Not what it seems: Desert Island

Not what it seems: Desert Island (click to enlarge the image). The obvious is sometimes hidden - this often applies to clinical evaluation of patients and research.

References:
http://xkcd.com/731

The Value of YouTube Videos for Cancer Patients - Mayo Clinic

Ruben Mesa, M.D., describes his experience using YouTube videos to provide in-depth information about blood cancers.

Evaluation of driving risk in dementia - practice parameter update

For patients with dementia, the following characteristics are useful for identifying
patients at increased risk for unsafe driving:

- Clinical Dementia Rating scale (Level A)
- caregiver’s rating of a patient’s driving ability as marginal or unsafe (Level B)
- history of crashes or traffic citations (Level C)
- reduced driving mileage or self-reported situational avoidance (Level C)
- Mini-Mental State Examination scores of 24 or less (Level C)
- aggressive or impulsive personality characteristics (Level C)


Evaluation of driving risk in dementia (click to enlarge the image).

The following characteristics are not useful for identifying patients at increased risk for unsafe driving:

- patient’s self-rating of safe driving ability (Level A)
- lack of situational avoidance (Level C)

References:
Practice Parameter update: Evaluation and management of driving risk in dementia. Neurology 2010;74:1316–1324 (PDF)

Wound Closure Adhesive Strips

Walgreens Wound Closure Adhesive Strips: adhesive strips used to secure, close and support small cuts and wounds.

Video: Awake Endotracheal Intubation

Video: Awake Endotracheal Intubation for "Fun and Knowledge" by an anesthesiologist from the Massachusetts General Hospital (MGH). Not sure about the "fun" part...

References:
Awake Endotracheal Intubation for Fun and Knowledge. Medgadget, 2010.

Takotsubo cardiomyopathy (broken-heart syndrome) in differential diagnosis of chest pain

Takotsubo cardiomyopathy (also called stress induced cardiomyopathy, apical ballooning, or broken heart syndrome) was first described in Japan 20 years ago. It is typically precipitated by acute emotional stress, hence the names “stress cardiomyopathy” or “broken-heart syndrome.”



Takotsubo cardiomyopathy is characterised by acute, reversible left ventricular dysfunction in a distribution,which does not correlate with the coronary artery blood supply. The left ventricular dysfunction occurs without obstructive coronary artery disease (CAD) and usually resolves spontaneously over a period of weeks.



The characteristic appearances on contrast angiography include:

- ballooned apical segment

- hypercontractile basal portion of the left ventricle

The appearances are reminiscent of the design of the traditional fishing pot used in Japan to trap octopus, hence the descriptive term "tako-tsubo" cardiomyopathy (octopus trap, tako tsubo). Such a trap, no more than simple ceramic jar, take advantage of the octopus’ preference for small, enclosed spaces and the security they seem to promise. They are simply left on the seabed and gathered later after octopi have had time to occupy them.



Although Takotsubo cardiomyopathy was initially considered rare, it could possibly be responsible for 1-2% of admissions for acute coronary syndrome in industrialised countries.

"Takotsubo Cardiomyopathy Caught on Tape" - Jems.com YouTube channel.



References:

Takotsubo cardiomyopathy. Banning et al. 340: c1272, BMJ.

Takotsubo Cardiomyopathy, or Broken-Heart Syndrome. SS Virani et al, Tex Heart Inst J. 2007; 34(1): 76–79.

Morikami museum.

Image source: Octopus trap, tako tsubo, Morikami museum.

Increasing Diet Polyunsaturated Fat in Place of Saturated Fat Reduces Risk of Coronary Heart Disease

Reduced saturated fat (SFA) consumption is recommended to decrease coronary heart disease (CHD), but there is an absence of strong supporting evidence from randomized controlled trials (RCTs) of clinical CHD events and few guidelines focus on any specific replacement nutrient. Additionally, some public health groups recommend lowering or limiting polyunsaturated fat (PUFA) consumption, a major potential replacement for SFA.

The overall pooled risk reduction was 19% (RR = 0.81), corresponding to 10% reduced CHD risk (RR = 0.90) for each 5% energy of increased PUFA.

These findings provide evidence that consuming PUFA in place of SFA reduces CHD events in RCTs. This suggests that rather than trying to lower PUFA consumption, a shift toward greater population PUFA consumption in place of SFA would significantly reduce rates of CHD.

References:

Mozaffarian D, Micha R, Wallace S (2010). Effects on Coronary Heart Disease of Increasing Polyunsaturated Fat in Place of Saturated Fat: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. PLoS Med 7(3): e1000252. doi:10.1371/journal.pmed.1000252
The long history of dieting fads: "soap should be eaten for its diuretic properties", wrote a prominent surgeon in 1810. Lancet, 2012.
How We Eat: Analyzing Half a Million Meals - 5 INFOGRAPHICS

Image source: Varieties of meat, Wikipedia, public domain.

Start metformin early when diabetes type II is first diagnosed

Initiating metformin soon after diabetes diagnosis and while A1C is low might preserve β-cell function, prolong the effectiveness of metformin, reduce lifetime glycemic burden, and prevent diabetes complications.

These findings support the current treatment algorithm for hyperglycemia management that recommends metformin initiation when diabetes is first diagnosed.

References:

Secondary Failure of Metformin Monotherapy in Clinical Practice. Diabetes Care March 2010 vol. 33 no. 3 501-506.

Mipomersen - antisense technology to lower LDL cholesterol

Homozygous familial hypercholesterolaemia is a rare genetic disorder in which both LDL-receptor alleles are defective, resulting in very high concentrations of LDL cholesterol in plasma and premature coronary artery disease. This study investigated the use of an antisense inhibitor of apolipoprotein B synthesis, mipomersen, to lower LDL cholesterol.

Patients aged 12 years and older who were already receiving the maximum tolerated dose of a lipid-lowering drug, were randomly assigned to mipomersen 200 mg subcutaneously every week or placebo for 26 weeks.

34 patients were assigned to mipomersen and 17 to placebo. Mean concentrations of LDL cholesterol at baseline were 11·4 mmol/L in the mipomersen group and 10·4 mmol/L in the placebo group. The mean percentage change in LDL cholesterol concentration was significantly greater with mipomersen (−24·7%) than with placebo (−3·3%).

The most common adverse events were injection-site reactions in 76% of patients in mipomersen group vs 24% in placebo group. 12% of patients in the mipomersen group had increases in alanine aminotransferase of three times or more the upper limit of normal.

Inhibition of apolipoprotein B synthesis by mipomersen represents a novel, effective therapy to reduce LDL cholesterol concentrations in patients with homozygous familial hypercholesterolaemia who are already receiving lipid-lowering drugs, including high-dose statins.

References:
Mipomersen, an apolipoprotein B synthesis inhibitor, for lowering of LDL cholesterol concentrations in patients with homozygous familial hypercholesterolaemia: a randomised, double-blind, placebo-controlled trial. The Lancet, Volume 375, Issue 9719, Pages 998 - 1006, 20 March 2010.

Researchers make synthetic HDL cholesterol with a core of gold

Lipoprotein structure (chylomicron) (left). Image source: Wikipedia, GNU Free Documentation License.

Contact lenses change color when blood glucose increases in diabetics

In the future, diabetics may be able to wear contact lenses that continuously alert them to variations in their glucose levels by changing colors - potentially replacing the need to routinely draw blood throughout the day.

The non-invasive technology, developed by Chemical and Biochemical Engineering professor Jin Zhang at The University of Western Ontario, uses extremely small nanoparticles embedded into the hydrogel lenses. These engineered nanoparticles react with glucose molecules found in tears, causing a chemical reaction that changes their color.

References:
Nanocomposites could change diabetes treatment. The University of Western Ontario, 2010.

Image source: OpenClipArt.org.

Preventing diabetes, biological passport for athletes and more from the Lancet

Low-dose combination therapy with rosiglitazone and metformin was highly effective in prevention of type 2 diabetes in patients with impaired glucose tolerance, with little effect on the clinically relevant adverse events of these two drugs.

Preventing type 2 diabetes with low-dose combinations: Lifestyle interventions aimed at reducing bodyweight, and use of metformin, thiazolidinediones, acarbose, and orlistat, reduce the risk of diabetes by 25—60% over 3—6 years

The biological passport and doping in athletics: A biological passport monitors an athlete's blood and body chemistry values over time to assess whether there has been a deviation from an established baseline, thus indirectly detecting illegal manipulation.

A long look at obesity: Even with their primitive understanding of nutrition, our neolithic forebears somehow made the “right choices”, thriving on a wholesome diet of nuts, seeds, and fruits with the occasional piece of meat. And what is more, their rare intake of animal protein could only have been obtained through vigorous exercise, which they would, of course, indulge in every day.

Acupuncture can spread serious diseases: bacterial infections, hepatitis B and C, even HIV

To prevent infections transmitted by acupuncture, infection control measures should be implemented, such as use of disposable needles, skin disinfection procedures and aseptic techniques.

Acupuncture may be risky as needles are inserted up to several centimeters beneath the skin. In the 1970s and 1980s most infections associated with acupuncture were sporadic cases involving pyogenic bacteria.

There is a new syndrome - acupuncture mycobacteriosis - infection caused by mycobacteria that rapidly grow around the acupuncture insertion point as a result of contaminated cotton wool swabs, towels and hot-pack covers. There is a long incubation period and the infection usually leads to large abscesses and ulcers.

References:

Acupuncture transmitted infections. BMJ 2010;340:c1268.

Acupuncture can spread serious diseases: experts. Reuters.
Does traditional Chinese medicine have a place in the health system? http://goo.gl/RH04o

Image source: Needles being inserted into a patient's skin, Wikipedia, public domain.

Video: Cleveland Clinic Doctors

There is a doctor for every patient and there is a patient for every doctor: 2,000 physicians from 80 countries.

Disclaimer: I was a Clinical Assistant Professor of Medicine at the Cleveland Clinic from 2005 to 2008.

6 (reasonable) things to do in a doctor’s waiting room

1. Make a list of your top health concerns.

2. Write questions down.

3. Make a list of all your medications.

4. Ask the office to check on your test results.

5. Confirm that the office has the correct insurance information.

6. Read something besides the magazines.

References:
6 things to do in a doctor’s waiting room. ConsumerReportsHealth.org.

Image source: picturestation.net, free license.

Glaucoma eye drops drug Latisse used OTC to make long eyelashes but some now face side effects

From the NYTimes:

Latisse is the same formula as Lumigan, Allergan’s eyedrops for glaucoma, which reduces eye pressure but also happens to grow lashes. Both are also known as bimatoprost ophthalmic solution. In early 2009, Allergan introduced the drug as a lash enhancer.

A former primary care doctor runs www.latisse.bz, which boasts that it is the “largest Latisse retailer.” All it takes to get Latisse mailed out — without ever seeing him — is filling out a medical history, which he reviews, and typing in a valid credit card number.

But if people use Latisse without seeing a doctor, the side effects may come as a big surprise.

Eyelid discoloration “may be reversible” according to the manufacturer. A rare side effect that has captured the most attention is the chance that one’s hazel or blue eyes could turn brown — forever.

References:
Long Lashes Without Prescription, but With Risks. NYTimes, 2010.

Image source: Eyelashes, Wikipedia, Steve Jurvetson, Creative Commons Attribution 2.0 Generic license.

Good and Bad Health Habits in U.S.: drinkers outnumber exercisers

The CDC study shows that six in 10 American adults were regular drinkers in 2005-2007, but only about three in 10 regularly exercised.

Since 1997, rates of cigarette smoking have declined by several percentage points, rates of obesity have climbed, and rates of alcohol use, exercise, and sleep have remained relatively unchanged.

Men were more likely than women to be drinkers (68% vs. 55%).

The more educated people were, the more likely they were to drink. 74% of people who have a graduate degree were drinkers, compared with 44% of people with a high school diploma.

Adults with higher levels of education were less likely to be smokers, be physically inactive, and be obese and to sleep six hours or less per night.

Twitter comments:

@kcb704: "The more educated people were, the more likely they were to drink." http://goo.gl/JDv1 // work hard, play hard..

@BrettLinda: Hold on... good or bad? RT @DrVes Good and Bad Health Habits in U.S.: drinkers outnumber exercisers http://goo.gl/JDv1

References:
Good and Bad Health Habits in U.S. WebMD.

Images source: Wikipedia, Free Documentation License.

Best and Worst BBQ Food - Cleveland Clinic Video

When it comes to hot dogs vs. hamburgers, go with the hamburger. Choose mustard over ketchup.

"Microscopic cancers are forming in human body all the time"

From TEDtalksDirector — May 17, 2010 - William Li presents a new way to think about cancer treatment: angiogenesis, targeting the blood vessels that feed a tumor. The crucial first (and best) step: Eating cancer-fighting foods that beat cancer at its own game.

"We're probably forming microscopic cancers all the time in our body. Autopsy studies from people who died in car accidents have shown that about 40 percent of women between the ages of 40 and 50 actually have microscopic cancers in their breasts. About 50 percent of men in their 50s and 60s have microscopic prostate cancers. And virtually 100 percent of us, by the time we reach our 70s, will have microscopic cancers growing in our thyroid. Yet, without a blood supply, most of these cancers will never become dangerous. Dr. Judah Folkman, who was my mentor, and who was the pioneer of the angiogenesis field, once called this "cancer without disease."

Sunscreen with high SPF needed at high altitudes: 8-10% increase in sun exposure for every thousand feet of elevation

Golfers playing in Vail, Colorado, at 2500 meters (roughly 8200 feet) above sea level, got significantly more burn protection from sunscreen with a sun protection factor (SPF) of 70+ compared to one with an SPF of 15.

There is 8-10 percent increase in sun exposure for every thousand feet of elevation. In the summertime, you can get anywhere from 40 percent to 50 percent greater sun intensity than at sea level.

References:
Sunscreen with high SPF needed at high altitudes, Reuters.

What sunscreen to use for children?

Study confirms sunscreen prevents melanoma http://goo.gl/16Vqd

Can You Get Sunburned Through a Car Window? http://goo.gl/M7Fwv - No, but penetrating UVA rays may be related to left-sided skin cancers.

Related:

Melanoma - JAMA Patient Page illustrates the ABCDE of diagnosis, 2011.

Image source: Amazon, for illustration only, not a suggestion to buy any products.
Only 25% of Children Wear Sunscreen Regularly. WebMD, 2012.

A licensed "doctor"

Erectile dysfunction is a strong predictor of death in men with cardiovascular disease

From CNN:

Men with cardiovascular disease and ED were twice as likely to die from all causes than men who did not have erectile dysfunction. And those with ED were 1.6 times more likely to suffer from a serious cardiovascular problem such as a heart attack or stroke.

Erectile dysfunction is something that regularly should be addressed in the medical history of patients; it might be a symptom of early atherosclerosis.

Men with ED who are going to a general practitioner or a urologist need to be referred for a cardiology workup to determine existing cardiovascular disease and proper treatment. ED is an early predictor of cardiovascular disease.

References:
Study: Erectile dysfunction may indicate heart disease, death risk - CNN.com.

ED, Depression, Heart Disease: Does the Existence of One Component of This Triad Necessitate Inquiring the Other Two? http://goo.gl/EKvKl

Image source: Viagra (sildenafil), Wikipedia, GNU Free Documentation License.

Peace and Love

Ringo Starr's Peace and Love Birthday Wish 2010: Ringo Starr asks everyone to join him in a Peace & Love moment on his birthday July 7 2010 at noon where ever you are. "Perhaps one day everyone will have a moment of Peace & Love all over the world".

Pediatrician retires at 89, enjoys seeing 40-50 patients a day, will become an artist

From Scripps Interactive Newspapers Group:

"How are you? Have you retired?"

"No," said Dr. Segal, "I need to keep practicing until I get it right."

"You took care of my baby for me."

"Wonderful. How old is your baby now?"

"He's 58."

Dr. Segal laughed when he recounted this story. But, then, Segal laughs a lot. Maybe that's how he practiced medicine for more than six decades. Because he found pleasure in his work. So many people are in a hurry to retire so they can start having fun. Segal never understood the reason to wait.

He had fun going to the office every day, had fun saying hello to children and making them well.

Segal got an art degree from Memphis State. When World War II broke out, there wasn't much demand for artists. So Segal went to medical school.

Six decades later, he's not one of those doctors who will tell you how much better things used to be. Sitting in his office during his last week of work, Segal mostly wanted to talk about how good we have it now."

References:
Geoff Calkins: Retiring Dr. Segal didn't wait to have fun — he worked at it. Scripps Interactive Newspapers Group, 2010.

Pediatrics and Medicine

Image source: Wikipedia, GNU Free Documentation License.

Former FDA commissioner on the killer combination of salt, fat and sugar - our food

David A Kessler, former commissioner of the FDA (the US Food and Drug Administration):

"Our favourite foods are making us fat, yet we can't resist, because eating them is changing our minds as well as bodies

For example, KFC's approach to battering its food results in "an optimised fat pick-up system". With its flour, salt, MSG, maltodextrin, sugar, corn syrup and spice, the fried coating imparts flavour that touches on all three points of the compass while giving the consumer the perception of a bargain – a big plate of food at a good price."

The ranks of overweight adults and children continue to increase. For the first time in history, overweight persons actually outnumber those who are malnourished. Obesity now kills more men and women in developed nations than war, terrorist attacks, or climate changes. On average, obese individuals forfeit about 9 years of life.

More on the same topic in the video below:



"Fake foods are more affordable. It's enticing people to eat more because they think they're saving money when they're really just buying heart disease." 10 Questions for Jillian Michaels. TIME, 2010.

References:

Obesity: The killer combination of salt, fat and sugar | David A Kessler. Guardian.

JAMA - Fat, Gluttony and Sloth: Obesity in Literature, Art and Medicine, July 7, 2010, Miksanek 304 (1): 101 http://goo.gl/eEos
Sweat Bees prefer sweaty people because the human diet is so salty that their perspiration is saturated with that essential nutrient. WSJ, 2012.