Diagnosis, treatment, and prognosis of glioma: 5 new things

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5 new ideas that are changing the management of brain tumor patients:

1. Prognosis and glioma subtypes. The cell of origin of the glioblastoma has never been defined. In his pioneering work “Death Foretold,” Dr. Christakis says “prognosis gives diagnosis its affective component, striking fear in patients and physicians alike.” There has been a lot of therapeutic nihilism about the treatment of glioblastoma, but that is now changing. Image source: Sen. Ted Kennedy who died of glioma in 2009.

2. Diagnosis and imaging mimics. Acute stroke in the luxury perfusion stage is probably the most common mimic of a brain tumor. Diffusion MRI sequences and perfusion CT scan are helpful in differentiating stroke from tumor by showing hypoperfusion as would be expected, rather than hyperperfusion seen in tumors.
3. Treatment and pseudoprogression. Temozolomide is an oral drug, which is changed into MTIC (methyltriazeno-imidazole-carboxamide), a DNA-methylating drug. The concomitant use of radiation therapy and adjuvant temozolomide in glioblastoma patients showed a median survival of 14.6 months.
Increase in contrast enhancement and mass effect can mimic tumor progression. The term “pseudoprogression” describes the inflammatory reaction to effective treatment. Increasing steroid doses can control the edema.
4. Antiepileptic drugs. Prophylactic use of antiepileptic drugs (AEDs) is not recommended in patients with brain tumor due to lack of efficacy. The interactions between AEDs and chemotherapy can also be problematic.
5. Quality of life issues. The incidence of common symptoms reported was fatigue (90%–94%), sleep disturbance (32%–52%), headache (50%), and cognitive impairment (50%). Ritalin, modafinil, and Aricept have all been shown to have a positive effect on mood and cognition. Cause of death was presumed brain herniation 73% of the time.
References:
Diagnosis, treatment, and prognosis of glioma. Five new things. Lynne P. Taylor, MD. Neurology November 2, 2010 vol. 75 no. 18 Supplement 1 S28-S32.
Image source: Sen. Kennedy who died of glioma in 2009, Wikipedia, GNU Free Documentation license.

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Exercise pioneer Jack LaLanne died at 96 and was doing great until the very end (video)

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Jack LaLanne, the fitness pioneer who inspired TV viewers to trim down, eat well and pump iron for decades (34 years), died at 96 of respiratory failure due to pneumonia at his home in California.

He ate healthy and exercised every day of his life up until the end. Just before he had heart valve surgery in 2009 at age 95, Jack Lalanne told his family that dying would wreck his image.

"The only way you can hurt the body is not use it," LaLanne said. "Inactivity is the killer and, remember, it's never too late."

His workout show was a television staple from the 1950s to the '70s. LaLanne and his dog Happy encouraged kids to wake their mothers and drag them in front of the television set. He developed exercises that used no special equipment, just a chair and a towel.

He said his own daily routine usually consisted of two hours of weightlifting and an hour in the swimming pool.

When he turned 43 in 1957, he performed more than 1,000 push-ups in 23 minutes on a TV show. At 60 he swam from Alcatraz Island to Fisherman’s Wharf handcuffed, shackled and towing a 1,000-pound boat. At 70, handcuffed and shackled again, he towed 70 boats, carrying a total of 70 people, a mile and a half through Long Beach Harbor.

He had a blog too: http://www.jacklalanne.com/blog

Jack LaLanne at Age 95 (CBS). He had just published his 11th book at the time.

Twitter comments:

@TracylynnHolt (Tracyfogelstrom-Holt) But lived an awesome LIFE...:):)

@DrVes: Sure. He was great. I wish everybody could make it to 96 in reasonable health... 🙂

@Thinkbirth (Carolyn Hastie): I love the videos, thanks for sharing "Jumping Jack" 🙂 so good to see that.

References:

Exercise pioneer Jack LaLanne dies at 96 at California home; inspired generations to get fit. Chicago Tribune.
Jack LaLanne, Fitness Guru, Dies at 96. TIME.
Jack LaLanne, Founder of Modern Fitness Movement, Dies at 96. NYTimes.

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Laptop Computer-Induced Erythema ab Igne

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Erythema ab igne is a skin reaction caused by exposure to heat. It is also known as hot water bottle rash, fire stains, and toasted skin syndrome. Ignis is the latin word for "fire".

In this case report a 12-year-old boy presented with erythema ab igne on his left thigh caused by the use of a laptop computer. This is the youngest of the 10 reported patients with this laptop-induced dermatosis since its first description in 2004.

Erythema ab igne is a reticular, pigmented, sometimes telangiectatic dermatosis that is caused by prolonged exposure to a heat or infrared source (see pictures from different cases at DermNet).

In laptop-induced erythema ab igne, the localization on the thighs and asymmetry are characteristic. The heat originates from the optical drive, the battery, or the ventilation fan of the computer.

References:
Laptop Computer–Induced Erythema ab Igne in a Child and Review of the Literature. PEDIATRICS Vol. 126 No. 5 November 2010, pp. e1227-e1230 (doi:10.1542/peds.2010-1390)
Erythema Ab Igne. eMedicine Specialties > Dermatology > Environmental.
Image explanation:  I was not able to find online photos of erythema ab igne labeled for reuse, hence the image of a laptop from Amazon.com.

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Steve Jobs on medical leave – transplantation specialist discusses two likely clinical scenarios

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From the WSJ:

William Chapman, transplantation chief at Washington University in St. Louis, hasn't examined Mr. Jobs personally, but said there are two likely scenarios in the CEO's case.

The first is that there was a transplant-related problem, though it would be unusual for that to happen a year and a half after the transplant.

A more likely possibility would be that the neuroendocrine tumor metastasized again. "It's really difficult to cure the disease with a liver transplant," said Mr. Chapman, adding that it's common to have some degree of recurrence. "Most people hope they reset the clock, gained some time and gained a quality of life even if you don't cure the disease."

Steve Jobs' speech at the 2005 Stanford graduation ceremony: “This is the closest I’ve ever gotten to a college graduation.”

He tells 3 stories from his life:

- Connecting the dots
- Love and loss
- About death

Mr. Jobs was diagnosed in 2004 with a rare type of pancreatic cancer called islet cell neuroendocrine tumor, which could be cured if surgery removed it promptly. He reportedly had surgery by the end of 2004 but began exhibiting weight loss in 2008. This type of cancer often metastasizes in another organ, usually the liver, during a patient's lifetime. A Tennessee hospital disclosed that Mr. Jobs had received a liver transplant there in 2009.
"Remembering that you are going to die is the best way I know to avoid the trap of thinking you have something to lose," Mr. Jobs said in the commence speech in June 2005, almost a year after he was diagnosed with pancreatic cancer.
I join everybody around the world in wishing Mr. Jobs a speedy recovery.
References:

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After a lung transplant, an aria: a story of survival from end-stage pulmonary hypertension

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TED talks: "You'll never sing again, said her doctor. But in a story from the very edge of medical possibility, operatic soprano Charity Tillemann-Dick tells a double story of survival -- of her body, from a double lung transplant -- and of her spirit, fueled by an unwavering will to sing. A powerful story from TEDMED 2011."

Tillemann-Dick was diagnosed in 2004 – at the age of 20 – with Idiopathic Pulmonary Hypertension, a disease that causes high blood pressure in the pulmonary artery, which connects the heart to the lungs. People with the disease typically have a two-to-five-year mortality rate after diagnosis.

Her physicians at Johns Hopkins put her on the lung transplant list at Cleveland Clinic. In September 2009, organs became available, and she had a double lung transplant. After a 13-hour surgery and 2 cardiac arrests in the OR, her recovery was extremely complicated but she is happy to be able to sing again.
If you have a minute, don't forget to check the comments on YouTube and the TED Talks site.
References:
Faith, Hope... and Charity. Cleveland Clinic.

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Diagnosing tuberculosis with cytokines IL-15, IL-10 and MCP-1, in addition to interferon-gamma

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A pattern of two cytokines, called MCP-1 and IL-15, was reasonably good at differentiating between persons sick with TB and persons infected but not sick.

Monocyte chemotactic protein-1 (MCP-1) is a small cytokine belonging to the CC chemokine family. According to the new nomenclature, MCP-1 is called chemokine (C-C motif) ligand 2 (CCL2).
A third cytokine called IP-10 also showed promise at differentiating between people who are infected and those who are not.
Interferon gamma-induced protein 10 kDa (IP-10) is also known as C-X-C motif chemokine 10 (CXCL10). It belongs to the CXC chemokine family.
These 3 cytokines could form the basis of a new test to quickly detect whether tuberculosis is dormant or active and infectious.


52 chemokines from 4 families have been described. They interact with 20 receptors (click here for a larger image).

What is the difference between cytokine, interleukin and chemokine?
Cytokines (Greek cyto-, cell; and -kinos, movement) are substances secreted by cells of the immune system which carry signals locally between cells. They are proteins, peptides, or glycoproteins.
Interleukins are a group of cytokines first found to be expressed by white blood cells (leukocytes). The name is a misnomer since interleukins are produced by a wide variety of cells, not only leukocytes.
Chemokines (Greek -kinos, movement) are a family of small cytokines, or proteins secreted by cells. The name is derived from their ability to induce directed chemotaxis in nearby responsive cells; they are chemotactic cytokines.

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Invasive dental treatment associated with increased risk for stroke and myocardial infarction

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Treatment of periodontal disease may reduce cardiovascular risk in the longer term, but studies have suggested a link among dental procedures, acute inflammation, and endothelial dysfunction.

This study included persons exposed to invasive dental treatment with a primary hospital discharge diagnosis of ischemic stroke or myocardial infarction from 2002 to 2006.

The rate of vascular events significantly increased in the first 4 weeks after invasive dental treatment (incidence ratio, 1.50) and gradually returned to the baseline rate within 6 months.

Invasive dental treatment may be associated with a transient increase in the risk for vascular events. However, the absolute risks are minimal, and the long-term benefits on vascular health will probably outweigh the short-lived adverse effects.

References:

Image source: Cross-section of a tooth with visible gums, or gingiva, Wikipedia, GNU Free Documentation License.

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Google Translate in Medicine (video)

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"Conversation Mode" is a new interface for Android Phones within Google Translate that’s optimized to allow you to communicate with a nearby person in another language.

In conversation mode, simply press the microphone for your language and start speaking. Google Translate will translate your speech and read the translation out loud. Your conversation partner can then respond in their language, and you’ll hear the translation spoken back to you. See an example below.

Google Translate in Medicine from Graham Walker on Vimeo.

References:
A new look for Google Translate for Android
Conversation Mode in Google Translate for Android

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CDC Discourages Patients from Ordering Personal Genomic Tests

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Dr. Khoury comments on the personal genomic tests that consumers can buy on the Internet to measure their genetic risk for multiple diseases.

Direct-to-consumer genomewide profiling to assess disease risk provides information about a person's genetic risk of 20 to 40 common polygenic diseases. The tests simultaneously genotype approximately 500,000 variant bases of a person's DNA. Consumers can purchase these tests, currently priced between $400 and $2,000, on the Internet
Proponents argue that providing this type of information directly to consumers may result in improved compliance with health-screening practices and more healthful lifestyle choices.
Skeptics assert that such testing has the potential to cause harm, including anxiety and increased use of unnecessary and expensive screening and medical procedures.
The clinical validity and utility of these tests have not been demonstrated, and given their cost, many observers argue that their sale raises consumer-protection issues.
In a recent study published in the NEJM, subjects who chose to undergo direct-to-consumer genomewide testing, had no short-term changes in psychological health, diet and exercise behavior, or use of screening tests.
References:
Beware the fortune tellers peddling genetic tests - BMJ http://goo.gl/F0DQt

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Participation in clean-up of oil spill associated with airway injury and chromosomal damage

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In 2002, the oil tanker Prestige spilled more than 67 000 tons of bunker oil, heavily contaminating the coast of northwestern Spain. The study population included local fishermen who were highly exposed (n = 501) or not exposed (n = 177) to oil. They were evaluated 2 years after the spill.

Elevated markers of airway injury

Persons exposed to oil were at increased risk for lower respiratory tract symptoms (risk difference, 8.0). However, lung function did not significantly differ between the groups. Exposed participants also had higher levels of exhaled vascular endothelial growth factor (risk difference, 44.8) and basic fibroblast growth factor (risk difference, 16.0).

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

Chromosomal damage

A higher proportion of exposed participants had structural chromosomal alterations (risk difference, 27.4), predominantly unbalanced alterations.

Participation in clean-up of a major oil spill was associated with persistent respiratory symptoms, elevated markers of airway injury in breath condensate, and chromosomal damage.

References:

Health Changes in Fishermen 2 Years After Clean-up of the Prestige Oil Spill. Ann Intern Med, October 19, 2010, vol. 153 no. 8 489-498.

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Alternative to alcohol – BBC video

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Psychologist and addiction expert Dr John Marsden takes part in a radical experiment as he trials an non-addictive drug alternative to alcohol:

A single injection reverses the 'drug' alternative to alcohol and Dr John Marsden is left to reflect on whether this is indeed be the way forward in reducing alcohol dependency in future generations:

Twitter comments:

@yayayarndiva (P. Mimi Poinsett MD): How about water? -- Searching for non-addictive alternative to alcohol - BBC video http://goo.gl/KYtss

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STOP-BANG questionnaire identifies patients with OSA at hight risk for surgical complications

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What is preoperative STOP-BANG?

This is a questionnaire that evaluates the following patient characteristics:

Snoring, Tiredness during daytime, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference, Gender

Patient population
135 adult patients undergoing elective surgery at a tertiary care center were administered the STOP-BANG questionnaire.
41.5% of patients had high risk scores for OSAS.
Patients at high risk of OSAS had a much higher rate of postoperative complications compared with patients at low risk (19.6% vs 1.3%).
STOP-BANG questionnaire predicts high risk
The STOP-BANG questionnaire is useful for preoperative identification of patients at higher than normal risk for surgical complications, probably because it identifies patients with occult OSAS.
References
Obstructive Sleep Apnea Syndrome and Postoperative Complications. Clinical Use of the STOP-BANG Questionnaire. Tajender S. Vasu, MD; Karl Doghramji, MD; Rodrigo Cavallazzi, MD; Ritu Grewal, MD; Amyn Hirani, MD; Benjamin Leiby, PhD; Dimitri Markov, MD; David Reiter, MD; Walter K. Kraft, MD; Thomas Witkowski, MD. Arch Otolaryngol Head Neck Surg. 2010;136(10):1020-1024. doi:10.1001/archoto.2010.1020
Image source: Wikipedia, public domain.

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How to succeed? Get more sleep

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In this 4-minute talk, Arianna Huffington (founder of The Huffington Post) shares a small idea that can awaken much bigger ones: the power of a good night's sleep. Instead of bragging about our sleep deficits, she urges us to sleep our way to increased productivity and happiness -- and smarter decision-making.

Quotes from the talk:

"I was recently having dinner with a guy who bragged that he had only gotten four hours sleep the night before. And I felt like saying to him, "You know what? If you had gotten five, this dinner would have been a lot more interesting."

There is now a kind of sleep deprivation one-upmanship. Especially here in Washington, if you try to make a breakfast date, and you say, "How about eight o'clock?" they're likely to tell you, "Eight o'clock is too late for me, but that's okay, I can get a game of tennis in and do a few conference calls and meet you at eight." And they think that means that they are so incredibly busy and productive, but the truth is they're not."

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No NSAID may be safe in cardiovascular terms – naproxen seems least harmful

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This BMJ meta-analysis included large scale randomised controlled trials comparing any non-steroidal anti-inflammatory drug (NSAID) with other non-steroidal anti-inflammatory drugs or placebo. Data synthesis included 31 trials in 116,?429 patients. Patients were allocated to naproxen, ibuprofen, diclofenac, celecoxib, etoricoxib, rofecoxib, lumiracoxib, or placebo.

Study outcomes

The primary outcome was myocardial infarction. Secondary outcomes included stroke, death from cardiovascular disease, and death from any cause.

Cardiovascular risks

Compared with placebo, rofecoxib (Vioxx) was associated with the highest risk of myocardial infarction (rate ratio 2.12), followed by lumiracoxib (2.00).

Ibuprofen was associated with the highest risk of stroke (3.36), followed by diclofenac (2.86).

Etoricoxib (4.07) and diclofenac (3.98) were associated with the highest risk of cardiovascular death.

Little evidence exists to suggest that any of the investigated drugs are safe in cardiovascular terms. Naproxen (Aleve, Naprosyn) seemed least harmful.

According to the corresponding BMJ editorial, Celebrex (celecoxib) is not much safer either: "All cyclo-oxygenase-2 inhibitors studied in large placebo controlled trials have been found to confer an increased risk of serious cardiovascular disease. This suggests that patients with a high risk of cardiovascular disease should avoid cyclo-oxygenase-2 inhibitors (COX-2). "

References

Cardiovascular safety of non-steroidal anti-inflammatory drugs: network meta-analysis. BMJ 2011; 342:c7086 doi: 10.1136/bmj.c7086 (Published 11 January 2011)

Editorial: Cardiovascular safety of NSAIDs. Wayne A Ray. BMJ 342:doi:10.1136/bmj.c6618 (Published 11 January 2011)

Image source: Wikipedia, public domain.

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Nursing student successfully challenges dissmissal from school because of Facebook photo

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A Kansas college is facing a legal challenge over its dismissal of a nursing student who posted online a photograph of a human placenta studied in class - the WSJ video is embedded above.
The lawsuit includes a letter that Ms. Byrnes wrote to the college apologizing for what she called a "lapse in judgment" but asking that she not be dismissed.
The school said the four students are allowed to reapply to continue their nursing studies in August 2011.
Most reader comments on the story follow this pattern: "I fail to see why this posting should result in dismissal from school. The student broke no confidentiality, and the posting was certainly not obscene."

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Too much of a good thing? Excess fluoride in water supply causes dental problems

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For the first time in nearly 50 years, the government is recommending lowering the fluoride in drinking water. Officials say many Americans are getting too much fluoride and it's causing some kids to have "splotchy" teeth. The AP's Kelly Daschle reports.

The US health department is recommending that water supplies contain 0.7 milligrams of fluoride per liter of water, replacing the current recommended range of 0.7 to 1.2 milligrams.

Learn how much fluoride is in your tap water. Call your local water municipality because the level varies from city to city. If it's above 0.7 milligrams per liter, you could consider filtering your water.

References:
U.S. Wants to Reduce Fluoride in Drinking Water. WebMD.

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Excessive Internet use may be linked to depression

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Excessive Internet use may be linked to depression. Spend a day offline and connect with friends and family.

Twitter comment by @MiriamETucker: But they're all online!

Your Internet use could be telling you something about your mental health. If you keep up with friends via Facebook or spend more time chatting online with strangers than with family, it might be time to disconnect the computer for awhile — and check in with yourself.

The researchers analyzed internet use and depression levels of 1,319 Britons aged between 16 and 51. An online questionnaire was used to measure participants' Internet use, the functions for which they used the Internet, and their depressive tendencies. Of these, 1.2 percent were "internet addicted."
"Excessive internet use is associated with depression, but what we don't know is which comes first -- are depressed people drawn to the internet or does the internet cause depression?"
Using the Web to replace your usual social circle could be a red flag. Instead of spending hours on message boards, pick up the phone and call someone.
Twitter comments:
@BiteTheDust (Robbo) re: internet and depression.... if you skype someone is that using the phone or using the internet? just asking 🙂
@amacdt Especially if you use video skype - it's a tough one. I find that I really enjoy talking to people with video

References:
Image source: Wikipedia, public domain.

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Why you should start blogging in 2011

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Quotes from an interview with Seth Godin and Tom Peters:

"Blogging is free. It doesn’t matter if anyone reads it. What matters is the humility that comes from writing it. What matters is the metacognition of thinking about what you’re going to say.

No single thing in the last 15 years professionally has been more important to my life than blogging. It has changed my life, it has changed my perspective, it has changed my intellectual outlook, it’s changed my emotional outlook.

And it’s free."

Don't limit yourself to your blog - use Facebook and Twitter
Blogging can be great for personal growth but there is a lot more interaction on Twitter and Facebook nowadays as compared to blogs. If you have a blog, you must also have a Facebook "like" page (previously called "fan" page) and a Twitter account. These serve the dual purpose of distribution and commenting channels ("two-way street").
For example, Facebook pages get a lot more interaction than blogs for some medical journals - you can count the comments on the NEJM Facebook updates (the range is 9-180) vs. their blog (0). The blog has comments enabled, of course.
Facebook is the clear "winner" in terms of commenting activity, it is not even close:

NEJM Facebook page vs. NEJM blog

The risks of blogging and social media use in healthcare
One Misguided Post, Photo, or Comment Online Can End Your Healthcare Career, according to this About.com guide. It makes you think: Why would any doctor use social media? Some of the benefits are outlined above.

Twitter comments:

@cmeadvocate (Brian S. McGowan PhD): Look at commenting activity on NEJM's Facebook page (100's) vs. NEJM's blog (

@rsm2800 (Robert S. Miller, MD): Striking difference
@kevinmd (Kevin Pho, M.D.): That's because the NEJM fb page has 170,000+ fans. Blog doesn't generate nearly that much traffic.
@DrVes: One of the reasons, yes. However, the commenting activity on many blogs is down. To compensate, a lot of them started embedding Twitter re-tweets as a substitute for comments. I did it too with this post (you are reading the example).
@DrVes: Thanks for re-tweeting this post http://goo.gl/o9rRl - Blogging introduced me to some of the smartest and most generous people in healthcare. Give it a try. It doesn't matter if anybody reads your blog when you start. If it's useful to you, somebody somewhere will find it useful too.
References:
Blogging can improve your attention span and focus - unlike social media sites which can be highly distracting http://goo.gl/K4O1V
Is having a blog useful in 2011? Scoble says yes... using Quora http://goo.gl/Gubor

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