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Monday, April 14th, 2008
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11:18 am - 1 in 4 (possible baby-related triggers)
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Soapbox topic of the day: Miscarriage.
In the U.S.:
1 in 10 people has diabetes. Trust me when I say we talk about it All the Friggin' Time with our patients.
1 in 12 people has heart disease, give or take. This is also on the Top 5 Things to Discuss with Patients.
1 in 3 of us will have cancer at some point in our lives. That's why we have all that screening, yeah?
1 in 2 elderly women has osteoporosis. Mary Tyler Moore's doing good work, indeed.
1 in 60 people have had a stroke, and 1 in 450 will have a stroke this year (bet you thought it was more common - I did). That's one stroke per minute, if you're counting - other diagnoses can be judged relative to that.
And there's a slew of much less common events that I actively screen for/discuss with my patients: 1 in 700 people has liver disease, 1 in 20,000 will have an abdominal aortic aneurysm at some point, and etc, etc, etc.....
1 in 4 pregnancies is miscarried (75% of these happen in the first 2 months). If we roughly estimate that half the U.S. population is women, and that perhaps two-thirds of them are in the "reproductive age range" (and I'm supposed to consider them as being "potentially pregnant," right?), that's a rough 1 in 10 chance that any of my patients will have a miscarriage. This isn't including the skew for the populations who actually see the doctor. Nor am I including the lovers/husbands/etc who will be profoundly impacted by a miscarriage (for whom I also have some responsibility, yes?).
I checked my endocrine module, then I went back and checked all my other modules: miscarriage is not discussed. I have no idea how to talk to patients about a) the real risk of miscarriage, b) what will happen, c) support options. At this point, I don't know how to practice good medicine when it comes to helping a woman (and her s.o. as needed) through a profound and incredibly common trauma.
This adds on to my soapbox of lack of sexual health education on my curriculum, a curriculum that's supposed to be one of the most inclusive and progressive in the country.
A few weeks ago, there was a lovely My Turn column on miscarriage, simply pointing out our cultural silence on the matter, as well as the ridiculousness of that silence. We've has massive movements to ensure that cancer patients, AIDS patients, and patients with all sorts of traumas, concerns, and conditions don't have to suffer in silence, or under stigma. Why is there such a profound silence, even in our institutions of medical education, on miscarriage?
I keep a little list of "things I will educate myself about because They won't do it." This is definitely going on there.
I'm not trying to be fear-mongering, but awareness, in this case, is always better. So be aware! You'll be better friends when it happens to someone you know, you'll be better prepared for the possibility if you're pregnant, and you'll know you're not alone if it happens to you. I don't know how much that's worth to a grieving mother, but it's better than a big void of nothing.
(tangent: I want you all to know that I keep track of the health experiences you share with me, as learning lessons. you can always e-mail me with more, if you want confidentiality. Rest assured they will shape me, and the kind of medicine I will someday practice.)
citations (now that this is open for the public): wikipedia, up to date, the u.s. census, the american diabetes association, my endocrine and GI modules.
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(13 comments | comment on this)
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| Saturday, March 15th, 2008
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12:04 pm - Overweight and Obesity Article Links
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| Wednesday, March 5th, 2008
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5:50 pm - citations and such
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someone asked about citations for my last post, and I have to admit, there aren't that many. Here's what I wrote back to them, in case you want to see my thought process as well. Now that I've calmed down from my initial frustration, I do admit - any barrier is better than no barrier. But that's a pretty large gray area of risk, really.
When I first looked this up online, I used: this source as a launching point because it was cited and seemed well-researched.
However, I also remembered Harold McGee using various forms of plastic food wrap in persimmon-ripening experiments in one of his culinary books, so I consulted that, which led me to 1) Wikipedia for various types of plastic wrap materials, and 2) two journals: Polymer and The Journal of Food Science (but I don't have the citations today..... I'll see if I can dig them up). Those gave me ideas on the porosity and thickness of various materials, which turns out to be related to the standards to which a particular polymer is made (logical, but it hadn't occurred to me). Polyvinylidene chloride (the original) is really quite impermeable, and if you can find someone who still makes it (perhaps a lab source), you could get a rather large roll of it and tear it off to size. I've heard from fellow cooks that "freeze-tite" a product by the makers of "stretch-tite" is "almost as good as the old saran," but that's for freezing cakes, not safe sex, so I can't make any claims other than food preservation.
LD polyethylene is far more permeable to water and other molecules (did you ever do the science experiment where you took different brands and put them over glasses of water for a week? anyway.....). Moreover, while it's a "good-fair" resistor to oil-induced breakdown, it's not completely resistant (nor is latex, admittedly). (citation).
A search of PubMed, as well as UpToDate, Micromedix, and MD Consult yielded nothing. I won't go off on a tangent about the paucity of studies on non-procreative sexual health.
So, the herpesviridae are 150 nm in size, approximately, retroviruses are about 120 nm, and HPV is tiny, at around 50 nm (citation, though any virology book could also be used). As the straight dope pointed out in the '90s, latex gloves are not made to the same standards as condoms, which makes condoms inherently safer than gloves. Why then, do we even bother saying "cut up a glove to be a dental dam?" Well, honestly, now that I've seen that, I'm not sure. I haven't looked any further into the matter, however. At least, not yet.
Okay, so a water molecule is about 0.01 nm (Wiki), which is clearly much smaller than HSV. So even if a plastic film isn't water-tight, it might still be virus-tight. True. And I don't know the size of most onion odor particles (dipropyl disulfide is still pretty small, but I don't know others), so I can't guess as to how they relate to viral particles, though I imagine it's along the same lines as water.
So I've seemingly just disarmed my own argument, right? Well, maybe. Here's my main problem: manufacturing standards. Just as latex gloves aren't held to the same standards as condoms, plastic film wraps are held to even less of a standard. Moreover, they're thinner material than condoms (or gloves). There isn't any available information that I can find related to the specific quality measures of food wrap, but I very much doubt it's as regulated as something manufactured specifically for the prevention of fertilization/STI transmission. I can't imagine SC Johnson would tell me, if they even have data, on the number of microtears per square foot they find acceptable. I have no citations for that, nor do I think any are available. Until the study is done, I feel it is important for me to not lead my patients into a possibly false sense of security. If I had a lab, I'd do the study myself. Maybe someday.....
To be fair, the odds of transmitting most viruses during oral sex are relatively small (unless you're actively shedding HSV). But HSV I infections of formerly HSV II-only territory are definitely on the rise. I have only seen one picture of a possible HPV infection on someone's oral mucosa obtained from a partner, and I don't know if that'll pan out as anything significant. To that end, any barrier is better than no barrier. And odds are that food wrap is probably good enough for most people. I don't know if that's something I should ever say to my patients. The odds may be acceptable for you, in which case, that's your decision. But I do object to putting the line "saran wrap is totally safe!" out there without the caveat that "we don't know that with any sort of proof."
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12:49 am - Public Service Announcement
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For the 2% of lesbians who use dental dams in the world (no data on heterosexuals, and none on M+M oral sex, of course) a public service announcement:
Despite what the internet and many books say, even if they're otherwise reputable sources, YOU CANNOT USE SARAN WRAP AS A DENTAL DAM
And you most certainly cannot use "Cling wrap" as stated in a book I saw over the weekend (and whose author will be getting an e-mail from me soon).
"But, but," you sputter in over-educated confusion, "I know I can't use regular old PVC clingwrap because it's totally porous and lets all sorts of nasty things through, but Saran Wrap is supposed to be safe because it's PVdC (polyvinylidene chloride) and as impermeable as latex!"
Ah, but you see, in 2004, SC Johnson made a switch in their formulation of Saran Wrap, and it is now made from Low Density Polyethylene (LDPE), which is, in fact, as porous as every other kind of plastic wrap. It might block some bugs, but Herpes? HIV? HPV? I doubt it. Do I know for sure? No. Do I want my future patients finding out the hard way? Definitely not.
Moreover, no one ever did a randomized control study to show that Saran wrap actually kept viruses at bay. Why would they? It probably does, sure, because it's considered mostly gas-impermeable. But no one ever really examined it. We know all about viruses and latex. Why take the chance? Gloves are abundant, and scissors are cheap.
Rant of the night: do we learn this in medical school? HECK NO!!!!!
But learn it we all should.
hmmph.
You've been PSA'd. Thank you for your attention.
And remember: Cling Wrap Saves your Vegetables not your Genitals.
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| Friday, February 22nd, 2008
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12:53 pm - Stem Cells for ![[info]](http://p-stat.livejournal.com/img/userinfo.gif) gefiltyfish
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I dug into a little for you, but I'm afraid it won't really help you decide.
Both Obama and Clinton are in favor of expanding stem cell research. Both were sponsors of the legislation to expand embryonic stem cell research (from "unwanted" IVF embryos currently in storage, and yes, with donor permission), which the President vetoed.
Examples of statements are:
"By vetoing funding for stem cell research once again, the President is deferring the hopes of millions of Americans who do not have the time to keep waiting for the cure that may save or extend their lives. The promise that stem cells hold does not come from any particular ideology, it is the judgment of science, and we deserve a President who will put that judgment first and make this promise real for the American people." (Obama)
and
"Now, this is research that...holds such promise for devastating diseases. Yesterday, I met with a group of children suffering from juvenile diabetes. I co-chair the Alzheimer's caucus in the Senate. I've worked on helping to boost funding for research to look for cures and a way to prevent so many devastating diseases. And we know that stem cell research holds the key to our understanding more about what we can do. So let me be very clear: When I am president, I will lift the ban on stem cell research." (Clinton)
The one thing I don't know is Hillary's actions in New York on stem cell research.
I do know, however, that Obama helped introduce and pass legislation in Illinois that allowed for the state-funded expansion of stem cell research (and also had a clause requiring donor consent for any IVF embryos). Verifying his exact role in that process is beyond my current capability, but if I see anything further....
So yeah, they're both in favor on continuing and expanding stem cell research, both embryonic and otherwise.
(Tom, I'm leaving this open for you ;P )
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(2 comments | comment on this)
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| Tuesday, February 19th, 2008
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2:07 pm - Health Care Stuff
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or: why I like Obama's health plan more then Clinton's. In medicine, it is my moral obligation to advocate for patients in the larger arena - it's part of my code as a doctor, and as a person. Health care reform is perhaps the biggest area I could try and tackle, but why not? It's important.
( cut for length and possible disinterest on your part )
I try not to talk politics too much, because I feel it's personal. But this is livejournal, where personal meets the world, right? I can count on one hand the number of my friends who have enough inside knowledge of the health care system to be interested in the differences between the two candidates, and I can't begin to express how critical such differences could be, and how absolutely necessary some sort of reform is. I've heard all the arguments against nationalized health care, and I have a counter-argument for most of them, but that's not why I'm posting this, so we can hash that out some other time.
But yeah, a little analysis from my corner.
Addendum: It has come to my attention that Hillary did, indeed, mention such things as improved research funding and mental health care in her recent speech in Madison, and perhaps elsewhere. I applaud that move. I wish she'd put such things on her website instead of the rather vague policy points that are currently there. I don't think I would've changed my mind, but it would have given me a more fair basis for making a decision.
Last, but not least, I'd also like to state for the record that I do not think either plan is the ideal. Both are band-aids for a current gap in health coverage, not an overall solution. However, either plan is a great leap forward relative to our current state, and the subsequent leaps will be smaller. I will endeavor to keep you more in the know as to the ongoing discussion in the future.
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(20 comments | comment on this)
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| Sunday, December 16th, 2007
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7:11 pm - Dear Bostonians/Former Bostonians
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I have a friend who's going to be presenting at an upcoming conference (CROI: the Conference on Retroviruses and Opportunistic Infections).
She'd like to know if you guys have any recommendations for a) relatively cheap and good places to stay and b) relatively cheap and good places to eat/hang out. All cuisines are welcome, and she likes clubbing.
Any suggestions?
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| Wednesday, November 14th, 2007
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4:19 pm - timesink for food
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courtesy of kelly, who I will blame if I fail the exams.
Free Rice: Pet your ego by testing your vocabulary and feeding rice to the starving.
Yes, I know you only get 10 grains of rice per word, but it's not hard to fill up a bowl, given how nerdy I know all of you are.
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| Friday, October 26th, 2007
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3:08 pm - Guinea Pig Retraction
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Anyone remember "Guinea Pig Kids," and/or "The House That AIDS Built" from a few years ago? The former was a BBC "investigative" documentary, the latter a book by HIV "dissident" Liam Scheff (who ironically rants bout the overblown media attention bird flu has gotten). Both were about the purported removal of HIV+ children from their homes so they could be used in experimental drug trials.
Well, The BBC has retracted and apologized the documentary, citing egregious flaws in the sources used. Aetiology, one of my favorite ID bloggers, gave a full report and analysis (she's a front-runner in the fight against HIV-denialism, and a great writer).
I know that I was partly taken in by the BBC, until I learned that during the time that the "house" was supposed to have operated, kids in foster care weren't allowed to participate in clinical trials. Go figure. But others of you have equally soft spots for HIV+ kids, so I thought you might've heard of the documentary without hearing of the recent retraction. So I'm sharing. bon appetit.
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(comment on this)
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| Tuesday, September 4th, 2007
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3:05 pm - things that make al gore cry
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I'm sitting by the giant glass windos of the library, studying for tomorrow's 3-subject 4-hour exam.
It's 86 degrees F outside. It's overly air-conditoned inside.
The heat vents are on.
hmmph.
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(5 comments | comment on this)
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| Tuesday, July 3rd, 2007
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5:44 pm - Open Letter
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Dear NPR:
I listen to All Things Considered on a fairly regular basis, and it usually provides very little for me in the way of controversy, at least to my over-educated, politically-moderate and inherently-yuppified mind. Until today.
At face value, to refer to MDR-TB as being a "milder" form of tuberculosis than XDR-TB is true. However, "milder" is a word that implies safety, which has nothing to do with MDR-TB. Regardless of whether or not Mr. Speaker's TB is XDR or MDR, his treatment will be long and costly. If he had infected anyone during his travels, their treatment will also be long and expensive, if they have the benefit of diagnosis and treatment at all. Two years and $100,000 worth of drugs with significant side effects does not usually equate to any form of the word "mild," and while admittedly XDR-TB is worse, I have come to expect a more careful word-choice from All Things Considered. People who are not already educated about tuberculosis and its forms may very easily be led astray by such a portrayal. I humbly suggest that if you're going to compare the two in the future, you refrain from using the word "milder" and use the phrase "less difficult to treat" or "more responsive to treatment" or something that implies the true relationship between XDR and MDR-TB, rather than a term that minimizes the significant danger MDR-TB poses to those exposed.
It was only with great restraint today that I kept myself from throwing something at my radio in frustration. Please, save my stereo, and choose your words more carefully in the future.
-A. E.
p.s. I note that in your online version of the article, the word "milder" does not appear. Thank you for that.
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| Tuesday, June 19th, 2007
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7:37 pm - Holly, I'm counting on you
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A public health moment.
from a blog I read:
"A few months ago I posited that the unfunded mandate of EMTALA might be unconstitutional. I had my ass handed to me was corrected by those who know more about actual, you know, laws and things. There is, however, little disagreement that EMTALA's obligations are an unfunded mandate. This year, ACEP is advocating for a bill in Congress, the "Access to Emergency Medical Services Act of 2007." Its aims are modest but the potential benefit is significant. Essentially, this bill would do three things:
1) Create a bipartisan commission to study implementation of the recommendations of last years IOM report, "Emergency Care: At the Breaking Point."
2) Direct CMS to create hospital quality measures to end the practice of boarding admitted patients in the ED.
3) Create a 10% bonus payment to physicians delivering EMTALA-mandated care to Medicare beneficiaries.
It's important to note that the Medicare bonus would a) apply to physicians of ALL SPECIALTIES, not just ER docs, b) not be offset by any reduction in other Medicare reimbursement, and c) not cause any increase in premiums for Medicare beneficiaries. The bill (HR 882 and S 1003) is beginning to develop significant momentum. There are as of this writing 86 co-sponsors to the bill in the House, and 7 in the Senate. People smarter than me say that the critical mass for action on a bill such as this generally is over 100 co-sponsors in the House and about 20 in the Senate. So we are getting close. A complete listing of the bill's sponsors can be viewed here.
If your Senator or Representative is not listed as a sponsor, please give him or her a call; use the links for contact info. Ask to speak to their LD (Legislative Director) for health care policy. Let them know that as an ER doc (or whatever sort of unique perspective you may have), you are concerned about ER overcrowding, patient boarding, ambulance diversion, and the lack of availability of on-call specialists. Ask them to review the bill and consider signing on as a co-sponsor. Given the political environment in Washington just now (i.e. a narrow majority and the pre-presidential season), there is no likelihood of any more sweeping reform, but a limited, focused bill like this does have a chance."
Holly - you'll note there's only one WI person on there, and it's not Tammy. I'd ask all the rest of y'all to pony up, too, but I know Holly's my resident political gunner (so go get'em girl!).
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(1 comment | comment on this)
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| Saturday, June 16th, 2007
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10:08 am - Kenya
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My friend, Brian, has taken his hippie-researcher self to Nairobi for the summer and is keeping a blog about the experience. If you're interested in following along, then Perspective Three is the place to go.
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| Thursday, June 14th, 2007
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9:31 am - bloody good deed
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to remind myself that I need to give blood soon. I'm probably CMV positive, but I know at least one of you is CMV negative (so go save the babies, dammit!)
from tiggers don't jump on this week's Change of Shift
"When transfusing a newborn, we can't just use any blood. The blood has to pass all the screening tests used to test blood for adults -- and one more. The blood has to test negative for Cytomegalovirus (CMV). 50-85% of adults in the US test positive for CMV, so we are seldom able to use directed donor blood. The families who request directed donation are upset at first, but once we explain the potential devastating effects of CMV infection in newborns, they realize that we are only trying to protect their baby. CMV can cause profound neurological damage in people whose immune system isn't working properly -- and especially in premature infants because their immune systems are immature.
With 50-85% of adults testing positive for CMV, we sometimes have to wait for safe blood for our babies. In the summer, when donations drop off, that is much more likely. While you're planning your summer, please give some thought to scheduling time to donate blood."
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(9 comments | comment on this)
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| Wednesday, June 13th, 2007
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8:27 pm - Tripod
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| Tuesday, May 29th, 2007
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9:04 am - oh, and...
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| Saturday, May 26th, 2007
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2:21 pm - Adventures with Famous People
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I've decided to re-open some blog posts to "the public" since non-ljers may someday want to read them ;).
So I had lunch with Susan Palwick and her partner (husband? whichever), Gary. And it was rocktastic.
Actually, the correct word for it is "comfortable." I can see why she's such a good hospital chaplain, because conversation was remarkably easy with both her and Gary. I hate to say "we bonded," because that sounds like we traded deep dark secrets into the wee hours, which was not the case. That sort of bonding is less and less real to me as time passes - it's too much too soon, so bound for trouble or dissipation. What we had was a very pleasant lunch with a little bit of "getting to know you" feel to it. It was a comfortable transition from "blog-o-buddies" (and recent ones at that) to "real life acquaintance-friends," and I can't wait to do it again next year :).
Next year, however, I will actually get tickets to WisCon and go to all the fun-sounding events.
It's one of those rainy days that can go either way, depending on how it's approached. I'm in a good mood, so it seems like a cozy sort of hot tea and books day. People in bad moods, however, are going to take one look out the window and feel like wallowing under the covers. The timing of the rain was good, however. It was gorgeously sunny and just on the chill side of summer for this morning's market. It was merely overcast for lunch. It's raining and decidedly cool now that I don't have to walk anywhere. Perfect.
Today, as part of my market adventure, I bought a bunch of Lovage, which is decidedly delicious - like a cinnamon/nutmeg-spiced celery. mmmm..... I'd like to try and make a pesto-like thing with it, perhaps with macadamia nuts or pistachios...... something for fish, or a very light ravioli. Though, in thinking, it could also make a decent dessert with apples or such.....
This afternoon, however, I think I will make mushroom strudel, as Lori gave me her almost dried-out mushrooms and I want to do something with them.
ah...... vacation.....
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| Sunday, May 13th, 2007
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7:55 pm - for Laura and Molly
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| Wednesday, May 9th, 2007
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2:45 pm - huh?
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okay, I know some people have changed lj accounts, gotten rid of them, etc, which is fine.
But Fred. Where the hell are you? What happened? Was there an announcement I missed? Will you even see this?
former fffgf-ers need to stick together, you ratty fiend.
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| Friday, March 30th, 2007
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5:45 pm - One more Step towards Self-Reliance
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For all you Vermonters, (or anyone else who actually likes to grow things to eat and etc....)
Apparently, the University of Georgia offers a free online class on how to preserve food. I found the link at kitchen gardeners international, and I haven't used it yet, but it seemed like a good idea (especially as I'm fully intending to make my meager budget stretch further this year through canning, etc).
Not that I need another class, but I figure I can take as long as I like, and it would be more fun than palpating my classmates.
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