April 19, 2014

SHM 2014: visceral reactions

The 2014 national meeting of the Society of Hospital Medicine was held March 25-27. I've been busy since I got back and am just now getting around to “blogging the conference.” This, I hope, will be but one of a series of posts about the meeting.Bob Wachter shared some of his thoughts the other day. I thought I'd read his post before starting. Bob can be a little provocative and sure enough

7 ways chronic illness imposes an extra burden on the young

From years of writing about chronic pain and illness, I’ve learned that young people carry several extra burdens, especially when their disability is invisible (as is more often the case than not). This piece focuses on young people, although some of its points apply to people of any age, depending on their circumstances.

1. Young people are treated as if their health issues can’t possibly be chronic. I confess that before I became a member of the community of the chronically ill, I thought that a young person — through their 30s at least — was either healthy (aside from the occasional cold or flu) or had a terminal illness. I had no idea that millions of young people live day-to-day with chronic illness. They suffer from symptoms that, while not life-threatening, affect every aspect of their lives: unrelenting pain; debilitating fatigue; shortness of breath or vertigo; damage to vital organs, such as the lungs and kidneys. Many of them have spent a good part of their childhood and young adulthood in medical settings; some have undergone multiple surgeries.

I know about this now, because I hear from young people almost every day. They read my books or my articles and write to me about their day-to-day challenges. For many of them, at the top of the list of those challenges is the fact that other people simply don’t believe that a young person could possibly suffer from a condition that might last a lifetime.

In short, the thoughts “young” and “acute” appear to go together in most people’s minds, but “young” and “chronic” do not.

When young people are treated as if their condition can’t possibly be chronic, not only do they feel hurt and disregarded, but they may begin to question their own perceptions and judgment: “Is my body really this sick and in pain? Everyone says it can’t possibly be the case, so maybe it’s all in my head.” This questioning can lead to self-recrimination and can seriously erode a young person’s self-esteem and sense of self-worth.

This ignorance about young people with chronic illness has other consequences. Several young people have told me that they’ve been openly challenged when they park in a disabled spot, even though they have the required placard or sticker. (By contrast, no one has ever challenged me.) A young woman with multiple sclerosis told me that someone spit on her when she didn’t give up her seat to an older person on the subway.

I feel frustrated and sad when young people tell me that they’ve been challenged by others in this way. No one is too young to suffer from an invisible disability, and everyone should give others the benefit of the doubt.

2. Young people are repeatedly told: “You’re too young to be in pain.” I’m not young, so no one has said this to me, but I’ve had countless young people write to me, saying that it’s one of the most frustrating and hurtful comments they have to listen to. No matter what their diagnosis, they’re continually told that they can’t possibly be in pain at their age. Imagine how hard it must be to respond skillfully to a comment like that.

Sometimes they’re even told they’re too young to have the very illness they’ve been diagnosed with, especially if it’s something we tend to associate with being older, such as Osteoarthritis. When this happens, young people have to listen to comments like: “No one your age gets arthritis” or “You’re too young to be in pain from arthritis.”

A 2013 study by the National Research Council and Institute of Medicine (NAC/IOM) showed, not just that Americans are getting sicker, but that young Americans are getting sicker. We need to raise awareness about the fact that chronic pain and chronic illness can strike anyone at any age.

I have a few comments on these first two burdens — comments that I’d like to address directly to young people.

First, regarding strangers who are rude, in my view, the best response is to immediately take care of yourself by not allowing their insensitivity to make you question yourself. The problem lies with their ignorance about chronic illness; it does not lie with you. I recommend working on developing a state of mind in which you are unconditionally your ally in this type of situation. Try to separate the person’s response to you from your response to yourself. In other words, you know you’re sick, and that should be good enough for you. It takes practice, but it’s worth the effort.

As for family and friends who say your condition can’t possibly be chronic or that you’re too young to be in pain, of course, you should try to educate them. But, in the end, not all of them may be receptive. When this happens, I recommend thinking about it this way: it’s better to have two friends and family members who believe you and are interested in what life is like for you than to have ten who don’t.

Many of my friends dropped away when I became chronically ill. I’ve learned to treasure the few who stuck around and the few who’ve newly entered my life, because I know they don’t question the chronic nature of my symptoms. I’ll stick with those who support me, and let the others go. This is an equanimity practice: working on accepting with grace that people’s behavior will not always conform to your wishes…and learning to be content with those who are there for you.

3. Young people worry that they’ll never find a romantic partner. Living day-to-day with an unpredictable medical condition makes it hard to sustain regular friendships no matter how old you are. It’s even harder to find romance. This is an ongoing worry for young people who are chronically ill. Many relationships don’t get past the first date. A young woman with Lupus recently wrote to me about a dinner date she’d had. The evening was going well, but when the guy found out that she wouldn’t be able to go to a concert on the weekend because she was scheduled to get chemotherapy, he lost interest in her all together.

When I got sick, I was fortunate to have a committed partner who took that “in sickness and in health” vow seriously. When I reflect on my limitations, it’s hard for me to imagine that I’d be able to find romance were I young. I may not get regular treatments as does the young woman with Lupus, but my illness severely restricts my ability to engage in activities. For example, this concert she spoke of would not only have to be during the day, but it would have to be close to home, and last no more than two hours. What are the odds of that being the case?

And even those criteria don’t cover my chances of being able to attend. My symptoms are so unpredictable that, even if I agreed to go to the concert, I might wake up the morning it’s scheduled and be too sick to go. Cancelling plans at the last minute (especially plans that involve expensive tickets!) is not exactly a recipe for beginning a romantic relationship.

It’s a sobering thought to reflect on how unlikely it would be for me to find romance were I young. On a positive note, it can happen if an understanding and patient person enters the life of a young person who is chronically ill. It helps to think of creative ways to meet people. One woman told me that she met her fiancé online through a dating site (be sure it’s a legitimate one). She said that the two of them had become so close via their back and forth emails that, when they finally met in person, it mattered not a bit to him that she was disabled.

4. Young people often can’t complete their education. College is usually a ticket to brighter employment prospects. But when chronic illness strikes, young people are often forced to drop out of school. Again, I’ve received dozens of notes from young people, saying things like: “I was unable to get my B.A. because of the unpredictability of whether I’d be able to attend classes on any given day”; “I was 2/3 of the way to my Ph.D. when the crippling pain of [fill in the blank] forced me to drop out of the program.”

When I served as the dean of students at the law school at U.C. Davis, I tried to help a young man who’d been sick with what the doctors initially thought was an acute viral infection. When, after six months, he still hadn’t recovered, he was given the diagnosis of Chronic Fatigue Syndrome. He was a dedicated student and was determined to get his law degree. When he and I realized that he could no longer keep up in his classes, I put him on a four-year program, which extended his studies by a year so that he could take a lighter class load. We thought that would do the trick.

But soon, he lost his ability to take care of his daily needs. Some days he couldn’t get out of bed at all. This meant that he not only had to miss classes, but he couldn’t get to the grocery store to buy food. It became increasingly clear that he could no longer live independently. And so, after completing 3/4 of the units toward his law degree, he had no choice but to withdraw from school and move back in with his parents who lived in another state.

I felt so bad for him. Little did I know that eight years later, I’d be given the same diagnosis and be forced, in effect, to withdraw from the very same school.

Young people with chronic illness often have to think outside the box when it comes to their education. This can be very difficult to do when a person is already struggling day-to-day with not feeling well. Hopefully, a dean of students or the Disability Services Office on campus can help with brainstorming and with creative solutions, such as moving to an extended program or taking some classes online.

5. Young people must sit by and watch others their age participate in activities that are out of reach for them. A few months ago, I read an article in The Atlantic that was written by the wife of a 33 year-old-man who’d been diagnosed with the autoimmune disease, Ankylosing Spondylitis. In the article, she quoted her husband describing how difficult and polarizing it was to be with people who weren’t sick:

It’s, like, I’m still only 33. I probably am still considered in a lot of people’s eyes [to be] youthful enough that I shouldn’t have to deal with thinking about this kind of stuff. I feel like my parents were still partying and drinking beers [at 33]. This is the age my Dad was when they had me. I don’t think [he] was worrying about what [expletive deleted] pills he was going to take or not take, you know what I mean? They were like “We’re out of Budweiser.”

Many young people tell me about their once-active lifestyles as hikers or marathon runners or social activists or yoga instructors. They’re frustrated, and sometimes they’re very angry. Always…they’re sad. Worst of all, they tend to blame themselves for their inability to be active. I tell them over and over: “It’s not your fault.” I also encourage them to focus on what they can do and to look for others (online or in-person) who have similar interests. It takes effort, but it’s well-worth it.

6. Young people may be stigmatized by others. Consider, for example, the  burden that a chronically ill child in grade school must bear. When I was that age, I got upset if I had a cold and had to miss a dance lesson or a field trip. Imagine having to miss weeks of school at a time and not being able to participate in extracurricular activities. Not only do these children have to cope with this “life interrupted,” but they may be stigmatized by others and suffer from terrible embarrassment.

When I was in grade school, all I wanted was to fit in or, at least, not be noticed. There was a boy named Alan in my 6th grade class who suffered from asthma so severe that he missed weeks of school at a time. When he did show up, everyone knew “this is the kid who’s always sick,” and we treated him differently because of it. There was certainly no fitting in, no anonymity for Alan. He was stigmatized.

I realize now how terribly hard this must have been for him. He had to deal both with his illness and with his peers treating him as different. I hope he’s had a good life, filled with love and understanding from family and friends. I wish I’d been compassionate enough to have been one of those friends.

7. Young people are burdened with worries about the future. Of course, people of all ages and health statuses occasionally worry about the future. But young people who are chronically ill have a lifetime of health-related worries ahead of them — worries that are likely to include: What will happen to my health in the years to come? Will my condition gradually worsen? Will I become more and more restricted in my activities? Will I be able to support myself? Will I be able to live independently or will I become increasingly dependent on my family?

I encourage young people to talk to friends and family — even doctors — about these issues. The more information they can gather and the more support they have, the better equipped they’ll be to plan for the future.


Chronic illness imposes an extra burden on the young. The challenges I’ve discussed make an already difficult life even harder. My heart goes out to these young people and their families, especially their parents who often become their caregivers. I’ve raised two children. I know how uneasy I felt every time one of them had an acute illness. I can only imagine how hard it would have been had one of them been chronically ill.

Toni Bernhard was a law professor at the University of California—Davis. She is the author of How to Be Sick: A Buddhist-Inspired Guide for the Chronically Ill and their Caregivers and How to Wake Up: A Buddhist-Inspired Guide to Navigating Joy and SorrowShe can be found online at her self-titled site, Toni Bernhard.

Your patients are rating you online: How to respond. Manage your online reputation: A social media guide. Find out how.

What physicians can do to curb over-the-counter medicine misuse

Every year, it is estimated that more than 126,000 hospitalizations and nearly 17,000 deaths in this country are linked to overuse of over-the-counter (OTC) pain medicine ingredients — specifically acetaminophen and NSAIDs (nonsteroidal anti-inflammatory drugs).

In my own practice, it’s not uncommon to find patients who are taking two to four times the recommended doses. This can have tragic results.

Continue reading ...

Your patients are rating you online: How to respond. Manage your online reputation: A social media guide. Find out how.

April 18, 2014

Sarcoidosis - 2014 Lancet review

Sarcoidosis is a systemic disease of unknown cause that is characterised by the formation of immune granulomas in various organs, mainly the lungs and the lymphatic system.

Sarcoidosis might be the result of an exaggerated granulomatous reaction after exposure to unidentified antigens in individuals who are genetically susceptible.

Diagnosis is made by symptoms, PFTs, CXR, CT, endobronchial ultrasound and PET for assessment of inflammatory activity.

Recognition of unexplained persistent disabling symptoms, fatigue, small-fibre neurological impairment, cognitive failure, and changes to health state and quality of life, has improved.

Mortality in patients with sarcoidosis is higher than that of the general population, mainly due to pulmonary fibrosis.


Sarcoidosis - The Lancet http://bit.ly/1eh9I5S
Image source: Lungs, Wikipedia, public domain.


I still love being an internist

Many internists feel frustration over administrative burdens, a payment system that encourages you to decrease visit length (could we just ban productivity measures forever), MOC, the possibility of MOL and numerous regulations.

A recent Daily Beast article provides a very slanted view – How Being a Doctor Became the Most Miserable Profession. Multiple friends have sent me this article. I can only describe this article as hyperbolic.

This wonderful counter post expresses my feelings – Sorry, being a doctor is still a great gig.

I think physicians complain far more, and far more publicly, than their situations warrant. For all their complaints, they still do incredibly well financially. They have more professional freedom than most working people. And they’re beloved.

I do know many happy physicians. These physicians focus on the positives in medicine.

Talk to most physicians and they still like interacting with patients. We all complain about various administrative issues, because we really do like spending our time with patients. We like the challenges that medicine provides.

I can not imagine doing anything else. I cannot imagine a profession or a job that would challenge me intellectually and provides me the emotional satisfaction of knowing that I am trying to help.

We who are glass half full (or 3/4 full) people, focus on the positives and not the negatives. Obviously the half empty folks have greater focus on the negatives and no longer get great satisfaction from patient care.

We have problems in medicine, problems that we must identify and work hard to eliminate. But being a physician is inherently a wonderful life. I, for one, feel very fortunate to have this profession.

April 17, 2014

Another chapter in the never endling clash between the collective and the individual regarding health care

The following comments were inspired by this insightful and very well written commentary by Margarit Gur-Arie entitled "Is the Nuremberg Code Obsolete?" After reading about where the cronies at IOM and the ideologues at Hasting Institute want to take us, I have to shout "It sure as hell better not be obsolete and do you people even know anything about the events that took place in Europe (or Macon county,Alabama for that matter)  in the 20th century and why we have the Code in the first place."

One of the more troubling developments in recent years in medical care is the seemingly increasing acceptance of the notion of the importance of the health of the collective even if sometimes to the determent of the welfare of the individual and that the latter seem to exist for the welfare of the former.

One of the latest twists here is that some are arguing that certain types of clinical research can be done without getting consent of the participants or even informing them about what it going on.

Quoting Gur-Arie:

" The Office for Human Research Protections (OHRP) held a public hearing in August 2013 regarding the nature of informed consent for randomized clinical trials...., two very distinct opinions regarding consent emerge from reading the various testimonies before the committee. The traditional opinion argues that there is a difference between treatment and research and that informed consent is required for both, including study of “standard care” interventions, CER and QI; that randomization always deprives research subjects of the judgment of their physician and that these issues are governed by law (e.g. the Constitution and such). The progressive view, presented by testimony from members of the Institute of Medicine (IOM), its Clinical Effectiveness Research Innovation Collaborative (CERIC), NIH and other research establishments, posits that randomization of “standard care” interventions poses no additional risks to patients, since doctors’ decisions are essentially like flipping a coin anyway, and therefore patients in this new learning system may be subjected to randomized CER and QI experiments without explicit consent and with minimal, if any, information (e.g. “something posted on the door”)."

 Related is this Hasting Center  report which speaks of   (with my bolding):

"The obligation of patients to contribute to the common
purpose of improving the quality and value of clinical care
and the health care system.
Traditional codes, declarations,
and government reports in research ethics and clinical ethics
have never emphasized obligations of patients to contribute
to knowledge as research subjects. These traditional presumptions
 need to change. Just as health professionals and
organizations have an obligation to learn, patients have an
obligation to contribute to, participate in, and otherwise facilitate learning.
This obligation is justified by what we call a norm of
common purpose. This norm of common purpose is similar
to what John Rawls calls the principle of the common good."

Wow, here is a group composed mainly of several ethicists from Johns Hopkins who presume to define an obligation for everyone and redefine the ethics of medical research, a goal they openly admit to in the first paragraph of their report.Everyone has an obligation to work for the common purpose of better health care.

Once all the health care providers and all the patients work together to participate in and gather the data about various medical tests and treatments the very smart people will be able to analyze it all and determine what is best for the collective. Utopian health care is within the reach of the  very smart people with ideas.

Top medicine articles for April 2014

A collection of some interesting medical articles published recently:

Noninfluenza Vaccination Rates Among U.S. Adults Remain Low - only 16% for Tdap in 2012 http://buff.ly/NcduqD

Adult Tonsillectomy Shown to Be Safe: 30-day mortality rate was low, at 0.03%. 1.2% had complications http://buff.ly/1c96hwI

Parabens in Our Lotions and Shampoos - they are in 15,000 personal care products - and mimic estrogen http://buff.ly/Ncer2n

Counter-intuitive Full-Fat Paradox: Whole Milk May Keep Us Lean - NPR reviews the evidence http://buff.ly/1aUOgax

Cat Bites May Lead to Serious Infections - they inject harmful bacteria deep into joints and tissue http://buff.ly/1ntVlPU

Having 3 items (TV, computer, car) increases risk of obesity and diabetes 3-4 fold in developing nations http://buff.ly/1aUPSRG

Prognosis of Adolescent Mental Disorders (anxiety, depression) - 40-50% continued to have problems as adults. From ages 21–29, 52% of women and 31% of men met diagnostic criteria at least once for anxiety or depression http://buff.ly/1ntWxmc

12% of U.S. spice imports are contaminated with insect/rodent parts, 7% contain salmonella http://buff.ly/N0HXr7

Drugs Made in India Set Off FDA Safety Worries: antibiotic and chemotherapy tablets had no active ingredients - NYTimes. India’s pharmaceutical industry supplies 40% of over-the-counter and generic prescription drugs consumed in U.S. The World Health Organization estimated that one in five drugs made in India are fakes http://buff.ly/N0ImcY

The French way of cancer treatment | Reuters http://buff.ly/N0K9Pe

Genotype-guided personalization may improve cost-effectiveness of prasugrel and ticagrelor for ACS http://buff.ly/NacAdE

Driving Under the Influence, of Marijuana - NYTimes http://buff.ly/NadpmF -- If you are pulled over on suspicion of drunken driving, the police officer is likely to ask you to complete three tasks: Follow a pen with your eyes while the officer moves it back and forth; get out of the car and walk nine steps, heel to toe, turn on one foot and go back; and stand on one leg for 30 seconds. Score well on all three of these Olympic events, and there’s a very good chance that you are not drunk. This so-called standard field sobriety test has been shown to catch 88 percent of drivers under the influence of alcohol. But it is nowhere near as good at spotting a stoned driver.

How to read articles about health. Most important rule to remember: don’t automatically believe the headline http://buff.ly/1bFpAni

The articles were selected from Twitter and my RSS subscriptions. Please feel free to send suggestions for articles to clinicalcases AT gmail.com and you will receive acknowledgement in the next edition of this publication.

On becoming a runner

Sometime in my weight loss journey I became a runner. Unlike many, I did not plan this, it just happened. When I started my journey walking dominated my movement strategy. I had a personal goal of 4-5 miles walking each day. This was easy and enjoyable. Then one day, I got to a slight downhill stretch and decided to jog. That felt good. So I started doing it more and more.

But I had a recurrence of my knee pain. Actually I get pes anserine bursitis. I kept running and walking, but the bursitis was threatening to limit my progress. One day last August, visiting my son in SF, I stopped into a Nike store. I wanted a lighter pair of running shoes than the local running store had recommended. That day I bought a pair of Nike Lunarglides. Within a week my knee pain had disappeared.

That helped a great deal. The next big discovery was run-walk-run. This program helped me greatly over the next 6 months. I made steady progress, improving my endurance and speed.

I developed a goal – run a 5k in less than 30 min. The first time I tried (on the treadmill), 5k took 35 minutes. Now I had a goal. The great positive side effect of running was the increased weight loss compared to walking. Running clearly helped me with my ongoing weight loss. 30 minutes is now relatively easy for 5k on the treadmill. I have done it several times outside, and hope to run a 5k next month for the first time.

Yesterday I ran 5k on the treadmill in under 27 minutes for the first time. The night before I had runner’s conversations about shoes, pace, and geeky runner details with a few friends. I have the bug.

If you do not run, you probably did not get this far into my rant. If you did and are interested I would like to share a series of stories of how running has greatly helped some people – How Running Changed Me. Many of these stories are about weight loss. They have the same idea in common, controlling portion size and making better food choices plus running.

Currently I am running around 20-25 miles each week. With the weather improving I am running outside more. Unlike many I enjoy treadmill running as well as outdoor running.

Becoming a runner has surprised me. For years I had pain when I ran. Fortuitously finding better shoes solved that problem.

One last word about shoes. If you want to start running, finding the right shoes, and the right size, makes all the difference. Before you buy shoes, please read this article and perhaps follow the links – Do You Pronate?: A Shoe Fitting Tale. This article gives the evidence that many shoes “experts” are wrong about pronation. My knee pain was not helped with “stabilization” shoes. I no longer look for such shoes, but rather focus on the sole – particularly liking Lunarlon (the Nike product) and the weight – really prefer lightweight shoes.

So later today, I plan to run around 3 miles. I have reached the point that I look forward to the run, and feel great afterwards. And it really helps my weight control.

April 16, 2014

Mumps Outbreak in Ohio

In addition to the ongoing measles outbreaks across the country, there is currently a large mumps outbreak in central Ohio.

Although not getting as much attention, the mumps outbreak, which began ...

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More Car Seat Recalls

TrendZ Fastback Car Seat Recall - Photo courtesy of the NHTSABaby Trend, Inc., in collaboration and cooperation with the National Highway Traffic Safety Association, is recalling about 16,655 of their  3-in-1 child restraints because, because like a recent Graco car seat recall, "it may be difficult to remove the child from the restraint, increasing the risk of injury in the event of an emergency in which a prompt exit from the vehicle is required."

Included in this car seat recall, are the 2011 and 2012 TrendZ Fastback 3-in-1 child restraints, including:


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April 10, 2014

More internists are failing the MOC exam-why could that be? Resistance to ABIM's MOC grows.

Why are more internists failing the Maintenance of Certification (MOC) exam? Kevin Pho on his medical blog offers two suggestions. See here. One reason is what I call the economically driven bifurcation of internists into hospitalists and officists and the disuse atrophy of hospital care skills in the office bound docs and the lack of familiarity with the preventive care changes and routine treatment of non acutely ill patients on the part of the hospitalists. If you don't treat respiratory failure,sepsis and acute heart failure on a regular basis you might just not do as well on the boards. The second reason Pho suggested is that the hassle factor in office care is now so high , with insurance,computer,and quality measures documentation  ever increasing that the fire in the belly to try and keep up with everything may be burning too low to try and keep current on conditions  you no longer are called upon to manage.

The suggestion that there should be one test for the hospital based internist and another for the officist has some merit but what about the dwelling number of dinosaurs who still try to do both. Of course that group is rapidly dying out.

And the more I read and hear about the absurd hoops internists are expected to jump through to try and satisfy the ever onerous non-test aspects of the ABPM's MOC process, the happier I am that I retired.See here for a great presentation of the clown-designed MOC program authored by the leadership at the American Board of Internal Medicine (ABIM).

I am pleased to see that there is at least some organized,as well as much unorganized, effort to resist or maybe even boycott the latest MOC affront imposed by the well paid folks at ABIM. See here and here. Further, mega kudos to Dr. Paul M. Kempen for his efforts to resist the MOC movement. Read what he has to say here. See here for Dr. Wes Fisher's comments re the big business that testing physicians has turned into.

Also of interest are the questions posed by Dr. Marc S. Frager to Dr. Richard J. Baron as well as Dr. Barron's reply.See here.

If you want to sign a petition to urge the ABIM to rescind their latest edicts regarding MOC ,go here

It is easy to find much anger and indignation directed towards the ABIM and recent revelations about possible conflicts of interests regarding its leadership has fanned the flames even more.

April 09, 2014

Do Not Track Kids Act of 2013

The Do Not Track Kids Act of 2013 (S. 1700) was introduced in the United States Senate and in the House as HR. 3481 last November.

The bill "amends the Children's Online Privacy Protection Act of 1998 to extend, enhance, and revise the provisions relating to collection, use, and disclosure of personal information of children, to establish certain other protections for personal information of children and minors, and for other purposes."


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April 07, 2014

World Health Day 2014

World Health Day - Photo courtesy of the WHOIt's World Health Day and the focus this year is on vector-borne diseases, or diseases that can be transmitted by the bite of mosquitoes, ticks, fleas, and water snails.

Unfortunately, while the CDC states that "vector-borne diseases account for 17% of the estimated global burden of all infectious diseases," it is important to remember that there are no vaccines to help prevent most of them. These diseases include dengue, schistosomiasis, leishmaniasis, Lyme disease, West Nile virus, Rocky Mountain spotted fever, Chagas disease, and malaria, which remains "one of the most severe public health problems worldwide."


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Update on New Meningitis Vaccines

While there are more than a few meningitis vaccines already available, some recent outbreaks of meningococcal meningitis and meningococcemia highlight the fact that at least one is sorely missing.

In addition to many sporadic cases, last year, eight students and one prospective student at Princeton University developed meningococcal disease in an outbreak that began in March 2013. At University of California, Santa Barbara, there were four confirmed cases in November 2013, including one student who became so sick that he had to have both of his feet amputated. Both outbreaks were caused by different strains of the serogroup B meningococcal bacteria, which isn't included in our current meningococcal vaccines (Menactra and Menveo).


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Walking to School Safely

Walking to School - Photo by Getty ImagesPeople often bemoan the fact that it doesn't seem like as many kids walk to school like they used to in the 'good old days.'

It would certainly be good if they did. Most kids need more physical activity, especially those who aren't involved in youth sports.


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April 06, 2014

Practice Is Changing

Yes, practice is changing and it has been for quite some time. But one has to wonder about the orientation and direction of that change. Small gains come at great cost and do nothing to prevent or reduce the disease. That does not mean the treatment is unnecessary but it does question the orientation and direction of health care with its emphasis upon the medical industrial complex.    

Yes, practice is changing. The patient was always the key to achieving optimum health. Perhaps medical care was too self-centered to recognize that aspect of their task but maybe we were training the wrong kind of practitioner. It takes a teacher and a motivator to mobilize the patient and keep them going. Family Medicine tried to do this but fell short of their goal with some exceptions. The potential for community and population health far exceeds that of traditional medical care. Schools of public health should lead the charge to design and implement models of community wide health care. Collection and analysis of health data will become more sophisticated but using the information to educate and motivate the public is the frontier of practice. For that task we will need fewer physicians, a better concept of HEALTH insurance and less domination of the system by hospitals. Time to redesign the county health department and introduce marketing of health rather than CAT scanners and MRIs. The highest level of technology in health is contained within the human body and we still know so little about it. Saturated fat, anyone? Or nutritional supplements? Walk everywhere you go and cover at least four miles each and every day! Now, that is something you can believe in.

Autism Group Awareness

Autism Speaks kids off World Autism Awareness Day on the NYSE - Photo by Astrid Stawiarz/Getty ImagesThis year, for Autism Awareness Month, how about being a little more aware of the differences in all of the autism organizations out there.

The very recent Chili's public relations blunder, in which they were planning to donate 10% of sales on April 7 to the National Autism Association, an anti-vaccine autism organization, highlights how important it is to know the organization you are supporting and or visiting information and advice.


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April 03, 2014

Measles Count Up To 108 Cases

A measles alert posted on a home of a child with measles by the health department. - Photo by Buyenlarge/Getty ImagesThe CDC has released the latest measles case count for the United States.

We are now up to 108 cases.

While that still may not seem like a lot to some people, ...

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April 02, 2014

Update on the Measles Outbreaks of 2014

A measles alert posted on a home of a child with measles by the health department. - Photo by Buyenlarge/Getty ImagesNot expectantly, the measles outbreaks of 2014 continue to grow larger.

We now have at least 89 cases in the United States, including:

  • at least 25 cases of measles in New York City, including 13 adults and 12 children, with 6 requiring hospitalization.
  • ...

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March 27, 2014

Responses to the latest CDC report on Autism Prevalence

When commenting on the 2012 CDC report on autism prevalence, I included the quote that autism spectrum disorders (ASDs) continue "to be an important public health concern" and we need a "coordinated response to identify risk factors for ASDs and meet the needs of persons with ASDs and their families."


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March 26, 2014

Saturated Fat

Here we go again. As more information becomes available, it appears saturated fat is not necessarily bad for health. But lifestyle and nutrition are complex and it is impossible to know everything that we need to know. I suspect this "new" perspective on saturated fat will hold up with some twists and turns along the way. Stay tuned.

March 19, 2014

2014 Alzheimer's Disease Facts and Figures Report from the Alzheimer's Association

The "2014 Alzheimer's Disease Facts and Figures" report from the Alzheimer's Association has been released. It is available as a .pdf document at Facts and Figures and has an accompanying YouTube video.

March 04, 2014

Neuropsychology Abstract of the Day

Robinson, G. & Ceslis, A. (2014). An unusual presentation of probable dementia: Rhyming, associations, and verbal disinhibition. J Neuropsychol. doi: 10.1111/jnp.12041. [Epub ahead of print]

We report a case of probable Alzheimer's disease who presented with the unusual feature of disinhibited rhyming. Core language skills were largely intact but generative language was characterized by semantic-based associations, evident in tangential and associative content, and phonology-based associations, evident in rhyming, in the context of prominent executive dysfunction. We suggest this pattern is underpinned by a failure to terminate or inhibit verbal associations resulting in a 'loosening' of associations at the level of conceptual preparation for spoken language.
© 2014 The British Psychological Society.

PMID: 24581283 [PubMed - as supplied by publisher]

September 29, 2011

Out of the hospital...

Beautiful fall days call for beautiful fall activities. This weekend, SWIMBO and I headed to Williams Canyon outside of Manitou Springs. Day one --- HIKE IT!

Looks like some bozo doesn't know how to read.

And for the next day's activities --- BIKE IT!


April 25, 2011

Gambling with Matches

"Match Day" came and went this year on March 17th; I find it interesting to look at the raw data from the residency match, as it gives one an idea of what the next generation of physicians are thinking about the future, and my chosen specialty in particular. It is also instructive to see what is put out as PR for the match and compare it to the match results themselves:
For Second Year, More U.S. Medical School Seniors Match to Primary Care Residencies
For the second year in a row, more U.S. medical school seniors will train as family medicine residents, according to new data released today by the National Resident Matching Program (NRMP). The number of U.S. seniors matched to family medicine positions rose by 11 percent over 2010. In Match Day ceremonies across the country today, these individuals will be among more than 16,000 U.S. medical school seniors who will learn where they are going to spend the next three to seven years of residency training.

I'd like to focus on three residencies --- Family Medicine, Internal Medicine, and General Surgery. For Family Medicine, 48% of the 2,708 slots this year went to US medical school graduates, compared with 44.8%, 42.2%, 43.9%, and 42.1% in the previous four years. For Internal Medicine, the numbers were somewhat higher, with 57.4% of the 5,121 positions being filled by US graduates, in comparison to 54.5%, 53.5%, 54.8%, and 55.9%. Both are a bit of a bump up, but the 11% rise noted for Family Medicine in the press release is a bit misleading, as the number of slots increased by 100 over 2010 as well.

General surgery numbers were a bit mixed, as there were more slots available this year (1,108 versus 1,077 in 2010), 81% of which were filled by US graduates; in comparison, the percentages were 83.1%, 77.4%, 83.1%, and 78.1% going back to 2007. Pediatrics and OB-GYN numbers are hanging in the low-to-mid 70% range for the same time period.

What does all of this mean? I'm not really sure. Not being a statistician, I can't say for sure but none of these numbers suggest a statistically significant change in the percentage of US medical school graduates going into these residencies, all political and PR posturing aside. One thing that many tend to forget is that subspecialty care will draw off many of these primary care physicians with time --- into cardiology, GI, neonatology, high-risk OB, plastic surgery, cardiothoracic surgery, etc.

If I was a betting man, I would bet that the minor increase in FP and IM numbers this year will not be sustained; there are too many financial forces working against the physicians in those specialties. And general surgery is not terribly different in the long run.

March 25, 2010

A Brief Anthropology of the Nigerian Healthcare Tier System and Her Primary Healthcare Exigency: comments

Tun left the following comments on an earlier post. Please read the original post first. I thank Tun for the comments.

Good (if slightly inaccurate) reading of Nigeria's medical history. Just wish to point out that the Colonial Medical Service started way before the Second World War. Indeed, the first set of medical officers were sent out in 1898. You are of course correct that primary attention was given to European personnel; but because part of the mandate of the service was to gather medical and scientific data, doctors had to be interested in treating locals.
You may wish to correct these in your blog so that some unknowing visitor may not be so misinformed.
Best wishes.

November 13, 2009

Lessons from my trip

I am in Monrovia for a scientific meeting. I have been here for about a week. I have learnt quite a lot during this short stay. I itemise my musings below:
1. The destruction caused by the Liberian war is of no small dimension
2. The attendant national retrogression is not quantifiable
3. The human spirit is resilient
4. The efforts of the government here to return a similitude of normal life has reached a fevered pitch
5. The favourable disposition of the average Liberian towards Madam Ellen Johnson Sirleaf is contagious
6. The plea of Liberia for assistance with capacity building is urgent and cogent
7. There is a marked presence of the international community here helping with national revamping
8. The dearth of quality translational research in the West African sub-region is alarming
9. Feeble efforts are being made by stakeholders to correct this dearth
These are some of my thoughts.

October 03, 2009

UroToday - Prospective evaluation of prostate cancer risk in candidates for inguinal hernia repair - Abstract


We found the incidence of concurrent prostate cancer with hernia to be low, but 51% of men had PSA values that suggested an increased relative risk of future development of prostate cancer. Men at increased risk of prostate cancer should be made aware of the impact that mesh might have on subsequent treatment options before mesh placement.

Many years ago it was thought that a prior laparoscopic hernia repair would be a major problem for a patient who had prostate cancer wanted a robotic prostatectomy.

Since 2003 the majority of robotic surgeons have performed robotic surgery through the abdominal cavity. With this approach, the bladder and blood vessels can safely be separated from the mesh with direct visualization.

I do not consider a prior hernia repair with mesh to be a significant concern prior to robotic surgery. The surgery should take a little longer, but removing the prostate is not a significant problem.

The only concern in patients that will undergo hernia repair is to make sure they do not have cancer at the present time. If they do and want surgery for prostate cancer, then a robotic hernia repair and robotic prostatectomy shoudl be done at the same time, avoiding 2 surgeries. I have performed over 100 of these combination hernia repairs and davinci prostatectomies.

May 18, 2009

Risk of prostate cancer unaffected by antibiotic treatment

Source: MedWire News

The average age of the patients was 62.9 years. Average total PSA before and after treatment was 6.05 ng/ml and 5.55 ng/ml, respectively. On biopsy, 23% of patients had histologically proven prostate cancer. There were no significant differences between men with and without prostate cancer in age, pretreatment PSA, free PSA, percent free PSA, and PSA density.

Average total PSA, free PSA, and PSA density decreased after treatment in men with and without prostate cancer. But the reductions in total PSA and PSA density were not significant in prostate cancer patients and the reduction in free PSA in cancer-free patients was not significant.

This paper looked at treating patients with an elevated PSA and a normal rectal exam with antibiotics. The reason why this is important is that many urologists prescribe antibiotics for men with elevated PSA values and only biopsy them if the PSA is still elevated.

This study did not show a significant difference for men with and without prostate cancer for PSA changes. Both groups had a decline in PSA values.

This is not a conclusive study and the use of antibiotics is still an option in treating men with a high PSA. I personally like to start with a biopsy and not antibiotics in men that have never had a prostate biopsy.

UroToday - Nephroureteral Stent on Suction for Urethrovesical Anastomotic Leak After Robot-Assisted Laparoscopic Radical Prostatectomy

Source Urotoday.com

I foudn an abstract about a way to manage urinary ascites that can rarely happen after dvP.

Conventional measures, including catheter traction, passive drainage, and needle vented Foley catheter suction, failed. On postoperative day 6 a unilateral nephroureteral stent was placed on intermittent suction.

Placement of one nephroureteral stent on suction device immediately stopped the urinary anastomotic leakage into the peritoneal cavity.

In case of a persistent urinary leak after RALP that fails conservative management, a nephroureteral stent on suction may aid to stop the anastomotic leak.

I have seen this problem a few times in the past 5 years. The best way to manage it, in my opinion, is to place a drain laparoscopically by the surgeon if one does not exist. I found that interventional radiology does not place as large a drain or in as good a place.

While I am placing the drain laparascopically, I also perform a cystoscopy to attempt to place 5 fr ureteral catheters for urinary diversion. I think the most important thing is to push the foleyin away from the bladder neck. I think foley traction on the anastamosis is what keeps the opening open.

February 05, 2009

Is the Complication Rate of Radical Cystectomy Predictive of the Complication Rate of Other Urological Procedures?

Source: UroToday

A higher hospital radical cystectomy volume appears to lead to a lower risk of complications only after other common urological oncological procedures, namely radical prostatectomy and nephrectomy, but not after nononcological urology procedures.

This abstract found that hospitals that performed radical cystectomy (removal of the bladder and surrounding tissue for bladder cancer) had less complcations for kidney and prostate cancer surgery as well.

I have been perfoming radical cystecomies my whole career and started perfoming these robotically 3 1/2 years ago. Although I thought performing the more complex surgery helpe me in other surgeries, I didnt realize that a study would show less complications for these other procedures.

December 21, 2008

Impact of Accessory Pudendal Arteries on Potency Following Robot-Assisted Prostatectomy

Source: UroToday from 2008 Wold Congress of Endourology

  • After multivariate analysis there was no significance with sacrificing an APA and time of potency recovery. There was no correlation with sacrificing an APA and postoperative quality of erections (94% vs 90% p=0.30) or mean IIEF-5 (22.4 vs 20.7 p=0.11).

  • As one of the few reports regarding anomalous venous anatomy during robotic prostatectomy, this study found no correlation between APAs and preoperative potency. Additionally the authors found no correlation between sacrificing APAs and 24-month potency return. The authors concluded that they found no effect on the time to return of potency, quality of erections or mean IIEF-5 scores at 24 months.

This is the first study that I have seen that addresses return of sexual function in men with accessory pudendal arteries. This is an extra artery that brings blood to the genital area that travels very close to the prostate and through the DVC (vein that brings blood back from the penis).

I usually try saving these arteries and usually I am successful, but it is good to know it is not a big deal to transect it if necessary.

The Prognostic Impact of Seminal Vesicle Involvement Found at Prostatectomy and the Effects of Adjuvant Radiation

Source: Urotoday

Patients with seminal vesicle positive disease who received adjuvant radiation compared to observation realized an improvement in 10-year biochemical failure-free survival from 12% to 36% (p = 0.001), in 10-year overall survival from 51% to 71% (p = 0.08) and in metastasis-free survival from 47% to 66% (p = 0.09), respectively.

Although seminal vesicle involvement is a negative prognostic factor, long-term control is possible especially if patients are given adjuvant radiation therapy. This therapy appears to be effective in patients with seminal vesicle involvement.

This one study showed an advantage of giving patients radiation if they had cancer in the seminal vesicles at the time of radical prostatectomy. Many factors need to be addressed in determining if radiation is necessary after surgery.

Robotic prostatectomy findings in patients with a single microfocus (5% or Less) of Gleason 6 Prostate Cancer at Biopsy

A Single Microfocus (5% or Less) of Gleason 6 Prostate Cancer at Biopsy-Can We Predict Adverse Pathological Outcomes?

Source: Urotoday

While a microfocus of Gleason score 6 prostate cancer on biopsy is commonly considered low risk disease, there was a greater than 1/5 risk of pathological upgrading and/or up staging. Patients with Gleason score 6 microfocal prostate cancer should be counseled that they may harbor more aggressive disease, especially when pretreatment clinical risk factors are present, such as advanced age or high clinical prostate specific antigen density.

The team at the University of Chicago looked at patients with only 1 small focus of cancer that was the lower grade (6) on biopsy. Overall 42 patients (22%) had adverse pathological outcomes, including upgrading in 35 [higher gleason score] (18%) and upstaging [cancer outside the prostate] in 16 (8%). I performed a similar study almost 2 years ago that also found the amount and type of cancer is underestimated on biopsy.

Robotic Inguinal Hernia Surgery at the time of Robotic Prostatectomy

Source: Journal of Robotic Surgery, Volume 1, Number 4 / February, 2008


Urological surgeons should be encouraged to perform a thorough inguinal exam during preoperative evaluation and intraoperatively to detect subclinical hernias. Inguinal herniorrhaphy done concurrently at the time of RALP is safe, with no added morbidity and should be routinely performed.

This is a paper Dr. Ahlering and I wrote which is a review of our results and techniques of fixing hernias during dvP.

Since conferring with Dr Ahlering on this paper, I have changed my technique to resemble his more.

The main point of the article is that hernias are common and it is beneficial for patients to have them fixed.

Robotic Partial Nephrectomy Study

Journal of Robotic Surgery, Volume 2, Number 3 / September, 2008


We report a large, multi-institutional series of RPN for renal tumors, confirming safety and feasibility reported in previous small, single-institution studies. Although we report the initial experience in RPN at each center, immediate oncologic results and perioperative outcomes approached those of more mature laparoscopic series. Robotic assistance may facilitate the technical challenges of precise tumor resection and renal reconstruction within acceptable warm ischemia times. Long-term outcomes are needed to establish the role of RPN in nephron-sparing surgery.

This was a large multi-institutional study that I was part of. This was the largest robotic partial nephrectomy study reported.

December 20, 2008

MedWire News - Prostate Cancer - Endocrine and radiotherapy 'standard care' for locally advanced prostate cancer

Source Medwire News

Adding local radiotherapy to endocrine treatment halves the 10-year prostate cancer-specific mortality in patients with locally advanced or high-risk local prostate cancer compared with endocrine treatment alone, researchers report.

"In the light of these data, endocrine treatment plus radiotherapy should be the new standard," Anders Widmark (Umeå University, Sweden) and team write in The Lancet.

This study looked at 875 patients with locally advanced prostate cancer (T3; 78%; PSA70; N0; M0) without evidence of distant spread. These men were from multiple centers in Norway, Sweden, and Denmark. In this set of patients, adding radiation helped men live longer compared to hormonal therapy alone.

The only difference in my practice, and in many centers in the US is that we sometimes perform surgery for these patients as well. The other difference is that these patients were given continuous endocrine treatment using flutamide, which is not as effective as other hormonal therapy regimens that we usually use (gonadotropin-releasing hormone ( GnRH) agonists).

December 18, 2008

Dr Moyad on Vitamin E- Do not take over 400 IU daily

Source: Dr. Moyad on December 2008 Newsletter

"It is now 100% official, high-doses (400 IU or more per day) of vitamin E supplements should not be taken by anyone, especially men trying to prevent, those diagnosed, or even treated for prostate cancer (in other words all men on planet earth)!!!"

Dr. Moyad is in my opinion, the most respected and knowledgeable authority on nutritional support and supplements for prostate cancer. He comments on how the use of high dose Vitamin E is not only beneficial, but likely harmful.

December 17, 2008

Robotic Partial Nephrectomy Versus Laparoscopic Partial Nephrectomy for Renal Cell Carcinoma: Single-Surgeon Analysis of >100 Consecutive Procedures

Source: UroToday

The mean total operative time (140 vs 156 minutes, P = .04), warm ischemia time (19 vs 25 minutes, P = .03), and length of stay (2.5 vs 2.9 days, P = .03) were significantly shorter for RPN than for LPN, respectively.

RPN can produce results comparable to LPN but has disadvantages, such as cost and assistant control of the renal hilum. Additional randomized trials are needed.

A friend and expert robotic renal surgeon, Dr Bhayani, discusses his results with robotic partial nephrectomy.

The most important finding is the improvement in warm ischemia time, the amount of time the kidney is not receiving blood supply.

Another important finding is that the operation can be done quicker robotically, which can translate into a cost savings that will partially offset the increased cost of the robotic equipment.

November 15, 2008

SELECT: Selenium, vitamin E show no benefit in prostate cancer prevention - - UrologyTimes

Source: Urology Times

Selenium and vitamin E supplements, taken either alone or together, do not appear to prevent prostate cancer, according to an initial, independent review of study data from the Selenium and Vitamin E Cancer Prevention Trial (SELECT).

The data also showed two concerning trends: a small but not statistically significant increase in the number of prostate cancer cases among the more than 35,000 men age 50 years and older in the trial taking only vitamin E; and a small, but not statistically significant increase in the number of cases of adult-onset diabetes in men taking only selenium.

Because this is an early analysis of the data from the study, neither of these findings proves an increased risk from the supplements, and both may be due to chance, according to the authors.

This was a well recruited study that started many years ago when I was at Indiana. We were one of the sites that were recruiting patients. This is the first analysis I have seen from this, so we will need to wait for more data to come out. According to early findings, neither Vitamin E nor selenium help prevent prostate cancer.

November 02, 2008

Medical News: ASTRO: Proton Radiation Fails to Impress in Prostate Cancer Study - in Meeting Coverage, ASTRO

Source: Med page today

Proton radiation for early prostate cancer had an acceptable tolerability profile but produced little evidence of a "gee whiz" impact to support its cost, according to preliminary results from a phase I/II clinical trial.

Two-thirds of patients had acute genitourinary or gastrointestinal toxicity, and a third had late GU/GI toxicity, Anthony Zietman, M.D., of Harvard and Massachusetts General Hospital, reported at the American Society for Therapeutic Radiology and Oncology meeting.

Although most of the toxicity was grade 2 in severity, the overall profile provided little reason for enthusiasm.

"The bottom line is that the treatment was safe, it was reasonably well tolerated, but probably no better tolerated than any other form of radiation that we give," Dr. Zietman said.

According to this study, the less available and much more expensive proton radiation therapy for prostate cancer is not much different than traditional radiation.

September 21, 2008

UroToday - Trial Evaluation of Erectile Function after Attempted Unilateral Cavernous Nerve-Sparing Retropubic Radical Prostatectomy With Versus Without Unilateral Sural Nerve Grafting for Clinically Localized Prostate Cancer - Abstract

Source Urotoday

The trial planned to enroll 200 patients, but an interim analysis at 107 patients met criteria for futility and the trial was closed. For patients completing the protocol to 2 yr, potency was recovered in 32 of 45 (71%) of SNG and 14 of 21 (67%) of controls (p=0.777). By intent-to-treat analysis, potency recovered in 32 of 66 (48.5%) of SNG and 14 of 41 (34%) of controls (p=0.271). No differences were seen in time to potency or quality of life scores for ED and urinary function. Limitations included slower-than-expected accrual and poor compliance with ED therapy: 65% for VED and 40% for injections.

The addition of SNG to a UNS RP did not improve potency at 2 yr following surgery.

This study was comparing men who were going nerve sparing prostatectomy on one side and adding a nerve graft on the other side. Nerve grafting takes more time and has some side effects depending on which nerve you use. This study, like many before it, did not find a benefit in performing a nerve graft.

I've always felt that this wwould be the case since the neurovascualr bundle is a series of small microscopic nerves, not a large nerve that you can see.