New hepatitis C treatment: 2 new medications may increase success rate to 70%

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Mayo Clinic: Four million people in the U.S., 100 million worldwide, are infected with Hepatitis C. It's a virus you can get from blood transfusions given before 1990, shared needles, unclean tattoo needles and sometimes sex.

In many cases it leads to cirrhosis of the liver and eventually liver cancer. Standard treatment with interferon and ribavirin only cures about 45% of all patients. But thanks to two new medications, up to 70% of people with hepatitis C may be be cured. More than 40 medications are in development.

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Night shift workers are fighting ancient rhythms that order them to hunt or forage

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From the National Geographic Magazine:

We sleep 1.5 hour less a night than we did just 100 years ago
We sleep on average 1.5 hour less a night than we did just a century ago. Some of our epidemic of insomnia or sleeplessness is probably just our refusal to pay attention to our biology. The natural sleep rhythms of teenagers would call for a late morning wake-up—but there they are, starting high school at 8 a.m.
The night shift worker sleeping in the morning is fighting ancient rhythms in his or her body that order him or her awake to hunt or forage when the sky is flooded with light. Yet he or she has no choice.
We fight these forces at our peril. Harvard's researchers note that going without sleep for 24 hours or getting only 5 hours of sleep a night for a week is the equivalent of a blood alcohol level of 0.1 percent. Yet modern business ethic celebrates such feats. "We would never say, 'This person is a great worker! He's drunk all the time!'?"
One in 20 medical residents admits to making a fatigue-related mistake that resulted in the death of a patient
A 2004 study included 2,700 first-year medical residents. These young men and women worked shifts that were as long as 30 hours twice a week. The research revealed the remarkable public health risk that this sleep debt entailed. "We know that one out of five first-year residents admits to making a fatigue-related mistake that resulted in injury to a patient. One in 20 admits to making a fatigue-related mistake that resulted in the death of a patient. One day people will look back on what will be viewed as a barbarous practice."
References:
The Secrets of Sleep. National Geographic Magazine, 2011.
Image source: A halo around the Moon. Wikipedia, GNU Free Documentation License.

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How to Use Social Media for Medical Education

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Here are a few suggested approaches for social media use in medical education:

- Peer student groups can utilize a private blog to share clinical experiences

- Course/program directors and staff can use a wiki to manage course/program materials and centralize frequently used documents

- Longitudinal preceptors can use a microblog (e.g., Twitter) to share links to journal articles, medical news, and reminders

- Admissions personnel can use social networks during the application, interview, and acceptance processes to build a community before students ever set foot on campus

- A public affairs office could generate podcasts to share graduate news, campus information, celebrations, and research success stories

Networked Teacher Diagram - Update
The Networked Teacher - Diagram, Flickr http://goo.gl/CVddi

References:
Saarinen C, Arora V, Fergusen B, Chretien K. Incorporating social media into medical education. Academic Internal Medicine Insight. 9(1):12-13, 19. Read the full-text PDF here.

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How To: Keep Your Family On-Board for Your Blogging Journey

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Some tips from ProBlogger:

- Create Healthy Boundaries. For example, I have established a “no computer time” rule for myself where I don’t use the laptop (or my smart phone) between the time I get home from work and when we get the kids to bed. By setting up this boundary, I free my time and my mind to enjoy my children, play outside or help my wife out with dinner each evening.

- Communicate Your Reasons for Blogging. Why are you investing all this time and effort into blogging anyway? Take the time to tell your loved ones why your blog is important to you and how you see it as a benefit for your family.

- Sacrifice Personal Time, Not Family Time

- Seek Their Input

References:
7 Tips to Keep Your Family On-Board for Your Blogging Journey. ProBlogger.
Image source: public domain.

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28% of Vermont doctors "to stop practicing medicine" after single payer reform – doctors on Twitter disagree

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According to BMJ, Vermont moves closer to becoming first US state to provide “socialised medicine”.

Vermont is set to become the first US state to launch a single payer healthcare plan after a bill passed both houses of the state’s legislature.

The plan is expected to be signed by Governor who originally proposed the idea that would abolish most insurance plans and would instead provide healthcare to all residents through public funding - a “single payer” scheme and is fiercely opposed by many conservative politicians as “socialised medicine.”

Some doctors in Vermont are unhappy about the proposed changes. In an online poll of 600 doctors conducted by a state representative and an ObGyn doctor, 28% said that they will stop practising medicine in the state if the plan is adopted.

Comments from Twitter:

@a_singledrop (Emily Lu): Seriously?

@movinmeat: calling their bluff.

@gruntdoc (GruntDoc): States as exp labs.

@backpackerchick (Hartley): In another era, doctors ****** about Medicare and found themselves richer than ever when it was enacted! What's good for the doctor (profits) is not necessarily good for the patient!

@RN_ing (Mary v. Seattle RN): Change is difficult... to be expected, but continue to want #singlepayor.

@irfandhalla (Irfan Dhalla): Single payer turned out to be well liked by docs in Canada. Will same happen in Vermont?

What do you think? Feel free to comment below, or post on Twitter.

References:
Image source: OpenClipArt.org, public domain.

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Automatic tracker ensures your doctor washed their hands

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The University of Illinois Medical Center has installed a system called HyGreen (Hand Hygiene Recording and Reminding System) which acts as a reminder to health care workers before they ever enter a patient's room.

The provider begins by cleaning his hands, then placing them under a sensor that recognizes the cleaning, and transmits a signal to a badge the provider is wearing. When they walk into the patient's room, that badge transmits an "all clean" signal to a sensor above the bed.

If a caregiver walks into a room without washing their hands, the sensor won't get that all clean signal and the badge will start buzzing.

References:
Tech Ensures Your Doc Washed Their Hands. NBC Chicago.

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Video: Teens See Dangers of Texting While Driving

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AssociatedPress — May 16, 2010 — Teenagers are driving through an obstacle course with their cell phones in hand to see why texting while driving is so dangerous.

Related:
Proposal: All cell phones sold in Chicago to allow parents to block their children from texting while driving. Chicago Tribune, 2011.

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For doctors: How to be a Twitter star in two easy steps

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Warning: The purpose of this article is to inspire you to use Twitter, not to scare you. There are plenty of other blog posts and newspaper articles about doctors posting pictures of body parts on Facebook and getting fired. This is not it. Social media is amazingly useful for doctors and patients if you use the tools responsibly, have common sense, and never share the 18 HIPAA identifiers online or offline with unauthorized parties. The advice below is derived from extensive personal experience. I have used social media for professional purposes, as a physician, for more than 7 years, while working at some of the leading institutions in the U.S. such as the Cleveland Clinic and the University of Chicago. My account @DrVes has just been ranked #6 on the list of the Most Influential People from Chicago on Twitter (selected by Chicago Tribune and Klout.com). My blog websites have had more than 7 million page views. Just as an example, every time I hit the "publish" button of the sites, the message reaches more than 25,000 people every single day: 15,700 RSS and email subscribers, 7,000 Twitter followers, 2,200 daily visitors, and 1,000 Facebook fans (statistics for the sites ClinicalCases.org and CasesBlog, AllergyCases.org and AllergyNotes, and the Twitter accounts @DrVes and @Allergy).

This is somewhat of a typical example nowadays. There are many other physicians who are much more popular than me on social media and make the stats above look minuscule. You can be one of them. Here is how.

The basics of Twitter use for busy doctors

Most doctors are really busy. Several questions always come up when doctors consider the use of social media for professional purposes: Who has time for Twitter? What am I going to say there? To whom? And why Twitter, to begin with? What about Facebook or YouTube? My office is a mess and I always say "ehhh" when recorded -- I don't want to do video. Do I need a blog too?

Good questions. Here are the answers.
The circle of online information for me is as follows: Google Reader -> Share on Twitter -> Get feedback -> Write a blog post -> Share via RSS and Twitter -> Get feedback, go on. You don't need to use all services.


The circle of online information (full version) (click to enlarge).

1. Who has time for Twitter?

You do. Twitter should take no more 30 minutes per day and it will be beneficial for you, your colleagues and your patients. You will learn more and will feel better about it. Make it part of your normal routine - just like checking the news. In fact, Twitter is just that - checking the news - and then sharing the ones that you find most interesting with your followers. This takes a single click, and 2 seconds. Ten tweets per day, 2 seconds each. This is 20 seconds. You can do it.

2. Why Twitter?

Start on Twitter because it is quick and relatively easy. Twitter has the lowest barrier to entry among all social media services. "Being on Twitter" requires just 10 short sentences per day, with approximately 7 words each. You can reach thousands of people with a single sentence. Would you like to share the latest guidelines for food allergy? Just click and all your Twitter followers will know about them instantly. You will also get feedback to your tweets via replies and re-tweets.

3. What am I going to say on Twitter?

The answer is simple. You are an expert. There is a flood of medical news that hits the wires every day. I want to know what YOU think is important. Share the 3-10 news items per day that you find interesting. I will subscribe to read them. Many will do the same.

4. Who is going to read my tweets?

As a physician, you are an expert in your field. You provide valuable insight - just be selecting what you think it’s important from the news of the day. Embed this little personal news stream in your practice page. Your patients will appreciate the helpful updates, hand-picked by their doctor. Your colleagues may find it interesting too.

5. What about Facebook or YouTube?

Those are nice but I would start on Twitter first, and then expand if you see the need to do so. It may be a good idea to start a like/fan page on Facebook for your practice and re-post some of the tweets there. This is simple and not time-consuming. It can be done automatically.

6. Do I need a blog too?

Only you can tell if you need a blog. If you feel that you need to expand beyond 7-8 words on Twitter, by all means, start a free blog on Blogger.com by Google or WordPress.com and see how that works for you. Start on Twitter and expand to a blog as a natural extension if you need to write longer or provide some background. Post your blog items in your Twitter feed.

How to be a Twitter "star" in two easy steps

This is easy. It’s a two-step process for beginners and it takes about 30 minutes per day. The best time is just after your kids go to sleep.

1. Review the news of the day from Google Reader. I have ready-made subscription RSS bundles for you below. Alternatively, you can check a service such as Webicina.com for RSS feeds in your specialty.

2. Post the news items that you like best on Twitter. Don’t post all 10 tweets at once. Schedule them evenly throughout the next day. The first tweet goes on at 7:30 am EST and the last one at 8:30 pm EST. You can use Seesmic Web to schedule tweets - it is simple, free, and just works. The alternatives include HootSuite and any number of scheduling services (some of them have a limitation of up to 10 tweets per day).

This summary did no address the other Twitter activities such as listening, engaging, search, chat, HIPAA compliance, etc. They will be discussed in future articles.

RSS bundles of medical news

You can use the following RSS bundles to subscribe to medical news items. The bundles are exported from my personal Google Reader page. They update automatically several times per day. When in Google Reader, just select the ones that you find interesting and share them on Twitter. Feel free to add your own comments to some of the tweets.

Top Twitter Doctors

This is a list of the Top Twitter Doctors arranged by specialty in alphabetical order - feel free to add your own suggestions. The list is open to anybody to edit:

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Chronic pancreatitis – The Lancet review

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There are two forms of chronic pancreatitis

Chronic pancreatitis is a progressive fibroinflammatory disease that exists in 2 forms:

- large-duct forms (often with intraductal calculi)
- small-duct form

Causes of chronic pancreatitis

Chronic pancreatitis results from a complex mix of:

- environmental factors - alcohol, cigarettes, and occupational chemicals
- genetic factors - mutation in a trypsin-controlling gene or the cystic fibrosis transmembrane conductance regulator (CFTR)
- a few patients have hereditary or autoimmune disease

Management of pain

Pain is the main symptom that occurs in two forms:

- recurrent attacks of pancreatitis (representing paralysis of apical exocytosis in acinar cells)
- constant and disabling pain

Management of the pain is mainly empirical, involving:

- potent analgesics
- duct drainage by endoscopic or surgical means
- partial or total pancreatectomy
- steroids rapidly reduce symptoms in patients with autoimmune pancreatitis
- micronutrient therapy to correct electrophilic stress is emerging as a promising treatment

Steatorrhoea, diabetes, local complications, and psychosocial issues associated are additional therapeutic challenges.

References

Chronic pancreatitis. Dr Joan M Braganza DSc a , Stephen H Lee FRCR b, Rory F McCloy FRCS c, Prof Michael J McMahon FRCS d. The Lancet, Volume 377, Issue 9772, Pages 1184 - 1197, 2 April 2011.

Image source: Wikipedia, public domain.

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For doctors: How to start using social media

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How to start

My advice for doctors who are interested in starting using social media for professional purposes is simple:

- Start on Twitter, expand to a blog as natural progression.

- Input your blog posts automatically to a Facebook like/fan page.
- Listen to the leading physicians, nurses and patients' voices on Twitter, and reply.
- Comment on blogs.
- Do not be afraid to share your expertise.
- Comply with HIPAA and common sense.

I posted this on Twitter yesterday: Doctors, when you don't have time to write a blog post, record a video - the orthopedic surgeon @hjluks shows how it's done: http://goo.gl/jL73J

Howard J. Luks, MD

@Doctor_V (Bryan Vartabedian) said, "My blog is my home. Twitter and Facebook are outposts."

I actually disagree a bit. My use of Twitter goes beyond a simple outpost though. It's my digital notebook and idea feedback system.

The circle of online information for me is as follows: Google Reader -> Share on Twitter -> Get feedback -> Write a blog post -> Share via RSS and Twitter -> Get feedback, go on.


The circle of online information (full version) (click to enlarge).

Substance over style

Going back to the video embedded above, I think that @hjluks is the current leader in creating original, honest, tell-it-like-it-is clinical content among physicians. This is an example to follow. The technical execution does not have to be perfect, as you will see from the discussion started on Twitter and summarized below. However, the content must be factually correct and professional.

@yayayarndiva (P. Mimi Poinsett MD) had a few comments about the technical aspects of the video such as "if you are going to do a video - make your background a tad less busy:)"

I actually liked the background - it's "authentic" and gives you something to look at during the 8-minute video.

@hjluks actually polled 100 patients on that. They like the laid back office view.

@yayayarndiva P. (Mimi Poinsett MD) thought that "authentically messy AND 8 min video with a head in bouncing chair - think I would rather read the transcript... I think docs like everyone else can sharpen their presentation skills with video... still good to continue. Video? A talking head doesn't confer authenticity- just a new toy:)... Or you could use Dragon software and dictate your post..."

@ePatientDave (Dave deBronkart) convinced @hjluks to do the transcripts, primarily for Google. "Otherwise, thy pearls of light are hidden under a YouTube bushel. I emphasize it's not just *marketing* SEO - it's for being findable for those in need", said @ePatientDave.

I agree. You need the transcript for SEO and quick info. SEO doesn't just apply to marketing - it's a way for people (real humans) to find you online.

Nothing beats video for authenticity though. I understand the concept of creating technically flawless presentations but if you wait to do a perfect video and you are a busy doctor, you may never do it. The same applies to blog posts - if you are going to write a blog post for 2 months, write a journal article instead.

I had some final encouragement for @hjluks: "You don't have to be pro with video. You are pro as orthopod - who uses video."

I think he liked that.

Do you need a social media policy for your medical practice?

Another good discussion point was brought up by an office manager of a pediatric group in Chicago: Do you need a social media policy for your medical practice? http://goo.gl/7APvI - I think you do.

John Sharp and I worked on a social media policy for Cleveland Clinic back in 2005 when all that was a big unknown in healthcare. It still is for many organizations - in terms of professional involvement and outreach. A social media policy provides some much needed guidance and boundaries.
The number one rule is very simple: comply with HIPAA and do not share any of the 18 identifiers: http://goo.gl/WR5MR
Top Twitter Doctors

This is a list of the Top Twitter Doctors arranged by specialty in alphabetical order - feel free to add your own suggestions. The list is open to anybody to edit:

Comments from Twitter and Facebook:
Bryan Vartabedian: "When I present this stuff I recommend doctors find 2-3 role models in their specialty and follow them. Watch and study how they do things. Great place to start."

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Postural Orthostatic Tachycardia Syndrome (POTS) – Mayo Clinic video

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Phil Fischer, M.D., discusses the latest research on Postural Orthostatic Tachycardia Syndrome (POTS).

Two free full text reviews are available via Dr. RW Notes.
Comments from Twitter:
@drjohnm (John Mandrola, MD): For EPs, POTS is one tough nut to crack.>>Helpful video.

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U-shaped link between Internet use and children health – beware of heavy use or very little/none

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Study participants were categorized into 4 groups according to their intensity of Internet use:

- heavy Internet users (HIUs; >2 hours/day)
- regular Internet users (RIUs; several days per week and 2 hours/day)
- occasional users (1 hour/week)
- and non-Internet users (NIUs; no use in the previous month)

Health factors examined were:

- perceived health
- depression
- overweight
- headaches
- back pain
- insufficient sleep
U-shaped link
Heavy Internet users of both genders were more likely to report higher depressive scores.

Only male users were found at increased risk of overweight and female users at increased risk of insufficient sleep.

Non-Internet users (NIUs) and occasional users also were found at increased risk of higher depressive scores.

Back-pain complaints were found predominantly among male non-Internet users.

There was a U-shaped relationship between intensity of Internet use and poorer mental health of adolescents. Heavy Internet users were confirmed at increased risk for somatic health problems.

Regular Internet use (up to 2 hours per day) is OK
Health professionals should be on the alert when caring for adolescents who report either heavy Internet use or very little/none. Regular Internet use as a normative behavior without major health consequences.
Take home point
Whatever the intensity of your Internet use is (if you are reading this, my guess is that the "intensity" of you sedentary lifestyle is high), don't forget the benefits of regular exercise:

"Health Promotion" video: Benefits of exercise.

References:
A U-Shaped Association Between Intensity of Internet Use and Adolescent Health. PEDIATRICS Vol. 127 No. 2 February 2011, pp. e330-e335 (doi:10.1542/peds.2010-1235)

Image source: Wikipedia, public domain.

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The high cost of healthcare in America (infographic)

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The high cost of healthcare in America (infographic) - click on the image to see the larger-size file. The site hosting the infographic, MedicalBillingandCoding.org, is one of the URL-grabbing portals that redirects to other sites, so be careful what you click there once you go beyond the image.

Why Your Stitches Cost $1,500 - Part One

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Statins slightly increase risk of cataracts, liver dysfunction, kidney failure and muscle weakness

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Statins do NOT prevent a long list of diseases

Statins were not significantly associated with risk of Parkinson’s disease, rheumatoid arthritis, venous thromboembolism, dementia, osteoporotic fracture, gastric cancer, colon cancer, lung cancer, melanoma, renal cancer, breast cancer, or prostate cancer.

Statins may decrease risk of esophageal cancer

Statin use was associated with decreased risks of oesophageal cancer.

Statins slightly increase the risk of liver dysfunction, kidney failure, muscle weakness and cataracts

Statin use was associated with increased risks of moderate or serious liver dysfunction, acute renal failure, moderate or serious myopathy, and cataract.

Is the risk the same with all statins?

Adverse effects were similar across statin types for each outcome except liver dysfunction where risks were highest for fluvastatin.

A dose-response effect was apparent for acute renal failure and liver dysfunction. All increased risks persisted during treatment and were highest in the first year.

How long does the risk last?

After stopping treatment the risk of cataract returned to normal within a year in men and women. Risk of acute renal failure returned to normal within 1-3 years in men and women, and liver dysfunction within 1-3 years in women and from three years in men.

What was the NNT and NNH?

Based on the 20% threshold for cardiovascular risk, for women the NNT with any statin to prevent one case of cardiovascular disease over five years was 37 and for oesophageal cancer was 1266 and for men the respective values were 33 and 1082.

In women the NNH for an additional case of acute renal failure over five years was 434, of moderate or severe myopathy was 259, of moderate or severe liver dysfunction was 136, and of cataract was 33. Overall, the NNHs and NNTs for men were similar to those for women, except for myopathy where the NNH was 91.

Conclusion

Claims of unintended benefits of statins, except for oesophageal cancer, remain unsubstantiated, although potential adverse effects at population level were confirmed and quantified.

Interestingly, the BMJ abstract did not mention increased diabetes risk that was reported in a previous study published in The Lancet.

References:
Balancing the intended and unintended effects of statins. BMJ 2010; 340:c2240 doi: 10.1136/bmj.c2240 (Published 20 May 2010).
Image source: Simvastatin. Wikipedia, public domain.

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Effect of deployment on mental health of soldiers: common disorders and alcohol misuse more frequent than PTSD

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This Lancet study examined the consequences of deployment to Iraq and Afghanistan on the mental health of UK armed forces from 2003 to 2009.

9990 (56%) participants completed the study questionnaire (roughly 8000 regulars, 1700 reservists).

The prevalence was:

- 19·7% for symptoms of common mental disorders
- 13% for alcohol misuse
- 4% for post-traumatic stress disorder (PTSD)

Deployment to Iraq or Afghanistan was significantly associated with alcohol misuse for regulars (odds ratio 1·22) and with post-traumatic stress disorder (PTSD) for reservists (2·83)

Symptoms of common mental disorders and alcohol misuse remain the most frequently reported mental disorders in UK armed forces personnel, whereas the prevalence of post-traumatic stress disorder (PTSD) was low.

References:
Image source: The Los Angeles Times.

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Effect of 16-Hour Duty Periods on Patient Care and Resident Education

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Dr. Amy Oxentenko details a study appearing in the March 2011 issue of Mayo Clinic Proceedings (available at: http://www.mayoclinicproceedings.com) that looked at the effects of 16-hour duty periods for residents, and the impact of reduced shift length on:

- patient care metrics
- education
- transitions of care
- work hours
- resident satisfaction

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Decompression illness – Lancet review

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Decompression illness is caused by intravascular or extravascular bubbles that are formed as a result of reduction in environmental pressure (decompression).

Types of decompression illness

The term decompression illness covers 2 entities:

- arterial gas embolism, in which alveolar gas or venous gas emboli (via cardiac shunts or via pulmonary vessels) are introduced into the arterial circulation

- decompression sickness, which is caused by in-situ bubble formation from dissolved inert gas

Both syndromes can occur in divers, compressed air workers, aviators, and astronauts, but arterial gas embolism also arises from iatrogenic causes unrelated to decompression.

Risk of decompression illness is affected by immersion, exercise, and heat or cold.

Clinical features of decompression illness

Manifestations of this condition include a wide range of symptoms and signs:

- itching and minor pain
- neurological symptoms
- cardiac collapse
- death

Treatment of decompression illness

First-aid treatment is 100% oxygen. Definitive treatment is recompression to increased pressure, breathing 100% oxygen.

Adjunctive treatments include fluid administration and prophylaxis against venous thromboembolism in paralysed patients.

Prognosis of decompression illness

Treatment is effective in most cases although residual deficits can remain in serious cases, even after several recompressions.

References:
Decompression illness. The Lancet, Volume 377, Issue 9760, Pages 153 - 164, 8 January 2011.
Image source: OpenClipArt.org, public domain.

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Aspirin 75 mg daily reduces incidence and mortality due to colorectal cancer

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High-dose aspirin (?500 mg daily) reduces long-term incidence of colorectal cancer, but adverse effects (bleeding) might limit its potential for long-term prevention. The long-term effectiveness of lower doses (75-300 mg daily) is unknown. This study in The Lancet assessed the effects of aspirin on incidence and mortality due to colorectal cancer over 20 years.

In the four trials of aspirin versus control (mean duration of treatment 6 years), 2·8% of 14,000 patients had colorectal cancer during a follow-up of 18 years.

Aspirin reduced the 20-year risk of colon cancer (incidence hazard ratio [HR] 0·76, but not rectal cancer (0·90).

Where subsite data were available, aspirin reduced risk of cancer of the proximal colon (0·45), but not the distal colon (1·10). Benefit increased with duration of treatment - aspirin taken for 5 years or longer reduced risk of proximal colon cancer by 70% and also reduced risk of rectal cancer (0·58).

There was no increase in benefit at doses of aspirin greater than 75 mg daily. However, risk of fatal colorectal cancer was higher on 30 mg versus 283 mg daily.

Aspirin taken for several years at doses of at least 75 mg daily reduced long-term incidence and mortality due to colorectal cancer. Benefit was greatest for cancers of the proximal colon, which are not otherwise prevented effectively by screening with sigmoidoscopy or colonoscopy.

References:
Long-term effect of aspirin on colorectal cancer incidence and mortality: 20-year follow-up of five randomised trials. The Lancet, Volume 376, Issue 9754, Pages 1741 - 1750, 20 November 2010.

Image source: Colon (anatomy), Wikipedia, public domain.

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