What to look for when buying sunglasses?

From the NYTimes:

Unprotected exposure to sunlight can cause significant damage to the eyes

Sunlight can burn the surface of the eye, causing a temporary and painful condition known as photokeratitis. Over time, unprotected exposure can contribute to cataracts, as well as cancer of the eyelids and the skin around the eyes.

UV exposure also may increase the risk of macular degeneration, the leading cause of blindness in people over age 65.

What to look for when buying sunglasses?

Look for labels indicating at least “98 percent UV protection” or that it “blocks 98 percent of UVA and UVB rays.” If there is no label, or it says something vague like “UV absorbing” or “blocks most UV light,” don’t buy them.

For the best defense, look for sunglasses that “block all UV radiation up to 400 nanometers,” which is equivalent to blocking 100 percent of UV rays

Sunglasses should cover the sides of your eyes to prevent stray light from entering. Wraparound lenses are best. Look for close-fitting glasses with wide lenses. Avoid models with small lenses, such as "John Lennon-style" sunglasses.

UV protection is not related to how dark the lens is. Sunglasses tinted green, amber, red and gray may offer the same protection as dark lenses.

Polarized lenses block the horizontal light waves that create glare. But remember, polarization in itself will not block UV light.

You should be able to find a pair of drugstore sunglasses for $10 to $20 that provide all the protection you need.

References:
Let the Sunshine in, but Not the Harmful Rays. NYTimes, 2011.

Image source: OpenClipArt.org, public domain.

Average time patients spend waiting to see a health-care provider is 22 minutes

The average time patients spend waiting to see a health-care provider is 22 minutes. Orthopedists have the longest waits, at 29 minutes; dermatologists the shortest, at 20.

Patient satisfaction dropped significantly with each 5 minutes of waiting time. Even the term "waiting room" has a bad connotation. Many offices prefer "reception area" instead.

"I live my life in seven-minute intervals," says Laurie Green, a obstetrician-gynecologist in San Francisco who delivers 400 to 500 babies a year and says she needs to bring in $70 every 15 minutes just to meet her office overhead.

Measures the health-care industry is trying to minimize waiting time include:

- "Open-access" scheduling
- Minimize office visits
- Advance preparation
- Huddling up: "Mr. Jones is in a 15-minute slot, but we know he's a 45-minute guy"
- Teamwork
- Cutting "cycle time"
- Keep patients informed
- Survey patients

References:

The Doctor Will See You Eventually. WSJ.
Patients directed to online tools don't necessarily use them: 25% checked website vs. 42% read same material on paper. Am Medical News, 2012.

Image source: OpenClipArt.org, public domain.

Managing fever of unknown origin in adults - BMJ review

Few clinical problems generate such a wide differential diagnosis as pyrexia (fever) of unknown origin. The initial definition proposed by Petersdorf and Beeson in 1961 was later revised. Essentially the term refers to a prolonged febrile illness without an obvious cause despite reasonable evaluation and diagnostic testing.

Definition

Classic adult fever of unknown origin (FUO) is fever of 38.3°C (101°F) or greater for at least 3 weeks with no identified cause after 3 days of hospital evaluation or 3 outpatient visits

Causes of FUO

Common causes of FUO are infections, neoplasms, and connective tissue disorders.

Investigations almost always include imaging studies. Serological tests may be indicated

Treatment of FUO

Empirical antibiotics are warranted only for individuals who are clinically unstable or neutropenic. In stable patients empirical treatment is discouraged, although NSAIDs may be used after investigations are complete. Empirical corticosteroid therapy is discouraged.

References:

Investigating and managing pyrexia of unknown origin in adults. BMJ 2010; 341:c5470 doi: 10.1136/bmj.c5470 (Published 15 October 2010).

Image source: Wikipedia, public domain.

"How to Conquer Your Fear of Doctors"

The term "content farm" describes a company that employs large numbers of often freelance writers to generate large amounts of textual and/or video content which is specifically designed to satisfy algorithms for maximal retrieval by search engines. Their main goal is to generate advertising revenue through attracting reader page views (source: Wikipedia).

This is what the content farms are producing nowadays:

How to Conquer Your Fear of Doctors (HowCast video). A mix of good and bad advice, don't take it seriously:

"How to Live to Be 100" (HowCast video). Some tips in the video may fall in the category "Do not try this at home":

Only 62% of referring PCPs received consultation results from specialists

Communication between primary care physicians (PCPs) and specialists regarding referrals and consultations is often inadequate, with negative consequences for patients.

A study found that perceptions of communication regarding referrals and consultations differed.

For example, 69% of PCPs reported "always" or "most of the time" sending notification of a patient's history and reason for consultation to specialists, but only 34.8% of specialists said they "always" or "most of the time" received such notification.

Similarly, 80.6% of specialists said they "always" or "most of the time" send consultation results to the referring PCP, but only 62% of PCPs said they received such information.

The 3 practice characteristics associated with PCPs and specialists reporting good communication regarding referrals and consultations were:

- "adequate" visit time with patients

- receipt of quality reports regarding patients with chronic conditions

- nurse support for monitoring patients with chronic conditions

Twitter comments:

@westr: Case for EHRs...

@Kind4Kids: but then the inpatient and outpatient EHR need to "communicate".

@GruntDoc: 0% of ED docs... -- Only 62% of referring PCPs received consultation results from specialists

References:

Referral and Consultation Communication Between Primary Care and Specialist Physicians. Arch Intern Med. 2011;171(1):56-65. doi:10.1001/archinternmed.2010.480

86% of Australian doctors report high rates of job satisfaction - see why

More than 80% of Australian doctors are moderately or very satisfied with their jobs, a national survey has found.

The survey, of 10 498 doctors, 19% of those who were contacted and eligible, found that 86% were moderately or very satisfied with their jobs, with no significant differences between GPs, specialists, and specialists in training. Hospital non-specialists were less satisfied.

The predictors of high professional satisfaction included:

- a good support network

- a household with a high income

- patients with realistic expectations w
- being able to take time off

- being younger or close to retirement

- having good self reported health.

Female GPs earn an average 25% less than their male counterparts and that GPs on average earn 32% less than specialists. The average annual pretax personal earnings of GPs and specialists were $US 180 000 and $US 316 570, respectively.

With Australia in the throes of national health reform, the researchers said that their findings set an important baseline for examining the effects of policy changes on doctors’ job satisfaction.

The survey was conducted between June and November 2008, before the Australian government announced its national health reform agenda.

The survey findings were published in the 3 January edition of the Medical Journal of Australia.

Twitter comments:

@gastromom (Meenakshi Budhraja): What are comparative figures in the US - 80% of Australian doctors report high rates of job satisfaction http://goo.gl/mchQT”

@PMillerMD (Philip Miller): 80% of Australian doctors report high rates of job satisfaction. / What is it in US? And if lower, why? I suspect payment morass.

@cotterj1 80% of Australian doctors report high rates of job satisfaction http://goo.gl/mchQT -> Explains why half the HSE docs are gone!

@SeattleMamaDoc (WendySueSwanson MD): "A good support network" goes long way.

@docmuscles (Adam Nally, D.O.) This was before the health care reform (HCR).

References:

Australian doctors report high rates of job satisfaction. BMJ 2011; 342:d119 doi: 10.1136/bmj.d119 (Published 10 January 2011)

Australian doctors’ satisfaction with their work: results from the MABEL longitudinal survey of doctors. MJA 2011; 194 (1): 30-33.

Image source: Wikipedia, public domain.

When physicians prescribe a new medication... confusion ensues

According to a 2006 study of physician-patient communication during primary care visits, when physicians prescribed a new medication they:

- did not tell the patient the name of the new medication in 26% of the cases (the other way to look at the data is that the physicians stated the specific medication name for 74% of new prescriptions)

- did not explain the purpose of the medication to patients in 13% of cases (explained the purpose of the medication for 87%)

- did not tell patient about adverse side effects of the medication in 65% of cases

- did not describe to patients how long to take the medication in 66% of cases

- did not tell patients the number of pills to take in 45% of cases

- did not tell patients about medication dosing and timing in 42% of cases

References:

Hospitals: Check doctor's communication skills before buying the practice. ACP Blog.

Physician Communication When Prescribing New Medications. Arch Intern Med. 2006;166:1855-1862.

Image source: Wikipedia, public domain.

Sports Health With Cleveland Clinic (video)

There are a lot more sports health-related video from Cleveland Clinic on YouTube. I find many of these useful but they often don't get the numbers of views they deserve, for example the video embedded above was watched only 20 times as of 03/23/2011 (it was posted on 01/10/2011).

What drug to add to maximal metformin therapy for diabetes?

Metformin is the recommended initial drug therapy for patients with type 2 diabetes mellitus (DM). However, the optimal second-line drug when metformin monotherapy fails is unclear.

All noninsulin antidiabetic drugs were associated with similar HbA1c reductions but differed in their associations with weight gain and risk of hypoglycemia.

The different classes of drugs were associated with similar HbA1c reductions (range, 0.64%-0.97%) compared with placebo.

Noninsulin antidiabetic drugs and their effect on body weight:

- thiazolidinediones, sulfonylureas, and glinides were associated with weight gain (range, 1.77-2.08 kg)

- glucagon-like peptide-1 analogs, alpha-glucosidase inhibitors, and dipeptidyl peptidase-4 inhibitors were associated with weight loss or no weight change

Sulfonylureas and glinides were associated with higher rates of hypoglycemia than with placebo.

References:

Effect of Noninsulin Antidiabetic Drugs Added to Metformin Therapy on Glycemic Control, Weight Gain, and Hypoglycemia in Type 2 Diabetes. JAMA. 2010;303(14):1410-1418. doi: 10.1001/jama.2010.405

Insulin treatment for type 2 diabetes: When to start, which to use - The Cleveland Clinic approach

Image source: Metformin. Wikipedia, public domain.

Microsoft software to "replace" radiologists - recognizes organs and structures in medical images

Microsoft Research, Mar 8, 2011: InnerEye focuses on the analysis of patient scans using machine learning techniques for automatic detection and segmentation of healthy anatomy as well as anomalies:



Antonio Criminisi is the the researcher shown in the video above.

The InnerEye research project focuses on the automatic analysis of patients' scans by using machine learning techniques for:

- Automatic detection and segmentation of healthy anatomy, as well as anomalies

- Semantic navigation and visualization

Microsoft Research methods aim to combine medical expertise and modern machine learning theory in the design of tools for computer-aided diagnosis, personalized medicine, and natural user interfaces for surgical intervention.

The InnerEye project has a host of famous collaborators, including Johns Hopkins Medical Institute, The University of Oxford, Cornell Medical School, Massachusetts General Hospital, the University of Washington, Kings College London, and Cambridge University Hospitals.

High-Performance Cancer Screening: See how a high--performance, 3-D rendering engine can be transformed into a real-world, life-saving medical application:



References:

Medical Image Analysis

InnerEye: Visual Recognition in the Hospital
A Search Engine for the Human Body. Technology Review.

Comments from Twitter:

@hrana (Hisham Rana, MD): No thanks. RT @DrVes: Microsoft software to "replace" radiologists - recognizes organs and structures in medical images http://goo.gl/HwNNx

@doctorwhitecoat (Vamsi Balakrishnan): Definitely not a replacement... but cool tool in development.

@DrVes: Well, of course it's not a replacement... :) Just as "Watson" supercomputer won't replace PCPs/specialists...

@doctorwhitecoat (Vamsi Balakrishnan): Watson can't replace 3rd year Med students either; it can't do scutwork...:)

@ILoveOrthopedix (Orthopaedic Resident): MS Radiology! very interesting - the ECG machines recognise patterns & give diagnoses, but all the doctors make their own diagnosis.

@drcrosby (Bradley Dick): Reminiscent of Robin Cook's "Brain"?! (http://en.wikipedia.org/wiki/Brain_(novel))

Oropharyngeal carcinoma increased by 22% in 6 years, related to rise in HPV

Head and neck cancer is the sixth most common cancer. Despite an overall marginal decline in the incidence of most head and neck cancers in recent years, the incidence of oropharyngeal squamous cell carcinoma has increased greatly, especially in the developed world.

In the United States, the incidence of oropharyngeal squamous cell carcinoma increased by 22% between 1999 and 2006.

The increase in incidence of oropharyngeal squamous cell carcinoma seems to be accounted for by a rise in human papillomavirus (HPV) related oropharyngeal carcinoma.

References:

Oropharyngeal carcinoma related to human papillomavirus. BMJ 2010; 340:c1439 doi: 10.1136/bmj.c1439 (Published 25 March 2010).

Image source: HPV types and associated diseases, Wikipedia, public domain.

Twitter comments:

@travispew (Travis Pew): So get your kids the HPV shot.

Bullying: What parents can do (CNN video)

Related:

Targeted student: 'It's hard not to say something'. CNN

Another CNN video.
DNA of children who experienced violence and bullying shows wear and tear that is associated with rapid aging http://goo.gl/FzY2i

Promise of Prevention: Effects of 4 Risk Factors on U.S. Life Expectancy and Disparities

This analysis included 4 preventable risk factors:

- smoking

- high blood pressure

- elevated blood glucose

- adiposity

The researchers estimated the effects of these 4 preventable risk factors on national life expectancy and on disparities in life expectancy and disease-specific mortality among 8 subgroups of the US population (the “Eight Americas”). The groups were defined on the basis of race, location and socioeconomic characteristics of county of residence, in 2005.

Who has the lowest number of risk factors?

Asians had the lowest mean body mass index, fasting plasma glucose, and smoking; whites had the lowest systolic blood pressure (SBP).

Who has the highest number of risk factors?

Systolic blood pressure (SBP) was highest in blacks, especially in the rural South - 5-7 mmHg higher than whites. The other three risk factors were highest in Western Native Americans, Southern low-income rural blacks, and/or low-income whites in Appalachia and the Mississippi Valley.

How much shorter is life expectancy if you have the risk factors?

These 4 risk factors reduced life expectancy at birth by 5 years in men and 4 years in women.

Life expectancy effects were smallest in Asians (M, 4.1 y; F, 3.6 y) and largest in Southern rural blacks (M, 6.7 y; F, 5.7 y).

Smoking and high blood pressure had the largest effect on life expectancy disparities.

Disparities in the 4 risk factors (smoking, blood pressure, blood glucose, and adiposity) explain a significant proportion of disparities in mortality from cardiovascular diseases and cancers. They also explain some of the life expectancy disparities in the US.

References:

Danaei G, Rimm EB, Oza S, Kulkarni SC, Murray CJL, et al. (2010). The Promise of Prevention: The Effects of Four Preventable Risk Factors on National Life Expectancy and Life Expectancy Disparities by Race and County in the United States. PLoS Med 7(3): e1000248. doi:10.1371/journal.pmed.1000248

Image source: Wikipedia, public domain.

Investigating easy bruising in a child

From BMJ:

In a child, unusual bruising or bleeding out of proportion to the injury sustained should be investigated.

All children under investigation for easy bruising or a bleeding tendency should have:

- full blood count
- blood film (peripheral smear)
- coagulation screen including a thrombin time, in addition to a Von Willebrand factor assay and assays of factors VIII and IX

This is to ensure that mild forms of haemophilia are excluded even if the activated partial thromboplastin time is normal

In 30% of cases of haemophilia, there is no family history: it arises secondary to new genetic mutations


The coagulation cascade. Black arrow - conversion/activation of factor. Red arrows - action of inhibitors. Blue arrows - reactions catalysed by activated factor. Grey arrow - various functions of thrombin. Image source: Wikipedia

References:
Investigating easy bruising in a child. Anderson and Thomas 341, BMJ.

Collecting family history predicts cancer risk better than 23andMe genetic testing

Collecting family history predicts cancer risk better than 23andMe genetic testing, according to a recent study from the Cleveland Clinic:

As you're sharing fond family memories, don't forget to bring up family health history -- it's the best gift you can give. Dr. Charis Eng comments on a study she led looking at the important role of family history in predicting future disease risk.

Whole genome sequencing fails to predict risk of most common diseases, according to BMJ.

Related reading

Beware the fortune tellers peddling genetic tests - BMJ http://goo.gl/F0DQt

Family History and Personal Genetic Risk Assessments: A Perspective on the Cleveland Clinic Study. 23andMe.com.

FDA panel: genetic testing should not be available directly to consumers without what amounts to a "prescription". WebMD, 2011.
Genetic testing is available for approximately 2000 clinical conditions - Preparing for Precision Medicine - NEJM, 2012.
How to talk to patients about genetic testing  http://goo.gl/kkW4m

Comments from Twitter

@23andMe: See our perspective of Cleveland Clinic study - http://bit.ly/c373aj - bottom line is 2 aren't the same, so can't compare h2h. Also, we agree that family history is a very important piece, and believe it complements detailed genetic info.

There are 25,400 scientific journals and their number is increasing by 3.5% a year

More scientific and medical papers are being published now than ever before. Is it possible to be an expert nowadays, asks BMJ.

Every doctor has an ethical duty to keep up to date. Is this just getting more difficult or has it already become impossible? Since Alvin Toffler coined the phrase “information overload” in 1970, the growth of scientific and medical information has been inexorable.

There are now 25 400 journals in science, technology, and medicine, and their number is increasing by 3.5% a year; in 2009, they published 1.5 million articles. PubMed now cites more than 20 million papers.

One response of the medical profession to the increasing scientific basis and clinical capacity of medicine has been to increase subspecialisation. This may restrict the breadth of knowledge of the ultraspecialist, but can such subspecialists still maintain their depth of expertise?

I described my approach in 5 Tips to Stay Up-to-Date with Medical Literature:

1. RSS Feeds for Medical Journals.

2. Podcasts.

3. Persistent Searches on PubMed, Google News and Google.

4. Text-to-speech (TTS) for journal articles.
5. Blogs and Twitter accounts.

If you have a blog or Twitter account, you can try to deal with the information overload from blogs, RSS and Twitter more efficiently by using this:

The circle of online information (click to enlarge).

References:
On the impossibility of being expert. BMJ 2010; 341:c6815 doi: 10.1136/bmj.c6815.

How to deal with the information overload from blogs, RSS and Twitter?

5 Tips to Stay Up-to-Date with Medical Literature

Electronic medical record (EMR) - review of pros and cons in Cleveland Clinic medical journal

Some negatives regarding the use of EMR:

- So far, electronic systems are not interconnectable
- Do electronic records improve or worsen the quality of care?
- Accuracy vs copying and pasting
- A third party in the examination room
- Devoid of real medical thought

A contrasting view:

- Connectivity will improve
- Staying focused on the patient, even with a computer in the room
- Doctor-doctor communication is enhanced

References:
The electronic medical record: Diving into a shallow pool? CCJM.
The electronic medical record: Learning to swim. CCJM.
"The iPatient is getting wonderful care across America. The real patient wonders, "Where is everybody?" NYTimes, 2011.

Blogs read by 20% of UK medical students, but only 8% write their own

A wide range of social media tools has become readily available in recent years, to the extent that the use of Facebook in particular is perceived as "second nature" by many students. There is increasing interest in the possibilities of using this social media services for medical education - blogs, wikis, Twitter and Facebook.

This UK study included a self-administered questionnaire survey of 212 first year medical students.

Over 90% used instant messaging. Social networking sites were also highly used - by 70%. There was no significant difference between males and females.

Blogs were read by 20% of students and a small number (8%) wrote their own blogs.

20% of males were users of media sharing and contributed to wikis.

Social bookmarking was rarely used by either gender.

Medical educators need to recognise the potential of social software in medical education but it is essential that students maintain the informality and privacy of these sites. The challenge is how to integrate social software into current curricula and institutional Virtual Learning Environments.

References:
Web 2.0 and social software: the medical student way of e-learning. Sandars J, Homer M, Pell G, Crocker T. Med Teach. 2010 Jun 18.

Comments from Twitter:

@DrVes I didn't expect that 8% of med students in the study wrote blogs - this is not my experience from teaching students and residents at Cleveland Clinic, Case Western and Creighton University.

@sandnsurf Medical education blog vs tumblr/posterous blog possibly. My students are at 10% for blog writing but 1% are actually medical.

@DrVes This is way higher than the stats here in the U.S. "Everybody's on Facebook, nobody has a blog"... :)

@doctorwhitecoat Not to jump mid convo, but at my school, I can say that most don't have blogs... at most maybe 3-5% and those that do... don't update.

@DrVes 2-5% is high. There was only one blogging student at Cleveland Clinic medical school who stopped after 1-2 years.

Related reading:

Assistant professor uses Twitter to teach students dental anatomy at Ohio State University - 113 of 200 students signed up, 56% http://goo.gl/jvyq7

Image source: Blogger.com.

Current school system is failing boys - how to re-engage them in learning - TED video

At TEDxPSU, Ali Carr-Chellman pinpoints 3 reasons boys are tuning out of school in droves, and lays out her bold plan to re-engage them: bringing their culture into the classroom, with new rules that let boys be boys. The first part of the talk points to some eye-opening facts about how the current school system is failing boys.