June 30th, 2009 by Medgadget in Better Health Network
Tags: Bones, Ceramic, Orthopedic Surgery, Prosthesis, Wood
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Wooden legs sure have come a long way since they were first used as artificial prostheses. In the latest issue of Journal of Materials Chemistry, there is a report on the recent developments at the Institute of Science and Technology for Ceramics in Italy in which scientists have turned wood into something similar to bone, a material that may one day be used to create custom replacement parts.
Researchers heated the wood to decompose organic material to leave only the carbon template. Then, they reacted the template with calcium, oxygen, and carbon dioxide to form calcium carbonate that was then converted to hydroxyapatite. This hydroxyapatite scaffold mimics the structure of bone. The advantage of this process is the architectural make-up of the wood’s structure that affords the ability of cells and blood vessels to grow through it, much like real bone.
‘Current [hydroxyapatite] production processes do not generate an organised hierarchical structure,’ says Anna Tampieri. ‘Materials able to maintain adequate properties at extremely high temperatures and mechanical stress are highly sought after for use in several different applications, such as space vehicles. An intriguing possibility is that of simultaneously achieving high values of strength and toughness, for which ordinarily there is a trade-off. In addition, new materials with extreme physical properties, such as thermal expansion or piezoelectricity, can be obtained.’
More from the Journal of Materials Chemistry : Trees take on tissue engineering; From wood to bone: multi-step process to convert wood hierarchical structures into biomimetic hydroxyapatite scaffolds for bone tissue engineering…
*This blog post was originally published at Medgadget*
June 30th, 2009 by DrRob in Better Health Network, Humor
Tags: Arm, Orthopedic Surgery, Physical Exam, Physical Medicine And Rehabilitation, Shoulder, Upper Extremity
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Yes, it’s time for another installment of my series on the physical exam. The goals of this series are:
- To educate my readers on the intricacies of the physical exam.
- To teach the anatomy and physiology as it relates to different parts of the human body.
- To delight my readers with my wit and fine prose.
- World peace.
So you see, through my hard work and persistence (writing almost 30,000 words about the physical exam so far), I have come nowhere near any of these goals. In fact, I have made absolutely no progress toward world peace. I think I’ve been banned in Iran for using the word “Shuttlecraft” too many times.
Maybe I just need some new goals. How about these:
- To irritate my high school English teachers.
- To cause at least 200 people to waste time that they could have spent watching Oprah.
- To make sure Canada stays north of us and does not sneak to Florida.
- To put those pesky French people in their place.
Yes, I think those are much better goals.
Extremely Upper
Our journey over the human body has now led us to the long things that stick out of the top of your torso that have those grabby things on the ends. We doctors call these things arms. There are some hoity-toity doctors who call them the upper extremities. These are the doctors you don’t want to invite to dinner, as they will probably tell you disgusting scientific facts about the food you are eating. Consider yourself warned.
The exam of the arms is usually only referred to vaguely during routine exams. Most docs don’t deal with the arms unless they pick up subtle clues that are discovered only by trained professionals, like when the patient says “I’m having problem with my arms”. We doctors are proud of our mad skills.
What I am driving at is that the arm exam is a problem-oriented exam. If you have a boo-boo, the doctor looks at it and sees if a kiss will make it better. If a kiss doesn’t work, usually an anti-inflammatory will (but we’ll get to that later). And boo-boo problems with the arm are usually specific to the longitude and latitude on the body. So today we will discuss the shoulder.
The Shoulder
The shoulder is a joint – meaning, it is a place where your body bends. Without joints, your arms would be unwieldy and you’d whack everyone who came near to you. Not only that; it would also make it impossible to put on deodorant. So between whacking people and offending them with your odor, a jointless existence would truly be a hard one. We all should thank our joints more often.
There is not a more complex joint in your body than your shoulder. Here are some amazing facts about the shoulder:
- There are three bones that are involved in different types of movement: the collarbone (clavicle), shoulder blade (scapula), and humerus (not humorous).
- There are at least 18 muscles that are involved in shoulder movement. Two of them have the word “rhomboid” in them. I like the word “rhomboid.”
- When people say the word “shoulder,” they may be referring to the joint, and they could be referring to the top part of their torso – between their neck and shoulder joints. This is a sad testimony to the English language and just serves to make the jobs of medical professional all the harder.
- The word “shoulder” rhymes with a lot of of words and so is very useful in poetry. For instance:
You shouldn’t have told her that she’s looking older
She wants you to hold her with arm on her shoulder
And go get the folder that llamas once sold her
But there on the boulder the weather is colder.
A fine Jell-O mould or perhaps something bolder
Has rocked her and rolled her but never controlled her
So anger may smolder at cellular slime mold or
Other thingies, sort of.
See? Pretty amazing, isn’t it? Try doing that with “elbow!” Perhaps Dino could write a haiku about it.
So it should not be seen as a coincidence that the shoulder has by far the largest range of motion of any of the joints in the body. This makes things very confusing for medical students when they have to describe the motion, as the joint doesn’t follow any of the rules the other joints have agreed upon. Most joints can be bent (flexed) and straightened (extended). Some joints (like the wrist) can be hyperextended and rotated as well. All the other joints are content with these motions. Is this good enough for the shoulder? Not even close.
Here are the basic movements of the shoulder:
1. Flexion – moving the arm forward toward the chest.
2. Extension – moving the arm toward your back.
3. Abduction – Being picked up by aliens and brought to their mother ship. (This also refers to lifting your arms up from your sides).
4. Adduction – Bringing your arms down back to your sides
5. Rotation – Turning the arm around the axis of the humerus bone.
I have suggested a few more motions that may be added to the roster:
6. Subflaxion – What you have to do to your shoulder to get your elbow in your ear.
7. Soufflétion – When your shoulder is mixed with eggs and baked at 400 degrees.
8. Mallardduction – When your shoulder gets down.
So far the shoulder committee hasn’t answered my mail. I’m not sure why.
But really, the shoulder is very confusing to many medical professionals. The range of motion is so great that it blurs the lines between the typical movements. For instance, adduction is supposed to be when the limb is moved toward the body’s midline. The shoulder makes this difficult. When you put your arm by your side and when you raise it over your head, you move it toward midline. Both could be considered adduction. The same is true with flexion and extension – when is the shoulder joint opened up and when is it closed?
Really, in this modern time we should give up this archaic nomenclature and instead use a GPS device to determine shoulder position.
Wow. 1000 words already and I haven’t gotten to the actual exam. I’ll give it a rest now and let you ruminate on words that rhyme with “elbow.”
I probably should sober up as well.
*This blog post was originally published at Musings of a Distractible Mind*
June 30th, 2009 by Happy Hospitalist in Better Health Network, Opinion
Tags: CMS, Donut Hole, Drugs, Finance, Generics, Medicare, Pharmaceuticals, Pricing, Seniors
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The drug makers have agreed to cover part of the costs of brand name drugs in the donut hole, that no man’s land of Medicare Part D where patients must pay for their own drugs.
As reported:
Obama said that drug companies have pledged to spend $80 billion over the next decade to help reduce the cost of drugs for seniors and pay for a portion of Obama’s health care legislation. The agreement with the pharmaceutical industry would help close a gap in prescription drug coverage under Medicare.
I see one problem with the assertion that drug companies will be “spending” $80 billion dollars to reduce the cost of drugs for seniors. Drug companies and by default, their board of directors have allegiance to their shareholders, not the the US government or the seniors of this country. I can assure you, this deal may look good on paper (for seniors) and it may benefit seniors a great deal (FREE=MORE) but it is also one step further to the promised land of the senior vote. And it will worsen access to drugs for everyone else. There is no free lunch in this world.
It may save seniors money, but it will not be revenue neutral. It will not save $80 billion dollars over 10 years or reduce overall costs of care. Somehow, someway, the costs will be shifted. It may mean higher drug costs for those privately insured or the uninsured. It may mean decreased access to compassion programs. It may mean higher costs to hospitals. Whatever the agreement means, it will not mean $80 billion dollars saved in the next decade.
Drug companies are not in the business of sacrificing their shareholders or bond holders for patriotic means. They are in the business of making money. And that means they have selfish interests to maximize their ROI for any agreement they make with the government.
The question isn’t really how wonderful this is for seniors. The question is how will buying off seniors affect the rest of America. And I’m telling you here, right now, you will see higher costs for everyone not lucky enough to bathe in a sea of FREE=MORE known as the Medicare National Bank.
*This blog post was originally published at A Happy Hospitalist*
June 29th, 2009 by Nancy Brown, Ph.D. in Better Health Network, Health Tips
Tags: Advice For Parents, Dating, Pediatrics, Psychology, Relationships, teens
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After you get over the urge to run and hide, lock your teen in the bathroom, shave his or her head, and save yourself, take a deep breath and think about what is important here. You are likely panicked because you know that sooner or later someone will break your teens heart – and there is nothing you can do about it, or is there?
Talk to your teen and share what you are feeling as well as what you know. Being new to the world of love/lust/hormones, there are some really great conversations to be had now about balance, friendship, and healthy relationships! First, your teen may be overwhelmed with how wonderful it feels to be in love and you can help remind your teen about balance, and the importance of not losing themselves for love. Your teen needs to stay “true to self” instead of becoming an appendage to the new love. Encourage your teen to stay connected to friends, school, outside activities, family, and sports, while making room for the new love.
You might mention that if that becomes an issue, you can help by setting limits on the amount of hanging out at home, phone, text, and computer time, to help her learn to balance life and love/lust/hormones. This is not a threat – just a supportive way to help your teen transition in the world of love!
Together you can set the expectations that honor this new part of life, make your teen feel listened to and involved with the new contract – the new couple spends time with the family, grades stay up, activities continue, chores, whatever else her life includes must all continue – because your teen has to be a “person” first before a girlfriend or boyfriend. The We’re Talking web site has a great section called the abcs of healthy relationships, which will provide many reminders about knowing when a relationship is not healthy.
Along those same lines, it is important to talk about the importance of friendship – and how you want the first few months together to be spent with family – because early in relationships the goal is to learn to trust each other, find things that you have in common, and become parts of each others lives. Friendship is stronger in the long run than hormones – and if either member of the couple is motivated by anything else other than love – s/he will not make it through the “getting to know all about you” phase.
P.S. Remember that the greater the age difference, and the more time alone they share, the more likely teens will take new love to sexual realms, so be aware and good luck!
This post, When Your Teen Starts Dating, was originally published on
Healthine.com by Nancy Brown, Ph.D..
June 29th, 2009 by Shadowfax in Better Health Network, Opinion
Tags: Internal Medicine, Mass General, Medical Errors, Physicians, Quality, Residency, sleep deprivation, Surgery, Training, Work Restrictions
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Surgery Residency, Massachusetts General Hospital and Work Limits – Health Blog – WSJ
It’s not surprising that newly minted doctors at one of the most prestigious hospitals in the country, and in a specialty with a particularly demanding residency, have been violating national limits on work hours.
But the Boston Globe’s report that Massachusetts General Hospital must rein in surgical residents’ hours is a reminder that the work limits put in place several years ago remain unpopular with many residents and senior doctors.
Not surprising in the least. I’m actually astonished that there’s anybody with the chutzpah to defend extended work hours for residents. I did my residency largely in the pre-hour-restriction era — there were hour restrictions on months in the ER, but effectively none for the off-service rotations — and it was a terrible way to deliver care. I did my time of q3 call in the units and q2 call on surgical services. This includes a memorable time when I was the sole intern on the pediatric surgical service and was on duty for ten days straight without leaving the hospital. That gives a new meaning to being a “resident physician!” (Actually, that’s the original meaning, if you must get picky about it.)
The care provided was just scary. I prided myself on being a machine and able to get through 36 hours of uninterrupted work without cracking; I used to run marathons and endurance was my forte. And I did get through it better than most. But after 24 hours with no down time (and there was never meaningful down time), you get stupid, and you make mistakes. I remember once, in the medical ICU I was surprised in morning rounds to find that one of my patients had had a swann-ganz catheter placed overnight. Caught flat-footed by this in front of the attending, I asked the nurse who had put in a swann without telling me, only to be informed that I had done the procedure! Apparently I was too sleep-addled to recall that I had done it! Fortunately, I had apparently done it right, because a swann involves threading a catheter through the heart into the pulmonary vessels and can be Very Bad [tm] if you screw it up. But I apparently did it by reflex without actually achieving a state of full wakefulness. This sort of thing was fairly routine, and I also remember well the overnight residents being excoriated in morning rounds for the errors and misjudgments they had made overnight. Great training, but not so great for the patients who were the victims of the mistakes.
It seems to me that the defenders of the status quo have donned their rose-colored glasses. They fondly remember the camaraderie and the pride in accomplishment that their residencies evoked, while conveniently forgetting the mistakes and omissions, while neglecting the depression and divorces and other personal costs of such an abusive training environment. And there’s the faux toughness: “I got through it, they can, too if they’re not too weak.” And the old guard romanticize the qualities of the “true physician” in their dedication to their patients above all else: “These younger doctors just don’t care enough.”
What a load of crap.
Look, it’s with damn good cause that other professions in which errors can hurt people have work time restrictions (truck drivers, airline pilots, etc), and it’s stupid and arrogant to think that we physicians are so awesome that we are immune to the human factors of fatigue and circadian rhythms that contribute to errors. When it’s inexperienced trainees working the ridiculous hours with minimal supervision (in many cases), the potential for fatigue-related errors is compounded.
I also question the motivations of some of those who defend the status quo. It seems strangely self-serving that residency directors who would otherwise have to find attending physicians or PAs to perform the work that residents do on the government’s dime are the ones to insist that the situation is just fine, or that “the evidence of benefit is lacking.” How cool is it that they can ignore reams of research on human factors, take the a priori position that the system is fine as it is, and demand formal evidence on “efficacy, safety and cost” before making any changes? That’s balls! It’s also fairly blatant obstructionism and should not be given any credence.
Dr Bob of Medrants has some thoughtful comments on the matter, mostly pleading for flexibility in the new rules. I would mostly agree, excepting that flexibility is best given to those who have proven themselves trustworthy, and residency directors (especially but not exclusively of surgical training programs) have repeatedly and flagrantly flouted the rules thus far imposed. Flexibility is fine, but accountability should also be demanded.
I would also take issue with Dr Bob’s comment that this “training system that has served our profession well for many years.” I look at the statistics on physician burnout, substance abuse, divorce, depression and suicide. They are terribly concerning. I would not lay all of this at the feet of residency, but I would say that the abusive (I’m sorry, “rigorous”) environment of residency training sets the tone for the culture of machismo that harms physicians as much as it harms patients. Nobody is well-served by the current system.
It is true that change might be painful. Reducing hours might mean reducing patient contacts and reducing the training opportunities for physicians. This might require academic centers to revalue the time of physicians in training, by which I mean that residents might no longer be used as free menial laborers. Maybe it doesn’t make sense to have a surgical resident “running the book” — many surgical residents never see the inside of the OR till their second and third years. The universities might have to hire PAs or NPs for the “scut work” instead of using MDs in training as glorified secretaries (what a waste of time and money).
I’m glad the Institue of Medicine and the ACGME seem to be on the right path with the recommendations. The reactionary response from the change-resistant academic centers will take some time and political will to overcome. I remember when they first imposed the rules, they followed it up by decertifying the Internal Medicine program at Hopkins for violating the rules. That effected the desired change, I can tell you! Hopefully, as the restrictions evolve, there will be accountability and enforcement until the culture starts to shift.
*This blog post was originally published at Movin' Meat*
