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Off to SHP I will be away from my computers for the next 2 days. In the event that I cannot find reasonable internet access - I will next post Wednesday p.m. I am off to give a workshop on Metabolic Acidosis at the SHP (formerly the NAIP) meetings in San Diego. The workshop is based on 5 cases of Metabolic Acidosis. If readers are interested, I can develop a series over the next couple of weeks presenting and discussing the cases - let me know. Have a great day! SARS update No good news on the SARS front. Rather than linking to multiple news stories, I will link and quote from the latest CDC briefing - CDC Telebriefing Transcript: SARS Update - March 29, 2003
The experts are mostly focussing on the coronavirus hypothesis. While they have more studies to complete confirmation, the data are becoming convincing.
Understanding how SARS spreads remains crucial. When do infected individuals become infectious. Once we truly understand this epidemiology, then we can better gauge future spread and how to prevent it. While close contact certainly puts one at great risk, some evidence in Hong Kong suggests that this virus might spread in more routine common cold fashion.
At the current time, we have no candidate treatments. Most patients will recover with good medical care - but 3-4% will die. Currently, sites of outbreaks are using aggressive epidemiological controls, trying to prevent the spread of this virus. We must remain alert and keep informed as this story unfolds. Posted byWhen estrogen is the only alternative
I agree entirely. Sometimes quality of life demands hormone replacement therapy. We are trying withdrawal each year, but do not know who often affected women will successfully withdraw. Posted byWhen doctors sell out I understand their financial motivation. I question their ethics. While it is easy to blame the insurance companies for many evils, we still should make responsible choices. Selling supplements (including Ephedra) does not seem a responsible, morally defensible choice. Bottom Line in Mind, Doctors Sell Ephedra
What is he thinking? While money is not necessarily the root of all evil, it certainly can cloud ones judgement.
One can only hate ranting about such behavior. One can understand their reasons, but reasons should not become excuses. They are wrong. Posted byPossible heal for carotid artery disease As I read the literature, treatment for carotid artery disease carries great risks. When a patient has had a TIA (transient ischemic attack) or RIND ( reversible ischemic neurologic deficit), and has significant carotid artery disease, then carotid endarterectomy can help prevent subsequent strokes, but only at the risk of intraoperative stroke. Overall, surgery does help, but the surgery does carry significant risk. Researchers have announced results of stenting the carotid artery - but the link gives few details. Study Said to Back Guidant Artery Device
Certainly promising results, which we need to scrutinize carefully. Which patients entered the study; what were the complications; was the there a control group? One should hesitate at developing too much enthusiasm from a newspaper report. We need to read the articles. Posted byQ&A 8 Sitting here, back at the Q&A desk. Today I will share both questions and comments. Receiving these comments provides a great reward - it tells me that some readers really care about my rants. And that is a wonderful feeling! Reframe the discussion how ever you feel is convenient. The bottom line is state medical boards do a pretty lousy job of patrolling the profession for substandard care, based in large part on failure of professionals and health service organizations to self-report problem physicians, and budget and staffing support received from state legislatures. And responsibility for budget and staffing support limits, as well as limited grounds upon which to trigger an investigation or disciplinary action, can be placed at the feet of the provider interest groups. This represents one of my excellent comments from the Bloviator (you should read his page regularly - just look over to the Medical Blog list). He forwards an interesting viewpoint on self-policing. I hope he is reading this rant - do lawyers do a good job of self-policing? He points out that State Medical Boards do not receive adequate funding. Thus, they have difficulty becoming proactive in searching for "problem physicians". He has served as counsel to a State Board - so I would not dare challenge him on that point. However, I believe this issue is indeed a side issue. Our problem stems from how our society defines and pays for malpractice. The entire concept of punitive damages is quite problematic. How can anyone adequately define those? As I (and many readers) have said repeatedly, the problem with malpractice settlements should concern everyone. If malpractice premiums and rewards continue to rise, then no rationalization for the high rewards will matter. If physicians cannot afford to practice, then patients will really suffer. In some ways we are considering the penalties for errors of commission, and as a society ignoring the costs of paying those penalities. I empathize with true malpractice victims. However, our current system works more like a lottery than a true check and balance. Trial lawyers are the problem here. We need an alternate system for judging and paying for real malpractice. Our health care system really does an excellent job of caring for most patients. But we never get extra rewards for great care. When we make an important diagnosis or help a patient through a crisis, we receive the same fees as when we care for a more straightforward, simple diagnosis. If the patient has a bad outcome (even if we really did everything right), we just might get sued. That cannot make sense to anyone. Our system of judging malpractice is broken. The penalties for malpractice are broken. As a result, medical care actually suffers. The current malpractice system discourages improvements in health care. I am a second year general surgery resident at a busy metropolitan academic center. I enjoy reading your medrants whenever I can find the time. Major kudos is due to you and your site. You have written often about the 80-hour workweek issue. I agree with most of what you have written. I can tell you though, from my own experience and from talking to friends that I have in other surgical residencies around the country, that compliance by surgery programs will be very poor. My program director has hatched a plan of pseudocompliance. "You can go home 6 hours after you finish call if you want to, but everyone else is staying. By the way, if you stay to work extra, its on your own time and you can't count it on your timesheets." Surgery programs have attitude (yes I know this is a generalization - but many colleagues around the country confirm that generalization). They truly believe they understand training better than any outside group. Some programs will comply; some programs will have the above attitude. We will have to follow the changes in July to see which specialities adapt well and which struggle. An endoscopy the other day revealed "very mild" gastritis (probably from taking Advil on an empty stomach), also "very mild" esophogial irritation from a bout with heartburn that I had during a particularly stressful period several months ago. The doc, who is does a great job with the endoscopy, does not do such a good job with followup and simply gave my husband on the way out a script for Nexium, with little direction. I have so many questions! First of all, I have lowish platelets, around 100,000. Does Nexium, like Tagamet, interfere with platelet counts. Secondly, is this drug really necessary??? If both problems are "mild," and if I really don't even feel heartburn anymore, can't I a)change my behaviors and cure the gastritis and b)assume that the esophagial damage is from an old problem and that the esophagus will heal itself, given time? By the way, I am a 47-year-old woman who takes no scripts, who hates taking pharmaceuticals and likes to believe she can heal herself holistically -- until something life-threatening comes along, at which point I will be grateful for life-saving drugs. I don't see this situation as a life-threatening one. Thanks for listening and for whatever advice you can offer. Thanks for the question. Giving advice on medical issues without actually talking with a patient and examining them and their medical record is a bad idea. Thus, I will couch my answer in generalities. I am not aware of proton pump inhibitors (the class which includes Nexium) causing problems with thrombocytopenia. A quick search did not find any such problems. Tagamet is a histamine-2 blocker - a different drug class. Not knowing your history of gastritis and esophagitis, I can make no comments on treatment. If you truly have endoscopic evidence of esophagitis, then I doubt holistic treatments will work. In general weight loss does help esophagitis. If your gastroenterologist does not discuss your diagnosis well, you might try going back to your internist or family physicians. They should be able to sit down and discuss your management strategy. If you do not have a generalist, you need one (as I rant about regularly). "We teach residents to consider a complete differential, but to concentrate on the four most common diagnoses - undiagnosed asthma, ACE inhibitor cough, post-nasal drainage, and gastroesophageal reflux disease (GERD)." How about chronic bronchitis? This comment came from a rant about cryptic cough. I did not make clear that I was talking about cryptic cough. Chronic bronchitis, in my experience, is rarely (if ever) cryptic). These patients have a productive cough and fit into a classic syndrome. If we take all cough presenstation, then chronic bronchitis is an important consideration. I knew one attending whose favorite retort to the "natural" argument was to snap, "Well, poison ivy's natural Well stated. and what about the "natural course of an illness?" We all know that over 90% of common maladies like Otitis Media, Sinusitis, and Pharyngitis will resolve with NO intervention. Try saying THAT to the next patient with a runny nose who asks for a "natural cure." While I do think we should prescribe antibiotics for bacterial otitis, sinusitis and pharyngitis, I agree that we are too quick to give patients antibiotics for viral infections. Why do we do this? It saves time and the patient expects it. I have always tried to avoid this behavior. Unfortunately, I see too many colleagues, residents and even students who start "a Z-pak" whenever they get a cold. We need to do a better job here! A pre=emptive apology for this rant. This is old news to the average otolaryngologist. OVERHWELMINGLY, patients who I see for chronic cough have underlying GERD. I'd guess that 80% have GERD, 10% have chronic sinusistis, and then there are about 10% "other." Most are not difficult to diagnose on history alone (not to sound facetious- most are easy to diagnose my simply LOOKING at them). Chronic sinusitis is easy to rule out- order a CT scan. The only problem you'll run into in that regard is that our radiology colleagues have a penchant for overreading these scans. (I would LOVE to see a blinded study of sinus CT scan interpretations by radiologists. I would wager that you'll get a substantially different interpretation by 5 out of 10 readers.) I have a pet peeve: I IMPLORE my generalist colleagues (and others) to stop using the term "post-nasal drainage" so flippantly. I peer into pharynges every day of my working life (X 20 years) and I can tell you that it is RARE to actually spot any kind of discharge trailing down the posterior oropharyngeal wall. The only other time one sees this is as a subtle finding on endoscopic exam- a modality that is not available to the average generalist. I'm constantly astounded at how many patients come in telling me that their Primary care doctor "spotted drainage down my throat." Don't you find it odd that everyone and his cousin talks about "post-nasal" drainage" and yet this is not a term that is loosely used by the one specialist in human medicine who ought to know the most about it? Sadly, most of my day is spent UNDIAGNOSING "sinusitis." These patients are almost always complaining of facial pain (shockingly, predominantly female, often depressed; usually with a background history of headache and other pain syndromes) i.e. "another sinus infection" and/or "post-nasal drainage" i.e. almost always symptoms of GERD. Is it any surprise that they don't get better with antibiotics? And the ones that do are often responding to a placebo effect. There has been, and continues to be, a lot of gold to be minded treating "chronic sinusitis" surgically. Please spare your patients needless antibiotics and surgery. Concentrate on SYMPTOMS, not preconceived diagnoses. If you do, you'll almost always come upon the right assessment the first time. Sometimes readers have better rants than DB. This is a great example. Thanks to Dr. Kranky for this post! Do you know of a medical study on use of Singulair for people with chronic sinusitis? I do not have asthma but have had injections for years, had 2 sinus surgeries and suffered 10 years of infections every 3 months (average). I've slightly improved via acupuncture, but still need help. (It does not help living in the humid Washington, DC area) First, read the comment about. Second, do you have chronic sinusitis or allergic rhinitis, or both. If you have allergic rhinitis, then Singulair can help (but is not better than nasal steroids). You might benefit from a fresh look at your symptoms and treatment. Again, not talking with you and having access to all your records, I cannot completely answer your question. One way to calculate the benefit is to measure the number of specialty referrals generated in a "shared" practice vs. the model that most of us feel is more beneficial- per given condition (or tentative diagnosis). AND factor in the number of visits to each primary care model BEFORE the referral was made. It's been my experience as a consultant that too many conditions were turned into "chronic" or "complicated" this or that, simply because there were 3, 4 different primary care physicians (sometimes PA's of NP's) on the given patient's care. Another excellent comment which complements (in my opinion) the point I tried to make. Continuity certainly has important benefits on satisfaction (for both patients and physicians). It also often leads to better care. I agree with the comment, although I do not know of a good study to confirm this observation. ... Once again, thanks for the comments and questions. On smallpox vaccinations Many readers remember my opposition to widespread smallpox vaccinations. I argued - as did many others - that we would put vaccinees (and their patients) at a small but significant risk that probably was greater than the risk of smallpox reappearing. I obviously had greater concern about making an error of commission than the risk of an error of omission. Now we may have a problem. The data are not yet clear, but apparently smallpox vaccine can cause cardiac problems. 2 States Suspend Smallpox Vaccinations
One can easily argue that the deaths all occurred in patients with heart disease. They might have died anyway. We will probably never know the truth here. Nonetheless, we have the perception of creating illness because of a postulated risk.
Posted by On continuity Patients want a relationship with their physician(s). Most physicians also want a stable relationship with their patients. And it helps medical care. Evidence Supports the Importance of Continuity in Primary Care
This article appears in response to a move in Great Britain to have patients register with a practice rather than with a specific doctor. Such decisions only occur when managers try to make medical practice more efficient . The doctor-patient relationship, when it works, benefits all. I believe this phenomenon is not restricted to primary care, but applies to any chronic illness (e.g., rheumatoid arthritis patients and rheumatologists, psoriasis patients and dermatologists, and you can imagine many more such relationships). One additional thought comes to me. As physicians try to see more patients per session, they have less time to develop that relationship. The greatest attraction to the generalist fields is, in my opinion, the long term relationship one develops with patients. These relationships take time to develop. They benefit from taking a small amount of time to chat. Perhaps this represents another appeal of retainer medicine. It gives the physician time with the patient. But managers and insurers cannot understand how to calculate that benefit. Some benefits are difficult to quantitate. Not being able to quantitate a benefit easily does not invalidate the benefit. Posted byWahington Post - Q&A on SARS Is SARS confusing you? This article does a nice job of summarizing what we currently know. The Mystery Virus: A Guide to Origins, Symptoms and Precautions You Can Take . As a brief added note, the evidence for coronavirus seems significantly greater than paramyxovirus at the present time. Posted byCanada's response Can we control SARS? Will travel restrictions help? Canada will try. Given the amount of travel between the US and Canada, this could help us greatly. Canada to Screen Airline Passengers for Respiratory Ailment
I hope such measures work. Unfortunately, I assume that some will travel during the incubation period, not becoming sick until they alight in a new location. Posted byOn gatekeeping I hate the word. Gatekeeping - AAAAAAAAAAARRRRRRRRGGGGGGGGHHHHHHH! I am not a gatekeeper, have never been one, will never be one. This is a gatekeeper:
If we could have this author help correct our reimbursement system. He understand the generalist value. Why doesn't everyone? Posted byChina and SARS No commentary is necessary here. Just read this and shudder. China's Response to Illness Was Typical Posted byAirport Screening for SARS This just might work. Health Screening Is Sought for Some Airports
While this seems a drastic measure, the medical rationale is clear. However, I remain skeptical that it will work. Patients seem to have a latent period during which they are not sick. If they are not aware of exposure, then they certainly could still carry the infection on the plane and to a new location. Posted bySARS update - validation of coronavirus hypothesis Scientists say SARS virus identified
Now the search for treatment continues. As the number of known cases increases, we will better understand the epidemiology. Having a diagnostic test will allow us to understand transmission. We should start to better gauge risk. This remains a frightening to me. A common cold virus becoming a serious pathogen will challenge our health care delivery system. Posted byMoynihan This blog will remain 99% medicine. However, I must comment on Daniel Patrick Moynihan. I generally vote Republican. My political philosophy is best described as Libertarian domestically and neo-conservative internationally. (see Robert Prather to better understand this - Neocons Vs. Paleocons. Regardless of ones political inclinations, Daniel Patrick Moynihan should represent the ideal in politics. He based his stands on principle and intelligence. Even when one disagreed with him, one had to reconsider ones own position, because he was so damn smart. Read this outstanding tribute from George Will - A Beautiful Mind. Oh, but that we could have the Congress full of his like! Posted byDaily SARS update China Raises Tally of Cases and Deaths in Mystery Illness
Meanwhile, I can find no new news on the virology. I am still intrigued by the two virus hypothesis (see yesterday's rant and a similar Medpundit rant today). On the containment front today's Wall Street Journal Online (subscription required) has an article on the Singapore response to SARS. While some might consider them draconian, one can easily argue that such measures are needed to control a potential disaster.
Hong Kong appears to now be emulating this approach. HK orders mystery virus quarantine. Finally, at least one editorial recognizes that the US public health system has acted aggressively and appropriately in anticipation of a possible outbreak in the US. SARS and public health preparedness
Posted by Insurance companies do stupid things Alice, the author of Feet First, frequently provides insightful comments here. She wrote one such comment yesterday, and I noticed she had a blog. So I clicked and found this story - Now I'm Really Mad. Please read the entire story - this excerpt will only give a slight taste of the entire meal.
The rant goes on and one quickly shares her frustration. I have added her blog to my medical blog list (she writes both about medicine, as well as anything else she cares to consider). Nice work Alice!!! Posted byNot enough time This blog has several recurring themes. One concerns paying generalists enough money to allow them to provide excellent care. This issue has more complexity than one might first assume. Some would argue that generalists make a good living - why are they complaining? When I talk to practicing generalists, they bemoan the time that they can designate to each patient. Financial considerations drive visit volume. Financial considerations continue to decrease the supply of new generalists. Thus, we have generalists retiring and retreading; we have a decreasing supply; and is yesterday's rant on Medicare suggest, we have increasing demand for services. We also should do more at each visit - improving medical care options require more time. A specific example is preventive care. Prevention is like motherhood and apple pie, everyone is in favor of prevention. Why do we do such a mediocre job? Time!!!! Not Enough Time for Primary Prevention
We all really no this (the we being physicians). This study confirms this important concept. We must continue to push this point. One advantage of retainer medicine is the time it allows one to practice 'state-of-the-art' care. Such care does cost more than we currently pay. Explain why it is not worth the extra money. Posted byNew additions to the medical blogroll I have added 2 blogs to my medical blogroll (in the left column). Living with diabetes is a patient's ongoing journey to live with her diabetes. She writes well, and does her research. She is a frequent and intelligent commenter on this site. Medical Weblogs should become a daily visit for all readers.
I am sure that I am leaving out other important sites - drop me a note and I should correct it. Posted byMore on the epidemiology of SARS The news becomes more frightening and more puzzling. How easily does SARS spread? Could the syndrome depend on a dual infection - two viruses? Casual SARS transmission?
So the epidemiologists continue to work on the mode of communication. We cannot control an epidemic unless we understand transmission. Meanwhile on the virology front things become even more confusing.
I find this very interesting speculation and also very concerning. If we need to address two viral infections simulataneously, then we have a much more complex situation. Will we have a major epidemic? This is the big question. I remain very concerned. Until we really understand both the transmission and the etiology, we can only guess at treatment and containment strategies. Posted byOn China and SARS - ABSURD!!!! This is ridiculous. We need protesters in the streets. We need a UN resolution. But will anyone notice? Please spread this outrageous story throughout the blogosphere. China Bars W.H.O. Experts From Origin Site of Illness We are trying to understand and contain a severe respiratory infection from which around 4% of the patients die. This is an astonishing death rate. Investigators are making great progress, but China will not cooperate.
Ridiculous! I am speechless. Posted byMedicare spending up - patients will pay more - doctors receive less Medicare Recipients Face 12.4% Rise in Premiums
Once again both patients and doctors are scheduled to financially suffer - because we are providing more (and better) care for patients. We have a significantly flawed formula for calculating premiums and physician reimbursement.
This finally starts to become clear. The Congress developed a formula based on the economy rather on the costs of the services. They pass laws requiring more administrative overhead, yet they link payment to the economy. But overhead is not linked. I think they will quickly hear that a crisis is imminent.
And every quality measure that Medicare uses is improving. Perhaps this care has good indications. Perhaps some testing occurs in response to the malpractice crisis. Should we not ask why rather than have a formula that just reacts to numbers? As I say repeatedly, improvements in technology and pharmacotherapeutics may lead to an increased percentage of GNP going to medical care. Why should we try to fix that percentage? We should strive to provide the best possible care. Or should we just try to control costs? So where is the money going? Medicare has broken the data down into categories.
All good reasons for doctors' fees to decrease. (I only hope that my sarcasm bleeds through!) Posted byOn autism As an internist, I know little about autism. Occasionally somone will ask me about it. I have even received at least one email which I could not answer. This article will have great interest to some readers - it discusses the thimerosal hypothesis - and gives all the evidence against thimerosal as a cause of autism. Vaccines and Autism, Beyond the Fear Factors Posted byNatural is not necessarily a welcome word to physicians - a case In Medicine, Nature Plays Dirty Tricks
Read the rest of the article to learn about Charlie, his diabetes, and the results of ignoring medical advice. Posted byAnother SARS article about coronavirus The CDC is honing in on a variety of coronavirus. More information in this article - Cold Virus Linked to Outbreak CDC Says New Version of Coronavirus Is Likely Cause
Medical research does work fast when necessary! Posted byCoronavirus? Information comes fast and furious on SARS. Here is the latest - New Coronavirus Suspected as Cause of Severe Acute Respiratory Syndrome
So what is coronavirus? I found this link that gives some information - Human coronavirus. It appears to be a cause of the common cold. At this time we must suspect a mutation has allowed this virus to cause pneumonia. As regular readers know, we will follow this story closely as it unfolds. Posted byChronic cough and GERD Patients often present to their generalist complaining of a common cough. We teach residents to consider a complete differential, but to concentrate on the four most common diagnoses - undiagnosed asthma, ACE inhibitor cough, post-nasal drainage, and gastroesophageal reflux disease (GERD). This month's CHEST has a very interesting article on the later diagnosis. This link probably will only work if your library has a subscription to CHEST online - Chronic Cough and Gastroesophageal Reflux Disease* Experience With Specific Therapy for Diagnosis and Treatment
This simple paragraph suggests that approximately 30% of chronic cough patients have their cough related to GERD. This is important information. They then ask the important question - does treatment matter?
Many patients need a 'prokinetic agent' in addition to the PPI. We no longer have the option of using cisapride, thus we will generally try metoclopramide (Reglan). This study helps place GERD into perspective as a chronic cough etiology. An accompanying editorial (by a fellow UAB faculty member) places this into clinical context.
Her excellent editorial - Chronic Cough Practical Considerations Posted byDoctors treat injured of both sides Being a physician is a constant source of pride. When I look in the mirror each morning, I know that my goals are to improve people's lives. Navy Docs can believe the same thing. 'Devil Docs' operate on friend and foe: In field operating room, wounds matter more than sides . This is as it should be!! Posted by Insulin resistance revisited I often rant about exercise and diet. The information in this link is not new - even to this blog. However, it is important enough to highlight once again. Eat less and walk more to keep diabetes at bay.
As I rant incessantly - diet and exercise - exercise and diet. Posted byThe latest on SARS Singapore and Vietnam are home to a third wave of SARS cases. Fortunately, investigators can still link these cases directly to previous cases (in terms of exposure). As evidence accumulates, one must have close contact to an infected individual. Barrier precautions do apparently work. Respiratory Illness Spreads to a Third Wave of Cases.
It appears that approximately 10 per cent of cases become very severe.
We can only hope that precautions will allow containment of this infection. However, we are already in the 3rd wave and this could get worse. We must follow this story carefully and be ready in case this infection becomes endemic. As an aid to keeping up to date, here is the CDC web page with the latest information - CDC - Severe Acute Respiratory Syndrome. Posted byQ&A 7 How am I suppose to chose? Am I prepared to die on the operating table, NO. Do I want to die slowly by staying 362lbs, NO. So now what? I know most people think obese people should be able to just stop eating and the weight will come off, but it doesn't work that way for everyone. Me being one of those people. I have a 12 yr old son that I want to live for. I want this surgery but how can I say, as I'm being wheeling into surgery "see you soon" knowing that he may never see me again..all because I want to be healthy. I'm so confused! This eloquent paragraph defines the problem of obesity. You know that your weight is a major problem, yet cannot succeed with conventional methods. Most physicians and readers do have difficulty understanding your situation. Peronally, I have succeed in modifying my diet and enhancing my exercise program. That must not work for you. So what are you to do? No one can make this difficult decision for you. When does one risk everything (albeit a low probability) to gain everything? I can tell you that on average having surgery will benefit you. But averages work for populations, not for individuals. Talk to some surgeons who specialize in this surgery. Interview them, and they might help you with your decision making. Good luck - we all hope you make the right decision for yourself. I'm not a doctor... my wife has Atrial Flutter. She feels much better in Sinus Rhythm. So isn't it a good idea to have "rhythm" control just from a quality of life point of view? And if she is in sinus, are the data clear that she should still be on warfarin? How about going back to warfarin if she should go into AF, but otherwise don't take it. She's been in sinus for several months now. Thanks for this interesting question. Let me first describe the difference between atrial fibrillation and atrial flutter. Heart rhythm normal starts with the atria (the 2 smaller chambers) contracting, and very soon thereafter the ventricles (the larger chambers) contract. In normal hearts these contractions synchronize to maximize blood flow through the heart and out to the body. Atrial fibrillation occurs when the atria no longer have coordinated contractions, rather they fibrillate (fibrillate refers to the act of fibrillation - muscular twitching involving individual muscle fibers acting without coordination). Thus, the atria "quiver" but do not send coordinated impulses to the ventricles. The ventricles receive irregular signals to contract. Thus, the rhythm becomes irregularly irregular. One danger of atrial fibrillation comes from the "quivering" in the atria. Since they do not contract properly, the blood tends to pool, allowing coagulation to occur. (oops another medical term - coagulation means that clots can form). The clots are the problem. They can grow to a large enough size that they cause problems when they "break loose" from the atria. Thus, the risk of stroke in untreated atrial fibrillation. Atrial flutter is a different rhythm. In this rhythm the atria do have coordinated contractions - usually at a very fast rate (think around 300 times per minute). This atrial rapid rate is usually modified by the electrical connection to the ventricles (what we call the AV node). The AV node handles the electrical impulses from the atria - passing on a signal to the ventricles to contract. A rate of 300 is too fast to pass on to the ventricles. Usually every other or every third signal gets through. Because atrial flutter usually causes symptoms immediately, most patients receive treatment to restore sinus rhythm. The unusual patient with chronic atrial flutter does have some risk for thrombi and emboli (blood clot terms - thrombi when they form - emboli when they break off and flow elsewhere and cause problems). When atrial flutter is succesfully treated, anticoagulation is generally not needed. If it became intermittent one might anticoagulate (especially if the patient alternated between atrial flutter and atrial fibrillation). I hope this complex answer helps. I just started taking Zetia after a muscle bout with Lipitor. What side effects will I have with Zetia? Hope to hear from you. Having not yet treated any patients with Zetia, I have to look this one up. The FDA says stomach pain and tiredness can occur. FDA information on Zetia. I hope that helps. Will the vaccine prevent other hpv like common warts and also when will it be available? Great question, which I cannot answer! I suspect that the vaccine will prevent some warts - but will probably only work against a small subset of HPV strains (those which most commonly cause cervical cancer). I have no idea on the timetable for this vaccine. Well, maybe. Services are services. But what about the consumer? I am facing 4 or 5 hours of work to sort out insurance problems caused either by the insurance company or by the doc's office. I've got a dentist who has filed 4 times for the same services (and was paid fully), and an internal medicine practice that just billed the insurance co. for services 8 months ago. Straightening this out will cost me 3 or 4 hours of weekend time. And no reimbursement! :) I have to go through this two or three times a year. First, thanks for the comment, and I do understand your frustration. The object of your frustration is the insurance companies not the health care professionals. Why should we charge you for filling out forms? Because we are running a business and time is money! The forms that I imply are extra forms. Another comment states it well - I am all for it. (Speaking as an MD.) Doctors spend huge amounts of time filling out these forms. I'm sure I don't have to convince *you*, but here is a partial list: And that is the point of the rant. And is use of hormones also a placebo for those of us who have had hysterectomies with oophorectomies, or those twenty-somethings in premature menopause? Since we are lumped in with all other women and all conceivable forms of hormones are now too dangerous to use (and goodness knows there are no side effects or risks in the antidepressants, bone-density enhancers, statins, antihypertensives, false teeth, dried-up-eyeballs, and, let me not forget, copious helpings of KY to "treat" that vag atrophy that we'll be switching to), I can only guess not. Gee, if hormones are that evil, maybe women should ALL have oophorectomies before menarche. Think of all the problems that would prevent! Premature menopause and oophorectomies represent a totally different situation than the studies address. One difficulty in medicine is the balance between belief and data. I prefer data. We must criticize studies carefully, but then understand what they tell us. I would prescribe hormonal therapy to patients with oophorectomy or premature menopause until around 50 years. With specific reference to vaginal atrophy, I understand that vaginal estrogen does help a great deal. Also, continued sexual activity seems to retard atrophy. ... Thanks for the many excellent comments and questions. I hope some of these answers are helpful. And thanks for reading!! More progress on SARS Crude Test Offers Hope for Tracking Mystery Virus. The data are sparse, but investigators claim to have developed an immunofluorsence antibody test.
The mystery continue to unfold. Investigators are honing in on a true answer. I want to read more about the possible treatment with ribavirin. Posted by |