Tuesday, May 31, 2005

Slate's Explainer on Priapism

(Occasionally I'm glad I'm not a urologist.)

Slate's Explainer
is usually a good read and often has medical topics:

At least 38 men who have taken Viagra have gone blind, and the drug's manufacturer said last Thursday that it would consider adding a warning to the label. Drug companies already warn consumers that Viagra and competitors like Levitra and Cialis have several other side effects, like blurred vision, headaches, indigestion, and painful erections that last four hours or more. What do you do with an erection that won't quit?

Call your doctor--and be very, very afraid... Priapism, a rare condition defined by prolonged erections in the absence of sexual arousal, is associated with certain blood diseases, hypertension, and recreational drug use. No matter what its cause, priapism can be dangerous if left untreated. A man who has a painful erection for more than 12 hours is at high risk for permanent damage...

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Grand Rounds XXXVI

Grand Rounds XXXVI, this week's best posts of the medical blogosphere, is up at Doctor Sanity.

Normalizing Patients

At some point during their hospital stay, most patients should be normalized. In the rush to manage more complex problems, this is easily overlooked. Normalization means turning a "patient" into a "normal person." This is accomplished by removing intravenous lines and catheters, stopping unnecessary medications, not drawing labs daily, getting people out of bed, and planning for discharge. A patient who is otherwise doing well may stay in the hospital for weeks (or even die) because of a complication like line sepsis, urinary tract infection from a catheter, or deep venous thrombosis. Sometimes, these complications may be prevented by early and aggressive normalization.

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Monday, May 30, 2005

Breaking Things

I'm experimenting. I don't know HTML, so I fully expect to break things. I've switched to a left-floating sidebar. I'd ideally like it to go all the way down, but I don't know how to do this. Comments on the new format are welcome. (Also, will people please email me at kidneynotes[at]gmail[dot]com if the haloscan comment system doesn't seem to be working? Thanks.)

Addendum: Regarding the left vs. right sidebar, I'm not sure which I prefer, but this site has a poll of professional site designers and the vast majority preferred right to left, so I'm going to switch back. Thanks for the comments.

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I'm Blogging This!

Hugh MacLeod at gapingvoid draws cartoons on the backs of business cards. He's hilarious.

The essay, "How to Be Creative," is good reading.

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Sunday, May 29, 2005

Kazakhstan's Spaceship Junkyard

(If the site is unresponsive, it's probably because of the slashdot effect.)

From Slashdot:
All space-bound rockets consist largely of fuel tanks and booster stages that fall back to earth when spent, never reaching orbit. In landlocked Baikonur, Russia's primary launching complex in Kazakhstan, these spaceships crash to earth. This photo essay visits the areas where the supporting rockets land, and shows the people living under the flight paths who contend with flaming spaceship wrecks several times each month...
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How to Destroy the Earth

In case you're interested: a site on destroying the Earth, hosted by a mathematics student at Cambridge University. From the preamble:

Destroying the Earth is harder than you may have been led to believe.

You've seen the action movies where the bad guy threatens to destroy the Earth. You've heard people on the news claiming that the next nuclear war or cutting down rainforests or persisting in releasing hideous quantities of pollution into the atmosphere threatens to end the world.


The Earth was built to last. It is a 4,550,000,000-year-old, 5,973,600,000,000,000,000,000-ton ball of iron. It has taken more devastating asteroid hits in its lifetime than you've had hot dinners, and lo, it still orbits merrily. So my first piece of advice to you, dear would-be Earth-destroyer, is: do NOT think this will be easy...

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The Tumor Was Eating Before He Was

Thanks to Warren Ellis. This article from the San Francisco Chronicle is about a man with a 25-pound tumor in his liver:

Wren, the chief of general surgery at the Palo Alto Veterans Affairs hospital, had always thought she would be able to deprive the tumor's arteries of their blood supply during surgery. But tests showed that such a strategy would make the surgery even riskier and make the 63-year-old Berkeley man's chances of survival far lower than the 50 percent she had expected.

"His tumor had arteries in it that were bigger than his liver's artery," Wren said. "It looked like a 20-pound turkey sitting in there..."

Although Frick's weight of about 180 pounds was fairly normal for a man 6 feet tall, Wren said he was malnourished. And instead of having the normal 6 pints of blood, his body had less than 4.

"The tumor was eating before he was," she said. "It was a giant parasite..."

Nine hours, 18 pints of blood and hundreds and hundreds of stitches later, the tumor was removed, and the surgery was declared a success. Wren said the cancer had not spread to other parts of Frick's body, and she believes the team got all of it.

But Frick still needed to be in intensive care for 12 days. His brother remembers how bad he looked during some of the early visits.

"There wasn't anything that didn't have a tube," Wesley Frick said. When he asked his brother how he felt, "he just made a slight, very nasty, hand gesture..."

Now the odds are very strong that Frick will be going home today. He leaves the hospital with a clear vision of what he wants for his life.

A crumb doughnut...

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Saturday, May 28, 2005

Friday, May 27, 2005

Google Print is Finally Up

...and it's worth the wait.

What is Google Print?

Google's mission is to organize the world's information, but much of that information isn't yet online. Google Print aims to get it there by putting book content where you can find it most easily -- right in your Google search results.

How does Google Print work?

Just do a search on the Google Print homepage. When we find a book whose content contains a match for your search terms, we'll link to it in your search results. Click a book title and you'll see the page of the book that has your search terms, along with other information about the book and "Buy this Book" links to online bookstores (you can view the entirety of public domain books or, for books under copyright, just a few pages or in some cases, only the title's bibliographic data and brief snippets). You can also search for more information within that specific book and find nearby libraries that have it.

Where do these books come from?

The book content in Google Print comes from two sources: publishers and libraries.

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Hemodialysis Arteriovenous Fistula

This dialysis arteriovenous fistula has worked well for seven years.

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Hemodialysis Arteriovenous Fistula

On the topic of vascular access for hemodialysis, these are needles in a one-year old arteriovenous fistula during a dialysis session.

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Characteristics of Pseudoscience Health Claims

Orac discusses the characteristics of pseudoscientific health claims, taken from Dr. Thomas Wheeler's course notes for A Scientific Look at Alternative Medicine.

Today's Dilbert

CDC Recommends Wide Use of Meningitis Vaccine

From the New York Times:

The Centers for Disease Control and Prevention recommended yesterday wider use of a new meningitis vaccine for adolescents and college freshmen.

The vaccine, sold as Menactra by Sanofi Pasteur, protects against infections caused by meningococcal bacteria. Such infections include a form of meningitis that can be rapidly fatal.

For the first time, the diseases center, a federal agency in Atlanta, recommended that all 11- and 12-year-olds be routinely immunized against meningococcal disease.

The agency also recommended using Menactra to protect high school freshmen or children younger than 15, whichever comes earlier.

In a third recommendation, the agency recommended that all college freshmen living in dormitories be immunized against meningococcal disease. The new recommendation strengthened an earlier one that said freshmen should consider such protection.

The CDC press release is here.

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New York City Webcams

NewYorkology has a collection of the best New York City Webcams.

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Thursday, May 26, 2005

A Patient's Experience

In Fearful Symmetry, a composer writes about her experience with an infected intravenous dialysis catheter:
Dear Bacteria That Actually Belong In My Body,

The antibiotic wasn't meant for *you*.

Please come back; I really, really, REALLY miss you.


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The Invisible Hand

Florence Nightingale Health Center on East 97th Street in New York City is closing after 38 years to be made into condominiums. Most patients in the 561-bed nursing home will need to be relocated; some have been there for decades. The invisible hand of the market both builds up and smacks down.

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Tuesday, May 24, 2005

Case of the Week

Some patients are difficult to classify. Nephrologists sometimes get referred these miscellaneous cases when other doctors are unsure which specialist they should see. (I don't know why this is. Possibly because, as specialists go, we're mostly good-natured and curious.)

Recently I saw a middle aged man whose complaint was "I stopped sweating three months ago." He had previously exercised several times weekly and sweated profusely. Since then, all sweating stopped and he was forced to give up exercise. Several times daily he took cold showers and drank ice water to help control his body temperature. He avoided sunlight. A basic workup was negative.

I've never seen this before. My best guess is that he has acquired idiopathic generalized anhidrosis, which is a disorder involving inflammation of the sweat glands and/or the sudomotor nerves. You stop sweating. I don't think there's a cure. I sent him to a neurologist for a skin biopsy and further studies and gave him advice on avoiding heat stroke.

(This is an interesting and awful disorder. In medicine, unfortunately, these two adjectives often coexist.)

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FDA Advisory on Deaths from Dextromethorphan Abuse (the Cough Suppressant in Robitussin DM)

While we're on the topic of abuse of nonprescription drugs, this is from Medwatch:

The Food and Drug Administration (FDA) is concerned about the abuse of dextromethorphan (DXM), a synthetically produced ingredient found in many over-the-counter (OTC) cough and cold remedies. The agency is working with other health and law enforcement authorities to address this serious issue and warn the public of potential harm, after five recently reported deaths of teenagers that may be associated with the consumption of powdered DXM sold in capsules.

Although DXM, when formulated properly and used in small amounts, can be safely used in cough suppressant medicines, abuse of the drug can cause death as well as other serious adverse events such as brain damage, seizure, loss of consciousness, and irregular heart beat.

DXM abuse, though not a new phenomenon, has developed into a disturbing new trend which involves the sale of pure DXM in powdered form. This pure DXM is often encapsulated by the "dealer" and offered for street use.

DXM has gradually replaced codeine as the most widely used cough suppressant in the United States. It is available OTC in capsule, liquid, liquid gelatin capsule, lozenge, and tablet forms. When ingested at recommended dosage levels, DXM is generally a safe and effective cough suppressant.

Additional information about the dangers of Dextromethorphan use and abuse can be found at the following SAMHSA National Clearinghouse for Alcohol and Drug Information links. store.health.org/catalog/mediaDetails.aspx?ID=371, www.family.samhsa.gov/get/otcdrugs.aspx.

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Grand Rounds XXXV

Grand Rounds XXXV, this week's best posts of the medical blogosphere, is up at Iatremia.

Monday, May 23, 2005

The CYP450 Test (One of the "Top Ten Medical Tests You Need")

When Kevin M.D. reviewed the Forbes article on the "top ten medical tests you need," our reaction to the inclusion of the AmpliChip CYP450 (cytochrome P450) test was the same: Wha? From the article:
Enzymes that encode CYP450 genes--or genes found primarily in the liver, where we metabolize drugs and other foreign substances that enter the body--impact the ability of prescription drugs to penetrate the bloodstream properly. That means that the efficacy of a drug depends upon the availability of these enzymes. The CYP450 test, developed by Indianapolis, Ind.-based Roche Diagnostics, measures the enzyme levels so that doctors can find the right dosage for your body and see if you have immunity to a particular drug. Recently cleared by the Food and Drug Administration, this test is somewhat pricey, ringing in at about $500.
I was curious about this cutting edge test that the author classified in the same category as, say, cholesterol profiling. When will patients begin asking for this test on their own? When will lawsuits be filed for adverse drug reactions that could have been potentially prevented by CYP450 testing? The following is a preliminary collection of information on the AmpliChip CYP450 test:How to arrange for patients to be tested isn't clear from Roche's web site.

Other sites that have discussed AmpliChip CYP450 testing include FuturePundit and MedGadget.

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Saturday, May 21, 2005

New Definition of Hypertension (Beyond Blood Pressure)

New proposed guidelines from the American Society of Hypertension define the disease as more than elevated blood pressure.

SAN FRANCISCO, May 15, 2005 -- Leading US hypertension experts unveiled a new definition of hypertension at the American Society of Hypertension Inc. (ASH) Twentieth Annual Scientific Meeting. The group has expanded the definition of hypertension beyond the numbers obtained from a blood pressure reading, and instead, urge that blood pressure be viewed as a part of a patient's overall risk for cardiovascular disease. The goal of the new definition of hypertension is to improve the way physicians conceptualize, diagnose and treat hypertension by encouraging them to think about the disease earlier than they commonly do now, with the ultimate goal of reducing the risk of cardiovascular disease linked to high blood pressure, such as heart attack and stroke...

The new definition of hypertension, developed by the Writing Group of the American Society of Hypertension (WG-ASH) characterizes the disease as a progressive cardiovascular syndrome with many causes that result in both functional and structural changes to the heart and vascular system. The authors of the new definition write that the early stages of hypertension can begin before an individual develops sustained elevated blood pressure, and can progress to damage in the heart, kidneys, brain, vasculature and other organs, often leading to premature morbidity and death. Cardiovascular disease is the number one cause of death in the US, followed by cancer and stroke, according to 2001 data released by the Centers for Disease Control and Prevention...

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Implantable Device for Depression

From the New York Times:

The Food and Drug Administration may soon approve a medical device that would be the first new treatment option for severely depressed patients in a generation, despite the misgivings of many experts who say there is little evidence that it works.

The pacemaker-like device, called a vagus nerve stimulator, is surgically implanted in the upper chest, and its wires are threaded into the neck, where it stimulates a nerve leading to the brain. It has been approved since 1997 for the treatment of some epilepsy patients, and the drug agency has told the manufacturer that it is now "approvable" for severe depression that is resistant to other treatment...

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Medicine by Phone

This seems like a potentially disastrous practice. From American Medical News:
TelaDoc Medical Services Inc. has assembled a network of physicians around the country to offer telephone treatment for minor, nonurgent problems of patients the doctors have never seen in person...
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Thursday, May 19, 2005

On a Flight Diverted

Blogborygmi tells the story of being on a recent flight from Greece which was diverted when one of the passengers was found to be on a terrorist watch list.
We got closer to the ground and I fretted that I couldn't spot the Boston skyline -- or even the ocean. What approach was this? As we touched down, the passengers applauded, but I was growing alarmed: this didn't look like Logan. I saw a fleet of gray military cargo planes outside a hangar. There were no passenger planes from my view, just wet tarmac and an overcast sky. Where were we?

Wednesday, May 18, 2005

Searching for Health Information Online

As a follow up to yesterday's post on using Google Ads as a window to what patients see online, this is an article from the Pew Internet & American Life Project on searching for health information online:
Eight in ten internet users have looked online for information on at least one of 16 health topics, with increased interest since 2002 in diet, fitness, drugs, health insurance, experimental treatments, and particular doctors and hospitals...
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Tuesday, May 17, 2005

Thoughts on Google Ads

I pondered whether including Google Ads would be disruptive or disreputable. I've kept them, not only to help support my espresso habit, but because they represent a valuable real-time commentary on what the markets find interesting. Even the ads I disapprove of -- like those advertising herbal cures for kidney failure or for centers offering transplants from "altruistic donors" -- show the types of advertising patients are exposed to and the types of alternative therapies they may be considering. (Put another way: ads are content.) I've decided the benefits of ads are worth purposefully including them, in small doses, in the main text.

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Grand Rounds XXXIV

Grand Rounds XXXIV, this week's best posts in the medical blogosphere, is at Galen's Log.

Monday, May 16, 2005

Vaccines for Nicotine and Cocaine

From DNC:

Researchers have found a way to provoke the body's immune system into blocking the effects of nicotine, and early tests suggest that the same approach might also be useful in combating cocaine addiction, as well as treating certain other medical conditions.

A vaccine to immunize people against smoking could be available within five years. Swiss scientists are understood to have carried out a successful trial of the new treatment on 300 heavy smokers. The volunteers have been receiving injections for six months to help them kick their habit...

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Sunday, May 15, 2005

Cold Medications with Pseudoephedrine are Going Behind the Counter

...because pseudoephedrine is used to make methamphetamine. From the Washington Post:

Many major chain retailers will remove most over-the-counter cold medications from store shelves over the next two months and put them behind pharmacy counters in an effort to help law enforcement tackle a growing problem with an illegal drug.

In some cases, customers will have to show their driver's licenses and sign a log to purchase relief for a throbbing allergy headache. Some retailers -- tight for space in the pharmacy -- are cutting back on the variety of products they will carry.

"It will be a big change for consumers," said Jody Cook, a spokeswoman for Rite Aid Corp. The move will affect more than 100 products, including common names such as Sudafed, Tylenol Cold and Claritin-D...

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Saturday, May 14, 2005

The Welcome to Medicare Exam

Medical Economics looks at the new Welcome to Medicare Exam in painful detail:

Beginning Jan. 1 of this year, Medicare is offering a new benefit: an initial preventive physical exam for new enrollees. The once-a-lifetime IPPE or "Welcome to Medicare" exam must be scheduled within the first six months of an individual's enrollment in Part B (the enrollment must begin on or after Jan. 1, 2005). Part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the exam signifies a new focus on prevention...

This new focus is good news for both patients and doctors. But to ensure that you're reimbursed for the Welcome to Medicare exam, you have to meet CMS's numerous requirements. We spell them out here...

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Slate's Medical Examiner on Amphetamines (Literally)

From Slate:
Depressives have Prozac, worrywarts have Valium, gym rats have steroids, and overachievers have Adderall. Usually prescribed to treat Attention Deficit Hyperactivity Disorder (read Sydney Spiesel in Slate on the risks and benefits), the drug is a cocktail of amphetamines that increases alertness, concentration, and mental-processing speed and decreases fatigue. It's often called a cognitive steroid because it can make people better at whatever it is they're doing. When scientists administered amphetamines to Stanford's varsity swim team, lap times improved by 4 percent. According to one recent study, as many as one in five college students have taken Adderall or its chemical cousin Ritalin as study buddies...
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Testing Blogger Mobile. Shot with a Treo 650.

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Stagecoach Hit And Run in New York City

From 1010 Wins Radio:

(NEW YORK) The wild West Side of Manhattan became Dodge City for a pair of horses turned loose in traffic Friday when a hit-and-run truck driver flipped a 120-year-old stagecoach onto its side, sending the runaway equines on an unscheduled jaunt across town.

The unlikely cross-century collision occurred around 10 a.m. on West 14th Street as the vintage Wells Fargo stagecoach from Chateau Stables was heading to a promotional appearance in Union Square, said Dave Sansoucie, a spokesman for the stables.

A passing truck hit the coach as it was heading east, metal crunching into wood, sending the coach's driver flying and flipping the vintage vehicle onto its side. Princess and Hero, the horses pulling the coach, were able to escape without injury when the accident occurred, Sansoucie said.

Suddenly liberated from work, the two horses continued heading east on a sunny spring morning. One was grabbed by a transit police officer about four blocks away on 13th Street and Fifth Avenue, while the other was taken into custody at 14th and Sixth, police said...

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Friday, May 13, 2005

The Girl Who Doesn't Age

BALTIMORE -- Imagine being frozen in time as a baby forever. It sounds impossible, but it describes Brooke Greenberg.

The Baltimore-area girl may look like a baby, but she's nearly a teenager. In most respects, Brooke looks and acts like your average 6-month-old baby -- she weighs 13 pounds and she is 27 inches long.

But Brooke is actually 12 years old, reported WBAL-TV in Baltimore.

Brooke doesn't age. Her syndrome remains undiagnosed and unnamed, and as far as doctors can tell, she is the only one in the world who has it....

Thursday, May 12, 2005

Google Scholar Review

There are several ways of searching the medical literature. Previously I used PubMed, the interface from the National Library of Medicine. I've recently switched to Google Scholar, which has these advantages:
  • Papers are listed not in order of publication, but in order of relevance, which is determined by PageRank, the same system used in regular Google searches.
  • Next to each publication is a link to other publications that cite it. This allows you to immediately determine whether a paper is influential and who it has influenced.
  • Scholar also includes searches of publications that don't make it to Medline, like books, small journals, and private collections.
  • Scholar uses the familiar uncluttered Google interface.
I tested Scholar by running searches of topics that I'm familiar with, like collapsing glomerulopathy, and it reliably listed the most relevant papers in the field first.

Addendum: A library professional tears Google Scholar a new one over here.

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Wednesday, May 11, 2005

Chimerism and the Vanishing Twin

From the New York Times:

Last month, when the champion American cyclist Tyler Hamilton was accused of blood doping, or transfusing himself with another person's blood to increase his oxygen-carrying red cells, he offered a surprising defense: the small amount of different blood found mixed in with his own must have come from a "vanishing twin..."

Whether Mr. Hamilton is guilty or innocent, his defense does refer to a real phenomenon. Researchers who have no involvement in Mr. Hamilton's case say it actually is possible for someone to have two types of blood in his body, without doping. They emphasize that they do not know whether this is the case with Mr. Hamilton.

One route to this odd state, called chimerism, is the vanishing twin. Dr. Helain Landy of Georgetown University, who has no involvement in the Hamilton case, has found that 20 to 30 percent of pregnancies that start out as twins end up as single babies, with one twin being absorbed by the mother during the first trimester.

Others researchers have found that in some cases, before the twin is absorbed, some of its cells enter the body of the other fetus and remain there for life. The cells can include bone marrow stem cells, the progenitors of blood cells.

Another route to chimerism is through the cells that routinely pass from a mother to fetus and remain there for life.

Dr. Ann Reed, chairwoman of rheumatology research at the Mayo Clinic, who uses sensitive DNA tests to look for chimerism, finds that about 50 to 70 percent of healthy people are chimeras. The more scientists look for chimerism, the more they find it. It seemed not to exist in the past, she said, because no one was explicitly looking for small amounts of foreign cells in people's bodies.

"Some believe that if you look hard enough you can find chimerism in anybody," said Dr. Reed...

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Hilarious Journal Articles Part 6

Pathological gambling associated with dopamine agonist therapy in Parkinson's disease.

Muhammad Ali Parkinson Research Center, Barrow Neurological Institute, Phoenix, AZ

From Bloomberg:

May 9 (Bloomberg) -- Pfizer Inc. and Boehringer Ingelheim Pharmaceuticals Inc. were accused of distributing a drug for treating Parkinson's disease that turned some people into gambling addicts, in a lawsuit filed in Ontario Superior Court...

Researchers at the Muhammad Ali Parkinson's Research Center in Phoenix examined data of almost 2,000 Parkinson's patients over the course of a year. Nine of the patients were diagnosed as pathological gamblers, and seven of them had started gambling within a month of an increase in the dosage of Mirapex or another Parkinson's drug they were taking.

Two patients lost more than $60,000, and none of them had a problem before taking the drugs, according to the study. Gerard Schick, a resident of Midland, Ontario, a city north of Toronto and near a government-approved Indian casino, lost about C$100,000 ($80,757) playing slot machines while taking Mirapex, Merkur said. Other Mirapex users who have come forward claimed to have lost as much as C$750,000 ($605,677), he said...

(Pathological gambling is a real problem, but the image of formerly slow-moving Parkinson's patients suddenly blowing all their money in Vegas made this paper worth including.)

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Tuesday, May 10, 2005


iHealthRecord is a free online health record designed for patients. From the website:
The iHealthRecord is a secure and confidential interactive personal health record. This service not only stores personal health information for you and your loved ones, but it provides interactive programs that help you better understand medical conditions and medications, all at no cost to you. You can create, manage and share your personal health information with your physician, or another care giver in case of an emergency. Other features of an iHealthRecord are as follows:
  • Secure email and Online Consultation with your doctor
  • Automatic email warnings if a medication that you take is recalled or has a safety notice from the FDA
  • Automatic education programs, written by medical societies and other national experts and sent to you, that are specific to your medications or conditions
  • Quarterly online reminders to keep your iHealthRecord current
  • The ability to access the iHealthRecord in an emergency
  • The ability to share your health record with family members and loved ones
  • All of your medical information stored in one place and accessible from anywhere and at any time
  • A convenient iHealthRecord wallet card that provides emergency contact information and directions to access your iHealthRecord
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Grand Rounds XXXIII

Grand Rounds XXXIII, a selection of this week's best posts in the medical blogosphere, is up at Azygos.

Monday, May 9, 2005

Spoiled Chicken Leads to Mexican Standoff in New York City Restaurant

Not with guns. Not really.

Stephen J. Dubner, one of the authors of Freakonomics, eats some spoiled chicken at a restaurant. He has an encounter with the manager. He would like the meal to be free, but the manager is unwilling. They are at an impasse. At the end of the story, the author pulls the trigger.

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Flee, Embryonic Frogs

From Scientific American:
Even before they've hatched, red-eyed tree frogs have a nose for danger. The results of a new study suggest that the creatures can detect the vibrations from a predator and hatch early in order to escape...

Kidney Failure Secondary to Milkshake

Thirteen people were infected with E. Coli 0157:H7 after drinking infected milkshakes. One of them developed kidney failure from hemolytic uremic syndrome:
Calgary -- A 15-year-old girl was on dialysis yesterday and in "fair to serious" condition after drinking a milkshake as a birthday treat at a popular Calgary eatery that health officials say is behind an E. coli outbreak...
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Sunday, May 8, 2005

Google Down Due to Web Accelerator or DNS Hijack?

On Saturday May 7 Google shut down for 15 minutes. Why? Sources have argued that it was an outage related to Google Web Accelerator (reviewed here) or alternatively, to a domain name server hijack. The Search Engine Journal has a discussion of both these issues.

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Methicillin Resistant Staphylococcus aureus (MRSA) Infections

I recently took care of an eighty year old man who lived at home and was admitted with pneumonia. He arrived in septic shock with acute renal failure and required mechanical ventilation, aggressive fluid resuscitation, medications to support his blood pressure, and emergency dialysis. This isn't all that unusual. What was unusual was the organism which caused his pneumonia: methicillin-resistant Staphylococcus aureus (MRSA).

MRSA is a aggressive bacteria which is resistant to most of the antibiotics that are first-line therapies for pneumonia. Hospitals are breeding grounds for resistant bacteria like MRSA, so it's much more common for people to develop MRSA pneumonia after they've been in the hospital, especially if they're on a ventilator. MRSA is not the usual organism that doctors think of when people come to the hospital from home. But this is clearly changing. In a recent study in the New England Journal, between 8% - 20% of all MRSA infections were acquired in the community.

The standard of care has evolved. Any life-threatening infection that could be caused by Staphylococcus aureus -- even if the patient is not hospitalized -- should be initially treated with vancomycin or another antibiotic that covers MRSA. This is one of those situations where you can't afford to be wrong.

Surprisingly, the patient did well. After MRSA was identified, he was treated with a prolonged course of Zyvox (linezolid), which has more activity against MRSA than vancomycin. He stayed in the hospital for two months and eventually came off dialysis, was weaned from the ventilator, and went home.

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New Critical Firefox Security Exploit

This just in. Basically, if you click anywhere on a page with the exploit, it loads and runs a malicious file on your computer.

(The temporary solution to the problem is to disable "allow web sites to install software" under tools, options, web features.)

Considering that new security vulnerabilities are identified each week, and almost every public computer is filled with spyware/adware, I propose we simply stop using computers altogether.

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Saturday, May 7, 2005

Brief Review of Google Web Accelerator

There's good and bad news about Google Web Accelerator. The good news is that it works. It works well. Pages load faster. Installation is easy. The bad news is that the privacy implications are unsettling at best and at worst, staggering. See here, here, here, and here.
A description of Google Web Accelerator:

Google Web Accelerator is an application that uses the power of Google's global computer network to make web pages load faster. Google Web Accelerator is easy to use; all you have to do is download and install it, and from then on many web pages will automatically load faster than before.

Google Web Accelerator uses various strategies to make your web pages load faster, including:

  • Sending your page requests through Google machines dedicated to handling Google Web Accelerator traffic.
  • Storing copies of frequently looked at pages to make them quickly accessible.
  • Downloading only the updates if a web page has changed slightly since you last viewed it.
  • Prefetching certain pages onto your computer in advance.
  • Managing your Internet connection to reduce delays.
  • Compressing data before sending it to your computer.
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Thursday, May 5, 2005

Stating the Obvious

In the hospital where I went to medical school, there was a bank. One of the tellers had Graves' disease. It was not subtle. All her findings were right out of the textbook: exophthalmos, a goiter, a slight tremor. For a year, every time I saw her, I thought "Hyperthyroidism and Graves' disease." Nearly every physician and student who came in there -- and there were hundreds -- must have thought the same thing.

A year later, she still didn't look well. I wondered why she wasn't improving with treatment. I mean, she must have been treated, right? On impulse, one day I asked, "Excuse me, do you have a thyroid disorder?" Her wide eyes widened even further and she said, "I was diagnosed last week. I was feeling terrible. I read about Graves' disease in a magazine and asked my doctor to test me."

This woman had gone an entire year with hundreds of people knowing her diagnosis and not telling her. I felt awful. Since then, I've been more inclined to speak up when I see someone with an obvious disease they might not know about. (This happens rarely.)

I was reminded of the bank teller's story by the "runaway bride." Jennifer Wilbanks also has goiter and exophthalmos, classic findings of Graves' disease. If she was hyperthyroid, this might also provide an explanation -- though not an excuse -- for her behavior. In the last week a handful of other people have suggested that she might have hyperthyroidism too.

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"First Aid for Health Care," Bruce Sterling's Column in Wired

I don't agree with everything Bruce says, but I enjoy his writing. From Wired:

Behold the disruptive innovation! An entire industry can putter along for decades, steadily improving its products, services, and bottom line - only to be suddenly eviscerated by people from nowhere using simple, inexpensive, profoundly powerful techniques. Disrupters start by serving people whom established players don't even recognize as customers. Eventually, the newcomers learn so much so quickly that they can't help but radically outperform the incumbents...

Intrigued by this challenge, I searched for the stupidest, most dysfunctional US industry I could find. The automotive and energy industries - beset by entrenched interests, sclerotic management, and stifling oversight - were tempting. But the worst has to be health care. Health care has every quality Christensen lists as dangerous: crippling regulation, overcharged customers, enraged victims with deep grudges, unnecessary goods and services, and a massive base of underserved wretches. The remarkably unhealthy US population blows more money on medicine than any other nation in the world, yet gets sicker anyhow.

Could a radically inventive disruption somehow render the whole tangled mess irrelevant? A system that eats 15 percent of the US gross national product is a broad field for disruptions. Some might bite a few links off the value chain, while others have potential to wreck the whole dysfunctional shebang. Let's consider a few scenarios...

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Wednesday, May 4, 2005

Runaway Bride Hyperthyroid?

See the updated post here.

The "runaway bride" (Jennifer Wilbanks) has many of the physical findings of hyperthyroidism and Graves' disease (goiter and exophthalmos). I'm a little surprised that more comments haven't been made about this. (There's a brief reference to her thyroid disease by someone who knows her may know her on this page.) If she was hyperthyroid, this might also provide an explanation for her behavior.

Addendum: I'm not certain from reading the linked post whether it was written by someone who knows her or is just speculating. Also, in the last week a handful of other people have suggested she might have hyperthyroidism too.

Tuesday, May 3, 2005

Dispatches From the Michael Jackson Trial

Slate has started blogging from the Michael Jackson trial again.

7:10 a.m.: Gosh, it's good to be back here in Jacko-ville. I didn't realize how much I'd missed this place.

I missed you, courtroom artist, wheeling around your big case of art supplies. Happy sketching today!

I missed you, TV sound guys, drinking your coffee behind the satellite trucks. You look so bored, with your boom-mikes hoisted on your shoulders. So bored, in fact, that I swear you've been practicing—standing in front of mirrors with your boom-mikes, trying out disinterested facial expressions.

And I missed you most of all, crazy fans outside the gate. You've brought a whole bunch of "We Love Michael" balloons with you this morning. But not helium balloons. Your regular balloons just fall at your feet and roll around aimlessly. As you gather together to start an impromptu shouting session, I get a warm feeling inside.

It feels like coming home.

And You Thought the Age of Anatomic Discovery Was Over

Vivette D'Agati wins the award for most poetic kidney pathologist. Although some knowledge of renal microanatomy helps, you don't need to know anything about the podocyte to appreciate her writing. Brief excerpts from the editorial in JASN, "And You Thought the Age of Anatomic Discovery Was Over":

In this modern age of molecular biology, it is hard to imagine that any significant new discoveries remain to be made in the field of renal anatomy. Just thumb through any textbook of nephrology and you will find the classic references falling into predictable historical eras. Anatomic advances tend to cluster in the first half of the 20th century. The introduction of micropuncture in the 1960s set the stage for investigations into renal physiology. And since the 1980s, we have all witnessed a dizzying explosion of knowledge in molecular biology, molecular genetics, and their applications to nephrology...

Despite these trends, the application of electron microscopy to the study of glomerular structure has provided a window of discovery that continues to shed new and exciting insights... Not before the wondrous scanning electron microscopic images of the podocyte in the 1970s could the complex cytoarchitecture of this cell be fully appreciated...

The article by Neal et al. in this issue of the Journal of the American Society of Nephrology renews our faith in the power of structural observations as it explores new, as yet uncharted frontiers in the field of podocyte microanatomy...

The article... defines three structurally distinct compartments of the urinary (or Bowman's) space. The first is the one we are all familiar with: the large open space that forms a broad shell delimited by Bowman's capsule on the outside and the glomerular globe on the inside. The second is the interpodocyte space that forms an anastamosing, branching region between individual podocytes. Third is the subpodocyte space, defined as the space bounded by the glomerular basement membrane (GBM) and foot processes below, and by the underside of the podocyte cell bodies and their processes above. A sizeable area, some 60% of the total filtration surface of the glomerulus, is actually covered by podocyte cell bodies at any one time... In these regions, the glomerular filtrate cannot enter the open urinary space without passing through the more restricted subpodocyte space, which serial sections depict as a long, narrow, and tortuous space serviced by small exit pores... In other words, to reach Bowman's space, the filtrate entering into the subpodocyte space must pass through tiny exit pores that occupy only 4% of the corresponding glomerular filtration area. (This is an astounding statistic and one that any commuter into New York City who must cross the George Washington Bridge during the peak flow of morning rush hour can well appreciate...)

The cytoarchitecture of the podocyte is becoming ever more complex. The article by Neal et al. gives us new appreciation for the underbelly of the beast and the unique anatomic compartment that is the subpodocyte space.

Monday, May 2, 2005

Grand Rounds XXXII

Tales of a MD/PhD Student hosts Grand Rounds XXXII, a selection of this week's best posts in the medical blogosphere.

Steroid Use By Middle-School Girls?

From Slate's Explainer column:
On Monday, the Associated Press reported that, according to "various government and university studies," 5 percent of high-school girls and 7 percent of middle-school girls have tried anabolic steroids. House Government Reform Committee Chairman Tom Davis repeated the statistics at Wednesday's hearing on steroid use in the National Football League. Are teenage girls really that into steroids?

The New Food Pyramid Redesigned

Image by Stone Yamashita.

The new food pyramid is so confusing that it's almost unusable. Slate asked four design teams to make it simpler to understand. From "Four Servings of Design":

If the USDA's recommended diet helps people live long and prosper, it won't be thanks to the design of the agency's new food pyramid. The flaws are myriad. There are no icons or labels to indicate which food group is represented by each band of the pyramid's vertical rainbow of stripes. The color choices are less than intuitive. The varying widths of the stripes represent the relative amounts of each food group you should eat, but you can't grasp that information in a glance. And the yellow stripe representing fats is so narrow it almost disappears. The old pyramid wasn't without flaws, but at least it clearly showed a diet hierarchy.

In short, after spending four years and $4.2 million, the USDA has screwed up a relatively simple concept. We gave four design teams a few days to rethink the presentation of the USDA's diet. Click here for a slide show of what they produced, with alternatives ranging from an interactive bar graph to a warning label.

Sunday, May 1, 2005

Epocrates MobileCME Review

Few ways of accumulating continuing medical education credits are this easy. As a plus, the articles are short, well-written, varied, and interesting. After you read them and take a brief quiz, the CME credits are emailed to you automatically after HotSyncing. If you have a Palm and use Epocrates, there are zero reasons not to download this. Here's a sample list of recent topics:
  • Cardiovascular Disease Risk Reduction
  • Depression in Women
  • Sudden Cardiac Death in Athletes
  • Gout
  • Full-Body CT Scans