practitioners who can help make an early diagnosis.

ACS scores for our practice
The use of risk scores to identify low-probability ACS has changed our clinical approach and has reduced uncertainty in decision-making. In 2015, EPM published several articles reporting the use of such scores. The best recent journal article was published by JAMA in November [4]. This is a good review for residents and clinicians, and describes the best and not-so-best of the scores.

Stay tuned for more next month.



  1. Fiorito-Torres, F et al. Idiopathic Intracerebral Hypertension (IIH)/Pseudotumor: Removing Less CSF Is Best. Neurology April 8, 2014 85:10, s:19-1.006
  2. Jacobs , I et al. Ovarian cancer screening and mortality in the UK Collaborative Trial of Ovarian Cancer Screening (UKTOCS): a randomised controlled trial. Lancet , published online December 17, 2015 http://dx.doi/org/10.1016/S0140-6736(5) 01224-6.
  3. Harihanan K and Hall M. Re:Diagnosis of ovarian cancer-regrettably a missed opportunity for education http://dx.doi.org/10.1016/S0140-6736(15)01236-2.
  4. Fanaroff AC et al. Does this Patient with Chest Pain Have Acute Coronary Syndrome? The Rational Clinical Examination Systematic Review. JAMA 2015 Nov l0; 314 (18):1955-65, doi:10.1001/jama2015.12735’.


Dr. Tintinalli is currently a professor and Chair Emeritus of Emergency Medicine at the University of North Carolina. In addition to teaching in the emergency medicine department, she is an adjunct professor at the UNC Gillings School of Global Public, and a frequent lecturer in the School of Journalism and Mass Communication. Dr. Tintinalli is double boarded in emergency medicine and internal medicine. She was the founder and first president of the Council of Emergency Medicine Residency Directors. She is a former president of ABEM as well as the Association of Academic Chairs in Emergency Medicine. She is a past winner of ACEP's James Mills award as well as ACEP's National Education Award. And of course, she is the Editor-in-Chief of 7 editions of her eponymous textbook, which is arguably the best-known EM text in the world.

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