Docnotes

HPV vaccine for cervical cancer

Merck is developing a vaccine for HPV.  This is important, and couldsignificantly reduce the incidence of cervical cancer.  Nonetheless ... it will be years before we know what will happen with this .. is it a safe vaccine?  Is it effective?  This is a nice review of the current state of affairs.

Do Family Practice Physicians Ask About Depression at Different Rates Than Internal Medicine Physicians?

This study was publised in 2000, but I just stumbled on it today.  It's an interesting paper, because it validates what we've been teaching (?preaching?) for years.  Family physicians are trained to address psychological issues as primary medical problems.  This is a required longitudinal component of family medicine education.  While many internal medicine residencies do educate their residents in this domain .. many do not .. and this is not explicitly a component of their training.   All family physicians are trained in this way.

Now there is a study that demonstrates that family physicians actually are more attentive to psychological problems. 

Laptop burns

From The Lancet:

The following story should be taken as a serious warning against use of a laptop computer in a literal sense. The patient, a previously healthy 50-year-old scientist and the father of two children, had been writing a report one evening in his home. Sitting comfortable in an armchair, he had placed his laptop computer on his lap while writing for about 1 h. The next day he noticed irritation and oedema of his penile prepuce. Furthermore, the ventral part of his scrotal skin had turned red, and there was a blister with a diameter of about 2 cm. ...

Ouch

Yesterday our server decided to

Yesterday our server decided to shut down at 5 AM.  We have a spare.  Just hadn't set it up yet to step into place all-of-a-sudden.  Turns out that the power supply, which has three fans, detected that fan #1 is not working.  So to protect the rest of the computer ... it shut down.

So I fedexed the power supply from our backup server to the web host that we're using because Compaq couldn't get their act together and help me .. despite many wasted hours on the phone with them.  Turns out that they have had persistent problems with this power supply.  Hmm.

Soo .. Sorry about the blackout .. and thanks for your patience.

Web usability, deep linking

So I'm surfin Medscape today, and I notice that they published my article from the AAFP conference.  Cool.  Of course, I want to e-mail my pal Dave in Seattle and tell him about it .. so I copy the link and e-mail it to him. (actually, I use the "e-mail this article" button on the page .. well designed).

Trouble is .. Dave's not a Medscape member. Maybe he should be.  He's an internist.  I'll bet they want him to be a member .. and so they want me to e-mail him a URL to the article.

Since I'm already logged in, when I click on the URL, I get right in to the site and I see the article.  But if one isn't logged in, all you get is the login page.

This is bad design. 

Perhaps Steve will appreciate a little constructive criticism:

The recipient of the URL has no idea what the sender has sent.  Is it worth the time to sign up?  "ugh .. not now" most will say .. as they wade through their morning e-mail pile.  Now the sender's e-mail hasn't accomplished much, and the recipient just gets annoyed.

Ironically, I was reading my (paper) copy of eweek today, and I found Jim Rapoza's "last word" article today on how deep linking draws visitors.  He's right.  Medscape should show the user the article I've linked to. 

At first, I thought that they should put a teaser paragraph up on this login page, with instructions on how to sign up, as NEJM does for their recently published articles. Want full text?  Gotta log in..   But as I think more about it, Medscape's goal is to have me see their site as a valuable resource.  The user won't see the site as a valuable resource if they don't see the whole article.  Piss them off ans give them a few paragraphs and it's not likely they'll be coming back to type in their DEA number..

I can already hear the "security" team whining about how jerks like me could then create web pages full of "deep" links to Medscape content that would be available to people without logging in.

So what.  Medscape could rather easily permit a full text "deep link" without login from external URLs (cgi.referrer <> "medscape.com) .. but require login for viewing from internal URLs.  This way, deep linking is preserved, but if the user wants to go anywhere within Medscape, they are encouraged to log in.

"Medscape is free"  you say .. "why make users log in at all?"  Steve will (I hope) weigh in on this one .. but I'm sure that it's very important for them to be able to report to their advertisers who the users are.  If I can't log in .... I'm just an IP address.

So . if we build it this way .. more openly .. users can see the article they linked in to .. but not others, but "internal" clicks would bring the user to a login page.   Yes .. of course there would be ways to circumvent this to see the content (copy/paste comes to mind!) .. but a minority of users would do this .. and it's too hard to do this on a regular basis.  The more they do this .. the more motivated they'll be that the content is good and they should make life easier for themselves by logging in.

So by providing more access to content, the content vendor can actually increase the likelihood that these users will end up as long-term members.

Heparin-induced thrombocytopenia

This week's chin-scratcher is looking more and more like this condition. It's a terrible situation .. in a patient who is otherwise quite healthy and "with it" despite her rather advanced age.  She's given her permission for me to post these images and brief summary.     88 year old woman who had hip surgery 1 month ago presented to the hospital with lower extremity swelling.  Doppler studies of the lower extremities showed some thromboses.  She was started on Heparin and then warfarin.  She was therapeutic on warfarin after a few days .. and then heparin subsequently stopped according to protocol.

The left 4th digit became discolored and it was initially thought to be an isolated incident.  INR was therapeutic.   That evening, the right arm and right foot became discolored.  INR went up to 6.2.  We corrected this with FFP, and she has not progressed since then.

Heparin antibody has been negative, which still makes me think of warfarin necrosis in the bask of my head .. though the hematologists are confident that HIT is the diagnosis .. as the antibody can be negative in 10% of cases with HIT.

Biopsy showed thromboses without inflammation .. making vasculitis or some other inflammatory process unlikely.

Multicentre aneurysm screening study (MASS)

From BMJ:

What is already known on this topic
Small trials have suggested that an ultrasound screening programme to detect abdominal aortic aneurysms in older men may be effective

There is uncertainty about the cost effectiveness of routine screening, with widely varying estimates

What this study adds
A cost effectiveness analysis of data from a large randomised trial with follow up over four years showed 47 fewer deaths and additional costs of £2.2m in the group invited to screening

The adjusted net cost per patient was £63.39 and per life year gained was £28 400

The projected cost per life year gained after 10 years was £8000, which is substantially lower than the perceived NHS threshold value

We may want to start screening for AAA.  My grandfather died of a ruptured AA.  It's still a very common cause of death in the US.  And AAA can be treated.

Eckerd.com -

Eckerd is now offering folks who have a TogetherRX card a discount on generic medications in addition to the medications offered by the TogetherRX member companies.  Hard to interpret this.  TRX is a program that was developed to provide seniors with a discount on medications.  This is good.  But it was/is also a method of directing patients toward the medications that the companies sell .. and not their competition.

So now with Eckerd offering doscounts on generics .. it looks good.  But this is also a method for getting more folks to get the card .. hence more people shifthing their brand name medications to those offered by the TRX partners.

No free lunch.

Guidelines for unsing Fresh Frozen Plasma (FFP)

When the INR is >6 (it is) and there is bleeding (there is) ... use FFP

Palm OS Charge Capture

A nice review of several Palm based applications for medical practice.