Podcasts from Conferences of University of Tennessee IM Residency Program

Online medical education has changed significantly during the last 2-3 years. When I first started lecturing about using Web 2.0 in Medicine in 2005, few members of the audience had ever heard of podcasts and even fewer shared my enthusiasm for them as a medium for continuous medical education. Fast forward 3 years later, and now some doctors wonder if they should even go to a conference if they can just download the podcasts... More and more institutions make their grand rounds and conferences available for free via downloadable audio and video files.

A few examples of useful podcasts for medical education are listed below:

University of Tennessee Internal Medicine Residency Program

Three years of grand rounds and noon conferences of the internal medicine residency program of the University of Tennessee have been recorded and posted as podcasts on this website. You can listen to the podcasts directly or subscribe vai iTunes. The podcasts are searchable by topic. This is probably the most useful and comprehensive podcast resource for residents and medical students. Highly recommended.

The are 268 audio lectures published on the UTHSC website as of January 2008 which cover most of the curriculum in internal medicine. The podcasts are available for free compared to the audio review courses by major institutions such as Johns Hopkins which cost $200-1,200.

The authors of the project use Libsyn (Liberated Syndication) as a host which is a good place to start if you want to produce your own podcast. Libsyn plans start from $5 per month with unlimited downloads and an upload limit of 100 MB per month. The UTHSC podcasts are encoded at 16 kbs, mono, 22 kHz which does not provide the best sound quality but produces very small files (3-5 MB for a 30-60-minute talk). The total size of all 268 podcasts is 1.3 GB. Libsyn supports RSS and the extended Apple iTunes podcasting tags.

Other Medical Podcasts

Texas Tech Medcast

The Texas Tech Medcast is a podcast for medical residents, medical students and practicing physicians. It has several series:
- SOAP Note 101 Series: designed for first-year medical students who are learning how to write an effective patient note for a medical record (SOAP)
- Geriatrics Series
- Continuity Clinic Series
- Diabetes Mellitus Series
- PreMed Forum Series

Boston University General Internal Medicine Rounds

Weekly selection of the General Internal Medicine Grand Rounds from Boston University Medical Center. The project is still in early stages of development and only a few podcasts are available.

Yale Medicine Podcast

Visit itunes.yale.edu or launch iTunes, then select Yale from the offerings under iTunes U. The podcast is included under “Yale Health & Medicine.”

EMS Lecture Series by Albany Medical Center

Online continuing education courses for EMTs and emergency medicine residents.

PeerView Podcasts

Podcasts in different specialties by the supplier of continuing medical education activities PeerView Press.


Podcasts in different specialties by 3 doctors. The project is still in early stages of development.

Medical podcasts: the future of continuing professional development? BMJ Career Focus 2008;336:29-30.
How to Use Web 2.0 in Medicine? Clinical Cases and Images - Blog, 05/2006.
Top 5 Medical Podcasts I Listen To. Clinical Cases and Images - Blog, 08/2006.

How to Embed MP3 Audio Files In Web Pages With Google or Yahoo! Flash Player. Digital Inspiration, 02/2008.
The iCritical Care Podcast: a novel medium for critical care communication and education. Journal of the American Medical Informatics Association 2007;14(1):94-99.
Joining the Podcast Revolution. J Dent Educ. 72(3): 278-281 2008.

Updated: 03/07/2008

"Poster Child" for Hospitalist Movement Changes Career Track: Confessions of an X-Hospitalist

The author of the blog In My Humble Opinion shares his rational behind a career change:

"I was once a hospitalist. In fact I was even featured in an article about hospitalists. Yep…that's me. Horrendous picture though… isn’t it? The patient I was taking care of was 97. She died about a year later in a nursing home. How do I know that? Because at the time I was transitioning to outpatient medicine. I became her primary care physician. So why did I make the change? And how much of a change was it for me? Recently I saw two patients discharged from hospitalist services. I think these cases illustrate the problems with this type of system."

The hospitalist system as a whole appears to be both viable and beneficial though. At least according to a recent NEJM study and the news about the planned IPO of one of the largest private hospitalist companies -- IPC The Hospitalist Co. ups deal size for IPO. According to MarketWatch: "The North Hollywood, Calif. provider of inpatient care raised $83 million by offering 5.2 million shares in the middle of its $15-$17 price range. In a sign of health, the company increased the size of the offering from 4.7 million shares."

Riding the Hospitalist Boom to an IPO. WSJ.

Confessions of an X-Hospitalist. In My Humble Opinion.
What the Heck is a Hospitalist? North Shore Magazine.
Today’s New England Journal Hospitalist Study. Wachter's World.
Outcomes of Care by Hospitalists, General Internists, and Family Physicians. NEJM.
Image source: sxc.hu

Being a good hospitalist includes talking with the patient and the outpatient physician. DB’s Medical Rants, 01/2008.
A List of Hospitalist Blogs
Another Study Questions the Value of Hospitalists
Definition of "Hospitalist" Added to Merriam-Webster Dictionary
What I Learned from Making the Website of the Cleveland Clinic Hospitalists
SHM Annual Meeting and Cleveland Clinic Hospitalist Section
Audio: Hospitalist Medicine. One of the executives of IPC, Glen Applebaum, discusses hospitalist medicine as a career. Podcasting Project for the UT Internal Medicine Residency Program.

Updated: 03/31/2008

Interesting Medical Websites

I you are interested in using the web for medical education, you can always rely on DavidRothman.net and ScienceRoll to find something useful.

A few examples are listed below:

- GoldMiner is a radiology search engine. I added it to the list of resources on ClinicalCases.org: Imaging: Electrocardiograms, X-rays, CT scans. Link via DavidRothman.net.

- FreeMD is "an electronic doctor that conducts an interview, analyzes symptoms, and provides expert advice — for free.” The website may not be an "electronic doctor" but is simple and easy to use. In my tests, the online diagnostic tool FreeMD worked well, and due to its extensive use of pre-recorded videos, it felt more interactive. Link via DavidRothman.net.

Performance of a Web-Based Clinical Diagnosis Support System for Internists. Mark L. Graber and Ashlei Mathew. J Gen Intern Med. 2008 January; 23(Suppl 1): 37–40.
Image source: Wikipedia

A Person Who Loves His Job

Steve Rubel is a public relations executive at Edelman and a well-known blogger. These are excerpts from his life stream:

steverubel: Work is my big hobby. I am truly lucky to have found a nexus between my passions and profession. (via Twitter / steverubel)

steverubel: I love days when I get into the office before the sun comes up. You feel like you're ahead of the game. (via Twitter / steverubel)

steverubel: You know you're getting old when you get up before 6 am (even on weekends) and get very sleepy by 9:30 or 10. (via Twitter / steverubel)

steverubel: The downside of getting up at 4 is being wiped out by 8.

Update 01/31/2008:

You have to love Steve's reply:

"A blogger notices from my lifestream that I love my job, which I do! Downside? It’s the Clinical Cases blog!"

A CommonCraft video explains what a microblogging platform is by using Twitter as an example.

Aggregated Lifestream Combines All Content Created by You Into One Site/Feed
Are you obsessed with your job? CNN.
Chronic stress at work can make you sick. Clinical Cases and Images - Blog, 03/2006.

Updated: 03/10/2008

Medical News: Exercise and Alcohol Effect on Health

Prticipation in sport is associated with a with a 20—40% reduction in all-cause mortality compared with non-participation. Exercise might also be considered as a fifth vital sign, according to the Lancet: http://goo.gl/gyxYf

Exercise or have a drink? It may be better to exercise AND have a drink

A study of 12,000 people over a 20-year period in Denmark found that exercise and drinking alcohol each had an independent beneficial effect on the heart. The effect was even greater when the two were practiced together. According to TIME magazine:

"People who don't drink at all and don't exercise had the highest risk of heart disease. People who drink moderately and exercise had a 50% lower risk. Teetotaling exercisers had a 30% decreased risk, as did moderately drinking couch potatoes. "There's an additional protective effect to doing both," says Gronbaek. "That's the new finding."

Weekly alcohol intake was inversely associated with fatal ischemic heart disease and had a U-shaped association with all-cause mortality.

The combined influence of leisure-time physical activity and weekly alcohol intake on fatal ischaemic heart disease and all-cause mortality. European Heart Journal 2008 29(2):204-212.
Work Out and Drink Up. TIME.
CNN Video: Alcohol and the heart.
A glass of wine daily may prolong life. How you can you predict which patient will have a bottle daily though?
Drinking Alcohol Daily Seems to Cut the Risk for Coronary Artery Disease the Most
Image source: Wikipedia.

Exercise slows telomere shortening (and aging)

Telomeres are the chromosome tips which shorten each time a cell divides, making them a possible marker of aging. A study of 2400 twins showed that physically active people had longer telomeres than sedentary people. According to the authors, this provides a powerful message that could be used by clinicians to promote the potentially antiaging effect of regular exercise.

Human chromosomes (grey) capped by telomeres (white). Image source: Wikipedia, public domain.

You need little more than your own body weight to exercise. This is a mnemonic and a mind map for exercises that can be done with just body weight: PLSS

P ushups
S itups
L unges
S quats

The Association Between Physical Activity in Leisure Time and Leukocyte Telomere Length. Arch Intern Med. 2008;168(2):154-158.
Physically Active People May Be a Decade Younger, Biologically, Than Sedentary People, WebMD.
How to stay healthy while traveling
Staying a Step Ahead of Aging. NYTimes, 01/31/2008.
Rethinking Drinking - NIH interactive website

Topolog: Videoblog by Prominent Cardiologist Eric Topol

Eric Topol is the former chief of cardiology at Cleveland Clinic and current Chief Academic Officer of Scripps Clinic. He publishes an interesting video blog on Heart.org called Topolog which includes:

- Topol's Selections -- a series of articles Eric Topol finds interesting

- Video posts. There have been only 6 posts since November 2007 (as of 01/28/2008) with the most recent one on ENHANCE trial with ezetimibe.

The embedding of the videos is disabled.

This is the RSS feed:


Firm Belief

GruntDoc reports from ER:

"Patient presents with CC ‘all my organs have been removed’. When queried as to how they’d be alive with no organs, answers ‘they put someone else’s’ in’. After exam showing no signs of drug or alcohol abuse, and notable for none but trivial scars of living, I pointed out that I’ve seen lots of patients with organ transplants, and they have rather remarkable scars, but you don’t. ‘They replaced my skin after’ was the response. There’s always an answer that refutes rationality."

Delusional Behavior. GruntDoc.com.

Cocaine FOR Chest Pain. CasesBlog, 2006.

Video: Tips on managing cellulitis by Dr. Enoch Choi

Dr. Enoch Choi is a family medicine physician in the Urgent Care Department of the Palo Alto Medical Foundation. He has recorded this helpful patient education video with tips on managing cellulitis as part of a series he publishes on YouTube and his blog Doctor Geek, M.D.

NEJM is a Journal (Only) No More

It is official. The venerable New England Journal of Medicine (NEJM) is a paper journal no more. Just visit the NEJM website to see what you have been missing if you have limited yourself only to the paper version of the journal. There is a slew of Web 2.0 and interactive features. I have been interested in the way medical journals use RSS (Really Simple Syndication), podcasts, videos, etc. for a while and was recently consulted by The Lancet to comment on their plain to introduce new tools to their website. Looking at the NEJM site, I have to say that there is a reason why they are still the leading authority in the medical publishing world. This is a list of some of the features a visitor encounters when landing on the NEJM homepage (see the screenshot below):

- Audio summary -- streaming audio and podcasts
- Interactive decision making tool using the "wisdom of crowds" concept
- Video of a roundtable discussion
- RSS Feeds
- Image challenge which also uses the "wisdom of crowds"
- Procedure videos
- Lists of Most Viewed, Most E-Mailed, Most Blogged, etc. articles
- "Listen to the full text of this article" feature

The homepage of NEJM is full of Web 2.0 features -- circled in red in the screenshot above. There are even more tools on the beta page of the journal at: http://beta.nejm.org/

In conclusion, the NEJM is using so many interactive features that it is putting even the most advanced blogs to shame. Comments are not available yet but this addition must surely be planned for not too distant future.

In recent years, the leading medical journals have become much more than a print medium for articles. The NEJM has gone beyond the RSS feeds and has created features which compel the reader to visit the website -- the ultimate goal of a portal site. RSS is so useful that if one can read it all in a RSS reader, there is little reason to click through the website. The NEJM seems to have found an elegant solution to this problem.

Try Web 2.0 in Medicine

I have collected RSS feeds and podcasts from the major journals in one-click subscription for iGoogle. Give it a try to see if it works for you:

RSS feeds of the major medical journals -- NEJM, JAMA, BMJ, Lancet and Annals and more

Podcasts of the 4 major journals

Make Your Own "Medical Journal" with iGoogle Personalized Page
Share iGoogle Tabs with Medical Journals, Podcasts and Gadgets
Annals of Internal Medicine Launches Podcast and Audio Summaries

If you ever wondered how to get from "Here" to "There," Google Maps is happy to help

If you ever wondered how to get from Here to There in France, this is the way:

Link and image source: Google Blogoscoped.

Also, and don't forget to make 200 U-turns if you want to get from Pennsylvania to New Jersey.

This is nothing compared to what you have to be prepared for if you want to go from Stanford to Stockholm -- Google recommends to "swim across the Atlantic Ocean" (only 3,462 miles).

Most of these technical glitches were fixed by the Google Maps team soon after they were reported by bloggers.

Google Maps Cartoon from Xkcd.com.

Updated: 08/14/2008

Interesting Journal Articles

Etanercept Treatment for Children and Adolescents with Plaque Psoriasis. NEJM, 01/2008.

Etanercept is a recombinant human soluble tumor necrosis factor-alpha (TNFα) receptor fusion protein. Etanercept (Enbrel) reduced disease severity in children and adolescents with moderate-to-severe plaque psoriasis.

Biomarkers of Inflammation and Thrombosis as Predictors of Near-Term Mortality in Patients with Peripheral Arterial Disease (PAD): A Cohort Study. Annals of Int Med, 01/2008.

Levels of D-dimer and inflammatory markers (serum amyloid A and CRP) are higher 1-2 years before death in patients with PAD. Increasing levels of those biomarkers are independently associated with higher mortality in PAD. This is a mnemonic for the 3 biomarkers included in the study -- CAD: CRP, Amyloid, D-dimer.

A Risk Score for Predicting Near-Term Incidence of Hypertension (HTN): The Framingham Heart Study. Annals of Int Med, 01/2008.

A HTN risk prediction score can be used to estimate an individual's absolute risk for HTN. The risk score can be used as a simple, office-based tool to help management of high-risk individuals with prehypertension.

Review: Update on Avian Influenza A (H5N1) Virus Infection in Humans. NEJM, 01/2008.

Daily Assessment of Pain in Adults with Sickle Cell Disease. Annals of Int Med, 01/2008.

Pain in adults with sickle cell disease (SCD) seems to be far more prevalent and severe than previous large-scale studies have portrayed.

Review: Update in Palliative Medicine. Annals of Int Med, 01/2008.

A Bridge to Nowhere — The Troubled Trek of Foreign Medical Graduates in Australia. NEJM, 01/2008.

Interactive feature: Management of Type 2 Diabetes. NEJM, 01/2008.

This interactive feature allows readers to decide on the diagnosis or management of a clinical case.

A time efficient way to stay up-to-date with medical literature

"How do you eat in elephant? In small bites." The same rule probably applies to staying current with the ever expanding avalanche of medical literature. One can try the following approach:

1. Subscribe the to the RSS feeds of the 5 major medical journals (NEJM, JAMA, BMJ, Lancet and Annals) plus 2-3 subpecialty journals in your field of interest.

Medical Journals tab: A screenshot of iGoogle with RSS feeds from the major medical journals.

2. Read the journal on the day it is published online, for example, NEJM on Wednesdays.

3. Use text-to-speech to listen to articles you do not have time to read.

4. Listen to journal podcasts. Click here to subscribe the podcasts of the 4 major journals in iGoogle.

Make Your Own "Medical Journal" with iGoogle Personalized Page
Share iGoogle Tabs with Medical Journals, Podcasts and Gadgets
Annals of Internal Medicine Launches Podcast and Audio Summaries
Text-to-Speech Programs and Continuous Medical Education
Image source: OpenClipArt, public domain.

Why Use Web 2.0: An Open Letter to Physicians

Bertalan Meskó explains how academic and private practice physicians can benefit from using Web 2.0 in Open Letter to the Physicians of the World.

He covers what I call the the 6 axes of medical education in Web 2.0 style:
  1. Web feeds (RSS)
  2. Podcasts
  3. Blogs
  4. Wikis
  5. Custom search engines
  6. Second Life virtual world
Bertalan's letter is worth-reading and the University of Debrecen is lucky to have him as a student.

My presentation on Web 2.0 in Medicine from December 2006 is below:

Open Letter to the Physicians of the World. ScienceRoll.com.
Image source: ScienceRoll.com, a Creative Commons license.

Photos from Davos 2008 by Scobleizer

Bono makes Al Gore Laugh. Originally uploaded by Robert Scoble (Creative Commons license).

Robert Scoble has uploaded a lot of interesting photos from the annual meeting of the World Economic Forum (WEF) in Davos to his Flickr account. Check them out when you have a minute or two to spare.

Putting photos into public domain. Scobleizer, 01/2008.

Updated: 01/31/2008

Orthopedic center calls patients "guests" and offers facials, massages and a filet mignon goodbye-dinner

According to the blog of the major newspaper in Cleveland:

"St. John West Shore Hospital opens a new spine- and orthopedic center Tuesday that offers guests -- they're not calling them patients -- facials, massages and a goodbye-dinner menu that includes filet mignon.

They'll hear about the butler who turns down beds and lays mints on the pillows and the concierge who provides wake-up calls and helps visitors find local restaurants. "This new unit has a hotel-, spa-like atmosphere," Noday-Krager said. "It's a totally different standard of care. It's just really five-star."

Because the amenities are included in the cost of the stay, they're covered by insurance."

Clinical Case: Noncompaction of the Left Ventricle

A 56 yo male came to the ER with progressive dyspnea, epigastric pain and diaphoresis for one week.

What was the cause of his symptoms?

Non-ischemic cardiomyopathy secondary to non-compaction of the left ventricle.

Read more in Noncompaction of the Left Ventricle – A Rare Cause Of Non-ischemic Cardiomyopathy on ClinicalCases.org.

What Do You Call a "Medical Library" in 2008? "Information Commons"

John D. Halamka of the blog Life as a Healthcare CIO shares some interesting ideas:
"In my CIO role at Beth Israel Deaconess, I oversee the medical libraries. In the past, Libraries were "clean, well lighted places for books". With the advent of Web 2.0 collaboration tools, blogging, content management portals, lulu.com on demand publishing, and digital journals, it is clear that libraries of paper books are becoming less relevant.

The end result is that the Medical Library has been renamed the Information Commons and the Department of Medical Libraries has been retitled the Department of Knowledge Services. Librarians are now called Information Specialists."
Way of the future.

Google is scanning books in such a fervor that you can see the fingers of the overworked human scanners in quite a lot of digital copies on Google Books. In the 21st century, paper is converted to digital medium via manual labor.

Hand Scanned in Google Book Search. Image source: Google Blogoscoped, a Creative Commons license.

My Interview With Google Discussing Google Book Search. The Efficient MD.

Knowledge Navigators Combat Information Overload. Life as a Healthcare CIO.
Hand Scanned in Google Book Search. Google Blogoscoped.
Google Books Adds Hand Scans. Tech Crunch.

What Do You Call A Medical Library. The Krafty Librarian.
NPR: “Who Needs Libraries?” (aidio), 01/2008.

Updated: 02/28/2008

Why Do I Blog?

A few answers are below:

Why I blog and tweet - retired surgeon/program director/dept chair Skeptical Scalpel shares best practice tips http://buff.ly/1E1zHdI

I'm a Finalist by Dr. Wes.

Why I blog by Kevin, M.D.

Why do I blog?

This blog is a type of educational portfolio. I also use it during my teaching months to make a list of the topics discussed during the rotation with the residents and get feedback. And last but not least, this is the "blog of ClinicalCases.org with medical, tech and other interesting stories."

Currently, there are more than 2,000 subscribers via RSS and more than 1,000 daily website visitors but even if nobody reads it, I will still keep the blog up. Why? Because I have found that writing a blog can be useful, educational, entertaining and time-efficient. It creates your own section of the web that you own and trust. It also creates a relationship with some of the smartest people around the world that you would probably have never had the chance to meet otherwise. If you do not have a blog yet, may be you should consider starting one. The 2 easiest and free options are Blogger.com by Google and WordPress.com.

There are many downsides of having a blog, of course. But just like with any useful treatment, the benefits outweigh the risks for most people. I am not sure what is the "number needed to treat (NNT)," though...

This Google video shows that it takes 2 minutes to start a blog on Blogger.com. Creating a web site has never been easier. From Twitter:
Ves Dimov, M.D.
AllergyNotes "Blogging keeps your mind sharp, improves your writing, brings you closer to intellectual people" http://tinyurl.com/9tuban

Ves Dimov, M.D.
AllergyNotes Blogging: A book that you write slowly over time http://tinyurl.com/9tuban

Ves Dimov, M.D.
AllergyNotes Blogging Is Like Going To The Gym… For Your Brain http://tinyurl.com/9tuban

Related reading: "One of the best decisions I’ve made in my career was to start a blog and a wiki, leaving a paper trail of ideas" http://bit.ly/GX7Z6C How To Use Your Blog To Make 2008 Your Best Year Ever! LifeHack.org. Using a Blog to Build an Educational Portfolio. Clinical Cases and Images - Blog. Topics Discussed During the Internal Medicine Rotation at Cleveland Clinic in October/November 2007. Clinical Cases and Images - Blog. Blogging Is Like Going To The Gym... For Your Brain. Adam Singer, The Future Buzz, 01/2009. Why Blog? Smartzville, 2009.
Why I blog? Life in the fast lane, 2010.
As A Busy Physician, Why Do I Even Bother Blogging? http://goo.gl/fSF3 - Excellent summary. Why blog? Notes from Dr. RW. A perfectly reasonable list. All doctors should consider blogging. It's do-it-yourself CME. Beautiful example of how blogs can disseminate medical information much more efficiently than journals, NEJM included (http://goo.gl/rOvNq).
Why I blog and tweet - retired surgeon/program director/dept chair Skeptical Scalpel shares best practice tips http://buff.ly/1E1zHdI

Is Açaí the Next "Superfood"?

Açaí Palm (pronounced [asaˈi]) grows in tropical Central and South America. Its fruit is a small, round, black-purple drupe, similar in appearance and size to a grape and supposedly contains 10 times more antioxidants than red grapes and 10-30 times the anthocyanins of red wine.

Dr. Perricone's calls Açaí superfood No. 1 on Oprah Winfrey's website. There are few studies in the peer-reviewed literature which seem to confirm the high antioxidant content of the berries.

The anonymous author of the Happy Hospitalist blog have tried taking Acai-based juice for 4 weeks and seems very happy with the result (or may be he was happy to begin with it?).

A colleague of mine was intrigued and took "Standardized Açaí, 60 Vcaps" by Nature's Way for 2 weeks but he did not report any significant difference. For now, I will stick to my cup of green tea in the morning.

Mona Vie Diary Week 4. The Happy Hospitalist.
Superfood No. 1: Açaí. Nature's Energy Fruit. Oprah.com.
Açaí Palm from Wikipedia, the free encyclopedia.
Image source: Wikipedia, public domain.

Hecklers and Fainters at Political Rallies on CNN Video

CNN Video: Hecklers and Fainters at Political Rallies.

At the end of the video, you can see how a 2-year-old handles a 3-year-old heckler who calls her "a baby." "I'm not a baby, I'm a human."

By the way, if you type the phrase "I am human" in Google, the cold mathematical algorithm offers the suggestion: "i am human and i need to be loved" (see the screenshot below). Isn't this something?

Interesting Journal Articles

Hydrocortisone Therapy for Patients with Septic Shock. NEJM, 01/2008.

Hydrocortisone did not improve survival in patients with septic shock, either overall or in patients who did not have a response to corticotropin.

Intensive Insulin Therapy and Pentastarch Resuscitation in Severe Sepsis. NEJM, 01/2008.

Intensive insulin therapy placed critically ill patients with sepsis at increased risk for serious adverse events related to hypoglycemia. Use of hydroxyethyl starch in the study was harmful.

Four no more: The ‘PSA cutoff era’ is over (PDF file). CCJM, 01/2008.

Platelet-Activating Factor, PAF Acetylhydrolase, and Severe Anaphylaxis. Peter Vadas et al. NEJM, 01/2008.

Serum PAF levels were directly correlated with the severity of anaphylaxis. It looks like PAF has a good chance of becoming as important in anaphylaxis diagnosis as BNP has become in CHF exacerbation.

Metformin for the Treatment of the Polycystic Ovary Syndrome. NEJM Review. John E. Nestler, M.D. NEJM, 01/2008

Major Depressive Disorder. NEJM Review. R.H. Belmaker, M.D., and Galila Agam, Ph.D. NEJM, 01/2008.

A time efficient way to stay up-to-date with medical literature

"How do you eat in elephant? In small bites." The same rule probably applies to staying current with the ever expanding avalanche of medical literature. One can try the following approach:

1. Subscribe the to the RSS feeds of the 5 major medical journals (NEJM, JAMA, BMJ, Lancet and Annals) plus 2-3 subpecialty journals in your field of interest.

Medical Journals tab: A screenshot of iGoogle with RSS feeds from the major medical journals.

2. Read the journal on the day it is published online, for example, NEJM on Wednesdays.

3. Use text-to-speech to listen to articles you do not have time to read.

4. Listen to journal podcasts. Click here to subscribe the podcasts of the 4 major journals in iGoogle.

Make Your Own "Medical Journal" with iGoogle Personalized Page
Share iGoogle Tabs with Medical Journals, Podcasts and Gadgets
Annals of Internal Medicine Launches Podcast and Audio Summaries
Text-to-Speech Programs and Continuous Medical Education
Image source: OpenClipArt, public domain.

Zero Benefit from Zetia (Ezetimibe)

I should archive today's news about the lack of benefit from Vytorin (ezetimibe, marketed as Zetia/simvastatin) in the the "I knew it" category of the blog, if there was one. There have been a few medications I have had doubts about for a while. Among them were Zelnorm, Vioxx, Avandia and Zetia, and I had tried to discuss alternative options with patients who wanted a new prescription for them.

Some examples of the blog coverage of the newly-released study are listed below:

Maybe lowering cholesterol does not matter. DB’s Medical Rants.
A quote from NYTimes: "While Zetia lowers cholesterol by 15 percent to 20 percent in most patients, no trial has ever shown that it can reduce heart attacks and strokes — or even that it reduces the growth of the fatty plaques in arteries that can cause heart problems. This trial was designed to show that Zetia could reduce the growth of those plaques. Instead, the plaques actually grew almost twice as fast in patients taking Zetia along with Zocor than in those taking Zocor alone."

Vytorin's Out, Simvastatin's In. Dr. Wes.
"A 30-day supply of Vytorin 10/20 (one of the lower-dose sizes), cost a whopping $97.17. Compare that to generic simvastatin 20 mg, at $5.82 - nearly 17 times the cost."

Unenhanced Results for Zetia and Vytorin. WSJ Health Blog.

Why statins decrease cardiovascular mortality but medications which "merely" lower cholesterol (like Zetia) appear to lack such benefit? One hypothesis is that statins have an antiinflammatory effect in addition to lowering LDL.

The share price of the drug manufacturer, Schering-Plough Corporation, dropped by almost 8% today.

Cholesterol Drug Has No Benefit in Trial, Makers Say. NYTimes.
3rd UPDATE: Vytorin Fails To Benefit Artery Vs. Statin Drug. CNN.com.
Lipitor Looks Better than Zocor in Retrospect. WSJ Health Blog.
Pulling Back the Curtain on Statins. Dr. Wes, 01/2008.
Health: Nothing but a number: Lifestyle changes to control cholesterol. Dr. Sidney Gottlieb, Cleveland Clinic Canada, National Post, 01/2008.
Image source:Ezetimibe, from Wikipedia, the free encyclopedia, public domain.

Updated: 01/31/2008

Annals of Internal Medicine Launches a Podcast in Chinese

Most members of the "big 5" club of medical journals (NEJM, JAMA, Lancet, BMJ, Annals) launched podcasts a year or two ago. Annals of Internal Medicine was the last in line with their Audio Summary in July 2007. Now however, the Annals suddenly jumped ahead of the pack by being the first medical journal to launch an international podcast. Not in Spanish or French but in Chinese -- a sign of the times which points where the global growth is. If you understand Chinese, which I am sure many of the well-educated reader of this blog do, feel free to subscribe to the Annals podcast here.

Alternatively, you can see the English-language podcasts by the the 5 main medical journals here.

Most people subscribe to medical podcasts by using iTunes/iPod/iPhone from Apple. A lesser known fact is that Google Reader can be used as a podcast program as well.

Click here to subscribe to all 4 journal podcasts in your iGoogle homepage.

Click here to subscribe the to the RSS feeds of the 5 major medical journals (NEJM, JAMA, BMJ, Lancet and Annals) in iGoogle.

Image source: Front page, Annals of Internal Medicine.

Taser MP3 Player on WSJ Video

WSJ Video: Taser MP3 player

The trademarked name Taser is an acronym for "Thomas A. Swift's Electric Rifle." Taser International introduced the Taser MPH -- the first combination of a hand-held MP3 player and a Taser. The 1-GB MP3 player, which can hold around 150 songs, is embedded in the device holster.

Anybody can buy a Taser for $349 (the MP3 holster is $73 including the headphones). With the wide availability of tasers for personal use, it looks like we will be hearing "Don't tase me bro" more often, unfortunately.

The U.N. has declared that Taser guns are a form of torture that can kill. On a side note, a study on pigs conducted by the Cleveland Clinic determined that a standard 5-second Taser application does not affect the functional integrity of pacemakers and defibrillators.

Taser, from Wikipedia, the free encyclopedia.
Do electrical stun guns (TASER-X26®) affect the functional integrity of implantable pacemakers and defibrillators? Europace 2007 9(7):551-556; doi:10.1093/europace/eum058.

Free Visual Dictionary of Medical Terms by Merriam-Webster

The new Merriam-Webster's Visual Dictionary incorporates 6,000 color illustrations organized by subject area. The full-color pictorial images are grouped into chapters outlining major themes such as:

Plants & gardening
Animal kingdom
Human being
Food & kitchen
Clothing & articles
Arts & architecture
Transport & machinery
Sports & games

The free online access is heavily supported by ads but the medical section may still be useful to patients and students. The links include audio files with pronunciation.

A Dictionary With a Point of View: Announcing Merriam-Webster's Visual Dictionary, Merriam-Webster, 2006.
Netter's Illustrated Human Pathology: A Searchable Collection of Images.
Image source: Merriam-Webster's Visual Dictionary

Updated: 01/22/2008

Botox injections are so passé, Lipo-dissolve may be the new craze

Botulinum toxin (Botox) injections for wrinkles is now the most common non-surgical procedure in the U.S.

A controversial new procedure called lipo-dissolve or injection lipolysis is taking the image-obsessed by storm in some parts of the country.

Botox is for wrinkles. Lipo-dissolve is for excess fat. It is less invasive than liposuction and consists of series of injections with various drug mixtures, called PCDC, or phosphatidylcholine deoxycholate (non-FDA approved) to remove fat. For large areas, for example, the abdominal area, as many as 120 injections may be required at one time.

Lipo-dissolve is not approved by the FDA and long-term effects are unknown.

Fat-Dissolving Injections: Too Good to Be True? NPR, 06/2007.
Injection lipolysis, from Wikipedia, the free encyclopedia.
Does Lipo-dissolve Work? Washington Post, 06/2007.
Can Shots Safely 'Melt Away Fat'? Washington Post, 06/2007.
Having a Little Work Done (at the Mall). NYTimes, 01/2008.
Image source: Wikipedia, public domain.

Nice Résumé. Have You Considered Botox? NYTimes, 01/2008.


Dental Students Spoof "The Office" on Google Video

"The Office" spoof (15 minutes), acted out by actual dental students from Loma Linda University for a class talent show. They own.

This is part II:

This is the sequel to the original "The Clinic" video. These videos were produced for a dental school talent show. For more videos, visit www.funnytooth.com.

Updated: 02/12/2009

2007 Medical Weblog Awards: Polls Are Open

Polls are open for the 4rd annual Medical Weblog Awards hosted by Medgadget (started in 2003). There are many excellent blogs listed as finalists. In fact, many more than you can reasonably expect to read if you still practice medicine full time.

Clinical Cases and Images - Blog is a finalist in 2 categories. Feel free to vote for this blog if you enjoy reading it:

Vote for Best Clinical Sciences Weblog

Vote for Best Medical Technologies/Informatics Weblog

In the category of Best Clinical Sciences Weblog, there is a similar late surge every year. This blog usually leads by a small margin until a day or two before the poll closes. Then, the tele-radiologist Sumer mobilizes a large number of supporters and wins by a margin of 100-200 votes. In any case, CasesBlog is honored to be a finalist in this venerable competition and everybody involved is planning to enjoy the process just as we do every year.

GruntDoc had a revolutionary idea in 2005: "I say we forget the online voting, all meet at a neutral site, and thumb-wrestle for the winner."

Update 01/23/2007:

Medgadget announces the winners of 2007 Medical Weblog Awards.

Dr. A Show 21: Wrap-up. Doctor Anonymous, 01/2008.
2006 Medical Weblog Awards: Polls Are Open
The Best Medical Blogs of 2005 on Medgadget.com

Updated: 01/23/2008

Inventor of cardiac bypass (CABG) - brilliant mind and outstanding surgeon - and yet he committed suicide at 77

Cleveland Clinic has been the site of numerous medical firsts, among them:

- invention of “artificial kidney” dialysis machine
- first coronary catheterization by Mason Sones in 1958
- first coronary bypass surgery (CABG) by Rene Favaloro in 1967

Several Cleveland hospitals have what I call "history corridors" with photos of historic events and people on the walls. Cleveland Clinic has one on the 9th cardiology floor illustrated with photos of physicians and scientists who made the Clinic what it is now -- the number one hospital in cardiology for 13 years in a row. Among the faces on the wall, one can recognize Mason Sones who performed the first coronary catheterization, Rene Favaloro who did the first coronary bypass surgery, our former CEO Floyd Loop who first used the internal mammary artery for CABG, our current CEO Toby Cosgrove, Eric Topol, Andrea Natale, and Steven Nissen. The same "history corridor" is featured at the Cleveland Hopkins airport. I have met Toby Cosgrove on 2-3 occasions but never knew he had overcome his dyslexia to become one of the world's most renowned cardiac surgeons, an inventor with 19 patents, who used to perform 700 surgeries per year. Remarkable.

Following the links from the Wikipedia entry about Cleveland Clinic, I was surprised to learn how the life of the inventor of the CABG, Rene Favaloro, had developed. Life is truly stranger than fiction:

"Dr. René Gerónimo Favaloro (July 14, 1923 – July 29, 2000) was an Argentine cardiac surgeon who created the technique for coronary bypass surgery in 1967.

In Argentina, as a small town rural physician, he read about developments in cardiovascular interventions, and developed an enthusiasm for thoracic surgery. At one visit to La Plata, he met Professor Mainetti, who pointed him in the direction of the Cleveland Clinic.

With few resources and some rudimentary English, he decided to travel to Cleveland. He first worked as a resident and later on as a member of the surgery team, working with Donald B. Effler, head of cardiovascular surgery, F. Mason Sones, Jr., who was in charge of the Angiography Laboratory and William L. Proudfit, head of the Department of Cardiology.

Every day, having hardly finished working in the surgery room, Favaloro would spend hours upon hours reviewing coronary angiograms and studying coronary arteries and their relation with the cardiac muscle. The Laboratory of Sones, father of the coronary arteriography, had the most important collection of angiograms in the United States.

At the beginning of 1967, Favaloro began to consider the possibility of using the saphenous vein in coronary surgery. On May 9, 1967, Dr Favaloro performed the first documented saphenous aortocoronary bypass in a 51-year-old woman who had total occlusion of the proximal third of the right coronary artery.

Four years later, in 1971 Favaloro, returned to Argentina with the dream of developing a center of excellence similar to the Cleveland Clinic, that combined medical attention, investigation and education.

Bearing that in mind he founded the Fundación Favaloro in 1975 along with other collaborators. He took great pride in having trained more than 450 residents from all over Argentina and the Americas.

By the year 2000, Argentina was already submerged in an economic and political crisis, and the Favaloro Foundation US$ 75 million in debt. Favaloro requested the government to pay its debts to the Foundation on repeated occasions without receiving an official response. On July 29 of that year, Favaloro took the tragic decision of committing suicide; in bitter irony, shooting himself in the heart. He was 77."

High-risk profession: Suicide rate of U.S. doctors is one per day http://goo.gl/oJMH

The Gift of Time is a short film about the doctors at the Cleveland Clinic.

René Favaloro from Wikipedia, the free encyclopedia.
Rene G. Favaloro, MD: The Passing of a Pioneer. Circulation. 2001;103:480.
In Memoriam: Tribute to René Favaloro, Pioneer of Coronary Bypass. Tex Heart Inst J. 2000; 27(3): 231–232.
High Achieving Dyslexics: Toby Cosgrove. I Speak of Dreams, 2004.
Toby Cosgrove in Cleveland Clinic Magazine, 2004 9 (PDF).
The First Coronary Artery Bypass was done by a rural doctor from Argentina who wanted to learn from Cleveland Clinic's famed surgeons http://goo.gl/hxChe
Image source: Wikipedia.

Unhappy People

Web 2.0

David Rothman is unhappy with the term "Web 2.0," which according to him, has no features and cannot be used. On the other hand, Dean Giustini has moved beyond Web 2.0 and is "featuring" Web 3.0 in his latest BMJ editorial. David seems to suggest the alternative term "Web Geekery" which does not sound much better than "Web 2.0." The conversation continues in The Beauty of the Dialectial Process.

Disclaimer: Actually, I believe I was the first to write about “Web 2.0 in Medicine” (in October 2005) but in hindsight, may be I should have stayed out of this altogether :)

Pain management

CNN journalist Glenn Beck is unhappy with his post-operative pain management and has written a hospital horror story.

As usual, with blog posts concerning emotion, comments are almost as interesting as the posts. Glenn Beck's blog does not have comments open but Kevin, MD more than compensates for it.

And you wonder why bloggers have heart attacks...

Disliking “Web 2.0″ and Hating “Web 3.0″ DavidRothman.net.
The Beauty of the Dialectial Process. DavidRothman.net.
Hospitals Gone Bad. Glenn Beck, 01/2008.
Glenn Beck: Put the 'care' back in health care. CNN.
Bloggers and Heart Attacks
Web 3.0 Shakes It Up - 'It's a Question of Semantics.' UBC Academic Search - Google Scholar Blog.
Cho A, Giustini D. Web 3.0 and health librarians: an introduction. Journal of the Canadian Health Libraries Association. 29:13-18, 2008.

Updated: 03/21/2008

Bloggers and Heart Attacks

Can the stress of blogging cause a heart attack? It is doubtful but one finds it difficult to ignore the fact that not one but two well-known and well-liked tech bloggers had a heart attack in recent weeks.

Marck Orchant (50) never regained consciousness after his massive MI on December 2. The 41-year-old Om Malik of GigaOM was far more lucky and is expected to make a full recovery after his heart attack on December 28, 2007 according to his own announcement in a blog post (where else?). According to NYTimes, " the chief operating officer for Mr. Malik’s company, Giga Omni Media, played down stress as a factor in Mr. Malik’s health. He noted Mr. Malik’s incessant smoking of cigars and cigarettes was a more likely cause."

Om has decided to change his lifestyle significantly and it looks like we will enjoy many more episodes of the show in the future:

"Now living a healthier life isn’t just one of my New Year’s resolutions, it’s doctor’s orders. Friends and family have purged my apartment of smokes, scotch and all my favorite fatty foods — I am even going to be drinking decaf. I won’t be refashioning my avatar’s stogie with a celery stick, but I will be taking better care of my health."

Om Malik is currently doing well: "Making such drastic changes wasn’t easy, but they offered me the best chance of staying alive — and 50 pounds and 12 months later, have clearly worked."

Related reading

Some Brand-Name Bloggers Say Stress of Posting Is a Hazard to Their Health. NYTimes.
Popular tech blogger Mark Orchant died of heart attack at 50
A Heart-to-Heart with GigaOM Readers. GigaOM, 01/2008.
AltaVista Founder Dies of a Heart Attack at 42
In Web World of 24/7 Stress, Writers Blog Till They Drop. NYTimes, 04/2008.
Introducing Om 2.0: The Avatar. GigaOM, 06/2008.
What I Learned This Year. Om Malik, 12/2008.
Video: Scobleizer talks with Om Malik about stress and changes he's made to his life. Kyte.tv.
Image source: Gray's Anatomy, 1918, public domain.
Dangers of unrecognized heart disease: Husband dies while giving wife CPR (both found dead, age 60, 59) http://goo.gl/LZ39U
NYC blogger dies of heart attack http://goo.gl/GLHWC
Is blogging bad for your health? Conservative blogger Andrew Breitbart, 43, dies "unexpectedly from natural causes". Wikipedia, 2012.

Comments from Twitter

@doctorwes: Uh, oh> RT @DrVes: Bloggers and Heart Attacks http://goo.gl/WlVkR

@scanman: This obviously applies to prolific posters.

@gruntdoc: This is why I'm not prolific...

Digg.com and Other Web 2.0 Songs

After the general Web 2.0 song became a YouTube sensation, now we have songs about specific web services like Digg.com (see the second video below). What is next -- a song about Dissect Medicine or Grand Rounds?

Web 2.0: Here Comes Another Bubble

Digg Song

Kina Grannis created the “Digg Song” and became an almost instant viral success, so much so that a record company has been in touch with her. Link via Dr Shock MD PhD. Song chorus:

"Gotta digg, gotta digg, gotta digg
Gotta make this story big!"

I have not heard about the "Diagnosis Wenckebach" singers being offered a record deal yet. Strange...

Web 2.0 Music Video: Here Comes Another Bubble
Digging Grand Rounds
Digg for Medicine: Nature Publishing Group Launches Dissect Medicine
Gotta Digg this One for Kina Grannis (Updated with interview). Gizmodo.com.

Embed Google Presentations in Your Website

The armamentarium of embeddable objects (photo slideshows, YouTube videos) just increased with another member -- Google Presentations. Users of SldieShare were able to embed presentations for years, so why is this news? Two reasons: the power of Google and the stickiness of Google account. In all likelihood, Google will be around in 5 (10?) years and your uploaded presentations will still be on their servers. On the other hand, nobody is really sure where SlideShare will be in 5 years. Google launched personalized accounts several years ago to improve user experience by saving settings but also to create "stickiness" -- higher likelihood that the visitors will stay around to use other Google services while already logged in. For example, Bloglines is every bit as good RSS reader as Google Reader but I use Google. Why? Because I am already logged in Gmail, Blogger, Docs, Bookmarks, and it just does not make sense to type/remember different passwords for Bloglines, SlideShare, BuzzWord, Del.icio.us, etc.

In any case, despite the initial lukewarm response by most bloggers, Google Presentations is a useful tool. Some nice features are:

- ability to share documents and collaborate
- online chat with multiple users during presentation
- embeddable presentations

I used Google Presentations when I hosted Medicine 2.0 -- the blog carnival about Web 2.0 and Medicine (see above). On a side note, it looks like we will have Web 3.0, 4.0, 5.0, etc. at some point in the future but this is a topic for another blog post.

Further reading:
Embed Google Presentations. Google Blogoscoped.
Embed PowerPoint Presentations Using Google Docs. Google Operating System.
Google Presentations Launches Today. CasesBlog, 9/18/2007.
Medicine 2.0, Blog Carnival About Web 2.0 and Medicine, Year 1, Issue 9. CasesBlog, 09/2007.
Web 3.0 and medicine -- Giustini 335 (7633): 1273 -- BMJ, 12/2007.

Updated: 04/08/2008

Educational Games: Virtual Hip and Knee Replacement

Virtual Hip Replacement: "Take on the role of the Surgeon throughout a hip replacement surgery!"

Virtual Knee Surgery

The animations, created by Edheads.org, are interactive and well-done. According to the FAQ page, Edheads is a non-profit organization, which creates educational web experiences that are free to teachers, students and parents.


Virtual Hip Replacement: Be a Surgeon! ScienceRoll.com
Image source: Edheads.org

Slideshow: Web 2.0 in Dentistry

Patricia Anderson is a librarian at University of Michigan who has posted several of her presentations on Web 2.0 and "eHealth" online. This one mentions a few Web 2.0 resources in dentistry and this makes it one of the few presentations on the subject.

David Rothman, who posted the slideshow, also links to DentalInformatics.com: a Virtual, Global Community for Anyone Interested in Dental Informatics.

The presentation is heavy on screenshots but I am happy to see it shows 2 projects I have been involved in: ClinicalCases.org and AskDrWiki.

Social Technologies for eHealth

Web 2.0 in Medicine Presentations by a University of Michigan Librarian. CasesBlog, 06/2007.

Web 2.0 and Medicine: The Slideshow. ScienceRoll, 02/2008.
Web 3.0 Concepts Explained in Plain English (Presentations). Digital Inspiration, 2009.

Interesting Journal Articles

Editorial: Meat Consumption and Cancer Risk.
Jeanine M. Genkinger, Anita Koushik. PLoS Medicine, 12/2007.

According to A Prospective Study of Red and Processed Meat Intake in Relation to Cancer Risk, elevated risks (20-60%) were evident for esophageal, colorectal, liver, and lung cancer, comparing individuals in the highest with those in the lowest quintile of red meat intake. Individuals in the highest quintile of processed meat intake had a 20% elevated risk for colorectal and a 16% elevated risk for lung cancer. In conclusion, both red and processed meat intakes were associated with increased risk of cancers of the colorectum and lung. Red meat intake was associated with an elevated risk for cancers of the esophagus and liver.

Systematic Review: Comparative Effectiveness of Treatments to Prevent Fractures in Men and Women with Low Bone Density or Osteoporosis.
Catherine MacLean et al. Annals of Int Medicine, 01/2008.

Authors conclude that good evidence suggests that bisphosphonates, estrogen, parathyroid hormone, and raloxifene prevent vertebral fractures more than placebo; evidence for calcitonin was fair. Good evidence suggests that bisphosponates prevent hip fractures more than placebo. The effects of vitamin D varied with dose. Raloxifene, estrogen, and estrogen–progestin increased the risk for thromboembolic events.

Systematic Review: Comparative Effectiveness of Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers for Treating Essential Hypertension.
David B. Matchar et al. Annals of Int Medicine, 01/2008.

Which class is better -- ACEi or ARB? According to this meta-analysis, ACE inhibitors and ARBs had similar long-term effects on blood pressure. No consistent differential effects were observed for other outcomes (infrequently studied over the long term), including death, cardiovascular events, lipid levels, progression to diabetes, left ventricular function, and kidney disease. may have a slight edge because ACE inhibitors were associated with a greater risk for cough. Fewer withdrawals due to adverse events and greater persistence with therapy tended to favor ARBs over ACE inhibitors.

Related editorial: Inhibitors of the Renin–Angiotensin System: Proven Benefits, Unproven Safety. Patrick S. Parfrey.

Meta-analysis: Effect of Monotherapy and Combination Therapy with Inhibitors of the Renin–Angiotensin System on Proteinuria in Renal Disease.
Regina Kunz et al. Annals of Int Medicine, 01/2008.

ARBs reduce proteinuria to a similar degree as ACE inhibitors. The combination of the 2 drugs (ACEi + ARB) seems to reduce proteinuria more than either drug alone.

Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries.
American College of Physicians, Annals of Int Medicine, 01/2008.

One Step Forward, Two Steps Back — Will There Ever Be an AIDS Vaccine?
Robert Steinbrook, M.D. NEJM, 12/2007.

Related article: Antibody-Based HIV-1 Vaccines: Recent Developments and Future Directions. PLoS Medicine, 12/2007.

The Challenges of Chagas Disease— Grim Outlook or Glimmer of Hope. Rick L. Tarleton, Richard Reithinger, Julio A. Urbina, Uriel Kitron, Ricardo E. Gürtler. PLoS Medicine, 12/2007. -- Chagas disease spreads in a particularly "disgusting" way: by kissing bugs that bite people's faces at night http://buff.ly/1pcdA2Z

A time efficient way to stay up-to-date with medical literature

"How do you eat in elephant? In small bites." The same rule probably applies to staying current with the ever expanding avalanche of medical literature. One can try the following approach:

1. Subscribe the to the RSS feeds of the 5 major medical journals (NEJM, JAMA, BMJ, Lancet and Annals) plus 2-3 subpecialty journals in your field of interest.

Medical Journals tab: A screenshot of iGoogle with RSS feeds from the major medical journals.

2. Read the journal on the day it is published online, for example, NEJM on Wednesdays.

3. Use text-to-speech to listen to articles you do not have time to read.

4. Listen to journal podcasts. Click here to subscribe the podcasts of the 4 major journals in iGoogle.

Make Your Own "Medical Journal" with iGoogle Personalized Page
Share iGoogle Tabs with Medical Journals, Podcasts and Gadgets
Annals of Internal Medicine Launches Podcast and Audio Summaries
Text-to-Speech Programs and Continuous Medical Education

Updated: 01/12/2008