Monday, April 30, 2007

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

Sunday, April 29, 2007

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

Saturday, April 28, 2007

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

Friday, April 27, 2007

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.

Thursday, April 26, 2007

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

Tuesday, April 24, 2007

Flickr: Mantis

Mantis, originally uploaded by Lawraa.

Links for 2007-04-23

Monday, April 23, 2007

"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 InitiativeTM (KDOQITM) 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 KDOQITM.

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

Sunday, April 22, 2007

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

Saturday, April 21, 2007

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.

Thursday, April 19, 2007

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

Wednesday, April 18, 2007

Links for 2007-04-18

Tuesday, April 17, 2007

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

Monday, April 16, 2007

Link for 2007-04-16

Saturday, April 14, 2007

Flickr: A Bright Moon

A Bright Moon, originally uploaded by erion904.

Links for 2007-04-14

Saturday, April 7, 2007

Links for 2007-04-07

Wednesday, April 4, 2007

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

Tuesday, April 3, 2007

Links for 2007-04-03

I'm writing "Tech Medicine" on

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