Nerves are Shot...or...Root of Evil

Well how sweet of you to ask. Thank you for your concern! Yes, I recently underwent a root canal, a procedure only slightly more pleasant than a DRE*. In case you were wondering a root canal** involves the following:
- The nerve and pulp are removed and the inside of the tooth is cleaned and sealed

All that remains now is my coronation ceremony in 2 weeks during which a crown will be placed upon the pulpless, nerveless head of my tooth.

The only thing that could possibly make this experience more of a treat, is that it happened on my post-call day. Yay for Saturday!! Your Humble Observer is in a special place right now.

*Digital Rectal Exam
** Other Famous Canals:
- Gowanus Canal - Brooklyn, NY
- Erie Canal - NY
- Panama Canal - Panama
- Grand Canal - Dublin Ireland
- Canal Saint Martin - Paris, France

Medical Code: The JUPITER Study

December 17, 2008

The JUPITER Study:
Large Dominant Force or Big Ball of Gas?

The medical world was abuzz on November 20, 2008 when the New England Journal of Medicine (NEJM) printed a ground-breaking study. The article titled “Rosuvastatin to Prevent Vascular Events in Med and Women with Elevated C-Reactive Protein” was published based on data from the Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) study. The study was aimed at trying to find a correlation between the use of HMG-CoA reductase inhibitors (commonly called “statins”) and a decrease in cardiovascular events like heart attacks and strokes among others.

You may recognize various drugs in this class as Lipitor (atorvastatin), Pravachol (pravastatin), Zocor (simvastatin), and, the drug under investigation here, Crestor. The main use of these drugs is to lower cholesterol. They have generally had much success and are, as of now, considered very safe. Anecdotally, many physicians have recognized these drugs’ ability not only to decrease cholesterol, but generally decrease the risk of heart disease, stroke, and the like in addition to their effect on cholesterol. Enter the Jupiter study.

The background of the study has to do with the idea that a marker in the body known as C-Reactive Protein (CRP) has recently become associated with an increase risk of cardiovascular disease, when elevated. Now, this doesn’t mean that if it’s elevated you will have disease, simply that if you do have cardiovascular disease, CRP is more likely to be high. What the study wanted to see is if Crestor could effectively bring down levels of CRP in otherwise healthy individuals and whether this had any influence on cardiovascular disease. The results were astounding.

In the study, participants were randomly assigned to two groups, one that received the drug and one that received a placebo (a pill with no actual medication). The trial was set to go for five years, but was stopped just short of two because the results of the data at that point were so good, they could not justify continuing the study and denying some participants this drug. According to the article in the NEJM, Crestor reduced patients LDL (“bad”) cholesterol by 50% and the CRP levels by 37%, and what was more astounding is that heart attacks, strokes, and death from heart disease were reduced by half in the group taking the drug.

The NY times and other media sources immediately jumped on this story, practically elevating Crestor and “statins” as a whole to the level of wonder drug. All the medical community could talk about for a while was this study. We, as medical students in Internal Medicine, received no fewer than 3 separate lectures just on this study alone. You can imagine what happened to AstraZeneca (the makers of Crestor) stock after the release of this study.

It all seemed great and wonderful, but a few things still needed to be addressed. In the mind of Your Humble Observer, testing this drug on patients who, by most criteria, were healthy besides an elevated CRP was fine, but what about groups at higher risk? Can you draw the same conclusions? Besides all of this, the question remains: So what?

It’s great that the drug worked so well for research purposes, but how does this apply clinically? Do we start screening everyone for CRP? Can you even use CRP as an effective screening tool? Who should start receiving “statins”? Too many questions were left unanswered amidst the excitement.

The very same issue of the NEJM featured an article by Dr. Mark Hlatky of Stanford University trying to bring some perspective to the study by asking some of the very same questions posed above. He also brings to light some shortcomings of the study:

”…the trial did not compare subjects with and those without high-sensitivity C-reactive protein measurements, nor did it compare the use of high sensitivity C-reactive protein with the use of other markers of cardiovascular risk.”

His conclusion I believe is the most important consideration for this study:

“Guidelines for primary prevention will surely be reassessed on the basis of the JUPITER results, but the appropriate size of the orbit of statin therapy depends on the balance between the benefits of treatment and its long-term safety and cost.”

Finally, the biggest strike against the study is that it was funded primarily by AstraZeneca which is a huge bias for the study.

The bottom line is, clearly the statins are great medications, and this study shows that they may have wonderful benefits, but we need to approach the use of the drugs in a systematic and objective manner, carefully applying this new information to clinical practice. It will be interesting to see how this information plays out in the years to come with new studies on this subject.

Raindrops on Roses...

One of my newest favorite things:

Looking directly at an attending and clearly telling him the correct answer to his question, only to have him ignore you, look around at the group, and proceed to say the answer, almost verbatim as you said it. Ya, that's good.

New Feature - Twittering on the Brink of Insanity

After recently being exposed to this whole "Twitter" thing, I've decided to give it a try for the ol' blog. Basically, this will be a method to keep the blog semi-updated in between direct posts. Just take a gander over to the left of the screen and you'll see what Your Humble Observer is up to at that moment.

Let's hope this doesn't push both you and I over the brink...

In Texto Veritas - Tell Me How You Really Feel

From: A.K.
Date: 2/20/09
Time: 07:42

"I wanna find the various people through history who have helped establish physics as a credible science and have sex with them."

Your Humble Observer's comment: Incidentally, I feel the same way about surgery.

P.S. If you can't see the sarcasm dripping off of this comment, you must have your sarcasm-o-meter checked.

Countdown to the End - Addendum

I made it. Got through my first surgery call which, incidentally, was the first time I've done a full 24-hr call. Details to follow. Can't think now.

Mind Boggling Phenomena - The Reason Evolution is Just A Theory

I've begun playing a new game while I'm doing my workouts at the gym:

"Herniated Disc or Cerebral Hemorrhage"

As a future physician, I cannot tell you how horrifying it is watching 85% of gym-goers execute their workouts. It's as if they're begging for some sort of injury. All I can do is guess which injury they are most likely to have.

The worst offenders are the giant apes of human beings. They manage to take the simplest exercises, bicep curls for example, and turn it into a sure-fire injury causing motion. But they've been doing this so long, they've managed to build waaaaaaaay too much muscle in the most inefficient manner.

Let me just simplify this for everyone...

1. When you're doing an exercise, it SHOULD NOT require more than one motion.  Namely, if your back is moving at any point during bicep curls, you're doing it wrong.

2. Most weight-related exercise requires both flexion and extension of a joint. You get a more efficient exercise if you move slowly through the flexion, hold it at maximum flexion briefly, and move through the extension even slower. If you can't maintain this form, you're using too much weight, and, once again, asking for an injury.

3. You must maintain your breathing throughout the exercise. It is most beneficial to exhale as you flex the muscle and inhale as you extend the joint. Failure to do this (specifically holding your breath throughout) can raise the pressure in your head and could cause problems with the blood vessels such as causing them to bleed.

Countdown to the End

Patients Say The Darndest Things #3

D: Sir, do you have any other medical problems?

P: No, no medical problems.

D: High blood pressure? Diabetes? Heart problems? Cancer?

P: Oh, you mean like medical problems? Ya, I’ve got blood pressure and diabetes.

No, no, I meant FINANCIAL problems the first time I asked. But I'm glad you are sharing your medical problems with me.

In Texto Veritas - USMLE Style Question for a Real-Life Situation

From: Your Humble Observer
Date: 2/7/09
Time: 12:07

A 26 yo male is sitting @ Starbucks when he is suddenly exposed to toxic levels of cheap Duane Reade perfume. What is the next best step in management?

A. Slap the @#!$% for exposing him to toxic fumes

B. Slap the husband for allowing her to wear that @#!$

C. Slap himself for not getting up and leaving

D. Lick her face

Nareg's Poll of the Day - Armenian or Persian?

I conducted an un-scientific poll over text message today. It was regarding the ethnicity of a doctor at the hospital I am at right now. For reasons of privacy, I will not reveal the name here on the blog, but here were the resutls:

11 people polled, percentages reflect eventual final answers

Armenian         27%

Persian             36%

I don't know    18%

Other                 9%

No Response     9%

Now, those results are not as interesting as the process of trying to elicit a concrete response. The question was "either-or". Meaning, those polled were given the name and 2 choices: Armenian or Persian. You'll notice above that at least 4 different responses were made when these choices were NEVER provided. Human nature is a funny thing, we can't stay within the lines. If proper responses were given, they were usually accompanied by additional comments. Otherwise I had to keep working to get a proper reply. Examples of responses:

"Huh?"

"What's the difference?"

"Persian Jew"

"Armenian. We think everyone's Armenian"

"Is it a Parskahye name?"

One person outright FAILED the poll. How someone fails a poll is beyond me, but this person managed, no names *cough* Diko *cough, cough*.

It was an amusing process to glean through my "data" to get actual numbers. In the end, Your Humble Observer has no better idea about the background of the name, but at least he now has new fodder for this and future blog posts.

Patients Say The Darndest Things #2

D: Ma’am, are you still bringing up sputum this morning?
P: Nah, I don’t have any spit ‘em.

Do you know what it takes to not burst out laughing in front of a patient?

Writing On The Wall - Damn! There Goes Saturday Night

What kind of a society do we live in that requires this to spelled out to us? As if we're assuming ASSAULTING someone doesn't carry a consequence.

Patients Say The Darndest Things #1

D: So, Mrs. T, what brings you into the hospital today?

P: An ambulance.

I actually heard "Wah, Wah, Wah" in the background right after this encounter.

Writing On The Wall - Naski? Kartoshka!

Seems like a narrow market.

O...M...G

Just back off the guy! He made a mistake, he's apologized and he's paid from both pocketbook and image. Enough!

Like Mike.

Everyone Put Your NWA Tapes Away.

Ok, everybody relax, settle down, and don't over-react yet. I say this as someone who has already over-reacted and has calmed down and is now trying to understand...


"The Fresno Police Department launches an internal investigation after a video...shows two officers beating a homeless man during an arrest...two Fresno Police officers, seen here repeatedly punching 52-year-old Glen Beaty, a homeless man, who police say resisted arrest."

These situations present themselves to us in life, and it is our duty as citizens of the US and human beings to look at them analytically and objectively.

I was quick to jump to conclusions, yell at the television about police brutality, and consider it shameful to be a Fresnan on a day like this. But thought it better to at least examine what we know (or at least, what we're being told):

A homeless man was being put under arrest for a felony warrant (for what, I can't say). The video begins with the two arresting officers holding the man on the ground and as they go to put handcuffs on him, one officer delivers several closed fist blows to the head. The video does not show anything prior to the incident, so what prompted the officer to beat the man is unclear. According to Fresno Police Chief Jerry Dyer, "One of the officers was punched by the suspect in the arm. The officer had his badge ripped off of his shirt. There was also an attempt to jab the officer in the arm with a pen that the suspect had taken from the officer’s shirt."

Things to consider:
1. First and foremost, the police have one of the most dangerous jobs in the world. They are constantly placed in harm's way. I don't think anyone would disagree with an officer using force if their own lives or safety are in danger. In this case, I am unaware if such a situation presented itself.

2. The main job of the police in a case like this is to arrest, take into custody, and remove from society those individuals who are SUSPECTED of breaking the law. That is all. They do not carry out punishment, certainly not before any sort of determination regarding innocence or guilt. As such, they cannot be allowed to use excessive force, by that I mean beyond what is necessary to neutralize a dangerous situation, on someone SUSPECTED of committing a crime. In this case, I am unaware of what the crime this man is suspected of nor can I say, based on what I've seen, whether blows to the head were required to neutralize the situation.

3. The police chief claims the man has a history of violence with three previous incidents with the police, including resisting arrest. Given this situation, he says, the force used may not have been excessive.

From what I can gather (please remember, we DON'T have the full clinical picture here, just shadows of truth) it appeared the man was already subdued and almost in cuffs when the officer went to the blows to the head. The video does not show the man resisting and it appears the officer may have gone overboard with his reaction. I must warn against the use of the 3-prior-incidents argument for or against the police. You can only react to what's happening now, not in times previous.
Our society cannot condone excessive physical force against the individual by any force, be it police, military, or other law-enforcement agencies. If you believe anything this country is founded on, you have to believe that all are innocent until proven guilty, AND WE MUST TREAT THEM AS SUCH. I hate to use this quote from a recent episode of 24, but truly it is the rules that make us better. It's the fact that we rise above the inhuman brutality of others that makes us a great society.
No human should live in fear of the police. They should respect them for the job that they do and the danger that comes along with that job. But we cannot just give in to overt acts of brutality, under the guise of safety. Should the investigation show that excessive force was used on this man, I hope that not only FPD, but society as a whole would stand firm against these practices, and that those responsible be held accountable.

Retrospective #3 - The Universal Language

September 16, 2006

Medicine: The Universal Language

Learning medicine involves learning an entirely new language, complete with a new set of nouns, verbs, adjectives, phrases, grammar, etc. Your concept of directions completely change. For example:

Up becomes Superior
Down become Inferior

Then, because nothing in medicine can be desctiptive enough, you get the fancy words like Distal for when you're moving away from your body along your arm or leg or Proximal for the opposite direction, and so on...you get the picture...

As if this wasn't all bad enough (yes, I can feel the collective eye rolling going on right now from Yeretsgeen Paula, Jerry, and Arman), we have to deal with professors who don't exactly speak the English language the way we would like. As a result I have put together this list that I like to call:

"Words That I Have Come To Hate Because of my Candian, Australian, and New Zealander Professors"

I Say It: Cervical (SERVE-uh-kul)
They Say It: serve-EYE-kul
This one irks me the most. I don't know why.

I Say It: Vessel (VEH-suhl)
They Say It: VyEE-suhl
I can't even write out how they pronounce this.

I Say It: Out (owt)
They Say It: Oot
I just hate this word in any context now.

I Say It: Skeletal (SKEH-luh-tuhl)
They Say It: skuh-LEE-tuhl
You get the picture


This is not comprehensive at all, and I'm sure will be added on to when our Belgian professor of Histology begins lecturing. Stay tuned...

In Texto Veritas - A Series of Unfortunate Events

From: A.K.
Date: 2/6/09
Time: 09:58

...It's been a rough morning...I forgot my chem clicker at home so I couldn't participate. I have a hole in my pants right in the crotch

Mind Boggling Phenomena - Super-Absorbant

I joined a gym today, oh boy....*

This gym really is a nice place: friendly staff, clean facilities, new equipment, sauna/steam room, etc. etc. etc. "So what's so mind-boggling about this?", you're asking.
I'll tell you:

With every new memberships comes a nice little goody bag, just as a "Thank-you-for-giving-us-waaay-too-much-money" gift. In this goody bag are the items depicted in the picture below. My particular favorite is the little pink box all the way to the right and top of the picture. I should be getting some good use out of that... :/



Just as an FYI (because inquiring minds want to know), the rest of the items are tooth whitening strips, an energy bar, a small bag of coffee, a razor and some shaving cream (now these I thought are super cool), body wash, two samples of cologne, and some hair ties (you know, so I can hold my luscious head of hair back).

*276 points to whoever can identify the song reference in the first line of this post.

The Toll

This is a protest. It may upset many but, frankly, this has been bottled up for some time so here we go...

"Lutzak ee parootyantz kotz, Der, jashagelov uzmarmin ko yev zaryoon. Park ee partzoons geragroghin uzmez..."
"We have been filled with your goodness, Lord, by partaking of Your Body and Blood. Glory in the highest to You who has fed us..."

Words that conclude the sacrament of the Eucharistic the Armenian Apostolic Church. The congregation, the Body of Christ, has just come into communion with one another, the saints, and with Christ himself by partaking of the Holy Body and Blood of Jesus Christ. The Church is one now.
An act of such magnitude shouldn't be taken lightly (though it is every single Sunday). It should be approached with the purity of mind and soul, and walked away from with deep reflection and awe at the sanctity of what you've done.

So then, why is it, that at this very moment, I'm confronted by a plate or a basket, and asked that my attention be turned away from this huge moment and instead focus on MONEY OF ALL THINGS?! Some churches at least have enough respect to keep these two separate, but more often than not, I'm running into the same problem. It's as if they can't pass the plate fast enough.
I'm sorry, but this is despicable. And my church is guilty of it. It's bad enough that the curse of the world is let into the sanctuary, but when it's in my face right after communion it just enrages me. There must be a better time, moment, situation for it.
I promise to double my donation on the way into the building (still not happy about that, but we must pick our battles) if we can just remove this outdated, disgusting practice from our Holy Divine Liturgy. Fair trade?

P.S. Spare me the "But that's the only way the Church can survive" nonsense. There are better ways, and you cannot justify this practice with that argument. It's wrong... PERIOD!

Mark 11:15

It's Always Sunny In NYC

It was 50 degrees Farenheit in New York today. This is considered a warm day. 

It was 61 degrees Farenheit in Fresno today. This is considered a cold day. 

*Sigh*