Douwe Rienstra, MD

Educational Activities

2006 | 2005 | 2004 | 2003 | 2002 | 2000 - 2001 | 1988 - 1999

2008

March 21, 2008 Donald E. Low, MD, a surgeon at Virginia Mason Medical Center reviewed treatment of hepatitis B.

March 7, 2008 Kimberly McLaren, MD of Virginia Mason Medical Center reviewed reviewed the boundaries physicians must put on relationships with patients.

February 29, 2008 Andrew Ross, MD, a gastroenterologist at Virginia Mason Medical Center diagnosis of people with bleeding into the GI tract. In about 90% of people, looking into the stomach and colon with a scope will discover the cause. Dr Ross discussed the problem of diagnosis in that last 10%. Often the bleeding comes from the small intestine in these cases. There are now new methods of examining the small intestine using a swallowed capsule. Also, new endoscopes can get down into the small intestine, and allow identification and treatment.

February 22, 2008 Shelly T. Karuna, MD, a research consultant at Virginia Mason, discussed Shared Decision Making: At the Confluence of Physician and Patient Expertise. Some of the patient decision aids they referenced are at www. decisionaid.ohri.ca

February 15, 2008 Roger W. Bush, MD, of the Virginia Mason Medical Center discussed Quality and Change Management, Educational Theory and Social Learning.

February 8, 2008 Michael J. Longo, MD, Deputy Section Head of Cardiology at Virginia Mason Medical Center discussed surgical complications. Such complications are much more common in people who already have serious medical problems, including history of stroke or heart attack, current heart disease, renal insufficiency, congestive heart failure, or diabetes. Additionally, if a patient cannot walk four blocks or climb two blocks of stairs, they are at much higher risk of cardiac complications during major surgery.

Such patients can be protected by giving them a cardiac stress test prior to surgery, so that the surgical team can know how their heart will respond during surgery.

Depending on the results of such studies, major reductions in surgical deaths occur with beta-blocking drugs. The same drugs may affect the heart adversely, so need to be used correctly and only in people who will benefit.

February 1, 2008 - Joel Sheinfeld, MD from Sloan-Kettering Cancer Center in New York reviewed controversies in the management of Low-Stage Nonseminomatous Germ Cell Tumors.

January 25, 2008 Drs Hugh W. Allen and Peter J. Manos of the Virginia Mason Medical Center discussed pain management and opiate treatment thereof.

January 18, 2007 - Carrie Horwitch, MD, in internal medicine at the Virginia Mason Medical Center discussed the role of laughter in good health.

January 11, 2008 Neil B. Hampson, MD, Medical Director of the Center for Hyperbaric Medicine at the Virginia Mason Medical Center reviewed the causes of carbon monoxide poisoning. Many people are not aware that carbon monoxide is a colorless, odorless, product of combustion. Dr Hampson has worked with governmental agencies to improve warning labels on charcoal briquets and portable generators, which resulted in dimishished death rates from those causes. Carbon monoxide poisoning results in headache, nausea, and eventually death. Dr Hampson estimates about half of people with carbon monoxide poisoning are identified by health care workers.

2007

December 14, 2007 Kris V. Kowdley MD, the Director of the Center for Liver Disease at the Virginia Mason Medical Center pointed out that 15 to 20% of the US population have some degree of fatty liver. Fatty liver is one more complication of the modern sedentary overfed lifestyle and resulting gain in weight. Fatty liver constitutes part of the metabolic syndrome, thet common constellation of excess abdominal weight, high blood pressure, slightly or greatly increased blood sugar, high cholesterol and triglycerides. Dr Kowdley calls this condition non-alcoholic fatty liver disease, or NAFLD, which he pronounces "naffle-dee." People with NAFLD can go to to develop cirrhosis, and about 3 percent progress to liver cancer.

Considering everyone with abnormal liver function tests, about 30% have NAFLD, and another 30% have the second stage of NAFLD, which is a form of hepatitis called non-alcoholic steatohepatitis.  .

Reducing weight and intake of high-fructose soft drinks can improve liver health, as can appropriate treatment of diabetes, and orlistat or bariatric surgury to reduce fat intake. Although statins can increase liver function tests, people with NAFLD may experience a reduction in such tests.

December 12, 2007 - Alan Greenwald, MD, orthopedic surgeon at Jefferson Healthcare Hospital, reviewed treatment of osteoarthritis of the knee.

December 7, 2007 Michelle Z. Gurvitz, MD and Karen K. Stout, MD, are cardiologists who work at Children's Hospital in Seattle. They discussed the care of people with congenital heart disease, not so much the technical but the social and institutional aspects of such care. When people have serious medical issues, medical care becomes a team endeavor.

November 30, 2007 - Residents at the Virginia-Mason Medical Center gave presentations on 1) syphilis 2) loss of consciousness associated with anti-thyroid antibodies 3) fatal stroke secondary to acetretin ( a synthetic cousin of vitamin A) given to a 42 year old man for psoriasis.

November 16, 2007 Constance D. Lehman, MD, PhD, Director of Radiology at the Seattle Cancer Care Alliance in Seattle outlined the current value of MRI in the field of breast cancer. Standard mammography is still the best screening method for women at an average risk of breasts cancer. Women who have a strong family history, chest irradiation, or a genetic tendancy to breast cancer benefit from MRI in addition to mammography. Women who are known to have breast cancer benefit from MRI for cancer staging, identification of silent tumors in the opposite breast, and more accurate surgery planning.

November 9, 2007 - Seth Schwartz, MD, an otolarygologic surgeon at Virginia-Mason Clinic gave a cost-analysis of treating hearing loss using cochlear implants. People with profound hearing loss can often regain some ability to hear through surgical implantation of a device into the nerve of hearing.

October 19, 2007 - Rebecca Ringer, a Seattle attorney, reviewed Washington law regarding medical record keeping.

October 5, 2007 Mary C. Pinder-Schenck, MD, of the Section of Hematology and Oncology at the Virginia Mason Medical Center detailed how breast cancer incidence dropped by about 5% in 2002 or so, probably because women decreased their use of estrogen replacement therapy.

Catherine J. Potts, MD, an internist at the Virginia Mason Bellevue reviewed methods used at Virginial Mason to be sure women are regularly screened for breast cancer.

September 21, 2007 Speaking at the Virginia-Mason Clinic Robert J. Keenan, MD of Drexel University College of Medicine in Pittsburgh, Pennsylvania reviewed current advances in treatment of lung cancer. Using a great deal of new technology, results are still poor, people surviving about an extra 18 months with the most intelligently applied chemotherapy.

September 28, 2007 Richard L. Rapport, MD, neurosurgeon at Group Health Cooperative in Seattle spoke at the Virginia-Mason Clinic about the biological basis of memory. In brief, we remember things by creating new nerve terminals to increase the number of active synaptic connections between two neurons. As we grow older, this ability decreases, but the old connections remain. This is why a demented person may remember very well what happened decades ago, but nothing about yesterday.

June 15, 2007 - Thomas Gallagher, MD, Associate Professor of Medicine at the University of Washington spoke on "Disclosing Harmful Errors to Patients: Recent Developments and Future Directions."

June 14, 2007 - Graham Nichol, MD of the University of Washington reviewed his collection of data on cardiac arrest occurring in the hospital. In contradistinction to what you see on television, more than half of people suffering a cardiac arrest do not survive to leave the hospital. The survival rate is even worse outside the hospital. Early use of a defibrillator is critical, as is effective chest compressions. If you needed another reason to leave your car at home and walk, or to buy and eat healthful food, this is another.

June 12, 2007 - Gregg VanderKleft, MD, a pain specialist, spoke at the Jefferson General Hospital Medical Staff Meeting about pain management in chronically and terminally ill patients.

June 1, 2007 - Patricia L. Dawson, MD, PhD, FACS, of the Comprehensive Breast Center at Swedish Cancer Institute-Providence Campus, makes her living treating breast cancer surgically, some of which is due to environmental toxins. In hopes of having to do less surgery, she reviewed environmental toxins and their adverse effects on health. Illnesses due to environmental toxins add billions of dollars to medical costs in Washington State annually. Sources of toxins include microwave popcorn bags, take-out containers, plastics including those used in medical care, as well as the more commonly known toxins.

Dr Dawson coordinated a study testing ten apparently healthy people from around Washington State for about 38 toxins. Everyone carried most toxins tested for, sometimes at or near harmful levels.

Erika Schreder, Staff Scientist with the Washington Toxics Coalition pointed out that federal law regulating the 80,000 harmful chemicals now in commercial use, was passed back in the 1970s. Whereas in Europe, manufacturers must prove a chemical safe before it can be sold, in this country the EPA must prove the chemical harmful and show how industry can replace it without undue hardship. In thirty years, the EPA has been able to remove just five toxins from the market. Many known toxins are in use because the EPA cannot overcome industry political pressure.

Certain corporations such as Kaiser Permanente, Herman Miller, Dell, Cascadian Farm, and The Body Shop are acting on their own to reduce toxins in the environment. One common toxin found in many consumber cosmetics are the parabens; in this case the label can be helpful.

You can learn more about this topic and the study on toxins in Washingtonians at www.pollutioninpeople.org .

May 18, 2007 - Kenneth Gross, MD, Head of Endocrinology and Diabetes at Virginia Mason Medical Center reviewed new concepts in the treatment of diabetes. He reviewed a number of studies on diabetes medications new and old.  Much research is sponsored by pharmaceutical firms, and the results massaged to generate the image they wish to promote.  Dr Gross made the unforgettable observation that "If you torture the data enough, it will tell you anything you want." 

And you, dear websurfer, would be amazed at the amount of time required to tease fact from fallacy in the field of medicine.

May 4, 2007 - Richard Thirlby, MD, surgery, and Cynthia Kirtland, M.Div, Chaplain, both of Virginia Mason Medical Center, spoke on spirituality and medicine. These speakers did not impose their religious beliefs on the audience, and gave the impression they would not impose them upon their patients.

Events in the news and a few articles in the medical journals lead me to add that if any physician or healthcare worker does suggest to you that they might have something to teach you about religion, that you run away as fast as you can. Our job is service, respect for our patients' beliefs, and attention to our responsibilities. It is not to pass judgement upon you for yours. Who is going to see to your medical needs if your healthcare workers decide to take on the role of pastor or religious advisor?

May 3, 2007 - Mary Disis, MD, a cancer researcher and physician at the University of Washington discussed immune system aspects of breast cancer. She and others are working on vaccines effective against breast cancer.

April 27, 2007 - Christopher Fellows, MD and Mark Hill, MD, both of the Heart Institute at Virginia Mason Medical Center reviewed the treatment of atrial fibrillation. As our population ages, this loss of rhythmicity of the heart's priming chambers becomes more common. Atrial fibrillation reduces a person's execise capacity and increases their risk of stroke. They discussed surgical treatment only, although attention to magnesium and potassium status, as well as thyroid disorders can be helpful as those sometimes play a role. In addition, people who consume more fish oil have less atrial fibrillation.

April 20, 2007 - Jakdej Nikomborirak, MD, sleep specialist, outlined some common-sense commandments of good sleep.

April 20, 2007 - Linda Mihalov, MD, Section Head of Gynecology and Gynecologic Oncology at the Virginia Mason Medical Center discussed sexual health after menopause. She notes that glycerin-based vaginal lubricants can promote yeast growth, and that silicone based products like Pjur or Liquid Silk are least likely to cause adverse effects.

Oral estrogen raises levels of sex-hormone binding globulin, which lowers testosterone levels. Transdermal estrogen is preferable in this regard.

April 13, 2007 - Michael Westley, MD, the Medical Director of Critical Care and Respiratory Therapy at the Virginia Mason Medical Center reviewed hand-washing and other infection-control procedures.

March 23, 2007 David Yu, MD, Department of Physical Medicine & Rehabilitation at Virginia Mason Medical Center discussed rehabilitation from stroke. He pointed out that contrary to our previous ideas, that the brain has the capacity to regenerate some of its function after damage. Modern stroke rehabilitation produces the best results when patients are prevented, for much of the time, from using their healthy limbs and forced to use their weakened limbs.

March 9, 2007 - Christopher L. Fellows, MD, Head of the Cardiology department at Virginia Mason Medical Center reviewed Sudden Death in Young Athletes. Every year in the US, about 500 to 1000 young adults die during physical activity. Most always they have asymptomatic heart disease. They may have been born with heart muscle diesase or atypical coronary arteries. The other common cause is viral infection of the heart muscle. Most often these cause no symptoms.

Considering there are perhaps 10 million young people participating in vigorous exercise, these conditions are rare. The question is, should we be screening our young athletes differently? A program in Reno, Nevada, ran about 6000 kids through a cardiology work-up and discovered about 10% with various heart abnormalities. After further testing, the cardiologists released all but 22 for athletics. One of those released later died during an athletic event.

Much of the difficulty arises because strenous activity causes changes in the EKG and echocardiogram that are difficult to differentiate from the changes occuring in a weakened heart.

While the idea of having a defibrillator at athletic events has appeal, experience shows that only about 1 of six of athletes who die on the field can be resuscitated. More often a spectator has the cardiac arrest.

March 2, 2007 - The Tacoma Medical Society reviewed some state-of-the-art of aspects of cardiology.

Dmitri Vasin, MD, a nephrologist (kidney specialist) from Bremerton pointed out that the goal is not just to reduce high blood pressure, but to reduce the likelihood of heart disease and stroke. These diseases are the outcome of metabolic abnormalities manifesting in increased blood pressure, cholesterol, blood sugar, abdominal weight gain, and poor aerobic fitness. He reviewed the biochemistry of high blood pressure and vascular disease, and how to choose medicines for prevention wisely.

Jaime Pugeda, MD reviewed recent understanding of the stents and other methods to reduce coronary blockages.

Daniel Heller, MD reviewed Xray methods (CT and MRI) of evaluating heart disease without catheters. He pointed out that ultrasound of the carotid arteries produces accurate results only in the hands of highly qualified technicians using the very best equipment. Anyone offering that test in the supermarket parking lot most likely will not provide accurate information.

Matthew White, MD identified patients in his practice at unusually high risk of heart disease and stroke. He worked with those patients to improve lifestyle and their medication plan. A year later, 75% of 34 people tested had reduced plaque in their coronary and carotid arteries.

Greg Brown, MD of the University of Washington showed that by lowering total cholesterol with a statin, the rate of heart disease falls by 30%. Add niacin, and the rate of heart disease falls by about 66%. Further, plaque in the coronary arteries shrinks.

David Clark, MD extended our understanding of heart failure, actually a much more common and subtle problem than usually recognized.

February 16, 2007 - The "Morbidity and Mortality Case Presentation" is an ancient medical tradition, consisting of a review of a medical case, sometimes involving a patient who suffered some adverse consequence of medical care.

Virginia-Mason clinic sponsored these presentations.  The first involved a patient who had swallowed a camera in a capsule for diagnostic purposes, and the camera became lodged in an unexpected stricture of the distal small intestine. The capsule and stricture were removed successfully in surgery.

The second patient had an irregular heartbeat that increased her risk of stroke. Doctors placed catheters in her groin which they advanced into the heart to treat the arrhythmia. The procedure was successful, but one of the catheters in the groin nicked an artery and the patient had bleeding into the groin requiring surgery. The surgeon noted that her anatomy was unusual, with the artery overlying the vein, rather than side-by-side as usual, thus explaining how the artery was punctured inadvertently. In fact, such a complication occurs occasionally during this type of procedure, even with normal anatomy.

The final patient was post-radiation for neck cancer, with one carotid artery completely blocked by arteriosclosis, and the other severely narrowed by a combination of the radiation and arteriosclerosis. Surgeons at VM opened the artery using several different methods over a period of two years, but each time it closed up again. Finally they placed a drug-eluting stent in the carotid, even though little research has been done on such stents in the carotid artery. Fortunately, this was successful for this patient.

February 13, 2007 - A psychiatrist from the Virginia-Mason reviewed delirium in hospitalized patients.

February 9, 2007 - Craige Blackmore, MD, MPH, Associate Director of Radiology at Harborview Medical Center in Seattle spoke at Virginia-Mason Clinic about imaging studies. These include any diagnostic test that produces a "picture" of part of the patient, such as an X-ray, CT scan, MRI, ultrasound test, and such. The question that physicians face every day is "is this imaging study worth the money the patient will pay for it?" Insurance companies ask the same question, and Dr Blackmore referred us to the Blue Cross website for practical guidelines.

February 2, 2007 - Lawrence Einhorn, MD, treated Lance Armstrong for testicular cancer. Mr Armstrong returned the favor, and Dr Einhorn now holds the chair of the Lance Armstrong Foundation Professor of Oncology at the Indiana University School of Medicine. He reviewed the treatment of testicular cancer, which along with choriocarcinoma is a highly curable cancer.

January 26, 2007 - Fred Govier, MD of the Virginia-Mason Clinic reviewed the causes and treatment of urinary incontinence. As of age 60, about 40% of all women have significant involuntary loss of urine. There are many reasons both men and women can lose urine. Over the past twenty years an amazing amount of progress has been made. Here in Port Townsend our urologist and physical therapy specialist can help the great majority of patients. Even with fairly severe incontinence, about 40% of women can expect to become completely dry, another 40% can expect to leak no more than once a week.

January 19, 2007 - Janet Nagamine, MD at the Virginia-Mason Clinic reviewed patient safety. Communication failures constitute a majority of medical errors. At this point in time, medicine lags the aviation industry in quality of team communication and function. Dr Nagamine gave specific recommendations for improvement. Gillian Erlich, RN, who works occasionally at our office, spends most of her time working at Harborview in Seattle. She reports that Harborview is making excellent use of the system outlined by Dr Nagamine.

January 12, 2007 - Several plastic surgeons at the Virginia-Mason Clinic reviewed newer techniques of breast reconstruction after mastectomy.

2006

December 1, 2006 - Kathryn "Kay" Koelemay, MD, MPH, a Medical Epidemiologist with King County, discussed measures being taken to deal with a bird flu epidemic, should one occur. She said the question was not "if" but "when." While government agencies are planning for this, I believe we are best advised to rely as much as possible on our own resources. Please see our January 2006 newsletter on personal and family disaster planning. For in a flu epidemic, one might need to remain at home for some time for reasons of isolation or quarantine. Whatever nutrients or vitamins you use to enhance immunity, you'd want to have on hand.

November 25, 2006 - I completed a twelve-hour home study course on management of pain and other distressing symptoms, and end-of-life care.

November 17, 2006 - Christian Guilleminault, MD, a professor in the Department of Psychiatry and Behavioral Sciences at the Stanford University School of Medicine spoke at the Virginia-Mason Clinic about disorders of sleep.

November 10, 2006 - Daniel Johnson MD of the Mayo Clinic spoke at the Virginia-Mason Clinic about CT examination of the colon. This technology seems safer than colonoscopy (using a flexible tube to examine the colon), and seems certain to diffuse from the medical centers out into the community as time passes. Of course, should something abnormal be found with CT, colonscopy would still be required to obtain tissue for examination.

November 9, 2006- Francis Kim, MD, of the University of Washington cardiology department, reviewed the effect that certain dietary fats have on inflammation and vascular function.

October 27, 2006 - Several doctors from the anesthesiology department at the Virginia-Mason Clinic reviewed newer methods of relieving pain. These include devices inplanted into the lumbar area to infuse drugs or use electrical stimulation to relieve intractable pain.

October 19, 2006 - Jeffrey Probstfield and Steven Kahn of the University of Washington discussed research showing that rosiglitazone, currently used to treat diabetes type 2, can also be used to delay the onset of diabetes in overweight people. Lifestyle interventions, including weight gain, reduction in fat intake, and exercise, are a bit more effective.

October 8, 2006 - Timothy Jacobs, MD, of the Virginia-Mason Clinic discussed genetic aspects of breast cancer. You can take a test to see of your family may carry one of the major genes for breasts cancer at http://www.myriadtests.com/provider/brca-risk-calculator.htm .

September 15, 2005 - Steven L Hauser, MD, from the University of California at San Francisco, spoke at the Virginia-Mason Clinic about the causes of multiple sclerosis. MS occurs because of an autoinflammatory response, and so has more in common with rheumatoid arthritis than with most other neurologic diseases.

MS occurs when people with a certain genetic makeup experience certain environmental challenges, which can be a viral infection or some still unknown trigger. There is no single gene that is responsible for MS. There are several, some of which increase susceptibility and some of which decrease it. Siblings of people with MS are about 40 times more likely to develop MS themselves, but often with different degrees of severity.

September 8, 2006 - Paul Pepe, MD, Medical Director of the Dallas Emergency Medical System, reviewed cardio-pulmonary resuscitation. When the heart has stopped, careful physiologic analysis shows that there is little benefit to breathing for the patient. People are more likely to recover from cardiac arrest when rescuers concentrate on chests compressions for the first four minutes, and defibrillate as soon as possible. When the heart has stopped, our need for breathing is much decreased. Breathing for the patient at this time interferes with the chest compressions, and results in about 10% survival compared to 15% survival when the rescuer concentrates on chest compressions.

June 9, 2006 - Steven Kirtland, MD, of Virginia-Mason Clinic spoke about sarcoidosis. This disease can be frightening because we do not know what causes it and it can cause significant breathing problems. Occasionally it can cause death. Most of the time, however, it resolves on its own without treatment.

June 2, 2006 - Richard Deyo, MD of the University of Washington spoke at the Virginia-Mason Clinic. He described how markteting, media, advocacy groups, and politics influence medical practice in such a way as to raise costs and reduce quality of care. Here are some of the points he raised.

Direct-to-consumer advertising is legal only in the US and New Zealand, and ensures that a new drug is widely disseminated quickly.

The National Sleep Foundation is an example of a purportedly health-oriented organizatiton that is actually mainly funded by pharmaceutical companies. Prior to the release of Lunesta, the Foundation sponsored a "National Sleep Awareness Week" and other similar activities. Also, around that time, companies "assisted" physicians in preparation of articles bashing older sleeping agents. These articles appeared in medical journals.

Hi-tech improves hospital margin. Advocacy groups push treatments before they have been proven safe and effective. As an example, over a billion dollars was expended on bone marrow transplants for breast cancer patients. Studies eventually showed it to be no more effective than more established treatments.

Media talk of 'breakthroughs' and 'catastrophes' sensationalizes medical news. 'Breakthroughs?' Real life advances are slow and steady. 'Catastrophes?' The more we attempt to achieve, the more painful and less understandable are our failures.

The FDA doesn't require new drugs to face head-to-head comparisons with older drugs. It should. Sometimes the older drugs are more effective. Hydrochlorothiazide (HCTZ) is one example.

Bob and Suzanne Fletcher were editors of the Annals of Internal Medicine. In 1992 they published an article by Michael Wilkes that impugned the accuracy of pharmaceutical ads in medical journals. Pharmaceutical companies reduced their advertising in that journal dramatically, and did not increase it until a new editor was appointed. (Sensitive, much?)

Betty Dong, UCSF, agreed to study Synthroid for its manufacturer, Boots, Inc. Boots designed the protocol, monitored the project, but in the end the generic proved as effective as Synthroid.  Dong had contracted with company not to publish without permission, and so she did not. The company published the study with an inaccurate conclusion favorable to themselves. When Boots sold Synthroid to Knoll Pharmaceuticals, Knoll relented and Dong's original findings were published in JAMA in 1997.

There are similar stories about Herb Needleman, who studied the neurotoxicity of lead paint. And James Kahn, at UCSF, about an AIDS vaccine that was ineffective. And David Kern, who reported the lung toxicity of nylon flocking, and lost his job.

All this raises costs. Less federal funding for research worsens problem.

Deyo suggested

Better post-marketing surveillance
An independent drug safety board, so the FDA can concentrate on approving new drugs and not face conflicts in evaluating drugs once they reach the market. We do the same thing in the airline industury, with the FAA and the National Transportation Safety Board.
Require preapproval of drug ads.
Give conditional FDA approvals, and phase in use of new drugs.

Dr Deyo is the author of "Hope or Hype: The Obsession with Medical Advances and the High Cost of False Promises"

May 26, 2006 - Several researchers from the Benaroyal Research Institute spoke at the Virginia-Mason Clinic. They discussed how elastic tissue degenerates in the arteries in people with arteriosclerosis, about immune tolerance therapy in autoimmune disease, and about susceptibility to cancer.

May 19, 2006 - Dan O'Connell, PhD, of the University of Washington spoke at the Virginia-Mason Clinic about the value of apology in health care. His charge was, to practice in such a way as not to harm patients. If patients are harmed by a medical error, they need to be recompensed. If patients are harmed, we need to hold the appropriate people accountable.

May 12, 2006 - Michael Sarr, MD, professor of surgery at the Mayo Clinic, spoke at the Virginia-Mason Clinic about necrotizing pancreatitis. For various reasons the pancreas can become inflammed and destroy itself using its own digestive enzymes. The risk of death is high in this condition. Dr Sarr reviewed the various methods used to treat this condition over the past twenty years, and why treatment protocols have evolved to the current standards.

May 9, 2006 - Scott Linquist, MD, Director of the Kitsap County Health District, updated the medical staff of Jefferson Healthcare Hospital on current infectious diseases including staph infections and tuberculosis.

May 5, 2006 - John Corman, MD, of Virginia-Mason Clinic spoke on treatments of prostate cancer using vaccines and other immunologic techniques.

May 4, 2006 - Daniel Drucker, MD, of the University of Toronto spoke about signalling molecules in the gastrointestinal tract. Much research in this area is leading to new drugs for diabetes and weight loss. Learn more at www.glucagon.com.

April 28, 2006 - Arnold Milstein, MD studies health care costs and talked about why they are high and how to reduce them. He called for better measures of quality and cost. He suggests that payments be set according to the efforts put forth by the patient and doctor. He thinks that we should have more rapid ways of testing which medical interventions are most cost-effective.

April 21, 2006 - April Stempien-Otero, MD of the University of Washington spoke at the Virginia-Mason Clinic about end-stage heart failure. In the US, there are about 2000 hearts donated each year and available for transplant. Recipients have about a 70% chance to live for five years or more. She outlined details of mechanical pumps used to keep patients alive waiting for transplant. These are not fun devices, but recent experience shows that by using these devices for a year or so, that the rest gained by the heart sometimes allows it to recover. Then the mechanical pump can be removed. This still is investigational.

April 20, 2006 - James Sevjar, MD of the National Center for Infectious Disease at Atlanta, Georgia spoke about mad cow disease. Actually, he titled his talk "Epidemiology and Clinical Features of Human Prion Disesase." These diseases occur not just in humans and cows, but also deer, elk, sheep, goats, cats, etc.

The prototypical illness of this type is Creutzfeldt-Jakob Disease (CJD) which causes rapidly progressing dementia and coordination problems in about one person per million per year. Meat from infected cows can cause a variant of CJD. About 160 people have been detected with this, worldwide. The British authorities were prescient in realizing that mad cow disease might spread to humans, and killed millions of cows before any human beings were affected.

You can read more about mad cow disease at http://en.wikipedia.org/wiki/Mad_cow_disease and CJD at http://en.wikipedia.org/wiki/Creutzfeldt-Jakob_disease.

April 14, 2006 - Peter Manos, MD and Joan Braun, RN reviewed measures taken at the major Seattle medical centers to deal with "difficult patients." They gave the example of a patient who required very great amounts of narcotic for pain relief. The nursing supervisor thought the patient exaggerated his reports of pain. The patient seduced the male intern and female nurse into taking his side. The patient, together with another nurse in the emergency department, instituted a disciplinary action against the nursing supervisor. A psychiatrist was consulted and instituted a special protocol for narcotic use in the patient. By that time the patient was requesting so much narcotic that his breathing rate become very slow. (Narcotics slow breathing in high doses.) He convinced the intern and nurse to give him even more narcotic, at which point he stopped breathing. He was given a narcotic antidote which brought him back to consciousness. At this point the intern and nurse were replaced, and the patient left the hospital. A few days later the emergency room nurse asked to have her name removed from the complaint against the nursing supervisor. This is because the ER nurse had loaned her car and credit card to the patient on the day he was discharged, and had not heard from him since.

The speakers reviewed other "difficult patients" with quite different situations, and how to deal with them.

March 31, 2006 - Mary Ann Abrahms, MD of the Iowa Health System, titled her talk "Mistake Proofing: Physician-Patient Communication." She points out that about half of Americans are not literate enough to read a bus schedule. Studies show that such people and their children are less likely to have adequate blood sugar control if diabetic, or poorer control of asthma if they have that condition. According to the Institute of Medicine, people with poor health literacy have poorer health outcomes. The complexity of the US health care system is beyond the health literacy skills of MOST adults. There are competing information sources, such as newspapers, magazines, television, the internet. Filtering the misinformation and forming a coherent idea of the facts is difficult even for very literate individuals.

March 24, 2006 - Carrie Horwitch, MD, of the University of Washington School of Public Health spoke at the Virginia-Mason Clinic about bird flu. He outlined the biology of the viruses and birds involved, the likelihood of a pandemic, and how we should prepare for a pandemic.

March 21, 2006 - Yolande Duralde, MD of Mary Bridge Children's Hospital spoke about the effects of methamphetamine abuse on children. As I understood her, children can be severely abused by their drug abusing parents and be returned to the parents after the parents enter treatment. Child service workers tell me that in this county there is inadequate supervision of drug-abusing parents. Such parents can have positive drug tests on multiple occasions and still be allowed to keep their children.

March 17-18, 2006 - I participate in the American Heart Association's "Advanced Cardiac Life Support" course at Jefferson General Hospital. CCU nurses from major Seattle hospitals teach this course annually. I first took this particular course in the early 1980's as a requirement to work as an emergency physician. Most of the other course participants in those years were also emergency room docs. Now, many RN's and other hospital workers participate in the course. The theory is that resusitation is more effective when a highly competent team is involved; also patients in cardiorespiratory failure in a hospital are cared for by RN's during that time that the physician is on the way to the bedside.

The techniques of cardiac resusitation have improved drastically since my first instruction on this in medical school in 1968. Our current understanding of how a dying heart comes back to life has resulted in fundamental changes in resusitation techniques. We practiced these current techniques over and over in a team and leader format.

March 10, 2006- The College of Medical Education of the Pierce County Medical Society sponsored a day-long meeting on mental health.

William Dean, MD, a urologist, spoke on meditation as adjunctive therapy for mental health disorders.

Steven Mitchell, MD, PhD, a psychiatrist, reviewed the extensive evidence that depression increases levels of the stress hormone cortisol, which increases destruction of brain cells, but worse, increases risk of diabetes and heart disease. People with depression are much more likely to develop heart disease; if they develop it, they are much more likely to die from it than non-depressed individuals.

Kelly Schloredt, PhD reviewed the continuum of self-harm and suicidal behavior in children and adolescents.

Steven Juergens, MD, a psychiatrist, reviewed details of choice and prescription of antidepressants. He reviewed the particular strengths and weakness of the different agents, how to reduce side-effects, and how to help patients who don't respond to the usual antidepressants.

Richard Schneider, MD, a psychiatrist, outlined a new conceptual model of insomnia. Many of his ideas can be found at www.scienceofsleep.net .

Fletcher Taylor, MD, a psychiatrist, points out that Lady MacBeth in Shakespeare's play suffers from post-traumatic stress syndrome. Often difficult for doctors to recognize, the syndrome occurs in people with too-close contact with death or serious injury. They have no trouble remembering, rather an impossibility to forget. They usually aren't aware of it at first, rather suffer discomfort or other abnormalities of bodily function.

Most people with PTSD recover within a year; about 10 to 25% will have continuing symptoms. SSRI's can be helpful for PTSD; paroxetine (Paxil) has been proven effective, but other SSRI's are often helpful too. People need doses up to 40 milligrams per day, and may need to wait three months to see a benefit. Fluoxetine, sertraline, prazosin effective, too. Prazosin is very inexpensive and especially helpful for disturbed sleep.

February 24, 2006 - Chris Fellows, MD, of the Virginia-Mason Clinic reviewed certain forms of cardiac arrhythmias and newer methods to prevent them from leading to death.

February 11, 2006 - Ten physicians from the University of Washington who work in the field of cardiology and radiology reviewed the current state of the art of cardiac imaging. For decades the best method of determining cardiac structure has been through placing catheters (tubes) into major blood vessels in the groin, threading these up into the heart, injecting a dye that shows up on X-ray, then taking a rapid series of X-rays to record the coronary arteries and the interior of the heart.

The limitation of this method is what you see on the X-ray is the dye that fills the space inside the blood vessel. The blood vessel itself does not show up. Blood vessels, however, are not rigid structures like pipes. They can expand, and usually do, when they are diseased. Thus the area inside the vessel can appear normal in a diseased vessel in which the plaque has pushed the wall of the vessel outward. CT and MRI are now able to show not only how much space there is inside the vessel for blood to flow through, but also how much and what kind of plaque is in that blood vessel.

This day, then, was given over to learning what radiologists can now do to learn exactly what a particular heart looks like and how it functions, without the risk of the catheter.

CT scanning produces images of the body by placing the person inside a machine that uses X-ray to produce 3-dimensional images of the interior structure of the body. Today these machines can produce an image of the entire head and torso in about 20 seconds. These are used in emergency departments for rapid assessment for victims of severe trauma. When directing this technology at the heart, they can produce images of the coranary arteries that are almost as detailed as those produced during catheterization. In addition, whereas catheterization just shows you where the blood is going within the vessels, CT scanning can show the plaque inside the artery wall and pick up coronary diease at a much earlier stage.

Magnetic resonance imaging (abbreviated MRI) produces 3-dimensional images of the interior structure of the body using strong magnetic fields. No radiation is required. Using recently developmented MRI technigues, we saw amazing images of blood flowing through beating hearts, illustrating both normal hearts and various abnormal conditions.

Echocardiography uses ultrasound to make images of the heart. No X-ray radiation is required. If you are familiar with the ultrasound used on boats for detemining depth, those have but one sensor, whereas current high-resolution medical ultrasound devices have 3000 sensors on an area the size of a postage stamp. Current generation devices can shouw blood flowing through the heart and the valves, in three dimensions and while the heart is beating. This I one way cardiac surgeons can see details of what they can expect to be finding and repairing at surgery. Much of this new echocardiographic technology is still available only in major medical centers.

Many of these techniques can allow us to see structures inside the body that transcend anything you saw on Star Trek. Some of the computer techniques seem to have been adapted from those used by the movie animation industry, and are very computer intensive. These machines can take a single image of an individual, subtract everything but bone, and so show you their skeleton in three dimensions. Then they can rotate that skeleton so you can see into every nook and cranny of it. They can do the same for the heart muscle, and for the spaces inside the heart and colon. On a screen, you can see the inside of the colon as it would look were you a small insect flying through it.

The machines that produce these CT images are mechanically complex; the smooth exterior of a modern CT scanner hides several electronic devices, each the size of a small microwave oven, that circle the patient at three revolutions per second.

Despite the complexity and technical sophistication of all these machines, they can produce incorrect images, especially if insufficient attention is given to technical details.

I advise against the "diagnostic studies" advertised in the newspaper that claim to screen for carotid artery narrowing, colon cancer, and other cancers. When last I looked into this, the technicians were not of the first rank and important technical details were omitted.

Much of what I outline above occurred in the first hours of the day. The speakers went on into much deeper water and elaborate detail. For example, ultrasound images made by catheters, called intravascular ultrasound (IVUS for IntraVascular UltraSound), are not commonly in use but allow much more precise and long-lasting treatment of coronary artery plaque.

One important point raised is that the danger of heart attack is better estimated by looking at the kind of plaque, not the degree of narrowing of the channel through the artery. Newer techniques provide a better view of the presence and type of plaque. We use different techniques depending upon what exactly we need to know, and how much we can pay to find out.

February 10, 2006 - Joel Sheinfeld, MD of Memorial Sloan-Kettering Cancer Center reviewed surgery for testicular cancer.

February 7, 2006 - David Baker, MD, of Harborview Medical Center reviewed the health consequences of methamphetamine use and addiction. He showed the CT scan of the brain of a 16 year old boy who went to a "rave" and was brought to the Emergency Department completely unresponsive. This is actually a common outcome of excessive use of "Ecstasy" and methamphetamine. Dr and his colleagues expected him to wake in time, as is usually the case, but ran a CT scan of his head just to be careful. To their surprise, the boy had a baseball-sized pool of blood in his brain, and died shortly as a result of that. Methamphetamine raises the blood pressure, and by this mechanism can cause bleeding into the head.

He showed the MRI of another, older, patient, who as a result of prolonged methamphetamine use had a huge clot in the major vein (the inferior vena cava) that carries blood to the heart from the lower part of the body. He showed photos of the dental disease that is universal witn severe methamphetamine abuse. He pointed out that methamphetamine use causes long-term damage to the brain structures responsible for our sense of well-being and contentment. He showed photos of the incredibly rapid aging of the body occurring in people who use methamphetamine. He had photos of severe burns of people manufacturing meth; the most tragic were those of children's faces.

Methamphetamine users are responsible for most identity theft. They have the time and attention to comb through large amounts of refuse to locate bankcard statements, social security numbers, and other data needed to help them obtain money to support their drug habit.

Methamphetamine acts as a slow poison that has the unfortunate side-effect of giving a person temporary euphoria while they are destroying themselves and, too often, their family.

January 27, 2006 - William DePaso, MD of Virginia-Mason Clinic described the methods used to improve efficiency in the Sleep Clinic, which allowed a major reduction in patient wait times and reduced the number of visits patients needed to make to get their needs met.

January 26, 2006 - Glenn Braunstein, MD of UCLA Medical School spoke at the University of Washington about the use of testosterone in the treatment of menopausal symptoms.

Women make male hormones at levels that maximize in their twenties, and then fall slowly thereafter. Low levels of testosterone result in dimished libido. Replacement improves libido and sexual function. The risk of facial hair is about 1 in 20; this will cease as soon as testosterone dose is reduced. There appears to no other risk of the low doses of testosterone that we use in women.

Estrogen given for treatment of menopausal symptoms can cause testosterone leves to fall even lower, so some women will note a decrease in libido with estrogen replacement that is not accompanied by testosterone. If anything, testosterone replacement reduces the risk of breast cancer.

January 20, 2006 - Timothy Dellit, MD of Harborview Medical Center spoke in the growing problem of drug-resistant staphylococcus. The acronym MSRA stands for methicillin-resistant staph aureus. People will often note a red area that's becoming infected and mistake it for a spider bite, when in fact this is resistant staph. There are many forms of these staph, but in this area they are usually respond well to the sulfa drug called SMZ/TMP, or to doxycycline.

This problem used to be more common in hospitalized patients, but is now becoming very common in people who aren't in the hospital. We are also seeing more staph resistant to vancomycin, the current "gold standard" of treatment. Newer drugs are available, but are expensive and have serious side-effects. These are all good reasons to avoid STD's, drug use, diabetes, and poor hygeine, as these are all risk factors for these infections.

January 12, 2006 - Anthony Blau, MD and Wylie Burke, MD of the University of Washington spoke about stem cells. Blau pointed out that Dr Donald Thomas receved the Nobel prize for his work here in Seattle to develop the use of stem cells. He made the first attempt at a human bone marrow transplant in 1955, but without success. He and his team then spent many years perfecting the process using dogs. Their first human success occurred in 1969. Now, around the world, over 50,000 bone marrow stem cell transplants are performed annually.

The federal government will fund stem cell research only on already existing stem cell "lines." These lines are stem cells that were harvested from fetal tissue years ago, mixed with mouse cells in the process of development, and have been kept alive in the laboratory since that time. The trouble is that newer techniques do not require admixture with mouse cells, and allow "cleaner" tissue for treatment of illness. Secondly, any cells grown in a laboratory gradually lose their qualities over time. Third, owners of existing cell lines are charging $5000 per line to license researchers to use them. Since each line has different properties, laboratories need to spend over a hundred thousand dollars just to find some type of cell that might be suitable for their research. Finally, federal funding limitations prevent development of techniques to transfer the patient's genetic material into donated human egg cells.

Researchers with private funding are able to develop stem cell treatments for currently untreatable diseasse without such restrictions.

About one-third of the US population opposes use of human embryos for stem cell research.

January 6, 2006 - Elizabeth Swisher, MD, of the University of Washington spoke at the Virginia-Mason Clinic about families in which breast and ovarian cancer are common. First, women need to know that 80% of breast cancer occurs in women with no family history.

However, there are families which carry genes which predispose them to gynecologic cancer. A woman may inherit these genes from her father, so may not be aware of the familial tendancy.

Once a woman has been identified to have high-risk genes, the traditional approach is careful surveillance or early hysterectomy once she has completed her child-bearing. In all women, there is abundant evidence that certain nutritional interventions can reduce the risk of developing these cancers.

In women who have been identified to carry the BRCA1 and BRCA2 genes, breast MRI offers better identification of early cancer than does Xray mammogram.

Hereditary non-polyposis colorectal cancer (HNPCC) is another illness caused by a genetic mutation that can greatly increase the risk of breast of endometrial and ovarian cancer. So, women with several family members with colorectal, uterine and ovarian cancer should be considered at risk for these cancers.

January 5, 2006 - I. B. Hirsch, MD, and D. L. Trence, M.D. of the University of Washington spoke on "Current and Future Tools in the Treatment of Diabetes." They discussed hormones other than insulin that are involved in the diabetic process. These include glucagon-like peptide 1 (GLP-1), exendin-4 (a reptilian analogue of GLP-1), and amylin. Drugs based on these hormones do reduce blood sugar when older drugs fail, tend to reduce weight, can lead to excessively low blood sugar and nausea, and are very expensive.

This year devices will become available that allow people to monitor their glucose levels every minute. Some of these systems can also inject insulin automatically.

Hemoglobin A1c measures of blood sugar control. The speakers use of these devices has shown them that many patients with normal hemoglobin A1c actually have excessively high and excessively low blood sugar levels at times when they happen not to be measuring their blood sugar levels. Such blood sugar excursions contribute to the progression of diabetic complications.

Use of these medications and devices is still difficult but holds much promise for improving health and extending life in people with diabetes.