You want to spark thought & discussion in a small clinical conference group. You ask the group just how they would manage this patient's refractory hypertension. All sorts of dynamics can take over. ...Who will offer up an answer first? Deference, bravado, lack of confidence, and pauses can reign. One way around this is a wireless handheld network. People key-in their answers and bingo, they see them on a screen.
But a lower-tech solution uses pen & paper, passing of answers, and raising of hands for an honest survey. I like this idea but have yet to try it.
...How it works:
1. You ask the questions.
2. Each participant simply writes answers on paper.
3. Then they exchange their answer-sheets two or three times.
4. Finally, you tally answers by a show of hands to represent not their personal answer, but each answer on the exchanged sheet in front of them. You get an honest survey that then opens discussion more freely, and focuses learning.
The authors of this technique report "participation rates of over 80%." (Found this described on page 198 in Evidence-based Medicine: How to Practice & Teach EBM by Sackett DL, Richardson WS, Rosenberg W, and Haynes RB/ Churchill Livingstone 1997, now in a second edition. They say a video tape demonstrating this technique is available from the Centre for Evidence-Based Medicine at Oxford, titled Clinical Disagreement about a Patient with Dysphagia. I could not find it on their site.)
Tonight Garrison Keillor sang a simple song written by Tom Paxton in the fall of 2001. You can hear the performance at the Prairie Home Companion website (it is 1:13:15 into the October 13, 2001 show) or read the lyrics in a Folknet discussion page.
More recently, groups from David Byrne & Russell Simmons' Musicians United to Win Without War to the Electronic Intifada have reacted to the violent reverberations post 9/11, some through song.
In the mid-to late 90's HyperCard was used to create, among other things, some medical educational software. HyperCard then lay fallow at Apple. A Scottish company has re-born HyperCard as an even more powerful creative tool. Revolution Express 2.1 is on sale for half price until tomorrow ($75.00).
"Revolution is a multi-platform software development tool that enables developers to easily and quickly create powerful applications for Mac OS X, classic Mac OS, Windows, Linux, and popular Unix systems... with native look and feel on all platforms. "
I had a small epiphany when I used "tabbed browsing" to read a journal. For example, I went to New England Journal of Medicine online and just clicked each interesting article (while holding down the command-key). The selected articles pop into a series of "tabs" at the top of the browser window. To read an article I just click on the tab...the article is instantly there...no waiting. Feels more like scanning a paper-journal...jumping instantly from article to article with no waiting. (I use Safari as my browser on my Mac.)
Harvey Pekar is an individual who worked as a file clerk at the Cleveland VA Hospital from 1966 to 2001. He writes stories. His story is told in the movie, American Splendor. It opens this month. (Long ago, between EKG readings, wise VA cardiologist Harold Schwartz filled us in about Harvey's creativity.)
September is Recovery Month. Jacob Reider points out an online tool to help locate substance abuse facilities within or near your zip code. (Created by the Substance Abuse and Mental Health Services Administration.) Another publicized number is 1-800-662-HELP.
Guggulipid (Commiphora mukul) is an over-the-counter herbal remedy taken to lower cholesterol. In a double-blind, randomized, placebo-controlled short term trial (8 weeks) published last week guggulipid did not lower cholesterol. Six patients developed a hypersensitivity rash, none in the placebo group.
The New York Times reports that this week Medicare will decide whether to cover lung volume reduction surgery. Projected annual costs are $1 billion to $15 billion. (Kara had raised questions about lung volume reduction surgery in an earlier post.)
Another innovative (expensive?) surgical technique in the local news is the arrival of Cincinnati's second surgical robot. Good Samaritan Hospital was first locally this year with a robot, now the University of Cincinnati has arrived. (Along with this potentially beneficial surgical technique come matters of credentialing, ethics and informed consent. ...Questions about when robot use is innovation and when it is experimentation, especially with initial use.)
The current issue of Annals of Internal Medicine talks about ethics & the physician-writer. How do you ethically publish patient stories? The authors suggest transparency regarding content (declaring the published work to be fiction, non-fiction or fictionalized account of true events), and transparency about patient consent.
For example...
"These stories are based on actual patients seen at the X clinic, in which the author practiced. Names and identifying details have been changed. Consent to publish was secured from all patients except one who died and apparently left no close relative or loved one. The author intends to donate any profits from this publication to the patients attending the clinic or to the X Foundation."
They give three other sample statements.
Coulehan J and Hawkins AH. Keeping faith: Ethics and the Physician-Writer. Ann Intern Med. 2003;139:307-11. (Online abstract not yet available...delayed because of power blackout?)
For a tutorial on basic genetics the Lancet recommends this NIH site. While aimed at the general public, there is lots to learn with clear graphics & text. ...Reminded me that hydroxyurea may work in sickle cell disease by turning on a gene to make more fetal hemoglobin.
(Update on Hydroxy Urea and Sickle Cell Disease: An August 13 JAMA article reports that hydroxyurea treatment of sickle cell disease led to a 40% reduction in sickle cell mortality after nine years. This has prompted lots of correspondence about the broader use of hydroxyurea.)
A young woman has sudden onset of dyspnea and chest pain. A CT scan shows pulmonary emboli. ...After heparin, how long should she stay on warfarin? Should we test for thrombophilia (clot predisposition) to predict her likelihood of recurrence? (She is not pregnant, has had no recent surgery, no recent long trips, no family history of clotting disorders, and is not on estrogen.)
In this week's Lancet British researchers who followed venous thrombotic events in a community of 200,000 found that thrombophilia testing does not help predict recurrence.
Our patient would fall into their study Group C: Venous thromboembolism with no pre-test identifiable clinical risk factor. At two years that group had a 20% recurrence rate of venous thromboembolism. The presence or absence of positive thrombophilia test results did not change the prognosis.
"Our results provide objective evidence that in unselected patients presenting with a first episode of venous thromboembolism, testing for heritable thrombophilia does not allow prediction of a new event during the highest risk period--that is, the first 2 years after anticoagulant therapy is stopped. This study also emphasises the predictive value of clinical risk factors. Testing might yet prove to be informative in patients from families with a strong predisposition to thrombosis; however, such testing is not useful in most patients."
Baglin T et al. Incidence of recurrent venous thromboembolism in relation to clinical and thrombophilic risk factors: prospective cohort study. Lancet 2003; 362: 523-2.
Note: Those who were treated for post-surgical thromboembolism had no recurrence of venous thromboembolism.
(For more on pulmonary embolism, especially British Thoracic Society Guidelines on management of PE and the role of D-dimer in diagnosis, see this earlier post.)
Jacob Reider demonstrates how you can use Google to calculate Body Mass Index, convert pounds to kilograms, or lots of other calculations.
"Recent storms associated with Solar Cycle 22 (the 11-year sunspot cycle that began in 1986) have had an unprecedented impact on electric power systems. The great geomagnetic storm of March 13, 1989, plunged the entire Hydro Quebec system, which serves more than 6 million customers, into a GIC-triggered blackout (GIC means "geomagnetically induced current"). Most of Hydro Quebec's neighboring systems in the United States came close to experiencing the same sort of outage."
"In contrast to today's more severe solar storm cycle, the preceding, relatively quiet 30-year period led designers of electrical systems to overlook the possible influences of GICs. Conventional threats—such as high winds, ice loading, or lightning—did not cause the Hydro Quebec collapse. Rather, it was the consequence of a threat that had never been considered on a system-wide scale across the continental network."
At this site doctors can learn enough to be dangerous about geomagnetically induced currents (GICs) and sunspots and power grid blackouts. (John G. Kappenman was the head of Transmission Power Engineering at Minnesota Power when this prescient piece was written in 1997. Geomagnetic Storms Can Threaten Electric Power Grid. Earth in Space, Vol. 9, No. 7, March 1997, pp.9-11 ).
Curiously, sunspotcycle.com mentions that over the past 24 hours Sunspot 431 has been nearing X-class (the most disturbing)...with the Northeast and parts of Canada in a blackout.
Found this while talking with my mother in Cleveland (she near her kerosene lamp and 2 inch battery-powered TV). Google search on "power grid map" returned this paper as one result, as I recall.
This 1997 piece by Kappenman et al continues with even more fair warning:
"The Quebec outage did not, in this instance, cascade beyond the province's borders. But if the disturbance had occurred under higher load conditions (nearer to summer or winter peak demand conditions, for instance), cascading outages might have spread across a region of the northeastern United States extending to the Washington, D.C., area.
"Extensive blackouts are the nightmare of the power industry. Once power is interrupted in large metropolitan areas, diversity of electric use on the network is lost. When power is restored, all thermostatically controlled electric loads come back on simultaneously. This stress, added to the higher demands of many devices such as motors and transformers, can draw up to 600% of normal load during restoration procedures.
"Such a blackout is also likely to cause transient voltage stresses and permanent damage to network equipment such as high-voltage breakers, transformers, and generation plants, which makes them unavailable for restoring power. Hours or days may pass before power can be restored. Oak Ridge National Laboratory assessed the potential impact of a widespread blackout in the northeastern United States from a geomagnetic storm event slightly more severe than the March 1989 blackout as a $3–6 billion loss in gross domestic product. This figure does not account for the potential disruption of critical services such as transportation, fire protection, and public security. Other assessments placed the 1989 and 1991 geomagnetic storm effects in a category equivalent to Hurricane Hugo and the San Francisco earthquake in their relative impact on the reliability of the electric power grid."
© 1997 American Geophysical Union
Geomagnetic Storms Can Threaten Electric Power Grid
Earth in Space, Vol. 9, No. 7, March 1997, pp.9-11
by John G. Kappenman, Minnesota Power, Duluth, Minn.; Lawrence J. Zanetti, Johns Hopkins University, Applied Physics Laboratory, Laurel, Md.; and William A. Radasky, Metatech, Goleta, Calif.
Yesterday's proposal from the Physicians for National Health Plan outlines comprehensive access to health care, as "Medicare-for-all"...private delivery of care within a more federally regulated market. An editorial asks others to present an alternative and not just "sit back and bemoan the existing state of affairs."
More than just a "Medicare-for-all" proposal the article moves into a murkier world of total market control; a massive overhaul of the marketplace to fix a massive problem (enter the ideologic warriors). "National health insurance would curtail the entrepreneurial aspects of medicine, including both the problems and the possibilities." Yet the authors assure that fee-for-service care and a variety of delivery models would let "physicians who work harder...make more."
The authors sense the complexities of totally managing a market..."National health insurance would eliminate many administrative and insurance worker positions, necessitating a major effort at job placement and retraining. Many of these displaced workers might be deployed as support personnel to free up nurses for clinical tasks; others might be retrained to staff expanded programs in public health, home care, and the like."
Alternatives are already on the table. Maine is one active state implementing universal access (not mentioned in the article), and Medicare limited to a segment of our population has been working for a long time. The article offers criticism of alternative proposals such as expanding Medicaid, vouchers and tax credits, or the Clinton Proposal. Can solutions exist in a mixed economy or is market control the one answer? The work done by the Physicians for National Health Plan (PNHP) is substantial, with years of careful documentation and publications. They sharpen the search for solutions. (Their proposal can be read online.)
And now a poem, "Those Winter Sundays" by Robert Hayden. The Writers Almanac points out that "once, Hayden confided that whenever he read this poem publicly, he feared he might break down."
Excellent comparative images of neurologic changes in HIV infection can be found at this NeuroAids site. An example of progressive multifocal leukencephalopathy (PML) is shown.
Clinical trials of special treatments for AIDS dementia complex (ADC) are found at the Neurologic AIDS Research Consortium (NARC) site.
This consortium also has brief summary of other neurologic manifestations of AIDS.
The Medical Clinics of North America published a thorough review (but I am still unclear on prognosis)...Clifford DB. AIDS Dementia. Med Clin North Am. 2002; 86(3): 537-50.
Here is a clinical review of pneumocystis pneumonia from Aimee Wilkin and Judith Feinberg while in the University of Cincinnati's Infectious Disease Department.
Found this link from Peter Sam's helpful Primary Care Clinical Practice Guidelines collection at UCSF.
Today's Cincinnati Enquirer reports on the relative under-support for healthcare infrastructure in Cincinnati. While a reduction of beds does not reflect a lack of investment, the bed reduction is of interest. Since 1984 the region's number of beds fell from 7414 to 3855...from 4.5 beds/1000 residents to 2.09. Also talks about whether Iameter's cost saving efforts did just that (saved costs for a consortium of regional corporate employers). ...Times and markets and technologies change; lots of points for discussion. (Mentions that no regional hospital made the American Hospital Association list of America's 100 "Most Wired" hospitals.)
Ralph Cautley directed me to a review of Out of Eden: The Peopling of the World by Stephen Oppenheimer. Like the earlier Journey of Man this book cites genetic evidence that humans left Africa, crossing from Djibouti to Yemen, around 80,000 years ago...then wandered through south asia. (More modern day wanderings, with Google, lead to discussion groups about the origin of humans, and online full text works of Darwin.)
People live under bridges around town. The Cincinnati Enquirer today reports that on Monday a federal court decides if the City can relocate people from these camps.
In the Rules of Golf:
"If any point in dispute is not covered by the Rules, the decision shall be made in accordance with equity."
Equity
"1. The state, quality, or ideal of being just, impartial, and fair. 2. Something that is just, impartial, and fair. 3. Law a. Justice applied in circumstances covered by law yet influenced by principles of ethics and fairness. "
American Heritage Dictionary
Equity or "justice" stands also as a basic principle of medical ethics. ...Simple in golf, complex in medicine. (Read more about the ethical concept of justice in an article for students, in a review by Ranaan Gillon, in an accompanying debate and in rage.)
Rose Zajac from the TriHealth Medical Library sends a reminder that in October the Public Library of Science (PLoS) publishes the first of its online journals. (This is a private project for freely distributed, online, full-text scientific research. The history of the project stems from the work of the former director of the National Institute of Health, Harold Varmus.)
Another unrelated smaller project, FreeMedicalJournals.com, serves as a repository of information about existing journals and their full-text access. (For instance, it lists New England Journal of Medicine as being full-text free access after six months.)
Do quinolone antibiotics prolong QT and lead to torsades de pointes? They seem to, but so do macrolides. And how frequent are clinical events? This full-text excellent online review suggests that prolongation is common but significant events are rare. It calls for an objective assessment of risk.
Grand Rounds this week is by Naiel Nasser from Bristol Myers speaking about quinolones.
Speaking of quinolones, remember that doxycycline is a recommended option in outpatient treatment of community acquired pneumonia. (Guidelines can always be reviewed at the National Guideline Clearinghouse, guideline.gov.)
This is an excerpt from Dr. Ball's paper (which is full text online):
"Thus, almost every quinolone investigated, however partially, provides some evidence of effects on cardiac conduction and some are associated with ‘clinically significant’ events. It is perhaps the latter phraseology which stimulates controversy as, taken alone, prolongation of the QTc is not a ‘clinical’ event."
"Although more extreme degrees of QTc prolongation are undoubtedly associated with a risk of torsade de pointes, such effects appear to be no more common with quinolones than with macrolides and the risk may vary between drugs and with co-risk factors. A blanket moratorium would therefore seem less appropriate than an objective assessment of risk; this is in progress for moxifloxacin and is suggested for other quinolones. "
© 2000 The British Society for Antimicrobial Chemotherapy
Journal of Antimicrobial Chemotherapy (2000) 45 , 557-559
Quinolone-induced QT interval prolongation: a not-so-unexpected class effect
Peter Ball
School of Biomedical Sciences, University of St Andrews, St Andrews, Fife, UK
Question arose about how often amylase is elevated in patients with pancreatic cancer (sensitivity). Could find no data after a quick search. Amylase would not seem to have a high positive or negative predictive value. Here is an excerpt from one paper on testing for pancreatic cancer, along with some links to patient information.
The following is a brief excerpt from a longer excellent review article which is copyrighted:
Sial SH and Catalano MF.Gastrointestinal tract cancer in the elderly.
Gastroenterol Clin North Am 2001; 30(2): 565-90
Copyright © 2001 W. B. Saunders Company
Laboratory Tests
No single laboratory test, including tumor markers, is diagnostic of pancreatic cancer . Routine laboratory tests usually are within the normal range except in patients presenting with bile duct obstruction. These patients present with elevated serum alkaline phosphatase and bilirubin values. Occasionally, patients may present with elevated serum lipase and serum amylase levels. In some patients, elevated serum aminotransferase, carcinoembryonic antigen, alpha-fetoprotein, and gamma-glutamyltranspeptidase levels are increased in patients with pancreatic cancers . The serum carbohydrate antigen, CA 19-9, level is increased in some patients presenting with pancreatic cancer . When using a cutoff value of 40 U/mL, 74% of patients with pancreatic cancer have elevated CA 19-9 levels. CA 19-9 may be elevated in 55% to 65% of patients with gallbladder and bile duct malignancies. Blood levels of CA 19-9 usually are elevated in patients in whom pancreatic cancer measures 3 cm or greater, limiting the utility of the test for detecting resectable pancreatic cancer .
Imaging Techniques
Diagnostic imaging techniques for pancreatic cancer include transabdominal ultrasonography, CT, endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), MR imaging, and angiography. The principal diagnostic imaging tests for pancreatic cancer are ultrasonography and CT. The sensitivities of ultrasound and CT in detecting pancreatic cancer are 60% and 90%. The role of MR imaging in diagnosing pancreatic cancer is evolving.
Copyright © 2001 W. B. Saunders Company
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Other links (not related to this paper):
MD Anderson has links to their ideas on imaging (they still prefer CT) and their own research on pancreatic cancer.
For patients there is a national pancreas information site (pancreatica.org).
The Cincinnati Post today highlights the St. Xavier Park area's coming alive. ...Home to medical students and other pioneers.
Acute onset of severe, persistent RUQ pain immediately after an obese man's a morning donut. White count = 15,500. No fever. Ultrasound shows many small stones in the gallbladder without bladder wall thickening. No dilated ducts. By morning, after morphine and antibiotics, his pain is better. He feels terrific and is discharged home.
...Biliary colic vs cholecystitis. Not clear on the distinction, but this review points out some of the features.
Carefully reviewed, practical articles on palliative care can be found at the The American College of Physicians (ACP) site. This collection of articles gives clear guidance for talking with patients on end of life decisions as well as symptom management.
The Robert Woods Johnson Foundation and the Medical College of Wisonsin (EPERC) both have excellent, deep, resources about palliative care. You will need to sign-up (free) to access materials from the EPERC site.
The British Medical Journal (BMJ), which is full-text online & free, posts updated collections of its articles by topic. Here is their updated post on Palliative Care. The quality of the articles varies widely. (Not much on pain control.) Some, on the other hand, are good resources and relevant to this month's work--such as the ABC's of rectal cancer, a review of radiation therapy, and an article on doctors' perception of palliative care and heart failure.
Here is debate coverage of Democrat proposals on healthcare access. Two candidates favor universal access. Others plan to extend Medicaid and child coverage, or cap premiums and create catastrophic coverage.
The great state of Maine has moved from the theoretical to the practical, implementing its Dirigo Health plan for universal access to healthcare.
Find current medically-related Palm (PDA) tools reviewed & linked by Dr. Kent Willyard. ...A thoughtfully put together, comprehensive site.