Wednesday, May 31, 2006

New England Journal of Medicine Audio Summary for June 1, 2006

From the NEJM:
This summary covers the issue of June 1, 2006. Featured are articles on multidetector computed tomography for acute pulmonary embolism, outcomes of in-hospital ventricular fibrillation in children, body-mass index and symptoms of gastroesophageal reflux in women, and unintended consequences of caps on Medicare drug benefits; review articles on panic disorder and on ambulatory blood-pressure monitoring; a case report that emphasizes thinking outside the box; and Perspective articles on the life-threatening malfunction of implantable cardiac devices and on the first months of the prescription-drug benefit.
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Flickr: Poppy field

From Flickr. Uploaded by si3illa on 26 May '06, 6.37pm EDT PST.

Tuesday, May 30, 2006

The Grand Rounds mp3

The mp3 of Grand Rounds 2.36, read by Talkr, is here.

Pre-Grand Rounds Interview on Medscape

Dr. Genes' interview with me is up on Medscape. (Nick did a great job, as usual.)

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Welcome to Grand Rounds 2.36, this week's best posts of the medical blogosphere.

The medical blogosphere is made up of a growing number of physicians, nurses, students, PAs, patients, scientists, social workers, administrators, engineers, IT professionals, librarians, EMTs, consultants, and many other people involved in health care.

On the right is a graph of the blogs that mention "Grand Rounds." The spikes on the graph represent Tuesdays, when Grand Rounds are traditionally posted.

Grand Rounds shares the same purpose as the annotated table of contents in printed medical journals like the NEJM and the Annals of Internal Medicine: it introduces noteworthy writing and encourages further reading.

It's been six months since I last hosted Grand Rounds. In that time, the blogosphere has doubled to over 41 million blogs.

Grand Rounds has also grown. This week, there were forty submissions. Of the many tools on the web designed to help humans deal with vast quantities of information, I've found to be among the most useful. ( is an online bookmarking service that allows you to easily browse links and share them with others.)

The page summarizing Grand Rounds 2.36 is here. Included are links to all the posts, short excerpts, and tags/keywords of all the topics on the right side of the page. is one way of viewing all the entries. I've also organized each by categories and included short quotes from each submission to highlight the variety of voices.

I have the pleasure of hosting Grand Rounds again this week. Here are the blogs:

Editor's PicksDoctors / PAs / PhDs Stories

From Doctor Hébert's Medical Gumbo:
This is the quandary I find myself in when I try to convince patients to forego antibiotic treatment for colds. Doing so benefits all of society. But does it benefit the patient in any way? Not very much. It takes real altruism to see the value in that argument, and -- how do I delicately put this ? -- we are not in the habit of raising altruists in this country.
From Dr. Deborah Serani:
I noticed, while visiting your terrific XXXXXXXX, that you have a copy of an actual XXXX. It would be more ethical if the reproduction of this XXXXXX was not posted. Test security is a highly regarded aspect in our field, and having that XXXXXXX posted can compromise validity and reliability in the XXXXXXXXX.
From Healthy Concerns:
Sometimes I am astonished, delighted and even moved by the stories that MedBloggers tell. Today I'd like to point you to just a handful of my favorites from the last couple of weeks.
From Doctor:
This week's issue of JAMA has a commentary essay about the new Electronic Medical Record system. I'd have to say that it's right on the money for how inconvinient sifting through any chart is these days. The essay is available here for free and is written in a format that really drives the point home! (highly recommended)
From Tundra Medicine Dreams:
Living a subsistence lifestyle—i.e., living off the land—requires a constant round of seasonal activities directed at acquiring food, heat, shelter and clothing. Most of the people living in villages, and quite a few living in Bethel, are doing exactly that. It is a constant procession of hard work with very few days off.
From UroStream:
However, this particular patient made his living as a porn star, known for his (ahem) "money shot", and a TURP would have been the end of his career. What to do? He was quite torn about his choices, and we (the residents) became quite involved with this "drama". He was basically deciding between the ability to urinate freely versus the ability to continue with his chosen profession.
From Wandering Visitor:
In taking care of patients, we have the opportunity to run the gamut of emotions. Patients can make us happy, angry, scared, and sometimes, either patients or their medical conditions can make us cry.
From Medical Humanities:
Last night I attended a wake. It was meant to be a party to celebrate 8 years of Medical Humanities at UCL but there was an inevitable air of sadness: UCL's pioneering Centre for Medical Humanities is no longer being funded and has been forced to close. It is understatement to say this is a great shame. The Centre has served as a crucible for the discipline in the UK.
Grand Rounds 2.0 and The Medical Blogosphere

From The Medical Blog Network:
In anticipation of TMBN hosting of the leading medblog carnivals, Health Wonk Review on 6/1 and Grand Rounds on 6/6, we have a major service update. In fact a real trifecta:
  • Blog Carnival Management: Automated system for managing entry submissions to blog carnivals.
  • Blog Listings & Member Profiles: All-new blog directory to give you improved ways to promote your blog(s).
  • Syndication & Revenue Sharing: A way to give back to our members, including bloggers interested in feed syndication.
From The Haversian Canal:
Grand Rounds, and its audience, continues to grow, and there have been several conversations about the conflict between linking to all who submit the products of their labor and providing readers with a relatively clean, concise introduction to the medical blogosphere. Some Rounds have pushed 100 submissions and the average is over 50. Maybe we should link to everybody. Maybe we should link to five. I don't know. As most hosts link to everyone, I am going to take the road less travelled, and I hope you will join me.

I will link to thirty articles from thirty authors. My goal is not to select the most popular bloggers or those I think are the best. I want the thirty best articles written. I don't care when they were written, how many times they've been edited, or what your credentials are.
From GruntDoc:
I've emailed Dr. Reider (who runs Medlogs) several times, and so far there's no inclusion of my feeds. (I'm linked in the sidebar, twice, which is nice but not getting the feeds in).

Is anyone else having problems getting their feeds included, and does anyone have a better / more effective way of contacting them?
From Enoch Choi of Medmusings:
I've volunteered to be the discussion leader of Bloggercon 4 in SF, CA... If we have enough interest, we can have a medblogger track. Who's in? email me at enochchoimd-thoughts AT yahoo DOT com.

We've got two venues committed now, so there will be at least two tracks. We're working on space for another track and I'm starting to put together a grid, and a list of DLs I want. If you've been a DL at a previous BloggerCon and are available to do this one, please let me know. No guarantees, but it would help to get things together more quickly, and given the closeness of the dates, time is of the essence.
Drugs and Technologies

From The Biotech Weblog:
According to a group of Finnish researchers, the carcinogenic damage caused by alcohol and smoking to the mouth, pharynx and esophagus can be accounted for in part, by the exposure of these organs to high concentrations of acetaldehyde... Since it has been known that the amino acid l-cysteine can bind to acetaldehyde and thereby eliminate its toxicity, scientists have developed l-cysteine products that could neutralize acetaldehyde and help prevent digestive tract cancers... The first commercial product, the l-cysteine containing chewing gum, was launched last week at the 11th International Congress of Oral Cancer.
From The Beast:
Big news in the myeloma world on Friday! Thalidomide was approved by the FDA for treatment of multiple myeloma. Thalidomide is an old drug with a dark past.
From Straight from the Doc:
The technology leader in products for reconstructive surgery of the extremities, Nexa Orthopedics, Inc. has recently received 510(k) clearance from the USFDA to market its pyrolytic carbon Carpometacarpal Implant (CMI).
From The Pharm Voice:
According to an animal model study conducted by University of Pittsburgh School of Medicine researchers whose results have been presented at the annual meeting of the American Urological Association, IP 751, a potent synthetic analog of a metabolite of THC (the principal active ingredient of marijuana) effectively suppresses pain in hypersensitive bladder disorders such as interstitial cystitis (IC).
From Diabetes Mine:
Thinking it over, my last post didn't really do justice to those USB flash drives specially designed to let you carry your medical records with you. (In Germany they call them "Sticks," while a cell phone is called a "Handy" ... pragmatic language)

Considering that we PWDs are constantly told to carry our full medical records along with us when we travel, the idea of putting it all on a tiny little stick is actually pretty interesting.
From Health Business Blog:
NEJM Editor Jeffrey Drazen has a letter to the editor of the Wall Street Journal today, responding to an article that demonstrated the New England Journal's laxity in scrutinizing the infamous Vigor trial of Vioxx.
Health Economics

From The Marketplace MD:
There was a disturbing story this week in the New York Times about how insurance companies take a long, long time to make payments to physicians. As Matthew Holt points out, this, by itself, is not news. The news was new data on exactly how long docs actually have to wait to get paid. The very worst insurance companies pay an average of 41.4 days after services are performed while the very best pay 29 days later. 29 days?!! That’s A MONTH!!
From Interested-Participant:
Here's the case of Tom Garrett, an 18-year-old leukemia patient, who must fly from Toronto to Calgary every 16 days to receive photoimmune therapy not available in Ontario. This is so despite the fact that at least one hospital in Ontario has the medical equipment necessary to provide treatment.
From Parallel Universes:
Early last month I wrote a post about how the high prices of medicines can "kill" sick patients. Much of the reason for high drug prices stems from the profit-oriented and patent-based global system for new drug development, marketing and pricing. Since the people behind this system operate only based on business methods and how to upset competition, the fate and welfare of poor sick people are largely neglected. Not all sick people have spare money to spend on medicines. More often than not, they would prefer buying food than medicine. And so, you know what happens next. They die even when they're not supposed to.
From InsureBlog:
Ms. Kiehl states that “(i)f you walk into a (doctor’s office) and ask, ‘What does it cost?’ they can’t tell you. (The medical industry)…is trying to keep this information a secret.” This statement is not only incorrect, but shows a lack of knowledge of the operations of physicians’ offices.
From Kevin, M.D.:
So, let's assume the reason we go to trial is to find the "truth" (i.e. whether medical error lead to the injury). We "test" with a malpractice trial. It has a false positive rate of 37 percent according to Studdert. This leaves us a test with a 63 percent specificity. Furthermore, the costs of performing this test are ridiculously high, which everyone agrees on...

From Doc Around the Clock:
Every once in a while when working the ED, we have a patient come in where we question whether or not their pacemaker is functioning correctly. In these instances we call the cardiology department and ask them to come down and interrogate the pacemaker. This is basically a technique where the pacemaker is checked via a computer to see if it is pacing the heart correctly and appropriately. Using the word interrogate in reference to an inanimate object always strikes me as funny. I always imagine the interrogator taking the pacemaker into an enclosed, darkened room, with nothing but a bright light shining on the device in question.
From Trick-Cycling for Beginners:
Occasionally, one gets bleeped for something so mind-blowingly trivial or downright stupid, one decides to add it to the list of Stupidest Things I Have Ever Been Called For. For two years, I have been swearing that I am going to compile such a list, and now, through the marvellous medium of the blogosphere, I am going to do just that.
From Fixin' Healthcare:
Well, I met with my consultant, Pogo. He called in another consultant and we reviewed the matter in great detail. It was my first time to meet the Lorax in person. Impressive fellow. Focused and no nonsense. Very little humor. But, Pogo made up for that and together they are a great team. Like most consultants they spent some of the time telling me what I already know.
From Ad Libitum:
Elevators are microcosms of human behavior in modern society. Riding up and down our hospital elevator, I’ve had countless opportunities to observe people. Of late, I’ve started trying to categorize them. There are a few distinct types of elevator passengers...
Medical Education

From The Rumors Were True:
So I'm not big-picture. The sooner I make peace with that, the sooner I can look at the glint form my shiny scalpel and forget about it. I'll sing the scalpel song that Todd from Scrubs taught me:

"Dum, did de dum, did de dum, did de SHINY SCALPEL!"
"Dum, did de dum, did de dum, did de GONNA CUT HIM UP!"
From Med_school:
Today, dear Medical School, you finally helped me accomplish what has held me back all those years in elementary school. This morning, during my Medical Physiology final, I finally surpassed that final hurdle that has prevented me from a perfect score on that coveted presidential fitness award. I have beaten my past demons.
Nurses Stories

From Emergiblog:
There are three theories to how triage should be handled.
  • The Down and Dirty Doorway Destination Decision
  • Surf ‘em and Turf ‘em
  • The Triage Trifecta
From PixelRN:
I am thinking about leaving the MICU for another type of nursing. I've been in the MICU for almost 2 years (if you include my student rotation). I've thought about leaving before, but up until now I hadn't crossed the threshold of thinking, "I'm leaving because I can't do this" to "I'm leaving because I don't want to do this."
Patients Stories

From All Blogged Up:
Now, she’s struggling with two very active toddlers, managing somehow to maintain a 4.0 at college … and the entire time, she’s in relentless pain. Close to discouraged tears, she called me and said, “Moof, the doctor sent me to the emergency room, and when I got there, they were rude, and harsh, and acted as if I was lying to them! They didn’t believe that I was in pain..."
From A Difficult Patient:
I won't go into details, but my doctor went beyond what should be done during a pelvic exam. He didn't ask my permission to do what he did, he didn't warn me before he did it, and what he did was entirely inappropriate. I never told anyone about this--I'm sure that no one would have believed me anyhow. Worse, I went back to this doctor. On that particular day, I left feeling confused, ashamed, and violated. But I rationalized his actions--He was my doctor, and I trusted him.

From NHS Blog Doctor:
Two weeks ago, Patricia Hewitt announced that doctors were to be instructed to offer pregnant women the choice of a home birth. I am implacably opposed to home births in the UK and I posted an article saying so. My reason for this opposition is straightforward. Safety. There are not adequate facilities to resuscitate a mother or baby in the home environment and it is not possible to predict who may need such resuscitation. Until such time as there are such facilitates, and this means country wide availability of Obstetric flying squads, able to respond within minutes, home births are not a sensible option.
From The Brown Stuff:
I've had reason to review my knowledge of morning sickness recently. Most women get this to one degree or other in pregnancy in the early stages of pregnancy. Most don't require treatment and it usually settles around the three month mark.

From GruntDoc:
Recently, I seem to be approached by more and more people with what amounts to "I have this problem, and I want you to fix it". This is usually medically related (IV access, meds), but is often just personality-conflict in action, or occasionally plain sloth.
From Disease Proof:
[Howard] Stern mentioned that over the weekend he read the article in The New York Times by Nicholas D. Kristof, entitled Killer Girl Scouts. Kristof argues, and Stern agrees, that high trans-fat content in food is no less a threat to Americans than Iranian dictators and terrorists organizations.

From Clinical Cases and Images:
According to a study, published in the journal Science, it looks like the first people with HIV caught the virus from Cameroon chimpanzees that harbor a simian immunodeficiency virus (SIV).
From Allergizer:
Dr. Yael Graif is the lead author of an article published in the latest issue of Journal of Allergy and Clinical Immunology. His study shows that a lot of children who get serious insect stings are not brought to the hospitals.
From Genetics and Health:
After recent discussions over genetic testing for autism (both prenatal and postnatal), I’m glad to have found this Philadelphia Inquirer editorial by Dr. Arthur Caplan, Emanuel & Robert Hart Professor of Bioethics, chair of the Department of Medical Ethics, and director of the Center for Bioethics at the University of Pennsylvania... The editorial makes me want to stand up and cheer. You must go read it. RIGHT NOW.
Also from Genetics and Health:
This chart from Google Trends comparing the search and news reference volumes for the terms genetics, genes, genome, and DNA surprises me somewhat.
From Breath Spa for Kids:
Preliminary results from on-going studies suggest that the stress caused by environmental exposure to violence is significantly linked to both poorer lung function in children and asthma exacerbations.
That concludes this week's Grand Rounds. Thank you for your submissions.

Next week's Grand Rounds will be hosted at Health Voices. (Please read this post prior to submitting.)

As always, thanks to Dr. Genes.

Saturday, May 27, 2006

Jack and Jill, The Back Story

Via Intueri:
Jack and Jill went up the hill to fetch a pail of water. Jack fell down and broke his crown and Jill came tumbling after. Jack had consumed about a fifth of gin about an hour prior to this incident. Due to this inebriation, he was unable to ambulate safely and subsequently could not coordinate his motor activity. It is unclear if he lost consciousness when his head hit the ground (he was yelling obscenities at the ambulance service and continued to scream expletives upon arrival at the emergency room; he was not directable and was ultimately placed in four point restraints due to his attempts to assault staff). However, he was moving all of his extremities and he clearly had a GCS of 15 at presentation. His blood alcohol level was near 400...
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Friday, May 26, 2006

"Rhythm Method" May Kill More Embryos than Other Methods of Contraception ("The Rhythm Method and Embryonic Death")

This is the nonintuitive argument of the week.

From the Journal of Medical Ethics:
[A] condom user ... can count on one embryonic death for each unintended pregnancy. A rhythm method user, however, should count on two to three embryonic deaths for each unintended pregnancy. Assuming a success rate of 95% for condom usage, we can count on an expectation of .5 pregnancies in 10 years. Hence, the expectation of embryonic death is .5 per ten years for a condom user, which is substantially lower than the expectation of two to three embryonic deaths per ten years on the rhythm method. Even a policy of practising condom usage and having an abortion in case of failure would cause less embryonic deaths than the rhythm method.
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Thursday, May 25, 2006

Wednesday, May 24, 2006

Flickr: Old Onion Face

From Flickr. Uploaded by adrians_art on 23 May '06, 6.59am EDT PST.

New England Journal of Medicine Audio Summary for May 25, 2006

From the NEJM:
This summary covers the issue of May 25, 2006. Featured are articles on pulmonary-artery versus central venous catheter to guide treatment of acute lung injury, peritoneal drainage versus laparotomy for necrotizing enterocolitis in infants, transmission of LCMV infection by organ transplantation, a new immune cell and the response to imatinib mesylate, and evolution in the classroom and the courtroom; a review article on bone quality; a video in clinical medicine demonstrating male urethral catheterization; a case report of a woman with a sudden change in mental status leading to admission to an emergency department; and Perspective articles on making patient safety the centerpiece of medical liability reform and on lymphocytic choriomeningitis virus.
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Tuesday, May 23, 2006

Hilarious Journal Articles #52: Laughter, Mr. Bean, Mobile Phones, and Dermatitis

Laughter counteracts enhancement of plasma neurotrophin levels and allergic skin wheal responses by mobile phone-mediated stress:
Laughter caused by viewing a comic video (Rowan Atkinson's The Best Bits of Mr. Bean) reduced the plasma nerve growth factor, neurotrophin-3 levels, and allergic skin wheal responses in patients with atopic dermatitis, whereas viewing a nonhumorous video (weather information) failed to do so. In contrast, stress induced by writing mail on a mobile phone enhanced the plasma nerve growth factor, neurotrophin-3 levels, and allergic skin wheal responses. However, previewing the comic video counteracted mobile phone-mediated enhancement of plasma neurotrophins or allergic skin wheal responses, whereas previewing the weather information failed to do so. Taken together, these results suggest that, in patients with atopic dermatitis, writing mail on a mobile phone causes stress and enhances allergic responses with a concomitant increase in plasma neurotrophins that are counteracted by laughter. These results may be useful in the study of pathophysiology and treatment of atopic dermatitis.
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New York Times OpEd on Kidney Donation

From the NYT:
MARCH was National Kidney Month. I did my part: I got a new one. My good fortune, alas, does not befall nearly enough people, and the federal government deserves much of the blame.

Today 70,000 Americans are waiting for kidneys, according to the United Network for Organ Sharing, which maintains the national waiting list. Last year, roughly 16,000 people received one (about 40 percent are from living donors, the others from cadavers). More are waiting for livers, hearts and lungs, which mostly come from deceased donors, bringing the total to about 92,000. In big cities, where the ratio of acceptable organs to needy patients is worst, the wait is five to eight years and is expected to double by 2010. Someone on the organ list dies every 90 minutes. Tick. Tick. Tick.
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Saturday, May 20, 2006

Web 2.0 in Medicine

Via Clinical Cases and Images:
I remember when I gave my first series of talks on Web 2.0 in Medicine at the Cleveland Clinic, people were coming to me after the presentation asking me where they can buy Web 2.0...

Thursday, May 18, 2006

AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2006 Update

AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2006 Update -- Smith et al. 113 (19): 2363 -- Circulation
Since the 2001 update of the American Heart Association (AHA)/American College of Cardiology (ACC) consensus statement on secondary prevention, important evidence from clinical trials has emerged that further supports and broadens the merits of aggressive risk-reduction therapies for patients with established coronary and other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease, and carotid artery disease. This growing body of evidence confirms that aggressive comprehensive risk factor management improves survival, reduces recurrent events and the need for interventional procedures, and improves quality of life for these patients.
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Flickr: Towing the Line

From Flickr. Uploaded by Steve Stone on 15 May '06, 7.00am EDT PST.

Hilarious Journal Articles #51: Cocaine Protects Against Fatal Heart Arrhythmias Caused By Tasers

Via Heart Rhythm 2006 and EurekAlert:
Cocaine intoxication serves as a protective agent against life-threatening arrhythmias that may result from electrical stun guns. The drug was found to reduce a healthy heart's vulnerability of developing ventricular fibrillation by 1.5 to two times above the study's baseline safety margin. Researchers at the Cleveland Clinic used a custom-built device to deliver a neuromuscular-incapacitating discharge in research animals that matched the waveform of commercially-available stun guns (TASER X-26). Dhanunjaya Lakireddy, lead author and fellow of electrophysiology at the Cleveland Clinic, concluded "There have been many news reports that tasers can increase the incidence of heart attacks in people on cocaine, but our findings show that these claims are unfounded and not based on science." Dr. Lakireddy said more research is needed to determine the relationship between cocaine and tasers on people with underlying heart conditions.
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Story of the Day: CPR Class

CPR Instructor: "Okay, so you're walking down the street, and you see someone laying on the ground. What do you do?"

Participant: "Well, you'd call 911, check for breathing..."

CPR Instructor: "No! You do the 'Brooklyn Step.'  You walk right over the guy. You don't know him, he doesn't owe you money, you just keep walking..."

(As told by a friend.)

While You're Tattooing "Do Not Resuscitate" On Your Chest

There's been a lot of press lately about an 80 year old woman who had "do not resuscitate" tattooed on her chest. This is a good idea, but it's too vague, since DNR only applies if a person's heart stops or they stop breathing. To eliminate any ambiguity, the following additional tattoos should also be considered:

"no artificial hydration or nutrition"

"no cardioversion for rapid atrial fibrillation"

"no intubation and mechanical ventilation for potentially reversible conditions"

"no pressors if hypotensive"

"no painful, high risk surgical procedures with a very low likelihood of success"

"...and no dialysis under any circumstances"

Wednesday, May 17, 2006

Flickr: Full moon

From Flickr. Uploaded by Arnold Pouteau's on 20 Apr '06, 9.04pm EDT PST.

Grand Rounds 2.34

Grand Rounds 2.34, this week's best posts of the medical blogosphere, is up at Doc Around The Clock.

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New England Journal of Medicine Audio Summary for May 18, 2006

From the NEJM:
This summary covers the issue of May 18, 2006. Featured are articles on HER2 and responsiveness to adjuvant chemotherapy, caffeine therapy for apnea of prematurity, progressive volume increase in polycystic kidney disease, language ability after early detection of hearing impairment; review articles on acute pancreatitis and on the detection of prelingual hearing loss; a case report of a woman with sudden onset of abdominal distention; and Perspective articles on health care reform in Massachusetts and on robotic surgery.
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Tuesday, May 16, 2006

Nephrology Cases #10: Cancer and Kidney Failure

A 65 year old man with previously normal renal function has a few days of poor appetite and is found to have a creatinine of 4 and widespread lymphadenopathy suspicious for lymphoma or leukemia. A urinalysis shows no proteinuria or hematuria. His renal function worsens despite intravenous fluids. What are the top four possible causes of his kidney failure? (Answers in comments.)

Google Notebook

The login page is here.

Thursday, May 11, 2006

Via Intueri, "Modern Cinderella Story"

Via Maria again, because often her writing demands to be linked:
Modern Cinderella Story. Musings while doing my laundry: What if, instead of the lost glass slipper, a man finds a solitary, obviously feminine sock in the dryer in the communal laundry room? And perhaps there is something alluring about this sock (fascinating print? delicate stripes? interesting color scheme?) and this causes him to try to find the (beautiful, stunning, whatever) owner of this sock? Or should he already know who the owner of the sock is? And then he lingers about her apartment, trying to figure out how not to look like a total freak with her sock?

Then I mused: What if, instead of a lost sock, it was urine in a specimen cup? Something about the urine—its golden hue, the positive test for methamphetamine and opiates, the clumpy, dark sediment settling to the bottom—makes him want to learn who produced this urine? But the specimen cup wasn’t labeled. But somehow, in this plot line, the woman who produced this urine is The One, so he must use what scientific resources he has available to find the woman who possesses the kidneys that produced this liquid gold….

Keeping my day job. Right.
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Via Intueri: "Five-Point Restraints"

Maria is a psychiatry resident:
And so it began—and it happened much more quickly than I had anticipated (although time may simply pass faster when one is actively struggling against five other human beings). I kicked, I floundered, I wriggled, I did my best to wrest myself from their grips. Before I knew it, however, one person each had a hold of each arm and leg. Their hands were placed outside of each of my knee and elbow joints, restricting my excess flailing. And then they picked me up off of the floor. Which sucked, because then there was nothing upon which I could brace myself. I continued to kick and jerk about—and started getting all sweaty and gross in the process. Two people in White Coats walked past, looking at the scene with perplexed expressions. Soon, I was plopped onto the hospital bed and as I tried to wriggle off, hands pinned my limbs (around my joints again) to the bed. The men were definitely exerting more force on me than the women—but there still wasn’t any jerking or pulling occurring. They oddly protected my joints (something I did not appreciate until after the episode was done). The leather restraint belt encircled my waist first. Then my hands were cuffed to the bed at the level of my waist. In the meantime, I continued to kick at my captors, but to no avail. (I later learned that even though legs are stronger than arms, arms and hands tend to cause more injury than legs and feet, hence the order of restraint.) The cuffs then went around my ankles and there I was, restrained to the bed. The right wrist restraint was a bit tight. I sat up and, in vain, tried to jostle myself off of the bed. Right. They then took my shoes off. “Why?” I asked, at this time resting—it takes a lot of energy to try to escape five people. “Because you could clock us in the head with these things,” one of them replied. “Plus, we would now be putting you into a hospital gown.”
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New England Journal of Medicine Audio Summary for May 11, 2006

From the NEJM:
This summary covers the issue of May 11, 2006. Featured are articles on inhaled corticosteroids and asthma in preschool children, inhaled corticosteroids in infants with wheezing, altered bone and mineral metabolism in patients receiving imatinib, the influence of donor C3 allotype on late renal-transplantation outcome, the regression of aortic aneurysms through pharmacologic therapy, claims, errors, and compensation in medical malpractice litigation and improving the quality of care through litigation against hospitals; a review article on lineage-specific hematopoietic growth factors; a case report of a woman with anemia and iron overload; a video in clinical medicine demonstrating arthrocentesis of the knee; and Perspective articles on lessons learned from Brazil about fighting HIV and on editorial independence.

Wednesday, May 10, 2006

Injury to Research Volunteers -- The Clinical-Research Nightmare (The TGN1412 Trial)

From the NEJM:
At 8 a.m. on Monday, March 13, 2006, eight healthy young men entered a trial of a drug under development by the small German immunotherapeutics company TeGenero. Six of the volunteers were assigned to receive active drug, and two were to receive placebo. The trial was being conducted for TeGenero by Parexel, a large contract research organization, at its facility at Northwick Park Hospital outside London. The six volunteers were to be the first humans to receive TGN1412, a humanized monoclonal antibody designed as an agonist of the CD28 receptor on T lymphocytes, which stimulates the production and activation of T lymphocytes. It was hoped that this product would benefit patients with B-cell chronic lymphocytic leukemia or autoimmune diseases such as multiple sclerosis or rheumatoid arthritis. Preclinical testing, including tests in rabbits and monkeys that used doses up to 500 times as high as the doses received by the first group of volunteers, reportedly showed no signs of toxicity.

However, after receiving injections of TGN1412, the six volunteers became desperately ill, had multiple-organ failure, and were transferred to an intensive care unit2 with what has been described as a cytokine release syndrome. As of April 5, five of the volunteers had been discharged from the hospital, and the other man appeared to be recovering. This unexpected and devastating outcome is currently under investigation by the relevant authorities under the supervision of the United Kingdom Medicines and Healthcare Products Regulatory Agency (MHRA), which originally approved the trial and its protocol. A preliminary report has now been completed and released. The serious injuries to these volunteers compel us to reassess the safety of such clinical trials in general, particularly those involving healthy volunteers.
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Tuesday, May 9, 2006

UpToDate for Palm

UpToDate for the Palm is being beta tested and should be available within 3 - 4 months.

Slate's Human Nature Columns Update

Slate's "Human Nature" columns are excellent. Recent articles include: "lesbian brains differ from straight women's brains," "being fat may improve your odds of surviving intensive care," "teens who take virginity pledges can't be trusted," "a 63-year-old woman will give birth..."

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Thursday, May 4, 2006

Rabies in New York City by Borough

The full report is here.

(Thanks to Cecily.)

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Hilarious Journal Articles #50: Half of Teen Virginity Pledges Retracted in First Year

From "Reborn a Virgin: Adolescents' Retracting of Virginity Pledges and Sexual Histories" -- Rosenbaum, 10.2105/AJPH.2005.063305 -- American Journal of Public Health:
Objectives. We examined retractions of virginity pledges and of sexual histories among adolescents taking part in waves 1 and 2 of the National Longitudinal Study of Adolescent Health.

Methods. Logistic regression analyses were used to compare respondents' reports of virginity pledges and sexual histories at waves 1 and 2.

Results. Among wave 1 virginity pledgers, 53% denied having made a pledge at wave 2; after control for confounders, pledgers who subsequently initiated sexual activity were 3 times as likely to deny having made a pledge as those who did not initiate sexual activity (odds ratio [OR]=3.21; 95% confidence interval [CI] = 2.04, 5.04). Among wave 1 nonvirgins who subsequently took virginity pledges, 28% retracted their sexual histories at wave 2; respondents who took virginity pledges were almost 4 times as likely as those who did not to retract reports of sexual experience (OR=3.88; 95% CI=1.87, 8.07).

Conclusions. Adolescents who initiate sexual activity are likely to recant virginity pledges, whereas those who take pledges are likely to recant their sexual histories. Thus, evaluations of sexual abstinence programs are vulnerable to unreliable data. In addition, virginity pledgers may incorrectly assess the sexually transmitted disease risks associated with their prepledge sexual behavior.
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The "Femoral First" Initiative

The "fistula first" initiative is a push to have more arteriovenous fistulas placed in chronic kidney disease patients prior to their first dialysis session. (This is the best way to receive hemodialysis.)

At an institution where many first dialysis sessions are performed in patients with poor access to medical care, I heard a nephrology fellow wryly refer to the "catheter first" or "femoral first" initiative. (This is the worst way to receive hemodialysis.)

Wednesday, May 3, 2006

New England Journal of Medicine Audio Summary for May 4, 2006

From the NEJM:
This summary covers the issue of May 4, 2006. Featured are articles on balloon angioplasty versus nitinol stents, children with elevated bilirubin levels, an antibody-deficiency syndrome due to mutations in the CD19 gene, inherited and somatic CD3ζ mutations in a patient with T-cell deficiency, and the current state of medical education; a review article on thrombotic thrombocytopenic purpura; a clinical problem-solving article entitled “Ring around the Diagnosis”; and Perspective articles on injury to research volunteers, on compensation for injured research subjects, and on disabled receptor signaling and new primary immunodeficiency disorders.
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More Professors Ban Laptops in Class

As the professor lectured on the law, the student wore a poker face. But that was probably because, under the guise of taking notes on his laptop, the student actually was playing poker - online, using the school's wireless Internet connection.
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Tuesday, May 2, 2006

Court Rules Terminally Ill Have Constitutional Right To Nonapproved Experimental Drugs

From the Washington Post:
Terminally ill patients have a constitutional right to obtain experimental drugs before the Food and Drug Administration has decided whether to approve them, a federal appeals court ruled yesterday.

Saying that dying patients have a basic "right of self-preservation," the court held that drugs that have passed the first phase of FDA review -- which determines whether a product is safe -- should be made available if they might save someone's life.
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Grand Rounds 2.32

Grand Rounds 2.32, this week's best posts of the medical blogosphere, is up at Polite Dissent.

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Google Scholar Blog Interview

I was interviewed by Dean Giustini of the Google Scholar Blog about searching the medical literature.

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Tequin Is Taken Off The Market Due To Blood Sugar Complications

From The Washington Post:
Approved for sale in 1999, Tequin has faced questions about its effects on blood sugar, being associated with both high- and low-blood sugar in some patients.

In February, the Food and Drug Administration required increased warnings on the drug's label. The manufacturer has warned that it should not be used by diabetics and said the elderly and those with kidney disease are more likely to have problems.

Miller said that while Bristol-Myers Squibb will stop making and selling the drug, stocks currently available are not being recalled. He urged people using Tequin not to discontinue it until they talk with their physician about an alternative.
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