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Grand Rounds 3.38 Immediate Release

Welcome to the latest round up of the best of the healthcare
blogosphere. Today it is my pleasure to offer you your weekly dose of Grand
Rounds, optimized for your state of mind.
I believe that there are two basic types of blog readers, and so you’re
getting Grand Rounds 2 ways (with a dash of cartoons thrown in for extra “feel
good” measure):

  1. Just
    the Facts
    : Distractible, hurried, currently in between seeing patients –
    or perhaps your kids, cats, dogs, llamas are begging for attention… or
    maybe you’re an ER nurse or surgeon who has no patience for long winded
    stories?  You’re category one and
    should proceed directly to Grand Rounds IR (immediate release – below).
  2. All
    the Details
    : Calm, peaceful, you enjoy good prose and a cup of chai
    latte.  You like reading all the
    juicy details of a grand rounds line up and will spend hours picking
    through the references – or maybe you’re an Internist or Psychologist who
    knows that the best medicine is found in the details?  You’re category two and should proceed
    directly to Grand Rounds XR (extended release – next post).

Many thanks to Nick Genes, father of Grand Rounds (who acts
behind the scenes to ensure the success of each host), and please check out
next week’s Grand Rounds at Code Blog: Tales of a Nurse.

Grand Rounds IR (asterisk
= honorable mention for great writing)

Happy Posts

*Starbucks Caters to Diabetics

Woman Saved by Bush Pilot in Frozen Tundra

*CEO Says He’s Sorry

Prayer Can Reduce Arthritis Risk?

*Disaster Unpreparedness [Cartoon]

Med School Graduation Ceremony [Cartoon]

Nurse uses Star Trek Mentor to Set Course for Kindness

Shrink Rap Podcast: Prank Call with Dr. Phil McGraw &

*Cape Cod Vacation Derailed by Flood, Stroke, Famine & Infection

The Evils of Hand Washing

Sad Posts

Triage in the ED [Cartoon]

*Sad Cases in ED

Elderly at Risk of Death From Tranquilizers [Cartoon]

Life as a Nurse Assistant in Vermont

Hot Topics



Healthcare Outsourcing (podcast)  [Cartoon]

Blog Censorship A

Blog Censorship B

Arrogant Docs [Cartoon]

Should Kim See Sicko?

Helpful Tips

To Fend off Bears

To Get the most out of Medicine, Web 2.0 style

To Get into Medical

To Avoid Kidney Damage from Contrast Agents

To Perform A Pyloromyotomy [Cartoon]

To Diet Successfully – Gluten Free [Cartoon]

Case Reports


Rare pancreatic tumor


Cost-benefit analysis of genetic testing

Commencement Speech for Harvard Medical
School Graduation

New Alzheimer’s Research [Cartoon]

New Genetic Research

Book Recommendation for Type 2 Diabetes

For the full text version complete with cheerful commentary, please go to Grand Rounds XR
(next post)

This post originally appeared on Dr. Val’s blog at

Grand Rounds 3.38 Extended Release

…continued from Grand Rounds 3.38

(asterisk = honorable mention for great writing)

Happy Posts

*Kerri from Six Until Me tells the heart-warming story of a
Starbucks Barista who understood her diabetic needs and treated her with
special care.

Traveling Doc from Borneo Breezes Blog, submits a post about
the bush pilots of the Canadian north.
Even though it’s summer time you’ll shudder at this arctic tale of a
native woman whose life was saved by a bush pilot and an Australian surgeon.

Tony Chen of Hospital Impact submits a post by Nick Jacobs, the CEO of Winder Medical Center.
In it Christopher apologizes for being ill tempered and snapping at a
woman who posted a paper sign on the wall.

Dr. Jolie Bookspan of the Fitness Fixer Blog offers a
fascinating look at the physical healing power of prayer.  Jolie reports that the movements involved in
Muslim prayer (including standing, bowing, kneeling, and sitting) can promote
flexibility, increase quad strength, and burn up to 80 calories/day.  She explains that similar prayer posturing
(found in Russian Orthodox prayer and some forms of yoga meditation) may be
equally useful.

Rita Schwab at MSSP Nexus Blog writes a really funny post
about disaster preparedness.  She muses
about how she had been taught to hide under her school desk in case of a
bombing, and even then (at the tender age of 8) wondered how the desk vs. bomb
equation would really pan out for her.
But the real amusement comes when you click on her link to the CDC’s
recommended communication releases on such plagues as tularemia.  Yes, the bacterium found in rabbits and
rodents (that perhaps 125 hunters succumb to each year in this country) is not
contagious from human to human and causes flu-like symptoms.  I’d give this a fear factor of 1 out of 10.  [Cartoon]

Dr. Bruce Campbell of Reflections Blog describes the medical
school graduation ceremony – the first time “doctor” is officially tied to the
graduate’s name.  [Cartoon]

Mother Jones, RN from Nurse Ratched’s Place, confesses to
being a trekkie.  She did find a good
role model in nurse Chapel, though.  Now
here’s my confession: I’ve been known to utter a few “Damn it, Jim-s!” when
asked to do non-medical related work at my current job.

at Shrink Rap pulls a “Jerky Boys” style practical joke on Dinah.  He uses prerecorded audio clips of Dr. Phil
McGraw to simulate a live Skype conversation with her, and gets Dr. Phil to ask
Dinah outrageous questions and give her bizarre advice such as, “I want you to
live as a gay woman.”  Poor Dinah falls
for it for a short time… and it’s rather funny, especially if you enjoyed the
Jerky Boys prank call to Hooters with Arnold Schwarzennegger clips.  [Cartoon]

Laurie at a Chronic Dose tells a hilarious story of 3 chronically ill family members who experience a comedy of errors during a vacation in Cape Cod.  Somewhere between the brain aneurysm, flood, sunburn turned staph cellulitis, and cell phone lost in the ocean, there’s humor in the midst of tragedy.

Susan Palwick from Rickety Contrivances of Doing Good describes the evolution of hand washing requirements for all staff (including chaplans) at her hospital.

Sad Posts

ERnursey from ERnursey: Stories from an Emergency Room Nurse
gives us an eye-rolling perspective on exactly how emergency departments are
abused by drug-seekers and non-emergent cases of ridiculousness.  Triage ain’t easy.  [Cartoon]

*Type B Pre-med from the blog by the same name, offers a
tear jerking slice of life from the ED.
A woman with breast cancer finds out that it has metastasized to her
brain while a 9 year old sexual assault victim waits for the doctor to see him

Christian Bachmann from Med Journal Watch reminds us that
tranquilizing medications are associated with shorter lifespans in the demented
elderly population.  [Cartoon]

Matthew at Path Lab tells the sad story of a bariatric patient’s woes in the hospital, and what daily life is like for nurse assistants.

Hot Buttons

Dr. Tara Smith at Aetiology, discusses the tragedy of
infanticide, and the events that led up to the recent murder of a newborn in Iowa.  She asks whether designated “safe havens”
(where mothers can drop off unwanted babies, no questions asked) are not
promoted enough by the media or if the state of mind of a woman who has just
given birth to an unwanted baby wouldn’t be receptive to that messaging.

Dr. Hsien-Hsien Lei interviews the CIO of Suracell Personal
Genetic Health to try to get to the bottom of whether or not nutrigenomic
testing is a form of hucksterism.  This
quote followed an objection about nutrigenomic supplements costing more
than similar products in health food stores: “Well, our clients like paying
more for what they believe is something better than the cheaper versions.”  Orac should take a look at this.

David Williams of Health Business Blog submits a
thought-provoking podcast of a recent interview he conducted with the founder
(founded in 2002) and creator of Planet
Hospital, Rudy
Rupak.  Rudy starts the podcast
explaining that his company arranges surgical treatment for travelers who need
emergent care in foreign countries, but later on explains that the primary
income stream for Planet
Hospital involves
healthcare outsourcing for American women who are “too wealthy for Medicaid and
too young for Medicare” and want cosmetic procedures or IVF done at a lower
price.  Rudy then explains that he has a
program called “the best of both worlds” where plastic surgeons travel overseas
to perform their procedures for cash – outside of malpractice laws and with
lower overhead. [Cartoon]

Henry Stern, at InsureBlog comments on the recent loss of
Flea and other medical bloggers.  He says
that “There’s a creeping reticence in the blogosphere… and maybe that’s a good

Amanda from It’s All About the Walls marries her frustration
with her own health issues with some frustration at the apparent censorship of
certain bloggers.

N=1 from Universal Health offers this challenge – doctors
should try to get outside of their egocentric shells and get to know (and learn
from) all of the knowledgeable, competent allied
health professionals around them, especially nurses. [Cartoon]

Kim at Emergiblog expresses deep inner conflict about going to see Michael Moore’s new movie, Sicko.  If she goes, she donates $10 to his cause, if she doesn’t go she’ll be left out of a hot topic of conversation.  This is a tough call, fair sister.

Helpful Tips

Dr. Auerbach from Healthline describes how to handle
encounters with bears.  I didn’t realize
that humans should respond differently, depending on the kind of bear.  Check out what to do if you run into a
Grizzly versus a Black Bear.

Bertalan Meskó from Science Roll lists some “Web 2.0”
activities for patients and physicians alike.
But Bertalan forgot about Revolution Health!

Sarah (a bubbly Aggie from Texas A&M) has some
practical tips on how to get into medical school.

Dr. Joshua Schwimmer from Healthline explains that
Gadolinium used to be the contrast agent of choice for patients with kidney
disease (since the regular iodine-based agents can cause “contrast
neuropathy”) but now new cases of a scleroderma-like condition (called
“nephrogentic systemic sclerosis”) have been associated with Gadolinium.   Bottom line: if you have kidney disease, any
sort of contrast dye is risky!

Dr. Lisa Marcucci from Inside Surgery offers up the
technical how-to’s for an open pyloromyotomy to repair baby stomachs.  Some little ones are born with a narrow,
thickened area in the junction between the stomach and the intestine so food
can’t pass through.  But thank goodness
for surgeons like Lisa who can fix them in a jiff!  [Cartoon]

Chronic Babe describes her impulsive eating habits and what
she’s going to do to try to avoid chocolatey, salty days in the future.  [Cartoon]

Case Reports

Dr. Ves Dimov of Clinical Cases and Images – Blog –
discusses the New England Journal’s recent case report of Acute Wiiitis
(contracted as an overuse injury from the Nintendo video game Wii remote
control).  He rightly points out that as
far as medical nomenclature is concerned, “itis” is more appropriately appended
to the name of the affected body part (e.g. tendon-itis).  As far as we know, a Wii remote is not part
of the human body – though one can see how the NEJM editors couldn’t resist
accepting the resident physician’s title selection.

Dr. Iñarrito-Castro from Unbounded Medicine presents a
fascinating case report of an exceedingly rare pancreatic tumor.  Beautiful imaging and photos.


Dr. Keith Robison of Omics! Omics! Blog describes his
thought process of what it might take to determine the underlying genetic cause
for one little girl’s unknown syndrome.
In the end he suggests that it might cost $1 million (to map her entire
genome) and result in no clinically useful benefit.  In this cost-benefit analysis, it looks as if
mom got it right – love the child as she is, and spend your money on mobility
enhancing equipment.

Dr. Joe Wright submits his commencement speech (for
Harvard’s graduating class of MDs and DDSs) for your consideration.

Girlvet from Madness: Tales of an Emergency Room Nurse
describes some promising research in Alzheimer’s Disease and how her own mom died in a nursing home from complications of the disease.  [Cartoon]

Nurse JC Jones from Healthline, highlights the recent
Wellcome Trust announcement of significant advances in the genetic
underpinnings of several major diseases. She includes a recent photograph of
James Watson (of Watson and Crick fame), who is now 79 years old.

Rachel from Tales of My Thirties highly recommends a book
about Type 2 Diabetes.


Now, because Dr. Val has a keen eye and is very meticulous, she has rounded up some savory morsels that she found on her own – these posts were not formally submitted to Grand Rounds 3.38, but will be included because she’s sure their authors wouldn’t object:

Dr. Richard Reece from MedInnovationBlog summarizes Regina Herzlinger’s arguments for consumer driven healthcare.

PandaBearMD explains why he believes that Chiropractors are quacks – and other controversial issues.

Kevin, MD points out that while websites designed to allow patients to rate doctors are gaining acceptance, websites that allow clients to rate lawyers are causing a legal meltdown.

Dr. Stanley Feld (former President of the American Association of Clinical Endocrinologists) takes a very well argued swipe at Dr. Steve Nissen’s recent article about Avandia in the New England Journal of Medicine.

Dr. Charles exposes the quackery of Dr. Heimlich (of the Heimlich maneuver).

Dr. Au from the Underwear Drawer accidentally summarizes the difference between men and women in a conversation with her husband about whether or not to save an old medical school name tag.

Dr. Rob from Musings of a Distractible Mind offers some hilarious genetic explanations for male/female differences.

Hallway Four captures a fascinating disconnect between what a patient thinks a doctor is doing and what a doctor is actually doing.

Dr. Hildreth at the Cheerful Oncologist gives us 8 ways to cope with a malpractice lawsuit.

Dr. Scalpel presents a case of a scratch (plus toenail fungus) sufferer presenting for a work excuse.

#1 Dinosaur argues that obese doctors are more empathic counselors for obese patients who wish to lose weight.

TBTAM recounts a sexual history dialogue in which a patient had condoms delivered at 5am from a local deli.

Ian from ImpactEDnurse continues the condom refrain with an interesting analogy: how practicing “safe nursing” is like practicing safe sex.

FLASHBACK:  And for the all time coolest classic blog post… let’s go back to GruntDoc circa 2004 for a look at the scariest menace in the ED: “Some Dude.”

Thanks for reading!  Hope you’ll tune in for our regular Wednesday feature of Revolution Rounds – the best of the 27+ person Revolution Medical Blogger team posts, organized and served up friendly by yours truly.This post originally appeared on Dr. Val’s blog at

Honesty: a new policy for drug companies?

I was struck by two different news stories today – one in the New York Times, and the other in the Washington Post.  Although the topics were different, the underlying theme was unified: drug companies (particularly Glaxo Smith Kline?) are coming clean with research data and marketing messages.  Sure, it might have taken a law suit by Eliot Spitzer to shine a light on the common practice of witholding negative research information from scientists… and it also may have taken a costly failure of an over-hyped diet pill by a competitor drug company to cause GSK to take the honest marketing track with Alli… But I like this new honesty, however we got to it.

Did you know that drug companies spend billions of dollars to research the safety and effectiveness of their drugs, but then are under no obligation to share what they learn with the general scientific community?  No, they share what they want to – generally the studies that show the largest effect or the greatest safety profile.  But now, physicians have been given access to the raw data collected in all the trials (showing benefit, no benefit, or harm) conducted by GSK.  And they’re having a field day!  A new study published in the New England Journal of Medicine is based on an analysis of GSK’s research, where they have found that Avandia (a popular diabetes drug) may put people at higher risk for heart attacks and heart related death.

Now here’s the devil in the details (as Dr. Charles rightly points out): the potential harm has been blown way out of proportion – the media has been citing “a 43% increase in heart attacks/myocardial infarctions and a 64%
increase in death from cardiovascular causes” when another way of stating what the authors found is that 86/14,371 patients or 0.598% of the patients taking Avandia had a heart attack, while 72/11,634 or 0.619% of people
not taking Avandia also had a heart attack.  Gee… which sound bite seems more scary?

Honestly, I feel worried for the general public who are now (with the new full disclosure of drug company data) sure to be victims of an onslaught of media hype around all sorts of small differences found in research studies.  Believe me, it’s important to sift through all this data to look for early signs of potential drug related health risks – but I think we should be careful before we terrify our patients with scary statistics.

Maybe in the midst of all this new honesty – we can have medical bloggers like Dr. Charles and the Revolution Health team help patients get to the bottom of things without having to have a PhD in biostatistics.  We need a voice of reason to translate research data for public consumption.  I’ll do my part – but since there are ~6000 research studies published per day in this world… I need some back up.  Any takers?This post originally appeared on Dr. Val’s blog at

References for HRT post

These are the references for the post about HRT and “chemo brain:”


1. Gross J. Lingering fog of chemotherapy is no longer
ignored as illusion. New York Times April 29, 2007 p1.

2. Paganini-Hill A, Henderson VW. Estrogen replacement
therapy and risk of Alzheimer’s disease. Arch Intern Med 1996;156:2213-7.

3. Tang MX, Jacobs D, Stern Y, Marder K, Schofield P,
Gurland B, Andrews H, Mayeux R. Effect of oestrogen during menopause on risk
and age at onset of Alzheimer’s disease. Lancet 1996;348:429-32.

4. Manly JJ, Merchant CA, Jacobs DM, Small SA, Bell K, Ferin
M, Mayeux R. Endogenous estrogen levels and Alzheimer’s disease among
postmenopausal women. Neurology 2000;54:833-7.

5. Chung SK, Pfaff DW, Cohen RS. Estrogen-induced
alterations in synaptic morphology in the midbrain central gray. Exp Brain Res

6. Jones KJ. Steroid hormones and neurotrophsim:
relationship to nerve injury. Metab Brain Dis 1988;3:1-16.

7. Nilsen J, Diaz Brinton R. Mechanism of estrogen-medicated
neuroprotection: regulation of mitochondrial calcium and Bcl-2 expression. Proc
Natl Acad Sci USA 2003;100(5):2842-7.

8. Nilsen J, Brinton RD. Mitochondria as therapeutic targets
of estrogen action in the central nervous system. Curr Drug Targets CNS Neurol
Disord 2004;3(4):297-313.

9. Alvarez-de-la-Rosa M, silva I, Nilsen J, Perez MM,
Garcia-Segura LM, Avila J, Naftolin F. Estradiol prevents neural tau
hyperphosphorylation characteristic of Alzheimer’s disease. Ann NY Acad Sci

10. Singh M, Meyer EM, Millard WJ, Simpkin JW. Ovarian
steroid deprivation results in a reversal learning impairment and compromised
cholinergic function in female Sprague Dawley rats. Brain Res. 1994;644:305-12.

11. McEwen B, Alves S. Estrogen actions in the central
nervous system. Endocrin Rev 1999;20:279-307.

12. Kampen DL, Sherwin BB. Estrogen use and verbal memory in
healthy postmenopausal women. Obstet Gynecol 1994;83(6):979-83.

Shaywitz SE, Shaywitz BA, Pugh KR, Fulbright RK, Skudlarski P, Mencl WE,
Constable RT, Naftolin F, Palter SF, Marchione KE, Katz L, Shankweiler DP,
Fletcher JM, Lacadie C, Keltz M, Gore JC. Effect of estrogen on brain
activation patterns in postmenopausal women during working memory tasks. JAMA

14. Duff SJ Hampson E. A beneficial effect of estrogen on
working memory in postmenopausal women taking hormone replacement therapy. Horm
Behav 2000;38(4):262-76.

LeBlanc ES, Janowsky J, Chan BKS, Nelson HD. Hormone replacement therapy and
cognition. Systemic review and meta-analysis. JAMA 2001;285(11):1489-99.

Zandi PP, Carlson MC, Plassman BL, Welsh-Bohmer KA, Mayer LS, Steffens DC,
Breitner JC. Hormone replacement therapy and incidence of Alzheimer’s disease
in older women. The Cache County
Study. JAMA 2002

MacLennan AH, Henderson VW, Paine BJ, Mathias J,
Ramsay EN, Ryan P, Stocks NP, Taylor
AW. Hormone therapy, timing of initiation, and cognition in women aged older
than 60 years: the REMEMBER pilot study. (Research into Memory, Brain function
and Estrogen Replacement). Menopuase: The Journal of the North American
Menopause Society 2006;13(1):28-36.

Shumaker SA, Legault C, Rapp SR, and the WHIMS investigators. Estrogen plus
progestin and the incidence of dementia and mild cognitive impairment in
postmenopausal women: The Women’s Health Initiative Memory Study: A randomized
controlled trial. JAMA 2003;289(20):2651-62.

Shumaker SA, Legault C, Kuller L, et al. Conjugated equine estrogens and
incidence of probably dementia and mild cognitive impairment in postmenopausal
women: Women’s Health Initiative memory Study. JAMA 2004;291(24):2947-58.

This post originally appeared on Dr. Val’s blog at

Hormone Replacement Therapy: It Might Be Good For Your Brain?

Every now and then I have the pleasure of featuring a guest blogger – someone whose medical opinions are particularly intriguing or controversial.  Dr. Avrum Bluming submitted a really interesting post last month about cancer – and whether or not we scientists really do understand it fully.  In this post, Dr. Bluming reviews the scientific literature on Hormone Replacement Therapy, and finds some interesting evidence that estrogen might actually be good for the brain – to reduce the risk of dementia.  He also suggests that “chemo brain” – the mental fog associated with cancer therapy (especially breast cancer), may be caused by a rapid decrease in estrogen.  Read his comments carefully and let me know if you find his analysis convincing… And watch out for the passionate “zinger” at the end!


The April 29th 2007 issue of the Sunday New York
Times carried a front-page article about the mental fog following treatment of
cancer with chemotherapy.(1) This fog, referred to as chemo brain, usually
clears, but, in approximately 15% of treated patients, may persist for years,
according to the article. All the patients presented
in the article were women, most or all were breast cancer survivors, and the
article does state that a possible cause of chemo brain in these women may be
the lowered estrogen in their bodies, due to their being catapulted into
premature menopause by treatment. The article further states that abrupt
menopause leaves many women fuzzy headed in a more extreme way than natural
menopause, which usually develops gradually. The article goes on to say that
studies of chemo brain have been conducted, overwhelmingly among breast cancer
patients because they represent the largest group of cancer survivors and
because they tend to be sophisticated advocates, challenging doctors and
volunteering for research.

In 1996 a
14-year study concluded that estrogen replacement therapy may be useful for
preventing or delaying the onset of Alzheimer’s disease.(2)

In 1997 a Columbia University study reported a significant
reduction in the risk of Alzheimer’s disease among postmenopausal women taking

In 2000 that same group reported lower levels
of circulating estradiol, the most common form of circulating estrogen, among
women who developed Alzheimer’s disease compared to those who did not.(4)

has been reported to stimulate nerve growth and synapse formation.(5) (Synapses
are nerve to nerve connections), and to play a beneficial role in nerve response to injury.(6)

In 2003 researchers at the University
of Southern California
identified a mechanism for estrogen-mediated nerve cell protection, which
involved preventing the accumulation of calcium within the mitochondria of the
nerve cells.(7,8)

has also been shown to prevent the buildup of the abnormal chemical called
hyperphosphorylated tau protein, characteristic of Alzheimer’s disease.(9)

administered to female rats who have had their ovaries removed enhanced the
rats’ learning ability.(10,11)

administration to postmenopausal women has been associated with improved verbal

A 2001 analysis of 29 published studies concluded that hormone replacement therapy was
associated with a 34% decreased risk of dementia.(15)

A 2002 study from Johns Hopkins reported a 67% decreased incidence of Alzheimer’s
disease associated with hormone replacement therapy.(16)

A 2006 study from Stanford and the University
of Adelaide in Australia
concluded that early initiation of hormone replacement therapy, from around the
time of menopause may contribute to improved cognition with aging and may delay

One can
often selectively quote the medical literature to support a particular point of
view. However, in the face of all these previously quoted studies, one should
at least look skeptically upon the 2003 report from the Women’s Health
Initiative, which found that combination estrogen plus progestin hormone
replacement therapy increased the risk for dementia when started in women over
age 65. The study reported increased dementia as early as 12 months after
starting HRT, but no increased incidence of mild cognitive impairment
associated with HRT use.(18)   If HRT
were really harmful to the brain, a finding that goes against most of what we
think we understand about the beneficial effects of estrogen on brain function,
one would expect early cognitive impairment to become apparent before
full-blown dementia was encountered.

A June, 2004 update of that same study concluded that even estrogen alone increased the
risk for dementia. This update reported an increase in mild cognitive
impairment as well, but the results for mild cognitive impairment were not
statistically significant after women who had this impairment at the start of
the study were excluded from analysis.(19)

The report
on chemo-brain from the New York Times should force us to look again at the
role of estrogen in maintaining normal brain function. Throughout history, male
dominated societies have adopted practices harmful to women. These include foot
binding, genital mutilation, and withholding privileges such as the right to
vote, hold office, and participate in government and education activities. We
should not add premature elimination of HRT, based on facile conclusions and
conflicting data to this list.

Avrum Bluming,
Clinical Professor of Medicine
of Southern California

(References on next post)

This post originally appeared on Dr. Val’s blog at

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