Victoria Wood - University Interview

"A nervous schoolgirl is interviewed as a potential student at a medical school. One of the funniest sketches ever. Sadly, she'd probably be good enough to get in now."

I'm glad that we don't have anyone like this in My Medical School. Psychologists are trained to "mirror" responses when talking with patients so their own beliefs and biases will not discourage a patient from disclosing important information...

But this is ridiculous! And rightfully so. :)

via Clinical Cases and Images via New Media Medicine

Blogging & Clinical Cases

DB's Medical Rants had a podcast reflecting on his one millionth hit. He talked about writing -- how his blog initially started off as a way to become a better writer and express himself, but he eventually found more and more people visiting his site. He had a few tips for fledgling bloggers and I found myself thinking about my own blog and motives.

Have I been focusing too much on the audience and the reader and not enough on myself and my own thoughts? What is my purpose for writing?

I haven't been posting as much as I intended to when I first started Not My Second Opinion. There are a number of reasons for this... I initially wanted to share my philosophical musings about various ethical topics in medicine, but I've regrettably found myself with very little time and energy to post on such topics in a meaningful way. My interest in posting something drastically wanes within the first few days... sometimes I get bored with the idea or I no longer think it is postworthy. Perhaps I have high standards of what a medblog constitutes after perusing the quality of my favorite blogs. Most of all, I'm worried about being held accountable for what I say -- which I find highly ironic considering the name i had settled on for this blog.

For the new year of 2007, I am going to make a few changes to my writing tone and style to reflect more of my deeper thoughts. It will be more unvarnished and more rough around the edges, but I hope that this bluntness will encourage more discussion (and be less taxing on the small portion of my brain dedicated to being sagely and wise.)

I'm going to start a new series of entries, inspired by clinicalcases.org. Every week, I will present a case that I've seen in the hospital. It will focus mainly on the clinical aspects of differential diagnosis and reasoning through the physical exam, but I will add my own personal thoughts in at the end as an emphasis for humanism in medicine.


One of my New Year's Resolutions is to devote a few more hours a week to writing. Not necessarily here for you, but for myself as well.

Curing what was once incurable... DM1!

In the days of Hippocrates, there was very little that a doctor could do. They could recognize a few common diseases, treat the symptoms and announce its probable course.

One disease that once held a death sentence was diabetes mellitus. An old native term for it was "pissing evil," reminiscent of something diabolical... but a 2nd-century A.D. Greek physician, Aretus the Cappadocian, named it so because it was like a sweet siphon. 'Diabetes' means siphon and ‘mellitus’ means ‘honey.'

Diabetics have polyuria (excessive urine) and glucosuria (sugary urine) which attracted bees and flies. It used to be diagnosed by someone drinking a urine sample and going "Ooh, this is sweet! This means death." Unpleasant for the taster for sure... but I'm not sure how diabetics feel about finger pricks nowadays as a pleasant alternative.

Diabetes comes in two types, one in which autoantibodies attack the pancreatic cells that produce insulin (DM I)and the other in which the body starts becoming resistant to insulin (DM II.) The end result is that the body detects less insulin and cellular sugar intake drops, raising blood and urine glucose levels. This is a condition that we can only treat palliatively with medications, diet and exercise recommendations.

We do not have a magical cure for diabetes... but we have recently discovered how to cure DM I in mice!

TORONTO - Researchers at The Hospital for Sick Children (SickKids), the University of Calgary and The Jackson Laboratory, Bar Harbor, Maine have found that diabetes is controlled by abnormalities in the sensory nociceptor (pain-related) nerve endings in the pancreatic islet cells that produce insulin.
...
“We started to look at nervous system elements that seemed to play a role in Type 1 diabetes and found that specific sensory neurons are critical for islet immune attack in the pancreas,” said Dr. Hans Michael Dosch, study principal investigator, senior scientist at SickKids and professor of Paediatrics and Immunology at the University of Toronto. “These nerves secrete insufficient neuropeptides which sustain normal islet function, creating a vicious circle of progressive islet stress.”
...
Using diabetes-prone NOD mice, the gold-standard diabetes model, the research group learned how to treat the abnormality by supplying neuropeptides and even reversed established diabetes.

This is an amazing discovery that may lead to radically new treatment for this chronic disease that kills 72,815 people a year (6th leading cause of death in the U.S), not to mention that it can cause blindness, kidney disease and force people to be amputated.

Who knows. Someday, people may look back at our "dark ages," wondering why we didn't surgically remove sensory neurons expressing the receptor TRPV1 and supplementally treat with injections of substance P.

Democrat Majority Threatened?!?

There was a lot of speculation in Washington when Democrat senator Tim Johnson went to the hospital that a Democrat majority would be threatened if he lost his seat in congress. He underwent brain surgery and there was a lot of concern about his future... and of the U.S. The Democrats have only a very tenuous grasp on the senate with a 51:49 majority and in case of a tie, Vice President Dick Cheney would step in with a tie breaker.

It was announced in the news today that Senator Johnson did not have a stroke. He had a congenital cerebral arteriovenous malformation (AVM.)

What's that?

MedPage today:

"AVMs are often silent, asymptomatic, and therefore undiagnosed until a hemorrhage occurs, or some other symptom occurs that results in the person getting a CT or MRI scan of the brain that reveals the lesion."
Arteriovenous malformations are congenital vascular abnormalities, and are so called because they consistent of tangles of abnormally connected vessels, with fistulas rather than capillaries forming arterial-to-venous connections, resulting in overly rapid blood flow that does not allow for proper oxygenation of tissues.
The abnormal vessels are also subject to leakage and rupture, and can lead to intracranial bleeding that can vary in severity according to where the defect occurs.

Here's a few other links to information on AVMs.

Radiology Picture of the Day: Cerebral Arteriovenous Malformation

Discover Magazine's Vital Signs: What's That Noise In Her?
A diagnostician facing his own medical troubles tracks down a killer defect.

• I really like this one because it addresses the problems that a doctor has in his diagnosis (which I already gave away the punchline for) so the main point deals with how he goes about dealing with the strange noise he hears and his own insecurities.

Fraud Alert

I got an email from UCLA today.

UCLA computer administrators have discovered that a restricted campus database containing certain personal information has been illegally accessed by a sophisticated computer hacker. This database contains certain personal information about UCLA’s current and some former students, faculty and staff, some student applicants and some parents of students or applicants who applied for financial aid. The database also includes current and some former faculty and staff at the University of California, Merced, and current and some former employees of the University of California Office of the President, for which UCLA does administrative processing.

I regret having to inform you that your name is in the database. While we are uncertain whether your personal information was actually obtained, we know that the hacker sought and retrieved some Social Security numbers. Therefore, I want to bring this situation to your attention and urge you to take actions to minimize your potential risk of identity theft. I emphasize that we have no evidence that personal information has been misused.

At first I was skeptical that this email actually came from UCLA. I'm not a student there... why would they have my information? I looked at the linked addresses and they were all legitimate. UCLA has a link on their website regarding this incident and their response.

gorram.

I didn't think that applying for medical school would put me at risk for identity theft!

Anytime you give someone your SSN and DOB, it is reasonable to assume that you might become a victim. I have no idea why they were still holding onto my information, but I'm glad that they had the courtesy (and legal responsibility) to inform me that I might be a victim.

I put a fraud alert on my file to prevent anyone from opening up new credit cards in my name. I requested my credit report online too... and whew! No suspicious activity noted.

Here's the crux of this entry: according to the Fair Credit Reporting Act, everyone is eligible to a free copy of their credit report every year. The problem is finding out how to do that online without coming across all of those websites that want you to order extra stuff.

Type into google: "site:.gov Free credit report" and the first link is the FTC's Website on Credit. I like using the "site:" feature on google... you can use it to scan for legit resources online with "site:.edu" and stuff like that.

Anyway. I just wanted to give you all a heads up on protecting your credit. How mature of me, eh?

The fraud alert and credit reports are free. Here is the contact information for the fraud divisions of the national credit bureaus:

• Equifax: (888) 766-0008 (http://www.equifax.com)
• Experian: (888) 397-3742 (http://www.experian.com/fraud
• TransUnion: (800) 680-7289 (http://www.tuc.com

A very long post on: Vaccination

Please read this, I think it is very important... and if you lack the time, just skip to the bottom for key points.

I started reading Flea's blog just a few days ago. He wrote an entry entitled "Killed by Vaccines?" A very dramatic title, I thought. Indeed, the content was quite shocking, involving the death of a young child allegedly by the administration of the common vaccine DTP. Seizures followed for months afterwards, coming and going and Marissa passed away at the age of 8 1/2.

What does DTP prevent? I know this! The first bacteria, Corynebacterium diptheriae, can cause a severe throat infection with a thick pseudomembrane that can cause breathing problems, heart arrhythmias, coma and even death. The second bacteria Clostridium tetani has a toxoid that causes such strong spasms it can lift a person off their hospital bed, not to mention respiratory failure and again, death. The third bacteria Bordetella pertussis causes a respiratory infection characterized by a whooping cough and vomiting. It can lead to complications like pneumonia, seizures and encephalopathy.

Flea ends with this:

What makes the story even sadder for Flea is that mom believes with perfect faith that vaccines killed her daughter. She refers to the child she lost as "Marissa (victim of childhood vaccines)". It's bad enough to lose a child. It's worse to remember her with a parenthetical moniker like this one.

For readers of this sad tale, it doesn't help that this mother describes herself as a "lay-homeopath" who practices cranial sacral therapy, and "unschools" her surviving children (whatever that means). Oddest of all, Lavender Essence provides a link in her side bar to this web site that includes an article entitled "Orgasmic Childbirth".Let's be clear about one thing. There is no credible evidence that vaccines cause any negative neurodevelopmental outcome whatsoever. I'm afraid that no amount of evidence, no matter how credible, is going to change Lavender Essence's mind. Period. End of sentence. End of paragraph. Shut up now and hit "Publish Post".

Hm. The internet is a great place to bring out extremes from all sides and there was an uproar from his commenters. I read a few of his links to get more of the story. Lavender Essence's story can be read here, at mothering.com.

I did some research and I found a few facts to support her case, even if they weren't accepted by the medical community as a whole. I'm not sure if Marissa received the DTP or the newer DTaP vaccine. The "a" refers to acellular pertussis, a multivalent antigen mix that provokes the same immunogenic response with less side effects. SOME OF THE RARE SIDE EFFECTS mentioned by NIH's Medline for DTP are:

collapse; confusion; convulsions (seizures); crying for three or more hours; fever of 40.5 °C (105 °F) or more ; headache (severe or continuing); irritability (unusual and continuing); periods of unconsciousness or lack of awareness; sleepiness (unusual and continuing); vomiting (severe or continuing)

oh my. The internet is a great place to find these sorts of rare occurences and amplify their responses. I think that it is important to recognize that these are rare side effects and should not be a reason to refrain from giving your children the DTaP vaccine. Perhaps if Flea had emphasized this more than the mother's "altie" beliefs, he would not have provoked such anger.

Here is my long post to the mother, which elucidates my own position:

Barefoot mama,

I too found your link through Flea's blog. I am a first year medical student and I wanted to thank you for sharing your experiences with the world. It is a brave thing to do and it sounds like you don't deserve the criticism and mockery you're receiving from so-called "rational people." It doesn't lessen your pain to have your views ridiculed and I am sorry that you have suffered even more in the sharing of your story.

You've lost a love of your life after so many months of hardship and suffering. Your daughter died from something that the medical profession struggled to understand, but failed. To make matters worse, many of them were dismissive and unsympathetic to your concerns. That is regrettable and I will strive to use this as a reminder to myself to be different when I have patients and need patience. :)
Believe it or not, but the majority of a good diagnosis comes straight from patient history, not the blood sticks, labs and scans that are done at fancy hospitals. A good diagnostician recognizes the trends and notes when something is up. It sounds to me like you were in the position to recognize a suspicious trend in Marissa, linking vaccines with the crippling seizures that she experienced. Your doctors were dismissive of them at first, because it is a rare occurrence to get such a violent reaction.

I typed in "vaccine side effect seizure" into PubMed just now, the repository of scientific journals, and I came up with one link on "immunization with DPT vaccine activated thiosemicarbazide-induced convulsive syndrome in mice." This shows a causal link in mice between DPT and seizures... which I found curious, even through my puzzlement of the Russian to English translated article.link:(Kovals'kaia, 1980.)

I do not post this to provide you with more evidence that your daughter suffered as a result of shots. I do this to let you know that I take your views seriously.

When I type in "vaccine seizure" into PubMed, the first link that comes up is this: [edited for length and grammar] "The boy started having attacks and jerks after the first injection of DTP. The EEG confirmed the typical features of hypsarrhythmia. Intramuscular ACTH was commenced for 2 weeks. No problem was reported until the age of 9 years when he started having attacks of jerking. He was treated with sodium valproate. Another 11 year old boy, his second cousin, had momentary black outs. The EEG showed findings of idiopathic epilepsy. Treatment with sodium valproate was commenced. The children of both cases belong to a family in which there is a tendency to seizures. It seems unlikely the triple vaccine produced the infantile spasms in case 1." (emphasis mine)(Lapatsanis, 2006.)

It is a dangerous thing to be misled by false information, be it "vaccinations can cause serious seizure disorders that would otherwise be preventable" or "vaccinations are dangerous to your health." Understand that Flea speaks bluntly not out of disrespect to you and your beliefs, but in the full understanding of the SEVERE consequences that would take place otherwise. He knows what diphtheria, tetanus and pertussis could do to a child. If you did not vaccinate and Marissa contracted one of these diseases, she would have suffered. Less than a handful of people contract tetanus each year, not because of any decrease in the prevalence of Clostridium tetani bacteria in rusty nails and dirt. Tetanus is not seen in hospitals precisely because of the aggressive public measures that have been going on in the past 100 years. Many doctors nowadays would consider themselves "lucky" (in purely academic sense) if they get to see a case of tetanus in their lifetime. Still they, know that a patient starts having a difficult time speaking (aka lockjaw) which progresses into muscle spasms that cause the entire body to arch back painfully, lifting the patient off the bed. When their diaphragm is involved, breathing is impaired and the only thing you can do at that point is put them on a respirator, pump them with meds and pray.

Imagine if instead of seizures, Marissa had tetanus and you had to live with the regret of knowing that you could have saved her life with a simple vaccine. This is basis for the “righteous fury” borne of medical professionals who see something they could prevent with simple public health measures, but parents refuse treatment. Flea is scared that you’re spreading false information and scaring people into refusing a vaccine. In fact, you might be spreading true information and there is something that doctors CAN do to intervene if a reaction to DTP is noted earlier. You might be speaking in the full understanding of the SEVERE side effects of a vaccine. Wikipediasuggests that you’re not alone. The thing is, this is not backed up by current literature and Flea’s position is. Additionally, the newer DTaP vaccine has a significantly reduced number of side effects. Why is DTP still used? A non-profit org called the "National Vaccine Information Center" claims that the profit margins for pharm companies are cushier with the more dangerous vaccine. *tilts head* That’s certainly something to get angry about, IMO.

Understand that everyone had their own experiences and emotions to color their comments. Flea’s are colored with his interactions with wary and resistant parents. Yours are colored with negative experiences with doctors. There are all sorts of parents and all sorts of doctors and it is unfair to stereotype either category as ignorant, stubborn and deaf to everything that does not fit their beliefs.
At the very least, consider yourself blessed that you found a good doctor. If any of your other children begin to manifest seizures of a familial type around 10 years of age, as the second article I cite suggests, you know who you can trust and who you can go to for advice on how to proceed.

Thank you for educating me. I will share my information with my fellow medical students and perhaps future tragedies can be averted and bonds of trust between patient and doctor will not be broken.

Kind wishes to you and yours,
Not My Second Opinion

I wrote this before I looked at a few more links about the old DTP vaccine, so I wasn't aware of all the goings on. Medicine tries to protect medicine and sometimes, it fails for a few people. Is it a deliberate cover-up? Are pharmaceutical companies or the government being negligent? Do we need to be so strict with vaccine administration?

It is sad that people suffer from disease. It is regrettable that we have a cure for some of these diseases -- a cure that comes before we get sick, but a cure nonetheless -- and some people refuse the cure. It is even worse when the cure makes someone sick, but their suffering is dismissed or attributed to something else by the people who are trying to make them better. Am I making sense? I sure hope so.

Key points:
Mom gets a DTP for her baby
Baby has fever that night and starts having seizures
At 13 months, she has a pattern of status seizures every fourth day
At 8 1/2 years old, her brain stem swelled up and she passed away
Is this a side effect of DTP? [edit (12/12): just to clarify, I'm only talking about seizures]
YES, but it is rare
Parents should be advised of side effects and educate their doctors if they do not know!
Docs are human too.

How To: Request Letters of Recommendation

I checked my email today and I was happy to see an email from an aspiring pre-med in My Medical School's mentorship program. He asked me the following questions about Letters of Recommendation (LORs):

1. How "early" is early enough to get LOR's? I'm planning to embark on a study abroad scholarship opportunity. [...]


2. So, I don't know if I should ask a LOR right now, or wait until January, or wait until I get back?? [...]


3. Maybe you could tell me any tips or advices on a good way to ask them for a LOR, & what they expect from you in order for them to write a good one for me.

I thought that these were excellent questions, certainly ones I wished I knew the answers to when I first started applying for medical school. I mentally wince when I review all the things that I could've done much better in "round 1" that still could have used a little polish in "round 2." I'm happy to share my wisdom to spare others the same agony, not because I'm a know-it-all (though I am a wanna-know-a-lot!)

Here's what I said in response: (scroll to the bottom for key points.)

• I think that it would be a great time to ask your professors for a LOR. It gives them some time to think about it and compose it while your experiences with them are still fresh in your mind.
  (Look into whether or not your institution has a Credential filing service that can take care of your LORs for you. Your LOR writers can submit their LORs to the service and they will send the letters for you, to the organizations you request in a confidential manner. It will save on all the envelopes you have to give to your professors, not to mention the worry that comes with your insecurities about the different stages of transit.)


• When approaching someone with an LOR request, schedule an appointment with them ahead of time and take some time to sit down and talk with them. Tell them what your intentions are and what they will be writing for, especially for your liberal arts/humanities professors. Come prepared with your curriculum vitae (CV) that they can hold onto and reference as they wish in the construction of the LOR. A lot of good things come out of this visit and I learned the hard way that it is not a good idea to ask someone via email -- it's a lot more difficult to follow up with them if you haven't established that bond before you bug them about things like that. :)


• If you're wondering how many to get and who to ask, look at the reqs for the schools you're interested in. I made an excel sheet to keep track of what I needed to do for which schools by what deadlines, because it can sneak up on you all too quickly if you're not organized. I'm not sure if this formatting will work, but here's the sample categories from mine:
  
  Medical Schools//Status//Website//LORs//2ndary due//progress//fee//interview


• It sounds like you still have a lot of time, so it's great that you're being proactive and you're thinking about these things! Scout out on the internet for a sample questionnaire. Some medical schools have a questionnaire that the recommenders fill out to address various areas. "Does this student apply critical thinking to your subject? Strongly agree<-->disagree." Then it all boils down to whether or not they would score you as a "Highly recommend," "Recommend," "recommend with reservations" and "do not recommend."
  
  The strongest LOR you can get is one that says "I would go to this person if I were sick and send my friends and family to see them too, without a doubt." I've heard of cases where faculty have actually gone out of their way to call the medical school to talk about the student, but of course, you can't ask your LOR writers to do any of these things for you. :)
  

Key Points on LOR requests:
It's always better to ask early than late.
Approach them face-to-face and chat with them about your interests.
Come organized with a CV and topics they should address in the LOR.
Use a Credentialing Service if it is offered by your institution.
Follow up with your LOR writers as the deadline approaches.

Other resources to check out:
http://www.psichi.org/pubs/articles/article_75.asp
http://www.studentdoctor.net/downloads/index.asp
http://notmysecondopinion.blogspot.com/2006/06/helpful-pre-med-links.html

Food and Drug Interactions

Last month, an antioxidant found in red wine was found to increase metabolic rates in humans and mice. Resveratrol has an implicated role in aging as it has been shown to extend the lifespan of rats (scroll to the very bottom), but Abel PharmBoy cautions us not to take these preliminary results too far. Wine also has tannins (procyanidins) that have a protective effect against heart attacks by suppressing the synthesis of a potent vasoconstrictor, endothelin-1.

Time to celebrate! What a great excuse for the upcoming Christmas holidays. ;)

If you're also celebrating with some red wine because of a miracle MAO inhibitor drug that has given you your life back after severe depression--
STOP!

My Pharmacology textbook by Golan told the tale of a young woman, Phyllis, who was prescribed a new drug to treat her depression. She recovered and went to a wine and cheese gala event to enjoy her favorite chianti with some fava beans. *cue disturbing Hannibal Lector slurping*

A short while later, Phyllis had a throbbing headache in the occipital region (back of her head) and recalling her doctor's instructions, she went to the ER. It was a good thing too... she had an alarmingly high blood pressure and she could have died. A new side effect profile was later proven linking tyramine-rich foods with MAO inhibitors. Tyramine resembles other neurotransmitters in her body and an excess release of these catecholamines kicked her body into high gear.

The following tyramine-rich foods are contraindicated with MAO inhibitors, according to the FDA:

Alcohol: Do not drink beer, red wine, other alcoholic beverages, non-alcoholic and reduced alcohol-beer and red-wine products.
American processed, cheddar, blue, brie, mozzarella and Parmesan cheese; yogurt, sour cream.
Beef or chicken liver; cured meats such as sausage and salami; game meat; caviar; dried fish.
Avocados, bananas, yeast extracts, raisins, sauerkraut, soy sauce, miso soup.
Broad (fava) beans, ginseng, caffeine-containing products (colas, chocolate, coffee and tea).

In a show of responsibility, holisticonline.com cites that St. John's Wort can be used for mild depression by minor MAO inhibiting action and therefore, tyramine-rich foods should be avoided.

Drug toxicity is often the cause of adverse side effects in the drug-food interaction. Other food-drug interactions are not as dramatic as the "cheese reaction." Still, there are other interactions that you should be aware of:

• Grapefruit juice has a very broad spectrum of competing drug effects. It inhibits the drug-metabolizing enzyme CYP3A4 in the intestines. Complicating matters in elderly people is the issue of "polypharmacy," taking numerous medications along with a high consumption of grapefruit juice. Calcium channel blockers, cholesterol medications, some psychiatric medications, estrogen, oral contraceptives and many allergy medications are affected by grapefruit juice.
• Alcohol can overwhelm the liver as it stops metabolizing drugs and starts converting the alcohol instead. This leads almost universally to drug toxicity and possibly even overdosage.
• Caffeine stimulates the central nervous system and certain drugs amplify its jittery, excitable effects. Bronchodilators (like theophylline and albuterol) and quinolone antibiotics (like ciprofloxacin)

It is ironic that certain things in our diet like cheese, beans, miso soup, grapefruit juice, caffeine and alcohol increase the concentration of drugs. You'd think that would be a good thing... but it is a tricky business, titrating drug concentrations to specific doses that are effective without being harmful. Leave the drug dose tampering up to the doctors and pharmacologists.

Be sure to check the instructions of any new medications you take to be sure that you're being safe! :)

The sites I checked out:
http://www.treatmentonline.com/treatments.php?id=1042
http://www.holisticonline.com/Herbal-Med/hol_herb_med_reac.htm
http://vm.cfsan.fda.gov/~lrd/fdinter.html

Back to the Suture

I'm fond of scars. They impart a sense of history with pain and suffering, then regeneration and recovery. They mark a person as different and the scar-bearer is changed forever. I've talked about a few of my scars in a previous entry. There are many more which are equally apparent and their stories are equally clumsily ridiculous. Enough about me, though...

Let's say that you get a nasty gash and you go to the ER or your neighborhood friendly family physician to get patched up. What goes into this process? What should you know? I will split this up into two parts, general instructions for patients and tips to keep in mind for doctors.

For Patients:

• You stumble into the office seeking help and you've just been told to take a number and sit down?!? Relax, you're not going to die of exsanguination. Unless you have a scalp wound. Those buggers keep on bleeding until they are stapled or sewed shut.
• It's a good thing you came in early. Even a short delay of three hours can greatly increase your risk of infection.
• You've had your tetanus shot in the past 5-10 years, right? Good. If not, expect to get a needle in your shoulder to make sure that you don't get lockjaw and die of tetani spasms as your whole body locks down and you stop breathing.
• Have you ever had an allergic reaction to iodine or iodine dye or anything like that? Then why is the doctor giving you BETADINE?!? Well... betadine doesn't cause an allergic reaction because of its chemical makeup.
• Have you ever been told that you have an allergy to lidocaine? Then why is the doctor giving you LIDOCAINE?!? Well, you're actually allergic to the preservative in the bottle and chances are high that you're getting the preservative-free version.

YEOWCH! The topical anaesthetic takes away most of the pain, but you still feel like wincing a bit from the uncomfortable feeling of someone tugging on your flesh to knit it back together. You're a brave trooper! :) What do you do now that you have spiky threads and a tender wound?

Here's what you need to know about your wound care:

• Keep it dry for ONLY 24-48 hours.
  It is okay to wash the wound carefully after that with soap or shampoo. Keep it clean.
• Daily washing can be supplemented with a little hydrogen peroxide to bubble off sticky bits of scabs (coagulum.)
• You don't need any antibacterial ointment. It's important that it is exposed to air; it helps with the healing. KEEP IT CLEAN, though.
• Go back and get your sutures removed as directed.
  Face: 3 days (cosmetic); 4-5 days (less cosmetic)
  Scalp, trunk, extremities: 7 days
  Joints: 10-14 days max
  Palm, soles: 14 days
• Steri-strips with may be placed in a "ladder" formation (rungs going across & the legs securing it on)
  
• Initially, your wound will look... okay. Nothing too bad.
• Then in about 2-3 weeks, it will get thick and red and tender and lumpy... some might even say ugly. Don't worry, this is normal.
• In 6-12 months, the scar you see is the scar you get. The affected area will never regain its original strength back, but it is important to stretch it so you don't lose its flexibility.
  

For Doctors:

1. The "Golden Period" is 6 hours. This is a period of time in which a wound can be sutured up safely with few complications like infection or scarring.The general vasculature of certain areas extends this period for some areas, 10 hours for the hand and 24 for the face; extra perfusion means better healing.
2. High Pressure Irrigation
   Use a 19 gauge needle on a 35 ml syringe to apply the needed 15 PSI of saline to reduce infection.
3. Antibiotics
   Dog/Cat/Human bite wounds require extra attention and Augmentin (875 mg BID) should be good. Most physicians feel it is necessary to prescribe a full weeks worth, but the majority of the bacteria is taken out in the first 24 hours.
4. Prep the wound with betadine solution, but keep it out of the wound itself.
5. NEVER shave eyebrows. They might not grow back. Avoid shaving hair at all, if you can. Gloss up hair with antibacterial ointment to move it out of the way for suturing scalp wounds.
6. Anaesthetics:
   NEVER use Lidocaine with Epinephrine on "fingers, nose, toes, hose and lobes" because Epi's vasoconstriction effects can cut off blood flow.
   The toxic dose of lidocaine is 50 cc of 1%.
   Bupivicaine is a great alternative to lidocaine. It has a slower onset, but the fact that it wears of slowly also has HUGE effects on patient comfort.
   Avoid injecting anaesthetic directly into the pads of the fingers; use digital blocks instead to numb up the entire finger instead. You're not using lido w/ epi on the fingers, right? Good! :)
7. Count the stitches you put in or have the patient keep track of them. Many people want to know the exact number for comparison's sake. Be prepared to give them an answer.
8. If you have nurses provide wound care instructions, make sure they don't say "keep the wound dry." This will make it very difficult to remove the stitches later on because of the extra tacky coagulum.

Source: the wonderful Dr. Waters
Thanks for a thorough and excellent suturing workshop!

your tapper is all fried

Signs of Congestive Heart Failure
TORCHED TAP

Third heart sound
Oedema
Rheumatic heart disease
Crackles in lungs
Hepatomegaly (tender; possible hepatojugular reflex)
Elevated JVP (jugular venous pressure)
Displaced PMI (point of maximal impulse)

Tachycardia
Ascites
Pulses alternans

your HEART FAILED

Causes of Heart Failure
Your HEART FAILED
Hypertension
Endocrine (hyperthyroidism, thyrotoxicosis)
Anemia
Rheumatic heart disease (RHD)
Toxins
Failure to take meds
Arrhythmia
Ischemia/Infarction/Infection
Lung (PE, pneumonia)
Electrolytes (renal failure)
Diet (beriberi, salt, fluids)

Proxy consent

Is it morally right for society to allow parents of children too young to make their own decisions to deny them the medical attention they require for survival for religious reasons?

• Yes, it is their child after all
• No, absolutely not
• I'm Not Sure

I see this as a question of responsibility. Ultimately, who is held responsible for the death of a Jehovah's Witness child if they get into a serious car accident and need stat blood transfusions in the ER? Is it the person who drove the car? Is it the ER physician? Is it the parents for refusing to give their child blood? Is it God? Everyone has different answers. "It was God's will" is often invoked as a way of accepting the passing of a loved one. However, gods do not swoop down and cast their miracles, blessings and curses down upon us on a daily basis, manipulating our fates in the same way that a storyteller casts roles for his characters and tells them what to say and do. We all have free will to do as we wish.

If we have the power, the capacity and the opportunity to save a life, then I feel that we are MORALLY OBLIGATED TO DO SO. With power comes responsibility, because where we once had no options but to grit our teeth and pray, we now have Choice. We can Choose to alter the fate of a human life in the case of emergency medicine.

Not everyone will choose to follow the same course of action.

"You have the right to choose", the Watchtower says. This biweekly publication for Jehovah's Witnesses originally introduced the ban on blood transfusions in 1945 and since then, it has complicated the treatment for their adherents. While I find it regrettable that JW's would refuse treatment, by the ethical principle of autonomy, they are allowed to do so as long as they give informed consent. This means that they fully understand all of their options and perform a cost-benefit analysis according to their own principles and make a decision. The difficulty underlying this is how it can be applied to young children.

The British Medical Journal has this to say on the subject of proxy consent:

With regard to religious based refusal of blood products by parents, courts in the western world are of the opinion that the child’s welfare is paramount and blood can be given. Consideration should be given to parental views and treatment moderated where possible but if conflict occurs, the child’s interests always come first.

Regarding adolescents, there is no worldwide consensus on the legal position of adolescents refusing blood transfusions, but recent cases suggest that the UK’s approach is probably the most acceptable. While many children raised in JW communities may never experience the "outside world", the judiciary would be wrong not to give them that opportunity. Religion is a powerful persuading voice, but it is also an individual belief. A limited life experience cannot truly give one the opportunity to rationalise a belief that may eventually lead to death.

Archives of Disease in Childhood 2005;90:715-719

Past courts have ruled similarly, citing differences between developed adult beliefs and those of their undeveloped children. In 1944, Prince v Massachusetts set out the reigning legal principle:

Parents may be free to become martyrs themselves. But it does not follow that
they are free, in identical circumstances, to make martyrs of their children...

In 1999, Alexis Demos was a 17 year old who refused to undergo a blood transfusion when she lacerated her spleen after a snowboarding accident. Her decision and that of her family was challenged by physicians and ultimately went to the Massachusetts Supreme Court where they ruled in favor of the physicians. What parents often forget is that they are not solely responsible of their child's welfare; doctors and nurses who care for the patient are emotionally affected as well. The death of a child who would have been saved under any other circumstances rests on their consciences.

However, the beliefs of Jehovah's Witnesses are not to be dismissed or ignored by the medical community. For them, this is not a routine medical procedure, it might be a test of their faith and a gauge for their quality of life. As one Jehovah's Witness told me, "If I receive a blood transfusion, I won't be living in the face of God and it would be better to die than face that." Those are strong words to live by (and die by.) Blatantly disregarding these strong beliefs would violate her autonomy and her personal well-being. Many surgeries can be performed with alternative blood products, saline infusions and "bloodless surgeries" that cater to their particular beliefs.

When I encounter patients with strong faiths, I will ask them about their faith in medicine and their faith in me. If I am going to help them, I think it is important that they believe in me and my dedication to best serve them.

The limits of Evidence-Based Medicine

The parachute has not been properly tested to the same degree as evidence-based medicine (EBM)!

BMJ 2003;327:1459-1461 (20 December), doi:10.1136/bmj.327.7429.1459
Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials

Study selection: Studies showing the effects of using a parachute during free fall.

Main outcome measure: Death or major trauma, defined as an injury severity score > 15.

Results: We were unable to identify any randomised controlled trials of parachute intervention.

Conclusions: As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute.

I got a good chuckle out of reading this. Basically, common sense must prevail over rigid adherence to scientific evidence, development of clinical criteria and other objective quantities. Sometimes EBM can project a total ignorance of human qualities... and I feel that this is the main problem underlying EBM's tense relationship with complementary and alternative medicine (CAM).

EBM and CAM both have the same objectives in mind -- they make the patient feel better. However, one of them demands PROOF. The other just cares if it makes you, the patient, feel better. As it has been shown time and time again, there is a degree of efficacy in placebo, where the mind actually is able to make the body feel better with a useless remedy. The placebo effect is a great friend to CAM adherents, because these people feel like they are regaining some control over their lives and their condition -- in doing something (even if it is nothing) they feel better.

Do EBM and CAM get along harmoniously? No. Do they have to? I don't think so. Orac, the EBM atheist/surgeon and full-time woo-hater, abhors the idea that medical schools have CAM in their curriculum. Even worse, AMSA, the premier med student organization, supports the woo.

I can see why this would trouble him. However, after participating in a retreat with the CAM department at my medical school this past weekend, I am not inclined to take the same hard line that Orac puts us up against. We spent very little time learning about the native medicine. (Which bothered me a lot.) We spent a lot of time learning about the native culture. (Which I have come to realize is the most important part of medicine that we cannot be taught through school.)

I think that it is vital to have CAM in medical school. We shouldn't be "so open-minded that our brains fall out," but at the same time, we need an understanding of these alternative medicines and the culture underlying them so we can be appropriate advisors. We care for the patients and obviously, they care for themselves because they ARE SEEKING TREATMENT... even if it is something that is not science-tested, doctor-approved.

In order to address CAM issues in the clinic, it is important to understand their theories and be accepting, not distainful. (Bedside manner is key!)

It is important to separate the roles of researcher and physician. It is the job of a scientist to be a skeptic -- and a doctor's role is to care. If someone takes their loved one to a reflexologist instead of a doctor with a complaint of "breast lumps" doesn't mean that they are loved any less. It doesn't mean that they are trying to prove something by being different. It does mean that you have to be respectful of their beliefs to regain their trust.

While your opinion is good and you think that it is right... it means nothing if patient has a different opinion of you and allopathic EBM.

Faint

One of my classmates donated blood for the first time last week. I thought it was very brave of him, considering how he was with needles. We practiced giving shots on each other intramuscularly (IM) and subcutaneously (subQ) with our clinical skills preceptor. He was very nervous about being stuck with a needle for our little blood draw...

"I can draw blood from other people just fine; I'm actually really good at it!" he said. He certainly was adept at taking someones blood. He did have some squeamishness about giving his own, though. He had some traumatic experiences with a gadolinium shot once and he passed out.

So this past Friday, I was waiting in line to donate and someone who was rejected came out of the bloodbank mobile. "One of your classmates just fainted in there!" he told me.

I knew right away who it was.

Some people have a vasovagal response to needles and blood. Emotional stress can trigger the hypothalamus in the brain to reduce their sympathetic "fight or flight" responses. As a result, their blood pressure drops precipitously from sudden slowing of the heart rate and their arteries dilate. Less blood flows to the brain and the decrease in oxgyen causes them to feel dizzy and in my classmate's case, pass out.

As blood flowed painlessly out of the venipuncture in my arm, Tom remarked about his current physiologic state. "My blood pressure was 110/80 before and it dropped to 80/70 when I passed out... now its back up, but now I'm tachycardic with a heart rate of 120!" Normally, the heart rate is between 60-100 beats/minute. "Explain that, pingpong," he asked me.

Ah... reflex tachycardia was likely induced as a way of bringing the blood
pressure back after vasovagal-induced vasodilation. After all, the blood
pressure is dependent on three factors: the heart rate, stroke volume and the
total peripheral resistance. In response to a drop in resistance (caused by the
peripheral blood vessels suddenly opening up and causing the heart to pump less
blood back to the heart,) the heart rate increased to compensate for the
loss.

If I were quick on my feet, I would have said something coherent and impressive like that. At the time, I just a bit flustered, hoping that I wouldn't be a victim to syncope (pronouced seen-coh-pee) as well.

I have my own little personal theory about this, which I shared with him as he was recovering:

"Back in the day, if you were attacked with a sword, you would've fallen to the ground and appeared dead, only to rise later on in the battlefield. It's a great survival mechanism..." I said cheerily.

"So, you're telling me that my grandparents were cowards?!?" he said in a somewhat horrified, but joking way.

"NO! I think they are survivors!"

It didn't occur to me at the time that what I said could've been construed as offensive. In retrospect, I realized that it certainly wasn't the most comforting thing to say to a good guy. He's got a great way of approaching his problems, though. Even though he was "black-balled from donating blood for ten years," he wanted to learn more about what was happening to himself. He wanted to turn this negative experience into a positive one.

I like that about my classmates. They are really good at that. Even if it would be his very first and last time donating blood.


Reference: PubMed
Clin Sci (Lond). 1991 Nov;81(5):575-86. The Vasovagal response.

2031 and 2048 predictions

http://abcnews.go.com/Health/story?id=2618973&page=1

Food labels will have been revised to reveal at a glance the overall nutritional
quality of any packaged food. Public school cafeterias will offer healthful
foods in two categories: mixed diets and vegetarian. Organic farming will
represent more than half of all agricultural productivity in the United States,
and 40 percent to 50 percent of the population will be vegetarian.
Some realms of nutrition will have changed much more dramatically.

A friend of mine responded to this estimation with surprise. 50% vegetarians? Well, at the current rate of seafood decline, we'll be out of fish to eat by 2048! (see later link) With mad cow disease and avian bird flu and other nasties, we'll have to rely on Quorn for meaty sustenance.

Nutrigenomic analysis will be part of a standard medical checkup, culminating in
a detailed printout offering tailored recommendations. With this power in their
hands, doctors will be reimbursed for offering dietary counseling, and will be
able to dispense worthwhile advice.

I like the sound of this. We are already modifying diets for the obese, diabetics and patients with coronary artery disease... wouldn't it be better to catch them before they get worse like we do with phenylketonurics? Look at a diet soda to see the dietary warnings for PKU people.

In the year 2031, parents will still tell their children to eat their broccoli
because it's good for them — that convention won't go away anytime soon.

Of course. How cute.


http://www.allheadlinenews.com/articles/7005411529

Wilson said if the situation continues as it is, all fish and seafood
creations could be extinct by 2048.

The paper is called "Impact of Biodiversity Loss on Ocean Ecosystem
Services" and features the work of ecologists and economists who studied the
role marine biodiversity plays in maintaining ecosystem services.

I will mourn my loss of shrimp, the most delicious crustaceans to roam the open seas. I suppose I will have to stock up for the next 42 years! ;)

Anticholinergic toxic effects

This mnemonic about atropine and scopolamine is rather poetic:

Sleepy as a sloth
Blind as a bat
Mad as a Hatter
Red as a beet
Hot as a hare
Dry as a bone

Bladder n' bowel lose their tone,
While the heart runs alone.

Jimson weed is common in the U.S. and ingestion of its leaves as a herb tea, chewed or smoked, causes these symptoms. However, the long onset makes a lot of users overdose while trying to get a cheap high.... and its not a fun one, as you could probably tell.

Belladonna, or deadly nightshade, is another plant that contains this alkaloid. "Bella Donna" means "beautiful woman," because atropine can be used to dilate the pupils (to simulate arousal.)

You might have been a "bella donna" if you've ever gone to the optometrist or ophthalmologist and they dilated your pupils to inspect your retina!

Community Health

There are four main principles of ethics in medicine: beneficence, non-maleficence, autonomy and distributive justice. Beneficence means to simply do good things, while non-maleficence means doing no harm. Autonomy refers to patient empowerment, giving them the right to choose their course of action in treatment.

Many doctors have no problems following the first three principles, even considering that a lot of very stubborn patients make aggravating and even detrimental health choices. However, the last principle proves to be the most difficult one to accomplish in medicine. Distributive justice reflects our Founding Fathers’ ideals on equality in the same way that autonomy reflects our nation’s independence.

Health disparities are a growing problem in our nation that can only escalate without a few policy and cultural changes. Universal health care is something that we have difficulty “buying into” because of our capitalist thinking… but the way our economy runs should not dictate the level of care that we administer to our citizens. Only recently have I start considering this equality of care as a true, guiding ethical principle alongside “do no harm.”

When I first heard about medical schools offering “free clinics,” I was very excited to be a part of something like that. I did not know what distributive justice was at the time -- I only saw it as an opportunity to get early hands-on clinical experience while being capable of providing a community service in healthcare to an underserved community. In my opinion, this provision is vital in the creation of a bond between students (like myself) and the people we would be seeing in our later years. I have a special interest in Primary Care, so learning how to cultivate this sort of connection was very important to me.

Much to my surprise and delight, My Medical School opened up the “Homeless Outreach and Medical Education (HOME) Project” at the Next Step transitional shelter right next to campus! A few months later, I matriculated. I showed up to the clinic the week before orientation started to get a feel for what we would be doing and I knew at once that this was something I wanted to be a part of. After going through interview after interview with various community health organizations during orientation week, I was selected to be a part of HOME. On my first day as a HOMEy (as we affectionately call ourselves,) I got to draw blood from a family medicine resident, before I even started my curriculum in medical school! I love the sorts of positive experiences and opportunities that HOME provides for us, bridging the gap between the science and clinical aspects of medicine with the art and community aspects.

We learned about community resource mapping and the importance of communicating with various organizations. We learned how to conduct valid surveys which would play into the first phase of our community projects, the needs assessment surveys. Dr. O was very gung ho about involving us in various projects to help the homeless. A few of the projects we are working on involve setting up various clinical services in the areas of dental health and mental health. The project that I am working on involves a mobile clinic that will go out on the road and take health services to the people who need it most. Since the future of the Next Step shelter residents is uncertain next year when the warehouse contract expires, I thought that it was very important for us to be able to go out on the road and see patients.

Last month, we had the opportunity to do just that. HOME set up a tent in a beach park with the “Helping Homeless/Hungry Have Hope” H5 program. We offered blood pressure screenings and first aid alongside the food and entertainment that H5 brought along. We had volunteers to spare, so a bunch of us went roaming through the homeless campsites with needs assessment surveys. The beach residents had a lot of very interesting stories to tell and I left with a sense of sadness and resolve. There were so many children there, just like those at Next Step, who are denied so many things and it is not their fault! The same applies for many of the adults as well, who cannot afford a home or even work at a job. One veteran I met wants to go back to work as a longline fisherman, but he needs surgery before that can be done. As a veteran, he only can get this surgery at an army hospital, but they won’t cover the cost. Another woman I met cannot go to work because she is afraid of losing her government benefits if she tries to raise her income for her family. It is a vicious cycle of poverty, but it is my hope that we can alleviate the problems for a few of these people to make a lasting positive difference in their lives.

We had a Halloween carnival for the kids of Next Step, transitional home to 92 homeless children. It took a lot of planning on the part of the medical students and Dr. O, but we had an incredible amount of support in terms of donations and manpower. I helped organize our volunteers and I also helped make some of the games. The children really enjoyed themselves and a lot of them spent the time cycling through the bouncy castle over and over and over again. Each health-related game came with a set of prizes they could win and their bags already started off with so much toys and candy, it was no wonder that many of them struggled to carry around their big bags of loot around. It was ironic that we had so much candy while we were trying to teach them about healthy habits and perhaps the kids knew that too. One MS-III told me "I asked the kids if they wanted any Reese's Pieces and they just wrinkled their noses... but when I asked them if they wanted pencils, they were really excited about that!"

What I love the most about HOME is the enthusiasm and dedication that everyone involved has and what I admire the most is the way that they excel at the tasks they are put to. Each Tuesday night, we set up clinic and see about two dozen patients in a few hours with just a handful of medical students! The attendings are all very open and friendly with us. It is a good time to get to know the third-years during their family practice rotations and sometimes we get to step beyond doing vitals to perform basic parts of the history and physical examination under their supervision.

I feel that HOME is a great integrating experience that ties in what we learn from clinical skills and basic science lectures with the psychosocial aspects of medicine (the “touchy-feely” stuff) that we discuss in our small group sessions and I am glad to be a part of it!

Medical Investigations into the Occult

My journey through medical school has been crazy , since I am given an incredible amount of freedom to pursue my own interests with little time to spare for the occasional lecture or two. I love lectures; I always attend them (though I have been known to sleep through a whole bunch as an undergrad rousing myself to take notes whenever I hear something new.)

Med school is all about learning new things -- but not all of these new things are all that interesting. If more lecturers paid attention to the times, maybe people would tune in more.

In a constant quest for case-relevance, I tune in to the hubbub that surrounds me... Halloween! I got the idea from Dr. Charles' elf entry and from Yahoo story about a paper entitled "Ghosts, Zombies and Vampires - Cinema fiction versus Physics Reality" by Costas Efthhimiou. They've got some great stories and I wanted to add a bit more. It might not be PC, it might not even wholly accurate, but gosh darnit, I hope it's educational and dare I say it?!? I hope it's amusing as well.

To start things off in my investigation into occult medical "mythdiagnoses", I turn to the classic Halloween monster of them all:

Vampires!

Vampires are photophobes and hemophiles, fearing sunlight but loving blood. This makes them the perfect candidates for porphyria! (wikipedia, lifespan) Porphyria is a group of genetic defects in heme synthesis. Accumulation of various intermediate products give rise to various symptoms like tea or wine-colored urine, neurological problems and photosensitivity.

My biochem professor speculated that King (correction: George) the III had a few bouts of acute intermittent porphyria and as a result, Britain lost in the American Revolution. People with other types of porphyria with buildups of tetrapyrrole get itchy or burning sensations in their skin in bright light. This can lead to hair loss, loosening of nail beds and retraction of gum lines (which is probably less disconcerting around Halloween.)

In all fairness, I have a link for the skeptics (straight dope.)

Vampires are said to have a strong aversion to garlic and with a little research, I learned that garlic does have an effect on blood. Ancient Babylonia and China used garlic for medicinal purposes and it is now believed that allicin is the active ingredient. Raw crushed garlic has the highest concentration of antiplatelet (platelet aggregation occurs before a fibrin clot forms and coagulates) and fibrinolytic properties.

Werewolves

A few types of porphyria (variegate and cutanea tarda) can cause hypertrichosis (wikipedia) or excessive hair growth... so these might have contributed to werewolf legends as well.

Since the phenotype is so readily apparent, it was much easier to find information about people with hypertrichosis vs porphyria. Hirsutism (wikipedia) is another type of excessive hair growth usually referring to women with high androgen production.

Familial hypertrichosis is not a myth. People with these X-linked conditions are often male, performing in circus shows. ABC news did a story on one such man a few months ago, entitled "Real-Life Werewolves," about a Mr. Gomez who is a 5th generation wolfman! Chuy the wolfboy also has an interview online and oddly enough, they are both men in mexican circus shows. They have interesting stories to tell.

It doesn't seem like they have any predisposition to howl at the moon or turn violent, but animals do bite more during a full moon. (BMJ, 2000.)

Is there a basis for killing werewolves with a silver bullet? None that I could find. Perhaps it is a Type I contact allergy to silver... copper or nickel is more common (I think.) Perhaps it has to do with the antimicrobial activity of something like silver nitrate...

Zombies

The Efthimiou paper I mention earlier has a compelling argument about the basis of zombie legends. Basically, Haitian voodoo priests use pufferfish tetradotoxin to paralyze victims and make them appear to be dead. When(If!) the toxin wears off, the subject awakens as if from the dead.

This is all well and good, but it doesn't quite match up to today's image of zombies as hungry, mindless monsters with rotting flesh. People suffering from lepromatous leprosy (WHO) match the physical description surprisingly well. They have an infection of Mycobacterium leprae and their immune systems have taken the wrong approach to getting rid of it. Leprosy affects the skin and nerves.

Peripheral neuropathy in places like the sural nerve (in the shin of the leg) causes the foot to drag on the ground, making them lift their legs higher to compensate. Damage to the radial nerve (though rare in leprosy patients) causes wrist drop.

Decreased sensation of these floppy feet and numb hands means that damage to them goes unnoticed. Toe and finger stubbing can lead to necrosis, as these tissues literally rot and fall off their body.

Zombies are not as much of a threat to medieval peasants as werewolves and vampires were, so I can't really think of any myths about how to kill them (other than decapitation, but that's not very subtle.) Oh! Mycobacterium are acid-fast bacteria. Holy water... acid... ok, it's a stretch.

Ghosts

I am not quite so convinced by Efthhimiou's arguments against vampires simply refuting it by demonstrating the implausability of exponential vampire growth assumes a 100% transmissibility rate which... ironically.... I find implausible! ;-) and ghosts, which he chalks up to temperature gradient differences and psychological expectations. Where's the weird phenomena in that explanation?

Well, I've stumbled across an excellent example for your reading pleasure!

Vic Tandy, an engineer, started working at a "haunted" lab in Coventry, England. Everyone had feelings of being watched and a lot of people were thoroughly creeped out. This engineer was working late one night and he saw a grey figure approach him at one point. "It would not be unreasonable to suggest that I was terrified," he says. The next day, he noticed that a fencing foil he was working on was vibrating. He was frightened at first, but after some investigation he found that his lab recently had installed an extractor fan.

This fan created a standing air wave projecting infrasound (wikipedia) at 19 Hz. This sound is not heard by human ears, but we can still perceive it as symptoms of uneasiness, dizziness and shortness of breath.

According to NASA, the human eyeball has a resonance of 18 Hz. In the standing airwave, the vibrating eyeball can cause a "smearing of vision". Hyperventilation is another symptom of whole body vibration. I've noticed that this sort of lightheadedness gives objects a special glow or aura afterward.

Interestingly, Tandy goes on to find 19 Hz infrasound again in a 14th century cellar in the Tourist Information Centre of Coventry.

So, never let it be said that the myths are all fictitious stories... there is a level of fact and fun can be had in finding it!

Happy Halloween!

Hobbits, Dwarves and Giants

Dr. Charles' entry on the genetic link to "elves" got me wondering about other mythical creatures.

Some 11-18 thousand years ago, a 3'6" tall tool-wielding "hobbit" roamed the island chain of Flores. Carl Zimmer of the Loom has a little timeline of what happened since their discovery and controversial claim to fame as a new species of humans. There is a big debate over whether or not the Homo floresiensis are pygmies, like those from Africa, or small children with microcephaly.

--

Shifting back to stories of fantasy, J.R.R. Tolkein's dwarves live in mountains where their short stature helps them survive the same way pygmies in the forest or on islands do. Dwarves have a fondness for ale, axes, beards, and gold.

People with dwarfism might not have the same predilictions, but the mythic dwarves are likely derived from the phenotypic characteristics of achondroplasia (Medline, OMIM entry). The autosomal dominant trait involves a genetic mutation of FGFR3, limiting bone formation from cartilage, particularly in the long limbs of the arms and legs. This results in short stature, disproportionately short limbs, a large skull and prominent forehead.

--

While little people have a problem forming bone, people with acromegaly (Mayo Clinic, OMIM) have a problem forming too much. Gigantism is caused by excessive secretion of growth hormone from the pituitary gland.

I remember reading a comic strip from Calvin and Hobbes referencing this... but people with gigantism don't grow to be skyscraper sized.

Andre the Giant is a famous example. He was a professional wrestler and he was in the Princess Bride. He was a very large man at 7' 2". This did not go without any consequences... his immense weight took a toll on his joints. His body grew too big for his heart and he died of congestive heart failure.

--

I'd like to add more, but I'm plumb out of ideas.

Stay tuned for the medical explanations of the occult, just in time for Halloween!

Avian Flu, What to Do? (III)

Do you live paycheck to paycheck? If you had to live at home, separated from the rest of the world (excluding your immediate family) for six months with little notice, would you be capable of this? Do you have enough emergency rations of food, water, batteries and toilet paper?

Neither do I. Even after the recent quake and subsequent blackout which left my family powerless, we haven't gone on a crazy rampage to stock up on our essentials. We had a gas-powered grill, but very little food to cook on it. We didn't want to open the fridge and freezer, instead opting to wait for the power to come back on. Seemingly inconsequential things suddenly became more important as I unconsciously flicked light switches on and off, attempted to put food into a non-responsive microwave and my stomach growled and grumbled the whole day. I quickly realized how powerless I am without electrical power. I learned how soft we've become in responding to unexpected events.

Now imagine a crisis in which everyone was ordered to stay at home. Public gatherings would be banned. Air travel would cease completely. Whole communities would be "socially distanced," exposed people would be quarantined for 10 days of monitoring and sick people would be swiftly isolated... hopefully waste disposal, food, medications and other necessities could be dropped off in some way.

The difficult thing is figuring out if you're the right sort of sick or not. Hospital doors would be barred with police and perhaps even National Guard protecting its borders to prevent desperate people from barging in... hopefully real emergencies would grant them access. People would be evaluated for their exposure and if they met the criteria, they would be taken to the hospital. They would develop an extreme shortness of breath, like that seen in SARS, and many people would need to be put on ventilators just to keep breathing.

Typical drugs to fight this disease would not work. Everyone would want to stock up on the presumed magic bullet but governments might have to ban private stockpiling. It would be given ineffectually by inexperienced (and scared!) users who might inadvertently increase the diseases' resistance instead of fighting it off.

There is not enough of this "magic bullet" to even protect the healthcare workers who would be treating sick people. Vaccines would not be made against the outbreak... the soonest they could be made would be 5-6 months and those would be shots in the dark. There is not enough ventilators to treat all of the sick people and many people would have to be taken off (and left to die) in a desperate triage situation to save someone else's life.

This would be the reality of the Avian Flu Pandemic.

The H5N1 virus replicates and sheds more virus silently for 12-24 hours before the host starts to feel ill with headaches, fevers, chills, sweating (diaphoresis), and difficulty breathing. Strangely, the bird flu is a lower respiratory infection (rather than an upper respiratory one like other flu viruses) so there is often no runny nose or sore throat... but stranger still, there might be diarrhea. After 4 days of feeling ill, the host's breathing would become so labored that he/she would have to go to the hospital. There, the host would get oseltamivir (Tamiflu) and be placed on a respirator. If they are lucky, they will live. If not, death would come after 9 days of illness.


This is a very scary and serious disease. A flu outbreak could break our nation, killing potentially millions of citizens despite our best efforts to contain the flu, cripple our economy when millions of people are suddenly banned from working or even seeing each other... we wouldn't even be able to have funerals for lost loved ones.

What can we do?
How can we prepare ourselves?
How can I help?

I don't mean to scare or alarm anyone; just tell the facts as they are right now. I certainly don't have all the answers, but I'll try to address a few points of each of these questions as I learned about them during a Bioevents conference.

I will focus on the specific response of Medical Students during a Avian Flu Pandemic in my next post.

Fey folk: Myth or Reality?

I was reading Dr. Charles' ScienceBlog today and I learned that a deletion of the elastin gene makes you an elf!

[edit: 9/26/07]I'm removing this cute pic of a kid with Williams because it is doing something funky with my pagecounts.

People with Williams syndrome "usually have a small upturned nose, long philtrum (upper lip length), wide mouth, full lips, small chin, puffiness around the eyes, and a prominent "starburst" or white lacy pattern on the iris of the eyes."

"Children with WS are more sensitive to music. Upon listening they become more emotionally involved, more attentive, with happy and sad feelings persisting much longer than normal and with greater intensity. This affinity for music, if fostered, can help many overcome developmental problems. Some children with WS can barely write, sign their own names, or navigate a stairway, yet can they learn to execute the slight hand movements needed to play the piano or drums."

I think it's pretty amazing how our myths are based on truth... stay tuned for the next episode in which we explore the scientific basis for vampires! :)


[addendum]
For the more technically inclined, here's a link to the Online Inheritance in Man (OMIM) information on the elastin gene and condition of WS.

Avian Flu, What to Do? (II)

I had a dream recently that I went to Indonesia for my summer preceptorship
experience. It wasn't quite what I expected... much more free time than
clinic time (which was nice, but difficult trying to get around not
knowing the language)... challenging to learn what was going on in the
hospital but I got a lot of cool procedural experience out of it... but
when I picked Indonesia, I figured that I'd get to be in the tropics,
working with colorful cultures and exotic microorganisms.

And indeed I did. When I went back home, I started to develop a dry cough.
Then I got a headache and sore joints. I was sick with the flu for a
few days and I would have dismissed it, I got diarrhea. My chest
started to close up and I found myself gasping for air. Fluid was
pouring into my lungs and out of my pores. In my dream, I contracted
the Avian Flu. Then, my family started getting the same symptoms...

For precisely this reason, I'm sure that there is absolutely NO WAY I could
go to Indonesia this summer, as much as I would want to. My Medical
School just wouldn't allow it with the terrorism, the lawsuit
liabilities and the health risk of contracting the Avian flu and
becoming Patient 0... as beautiful and exciting as Indonesia would be
as a vacation/learning opportunity. ;)

The Avian Flu Pandemic is a big worry in the health community but I feel that it is blown off by the general public. What's the big deal? It's just the flu; I've gotten that before.

Here's a few facts about the flu.

Influenza di freddo means "influence of the cold (winter)" in Italian.
Unlike some other microorganisms, the flu virus lies dormant during the summer
months and becomes active. Some speculate that it has to do with the
temperature or the humidity change or the fact that everyone crowds up
indoors -- but we don't really know why this happens. Subtle changes in
the virus' single-strand of RNA alters its envelope and capsule
proteins so each year, we are susceptible to the same viral infection. Hemagglutinin and neuramidase (of H5N1 fame) are the major antigens on the surface of the viral package. This process is called antigenic drift.

Our bodies develop immunity to the flu if you catch it naturally, but it is to past bugs, not present ones. If you get the flu shot, you are getting a vaccine granting you immunity to the Top 3 predicted modified viruses for this year by Top scientists. It's not full protection (washing your hands and having good hygiene also help) but it's better than getting sick.

The regular flu season comes around November or so and peaks in February.
Every 2.4 years, we get a flu epidemic. This means that we have more
cases of the flu than the expected endemic proportions and this
"outbreak" lasts from 6-8 weeks. Since 1580, we have had numerous flu
epidemics recurring about every 14 years. The last epidemic we had was 38 years ago, but the "Spanish Flu" is the most memorable one.

The "Spanish Flu" outbreak of 1918 killed between 50-100 million people in the course of a few months -- that's more than the 38 million casualties of World War I. That's about a third of our current U.S. population wiped out. That's how deadly the flu can be. When the flu virus undergoes antigenic shift, we are completely susceptible to it and our bodies react with disastrous consequences. The Spanish Flu probably came from Kansas where to different strains of the flu combined.


That's enough for today. You can visit the Flu Wiki if you are interested in learning more @
http://www.fluwikie.com/

My next post will compare the regular flu season to the H5N1 flu pandemic that we are so worried about.

Avian Flu, What to Do? (I)

I just finished with my first round of tests of medical school. I tried to keep up with my posting by putting up a few mnemonics that I thought were useful and good to know... many of them were invented by my good friend Knewton.

Now that I'm out of that study grind, I wanted to move on to something else. This week, I will feature different aspects of the Avian Bird Flu and what the role of medical students would be in the case of a pandemic outbreak.

In case you didn't know, last week was "Pandemic Flu Awareness Week!" My Medical School put on a Bioevents conference for the med students in which we suspended regular classes for a day long seminar on different aspects of the Avian flu: introduction to the flu, the microbio and clinical aspects, a public health response, a medical response, mental health implications and case studies.

Regrettably, the majority of my class dug out after lunch to study for our exams... and in my opinion, this was a mistake. First off, it was disrespectful to the speakers who came to talk with us and second, you're blowing off what might become the most critical service we will provide?!? (We're not sure when the Avian Flu will become a pandemic outbreak, but we know it WILL happen...) I'm very passionate about these sorts of public health situations.

That's why I wanted to disseminate the information I've gathered to share with you. It is important that everyone knows what is expected of them during a disaster situation. As Sunday's earthquake and subsequent blackout attests... My State isn't quite ready to handle the sheer enormity of this task without the full cooperation and understanding from our citizens.


Sorry, I know this is a big teaser, but stay tuned as I introduce you to the flu as we know it!

cut and PASTE risky behaviors away

Mnemonic for helping adolescents give up risky behaviors

PASTE

Problem - define the problem
Alternatives - list possible alternative solutions and list pros and cons
Select an alternative
Try it
Evaluate the choice and modify it if needed

Cancer MALADIES

Mnemonic for the 8 characteristics that a cell can acquire to become cancerous!

MALADIES

Metastasis/invasion
Angiogenesis
Limitless replicative potential
Apoptotic signal resistance
Defect in DNA repair
Inhibitory growth signal resistance
Evasion of immune surveillance
Self-sufficiency for growth

Testicular lump: OVA+TESTES=HATCH

Here's a quick and dirty mnemonic for the differential diagnosis of testicular lumps:

Orchitis
Variocele
Autoimmune orchitis

Tumor
Epidermal cyst
Spermatocele
Torsion
Epididymitis
Scrotal trauma

Hydrocele
Abscess
Testicular microlithiasis
Cryptorchidism
Hernia

Losing your ADLs is like falling down the DEATHSHAFT

A mnemonic for Activities of Daily Living (DEATH) and Instrumental Activities of Daily Living (SHAFT)

Dressing
Eating
Ambulation
Toilet
Hygiene

Shopping
Housekeeping
Accounting
Food preparation
Telephone/Transportation

Differential Diagnosis: A VITAMIN C/I VINDICATE AIDS

Mnemonics for recalling the various arenas of the differential diagnosis when presented with a problem case.

A Vitamin CDE

Acquired
Vascular
Inflammatory
Trauma/Toxin
Autoimmune
Metabolic/Medication
Infection
Neoplastic
Congenital
Degenerative
Endocrine/Electrical

I Vindicate AIDS

Inflammatory
Vascular
Infectious
Neoplastic
Degenerative
Idiopathic
Congenital
Autoimmune
Trauma
Endocrine/Metabolic
Allergic
Iatrogenic
Drugs
Social

*I bolded the ones that are special additions for the longer mnemonic... I'd recommend just starting off with a shorter one and tossing in the later considerations as needed.

THE STAPH CELL

Mnemonics to help you remember the various virulence factors in S. aureus.

THE STAPH CELL
TSST
Hemolysin
Enterotoxin
Staphylokinase
Teichoic acid
A (Protein A)
Penicillinase
Catalase/coagulase
Exofoliatin
Leukocidin
Lipase

And to remember what category these S. aureus factors belong to...
"Disabling" factors
Handi-Capped Parking Lessens Ambulation
Hemolysin
Coagulase
Leukocidin
A (Protein A)

"Invasive" factors
Hungry Staph Likes To Pigout!
Hyaluronidase
Staphylokinase
Lipase
Teichoic acid
Protease

"Military" factors
At Ease (2Es)
Assault proteins:
TSST
Enterotoxin
Exofoliatin

My scars make me unique.

Perhaps when I smile, your eyes are not drawn to my dazzling pearly whites. You might notice the half-moon shaped scar that crinkles like a dimple when I smirk. Or maybe the scar slashing across my upper lip. I might be tilting my head just so and you'd also see the scars underneath my chin and the flattened red keloid on my cheek.

Such scars seem like the beginning of some great story and many people might be hesitant to ask me about it. Was I attacked by rabid dogs at a young age? Did I get into a knife fight trying to save an old lady from a group of gangbangers? Was I the sole survivor of an Unforgivable Curse (tm) like Mr. Harry Potter?

No, my dear friends, it was a mere speed bump at the bottom of a great hill that did this hero in. I was always a clumsy kid. I have scars on my forehead from a thump on the corner of my uncle's bed during my third Thanksgiving dinner. I seem to have a thing for holiday accidents.

It was a chill and eerie Halloween morning that I went bike riding with my dad. I was groggy and I was riding on a new bike I'd never rode on before with very sensitive front brakes. I closed my eyes as I raced down a hill in the quiet botanical garden a few blocks away from my house... and at some point I lost consciousness for about 10 seconds because I found myself on the ground with about 10' of street gravel rubbed into my face. (It's rather strange how my story seems so silly and similar to Dr. Charles.)

My parents took me to the ER and I had a few rocks the size of quarters taken out of my cheek.


A few weeks later when the itching was subsiding and the keloid was injected with steroids to make it sink down, I was asked if I wanted cosmetic surgery.

"Nope!" I'm proud of my scars. While they might be reminders of my idiocy, they give my face character. They make me a unique person. If I were ever cloned in a laboratory and someone tried to replace me with my identical double, people who know my face would know which one is me.

And that makes me smile even more.

Pop Culture Education: Brains and Balls

Pinky and the Brain educate the masses on the Anatomy of the Brain. I'll definitely be using this when we get into the neuro unit! :)

---------------------

And a more risque video... Rachel Gets Fruity for Testicular Cancer!
The music makes it seem as though it is not safe for work or school. I showed it to my group while doing a presentation on testicular self-exams (TSEs) and I justified it by saying "just thought you would rather hear about the exam from someone else." It is provocative in the thinking sense. ;)

The only catch is that the U.S. Preventative Service Task Force actually advises against the teaching of TSEs, because the cancer is uncommon and when detected early by the doctor, they have a good outcome. This seems a bit bizarre to me. If people are worried about their testicles, they should be told by their doctors what is unusual and when they should be checked by a professional.


I think it is a great thing to have these sorts of pop culture education moments. Let me know if you've seen any good ones too!