PGH Modified Yale Insulin Infusion Protocol

Still have not updated the blog as promised … will be starting over soon :)

For now, you can download my presentation on “Intravenous Insulin Therapy: The Yale Insulin Infusion Protocol” from slideshare.net. This was presented at the 1st Intravenous Therapy Nursing Update 2011 at the Philippine General Hospital.

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Social Media and Medicine

Still toxic … have another thesis presentation coming up.

Below is my presentation which I gave last Friday at the 2011 Joint Annual Convention of the Philippine Lipid & Atherosclerosis Society and Philippine Society of Hypertension. With all that I’ve learned making this presentation, will be revamping this site soon (hopefully!).

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Web 2.0 and Medicine

It’s been more than a month since I posted anything here … busy finishing my thesis in medical informatics. This site will have a major update soon!

But for now, I’m posting a presentation I gave for the Lourdes Manahan Memorial Lecture at the 2011 annual convention of the Philippine Rheumatology Association.

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Presentation on Smoking Wins the World’s Best Presentation Contest 2010

Do you have a SlideShare account? Get one now if you don’t have one yet. I not only use it to upload and share my presentations but every so often I also browse a few of the thousands of presentations on SlideShare for some presentation tips. In this post, I’d like to share the winners of the World’s Best Presentation Contest 2010 hosted by SlideShare. I especially like the first place winner as it tackles a health topic – smoking.

I really like the melding of the message and the pictures in this presentation, it packs a punch!  It provides a good example of thinking visually, creating twitter-friendly headlines and dressing up the numbers – tips from presentation coach Carmine Gallo.

If you know anyone who smokes … show them this presentation! It’s time to stop smoking!

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Lifestyle Change with HealthSeeker on Facebook

HealthSeeker

I have a strong family history of diabetes. I know my risks! Can Facebook help me move toward a healthier lifestyle? Check out the HealthSeeker app. I just joined up today :)

Their disclaimer reads:

Content for the HealthSeeker Game has been developed by either Joslin Diabetes Center (Joslin) or the Diabetes Hands Foundation (DHF). HealthSeeker™ is made possible through support provided by Boehringer Ingelheim Pharmaceuticals, Inc.

Any content created for or included in the HealthSeeker Game is for the purpose of providing information only. It is not intended as the practice of medicine or the provision of medical care or services, nor is it intended to provide individualized medical or nutritional services. This game does not provide medical advice.

Although we believe the information included as part of the HealthSeeker Game to be accurate at the time it is first provided, because medical information changes rapidly, Joslin, DHF and BIPI make no representation, express or implied, as to the accuracy, completeness or timeliness of the information. The content provided is not meant to be a substitute for medical advice, diagnosis or treatment, or for the individualized advice of a nutritionist or registered dietitian. Always consult your provider or other healthcare professional with any question regarding any medical or mental health condition, or before altering or undertaking any exercise or nutritional program or before taking any supplement referred to in the HealthSeeker Game.

Hmm, which mission should I pick?

  1. Over the Rainbow: The Fruits and Veggies Mission
  2. Size Matters!
  3. Snack Attack!
  4. The Phat Mission!
  5. A New Beginning!
  6. Chill out! The Anti-Stress Mission
  7. Jack Sprat Could Eat No Fat
  8. I WILL Move it! Move it!
  9. A Dash’ll Do Ya: The Sodium Mission
  10. Groovy Grains! The Whole Grain Mission
  11. What the Fiber?
  12. It’s a Numbers Game! The Monitoring Mission
  13. Carbs Count
  14. Move it! Move it!
  15. Roughin’ It: The Fiber Mission

When you click on a mission, you’re given an action plan for the week. For example, “Weigh yourself at the same time of the day.” This must be done at least once this week. When you complete a mission, you gain experience points.

Of course, it’s a social game. You can invite your friends to join you in the game. An interesting concept that just might be working :)   there’s 3354 monthly users already and it was just launched last June. Will let you know how this turns out for me!

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Diabetes and Pre-employment Clearance

seafarer

"The Seafarers Memorial by Michael Sandler 2001" by mira66, http://www.flickr.com/photos/21804434@N02/4074992551/. Accessed 23 Nov 2010

Last November 10, the Maritime Association of Doctors and Clinics (MARDOCS) invited me to talk on diabetes and obesity. MARDOCS had their first convention which gathered manning agencies doctors, nurses and staff of pre-employment clinics at the Hyatt Manila.

Diabetes and obesity are important concerns for the seafaring industry as these conditions continue to increase in the workforce. Endocrinologists like myself often receive referrals to evaluate seafarers who are diagnosed diabetic, or who for the first time have been found to have glucosuria, or elevated fasting blood sugar / HbA1c. Are you aware of Administrative Order No. 2007-025 from the Department of Health which discusses the “Revised Guidelines for Conducting Medical Fitness Examinations for Seafarers”?

DOH AO 2007-025 defines “Fit for Sea Duty” as a seafarer who is “able to perform safely the duties of his position aboard a ship in the absence of medical care, without danger to his health or to the safety of the vessel, crew and passengers.” Fasting blood glucose is NOT required for new applicants and serving seafarers less than 40 years old though a routine urinalysis is.  Glucosuria on urinalysis often triggers measurement of fasting blood glucose though, in most of the referrals I receive. Lab work-up for seafarers 40 and above include fasting blood glucose, creatinine, uric acid, total cholesterol, triglyceride and ECG.

Under this guideline, the following endocrine conditions require further investigation and complete assessment:

  • Acromegaly
  • Adrenal insufficiency, uncontrolled
  • Uncontrolled type 2 diabetes mellitus
  • Diabetes mellitus requiring insulin
  • Hyperthyroidism, diffuse toxic goiter, toxic nodular goiter, thyrotoxicosis, thyroiditis
  • Obesity, incapacitating or body mass index of 34 and above with or without co-morbid pre-existing conditions
  • Osteoporosis
  • Pheochromocytoma

In my presentation, I defined diabetes, impaired fasting glucose, impaired glucose tolerance and prediabetes. I enumerated the risk factors for diabetes and who should be screened. I also talked about the use of HbA1c in diagnosing diabetes, in addition to fasting blood glucose and the glucose tolerance test. I’m often “rushed” to give endocrine clearance for seafarers with elevated blood sugars, so I also had a slide explaining when we can reasonably expect glucose to go down when an oral hypoglycemic agent is started. More importantly, I shared with them the current glycemic targets recommended by the American Diabetes Association. Finally, I defined obesity and compared the BMI cut-offs according to the WHO and the Asia Pacific classification.

You can view my presentation below:

Diabetes, Obesity, BMI, what are the limits?

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Marketing of Avandia, Avandamet and Avandaryl Suspended in the Philippine Market

stop sign

"Danger" by asifthebes, 25 Feb 2009. http://www.sxc.hu/photo/1152462. 30 Oct 2010

Yesterday, I received a letter from the Glaxo Smith Kline (GSK) rep at my clinic. Dated 27 October 2010, it was signed by Dr. Joven Q. Tanchuco (Medical Director, GSK Philippines). According to this letter, GSK has been “ordered to cease and desist from further importing, distributing, selling and offering for sale the rosiglitazone containing medicines rosiglitazone maleate (Avandia), rosiglitazone maleate + metformin (Avandamet), rosiglitazone maleate + sulfonylurea (Avandaryl).” This order came from the Philippine FDA. It was dated October 18 and received by GSK Philippines on October 22.

GSK recommends the following:

Prescribers are advised not to issue any or new repeat prescriptions of rosiglitazone-containing medicines.

Prescribers are advised to review currently treated patients and switch them to suitable alternative treatment.

Patients are advised to make an appointment to discuss their treatment and not to stop taking rosiglitazone maleate (Avandia), rosiglitazone maleate + metformin (Avandamet), rosiglitazone maleate + sulfonylurea (Avandaryl) without consulting their doctor.

More importantly, these medicines will continue to be available to patients only until November 19, 2010 to help patients transition to alternative treatment as discussed and agreed upon with their physicians.

I applaud the Philippine FDA decision as it is always wise to err on the side of caution. Primum non nocere. First, do no harm. We still await the results of the US FDA review of the RECORD data, a clinical trial that used rosiglitazone.

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Medical Errors: How Handheld Devices can Help

eraser

Eraser by gulden, 22 Sept 2006 http://www.sxc.hu/photo/621943. Accessed 22 Oct 2010

If you searched for “medical errors” in PubMed, you will find that it is a MeSH term:

“Errors or mistakes committed by health professionals which result in harm to the patient. They include errors in diagnosis (DIAGNOSTIC ERRORS), errors in the administration of drugs and other medications (MEDICATION ERRORS), errors in the performance of surgical procedures, in the use of other types of therapy, in the use of equipment, and in the interpretation of laboratory findings. Medical errors are differentiated from MALPRACTICE in that the former are regarded as honest mistakes or accidents while the latter is the result of negligence, reprehensible ignorance, or criminal intent.”

I’m not aware if we have data on medical errors for the Philippines but an Institute of Medicine report estimates that at least 44,000 Americans die each year from preventable medical errors.  So much for honest mistakes!

palm_pilot

re-ality, 9 Apr 2006, http://www.flickr.com/photos/re-ality/126577972/. Accessed 22 Oct 2010

I started using a handheld device in 1997. Back then, it was a Palm Pilot Professional. It only had 1 mb of RAM and a monochrome screen.  It ran on two AAA batteries. :)   One of the first applications I had on it was Epocrates, a free drug database. Currently, Epocrates not only offers the “premium” drug database version but also applications that deliver medical content (CME) and information about lab tests and diseases. I continue to have Epocrates in my iPod touch and I mainly use it to check for drug interactions and renal dosing. Occasionally, I will check it for drug contraindications (i.e. in pregnancy) and adverse reactions.  I truly believe that having a drug database in my handheld device (a long line of Palm devices, and lately the iPod touch) has helped me to avoid one type of medical error – medication error.

A paper by Dallenbach MF et al, tested the ability of Epocrates RX (used by a general internist) to correctly identify clinically significant adverse drug reactions (ADRs) in the outpatient clinic.  The comparator was a clinical pharmacologist using a drug-drug interaction compendia.  1801 prescriptions from a clinic were reviewed retrospectively. The first eye-opening piece of data from this paper was that the prevalence of potential ADRs was 23%!  When Epocrates RX was compared with the clinical pharmacologist, the sensitivity of Epocrates RX to correctly identify clinically relevant adverse drug interactions was 81% (95%CI 77%–85%) and the specificity was 88% (95%CI 86–89%). The positive predictive value was poor (67%, 95%CI 62%–71%) but the negative predictive value was excellent (94%, 95%CI 92%–95%). The authors discuss the shortcomings of the Epocrates RX but I believe these can be easily overcome as the software releases updates regularly.  What might be a problem is if the MD user does NOT regularly update his device (requires an internet connection).

I have also installed other drug databases on my iPod touch like Medscape (which also contains information about common conditions and procedures) and Medicinal Herbs, since more and more patients use herbal supplements.

Epocrates RX from iTunes App Store, Accessed 22 Oct 2010

Lastly, what I particularly like about Epocrates RX for the iPod touch is the pill ID picture. While this feature requires an internet connection, I have used it several times to identify drugs that my patients could describe but not recall the name. “Doctor, it’s white, round and small!”  Just how many tablets look that way?!

Reference:

Dallenbach MF, Bovier PA & Desmeules J. Detecting drug interactions using personal digital assistants in an out-patient clinic. QJM 2007; 100(11):691-7.

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The Presentation Secrets of Steve Jobs

apple

Apple iPhone. AZRainman, 27 Aug 2007. http://www.flickr.com/photos/azrainman/993139738/ Accessed 13 Oct 2010

I highly recommend that you read this book by Carmine Gallo, “The Presentation Secrets of Steve Jobs: How to be Insanely Great in Front of Any Audience.” If you give lectures like I do, you’ll surely appreciate the great tips in this book!  Click here for a Slideshare presentation that summarizes the book.

I’m no Steve Jobs when I give my presentations :) – I’m not comfortable at all moving away from the podium just yet. But since I’ve read this book, I’ve done my best to eliminate the clutter from my slides.  It has been so difficult for me to get rid of the bullet points! I’ve added more pictures and tried limiting the number of words per slide to take advantage of what psychologists call the “Picture Superiority Effect (PSE)”.  Apparently, concepts are more likely to be remembered if they are presented as pictures rather than words.

Then there’s the rule of  three, an old presentation technique that’s not so easy to adhere to when you’re given a broad topic to discuss. But I’ve found that planning your presentation around three major points makes it simpler both to develop and deliver. Structuring your presentation with this rule in mind also makes it easier for your audience to remember your talk’s important points. Politicians and advertisers have taken advantage of this rule of three. Take a look at the following examples:

Stop, look and listen.

I came. I saw. I conquered.

Sex, lies and videotape

Government of the people, by the people, for the people

The good, the bad and the ugly

Even the time spent making the presentation can be divided into three’s: one-third of the time for collecting and organizing ideas, one-third for creating the slides and one-third for rehearsing!  How much time do you spend on preparing for a presentation? According to Carmine Gallo, design experts recommend spending 90 hours for a presentation that has 30 slides :) Wow! I must admit I need to work on rehearsing – I spend most of the time finishing my slides the night before the lecture, ha! ha!

“One more thing …” Don’t you just love it when Steve Jobs says that? Anyway, the book advises that “you reveal a holy shit moment.” How does one do that in a medical presentation? It’s difficult but I’ve realized that this “moment” happens when you reach out to the audience. I remember giving a presentation on prolactinoma in pregnancy at a convention. People noticeably perked up when I shared that I had a prolactinoma and had conceived while on bromocriptine!  On another occasion, I was talking about personal digital assistants (PDAs). I sensed a great connection with the audience when I showed a picture of my very first PDA – the PalmPilot Professional with its monochrome screen and triple A batteries :) I guess I just have to work on making more of those moments happen.

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Mobile Phones: Reservoirs of Nosocomial Pathogens

no cells

mzacha "No cells" 8 Jan 2009 http://www.sxc.hu/photo/1131636 Accessed 9 Oct 2010

Is your phone “bugged”? How “germy” is your phone? When was the last time you cleaned it? These are valid questions, considering that doctors bring their phones everywhere!

A study by Ulger et al. entitled “Are we aware how contaminated our mobile phones with nosocomial pathogens?” provides some answers.  Two hundred health care workers’ hands and mobile phones were cultured. These health personnel worked at the OR and ICU.  Eeeww, the bacterial contamination rate of mobile phones was a whopping 94.5%! Predictably, similar bacteria were isolated from phones and hands. Nearly half (49%) of the phones had one bacterial species while 34% had two different species.  And alarmingly, some of the phone isolates were resistant strains: 31.3% of the gram negatives were ceftazidime-resistant and 52% of the S. aureus strains were methicillin-resistant.

Only 10.5% of the participants routinely cleaned their phones. So that meant 89.5% never cleaned their phones, yucch!  Interestingly, participants who wore rings tended to have higher mean colony counts on their phones though it was not statistically significant.  The authors conclude that,

“Mobile phones used by health care workers in daily practice may be a source of nosocomial infections in hospitals.”

Obviously, we can’t ban cell phones from the hospital environment. But this serves as a reminder to all of us that we should not only adhere to the hospital’s hand washing policy but clean our phones regularly as well.  I don’t want to advertise anything here but one can find several phone-disinfecting wipes on the market. :)

Reference:

Ulger F, Esen S, Dilek A et al. Are we aware how contaminated our mobile phones with nosocomial pathogens? Annals of Clinical Microbiology & Antimicrobials 2009, 8:7

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