Meetings Attended 2010

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2010

December 10, 2010  William T. Hurley, MD, works as Emergency Physician at Harborview Medical Center.  He reviewed medical team techiques used to minimize medical mistakes. 

November 19, 2010  Jeffrey A. Hunter, MD, the Director of Bariatric Surgical Services at the Virginia Mason Medical Center reviewed recent advances in surgery to help people lose weight.  As time has passed, they have discovered that up to twenty percent of the lap-band patients have to have a second operation because of problems resulting from the first operation. 

More commonly done is an operation called the gastric bypass, or Roux-en-Y, in which attaches the small intestine to the stomach so that part of the small intestine is bypassed.  The original idea was to reduce assimilation of nutrients since food did not travel through part of the small intestine.  Now it seems more likely that the surgery changes the signalling inside the GI tract thus reducing hunger and increasing metabolic rate.  

The lap-band procedure no longer is performed in Europe, and is falling out of favor here.  Too often people have complications from it, and over the long term, people tend to regain weight because the procedure does not have the beneficial metabolic benefits of the gastric bypass procedure.

November 11, 2010 Stephen A. Lopez, MD talked about an unusual Helicobacter infection.

November 5, 2010 Paul L. Sicuro, MD, director of CT services at the Virginia Mason Medical Center talked about how to reduce the radiation dose used in medical imaging.  We all get radiation from the radon in our homes, cosmic rays, and other natural sources of radiation.  Currently in the US, the average person gets about as much radiation from medical x-rays as they do from natural radiation. 

Changes that decrease the dose include:

==With fluoroscopy, in which live x-ray monitoring guides certain prodedures such as finding foreign bodies or placing catheters in the heart or elsewhere, the x-ray image is flashed on and off like a strobe light rather than being left on all the time.

==With CT scans, new computrer software allows improved images with lower radiation doses.

==Shielding is placed over sensitive tissues such as the thyroid, the breasts, the gonads, and other organs.

==Elimination of unnecessary x-ray proceduces through collaboration between the patient's physician and the radiologst.  

==Experience shows that often a lower dose will produce an image that answers the clinical question just as well as the traditional higher dose.   That is, when the CT scanners are sold to the radiologist, the vendor wants to produce as detailed an image as possible, which requires more radiation.  Secura and other radiologists are working to see how low they can turn down that radiation.

If you read further about this, remember that 10 milliSieverts = 1 rad = 1 rem.  More information at radiologyinfo.org

October 29, 2010 John A. Ryan, Jr, MD, a surgeon at Virginia Mason Medical Center spoke on the history of surgery.  You can learn more about what he said by Googling William Beaumont, John Blodgett, Charles Bulfinch, Thomas Edison (surgeons worked by light from skylights prior to Edison, and it is difficult to fix what you can't see), LBJ (Medicare has played a huge role in the development of American medicine), and Steve Jobs: Personal Reflections of 50 Years in Surgery.

October 22, 2010 Patricia Coffey, PhD discussed reproductive health in developing countries.   Worldwide, about half a million women die each year in pregnancy.  The bulk of those die in countries so poor that contraceptives are difficult to obtain.  Among the top six are Nigeria, Afgnanistan, and Pakistan, countries with close ties to the West.

Political forces in our country vigorously oppose provision of contraceptives to women in those conutries, citing the will of God.

Her NGO develops contraceptive devices for use in developing countries.  They went though over 200 designs for their diaphragm to find one that did not require fitting and sizing, as our standard diaphragms do here.  It does not fit all women, but one size fits most women.  They tested it overseas and found women preferred it to the standard Ortho diaphragm, and that it is effective in preventing conception.   They have also developed injectable contraceptives and female condoms.

October 15, 2010  Stephen Salloway, MD, Professor of Clinical Neurosciences and Psychiatry at the Warren Alpert Medical School of Brown University spoke at the Virgina-Mason Clinic about dementia, with special attention to Alzheimer's dementia (AD).  

Memory and cognition declines with age in all of us, but of course much more rapidly in dementia.   Analysis of spinal fluid can give early clues to Alzheimer's, as can a PET scan.  Genetic testing can indicate risk though I do not see how this helps patients as we have no treatment.  

Of the several drugs intended to treat AD, none are very effective.  Dr Salloway directs much attention to the families and others caring for the dementia patient.  People with AD cope better at home, and costs are less than they would be with institutional care.

Current efforts at treatment are focussing on synthetic antibodies that seem to clear amyloid, an abnormal protein that develops with AD, from the brain.

Oct. 8, 2010 Breast Cancer:  Virginia-Mason Clinic reconsiders its policy of screening every woman over the age of 40 on the basis of recest studies quentioning the value of mammography as currently recommended.  

Sept. 17, 2010  Michael D. Williams, MD in the Section of Endocrinology at the Virginia Mason Medical Center reviewed "Thyroid Nodules and Thyroid Cancer."

About one in ten persons, women more than men, has a thyroid nodule greater than 2/5 of an inch in diameter, though often we do not detect them.   Thyroid nodule more likely to be melignant if male, age less than 30 or greater than 60, family history of endocrine cancer, history of head or neck irradiation, or elevated TSH.  

Nodule suppression with thyroid hormone supplementation works about 40% of the time, but may result in adverse effects such as osteoporosis.  

Sept. 10, 2010   Pat Croskerry MD, PhD, a professor in the Department of Emergency Medicine at Dalhousie University in Halifax, Nova Scotia, spoke at the Virginia-Mason Clinic, titling his talk "Gaining Insight into Diagnostic Error".   He contrasts intuitive thinking, the most common style of thnking, with analytic thinking.  The latter is more costly in time and effort, but less prone to error.  

He highlighted Jerome Groopman's book "How Doctors Think" as a concise tutorial of medical decision making and how we can avoid errors.  He then discussed sources of diagnostic error and outlined methods to reduce them.

September 15, 2010 Robert Superko reviews cholesterol sub-fractions and their meaning for heart disease.  He also reviewed genetic tests to help us target therapies to prevent heart disease.

September 16, 2010 Stephanie Paige, MD, from UW Medical Center reviewed what we know about the effect of testosterone on the prostate.   Her punchline is that we really don't know, that there have been no long-term prospective randomized trials, and we won't know for many years.  

What we do know is that as men age, and their testosterone levels fall, their incidence of prostate cancer goes up. And once they have prostate cancer, we can inhibit that cancer by blocking testosterone.   Most of the testosterone that enters the prostate is reduced to dihydrotestosterone, though only 10% of the testosterine in the serum is. About 1% of serum testosterone is metabolized to estradiol, important for bone strength.  

Levels of testosterone do not correlate with the incidence of prostate canecr.  Supraphysiologic doses of testosterone do not increase PSA, though physiologic doses do.        

In 19,000 men over age of 55, finasteride 5 mg daily was associated with a risk of prostate cancer with high Gleason score of 18% , compared to 22% with lower Gleason score with placebo. 

With testosterone antagonists, there are still significant levels of testosterone in the prostate, which probably arise from within the prostate.

Oral testosterone results in marked spikes in serum DHT. Transderm DHT reduced serum testosterone, (negative pituitary feedback), but no change in intraprostatic androgens or prostate epithelial cell gene expression.

Europeans use DHT, have also found no change in prostate volume or PSA.   It looks like exegenous angrogens do not increase intraprostatic angrogen, at leas in short term small trials.  

Theory is that the prostate testosterone receptor becomes saturated at physiologic levels of testosterone, and higher levels have no effect.

Endrocrine Society considers treatment for symptomatic men with morning levels below normal for healthy young men, but not if PSA .gt 4 or prostate canecr.

Men with prostate cancer, apparently cured with absent PSA, who have severe hypoangrogenic symptoms, sometimes are given testosterone by Dr Page.  

June 18, 2010 Anthony L. Back, MD, a professor of oncology at the University of Washington, outlined ways physicians could improve communication with seriouly ill people.

June 15, 2010 Dmitri Vasin, MD, nephrologist from Bremerton spoke about how certain genetic tests could improve our treatment of heart disease.

Dr Vasin pointed out that most of our scientific studies describe populations, whereas with genetic testing, we can treat people as the individuals they are.

You can learn more on Dr Vasin's website at renalremission.com.

June 11, 2010 Michael Myint, MD, is the Medical Director Epidemiology, Infection Prevention and Antimicrobial Stewardship at the Virginia Mason Medical Center. He titled his talk "Multi Drug Resistant Organisms and Healthcare Infections: Is this the Beginning of the Post Antibiotic Era?"

While staphylococcus was sensitive to penicillin for the millenia preceding the introduction of penicillin in 1942, by 1947 staphylococcus had developed an enzyme that inactivated penicillin, temporarily gaining the upper hand in what has become an ongoing struggle. Office-based physicians such as myself have an easier time of it, as the bacteria seen in hospitalized patients develop antibiotic resistance so quickly that world-wide coordination is required to track and reduce the death rate from such infections.

Bacteria continually evolve. We live in symbiosis with trillions of bacteria, and every time we take, say, minocycline, we kill billions of them. The bacteria that survive to repopulate our skin, our nose, our gastro-intestinal tract have one thing in common; they are resistant to minocycline.

Hence Dr Myint's charge of "Antimicrobial Steward". We humans, both patient and physician, need to use antibiotics wisely. The advice to soldiers used to be "Don't shoot til you see the white's of their eyes", in order not to waste ammunition and be ready when action really is needed. With bacterial infections, it is even more important to save antibiotics for the right time and situation, because when we shoot before we see the whites of their eyes, we make the bacteria stronger.

June 6, 2010 Today I reviewed a number of journal articles on glaucoma screening. The US Preventive Services Task Force does not recommend for or against such screening. The American Academy of Family Practice endorses this position.

While measurement of the intraocular pressure stands in the public mind as the best test for glaucoma, there are several methods, none perfect, and the best is the DDLS, the disk damage likelihood scale. Inspection and measurement of the optic nerve head in the back of the eye gives an idea of the health of the optic nerve, which is the area of risk with glaucoma. Full implementation this method involves equipment not found in a primary care office, but examination of the eye after dilation can give an idea of the health of the eye and determine the need for a full ophthalmologic exam.

June 4, 2010 Christopher M. Bernards, MD of the Virginia Mason Medical Center Department of Anesthesiology reviewed newer concepts in the treatment of pain. One is that tolerance to opiates occurs because our bodies have pro-nociceptive systems that detect pain and become more active when pain-relievers are given. So, people who develop increasing pain despite opiates often respond to ketamine because it blocks the NMDA receptor, which is involved in the pro-nociceptive system.

Often we see people with severe lumbar pain who have relatively normal anatomy on MRI. (And others with a terrible looking MRI who have no pain at all.) As it turns our, when lumbar disks from such people are analyzed at surgery, the disks have high levels of inflammatory substances.

Anthony J. Gerbino, MD reviewed treatment of scleroderma with myophenolate mofetil

May 28, 2010 Drs Cyrus Cryst, Andrew S. Weiss, and Michael Sutters of the Virginia Mason Medical Center reviewed kidney disease, kidney failure, and kidney transplantation. High blood pressure greatly hastens kidney failure; they discussed optimal treatment of high blood pressure. Nighttime blood pressure is most predictive of stroke and kidney disease, morning next predictive.

People in Africa have had no reason to lose their genetic tendency to retain sodium, because they live in a salf-poor environment. Move them to a salt-rich environment, and they are much more likely to develop high blood pressure than are their distant cousins who lost those salt-retaining genes through a long sojourn in Europe.

Renal sympathetic nerve ablation reduces elevated blood pressure.

Even with a successful kidney transplant, half the transplants fail by the end of ten years. The best treatment, then, is prevention, with an emphasis on blood pressure control.

Each year in the US, people die, of whom about 50,000 have authorized organ donation

May 21, 2010 Nathaniel J. Soper, MD, a surgeon at the Northwestern University Feinberg School of Medicine in Chicago, reviewed laparoscopic surgery. Currently, surgeons are removing gallbladders by inserting instruments through the mouth or vagina. Personally, if I had to have my gallbladder removed, I'd stick with the current mainstream methods.

Dr. Soper reviewed as well advances in robotic surgery, and advanced imaging systems that can take data from a CT scan or MRI and superimpose that on the surgeon's view through a scope, and show him what lies beyond the tissue he can see, such as a tumor hidden in the liver.

April 16, 2010 Fred E. Govier, MD of the Virginia Mason Medical Center reviewed infections.

April 9, 2010 Thomas M. Green, MD, Merry M. O'Barr, RN, CNOR, RNFA, and Lyle S. Sorensen, MD of the Orthopedics department of the Virginia Mason Medical Center arrived in Haiti 17 days after the earthquake. With them they brought all the medical and surgical equipment and supplies they thought they would require, there being no resources in Port au Prince. The hospital was still standing, with electicity and running water. The Virginia Mason team considered themselves lucky as they had brought tents with them to sleep in, and lucky that they were the ones being begged for food, and not being on the hungry end of the deal. As in the television show MASH, patients came in in trucks and helicopters, decisions had to be made as to whom to operate on first, and work went on as long as crews could stand. Equipment eventually ran low, so the VM team traded supplies with a Baptist mission hospital and scavenged supplied from military equipment depots. Unlike teams from other medical centers, the VM team remained for a month. This was valuable because even amid the devastation, politics

April 2, 2010 Michael Westley, MD, Head of Critical Care Medicine at the Virginia Mason Medical Center reviewed methods they use at their hospital to improve the outcome of in-hospital cardiac arrest and other life-threatening events. Methods include twice-weekly drills with post-drill de-briefing, simulations, better-organized crash carts, check-lists, team interaction training. Hospital resuscitation may require six or more people, each with a specific task. Yet, each time one occurs there will be a different team leader, a different pharmacist, different nurses, a different recorder, different respiratory therapists, differest house physcians, all arriving in the room at a different point in the process. From the start, though, action must be undertaken to assure the best outcome for the patient, and the unique group of health-care workers needs to self-organize while this is happening. Dr Westley and his co-workers organize the crash cart, and the medications and supplies there, in such a way as to make common errors impossible. They set up procedures to allow teams to self-organize more competently.

March 26, 2010 Resident physicians at Virginia Mason reviewed various topics. First, as a cosequence of excessive weight gain, fat will infiltrate the liver. As this progresses, auto-immune processes can begin, which can lead to serious liver damage.

Second, a resident outlined her experience working in a clinic for the un-insured.

Third, a resident discussed the causes of blood in the semen. Below 40 years of age, infections or congenital malformations lead the list, while above the age of 40, tumors are a concern, though other causes include medications (including aspirin) and many other illnesses.

Fourth, a resident reviewed a patient with nutritional problems following gastric bypass secondary to poor adherence to dietary guidelines.

March 19, 2010 Ravi S. Krishnan, MD, of the Virginia Mason Medical Center illustrated treatment of skin cancer with Mohs micrographic surgery.

March 18, 2010 - Dr Robert Terkeltaub from the UCSD medical center reviewed newer information about gout. Longevity and the increased prevalence of chronic disease has doubled the number of people developing gout. About a quarter of people with gout develop it as a side effect of aspirin, diuretics, niacin, transplant medications, and other drugs. Diet and alcohol use bring more gout, which comes with weight gain and decreases exercise. Light "healthy" beer, large portions, junk food, high fructose corn syrup (HFCS). The standard 9 inch dinner plate from 1960 held only 800 calories, whereas today the wedding registration people tell you that 12 inch is now the standard size, a plate that holds twice as many calories. The fructose in HFCS becomes uric acid, the cause of gout, when metabolized.

Dual energy CT identifies soft-tissue uric acid. Ultrasound can be helpful.

Colchicine now branded, best dose 0.5 milligrams three times daily. Treat flare 1.2 mg, then 0.6 mg an hour later, safer and more effective than higher dose. Prednisone at 35 mg qd. Best to lower urate soon, as tophi develop in about 10 or 15 years. Weight loss decreases urate by 10%. Uricosuric drugs ineffective if GFR lt 60, and contraindicated if uric acid overproduced. Aim at serum urate lt 6, though Europeans aim at 5. Major allopurinol hypersensitivity syndrome affects 1 person per thousand, carries a 25% mortality rate, can cause Stevens-Johnson, especially with HLA-B58 (more common in Asians). More common early in therapy, more common with CKD and diuretics. Start with low dose, give twice a day at doses greater than 300 milligrams a day. Flares result from tophus remodeling, occur during effective urate-lowering therapy, patient benefits from continued therapy. Colchicine 0.6 milligram twice a day can reduce flares.

March 12, 2010 Mary L. Farrington, MD, an allergist at the Virginia Mason Medical Center, reviewed IgE-mediated food allergy. The most common food allergens in children are eggs, milk, soy, wheat, peanut, and tree nuts. About half of children will outgrow this. Adults similarly usually react to just a few foods. The best test are food challenges, comparing reaction to a capsule with a food in it compared to a placebo capsule. About 30% of the time, people react to the placebo capsule. IgG food allergy tests do not truly identify allergy.

March 5, 2010 John C. Graffe, a trial attorney, listed the common medical errors that lead to lawsuits.

February 26, 2010 Kris V. Kowdley, MD, of the Virginia Mason Medical Center, focuses his work on liver disease. He outlined how excess weight and excess iron in the diet can lead to severe liver disease. One minor point he mentioned is that exercise improves health even if weight remains the same, by returning certain inflammatory and metabolic processes more towards normal.

John M. Ravits, MD, a neurologist, has advanced our understanding of amyotrophic lateral sclerosis, and reviewed much of what he has learned.

February 19, 2010 Nancy Tipton, MD, a gynecologist at the Virginia Mason Medical Center, discussed the most common STD in women, Chlamydia. This affects something in the range of a quarter of sexually active young women. Screening should be routinely performed in such women as a part of normal well-person screening.

February 12, 2010 Michael A.S. Jewett, MD, a researcher and professor at the University of Toronto, spoke at the Virginia Mason Medical Center about different testicular cancers.

February 5, 2010 Kas Ray Badiozamani, MD, works as a radiation oncologist at the Virginia Mason Medical Center. His specialty is treating cancer with radiation. Newer techniques include extremely expensive machines that track a cancer as it moves with breathing, that changes what formerly were rectangular beamss into precisely shaped beams that more exactly target the cancer and avoid adjacent healthy tissue.

While radiation oncology advances in capability to help people with cancer, work remains to be done.

1. Because cancer spreads with initial microscopic extensions that do not show up on an X-ray, sometimes narrow targeting can fail as well.
2. Targeted higher-dose treatment doesn't necessarily improve longevity.
3. People differ in biologic make-up, so all do not respond the same.
4. Some of the techniques run up against the law of diminishing returns.

The solution may lay in the direction of improved identification of function of an individual's genes, proteins, and other biologic functions, and modification of treatment to prevent side-effects they might otherwise suffer.

January 29, 2010 Christopher L. Fellows, MD, of the Virginia Mason Medical Center spoke on the electrical system of the heart, and the history and use of defibrillators and pacemakers.

January 22, 2010 Mark H. Meissner, MD, Professor of Surgery at the University of Washington spoke about the prevention and treatment of life-threatening blood clots in the deep veins. Severe trauma, critical illness, being overweight, and pelvic surgery really raise the risk of such clots, so unless there is a compelling reason not to, such patients are usually given medication to prevent such blood clots.

January 15, 2010 John F. Kokesh, MD, an ENT doc in Anchorage, Alaska described the telemedicine system physicians use in Alaska. Given the extremely low population dessity, the system allows transmission of photos, X-rays and other diagnostic tests, text, etc between remote and central healthcare facilities. This allows application of up-to-date medical care in very remote areas. For the specialists in the medical center, these consultations can be squeezed into spare tiem while waiting to go into the operating room, or during times when patients miss their appointments. The same specialists, in the process, educate the primary care people out in the field, who over a span of time expand their knowledge to complete tasks they would previouly had to refer to the specialist.

January 8, 2010 Theresa A. Nester, MD, the Associate Medical Director of the Puget Sound Blood Center reviewed some of the issues and procedures used in the transfusion of blood. The procedures used in blood banking are as protocol and rule-driven as are commercial airlines, and unsatisfacty outcomes as carefully studied to prevent recurrence.