CasesBlog - Medical and Health Blog: August 2008

Using Evernote as Electronic Medical Records Software

Let me be clear: I'm not suggesting that Evernote is a substitute for any of the excellent commercial EHRs currently available. The following is presented as a proof of concept only for how a simple, inexpensive, customizable EHR built on Evernote might work.

Evernote has confirmed by email that, "At this time we do not plan to pursue HIPAA certification for our (consumer) Evernote service."

Of course, if you're concerned about transmitting information to the Evernote servers, you can always instruct Evernote to keep all data on your local computer. This bypasses the HIPAA issue and you'd still be able to use Evernote, but this means that you won't be able to access patient data from the web unless you use a program like GoToMyPc.com.

References:
How Doctors Can Use Evernote As A Professional Memory Accessible Anywhere, Part 2: Using Evernote as an Electronic Health Record (EHR). EfficientMD, 08/2008.

Slideshow: Web 2.0 In Clinical Research

Web 2.0 In Clinical Research

view presentation (tags: informatics web2.0)

Slideshow: Web 2.0 In Clinical Research by John Sharp.

Links to some of the sites which were referenced:

ClinicalCases.org used to teach ICU topics to residents

One of the latest applications of our free case-based curriculum of clinical medicine, ClinicalCases.org, was in the teaching of the residents at Moses Cone Family Medicine Residency.

The faculty used the following cases for review of Acute Respiratory Failure:

Clinical Cases and Images: Atelectasis due to Hypoventilation and Mucus Plug

Clinical Cases and Images: Weaning & Extubation Criteria in a Patient with Septic Shock and Respiratory Failure

Respiratory Depression in COPD Patient

COPD vs. CHF Exacerbation

Respiratory Arrest

Moses Cone Family Medicine Residency: ICU Goals, Objectives & Resources.

Where is Moses Cone Family Medicine Residency Program?
The Moses H. Cone Memorial Hospital is in Greensboro, North Carolina.

Clinical Case: How to Diagnose Common Variable Immunodeficiency (CVID)?

A 65-year-old female has a history of frequent UTIs for the last year. Serum immunoglobulins showed low levels of IgG 515 mg/dL (reference range 700 to 1600), IgM 30 (reference range 40 to 230), IgA 50 (reference range 70 to 400).

What is the reason for the low levels of immunoglobulins?

Five immunoglobulin classes (mind map)

What is the diagnostic work-up for CVID?

What treatment options would you suggest?

Read the rest of the case here: How to Diagnose Common Variable Immunodeficiency (CVID)? from AllergyCases.org.

CNN Video: Going to the Dentist in Mexico

A patient without a dental insurance uploaded a video of herself driving across the border to Mexico for dental treatment. The cost of 2 wisdom teeth extractions and 2 fillings: $ 160.

CNN.com made all their videos embeddable just like YouTube. This feature is useful for both bloggers and CNN since it drives traffic back to the site.

Erectile Dysfunction Medications Related to Transient Amnesia, FDA Warns

According to WebMD:

All three erectile dysfunction drugs -- Cialis, Levitra, and Viagra -- now list rare reports of transient global amnesia on their labels.

What is transient global amnesia (TGA)?

TGA is a brief episode amnesia lasting less than 24 hours, without causing other problems. TGA has been a well-described phenomenon for more than 40 years.

Diagnostic requirements for TGA include:

- The attack was witnessed and reported as being a definite loss of recent memory (anterograde amnesia).
- There was an absence of clouding of consciousness.
- There were no focal neurological signs or deficits during or after the attack.
- There were no features of epilepsy, and the patient did not have any recent head injury or active epilepsy
- The attack resolved within 24 hours

The underlying cause of TGA is unclear. It may be due to venous congestion of the brain, leading to ischemia of the hippocampus (involved with memory, shown in the image above). The ischemia may be triggered by immersion in cold water, sexual activity, severe emotional stress and vigorous exertion.

The prognosis of TGA is very good but the annual recurrence rate is 4-5%.

There is no proof that the erectile dysfunction drugs actually cause transient global amnesia, which can happen for various reasons, and can be triggered by the sexual encounter itself.

However, FDA required that all erectile dysfunction drugs must list the TGA warning on their labels in the "Post-Marketing" section.

Note: All those ready to make "such a convenient excuse" jokes must be aware that TGA can be a very disturbing experience for the patient.

References:

Cialis, Viagra Labels to Note Amnesia. WebMD.
Hodges JR, Warlow CP Syndromes of transient amnesia: towards a classification; a study of 153 cases. Neurosurg Psychiatry 1990;53:834–43.
Transient global amnesia, from Wikipedia, the free encyclopedia.
Transient Global Amnesia. eMedicine.
Sex, then amnesia...and it's no soap opera. CNN, 2009.
Image source: Hippocampus, from Wikipedia, public domain.

Related reading:

“Forgettable” Sex: A Case of Transient Global Amnesia Presenting to the Emergency Department http://goo.gl/6Rfrt
How sex and stress made one man lose his memory. The Daily Mail, 04/2010.

Men who use ED drugs have higher rates of STDs, particularly HIV infection - Ann Intern Med http://goo.gl/UH78

ED, Depression, Heart Disease: Does the Existence of One Component of This Triad Necessitate Inquiring the Other Two? http://goo.gl/EKvKl

Annals of Int Med: The Death of a Clinician-Educator

The Annals of Internal Medicine published an interesting and thought-provoking piece called
The Death of a Clinician-Educator by Dr. Kimberly Manning, a junior faculty at Emory University. I can certainly share some of the feelings expressed by the author.

The full text is paid subscribers only for the next 6 months but you get a nice bonus if you listen to the Annals podcast -- the author reads the whole piece herself (MP3 file, 10 MB).

Cleveland Clinic launches a fully equipped mobile ICU ready to be dispatched worldwide

According to MarketWatch:

"Cleveland Clinic has launched a comprehensive critical care program that provides specialized care by Cleveland Clinic physicians, nurse practitioners and critical care nurses to domestic and international patients through means of mobile intensive care unit, helicopter and fixed-wing jets.

"While in the air, our team has the full complement of Cleveland Clinic expertise at

its disposal via direct communication with the Clinic or back to the referring physician," said Marc Harrison, M.D., Director of Medical Operations and Associate Chief of Staff, Cleveland Clinic.

The program will offer uninterrupted service for patients via a diverse fleet of vehicles including ground ambulance, helicopter, and two fixed-winged jets. The jets are configurable for virtually every critical care scenario including mechanical ventilation, balloon pump and ECMO.

The fleet will be stored at Cleveland Clinic with the exception of the two Beechjet 400 medical aircrafts, which will be based at Cleveland's Burke Lakefront Airport."

The jets are equipped to provide ICU care during transcontinental flights, enabling very ill foreign patients to be transferred to the Cleveland Clinic.

References:
Cleveland Clinic Launches Fully Dedicated International Comprehensive Critical Care Program. MarketWatch.
Cleveland Clinic launches mobile ICU. Crain Communications Inc.
Image source: CC logo, jet - public domain.

Stay Alive, Don't Text and Drive

From ConsumerReports.org:

"According to a survey by AAA and Seventeen magazine, 61 percent of 16- and 17-year-olds admit to risky driving habits and of those, 46 percent say they text while driving. Fifty-one percent of those teens say they drive while talking on their cell phones.

Studies have shown that a person using a cell phone while driving, hands-free or not, is four times more likely to crash and, as a result, land in the hospital, and that using a cell phone while driving is as risky as driving drunk."

Phone condom ($1.99) is a plastic bag that zips up and holds the phone so that you don't text and drive - NYT http://goo.gl/u0mRA

Image source: OpenClipArt.org, public domain.

Clinical Image: What is Bochdalek's Hernia?

In 1848, Bochdalek described the congenital defect in fusion of the posterolateral foramina of the diaphragm.

Bochdalek's hernia on the left

Bochdalek's hernia on the left

Most Bochdalek's hernias occur on the left side, allowing protrusion of the abdominal viscera into the chest. Previously unrecognized Bochdalek's hernia in adults is often diagnosed incidentally.

Read more here in Bochdalek's Hernia from Clinical Cases and Images.

11 Things of Note in Medical Web from Summer 2008 -- My Opinion

The Social Media Starfish created by Darren Barefoot (a Creative Commons license) illustrates some of what I call "6 Axes of Medical Education in Web 2.0 Style":

Dean Giustini of UBC Academic Search - Google Scholar Blog posted his selection of
11+ Things of Note in Medical Web - Summer 2008. Here is my opinion on some of the services on the list. Please check the original post for all website links.

1. Surfing the mobile web - (i.e. Apple iPhone for physicians).

Although I do not have an iPhone, I use the mobile web for medical information daily through the combination of Opera mobile browser, Windows Mobile-based phone (Moto Q9c) and unlimited mobile Internet (Sprint SERO).

2. Micromedia (or microbloggging) - (Twitter, Identi.ca).

I started microblogging on Twitter just 2 months ago but already find it useful and entertaining which are the 2 most important components of any educational activity. It helps you follow the thought leaders in a particular field and communicate with like-minded people.

3. Micromedia Aggregation/search - FriendFeed (and microcarnival for doctors), Monitter, Twittersearch, Twellow.

I integrated all my publication channels into into one "super-feed" in FriendFeed -- it includes blogs, Picasa photos, Twitter and Google Shared Stuff. Although I input quite a lot of information in FriendFeed, I rarely use the "output" -- there is just too much information "noise" there.

4. Social Networking - DoctorsHangout, Facebook, Genepartner, Healtheva, Intermedi, LinkedIn, Sermo, SocialMD, Within3.

Although I have accounts for Facebook and Sermo, I do not use them regularly. Facebook is a nice way to stay in touch with colleagues and friends, but they can just follow my blogs instead.

5. Personal health tracking - My Digital Health, Google Health, Medsphere, Microsoft HealthVault, Quantified Self.

I started using Google Health immediately after its launch and so far I find it useful but not great. I tried Microsoft HealthVault but did not find it very compelling and do not use it currently.

6. Video aggregation - YouTube, bliptv, WebMed Technology.

I use YouTube quite often both as a viewer and "director" -- many of my travel videos are uploaded there. It is easy to upload videos but the conversion quality is grossly insufficient.

7. Bookmarking & infoclouds - Amedico, CiteMD, Connotea, Delicious, Diigo, LabMeeting, PeerClip, Wordle.

I use Google Bookmarks daily and although it is not a social media service yet since you do not share your links, it gets the job done for basic bookmarking.

8. Virtual reality - Lively, Second Life.

I have accounts for both Lively and Second Life but never use them. They would just take up too much of the little time I have and one has to set the limits somewhere.

9. Google/Wikipedia challengers - Cuil, Knol, Medpedia.

Wikipedia is a vast and useful resource, and in general, getting better. Regarding Google Knol, I do not see why an expert cannot just have a blog to share his knowledge instead of a "knol'...

10. Medical search - InfoMedmd, Ologeez.

Currently, I limit my medical searches to Pubmed, plain old Google, Google Scholar and UpToDate. This approach provides the answer in 99.9% of the cases.

11. Web 2.0 leaders.

Berci Mesko, Joshua Schwimmer and Dean Giustini are currently the best people to follow if you want to stay on top of the new developments in Web 2.0 and medicine. I expect this to change as Berci graduates from medical school next year and will have less time for blogging but he is such a discovery/publishing machine that there may not be a slowdown at all.

Does Michael Phelps have Marfan syndrome?

Michael Phelps holds the record for the most gold medals won at a single Olympics, a total of eight, and is arguably the best Olympic athlete ever.

With all NBC ads about "giant feet" and the highly publicized facts about his physical features, some of my colleagues pointed out that Mr. Phelps has quite a few features of Marfan syndrome.

His height is 6'4" and his arm span of 6'7" is greater than his height. According to Cleveland Leader, "that is a ratio of 1.04, which is just shy of the clinical cutoff of 1.05. He is also said to have hypermobile joints in his knees, shoulders and ankles." Mr. Phepls also has large hands and feet. Marfan syndrome is an inherited connective-tissue disorder which presents with tall stature, ectopia lentis, mitral valve prolapse, aortic root dilatation, and aortic dissection.

In his book, "Michael Phelps: Beneath the Surface" written by both Phelps and Brian Cazeneuve, he writes about the scare of the possible diagnosis of Marfan syndrome:

"My heart rate was accelerating and Bob suggested I see the doctor. Because I was very flexible and had long hands and feet. I had some early symptoms of Marfan Syndrome, a disease that affects connective tissues and can be fatal if there is leakage to the vessels that lead to the heart. If you reach out your arms and form a T and your wingspan is longer than your height, you can be at risk. In my case, those measurements have always been very close. I didn't know at the time why the doctor decided to look into this. My mom and Bob didn't want me to freak out, so they told me it was simply a good idea for young athletes to have an EKG test in order to look at the heart.

Fortunately everything was, and still is, okay. I have been tested once a year ever since at John's Hopkins under the direction of Dr. Peter Roe and the tissues are strong, the aortic rout is clear and my heart is in good shape - as long as my Baltimore Ravens are winning."

From page 66, Michael Phelps: Beneath the Surface, Google Books.

From the description above, it looks like Michael Phelps does not fulfill the criteria of a full-blown Marfan syndrome according to his doctors. If he were to have Marfan syndrome however, strenuous exercise would be generally contraindicated according to the American Heart Association.

The Age/Yahoo comments on "another bodily trait might also have helped transform Phelps into the perfect, indefatigable swimming machine. In sixth grade, the Maryland native was diagnosed with Attention Deficit and Hyperactivity Disorder and prescribed Ritalin to curb his near boundless energy.

After growing frustrated with the drowsiness caused by the drug, Phelps turned to sport, where the symptoms that so agitated teachers greatly impressed coaches.

"I had so many outlets for energy release. I'd go from a lacrosse game to a baseball game to swim practice," he wrote."

We all want our heroes to be perfect but they never are. Their biggest strength however lies in overcoming their own shortcomings and giving inspiration for millions around the world to do the same.

Image source: Wikipedia, public domain.

Case Presentations on YouTube

Internal medicine tutorial, case study 1

The YouTube user mhussam seems to be an Egyptian physician who has uploaded 9 case presentations.

This is an interesting proof of concept that may deserve further exploration.

Last year, we posted about a pathologist with the screen name of WashingtonDeceit who had uploaded 544 histopathology videos since he joined YouTube on February 03, 2007. The videos lasted between 2 and 5 minutes and were professionally made and narrated.

We asked the nephrology fellows at the Cleveland Clinic what they thought about the renal histopathology videos via an anonymous web-based survey (SurveyMonkey.com). They actually found them quite useful and the abstract was published in the supplement of the Journal of the American Society of Nephrology from the annual ASN meeting (Renal Week 2007).

Histopathology Kidney -- Interstitial nephritis

References:
544 Histopathology Videos on YouTube
YouTube as a source of information on immunization: a content analysis. Keelan et al. JAMA. 2007 Dec 5;298(21):2482-4.

A Surgeon and Genetics: "What I cannot see does not exist. So forget about genetics!"

Berci Mesko is a 6th year medical students in Hungary with a passion for genetics and Web 2.0. He reports mini-impressions of his surgery rotation on Twitter:

One of the surgeons told me tonight: "What I cannot see does not exist. So forget about genetics!"

Well, I'm not so sure -- consider this link:

Colorectal Cancer Gene Mutation Found. Odds of Developing Colorectal Cancer May Be 9 Times Higher for Mutation Carriers. WebMD.

"The mutation, which lies in a gene called TGFBR1, was found in about 10% to 20% of the 242 colorectal cancer patients the researchers studied, compared to 3% of 195 adults without colorectal cancer.

The researchers aren't recommending TGFBR1 gene tests just yet. But such tests "may become part of clinical practice when evaluating a patient's colon cancer risk."

There is a relationship between genetics and surgery after all.

Disclaimer: The author greatly respects surgery and surgeons.

Image source: Stomach diagram, Wikipedia.

Matrix Video 101: The Medical School

Matrix 101: The Medical School

One of the stars in this spoof of the movie The Matrix is Dr. Segal, a former colleague of mine.

The video below is a spoof of "The Office" acted out by actual dental students from the Loma Linda University for a class talent show:

"The Office" spoof (15 minutes).

Useful Blog Add-Ons Which Improve Visitor Experience

Digital Inspiration is one of the most innovative tech blogs with many useful and practical tips for fellow bloggers. The latest one is a list of Useful Blog Add-Ons & Tools That Improve Visitor Experience:

Google Talk Badge

Web2PDF Online

Zoho Creator for forms

ShareThis or AddThis

Scribd iPaper to embed PDF files and Microsoft Office documents

Yahoo! Media Player to link to MP3s

Translate Gadget

"Murder mystery" -- Thousands of people dying within 24 hours of spike in microscopic pollution in cities

From Northwestern University NewsCenter:

"It was a murder mystery playing out in major cities across the country and perplexing scientists. Thousands of people were dying from strokes and heart attacks within 24 hours of a spike in microscopic pollution -- tiny particles that spew from the exhaust of diesel trucks, buses and coal-burning factories.

Northwestern researchers have discovered that this microscopic air pollution spurs hyperclotting of the blood. The study found that lungs inflamed by the pollution secrete a substance, interleukin-6, which causes an increased tendency for blood to coagulate or clot.

In the study in mice, researchers observed a 15-fold increase in interleukin-6 24 hours after the mice were exposed to the pollution. In people, interleukin-6 also raises the levels of a substance called CRP, which is correlated with death from cardiovascular disease.

Among the metropolitan areas, Los Angeles has the most year-round particle pollution. Chicago ranks 11; New York, 17 and Washington D.C., 20.

The level of particulate matter in the air in Chicago is 20 micrograms/m3. The level of particulate matter in Beijing is 260 micrograms/m3 — 13 times as much as Chicago.

The risk of dying from a heart attack or ischemic stroke jumps a whopping 30 percent with each additional 10 micrograms of pollution."

References:
Microscopic Pollution May Trigger Heart Attacks/Strokes by Spurring Blood Clots. Northwestern University NewsCenter.
Air Pollution May Hurt the Heart. WebMD.
Image source: Air pollution, Wikipedia, public domain.

Updated: 08/14/2008

Video: Walt Mossberg Reviews Flock for WSJ

Walt Mossberg reviews Flock, a Web browser that tacks on some special features for social networkers and bloggers

I tried Flock in 2005 but it had too many features that I did not need. Therefore, I still rely on the trustworthy duo of Firefox and Opera browsers.

References:
Flock Web Browser Eases Multitasking But Has Drawbacks. WSJ, 2008.
Flock to Open Office - New Releases, 2005.

Clinical Case: How to Treat an Exacerbation of Atopic Dermatitis?

An 18-month old boy is here for a follow-up of atopic dermatitis. He was last seen at the clinic 3 months ago and at that time his mother described his symptoms as "8" - the lesions were affecting his face, elbows, the areas behind the ears and knees, and the pubis. He was prescribed Elidel (pimecrolimus) and hydrocortisone 1% for the face BID, and Elidel and triamcinolone 0.1% (Kenalog) for the body BID. The symptoms improved significantly and the mother downshifted local therapy to triamcinolone 0.1% daily a month ago. She also stopped Singulair. Two weeks ago, the skin lesions re-occurred, including new ones on the face and back.

What treatment options would you suggest?

Read the rest of the case here: Treatment of Exacerbation of Moderately Severe Atopic Dermatitis from AllergyCases.org.

Topical Treatment of Atopic Dermatitis

References:
Atopic Dermatitis: A Short Review. Allergy Cases.
Blog articles from AllergyNotes
Image source: Wikipedia, public domain.

Reuters features a post from this blog: Angioedema - a 24-hour photo diary by a patient posted on Flickr

Reuters.com features my blog post: Angioedema - a 24-hour photo diary by a patient posted on Flickr.

They used BlogBurst RSS-based Blog Syndication Network for Online Media to re-publish the post from Clinical Cases and Images - Blog.

I was not asked for permission to use the post but since it is based on Flickr (Creative Commons license) and Wikipedia (public domain), I am not inclined to make a big deal about it.

Several media outlets and journals mentioned the blog and ClinicalCases.org in the last 2 weeks alone: The Los Angeles Times, Reuters, Journal of General Internal Medicine and Journal of Medical Internet Research.

Previously, the project was featured and referenced in BMJ (3 times), Journal of the American College of Cardiology, Journal of the American Society of Nephrology, Cleveland Clinic Journal of Medicine, sBMJ, eMAJ, Clinical Infectious Diseases, BMC Education, Journal of General Internal Medicine, Journal of Medical Internet Research, Nursing Education Perspectives, Baylor College of Medicine Web Digest and Medscape (2 times). It also mentioned by the The Los Angeles Times. The project was presented at multiple national and international scientific meetings.

Mobile Websites from PubMed: Search Abstracts and Find Disease Associations

PubMed is a free service of the U.S. National Library of Medicine that includes over 18 million citations from MEDLINE for biomedical articles back to the 1950s.

The service has several web interfaces adapted for mobile devices:

PubMed for handhelds web site

Pubmed Mobile also offers a Disease Associations service which searches case reports to find if the typed symptoms and signs match a particular condition:

Disease Associations with GSpell

The National Library of Medicine also has downloads for mobile devices like Palm and Pocket PC (called Windows Mobile since 2003). There is no iPhone application yet.

References:

Mobile Pubmed: Three ways to look up the literature online. The Palmdoc Chronicles.
Medical sites for mobiles. UBC Wiki.

PubMed launches web app, allows mobile search of medical literature on smart phones http://goo.gl/iYwGN
PubMed adds social features - save and share your favorite articles http://goo.gl/pB306

ClinicalCases.org Featured in the Los Angeles Times

Clinical Cases and Images (ClinicalCases.org), our free case-based curriculum of clinical medicine, was recently featured in a Los Angeles Times article about medical blogs:

Medical blogs for doctors and patients alike. LA Times.

"Clinical Cases and Images. A teaching blog with a comprehensive collection of cases in all areas of medical specialty."

Screenshot of the blog list

I have mentioned several times before that ClinicalCases.org is not a blog but a collaborative attempt to build an online case-based curriculum of medicine. CasesBlog is the blog I started in March 2005 (3 years ago) to collect ideas, interesting stories and post relevant news about the Clinical Cases and Images project.

However, the LA Times coverage of the medical blogosphere is relatively well-measured and I am not going to complain too much about an occasional misclassification, especially when featured among some of the "grandfathers" of the medical blogging world such as Kevin, M.D., GruntDoc, and the former president of the SGIM Robert Centor.

By the way, the medical blogosphere includes not only physicians and nurses but also medical librarians and journalists. Where else can you find pearls such as the one below? It reflects the thoughts of the prominent medical reporter for the Cleveland Plain Dealer Chris Seper while recording the weekly medical podcast for the newspaper:

"Just under my desk again to do voiceovers. A very large, but dead, insect was waiting for me. Always good to have an audience."

This video shows that it takes about 2 minutes to start a blog on Blogger.com, a service by Google.

References:
Another Milestone: Two Million Page Views for Clinical Cases and Images
Doctors talk shop on medical blogs. LA Times.
Medical blogs for doctors and patients alike. LA Times.

Related:
Online medical blogging: don't do it! CMAJ • July 29, 2008; 179 (3).

Largest Steam Locomotive Ever Built On Display in Omaha

Click to see the album Big Boy Steam Locomotive in Kenefick Park, Omaha

From Wikipedia:

"Centennial No. 6900 is the largest and most powerful diesel-electric locomotive ever built. Big Boy No. 4023 is the world's largest steam locomotive.

The Big Boys were specifically designed to meet the need to pull a 3,600 short ton (3300 metric ton) freight train over the long 1.14% grade of the Wasatch Mountains in Utah and Wyoming.

The Big Boys rendered important service in the Second World War, especially since they proved so easy to fire that even a novice could do a fair job. Since many new men who were unsuited to combat service or exempted were hired by the railroads to replace crewmen who had gone to war, this proved advantageous. During the war, after German agents filed reports that the Americans had giant steam engines that were moving huge trains full of vital war material over steep mountain grades at high speed, their reports were dismissed as "impossible". Their performance in moving a huge volume of war material throughout WWII was repeatedly cited and the Big Boys are generally acclaimed as having made a huge contribution to the war effort."

Read more at Big Boy Steam Locomotive #4023 in Kenefick Park, Omaha from Hit the Road - See America and the World.

Tips on Physical Exam from the Blog Musings of a Distractible Mind

Musings of a Distractible Mind offers tips on physical examination -- the post series covers a complete HEENT exam plus more:

References:
Physical exam posts from Musings of a Distractible Mind.
Physical Examination Videos. Clinical Cases and Images.
Image source: Wikipedia, a GNU Free Documentation License.

Pages