Docnotes

David Pepper MD - Stops Crime

From the fresnobee.com | Local News:

One of the most passionate and persistent of critics to visit City Hall was Dr. David Pepper. In 1997, street racers welcomed him to the Tower District. Two drivers charged down Van Ness Avenue at 90 mph.

One car jumped a curb and crashed into Pepper's new home. He paid $19,000 for repairs. His car was next. It was totaled a year later when two trucks careened down his street. He persuaded neighbors and other doctors to speak to the City Council, "and tell them that speeding is a huge problem in this area."

They asked for more stop signs, crosswalks and traffic officers. Stop signs eventually were added to Pepper's neighborhood, but his crusade against bad drivers continued. Van Ness Avenue is often dotted with homemade signs demanding that drivers slow down to obey the 30 mph speed limit.

 Pepper decided in 1999 that speeding problems extended far beyond his neighborhood. Drivers whizzed throughout the city, he says, because police were not writing tickets. The results were deadly. During a five-year period beginning in 1997, 186 people died in Fresno collisions, more than any other California city with a similar population size. Fresno's fatalities topped those of Long Beach (142 from 1997 through 2001), Sacramento (178) and Oakland (181), according to the California Highway Patrol.

Dave Pepper is a family physician who has clearly had an impact on the health of his community.  Nice going, Dave.

Coenzyme Q10 Decreases Cardiac Events

Coenzyme Q10 Decreases Cardiac Events - December 15, 2003 - American Family Physician

toy safety

ToySafety.net

ToySafety.net is a project of the National Association of State Public Interest Research Groups (PIRGs). The information contained on this site was researched and compiled by state PIRG staff across the country and published in the state PIRGs' 18th annual Trouble In Toyland report.

RSS - Shellen - Winer - Atom

Boring technology topic:

Dave Winer points to Jason Shellen's proposal for using a CSS to make XML look nicer in Atom.

No reason not to do this in RSS too ... here it is.

How I did it:

I had to modify my MovableType 2.0 template (view source if your browser tries to open it) to make it look better.  Now my feed may even look "un funky" to Dave.

I copied Jason's CSS example and modified it some to work on the RSS format.  

Then I found  Eric Kidd's dormant weblog.  He did this about a year ago.  His CSS is better than Jason's.

I can't get rid of the spaces .. (NBSP) ugh ..

NHS

From the Adam Smith Institute Weblog - Private health: bigger than NHS!

This week, BBC Radio 4 asked me to do an interview on the origins and growth of the non-state healthcare market. Boning up for it, I was reminded just how significant the independent sector is. It provides 85 percent of the UK's residential care beds, for example, and 20% of all acute elective surgery - that's the stuff like hip replacements that isn't exactly life-threatening, but which you want to get done fast anyway. Indeed, the independent sector has more beds than the NHS and local-authority care homes put together! It employs almost as many people - roughly 750,000 of them - and it accounts for a quarter of UK health and social care spending. In addition to the 15,000 nursing and residential care homes that the sector provides, private agencies care for more than 200,000 people in their own homes.

Of course, the other (unanswered) question is whether this is good.  If the NHS needs so much supplementation for those who can afford it, what happens to those who can't afford it?  This makes for a very compelling case that a two-tier healtchare system doesn't ration healthcare resources.

huh?  yes .. I said ration.  With limited resources, and infinite need, we need to RATIONALLY deliver the limited resource.  This is rationing, and despite the negative connotation usually assocated with it .. this is not a four-letter word.

Bottom line is well summarized in The Onion this week.

Flumist

Flu-shot shortage may aid MedImmune

This is a no-brainer.  We're out of vaccine, and only one local pharmacy carries the stuff. 

Who killed JFK? 

Is the Flu crisis of 2003-2004 real?

Another Oliver Stone Movie?

Specialty Care

Family Practice News Online reports on how pedatic ERs will more likely refer kids to specialty care rather than back to their primary care physicians. 

Steffie Woolhandler

New York Times: A Conversation With | Steffie Woolhandler: Heal Health Care System? Start Anew

Steffie is one of my heroes.  It's now been 14 years since The original paper appeared in the New England Journal of Medicine.  Yikes.  I was applying for medical school at the time, and a friend of mine sent me a copy of a draft version of the article. 

In medical school, I helped start an Albany chapter for the Physicians for A National Health Program .. and when this new thing called the Internet came along, I built the organization a website and hosted it on a server I managed in 1995.

These days I don't have enough time to work on PNHP stuff very much, but this doesn't mean I'm not still passionate about it.  Tha huge administrative overhead that the US insurance industry adds to the cost of healtcare in this country is terrible.  Read the Woolhandler article -- it's very compelling.

Clinical Pearls

Today's unrelated tidbits:

• A great tool for helping men with a decision for/against PSA testing.  This thing is buried deep in the guts AAFP website - so deep that I couldn't find it.  Here it is. 
• A very good review article on dx/work-up of fatigue.
• Excellent guidelines on Otitis, pharyngitis and bronchitis
• Baysean Calculator.

The last one is the best of many calculators out on the web.  Here's why - it combines the calculations of likelihood ratios with the calculation of PPV and NPV.  Huh?  Terms for normal humans: 

a) How good is the test that I'm doing for this disease? (sensitivity) let's take one that is VERY common:  the "rapid strep" test.  It's pretty good, but not perfect.  Let's say it's 85% sensitive.  This means that 15% of the time it will miss strep throat.  So ... does a patient in my office with a sore throat and a negative "rapid strep" have a 15% chance of having strep throat?  Nope.  Read on.

b) How accurate is the test? (specificity).  If I get a positive result - how sure can I be that the patient really has it?  In the case of the rapid strep - darn sure.  Let's say 99%.

c) How likely is THIS patient to have this disease given their symptoms?  Long story - Kids are more likely to have it than adults.  Let's say an adult has a 10% chance of having a sore throat caused by strep - and a kids have a 25% chance. 

So now we can use the calculator.  Enter a prevalence of 25% (it's a kid with a  sore throat) and a sensitivty of 80% and a specificty of 99%. 

PTL- .. The post-test likelihood of a negative test = .048  So a kid with a negative rapid strep has only a 5% chance of having strep throat - not 15% like we thought above.

But we can play with this plot even more.  We know from the long story above (click it - it's a very good article) that the kid with a cough and no adenopathy is much less likely to have strep than the kid with no cough and positive anterior adenopathy.  So let's say our patient has a cough and runny nose and not much of a fever.  Hmm .. doesn't sound much like strep.  But he does have a sore throat.  Let's move his "prevalence" score to 10%.

Yikes.  Now the PTL- is .01 -- not very likely that this kid has strep.

So now you see why I'm not compelled to send a follow-up culture (with sensitivity of 90% rather than 85%) if I get a negative rapid strep.

 

More Pertussis

In this month's Cortlandt Forum is a good little review on pertussis. We continue to see it in the office this week. Many kids on erythromycin - though I gather that some physicians in the area are using azithromycin for 5 days. Not much research to support this - so I'm sticking with erythro for 14 days.