Don't Bury the Lede
Mark Crislip
A lede is the introductory section in journalism and thus to bury the lede refers to hiding the most important and relevant pieces of a story within other distracting information. The spelling of lede is allegedly so as to not confuse it with lead (/led/) which referred to the strip of metal that would separate lines of type.
My job is simple, me find bug, me kill bug, me go home. People want to know three things from me: what does the patient have, why do they have it, and how best to treat it. I try to get get to the point with my consults, so my notes, at least the important parts of the note, are short and sweet.
We are not paid by the word, but what we do, and the fewer used to document what we do, the better.
But it seems others cannot get to the point anymore. All text pages need is your name and return number. And when I call, lede with what is important. Question or consult. I had one page recently, "Want to talk to you about a patient." OK, Five minutes later, the doc ended... so we want to get you involved in the case. You mean a consult? Yep. Hell. Lede with that. We could have stopped after the patient's name and room number because that is all I need. Or want.
Consult. Beelzebub. Room 666.
Not that we have a room 666. It goes from 665 straight to 667, which really is 666 and is still cursed.
Or the caller goes on for several minutes before getting to what is the lede: the syphilis serology. Or the blood culture results. Or the LP results.
Recently residents have taken to paging me and saying, we thought we would reach out to you. And that means just what exactly? A consult? A question? You need a hug? No clarity or precision anymore.
Lede with what is essential when you call me.
And get off my lawn.
A common outpatient consult is prolonged fevers and transaminitis. Usually, they have a negative A, B, C, CMV, and EBV. Usually, there is no clinical reason to suspect CMV and EBV by other labs. But people tend to forget about E. A vowel movement, I suppose.
But that is what the patient had; the hepatitis E IgM was positive.
The curious reason was why. There are 4 Hepatitis E genotypes. 1 and 2 are fecal-oral/water-borne, while 3 and 4 are food-borne.
Mostly from eating pig meat, innards, home-prepared pork products, or tasting raw pig meat. One guy got it from his pet pig. Really. In Denmark and Germany, it is primarily an asymptomatic zoonosis from eating swine and wild boars. Especially common after flooding.
It is in US pigs,
Hepatitis E virus RNA was detected in 6.3% and HEV IgG in 40% of 5,033 serum samples from market-weight pigs at 25 slaughterhouses in 10 US states.
Splitting hares is a risk. And rats in LA. And ferrets. And eating camel meat and milk. There goes my diet. I'll miss camel sashimi.
Pets and eating liver are the risks; I assume these risks are rarely combined. I bet Hannibal Lecter is seropositive.
I could find no smoking gun (a new form of BBQ?) dietary reason for Hepatitis E, but about 21% of Americans are seropositive, although other studies have put it at 6%.
The weighted national seroprevalence of HEV in the U.S. is much less than previously reported. Using data obtained with a high performance assay, the seroprevalence of HEV was estimated at 6.0% in the U.S. Based on these results, the seroprevalence of HEV is only one-third as high as previously reported.
So it is likely common and just as commonlymissed. And why I only eat deep-fried food.
And why the alphabet soup? Why A,B,C,D,E? It is the worst way to classify organisms if you want to learn/remember them.
I really can't find why. The closest is
Dr. F.O. MacCallum came to the conclusion that there are two types of hepatitis, which he classified as “infectious hepatitis” (later identified as hepatitis A-HAV infection) and “homologous serum hepatitis” (later labeled as hepatitis B virus infection). This old classification corresponds to the MS1 and MS2 stratification used at the Willowbrook Institute during the controversial, yet important human transmission and prevention studies by Krugman et al.
So I guess A and B were shortcuts, a simple way of distinguishing the two, and C (non-A non-B when I was a resident), D, and E were named from laziness and a lack of imagination. There is also an F, a G, and then they skipped to TT. Of course they did.
Rationalization
Why Do We 'Bury the Lede?' We buried 'lead' so far down that we forgot how to spell it https://www.merriam-webster.com/words-at-play/bury-the-lede-versus-lead
Time trend of the prevalence of hepatitis E antibodies among farmers and blood donors: a potential zoonosis in Denmark https://pubmed.ncbi.nlm.nih.gov/18781880/
Phylogenetic and case-control study on hepatitis E virus infection in Germany https://pubmed.ncbi.nlm.nih.gov/18983248/
Hepatitis E Virus Infection in European Brown Hares, Germany, 2007–2014 https://wwwnc.cdc.gov/eid/article/25/6/18-1618_article
Hepatitis E virus in rats, Los Angeles, California, USA https://pubmed.ncbi.nlm.nih.gov/22172320/
Chronic Infection With Camelid Hepatitis E Virus in a Liver Transplant Recipient Who Regularly Consumes Camel Meat and Milk https://pubmed.ncbi.nlm.nih.gov/26551551/
Epidemiology of hepatitis E virus in the United States: results from the Third National Health and Nutrition Examination Survey, 1988-1994 https://pubmed.ncbi.nlm.nih.gov/19473098/
Current epidemiology of hepatitis E virus infection in the United States: low seroprevalence in the National Health and Nutrition Evaluation Survey https://pubmed.ncbi.nlm.nih.gov/24824965/
The History of Hepatitis A https://aasldpubs.onlinelibrary.wiley.com/doi/full/10.1002/cld.1018
History of the Discovery of Hepatitis A Virus http://perspectivesinmedicine.cshlp.org/content/9/5/a031740.full
Hepatitis F, G, and TT Viruses https://www.ncbi.nlm.nih.gov/books/NBK13296/