A Wikipedia wizard and blogger... and I happen to know him

BMJ Career Focus profiles Bertalan Mesko who "combines being an editor and administrator of Wikipedia with medical student studies."

Bertalan is the author of the popular blog ScienceRoll.com which often features new Web 2.0 tools for medical education. He is also is the founder of a blog carnival about Web 2.0 and medicine called -- what else -- Medicine 2.0.

References:
A Wikipedia wizard and blogger. BMJ Career Focus, 08/2007.
Interview With Medical Blogger Berci Mesko. TiroMed.com, 11/2007.
Image source: BMJ Career Focus.

Related:
Listen to Berci Mesko: After the Dr. Anonymous Show. ScienceRoll.com, 03/2008.

Updated: 03/07/2008

Prolonged immobilization increases risk of DVT -- how do you define prolonged immobilization?

Acquired risk factors for deep vein thrombosis (DVT) can be summarized in the mnemonic SICC PT:

Surgery
Immobilization
Cancer
Contraceptives

Pregnancy
Trauma

Prolonged immobilization can cause circulatory stasis which is one of the predisposing factors for DVT described by Virchow in his famous triad: endothelial injury, stasis and hypercoagulability.

How do you define prolonged immobilization?

According to the literature search I did:

- For travelers, prolonged immobilization is defined as a flight longer than 6-10 hours (most studies use a cut-off of 8 hours)

- For nursing home residents, the definition of prolonged immobilization varies between less than 15 days (increased risk of DVT) and/or longer than 3 months (no increased risk)

Nursing home residents with DVT

According to one study, the most powerful risk factor for DVT in patients older than 65 years was prolonged bed rest for up to 14 days, with a 5.6 times greater risk of DVT.

Travel-associated DVT

In a trial of previously healthy patients who traveled at least 8 hours per flight (median duration 24 hours), duplex ultrasound showed an asymptomatic DVT in 10 % of participants. In other studies, the reported risk of symptomatic DVT after flights of more than 12 hours was 0.5%. According to a 2006 Lancet study, activation of coagulation occurs in some individuals after an 8-hour flight.

Prevention of travel-associated DVT

A review of 10 randomized trials concluded that the use of compression stockings on flights lasting 4 hours or more led to a substantial reduction in asymptomatic DVT. There is no evidence that aspirin is helpful in this setting.

References

Risk Factors for Deep Vein Thrombosis in Inpatients Aged 65 and Older: A Case-Control Multicenter Study. Journal of the American Geriatrics Society 52 (8), 1299–1304, 2004.
Overview of the causes of venous thrombosis. UpToDate, 15.2, accessed 08/28/2007.
Literature Review of Deep Vein Thrombosis in Air Travellers. The Internet Journal of Surgery. 2007. Volume 10 Number 1.
Coagulation May Be Activated by Prolonged Air Travel. Medscape, 2006.
Travel and the risk of symptomatic venous thromboembolism. Thromb Haemost. 2003 Mar;89(3):499-505.
Is prolonged immobilization a risk factor for symptomatic venous thromboembolism in elderly bedridden patients? Results of a historical-cohort study. Thromb Haemost. 2004 Mar;91(3):538-43.
Image source: Saphenous vein, Gray's Anatomy, 1918 (public domain)

Further reading

Massive Lower Extremity DVT Treated with Thrombolysis
Suspected DVT - To Treat or Not to Treat?
INR 17 and Hematuria: What To Do?
Who is at risk for venous thrombosis on long haul flights?. Retired doc's thoughts.

The risk of VTE (blood clots) is 3 times higher in passengers on long-distance flights than in the general population http://goo.gl/Tk45Z
Exercises for air travel — Cleveland Clinic Journal of Medicine http://goo.gl/YYZHy

Online Case Book by Yale School of Medicine

The Case Book by the Yale University School of Medicine covers several areas:

Doctor Patient Encounter > Interview Skills Cases
Internal Medicine Clerkship
Modules > Renal Cases
Primary Care Clerkship > Cardiothoracic cases
Surgery Clerkship

The Internal Medicine Cases are most well developed but since they are clearly written for teaching purposes during the rotation, there are only questions but no answers. The cardiothoracic cases provide both.

Image source: Case Book by Yale University School of Medicine.

Dr. Wes Interviewed by Healthcare Blogger Code of Ethics

I am a regular reader of Dr. Wes' blog described as "musings in the life of an internist, cardiologist and cardiac electrophysiologist."

Westby G. Fisher, MD, FACC (Dr. Wes) practices at EvanstonHealthcare and is an Associate Professor of Medicine at the Feinberg School of Medicine, Northwestern University, Evanston, IL. He was interviewed recently by Rob Lamberts of Healthcare Blogger Code of Ethics:

"Describe yourself.

I started as a science and computer geek who became a biomedical engineer, then doctor in a subspecialty that combined my interests. I work, I play, I care, like everyone else."

You can read the whole interview at Healthcare Blogger Code of Ethics.

Medical blogging is hard work - Dr Wes spends 60-90 minutes most early mornings writing or researching new posts (http://goo.gl/PFsZV).

Further reading:

Why I Have the Best Job in the World. Dr. Wes, 09/2007.
The Dr. Wes Interview. Doctor Anonymous, 01/2008. Check out the archived copy.
Image source: Dr. Wes' blog

Allergy to Mustard

Mustard allergy is reported relatively rarely but is a growing concern, at least in Europe. According to a 2003 editorial in the European Journal of Allergy and Clinical Immunology, mustard was the fourth most prevalent food allergen in children, behind eggs, peanuts, and milk.

Boston Globe has recently published a case of a 3-year-old girl who is allergic to mustard -- read more on AllergyNotes.


Mind map of food allergy. Source: Food Allergy: A Short Review, AllergyCases.org.

Image source: Wikipedia, GNU Free Documentation License.

MedCalc Has a Windows Mobile Version Now

The venerable free medical calculator MedCalc for Palm now has a Windows Mobile version as well. MedCalc was my PDA calculator of choice during residency but since I switched to Pocket PC (now called Windows Mobile), I had to use Archimedes instead.

It is nice to see that MedCalc is still alive and getting updated. I have assembled a long list of free PDA software here: Free Medical Programs for Windows Mobile / Pocket PC.

Image source: MedCalc.

Ohio Summer Festivals: Cuyahoga County Fair

Rabbits at Cuyahoga County Fair. Click on the images above to see the description about each breed.

Cuyahoga County Fair is just one of the many Ohio Summer Festivals and Fairs.

Related rading:
A Frugal Guide to the Iowa State Fair (or Any Similar County or State Fair). The Simple Dollar, 08/2008.

Updated: 08/09/2008

My Favorite Medical Handbook: Oxford Handbook of Clinical Medicine (OHCM)

I remember Oxford Handbook of Clinical Medicine (OHCM) since its first edition and it looks it has only gotten better. When preparing for USMLE several years ago, I used to refer to OHCM and First Aid for USMLE often and it helped - my scores were 96, 97, 93 on USMLE 1, 2 and 3 (99 is the maximum). The study plan was based on those handbooks, "regular" textbooks, self-made notes, mnemonics and mind maps. It was surprising how long the effect lasted -- my in-service exams scores during the internal medicine residency were 98, 96, 98 during PGY 1, 2 and 3 respectively, and I did not need to study more than 2 weeks to pass ABIM.

Scores are nothing without sound clinical judgment, of course. OHCM was the handbook that I found most useful and reader-friendly. It goes beyond being simply a medical handbook, for a start, it often reminds you that patients are much more than "strokes" or "pneumonias" and there is more to life than medicine. The section Thinking About Medicine -- Your Inner Peace on ClinicalCases.org is named after the first chapter of OHCM -- you can browse through the book on Google Books or download the chapter for free from Oxford University Press here:

Chapter 1: Thinking about Medicine (PDF, 464 KB)

It is nice to see that OHCM now even has an iPhone edition ($44.95).

Mini Oxford handbook of clinical medicine By Murray Longmore, Ian Wilkinson, Supraj R. Rajagopalan from Google Books:



References:
Skyscape books for iPhone. Skyscape.com, 08/2007.
How to Score Well on the Boards? Clinical Notes, 2004.
How to Study, Clinical Cases and Images - Blog, 2007.
Image source: UnboundMedicine.com.

Updated: 08/21/2009

Deadly effect of experimental treatment and rules of research conduct

The Washington Post and the WSJ Health Blog comment on the deadly effect of an experimental treatment for arthritis and the breach of guidelines for clinical trials:

"Two fundamental rules of clinical research were violated that day, experts said.

First, (the informed) consent forms are to be taken home and considered, not signed on first sight.

Second, when a patient's own doctor is a principal investigator in a study, someone else is supposed to make the proposal."

Update 11/26/2007:
The following investigation found no evidence the experimental drug caused the death of the patient described above and the clinical trial is set to resume.

References:
Death Points to Risks in Research. Washington Post, 08/2007.
Hope Trumped Skepticism as Patient Mulled Study Risk. WSJ Health Blog, 08/2007.
Gene Therapy Study to Resume After Patient Death. WSJ Health Blog, 11/2007.
Image source: OpenClipArt.org, public domain.

Related:


Informed Consent. Family Medicine Notes, 03/2008.

Updated: 03/31/2008

Impressions of Mayo Clinic Libraries

David Rothman shares his experience with visiting the medical libraries of the esteemed Mayo Clinic:

"As Melissa took me on a tour of Mayo’s many excellent libraries (this took hours and we still didn’t get to a couple of them), I found myself constantly impressed by Mayo’s art and architecture."

David links to some interesting publications by one of the Mayo Clinic librarians:

If you feed them, they will come: A prospective study of the effects of complimentary food on attendance and physician attitudes at medical grand rounds at an academic medical center.
Segovis CM, Mueller PS, Rethlefsen ML, Larusso NF, Litin SC, Tefferi A, Habermann TM.
BMC Med Educ. 2007 Jul 12;7(1):22.

Cool tools: Google, RSS, Podcasts, oh my!
Rethlefsen ML, Segovis CM.
Minn Med. 2006 Nov;89(11):32-6.

According to David, "the Mayo School of Medicine accepts only 42 students per year, so students there tend to be particularly brilliant."

It looks like Cleveland Clinic Lerner College of Medicine of CWRU follows the Mayo medical school footsteps by educating small classes of physician-scientists who graduate with a combined MD/PhD degree. I am happy to be on faculty at the Clinic medical school and have been impressed by the research interest of the students. Just last week, I discussed the groundbreaking glioblastoma multiforme research which one of them was planning and the possibilities the mind maps tools like Bubbl.us offer to visualize the process.

References:
Visit to the Mayo Clinic, 7/18/2007. DavidRothman.net.
Becoming a Clinical Assistant Professor of Medicine and Web 2.0 Projects, Clinical Cases and Images - Blog, 10/2006.

Practical advice on prostate examination

Tundra PA summarizes a few practical points on prostate examination:

"When I told Dr. H. about the physical exam and my concern that I had felt a nodule in Evan’s prostate, he held out his arm with the wrist extended. Pressing the bony prominence just distal to the radial pulse, he said “prostate nodule.” Pressing the large muscle at the base of the thumb, he said “normal prostate.” Pressing the space on the back of his hand between thumb and forefinger, he said “boggy prostate.”

Update 09/03/2007:
Tundra PA has a follow-up of the story.

References:
A PSA Story. Tundra Medicine Dreams, 08/2007.
Cancer: Digital Rectal Examination for Prostate Problems. WebMD.
Image source: Wikipedia, public domain.

Related:
Prostate Cancer with Bone Metastases and PSA of 900
3 New Diagnoses This Year

Embeddable Maps by Google - As Easy as YouTube

This is where I go to work every weekday and many weekends -- one of the best hospitals in the world -- Cleveland Clinic:


View Larger Map

From Google Maps blog:

"Today we're excited to announce a new feature on Google Maps that allows you to add maps to your blog or website just by copying and pasting a snippet of HTML. And once you embed the map, it has all the same functionality of the Google Maps you know and love; it's clickable, draggable, and zoomable.

Adding a map to your website or blog is now as easy as embedding a YouTube video. No programming skills are required, and there's no need to sign up for a Maps API key."

And this is not all -- Google turns Google Earth into a telescope.

References:
YouTube-style Embeddable Maps. Google LatLong Blog.
Sky: The final frontier. Google LatLong Blog.
Google turns Google Earth into a telescope. Googling Google.

WSJ Blog: How I treat high cholesterol in rural Illinois?

Ben Brewer, a family doctor in rural Illinois, tries to get LDL to 100 or lower. For patients with heart disease or diabetes he tries to get it to 70.

He uses generic statins like simvastatin which his patients can afford.

More questions are answered in Dr. Brewer's forum at WSJ.com.

References:
A Family Doc Asks Three Questions About Cholesterol Drugs. Jacob Goldstein, WSJ Health Blog, 07/2007.

Related:
A 33-year-old man has a low HDL level. Should you treat him? Clinical Cases and Images.
Pfizer Discontinues Drug Which Increases HDL Due to Higher Death Rate. CasesBlog, 12/03/2006.
Health: Nothing but a number: Lifestyle changes to control cholesterol. Dr. Sidney Gottlieb, Cleveland Clinic Canada, National Post, 01/2008.
Image source: Cholesterol. Wikipedia (public domain).

Updated: 01/31/2008

Weekly Dermatology Podcast

Dermatology Weekly Update is weekly podcast of the latest research and news in dermatology.

It looks interesting but there is no word on who the authors are, so use it at your own risk. Most web sites should have at least 2 mandatory sections:

- About us
- Contact us

With the latest update of Google Reader, you can play podcasts directly from the application. Alternatively, click the "pop-out" link to detach the podcast player so that you can browse the rest of the feeds while listening.

Link via Medical Lecturer.
Image source: Dermatology Weekly Update.

Medicare Will Not Pay for Hospital Errors -- How Do You Define a Hospital Error?

According to KidneyNotes:

"Look for the definition of an "error" to be expanded dramatically... Central line infection? C. difficile colitis? Ventilator associated pneumonia?"

The initial six conditions on the Medicare list are:

1. pressure ulcers
2. catheter-associated urinary tract infections
3. Staphylococcus aureus (shown above) septicemia
4. air embolism
5. blood incompatibility
6. object left behind in surgical patient

Number 2 and 3 are hospital-acquired infections and numbers 4-6 were to be called "never events." Besides those on the list for 2008, seven more conditions are under consideration for 2009, according to AMNews.

Further reading:
Medicare Says It Won’t Cover ‘Preventable’ Hospital Errors. NYTimes, 08/2007.
Medicare plans to stop paying for 6 hospital-acquired conditions. AMNews staff, June 18, 2007.
Medicare No Longer Willing to Pay Hospitals for Preventable Medical Errors. MSSPNexus Blog, 08/2007.
Medicare won’t pay for mistakes? Notes from Dr. RW, 08/2007.
An Inexact Science. Musings of a Dinosaur, 08/2008.
Preventable medical errors, from Wikipedia, the free encyclopedia.
Let Me Sprinkle Some Fairy Dust On My Patient. The Happy Hospitalist, 01/2008.
Image source: Wikipedia, CDC.

Updated: 01/15/2008

Using Blog Software to Create a "Regular" Website

Web blog software can be used for more than writing blogs. The current blog platforms are suitable for creating and maintaining a "regular" web site, i.e. a site which is not a blog (with entries arranged in a reversed chronological order). I have adapted the free Blogger.com by Google to create 4 such web sites:

• ClinicalCases.org
• PeriopMedicine.org
• AllergyCases.org.
• ClevelandClinic.org/Hospitalist
  

BloggingPro.com has a nice summary on using the WordPress server installation (not the free WordPress.com version) as a content management system (CMS) rivaling Drupal: Feature: 5 Reasons to Use WordPress as CMS.


This Google video shows it takes about 2 minutes to start a blog on Blogger.com. Creating a web site has never been easier.

References:
What I Learned from Making the Website of the Cleveland Clinic Hospitalists, 8/11/2006.
Using Web Services to Enhance a Medical Education Course, 2/20/2007.
Using a Blog to Build an Educational Portfolio, 1/15/2007.
Tips for New Bloggers: Sticky Posts in Blogger, 08/20/2007.

Updated: 08/20/2007

Elvis Presley's personal physician

According to Wikipedia:

George Nichopoulos, also known as "Dr. Nick," was Elvis Presley's personal physician. He began treating Elvis in 1967, and took it on as a full time job in 1970 until Elvis' death in 1977.

In 1977 alone, Dr. Nick had prescribed 10,000 doses of amphetamines, barbiturates, narcotics, tranquilizers, sleeping pills, and laxatives for Presley. He says he did it because he 'cared'

Blood tests showed traces of 14 different drugs in Elvis's body at the time of his death.

In 1995 Nichopoulos had his license permanently suspended by the Tennessee Board of Medical Examiners, after it was revealed that he had been over prescribing to numerous patients for years.

After he was stripped of his credentials in 1995, Dr Nick took a job evaluating medical insurance claims by FedEx employees, where he still works today, paying off his many legal bills.

References:
Doctor Feelgood. The Observer, Sunday, August 11, 2002.
Rock Idol Elvis Presley Dies at 42. Washington Post, Thursday, August 17, 1977.
Image source: Dr.Nick - ο έλληνας γιατρός του Ελβις.

Flickr Images...

Yeah, right.

Source: Xanboozled, a Creative Commons license.

Annals of Internal Medicine Launches Podcast and Audio Summaries

The Annals of Internal Medicine is the latest member of the "Big Five" of general medical journals to launch a podcast. The other four -- NEJM, JAMA, BJM and Lancet -- have been experimenting with portable audio for a while now. Click below to see the coverage of their podcasts on this blog over time:

1. NEJM, 11/2005.
Feed: http://podcast.nejm.org/nejm_audio_summaries.xml

2. Lancet, 4/2006.
Feed: http://podcast.thelancet.com/lancet.xml

3. JAMA, 4/2006.
Feed: http://jama.ama-assn.org/misc/jamapodcasts2006.rss

4. BMJ, 9/2006 (the podcast is not active now).

5. Annals, 7/2007.
Feed: http://media.acponline.org/feeds/annals.xml

Podcasts and text-to-speech programs to convert text to MP3 files can be beneficial to medical education. For example, the podcast/videocast coverage of the 2006 meeting of ACAAI is lively, comprehensive and summarizes most new developments if the field.

Most people subscribe to medical podcasts by using iTunes/iPod/iPhone from Apple. A lesser known fact is that Google Reader can be used as a podcast program as well.

Click here to subscribe to all 4 journal podcasts in your iGoogle homepage.

References:
Stop Going to Conferences for the Lectures. Listen to Podcasts Instead. Efficient MD, 06/2007.
Image source: Annals of Internal Medicine.

Updated: 08/18/2007

PubMed Suprise: A Researcher with 600 Co-Authors on a Single Article

It is somewhat striking to see a list of several PubMed articles with roughly 600 co-authors under each of them. ScienceRoll suspected that the first author (Aubert B.) must have a lot of friends and asked for an explanation. Here it is.

The last name in the author list is "BABAR Collaboration." A Google search shows that "BABAR is a High Energy Physics experiment located at the Stanford Linear Accelerator Center, near Stanford University, in California. The goal of the experiment is to study the violation of charge and parity (CP) symmetry in the decays of B mesons." According to Wikipedia, a meson is a strongly interacting boson, that is, it is a hadron with integral spin. I hope this makes it clearer :)

The BABAR Collaboration consists of approximately 600 physicists and engineers from 75 institutions in 10 countries. This can probably explain the 600 co-authors.

Related reading:

BaBar experiment from Wikipedia, the free encyclopedia.
500 authors of Grand Rounds 
The "BIG 1-98" randomised clinical trial really is big: 885 authors are listed on this Lancet article http://goo.gl/lKEfw via @JRBtrip

Working near a laser printer = Second hand smoking?

Digital Inspiration links to an Australian study which claims that some laser printers release large amounts of small particles in the air which can potentially have adverse long-term health effects:

"If your cubicle is located somewhere near the common office printer, either ask the support staff to move the printer elsewhere or you shift your desk to a different place in the office as in the current setup, the air around you may be highly polluted."

More research is needed before a final recommendation can be made, as usual, but the study results could be something to have in mind. Printing less, potentially saves trees and keeps the air clean. You can save electronic texts online in Yahoo MyWeb, GMail, Google Notebook or any other service you prefer.

References:
Laser Printers in Office Turn Employees into Passive Smokers. Digital Inspiration, 7/2007.
Image source: Wikipedia, GNU Free Documentation License.

Blogging, Microblogging and Facebook

Steve Rubel of MicroPersuasion comments on a recent trend -- he blogs less and spends more time on Twitter ("microblogging" in 140 characters or less) and Facebook.

It seems like the "influentials" in the tech blogging world are also moving in the same direction. Has the blogging peaked or has it just become relatively more mainstream?

Among medical bloggers, Joshua Schwimmer also uses Twitter and has transformed KidneyNotes into a collection of selected links. He writes 2 other blogs -- Tech Medicine and EfficientMD, and has a profile on LinkedIn.

It will be interesting to see how microblogging (Twitter) and social networking (Facebook) will shape the future of medical blogging as we know it.

References:
When Less is More and More is Less. Micro Persuasion, 07/2007.
Newbies Guide to Twitter. ChrisBrogan.com, 08/2007.
Identity Through Online Lifestreams. Micro Persuasion, 08/2007.
Image source: Twitter.com.

Would you like to see Dr. Google or Dr. Microsoft for your personal health records?

According to the New York Times:

Microsoft’s software powers more than 90 percent of all personal computers, while Google is the default starting point for most health searches. People are increasingly turning to the Web for health information and advice. A Harris poll found that 52 percent of adults go to the Web for health information, up from 29 percent in 2001.

"Today, only about 20 percent of the nation’s patient population have computerized records. Under federal law, people can request and receive their personal health data within 90 days. But the process is complicated, and the replies typically come on paper, as photocopies or faxes."


Adam Bosworth talks about GoogleHealth. Image source: AlphachimpStudio, a Creative Commons license.

More or less, the current equation is as follows:

Microsoft = personal computer
Google = Internet

Both Google and Microsoft are reportedly preparing products aiming at the potentially huge market of personal health records.


A screenshot of Google Health. Image source: Philipp Lenssen, a Creative Commons license.

Microsoft’s offering is scheduled to be announced this fall, while Google’s will probably be introduced next year. The launch of new software products frequently faces multiple delays and missed deadlines -- Windows Vista is a good example. Most likely, "Dr. Google" or "Dr. Microsoft" will not be available to see you before 2008-2009.

Update 10/06/2007:
Microsoft launches an online personal health record portal called HealthVault.com.

References:
Dr. Google and Dr. Microsoft. NYTimes.
Google Health Prototype. Google Operating System.
First Google Health Screenshots. Philipp Lenssen.
Who's your patients' best friend? Google!
Google Finds Correct Diagnosis in 58 % of Cases Published in NEJM
Google, M.D. In Action
Google, M.D. In Action - Part II
"Google, M.D." at the Clinic
Image source: Doctors Using Google by Philipp Lenssen, used with permission.

Related:
Microsoft HealthVault and Google Health - The 'Coke and Pepsi' of Online Health (PHR). ReadWriteWeb, 10/2008.
Google now wants to diagnose your disease, offers differential diagnosis based on 10 sites and Wikipedia http://goo.gl/SD1qM

U.S. Life Expectancy Shorter Than 41 Countries

According to the National Center for Health Statistics, the life expectancy in the U.S. is shorter than 41 countries including most of Europe and Japan.

Dr. Christopher Murray, head of the Institute for Health Metrics and Evaluation, comments that "something's wrong here when one of the richest countries in the world, the one that spends the most on health care, is not able to keep up with other countries."

What are the likely causes?

- High prevalence of obesity in the U.S.
- Racial disparities
- Relatively high infant mortality rate
- 45 million Americans lack health insurance

The life expectancy ranges from 82.6 years in Japan to 39.2 years in Swaziland - see the map. Many of the countries with the lowest life expectancies, e.g. Swaziland, Botswana, Lesotho, Zimbabwe, Zambia, Mozambique, South Africa, Central African Republic, and Namibia, are suffering from very high rates of HIV/AIDS infection, with adult prevalence rates ranging from 10 to 38 percent (source: Wikipedia).


Life Expectancy Falls In Pockets of U.S. WSJ Health Blog. In the the animation, greener equals longer life expectancy.

References:
A color-coded map of the world’s most and least emotional countries http://bit.ly/Ytxx6B
U.S. life span shorter. Associated Press, 08/2007.
List of countries by life expectancy, from Wikipedia, the free encyclopedia.
World’s Best Medical Care? NYTimes, 08/2007.
U.S. life expectancy lags behind other countries'. CNN.
Image source: Wikipedia, GNU Free Documentation License.
How low can you go? Megan McArdle, 08/2007.
Life Expectancy Falls In Pockets of U.S. WSJ Health Blog, 04/2008.

Should mesalamine be stopped prior to noncardiac surgery to avoid bleeding complications?

A 53-year-old Caucasian male with a past medical history of Crohn's disease, hypertension, hypercholesterolemia, osteoarthritis and atrial fibrillation takes mesalamine (Asacol) to control his diarrhea. His other medications include atenolol, warfarin and simvastatin. He also takes oxycodone and acetaminophen prn for hip pain. The physical examination is normal apart from irregularly irregular cardiac rhythm. The electrocardiogram shows atrial fibrillation with heart rate of 67 beats per minute. His exercise tolerance corresponds to 6 METs.

The patient is seen by an internal medicine physician for preoperative evaluation one week prior to surgery for total knee replacement for osteoarthritis of the left hip.

The patient inquires whether she should stop mesalamine to avoid bleeding complications during surgery. His primary care physician told him that non-steroidal anti-inflammatory drugs (NSAIDs) may increase the bleeding risk.

Should we stop mesalamine to avoid bleeding complications during surgery?

No.

Mesalamine (Asacol) does not affect platelets the same way aspirin and other NSAIDs do.

According to one study, there was not effect on platelet aggregation during normal treatment with 5-aminosalicylic acid when given at a dose of 1.5 gm po qd or even after IV administration. All in vivo and in vitro tests were negative for inhibition of platelet aggregation in contrast to the inhibition seen with aspirin (acetylsalicylic acid). Authors concluded that treatment with mesalazine does not constitute a hazard to patients with IBD in regard to prolonged bleeding time caused by an influence on platelet aggregation or fibrinolytic activity.

This is one of the series of perioperative questions I will answer on this web site. They will be submitted as clinical vignettes to the Cleveland Clinic Annual Perioperative Summit next year. This year's summit is in September and several of the perioperative cases in nephrology will be presented as posters and published as abstracts in the Cleveland Clinic Journal of Medicine.

References:
Lack of effect of 5-aminosalicylic acid on platelet aggregation and fibrinolytic activity in vivo and in vitro. Winther K, Bondesen S, Hansen SH, Hvidberg EF. Eur J Clin Pharmacol. 1987;33(4):419-22.
Image source: Wikipedia, Free Documentation License.

Updated: 12/14/2009

Medical University of South Carolina Launches a Comprehensive Podcast/Videocast Portal

Medical University of South Carolina (MUSC) Health Podcast portal features both audio and video podcasts:

"Our audio podcasts are hosted by various MUSC faculty, physicians and special guests. These podcasts cover a wide range of current health topics, featuring MUSC patients, physicians, and staff. Listen to patient stories, learn about new procedures being offered at MUSC, and hear the latest news on how to stay healthy."

Cleveland Clinic also offers Free Audio and Video Podcasts for Health Professionals and patients.

Link via Medical Lecturer.

Procedure Videos: Venipuncture

Preparation for Venipuncture


Performing Venipuncture

Uploaded by Slyswami.

Related:
Peripheral Intravenous Cannulation. NEJM Video in Clinical Medicine, 11/2008.
Bevel Dow. Musings of a Dinosaur.
Why I Do Blood Draws. Musings of a Dinosaur.

Updated: 06/022/2009

CNN: 5 Operations You Don't Want to Get

On the CNN list:

1. Hysterectomy
2. Episiotomy
3. Angioplasty
4. Heartburn (GERD) surgery
5. Lower-back surgery

References:
5 operations you don't want to get -- and what to do instead. CNN, 07/2007.

Video: Changing World

Did You Know? 2.0 - video powered by Metacafe

Link via Digital Inspiration.

6 Tips on Staying Up-to-Date in Genetics (and Any Specialty)

Bertalan Meskó of ScienceRoll.com shares 6 tips on staying up-to-date in genetics but they apply to most specialties in medicine and science.

The 6 tips are:

1. Follow the most reliable genetic sites
2. Follow the best genetic blogs
3. Use RSS web feed and follow the genetic journals
4. Use services/tools like UpToDate
5. Follow the blog carnivals
6. Follow the genetic wikis

I would add a few more suggestions:

1. Subscribe to Google News alerts in your field of interest via web feeds.
2. Subscribe to podcasts in your specialty. See our IAMSE abstract on the topic.
3. Use text-to-speech to listen to journal articles. See our IAMSE abstract on the topic.
4. Create an iGoogle page as your own "super journal" powered by web feeds. See our IAMSE abstract on the topic.
5. Search YouTube, VideoJug for related videos.
6. Listen to conferences podcasts/videocasts.
7. Start a blog as an educational portfolio to record your thoughts.
8. Use Google Bookmarks to save interesting articles you find online.

References:
7 Tips: How to be up-to-date in genetics/genomics? ScienceRoll, 2007.
Interesting Ideas from 11th Annual Meeting of IAMSE. Clinical Cases and Images - Blog, 2007.
Using a Blog to Build an Educational Portfolio. Clinical Cases and Images - Blog, 2007.
15 Steps to Cultivate Lifelong Learning. LifeHack.org, 07/2007.
Video presentations: Novel concepts and easy-to-use web tools for researchers. European Molecular Biology Laboratory, 2006.

"Change of Shift" Blog Carnival - Nursing Grand Rounds

The latest edition of Change of Shift: A Nursing Blog Carnival is up.

The carnival is "a place for nurses and other members of the health care team, including students and patients to send their nurse related stories and ideas."

Image source: Emergiblog

A Web 2.0 Review in the Medical Journal of Australia Mentions This Web Site

David Rothman links to a comprehensive review of the use of different Web 2.0 tools in medicine in the Medical Journal of Australia: The effect of Web 2.0 on the future of medical practice and education: Darwikinian evolution or folksonomic revolution?

In the section about blogs, the authors mention this web site along with Dean Guistini’s UBC Academic Search — Google Scholar Blog, David's blog, and ScienceRoll.

The article provides a good overview of most of the basics of what I call the 6 axes of medical education in Web 2.0 style:

1. Web feeds (RSS)
2. Podcasts
3. Blogs
4. Wikis
5. Custom search engines
6. Second Life virtual world

Unfortunately, the review failed to mention AskDrWiki which is, in my opinion at least, one of the best medical wikis providing high-quality and unique content. AskDrWiki features more than 140 coronary angiogram videos from the number one heart center in America for 13 years in a row -- Cleveland Clinic.

Such omissions can be fixed in the future by using an approach similar to the newly-launched Google News comments -- if you are included in a news story and you want to clarify a point, comments can be added directly to the news report.


My presentation on Web 2.0 in Medicine from December 2006.

References:
The effect of Web 2.0 on the future of medical practice and education: Darwikinian evolution or folksonomic revolution? Rick McLean, Brian H Richards and Janet I Wardman. MJA 2007; 187 (3): 174-177.
MedLib Blogs (including this one) in the Medical Journal of Australia. DavidRothman.net, 08/08/2007.
Google News Adds (Special) Comments. Google Blogoscoped, 08/08/2007.

Baby Einstein DVDs May Slow Language Development? Also, Please Cite Your Sources

A new study showed that for every hour per day spent watching educational DVDs like Baby Einstein, infants understood 6-8 fewer words than those who did not watch them. Children with larger vocabularies had parents who read to them or told them stories.

The American Academy of Pediatrics recommends against watching television by children under 24 months.

There are at least 31 news reports on the story found on Google News but none of them links to the original source -- supposedly, an article in the Journal of Pediatrics. I checked the online version of the journal twice but I was still not able to find the study in question. After performing a PubMed search, it became clear the study was actually published in the Archives of Pediatrics & Adolescent Medicine and not in the Journal of Pediatrics.

Linking to the original source of the story should be one of the gold standards of the web journalism and it was obviously not done in this case.

References:
DVDs Don't Produce Brainy Babies. U.S. News & World Report.
Baby Einsteins: Not So Smart After All. Time.
'Baby Einstein' Videos Ineffective, Study Finds. NPR (audio).
Audio: Study hits at the heart of Baby Einstein. MarketWatch.com.
Study: Babies Raised By Videos Approximately As Dumb As Expected. Gawker.com.

Health Organizations and Journals Show More Interest in Blogs

My colleagues and I presented posters/abstracts on different aspects of blog use in medicine at the 2006 American Society of Nephrology (ASN) Meeting, the 2007 American College of Cardiology (ACC) Meeting, the 2006 Annual Perioperative Summit at the Cleveland Clinic, and the 2007 Annual Research ShowCASE at Case Western Reserve University. The interest by the attendees has always been great.

A dentist blogger was recently asked to present on "Blogs and Their Use in Dentistry" at the American Acdemy of Pediatric Dentistry's Annual Session.

The Annals of Emergency Medicine recently featured a summary of popular blogs authored by EM physicians (link via GruntDoc). What is next? The Annals of Internal Medicine with an article about popular IM blogs? The Annals of Allergy, Asthma, and Immunology with the summary of popular allergy blogs? The blogs are gradually hitting main stream in the minds of medical publishers about a year after they became commonplace in the general media. Most major newspapers and TV stations now have blogs. Medical journals and hospitals cannot be far behind.

Blogs offer a unique way to connect with readers/customers. They are instant and look spontaneous. Subscription via web feeds creates a relationship. This is just one aspect of why blogs are influential. The other is their popularity. Google changed our world. When I teach case-based management of DKA to residents at the Cleveland Clinic, I do not give them the web address anymore. I just tell them "search Google for "DKA case" and you will find the case we discussed today at number 1 or 2 in the search results."

References:
Web 2.0 in Medicine Presentations at Research ShowCASE in Cleveland
Cleveland Clinic Perioperative Medicine Summit
American Society of Nephrology (ASN) Renal Week 2006
Wow, I made Annals of Emergency Medicine! GruntDoc, 04/2007.
Emergency Medicine in the Blogosphere: The Irreverent Wit of the Specialty’s Unofficial Voice. Annals of EM, Vol. 49, Issue 5, Pages 612-614 (May 2007).

Flickr: Swallow Brothers

Swallow Brothers

Source: Kuribo, a Creative Commons license.

Foxit Reader is Better than Adobe Reader for PDF

Adobe Reader is a big program and takes 10-15 seconds to start. You cannot edit or add text to a PDF unless a form is embedded specifically for that purpose.

Foxit Reader deals with those limitations in a heartbeat. This small 1.7-MB program starts in just one second and the Typewrite features allows you to add text to any PDF despite the fact that the form entry may not have been embedded originally. The Foxit Reader is free and its counterparts of Adobe Acrobat (Editor, Creator) are reasonably priced at $ 50-100 compared to more than $ 500 for Adobe Acrobat Professional.

I have heard about Foxit before but never got around to try it. Last week I read that Larry Page insisted for months that Google included Foxit instead of Adobe Reader in Google Pack and decided to give it a try. The current version of Foxit Reader is a significant improvement over Adobe Reader, adds useful features, has a small foot print and is easy to use.

References:
Foxit Reader from Wikipedia, the free encyclopedia.
PDF Hammer -- edit your PDF files online for free.
Image source: Foxit

Related:
16 Free Online Tools for Working with PDFs. DavidRothman.net, 03/2008.

Updated: 03/12/2008

Clinical case: Should we stop raloxifene (Evista) prior to surgery?

A 69-year-old Caucasian female with a past medical history of hypertension, hyperlipidemia, osteoarthritis and severe osteoporosis takes the oral selective estrogen receptor modulator raloxifene. Her other medications include hydrochlorothiazide and atorvastatin. The patient takes ibuprofen and the combination of oxycodone and acetaminophen prn for knee pain.

She is seen by an internal medicine physician for preoperative evaluation three weeks prior to surgery for total knee replacement for osteoarthritis of the right knee. Physical examination reveals decreased range of motion of the right knee but is otherwise normal. The electrocardiogram recorder in her primary care physician's office shows normal sinus rhythm.

The patients and her primary care physician want to know whether she should stop taking raloxifene prior to surgery.

Should we stop Evista prior to surgery?

Yes.

Indications for use of selective estrogen receptor modulators (SERMs) such as tamoxifen and raloxifene (Evista) have expanded beyond breast cancer treatment to prevention and treatment of osteoporosis. Both tamoxifen and raloxifene increase the risk of VTE (DVT and PE).

A review in UpToDate recommends tamoxifen and raloxifene be discontinued for 4 weeks before surgeries associated with a moderate or high risk of venous thromboembolism (VTE).

If the patient takes those drugs for breast cancer treatment, a consultation with an oncologist is recommended.

This is one of the series of perioperative questions I will answer on this web site. They will be submitted as clinical vignettes to the Cleveland Clinic Annual Perioperative Summit next year. This year's summit is in September and several of the perioperative cases in nephrology will be presented as posters and published as abstracts in the Cleveland Clinic Journal of Medicine.

References:
Should selective estrogen receptor modulators be discontinued prior to noncardiac surgery? UpToDate (paid subscription required).
Hormone therapy and thromboembolic disease. Hemostasis and thrombosis. Current Opinion in Hematology. 14(5):488-493, September 2007.
The World Health Organization has an online Fracture Risk Assessment Tool.
Image source: Flickr, a Creative Commons license.

Updated: 12/14/2009

What is the difference between an internist and a family physician?

DB’s Medical Rants explores the differences between internists and family physicians in 4 postulates.

It seems like with time, as the U.S. health system evolves, internists will morph into hospitalists and family physicians into outpatient doctors. A similar arrangement, with outpatient GPs who almost never go to the hospitals and inpatient doctors, works relatively well for many European countries.

References:
Internists have different skills than family physicians. DB’s Medical Rants.

Further reading:
Retired doc's thoughts and Musings of a Distractible Mind comment on the implications of switching to hospitalist care for inpatients.
Practicing cost-effective medicine. One clinician's top 10 tips. Robert M. ACP Hospitalist, 2007.
Image source: OpenClipArt.org, public domain

Updated 09/20/2007