In sheep, the phosphodiesterase inhibitor sildenafil (Viagra) prevents the catastrophic changes in pulmonary artery pressure that fat embolism can cause:
Sildenafil Prevents Cardiovascular Changes after Bone Marrow Fat Embolization in Sheep.
This is the best summary I've read of the barriers to implementing significant change to our current health care system:
Sicko: Socialism in a capitalist society?:
To accomplish any meaningful reform, Americans will have to dismantle the insurance and pharma lobbies at a minimum, and begin to tackle the question of how to deliver universal health care without tying it to employment, marital status, or other qualifiers (and figure out how to put all those unemployed pharma and insurance reps to work, too). Once those lobbies have been set aside, the questions of how to implement a healthcare system which avoids the pitfalls faced by Canada, the UK and France, embraces the positives in the Cuban system, and essentially folds a socialist system into a capitalist society will have to be addressed."
[Via Kevin, MD - Medical Weblog]
Pennsylvania has chosen an interesting strategy to keep doctors from leaving the state. Rather than fix the current jackpot medical malpractice system they've decided to try to trap doctors that are already here.
The first example of this was something called the MCARE abatement program. The Medical Care Availability and Reduction of Error (MCARE) Act replaced an existing catastrophic coverage fund with a new fund to cover awards which exceeded the primary coverage provided by professional liability policies. Each physician must pay into the fund a percentage of their primary premium to sustain the fund.
The MCARE abatement program (or Health Care Provider Retention Program) provides some financial relief from paying premiums to the fund. How much relief a physician gets depends on the practitioners specialty. And here we come to trap number one. If you accept the abatement, you agree to practice in the state for the year in which you receive the abatement AND the next year. If you leave early, you have to pay back the full amount of the abatement.
The legislature is now working on trap number two--a physician loan forgiveness program. For a period of ten years, for every year a physician practices in Pennsylvania after completing training the state will pay off ten percent of their student loan debt. If they leave early (say, after five years), they have to pay the state back ALL of the money the state paid toward their loans.
With only three weeks to go until the release of the iPhone the frenzy is peaking. What features will it have? What is the twelfth icon? Will it have a SIM tray? Where will be the best place to buy one? I decided to today that I don't care. Let me explain why I won't be buying Apple's iPhone.
I've learned not to buy the first of anything Apple puts out. Though I love the company and have been buying their computers and other devices since the beginning, I think that (especially recently) there's good reason to be patient and let other people help Apple work out the kinks.
I ordered the MacBook on the day it was announced....and had the heat-sink problem. I ordered the 24" iMac the day it was announced...and had it up and die on day four of owning it. There are other examples of released hardware that was flawed initially but improved with each revision that, thankfully, I didn't experience myself. The bottom line is that being first has a price and that it's worth giving Apple a chance to learn from the initial release and improve the hardware with subsequent revisions. That doesn't mean waiting for the next model. Apple revises hardware between new releases, too.
The second reason for waiting is that the device you really wanted is usually the second one in the model line, not the first. But you compromise, tell yourself it's still worth getting the first one, but it's not. Because as soon as the second version comes it, you decide you should have waited. That's what happened to me with the Newton. I bought each new model as it came out (and still have a 2100).
What do I expect in the second version of the iPhone that I think makes it worth waiting for? Better-than-EDGE speed, for one thing. A camera that's better than 2 megapixels for another. GPS for a third. And many fewer problems.
Today, I put down my own good money for a Nokia N95. Five megapixel camera, built-in GPS, and a mature OS that has lots and lots of third-party apps. With iSync and the release of Nokia Media Transport yesterday (nice write-up here), adding contacts, calendars, iTunes music, photos, and videos just got a lot simpler.
I track about one hundred news sources with Google Reader. By subscribing to a site's RSS feed, I can see updates as they happen without having to visit the web page itself. Very efficient.
Google has a mobile version, too. Thought this stripped-down version is excellent for cell phones, the interface is too simple for someone with a more capable internet device such as a PDA, UMPC, smartphone, or Nokia N800 internet tablet.From reading the forums at internettablettalk.com I just found ReaderMini:
Texas enacted tort reform in 2003, capping damage awards at $250,000. In an article titled "Insurance companies, doctors flock to Texas" David Hendricks passes along some facts I hope Pennsylvania legislators take to heart:
[Kevin, MD]
Currently pending in the Pennsylvania Legislature is House Bill 1256 to amend the state law that currently requires CRNA's to be supervised by physicians. If enacted, Certified Registered Nurse Anesthetists would no longer be 'supervised' but 'shall administer anesthesia in collaboration with a physician or dentist' (emphasis mine). Furthermore, such collaborating physician only needs to be available electronically (i.e. a phone call away). I'm told that this new language would essentially give CRNA's the ability to practice independently in the State of Pennsylvania.
I think this is a very, very bad idea. In a year when the Governor has made patient safety a centerpiece of his legislative agenda, telling CRNA's that they can practice without supervision seems to me to be a step in the wrong direction. CRNA's are nurses. Highly trained (and the most highly paid) advanced practice nurses, yes, but still nurses. The proposed legislation seeks a substantial change in the status quo and should not be enacted without clear proof that the quality of care Pennsylvania's residents receive will not be adversely affected.
The CRNA lobby is arguing that you really only need anesthesiologists in teaching institutions. I hope our legislators will pause to consider how silly this assertion is. I know a lot of CRNA's. A few of them are very, very good. I would let any one of my physician colleagues (that's about forty people) give my family members an anesthetic. I would only let a handful of CRNA's do the same, and then only with physician supervision immediately available.
Perhaps we should amend this bill so that only the Governor, and members of the legislature and their families will receive anesthesia only from CRNA's and without physician direction for, say, the next ten years and see how good an idea they think this is.
Pennsylvania's citizens are aging. They need physicians to evaluate them before, during, and after their surgery and anesthesia. If you're in favor of this bill, you're probably also in favor of RN First Assistants doing routine cholecystectomies and other surgeries. Those performing surgery have to try really hard to kill a patient. We just have to not pay attention for one minute.
One of my almost daily frustrations is the imprecise description of what kind of diabetes patients have. I'm often told, or see written, that a patient has 'insulin dependent diabetes' just because they are taking insulin. Dr. RW points to the second in a series of articles on diabetes in the journal Clinical Diabetes. It's a good review for me that I may use as the basis for a 'refresher' for the nurses...
[Dr. RW]
Lots of other good data in that article, too, such as the time-line for closure of other OB units in the greater Philadelphia area:
A recent Health Affairs article titled Changes In Physician Supply And Scope of Practice During A Malpractice Crisis: Evidence From Pennsylvania has gotten a great deal of national media attention. It's conclusion was as follows:
I've been thinking about this article for a while now. I've written to the lead author asking about the inclusion of medical residents-in-training in their statistics but have yet to hear back. Including residents may hide important trends. For example, new residency programs may have opened during the study period. Trading doctors who are fresh out of internship for experienced specialists is not a good deal, but the numbers as used wouldn't show this.
Another question I have is 'compared to what?' What has happened in other states during this time? According to the Dauphin County Medical Society, among the twenty most populous states, only Pennsylvania and California saw their physician supply drop during the study period. All others saw an increase of 10-20% in physician supply.
