So congratulations to all of you newly minted interns and let us be the first to inform you that there are some very psyched soon-to-be-PGY-2's ready to exert some influence.
Monday, March 19, 2007
So congratulations to all of you newly minted interns and let us be the first to inform you that there are some very psyched soon-to-be-PGY-2's ready to exert some influence.
Saturday, March 17, 2007
When it rains, it pours. And this week it was pouring 70-something talk show hosts with serious vascular issues. First Regis and now Larry King. Charles Grodin and Charlie Rose better pack a bag.
While Reege is hopefully thinking about discharge, the 73 yo King is fresh out of a carotid endarterectomy (CEA) and his camp says he'll be back by Monday to interview Sen. Barack Hussein Obama (that name is like a SNL joke - he couldn't have worse luck if his name was Stalin Bitler).
Larry King is no stranger to vasculopathy and has a history of 4-vessel CABG way back in 1987. Which also implies that he has probably had subsequent cardiac caths to open of some grafts or possibly even an ancient native vessel. King's propensity for vascular disease makes one wonder what risk factors he wields.
It is very likely he is hypertensive and most certainly takes a statin for high cholesterol. Is he diabetic, too? Probably not - all those years of poorly controlled blood pressure, cigarettes, drugs?, and booze is most certainly enough to give you the old coronary-carotid double feature.
Prior to surgery King definitely had a carotid ultrasound to assess the degree of stenosis. The question is, did symptoms prompt this vascular study or was it a smart doc who knew the talk show host's propensity for vascular atherosclerosis? Either way, he had enough of a lesion to dictate that medical therapy, compared with surgical revascularization, would be more likely to result in a stroke or even death.
What about his outcome? Well, all of the following characteristics have been associated with an increased risk of poor outcome (stroke, myocardial infarction, or death) at 30 days after CEA:
- Age 80 or older
- Severe heart disease
- Severe pulmonary dysfunction
- Renal insufficiency or failure
- Stroke as the indication for endarterectomy
- Anatomical issues including limited surgical access, prior cervical irradiation, prior ipsilateral CEA, and contralateral carotid occlusion
Carotid endarterectomy (CEA) is most often done through a neck incision either bordering the sternocleidomastoid muscle, or more esthetically, with a horizontal incision in a skin crease at the level of carotid bulb. Either way, the scar will be small and discrete enough to be covered by a good layer of pancake, so don't expect to see it on Monday unless King wants you to.
The underlying platysma (muscle) and sub-Q tissues are dissected and the carotid artery is isolated, from the common carotid to well beyond the bifurcation of its internal and external branches. After proximal and distal control of the artery is obtained, the patient is given anticoagulated. The internal, common, and external arteries are then clamped sequentially and a the artery is opened at the level of the bifurcation and extended proximally and distally. Some surgeons use a cerebral shunt which is inserted at this time.
The carotid plaque, consistently found at the carotid bifurcation and the origin of the internal carotid artery, is dissected out and removed through a dissection plane developed between the media and intima. Surgeons take great pains to create a smoothly tapered transition between the endarterectomized portion of the artery and its normal distal extent. This maneuver avoids intimal flaps which might lead to arterial dissection after flow is reestablished or perhaps become a nidus for platelet adhesion and thrombogenesis.
Before the artery is closed, the internal carotid artery (ICA) is unclamped distally and flushed free of debris in a retrograde fashion. This vessel is then reclamped and the common and external arteries are opened. This way, all the left over aretreial "gunk" is jettisoned via the external carotid artery prior to restarting antegrade flow, i.e. that blood which goes to the brain. This technique is based on prior experience showing that patients were coming out of surgery with new neurologic events despite the best efforts of the surgeons to remove all the plaque adhered to the wall of the artery. [Interestingly, when carotid stenoses are done percuatneously, i.e. by catheter, interventionalists use a distal occlusion device to prevent embolic events. However, the interventional community is having a tough time showing benefit, or even equivalence to CEA.]
Once hemostasis is achieved, a Jackson Pratt drain is left in the wound to minimize neck hematomas and the muscle and skin are closed. when King was waking from his anesthesia, a neuro check was performed and repeated probably every 10 mins for the first hour and then every hour during recovery to make sure the talking head wasn't slurring as a result of the arterial manipulation.
Below is a sweet slide presentation we found that provides a step-by-step approach to carotid surgery.
Wednesday, March 14, 2007
Here's what happened when we searched Google images for "The Match". Hopefully, you felt - not necessarily looked - like this guy on Monday, and not like the pic we didn't post of the girl with her head in her hands.
On Monday, March 12th, 4th year medical students all over the United States logged on to find out whether they did, or did not, match into any residency program.
For those of you who did not raise your arms with joy, keep the faith - at least you're not that dude in the picture. Also, if you want it bad enough, there are plenty of things you can do to improve your chances of matching next year or even filling an OpenSpot later on this year. Here are 4 courses of action to start:
1. Find somewhere to do research. But do your research first. Unfortunately, toiling under the assistant biochem tecaher's assistant most of the year will not serve you well. However, working for the assistant program director may yield great results.
2. Call Around - Every program that has OpenSpots does not necessarily advertise them well or enter the scramble or even try very hard to fill them. So, how hard is it to make 25 phone calls to programs in and around your area and in your specialty. Also, you might consider calling programs from a specialty that you could see yourself doing but may not have been your first choice.
3. Call a Trusted Mentor - This might be a good time to call that teacher or professor in your life that has some connections and work it! You would be amazed how much can change with a phone call from a friend. Swallow your pride, hide that ego and use every possible connection you have to see if you can get a break. Believe us, others did it!
4. Go to OpenSpots.com - Yeahg, it's a shameless plug but it's the most helpful webiste out there if you are post-scramble and pre-unemployment. We spend all the time finding these poorly advertised spots and you can view them for a paltry fee (just enuf to keep our servers functioning).
Tuesday, March 13, 2007
"I got to do it," Philbin said at the start of "Live With Regis & Kelly." "Darn it, I don't want to do it. Nobody wants to do it, I guess."
The diminutive but spry 75 yo male had been on a short hiatus, most likely to evaluate some ongoing chest pain issues that he had admitted to: "I had been feeling chest pains, you know, and, uh, shortness of breath and all those little symptoms that you hear about."
Philbin's refreshing candor about such a serious operation will most likely go a long way to educating his viewers about coronary artery disease and its treatment options. It also cuts out a lot of the investigative and speculative fun of our Celebrity Illness article, but don't worry, there's plenty to discuss.
Reege, as he is affectionately known, most likely presented to his PMD with c/o chest pain and fatigue and who knows what else. The guy is a huge college football fan and constantly boasts about his superior physical shape which will serve him well during this process.
Upon hearing his symptoms, it is possible that Reege was sent directly for cath, (i.e. cardiac catheterization) but more likely had a exercise-nuclear stress test first which should have suggested significant ischemia. Either way, coronary angiography was performed.
Why isn't he going for stent you ask? Currently, there are only a few hard and fast indications for CABG: 1) Left main (LM) coronary artery blockage >50%; 2)Triple vessel disease or 2-vessel disease involving the early portion of the left anterior descending artery (LAD).
If it was the former, there would have been no discussion and Reege would have most likely already been on the OR table by now. Thus, it is much more likely that he has stable multivessel disease and will have a left internal mammary artery (LIMA) graft to the LAD as well as some saphenous vein grafts harvested form his legs.
Coronary artery bypass graft surgery is associated with significant morbidity. Major complications include death, myocardial infarction (MI), stroke, wound infection, prolonged requirement for mechanical ventilation, acute renal failure, and bleeding requiring reoperation. This doesn't even include the nearly 50% incidence of post-op atrial fibrillation and all fo the complications inherent in AF. Using registry data in the United States, the perioperative and in-hospital mortality rate after CABG averages about 1% for the lowest risk elective patients, and 2-5% for all patients.
There are a few risk-predicting algorithms as outcome is hinged on comorbids but we're not gonna go there. Here are some factors that have a major impact on survival and complications:
- Pre-op LV function
- Kidney function
- Coronary diameter
- Operator experience
Are we getting too data-y for you? It's a tough surgery and you should know this before you send patients (or go for it as a patient) for what has become thought of as a fairly routine deal. It is also important to keep in mind that it has amazing benefits in almost 98% of patients.
Philbin will be facing a difficult recovery as his sternum will be sawed open to expose the heart and although he will be under general anesthesia at the time - he hopefully won't stay that way. After the recovery room, he'll be monitored in a special cardiac surgery ICU where they will hope to extubate him as soon as he can tolerate it. He will also have chest tubes and a pericardial drain following the surgery, all which will hopefully come out after POD#3. He should be out of the hospital b/n 5-7 days where he will gently recuperate and be maintained on good pain meds.
After about a month, Reege will be able to get his groove on again and we predict a late April/early May return for the daytime maven of talk.
We wish Philbin a speedy recovery and hope that he uses this opportunity to educate his audience about his experience and the preventive measures that can take in order to avoid a similar prognosis.
Friday, March 09, 2007
Several articles report that Lilly Rose was originally admitted for "blood poisoning" after stepping on a rusty nail at Depp's country home.
'Blood poisoning?' Another one of our favorite media pseudo-medical phrases. Why can't they use bacteremia, or infection, or even blood infection.
We decipher "blood poisoning" to mean bacterial infection disseminated to the blood causing a sepsis like picture. And considering the circumstances, i.e. rusty nail, one would have to assume that the offending bug would be Clostridium tetani, or tetanus. Or is it?
Actually, probably not. While more than 90% of pedal puncture wounds result from stepping on a nail. The most common organisms implicated in penetrating wounds are Staph aureus, beta-hemolytic streptococci, and then various anaerobic bacteria. Also, Pseudomonas aeruginosa is often responsible for infection when the injury is due to object penetration through shoes and socks.
Importantly, puncture wounds have the capability to infect deep spaces of the foot, including bones, joints, tendons, and deep fascia, and serious complications can arise. Therefore, the depth of penetration is hugely important.
The signs of more extensive injury are those typical of any infection, i.e. redness, warmth, pain, and swelling. If the offending object is still partly in there, e.g. broken glass or sea shell, it must be removed and the wound must be extensively debrided. Empiric ABx should be started to cover the most common bugs, i.e. S. aureus but anti-pseduomonals should be strongly considered as psudomonal osteomyelitis/-chondritis can be catastrophic.
It is our suspicion that Depp's daughter probably was treated inadequately or conservatively at first or perhaps even his the injury from her parents as kids can do and then presented 2-3 days after the injury with a warm, red, swollen foot. Imaging studies were performed for sure which included plain old x-rays to look for air and possibly a CT. CBC, Chem, and ESR were quite important in documenting infection and blood cultures were probably being sent every time the little one spiked a fever.
When she manifested systemic evidence of infection, broad spectrum IV antibiotics were certainly started and the wound was opened, any pus was removed, and the wound was most likely left open to heal on its own rather than sew it shut again.
Typically, in systemic bacterial infection, i.e. bacteria in the blood (bacteremia) patients will experience signs of sepsis: hypotension, tachycardia, fever, increased WBC. In addition to stroing anti-microbial therapy, IV fluids were probably used and maybe even pressors for blood pressure support.
This is a very scary situation for a little girl and her parents. We are happy to hear that she is out of the hospital and recovering. An interesting infectious disease topic nevertheless which proves our mantra: It sucks to be an interesting patient, but it's great to have an uneventful recovery.
Baldwin G, Colbourne M: Puncture wounds. Pediatr Rev 1999 Jan; 20(1): 21-3[Medline].
Patzakis MJ, Wilkins J, Brien WW, Carter VS: Wound site as a predictor of complications following deep nail punctures to the foot. West J Med 1989 May; 150(5): 545-7[Medline].
Wednesday, March 07, 2007
What is Joost™?
Joost™ is a new way of watching TV on the internet, which uses new and established technologies to provide the best of both the internet and TV worlds. We're in the process of making it as TV-like as we can, with programmes, channels and adverts. You can also see some things that we think will enhance the TV experience: searching for programmes and channels, for example, as well as social features like chat. There are many more new features to come!
Joost™ uses secure peer-to-peer technology to stream programmes to your computer. Unlike other TV and video-based web applications, it does not require users to download any files to their computers or browse through complicated websites.
Unfortunately, not everyone can enjoy this awesome new service as they are still in Beta testing but if you are lucky enough to know someone who has access, they can send you an entry ticket. Or, you can go to Joost.com and apply yourself. Good luck.
Tuesday, March 06, 2007
I was really looking for an excuse to include this pic of me and my son, Sammy, at the beach in Naples, Florida. If you have not been to the west coast of FLA, I highly recommend it. There is something a lot more laid back and relaxed about this area.
It does have the money of Palm Beach and Miami but it doesn't have all the cheese. And there's alot of cheese on the East Coast of FLA. For the prices, I just do not see the sense of going to played out, overcrowded, overrated bars and restaurants when I'm on vacation. If I wanted to do that, I could wait unitl the summer and go to the Hamptons.
This picture very accurately depicts the relaxing, mellow vive of Old Naples and I would go back any time.
Monday, March 05, 2007
The cat-like veep has amazing luck or a ridiculously attentive medical staff. Following an around-the-world trip which included more than 60 hrs of air travel, Cheney complained of slight calf pain which elucidated the DVT.
We can only assume that Cheney is already on standard anti-platelet therapy, aspirin and Plavix, considering his multiple stent history. Throw in some warfarin for this latest diagnosis and his blood will be "thinner" than Nicole Richie. Speaking of "thin blood", why do we use this euphemism and who came up with it? The blood's viscosity does not change at all. Is it really that hard to explain or understand that platelets help clots to form and these medications prevent the bonding of platelets to each other? It is due time that the media and PR flack start speaking of medical treatments in real terms rather than 3rd grade metaphors. If advertisors can advertise directly to consumers than consumers should understand medical terminology rather than psedo-scientific analogies.
Back to Cheney's hard-to-believe medical history, Dr. Cameron Akbari, a senior vascular surgeon at Washington Hospital Center in the District of Columbia, said Mr. Cheney’s history of heart disease puts him at only “a very slightly increased risk” of developing a deep venous thrombosis.
“Reasons No. 1, 2, 3, 4 and 5 why he developed this are he was on a very long plane ride,” Dr. Akbari said.
Ok. But why does he keep clotting every portion of his vascular bed. I am quite sure that Cheney has had the over-ordered hypercoagulable work-up, but he should also be tested for aspirin and clopidogrel resistance.
To clarify, it is unlikely that the clot lodged in Cheney's left leg is actually sitting in his calf. The vast majority of these thrombi sit in the larger, more proximal venous system. And lastly, Coumadin or Warfarin, will prevent further propagation of this clot but will not dissolve the clot - so the risk of PE is still there all you anti-Chenites.
One more interesting historical note: Warfarin was named in honor of the Wisconsin Alumni Research Foundation who discovered that coumarin, a byproduct of moldy silage, was a potent anticoagulant and the cause of bleeding cows. Warfarin was first registered for use as a rodenticide in the US in 1952, but its true mechanism of action, the inhibtion of vitamin K-dependent cofactors was not elucidated until 1978.
Sunday, March 04, 2007
The risk of illness was 'quite low,' but anyone who ate raw food at the magazine's Feb. 14 party was urged to receive a preventive shot by Wednesday, the LA County Department of Public Health said Tuesday.
The affected employee was placed on medical leave, said Carl Schuster, president of Wolfgang Puck Catering.
'We immediately worked to take every precaution to further safeguard our patrons and other employees,' Schuster said in a statement.
Sports Illustrated said in a statement that it was taking the situation very seriously and was working directly with county health authorities.
'We are alerting our guests and staff as quickly as possible to ensure they receive the relevant health warnings,' the statement said.
Hep A (HAV) is usually spread via the fecal-oral route, i.e. infected people share the yellowing virus through food and water that they handle – after touching their ass. It is more prevalent in low socioeconomic areas in which a lack of adequate sanitation and poor hygienic practices facilitate spread of the infection.
To get technical on your ass, (and for those of you prepping for Boards) Hepatitis A is a 27 nm, nonenveloped, icosahedral, positive-stranded RNA virus classified in the Heparnavirus genus of the Picornaviridae. But you knew that.
According to our favorite medical resource, UpToDate.com, community outbreaks due to contaminated water or food have also been described, shellfish being the most popular offender. However, several outbreaks related to consumption of “contaminated” green onions have been reported in the literature.
HAV infection usually results in an acute, self-limited illness and only rarely leads to fulminant hepatic failure.
The two most common physical examination findings are jaundice and hepatomegaly, which occur in 70% and 80% of symptomatic patients, respectively. Less common findings include splenomegaly, cervical lymphadenopathy, evanescent rash, arthritis, and, rarely, a leukocytoclastic vasculitis.
Laboratory findings in symptomatic patients are notable for marked elevations of LFTs (usually >1000 IU/dL), serum total and direct bili, and alk phos. Typically, ALT is higher than the AST and bilirubin levels above 10 mg/dL are not uncommon.
The diagnosis of acute HAV infection is made by the detection of anti-HAV antibodies in a patient with the typical clinical presentation. Serum IgM anti-HAV is the gold standard for the detection of acute illness.
Because the disease is usually self-limited, the treatment is supportive.
But believe us, it would be a lot more than supportive if one of the celebs turned yellow.