Ask Dr Wiki Receives Not For Profit Status!

It has been close to a year since we started AskDrWiki.com. One of our initial objectives was to obtain 501(c)(3) status from the IRS. After filling out what seems like thousands of forms we received our letter from the IRS this week approving us as a non profit company. I hope that this will help increase collaboration and contributions by removing the perception of a financial interest and allow us to continue on our mission of creating a free online source of up to date medical information.

Another Lesson Physicians Can Learn from their Kindergarden Teachers

Free Online Wiki could Save Schools Billions
An article in the USA Today by Greg Toppo, describes how Free-Reading.net, a wiki reading program for kindergartners and first graders may make big, bulky - and expensive - textbooks go the way of the film strip. The wiki which allows teachers to post their own lessons, comments and modifications has been approved by a textbook adoption committee in Florida and is awaiting approval by the state’s incoming education commissioner.

Since Florida is one of the five textbook markets in the USA, its move could lead to the development of other free materials that might someday challenge the dominance of a handful of big education publishers. Schools spend $4.4 billion for textbooks in the 2006-2007 school year, so the prospect of free state approved materials could have profound influence on how schools spend money.

Can healthcare providers learn a lesson from our Kindergarden teachers using Free-Reading? We hope so! If the medical information that is published on a medical wiki is free and high quality it will be hard to ignore.

The Cost of Medical Information....Priceless

Cost of 5 new textbooks............................................ $750
Cost of First Year Subscription to Up to Date....... $495

Having all of your Medical Information Stored on a Medical Wiki for Free.....PRICELESS


Medical textbooks and subscription based medical websites, such as Up To Date consume an enormous amount of dollars from physicians, nurses and medical students yearly. I recently purchased several textbooks with a average purchase price of $155 per text book and it is not unusual to find some medical textbooks to be priced in the $200- 300 range. Since my medical training started I have noticed a creep in the cost of textbooks which are likely due to more graphics, color photos, and bundling of books with a CD-ROM, but should we expect medical students, nurses, and residents to continue to pay these prices on little to no salary?

For the residents and students who have a library who will pay the cost of a site license for subscription based site, such as Up to Date, they are a great source of information. For users who work in smaller hospitals or clinics the price of $495 for an individual subscription to these services can be prohibitive.

A wiki, on the other hand with 500 GB of storage cost less than $100 a year. This amount of storage would equal 51 million pages in a medical text book. That is a lot of information and could be a potential huge savings for medical professionals.

Are Physicians Starting To Wiki a Diagnosis?

The BMJ article on Googling for a diagnosis published last year brought attention to the use of the internet to help make the correct diagnosis. We have also noticed a trend that we have seen on AskDrWiki, which is use of the word "wiki" that accompanies a medical search query. We have had over 1400 queries this year in which a medical term was linked with the word wiki.

Such as "cardiac index wiki", "empiric trial wiki", "amyloidosis wiki", or "captopril wiki". Clearly medical students, nurses, and physicians are not only Googling for a diagnosis but they are also directing their search toward a wiki.

We hope that we can help make another tool for the physicians bag that can help diagnose difficult cases.

AskDrWiki and RadsWiki Collaborate

We are very excited about our new collaboration with Radswiki. One of the most powerful features of a wiki comes from the ability to wiki link to other articles in the wiki. With the growing list of medical wikis this benefit may be lost. We hope that we can continue to collaborate with other wikis and build a true quality multi specialty medical wiki. We recognize the need for subspecialty wikis, like Radswiki, just as there are subspecialty text books, but we hope that other subspecialty wikis will also work with us to establish an integrated medical wiki.

Wikis in Plain English

Thanks to Common Craft Show for posting a Wikis in Plain English Video. Sometimes it is hard to explain to someone exactly what a wiki is and how it works. They did a nice job.

Editorial Policy Published

Our editorial policy will now be published on AskDrWiki and is included below. If anyone has any comments, suggestions, or ways we can improve the policy please let us know. Thanks to David Rothman for initially suggesting that we include this on the site.

Purpose
AskDrWiki.com is a website designed to provide health information for physicians, nurses, and medical students. The aim of of the site is to provide a source of reliable medical information that is easy to access on the internet. The information published on the site is not meant to supersede medical training but to serve as a repository of medical review articles to give medical professionals an online repository where they can review medical topics.

User Credentialing
AskDrWiki users must be credentialed based on their medical training before they are allowed to publish. All new users will be required to submit their medical training, degree, and current hospital or medical school. All credentialed users will be listed on the editorial board and are encouraged to publish their resume or curriculum vitae stating their education, medical training, board certification, and research. This process will remove the transparency of anonymous article creation and provide an extra level or credibility.

Article Submission

1. All articles will be submitted by credentialed medical professionals.
2. To qualify for publication material must be clearly presented and referenced with peer reviewed literature.
3. If medical topics written about are not referenced and are based on anyone's individual or anecdotal experience (The Art of Medicine) they should be designated as such.
4. Controversial topics may be presented, but they should be identified as such and every effort must be made by the editor to ensure that a balanced view of each controversy is represented based on referenced literature.

Article Review

1. Once articles are submitted they will be reviewed by specialty editors and can be added or edited by the AskDrWiki community.
2. Notification of new or changes in articles will be made through RSS Feeds.
3. Using Wiki technology users can scrutinize the content and add or edit the article. If there is a disagreement in the article efforts to come to a consensus will be made on the discussion page which is an inherent part of the wiki process.

Original Research
Any original research published on AskDrWiki is subject to peer review and open commentary from the AskDrWiki community. Edits and comments can be seen on the edits and history page. A conflict of interest statement must also accompany the article. Each original research contribution will be labeled as original research on the page.

Copyrights
AskDrWiki is a free site licensed under the terms of the Creative Commons license. Work that infringes on copyrights will not be allowed.

Sponsorship/ Conflict Of Interest

1. AskDrWiki is a non profit website funded by the Open Access Medical Informatics Group (501c3 status pending).
2. It has no financial agenda or purpose to refer patients to particular medical centers or providers.
3. The content is determined by its users and at no time is there any influence by advertising.
4. Editors do not receive compensation for content they have written.
5. The site is supported by donations and does not allow banner ads or pay per click advertising.

Disclaimers
All opinions expressed on AskDrWiki are those of their authors and not of their employers. Information provided here is for medical education only. It is not intended as and does not substitute for medical advice. If you are a patient, please see your doctor for evaluation of your individual case. Under no circumstances will the authors be liable to you for any direct or indirect damages arising in connection with use of this web site. Patient data published on this web site is modified and information from several cases may be compiled into one posting for teaching purposes and to protect patient confidentiality. Cases course and description do not follow real cases. The appearance of external hyperlinks to other web sites does not constitute endorsement. We do not verify, endorse, or take responsibility for the accuracy, currency, completeness or quality of the content contained in these sites. All clinical cases on this website are published in strict compliance with HIPAA. Report any violations to doctorwiki@gmail.com

Implementation of AskDrWiki Editorial Board

We have always felt that to ensure that the medical content published on the wiki is reliable, contributors must not be anonymous and should be identified with their name and degree. This has been implemented on our Who is Dr Wiki Page and we will also encourage users to also post their resume or curriculum vitae on this page as seen on the left.

We are hoping that this will add another level of credibility to the site and continue to move the site in a safe direction.

AskDrWiki in The AMA News

An article in the AMA News by Pamela Dolan appeared this week about medical wikis specifically about AskDrWiki and Pubdrug. The article also included statements made by David Rothman, his full interview can be seen on his blog.

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AskDrWiki Logo

Our new logo is now finished!

We chose this as our new logo because we feel the different pieces of the caduceus represent all of the different contributions to AskDrWiki. It is our hope that these pieces through mass collaboration can collectively come together to advance medicine by creating an extraordinary wealth of information.

We are sure that there will be challenges with the use of medical wikis but we feel that we will also create tremendous opportunities. Medical wikis are more than just a piece of software that enable multiple people to add and edit articles. They are a tool that will bring together the talents of dispersed physicians to create a new era of collaborative medicine.

Wiki for physicians gains foothold

Nice article by Ken Terry in the Medical Economics Infotech Bulletin published about AskDrWiki discussing the differences between AskDrWiki and Evidenced Based Medicine Sites such as Uptodate, BMJ Clinical Evidence, and DynaMed.

The Full article can be found at the Medical Economics Website.

Wikitext Tutorial for Ask Dr Wiki

Since Medical Wikis have been attracting more attention this week we have received some great suggestions on ways we can improve this technology. We are always open minded to comments and we feel that the only way for this technology to succeed is to take input from the medical blogospshere and implement these changes.

The main complaint and concern we have heard is the difficulty in entering Wikitext. Wikitext language or wiki markup is a markup language that offers a simplified alternative to HTML and is used to write pages in wiki websites such as AskDrWiki and Wikipedia. Wikitext is very easy to learn, and most contributors can learn it quickly, but does present a hurdle that users have to cross before they start contributing.

Given this complaint we have made a short power point presentation to try to educate our users on how to enter Wikitext and we hope this will help some of our users get started.

We hope that in the future Mediawiki, which is the software that AskDrWiki and Wikipedia uses, will implement a good WYSIWYG (What You See Is What You Get) editor, but until then we will teach our medical contributors wikitext. After years of college, medical school, and postgraguate training we feel they can learn.

Ask Dr Wiki in the News

This week has been an exciting week for Brian Jefferson and I since the Plain Dealer article by Zachary Lewis was published on the front page. We have had an enormous number of visitors because of this article and we have received some great suggestions from visitors as well as from blogs. Over the next week we will start implementing some of these changes in the hopes of making a medical wiki that provides safe and up to date information.

Some changes and suggestions that we will implement.
1. Creation of an editorial policy as per the suggestion of David Rothman
2. Create a list of all contributing editors with their pertinent credentials
3. Creation of a New Logo
4. Protection of Pages on the Wiki that contain any medication dosages so these pages can not be altered.
5. Addition of a clinical pharmacist to the editorial board.
6. Addition of a AskDrWiki page on Wikipedia.
7. Addition of a General Surgery, ENT, Vascular Surgery, Dermatology, Emergency Medicine, and Basic Science Editors

We would also like to thank Ves Dimov from Clinical Cases and Images , David Rothman from davidrothman.net, and Bertalan Mesko from scienceroll.com for their advice.

Other comments this week on AskDrWiki include:
eHealth and The Krafty Librarian

EKG of the Week:Non Reentrant Fast/Slow Supraventricular Tachycardia

Characteristics:
This is an extremely rare tachycardia which occurs when a single sinus impulse conducts down an AV node with both a slow and fast pathway. When most impulses reach the AV node they conduct down both the slow and fast pathway. Since conduction is faster down the fast pathway it beats out the slow pathway conduction and depolarizes the ventricle. The impulse traveling down the slow pathway either collides with the impulse from the fast pathway that is now traveling back up the slow or the impulse traveling down the slow pathway reaches the ventricle and finds the ventricle refractory. In the above EKG the sinus impulse represented by the P wave in the beginning of the rhythm strip conducts down the fast pathway resulting in the first QRS complex; the impulse from the slow pathway also depolarizes the ventricle seen as the second QRS complex. You will notice that there is no p wave between the first and second QRS complexes. Therefore the first sinus beat results in a doubling of the ventricular sinus rate. This sequence is repeated again in the 7th and 8th QRS complex. It is an extremely rare tachycardia and is resistant to multiple antiarrhythmic medications. The above patient underwent ablation of their slow pathway and no further episodes were observed. See www.askdrwiki.com for more interesting EKGs.

Ask Dr Wiki Will Now Require Proof of Credentials

Since Brandon Keim published his article in Nature Medicine titled WikiMedia, the subject of crendentialing has been a topic that has been discussed on DavidRothman.net and meredith.wolfwater.com. After hearing their arguments we have decided that they are correct. In order to create an expert medical wiki we need to prove that future users have real medical credentials. We will now require users to submit their real names, degree, and hospital or medical school and will then confirm their credentials before we allow them to create or edit articles. The comments and suggestions from everyone who weighed in are appreciated!

Reference:
Brandon Keim: WikiMedia; News@Nature 13, 231-233

EKG of the Week: Primum Atrial Septal Defect

Characteristics
Patients with Atrial Septal Defects may have Atrial Fibrillation, Atrial Tachycardia, or Atrial Flutter, but these arrythmias are not usually seen until patients grow older. Features also seen on the EKG include Right Atrial Enlargement, PR prolongation and advanced AV block. When you suspect a patient has an ASD based on the findings of an incomplete Right Bundle Branch Block with a rSr' or rSR' the next thing you should do is examine the frontal plane QRS. The frontal plane QRS is the most helpful clue to help you differentiate Secundum ASD from Primum ASD. In Primum defects left axis deviation is seen in most patients with an axis of > -30 degrees and very few patients have right axis deviation. In contrast Secundum defects have an axis between 0 degrees and 180 degrees with most cases to the right of 100 degrees.

In the EKG above, you can see an example of the rSR' pattern in V1 with a R' greater than S with T wave inversion which is commonly seen in volume overload. See www.askdrwiki.com for more interesting EKGs

References
Pryor R, Woodwork MB, Blount SG: Electrocardiographic Changes in Atrial Septal Defects:Ostium Secundum versus Ostium Primum defect. Am Heart J 58:689, 1959.

EKG of the Week: Ashman's Phenomenon

Characteristics
Physiologic abberation of a complex on a EKG is called Ashman's Phenomenon and is seen in normal subjects. It occurs when the conduction system does not have time to recover and most commonly occurs in the Right Bundle because it is the segment of the conduction system that has the longest refractory period. Following the Right Bundle Branch the Left Anterior Fascicle is the next most common site of conduction delay resulting in a Left Anterior Hemiblock or a Left Anterior Fascicular Block on EKG. It is usually seen when there is a combination of a long cycle followed by a short cycle as seen above in the ninth complex that conducts with a Right Bundle Branch Block morphology after a long RR interval. See www.askdrwiki.com for more EKGs

References
Ashman R, Byer E:Aberration in the conduction of premature ventricular impulses. J La State Med Soc 8:62, 1946

EKG of the Week 2/11/2007

Characteristics
Normal activation of the left ventricle proceeds down the left bundle branch, which consist of two fascicles the left anterior fascicle and left posterior fascicle. Left Anterior Fascicular Block (LAFB), which is also known as Left Anterior Hemiblock (LAHB), occurs when a cardiac impulse spreads first through the left posterior fascicle, causing a delay in activation of the anterior and lateral walls of the left ventricle which are normally activated via the left anterior fascicle.

Although there is a delay or block in activation of the left anterior fascicle there is still preservation of initial left to right septal activation as well as preservation of the inferior activation of the left ventricule (preservation of septal Q waves in I and aVL and small initial R wave in leads II, III, and aVF). The delayed and unopposed activation of the remainder of the left ventricle now results in a shift in the QRS axis leftward and superiorly, causing marked left axis deviation. This delayed activation also results in a widening of the QRS complex, although not to the extent of a complete LBBB

Criteria for LAFB

1. Left axis deviation (usually between -45° and -90°), some consider -30° to meet criteria
2. QRS interval less than 120ms
   
3. qR complex in the lateral limb leads (I and aVL)
4. rS pattern in the inferior leads (II, III, and aVF)
5. Delayed intrinsicoid deflection in lead aVL (> 0.045 s)

Exceptions
It is important not to call LAFB in the setting of a prior inferior wall myocardial infarction which may also demonstrate left axis deviation due to the '''initial forces''' (Q wave in a Qr complex) in leads II, III, and aVF. As opposed to LAHB, the left axis shift is due to '''terminal forces''' (i.e., the S wave in an rS complex) being directed superiorly,

Effects of LAHB on Diagnosing Infarctions and Left Ventricular Hypertrophy
LAHB may be a cause of poor R wave progression across the precordium causing a pseudoinfarction pattern mimicking an anteroseptal infarction. It also makes the electrocardiographic diagnosis of LVH more complicated, because both may cause a large R wave in lead aVL. Therefore to call LVH on an EKG in the setting of an LAHB you should see the presence of a “strain” pattern when you are relying on limb lead criteria to diagnose LVH.

Clinical Significance

1. It is seen in approximately 4% of cases of acute myocardial infarction
2. It is the most common type of intraventricular conduction defect seen in acute anterior myocardial infarction, and the left anterior descending artery is usually the culprit vessel.
3. It can be seen with acute inferior wall myocardial infarction.
4. It also associated with hypertensive heart disease, aortic valvular disease, cardiomyopathies, and degenerative fibrotic disease of the cardiac skeleton.

References

1. Mirvis DM, Goldberger AL. Electrocardiography. In: Braunwald E, Zipes DP, Libby P, eds. Heart disease: a textbook of cardiovascular medicine, 6th edn. Philadelphia: WB Saunders; 2001:82–125.
2. Surawicz B, Knilans TK. Chou’s electrocardiography in clinical practice: adult and pediatric, 5th edn. Philadelphia: W.B. Saunders; 2001.

EKG of the Week 2/4/2007

Introduction
This EKG can be solved with the use of the Brugada criteria published in Circulation in 1991. The criteria were established because the conventional criteria used to differentiate a Wide Complex Tachycardia lacked specificity. The Brugada criteria consisted of four criteria established by the authors, which were prospectively analyzed in a total of 554 tachycardias with a widened QRS complex (384 ventricular and 170 supraventricular). The sensitivity of the four consecutive steps was 0.987, and the specificity was 0.965.

Four Brugada Criteria for Diagnosis of Ventricular Tachycardia
1. Lack of an RS complex in the precordial leads
2. Whether the longest interval in any precordial lead from the beginning of the R wave to the deepest part of the S wave when an RS complex is present is greater than 100 ms
3. Whether atrioventricular dissociation is present
4. Whether both leads V1 and V6 fulfilled classic criteria for ventricular tachycardia.

Diagnosis
Monomorphic Ventricular Tachycardia. See www.AskDrWiki.com for more info about the Brugada Criteria.

References
A New Approach to the Differential Diagnosis of a Regular Tachycardia With a Wide QRS Complex. Pedro Brugada, MD; Josep Brugada, MD; Lluis Mont, MD; Joep Smeets, MD; and Erik W. Andries, MD. Circulation 1991;83:1649-1659

EKG of the Week 1/27/2007

Background
Apical Hypertrophic Cardiomyopathy is a specific variant of Hypertrophic Cardiomyopathy. This disease has been first described in Japan by Yamagutchi where the prevalence is much higher than in the western world. It is characterized by hypertrophy that is confined to the apex which causes a ace of spades like configuration in RAO on the left ventriculogram.

EKG Characteristics
Giant negative T waves and tall R waves in the left precordial leads are the ECG hallmarks of the Japanese form of apical hypertrophy as seen on the EKG seen on the tracing above. Typically T waves in V4-V5 has the greatest degree of T wave depth possibly due to their proximity to the apex of the Left Ventricle which may result from the reversal in the direction of the vector of repolarization or myocardial ischemia due to hypoperfusion of the hypertrophied ventricle. Other findings on EKG include Left Atrial Enlargement, Right Atrial Enlargement, Left axis deviation, and First Degree AV Block.

See www.askdrwiki.com for more EKGs.

EKG of the Week 1/18/2007

This EKG shows marked right axis deviation (Negative vector in Lead I and Postive Vector in Lead aVF) as well as loss of voltage across the precordium seen in V1-V6. If you look closely you will notice there are negative or inverted p waves in lead I and aVL which is a clue to the diagnosis. The differential for inverted p waves in lead I and aVL is Dextrocardia or Reversed Arm Leads. Since there is loss of voltage across the precordium this is Dextrocardia. See more interesting EKGs on www.askdrwiki.com

EKG of the Week 1/5/2007

This EKG shows a slow wide complex tachycardia with intermittent narrow complex beats. The 5^th and 10^th beats are sinus rhythm and close examination of these beats will give you a clue to the cause of the wide complex rhythm. In Leads II and III you can appreciate ST elevation indicating an acute current of injury due to a myocardial infarction. The wide complex beats therefore represent an Accelerated Idioventricular Rhythm or AIVR which is usually seen following reperfusion after an acute infarct.

Accelerated Idioventricular Rhythms are ectopic ventricular rhythms at rates between 40 bpm and 100 to 120 bpm. The ventricular origin of this rhythm can be demonstrated by the usual EKG criteria which include AV dissociation, fusion, and capture complexes. In this EKG the 4^th beat represents a fusion complex and the 5^th beath represents a capture beat proving that these beats are ventricular in origin. The incidence of Accelerated Idioventricular Rhythms following acute MI is reported to be between 8 and 36 percent. This rhythm can also be seen in patients with primarily myocardial disease, hypertensive, rheumatic, and congenital heart disease. It can also be caused by digoxin. See more on www.askdrwiki.com

www.AskDrWiki.com is Launched

The use of medical Wikis can be a powerful tool for physicians in practice, fellows, residents, and medical students. A community of medical providers from all over the world discussing and publishing on medical related topics will become an invaluable resource for a physician in the future. There are several obstacles to overcome including:
1. Verifying that the information inputted into a medical wiki is based on scientific literature and is peer reviewed.
2. Keeping the sites free of vandals and advertisers
3. Building a community that will regularly contribute to the wiki
4. Ensuring that patient confidentiality is not compromised.

I hope to solve the problems above and work to make medical wikis an everyday part of our practice.