Today's Interesting Links

Misleading Drug Ads
FDA races to keep up with drug ads that go too far - USA Today. Misleading commercials make a lot of patients to have unrealistic expectation about the new "miracle" drug thy saw on the TV and want to try. It is no laughing matter, especially knowing that when a patient wants a particular drug, in 70% of the cases, they go out of their doctor's office with the prescription for the drug that they wanted.

Questions & Answers for USMLE Step 1
Step Prep.com is a Question & Answer version of the now famous book First Aid for the USMLE Step 1. And best of all, it is free. The buzz words (Rapid Recall Pathology associations) can be useful even you review for ABIM, I guess. See more test-taking tips in How to Do Well on the Boards - USMLE, ITE, ABIM?
(via Grahamazon.com)

Text-to-Speech RSS Feeds
Speakwire reads RSS feeds to you using text-to-speech synthesis. It is an interesting application although the quality is not as good as the leading software like 2nd Speech Center (more in Text to Speech Wonder).

Really Easy Website Spellchecker
Spell Check.net lets you run an easy spellcheck of a whole web page (free). It is never too late to check your blog for any errors. Did I do that today... :-)

The True Love According to a Psychotherapist

How to save a marriage that lasts longer than 10 years - you will know when you read this interesting NY Times story - Bending the Boundaries for a Couple Who Lost the Spark.

This is a part of the generally well-written CASES series in NYT. Most (if not all) of the authors are physicians. The section almost feels like a blog with many authors. Something like a multi-faced Dr. Charles describing his patient encounters.

For best results, subscribe to the NYT RSS feed... :-)

Balloon Festival in Chagrin Falls, Ohio

Chagrin Falls


Hot air balloons are the oldest successful human flight technology, dating back to the Montgolfier brothers in France in 1783. A hot air balloon uses a single layered, fabric gas bag (lifting envelope), with an opening at the bottom called the throat.



Attached to the envelope is a basket for carrying the passengers. Mounted above the basket is an "air heater" which injects a flame into the envelope, heating the air within. Raising the air temperature inside the envelope makes it lighter than the surrounding air.

I was wondering why the balloons take off is at 6 AM or 6 PM, the answer is that the lift of the balloon is determined by the temperature difference between the inside and outside air. On a hot day, the balloon cannot be loaded as much as on a cool day, because the temperature required for launch will exceed the maximum sustainable for nylon. Most hot air balloon launches are made during the cooler hours of the day, at dawn or two/three hours before sunset.


A gasoline powered fan is used to blow cold (outside) air into the envelope. The cold air partially inflates the balloon to establish its basic shape before the burner flame is aimed into the throat heating the air inside.


The top of the balloon has a flap of fabric that can be pulled open to release hot air for descent. A crew member stationed opposite the throat, holds a rope tied to the apex of the balloon. The "crown-man" acts as a dead weight in order to slow the envelope's rise so that the envelope can achieve maximum inflation before standing erect.


When the pilot is ready for launch, more heat is directed into the envelope and the balloon lifts off gradually.


In the United States, hot air balloon pilots must have an FAA license. A new commercial-made hot air balloon will cost $20,000 to $30,000.


The balloons fly at dawn or at sunset when the air is cooler.

The text is based on the article Hot air balloon from Wikipedia

References:
2004 Heinen Blossom Time Balloon Festival in Chagrin Falls, Ohio
2004 Coshocton Hot Air Balloon Festival from Coshocton, Ohio
Ravenna Balloon A-Fair in September
Flag City Balloon Fest in Findlay, Ohio in August
Grove City Balloon Festival

Medical Rounds - Free Online Lectures from the University of British Columbia

This can be very useful. The lectures are in the QuickTime streaming format. You can use the search box to find a talk of interest, or browse through the available presentations by category.

Digital Photography Update

NY Times has a nice articles on ultra-slim cameras (less than 0.8 inches) - These Cameras Are Lean but Not Spare. Not surprisingly Cannon and Nikon and the best. The 3 x optical zoom is the maximum due to the small size of the camera. The interesting trick is that there is no need for a telescoping obective anymore ("zoom-zoom", remember...). The manufactures created a reflecting system within the camera that takes care of the optical zoom.

Only a small percentage of the digital photos are ever printed but if you want to have a picture than you can touch, go to:

-Walmart.com - 19 cents per photo, choose the one-hour option and pick up the photos at the local Walmart store


-Snapfish just starting offering a new price - 12 cents per photo, the lowest on the market. Snapfish was bought by HP recently.

References:
Our Annual Guide to Buying A Digital Camera by Walter Mossberg in WSJ
Less Cursing, Better Pictures: 10 Suggestions - NYT 6/05

Interesting Articles in Today's NEJM

If you can read only one journal, let it be NEJM. Whatever is there, it will be in the next edition of Harrison's.

There are several interesting articles in today's NEJM:

Statins and the Risk of Colorectal Cancer. Did we find the magic drug?
Statins were associated with a 47 % relative reduction in the risk of colorectal cancer. Statins for reducing the rate of cardiovascular events are the standard of care. How about a statin for everybody over 50? Are we heading towards the Polypill?

Exhaled Nitric Oxide (NO) to Guide Treatment in Asthma
No more painful recollections of wheezing symptoms, inhaler use and PEF recordings. Just check the NO in the exhaled air, and you known where you stand with your asthma control.

Will nitric oxide be for asthma what HbA1c is for diabetes (the best test to monitor the activity of a chronic disease)? The NEJM editor is asking the same question - Targeting Biologic Markers in Asthma -— Is Exhaled Nitric Oxide the Bull's-Eye?

Long-Term Outcomes of CABG versus Stent Implantation
CABG was better. It looks like cardiovascular surgeons will not be without a job in the future after all.

By the way, the NEJM has a very interesting online-only section - Featured Images in Clinical Medicine (free access). Great for rapid review.

Use Your PDA to Access Internet from Anywhere

Why?
Because it is so nice. You can check the latest UpToDate edition online (subscription required but you can get a one-month-invitation) without going through the cumbersome process of installing it on your PC, buying the bulky 1 GB card and transferring it to PDA. Pure and simple. You can also check eMedicine, Pubmed, or if everything else fails to answer your clinical questions - check the plain old Google.

How to do it?
If you have a new PDA like HP iPaq hx 4705 (the best on the market right now), there are two buttons in the wireless connection area:

-Wi-Fi
-Bluetooth

Wi-Fi is great but only a few places have open networks, the University Circle in Cleveland and the Cleveland Clinic are among them.

We will talk more about the Bluetooth connection because you are independent when you use it. Like a cowboy in the prairie. Just your PDA and a cell phone.

The PDA connect to the cell phone via Bluetooth, then the phone connects to internet and that's it - you have Google on the iPaq!

What do you need?
-iPaq (HP) or Axim (Dell) with Wi-Fi and Bluetooth
-Bluetooth phone
-GPRS or EDGE network provided by a cell phone company

Suggestions:
-PDA - the above mentioned - iPaq or Axim
-Phone - T-mobile Bluetooth enabled phone
-Mobile company - right now T-mobile has the best price on GPRS data - $ 20 per month (on top of the regular cell phone bill)

How fast is the connection?
-Wi-Fi is DSL/Cable fast, this is broadband
-Bluetooth-GPRS is slightly faster than a 56K-modem
-EDGE is 2 times faster than GPRS (not offered by T-mobile yet)

One more advantage - you will never be lost again - you have Google maps, MapQuest and Yahoo maps in the palm of your hand.

Enjoy!


References:
T-mobile Personal Coverage Check offers detailed map showing what is the coverage in the areas where your live and work. This is something that all mobile carriers should do.

With Cell Plans, It's the Coverage, Not the Phone, That Counts - WaPost
T-Mobile’s Personal Coverage Check offers street-level cellphone coverage maps - Endgadget

Useful Pocket PC Programs
Free Medical Programs for Windows Mobile / Pocket PC

Nokia 770 Internet Tablet
Beyond Wi-Fi: Laptop Heaven but a Price - NYT 6/05
A Dizzying Array of Options for Using the Web on Cellphones - NYT 6/05
HOW TO: Setting Up a GPRS Connection for Win XP and USB using Smartphone 2002 - Unwired
Ohhh. The pain, the pain: The Bluetooth pain - ZDNet, see the photocast here
Securing Bluetooth Devices - PC Mag 9/05
Good Laptop Gains Little From Built-In Cell Receiver - WaPo 7/05

Faulty Defibrillators by the Two Major Manufacturers

Read more in the NYT story - Maker of Heart Device Kept Flaw From Doctors.

End of the Road for Crestor?

In a study published in Circulation, the incidence of adverse events with rosuvastatin (Crestor) was 2 times higher than simvastatin (Zocor), and 6.8 times higher than atorvastatin (Lipitor).

In the big scheme of things, this translates to 6 per million deaths with Crestor, 3 per million for Zocor, and 2 per million for Lipitor. Not that common.

Still, do you really want to use a drug that has a higher mortality than the medications in the same group? Probably not.

Suddenly, Consumer Reports "Best Buy Drug" reviews seem a bit more scientific. Lipitor was their top choice for those who needed to reduce the LDL cholesterol by more than 40%.

Source:
Reuters, Circulation - 05/05

Free Site Search for Medical Bloggers

The Master.com provides a free site search covering 5,000 pages. It can be very useful for medical (or any) blogs. The Blogger hosted blogs have a Google site search embedded in the navigation bar at the top but it lags behind the site updates in months.

We have been using Pico Search which is pretty good but has a limit of 250 pages only and this is clearly not enough.

While browsing the Cleveland Clinic website, I noticed that they use the Master.com/Thunderstone paid search. The same service (with a limit of 5,000 pages) is provided for free. You just need to register and place the form in your site template. Enjoy!

iGoogle Portal -- Never Say Never Again

The folks at Google did what they told at the beginning they would never do - they created a portal. This is the new Google personalized page. It looks pretty nice actually, similar to the Google customized news which I use daily.

It is funny because Google was so anti-clutter, anti-portal and anti-registration when they started in 1998. And look where they are now. Never say never again. There is a famous Woody Allen quote: "If you want to make God laugh, tell him about your plans". By the way, you can integrate daily quotes in your Google page.

Now we are waiting for the RSS integration in 1-2 months, and all the medical and other news feeds can be put there (similar to Bloglines). Kevin MD is a must read, and this blog RSS is not that bad either.

BMJ is already on the RSS bandwagon, it is time for the NEJM, AMA, Annals of Int Med and Lancet (the big five) to jump on.

To use the personalized page, you need a Google account which is free or a Gmail account (free after invitation). Gmail is great and if you do not have an invitation yet, go to isnoop.net and get one.

In summary, there are the three things I suggest you try (if not using them already):

-Google personalized page - Gmail, weather, driving directions, news

-Google customized news - just the news you want to read, make your own categories, e.g. Cleveland, residency, Florida, PDA, etc.

-Findory - this webpage actually learns what you are interested in (the more you use it) and gives these stories to you

Check them out, these services are so useful you will be glad you did.

Update 3/2/2006:
In a world with infinite storage, bandwidth, and CPU power. Geeking with Greg.

Updated 9/30/2007:
Findory shuts down on November 1, 2007. Geeking with Greg.


How to use iGoogle

Related:
iGoogle, a More Profitable Google Homepage. Google Operating System, 05/2008.

Updated: 05/02/2008

Why the doctors are not paid by the hour?

Dr. Gross brings up an interesting question in today's reimbursement driven world (NYTimes). Everybody else charges by the time they spend dealing with your problem - your lawyer, mechanic, plumber.

Why not your doctor? Nobody pays him to listen to you for half an hour although this may be exactly the thing that you want him to do. Your doctor has to document your problems in the chart and how he is planning to deal with them. Some problems take 10 minutes, some problems take 1 hour and 10 minutes. The reimbursement for a particular problem is the same although all patients are different.

Nobody wants their doctor to be as fast as the 10-minute Jiffy-Lube change. So many patients feels rushed because their doctor is pressured to see a patient every 10 minutes to cover the overhead. May be a change in the current reimbursement practice will make the things better for both patients and doctors...

Reference:
How Much for an Hour of Schmoozing, Doc? - NYTimes, a free registration is needed to read the article

Different Incomes Lead to Different Outcomes

NY Times reporters take a look at two different patients with AMI and how their life changed after the event. Unfortunately, today as it has been throughout the human history, the size of your income can have a profound effect on your health.

Read more in Life at the Top in America Isn't Just Better, It's Longer - NYT.

Image source: finpipe.com

Do It Yourself EMR (Electronic Medical Records)

The introduction of EMR is slow because of cost, lack of a common industry-wide standard and other issues.

Last week, the AMA launched the iHealthRecord website which lets patients save their medical history online for free. The physicians are charged $ 25 per month to access their patients' information.

(Via Wash Post)

Update 3/22/2007:
EHRs Fix Everything - and Nine Other Myths. Family Practice Management, 2007.

More resources:
Doctors Slowly Going Digital With Records - Wash Post 05/05
EMR, the new threat to your medical privacy. ConsumerReports.org
How Doctors Can Use Evernote As A Professional Memory Accessible Anywhere, Part 2: Using Evernote as an Electronic Health Record (EHR). EfficientMD, 08/2008.
Debate: Do Electronic Health Records Help or Hinder Medical Education? PLoS Medicine: http://is.gd/z9or

Medical Malpractice Liability in the Age of Electronic Health Records - NEJM, 2010 http://goo.gl/cGZG9

Useful Pocket PC Programs

How to Run Palm Programs on a Pocket PC

Many physicians have migrated to Pocket PC/Windows Mobile PDAs and abandoned the good old faithful Palms.

The only problem is that most of us still have at least 2-3 well trusted Palm-only programs that regrettably do not work on Pocket PC. The solution is StyleTap -- a new application for Windows Mobile that enables you to run Palm software on Windows PDAs. You can download a free 14-day trial version. The full program is $ 30 (via MedPDA.net).

iSilo for Pocket PC

This program will allow you to run some of the best Palm tools on your Pocket PC. Palm Brain for Easy Interpretation of EKGs (download here) and the UCSF Hospitalist Handbook are just a few free Palm programs that work seamlessly on Windows PDAs with the new iSilo ($ 20).

Multi IE

This Pocket IE browser enhancement is a definite must-have for your internet-enabled Pocket PC. You can open multiple windows, view a full screen mode and many more. Multi IE sits on top of Pocket IE and provides a multitude of features. Download the 15-day trial version to see for yourself (the full version is $ 18). Multi IE was a finalist in the Pocket PC Magazine 2004 Awards.

References:
Free Medical Programs for Windows Mobile / Pocket PC
Use Your PDA to Access Internet Everywhere
Go with the Flow! - Travel advice and PDA programs from PocketPC Magazine
More Medical Schools Requiring PDAs. Associated Press.
5 Windows Mobile freeware programs I'm thankful for. Download Squad.

Updated: 08/11/2007

Interesting Flickr Photos

With more than 17 million photos, the image host Flickr is becoming more and more interesting. We use their Zeitgeist to post clinical images in the side bar of this website.

Spain
There is a whole photo session from Spain - check out the Flying torero and the other 80 photos. Then read the post Summertime: I'm missing Spain on RussellBeattie.com

Life Through A Lens' Photos
Birds, Wild Animals and Orchids

A dog and a cow

Solar System in a piece of wood


References:
How to find the best photos on Flickr. Lifehacker.com

Thoracentesis - Procedure Guide

Authors: V. Dimov, M.D., The Cleveland Clinic, B. Altaqi, M.D., Trover Foundation Health Care System

See the slide show or click on the images below for step-by-step instructions.


Indications

Pleural effusion which needs diagnostic work-up
Symptomatic treatment of a large pleural effusion


Contraindications

Uncooperative patient
Uncorrected bleeding diathesis
Chest wall cellulitis at the site of puncture


Relative contraindications

Bullous disease, e.g. emphysema
Positive end-expiratory pressure (PEEP) mechanical ventilation
Only one functioning lung
Small volume of fluid (less than 1 cm thickness on a lateral decubitus film)


Procedure Step-by-Step

Explain the procedure to the patient and obtain a written informed consent, if possible. Explain the risks, benefits and alternatives (RBA). Benefits may inlcude less SOB, obtaining a diagnosis, and risks may include pneumothorax, bleeding, or even death.


Fig. 1. Get the standard thoracocentesis kit. In addition to the kit, you will need two 1-liter vacuum bottles and Bethadine for cleaning the area. Prepare the necessary equipment for the pleural tap.


Fig. 2, 3, 4, 5. Find the anatomical landmarks before you perform the thoracocentesis.


Fig. 6, 7. Clean the area with iodine.


Fig. 8, 9. Open the kit and make sure that you know which tube and needle are used for.


Fig. 10, 11. Practice sliding the flexible catheter.


Fig. 12, 13. Prepare for local anesthesia.


Fig. 14, 15. Prepare the area.


Fig. 16, 17, 18. Perform the procedure (under supervision, if you are not certified). Anesthetize the skin and pleura, try to reach the effusion fluid.


Fig. 19, 20. Prepare the flexible catheter.


Fig. 21, 22, 23, 24, 25. Pass the flexible catheter over the tap needle into the pleural space and begin aspirating the fluid in the vacuum tubes.


Fig. 26, 27.

Complete the procedure, check for complications - mainly pneumothorax and bleeding. Order a CXR to rule out pneumothorax.

Send the pleural fluid in the 1 L bottle to the laboratory. Compare the pleural fluid to the corresponding blood tests, in order to differentiate between transudate and exudate. If the patient had blood draws this morning, you can order some additional enzymes as AOT (add-on tests), if not already done before the tap.


Complications

Pneumothorax (3-30%)
Hemopneumothorax
Hemorrhage
Hypotension due to a vasovagal response
Pulmonary edema due to lung reexpansion
Spleen or liver puncture
Air embolism
Introduction of infection


Write a procedure note which documents the following:

Patient consent
Indications for the procedure
Relevant labs, e.g INR/PTT, platelet count
Procedure technique, sterile prep, anesthetic, amount of fluid obtained, character of fluid, estimated blood loss
Any complications
Tests ordered


References:
Procedure Skills and ACLS Refresher
Thoracentesis - The UCSF Hospitalist Handbook
Diagnostic Approach to Pleural Effusion in Adults. Am Fam Phys, Vol. 73 No. 5, April 1, 2006.
Patient information: Thoracentesis - Medline Plus
Patient information: Pleural effusion - Medline Plus
Is Ultrasound-Guided Thoracentesis Safer? - AFP
Thoracentesis Best Practices: Slideshow. Medscape, 2011.