NCBI's Images Database

The National Center for Biotechnology Information (NCBI) has released an image database built from the full-text articles in the PubMed Central repository. When the database went online in October, it held more than 2.5 million images. For more background, read the NIH Press Release.

The images can be graphs, line drawings, illustrations, radiography, or photographs. To see some of the range of resources, view the results of this search on chorea.

While I find that quick word searches have worked well for my uses, there is an extensive help page explaining other ways to search as well as dissecting the images results page.

The database includes extensive holdings of genomic images, but I can see the database being useful in a community hospital setting. Perhaps you have just attended an in-service on wound vacs and wondered what types of wounds these devices are used to treat. The results aren't pretty, but here they are.

Please do keep in mind that while viewing these images to open to anyone, use of the images must comply with their copyright status.

3 comments - Posted by Steve Rauch at 12:11 PM - Categories:

On Become a "Branch Campus"

Subject examinations, aka shelf exams, are administered to medical students as they complete their clinical rotations or clerkships. This morning, a third year student from Rocky Vista University College of Osteopathic Medicine took his examination here at Community Hospital.

Several RVUCOM students are spending the year in Grand Junction and are doing most of their clinical rotations with local physicians. Being able to take their examinations here saves them from making the winter drive across I-70. (View the current road conditions across the state thanks to the Colorado Department of Transportation.)

This step comes as we completed the requirements from the National Board of Medical Examiners to be a "branch campus" of Rocky Vista for testing purposes. We had to be located at least two hours from the college - no problem meeting that requirement, we needed to have the appropriate facilities, and we needed to have an Associate Executive Chief Proctor.

Heather Gray agreed to be our initial AECP; now Dan Thomas has taken over that position. Heather and Dan, along with Connie, Erica, and myself are the proctors who can administer the examinations. We surely have one of the highest proctor-to-student ratios of any NBME site, but feel this is a valuable service to offer the medical students.

1 comments - Posted by Steve Rauch at 3:44 PM - Categories:

Legionnaire's Disease

I have always enjoyed reading mysteries, the complete Sherlock Holmes was the first hardcover book I bought. I equally enjoy doing puzzles: crossword, acrostic, Sudoku, and jig-saw. These two interests seem to come together whenever I read about public health outbreaks. Two recent studies on Legionnaire's Disease help to illustrate how epidemiologists work to to discover the missing pieces from the facts they need to solve an outbreak.

When cases of Legionnaire's disease cropped up last year in Alcoi, Spain, molecular analysis linked the cases to one another, and to a series of cases that occurred earlier in the decade. However, the cases occurred in two different parts of the city, and at two different periods of time.

Legionnaire's disease is associated with exposure to atomized water that is contaminated by the bacteria causing the disease. Usual sources are stationary. The CDC guidelines have investigators ask specifically about exposure to these potential sources: showers, decorative fountains, humidifiers, hot tubs, wet saunas, cooling towers, respiratory therapy equipment, and evaporative condensors. During the earlier outbreak, investigators had tested the usual locations. With the new outbreak, they knew they had to find a water source that fit the time and location parameters.

The likely suspect turned out to be an asphalt milling machine - a device that scrapes asphalt from a street so that the new paving remains at the same level. Water is sprayed during the process to control dust. This particular device was filled from a spring, not from the city water supply, which likely allowed for the original contamination. The machine was removed from service, cleaned, and renovated to use dripping water rather than spraying water. No further cases turned up. Read all about it in Emerging Infectious Diseases.

Sporadic cases of Legionnaire's Disease often occur with no source ever being determined. In England and Wales, studies found that professional drivers were five times more likely than normal to contract the disease. This was not an ongoing outbreak that could be molecularly analyzed, but did provide investigators a population to survey. Drivers who had contracted Legionnaire's were contacted and asked to participate in a survey as a case group. The same survey was given to individuals of the same age, gender, and geographic location to provide a control group.

One of the interesting results came from a question about using screenwash - either prediluted or concentrate. Whereas 50 of 51 members of the control group used it, only 34 of 49 cases used it. The case group also drove more with their windows down, and drove through industrial locations (another possible source of exposure). Public health officials conjecture that the windscreen washer reservoir is in a warm location (the engine compartment), the water is atomized by the windscreen sprayer, and the drivers are exposed to the contaminated spray through the open window.

This case control study cannot prove causation; but it seems to be well-done and has led to a public health effort to have drivers use screenwash in their windscreen wiper system. After a few years, we might well see a follow-up study to compare the rate of Legionnaire's Disease compared to the rate of use of screenwash by British drivers. This study was written up in the European Journal of Epidemiology.

0 comments - Posted by Steve Rauch at 1:26 PM - Categories:

Encountering Negative Comments

Our daughter recently made the decision to go to graduate school. Once she chose a school, the real work began: getting her moved to and settled into Salem, Oregon

It was interesting to see how many pieces of information about the move we could obtain over the Internet. In some cases we arrived fully informed, and in others decisions were made before we started.

• Possible apartments (including the one she selected)
• Health Insurance possibilities
• Medical and dental care providers
• Closest Apple Store on our drive there (a MacBook Pro was in her future)
• List and location of reputable mechanics
• How to title and register her car
• How to get a driver's license
• Banking that provided a safe deposit box, nearby ATMs
• Renter's and car insurance

The one service that remained elusive was Internet access. The phone company required the additional expense of an ISP. The cable company wanted to bundle services she did not need. The third option was a wireless provider that covers many parts of the Pacific Northwest. But searches turned up many negative comments on their coverage, their contract, and their customer service. I asked the college IT folks, but received no clear direction.

Once we were in town, I decided to go with the wireless solution but not opt for the two-year contract. That evening, my daughter easily got online, and has not had any problems these few weeks getting a much more robust connection that I get from my own home. I was puzzled comparing all the negative comments to her actual experience.

One of the emails in my INBOX when I got back to work was the announcement of a new HeartBeat issue from Wendy Leebov. I have long been familiar with her works and had subscribed to this free newsletter on patient satisfaction. The lead story in August was how much faster and farther negative comments spread in today's world of social networking. The old rule of thumb was that a happy customer told 4 others, and an unhappy customer told 20 others. Leebov cites a new book that updates the ratio to 3 to 3,000.

I wondered if this is what I ran into with my search for Internet service providers? Surely some people were genuinely disappointed by the performance of this wireless Internet service and said so. But others were likely taking advantage of anonymity and the ease of posting comments to overstate the situation. Were some even working for competing services?

In choosing the wireless Internet service, I was willing to challenge the negative comments because I was not risking a great deal - one month of service and a wireless modem. But can we in health care expect our customers to take a risk with their next elective surgery? Fortunately for us, Wendy Leebov goes on to outline steps we can take to forge positive messages and how to take on negative ones. Her steps include:

• We can LISTEN
• We can INVITE feedback
• We can respond to feedback, quickly, honestly, and openly
• We can plant seeds

Read all of her comments on page 2 of the August HeartBeat. If you'd like to read the other HeartBeat articles, all issues are archived online.

0 comments - Posted by Steve Rauch at 12:00 PM - Categories:

HealthCare.gov

Twice within the past year I helped our daughter find health insurance in a new state. While I don't hope to get another chance to go through this process soon, a new government web site should make the experience more palatable.

HealthCare.gov went online at the beginning of July. The main information categories are Find Insurance Options, Learn about Prevention, Compare Care Quality, and Understanding the New Law. A final section is arranged by target audience: Families with Children, Individuals, People with Disability, Seniors, and Young Adults.

I was drawn to the insurance options section. On page one I selected a state and the user category that best described the applicant. On page two I gave the age range, insurance status, listed any special populations that have significance for insurance (veteran, pregnant, have a medical condition, etc.). The results are grouped by type of health insurance. It seemed lots easier than the multiple searches I had tried on my own.

The prevention page is currently a lead-in to healthfinder (an HHS web site with health information resources). The quality page is a lead-in to the Hospital Compare web site. There is more content regarding the new law, including an interactive timeline and pre-existing conditions insurance plans.

Although HealthCare.gov just went online, this news release outlines some of the planned enhancements. I would like to see the prevention section add resources like MedlinePlus and some of the other health information resources that many of us already use.

While I would find value in having a single place to search for health insurance plans, there is content here for small employers, veterans, seniors, persons with pre-existing conditions, and anyone just wanting to understand the jargon of health insurance plans.

0 comments - Posted by Steve Rauch at 1:51 PM - Categories:

Oral Allergy Syndrome

The first weekend in June, while the temperature was breaking the 100 degree mark, I enjoyed my first watermelon of the year.

About this same time last summer I did the same thing. Our son was home and asked me if the watermelon made my mouth itch. When I asked for more information, he said eating watermelon made the inside of his mouth and ears itch. The sensation dissipated quickly, but occurred each time he had watermelon. It happened the following week with a different watermelon.

Puzzled, I searched the medical literature to find out what this was and discovered OAS - oral allergy syndrome. Certain foods cause a sensation of itchiness or tingling in the mouth and throat.

Research into this condition is ongoing, but the current thinking is that many persons with pollen allergies develop OAS to foods that have a protein that the body confuses with the offending pollen. Cooked fruits and vegetables do not cause OAS, the proteins are broken down and do not trigger the pollen reaction.

This condition is also called pollen-food allergy syndrome, to describe what triggers the reaction instead of giving its physical location as OAS does. Researchers are mapping the fruits and vegetables that might cause this reaction based on different pollen allergies. For example, ragweed has its associated foods, birch allergy has its associated foods, etc.

Fresh fruits and vegetables become a staple of my summer and fall diet; I frequent farmers' markets to supplement my own garden. While I enjoy apple pie, I cannot imagine never enjoying a fresh apple. I am glad that I have never developed OAS.

Our son never had more of a reaction than the itchiness that dissipated quickly. A hallmark of OAS is that it only affects the mouth and throat area, a systemic reaction indicates something more than OAS. Our son told me that bananas have also started to trigger a reaction this year - another fruit on the ragweed list. He has stopped eating the foods that cause a reaction. Some individuals can have a stronger reaction, and those situations probably warrant a visit with ones health care provider.

For further information, read the Wikipedia entry on Oral Allergy Syndrome. The American Academy of Allergy Asthma and Immunology published this page on ragweed and OAS in 2007. For a view from across the Atlantic, a British consumer health site focused on food issues published this look at OAS and its possible modern triggers.

0 comments - Posted by Steve Rauch at 9:39 AM - Categories:

Evidence-Based Papyrus

In our modern medical world, evidence-based practice has reached buzzword status. The phrase, its three-letter acronym, and its discipline-based variants appear everywhere, giving the impression that evidence-based practice is a modern phenomenon.

Now, thanks to the efforts of collectors, curators, and translators, we have access to an Egyptian medical treatise from at least 1,600 B.C. View the Edwin Smith Surgical Papyrus [requires Adobe Flash player]. After the page loads, use your mouse to drag the scroll open. With the zoom icon at the bottom of the page you can magnify the hieroglyphic script. With the text icon, you can highlight the cases within the scroll. Selecting a case scroll brings up an overlay page that transliterates the text.

The scroll, as it currently exists, presents 48 trauma and wound cases. Each case has a description, diagnosis, prognosis, treatment, and further explanations specific to the case. The prognosis seems to include one of these three phrases:

• An ailment I will handle
• An ailment I will fight with
• An ailment for which nothing is done

These prognoses seem to be based on the existing evidence, resulting in an ancient system of triage. A serious perforation of the temple is "an ailment I will handle"; a split temple is "an ailment I will fight with"; and a fracture of the temporal bone is "an ailment for which nothing is done". It must have taken time to determine which injuries fell into which category. This papyrus likely sought to pass down that experience.

Among the treatments, a dressing with oil and honey is listed frequently. At first glance, this might seem far from evidence-based, but these substances address two of the four items that comprise the TIME acronym of modern wound healing: Tissue, Infection, Moisture control, and Epidermal margin.

Honey is a well-known wound dressing. View PUBMED search results for english language articles on honey and wound healing. In recent years, the Food and Drug Administration has approved a wound dressing called MEDIHONEY™.

While health care has certainly advanced in the last 3,600 years; but let's not assume the ancient Egyptians were not also asking themselves: is this injury treatable? and what treatment produces the best outcome? And clearly, they must have had a medical librarian to index and store their papyrus documents ;-)

1 comments - Posted by Steve Rauch at 10:28 AM - Categories: