VPN Outlawed in Michigan?
Some of the nerds on Slashdot are saying that this Michigan law would make VPNs illegal. The source of the /. posting is from freedom to tinker .. a technology weblog ...
March 30, 2003
Expert opinions
From :RangelMD.com ... Chris responds to an article in the Boston Globe that revies this article in BMJ.
He's right: while consultands often change care ... we don't know that they always improve care.
Fussy Baby
From the AAFP's website: ICD-9 Changes for 2002-2003 - Family Practice Management
Two codes that I will find useful:
780.91 Fussy infant (baby)
780.92 Excessive crying of infant (baby)
March 29, 2003
Blogshares
Kinda funny - "blogshares" .. a stock market game for weblogs .. 
Lindane Warning
FDA Issues Health Advisory Regarding Labeling Changes for Lindane Products
Labeling for Lindane products has been changed to include a boxed warning which highlights the most important safety issues associated with use of these products. The boxed warning contains information to better inform both healthcare professionals and patients regarding the potential risks associated with the use and misuse of Lindane. The warning emphasizes that Lindane products have been, and continue to be, indicated as a second-line therapy for the treatment of scabies and lice. While FDA believes that the benefits of Lindane outweigh the risks when used as directed, given the potential for neurotoxicity, patients should only be treated with these medications if other treatments are not tolerable or other approved therapies have failed.
This is an important warning .. since many sources (such as this "tip" in American Family Physician) list Lindane as one of many treatment options - without advice about which product should be considered first-line and which should be reserved for resistant cases.
March 27, 2003
SARS - Inside Story
Bruce sent me this Wall Street Journal Article on SARS. It's an incredible view of the genesis of the outbreak in Hong Kong.
March 26, 2003
Substance Abuse Treatment
SUBSTANCE ABUSE TREATMENT FACILITY LOCATOR:
"Your search has found 361 facilities within 100 miles of your starting point. The map shows the location of the 10 closest. For more information about each one, scroll down below the map."
From the DHHS - This website provides information on substance abuse treatment facilities in your area. The link above is to my zip code ... try yours.
"The Substance Abuse and Mental Health Services Administration (SAMHSA) is pleased to provide this on-line resource for locating drug and alcohol abuse treatment programs. The Substance Abuse Treatment Facility Locator lists:
- Private and public facilities that are licensed, certified, or otherwise approved for inclusion by their State substance abuse agency
- Treatment facilities administered by the Department of Veterans Affairs, the Indian Health Service and the Department of Defense.
SAMHSA endeavors to keep the Locator current. All information in the Locator is completely updated each year, based on facility responses to SAMHSA's National Survey of Substance Abuse Treatment Services. The most recent complete update occurred in October, 2001. New facilities are added monthly. Updates to facility names, addresses, and telephone numbers are made monthly, if facilities inform SAMHSA of changes."
Contraceptive options
In this month's American Family Physician, there is a good article on Counseling Issues in Tubal Sterilization.
It's more than just a discussion of tubal ligation. There's a good table which lists some of the pros and cons of many contraceptive options - including newer options like Nuvaring and Evra.
I wonder if the pharmaceutical companies are choosing the names of their medications based on whether the domain names remain available ...
Autism
From DB's Medical Rants: an article in the NY times about Autism and vaccines.
The article is well written, and provides an overview of the issue of Thimerosal in vaccines. Nonetheless, I'm troubled by the author's lack of understanding of the definition(s) of Autism. She cites figures that depict a significant increase in the prevalence of Autism over the last 30 years, but fails to mention that the diagnostic criteria have changed - so many more kids "qualify" as Autistic who would not have in the 1970's - especially those with Asperger syndrome. I wonder if there is an increasing prevalence of Autism in the kids of NY times reporters ... as they seem to have an especially strong interest in this topic . as it's the third article (1,2) on this topic in the last 4 months.
As we read in this recent paper:
Increased recognition, the broadening of the diagnostic concept over time and methodological differences across studies may account for most or all of the apparent increase in prevalence, although this cannot be quantified
Some other references:
Prevalence study (JAMA - 2003)
Increasing Prevalence? (Review - Journal of Pediatric Child Health 3/2003)
March 25, 2003
Migraines & Celiac
Medscape: Migraine Linked to Celiac Disease
About 4% of migraine sufferers may have celiac disease and symptom control may be improved with a gluten-free diet, according to the results of a study published in the March issue of the American Journal of Gastroenterology.
Celiac disease is certainly the disease of 2003. I think I've diagnosed 5 patients this year already! Though I think that over time we'll learn that there are varying levels of wheat and/or gluten sensitivity ...
SARS
From the WHO:
Severe Acute Respiratory Syndrome (SARS) is a disease of unknown etiology that has been described in patients in Asia, North America, and Europe. The information in this report provides a summary of the clinical characteristics of SARS patients treated in Hong Kong Special Administrative Region (China), Taiwan (China), Thailand, Singapore, the United Kingdom, Slovenia, Canada and the United States since mid-February 2003. This information is preliminary and subject to limitations because of the broad and non-specific case definition.
Most patients identified as of March 21, 2003 have been previously healthy adults aged 25-70 years. A few suspected cases of SARS have been reported among children (≤15 years).
The incubation period of SARS is usually 2-7 days but may be as long as 10 days. The illness generally begins with a prodrome of fever (>38°C), which is often high, sometimes associated with chills and rigors and sometimes accompanied by other symptoms including headache, malaise, and myalgias. At the onset of illness, some cases have mild respiratory symptoms. Typically, rash and neurologic or gastrointestinal findings are absent, although a few patients have reported diarrhoea during the febrile prodrome.
After 3-7 days, a lower respiratory phase begins with the onset of a dry, non-productive cough or dyspnea that may be accompanied by or progress to hypoxemia. In 10%-20% of cases, the respiratory illness is severe enough to require intubation and mechanical ventilation. The case fatality among persons with illness meeting the current WHO case definition for probable and suspected cases of SARS is around 3%.
Chest radiographs may be normal during the febrile prodrome and throughout the course of illness. However, in a substantial proportion of patients, the respiratory phase is characterized by early focal infiltrates progressing to more generalized, patchy, interstitial infiltrates. Some chest radiographs from patients in the late stages of SARS have also shown areas of consolidation.
Early in the course of disease, the absolute lymphocyte count is often decreased. Overall white cell counts have generally been normal or decreased. At the peak of the respiratory illness, up to half of patients have leukopenia and thrombocytopenia or low-normal platelet counts (50,000 – 150,000 / μl). Early in the respiratory phase, elevated creatine phosphokinase levels (up to 3000 IU / L) and hepatic transaminases (2- to 6-times the upper limits of normal) have been noted. Renal function has remained normal in the majority of patients.
Treatment regimens have included a variety of antibiotics to presumptively treat known bacterial agents of atypical pneumonia. In several locations, therapy has also included antiviral agents such as oseltamivir or ribavirin. Steroids have also been given orally or intravenously to patients in combination with ribavirin and other antimicrobials. At present, the most efficacious treatment regime, if any is unknown.
March 24, 2003
Paxil (Paroxetine,Seroxat)
bmj.com: Lawyers may seek judicial review of panel reviewing paroxetine.
This is the latest volly in a conflict between patients and pharmaceutical manufacturers over what happens when the medication is withdrawn.
It's been well described that Paroxetine is associated with more symptoms of withdrawal than other SSRI's. I've seen this so often that I no longer prescribe Paroxetine. I also do my very best to switch patients to another SSRI if they were prescribed it by a previous physician. Most patients are happy to switch. It's a 1:1 switch .. so there is no need to taper OFF Paroxetine when starting another SSRI:
| Paroxetine | Fluoxetine | Sertraline | Citalopram | |
| 20 mg | 20 mg | 50 mg | 20 mg | |
| 40 mg | 40 mg | 100 mg | 40 mg | |
| half-life | up to 21 hrs | 4 - 15 days | 22-36 hrs | 36 hrs |
While the short half-life may account for some of this effect, I think that there is also something unique about this drug that causes trouble when people discontinue it.
OpenClinical
OpenClinical is a great resource for anyone involved in implementing IT in healthcare.
They have a clinical section which reviews decision support systems, and provides links to many vendors
Their suppliers section is probably the most comprehensive review of knowledge resources for healthcare.
IMKI
IMKI:
- IMKI'S MISSION
Create the tools for development, dissemination and implementation of high quality decision support rules.
Increase the availability and use of computerized decision support rules in clinical medicine.
Catalyze the development of a robust community of clinical decision support rule writers and rule implementers.
- IMKI'S INITIATIVES
IMKI's program areas bring the best medical evidence to the point of care. The organization has received a grant from The Robert Wood Johnson Foundation to develop the following initiatives:
- An Internet-based, searchable Rules Library of evidence-based rules for inclusion in point-of-care clinical decision support (CDS) systems.
An Internet-based rule-authoring tool that allows clinicians to write new rules and includes a system for disseminating the Public Library.
An Implementation Support Network, a facilitated forum for delivery systems implementing
CDS systems.
Their board is full of well-placed representatives from many of the more important software vendors (Siemens and GE for example) - so one could presume that the rules engines in the products of those vendors would be compatible with the end-products of the IMKI initiatives.
The web resources page and the articles page also provide excellent background documents for those considering physician-order-entry projects.
March 23, 2003
SARS
One of my partners saw a patient on Friday who may have SARS. The patient had recently been to Toronto, and had many of the symptoms consistent with the disease. Now that there is emerging concensus that this is a viral illness.
"Go to the ER"
Richard and Allen talk (tongue-in-cheek) about sending patients to the ER. Unlike Craig who just closed his practice ... I deftected from the academic medical center's "primary care network" (6 months before it imploded) about 18 months ago. nbsp; So my practice is building. Wo do our very best to keep our patients out of the emergency departments. The patients we have the most trouble with are those who are accustomed to the "Go to the ER" mantra from their previous physicians .. and just show up without even calling us .. for minimal problems.
We'll happily stitch up the finger from a Sunday Morning Bagel-cutting accident -- or check an ear in a child with a fever.
It's better care than the ER ... where the Mantra is "meet-em, treat-em and street-em." ;-)
Medical Weblogs
Medical Weblogs Medlogs.com is now much more than a list of medical weblogs -- it's a weblog aggregator.
March 22, 2003
Eipdural Anesthesia
A Comment from Dr Bradley last week on my comment about the epidural analgesia issue.
He's right. The authors did not conclude that their findings supported a rationale for witholding or even re-thinking epidural analgesia.
That's not quite what I'm saying though ... and I suppose that my non-intervention bias is revelaing itself here.
My preference -- in my practice of maternity care -- as in my practice of medicine in general -- is to avoid any intervention unless it's clear that such intervention is necessary and appropriate.
Is an antibiotic intervention appropriate for the treatment of a cold? Of course not .. but many physicians still do.
When I am involved in maternity care, I always make decisions with my patients -- not for them. The decision to have an epidural is not necessarily risk free. A few references:
- Pro-Con forum on epidural analgesia from the Society of Obstetric Anesthesia and Perinatology
- A Boston University Study demonstrates that children born to mothers who had epidurals showed poorer performance on the orientation and motor clusters on the Neonatal Behavioral Assessment Scale (NBAS) during the first month of life. The authors also found that there epidurals were associated with longer labors, greater amounts of oxytocin used, and more instrumentation.
- This study from Austria which demonstrated that "The use of EA was associated with a decreased spontaneous delivery rate (50.0 vs. 79.2%), increased forceps delivery rate (30.7 vs. 4.0%) and increased vacuum extraction rate (3.5 vs. 0.7%). The caesarean section rate was not significantly changed in patients with EA (14.4 vs. 13.0%). Fever greater than 38 degrees C during labour and intrapartum haemorrhage exceeding 500 ml were associated with the use of EA."
... but ...
These studies don't account for all off the possible confounding variabes (especially the Viennese study .. in which a minority or patients received epidurals. One could easily argue that the more troublesome deliveries were associated with epidurals.)
We must remind ourselves of the basic rule of correlation: no causality can be inferred. Does Tick cause Tock? of course not. But the r value is 1.
So .. I think that there is enough data to support the concept that there may be increased risk from epidural analgesia. And this is really all I was saying in my commentary. We should think twice (or thrice!) before intervening in what is usually a normal healthy event. A "routine" epidural may very well be a component of the obstetric practice of many physicians. I would argue that this isn't good care, and that the epidural should be presented as an option - with risks, benefits and alternatives carefully presented - just as with all interventions.
Family Medicine Match
2003 Match Results Unwelcome, But Not Unexpected -- American Academy of Family Physicians:
Despite diligent efforts by the Academy and other family medicine organizations, preliminary results released March 20 by the National Resident Matching Program show that family practice continues to struggle to position itself as the specialty of choice among medical students deciding on a career path.
It's hard to explain the shift away from family medicine over the last 3 years. Our residency actually filled this year - with all US graduates. And of 130 medical students - 16 went in to family medicine. This is down from a few years ago, when we were routinely graduating 20 - 25 students into the speciality.
I had an advisee whe struggled with her choice a great deal this year -- hmm .. I think I always have one ot two who struggle a bit .. but this one didn't know until "match day" whether she would be a family physician or go into medicine-pediatrics.
In my mind, the differences are vast, but she seemed to give some thought to the fp-bashing coming from ofther physicians - especially (primarily?) other generalists: pediatricians and internists.
Weblog Fixed - HIT
I've got the weblog completely migrated from Radio to MovableType. Hardest parts were the archives and images. Radio saves archives as YYYY/MM/DD.html .. and MT doesn't .. but I was able to get it tow work by using a daily archive template with "<$MTArchiveDate format="%Y/%m/%d.html"$>" ... The images were harder to do v.. but I ended up just moving the directories to the new server .. so my post on Heparin-Induced Thrombocytopenia one again has the images intact.
I still need to figure out how to post images in MT.
March 21, 2003
Weblog Hosting
When I moved the weblog from Radio to MovableType, I decided to move it off of my own server and into a web host. THe primary reason for this was that as the traffic to the oncalls.com server has increased, so has the traffic to the weblog.
While the weblog is interesting -- it's not as important as oncalls - since people actually pay for the oncalls service. Time to move my little hobby off of the production server.
So I found Pure Energy after a little web search. They've been great. A + web hosting - and very inexpensive. Very helpful with inital setup and transition .. and today I've finaly got things squared away so that movabletype is emulating the old Userland Radio archive format - so the google links are no longer broken.
Baghdad
Have been reading Where is Raed ? .. a weblog from Baghdad. Meat is unsafe to buy or eat .. bread remains available, and some dairy products & vegetables remain available. You won't see that on CNN.
Neuroblastoma
I'm on a roll this morning ... another one from The Lancet:
Neuroblastoma, the most common extracranial solid tumour in children, originates in cells of the neural crest and is found mainly in the adrenal gland but may also be found anywhere along the paravertebral sympathetic chain in the chest or retroperitoneum. It is the most common neoplasm in infants and the leading cause of cancer deaths in children aged 1-4 years
This paper is an excellent case report of a 2 year old with nonspecifi findings. It's a good reminder of the constellation of symptoms that should cause one to think of Neuroblastoma.
Dave Winer
War is not an excuse to turn off your minds. We need our minds more than ever.
From The Lancet:(free registration required)
Treatment of asymptomatic abnormal vaginal flora and bacterial vaginosis with oral clindamycin early in the second trimester significantly reduces the rate of late miscarriage and spontaneous preterm birth in a general obstetric population.
Lancet 2003; 361: 983-88
? so should we start to screen at 18 weeks for BV? I'm not yet convinced.
March 20, 2003
PSA Screening
In this week's JAMA:
If practice were evidence-based, PSA screening would be less common among men than colorectal cancer screening, a preventive service of broad acceptance and proven efficacy.
The article is a review of data collected on men between 40 and 50. Since the evidence for PSA testing remains less than compelling, one would expect that colorectal cancer screening would be more common, since it's darn clear that it saves lives.
Not so. 75% of men had PSA tests vs 63% with colorectal screening.
Hmm .. after some struggle with our EMR, I can say that the practice in my office (3 physicians) reflects the evidence quite well. Greater than 70% colorectal screening .. and less than 50% PSA.
Having ths discussion about PSA testing is challenging. Here's a nice little handout from across the pond.
I have very few memories from the 1960's .. but I can remember (I was about six) the protests in 1969 in Harvard Square. 30+ years later ... we get more of the same .. Makes me want to go back to Cambridge ...
I'm so sad about this war thing. Very very sad.Kevin Sites Blog has some pictures from real humans in Iraq. I am now compelled to renew my membership in Physicians for Social Responsibility. They have been quietly active in their work against this war.
March 19, 2003
Physician Order Entry Primer
A Primer on Physician Order Entry. It's actually a bit dated - from 2000 - but most of the issues remain the same forever. A useful resource.
March 17, 2003
New Website
I've completed a few projects tonight.
a) A little programming project for work - a little coldfusion and WDDX.
b) The Weblog has now moved to MovableType - nearly all of the old posts are moved over, but URLs are different - so it will take Google a while to re-index things. The primary domain name is currently docnotes.com .. and docnotes.net redirects to the .com address. I'll get that fixed soon - I don't like the .com as much as the .net.
Snow finally melting ...
March 16, 2003
Testicular Self-Exam
In Pediatrics this week, we learn that "Fewer than half of the pediatric residents teach TSE to their adolescent patients."
Testicular cancer is the most common cancer in young men. I tell my patients that I diagnose it about once a year.
Peripheral Artery Disease
In This paper in the current BMJ reminds us that surgery is a last resort in peripheral vascular disease -- and there's lots for us for us to do so that the disease doesn't progress.
March 13, 2003
Picked up off the Medscape RSS feed:
Epidural Analgesia and Severe Perineal Laceration in a Community-based Obstetric Practice. Perineal trauma during vaginal delivery can have serious consequences. Long-term adverse effects of severe perineal laceration include chronic fecal incontinence, dyspareunia, perineal pain, and rectovaginal fistula.
Journal of the American Board of Family Practice [Medscape Family Medicine Headlines]
It's a good article, and provides us with more reasons NOT to support knee-jerk epidurals for our laboring patients. In my residency .. it felt like we NEVER did epidurals ... (though I think it was actually about 20% of the time). Since my residency, I've noticed that about 70% of our patients receive them. I'm not sure what accounts for the difference.
March 11, 2003
My annual license renewal for Userland Radio is approaching .. and I'm testing MovableType as an alternative to Radio. So far -- not bad.
March 10, 2003
Wireless Handheld Computing.
Wireless Handheld Computing. This article provides a practical overview of 2 essential components of pervasive computing -- handheld and wireless computing.
Medscape TechMed eJournal[TM] [Medscape Technology and Medicine Headlines]
Bedside, Zixcorp
Oh my, it's been quite a while since my last post. I've been at home most of the last week with a terrible cold. I'd even wonder if it was influenza out loud ... but I'm a bit of a flu-non-believer. I believe that it exists .. but most winter colds are .. colds, not "the flu." So I have a bad cold. Just starting to feel OK after 1 week. No more night sweats, but still congested and coughing a bit.
On to the e-mail in-box:
1) Carl Gandola has a new weblog ... bedside.org. Looks great .. and he's on a roll ... several interesting posts today .. including this one about the US Living Will Registry
2) I had an e-mail conversation this weekend with a PR guy hired by HealthyEmail/Zixcorp. They're helping me to understand the company. Turns out that I posted some information last week that contradicts with their ideas of how HealthyEmail should be interpreted.
The whole thing is documented here
And here's the Application that Zixcorp filed with the Texas Secretary of State to create HealthyEmail.
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