Saturday, December 31, 2005

RangelMD writes about Eight Crazy Medical Facts. Number eight:
Healthy booger eaters - And finally in the most disgusting category is the speculation that mucophagy is good for you because it boosts the immune system by exposing it to bacteria found in nasal mucus. All I know is that mucophagy is very likely to be detrimental to your social life and your odds of getting lucky. Don't do it! At least not around me.

Friday, December 30, 2005

DrAndy:
Are long-acting beta agonists (LABAs) safe. I've argued in the past that they are, but now a perspective piece in the NEJM argues that they are not. (Inexplicably, it is not available as free fulltext. If you are going to publish editorials on controversial, life-threatening topics, I think you should make them available to people).

Fernando Martinez, a respected asthma researcher and participant in the FDA panel discussion about LABAs presents some new data and argues they should be used only as a last resort.
Dr. Gault wrote:
It has been the experience of pulmonary docs and allergists that for most patients the addition of a LABA to ICS is beneficial yet there may well be the possibility of a rare serious side effect.
Both doctors admit that there may be something to this issue, but, at the same time, indicate that patients and treating physicians have recognized clinical improvement in patients when ICS/LABA meds were added. Perhaps this will end up being like the Vioxx issue, where a few people are adversely affected by a drug while a great number are helped. How many people are worse off now that Vioxx has been removed from the market? How many people will see their asthma control suffer if Advair is removed from the market?
The American Academy of Emergency Medicine has added section to their website called Remarkable Testimony. Here is there summary:
The number of lawsuits filed against emergency physicians is growing. The burden of dealing with these legal actions goes beyond the financial challenges of increased malpractice premiums. Other effects include time lost from work or personal time and the effects on the physician's morale. Many physicians feel that an increasing number of these lawsuits have little or no legitimate basis. These frivolous suits sometimes represent attempts to get a quick settlement from insurance companies eager to hold down costs.

In order to file a malpractice claim, many states require plaintiffs to have an opinion from an expert that malpractice has occurred. A number of these so-called experts are physicians who seem willing to make any statement, no matter how outrageous, in support of a malpractice claim. These physicians can profit handsomely from their willingness give such testimony.

Alarmingly, a number of leaders in our specialty have chosen to supplement their income by giving "expert" testimony that is unfounded in current medical standards and practice.

AAEM has responded to suggestions by several members by creating this web site. It is designed to bring to light testimony by expert witnesses that is remarkable either because of its spurious nature or because it is particularly helpful to the emergency physician defendant. It is hoped that by publicizing such testimony, and the individuals who offer it, emergency physicians may find some measure of relief from the ongoing crisis.
Here is part of the first listed:
Bertha Walker presented to the emergency department at a hospital in Kansas. She was evaluated and admitted. She was ultimately diagnosed as having a stroke and died. Later, the doctors participating in her care were sued for failing to give thrombolytic agents.

...

Dr Tarlow describes tPA as "…that special magic bullet drug…"
Comment: This highly laudatory description of tPA exceeds even the most enthusiastic endorsements of those proponents of the use of tPA in acute stroke.
Hopefully, the scorn associated with publicity may limit some of this garbage that is fed to juries. Additionally, I would like judges to understand the position of the academies, through examples like these, and rule testimony as so far outside the mainstream that allowing the jury to hear it would be prejudicial.

Thursday, December 29, 2005

Somebody help me figure this out. I know that CMS has all these rules about what you have to document in order to get paid, right? So, in order to bill for a day in the hospital, you have to follow the rules, right?

How does an orthopedist get paid when an entire day's progress note is "Hgb 10.2" and signature. Are they paid by the case and not the day?
Don't measure glucose until you can see the whites of their eyes!
John Burd himself is quoted as saying: "People have been working on (non-invasive glucose testing) for decades and we think we've learned from their mistakes and we're coming up with a great product." Keep your eye on Oculir.
An excellent discussion of the use of lethal force by law enforcement by someone who's "been there, done that."
Baby Sitter Charged In Case Of Drunk 2-Year-Old
A 37-year-old man was charged with child endangerment after one of two toddlers he was baby-sitting was found drunk, authorities said.

Suffolk County sheriff's deputies investigating a family court case peered through the window of a Patchogue home Tuesday and saw Juan Reyes passed out with the children wandering around the house.

They managed to rouse Reyes, who was the only adult at home with the two toddlers, ages 2 and 3, according to the sheriff's office. The deputies said Reyes appeared extremely intoxicated.

The deputies also noticed the 2-year-old was having difficulty standing, had bloodshot eyes, smelled of alcohol and was lethargic.

The toddler was taken to the hospital, where tests revealed he was legally intoxicated, with a blood-alcohol content of 0.094 percent, the sheriff's office said. In New York, a driver is considered drunk with an alcohol content of 0.08 percent or greater.
Two things:

It's a good thing this kid couldn't find the keys to the car.

I hope the FDA approves Vivitrol for kids to prevent this kind of problem.
As we move more and more drugs OTC, China goes the other way.
PEOPLE trying to buy prescription drugs in the city will actually have to show their prescription or medical report to the pharmacists starting on Sunday, as the Shanghai Food and Drug Administration tries to strengthen oversight of medication sales.

China only began dividing medications into prescribed and over-the-counter drugs in 2000. Currently, people can buy almost any prescription drug simply by leaving their names and phone numbers with the pharmacist.

The new system is being set up as a one-year pilot program.

National authorities are calling on all local governments to tighten controls on prescribed drugs, but giving them room to create their own policies.

"Prescribed medicines account for 75 percent of all drugs sold in China, but they account for more than 97 percent of reported adverse reactions," said Lan Fen from the State Food and Drug Administration. "About 41.2 percent of bad reactions are caused by improper use of antibiotics."
Not to mention the impact of all those antibiotics on drug resistance.
Alcoholism Drug Still Awaits Final Approval
Vivitrol, known as Vivitrex while it was being tested, is an injectable, extended-release version of naltrexone, a now-generic pill that's prescribed to alcoholics to discourage them from resuming drinking. The once-a-month injection of Vivitrol will be marketed as a way to improve patient compliance over the once-a-day naltrexone pill.
I didn't know about this drug before I saw this article. I have never used naltrexone for alcoholics and the articles I have read since comment that most doctors either don't know about it or don't use it because of poor compliance. This monthly injection may change that. Especially if the courts order its use in connection with DUI, domestic violence, etc.


More
In the placebo group, the median number of heavy drinking days was reduced from 19 days per month in the month prior to the study (baseline) to six days per month over the six-months of placebo treatment. The placebo group received treatment consistent of placebo injection, monthly medical attention and counseling.

The Vivitrex treatment group showed a 48% further reduction in heavy drinking over the placebo group. Over the six-month treatment period, the median number of heavy drinking days was reduced from 19 days at baseline to three days per month in the Vivitex group compare to six days per month in the placebo group.

Wednesday, December 28, 2005

Amazon is amazing. I bought one of these today for a friend.

The hospital where I work was independent until it was bought out, recently, by a large corporation. The corp has described plans to enlarge the hospital with expanded ICU space, a heart surgery center and to close a nearby hospital owned by the same corp. They have already begun to shift some of the inpatient load. This is concerning to those of us who work in the ER, as we already have a significant problem with bed availability. Any ER docs out there without this complaint?

It is not unusual for us to have a patient remain in the ER several hours after admission, waiting for "the room to be cleaned." Aside from the passive tense of that comment, we have some concern that room assignments are shifted to keep the patient off the floor, at least until shift change.

That makes this article that much more concerning. Maybe we can use this data in discussions with nursing administration:
The potential for errors being made during long patient stays in emergency rooms is among the medical dangers that will be studied through grants awarded to 10 doctors by the malpractice insurer for Harvard-affiliated hospitals.

Emergency room ''boarding" -- when patients are examined, treated, and admitted to a hospital, but kept waiting for a room -- is fraught with risk, said Dr. Shan Liu, an emergency-room doctor at Massachusetts General Hospital and a student at the Harvard School of Public Health.
As bad as it seems for us, other professionals have malpractice problems as well.
In its most recent study of claims experience, from its more than 7,000 accounting professional clients in 44 states, the Redwood City, Calif.-based insurer has found tax work accounts for the most claims filed and the highest total dollar volume of damages sought. Camico is second, behind a program sponsored by the American Institute of CPAs (AICPA), among the profession’s most prominent professional liability insurance carriers.

Tax ranks highest among the service areas generating claims because it is among the services accounting professionals are most likely to offer and its technicalities can mean a minefield of risks. The technical nature of tax work “places most of the burden for decision-making on the CPA (s),” who at the same time “are limited in what they can ask clients,” says Ron Klein, Camico’s vice president of claims.

“It's much like a patient seeing a doctor about a serious, complex medical condition; the problem and treatment are so critical that the patient will ultimately go with the treatment the doctor recommends.” he adds.

Following tax on the list of leading areas for generating claims are, in respective order: financial statements, investment fraud and defalcation. Within tax work, technical income tax issues are the primary area of loss, followed by S and C corporation elections and estate planning.
Primer for politicians (page 1): Talk a lot about ethics. The suckers voters like to hear about ethics. If you go so far as to form a committee, be sure not to give it any real power, like subpoena or investigate powers. Better yet, make sure that the committee only meets when you ask for advice. That way, you don't ever have to convene the committee. If you actually name members, make sure they are all your cronies like-minded in their dedication to ethics.
Special ethics panel has never met

Three-year lull calls into question Bredesen's commitment, some say.

In the months after Gov. Phil Bredesen's inauguration, he talked big about ethics and about fairness, signing a series of executive orders that created a special ethics committee and a panel to ensure that state workers are promoted properly.

"One thing I want to do is return a higher degree of confidence to people in state government," Bredesen said at a February 2003 Cabinet meeting as he signed executive orders that would create what he called "the toughest ethics policy in the history of Tennessee."

But if the talk was big, the action was little, if any. The governor's special ethics committee, created in that Cabinet meeting, did not meet even once.

And the panel he created in October 2003 to ensure that the state promotions process was conducted fairly never met, either.

Now, after the Department of Safety's top leadership has been swept away in an ethics scandal over deep-seated cronyism in the Tennessee Highway Patrol, and with the governor's closest aide beset by his own ethics issues, some have started asking questions about why the governor has let these panels languish.

"I was bothered then," said printing company owner Gary Marlar of Nashville, who has begun following ethics issues since Bredesen took office. "Now, I feel I've been smacked in the face."

The reason that at least the governor's ethics committee never convened is "there have been no issues that have risen to the level that would require a recommendation from this body," Bredesen spokeswoman Lydia Lenker said. "Any issues that have come before the governor, he has dealt with quickly and with a firm hand."

The governor's critics say that the committee to examine hiring and promotions created by Bredesen in October 2003 might have uncovered cronyism in the Highway Patrol. A Tennessean investigation published last month showed that two-thirds of THP promotions under Bredesen's administration went to officers who gave money to his campaign, or had family members or political patrons who did.

More than half in that group were promoted even though they were competing against officers with higher promotion scores.

This panel "is advisory only," said Lenker, who confirmed that no one was ever appointed to the board. "It is not charged with any investigatory powers. As a part of our review of all boards and commissions, we have taken a look at this board to see if its functions are duplicative of other state boards, commissions and agencies. It is currently under review."

After Operation Tennessee Waltz, when federal agents arrested four sitting legislators in a bribery and extortion sting, Bredesen came alive on all things ethical. He began planning a special session on ethics. He put together a citizens panel that was to generate ideas on how to rein in a legislature perceived as greedy and out of control. The governor also put out his own ideas on what might be done.

The committee charged with overseeing fairness in hiring and promotion deals chiefly with fairness as it relates to race, gender and sexual orientation — and the Bredesen administration has never been accused of unfairness as it relates to those issues.

But some are seeing those efforts in a new light, with the realization that Bredesen's first big announcement on ethics just after he took office was followed by very little action. That has some legislators raising questions as they are about to embark on a special session on ethics that Bredesen himself called.

State Rep. Donna Rowland, R-Murfreesboro, said she was suspicious that Bredesen created the committees and never followed through. "I am not aware that those committees have even been established," Rowland said. "Why are they not being used for these investigations as step No. 1?"

And Rep. Glen Casada, R-College Park, said that it appeared there may be exceptions to the ethics rules for those closest to the governor.

"Like most Tennesseans, I thought you would treat your political appointees in the same manner as all state employees are treated," Casada said in a letter he wrote to Bredesen last week. "It now appears that friends of the Governor get special treatment."

Tuesday, December 27, 2005

THP urges safe driving during holidays

At other times, drive however you please.

Official notice from Visit Tennessee, Inc.
FDA OKs STAAR's optical implant
The Food and Drug Administration has approved a surgically implantable lens designed to treat nearsightedness, giving myopic adults another alternative to eyeglasses or Lasik surgery, STAAR Surgical Co. said Friday.

The news sent Monrovia-based STAAR's stock soaring. Shares were up $2.74 to close at $8.51 Friday on the Nasdaq Stock Market.

The Myopic VISIAN ICL is profitable on the international market, but the company loses money in the United States, said David Bailey, chief executive officer and president of STAAR Surgical. "This launch is the fastest route to profitability in the U.S.," he said.

The ICL is approved for sale in 41 countries. It has successfully been implanted in more than 40,000 eyes worldwide, the company said.

It will join on the market another implantable lens, the Artisan, made by the Dutch company Ophtec B.V. and approved by the FDA in 2004.

The lens is placed behind the iris and is invisible when in position, Bailey said. It's a permanent correction, but it can be removed if needed, he said.

The procedure appeals to those unsuitable for laser treatment, such as people with dry eyes or high levels of myopia, Bailey said.
FDA: Barley Products Can Claim Heart Benefits
Cereals, breads and other products containing whole or milled barley grain can now claim to reduce the risk of heart disease, U.S. health officials said Friday.

The U.S. Food and Drug Administration's ruling allows companies to immediately begin advertising the benefit on their product packages, which many food makers hope will help boost consumer sales. To qualify, barley-containing foods must provide at least 0.75 grams of soluble fiber per serving, the agency said.

Barley is a cereal grain grown mostly in the western United States, as well as in Australia, Canada and other countries, according to the National Barley Foods Council, which first petitioned the FDA for the decision in 2003. While much of the crop is used for animal feed and beer, people can cook pearl barley as a rice-like dish. Barley flour and grains are also used in baking and in cereal.

Like other grains, barley contains fiber that health experts say can help reduce the risk of coronary heart disease, which can restrict blood flow and lead to chest pain and heart attacks. About 13 million Americans are diagnosed with the condition, according to the American Heart Association.
An interview of AR by ST.

AR is a 14 year-old girl who was brought to the ER by EMS after the Sheriff's Drug Task Force raided a home with a meth lab. ST is a counselor with Child Protective Services.

ST: Do you know why you are here?

AR: My mother was arrested and the cops said I had to come here.

ST: Do you know why your mother was arrested?

AR: The cops say she was making meth.

ST: Was she?

AR: My mom said to keep my mouth shut.

ST: What we discuss today is going to be used to help you, not to hurt your mother. I need to know what chemicals you may have been around.

AR: I don't know what kind of stuff I been around. Lots of stuff.

ST: Do you feel safe at home?

AR: I guess I do. But I been worried about my Sissy and Bubba.

ST: How old are they?

AR: Sissy is 10 and Bubba is 3.

ST: What are you worried about?

AR: Well, them chemicals you talked about. And the people that come over.

ST: What about the people?

AR: They always have guns. My momma has a rule that you have to leave you guns and knives at the door. There's always a big pile on the floor at the front.

ST: Do you touch them?

AR: No. But Bubba got 'hold of one once. A gun, I mean. I don't know what kind. But Sissy and me had come out to clean and found him in the front hall waving a gun around. He wouldna shot it, I mean he don't know how. But we were afraid of an accident. Sissy and me was real scared until we got it from him.

ST: Why didn't you get your mother?

AR: She was asleep and we couldn't wake her up.

ST: How often did your mother have people over?

AR: Oh, there was people over all the time. But sometimes she would have these parties and lots of people would come over. The would use drugs and drink and have sex. Everybody would end up naked on the floor of the living room.

ST: And you and your brother and sister were part of this?

AR: No, ma'am. I mean, we would watch TV in momma's room. When everything would get quiet, me and Sissy would come out and pick up all the needles so as Bubba wouldn't get into them. That was scary.

ST: Scary?

AR: Yeah. You know you can get sick from them needles. That's why we can't let Bubba get ahold of 'em.


There was more, but you get the drift. These kids come into the ER in incredibly filthy clothes, malnourished and having been exposed to toxic waste, not to mention the clouds of smoke around the house from the people smoking meth. As this interview demonstrates, they are also exposed to sex and weapons, often to great detriment.

I am sick and tired of advocates for legalizing drugs claiming that this doesn't hurt anyone other than the user. These kids are behind the 8 ball. Look at the example that has been set for them. This environment was not created because the drug was illegal, but because of the way the drug makes people act.

UPDATE:
Advocates for legalizing drug use, such as those in the comments, ignore the realities of use of mood altering drugs. The mother described in this interview did not behave the way she did because the drugs were illegal, but because they were available and for the effect. I agree that the kids would not be exposed to some of the chemicals if the drugs were manufactured legally and sold OTC, but the neglect, malnourishment and exposure to needles, guns and sex would still be present.
Go forth and read Grand Rounds. Then come back here, of course.

Monday, December 26, 2005

Via Instapundit, Global Polio Largely Fading:
The 17-year effort to eradicate polio from the world appears to be back on track after nearly unraveling in the past three years.

A new strategy of using a vaccine targeting the dominant strain of the virus appears to have eliminated polio from Egypt, one of six countries where it was freely circulating. That approach is on the verge of doing the same in India. Twenty-five years ago, India had 200,000 cases of paralytic polio a year. A decade ago, it was still seeing 75,000 cases annually. Through November this year, it recorded 52.

Such dramatic successes, many the result of a more potent formulation of polio vaccine, have once again made eradication of the paralyzing viral disease a realistic goal. Only one human disease -- smallpox -- has ever been wiped out, and that was almost three decades ago.
From 7500 to 52. Wow. So immunizations actually work. I agree with Professor Reynolds that the anti-immunization hysteria has slowed this process.

Saturday, December 24, 2005

A leading med-blogger, Medpundit, writes:
This time of year, I always see a sharp increase in patients who are suffering emotionally. Whatever it is - too much togetherness, too many unmet expectations, financial stress, temporal stress - the week before Christmas my practice sees an influx of depression and anxiety. And always - always - the final office day before Christmas, someone comes in threatening suicide. Do you know how hard it is to find a psychiatrist on the last day of the week before Christmas? As hard as it is to convince a suicidal patient to go to the emergency room for a psychiatric evaluation and admission.
Interesting comments regarding suicide, as well, from inteuri:
Psychiatry residents need reminders that suicide is not normal. We frequently talk to people who have attempted suicide and after a while, we become cavalier about the whole affair. We forget about all of the potential pain and uncomfortable emotions that formed the foundations of the attempts and instead, crank through these suicide evaluations as if we were running through a checklist of things to pack on a trip. It becomes an “us” versus “them” issue. And we start to feel annoyed that yet another person had tried to overdose on some medication….
I worry more about the people who hurt themselves and then deny suicidal ideation in the ER. I mean, come on, if you really want to kill yourself and you know that telling the ER doc that's what you want to do will get you locked away, wouldn't you say, "No, Doc, I don't want to die. I just did this for attention. The knife just slipped."

When I was working at Mercy Hospital in San Diego on the trauma team, I had a patient who had jumped of an overpass onto a very busy street. Miraculously, the fall didn't kill her and none of the cars hit her. She did suffer multiple spinal compression fractures, fractures of both femurs and calcanei and assorted other injuries. One morning I walked into the neurosurgical ICU (on the 10th floor) and saw her with her eyes deviated up and to the left. I was worried about a bleed and called her name. She rolled her eyes toward me and said good morning. Relieved, I asked her what she was doing. She answered that she was looking at a window, wondering if it would open. This was SERIOUS suicidal intent. Even with her level of injury, she was still trying to find a way to die.

I pray for her and others like her.

Friday, December 23, 2005

Of course, this is a good idea.
The FDA has approved the first West Nile Virus blood test to screen donors of blood, organs, cells, and tissues.

“This new test will help protect patients who receive blood and other such products against West Nile infection,” states the FDA in a news release. The test checks for viral genetic material.

To date, there have been 30 documented cases of people who most likely acquired West Nile virus from a blood transfusion, including nine who died.

Thursday, December 22, 2005

From the comments on this post at GruntDoc (doesn't his blog look great?):
My wife, a fellow emergency physician here at Landstuhl Regional Medical Center (Germany), had a 30yo male with classic signs for appendicitis (i.e. RLQ pain, RLQ ttp, rebound, guarding) a few nights ago. After completing her Hx and PE she called the SOD (surgeon of the day) for a consult stating that she believed her patient had an acute appendicitis that required surgical intervention. The surgeon, of course, asked her what the CBC and UA results were... She stated that they were still pending.

The SOD went off on her questioning her reasoning for a surgical consult without the benefit of laboratory results... Taking the high road she calmly stated that the labs were pending and would be resulted shortly after his arrival to the ED. Upon his arrival he berated her in front of the entire ED staff for a premature consult. Again, taking the high road, she thanked him for arriving in the ED so quickly and directed him to the patient's bedside. Moments after examining the patient he filled out a buck slip and took the patient to the OR for his appendectomy -- the labs were still pending as he wheeled the patient to the OR...
Unfortunately, our surgeons sometimes ask for the CT results and castigate us if we haven't done one. I can't keep track of who wants one and who doesn't. What bothers me the most is that we (the ER docs) can predict, based on the time of day, whether a particular surgeon will ask for a CT. If it is almost time for the doc we call to go off call, the chances are high we will be asked to order a CT. If it is 5am, we will be asked for a CT. If we get a CT in the evening and end up delaying the call to the surgeon until, say, midnight, we will be asked why we got the CT.

Follow the link to find out the results of the surgery.
The information regarding the use of levonorgestrel for "emergency contraception" is conflicting and is spun by advocates/opponents. Even the use of this phrase ignores the possibility that fertilization would have occured by the time the pill is taken, and the pill works by preventing implantation. Opponents point out that this is abortion, not contraception.

Some authors have tried to redefine the beginning of a pregnancy as when implantation occurs, not fertilization. However, basic biology defines the creation of a new organism at the time of fertilization.
"Fertilization is a sequence of events that begins with the contact of a sperm (spermatozoon) with a secondary oocyte (ovum) and ends with the fusion of their pronuclei ... and the mingling of their chromosomes to form a new cell. This fertilized ovum, known as a zygote, is a large diploid cell that is the beginning ... of a human being." (Moore, Keith L., Essentials of Human Embryology. Toronto: B.C. Decker, Inc., 1988, p.2.) "Although human life is a continuous process, fertilization is a critical landmark because, under ordinary circumstances, a new, genetically distinct human organism is thereby formed. ... The combination of 23 chromosomes present in each pronucleus results in 46 chromosomes in the zygote. Thus the diploid number is restored and the embryonic genome is formed. The embryo now exists as a genetic unity." (O'Rahilly, Ronan and Müller, Fabiola. Human Embryology and Teratology, 2nd edition. New York: Wiley-Liss, 1996, pp. 8, 29). "Almost all higher animals start their lives from a single cell, the fertilized ovum (zygote). ... The time of fertilization represents the starting point in the life history, or ontogeny, of the individual." (Carlson, Bruce M., Patten's Foundations of Embryology, 6th edition. New York: McGraw-Hill, 1996, p.3.) "Embryo: An organism in the earliest stage of development; in a man, from the time of conception to the end of the second month in the uterus." (Dox, Ida G. et al. The Harper Collins Illustrated Medical Dictionary. New York: Harper Perennial, 1993, p. 146.) "The fertilized egg, now properly called an embryo, must make its way to the uterus." (Carlson, Bruce M., Human Embryology and Developmental Biology. St. Louis: Mosby, 1994, p.3).
Many are advocating the clearance of the "Morning After Pill" to be sold OTC. Many of those same people are critical of the FDA for delaying this approval. I can't imagine why the FDA would consider approving MAP for sale OTC if politics were out of the picture. The only reason to sell MAP OTC is related to "women's rights" and is a political issue. What other hormonal medication is sold OTC? Why aren't regular OCP's sold OTC? How do the propronents think these can be kept from girls under whatever age they think is politically palatable?

Why do so many argue that MAP is not an abortofacient? Obviously they want to ignore the issue of abortion. Ignoring this issue is a political issue. They know the debate would be much broader if this issue were included.

Opponents argue that making MAP easily available would increase the rate of STD's by decreasing the incentive to use condoms. If your primary reason for using a condom is contraception, this would make sense. Why use a condom when you can just pop a pill after sex and prevent pregnancy? OTOH, I hope we are educating people about the risk of STD and the need for barrier methods (or my recommendation, abstinence).

UPDATE:
In response to a question in the comments about anti-implantation vs anti-ovulation, the company that manufactures Preven, Roberts Pharmaceutical, stated, "more often it would prevent implantation."
Jennifer Kessell, spokeswoman for Roberts Pharmaceuticals, the Oakville, Ont., Canadian manufacturer of the drug, sells Preven as though it were a new shade of eyeliner. "They're not sure of the ins and outs of it," she says. "But it's thought to work two main ways." First, by delaying ovulation, and second, by preventing implantation of a fertilized egg into the women's uterus. More often it would prevent implantation, she confirms. Ms. Kessell offers Preven as an alternative to abortion which "ends the life that is already implanted." She also calls it "emergency contraception" that prevents pregnancy.

But isn't Preven for women who believe they are already pregnant? Is this a new definition of pregnancy? "There's different definitions [of pregnancy] depending on where you live," offers Ms. Kessell. "Most doctors would say pregnancy begins at implantation," she continues. Only "anti- abortionists" would say life begins "when the sperm meets the egg. Period." Pregnancy begins when a woman is "comfortable" with it beginning, she adds . "It depends on your own personal views and what you want to believe."
Pro-abortion groups have tried to redefine pregnancy as beginning with implantation, not with contraception. I don't know any physicians who hold this view. Of course, this view would be very convenient for those who don't want to have the drug labelled as an abortofacient. The quotes above should clearly indicate the scientific falacy of this viewpoint.
Why are so many people worried about change? Why are the animal rights folks so worried about species going extinct? What's so bad about global warming?

Do these people think the world would be better off if the climate was exactly the same as it was a million years ago? Five million years?

What if no species had ever gone extinct?

Of course things have to change. Medicine has changed noticeably since I graduated medical school and that wasn't that long ago. We cure diseases now that would have killed patients even 20 years ago. The average lifespan is much longer now that 100 years ago.

I don't think I would enjoy the beach during the ice age as much as I do now that there has been some global warming.

Who knows what kind of awesome life forms might develop if we killed off a few species that would have eaten them and warm the place a few degrees?
Polar Wrap's ToastyFeet with Aerogels nanotechnology
Polar Wrap launching ToastyFeet insole liners using patented nanotechnology from Aspen Aerogels to protect feet from sever cold and help to get rid from heavy shocks.

In fact, ToastyFeet just might protect you from cold symptoms.
As reported by Reuters on November 14th, British researchers claimed that exposing bare feet to cold water for 20 minutes increases a person's chance of getting cold symptoms.

The researchers said that cold feet cause a constriction to blood vessels in the nose which can aid the cold virus, according to Reuters.

'It's clear that to keep from getting a cold, you need to keep your feet warm,' said McCormick.

'In the winter, it often feels like you're standing on ice.

That's because the soles of your shoes or boots are where your feet need to be protected from the cold the most.'

But why isn't your footwear keeping out all of the cold?
'Because most insulation requires loft -- like the loft in a cotton ball or fiberglass house insulation,' said Marc Lebel, Vice President of Aspen Aerogels, 'but when you step on it, it gets compressed and loses its loft and therefore its insulating power.'

But Aspen Aerogels' insulation doesn't require loft.

Its structure contains nanometer-sized pockets of air that can maintain thermal protection and shape even when you step on it.

In partnership with NASA, this same flexible aerogel technology is being developed for next generation space suits.

Wednesday, December 21, 2005

I am honored to have been invited to guest blog at KevinMD. Go there to see what I have to say and to browse some of the other guest bloggers.

Friday, December 16, 2005

Listening to lung sounds is such a variable experience. So many people talk to you while you have the stethescope in your ears, moan/groan/hum while breathing or even hold their breath. A lot of the time, they will take a deep breath and hold it. Or breath so slowly that you can't hear anything.

I have developed a habit of saying, "OK, can you take a deep breath, in and out." Sometimes I have to say, "Don't hold your breath, just breath in and out."

Just now, a patient was humming I Wish You a Merry Christmas while I was trying to listen. Good humming, though.

Thursday, December 15, 2005

CostRx: High premiums killing specialties

The first installment of CostRx features an interview with Washington-based neurosurgeon David Curfman on how skyrocketing medical malpractice insurance premiums are driving up the cost of healthcare and driving doctors out of the profession.

Q. On the topic of soaring medical malpractice premiums, you have stated that, if something isn't done about the problem in the next five to 10 years, we will have a real crisis on our hands. Can you explain?

A. Well, I think it's going to be sooner then another decade. I very strongly believe that it's already an evolution. In probably the last three or four years, it's gotten fairly severe. My prediction in 2002 -- I gave a talk on this -- was that I thought both neurosurgery and obstetrics were going to collapse by roughly around 2009 or maybe 2010.

Q. Can you define what you mean when you say "collapse?"

A. What I mean by that is that a good portion of the people in the field who are remaining by then, those who are still paying the huge amount on a premium for malpractice insurance, their overhead is going to exceed their income to the point that there's no way that they can stay in business. In fact, there are many neurosurgeons -- and the same applies to obstetrics -- that, unless you dramatically change your profession from one of either solo practitioner (or) private practice -- in other words, non-institutional -- you're not going to be able to survive.

The few who have changed their practice have gone on to be part of a big HMO or have sequestered themselves in a government facility (like) a veterans hospital, or have gone with some hospitals where they're actually hiring neurosurgeons and obstetricians to do the work that they would have never have done as recently as five years ago. ... This is a crisis of major proportion that's hitting the big hospitals in the big cities -- inner cities -- that are faced with a lot of people who have no insurance or have very, very meager coverage on a Medicaid policy.
You have to be very careful giving meds to pregnant women. Like this:
The Food and Drug Administration has warned pregnant women and their doctors away from the anti-depressant Paxil because of an increased risk of heart defects in newborns.

With the warning, the agency for the first time placed a popular anti-depressant — one in the same drug class as Prozac and Zoloft — into its second-highest category for risk of birth defects.
In a comment below, Michelle wrote:
hi, i need your help in doing a survey about blogging for my Master's thesis. Would it be alright for you to give me your email so i can send to you? Your help would greatly aid my thesis.
Michelle, my e-mail address is in the sidebar to the right. It is 8drtony 8at 8drtony.biz Leave off the spaces and 8's.

Feel free to write to me. If you would like to put your e-mail in the comment section of this post, perhaps other bloggers would write to you, also.

Wednesday, December 14, 2005

Bredesen is right to clean house at THP
Let the housecleaning begin at the Tennessee Highway Patrol. The more we learn about the behind the scenes operation of THP, the worse the whole mess looks. While the THP scandal didn't begin with the administration of Gov. Phil Bredesen, he has promised to end it.

For decades, THP has been as much a political operation as it has been a law enforcement operation. That has earned THP officers and officials some nice perks. There is a host of special rules that apply to THP officers that few others in state government benefit from. Everything from special pay raises to the politics of promotions within the department is now coming under intense scrutiny.
So Governor Bredesen want to hire a consulting firm to do advise on the housecleaning:
Nicely, Finance Commissioner Dave Goetz and Deputy Personnel Commissioner Nat Johnson told the panel that plans are under way to hire Kroll Government Services Inc., a New York-based security consulting firm, to conduct a review of Highway Patrol practices.
But the estimated $100,000 to $200,000 contract is a no-bid contract because of the need to act quickly:
Sens. Rosalind Kurita, D-Clarksville, and Jerry Cooper, D-Morrison, questioned the plan to sign up Kroll without a competitive bidding process. Goetz said the paperwork for that would take "six to eight weeks." He said the administration wants to move forward quickly.
The problem is, the firm for which the no-bid contract is proposed has ties to the Bredesen campaign:
Michael Shmerling, a former Nashville businessman who is listed on the company Web site as head of another Kroll division, has donated at least $7,500 to Bredesen's campaigns since 2001, a review of finance disclosure records after the meeting indicated.
I can understand the need to hire a consulting firm and also the need to award a no-bid contract, in the interest of expediency, but wouldn't it be better if the contract went to a company whose officers had not contributed to the governor's campaign.

This sounds like the criticism of the Bush administration for no-bidding the work they gave Halliburton in Iraq. However, this article doesn't describe that Kroll is in a unique position, as Halliburton was.
Interesting.
Medical malpractice insurance companies have started turning a profit in West Virginia since the Legislature passed several rounds of limits on malpractice lawsuits, state Insurance Commissioner Jane Cline told lawmakers Sunday.
...
With insurers doing better in the Mountain State than the national average, Cline said that in the past year, at least three companies have sought to reduce the rates they charge doctors.
Sort of puts a lie to the claim that malpractice tort reform didn't affect insurance rates, doesn't it.
I just wrote an order for "Vit B12 1mg IM weakly."
Europe Botching Afghanistan Duties

A very interesting look at the role of the "Great" European countries in Afghanistan.

I have an idea. Let's really get France involved. We should convince them to be trainers for the insurgency. This would get them out of our hair, make them happy doing something to oppose, decrease military readiness of the insurgency and, best of all, support our textile industry.

After all, somebody has to supply all those white flags they will be needing. Perhaps they could give them out in lieu of diplomas as the insurgents graduate training.
Another try at a rotavirus vaccine. What a boon this would be if it doesn't cause problems.
A new vaccine against a sometimes deadly diarrheal infection in infants does not appear to cause the problems associated with an earlier vaccine, though the government says it needs more information.

A Food and Drug Administration reviewer wrote that RotaTeq, drug company Merck & Co.'s vaccine against rotavirus, is "highly likely" to be effective based on the results of a study that showed a decrease in rotavirus-caused illness.

Monday, December 12, 2005

Would you die to save the life of your child? Most of us would reply, "In a heartbeat!" So why would this be such a surprise? (HT KevinMD)

Thursday, December 08, 2005

OK, Greg, this is pretty funny.
This is scary. Especially as my hospital is about to introduce a new computer system.

When I was in the Navy, we used a system called CHCS. The system had the capacity for the physicians to enter orders on inpatients, but this wasn't used. Basically, so many docs refused to do it that it became impractical.

What we did use was the prescription entry function. This shifted the work of entering the prescription into the computer from a pharmacy tech to the physician.

It had several good points, though. The system would prompt you with the proper dosage and you couldn't write for something that wasn't available or in a preparation that wasn't available. You couldn't write for a drug that wasn't carried in your local pharmacy which meant you didn't get a phone call later. You couldn't order Amoxil 550mg for example.

You could put together drug sets and just type in the name of the set. You could create sets of meds based on weight. You type in a kid's weight and it offered you a list of pediatric meds with the correct dosages already calculated.

Putting together sets of inpatient orders could be useful. You would be prompted with orders based on EBM and the computer could help you with the intensity of service and severity of illness necessary to get paid, or get the hospital paid.
Step 1: Get Nationalized Health Care

Step 2: By limiting resources (you have to do this, you cant' afford anything else) you informally begin rationing health care. People die while waiting for care.

Step 3: Introduce rationing of health care in a potentially palatable way. Blame it on the patient.

Step 4: Formalize rationing of health care through legislation.

Step 5: Discontinue health care benefits for those who are "too old." Why waste the money?

Step 6: "Allow" euthanasia.

Step 7: "Encourage" euthanasia. As in "Don't you want to do your part for your descendants?"

Step 8: Legislate euthanasia. I mean, didn't you see the movie?
If medical treatment were covered by the mainstream media:

MILLIONS OF INNOCENTS SLAUGHTERED

In an exclusive interview, we have obtained this information from a certain E. coli.

Incredibly, Mr. coli has survived a recent, unprovoked attack by government approved forces. Attacking in overwhelming numbers, the agents, known as "white cells" destroyed Mr. coli's entire community.

The details are staggering. "All we wanted was to survive," Mr. coli relates regarding his friends, family members and others in the community. "We were just hanging around, dividing, you know, for survival of the species, when the attackers swept in. No mercy. We were all targeted."

Fortunate to have mutated at the last minute, Mr. coli was the only survivor. "I was lucky to get out. Those white cells were inhuman. I saw them eating other coli's whole."

“And don’t get me started on calling them ‘white cells.’ These cells greatly outnumber the downtrodden bacteria. Our minority status is being ignored. I demand that the administration immediately give me nutrients as reparation.” These remarks were submitted as part of a package of prepared comments by the Reverend Gimme More, of the Church of the Feculent.

Unnamed sources high in the government have verified that it is government policy to use overwhelming force and try to destroy any bacteria immediately upon detection. This policy does not take into account the rights of the bacteria and doesn't allow for due process.

"No Geneva Protocols are observed," according to our source. "The Attorney General has advised that we should follow a 'take no prisoners' approach."

Kleb Siella, a spokesman for the Bringing U Global Sickness, or BUGS, has details of the use of Weapons of Mass Destruction. "I have personally seen white blood cells release chemical weapons in the vicinity of newly divided cells. These babies were eaten away by the chemicals they call 'enzymes.'"

We have uncovered details that, high up in the thalamus, the President and his staff are plotting to use thermal weapons! President M. O. Ron reportedly told his Secretary of Defense, Luke O. Cyte, to try raising the temperature in an attempt to cook these helpless, harmless residents. Critics, being much smarter, have pointed out that this is a violation of the Kyoto treaty.

Of course, this is proof positive that the administration is responsible for global warming.

Stated Mr. Siella, "The position that these are invaders is preposterous. That is just more bias against immigrants from a hostile administration."

Claiming to have formed a coalition, Secretary of State Chemo Tactic has attempted to attract others to join this blatantly illegal attack against residents in our body. Some have said that Secretary of Nutrition, Pan Creaz, has informed the muscles that she will withhold glucose if they don't immediately begin shivering. This action will result in raised temperatures, a maneuver that has been criticized by foreign leaders such as President Jacque Pneumococcus. "We won't participate in this illegal action," President Pneumococcus stated forcefully.

“Whenever he speaks, I just get lightheaded and short of breath,” stated Senator Diz Pnea, wife of the former president. “He is so handsome. I would believe him over our selected/not elected President M. O. Ron anyway. Don’t you just love that accent?”

Additional opposition has come from Senator Ima P. Nis. “When I was visited by Gon O. Rhea, I just sat back and enjoyed it. Why is he so angry? These bacteria have a right to live, too. And I look French and served in Vaginanam,” added the former candidate for the presidency, who would have won, had not his opponent caused premature division of some cells in the colon and co-opted their votes. "Besides, I voted for it before I voted against it."

You may recall, because we write about it 3 times every day, that Senator Nis is a decorated war hero, having served in Vaginanam for 30 minutes. Others have criticized his service, saying it was only 60 seconds, but Senator Nis is quick to point out that he was withdrawn prematurely and that his opponents don’t even know the difference between two inches and six inches.

None other that the mighty Secretary General of the United Nosepickers, the UN, has labeled the current slaughter “germicide.” Secretary A. Nus has vowed to bring charges in the International Court of the Hepata for this illegal, unilateral action.

National Security Advisor Andy Biotic denied that this action was illegal or unilateral. He pointed to resolutions by the Cortex authorizing the use of force for defense of the corpus. He listed other coalition members, such as Mucus, Cilia and T-Cells.

But everybody knows he’s a liar with ties to multiple drug companies.

Former CEO of Ortho-McNeil, Vice-President Leva Quinn continues to refuse access to records of his (probably illegal) “Immune System” committee meetings. These meeting were held in the Thymus during the first term.