Thursday, March 15, 2007
CDC: Insurance Affects New Patient Acceptance
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Percentage of Office-Based Primary-Care Physicians Who Did Not Accept New Patients, by Expected Payment Source --- National Ambulatory Medical Care Survey, United States, 2003--2004
"Although 94.2% of primary-care physicians reported in 2003--2004 that they were accepting new patients, acceptance varied by the patient's expected payment source. Among the physicians, 43.0% did not accept new charity cases, 29.3% did not accept new Medicaid patients, and 20.3% did not accept new Medicare patients. Only 7.0% did not accept new patients who self-paid."
Monday, March 12, 2007
CDC: Quadrivalent Human Papillomavirus Vaccine
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Recommendations of the Advisory Committee on Immunization Practices (ACIP)
"Routine Vaccination of Females Aged 11--12 Years
ACIP recommends routine vaccination of females aged 11--12 years with 3 doses of quadrivalent HPV vaccine. The vaccination series can be started as young as age 9 years.
Catch-Up Vaccination of Females Aged 13--26 Years
Vaccination also is recommended for females aged 13--26 years who have not been previously vaccinated or who have not completed the full series. Ideally, vaccine should be administered before potential exposure to HPV through sexual contact; however, females who might have already been exposed to HPV should be vaccinated. Sexually active females who have not been infected with any of the HPV vaccine types would receive full benefit from vaccination. Vaccination would provide less benefit to females if they have already been infected with one or more of the four vaccine HPV types. However, it is not possible for a clinician to assess the extent to which sexually active persons would benefit from vaccination, and the risk for HPV infection might continue as long as persons are sexually active. Pap testing and screening for HPV DNA or HPV antibody are not needed before vaccination at any age. "
Sunday, March 11, 2007
Barbecued Ribs
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I love barbecued ribs. I never tried to make them at home because I thought it must be too time intensive. Barbecued ribs have to be made on a barbecue, right? Wrong. Barbecued ribs can be made in a crock pot. I think these ribs are as good if not better than any you'll find in a restaurant (even a Texas barbecue restaurant). I'm posting it here because I've promised several nurses I'd bring in the recipe, always forget, so now I can just point them here.
Ingredients:
- 3.5 pounds baby back ribs
- 0.25 c brown sugar
- 0.5 tsp black pepper
- 3 tbsp liquid smoke
- 2 cloves garlic, finely chopped
- 1 tsp salt
- 1 medium onion, sliced
- 0.5 cup Coke (not diet!)
- 1.5 c. barbecue sauce (I like Cattleman's)
1. Remove inner skin from ribs (I use pliers to make this easier). Mix brown sugar, pepper, liquid smoke, garlic, and salt. Rub mixture onto ribs and cut them into 4 inch pieces. Layer ribs and onion in crock pot.
2. Cover and cook on low setting for 6-9 hours (depending on how your crock pot interprets 'low').
3. Remove ribs from pot. Drain and discard liquid.
4. Dip ribs into barbecue sauce, place ribs back into crock pot and pour any remaining sauce over ribs. Cook on low for an additional hour.
This recipe makes enough for 2-4 adults, depending on their appetite. For our family of 4, I make a double recipe (7 lbs of ribs) so there are sure to leftovers. I have tried this recipe with spare ribs instead of baby-back ribs and found it much too greasy for my liking.
Own Your Own Cable Modem? Check The Speed!
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I have cable modem service to my home via Comcast. I bought my own modem, the Motorola 4100, about three years ago so I wouldn't have to pay the cable modem rental fees. Since the modem only cost about $50, I've saved about one hundred dollars over that time period.
I had Comcast come install two CableCards in my new Tivo Series 3 and the installers commented on what an old modem I had. They went on to explain that one advantage of renting a modem is that, when the modem limits download speed, Comcast will replace it with a faster one. Having just installed a new Airport Extreme Pre-N wireless router, this seemed like something to check out.
After reading the spec. sheets on both modems it looks to me like their download speed is the same (38 Mbps). However, the Motorola 5101 I just installed is faster in my tests. Maybe it's the DOCSIS 2.0 support. Well, I'm just an unfrozen caveman anesthesiologist but I know speed when I see it...16 Mbps:
If you bought your own modem several years ago, consider upgrading it. The results might surprise you.
Friday, March 9, 2007
Lifehacker: Gmail Manager
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Download of the Day: Gmail Manager (Firefox) - Lifehacker
" The Gmail Manager Firefox add-on obviates the need to keep your Gmail open in a tab all the time by displaying your email info in a statusbar pop-up, as shown."
A must-have for a Firefox Gmail user
Thursday, March 8, 2007
Send Addresses From Google Maps To Your BMW
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well, in Germany anyway...
Why Are C-Section Rates Still Going Up?
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As an anesthesiologist I provide anesthesia for cesarean sections quite often. In fact, when I'm on overnight call it's what I spend most of my time doing. Usually, anesthesia for c-section consists of a spinal anesthetic, or using a pre-existing epidural catheter, or (more rarely and usually only in emergencies) a general anesthetic. I am therefore quite interested in the subject of cesarean section rates and what effects how often they are done. I learned some things from this article [free full text]:
Cesarean Delivery and The Risk-Benefit Calculus
1. Parturients are different--they are heavier and older.
2. The number of premature and low birth-weight babies has grown.
3. Vaginal breech deliveries are no longer recommended.
4. Operative deliveries (forceps or vacuum) are less common due to better data describing their risks.
5. More labors are induced (20% in 2003 vs 9.5% in 1990) and induced labors are more likely to result in C-section.
6. Changes in provider behavior
"At least one study found that physicians' malpractice premiums, the number of claims against physicians and hospitals, and the physician's preception of the risk fo being sued were all positively correlated with the likelihood of cesarean delivery. Many in the field defend the rising cesarean rates by citing concern about legal jeopardy, and indeed lawsuits often allege a failure to perform a timely cesarean delivery."
Look at John Edwards' list of law cases (thank you, Google). Notice the medical malpractice cases:
MEDICAL MALPRACTICE CASES
Another specialty Edwards developed was in medical malpractice cases involving problems during births of babies. According to the New York Times, after Edwards won a $6.5M verdict for a baby born with cerbral-palsy, he filed at least 20 similar lawsuits against doctors and hospitals in deliveries gone wrong, winning verdicts and settlements of more than $60M.
|
| Case |
Summary of Facts |
Case Type |
Result |
Griffin v. Teague, et al.
(Mecklenburg Co. Superior Ct., NC, 1997) |
Application of abdominal pressure and delay in performing c-section caused brain damage to infant and resulted in child having cerebral palsy and spastic quadriplegia. Verdict set record for malpractice award. |
Medical Malpractice |
$23.25M
verdict |
Campbell v. Pitt County Memorial Hosp.
(Pitt County, NC, 1985)
|
Infant born with cerebral palsy after breech birth via vaginal delivery, rather than cesarean. Established North Carolina precedent of physician and hospital liability for failing to determine if patient understood risks of particular procedure. |
Medical
Malpractice |
$5.75M
settlement |
| Wiggs v. Glover, et al. |
Plaintiff alleged infant's severe cerebral palsy was caused by negligent administration of pitocin, failure to use fetal monitor, or timely intervening in baby's fetal distress. |
Medical
Malpractice |
2.5M
settlement |
| Cooper v. Craven Regional Med. Ctr., et al. |
Infant suffered severe brain damage after obstetrician failed to moderate use of Picotin after baby displayed clear fetal distress. |
Medical
Malpractice |
$2.5M
settlement |
Dixon v. Pitt County Memorial Hospital
(Pitt County, NC) |
Birth-related injuries including cerebral palsy and mental retardation allegedly caused by obstetrician's failure to diagnose fetal distress, including umbilical cord wrapped around baby's neck prior to delivery. |
Medical
Malpractice |
2.4M
settlement
|
Despite the increase in c-section rates nationwide, we have seen no reduction in the cerebral palsy rate...
Details On Why We Get Migraines
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"A University of Iowa study may provide an explanation for why some people get migraine headaches while others do not. The researchers found that too much of a small protein called RAMP1 appears to "turn up the volume" of a nerve cell receptor's response to a neuropeptide thought to cause migraines.
"The neuropeptide is called CGRP (calcitonin gene-related peptide) and studies have shown that it plays a key role in migraine headaches. In particular, CGRP levels are elevated in the blood during migraine, and drugs that either reduce the levels of CGRP or block its action significantly reduce the pain of migraine headaches. Also, if CGRP is injected into people who are susceptible to migraines, they get a severe headache or a full migraine.
"We have shown that this RAMP protein is a key regulator for the action of CGRP," said Andrew Russo, Ph.D., UI professor of molecular physiology and biophysics. "Our study suggests that people who get migraines may have higher levels of RAMP1 than people who don't get migraines." "
The abstract is here.
Wednesday, March 7, 2007
Aspirin/NSAIDs For Colorectal Cancer Prevention Discouraged
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"People who are at average risk for colorectal cancer, including those with a family history of the disease, should not take aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) to try to prevent the disease, according to a new recommendation from the U.S. Preventive Services Task Force. The recommendation is published in the March 6 issue of the Annals of Internal Medicine."
"USPSTF assessment: Overall, the USPSTF concluded that harms outweigh the benefits of aspirin and NSAID use for the prevention of colorectal cancer."
[AHRQ]
Tesla Motors' Plan
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The Tesla Motors Blog, this entry by marketing chief Darryl Siry, sums up their business plan:
"We have just announced that we will build an assembly facility in Albuquerque, N.M., to build our WhiteStar sports sedan in the future. We will establish company-owned sales and service centers where our customers can get their vehicles serviced. We have the plans, the management, and the access to capital to achieve our vision of being the leading designer and manufacturer of the most desirable electric vehicles in the world. We expect to grow into a multi-billion dollar company selling hundreds of thousands of vehicles. It might take some time but that is what we are going to do."
AFP: Preparation of the Cardiac Patient for Noncardiac Surgery
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Excellent Lee Fleisher article in American Family Physician [free full text] for any primary care physician who is asked to do pre-op medical evaluations (note I didn't use the word 'clearance').
Medicare To Cut Physician Fees 9.9% in 2008
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It's official (pdf). The Center for Medicare and Medicaid plans on cutting the physician fee schedule 9.9 percent as of January 2008. Five percent for 2007 (which cut was postponed due to a temporary one year patch), and 4.9% for 2008.
Tuesday, February 27, 2007
JAMA: Prevalence of HPV Infection Among Females in the United States
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Prevalence of HPV Infection Among Females in the United States [free full text]
"Our study provides the first national estimate of prevalent HPV infection among females aged 14 to 59 years in the United States. Overall, HPV prevalence was high (26.8%), and prevalence was highest among females aged 20 to 24 years [ed. where it was 44%]. Our data indicate that the burden of prevalent HPV infection among women was higher than previous estimates. However, the prevalence of HPV vaccine types was relatively low."
Remember, prevalence is the proportion of cases that are present at a single point in time.
For a background primer on HPV infection, see the excellent JAMA Patient Page.
Even Malpractice Lawyers Need Doctors, Sometimes
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In An Eye For An Eye, Charity Doc describes a close encounter with a malpractice attorney who once sued him. I'm not sure I would have been as, um, gracious....
"Yeah, I'm a personal injury lawyer. I have no problems telling doctors that. I get better care that way, actually. Makes you guys more careful around me."
"Yes, I know you very well, Mr. Cochran. You were the plaintiff attorney accusing me of being a baby killer, remember?!"
Monday, February 26, 2007
Lieberman on Iraq
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OpinionJournal - Featured Article
"We are at a critical moment in Iraq--at the beginning of a key battle, in the midst of a war that is irretrievably bound up in an even bigger, global struggle against the totalitarian ideology of radical Islamism. However tired, however frustrated, however angry we may feel, we must remember that our forces in Iraq carry America's cause--the cause of freedom--which we abandon at our peril."
Sunday, February 25, 2007
YouTube: Episure AutoDetect Syringe for Epidurals
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More YouTube instructional video goodness. This time demonstrating a special syringe to aid in identification of the epidural space--the Episure AutoDetect Syringe.
"(A)n automatic Loss of Resistance (LOR) syringe that provides an objective, visual confirmation that the Epidural Space has been identified. Whether you administer epidural anesthesia regularly or infrequently, we are confident that the Episure AutoDetect syringe will give you enhanced control and sensitivity."
Looks like a very nice training tool.
I personally use the Australian Grip. I learned it from an Australian anesthesiologist (hence my naming of it). I place the Tuohy needle in the interspinous ligament and attach a saline-filed glass syringe. I then apply pressure with the palm of my dominant hand to the plunger only, not touching the hub or needle. On entry of the epidural space, pressure on the plunger causes saline to shoot out of the Tuohy needle opening and the needle stops. The one wet tap I've had with this technique has been in a patient who must have had a non-union of the ligamentum flavum.
[Indigo-Orb]
YouTube: Site-Rite Instructional Video
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The AHRQ published Making Health Care Safer: A Critical Analysis of Patient Safety Practices in 2001. Chapter 21 deals with Ultrasound Guidance of Central Vein Catheterization. I thought I'd include a link to a YouTube video that shows how this device is used:
Although the device has advance considerably since then (see below), the images it provides are still pretty much the same.
I will often use the device to locate and mark an internal jugular vein before draping the patient as I find the use of the needle guide extremely cumbersome.
[Site-Rite]
Friday, February 23, 2007
Are Alphanumeric Pagers Obsolete? That Depends.
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Ever since I was an intern I've worn a pager while at the hospital--and at a lot of other times, too. They used to be as big as a pack of three by five cards, but now they're quite tiny (think matchbox). But it's still an item you have to remember to put on each day, an item that weighs on your waistline. Back when there were only pagers that wasn't a big deal. Wearing a pager was a status symbol.
But now that belt or waistline space is more crowded. There's probably a cell phone and a PDA. There may also be a Spectralink phone or two for in-hospital calls. If you're really important, you may have more than one or two pagers. It's enough to make your scrubs sag.
Someone explained to me once (and I don't have a reference for this) that FCC law prevents device manufacturers from integrating a digital pager into another electronic device such as a cell phone or pda and that this was done to protect the paging industry. Is that true? Does anyone know?
My group still carries pagers because we know they always work, no matter where we are. In a surgery center in the basement of a medical office building or far out of town, away from cell towers, the digital pager will let us know someone wants to talk to us.
As the Palmdoc Chronicles points out in his post titled Alternative to Paging, there are more options than there used to be: SMS/Texting, Push E-mail, IM, Push to talk. To the best of my knowledge, however, none of them offer the reliability of paging. If someone needs to be intubated, or needs an epidural, or is coding, 'Sorry, did you IM me? I didn't get it' isn't going to cut it.
The one upgrade I would love to have to our pagers is the ability to send text messages over them. For example, instead of getting paged to '3968', calling that number only to be asked to go do an epidural in labor room 8, I could just receive the message on the pager: 'Epidural labor 8.' See? Our pagers are hospital provided and the service I describe costs more. I have not been sufficiently persuasive in my appeals to get them to spring for the extra feature. When I offered to pay for the cost of the alphanumeric service over and above what regular digital paging service costs, I was told we can't do that either because they can't 'split out' a subgroup of the pagers.
Now, I realize I'm just an unfrozen caveman anesthesiologist, but if you know that 40 pagers are using a service that costs ten dollars more per month and I cut you a check for $400 each month, wouldn't that make us even?
"Ladies and gentlemen of the jury, I'm just a caveman. I fell on some ice and later got thawed out by some of your scientists. Your world frightens and confuses me! Sometimes the honking horns of your traffic make me want to get out of my BMW.. and run off into the hills, or wherever.. Sometimes when I get a message on my fax machine, I wonder: "Did little demons get inside and type it?" I don't know! My primitive mind can't grasp these concepts."
Tesla Motors - Cut From A Different Cloth
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Tesla Motors - the Tesla blog
"From the earliest days of our work developing the Tesla Roadster’s body, we realized we had several major challenges on our hands. We had to achieve a low level of aerodynamic drag to increase efficiency, and we had to keep our mass down in order to maintain a high power-to-weight ratio and achieve maximum acceleration. Equally important was our imperative to create a body style for the Tesla Roadster that made people desperately want the car - irrespective of its efficiency or level of performance."
I sincerely hope my next car will be a Tesla. Not the Roadster but the not-yet-in-production WhiteStar .
Seen Emoticons? How About Assicons!
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I received this in an e-mail today (if the word 'ass' offends you, don't continue reading):
"We all know those cute little computer symbols called "emoticons," where:
:) means a smile and :( is a frown.
Sometimes these are represented by :-) and :-(
Well, how about some "ASSICONS?"
Here goes:
(_!_) a regular ass
(__!__) a fat ass
(!) a tight ass
(_*_) a sore ass
{_!_} a swishy ass
(_o_) an ass that's been around
(_x_) kiss my ass
(_X_) leave my ass alone
(_zzz_) a tired ass
(_E=mc2_) a smart ass
(_$_) Money coming out of his ass
(_?_) Dumb ass
"
