Kava drinking increases liver GGT levels

The Honolulu Advertiser had an article in the paper this morning about how Kava drinking creates a "liver anomaly."

"There's some evidence of something happening in the liver," said Dr. Janet Onopa, an assistant professor of medicine at the John A. Burns School of Medicine who analyzed the data and reviewed the lab reports. "But it doesn't seem like anything catastrophic."
....
The blood work revealed elevated levels of the liver enzyme GGT — or gamma-glutamyl transpeptidase — in 65 percent of the kava drinkers. The levels of GGT increased with increased kava consumption.
In the control group, high GGT levels were only seen in 26 percent of the non-drinkers.
"We don't know exactly what a high GGT in and of itself means," Onopa said. "It's possible that kava just induced that enzyme without doing any liver damage."

Kava is a traditional drink of Samoa and Fiji. The active ingredient, kavalactone, comes from the root of the plant Piper methysticum. It causes numbing of the lips and tongue when consumed and a mild intoxication of calming quality. Some ill-prepared concoctions still contain parts of the leaves and stem of the plant and this can cause severe liver damage and hepatotoxicity.

I've scoffed at Kava drinking before, but I had some last spring break as a part of a Hawaiian cultural experience. Despite its dirty brown yellow watery appearance and its strange numbing effect, it's not that bad. It's nothing that I would choose to drink, but I can see why many Polynesians drink it.

As for the effects of GGT, gamma-glutamyltransferase is a liver enzyme used like alkaline phosphatase (ALP) as a marker of liver damage. In conjunction with elevation in other liver enzymes like ALT and AST, an assessment of liver health is made.

I think it is irresponsible to imply that the elevated GGT levels signify something other than liver damage. If these enzymes that are normally in biliary liver cells are released into the blood stream in large amounts... to me, it means that they are dying off in larger amounts.

At least they end the article this way:

Even with the high GGT enzyme results of the UH study, the men said they aren't about to change their kava-drinking habits.

But Brown, the lead author of the study, said heavy kava drinkers might consider getting their liver functions tested.

"You want your liver profile to be normal," she said. "If something is causing that to be abnormal, then you should discuss it with your doctor and have your doctor run a liver profile. Then take your doctor's advice."

References:
Honolulu Advertiser, 9/22/07. "Hawaii kava study finds liver anomaly" http://the.honoluluadvertiser.com/article/2007/Sep/22/ln/hawaii709220345.html
Samoan Sensation. http://www.samoa.co.uk/drink.html
Wikipedia, “Kava.” 20067 http://en.wikipedia.org/wiki/Kava

Something I noticed

I summarized the slides of a long-winded & technical professor and I made this observation:

 

Research faculty are interested in rare and novel things, while clinical faculty are more interested in impact and applicability.  It makes sense after all... the sorts of people who are attracted to research are the ones who seek out unknown things and attempt to answer questions, while doctors are interested in how they can diagnose and treat a specific disease.

 

This certainly has an effect on how they approach their lecture teaching styles.  I've noticed myself sliding into the clinical role more and more.  When I'm faced with a fact, I have to make the brutal decision -- is this something important enough that I need to try and memorize it?  How will I use this fact in the future?  No longer is there the simple joy of learning something new... there's too many new and exciting things to learn!  I have to prioritize.

 

I'd like it if our professors could understand this and help us out with this process to spare us some of the pain-staking process of going to lecture, getting next to nothing from it, doing independent reading, synthesizing our knowledge, summarize it, share it with others and HOPE TO GODS that it is the right stuff we're focusing on.

Family Medicine Interest Group T-shirts

We've got a Family Medicine Interest Group t-shirt competition and I thought I'd try my hand at some art. Our president came up with a great idea for a shirt; the back has a bunch of organ systems with our name in the middle. His original design for the front was an "evolution" of man from baby to geezer. It reminded me of an old riddle:

What walks on four legs in the dawn, two legs at noon and three legs at dusk?
Answer: Man. (Or Family Medicine. ;)

I modified his design by removing the intermediary figures and tossing in a sun and a moon. I like it a lot. So inspired, I tried to come up with some other ideas.
I searched through a bunch of clip art pictures on OpenClipArt.org for something that I could utilize and I came up with the funny idea for this one. I doubt our advisor would approve. :)

My last idea is still undeveloped. I wanted to try something Hawaiian, so I thought I'd go with the word "Ohana" to substitute for Family. My initial thought was to do something with Stitch from Lilo and Stitch. I kept trying to quell that. I thought about what Ohana meant... Here's what wikipedia had to say:

ʻohana means family in an extended sense of the term including both blood-related or extended. It emphasizes that family and friends are bound together and members must cooperate and remember one another.
... The root word "ʻohā" refers to the root or corm of the kalo, or taro plant (the staple "staff of life" in Hawaii), which Kanaka Maoli consider to be their cosmological ancestor.

Well, that flopped. I still have to figure out how to incorporate the idea of taro into Family. And Medicine. Hrm.

Don't sacrifice personality for character.

This is just an bit of advice I've formulated today.


I'm probably over-analyzing this, but if there's any place to share it, I figure that this is the best.

What does that mean?
I think of Personality as those cute little quirks that make you uniquely you. They are the things that people do to imitate each other.

Character is the sort of thing that Calvin's dad would always evoke as a way of getting Calvin to do hard work. "Shoveling snow builds character." "Aww... I wanna play with Hobbes!" Character is the ideals of what you want to become.

Why am I bringing this up?
I feel as though I've traded out part of my Personality for Character. When I came to school today, I got multiple comments about my appearance. It wasn't any particularly special day for me; I was just dressed in an aloha shirt and some slacks for Project HOME in the evening. Even at HOME, where everyone was wearing aloha-formal-attire, they were impressed.

"You look like a doctor!" A classmate remarked. "You could march around and people would say 'Hey doc, we need you to save this patient!'" Really? That's cool. I've captured the respectable & conservative aura so soon. I'll admit, it's been the main reason why I'd never get a tattoo or a piercing. I'd lose that sort of asian doc credibility.

So what's the problem?
I only play Doctor at school. It's just a Character I slip into. It's all about professionalism, respect, integrity, compassion and humanity. However, school has taken over my life, slowly and surely. It's hard for me to make a distinction about when I need to behave and when I can relax and be myself again. Can I screw around and study at school after hours? I do sometimes, but I think the impression that a lot of people get is that I'm all work, no play. School is school, to me.

Sure, it's easy to say "be yourself all the time," but I don't really want to get into trouble all the time. It's easier to channel just parts of myself... but it makes me more bland.

I've been hanging out with a new group of people at school recently and I really like their company. They are doing research, so they are as dorky as my med school friends. I went out to out to eat and sing Karaoke with them on friday. How surprising it must have been for them to see me as a funny/wacky karaoker, singing myself hoarse. How unusually fun-loving.

Another thing that reminded me of this recently is that my friends like to do imitations of our classmates. I've wondered if they do one of me... but I think that they don't. It's as though I've washed out those characteristics right out. A few nights ago, we had an executive officer meeting, but I wasn't invited. It was as though I were totally forgotten on the invite list! (BTW, if lynn reads this, she'd feel totally guilty. that's not my intent here.) it was funny to me, because i wondered -- am I that forgettable?

Gods, I hope not.

Thinking back, this is not a new conflict for me. I will always be struggling to maintain balance between my school life and personal life, my Character and Personality. Who I am and who I want to become.

Reflection on a reflection

I wrote an email out to the med school classes to recruit for a mentorship program. It was interesting, because I wrote as if you, my blog readers, were my main audience and apparently it was well-received. When I came to school today, two of my classmates came up to me and said "I read your email last night!"

They seemed excited about that for some reason. "Yeah, it was like a bedtime story for me..." one woman said. Whoa! Bedside tales by Yours Truly. "It was inspirational," said another. I was flattered. I didn't really expect that it would recruit more people to join the club; I just wanted to share my reasons for why I joined. I think that is my approach to a lot of things in life.

I thought I'd share it with you as well.

I had my first musculoskeletal CSP (clinical skills preceptorship) today and I was just thinking about what it means to be a preceptor. These doctors take time out of their busy schedules to help train us to become great doctors! They probably remember bumbling through the questions in the history and getting confused during the physical exam. All in all, having access to helpful preceptors so early in
our careers helps to ease us into our roles as confident providers.

Teaching is a great skill to have! You don't have to wait until you get your M.D. degree to make a difference in the training of future doctors. Mentoring is a skill that the Medical Student Mentorship Program fosters. With that in mind, I just wanted to remind you about MSMP's upcoming Mingler! This event will be taking place this Friday 9/7/07 at My University's Center 5:30-8pm. If you are curious, please come on down.

Your parking passes are valid on campus after 4pm!
If you need a ride, I'd be more than happy to take you there. Check out our website for contact info.

Mingler details: First we will meet in the meeting rooms on the third floor for some icebreakers to introduce the mentors to the potential mentees. Then we will adjourn to the Gameroom on the lowest floor for some pizza, salad and billiards/games.
Please RSVP if you are interested in attending. Also, we would like you to submit an
online MENTOR application by Saturday, 9/8/07 so we can have the mentor/mentee
matchups finished by Sunday.

Cheers,
Not My Second Opinion, MS-II, MSMP board



P.S. I know that this has been "club week" at school and there has been a lot of activity. You might be wondering why you should join yet another club. MSMP is unique among the interest groups because it extends beyond the medical school community and it is worthwhile! After all, it made a difference for me, since I'm a med student today. :-)

On oops disclosures

Dr. Michael Wilkes's Second Opinion on KCRW on disclosure.

I've commented with my thoughts on disclosure of a cancer diagnosis to a Japanese patient before in "Shh! He doesn't know!" Culturally, it is acceptable for the family to request that this information be withheld from the patient -- something that I found ethically repugnant a year ago.

If a patient asks "why am I getting this treatment", is the family asking us to lie for them? How far is this betrayal of trust expected to go?

However, my recent visit to Japan made me reconsider this. There is a trend in Japan towards more Western values and practices in Medicine (among other things) and cancer disclosure is still a contentious topic there. I asked a few doctors (one was a cardiologist, the other, a resident training in GI) how they approach the subject.

The resident told me point blank that he followed the family's wishes and didn't tell the patient. He echoed the sentiment "a lot of patients cannot handle a diagnosis of cancer." I was surprised to hear this. Cancer isn't the death sentence that it used to be. The elder cardiologist agreed with me and told me that he tells his patients regardless of what the family wants. "It's their right to know," he said. Of course, he did have training in the U.S., so that might have affected his cultural judgement.

I'm not sure how I feel about the situation mentioned by Dr. Wilkes. If I were the surgeon, what would I do?

*deep inhalation*

I'd like to think that I could do the right thing and respect the family's wishes while still fulfilling my role as a doctor. Before the diagnosis is even made, I would like to approach the patient and tell him/her "now, one of the things we are testing for is cancer. If it turns out to be cancer, how would you like this to be handled?"

This gives the patient an opportunity to "opt-out" and puts patient decision-making in the hands of the family. I think this is culturally sensitive for both parties and it has the advantage of forewarning the patient of their potential diagnosis. If they are keen, they probably suspected cancer all along. Perhaps it's just reassuring for some patients to know that they are being taken care of as best as possible without having to worry about the prognosis.

Ankle Sprain

Monday was my first day back at school and I've jumped headfirst into learning!

There was a case presentation on someone who fell down and broke their leg. Just a few hours after that, I was running around and I slipped off a stair and rolled my ankle. It was already weak to begin with because I had injured it before. Musculoskeletal problems and rehabilitation all of a sudden became more interesting to me. :-)

I applied the RICE treatment for my ankle on the first two days to control the swelling and pain.
R = Rest as much as possible
I = Ice, for 15 min, twice a day
C = Compression, with ACE wrap, wrapping twice around the foot first to secure it, then alternating in figure-8s around the foot, overlapping by at least 1/3
E = Elevation assists with drainage

My biggest question now is: what can I do to prevent this from happening in the future?

Here are some of the exercises I am supposed to do twice a day as 3 sets. (Whoa! That's a lot more rehab than I expected.)

• Sit on a firm chair or stand up. Loop one end of surgical tubing around the ball of the foot with the injured ankle. Hold the other end of the tubing in your hand. Put your heel on the floor. Stretch the tubing by pushing down with your foot, the way you push on the gas pedal of a car.
• Sit on a firm chair or stand up. Loop one end of the tubing around the leg of a sturdy table. Loop the other end of the tubing around the foot with the injured ankle. Stretch the tubing by pulling up with your foot (lifting up your foot), using your ankle, as if you were trying to pull the table toward you. (This motion is the opposite of trying to "step on the gas.")
• Sit on a firm chair or stand up. Loop one end of the tubing around the leg of a sturdy table. Loop the other end of the tubing around the foot with the injured ankle. Stretch the tubing by moving your foot out to the side, away from the leg of the table.
• Sit on a firm chair or stand up. Loop one end of the tube around the leg of a sturdy table. Loop the other end of the tubing around the foot with the injured ankle. Stretch the tubing by moving your foot to the middle, toward your good ankle.

Exercises and advice by "How to Care for Your Ankle Sprain" 10/1/2002. American Family Physician.

Curves of Paget's Disease

Paget's disease, aka osteitis deformans, is a "hot" disease of bone, where your bones are first degraded faster than they are built, then they recover, but in a strange and brittle way. Normally, your body is in a constant state of flux that remains relatively balanced -- unless you're vitamin D deficient (leads to rickets or osteomalacia), estrogen deficient (postmenopausal osteoporosis), etc.

A year has passed...

I've completed a full year of medical training and the biggest lesson that I've learned is that I don't know much.

The first patient that I saw with a group of my peers was last year, about this time -- we had just finished learning how to ask a patient about their past medical history and their background information. Our interview with an 80 year old woman turned into a recounting of her personal story, how she came to the state, worked in the fields, raised three children, survived two heart attacks and pneumonia last year. Other parts of her story came out in more subtle ways. She was able to recall details of her past perfectly -- but more recent memories from last week's procedures that brought her to the ICU were more fuzzy. It turned out that she had been diagnosed with Alzheimer's... our preceptor commented how it was therapeutic for her to reflect on her past with us.

This theme stuck with me as I learned more and more how the greatest gift I could give a patient, here and now, is my time and understanding. A lot of doctors are stressed out and they are only given a 15 minute window to see patients! As a "non-essential" part of the medical team, I have the luxury to spend more time with the patient.

I have volunteered at a homeless shelter providing free medical care and we recently expanded our services to another shelter. Time and time again, I have been drawn into a patient's story that went beyond their chief complaint to their underlying condition... how they lost the security of a warm bed and home to call their own. One man came in because of bedbug bites. He used to be a prize-winning chef, but he screwed it all up selling drugs. He was caught and went to prison for a little while, but when he got out, he found out that no one would hire him because of his prior conviction. In his despair, he confessed to me that he had a child on the way and if he was missing from the shelter in a few weeks, it's because he's back on the streets dealing drugs. I asked him about what was important in his life... he said that it was his girlfriend and their new child. I told him to think about the life that child would have and how much more difficult it would be if he were a drug dealer. He ranted on for a while and the visit went on for close to an hour. He said that he felt better afterward. I was glad that I listened to him... and I hoped that he listened to me. I saw him a few weeks later still at the shelter, but he has a black eye and the white of his eye had turned blood red. I hope beyond all hopes that he hasn't resorted to crime and drugs again.

Recently, I saw a series of patients in the clinic that really made me realize how much my volunteer work at the shelter has changed my outlook.

- difficult man

- emotional, obese woman w/ recent dx of DM

- possibly drunk & pregnant woman w/ a painful boil on her thigh - worried about baby!

What makes a good doctor?

When you find the answers to this question, you will have found yourself.

One of the most touching parting gifts from my ex-girlfriend before she left for Japan and I went to medical school was a simple project: she gave me a red ribbon and a bunch of colored construction paper squares with slits cut into them so they could be threaded on. The quote above was written on the front with the query "What makes a good doctor?" and the assignment was one that I took to heart.

Now, when I came across something difficult in my journey, something that I found worthwhile enough to blog about, I also try to summarize it on a colored square to hang on the red ribbon. This art project is a constant reminder to me of the important lessons I have learned. This entry will be my electronic file of my ponderings as I journey to find myself.

1. Being Proactive: I drew blood during my first week of medical school! The act of being proactive is not about being aggressive or stubborn, it is about being open and willing.
2. "Yes-And": Stephen Colbert's commencement address on improvisation, silliness and refusal to become a cynic
3. Competence: Strive to be your best, but don't fret about your inadequacies!
4. Motivation: a nephrologist preceptor told me "95% of being a good doc is how badly you want to be good."
5. Sacrifice: Make the most of your spent time and energy - make it meaningful
6. Ask an unscripted question
7. Resist complaining, stay positive
8. Count something
9. Write something
10. Change
    

Fwd: FW: New Medical Student Org

I was sent this in the mail today and I thought I'd pass it along. I am quite hesitant about "hanging up my shingle" so to speak, because of the intimidating business logistics involved. How much time would I actually spend with patients? Should I join a physician group so I don't have to worry about starting from square one and hiring all the staff? Should I set out on my own so I can be completely independent? Would I be happy with that?

I have no idea what problems lie ahead on this path to primary care. And I'm glad that a student organization has set out to tackle some of these worrisome issues.

You came to medical school to acquire the knowledge and technical skills necessary to make your mark in the world of medicine – but when you leave, will you be equipped with the right tools to make the important career decisions in your near future? Given the increasing financial pressures on the practice of medicine and the growing medical student debt load, today's medical graduates are navigating a more complex terrain than ever before. We owe it to ourselves and to our future patients to make informed decisions about how we choose to practice medicine.

The Business of Medicine (BOM) is a student-run, non-profit organization that was founded in 2006 by medical students at Georgetown University. BOM's mission is to increase medical student awareness of financial challenges and opportunities impacting the practice of medicine. Simply put, we recruit thought leaders and experts to speak at medical schools. Topics covered include Financial Planning, Residency Selection, Post-Residency Career Paths (private practice, hospital-based medicine, academic medicine, etc), Reimbursement, Health Insurance, Medicare/Medicaid, Physician Income and many more.

BOM also maintains a website with links to the most high yield resources on Debt Management, Insurance/Policy, Malpractice, and Career Development. Each link posted has been screened by medical students to provide the most concise, relevant, and accurate information available on the topic. We invite you to explore our website at: http://www.businessofmedicine.org/ and hope that it will help save you time in the future. We welcome your comments and suggestions for improvement as we continue to develop and keep our site up-to-date. It is truly a site for medical students by medical students!

You've invested valuable time, energy, and financial resources into the process of becoming a physician. We invite you to join us in our mission to bring BOM to medical students nationwide and to empower yourself by learning how to best protect this investment.

For more information about how you can get involved, please contact us at bom@businessofmedicine.org. We look forward to hearing from you!

Time-tested science

A publication for every fact, a life for every arrow.

This is just something I've been pondering for a while... all throughout my studies, I come across piles and piles of research which must be quickly "triaged" into a read, file, or discard category. So much research goes into each simple little fact in a textbook, demonstrating a link from A->B. Someone could devote their entire life towards this modest goal, because there are so many different methods of experimentation!

My embryology teacher in undergrad put it best as "show it, block it, move it."

1. Show it: First things first. You need to run epidemiological studies, immunofluorescence studies, etc. to show that a certain gene/enzyme/disease/factor is present in association with whatever you're studying. And you need to do assays, dig through piles of charts, or run huge randomized polls of selected populations...


2. Block it: Then, you can stop it. This can be tricky in some cases. You need to demonstrate that a disease/condition/observation disappears in the absence of the variable you're tweaking.


3. Move it: Then, you can move it. Can you create the disease/condition/gene product with the modest introduction of your tweak somewhere else? This is the most ethically questionable of the three principle study designs, since you cannot induce diseases in humans and expect to get away with it. Often, animal studies are performed with the hope that it can apply to other models as well.

Three simple concepts. Yet the execution of them can take trial after trial, assay after assay, tons of paperwork to get funding and support and recognition.

I'm surprised sometimes that scientific progress hasn't halted altogether, given the amount of work, time and money it requires. I have a great appreciation for the unsung heroes of the laboratory whose obscure brilliance might only be recognized by a super-select few. (Few? Can I even use that as a noun? It sounds okay to me.)

Writing a Personal Statement

This is the most difficult part of any application -- the free and creative portion in which you distill your essence into something that falls within the 5300 character limit.

How do you do this? I've talked about my own personal statement in the past.

TheReporter has some other tips and thoughts on writing a personal statement:

Humility and honesty that must come out in your essay.
A successful personal statement FOR MEDICAL SCHOOL is about the patients, and their perceptions/feeling, more than anything else. Try this before you do your next draft: describe a patient's experience/thoughts, from the first person viewpoint, from the time they first suspect they are ill to the time they see a doctor.

This goes beyond a mere essay to get into medical school. We're talking about a philosophy on how to approach patients. How a doctor ought to use the Golden Rule. This is a life-long concept... and what TheReporter is really doing is asking -- are you the type of person who has enough social intelligence that you can put yourself in someone else's shoes? How did that make you feel?

Writing a personal statement is not about echoing the tired cliche of "I want to help people" or "I want to be like Dr. X and Y because they changed my life." A personal statement should be a personal revelation with emotional content that makes people tilt their heads and go "hm..." Find your personal character flashback moment.

Strive for insight, but don't push the boundaries and make bolder claims than you can support. Practice expressing yourself. Take chances and open up with a patient when you reach a point of awkward silence when they wonder why you're in the exam room. Smile. Laugh. Ask questions. Creating experiences will inevitably lead you down a road that you can look back on and say "wow, I've got a lot of material I can draw on for a personal statement."

Healthcare Blogger Code of Ethics

I just came across this concept through Nick Gene's Pre-Rounds Interview with Dr. Lei of Eye on DNA.
Med Blogger Code of Ethics:

1. Clear representation of perspective - readers must understand the training and overall perspective of the author of a blog. Certainly bloggers can have opinions on subjects outside of their training, and these opinions may be true, but readers must have a place to look on a blog to get an idea of where this author is coming from. This also encompasses the idea of the distinction between advertisement and content. This does not preclude anonymous blogging, but it asks that even anonymous bloggers share the professional perspective from which they are blogging.
2. Confidentiality - Bloggers must respect the nature of the relationship between patient and medical professionals and the clear need for confidentiality. All discussions of patients must be done in a way in which patients’ identity cannot be inferred.
3. Commercial Disclosure - the presence or absence of commercial ties of the author must be made clear for the readers. If the author is using their blog to pitch a product, it must be clear that they are doing that. Any ties to device manufacturer and/or pharmaceutical company ties must be clearly stated.
4. Reliability of Information - citing sources when appropriate and changing inaccuracies when they are pointed out
5. Courtesy - Bloggers should not engage in personal attacks, nor should they allow their commenters to do so. Debate and discussion of ideas is one of the major purposes of blogging. While the ideas people hold should be criticized and even confronted, the overall purpose is a discussion of ideas, not those who hold ideas.

I agree with these ideas, especially those about Reliability of Information. There's so much garbage out on the internet that obscures the truth... it's important for health professionals to ensure that they are providing a refuge from this refuse!

The New News (Google Comments & my own)

A story recently came out about Baby Einstein in the newspapers. They cited the "Journal of Pediatrics" for publishing a story on the paradoxical effect of educational DVDs with children under 24 months. These infants understood fewers words than children of parents who read to them, according to Clinical Cases and Images. CCaI went on to claim that many official news sources failed to link their online articles to the original study and in fact, the Archives of Pediatrics & Adolescent Medicine was the publisher.

However, when I read the article that CCaI posted, it did not coincide with the information suggested in the original articles. It proves CCaI's point though... check your sources! ;-)


In related news, google news is adding the ability to comment on news -- if you are a part of the news story. This has the potential to provide rebuttals (as seen by McDonald's in response to astudy that kids find carrots and veggies wrapped in McD packaging tastier). It has the potential to provide further information DIRECTLY FROM THE SOURCE (as seen in the FDA approval for a new HIV-drug Selzentry.)

I think that the internet will revolutionize how we receive our news. After all, I learned about all of these stories through Clinical Cases and Images... a blog targetted to educating IM residents in the Cleveland Clinic. Unless traditional newspapers can adapt, adopt and become adept with new technology, they will swiftly find themselves outstripped by other alternative news sources.


[edit] Hm... Medgadget provides a little more info from the original Times article, confirming CCaI's reference.

Led by Frederick Zimmerman and Dr. Dimitri Christakis, both at the University of Washington, the research team found that with every hour per day spent watching baby DVDs and videos, infants learned six to eight fewer new vocabulary words than babies who never watched the videos. These products had the strongest detrimental effect on babies 8 to 16 months old, the age at which language skills are starting to form. "The more videos they watched, the fewer words they knew," says Christakis. "These babies scored about 10% lower on language skills than infants who had not watched these videos."

However, the article does not make the bold claims that the authors suggested... or maybe I'm reading it wrong.

Television and DVD/Video Viewing in Children Younger Than 2 Years
Frederick J. Zimmerman, PhD; Dimitri A. Christakis, MD, MPH; Andrew N. Meltzoff, PhD
Arch Pediatr Adolesc Med. 2007;161:473-479.Time Magazine reports on the findings that the popular Baby Einstein video series, meant for infants, lacks scientific merit when it comes to spoken word, and seems to actually do harm.

Drinking

My other post on alcohol has proven to be very popular... it's on the second page of Google if you type in "Alcohol allergy!"  :)

 

Here's some other facts about alcohol that you probably should know:

 

12-ounce bottle of beer = a 5-ounce glass of wine = a 1.5-ounce shot of 80-proof liquor = 11-14 grams of alcohol.

 

>60 grams per day for ~2-4 weeks leads to fatty liver (steatosis)

>80 g/d for ~2-4 weeks leads to alcoholic hepatitis

>160 g/d for ~2-4 weeks leads to cirrhosis

 

Drinking a six pack of beer a day can turn your liver from an efficient energy producing machine into a fatty sludge.

 

A beer gut might just be a superficial symptom of underlying pathology.  While steatosis is reversible, cirrhosis is not.  When your liver starts building up scar tissue, blood that normally comes from your gut is shunted to other places.  Blood waste products build up in your blood stream and you might turn a sickly shade of yellow (jaundice) or start having mental difficulties (hepatic encephalopathy.)  You might bleed into your stomach and start vomiting up a lot of blood (hematemesis due to esophageal varices.)  You might get hemorrhoids and you bleed out of your rectum.

 

Not pleasant.

The lesson -- if you decide to drink, drink in moderation.

Gupta v Moore on "Sicko"

Michael Moore has a new movie out, entitled "Sicko." It speaks out about the current situation of our health care system in the U.S. My class is having a summer outing to go and see the movie tomorrow, but I won't be able to make it. However, the movie is not far from my mind. I'm currently volunteering at two homeless clinics and I'm reminded almost daily how difficult it is for these people to get good, reliable health care. Having universal health care would be a great step in the right direction. In some ways, they sort of have this already, in the form of ER visits. Our country does not turn anyone away from the emergency room... but I sometimes wonder what happens in other countries with socialized medicine. Are they rejected at the door if they aren't a citizen that pays taxes? Why do a lot of companies provide health insurance supplemental to that provided by the government?

Dr. Gupta wrote a story for CNN about how Michael Moore "fudged" some of his facts. They played his piece right before inviting Moore to respond and he went OFF.


Moore is a very passionate person. He's great with theatrics too, accusing CNN of failing to do it's job in fair reporting, trashing Fahrenheit 9/11 and now his new movie, when they both will be shown to be right on the dot... he was even pushing to get them to apologize to the American public for pandering. I don't think he ever means to be deceitful and if there's anything that will rile him up... it's lies. Accusing him of lying is probably the worst button you could push. I think he speaks the truth on his facts. I also agree with an assertion by Dr. Gupta made a few days after the initial report that Moore "cherry-picks" his data. Michael Moore is a movie-maker and documentarian..ist? He is not a scientist... he doesn't spend his time publishing factual journal articles. What he has proven to be very good at though... is simply getting people to talk about important issues. :)

Dr. Gupta's reply can be read here: http://www.cnn.com/HEALTH/blogs/paging.dr.gupta/2007/07/my-conversation-with-michael-moore.html
He made an admission that he misspoke on Sicko's claim of Cuba's health care cost per person as $25... when in fact, the movie said it was $251, the same value that he quoted.

One of the things I found most interesting was reading the replies on Dr. Gupta's blog.

If you admire this man, then why were you nit picking his movie? It seems to me that you should try to make his data better.

As a former overweight American, I think Michael Moore should follow the path I took and lose some weight. Obesity is the best example of preventative medicine. I appreciate Mr. Moore doing a film on our healthcare system, and agree we need an overhaul of the system. That being said, it is ridicule that Mr. Moore constantly assails the government yet thinks they are capable of running a healthcare system.

...But the most important thing is that people in those countries can buy private healthcare for a fraction of what American people do. The reason is that there is not an oligopoly as there is in the US. Another thing is that in all these countries to study to be a physician is basically free for the student.

Whoa, really? I'd like to have free healthcare and FREE HEALTHCARE EDUCATION. Now, that would be a truly rewarding public service!

Ecylse, the "Zorse"

What the heck is going on with this horse? It's part zebra, apparently.

while most zebra-horse crossbreeds sport stripes across their entire body, Eclyse only has two such patches, on its face and rear.

The one-year-old zorse was the accidental product of a holiday romance when her mother, Eclipse, was taken from her German safari park home to a ranch in Italy for a brief spell.

There she was able to roam freely with other horses and a number of zebras, including one called Ulysses who took a fancy to her.

When Eclipse returned home, she surprised her keepers by giving birth to the baby zorse whose mixed markings betray her colourful parentage.

Via DailyMail

At first, I thought that this would be a good example of mosaicism, but upon further research, I found out that this would require a mutation. I guess I was thinking something more like X-inactivation, seen in the colorful coat coloring of a calico cat.

In any case, I thought that this was a striking example of genetics in action. Yay weird science!

"Flea" Bite

A while ago, I started to read the posts of "Flea," a pediatrician blogger so named by snarky surgeons who call pediatricians "fleas."

He took to his pseudonym well, offering biting commentary in the medical field, often offering harsher truths than I thought appropriate, as evidenced in my response to his entry on Lavender Essence and vaccines. A doctor has a position of high responsibility and respect and it requires a certain amount of professionalism... which apparently, extends to blogs. You cannot let your guard down, even when you use a blog as an outlet for something as frustrating as a malpractice lawsuit.

Flea's posts became irregular and more and more of them cited an ongoing court case he was involved in. I thought that this was a risky thing to do and as many speculated when his blog was completely erased -- it did not bode well for the outcome of his trial.

Indeed, he was featured on the FRONT PAGE of the Boston Globe just a few days ago! That's crazy scary. I would not want something like that to happen to me.

Worried about how a blog might affect your career and your reputation if you should be discovered? Clinical Cases and Images offers a few pieces of advice: write as if your patients and your boss reads your blog everyday. Conform to HIPPA. I added a disclaimer to my sidebar, but I don't have the traffic/notoriety/fame that Flea, Respectful Insolence or Dr. Dimov have to warrant full disclosure.

Kevin, M.D. offers his own comments and summarizes the responses in the blogosphere.
Eric Turkewitz, personal injury lawyer provides some links to the ongoing story.

TSH effects: hyperTRICEPS

Since I'm on the topic of hyperthyroid, I thought I'd share a little mnemonic I just made about the steps of thyroid hormone synthesis that are affected by TSH stimulation.

HYPER TRICEPS
HYPERplasia of the follicle cells
Trapping
tRansport
Iodination
Conjugation
Endocytosis
Proteolysis
Secretion

Autoimmune hyperthyroid, aka Grave's Disease, creates antibodies that resemble TSH and trigger all of these steps willy-nilly without any regulation! This makes your follicular cells very hungry for iodine and they start sucking out all of their stored colloid and dumping the hormones out into the system.

I'm not going to bore you with all of the nitty gritty details. For that, you can go to Boron & Boulpaep or my favorite, Guyton and Hall.

PHASED up hyperthyroid

I've talked about the exopthalmos you see in Grave's disease before.

Here's a way to remember a few of the signs of Hyperthyroid!
PHASED up thyroid
Palpitations
Heat intolerance
Appetite
Sweaty
Emotions/energy lvl/Eyes
Diarrhea

Patients who have hyperthyroid might be noticed by their weird-looking appearance. They have bulging eyes, a strange lumpy neck and they are always anxious. This disease is usually caused by an autoimmune disease that attacks and activates the thyroid gland located in the neck. Increased levels of thyroxine (T4) and T3 hormone lead to a high energy state, which can cause weight loss, muscle weakness, and the increased basal metabolic rate makes them feel hot and sweaty.

I know someone who had this. She told me about her diagnosis and I looked up a few of the symptoms and asked her about them. I remember thinking that she did look a little bit weird, but I couldn't quite place my finger on it. In retrospect, she did have an enlarged thyroid, she was very thin and her eyes were a little bit buggy. Now that she has had treatment (not sure if it was selectively radioactive iodine or medication)... she looks a lot better. I'm sure she feels a lot better too.

Portable ePaper

I'm waiting for the day that they invent ePaper. I'd like to be able to take notes on something thats flexible and portable, something that I could read hundreds of books on with the flip of a page, that requires very little power, and it has wireless access to the internet.

I think that having a device like this would greatly improve my own speed and productivity and more importantly, it would be TOTALLY RAD. A lot of docs these days have palm pilots or Treo phones with mini keypads and stuff like that, but they are so tiny! I rarely use my palm pilot because it makes a highpitched electronic sound that gives me a headache.

My tutorial group was talking about our proposed electronic purchases yesterday. One girl was displeased with her old Treo. Someone else commented on about getting a tablet PC.

And then, I saw this today on Geekologie.
Holy cow, this laptop is thinner than a penny is wide! It's almost as thin as the new Razr phones! And it uses flash memory (the same stuff that comes on jumpdrives and in digicams) so the battery life is >12 hours.

Whoa. I can't wait to buy this, jewelry and purse-looking straps be damned! It is a sweet device.

*stressed*

I've been staying up very late these past few weeks studying. I've been worried about the upcoming exams on gastroenterology (mouth to butt), endocrinology (hormones and such) and hematology (blood and immune cells). Our exams will cover our knowledge of common procedures and practices involved in the most common diagnoses of these fields, anatomy, histology (microscopic anatomy), pathology (Dana Scully autopsy work!), physiology, genetics, biochemistry, etc.

Whew. It's a chore just to try and list the topics that we are supposed to know about. I feel pretty confident about the most recent material since I've kicked my butt into high gear... but I'm VERY stressed out about older material.

Our ex-Secretary of Defense said it best:

The Unknown
As we know,
There are known knowns.
There are things we know we know.
We also know
There are known unknowns.
That is to say
We know there are some things
We do not know.
But there are also unknown unknowns,
The ones we don't know
We don't know.

—Feb. 12, 2002, Department of Defense news briefing

I'm at that stage where I don't really know what it is that I don't know. There's something different about feeling confident with material that doesn't quite cut it when you're faced with a blank page and you're told to "write the mechanism for diarrhea caused by E. coli."

The best way to face this stress is to study, I suppose. And the best way to prove to myself that I've been learning more material than I've been forgetting it is to apply it and start grinding away at mechanisms on scratch paper.

I noticed that I've stopped writing here in lieu of studying, when in fact, this is my best outlet for expressing myself, educating myself and conveying my thoughts in a coherent way that will pay off in the future. I plan on picking this blog up again. I'll use it less as an opportunity to teach and more as a way to figure out what the heck I'm going to do from where I am! :)

Gratitude

Every subunit in our curriculum, we are randomly assigned a new preceptor who we visit in the hospital, to learn more about the subject at hand. Currently, we are in the hematology unit, learning about blood diseases -- and I hear stories about other groups who visit the pathologists in hospitals to read blood smears, learn about leukemia and all sorts of cool things.

What did my group have to look forward to for these past few weeks?

Lets see... we visited two patients who had lung cancer. Another patient who had colon cancer. Another patient who had carcinoid syndrome (which is actually quite interesting in terms of manifestation of cancer.) So yes, there was a lot of cancer. It can be a sobering and sad subject, especially when we reach that awkward point in the Q&A when the patient probes us about what they think the future will hold. Hoo boy... that's rough.

Soured by this experience, I found myself complaining today about how our preceptor is a "fallback" guy. Basically, my theory was that if the school couldn't find enough doctors, they picked him up since he was in previous units as well.

In retrospect, those were harsh words. As I printed out my history and physical write-up to present to my preceptor tomorrow, it came out upside down on the back page. I saw the scenario unfolding in my mind -- he carefully reads the page, much to my surprise and flips it over, remarking that the back page is upside down. In my mind's eye, I had two different replies:

Honestly, I thought you weren't even going to read it.

Sorry, I had trouble figuring out the instructions for backside printing at school. You'd think by now I'd get the hang of it, by now...

The first one shocked me. I couldn't believe that I'd think of saying that to a doctor! Did I really have that little respect for him? He's not a bad doctor; he's just very dull. And to top it off, he doesn't have any patients relevant to the topics we are learning about.

Sometimes it can be difficult to muster up gratitude. He does deserve it though. I imagine that he doesn't get the best treatment from medical students, even though he went out of his way and volunteered to help teach us about hematology when no one else would. I'm glad that he let us visit the blood bank to learn about their lab procedures and techniques last week.

We've had opportunities to shadow doctors, who all have different styles for teaching and presenting. I don't know how he responds to feedback, but I hope that our suggestions are met with gratitude. In much the same way that he's helped us to learn, I hope we can help him teach future students.


[edit]
I spoke too soon. We had an excellent session today with him -- and we had the opportunity to meet with an elderly gentleman who had the misfortune of being diagnosed with multiple myeloma. It was a good learning experience for us, it was something heme-related and much to our surprise and joy, we got out early!

[edit #2]
Upon further consideration, I recall my mother used to tell me when I was young: "complaining about something being boring just means you're not thinking enough to make it interesting." I started asking more questions and getting more engaged in my preceptorship and this attitude shift really paid off. I felt as though I made a good connection with the doctor and I learned a lot.

Pet food scare

Perhaps you've heard about "melamine" in regards to contaminated pet food that's causing renal failure in pets across the country. Have you ever wondered what that chemical actually is? I certainly did and my ears perked up when I heard about it via TerraSigillata at ScienceBlogs.com (via the Knight Science Journalism Tracker at MIT.)

David Brown at the Washington Post ... does a terrific job of explaining how the modestly toxic substance, melamine, can cause renal failure when combined with cyanuric acid. Not widely reported in the press is the fact that cyanuric acid, another nitrogen-rich compound, has also been found to contaminate some wheat gluten and wheat flour from China.

What do a dead cat in Ontario and a motel swimming pool in Phoenix have in common?

In certain circumstances, they both contain melamine-cyanuric acid crystals.

Gout works in much the same way, when foods rich in purine are consumed and inadequately excreted from the body via the kidneys. Uric acid crystallizes in the joints, usually in the big toe for some reason and causes immense pain aka tophus. It makes sense, since needle-like crystals are spontaneously forming there.

A Grave Disease

From OverMyMedBody!

This just ain’t right. This guy must have some sort of malformation of his orbital ridge, or something, cause I have no idea how he’s getting his globe (eyeball) so far out. I think it’s real–you can see the lateral rectus muscle as the camera pans to the side…

I think this person has Grave's opthalmopathy. I don't know much about medicine yet, especially about the eyeball, but if you have a condition known as autoimmune hyperthyroidism aka Grave's disease, your eyes bug out like crazy! This happens because your body attacks the tissue behind your eyes and this triggers inflammation and an increase in glycosaminoglycan (GAG) production. It happens in the pretibial (shin) area as well. Here's a funny video I found on YouTube:


Grave's disease is typified by restlessness, irritability, hyperactivity, weight loss, muscle weakness, heart palpitations, eye problems, sweating and heat intolerance. For a clinical assessment of orbitopathy, click here. Pages 11-16 have some crazy pics of red, swollen eyes and stuff like that too.
Dickinson, A.J. Controversies in the clinical evaluation of active thyroidassociated
orbitopathy: use of a detailed protocol with
comparative photographs for objective assessment. Clinical Endocrinology (2001) 55, 283-303

Readiness

I took a sample midterm today.

It was a strange feeling for me to totally bomb something like this. I'm glad that it doesn't count for anything, but I totally expected to flunk it anyway. I stopped studying for close to a month and I only started getting back into the groove of studying again about a week ago. My interest in the GI subunit was near zilch and even though I tried studying at school in the beginning, I didn't feel like I had the support of my fellow classmates. I started studying at home more often, which to be quite honest, was more like staying at home more often. I nearly doubled the amount of sleep I was getting a night, but I felt less rested than before. With my interest waning, my mood depressed and my short attention span, I found myself attracted to watching episodes of Scrubs on the internet. I would spend hours, watching episode after episode and pretend that it was somehow "helping me study."

Ha! I should have seen the warning signs earlier. I didn't turn to my friends at school for help. I had a difficult time even talking about it with my parents, who must have assumed that I was staying up late studying and that I must have been waking up in time for my classes.

In any case, I was not ready to take the anatomy and pathology exam today. I studied a little bit last night, which felt awfully productive to me at the time -- but I still got nearly all the questions wrong on the test. I felt like studying was just a waste of my time... which is a total shame. Yes, I felt ashamed for sure.

---------

We have a second portion of our midterm online which we can take up until Friday. I wanted to study for that tonight, but my fellow classmate (and small group tutorial buddy) was celebrating his birthday. I carpooled with some people over to Mai Tais tonight and I planned to stay there for just a few hours, but that turned into a whole evening when a bomb threat canceled Sarah's other evening plans and I said "sure, we can hang out here longer." I wanted to be ready when I took the essay and multiple choice questions; everyone who had taken it said that it was a waste of time to study for it because it was just so weird and different from what they had expected.

I spent about half an hour fidgeting and wondering if I should just walk back to campus. I overheard Josh saying "I don't feel well, I think I'm going to go home soon." Kapua frowned playfully and called him a party-pooper. I kept an eye on him, wondering when he was planning on leaving... when he suddenly started falling down.

I grabbed him as his knees buckled and his eyes rolled up. "Josh, Josh, are you ok?" He said that he wasn't feeling well. That seemed pretty obvious to me when he had collapsed at a busy bar, nearly knocking a few people over. He stood up and promptly fainted again, this time, hitting his head on the side of the bar with a loud "THUNK."

He regained consciousness shortly after that and a bunch of us escorted him outside, where he was given water, juice, crackers and his vital signs were assessed. He was pale, sweaty and somewhat shaken.

He ended up leaving with a few people to go to the ER and get checked out.

Thinking back on the whole thing, I wonder if I could have done anything else for him at the time. I certainly wasn't the one to spring into action after he collapsed. Well, I caught him and recognized that he wasn't doing so hot, but that was about it. He's a bit larger than me, so I thought at the time it was reasonable to let bigger guys in to try and lift him up.

In any case, that was the most exciting part of the night. There we were, a bunch of med students surrounding our classmate running through our differential diagnoses of syncope ("sin-coh-pee"), asking him questions about how much alcohol he drank (just 3 beers), a history of diabetes (no, only thing he could think about in his family was hypercholesterolemia), and his last meal (onion rings about 2 hours ago.)

Even though I was bummed out about this morning, it was a swift kick in the arse to remind me to study harder so I can stay in medical school. My quick reaction to Josh fainting made me realize why I want to be a doctor so badly. I'd like to know how to spring into action and really help someone in these unexpected times.

I'd like to be ready.

[edit] Josh sent an email to our class thanking everyone for their concern. He's going to be okay, he just had a combination of locking his knees, sleep deprivation and low-intake hypoglycemia.

Learning Life Skills

Today I learned how to intubate a patient.

It was a random thing that one of the MS-4s offered at the end of our anatomy class today. It was our first class challenge, really... something that some of us found very difficult and others, less so.

You hold this metal pipe with a little flashlight and a curved metal stick. Then you maneuver the whole device to down the throat of an unconscious patient, lift the tongue, visualize the epiglottis, lift that up out of the way as well and maintain your position while you get the tube ready. You can't brace yourself against the teeth because you can crack them or break them outright. A lot of people struggle at this point, arms quaking from the effort of lifting in the appropriate but awkward position. You sneak the tube in, inflate the cuff to seal the airway and remove the wire guide. A few pumps with a bag tells you if you stuck the tube into the airway if the chest moves up and down. If the stomach moves instead, then you hit the esophagus instead.

I actually intubated three times today with a 3:0 record! Granted, they were on mannequins in our simulated patient lab, but I still enjoyed it. It was really cool to successfully place a tracheal tube, so much so that I couldn't help but brag afterwards about how I learned a "life-saving skill" to one of my classmates who wasn't able to intubate. She took the dig in stride and I padded it a little by adding that she must have had trouble because of her tendonitis (which made her wrists sore on both sides at the same time!)

After a little mulling over, I don't know how I feel about this.
I am relieved that I actually have some clinical skill.
I look forward to the day when I can confidently perform this tricky maneuver.
I am happy that today, it isn't something that I necessarily needed to struggle with.

However, after watching "My Ocardial Infarction" from Scrubs, where J.D. experiences a humbling moment in which he falls behind Elliot in skill after bragging, I realized that I learned a bigger lesson today.

You can't let your ego get in the way of doing things well.
I feel that my classmates deserve more support than I deserve praise.

I heart House

There's only two TV shows that I'll drop all of my studying to sit back and enjoy. The first one is Lost on Wednesday nights. The second one is House on Tuesday nights. I've missed a lot of House, but I always keep myself up to speed on the best website ever!!!

Scott is a family doctor that runs Polite Dissent, home to House MD reviews. He posts a summary of the case with links to all the diseases mentioned and then he provides his own analysis of the results. "House" is rarely up to par with real medicine.

When I was watching tonight's episode, I was all happy because I thought I cracked the case halfway through. I commented on his blog. Here's a longer version of my analysis:

Hey, a first-year med student here. I thought I'd try my hand at a diagnosis tonight. When they mentioned strep infections, I thought about post-strep glomerulonephritis as the cause of the bleeding. It bothered me that it wasn't even mentioned. Do the writers even bother looking up the common differential diagnoses anymore? Rheumatic heart disease-induced clots come from atrial fibrillation (which would be easily seen on an EKG,) but I guess an RF vegetation could have embolized. :-\ The balloon catheterization struck me as bad medicine.

Before they came up with Mirror syndrome, I was rooting for Budd-Chiari syndrome.

My differential diagnosis went something like this:
Since this is a TV show, they'll pick something totally random and rare. It needs to have a cool name and involve as many different organs as possible. Hyperestrogenism is a hypercoagulable state. This could cause clots to form and cause strokes and a blockage of the hepatic vein. The hepatic vein blockage could be asymptomatic at first. Blood would back up in the portal venous system and jaundice would result. Weird splanchnic vasoconstriction would have fetal abnormalities and possible kidney involvement with the hepatorenal syndrome. Acute tubular necrosis could cause protein and blood to show up in the urine. It's all a stretch, but "House" always is.

My fun diagnosis was shattered when the transjugular procedure was clean. Drat! Besides, my diagnosis neglected to consider the ethical and curable issues... a "House" diagnosis needs to be controversial and it needs to have a miraculous recovery at the very last second.

I don't know how corticosteroids leads to pulmonary edema. I don't know how it speeds up the development of the fetal lungs also. If the fetus had a lower urinary tract blockage that restricted the development of the lungs, wouldn't there be oligohydramnios? Wouldn't that lead to POTTER sequence? Less amniotic fluid (which is just baby pee) would mean less room for the baby to grow, which could cause problems with limb development.

I didn't know enough about fetal development, so I just went along for the ride after that.

I liked all the drama in this episode. I thought that there were a bunch of very interesting role reversals... House/Cutty, Chase/Cameron, Cutty/Wilson. The way House stared at his hand at the end of the episode makes me think that there's potential for him to want a baby with Cutty! Haha! That would eat away at Cameron and in turn, break poor Chase's heart.

Shhh! He doesn't know!

Scene: A Japanese patient goes to a clinic complaining of abdominal pain and trouble eating. In the waiting area, a strange man greets him and tells him a story. "I know a man who had stomach cancer," he says. "He had terrible stomach pain." The patient's face pales as he hears this. "He had black stool that smelled terrible." The patient shudders and looks away. "They told him it was just a stomach ulcer. He could eat whatever he wanted as long as it wasn't too rough. He died a few months later."

The patient is called into the office where he is told that he had he only has a stomach ulcer and he can eat whatever he wants, as long as it isn't too rough. He looks the doctor in the eye and says "is it cancer? Tell me if I have stomach cancer!" The nurse keeps her head low and scurries away. Another doctor cannot meet his gaze.

Implicitly, he knows what this means and resigns himself to his fate.
/end scene

This is a scene from Ikiru, where a dying bureaucrat decides to spend the remainder of his life building a playground.

Why didn't a doctor disclose the cancer diagnosis to his patient? He outright LIED to the patient who was under considerable distress. This scene bothered me a lot when I saw it for the first time. Then I learned a little bit more about the Japanese cultural aspects that made this behavior acceptable. It's still something I'm not comfortable with, but at least I know what they are thinking now.


In traditional Japanese culture, a terminal diagnosis is not disclosed to the patient. It is thought that this knowledge of an impending death only brings stress and consternation for the patient, who would have otherwise died in a happier state. So instead of telling the patient, the Japanese doctor tells the family. They decide what is best for the patient in what has been termed "family autonomy."

Japanese people have a more interdependent construal of self. They are more prone to say things indirectly to avoid conflict and confrontation. They want everyone to get along.

An important Japanese value is amae. This is "indulgent dependency," or "the accepted perogative of the individual to depend on the benevolence of another." It is tolereated by Japanese people, but it might seem like spoiled whining to Americans. The way I'd interpret it is something along the lines of:
"Please help me, I cannot help myself, I need someone to take care of me!"
This type of pleading puts responsibility of care into the hands of a loved one, boss or someone else that's of a higher position.

Still, this runs at odds with everything I'd want from a doctor. Paternalism, the feeling that "doctor knows best" is an idea we've abandoned for about 40 years now. It is starting to be discarded in Japan as well, as more and more people expect the truth from their physicians, no matter how painful the news may be.



Resources
Fetters, Michael. “The Family in Medical Decision Making: Japanese Perspectives” Journal of Clinical Ethics. Summer 1998. 9(2)132-146.
Powell, Tia. “Culture and Communication: Medical Disclosure in Japan & U.S.” American Journal of Bioethics. 6(1):18-19, 2006.

X-Ray of a Kiss

Geekologie, a website that I love to visit to see funky new gidgets, gazmos and kickawesome stuff, put up this picture of an X-Ray of a Kiss.

They must have coated their faces with contrast and then touched it up with Photoshop or something like that, because there's no way that a regular X-ray has that kind of resolution.

It's very pretty though... and maybe that's how Superman sees the world. Man, I wish I had X-ray eyes. Not only would I be able to see through female articles of clothing (abusing my powers for evil), but I would also be able to quickly diagnose pneumonia, osteoporosis, and ID broken bones (Yay for Good uses!)

Consciousness is...

Consciousness is...
A)Biological - Brain, senses.
B)Spiritual - Soul, heart, spirit
C)A good topic for debate; my answer is too long.
D)A big, scary word.

I'll go with letter C.
Consciousness is a word that we can't help but take for granted and it is certainly one that we cannot fully comprehend. We know what it means to be unconscious, but we can't ever be conscious of being unconscious, see? It's a Catch-22.

I enjoy consciousness. It is a state of self awareness. It is a state of worldly awareness. It is the process of sorting information and making decisions and acting out of our own free will, in some sort mind-numbingly bizarre way!

I am comfortable with biological answers. My brain processes involve neurotransmitters and nerve impulses traveling from sensory inputs derived from the vibration of molecules flying into my nose and ears, the searing energy from a ball of gas millions of miles away flying into my eyes, the tactile trauma I experience by bumping into all sorts of objects and somehow this all get sorted out in a coherent manner by my cerebral cortex that decides what to do with all this input. Equally miraculous, this process happens in nearly everyone I know and even more amazing to me, we all somehow agree on the meaning of these signals. There are some differences in opinion, but it's still crazy for me to ruminate on these sorts of things.

I am uncomfortable with spiritual answers. How can we divulge the concept of a spirit away from the senses and the translation of these important signals? Without any senses, without any meaningful input, how can we possibly produce any meaningful actions, any intelligent output?

Still, lingering doubts remain. At some level of inhibitory and activating synaptic nerve potentials, the addition of these signals and propagation of selected nerve signals doesn't add up to Me being ME. Maybe I don't fully understand the complexity of this simple process. Perhaps I somehow pull myself up out of the swamp of the unknowing by my own bootstraps into the thinking world.

Maybe I'm not a ME, but a WE. Each part of my brain, each organ of my body has it's own collective consciousness. Each cell in my body lives on with a purpose -- not necessarily one of sustaining My life, but perhaps its own, in ways that tangentially benefit the whole Me.
I live because of these connections, these communications between cells. I think because it somehow serves a greater purpose for my body. And the more I think about why I think, the gladder I am that I can.

I've said some pretty poetic stuff in my past entries on Philosophy that I reread just now. My favorite line is:

It is cool to think that [consciousness] is an aggregation of quantum activity that takes off as massive butterfly effects in our heads. I don't think that this necessarily implicates the additional driving meta-physical force of consciousness, nor does it happen continually. Every so often, metaphorical dominoes are dumped out onto a table and a few of them align, waiting for the quantum flutterby. This is the exception, not the rule.

the Balloon is RUINED!!!

Causes of pericarditis
RUINED

Radiation/Rheumatic fever
Uremia
Infection/Injury/Infarct
Neoplasm
End Stage Renal Disease
Dressler's syndrome

Ok, so this mnemonic is a little bit over the top, but so is the cure if you destabilize.

Pericarditis is inflammation of the pericardium, a "plastic" bag that surrounds your heart. If too much fluid flows in, be it blood or pus or anything like that, then you get a cardiac tamponade and your heart stops pumping blood. It needs to be dealt with swiftly and sometimes, punching a needle through the chest wall to draw the fluid out of the pericardium is necessary. That's pretty scary, because you don't want to hit the lungs or the heart... just the pericardium.

Types of Shock

People in shock need to relax with some COVe SAND.

Cardiogenic
Obstructive
Volume(hypo)
e

-Septic
-Anaphylactic
-Neurogenic
Distributive

S, A, and N are all types of Distributive shock (where volume mobilized into the interstitial fluid because of infection or acute inflammation causes hypoperfusion.)
1. Cardiogenic: pump failure
2. Obstructive: mechanical impedance of blood flow
3. Volume(hypo): ↓ intravascular V
4. Distributive: ↓SVR, widespread vasodilation/vascular permeability
• Septic: bacterial Ag-induced inflammation
• Anaphylactic: hypersensitivity reaction
• Neurogenic/vasogenic: imbalance of PSNS & SNS
Clinical definitions for the progression of septic shock
Bacteremia “blood poisoning” -> SIRS -> sepsis -> severe sepsis -> septic shock
Associated with fever, chills, fatigue & malaise

Systemic inflammatory response syndrome (SIRS): 2+ of the following:
1. T > 38°C or <>
2. HR > 90
3. RR > 20 or PaCO2 <>
4. WBC >12, <4,>10% immature (band) forms

Sepsis: 2+ of the following as a result of a documented infection:
1. Rectal T > 38°C or <>
2. HR > 90
3. RR > 20
4. >1 of the following manifestations of inadequate organ function/perfusion also must be included:
a. Alteration in mental state
b. Hypoxemia (PaO2 <72>
i. (overt pulmonary disease not the direct cause of hypoxemia)
c. Elevated plasma lactate level
d. Oliguria (UOP <30>

Severe sepsis: This is sepsis & SIRS associated w/ hypotension, hypoperfusion and altered mental status
o Hypotension: SBP <90>40 from baseline
o End-organ hypoperfusion: cool or mottled extremities, weak or absent peripheral pulses; lactic acidosis; splanchnic vasoconstriction -> oliguria, bowel ischemia and hepatic dysfunction
o Altered mental status: ↓brain perfusion -> restless, agitated, confused, lethargic or comatose

Septic shock: severe sepsis complicated by persistent hypotension after fluid therapy.

References/Resources
CMDT 2006. (Hypotension & Shock, pp 477-80.)
McCance & Huether, Pathophysiology 5th ed. 2006.
eMedicine. Septic Shock. Accessed 11/26/06.

Lost in Translation

I like to quote movies. The title of this entry popped into my head as I thought about the content of this entry and I think it is especially pertinent.

A lot of people laugh about movie quotes... for me, it is about finding someone else who can recognize what I'm saying and we identify with each other. We make a connection.

This sort of "reference recognition" is the basis for a lot of jokes, even in medical school. I've made very subtle jokes about people being uptight by talking about their colonic tone... a classier version of Wayne's World's "Sphincter says what?" sort of a thing. My classmates get it right away and they thought it was hilarious.

Unfortunately, this sort of joke is hinges on its exclusivity. Only people who understand the reference get the joke. People who need the joke explained to them rarely laugh about it because in the process of explanation, the humor is lost. :) Inside jokes are brutal this way. :-\

Yesterday, my Anatomy professor was talking about raising our hands. She said "From now on, you guys will be thinking in your heads 'Infraspinatus (first 15 degrees), Deltoids!'" The class laughed. I didn't really, because I realized that this was a broader joke than I first realized. Last week, my friends made the exact same joke in reference to suprascapular nerve damage!

"How would you lift your arm if you couldn't move your infraspinatus?!?"

They took turns inventing various methods (all of which looked retarded.) Batting up the arm with a flick of the hip up into the air won first prize. I said 'man, I hope you guys don't crack up when you meet a patient who does the exact same thing!' I meant it in a nice way. Sort of.


The purpose of this joke, of course, was for reference. Now that we laughed about it, we would never forget which muscles ABduct the arm and when they worked.

However... these jokes don't work on the laypeople! A lot of things I find completely hilarious right now wouldn't make any bit of sense to non-medical types.


Even worse, I'm afraid that I'll forget this more and more as I become a doctor. Sarah talked about this earlier today, mentioning how third-years at the homeless clinic were asking their patients if they had "hematochezia," which is basically blood in their stool. "Stool?!?" she added... "they don't even know what stool is!!! Say poop."

A lot of things get lost in translation. For the sake of my future patients though... I'll have to remind myself to become well-versed in cute and poetic analogies to explain things. I've got a few already that I'm awful fond of and I know that they will be more valuable than most of my medical knowledge when I communicate with patients.

It isn't about dumbing down the vocabulary. It isn't about talking down to the patient. It is about effectively communicating with them so everyone is on the same page! They won't tune out the big intimidating words. I'll work hard on giving them just one a session and try to include one analogy or story. I think that this will take me far in translating medicalese into something that is actually INFORMATIONAL.

How cute. I think I started already with this entry. :)

Apple/day

I was in a study group session this past weekend and we were discussing a farmer w/ pneumonia who didn't go in to see the doctor until it got really bad.

The question came up: "why do some people refuse to see doctors?" I was responsible for writing that part of our study guide up and I just wrote a few notations about the topic.

Be 2) Why do some patients avoid going to the doctor?
· Support (from partner, low finances, etc.)
· Not help-seeking
· Afraid of diagnosis – “not sick until the doctor tells them that they are”
· No time, lot of work = stress + better things to do
· No trust in physicians

I wanted to talk a bit about #3 here. "Afraid of diagnosis."

People have ths idea that we are born perfect and healthy into this world, but unfortunately, that is not true. It has been said that we start dying the minute we are born. Technically, we start dying even before that while we are still in the womb.

We fight a constant battle to acheive tenuous homeostasis.
We have to work to stay healthy.

I think a big reason why people with high blood pressure, high cholesterol and high glucose don't want to see the doctor is because they feel healthy. They don't want to hear how their sodium, fat and sugar might be affecting them. They don't want to hear how eating right and exercising might save their life and positively affect their quality of life.

They don't want to be sick.

Are they sick? Diagnosing someone with "Hypertension", "Coronary Artery Disease" or "Diabetes Mellitus" doesn't change who they are. It doesn't necessarily change how they feel either, though the hope is that their feelings will change their behavior.

The approach I think that should be used is to tell them that if they don't feel sick, then they aren't sick. However, they do have a problem that could be fixed with some lifestyle modification. Too much influence from environmental or genetic factors might require pharmacologic intervention. On this, I'd say the following:

"Just because you're taking medication it doesn't mean that you've got a disease or an illness. You're taking these pills to prevent you from getting sick. "

This apple a day will keep the doctor away... the single ounce of prevention that'll be worth a pound of cure.

Random Statistics about "Five"

"Did you know that each cigarette you smoke robs you of 5 minutes of your life?"

This is a statistic that I should have mentioned this past weekend when a friend of mine was chastising someone at a party for smoking. I didn't want to get too involved because I knew that it was a "downer" type of talk to be having at a fun birthday party... but it is important to realize how bad smoking can be, if not for yourself, but for those around you as well. It has been proven to exacerbate asthma. It can lead to lung cancer and emphysema or chronic bronchitis, two examples of COPD (chronic obstructive pulmonary disease.)



Five is bouncing around in my head today.
Tuberculosis (TB) is an infectious lung disease that has a chance of being "reactivated" after the initial infection.
So you have a 5% chance of getting reactivated TB in the first 2 years.
Then there is an additional 5% lifelong chance of reactivation
And for people infected with HIV, a "high-five" or 5+5% chance of being infected EACH YEAR!

That's all I got, folks. Hopefully I can spare some time to organize my thoughts better and write something out.

One less reason...

Photo credit: superfantastic on Flickr

I'm trying to hit the 5 R's of smoking cessation . There might be a number of roadblocks for smokers towards a successful quit date.

"Oh, I tried, but I had a hard time."
"I didn't know how to start."
"It's hard because I don't have any support."

If any of these reasons sound familiar, then you now have one less reason to continue smoking!

Here are some resources I found online that might help you, + 1 for doctors.

CME webcast for doctors

Office resources and patient education materials

Smoking: Steps to Help You Break the Habit
A good website from Familydoctor.org about smoking addiction and how to quit

National Network of Tobacco Cessation Quitlines
DDHS has a national quitline number, 1-800-QUIT-NOW
The toll-free number (1-800-784-8669) is a link to the national network of tobacco cessation quitlines

Nifty interactive Quitline map, showing local websites, phone numbers and services
http://www.naquitline.org/index.asp?dbsection=map&dbid=1

More than a number

What exactly does 200 Calories mean?

One calorie is a measurement of heat that it takes to raise 1 gram of water 1 degree Celcius at 1 atmospheric pressure. A "Calorie" with a capital "C" is a kilocalorie... and the unit that we usually refer to in our diets. So, 200 Calories raise 200 kg of water 1 degree celcius.

That's a fun fact for trivia geeks, but nearly meaningless to people who are trying to diet.

Here's a website that shows you what exactly 200 Calories look like.

iVillage has a few tasty 200 Cal snack options and the Cleveland Clinic has a few other 200 Cal recommendations.

Alternative source of stem cells

My favorite thing about science is that discoveries are borne out of necessity. Progress is rarely hindered by obstacles and restrictions; they are simply hurdles to be overcome. Rising gas prices, global warming and consumer dissatisfaction will drive us to seek alternative fuels.

Similarly, the moratorium on embryonic stem cell research has forced researchers to consider alternative sources for stem cell research. Amniocentesis is a procedure performed during pregnancy to diagnose a number of genetic and chromosomal abnormalities. Down Syndrome, spina bifida (or other neural tube defects like anencephaly), Rh factor incompatibility and lung maturity can all be detected.

Recently, researchers at Wake Forest University School of Medicine have found that left over amniotic fluid has stem cells in an intermediate stage between embryonic stem cells and adult stem cells. Leftover amniotic fluid can stored in a bank and with a storage of just 100,000 specimens, a perfect genetic match can be made for 99% of the U.S. population, potentially revolutionizing transplantation.

If these preliminary results withstand political and scientific scrutiny, we may be on the brink of a whole new line of research with direct medical benefits.

http://www1.wfubmc.edu/news/NewsArticle.htm?Articleid=2020
http://www.biotech-weblog.com/50226711/stem_cells_derived_from_the_amniotic_fluid.php

5 Rs for Encouraging Behavior Change

We were taught this in the context of smoking cessation, but as the teacher pointed out, it can be used for much more than that.

• Relevance:
  Tailor advice and discussion to each patient
• Risks:
  Outline the risks of continued smoking
• Rewards:
  Outline the benefits of quitting
• Roadblocks:
  Identify barriers to quitting
• Repetition:
  Repeat the message at each visit

Eschara

Got a scar story?

I told one about my most memorable Halloween, when I took a spill on a bike and had the most grotesque face for months afterwards. Little bits of spidery black stitches, hot red slashes across my cheek and jaw... yuck.

Anyway, an annotated version of it is on Eschara. I think that this has the same appeal as Post Secret does, in revealing an intensely personal story to the world but at the same time shielded by anonymity.

I really like this idea, so if you have a digital photo and some time, feel free to submit a tale of your own accidental tattoo. :)