Saturday, April 29, 2006

The Sopranos and Zosyn

(I should create a section dedicated to email postings via Treo while on weekend call.)

In a recent Sopranos episode, Tony is shot by his uncle with Alzheimer's and is in septic shock in the intensive care unit. Meadow, his daughter, knows a bit about medicine from shadowing doctors in Columbia's ICU, so she asks the attending surgeon -- who's a bastard, and is perfectly written and acted -- which antibiotic Tony is on. "Zosyn," he replies, and walks away.

My first thought was, "Good choice."

My second thought was, "I wonder if Zosyn payed for that?"

My third thought was, "Someone, somewhere, is going to request Zosyn because they saw it on The Sopranos..."

Know Your Patient's Face

A colleague recently picked up an occult pericardial effusion in a dialysis patient which required a pericardial window. The tip-off was the loss of nasolabial folds -- in a previous patient, she had seen facial swelling associated with a pericardial effusion, so she was suspicious enough to check an echocardiogram. Because she knew him well, she was able to pick up the subtle change in her patient's face.

Nurses Quote of the Day: A and O Times Three

A nurse said to a patient, who happened to also be a nurse, "Are you alert and oriented to person, place, and time?"

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Friday, April 28, 2006

New Feature: Your Network

From the blog: users discover interesting things on the Web every day. We want to make it easier for you to find and connect to these people, so that you can benefit from their knowledge and they can benefit from yours. Today the “inbox” feature lets you subscribe to other users’ bookmarks, but most people don’t know about it and it’s not terribly easy to use in your everyday life.

To make sharing easier, we’ve just released a new feature called “your network”. You can add other users to your network either by visiting their pages or from the your network page itself. Once someone is in your network, you can keep track of their latest saved public bookmarks. And when you save new bookmarks you can easily share them with people in your network just by clicking on their username.

Your network replaces the user subscriptions functionality previously offered by the “inbox”. If you had any existing user subscriptions in your inbox we automatically moved them over to your network, so you haven’t lost any connections you already had.
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Thursday, April 27, 2006

Michelle Rodriguez (from Lost) Blames Steroids for Bad Behavior

Via the New York Post:
Lost star Michelle Rodriguez has blamed her drunk-driving and subsequent bad behavior on her use of steroids...

The actress insisted in court the steroid injections she had been taking twice monthly to treat allergies to "dust and cockroach resin" made her "manic..."

During her December arrest for drunk driving in Hawaii, she screamed and yelled at officers, at one point daring them to "put a gun to my head and shoot me."
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Patient Quote of the Day Number Two

"Don't do anything I wouldn't do!" says an oxygen-dependent 84 year old woman admitted for a COPD exacerbation.

Google SketchUp: Free 3D Modeling

From SketchUp:
Google SketchUp (free) is an easy-to-learn 3D modeling program whose few simple tools enable you to create 3D models of houses, sheds, decks, home additions, woodworking projects – even space ships. You can add details, textures and glass to your models, design with dimensional accuracy, and place your finished models in Google Earth, share them with others by posting them to the 3D Warehouse, or print hard copies. Google SketchUp (free) is a great way to discover if 3D modeling is right for you.
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Flickr: Namib Desert, Namibia

From Flickr. Uploaded by photo707 on 27 Apr '06, 8.35am EDT PST.

Patient Quote of the Day: What's Your Penicillin Allergy?

"What is your allergy to penicillin?"

"I don't remember what happened the last time I took penicillin, because I had to have a tube down my throat."

Wednesday, April 26, 2006

New England Journal of Medicine Audio Summary for April 27, 2006

From the NEJM:
This summary covers the issue of April 27, 2006. Featured are articles on lung recruitment in ARDS, Helicobacter pylori infection and thyroxine dose in multinodular goiter, vitamins C and E and the risks of preeclampsia and perinatal complications, a variant of hepatitis B virus with primary resistance to adefovir, and disclipining the stem cell into myogenesis; a review article on hematopoietic stem-cell transplantation; a case report of a man with a painful bone mass and lesions in the liver; a Video in Clinical Medicine demonstrating nasogastric tube insertion; and Perspective articles on the South Asian earthquake six months later and on grooming the next generation of global health workers.
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Tuesday, April 25, 2006

Hilarious Journal Articles #49: Attitudes, Perceptions and Knowledge about the Vagina: the International Vagina Dialogue Survey

From Contraception:
Background The International Vagina Dialogue Survey examined women's attitudes, perceptions and knowledge regarding the vagina. Methods In total, 9441 women (18–44 years) from 13 countries underwent online interviews during April/May 2004. Results The majority of the women thought that vaginal health did not receive the attention it deserves (66%) and that society has too many misconceptions about the vagina (65%); indeed, 78% agreed that society's taboos surrounding the vagina contribute to women's ignorance. Only 39% of the women had ever read an informative article on the vagina, although 83% would like to read such an article. Although 79% of the women relied on advice from healthcare professionals (HCPs) when choosing a contraceptive, <50% were comfortable talking to HCPs about vagina-related issues. Conclusions A more open and informative approach is needed with regard to the subject of the vagina in order to empower and educate women about their bodies and in matters such as choice of contraception.
(Thanks to Cecily.)

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How Do You Have Sex With A Holter Monitor?

Via Medical Blogosphere Grand Rounds, from ChronicBabe:
The surest way to a geek's heart is to offer them a technological challenge. I can't think of anything more befitting than trying to have sexual intercourse while wearing a portable Holter monitor, aka electrocardiogram (ECG) machine...

(Sarah Beckley is a Chicago native, freelance writer, and jewelry designer who also happens to have a chronic heart condition called Hypertrophic Cardiomyopathy.)
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Grand Rounds 2.31

Grand Rounds 2.31, this week's best posts of the medical blogosphere, is up at Health Business Blog.

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Monday, April 24, 2006

Neuroeconomics: Researchers Find Neurons Encoding Values of Different Goods

Via EurekAlert:
Researchers at Harvard Medical School (HMS) report in the April 23 issue of Nature that they have identified neurons that encode the values that subjects assign to different items. The activity of these neurons might facilitate the process of decision-making that occurs when someone chooses between different goods.

"We have long known that different neurons in various parts of the brain respond to separate attributes, such as quantity, color, and taste. But when we make a choice, for example: between different foods, we combine all these attributes--we assign a value to each available item," says Camillo Padoa-Schioppa, PhD, HMS research fellow in neurobiology and lead author of the paper. "The neurons we have identified encode the value individuals assign to the available items when they make choices based on subjective preferences, a behavior called 'economic choice.'"

Everyday examples of economic choice include choosing between working and earning more or enjoying more leisure time, or choosing to invest in bonds or in stocks. Such choices have long been studied by economists and psychologists. In particular, research in behavioral economics shows that in numerous circumstances, peoples' choices violate the criteria of economic rationality. This motivates a currently growing interest for the neural bases of economic choice--an emerging field called "neuroeconomics." In general, it is believed that economic choice involves assigning values to available options. However, the underlying brain mechanisms are not well understood.
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The Tongue as Interface For Soldiers (The "Brain Port" Device)

Via ABC News:
A narrow strip of red plastic connects the Brain Port to the tongue where 144 microelectrodes transmit information through nerve fibers to the brain. Instead of holding and looking at compasses and bluky-hand-held sonar devices, the divers can processes the information through their tongues, said Dr. Anil Raj, the project's lead scientist...

In testing, blind people found doorways, noticed people walking in
front of them and caught balls. A version of the device, expected to be
commercially marketed soon, has restored balance to those whose
vestibular systems in the inner ear were destroyed by antibiotics.
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Sunday, April 23, 2006

The Genetics of Chronic Fatigue Syndrome

In Pharmacogenomics:
The articles published in this special issue of Pharmacogenomics culminate from a multidisciplinary group of researchers, demonstrating that data integration and multidisciplinary collaboration can yield novel approaches for handling large, complex data sets and reveal new insight and relevance to a complex illness such as chronic fatigue syndrome (CFS). Data were generated from a 2-day clinical study of CFS and comprised clinical, genomic and genetic information. The data, including over 500 clinical and epidemiological measurements and 20,000 gene expression measurements, was shared with 20 investigators who were challenged with integrating the data to delineate the heterogeneity of the study population and identify biological correlates of CFS.
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Flickr: Hayden Planetarium, New York, NY

From Flickr. Uploaded by agracombe on 21 Sep '04, 12.49pm EDT PST.

Flickr: any other place

From Flickr. Uploaded by Tsunami Notes on 16 Apr '06, 6.05am EDT PST.

Saturday, April 22, 2006

Flickr: Bucky's dream

From Flickr. Uploaded by IrenaS on 19 Apr '06, 6.35am EDT PST.

Friday, April 21, 2006

"How to Conduct a Physical Exam on an Assaultive Patient"

Via Intueri:
1. If possible, learn why the assault occurred. Did the patient feel cornered? Did s/he perceive the police as engaging in offensive maneuvers and thus reacted defensively? Did s/he believe that other people were trying to trying to steal his/her identity by staring into his/her eyes for exactly ten seconds? Inquire into the specifics of the assault prior to speaking with the patient. This information will help guide your interactions with him/her.

2. Introduce yourself to the patient and inform him/her that you shall be performing a physical exam. You may need to explain, in detail, what a “physical exam” is, as some patients may believe that this entails invasive maneuvers, while others do not realize that this means you will be touching the patient. Something succinct, such as “I will listen to your heart and lungs, push your belly, tap you with this hammer”, usually suffices. (NB: Some people may take offense to the word “belly”, as that may insinuate that their torsos are of larger mass than you deem appropriate. Choose your words wisely.)

3. Observe the patient’s reaction to your announcement. Should s/he immediately threaten to hit, bite, spit at, or kill you in a loud voice while giving you The Stare of Death, it would be wise to defer the exam. Your personal safety is important....
(The whole thing is well worth reading.)

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Nurse's Quote of the Day

"Should these blood cultures be sent stat?"

(Followed by laughter when she realized what she'd said.)

When Did Acute Renal Failure Not Become An Indication For Hospital Admission?

When did a newly diagnosed creatinine of 4.5 not become an indication for admission to the hospital? Why did I just have to spend 20 minutes arguing with the medical director of an insurance company that payment for my patient's admission should not have been denied? ("The patient did not need to be admitted. The creatinine was not greater than 5, which is our guideline for hospital admission. You are welcome to appeal our decision.")
Why did I have to convince him that the increased creatinine was truly acute, likely due to interstitial nephritis from an antibiotic, and we had no way of knowing whether he would get worse, need a kidney biopsy, and require high dose steroids?
Eventually, payment for the admission was granted, which is the only reason I'm not naming names.
And the patient did fine and the renal failure resolved.
But am I pissed off.

Motorola Patents Electrical Shock Alert for Mobile Phones

Via MobileBurn:
Motorola has recently received a patent for a completely silent way of alerting users to incoming calls and messages. No, this isn't the usual vibrating system - the Motorola patent involves alerting the owner using mild electric shock.

The system, not unlike the massage and weight loss systems currently available on the market today, uses a small pad containing electrodes that are wirelessly linked to a handset. When an event occurs on the handset, an electric potential is placed across the electrodes, stimulating the skin and underling muscles, thus alerting the wearer.
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Flickr: Whale ...

From Flickr. Uploaded by asmundur on 15 Apr '06, 6.17am EDT PST.

Thursday, April 20, 2006

New Google Scholar Feature: Recent Articles

Google Scholar is my preferred method of searching the medical literature. (See here for a review.) One major advantage is that articles are displayed according to number of citations, but this leaves open the possibility that classic, frequently-cited, but very outdated articles may be displayed first. A new feature, "recent articles," corrects this problem by ensuring that only recent papers are displayed.

Another major problem with Google Scholar is that very new articles are not included in the database. Also searching PubMed (from the National Library of Medicine) ensures the newest articles will be found.

As an example, here are three searches for "hyponatremia" using these methods:
See ResourceShelf for more information.

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Google Page Creator is Live

Anyone can now sign up for a Google Page Creator account at

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Obstacles to Generic Drugs Criticized

From The Washington Post:
The brand-name drug industry is aggressively working to keep blockbuster drugs widely used by the elderly from being sold in cheaper generic versions when their patents expire, the organization that represents pharmacy benefit managers said yesterday.

With an unprecedented number of top-selling drugs scheduled to go off patent within five years, the organization said, branded drug companies are constructing roadblocks to potential savings of $23 billion to seniors and the Medicare system.
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Wednesday, April 19, 2006

Flickr: goldbelly anemonefish (クマノミ) #2407

From Flickr. Uploaded by Nemo's great uncle on 16 Apr '06, 5.47am EDT PST.

New England Journal of Medicine Audio Summary for April 20, 2006

From the NEJM:
This summary covers the issue of April 20, 2006. Featured are articles on the efficacy and safety of corticosteroids for persistent ARDS, a therapeutic intervention for prehypertension, oral ondansetron for gastroenteritis in a pediatric emergency department, clopidogrel and aspirin versus aspirin alone to prevent atherothrombotic events; a review article on scabies; a case report of a man with hemoptysis and a pulmonary infiltrate; and Perspective articles on private health care in Canada, on the NIH budget and the future of biomedical research, and on the challenge of reporting subgroup analyses.
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Patient Quote of the Day: I Got the IUD!

"My boyfriend keeps popping the condom because he wants me to get pregnant... but he doesn't know I got the IUD!"

(Thanks to C, whose patient quotes are often better than mine.)

Health Insurers Are Near-Monopolies

Via ABC News:
Consolidation among health insurers is creating near-monopolies in virtually all reaches of the United States, according to a study released Monday.

Data from the American Medical Association show that in each of 43 states, a handful of top insurers have gained such a stronghold that their markets are considered "highly concentrated" under U.S. Department of Justice guidelines, often far exceeding the thresholds that trigger antitrust concerns.

The study also shows that in 166 of 294 metropolitan areas, or 56 percent, a single insurer controls more than half the business in health maintenance organization and preferred provider networks underwriting.
The press release is here.

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Tuesday, April 18, 2006

Grand Rounds 2.30

Grand Rounds 2.30, this week's best posts of the medical blogosphere, is up at Fat Doctor.

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Schizophrenia and Neuregulin

From The New York Times:
Researchers have made progress in understanding how a variant gene linked to schizophrenia may exert its influence in the brain. The findings are tentative but, if confirmed, could yield deep insights into the biological basis of the disease. The gene, called neuregulin-1, was first implicated in schizophrenia in 2002 by DeCode Genetics, a Reykjavik company that looks for the genetic roots of common diseases in the Icelandic population. But how the variant form of the gene contributed to the disease was far from clear, in part because even the normal gene's function is far from understood....

Neuregulin is one of about 10 genes so far linked to schizophrenia. It plays many different roles in the brain, some concerned with synapses, the interconnections between neurons, so derangements of its function are a plausible source of schizophrenia. It is a long road, however, from knowing a variant gene is linked with a disease to understanding the biology of how the disease is caused.
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Monday, April 17, 2006

The Blog of Dr. Taraneh Razavi, Google's Staff Physician

These are practical but not all inclusive responses to FAQ's from my Google and my private practice patients. For every person who asks a question there are several others who have the same concern. I hope this post will be helpful to many and will take out some of the guess work for living a healthier life. Please note the obligatory disclaimer that this is not a substitute for medical advice, and that you need to contact your doctors with any specific questions. I wish you good health.
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Technorati State of the Blogosphere, April 2006 Part 1: On Blogosphere Growth

Via Technorati:
# Technorati now tracks over 35.3 Million blogs
# The blogosphere is doubling in size every 6 months
# It is now over 60 times bigger than it was 3 years ago
# On average, a new weblog is created every second of every day
# 19.4 million bloggers (55%) are still posting 3 months after their blogs are created
# Technorati tracks about 1.2 Million new blog posts each day, about 50,000 per hour
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Saturday, April 15, 2006

Noelle, The Robot Birth Simulator

Noelle has given birth in Afghanistan, California and dozens of points in between. She's a lifelike, pregnant robot used in increasing numbers of medical schools and hospital maternity wards.

The full-sized, blond, pale mannequin is in demand because medicine is rapidly abandoning centuries-old training methods that use patients as guinea pigs, turning instead to high-tech simulations...

She can be programmed for a variety of complications and for cervix dilation. She can labor for hours and produce a breach baby or unexpectedly give birth in a matter of minutes.

She ultimately delivers a plastic doll that can change colors, from a healthy pink glow to the deadly blue of oxygen deficiency. The baby mannequin is wired to flash vital signs when hooked up to monitors.

The computerized mannequins emit realistic pulse rates and can urinate and breathe.
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Spironolactone to Treat Proteinuria and Chronic Kidney Disease

This trial suggests that, in patients with significant proteinuria, spironolactone + ACEI is roughly twice as good as ACEI + ARB (and equal to spironolactone + ACEI + ARB).

Double-Blind, Placebo-Controlled Study on the Effect of the Aldosterone Receptor Antagonist Spironolactone in Patients Who Have Persistent Proteinuria and Are on Long-Term Angiotensin-Converting Enzyme Inhibitor Therapy, with or without an Angiotensin II Receptor Blocker -- Chrysostomou et al. 1 (2): 256 -- Clinical Journal of the American Society of Nephrology:
Studies have shown that dual therapy with angiotensin-converting enzyme inhibitors (ACEI) and either angiotensin II receptor blockers or aldosterone receptor antagonists is more effective in reducing proteinuria than either agent used alone. The questions that remain are as follows: (1) Which of these agents should be used as dual therapy with the ACEI? (2) Does a higher level of blockade of the renin-angiotensin-aldosterone system with triple therapy offer an advantage over dual blockade? A 3-mo randomized, double-blind, placebo-controlled study was performed in 41 patients with proteinuria >= 1.5 g/d. Four treatment groups were compared: (1) Ramipril + spironolactone placebo + irbesartan placebo, (2) ramipril + irbesartan + spironolactone placebo, (3) ramipril + irbesartan placebo + spironolactone, and (4) ramipril + irbesartan + spironolactone. The percentage change in protein excretion differed according to treatment arm (ANOVA: F3,35 = 8.6, P < 0.001). Pair-wise comparison showed that greater reduction in protein excretion occurred in treatment regimens that incorporated spironolactone. The reduction in proteinuria at 3 mo was as follows: Group 1, 1.4%; group 2, 15.7%; group 3, 42.0%; and group 4, 48.2%. The reduction in proteinuria among patients who were taking spironolactone-containing regimens was sustained at 6 and 12 mo. This study suggests that aldosterone receptor blockade offers a valuable adjuvant treatment when used with ACEI therapy for the reduction of proteinuria. Results suggest no advantage of triple blockade over dual blockade of the renin-angiotensin-aldosterone system to reduce proteinuria.
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Should We Regulate Junk Food Like Cigarettes? The War on Fat.

From Goodbye, War On Smoking. Hello, War On Fat in Slate:
In a span of two months, smoking bans have been imposed in Scotland, enacted in England, Denmark, and Uruguay, proposed by the government of Portugal, and endorsed by the French public. China has banned new cigarette factories. In Virginia, our third most prolific tobacco state, senators voted to ban smoking in nearly all public places. The Arkansas legislature, backed by a Republican governor, passed a similar ban and voted to extend this policy to cars in which a child is present. Tobacco companies have won a skirmish here or there, but always in retreat.

So, we've found a new enemy: obesity. Two years ago, the government discovered that the targets of previous crusades—booze, sex, guns, and cigarettes—were killing a smaller percentage of Americans than they used to. The one thing you're not allowed to do in a culture war is win it, so we searched the mortality data for the next big menace. The answer was as plain as the other chin on your face. Obesity, federal officials told us, would soon surpass tobacco as the chief cause of preventable death. They compared it to the Black Death and the Asian tsunami. They sent a team of "disease detectives" to West Virginia to investigate an obesity outbreak. Last month, the surgeon general called obesity "the terror within" and said it would "dwarf 9-11."
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Friday, April 14, 2006

Flickr: Dalveen pass HDR

From Flickr. Uploaded by krmuir on 14 Apr '06, 1.07pm EDT PST.

CDC Report on Multi-State Mumps Outbreak

From the CDC:
Multi-state Mumps Outbreak
The state of Iowa has been experiencing a large outbreak of mumps that began in December 2005 (1). As of April 12, 2006, 605 suspect, probable and confirmed cases have been reported to the Iowa Department of Public Health (IDPH) (IDPH, unpublished data). The majority of cases are occurring among persons 18-25 years of age, many of whom are vaccinated. Additional cases of mumps, possibly linked to the Iowa outbreak, are also under investigation in eight neighboring states, including Illinois, Indiana, Kansas, Michigan, Minnesota, Missouri, Nebraska, and Wisconsin (CDC unpublished data, April 14, 2006).

In addition, the Iowa Department of Public Health has identified two persons diagnosed with mumps who were potentially infectious during travel on nine different commercial flights involving two airlines between March 26, 2006 and April 2, 2006. The origin and arrival cities for these flights include Cedar Rapids and Waterloo, IA; Dallas, TX; Detroit, MI; Lafayette, AR; Minneapolis, MN; St. Louis, MO; Tucson, AZ; and Washington, D.C. (2).
The source of the current US outbreak is unknown. However the mumps strain has been identified as genotype G, the same genotype circulating in the United Kingdom (UK). The outbreak in the UK has been ongoing from 2004 to 2006 and has involved > 70,000 cases. Most UK cases have occurred among unvaccinated young adults (3). The G genotype is not an unusual or rare genotype and, like the rest of known genotypes of mumps, it has been circulating globally for decades or longer.

Mumps clinical manifestations and transmission
Mumps is an acute viral infection characterized by a non-specific prodrome including myalgia, anorexia, malaise, headache and fever, followed by acute onset of unilateral or bilateral tender swelling of parotid or other salivary glands (4). In unvaccinated populations, an estimated 30-70% of mumps infections are associated with typical acute parotitis (4, 5). However, as many as 20% of infections are asymptomatic and nearly 50% are associated with non-specific or primarily respiratory symptoms, with or without parotitis (4).
Complications of mumps infection can include deafness, orchitis, oophoritis, or mastitis (inflammation of the testicles, ovaries, or breasts respectively), pancreatitis, meningitis/encephalitis, and spontaneous abortion. With the exception of deafness, these complications are more common among adults than children (4).
Transmission of mumps virus occurs by direct contact with respiratory droplets, saliva or contact with contaminated fomites. The incubation period is generally 16-18 days (range 12-25 days) from exposure to onset of symptoms (4, 6). Mumps virus has been isolated from saliva from between two and seven days before symptom onset until nine days after onset of symptoms (4, 6).

Mumps Prevention
The principal strategy to prevent mumps is to achieve and maintain high immunization levels. The Advisory Committee on Immunization Practices (ACIP) recommends that all preschool aged children 12 months of age and older receive one dose of measles-mumps-rubella vaccine (MMR) and all school-aged children receive two doses of MMR, and to ensure that all adults have evidence of immunity against mumps (5). As noted below, two doses of mumps vaccine are more effective than a single dose. Consequently, during outbreaks and for at-risk populations, ensuring high vaccination coverage with two doses is encouraged. For example, health care workers may be at increased risk of acquiring mumps and transmitting to patients and thus should receive two doses of MMR vaccine or provide proof of immunity. Since vaccination is the cornerstone of mumps prevention, public and private health entities concerned about spread of mumps in a population can review the vaccination status of populations of interest and work to address gaps in vaccination.

Mumps Vaccine Effectiveness
Data from outbreak investigations have shown that the effectiveness of MMR against mumps is approximately 80% after one dose and limited data suggest effectiveness of approximately 90% after two doses. Available evidence suggests that mumps vaccination should provide immunity against the genotype G virus responsible for the current US outbreak. A study of a 2005 New York outbreak that began with imported disease from the UK (7), demonstrated vaccine effectiveness in the expected range for both one and two doses (New York, unpublished data). However, since the vaccine is not 100% effective, some cases can occur in vaccinated persons. When a highly-vaccinated population is exposed to disease, most cases of disease would be expected to be among vaccinated persons. Mumps vaccine has not been shown to be effective in post-exposure prophylaxis and an interval of 2-4 weeks after vaccination may be required for the vaccine’s full immunogenicity to be achieved. For these reasons, and because of the mumps’ incubation period of 12-25 days, during an outbreak, newly-vaccinated persons may develop mumps disease as long as a month after vaccination (4, 5).

Control of mumps outbreaks
The main strategies for controlling a mumps outbreak are to define the at-risk population and transmission setting, identify and isolate suspected cases, and to rapidly identify and vaccinate susceptible persons or, if a contraindication to MMR vaccine exists, to exclude susceptible persons from the setting to prevent exposure and transmission. Specific strategies are listed below.

1. Offer MMR vaccine to persons without evidence of immunity. Evidence of immunity includes physician diagnosis or laboratory evidence of mumps infection, birth before 1957 or one dose of MMR vaccine. For pre-school aged children, the first MMR dose should be administered as close to age 12 months as possible. Although birth before 1957 is usually considered proof of immunity, during an outbreak, vaccination can be considered for this age group if the epidemiology of the outbreak suggests that they are at increased risk of disease. Since two doses of MMR vaccine is more effective than one dose for preventing mumps, a second dose of MMR vaccine is recommended for the following groups: health care workers, school-aged children, students at post-high school educational institutions and other age groups considered at high risk of exposure (5, 8).
2. Surveillance for mumps should be enhanced in all affected areas for persons with parotitis or other salivary gland inflammation. Enhanced surveillance should continue for 50 days (two times the maximum incubation period) after the date of illness onset in the last identified case. CSTE approved case definitions and case classifications for mumps are available (5).
3. Persons with suspected mumps should be tested and reported immediately to local public health officials. Information on collection and testing of clinical specimens for mumps will be available by Monday April 17, 2006 at Testing is essential as not all cases of parotitis are mumps, although mumps is the only known cause of epidemic parotitis.
4. Persons suspected of having mumps should be isolated for nine days after symptom onset (5, 6). In health care settings, the use of respiratory precautions is recommended (5).
5. Exclusion of persons without evidence of immunity to mumps from institutions such as schools and colleges affected by a mumps outbreak (and other, unaffected institutions judged by local public health authorities to be at risk for transmission of disease) should be considered. Once vaccinated, students can be readmitted to school.

The period of exclusion for those that remain unvaccinated should be for at least 25 days after the onset of parotitis in the last person with mumps in the affected institution (5, 6).

Additional information on mumps and the prevention and control of mumps outbreaks, including vaccination, can be found at the following website:

1. Centers for Disease Control and Prevention. Mumps Epidemic---Iowa, 2006--- April 7, 2006. MMWR 2006;55(13):366-8.
2. CDC. Exposure to Mumps During Air Travel --- United States, April 2006. MMWR. 2006;
3. CDC. Mumps epidemic – United Kingdom, 2004-05. MMWR 2006;55;173-5.
4. Plotkin, SA, Orenstein WA, et al. Vaccines, 4th Edition, 2003, p.441-5.
5. CDC. Measles, Mumps, and Rubella -- Vaccine Use and Strategies for Elimination of Measles, Rubella, and Congenital Rubella Syndrome and Control of Mumps: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1998; 47(RR-8);1-57.
6. Red Book: 2003 Report of the Committee of Infectious Diseases, American Academy of Pediatrics, pp 439-443.
7. CDC. Mumps outbreak at a summer camp – New York, 2005. MMWR 2006;55:175-77.
8. Vaccine Preventable Diseases Surveillance Manual, 3rd Edition, 2002, p. 7-1 – 7-12.

In A Switch, Girl's Old Heart Takes Over From Her Failing Transplanted Heart

From the Washington Post:
British doctors announced Thursday that they had successfully removed a heart that had been given to a girl in an unusual transplant procedure and that her own once-failing heart had recovered and was keeping her alive by itself.

The girl's own heart was left in her body during what is known as a "piggyback" transplant in 1996. The organ now appears to be working after a decade of rest.
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LactMed, a Database of Safety of Drugs in Breastfeeding

From the National Library of Medicine:
A peer-reviewed and fully referenced database of drugs to which breastfeeding mothers may be exposed. Among the data included are maternal and infant levels of drugs, possible effects on breastfed infants and on lactation, and alternate drugs to consider.
Via Women's Health News.

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Thursday, April 13, 2006

Flickr: coney island snake lady

From Flickr. Uploaded by pixietart on 8 Apr '06, 2.49pm EDT PST.

Hilarious Journal Articles #48: MRI Images of Sex

From Magnetic resonance imaging of male and female genitals during coitus and female sexual arousal -- Schultz et al. 319 (7225): 1596 -- British Medical Journal:
Objective: To find out whether taking images of the male and female genitals during coitus is feasible and to find out whether former and current ideas about the anatomy during sexual intercourse and during female sexual arousal are based on assumptions or on facts.
Design: Observational study.
Setting: University hospital in the Netherlands.
Methods: Magnetic resonance imaging was used to study the female sexual response and the male and female genitals during coitus. Thirteen experiments were performed with eight couples and three single women.
Results: The images obtained showed that during intercourse in the "missionary position" the penis has the shape of a boomerang and 1/3 of its length consists of the root of the penis. During female sexual arousal without intercourse the uterus was raised and the anterior vaginal wall lengthened. The size of the uterus did not increase during sexual arousal.
Conclusion: Taking magnetic resonance images of the male and female genitals during coitus is feasible and contributes to understanding of anatomy.

Thanks to Pharyngula.

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Wednesday, April 12, 2006

New England Journal of Medicine Audio Summary for April 13, 2006

From the NEJM:
This summary covers the issue of April 13, 2006. Featured are articles on abdominal sacrocolpopexy with Burch colposuspension to reduce urinary stress incontinence, homocysteine lowering with folic acid and B vitamins in vascular disease, homocysteine lowering and cardiovascular events after acute myocardial infarction, the effect of telithromycin on acute exacerbations of asthma, and glucose transport and type 2 diabetes; a review article on trans fatty acids and cardiovascular disease; a case report of a woman with a mass in the pelvis; a video in clinical medicine showing the placement of an arterial line; and Perspective articles on the health care infrastructure in post-Katrina New Orleans, and on access to the scientific literature.
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Abstinence Education for Medical Students

Via Slate:
As Michael Specter pointed out in The New Yorker last month, the Bush administration spends hundreds of millions of dollars touting the benefits of abstinence. Most abstinence-promoting programs waste the government's money funneling misinformation directly to adolescents. But one such group, the Medical Institute for Sexual Health, has another audience in mind—medical students. With the help of Congress, the institute has finagled $200,000 out of the Centers for Disease Control and Prevention to develop a sexual-health curriculum for doctors in training. It's a small bit of pork, but it represents the hijacking of a government agency that normally funds research based on merit. And the CDC's imprimatur could persuade medical schools to use the institute's work.

Based in Texas and Washington, D.C., the Medical Institute provides technical material on sexual health to youth organizations and educators. Its founder, Dr. Joe McIlhaney, served as adviser to President George W. Bush while he was governor of Texas and now sits on the Presidential Advisory Council on HIV/AIDS, as well as on the Advisory Committee to the Director of the CDC. Unlike some conservative groups, the Medical Institute strives for medical respectability, focusing on public-health arguments in favor of virginity rather than moral virtues. The institute objects to being called "abstinence-only," perhaps because it wants to distance itself from more blatantly ideological groups, or perhaps because according to a recent poll, most Americans believe that abstinence-only education doesn't work. Yet the institute mainly discusses condoms to disparage them and sexually transmitted diseases to assert that only abstinence offers reliable protection. Its core message is that "the behavior choices necessary for optimal health are sexual abstinence for unmarried individuals and faithfulness within marriage."
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"Disease Mongering"

The Public Library of Science has a collection of articles on "disease mongering" from a recent conference.

I don't believe many of the arguments, but "disease mongering" has received much press because of this article in the British Medical Journal.

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Flickr: Moonlight & Cloud - Hong Kong

From Flickr. Uploaded by 62Lofu on 9 Apr '06, 12.56pm EDT PST.

Tuesday, April 11, 2006

Medical Conversation of the Day: Status Epilepticus

"So if you walk in on a patient who's had a stroke, and they're grunting rhythmically, and they have automatic movements of their left arm, and they're unresponsive to noxious stimuli, what could be going on?"

"They're masturbating?"

"Sure. But it could also be nonconvulsive status epilepticus..."

(I hate walking in on people in nonconvulsive status. This has happened a few times, unfortunately, most recently today.)

Grand Rounds 2.29

Grand Rounds 2.29, this week's best posts of the medical blogosphere, is up at Anxiety, Addiction and Depression Treatments.

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Diet Soda Safe Despite High Benzene Levels, Per FDA

From the Washington Post:
Cancer-causing benzene has been found in soft drinks at levels above the limit considered safe for drinking water, the Food and Drug Administration (FDA) acknowledged Wednesday. Even so, the FDA still believes there are no safety concerns about benzene in sodas, said Laura Tarantino, the agency's director of food additive safety.

"We haven't changed our view that right now, there is not a safety concern," she said. "But what we need to do is understand how benzene forms and to ensure the industry is doing everything to avoid those circumstances."
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"Blood Alcohol Levels: A Visual Representation"

Via intueri:
The graph above offers a visual representation of one person’s various blood alcohol levels (y-axis) over the span of about ten years (x-axis). This individual met DSM-IV criteria for alcohol dependence (and answered “yes” to all of the CAGE questions, including that most disheartening inquiry, “Have you every drank any alcohol in the morning as an eye-opener?”) and was admitted to at least four different services (neurology, orthopedics, general surgery, and psychiatry) within the hospital....
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Monday, April 10, 2006

Lithotripsy For Kidney Stones May Increase the Risk of Diabetes and Hypertension

From The Journal of Urology, Diabetes Mellitus and Hypertension Associated With Shock Wave Lithotripsy of Renal and Proximal Ureteral Stones at 19 Years of Followup:
SWL has revolutionized the management of nephrolithiasis and it is a preferred treatment for uncomplicated renal and proximal ureteral calculi. Since its introduction in 1982, conflicting reports of early adverse effects have been published. However, to our knowledge the long-term medical effects associated with SWL are unknown. We evaluated these adverse medical effects associated with SWL for renal and proximal ureteral stones. Materials and Methods Chart review identified 630 patients treated with SWL at our institution in 1985. Questionnaires were sent to 578 patients who were alive in 2004. The response rate was 58.9%. Respondents were matched by age, sex and year of presentation to a cohort of patients with nephrolithiasis who were treated nonsurgically. Results At 19 years of followup hypertension was more prevalent in the SWL group (OR 1.47, 95% CI 1.03, 2.10, p = 0.034). The development of hypertension was related to bilateral treatment (p = 0.033). In the SWL group diabetes mellitus developed in 16.8% of patients. Patients treated with SWL were more likely to have diabetes mellitus than controls (OR 3.23, 95% CI 1.73 to 6.02, p <0.001). Multivariate analysis controlling for change in body mass index showed a persistent risk of diabetes mellitus in the SWL group (OR 3.75, 95% CI 1.56 to 9.02, p = 0.003). Diabetes mellitus was related to the number of administered shocks and treatment intensity (p = 0.005 and 0.007). Conclusions At 19 years of followup SWL for renal and proximal ureteral stones was associated with the development of hypertension and diabetes mellitus. The incidence of these conditions was significantly higher than in a cohort of conservatively treated patients with nephrolithiasis.
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Sunday, April 9, 2006

Advances in Bio-weaponry

Via Slashdot:
"Technology Review is running an eye-opening article on how biotechnology has advanced to the point where producing bio-weapons that were once only possible with the backing of governments with enormous resources is now possible with equipment purchased off eBay. You can now purchase a mini-lab of equipment for less than $10,000. The writer also interviewed a former Soviet bioweaponeer, Serguei Popov, who worked at the Biopreparat, the Soviet agency that secretly developed biological weapons. Popov has since moved to the US and provided a great deal of information on the types of weapons the Soviets were developing."
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Saturday, April 8, 2006

Recommendations: Red Cross Emergency Preparedness Kit

From the Store:
Battery Powered Flashlight (batteries included)
Battery Powered Radio (batteries included)
Emergency Blanket Food Bars (4,800 calories total)
Work Gloves (one pair)
Light Sticks (3 each one lasts 12 hours)
Moist Towelettes (6)
A Breathing Mask (NIOSH-N95)
Plastic Sheeting (10' x 10')
Rain Poncho
Personal First Aid Kit
Roll of Duct Tape
Water (2 quarts)
Water Container (2.5 gallon)
First Aid/Preparedness Instruction Booklet
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Chief Complaint of the Night

From GruntDoc:
"I was assulted with a telephone, and now my ear is ringing."
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Friday, April 7, 2006

Flickr: nyc hdr again

From Flickr. Uploaded by Automatt on 2 Apr '06, 8.44pm EDT PST.

Necropsy of Hal, the Central Park Coyote

From the Smoking Gun:
A necropsy on Hal the coyote has concluded that several factors--including heartworm infection and internal bleeding caused by his ingestion of rodent poison--contributed to the death of the former Central Park resident.
The full necropsy report is here.

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Why Doesn't Praying For Patients Help? Some Hypotheses.

From The Deity in the Data, By William Saletan, in Slate:
Patients who knowingly received prayers developed more post-surgery complications than did patients who unknowingly received prayers—and patients who were prayed for did no better than patients who weren't prayed for. In fact, patients who received prayers without their knowledge ended up with more major complications than did patients who received no prayers at all....

They're implicitly sketching possibilities as to what sort of God could account for the results. Here's a list. 1. God doesn't exist. This is the simplest explanation, favored by atheists. You pray, but nobody's there, so nothing happens. 2. God doesn't intervene. This is the view of self-limiting-deity theorists and of the Committee for the Scientific Investigation of Claims of the Paranormal. God may be there, but He's not doing anything here. 3. God is highly selective. The positive effect of prayer on the study's participants "could be smaller than the 10% that our study was powered to detect," the authors suggest. Maybe God heeds prayers, but not enough of them to reach statistical significance.... (long, hilarious list follows)

17. God is malevolent. Patients who received prayers were marginally more likely to develop complications (52.5 to 50.9 percent) and substantially more likely to develop major complications (18.0 to 13.4 percent) than patients who received none. You can't blame the major-complication gap on psychology, since both groups were told that they might or might not be prayed for. In the teleconference, one of the study's authors tried to explain the gap away—"We don't feel confident statistically that that difference is at the level of significance barely that it's actually perhaps real"—whatever that means. But another called it a "possible hotspot," and the editorial warns that in clinical research, "assumptions of Divine benevolence … could only be considered scientifically naïve," since "in the history of medicine there has never been a healing remedy that was actually effective without having potential side effects or toxicities."
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Wednesday, April 5, 2006

New Jersey Medical School Gives Blatant Lesson in Spoils System

From The New York Times:
Rarely has an institution offered as explicit a lesson in the spoils system as New Jersey's state medical school, which codified its highly elaborate system of political favoritism in a series of memos, e-mail messages and spreadsheets. The university's president, Dr. John Petillo, assigned job applicants a numerical ranking of 1 to 3 based on the political pull of their sponsors, according to documents released this week by a federal monitor, and ordered his staff members to deliver a formalized set of courtesies that the applicants' status entitled them to.

The documents are remarkable not so much for their content as for their very existence. Many people know applicants who landed government jobs on the basis of whom they knew, but it is highly unusual to get such an inside glimpse at how the favoritism skews the selection process.

In an age when most political officials are well schooled in spin control and careful not to commit any of their embarrassing moments to paper, here was one of the nation's largest medical institutions, a place entrusted with providing health care to hundreds of thousands of people each year, keeping a written playbook on how administrators padded the payroll with people whose connections outshone their qualifications.
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Free ICD-9 Coding Program for Palm or Pocket PC from PDR is offering a free ICD9 coding program here.

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Avian Flu: Germany

From the Wall Street Journal Avian Flu News Tracker:
7:00 a.m.: German authorities have confirmed the country's first case of the deadly H5N1 bird-flu strain in domestic poultry, the Social Affairs Ministry of the state of Saxony said. The infected birds were found earlier this week on a poultry farm near Leipzig, where more than 10,000 animals already have been slaughtered as a precaution, the ministry said.
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Tuesday, April 4, 2006

Tobacco Company Sues Secondhand Smokers

From The Weekly World News:
The B.S. Raleigh Tobacco Company is fighting back. They're tired of people enjoying their products for free. That's why they've filed a $5 billion classaction lawsuit to penalize millions of secondhand smokers.

"If people ain't gonna buy our cigarettes, they shouldn't be able to enjoy other people's smoke," declared Raleigh President Frank Thermal.
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Deadly Mold

I walked to the hospital floor. Three of my patients were there.

It was empty. And quiet. No patients anywhere. A lone nurse was sitting at the nursing station, writing.

"What happened to everyone?" I asked.

She shrugged.

"Deadly mold," she said.

Grand Rounds 2.28

Grand Rounds 2.28, this week's best posts of the medical blogosphere, is up at UroStream.

Sunday, April 2, 2006

Plavix Slogan Variations

"Ask your doctor about Plavix today, because no matter how formidable you are, you're no match for a dangerous clot."

You're no match for a dangerous clot.
You're no match for a deadly clot.
You're no match for a deadly thrombus.
A deadly thrombus vs. you: no match.
A deadly thrombus will do you in.
A pernicious thrombus will do you in.
A dastardly thrombus will do you in.
A dastardly clot will do you in.
You ain't got nothing on a dastardly clot.
The dastardly clot, it burns...
Curse you, dastardly clot.
For a dastardly clot, you are no match.
For a deadly clot, you are no match.
For a dangerous clot, you are no march,
You are no match for a dangerous clot.

Flickr: The Watcher

From Flickr. Uploaded by Kenny Maths on 29 Mar '06, 2.08am PST.

Saturday, April 1, 2006

Gmail Turns Two

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Israel Suspects Journalists Spreading Bird Flu

From the Mail & Guardian Online:
Israel suspects journalists, particularly press photographers, of being behind the spread of deadly bird flu in the Jewish state, an agriculture ministry official told Agence France-Presse.

"It's one of our working hypotheses," the official said, asking not be identified.

"Bird flu can be transmitted on clothing, footwear, the wheels of cars and even on cameras," the official added.

"The journalists who came to cover the outbreak then went back to homes and offices across the country..."
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