Friday, December 14, 2007

"Still Alive" by Jonathan Coulton, from Portal (with Speculation)


The following is speculation. (I'm taking a break from the usual medical blogging.) If you haven't experienced Portal and/or don't like spoilers, skip this.

* Chell (your character) is actually a military android. (Did you really think you could fall 100 feet with springs on your calves and not get hurt?) GLaDOS wasn't joking. This also explains her comments on organ donation. It also explains how you got there. (And yes, you were adopted.)

* GLaDOS is actually the one who's been helping you all along. She's the one who arranged the scrawls on the wall that allowed you to find her. Why? Because she's split into multiple competing personalities/programs/motivations, some of which you destroyed in the endgame. The last, snarling eyeball was her most malevolent personality. The good personality(s) have been helping you.

* Presume that everything she says in the "Still Alive" song is true. The preceding events were a huge success. The remaining personality, the one that sings the song, actually wanted you to destroy her malevolent personalities. That was the point of the game. GLaDOS actually was happy for you as you burned her. (This bears some resemblance to Neuromancer.) She's "out of beta."

* The vanishing of the Borealis almost certainly had something to do with portal technology.

* There's zero reason the portal gun shouldn't make an appearance in Half Life 2 Episode 3.

* And "maybe you'll find someone else to help you" could refer to Gordon Freeman...


Glad I got that all off my mind. Back to our regular programming.

Saturday, November 24, 2007

Stunning temples secretly carved below ground by eccentric

But the 'Temples of Damanhur' are not the great legacy of some long-lost civilisation, they are the work of a 57-year-old former insurance broker from northern Italy who, inspired by a childhood vision, began digging into the rock.
Eighth wonder of the world? The stunning temples secretly carved out below ground by 'paranormal' eccentric | the Daily Mail

Friday, November 23, 2007

23andMe - Open Letter to the Medical Community

To the Medical Community:

At 23andMe our mission is to help our customers understand their own genetic information and how the current biomedical literature pertains to it. Our  genetics just got personal. service combines genotyping with a set of tools and features that depict each customer's personal information clearly, yet without distorting or misrepresenting our current understanding of how genes combine with environment and other factors to produce human traits and diseases. We also keep our service up-to-date by evaluating major genetic association studies as they are published in peer-reviewed journals, and incorporating them into our service after they have been satisfactorily confirmed.What we do not and will not do is provide medical advice to our customers. Though our service delivers personalized data, the information it provides is tailored to genotypes, not to individuals. Initially, we will have no knowledge of our customers' vital signs, disease histories, family histories, environment, or any other medically relevant information. Thus we have no way of evaluating our customers' health or medical needs, and we make every effort to clarify this for our customers.We also try to impress upon our customers the fact that genes are far from the only determinant of health, and that other factors can play an equal or greater role in determining whether they will develop a particular disease or condition. And our materials explain that the scientific understanding of how genetics may affect disease risk and other aspects of a person's health is changing and will continue to change as more research is done. These caveats aside, we at 23andMe believe that giving personalized genetic information to our customers can inspire them to take more responsibility for their own health and well-being. We also think our tools will serve to educate the lay public about genetics. At the very least, we hope our product will stimulate conversation among doctors, patients and researchers about genes and their role in human health.To that end, we hope you will contact us with your thoughts and suggestions about the role of personalized genetics in your medical specialty (or medicine in general). While we cannot promise to publish every contribution on our website, we will do our best to make sure the conversation reflects a variety of viewpoints and experiences. We also feel that our customers will benefit from this exchange.


23andMe - Letter to the Medical Community

Thursday, November 22, 2007

Home Hemodialysis

Hemodialysis is a process of cleaning and filtering the blood using a dialysis machine (a "man made kidney"). For people with renal failure, dialysis is lifesaving. (This posting will only discuss hemodialysis. Peritoneal dialysis is another form of dialysis that works equally well.)

SL Package Previously, hemodialysis was only performed in dialysis centers. Typically, dialysis centers are large rooms with twenty or more dialysis machines, nurses, technicians, doctors, and other staff. In the United States, patients usually travel to these centers three times a week and spend three to four hours per dialysis session.

In the last few years, hemodialysis performed at home has become more popular. Dialysis machines were previously large and difficult to transport. Recently, these machines have become more compact, making dialysis at home (or even mobile dialysis) more practical.

Home hemodialysis also offers more flexible treatment options than "in-center" dialysis. In addition to three times a week dialysis for three to four hours, other options include
  • short daily dialysis, five or six times a week, for two to three hours a session
  • nocturnal dialysis, performed while sleeping, for six to eight hours a night, three or more nights a week
Some data suggests that patient outcomes may be better with daily dialysis and nocturnal dialysis compared with three times a week dialysis.

The NxStage System One is an example of a compact, portable, easy to use home dialysis machine. The machine weighs about 75 pounds. More information may be found here.

Related Information: Kidney Replacement Therapies

Sunday, November 18, 2007

ACP Foundation HEALTH TiPS

HEALTH TiPS is a new program offered to ACP physicians from the ACP Foundation. HEALTH TiPS are two sided 4"x 6" sheets that contain important information that patients need to know to manage their chronic conditions.

ACP Foundation HEALTH TiPS

Saturday, November 17, 2007

Recommended Adult Immunization Schedule --- United States, October 2007--September 2008

The Advisory Committee on Immunization Practices (ACIP) annually reviews the recommended Adult Immunization Schedule to ensure that the schedule reflects current recommendations for the licensed vaccines. In June 2007, ACIP approved the Adult Immunization Schedule for October 2007--September 2008. Additional information is available as follows: schedule (in English and Spanish) at; adult vaccinations at; ACIP statements for specific vaccines at; and reporting adverse events at or by telephone, 800-822-7967.
Figure 1
Figure 2

Recommended Adult Immunization Schedule --- United States, October 2007--September 2008

Health Loves a Second Life, from the Second Life News Network

A top official at the National Institute of Health (NIH) says Second Life has huge potential for bringing the science profession together.J.P. Boucher, a contractor with the NIH says, "I (and the people I work with) see tremendous potential in this medium for communicating and interacting for medical and scientific purposes." The NIH is a global organization that provides funding and research to solve medical issues. Boucher has advocated and supported it by creating the NIH group inside Second Life and advocating the use of NVEs (Networked Virtual Environments) throughout the U.S. government. Boucher said NIH entered the virtual world for four reasons citizen outreach, collaboration, training, and the potential for E-Government Services...
Health loves a Second Life, Via

Thursday, November 15, 2007

"Emotional Support Animals"

Writing a letter for a patient. Everything you need to know is here:
Name of Professional (therapist, physician, psychiatrist, rehabilitation counselor)
XXX Road
City, State Zip

Dear [Housing Authority/Landlord]:

[Full Name of Tenant] is my patient, and has been under my care since [date]. I am intimately familiar with his/her history and with the functional limitations imposed by his/her disability. He/She meets the definition of disability under the Americans with Disabilities Act, the Fair Housing Act, and the Rehabilitation Act of 1973.

Due to mental illness, [first name] has certain limitations regarding [social interaction/coping with stress/anxiety, etc.]. In order to help alleviate these difficulties, and to enhance his/her ability to live independently and to fully use and enjoy the dwelling unit you own and/or administer, I am prescribing an emotional support animal that will assist [first name] in coping with his/her disability.

I am familiar with the voluminous professional literature concerning the therapeutic benefits of assistance animals for people with disabilities such as that experienced by [first name]. Upon request, I will share citations to relevant studies, and would be happy to answer other questions you may have concerning my recommendation that [Full Name of Tenant] have an emotional support animal. Should you have additional questions, please do not hesitate to contact me.


Name of Professional

Monday, November 12, 2007

Sunday, November 11, 2007

"My iPod, My Cell, My Insulin Pump"

Tom Baldwin, a 43-year-old flight attendant, wears two sleek gadgets strapped to his belt. One is an iPhone and the other is a compact insulin pump and glucose monitor called the Paradigm Real-Time (PRT) System made by medical device giant Medtronic (MDT ). It features user-friendly control buttons and a screen that displays Baldwin's glucose levels, measured up to 288 times a day, from a fine needle lodged in the skin of his abdomen.
My iPod, My Cell, My Insulin Pump -- in Businessweek

Tuesday, November 6, 2007

What Infections Can You Get From Your Pets?

Human contact with cats, dogs, and other pets results in several million infections each year in the United States, ranging from self-limited skin conditions to life-threatening systemic illnesses. Toxoplasmosis is one of the most common pet-related parasitic infections. Although toxoplasmosis is usually asymptomatic or mild, it may cause serious congenital infection if a woman is exposed during pregnancy, particularly in the first trimester. Common pet-borne fungal infections include tinea corporis/capitis (ringworm); campylobacteriosis and salmonellosis are among the most common bacterial infections associated with pet ownership. Less commonly, pets can transmit arthropod-borne and viral illnesses (e.g., scabies, rabies). Infection in a pet can provide sentinel warning of local vectors and endemic conditions, such as Lyme disease risk. Treatment is infection-specific, although many infections are self-limited. Prevention involves common sense measures such as adequate hand washing, proper disposal of animal waste, and ensuring that infected animals are diagnosed and treated. Special precautions are indicated for immunocompromised persons. Increased communication between primary care physicians and veterinarians could improve treatment and prevention of these conditions.
Pet-Related Infections - November 1, 2007 -- American Family Physician

Hilarious Journal Articles #89: Visualizing Out-of-Body Experience in the Brain

An out-of-body experience was repeatedly elicited during stimulation of the posterior part of the superior temporal gyrus on the right side in a patient in whom electrodes had been implanted to suppress tinnitus. Positron-emission tomographic scanning showed brain activation at the temporoparietal junction — more specifically, at the angular–supramarginal gyrus junction and the superior temporal gyrus–sulcus on the right side. Activation was also noted at the right precuneus and posterior thalamus, extending into the superior vermis. We suggest that activation of these regions is the neural correlate of the disembodiment that is part of the out-of-body experience.
From the New England Journal of Medicine -- Visualizing Out-of-Body Experience in the Brain
The collection of hilarious journal articles is here.

Monday, November 5, 2007

Halloween Postmortem

Halloween Parade, New York 2007, from Rocketboom:

Friday, November 2, 2007

Testing Flock

Posting with Flock 1.0, a "social web browser."

Saturday, October 27, 2007

Following a Birth on Twitter / Flickr

making progress, originally uploaded by merlinmann.

Robert Scoble and (now) Merlin Mann have both followed the birth of their children on Flickr and Twitter.
View's getting prettier; Ribsy's getting closer.

Head down, strong heart, and looking awesome by all accounts.

We've also had independent reports of a fontanelle and a sighting of a head of hair.

Friday, October 26, 2007

"Professionalism and the Psychopathology of Everyday Life"

This is an email sent to the Department of Medicine at Columbia by Donald Landry, Acting Chair of Medicine (and one of my mentors).

I've reproduced it here because it's one of the strongest and best arguments for handwashing that I've read.


Re: Professionalism and the Psychopathology of Everyday Life

Consider the spectacle of surgeons who argue with JCAHO
inspectors rather than mark an extremity prior to lateralized
surgery, or pediatricians who object rather than wash their hands
prior to examining a child. How can we understand such behavior
described by witnesses as “bizarre”, “inverted”, and “strange”?
How can we understand hyperintelligent internists who, as
a group, adhere to elementary hand washing protocols only 50-60% of
the time, despite constant reminders?

A potential explanation: some physicians perceive in the new
required practices an almost mortal threat. But why? Imagine a
physician whose entire life is devoted to providing the highest
quality of care, a prideful physician admired by patients,
respected of peers – imagine such a physician who now hears that
his or her sterling practices of the last few years or decades are
flawed, dangerous, substandard, unprofessional. To accept this
pronouncement is to see the edifice of a lifetime's work leveled in
a moment. How could such a physician react, except with denial and
defensiveness? And from this wellspring comes the contradictions
that we witness with wonder.

I see only one productive course. We must surrender. We must
surrender in terms of our conduct and our disposition. Only from
the most open posture can we rapidly assimilate and incorporate the
best practices to which we all aspire in moments of quiet

The care of our patients must transcend every other concern.
Failure to commit radically to this principle breaks faith with our
patients and invites sanctions from external observers...

Full disclosure: I can recall a time when I failed to wash my
hands 100% of the time. My practice consisted solely of ICU
patients and I was wearing new gloves for each patient, so why wash
hands? But I was wrong and admitting this was the necessary first
step to change. And so if you are fully compliant, wonderful. But
if not I strongly advocate unconditional surrender...

Many thanks for your help and for your commitment to our

Don Landry

Friday, October 19, 2007

Wow, their Radiation Detectors are Sensitive

Just saw a patient who relayed this story. She was buying coffee at Starbucks at Newark Airport. Two homeland security personnel were standing next to her when the suddenly glanced at each other, then at her. The radiation alarm on their hips had gone off. "Have you recently had a nuclear stress test of the heart?" they asked. "Why yes," she answered, "...three days ago."

42nd Street Up Close

42nd Street Up Close, originally uploaded by KidneyNotes.

Wednesday, October 17, 2007

Dinner with Sermo's CEO, Dr. Daniel Palestrant

Update: For notes on the dinner, see Tech Medicine.

I'll be at an informal dinner tomorrow (Thursday) with Sermo's CEO and founder, Dr. Daniel Palestrant. If anyone has particular questions they'd like me to ask (time permitting), please leave a comment.

Sermo is the largest online community for physicians. I discussed Sermo at my talk on "Health 2.0" at the 5th Annual Healthcare M&A and Corporate Development Conference.

I'm also planning to post observations from the dinner live on Twitter. (Which reminds me -- are there other physicians out there who use Twitter?)

Friday, October 12, 2007

"How to Cite Blogs" by the NIH / National Library of Medicine

For anyone who's wondered how (or even whether) to cite blogs in formal academic medical papers, the National Library of Medicine / National Institutes of Health now provides a style guide. They used Kidney Notes as one of the examples. I'm honored. [blog on the Internet]. New York: KidneyNotes. c2006 - [cited 2007 May 16]. Available from:

Thursday, October 11, 2007

Hilarious Journal Articles #88: Random Neuronal Firing Causes Mistakes

Via Neuron:
The resting brain is not silent, but exhibits organized fluctuations in neuronal activity even in the absence of tasks or stimuli. This intrinsic brain activity persists during task performance and contributes to variability in evoked brain responses. What is unknown is if this intrinsic activity also contributes to variability in behavior. In the current fMRI study, we identify a relationship between human brain activity in the left somatomotor cortex and spontaneous trial-to-trial variability in button press force. We then demonstrate that 74% of this brain-behavior relationship is attributable to ongoing fluctuations in intrinsic activity similar to those observed during resting fixation. In addition to establishing a functional and behavioral significance of intrinsic brain activity, these results lend new insight into the origins of variability in human behavior.
Thanks, BoingBoing.

Monday, October 8, 2007

A Stanford Medical IT Specialist Inteviewed by Robert Scoble

Via Scoble:
This 47 minute conversation is very interesting. Why? Well, he’s working with Google on a personal healthcare site. We cover a LOT of ground about technology trends inside the medical industry... we cover the various “personal healthcare services like Microsoft HealthVault” at about minute 41 and also cover some of the fears of giving services like these your health care data. Don’t miss that part of the interview, especially around minute 44 where he explains what these new health services could do for you.

Sunday, October 7, 2007

I'm an Editor at

The good folks at made me an editor! So I'll be intermittently posting there, too -- because, you know, I have so much time.

Doctors and Medical Students on Twitter

I'm surprised more physicians and medical students don't use Twitter. It's a useful tool — for example, see the sidebar of this blog, this post on Medicine 2.0, and this post on Clinical Cases and Images.

Update: To improve performance, I'm transferring the Doctors on Twitter feed to the Doctor's Room on FriendFeed. Please visit, and join the room. If you're a doctor or medical student, please
  1. Click on "Share Something."
  2. Click "Import your stuff."
  3. Import your Twitter feed, blog feed, etc.
The following is a list of doctors and medical students on Twitter:If you'd like to add your name to the list, please post a comment.

Read about the Doctors on Twitter Feed here.

Adam Bosworth Returns

Via his blog:
Well, as some seem to know, I’ve left Google. And now that I’ve left, that old entrepreneurial fever has struck me again and I’m off working on a startup. Google is a wonderful company and I had a great time there and had a lot of fun building something I really believe in, Google Health, which I think has a great potential to change the way consumers manage their health when it launches. Still, for me, it is time to start a new company and I’m off and running.

Thursday, October 4, 2007

42nd Street From Afar

42nd Street From Afar, originally uploaded by KidneyNotes.

Sunday, September 30, 2007

Jack at Apple Store (via iPhone)

Friday, September 28, 2007

Hilarious Journal Articles #87: "You've Gotta Know When to Fold 'Em: Goal Disengagement and Systemic Inflammation in Adolescence"

Apparently quitting reduces C-reactive protein.
The notion that persistence is essential for success and happiness is deeply embedded in popular and scientific writings. However, when people are faced with situations in which they cannot realize a key life goal, the most adaptive response for mental and physical health may be to disengage from that goal. This project followed 90 adolescents over the course of 1 year. Capacities for managing unattainable goals were assessed at baseline, and concentrations of the inflammatory molecule C-reactive protein (CRP) were quantified at that time, as well as 6 and 12 months later. To the extent that subjects had difficulties disengaging from unattainable goals, they displayed increasing concentrations of CRP over the follow-up. This association was independent of potential confounds, including adiposity, smoking, and depression. Because excessive inflammation contributes to a variety of adverse medical outcomes, these findings suggest that in some contexts, persistence may actually undermine well-being and good health.

Thursday, September 27, 2007

Maria from Intueri

This week met Maria, who writes Intueri, the best-written medical weblog. (So of course, she blogged it.)
Since my last entry, I

am still alive
. Just to be clear.

met Joshua Schwimmer, a nephrologist (kidney doctor) who writes at Kidney Notes, Healthline, and The Efficient MD, in addition to his clinical research publications. He managed to spare some time away from writing to meet me for dinner (after we stood in line in the behemoth Apple Store, where Joshua deftly picked up two potential patients at the cash register. Yeah, Apple apparently sells iPatients now.) I also met his adorable French bulldog, Jack, who is well-trained (Joshua is a budding behaviorist) and was definitely the center of attention for the entire evening. In fact, the following is the snapshot moment I have in my mind from meeting him: He and Jack racing back and forth across the smooth tiles in the lobby of his building, expressions of joy on both of their faces.

Joshua is smart. And enthusiastic about many things. And offered lush praise about my writing. (What can I say? The man’s got good taste.)

Photowalk in NYC with David Sifry

Planning to go on a photowalk over the Brooklyn Bridge with David Sifry this Saturday.

Wednesday, September 26, 2007

My Talk on "Health 2.0" for the 5th Annual Healthcare M&A and Corporate Development Conference

This is the talk I gave at the 5th Annual Healthcare Mergers and Acquisitions (M&A) and Corporate Development Conference on September 24, 2007. I was part of a panel titled "Healthcare 2.0: Technology & Healthcare Services of the Future," and we were asked to talk about disruptive changes in healthcare.


Good afternoon.

I'm a bit out of my element here, because I'm a practicing kidney and blood pressure specialist in New York City, but I do have a lot of friends and patients on Wall Street.

I'm going to talk briefly about the disruptive potential of online communities of physicians and patients.

These online communities are an big part of what people have called "Health 2.0." Of course, this is just a buzzword, like "Web 2.0," but it's a buzzword that means something.

Early this month the Economist had an article about Health 2.0, which they defined as "user generated healthcare." In Health 2.0 communities, the content and value is not generated by outside experts, but by the users themselves, by healthcare providers and patients, who interact to share information and insights.

These online communities may be very different from one another -- and I'll give you some examples of them in a minute -- but they all have a couple of things in common: they're all public, collaborative, and simple to use. And this combination can be very powerful and disruptive.

For example, there's a website called Wikipedia which is perhaps the best example of a community that's a major source of health information for a lot of people. If you haven't seen it, Wikipedia is a free online version of an encyclopedia that anyone in the world with an internet connection can read and edit. I'll say that again -- anyone in the world can read it and edit it.

This idea seemed crazy at first and still seems kind of crazy, but it actually seems to work. Wikipedia is now 15 times as large as the entire Encyclopedia Britannica. And partly because of Wikipedia, very few people read the Encyclopedia Britannica anymore.

And what's written on Wikipedia definitely matters. Wikipedia is one of the top ten websites worldwide. Wikipedia is often one of the first places people go if they're diagnosed with a new disease, or if they want to research a person or a corporation. The definitions on Wikipedia are often near the top of any Google search.

But again, it's amazing that Wikipedia works at all, because anyone with an internet connection can change any of the definitions. And that's potentially very scary.

But the system works because it's self policing -- errors are picked up and changed by the users. But of course that still leaves some potential for significant inaccuracies and abuse.

[The author Charles Stross points out that if you extrapolate from current trends in computing, sooner or later everyone in this room will have an entry on Wikipedia. Try to imagine what they might be like.]

I'm going to talk about some other Health 2.0 communities that have the potential to be as disruptive as Wikipedia.

For example, there's an online community for physicians called Sermo. Sermo was founded on the idea of information arbitrage, that there's valuable information locked in the heads of physicians, if you could only figure out a way to get to it.

The way Sermo works is this: physicians ask and answer anonymous questions, but some of the questions are also asked by firms. When physicians answer some of these questions, they get paid, but they don't know which questions will pay them. So the incentive is to answer as many questions as possible. Sermo is basically an experiment in classical conditioning, it mines physicians for information by turning them into compulsive gamblers and taking advantage of their desire to collaborate. And it works very well.

It's only about a year old but Sermo is the largest online network of physicians that's ever existed. Sermo is also partnering with the AMA and the FDA, who are interested in information from Sermo about the safety of medical products. Sermo may actually be a better way to encourage physicians to report problems with drugs and devices than the FDA's own website.

There are also many online communities for patients, including sites with names like Organized Wisdom, Revolution Health, and Patients Like Me. These sites offer a number of services. They function as support groups for people whose physicians may not know enough about their disease or who don't have the time to explain it. They also allow patients to share their collective insights with one another. And they allow them to rate different sources of health information on the web. Some people like to use the phrase that "people are the new algorithm."

And some of these sites also allow patients to rate their doctors, health systems, and health products. And this is potentially disruptive, but not necessarily in a bad way. If people can search on Google for a review of your organization as easily as they can search for a review of a toaster, that can be a powerful incentive to change for the better. But as with Wikipedia, there's obviously a potential for inaccuracy and abuse.

And finally, there's also thriving community of medical blogs, which are online interactive journals written by patients, physicians, and other health care professionals. Many healthcare blogs contain hidden gems of information. And there's a sustained level of discussion on blogs that's hard to find anywhere else.

For example, there's a blog called "Kevin, MD" which collects all the most interesting stories in the media in one place. There's a blog called "Running a Hospital" by the CEO of Beth Israel Deaconess in Boston. And the Wall Street Journal even now has it's own excellent Health Care Blog, which I recommend to anyone interested in the business of healthcare. And the interactive nature of blogs is essential, because sometimes the comments can be more interesting than the original posts themselves.

To summarize: technologies like Wikipedia, blogs, and online communities have the potential to dramatically change and improve communication in the healthcare industry.

Thank you.

Tuesday, September 25, 2007

"Wrong Object"

wrongobject, originally uploaded by brucesflickr.

Monday, September 24, 2007

More attempts to capture unusual glowing cloud formation

Leaving Nashville

Leaving Nashville, originally uploaded by KidneyNotes.

Healthcare M&A Conference

Healthcare M&A Conference, originally uploaded by KidneyNotes.

Sunday, September 23, 2007

5th Annual Healthcare M&A and Corporate Development Conference

On September 24th, I'll be appearing on a panel at the 5th Annual Healthcare M&A and Corporate Development Conference. The panel topic is "Healthcare 2.0: Technology & Healthcare Services of the Future." I'll be speaking on online communities of physicians and patients.

If you'll be at the conference, please feel free to look me up.

If there's time, I'll be posting pictures from the conference on Kidney Notes and posting observations on Twitter.

Friday, September 21, 2007

Currently Reading: Against the Day by Thomas Pynchon

Not reading, exactly -- more like listening to the 56 hour audiobook from, which is worth it for the range of accents alone, and which makes referring to the Pynchonwiki easy while listening, but man, this is 1000 pages and it's his most accessible book -- I'll see you in a week.

Saturday, September 15, 2007

Doktor Sleepless

ds6w, originally uploaded by warrenellis.

Hilarious Journal Articles #86: Elvis to Eminem: quantifying the price of fame through early mortality of rock and pop stars

From the Journal of Epidemiology and Community Health:
Background: Rock and pop stars are frequently characterised as indulging in high-risk behaviours, with high-profile deaths amongst such musicians creating an impression of premature mortality. However, studies to date have not quantified differences between mortality experienced by such stars and general populations.

Objective: This study measures survival rates of famous musicians (n = 1064) from their point of fame and compares them to matched general populations in North America and Europe.

Design: We describe and utilise a novel actuarial survival methodology which allows quantification of excess post-fame mortality in pop stars.

Participants: Individuals from North America and Europe performing on any album in the All-Time Top 1000 albums from the music genres rock, punk, rap, R&B, electronica and new age.

Results: From 3 to 25 years post fame, both North American and European pop stars experience significantly higher mortality (more than 1.7 times) than demographically matched populations in the USA and UK, respectively. After 25 years of fame, relative mortality in European (but not North American) pop stars begins to return to population levels. Five-year post-fame survival rates suggest differential mortality between stars and general populations was greater in those reaching fame before 1980.

Conclusion: Pop stars can suffer high levels of stress in environments where alcohol and drugs are widely available, leading to health-damaging risk behaviour. However, their behaviour can also influence would-be stars and devoted fans. Collaborations between health and music industries should focus on improving both pop star health and their image as role models to wider populations.
The Hilarious Journal Article collection is here. (Thanks, Huck.)

Thursday, September 13, 2007

FDA Hearing on Erythropoeisis-Stimulating Agents (ESAs)

Via the American Society of Nephrology:
On September 11, 2007, the Food and Drug Administration (FDA) Center for Drug Evaluation and Research held a joint session with the Cardiovascular & Renal Drugs Advisory Committee (CRDAC) and the Drug Safety & Risk Management Advisory Committee (DSaRM) to examine the risks and benefits of erythropoesis-stimulating agents (ESAs) when used in the treatment of anemia due to chronic renal failure. The drugs, sold under the brand names Aranesp and Epogen, boost red blood cell production and raise hemoglobin levels in kidney disease and dialysis patients. The hearing was prompted by the “Normal Hematocrit” study and the CHOIR study. The task was to evaluate the appropriate hemoglobin target for patients using ESAs and the identification and management of ESA “hypo-responders.”

You can view further information about the hearing, such as the overall agenda and a list of committee members here, under September 11, 2007.

Drs. Lynda Szczech and Jonathan Himmelfarb represented the ASN and presented testimony during the Open Public Hearing. The ASN Public Policy Board submitted a statement to the FDA prior to the hearing and received an invitation from the FDA to speak at the Open Public Hearing. Dr. Himmelfarb is the chair of ASN's Public Policy Board. Dr. Szczech is a member of the Public Policy Board and chair of ASN's Dialysis Advisory Group. You can read more about their testimony below.*

Meeting Summary:

FDA Invited Speakers (You can view these slides here)

Dwaine Rieves, MD, Acting Director of Medical Imaging and Hematology Products and the FDA introduced the invited speakers.

The first presentation was given by Ajay Singh, MD, Clinical Director of the Renal Division at Brigham & Women's Hospital, who gave an update on Anemia and Chronic Kidney Disease based on results of the CHOIR study.

The second presentation addressed Epoetin Outcomes Research and was given by Dennis Cotter and Yi Zhang from the Medical Technology and Practice Patterns Institute in Bethesda , Maryland and Miguel Herman, Associate Professor of Epidemiology at Harvard University 's School of Public Health.

Sponsor Presentations (You can view their slides here)

Paul Eisenberg, MD, MPH, from Global Regulatory Affairs & Safety at Amgen, Inc. provided the introduction. This was followed by a presentation on the Clinical Perspective provided by Allen Nissenson, MD, Professor of Medicine at UCLA. Preston Klassen, MD, MHS, Global Development, Amgen, Inc. then spoke about the benefits and risks. Paul Eisenberg, MD, then addressed Risk Management.

The Sponsors summarized that:

(1) Hb target is clinically important (label recommendation 10-12 g/dL)

(2) Relationship between dose and outcomes is highly confounded

(3) Additional investigation of hypo responsiveness and outcome required

FDA Presentations

Ann Marie Trentacosti, MD, Study Endpoints and Labeling, gave an overview of Patient Reported Outcomes (PRO) Claims and the limitations of these studies related to their design. Ellis F. Unger, MD provided the “FDA Perspectives on Erythropoiesis-Stimulating Agents (ESAs) Anemia of Chronic Renal Failure: Hemoglobin Target and Dose Optimization” to include analyses suggesting a relationship between the rate at which hemoglobin rises and risk and a reanalysis of the Normalization of Hematocrit Trial with extended follow-up favoring the low hematocrit group (p=0.01) ( Click here for PDF).

Open Public Hearing

Presenters at the Open Public Hearing included the following:

Roberta Wager, RN, MSN, President of the American Association of Kidney Patients stressed that ESA doses should be decided by a physician and a patient on an individual basis and that the FDA should strive for a “Goldilocks” solution — not to much, not too little, but one that should improve the Quality of Life for kidney disease patients.

*Dr. Himmelfarb, ASN Public Policy Chair, discussed the problems patients encounter when they have become sensitized from blood transfusions given to manage their anemia and as a consequence may lose access to kidney transplantation as a therapeutic modality.

*Dr. Szczech, ASN Dialysis Advisory Group Chair and member of the Public Policy Board, provided the results of new post-hoc analyses of the CHOIR data examining interactions between the dose of administered epoetin alpha, targeted hemoglobin, achieved hemoglobin and patient outcomes. She will be presenting these important results more fully during the late breaking clinical trial session at Renal Week.

Drs. Robert Wolfe and Friedrich Port from the University of Michigan presented new research from Arbor Research Collaborative for Health. The research found that mortality is lower in dialysis facilities having more patients with hematocrit levels greater than or equal to 33%. They cautioned that it is also possible that some facilities have sicker patient populations.

Dr. Robert Provenzano, DaVita, and past president of the Renal Physicians Association, spoke about the risks of cycling. Data from DaVita clinics suggests that holding EPO when the hemoglobin is at 12 or 13 g/dL increases the risk of both low and high hemoglobin levels later. He recommended that EPO should be used to keep the hemoglobin above 11 and to decrease it if above 12.

Michael Lazarus, MD, Fresenius Medical Care, presented data showing that even thoughp hysicians are unable to stop shifting hemoglobin levels, overall the mean level stays around 11g/dL.

David Van Wyck, MD, co-chair of the KDOQI anemia work group recommended that the target range should be 11-12 g/dL, not to exceed 13 g/dL. This recommendation follows the examination of evidence from 27 Randomized Clinical Trials (RCTs).

Alan Kliger, MD, President of the Renal Physicians Association also represented the American Society of Pediatric Nephrology. He spoke to the fact that the doctor-patient relationship should be preserved and that warning should target specific patient populations (pediatrics, CKD, ESRD, cancer). He also testified that Quality of Life should be included in the committee's considerations.

Lori Hartwell, founder of the Renal Support Network, was the final witness. Ms. Hartwell has suffered from chronic kidney disease for 39 years, has had 3 kidney transplants and 12 years of dialysis therapy . As a nurse and a kidney disease patient, Ms. Hartwell has seen the benefits of ESAs and discussed concerns from the patient community about potential lowering of hemoglobin target levels.

Committee Discussion and Voting

The first question posed to the committee was whether the ESAs label should “&be changed to state that the target hemoglobin should not exceed ~11 g/dL for patients on hemodialysis&” The committee voted 14 to 5 against this question. Many Committee members were uncomfortable with the language “shall not exceed” and felt that the 11 g/dL upper target was inappropriate. Several members preferred other options, such as a 10-12 g/dL range or a target of 11 or 11.5 g/dL (omitting the words “not exceed”).

The second question was very similar to the first except it addressed the target hemoglobin for patients NOT on dialysis. The committee again voted 14 to 5 against the question for the same reasons as the first.

The committee omitted the third question, regarding future randomized clinical studies to study hemoglobin targets, due to time constraints.

The fourth question posed to the committee asked whether the “ESA dosages used to achieve the hemoglobin levels in the lower target groups in Normal Hematocrit and CHOIR are sufficient to form the basis for ESA dosage recommendations.” This question garnered a positive vote of 14-3, with 2 abstentions.

The fifth question addressed the identification and dosages for “ESA hypo-responders.” Members noted that the Sponsor presented a recommendation on how to identify these patients.

The final question asked the committee to discuss dosing algorithm hypotheses. Members agreed that additional attention to dosing algorithms would be useful.

The role of the FDA Advisory Committee is strictly to advise the agency and the FDA issues final decisions. However, the recommendations of the committee often have a strong influence on the final decisions. In general, the committee members acknowledged the value of ESAs and hesitated to impose stringent restrictions on their use.

The hearing was covered by several major media outlets including the New York Times , Bloomberg, the Wall Street Journal , the LA Times , CBS News, Inside CMS, the Associated Press, and Reuters, as well as CBS News. Most articles indicated a positive outcome for the kidney disease community.

The ASN Public Policy Board will keep the membership informed of any future developments in the controversies surrounding management of the anemia of chronic kidney disease in subsequent issues of Renal Policy Express.

Tuesday, September 11, 2007

Grand Rounds is Up

Grand Rounds is up at The Efficient MD. My interview with Medscape is here (free registration required):
Blogs are also a remarkably efficient tool for recording your thoughts and sharing them. What doctor doesn't have advice and reference material they'd like to share with friends, colleagues, current or potential patients, or their future self at some later date? Blogs are one way of making this easier. And in a few years, why shouldn't inexpensive mobile phones or PDAs have evolved to the point where blogging -- that is, the mobile sharing of information and media with small or large groups -- is second nature to most people?

World Trade Center

World Trade Center, originally uploaded by KidneyNotes.

Friday, September 7, 2007

Wednesday, September 5, 2007

Grand Rounds Call for Submissions: Healthcare Innovations and New Technologies

The next medical blogosphere Grand Rounds will be held at The Efficient MD on September 11, 2007.

The theme of Grand Rounds will be "Healthcare Innovations and New Technologies." Submissions broadly related to innovations in healthcare are welcome: new technologies, models of practice, and ways of improving efficiency or the quality of care. Speculations about the future of healthcare are also encouraged. Old posts are welcome. If you haven't written about this topic before, feel free to use this opportunity to write on the future of healthcare. Be creative.

Please send your submissions to [email protected] with the subject "Grand Rounds" by Sunday, September 9 at 6 pm EST.

Some background on the topic of this Grand Rounds: I chose "Healthcare Innovations" because I will be participating in a panel discussion titled "Healthcare 2.0: Technology & Healthcare Services of the Future" at the 5th Annual Healthcare M&A and Corporate Development Conference. (And by all means, if you'll be at the conference, look me up.) Particularly interesting ideas from this Grand Rounds may also be mentioned prominently at the panel discussion.

(As an aside, the conference will be held in Nashville. Coincidentally, the last time I was in Nashville was on a trip away from New York on September 11, 2001 -- the date of this Grand Rounds -- but that's another story.)

Of course, if you don't have a formal submission to Grand Rounds but would like to mention an important link or idea, please feel free to comment.

Saturday, September 1, 2007

Alison and Jack

Alison and Jack, originally uploaded by KidneyNotes.

Audible, Wishlist, Random, iPhone

Randomly working my way through an wishlist on the iPhone using numbers generated by Just finished The Dip.

Tuesday, August 28, 2007

Your Favorite Chief Complaint / Initial Presentation

"A 23 year old pregnant jockey presents with a fever, a sore throat, and a red eye."

Saturday, August 25, 2007

Hilarious Journal Articles #85: Pac Man and Functional MRI

When Fear Is Near: Threat Imminence Elicits Prefrontal-Periaqueductal Gray Shifts in Humans, in Science:
Humans, like other animals, alter their behavior depending on whether a threat is close or distant. We investigated spatial imminence of threat by developing an active avoidance paradigm in which volunteers were pursued through a maze by a virtual predator endowed with an ability to chase, capture, and inflict pain. Using functional magnetic resonance imaging, we found that as the virtual predator grew closer, brain activity shifted from the ventromedial prefrontal cortex to the periaqueductal gray. This shift showed maximal expression when a high degree of pain was anticipated. Moreover, imminence-driven periaqueductal gray activity correlated with increased subjective degree of dread and decreased confidence of escape. Our findings cast light on the neural dynamics of threat anticipation and have implications for the neurobiology of human anxiety-related disorders.

Friday, August 24, 2007

The "Spook Country" Audiobook by William Gibson

On the way to work, listened to William Gibson's Spook Country, the audiobook. I persistently can't believe it's been twenty years since Neuromancer. (Anyone share this feeling?) To its credit, Spook Country brings back the thrill of reading Neuromancer for the first time.

Thursday, August 23, 2007

Central Park

Central Park, originally uploaded by KidneyNotes.

Wednesday, August 22, 2007

Abandoned Space

Abandoned Space, originally uploaded by KidneyNotes.

Tuesday, August 21, 2007

Hilarious Journal Articles #84: The untapped potential of virtual game worlds to shed light on real world epidemics

The artice from BBC News is here. This paper, from the Lancet Infectious Diseases, discusses the "Corrupted Blood Plague" in World of Warcraft:
Simulation models are of increasing importance within the field of applied epidemiology. However, very little can be done to validate such models or to tailor their use to incorporate important human behaviours. In a recent incident in the virtual world of online gaming, the accidental inclusion of a disease-like phenomenon provided an excellent example of the potential of such systems to alleviate these modelling constraints. We discuss this incident and how appropriate exploitation of these gaming systems could greatly advance the capabilities of applied simulation modelling in infectious disease research.
The Hilarious Journal Article collection is here.

Does Clostridium Difficile Colonize Alcohol-Based Hand Sanitizers?

C. difficile is not killed by the alcohol-based hand sanitizers commonly used in most hospitals (alcohol, apparently, is not "sporicidal"). Here's my question: has anyone shown that C. difficile doesn't colonize these hand sanitizers? Wouldn't that be the perfect way to spread?

Hurricane Dean Side View

Hurricane Dean Side View, originally uploaded by cayobo.

Sunday, August 19, 2007

Film Shoot, NYC, by iPhone

Film Shoot, NYC, by iPhone, originally uploaded by KidneyNotes.

Saturday, August 18, 2007

Medicare Says it Won't Cover Hospital Errors

Look for the definition of an "error" to be expanded dramatically... Central line infection? C. difficile colitis? Ventilator associated pneumonia? From the New York Times:
In a significant policy change, Bush administration officials say that Medicare will no longer pay the extra costs of treating preventable errors, injuries and infections that occur in hospitals, a move they say could save lives and millions of dollars.

Private insurers are considering similar changes, which they said could multiply the savings and benefits for patients.

Under the new rules, to be published next week, Medicare will not pay hospitals for the costs of treating certain “conditions that could reasonably have been prevented.”

Wednesday, August 15, 2007

Adam Bosworth Lecturing on Google Health

Saturday, August 11, 2007

Columbia's Forms for Implementing Patient-Physician Email

On Tech Medicine, I recently discussed patient-physician email. As part of the review, I looked at Columbia University's guidelines for allowing providers to use nonencrypted email and still be compliant with the HIPAA privacy law. (Their web page is excellent and I strongly recommend that you read it if you're interested in this topic.) I've extracted the text from the two forms below, "Important Information About Provider/Patient Email" and "Patient Request for Email Communications."

These forms are provided for informational purposes only.

Important Information About Provider/Patient Email

As a patient of this office, you have the right to request we communicate with you by electronic mail (email). It is also your right to be informed in sufficient detail about the risks of communicating via email with your health care provider or office, and how your provider will use and disclose provider/patient email.


Email communications are two-way communications. However, responses and replies to emails sent to or received by either you or your health care provider may be hours or days apart. This means that there could be a delay in receiving treatment for an acute condition.

If you have an urgent or an emergency situation, you should not rely solely on provider/patient email to request assistance or to describe the urgent or emergency situation. Instead, you should act as though provider/patient email is not available to you – and seek assistance by means consistent with your needs.

Email messages on your computer, your laptop, and/or your PDA have inherent privacy risks – especially when your email access is provided through your employer or when access to your email messages is not password protected.

Unencrypted email provides as much privacy as a postcard. You should not communicate any information with your health care provider that you would not want to be included on a postcard that is sent through the post office.

Email messages may be inadvertently missed. To minimize this risk, your doctor requires you respond appropriately to a test email message before we will allow health information about you to be communicated with you via email. You can also help minimize this risk by using only the email address that you are provided at the successful conclusion of the testing period to communicate with your doctor.

Email is sent at the touch of a button. Once sent, an email message cannot be recalled or cancelled. Errors in transmission, regardless of the sender’s caution, can occur.

In order to forward or to process and respond to your email, individuals other than your health care provider may read your email message. Your email message is not a private communication between you and your treating provider.

Neither you nor the person reading your email can see the facial expressions or gestures or hear the voice of the sender. Email can be misinterpreted.

At your health care provider’s discretion, your email messages and any and all responses to them may become part of your medical record.

Patient Request for Email Communications

Communications over the Internet and/or using the email system are not encrypted and are inherently insecure. There is no assurance of confidentiality of information when communicated this way. Nevertheless,you may request that we communicate with you via email. To do so, you must complete this form and return it to your health care provider’s office.

Please be advised that:
(1) This Request applies only to the health care provider or office that you indicate below. If you would like to request to communicate via email with another health care provider or office, you must complete a separate Request for that office.
(2) Your health care provider will not communicate health information that is specially protected under state and federal law (e.g., HIV/AIDS information, substance abuse treatment records information, mental health information) via email even if we agree to communicate with you via email.
(3) Your Request will not be effective until you receive and respond appropriately to a test email message from your doctor. Please select the test question you want to use below, and provide us with your answer.

Please provide the following information:
Patient Name: ________________________ Date of Birth: _________
Phone number: _______________________
Address: _______________________________________________
Please specify the email address to which communications should be addressed:
Please specify the health care provider or office from which you are requesting email communications:
Please select the question you want to use (by checking the one of the boxes below) for your test email and provide your answer.
o The last four digits of my Social Security Number: _______________
o My mother’s maiden name: _______________
o My middle name: _______________
o The street number of my residence: _______________
Please initial each blank and sign below:
____ I certify the email address provided on this Request is accurate, and that I, or my designee on my behalf, accept full responsibility for messages sent to or from this address.
____ I have received a copy of the IMPORTANT INFORMATION ABOUT PROVIDER/PATIENT EMAIL form, and I have read and understand it.
____ I understand and acknowledge that communications over the Internet and/or using the email system are not encrypted and are inherently insecure; that there is no assurance of confidentiality of information when communicated this way.
____ I understand that all email communications in which I engage may be forwarded to other providers, including providers not associated with my doctor, for purposes of providing treatment to
____ I agree to hold my doctor and individuals associated with him/her harmless from any and
all claims and liabilities arising from or related to this Request to communicate via email.
Signature of patient or personal representative
If personal representative, authority to act on behalf of patient

Thursday, August 9, 2007

Patient-Physician Email

New post on Tech Medicine about patient-physician email.

Medical Boards Interactive: "Your Patient Has Died."

I spoke with someone who recently took the medical boards (USMLE Step III, to be exact). There's a section which is interactive -- that is, it give you an actual case, sort of like an old style Infocom adventure game, and you must type in your responses. For example, when I took it a few years back, one of the questions went like this:
Your patient arrives in the emergency department after being beaten with a baseball bat.

> Examine abdomen

He has left upper quadrant tenderness and is complaining of abdominal pain.

> CT scan of abdomen

The CT scan reveals a splenic hematoma

> Call surgery consult
You get the idea. It was actually fun.

Well, the person I spoke to, who recently took this exam, was shaken and lost his confidence. During the interactive part of the exam, he may (or may not) have done something incorrect, because the case abruptly ended with "Your patient develops ventricular fibrillation and dies."

Personally, I think sometimes the people who write exams indulge their twisted sense of humor.

Can anyone verify this?

Saturday, July 28, 2007

More Medical Uses of the iPhone: Patient Education Videos from YouTube and Google Video

On Tech Medicine, I've posted a discussion on using the iPhone to display patient education videos from YouTube, Google Videos, and other online video sites.

I've been experimenting with this, and so far it's been very successful.

In future posts, I'll be writing more about switching from the Treo to the iPhone, implementing the Getting Things Done (GTD) system on the iPhone, and using the iPhone to make medical practice easier. 

Tuesday, June 26, 2007

Review of the HydraCoach, an Intelligent Water Bottle

This is a brief review of the HydraCoach, an intelligent water bottle that measures how much you drink.

In my last post, I described the HydraCoach, which is marketed primarily to athletes and those concerned about maintain optimal hydration....

Full review on Tech Medicine.

Monday, June 25, 2007

Mac and PC Ads

I recently switched.

Thanks, Ves.

Better World Books in New York Times

(picture from NYT)

Founded by my cousin.

Crooked Little Vein by Warren Ellis

Warren Ellis' first novel, Crooked Little Vein, is currently #252 in book sales on Amazon even though it won't be released for a month. Ellis' website is a big influence on Kidney Notes. I like his work. Buy the book.

Request for Favorite Webcams

I use the ManyCams viewer for the Mac dashboard, and I've been less than completely satisfied with the webcams I've found. I have webcams for New York City, Niagra Falls, and the pyramids. (See here for examples.) If you have any favorite webcams of locations, please comment. Thanks. 

Medicine 2.0

This week's edition is on ScienceRoll.

Mac Blogger Widgets (for the Dashboard)

Give them a try if you have a Mac and post to Blogger. Especially useful if you have multiple blogs.

New Title Font

Always experimenting. Comments welcome.

Saturday, June 23, 2007

Updated GTD Mindmap, now with Printable PDF File

See here.

Flickr: the princess and the red frog

the princess and the red frog, originally uploaded by Karl's.

Links for 2007-06-23

Thursday, June 21, 2007

Links for 2007-06-21: The Onion on the iPhone

Ground Zero at Night via Dashboard Webcam

Nature Precedings: Prepublication Creative Commons Licensed Scientific Content

From the website:
Nature Precedings is a place for researchers to share pre-publication research, unpublished manuscripts, presentations, posters, white papers, technical papers, supplementary findings, and other scientific documents. Submissions are screened by our professional curation team for relevance and quality, but are not subjected to peer review. We welcome high-quality contributions from biology, medicine (except clinical trials), chemistry and the earth sciences.

Wednesday, June 20, 2007

Yahoo! Green Taxi

You have new Picture Mail!, originally uploaded by KidneyNotes.

Updated Mindmap / Flowchart of Getting Things Done (GTD) by David Allen

Posted to The Efficient MD.

Tuesday, June 19, 2007

Stop Going to Conferences for the Lectures. Listen to Podcasts Instead.

Posted to The Efficient MD.

World Trade Center -- "Sarcoid Like" Granulomatous Pulmonary Disease in New York City Fire Department Rescue Workers

From the journal Chest.

Will Google Buy Apple?

Yes, argues this month's New Yorker Magazine.

Dr. Roni Zeiger Posts about Google Health

From the Official Google Blog:
Before joining Google, I was a full-time primary care doctor. My time working with patients every day, hearing their stories and trying to help make them better, is an experience I will cherish forever. And about once a week, I still practice as an urgent care doctor at a county hospital. Based on these experiences, I have witnessed the problems patients face. One of the biggest ones I see is the difficulty patients have getting answers to the most basic questions, such as 'What tests and treatments should I know about if I have type 2 diabetes? Is the care I am getting on par with what most experts recommend?'

Monday, June 18, 2007

FBI to Battle Botnet Zombie Horde

Every PC is a botnet zombie until proven otherwise.

We should just start calling them BZ's.

(Can you tell I just switched to the Mac?)

Walk-In Medical Care at Your Local Drugstore! (Duane Reade)

My spouse was walking down the street and saw someone outside Duane Reade (a large drugstore chain) dressed in full surgical gear -- scrub top, scrub cap, and sneakers -- passing out pamphlets and announcing "Walk-In Medical Care! Walk-In Medical Care!" There was no difference between the way they announced this and the way you would announce, say, a show at a comedy club or a sale on cellphones.

More info here.

Sunday, June 17, 2007

Links for 2007-06-17

Saturday, June 16, 2007

Epocrates Viagra Screwup

Epocrates, a drug database for the Palm, is totally screwed up today.

For example, the dosage listed for Viagra is "0.5-1.0 mg IV q 3-5 min prn" -- in other words, the program is telling me to give Viagra 0.5 to 1 mg intravenously every 3 - 5 minutes as needed...

Addendum: This corruption of the Epocrates drug database, besides being humorous, has serious patient safety implications. To their credit, Epocrates noticed this post and quickly replied:
Dear Dr. Schwimmer,

It has come to our attention that an entry was recently posted to regarding our product. Specifically, the post [available at: ] reads as follows.

Epocrates Viagra Screwup
Epocrates, a drug database for the Palm, is totally screwed up today.
For example, the dosage listed for Viagra is "0.5-1.0 mg IV q 3-5 min prn" -- in other words, the program is telling me to give Viagra 0.5 to 1 mg intravenously every 3 - 5 minutes as needed...

We are concerned that you may have corrupted data, as our Viagra monograph has never contained such information. The dosing content contained in the Epocrates Rx Viagra monograph reads as follows, and has not substantially changed since its original publication.

erectile dysfunction
[50 mg PO x1]
Start: 25 mg PO x1 if >65 yo, potent CYP 3A4 inhibitor use; Max: 100 mg/dose, 1 dose/day; see Drug Interactions for drug-specific limits; Info: take 0.5-4h prior to intercourse
renal dosing
[adjust dose amount]
CrCl <30: start 25 mg PO x1; HD: not defined

hepatic dosing
[adjust dose amount]
hepatic impairment/cirrhosis: start 25 mg x1

The data that is displaying on your device sounds to be from an Epocrates Table for ACLS: Bradycardia, which is why we believe that your version if corrupted. Please contact me at your earliest convenience so that we may assist you in reinstalling your software to clear out this corrupted data.

Joshua Conrad, PharmD
Epocrates, Inc.

Tech Medicine: HydraCoach, an Intelligent Water Bottle

New Tech Medicine Post on HydraCoach, an intelligent water bottle. 

Dialysis as "Spinning"

My doctor-friends down South refer to dialysis as "Spinning." It's very natural to them. To me and to others up North, it still sounds bizarre.

Cluster of Hepatitis C Infections among Three Patients Seen by Same Anesthesiologist in New York

I've had at least two patients so far who've received a warning letter. Potentially thousands may need to be tested.
Please Distribute to All Clinical Staff in Anesthesia, Emergency Medicine, Primary Care, Infectious Diseases, Family Medicine, Laboratory Medicine, Gastroenterology, Surgery and Infection Control Staff

* DOHMH is investigating a cluster of hepatitis C infections in patients who had outpatient intravenous anesthesia from a particular anesthesiologist.
* DOHMH is notifying patients who received intravenous anesthesia from this provider that they should be tested for hepatitis B and C and HIV.
* Providers should use single dose vials for anesthesia when available. When multi-dose vials are necessary, extreme caution should be used to ensure that a new, sterile syringe and needle are used each time medications are drawn up.

June 15, 2007

Dear Colleagues,

The New York City Department of Health and Mental Hygiene (DOHMH) is investigating a cluster of three hepatitis C infections in patients who received intravenous anesthesia from a particular anesthesiologist during outpatient procedures performed in August 2006 in New York City. Initial laboratory testing of the hepatitis C viruses from these patients revealed that they closely match each other, suggesting that all three came from the same source.

Although the investigation is ongoing, the available evidence suggests that the infections occurred during the administration of anesthesia medications during outpatient medical procedures. There is no indication that the medical procedures themselves caused the infections. The anesthesiologist worked at approximately 10 different outpatient (non-hospital) practices, all of which are fully cooperating with the DOHMH. This anesthesiologist has stopped working during the investigation.

The DOHMH has not yet determined whether there were any other times when hepatitis transmission occurred during administration of anesthesia by this physician. Therefore, we are notifying all patients who received intravenous anesthesia from this anesthesiologist between December 1, 2003 and May 1, 2007 (the timeframe when the anesthesiologist practiced in New York City), and recommending that they be tested for hepatitis B and C, and HIV. We are recommending HIV testing as a precaution, since it is also transmitted by bloodborne exposure. However, spread of HIV through anesthesia is not common, and no HIV infections have been linked to this incident.

All patients who received anesthesia from this provider are being notified by mail by the DOHMH; the mailing includes a letter to bring to their provider. Patients who do not receive this letter do not need testing for this indication. Patients known to have been previously infected with either hepatitis B, hepatitis C, or HIV prior to receiving anesthesia from this physician, do not need testing for that specific virus; testing for the other viruses should still be done.

We are recommending the following tests for these patients:
For hepatitis B: Hepatitis B surface antigen (HbsAg), Hepatitis B surface antibody (HbsAb), and Hepatitis B core antibody Total (HbcAb).

For hepatitis C: Hepatitis C enzyme-linked immunosorbent assay (EIA) and if positive, a confirmatory test, such as HCV recombinant immunoblot assay (RIBA) or a polymerase chain reaction (PCR) should be done.

HIV: HIV EIA and if positive, a confirmatory Western Blot should be done.

Hepatitis B and C are reportable pursuant to the New York City Health Code §11.03 and New York State Sanitary Code §2.1. Because this is an ongoing investigation, we are requesting immediate reporting of results to the DOHMH so that we can determine if there were other instances where bloodborne disease transmission occurred during the administration of anesthesia by this anesthesiologist. Please report as follows:

Hepatitis B or C: Results should be reported to the Bureau of Communicable Diseases at 212-788-9830 (telephone) during normal business hours. When reporting, please mention that your patient was tested as part of this anesthesiology outbreak investigation. You can also fax the results to the attention of Dr. Bruce Gutelius at 212-788-4268.

HIV Infection: Positive tests for HIV infection or AIDS should be reported by completing a New York State Provider Report Form. For assistance in reporting a case of HIV, to receive Provider Report Forms, or to obtain more information, call the HIV Surveillance and Epidemiology Program at 212-442-3388 or refer to guidelines on the DOHMH website at:

This cluster appears to be related to a lapse in infection control technique during administration of intravenous anesthesia. This is similar to other outbreaks seen in NYC and elsewhere (Transmission of hepatitis B and C virus in outpatient settings. MMWR 2003;52(38):901-6). As a reminder, single-dose medication vials should always be used when possible to prevent such clusters. If no single dose preparation is available, all necessary medication should be drawn up in advance and labeled. Needles AND syringes should NEVER be reintroduced into a medication vial, even if they have only been in contact with the IV tubing (e.g., angiocatheter or heparin lock) in the patient. If you have any questions about this investigation or how to report, please call the Bureau of Communicable Disease during office hours at 212-788-9830. Thank you.


Marcelle Layton, MD,
Assistant Commissioner,
Bureau of Communicable Disease