Ten most expensive conditions treated in Hospital
Showing posts with label General. Show all posts
Showing posts with label General. Show all posts
Stop Smoking Now
November 26, 2008
Amazing response by the human body to return to normal if you quit smoking right now. On the other hand, this also shows how much harm cigarettes do to you.
Banjo center of brain
November 15, 2008
Bluegrass legend Eddie Adcock recently underwent brain surgery to treat a hand tremor. During this procedure, his surgeons placed electrodes deep into his brain to stimulate the thalamus at just the right spot to inhibit his tremor.
Alas, the banjo center of the brain is not an area well-known to neuroanatomists. To pick the optimal location for the electrodes, the surgery was performed under local anesthesia while Eddie played his banjo. He was thus able to update the surgeons in real-time as to whether the tremor was better or worse, letting them get the lead placement just right.
Alas, the banjo center of the brain is not an area well-known to neuroanatomists. To pick the optimal location for the electrodes, the surgery was performed under local anesthesia while Eddie played his banjo. He was thus able to update the surgeons in real-time as to whether the tremor was better or worse, letting them get the lead placement just right.
The BBC has posted some remarkable video and audio clips recorded during this surgery. The audio beginning at the 3:49 marker moved me the most. In this bit, the BBC interviewer asks Mr. Adcock to play the banjo with his stimulator on and off. The difference is pretty clear, even to the non-bluegrass ear.
Phobias
November 6, 2008
I have phobia of heights. You may have other phobias. This gives extensive list of Phobias..
How to survive a nuclear attack!!
September 12, 2008
Hope we never need this on!!
The face of nuclear terror has changed since the Cold War, but disaster-medicine expert Irwin Redlener reminds us the threat is still real. He looks at some of history’s farcical countermeasures and offers practical advice on how to survive an attack.
Beware of Red Bull
August 16, 2008
Drinking even one can of red bull can produce hyper reactive plateletes and may lead to CV events..Read report from Australia..
Herbal supplements and surgery
August 14, 2008
Lots of patients consume herbal medications and some take concoction of many. This article deals with interaction of such remedies during surgery..Read more.
RCTs and parachutes
August 8, 2008
In the tight-sphinctered world of academic medicine, it's always delightful to find a journal that still has a sense of humor. The following satirical paper from the British Journal of Medicine made me laugh and laugh.Smith GCS, Pell JP. (2003). Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ, 327(7429), 1459-1461. DOI: 10.1136/bmj.327.7429.1459
In a nutshell, this paper rightfully points out that no one has ever done a randomized, controlled trial (RCT) on the efficacy of parachutes. Furthermore,
Advocates of evidence-based medicine have criticised the adoption of interventions evaluated by using only observational data.
To be funny, satire has to contain enough truth about its subject to properly skewer its underlying fallacies. Smith and Pell's excellent paper carries the concept of parachute efficacy through the usual machinery of evidence-based medicine, all the way to the following hilarious reductio ad absurdum conclusion:
We think that everyone might benefit if the most radical protagonists of evidence-based medicine organised and participated in a double-blind, randomised, placebo-controlled, crossover trial of the parachute.
From skimming through the comments stimulated by this paper, it seems that not all of the BMJ readers recognized it as satire, even though the article concludes with the following contributors' statement:
GCSS had the original idea. JPP tried to talk him out of it. JPP did the first literature search but GCSS lost it. GCSS drafted the manuscript but JPP deleted all the best jokes. GCSS is the guarantor, and JPP says it serves him right.
A Bit More on Evidence-Based Medicine
The formal term "evidence-based medicine" (EBM), is a relative newcomer on the medical research scene, and is based on early publications by Cochrane in 1972 and Sackett and Guyatt in the early 1990's. Their idea is a simple one: make clinical decisions based on a synthesis of the best available evidence about a treatment.
Just a few decades later, there are way many EBM advocates who are way too ready to blindly wield EBM like a mighty sword without understanding its limitations. IMHO, one of its biggest limitations is the current EBM definition of "best available evidence". For example, consider the Oxford Centre for Evidence-based Medicine Levels of Evidence (May 2001):
Level Therapy/Prevention, Aetiology/Harm
1a systematic review (with homogeneity*) of RCTs
1b Individual RCT (with narrow Confidence Interval‡)
1c All or none§
2a systematic review (with homogeneity*) of cohort studies
2b Individual cohort study (including low quality RCT; e.g., <80%>Oscillococcinum). However, the solutions usually employed are so dilute there is not a single molecule left of the original agent. Scientific likelihood of any benefit over that of plain water = zip.
Homeopathy counters this with the claim that the diluting water has a "memory" of the original agent, even though it's all gone. However, there is no scientific evidence of such a "memory" effect. Besides, when one considers how much of our planet's water passes through human kidneys, it seems likely that any possible "memory" of Oscillococcinum would be swamped by just the "memory" of used beer.
Bottom line: scientific likelihood of any benefit of homeopathy over that of plain water again = zero/zed/zip.
In this case, the basic science is so overwhelmingly against any benefit that it seems ridiculous to perform an RCT of homeopathic claims. Even if a marginally weak effect were suggested by a clinical trial, the a priori implausibility of homeopathy makes it hard to put much confidence in the result.
Parachutes
The physics of falling bodies, on the other hand, has been understood for a long time, particularly when there is atmospheric drag. The terminal velocity of a falling human in air is about 55 m/s (120 mph). Scientific likelihood of survival = almost 0% (a few fluke cases have been reported of lucky folks surviving parachute failures).
A properly designed parachute can decrease this falling speed to as little as 2.1 m/s, about the speed you'd develop by jumping off a 9 inch stool. Scientific likelihood of survival = virtually 100%.
In this case, the basic science is overwhelmingly in favor of survival. Therefore, I'm willing to take my chances with a parachute during my next plunge from a height -- RCT or no RCT.
Syndicated from samurai radiologist.
Clinician's Long Tails
August 7, 2008
DB has written a series of posts on this concept (here, here, here, here, here and here). There’s little I can add but I wanted to get them into my own links, and going through the exercise below has helped my understanding of the concept.
The long tail refers to the horizontal tail of a power law graph. This is a polynomial function which has garnered great interest because of its applicability to a large number of phenomena in commerce and nature. When applied to differential diagnosis the horizontal axis can be visualized as an array of diseases of increasing rarity the farther away from the origin. The vertical axis represents the probability of the given disease explaining the patient’s presentation. A small number of common diseases are clustered toward the origin (to the left). Toward the right (in the long tail) are uncommon diseases, becoming increasingly rare as the graph approaches the horizontal axis as an asymptote.
Individual diseases in the long tail are uncommon. But, because the tail is long (there are many rare diseases), in the aggregate a significant number of patients is represented. That principle, a challenge for the clinician, is explained here.
DB uses the sore throat as an illustration. Pneumonia is another example. Pneumococcal pneumonia would be near the origin. Blastomycosis, ANCA associated pulmonary capillaritis and bronchoalveolar carcinoma, diseases which can present as “pneumonia”, are in the long tail. For recurrent abdominal pain irritable bowel syndrome would belong on the left, with celiac disease and acute intermittent porphyria occupying positions progressively to the right. And so on.
The challenge of the long tail is knowing when to enter it and, once you do, to generate a wide enough differential diagnosis to encompass the disease the patient has, and finally to select appropriate tests to pinpoint the diagnosis. That’s why the long tail separates clinicians from automatons. Algorithms and guidelines won’t help. Up to Date may not even help! What’s needed is judgment along with a vast fund of knowledge about diseases. Key to knowing when and when not to enter the long tail, as DB explains, is knowledge of natural history. How long, for example, should it take your patient with pneumonia to get better? At what point, as a corollary, should you start searching for another diagnosis?
The description of this cognitive process and the contrast between clinician and automaton makes a compelling case for the revival of the original concept of the internist.
Syndicated from RW.
The long tail refers to the horizontal tail of a power law graph. This is a polynomial function which has garnered great interest because of its applicability to a large number of phenomena in commerce and nature. When applied to differential diagnosis the horizontal axis can be visualized as an array of diseases of increasing rarity the farther away from the origin. The vertical axis represents the probability of the given disease explaining the patient’s presentation. A small number of common diseases are clustered toward the origin (to the left). Toward the right (in the long tail) are uncommon diseases, becoming increasingly rare as the graph approaches the horizontal axis as an asymptote.
Individual diseases in the long tail are uncommon. But, because the tail is long (there are many rare diseases), in the aggregate a significant number of patients is represented. That principle, a challenge for the clinician, is explained here.
DB uses the sore throat as an illustration. Pneumonia is another example. Pneumococcal pneumonia would be near the origin. Blastomycosis, ANCA associated pulmonary capillaritis and bronchoalveolar carcinoma, diseases which can present as “pneumonia”, are in the long tail. For recurrent abdominal pain irritable bowel syndrome would belong on the left, with celiac disease and acute intermittent porphyria occupying positions progressively to the right. And so on.
The challenge of the long tail is knowing when to enter it and, once you do, to generate a wide enough differential diagnosis to encompass the disease the patient has, and finally to select appropriate tests to pinpoint the diagnosis. That’s why the long tail separates clinicians from automatons. Algorithms and guidelines won’t help. Up to Date may not even help! What’s needed is judgment along with a vast fund of knowledge about diseases. Key to knowing when and when not to enter the long tail, as DB explains, is knowledge of natural history. How long, for example, should it take your patient with pneumonia to get better? At what point, as a corollary, should you start searching for another diagnosis?
The description of this cognitive process and the contrast between clinician and automaton makes a compelling case for the revival of the original concept of the internist.
Syndicated from RW.
Lesson for us: Use proper blood pressure cuffs
Blood pressure that is fluctuating is common in wards and apart from personnel variation, using improper blood pressure cuffs can end up in serious trouble for patients. Read this lesson of the week from BMJ.
Lesson of the week.....
Lesson of the week.....
Biotics: what you need to know
August 5, 2008
Prebiotic is a selectively fermented ingredient that allows specific changes, both in the composition and/or activity in the gut bacteria leading to benefits for the host well being and health. Synbiotic is a combination of prebiotic and probiotic.
Bifidobacteria and lactobacilli have been shown to have potent antipathogenic properties for potentially providing health benefits.
A successful prebiotic has the following properties:
1. Is not destroyed or absorbed in the gut on its journey from mouth to the colon.
2. Undergoes bacterial fermentation in the gut.
3. Selectively promotes the number and/or activity of the indigenous beneficial bacteria like bifidobacteria and lactobacilli
While dietary fiber may act as prebiotic, the most promising however are fructo-oligosaccharides (FOS) because of their selective fermentation towards the more healthy gut bacteria.Galacto- oligosaccharides (GOS) are used in infant formula foods. Both FOS and GOS meet the criteria for prebiotics as outlined above. Inulin type fructans have positive prebiotic effects. Other products with possible prebiotic potential include soybean oligosaccharides from soybean whey. Isomalto- oligosaccharides may be regarded as a quasi-prebiotic since it is partially metabolized in human gut.
Possible health benefits of prebiotics include:
Dose of prebiotic: 5-8 g per day
Products on the market that may be fortified with prebiotics include diary products, health drinks, infant formula, cereal, dried instant as well as canned foods, and pet foods etc.
Do you or someone you know takes probiotics or prebiotics? If yes, in what form do you take and do you think it makes a difference? Please share your thoughts.
Bifidobacteria and lactobacilli have been shown to have potent antipathogenic properties for potentially providing health benefits.
A successful prebiotic has the following properties:
1. Is not destroyed or absorbed in the gut on its journey from mouth to the colon.
2. Undergoes bacterial fermentation in the gut.
3. Selectively promotes the number and/or activity of the indigenous beneficial bacteria like bifidobacteria and lactobacilli
While dietary fiber may act as prebiotic, the most promising however are fructo-oligosaccharides (FOS) because of their selective fermentation towards the more healthy gut bacteria.Galacto- oligosaccharides (GOS) are used in infant formula foods. Both FOS and GOS meet the criteria for prebiotics as outlined above. Inulin type fructans have positive prebiotic effects. Other products with possible prebiotic potential include soybean oligosaccharides from soybean whey. Isomalto- oligosaccharides may be regarded as a quasi-prebiotic since it is partially metabolized in human gut.
Possible health benefits of prebiotics include:
- 1. Improved lactose tolerance
- 2. Improved resistance to pathogens resulting in decrease in gastrointestinal infections and respiratory infections
- 3. Decrease in cholesterol
- 4. Increased bacterial synthesis of vitamins
- 5. Protection against allergies by reducing gut inflammation
- 6. Improved absorption of calcium and magnesium
Dose of prebiotic: 5-8 g per day
Products on the market that may be fortified with prebiotics include diary products, health drinks, infant formula, cereal, dried instant as well as canned foods, and pet foods etc.
Do you or someone you know takes probiotics or prebiotics? If yes, in what form do you take and do you think it makes a difference? Please share your thoughts.
Lazy in and lazy out!
August 4, 2008
Of course, I would expect nothing less. This is America after all, where they encourage laziness in every possible way. I could understand if it was a disability access issue, but I've never seen an escalator that is wheelchair accessible. So that argument doesn't fly. It FAILS
A Journey to Center of Your Mind by VS
August 3, 2008
The Most Electrifying Lecture You'll Ever Hear
I've heard a lot of lectures in my life but never one like this. This is neuroanatomist Dr. Jill Bolte Taylor giving a talk on the functional differences between the right and left hemispheres of the brain. She's passionate about her subject as she actually suffered a massive intracranial hemorrhage that trashed her left brain. Dr. Taylor brilliantly describes the experience and sensations both as a stroke victim and as a scientist.
Not that I want to replicate her experience but man do I wish I could teach like her! Check it out and prepare to be riveted by the most amazing 20 minute talk you've ever heard.
It makes me never want to step up to a podium again.
Not that I want to replicate her experience but man do I wish I could teach like her! Check it out and prepare to be riveted by the most amazing 20 minute talk you've ever heard.
It makes me never want to step up to a podium again.
Doctor and patient relationship- Is it healthy?
August 2, 2008
NewYorkTimes Tara Parker-Pope's piece this week hit the nail on the head. The doctor-patient relationship is in trouble...big trouble!
Parker-Pope has a way of accurately encapsulating today's health issues and this issue is no different. Since this is a relationship I know well, I was impressed how accurately she described it - the good, the bad, and the ugly.
I've had many wonderful moments with families but there have been many times I leave a room scratching my head, wondering what I could have done to have helped that family feel more at ease. While I admit there are times I could have phrased something better or been more tactful, there are even more times when all my best efforts don't seem enough. Those are the times that worry me.
My list of why the doctor-patient relationship is in trouble is similar to Parker-Pope's list. In my mind, the major reasons for the decline include, in no particular order:
1. physician dissatisfaction with clinical life
2. physician dissatisfaction with income
3. unreasonable or unfair patient or family expectations
4. "Dr. Google"
5. A decline in the respect given to experts for their education and training
6. A health care system that doesn't allow enough time for good communication
7. People not following advice given without consulting their doctor first then calling to complain they are not better
8. People not understanding that pills and antibiotics are not the cure for most things
9. People not understanding that tests are not the path to most diagnoses
10. People not taking ownership for their own health day to day
One of the doctors interviewed by Parker-Pope described a typical health care encounter almost like a face-off. Great analogy! That is just what it feels like much of the time - but it doesn't have to be that way.
To turn this mess around, we all have to do our part in the system to de-escalate the relationship. Since this is a relationship, everyone has to accept responsibility for what they bring into the room and work on their part of the friction. So, while us docs are working on communication and better listening, patients and families have some work to do, too. They need to cut us some slack and understand we are only human. And, a little respect would go a long way. It is so difficult to try and help someone when they sort of cop an attitude because of something found in a Google search. As I've mentioned in prior posts, reading a medical lithograph and interpreting it are very different. there's a reason we have 4 years of medical school and 3+years of residency training. If people want us to respect their questions and fears, which we all try to do, our expertise has to be respected, too.
As for the medical system, that is broken and needs to be fixed. It is destroying morale and the work environment actually driving doctors from clinical medicine more often than most people want to discuss. We are not being greedy to want to be paid fairly for our time given how many hours a week a logged in caring for people. And, it is not greedy to want to have a family life and some personal time, either. There has to be a way to pay doctors fairly while structuring a work environment that is supportive and recognizes that we all have lives outside of medicine.
The good news is that we are finally having a conversation about this very difficult and important topic. That's the first step to finding a solution and improving the satisfaction on both sides of this face off. If we work at it and succeed, we'll find ourselves still facing off - but on the same side of the puck with both of us against the medical problem. That's the way it used to be, and the way it needs to be again.
Posted by DrGwenn
Parker-Pope has a way of accurately encapsulating today's health issues and this issue is no different. Since this is a relationship I know well, I was impressed how accurately she described it - the good, the bad, and the ugly.
I've had many wonderful moments with families but there have been many times I leave a room scratching my head, wondering what I could have done to have helped that family feel more at ease. While I admit there are times I could have phrased something better or been more tactful, there are even more times when all my best efforts don't seem enough. Those are the times that worry me.
My list of why the doctor-patient relationship is in trouble is similar to Parker-Pope's list. In my mind, the major reasons for the decline include, in no particular order:
1. physician dissatisfaction with clinical life
2. physician dissatisfaction with income
3. unreasonable or unfair patient or family expectations
4. "Dr. Google"
5. A decline in the respect given to experts for their education and training
6. A health care system that doesn't allow enough time for good communication
7. People not following advice given without consulting their doctor first then calling to complain they are not better
8. People not understanding that pills and antibiotics are not the cure for most things
9. People not understanding that tests are not the path to most diagnoses
10. People not taking ownership for their own health day to day
One of the doctors interviewed by Parker-Pope described a typical health care encounter almost like a face-off. Great analogy! That is just what it feels like much of the time - but it doesn't have to be that way.
To turn this mess around, we all have to do our part in the system to de-escalate the relationship. Since this is a relationship, everyone has to accept responsibility for what they bring into the room and work on their part of the friction. So, while us docs are working on communication and better listening, patients and families have some work to do, too. They need to cut us some slack and understand we are only human. And, a little respect would go a long way. It is so difficult to try and help someone when they sort of cop an attitude because of something found in a Google search. As I've mentioned in prior posts, reading a medical lithograph and interpreting it are very different. there's a reason we have 4 years of medical school and 3+years of residency training. If people want us to respect their questions and fears, which we all try to do, our expertise has to be respected, too.
As for the medical system, that is broken and needs to be fixed. It is destroying morale and the work environment actually driving doctors from clinical medicine more often than most people want to discuss. We are not being greedy to want to be paid fairly for our time given how many hours a week a logged in caring for people. And, it is not greedy to want to have a family life and some personal time, either. There has to be a way to pay doctors fairly while structuring a work environment that is supportive and recognizes that we all have lives outside of medicine.
The good news is that we are finally having a conversation about this very difficult and important topic. That's the first step to finding a solution and improving the satisfaction on both sides of this face off. If we work at it and succeed, we'll find ourselves still facing off - but on the same side of the puck with both of us against the medical problem. That's the way it used to be, and the way it needs to be again.
Posted by DrGwenn
Health - How many times your patient sees You
June 22, 2008
Which country makes most trips to the doctor?
THE Japanese make most visits to the doctor of any rich country. Each person goes 13.8 times a year on average according to the OECD. The high rate could be explained in part by Japan's high ratio of older people who require more care. Americans see a doctor less than four times a year, although the high number people without medical insurance may be a factor. Neighbouring Mexicans are the most doctor-shy. See this chart posted in Economist..
THE Japanese make most visits to the doctor of any rich country. Each person goes 13.8 times a year on average according to the OECD. The high rate could be explained in part by Japan's high ratio of older people who require more care. Americans see a doctor less than four times a year, although the high number people without medical insurance may be a factor. Neighbouring Mexicans are the most doctor-shy. See this chart posted in Economist..
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Old and Flexible!
How old is old Kan? Some times thats not easy to judge. I am getting on 57 and some days i feel young and other days old. It is interesting to read this post that i have syndicated from hospitalist..
At what point do you draw the line? Look at This old and flexible old lady. People come in many states of health. Clinically, I say it over and over again. Those who don't smoke and who exercise on a regular basis look much younger than their stated age. Those that smoke and don't exercise look much older than their stated age. There is the physiological age and the birth age. 90 year olds look like 60 year olds. 60 year olds look like 90 year olds.
Walking a day in my shoes involves a continuous evaluation of the whole clinical picture. I don't consider myself a specialist per say of any organ system. But I do consider myself a specialist of all organ systems. It's called internal medicine. And I fine tune my practice for hospital based presentations. Every day I must make decisions. Decisions on how to evaluate new abnormalities that present themselves. Decisions on how to manage known chronic medical conditions. But how do I decide? How do I decide what to do and when to do it. What to order. What not to order.
Many non practicing policy bench warmers would like to believe that practicing medicine is nothing more than following a guideline. For example, from the public's point of view, if they came across this website, they may be lead to believe that being a doctor is simply following rules. It couldn't be farther from the truth.
Let me give you an example. What do you do when an independent 95 year old man comes to the hospital with a 3 week history of weakness and found to have anemia. A hemoglobin of 6. What do you do when this same 95 year old man is found to have paroxysmal SVT with bursts of 180 and sinus rhythms of 40? What do you do? What do you do when you find moderate to severe mitral regurgitation with pulmonary pressures of 60 mmHg?
What do you do? Do you follow the guidelines (if they exist) and treat each problem as an independent entity, devoid of a living person? Or do you look at the big picture?
How do you make a decision on how aggressive to be? We all want to sit here and say that age should not be an independent predictor for making medical decisions. I ask why shouldn't it be. Why should we not employ age in the equation of resource allocation. Let me ask you this:
Would you put a $30,000 defibrillator into a 60 year old patient with sudden cardiac arrest due to ventricular tachycardia and concurrent colon cancer with metastatic lung and liver lesions? How about a $5,000 pace maker? If you would, why would you. If not why not? What would be the basis of your decision? These are clinical decisions that are made every day. Judgement calls by medical professionals. You can't write guidelines for this stuff. Some doctors lose site of the big picture and do things to patients because they can. Because they lose sight of the big picture. And sometimes, when you focus on the nail, it's just easier to ignore the house falling apart around you.
Good hospitalists are able to provide a big picture look at patient care and health care utilization in the hospital. You could call it expert medical opinion based rationing. That's what it is. And it's perfectly ok to limit ineffective and costly care with limited expected benefit. In the case of my 95 year old man. Imagine if a cardiologist or a gastroenterologist was primary. The gastro consults the heart. When the kidneys get stunted from the cath dye, the kidney docs come on board. When the temperatures start rising after a vomiting episode, on come the ID docs and the lunginators.
When I admit this patient, this patient is mine. I make the decision when a heart doctor is appropriate. When a lunginator or when the fever beavers are needed. But when a specialist admits this kind of patient, anything outside their organ leads to a cornucopia of specialists with macular degeneration. With out a hospitalist, or internist, or family practice specialist the big picture is often lost in a sea of "check with Dr. Fever Beaver. That's not my area." I see it all the time when we come on board patients who have compartmentalized.
My 95 year old has an actuarial life expectancy of about 2 1/2 years. Not until you hit age 112 is the life expectancy less than one year. Does that mean we should do everything possible because the patient has a life expectancy of over one year? I don't think so. I make decisions not to pursue abnormalities every day. I make decisions not to make patients lives more miserable. I make calculated decisions based on risk and benefit all the time. Sometimes I discuss my thoughts with the patient. Sometimes I don't. Sometimes I don't give them the option of a pace maker. Some times I tell them dialysis is not an option. Sometimes I tell them that their granny would not survive that procedure or surgery. And I feel completely at ease because I know that not doing many things by the guideline is often times cheaper and will have no meaningful change in long term outcomes. In other words, death is natural.
Do I think I need to offer a pacemaker to a 95 year old with colon cancer? How about a 95 year old without colon cancer? Do I even need to offer a colonoscopy to a 95 year old who may have colon cancer? I often don't know the answer to my own questions because I need to be there, in the thick of things to really understand how to answer my own questions. Guidelines are just that, but often worthless when you are dealing with real life situations. A 95 year old is the equivalent of a patient with cancer with a 2 year expected survival. As a nation we have to accept our mortality and start serious discussions about resource utilization across many spectrums of disease. That includes end stage disease. But that also includes end stage age. If we are going to realistically fund future generations, then the talks must begin now.
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Mr Bean!
I like to watch Mr Bean movies and he is irritatingly funny sometime. Click here to see him.. ha ha ha
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