Links for 2007-04-30: Searching for Health Information Online, Ceiling Height and Performance, New Apple Store

• Tech Medicine: Searching for Health Information Online (Part 3)
  In this part, I'll compare three other methods of searching for health information: UpToDate (a "top-down" approach), Google Search (a "bottom-up" approach), and Google Co-op (a "hybrid" approach).
• Hilarious Journal Articles #81: The Effect of Ceiling Height on How People Think, Feel, and Act
  Meyers-Levy and co-author Rui (Juliet) Zhu found that, depending on the situation, ceiling height will benefit or impair consumer responses.
• Apple Store to Take Up Full NY Block
  The NY Post just announced that they are installing a new store at 9th Avenue and 14th Street, way out in the Meatpacking District.

Links for 2007-04-29: Mac Menubar, Twitter on NPR

• What's in my menubar? | 43 Folders
  Seems like every time another Mac user looks over my shoulder, they freak out over the number of little icons I have up in my menubar.
• On Point : The World According to Twitter - NPR
  Non-stop, instant communication from anywhere, all the time. Hyper-connectivity, always present, in a non-stop global mind-share of twittering micro-thoughts.

Links for 2007-04-28: Emergency Medicine Bloggers, Xgrid, Pre-Rounds, Lifehacks, Authors@Google, Cardiac MRI

• Annals of Emergency Medicine - Emergency Medicine Bloggers
  "The medical blogosphere reminds me of a cocktail party, or maybe an old-time physician's lounge, although I've never really seen one," he said. "It's invaluable to a resident like me, to listen in on EM attendings comparing patient stories..."
  
• Apple - Mac OS X Server - Xgrid
  Now any individual or workgroup can quickly build a low-cost supercomputer. Introducing Xgrid, the first distributed computing architecture to be built into a desktop or server operating system.
• Medscape Search -- Pre-Rounds Interviews with Medical Bloggers (Nicholas Genes)
  I've missed a few. Here they are, in chronological order.
• Quernstone.com NotCon'04 page
  Danny O'Brien's Life Hacks.
• YouTube - Broadcast Yourself. Authors@Google
  @Google events--such as the Authors@Google and Women@Google series--featuring everyone from newsmakers to bestselling authors.
• Apple - Science - Profiles - Virginia Commonwealth University - Cardiac MRI
  "We use WebPAX to unwind what can be a very twisted pretzel," says Grizzard. "It gives us the best shot at doing that — to mentally construct a three-dimensional anatomy from two-dimensional images."

Links for 2007-04-27: The Earthlike Planet, Survival of the Sickest, RIP EMR?

• Gliese 581 c - Wikipedia, the free encyclopedia
  Gliese 581 c (IPA: [ˈgliːˌzə]) is an extrasolar planet orbiting the red dwarf star Gliese 581. It appears to be in the habitable zone of space surrounding the star, where the surface temperatures of any planets present might maintain liquid water.
• Blogborygmi - Survival of the Sickest
  There was a Daily Show episode last month, where Jon Stewart interviewed Dr. Sharon Moalem about his new book, "Survival of the Sickest."; The topic of his book -- that many human diseases persist because they actually confer a survival advantage -- is a r
• RIP, electronic medical records? | InfoWorld | Column | 2007-04-26 | By David L. Margulius
  Fast-forward two years and several billion dollars.. A 22-year-old staffer blasts an e-mail to the entire company, claiming the project is being poorly executed and jeopardizing Kaiser's ability to provide quality health care.

Links for 2007-04-26: Feed Readers, Medical Pearls

• Clinical Cases and Images: Best Web Feeds Reader for Medical and General Information
• Medical Pearls
  Medical Pearls are a collection of free, email-based educational services for medical trainees (including medical students, medical residents and clinical fellows).

Flickr: Mantis

Mantis, originally uploaded by Lawraa.

Links for 2007-04-23

• davidrothman.net » List of Medical Wikis
• A Cost Analysis of Windows Vista Content Protection
  Windows Vista includes an extensive reworking of core OS elements in order to provide content protection for so-called "premium content", typically HD data from Blu-Ray and HD-DVD sources. Providing this protection incurs considerable costs...
• Reuters/Second Life » Second Life Sketches (Warren Ellis): From Hell's Kitchen to Dune
  I lurched up the steps from the subway on to the main junction at Hell's Kitchen into complete chaos.
• Shiira Project
  A new web browser for the Mac.
• Health Blog : Sleep on the Cheap
  FDA just said there are 13 companies approved to make and sell generic Ambien.
• 24 Hours of Flickr
  To celebrate this global community, we invite you to join us in "24 Hours of Flickr" – a day-long global photo project. On May 5, 2007, grab your camera and whatever else you need, and chronicle your day in pictures.
• FDA Approves First Generic Versions of Ambien (Zolpidem Tartrate) for the Treatment of Insomnia
• Could less rigid privacy laws have prevented the Virginia tragedy?-Business-Law-Columnists-TimesOnline
  Under HIPAA, it would have been unlawful for the psychiatric hospital that treated student Cho Seung-Hui, who shot 32 people at Virginia Tech university this week, to compare notes on his therapeutic progress, or lack thereof, with his counselors or dean.

"National Kidney Foundation Releases Preliminary Anemia Guideline Update"

New Evidence Spurs Re-examination of 2006 Recommendations

Orlando, Florida
April 12, 2007

After reviewing new information about anemia management in chronic kidney disease (CKD), a National Kidney Foundation Kidney Disease Outcomes Quality Initiative^TM (KDOQI^TM) work group is today issuing a draft update to its 2006 Clinical Practice Guidelines on Anemia and CKD. The draft is being sent to over 1000 stakeholders for review and comment, prior to being finalized and published.

A key aspect of the new update is that the work group was able to clarify key aspects of a Hemoglobin (Hb) target for patients receiving Erythropoiesis Stimulating Agent (ESA) therapy . In the new statements, the work group recommends what factors should be considered in selecting a Hb target and states that the selected Hb target should generally be in the range 11.0 to 12.0 g/dL. They point out that because of natural fluctuations, actual Hb results will vary widely from Hb targets.

Also, after reviewing the latest results from six new randomized controlled trials about anemia management in chronic kidney disease (which doubled the number of CKD patients studied), the work group was able to upgrade one of its opinion-based statement to an evidence-based guideline recommending that, in dialysis and non-dialysis CKD patients receiving Erythropoiesis Stimulating Agent (ESA) therapy, the Hb target should not be above 13.0 g/dL.

"We want all clinicians who treat patients with chronic kidney disease to have guidelines based on the most up-to-date and reliable science available," says Mike Rocco, MD, Vice-chair of KDOQI^TM.

The work group -- made up of 16 volunteer experts in nephrology, hematology, epidemiology, nutrition, pharmacology, nursing, internal medicine and pediatrics -- previously worked for two-years analyzing peer-reviewed data on diagnosis and treatment of anemia at all stages of CKD. Their initial Guideline was published last May. The work group reunited on February 4, 2007, to update their initial recommendations taking into account the latest evidence and the studies included in the first Guidelines.

Anemia in end-stage renal disease (ESRD) is associated with increased mortality and hospitalization, decreased mental acuity, cardiac enlargement, heart failure, reduced health-related quality of life and impaired rehabilitation. "The work group clearly felt that the evidence is even stronger now that their initial recommendation to choose Hb targets below 13.0 g/dl is very appropriate for CKD patients," says Dr. Michael Rocco.

The recommendation to keep Hb targets below 13.0 g/dL is based on a review of all-cause mortality and adverse cardiovascular events in clinical trials where patients were assigned to Hb targets exceeding 13.0 g/dL. Evidence showing a trend toward greater number and severity of cardiovascular events in dialysis and non-dialysis patients assigned to Hb targets above13.0 g/dL was rated to be of moderately high quality for showing harm, and of high quality for showing lack of benefit.

"The statement about Hb targets above the 13.0 g/dL threshold reflects our judgment that greater weight should be given to potential harm than to uncertain benefit," says Dr. David Van Wyck, Co-Chair of the Work Group, who will present the update at the NKF's Spring Clinical Meetings. However, he pointed out that the work group agreed that further research is needed and should be encouraged.

The US Food and Drug Administration (FDA) has placed an upper limit for target Hb at 12.0 g/dL. Recently, the agency issued a black boxed warning for ESAs in light of new data that suggested non-dialysis CKD patients who were taking ESAs at doses designed to raise Hb to above 13 g/dL had a higher risk of death, blood clots, strokes, and heart attacks.

"Following the Script: How Drug Reps Make Friends and Influence Doctors"

From the Public Library of Science (PLoS). The full text of the article is available under a creative commons license.

It's my job to figure out what a physician's price is. For some it's dinner at the finest restaurants, for others it's enough convincing data to let them prescribe confidently and for others it's my attention and friendship...but at the most basic level, everything is for sale and everything is an exchange.

—Shahram Ahari

You are absolutely buying love.

—James Reidy [ 1]

In 2000, pharmaceutical companies spent more than 15.7 billion dollars on promoting prescription drugs in the United States [ 2]. More than 4.8 billion dollars was spent on detailing, the one-on-one promotion of drugs to doctors by pharmaceutical sales representatives, commonly called drug reps. The average sales force expenditure for pharmaceutical companies is $875 million annually [3].

Unlike the door-to-door vendors of cosmetics and vacuum cleaners, drug reps do not sell their product directly to buyers. Consumers pay for prescription drugs, but physicians control access. Drug reps increase drug sales by influencing physicians, and they do so with finely titrated doses of friendship. This article, which grew out of conversations between a former drug rep (SA) and a physician who researches pharmaceutical marketing (AFB), reveals the strategies used by reps to manipulate physician prescribing.

Better Than You Know Yourself

During training, I was told, when you're out to dinner with a doctor, "The physician is eating with a friend. You are eating with a client."

—Shahram Ahari

Reps may be genuinely friendly, but they are not genuine friends. Drug reps are selected for their presentability and outgoing natures, and are trained to be observant, personable, and helpful. They are also trained to assess physicians' personalities, practice styles, and preferences, and to relay this information back to the company. Personal information may be more important than prescribing preferences. Reps ask for and remember details about a physician's family life, professional interests, and recreational pursuits. A photo on a desk presents an opportunity to inquire about family members and memorize whatever tidbits are offered (including names, birthdays, and interests); these are usually typed into a database after the encounter. Reps scour a doctor's office for objects—a tennis racquet, Russian novels, seventies rock music, fashion magazines, travel mementos, or cultural or religious symbols—that can be used to establish a personal connection with the doctor.

Good details are dynamic; the best reps tailor their messages constantly according to their client's reaction. A friendly physician makes the rep's job easy, because the rep can use the "friendship" to request favors, in the form of prescriptions. Physicians who view the relationship as a straightforward goods-for-prescriptions exchange are dealt with in a businesslike manner. Skeptical doctors who favor evidence over charm are approached respectfully, supplied with reprints from the medical literature, and wooed as teachers. Physicians who refuse to see reps are detailed by proxy; their staff is dined and flattered in hopes that they will act as emissaries for a rep's messages. (See Table 1 for specific tactics used to manipulate physicians...)

Links for 2007-04-23

• Trimming the attention sails at Like It Matters
  You are what you pay attention to.
• MacBreak: Minimize distractions on your Mac | 43 Folders
• Corzine, Still at Risk, Is Breathing on His Own - New York Times
  Gov. Jon S. Corzine was breathing on his own for the first time in a week on Friday after doctors removed a mechanical ventilator that had been helping him breathe since he was critically injured in a car accident.
• JAMA -- Abstract: Dialysis Facility Ownership and Epoetin Dosing in Patients Receiving Hemodialysis, April 18, 2007, Thamer et al. 297 (15): 1667
  Dialysis facility organizational status and ownership are associated with variation in epoetin dosing in the United States. Different epoetin dosing patterns suggest that large for-profit chain facilities used larger dose adjustments and targeted higher h
• Health Blog : Anemia Drugs: How Much Is Too Much?
• Cornell University: Computer Workstation Ergonomics Guidelines
  Creating a good ergonomic working arrangement is important to protecting your health. The following 10 steps are a brief summary of those things that most Ergonomists agree are important.
• Outsourcing Breast Milk | TIME
  Wet-nursing (hiring a woman to breast-feed your baby), which most of the Western world abandoned in the 19th century, is making a minor comeback among young moms.

Interview with CEO of Fresenius at WSJ

"Ben Lipps, the CEO of Fresenius Medical Care, came by to speak with us this week. The German company runs dialysis centers around the world, so we were eager to ask Lipps about the ongoing controversy over the use of anemia drugs (such as Amgen’s Epogen) at U.S. dialysis centers."

The original post is at the Wall Street Journal Health Blog.

Links for 2007-04-22

• April 18, 2007: Science Talk Atul Gawande, Author of Better: A Surgeon's Notes on Performance
  In this episode, surgeon, writer and MacArthur grantee Atul Gawandee talks about his new book Better, which focuses on performance as a science.
• Modern Medicine
  ModernMedicine is an innovative online clinical decision-support resource that provides healthcare professionals with instant answers to clinical and practice management questions from highly credible and trusted sources.
• "Missed Signals" - New York Times
  If the potassium was high because of his kidney failure, what had caused his kidneys to fail?
  

Links for 2007-04-21

• Who is Sick? -- epidemiology with Google Maps
  "Post your sickness to a map... Search and filter for sickness by location, symptoms..."
• Open Medicine Blog
  Medical librarians work to provide access to this vital lifeblood of information, and we teach health professionals how to locate reliable scientific evidence. But we clearly need to do more.
• Presentation: How Web 2.0 is Changing Medicine
  Dean Giustini's slides from his presentation last week at the 2007 Emerging Trends in Scholarly Publishing seminar, National Press Club, Washington, D.C.
• intueri: to contemplate
  "He's a 34 year old guy who jumped off of a high bridge, sustained a pelvic fracture, shattered his left femur, cracked a few of his left ribs, and fractured his left ulna. Can you see him for this suicide attempt?" the orthopedic surgeon asks.
• SlideShare
  "A place to share and discover presentations and slideshows."
• Apple plugs 25 security holes | The Register
  Apple today fixed 25 vulnerabilities in the Mac OS X 10.4.9 operating system, courtesy of a 16MB patch for download.
  

"How Web 2.0 is Changing Medicine" by Dean Guistini

Hilarious Journal Articles #80: Niacin Intoxication from Pumpernickel Bagels

From the Morbidity and Mortality Weekly Report:

On April 27, 1983, 14 (20%) of 69 persons attending a brunch had acute onset of rash, pruritis, and sensation of warmth. The illness was of relatively short duration, with an incubation period of approximately 30 minutes after consumption of one or more pumpernickel bagels served at the brunch. Of 25 persons who ate the bagels, 14 (56%) became ill, whereas none of the 44 persons who did not eat pumpernickel bagels became ill. The bagels had been produced at a local bagel factory from a batch of dough originally prepared on April 23.

A review of reports from the hospital emergency room serving the area revealed that an emergency-room visit was made by one person with similar symptoms on April 24 and by two other persons on April 27. All three had eaten pumpernickel bagels made from the same batch of dough.

Because the pumpernickel bagels were very light in color, the ingredients were suspected. Investigation revealed that, in an attempt to enrich the pumpernickel flour, a large quantity of niacin had been added, apparently from an improperly labeled container. Laboratory studies revealed 60 times the normal level of niacin in the pumpernickel flour. On the basis of these data, each bagel contained approximately 190 mg of niacin; the recommended dietary allowance for niacin is 6.6 mg/1000 calories or about 13 mg/day for the average adult. Measures have been taken to assure proper labeling of all ingredient containers in the bagel factory.

Hilarious Journal Articles #79: Use of Niacin in Attempts to Defeat Urine Drug Testing

From the Morbidity and Morality Weekly Report:

In addition to its use as a nutritional supplement, niacin (nicotinic acid or vitamin B3) is medically prescribed to treat hyperlipidemia and hypercholesterolemia. Use of niacin in low doses usually leads to few adverse drug reactions (ADRs); however, at larger doses, niacin can cause skin flushing, itching, and occasionally more serious effects (1). The 2005 annual report of the American Association of Poison Control Centers documented 3,109 reports of exposures to niacin (2). During 2006, the Rocky Mountain Poison and Drug Center (RMPDC) in Denver, Colorado, received multiple calls regarding ADRs after nonmedical use of niacin. A review of call records indicated various uses of niacin, including attempts to alter or mask results of urine drug tests, although no scientific evidence exists that ingestion of niacin can alter a drug test result. To determine the extent of niacin use in attempts to alter drug test results, reports to RMPDC of niacin ADRs were reviewed for the period January--September 2006. The results identified 18 persons who reported nonsuicidal, intentional, nonmedical reasons for using niacin, including eight who specified altering drug test results as their reason for using niacin. Ten other persons, among an additional 18 who offered no reason for niacin use, were categorized as possible users of niacin to try to alter drug test results because of their ages or the amount of niacin ingested. Clinicians, especially those whose patients include teens and young adults, should be aware of the potential use of niacin in attempts to defeat urine drug tests.

RMPDC serves Colorado, Hawaii, Idaho, Montana, and southern Nevada, a total population of approximately 10 million. RMPDC staff members searched their database for telephone calls reporting niacin exposures during January--September 2006. Calls regarding niacin exposures were divided into six categories: 1) unintentional dosing errors in therapeutic users, 2) ADRs after therapeutic use, 3) pediatric unintentional exposures, 4) suicide attempts, 5) ADRs with no reason given for niacin use, and 6) ADRs after nonsuicidal, intentional, nonmedical use. Data collected included the person's age, sex, circumstances of exposure, symptoms, and outcome. Persons who gave no reason for niacin use but were aged <30 years or who reported taking at least 1,000 mg or "large amounts" of niacin in one ingestion were cateogorized as possible users of niacin to defeat urine drug testing. The study was approved by RMPDC's institutional review board and granted a waiver of consent.

A total of 92 calls (72 from persons at home and 20 from health-care providers) reported exposures to niacin. Thirty calls (33%) reported dosing errors or ADRs after therapeutic use, 23 (25%) referred to unintentional pediatric exposures, and 18 (20%) reported ADRs after nonsuicidal, intentional, nonmedical use. An additional 18 calls (20%) reported niacin ADRs with no reason stated for the exposure. Three calls (3%) described attempted suicides.

Among the 18 persons who said their ADRs resulted from nonsuicidal, intentional, nonmedical use of niacin, the median age, excluding three adults of unknown ages, was 18 years (range: 15--50 years). Eight of the 18 persons said they took niacin (1,000 mg--8,000 mg) to alter or mask a drug screening; eight others said they took niacin (400 mg--5,000 mg) to "purify, cleanse, or flush" their bodies; and two said they used niacin as a diet pill. Among the 18 persons who gave no reason for niacin use, eight were aged <30 years, and two patients of unknown age reported taking a 2,000-mg dose and "large amounts" of niacin, respectively; under the case definition, those 10 persons were categorized as possible users of niacin to defeat urine drug testing.

Calls regarding the 18 persons who either said their ADRs resulted from attempts to alter drug test results or who were categorized as possible users of niacin for that purpose came from all five states covered by RMPDC. Twelve calls came from Colorado, two from Idaho, and one each from Hawaii, Montana, and southern Nevada; one call came from California via a manufacturer's hotline telephone number. Among the 28 who either gave a nonmedical reason for niacin use (18 persons) or who stated no reason but were categorized as possible users of niacin to alter drug test results (10 persons), the most common ADRs reported were tachycardia, flushed skin, rash, nausea, and vomiting. Thirteen of the 28 were treated at or referred to a health-care facility. No deaths were reported.

Links for 2007-04-19

• NEJM -- Case 12-2007 -- A 56-Year-Old Woman with Renal Failure after Heart-Lung Transplantation (free full text)
  A 56-year-old woman with a history of primary pulmonary hypertension and heart and lung transplantation was admitted to the hospital because of renal failure.
• Amnesty™ Generator for OS X
  Easily convert millions of web widgets, games and videos – designed to live on home pages, blogs or MySpace – into widgets for your Dashboard.

Links for 2007-04-18

• hospital impact - Consumer's Guide to the top Healthcare 2.0 websites
• 25 books for under $5 on iTunes
  
• Apple Matters | April 17, 1977: Apple II Introduced
  A modest success at first, demand skyrocketed when VisiCalc and a disk drive showed up.
• Google's medical push | Digital Markets | ZDNet.com
  Since December, Bosworth, Vice President, Engineering, has been making a Google case for empowering consumers via health information technology.
• Official Google Blog: How do you know you're getting the best care possible?
• Tech Medicine: Searching for Health Information Online (Part 1)
  Recently, a patient remarked that &quot;On the Internet, you're always a few clicks away from certain death.&quot; He had searched online for his diagnosis and found a wealth of information, but he quickly realized that much of it was irrelevant, unduly alarming, or just plain wrong.
  

I was quoted in the Google Annual Report.

Unexpectedly, I was quoted on page 3 of this year's Google Annual Report. That was nice of them.

(The original interview about searching the medical literature was posted on Dean Guistini's Google Scholar Blog.)

-- Joshua Schwimmer, MD, FACP, FASN

Link for 2007-04-16

• Online social networking brings further change to doctor-patient relationships
  A new generation of healthcare Web sites is connecting patients to each other, allowing them to share information and advice on virtually any medical condition. (Organizedwisdom.com is used as an example of this type of site.)
  

Flickr: A Bright Moon

A Bright Moon, originally uploaded by erion904.

Links for 2007-04-14

• Amazon.com: Panasonic DMC-FX07R 7.2MP Digital Camera with 3.6x Optical Image Stabilized Zoom
• Open Culture: The Top 25 Educational Podcasts on iTunes
  

Links for 2007-04-12

• Tech Medicine: The Use and Misuse of Automatic Blood Pressure Monitors
• Tech Medicine: Creating DNA Art
• Tech Medicine: Notes on the Technology Entertainment Design (TED) Conference
• Tech Medicine: An Introduction to Medical Podcasts (Part 1)
• Tech Medicine: The Value of Mind Mapping
• Tech Medicine: An Introduction to Medical Podcasts (Part 2)

Links for 2007-04-10

• iGTD
• Herbal supplement may help treat recurrent bladder infections - USATODAY.com
• Clinical Cases and Images: Free Tools for Bloggers

Links for 2007-04-08

• NEJM -- Does Preventive Percutaneous Coronary Intervention (PCI) Work?
• Is it dangerous to inhale your father's cremated remains? - By Torie Bosch - Slate Magazine
  But if [Keith Richards] did snort his dad, would that have been unhealthy?
• I love my new Mac (list of cool utilities) - Scobleizer
• Basic Mac OS X Security | Mac Geekery
• JungleDisk - Reliable online storage powered by Amazon S3™
• Thousand-yard stare - Wikipedia, the free encyclopedia

Links for 2007-04-07

• Neurological Correlates of High-Risk Behavior: Alphonse Capone Case Study
• WSJ Health Blog: The Courage to Let Clogged Arteries Be
  "People like the idea of an open artery," Szot said. "They come back from the cath lab and say, 'Thank you for saving my life.'"

Links for 2007-04-04

• We Feel Fine / mission
  Since August 2005, We Feel Fine has been harvesting human feelings from a large number of weblogs. Every few minutes, the system searches the world's newly posted blog entries for occurrences of the phrases "I feel" and "I am feeling". When it finds such

Links for 2007-04-03

• Stalking Strangers' DNA to Fill in the Family Tree - New York Times
• Getting started (or reacquainted) with Quicksilver | 43 Folders
  Quicksilver can be used to launch files and applications, manipulate data, and seamlessly plug into almost any application on your Mac so that you can perform actions as soon as you think of them in a few short keystrokes.

I'm writing "Tech Medicine" on Healthline.com

I'm now writing Tech Medicine, a blog about technology in medicine. It's hosted on Healthline.com, a search engine for medical information. The Tech Medicine feed is here. The latest post is "Creating DNA Art."

Links for 2007-04-1

• "How Doctors Think" reviewed by Michael Crichton
• The Gapminder World 2006, beta
  Visualizing countries of the world.
• DNA 11 - From Life Comes Art. DNA art, DNA portraits, personalized art, fingerprint art