My Electronic Medical Record Reality

I love my electronic medical record (EMR). I can type about 100-110 words a minute, but I just installed Dragon Medical.  It is amazing.  I can now dictate 600 words per minute.  My day just sped up and I might make it home for dinner!

Those of you that know me know that I have been using an EMR since 2002 when I opened my practice.  Many people I spoke to told me I was "nuts" to consider practicing Solo.  When I told them I had purchased and EMR they would roll their eyes and moan.

Times have changed slightly.  Recent data states that 36-41% of physicians are using at least a partial EMR/EHR this year.  That's up from 17% just two years ago. Much of this change is due to the government mandate to adopt electronic health records (EHRs) by 2014.

So, why am I a fan?  Yes, it feels like another government push to monitor our actions and control our decisions. And yes, they changed the acronym, too. But, I think there are some benefits to be had with these changes. Before congress ever got their fingers on it, I realized that EHRs could offer me five areas of freedom.

Automation:
In medical school and residency I found that I was often rewriting the same information over and over and over . . . . "Cardiovascular exam reveals heart with a regular rate and rhythm without murmur.  No lifts or thrills. . . " And one day I thought, "That's true, there are no 'lifts or thrills' to writing this again and again."  I found that in most cases I was re-writing much of the same information multiple times each day with only a few differences between patient exams. I remembered some basic programing skills I picked up in junior high school demonstrated then that I could get a computer to write the same things repeatedly a whole lot faster than I could write them with my black pen (and it would be legible, too).


Efficiency:
I knew that my home computer could calculate my checkbook for me, and my telephone could store all my contacts at my fingertips.  Why couldn't my office computer make my writing of chart notes easier, more legible, and then transmit that data to a pharmacy or to a lab?  Why couldn't I have all my laboratory data in on place that I could compare and trend?
I realized two very important things.  First, doing today's work today (and actually finishing it) seemed to make me feel better at the end of the day.  Second, I spent 13 years of my life and thousands of educational dollars learning to make difficult life-or-death decisions. If what I am really being paid to do is make important decisions, then why am I doing all the other stuff that takes up all the time in my day? I found that on days I made decisions more efficiently and finished all of the day's work today, I felt much happier.  The sky seemed "bluer."


Mobility:
I can't tell you how many times I have been at the grocery store or at the restaurant and a patient would call with a question about a lab or an x-ray or a medication that my Physician Assistant had written that I knew nothing about.  Isn't there some way I could use the same phone that I carry around everywhere with me to check these things?  I could use my phone in real time to check stocks, my bank account, and see the dress made of steaks Lady Gaga is wearing.  Why can't I check my charts?  Well, now, I can, and I do.  I use Remote Desktop for Android by Xtralogic. Once in a while, now, I can enjoy the blue sky.


Legibility:
My handwriting looks like chicken scratch, especially after a long day. The busier the day, the more hen pecked it looks.  I found that I can type or dictate much faster than I can legibly write. Why am I still writing in paper charts? I'm not.  My nurse transcribes the first part of my note in the room for me while I do my examination.  Then, between patients, I put the finishing touches on my note with Nuance's Dragon Medical voice recognition dictation software that works seamlessly with my EMR.


Writer's Cramp:
With an electronic medical record I no longer get writer's cramp.  My third finger no longer has that painful callous; now I just have to avoid carpal tunnel.

Retrieve Data, Understand Data, Make Your Decision:
I remember as a medical student some great wisdom from on of my supervising residents. He stated that we were trained to make decisions, and any tool that would help you rapidly retrieve the data, rapidly understand that data, and then make relevant decisions based on that data was well worth its cost.  Well, I found that is exactly what the EHR does and they can be fine tuned to do it for you individually.

So, I dove in head first.  I looked at a number of systems.  I demoed a number of systems.  Two of my favorites took up an entire Saturday playing with them on my home computer.  I quickly realized which one I liked after playing with the demo for an hour.

Colonoscopy Anyone?
I will warn you; however, selecting and implementing an electronic health record is like having a GI prep and colonoscopy without the sedation.  It can be done, but it can be unpleasant.

It took an entire day to load the software on each of the workstations and server in my office.  It took another 2-3 days to train my staff to use the software.  It took us 2-3 months to realize that the computer will change the workflow drastically.  (It took me a week to realize that there is nothing wrong with changing the workflow.)  It took me a month to realize that you can practice medicine "outside the box."  The workflow methodologies you learn in medical school and residency and establish in your office are malleable.  And often your efficiency drastically improves when you accept this and then change them.  There is a learning curve.  When you accept this curve and stop fighting it, using your EHR becomes enjoyable.

What really makes it worth while is when all the parts of the puzzle fall into place.  Lab interface, electronic prescribing, interoffice and inter-patient communication links allow streamlining of processes. You really can do today's work today.

Yes, I know. I neglected to mention which system I am using.  I couldn't do that.  Praxis.  I use Praxis EMR and I love it.

(The first in a series of articles on EHR adoption, use, and integration)

Lack of Sleep Causes Weight Gain

ScienceDaily (Oct. 4, 2010) — Cutting back on sleep reduces the benefits of dieting, according to a study published October 5, 2010, in the Annals of Internal Medicine.

When dieters in the study got a full night's sleep, they lost the same amount of weight as when they slept less. When dieters got adequate sleep, however, more than half of the weight they lost was fat. When they cut back on their sleep, only one-fourth of their weight loss came from fat.

They also felt hungrier. When sleep was restricted, dieters produced higher levels of ghrelin, a hormone that triggers hunger and reduces energy expenditure.

"If your goal is to lose fat, skipping sleep is like poking sticks in your bicycle wheels," said study director Plamen Penev, MD, PhD, assistant professor of medicine at the University of Chicago. "Cutting back on sleep, a behavior that is ubiquitous in modern society, appears to compromise efforts to lose fat through dieting. In our study it reduced fat loss by 55 percent."

The study, performed at the University of Chicago's General Clinical Resource Center, followed 10 overweight but healthy volunteers aged 35 to 49 with a body mass index ranging from 25, considered overweight, to 32, considered obese. Participants were placed on an individualized, balanced diet, with calories restricted to 90 percent of what each person needed to maintain his or her weight without exercise.

Each participant was studied twice: once for 14 days in the laboratory with an 8.5-hour period set aside for sleep, and once for 14 days with only 5.5 hours for sleep. They spent their waking hours engaged in home- or office-like work or leisure activities.

During the two-week, 8.5-hours-in-bed phase, volunteers slept an average of 7 hours and 25 minutes each night. In the 5.5-hour phase, they slept 5 hours and 14 minutes, or more than two hours less. The number of calories they consumed, about 1,450 per day, was kept the same.

The volunteers lost an average of 6.6 pounds during each 14-day session. During weeks with adequate sleep, they lost 3.1 pounds of fat and 3.3 pounds of fat-free body mass, mostly protein. During the short-sleep weeks, participants lost an average of 1.3 pounds of fat and 5.3 pounds of fat-free mass.

Getting adequate sleep also helped control the dieters' hunger. Average levels of ghrelin did not change when dieters spent 8.5 hours in bed. When they spent 5.5 hours in bed, their ghrelin levels rose over two weeks from 75 ng/L to 84 ng/L.

Higher ghrelin levels have been shown to "reduce energy expenditure, stimulate hunger and food intake, promote retention of fat, and increase hepatic glucose production to support the availability of fuel to glucose dependent tissues," the authors note. "In our experiment, sleep restriction was accompanied by a similar pattern of increased hunger and … reduced oxidation of fat."

The tightly controlled circumstances of this study may actually have masked some of sleep's benefits for dieters, suggested Penev. Study subjects did not have access to extra calories. This may have helped dieters to "stick with their lower-calorie meal plans despite increased hunger in the presence of sleep restriction," he said.

The message for people trying to lose weight is clear, Penev said. "For the first time, we have evidence that the amount of sleep makes a big difference on the results of dietary interventions. One should not ignore the way they sleep when going on a diet. Obtaining adequate sleep may enhance the beneficial effects of a diet. Not getting enough sleep could defeat the desired effects."

The National Institutes of Health funded this study. Additional researchers include Dale Schoeller, PhD, of the University of Wisconsin, Madison, WI; plus Jennifer Kilkus, MS, and Jacqueline Imperial, RN, of the University of Chicago's General Clinical Resource Center; and Arlet Nedeltcheva, MD, at the University of Chicago at the time of the study but now at the U.S. Food and Drug Administration.

Source: ScienceDaily

www.sciencedaily.com/releases/2010/10/101004211637.htm

Legalize Marijuana? This Issue Again?

Ok, I'm just going to come right out and say it.  Legalizing marijuana is the stupidest medical idea I have heard in long time.
Well, wait, a stimulus package comprised of tax dollars to an economy in recession with medical care for all when only 40% of our populous pays taxes is more brainless, but what do you expect from a congress that "doesn't read the bills" and has to "pass them before we see what's inside of the bills."
Legalization of marijuana is, again, on the ballot in Arizona for the fourth time. Voting this down three times isn't enough?
I've been asked by many my opinion of this proposition.

I thought I'd just pen my response.
Proponents of the proposition claim it relieves pain and suffering.  Yes, any analgesic can do that. However, most analgesics can do it much more effectively than THC (Delta-9-tetrahydrocannanbinol), the most potent form of the analgesics found in marijuana.
The fact that it is a weak analgesic is the first problem.
The second problem is multiple side effects.  More than 400 compounds have been isolated from the marijuana leaf, sixty of which are know as cannabinoids.
Behavioral Side Effects
THC is the strongest, producing psychoactive euphoria, relaxation, perceptual alteration and diminished memory and concentration.  If you are wanting relief from pain, this is not the medication to use.  It is a great medication if your desire is to have an "out of body experience," but that is not what a physician is attempting to do in patients with chronic pain.
Severe Dependence
A cross sectional study recently showed that by age 17 cannabis is 2 1/2 times more likely to cause dependence than other habit forming drugs. It is a "gateway" drug, one demonstrated multiple times to lead to narcotic dependence.
Cardiac and Respiratory Side Effects
THC is made available to the body through either smoking it or ingesting it.  Smoking a single joint is equivalent to smoking 20 cigarettes (not something you want to do in regards to lung cancer risk).  Ingestion is highly unpredictable and fluctuates significantly based on stomach acid content. (This is a significant problem as over-ingestion can lead to significant cardiac effects including doubling of heart rate, dizziness and loss of consciousness, heart attack and stroke.)
Mental Side Effects
I have frequently seen patients in the emergency room with side effects including delirium, mania, and paranoia due to THC.  I have a number of patients whose panic attacks are exacerbated by their use of marijuana.  I have a few patients who experience flashbacks from its previous use. Short term memory impairment is significant in these patients.
A large Swedish study of 50,000 people demonstrates a dose response relationship between frequency of cannabis use and schizophrenia over a 15 year period.  Five other studies show a 2-fold increase in risk for schizophrenia after cannabis use.
Immune System Side Effects
THC impairs the body's immune system and prevents its ability to fight viral and bacterial infection.
The tar content in a marijuana cigarette is 3 times greater than that of a cigarette and has been shown to deposit 33% more in the respiratory tract than a cigarette. There is a link between frequent cannabis use and esophageal cancer.
Hormonal and Reproductive Side Effects
Testosterone levels have been shown to decrease with THC use decreasing reproductive abilities and changing the ovulatory cycle in females. Reduced birth weight is a know side effect of cannabis use.  Three studies have shown an increased risk of leukemia  in children whose mothers used cannabis during pregnancy.

In my mind, the risks significantly outweigh the benefits and legalization of a drug with such significant side effects is not worth the limited and minimal benefit.  It is a "no brainer" and if marijuana is legalized the side effects will lead to many more "no brainer" patients.

Low Carbohydrate Diets Finding Great Success

Spent part of the morning reviewing 20 years of journal articles on the "Science of Dietary Carbohydrates, Glucose and Insulin."  Fascinating reading. It is interesting that prior to the advent of insulin as a treatment for diabetes, the most common treatment from 1915-1920 used by William Osler for diabetes was significant carbohydrate restriction.

In 1999 a study was published in Pediatrics looking at twelve obese teenage boys.  They were randomly fed low glycemic equal calorie meals followed by high glycemic index meals or vise-versa.  The fascinating result was that when fed following a low glycemic meal, the boys at 81% more if the meal was high in glycemic index.  The fascinating factor is that their insulin levels were much higher which would correlate with notable weight gain and cholesterol rise based on other research.
Another study completed in 2005 helps to quash safety concerns about low carbohydrate diets and shows them to be just as effective in weight loss and more effective in lowering triglycerides, raising HDL in patients with type II diabetes then low fat diets.

My patient's in the office have had tremendous success with low carbohydrate dietary changes over the last 12 months. Every patient in my practice following a very low carbohydrate diet has drastically improved their cardiovascular risk, lipid profile, and significantly reduced their weight. In those patient with type II diabetes, they have additionally had significant improvement in their blood sugar control, average blood sugars (HbA1c) and there triglycerides (on of the lipid measures placing these patients at risk for heart disease). This correlates closely with recent studies reflecting similar results in the medical literature.  It is essential, however, to be monitored regularly on these types of diets, as rapid and significant metabolic changes can and do occur. Medications, blood pressure, and blood sugar control need to be closely monitored when following a low carbohydrate diet. Close follow up with your physician is highly recommended.

Removal of Your Parental Rights in United Nations Convention on Rights of Child

I am worried.  I am really worried.  I see children and their parents in my office every day.  A small bit of legislation is trying to be slipped past us as parents, physicians, and leaders.  If it works, it will supersede state law.  It sounds harmless and "fluffy" but it has the teeth of a shark.


Please read the twenty things listed below that this Convention on the Rights of the Child (CRC) will do if ratified. This is bigger than Obama Care. If this at all frightens you, then to go www.parentalrights.org, sign up and share this with everyone you know.

Why am I worried?  If this legislation is passed, it will remove a number of basic rights you and I have as parents and place them in the hands of world government.  I realize that you have heard all the conspiracy theories and I am not sharing the most recent.  Real legislation has been written and our progressive, soon to be lame duck, congress is attempting to place this on the table within the next month as their last heave-ho!  A number of countries have adopted the CRC and the State of Washington had a mirrored set of CRC laws on their books (trying them as an "experiment") until they were repealed due to the significant "hand tying of parents" that occurred. 


If this passes, it will remove the parental right to choose where the child is educated or participate in home school.  It will remove religious freedom.  It will remove the right of parents to enforce standards and discipline in the home.

Ten things you need to know about the structure of the CRC:

• It is a treaty which creates binding rules of law.  It is no mere statement of altruism.^1.
• Its effect would be binding on American families, courts, and policy-makers.^2.
• Children of other nations would not be impacted or helped in any direct way by our ratification.^3.
• The CRC would automatically override almost all American laws on children and families because of the U.S. Constitution’s Supremacy Clause in Article VI.^4.
• The CRC has some elements that are self-executing, while others would require implementing legislation.  Federal courts would have the power to determine which provisions were self-executing.^5.
• The courts would have the power to directly enforce the provisions that are self-executing.^6.
• Congress would have the power to directly legislate on all subjects necessary to comply with the treaty.  This would constitute the most massive shift of power from the states to the federal government in American history.^7.
• A committee of 18 experts from other nations, sitting in Geneva, has the authority to issue official interpretations of the treaty which are entitled to binding weight in American courts and legislatures.  This effectively transfers ultimate authority for all policies in this area to this foreign committee.^8.
• Under international law, the treaty overrides even our Constitution.^9.
• Reservations, declarations, or understandings intended to modify our duty to comply with this treaty will be void if they are determined to be inconsistent with the object and purpose of the treaty.^10.

Ten things you need to know about the substance of the CRC:

• Children would have the ability to choose their own religion while parents would only have the authority to give their children advice about religion.^13.
• The best interest of the child principle would give the government the ability to override every decision made by every parent if a government worker disagreed with the parent’s decision.^14.
• A child’s “right to be heard” would allow him (or her) to seek governmental review of every parental decision with which the child disagreed.^15.
• According to existing interpretation, it would be illegal for a nation to spend more on national defense than it does on children’s welfare.^16.
• Children would acquire a legally enforceable right to leisure.^17.
• Christian schools that refuse to teach "alternative worldviews" and teach that Christianity is the only true religion "fly in the face of article 29" of the treaty.^18.
• Allowing parents to opt their children out of sex education has been held to be out of compliance with the CRC.^19.
• Children would have the right to reproductive health information and services, including abortions,  without parental knowledge or consent.^20. 
• Parents would no longer be able to administer reasonable spankings to their children.^11.
• A murderer aged 17 years and 11 months and 29 days at the time of his crime could no longer be sentenced to life in prison.^12.

---

NOTES:

1. -Vienna Convention on the Law of Treaties, Article 26 “Pacta sunt servanda”:
   “Every treaty in force is binding upon the parties to it and must be performed by them in good faith.”
   
   United States Constitution, Article VI: “This Constitution, and the Laws of the United States which shall be made in pursuance thereof; and all Treaties made, or which shall be made, under the Authority of the United States, shall be the supreme Law of the Land; and the Judges in every State shall be bound thereby, any Thing in the Constitution or Laws of any State to the Contrary notwithstanding.”
   
   UNICEF  “Convention on the Rights of the Child” says: “the Convention is a universally agreed set of non-negotiable standards and obligations.” Available at http://www.unicef.org/crc/ on 12/2/2008.
   
2. -Vienna Convention Article 26 (supra);
   
   United States Supreme Court, Whitney v. Robertson, 124 U.S. 190 (1888): “By the Constitution of the United States, a treaty and a statute are placed on the same footing, and if the two are inconsistent, the one last in date will control, provided the stipulation of the treaty on the subject is self-executing.”
   
3. -Vienna Convention (supra) and Article 2 (g):  “‘party’ means a State which has consented to be bound by the treaty and for which the treaty is in force”
   
4. -United States Constitution, Article VI (supra, Note 1)
   
5. -Arlene Bowers Andrews, Implementing the U.N. Convention on the Rights of the Child, 171 (Greenwood Publishing Group 1999): “The Convention is generally regarded as having two classes of rights for the purposes of self-execution, one class that is self-executing and one that is not self-executing."
   
6. -United States Supreme Court, Medellin v. Texas, 552 U.S. ___ (2008), at 170 L.Ed. 2d 190, 219, “And  whether the treaties underlying a judgment are self-executing so that the judgment is directly enforceable as domestic law in our courts is, of course, a matter for this Court to decide.”
   
7. -Inter-Agency Standing Committee Reference Group on Humanitarian Action and Human Rights,Frequently Asked Questions on International Humanitarian, Human Rights, and Refugee Law, (2002), available at http://www.icva.ch/doc00001023.html#24:
   “Human rights law also contains provisions obliging states to implement its rules, whether immediately or progressively. States must adopt a variety of legislative, administrative, judicial and other measures that may be necessary to give effect to the rights provided for in the various treaties. This includes providing for a remedy before domestic courts for violations of specific rights and ensuring that the remedy is effective. The fact that a state has a federal or devolved system of government does not affect a state's obligation to implement human rights law.”
   
   United States Supreme Court, Reid v. Covert, 354 U.S. 1 (1957): “To the extent that the United States can validly make treaties, the people and the States have delegated their power to the National Government and the Tenth Amendment is no barrier.”
   
8. -United Nations Convention on the Rights of the Child, Articles 43 (amended) and 44. Available athttp://www2.ohchr.org/english/law/crc.htm#art43.
   
9. -Vienna Convention, Article 27: “ A party may not invoke the provisions of its internal law as justification for its failure to perform a treaty.”
   
10. -Vienna Convention, Article 19, available at available athttp://www.jus.uio.no/lm/un.law.of.treaties.convention.1969/19.html; also
    
    Louis Henkin, U.S. Ratification of Human Rights Conventions: The Ghost of Senator Bricker, The American Journal of International Law, Vol 89 No 2, 343-344 (Apr. 1995):
     “Reservations designed to reject any obligation to rise above existing law and practice are of dubious propriety: if states generally entered such reservations, the convention would be futile.  The object and purpose of the human rights conventions, it would seem, are to promote respect for human rights by having countries—mutually—assume legal obligations to respect and ensure recognized rights in accordance with international standards. Even friends of the United States have objected that its reservations are incompatible with that object and purpose and are therefore invalid.
    …By adhering to human rights conventions subject to these reservations, the United States, it is charged, is pretending to assume international obligations but in fact is undertaking nothing.”
    
11. -United Nations Convention on the Rights of the Child, Article 37(a):
    “No child shall be subjected to torture or other cruel, inhuman or degrading treatment or punishment. Neither capital punishment nor life imprisonment without possibility of release shall be imposed for offences committed by persons below eighteen years of age”
    
    United Nations Committee on the Rights of the Child, General Comment No. 8 (2006): The right of the child to protection from corporal punishment and other cruel or degrading forms of punishment (arts. 19; 28, para. 2; and 37, inter alia), CRC/C/GC/8, (2006):
    “The Committee is issuing this general comment to highlight the obligation of all State parties to move quickly to prohibit and eliminate all corporal punishment…. Addressing the widespread acceptance or tolerance of corporal punishment of children and eliminating it, in the family, schools and other settings, is … an obligation of State parties under the Convention.”
    
12. -United Nations Convention on the Rights of the Child, Article 37(a), (supra)
    
13. -The UN Convention on the Rights of the Child: A Guide for Children and Young People (April 2008), available at http://www.scotland.gov.uk/Publications/2008/04/01081649/1: “You have the right to choose your own religion and beliefs.  Your parents should help you think about this.”
    
    Geraldine Van Bueren, International Rights of the Child, Section B, University of London, 29-30 (2006):
    “Unlike earlier treaties, the Convention on the Rights of the Child does not include a provision providing for parents to have their children educated in conformity with their parents’ beliefs. In addition, the child’s right to freedom of expression and the right of the parents to initially give direction and later only guidance, strengthens the argument that children are entitled to participate in decisions so that their education conforms to their own convictions....  The second question is whether a child has the right to choose a religion.
    Under the Convention on the Rights of the Child, parents do have the right to provide direction to the child. Such parental power, however, is subject to two restraints:
    • First, such direction should take into account the evolving capacities of the child, as expressly required by the Convention.
    • Second, the direction should not be so unyielding that it equals coercion.
    It can also be argued that the right to freedom of religion in the Convention on the Rights of the Child ought to be read together with article 12 which gives the child the right to express his own views in the matter of choice of religion."
    
14. -United Nations Convention on the Rights of the Child, Article 3(1): “In all actions concerning children, whether undertaken by public or private social welfare institutions, courts of law, administrative authorities or legislative bodies, the best interests of the child shall be a primary consideration.”
    
    Geraldine Van Bueren, International Rights of the Child, Section D, University of London, 46 (2006):
    “Best interests provides decision and policy makers with the authority to substitute their own decisions for either the child's or the parents', providing it is based on considerations of the best interests of the child.  Thus, the Convention challenges the concept that family life is always in the best interests of children and that parents are always capable of deciding what is best for children.”
    
15. -United Nations Convention on the Rights of the Child, Article 12(1): “State parties shall assure to the child who is capable of forming his or her own views the right to express those views freely in all matters affecting the child, the views of the child being given due weight in accordance with the age and maturity of the child.”
    
    Inter-Agency Standing Committee Reference Group: “Human rights law also contains provisions obliging states to implement its rules, whether immediately or progressively. States must adopt a variety of legislative, administrative, judicial and other measures that may be necessary to give effect to the rights provided for in the various treaties. This includes providing for a remedy before domestic courts for violations of specific rights and ensuring that the remedy is effective.”
    
    Geraldine Van Bueren, International Rights of the Child, Section D, 137: “State parties are obliged to ‘assure’ to children who are capable of forming views the rights to express those views ‘in all matter affecting the child’ and to give those views’ due weight in accordance with the age and maturity of the child’.  By incorporating a reference to ‘all matters affecting the child’ there is no longer a traditional area of exclusive parental or family decision making.”
    
16. -ibid., at 36: “[T]he United Nations Committee on the Rights of the Child, criticized Egypt and Indonesia on the proportion of their budget spent on defence, as compared to the proportion spent on children’s social expenditure."
    
    The Committee also criticized Austria, Australia, Denmark, the United Kingdom, and others failing to spend enough tax dollars on social welfare for children:
    
    Paragraph 46, Concluding Observations of the Committee on the Rights of the Child: Austria, Committee on the Rights of the Child, 38th sess., U.N. Doc. CRC/C/15/Add.251 (2005).
    
    Paragraph 17 and 18, Concluding Observations of the Committee on the Rights of the Child: Australia, Committee on the Rights of the Child, 40th sess., U.N. Doc. CRC/C/15/Add.268 (2005).
    
    Paragraphs 18 and 19, Concluding Observations of the Committee on the Rights of the Child: Denmark, Committee on the Rights of the Child, 40th sess., U.N. Doc. CRC/C/DNK/CO/3 (2005).
    
    Paragraph 10, Concluding Observations of the Committee on the Rights of the Child: United Kingdom of Great Britain and Northern Ireland, Committee on the Rights of the Child, 31st sess., U.N. Doc. CRC/C/15/Add.188(2002).
    
17. -United Nations Convention on the Rights of the Child, Article 31(1): “States Parties recognize the right of the child to rest and leisure, to engage in play and recreational activities appropriate to the age of the child and to participate freely in cultural life and the arts.”
    
18. -American Bar Association, Center on Children and the Law: Children's Rights in America: UN Convention on the Rights of the Child Compared with United States Law, p. 182.
    
19. -Paragraph 52, Concluding Observations of the Committee on the Rights of the Child: Ireland, Committee on the Rights of the Child, 43rd sess., U.N. Doc. CRC/C/IRL/CO/2 (2006):
    “While noting that social, personal and health education is incorporated into the curricula of secondary schools, the Committee is concerned that adolescents have insufficient access to necessary information on reproductive health.  The education is optional and parents can exempt their children.”
    
    Paragraph 14, Concluding Observations of the Committee on the Rights of the Child: United Kingdom of Great Britain and Northern Ireland, Committee on the Rights of the Child, 8th sess., U.N. Doc. CRC/C/15/Add.34 (1995).
    
20. -Katie Hatziavramidis, Parental Involvement Laws for Abortion in the United States and the United Nations Conventions on the Rights of the Child: Can International Law Secure the Right to Choose for Minors?, 16 Tex. J. Women & L. 185, 202-203 (Spring 2007):
    “The unmistakable trend in the United States is to consistently increase anti-choice legislation, particularly with respect to minors. Ratification of the U.N. Convention on the Rights of the Child by the United States holds a strong possibility of assisting minors who seek abortions without parental interference.  [*203]  The Convention may offer the best hope for securing adolescent reproductive freedoms on a global level. If enough diplomatic pressure were exerted on the United States to compel it to ratify the treaty, the CRC could provide significant improvements in the outlook for reproductive freedom for minors.”
    
    Paragraph 3, Concluding Observations of the Committee on the Rights of the Child: Columbia, Committee on the Rights of the Child, 42nd sess., U.N. Doc. CRC/C/COL/CO/3 (2006): “The Committee notes with appreciation…decisions of the Constitutional Court on…the partial decriminalization of abortion.”
    
    Paragraph 55, Concluding Observations of the Committee on the Rights of the Child: Chile, Committee on the Rights of the Child, 44th sess., U.N. Doc. CRC/C/CHL/CO/3 (2007): “The Committee…is concerned over the high rate of teenage pregnancies, the criminalization of the termination of pregnancies in all circumstances….”

(Taken from Parental Rights.org)

Weight Loss Drug Sibutramine (Meridia) Pulled From the Market

A popular weight loss drug, Sibutramine (Meridia) was pulled from the market today by Abbot Labs after recommendation of the FDA.  It appears that post-marketing analysis showed increased risk in nonfatal myocardial infarctions (heart attacks) and nonfatal strokes.  The study, called the Sibutramine Cardiovascular Outcomes Trial (SCOUT), demonstrated a 16% increase in the risk for serious cardiovascular events such as nonfatal heart attack, nonfatal stroke, the need for resuscitation after the heart stopped, and death in a cohort of patients given sibutramine compared with another given a placebo. 

The FDA advised physicians to discontinue prescribing the medication due to the increased cardiovascular risk noted above.  Reassuring news is that there are no permanent side effects to the medication and the study reveals that the increased risk returns to normal once the medication is discontinued. This study and previous studies do no show any long-term consequences in patient's taking the medication. There is, also, no withdrawal effect noted with this medication.
This comes as a challenge as there are only a few medications on the market now that are helpful with weight reduction including phentermine, diethylpropion, and the over the counter Orlistat (found in over-the-counter Ali and prescription Xenical. Use of Orlistat has been liked to liver injury in a few patients and needs to be monitored if considering use of this medication.
In light of the findings surrounding sibutramine, the FDA also warned consumers against the use of Slimming Beauty Bitter Orange Slimming Capsules, sold over the Internet, because they contain sibutramine. Interestingly, sibutramine is not listed on the product label.

Doc, Why Do I Have Leg Pain?

(Great article taken from WebMD about frequent causes of leg pain.  I've re-posted it here for all to read.)

Lower Leg Pain: Causes and Treatments

If you're suffering from lower leg pain, you may wonder if it's serious or something you can treat at home. What follows is an overview of several causes and types of treatment for lower leg pain. Be sure to see your doctor if you have any question about your leg pain or if symptoms get worse.

Lower Leg Pain: Bones, Joints, and Muscles

Muscle cramps . This sudden, tight, intense lower leg pain is sometimes called a "charley horse." Often caused by muscle fatigue, heat, or dehydration, muscle cramps are more common among older people, endurance athletes, or athletes who are not well conditioned. In most cases, you can ease muscle cramps by stopping whatever triggered them. If needed, gently stretch or massage your lower leg muscle. Applying heat to tight muscles or cold to tender muscles may ease some symptoms. Proper conditioning and stretching can help prevent problems in the future.

Shin splints . This type of lower leg pain occurs when connective tissues and muscles along the edge of the shin bone become inflamed. This often occurs afterrunning or jumping, especially on hard surfaces. The repetitive force overloads muscles and tendons. Flat feet and too much outward rotation of the foot and leg can also contribute to this problem. Pain usually goes away with rest. It also helps to apply ice, take anti-inflammatories, and avoid anything that causes pain. Once pain lessens, stretch and strengthen your lower leg. To prevent future problems, wear supportive shoes and avoid running on hard surfaces.

Inflamed or torn tendons or muscles. One of the first signs of tendonitis (an inflamed tendon) is pain in the lower calf or back of the heel. Apply ice, take anti-inflammatories, and avoid anything that causes pain. Supportive shoes that lessen tension on tendons may also help. Just as with shin splints, wait until pain lessons to stretch and strengthen your leg. If pain is severe, the Achilles tendon may be ruptured. This can result from intense activity and not warming up well enough. See your doctor.

Broken bone or a sprained knee or ankle. A fracture (broken bone) or sprain (injury to ligaments from overstretching) can also cause leg pain. For mild sprains, try rest, ice, compression, and elevation (RICE). For a more severe sprain or fracture, apply ice and see your doctor right away. You may need a cast or brace. You may also need physical therapy to improve movement and speed recovery. Over time, gradually increase strength to support your weakened leg.

Lower Leg Pain: Veins and Arteries

These are some of the more common sources of lower leg pain caused by problems in blood vessels:

Blood clot. A blood clot that develops in a vein deep in the body is called deep vein thrombosis (DVT). Most deep vein blood clots develop in the lower leg or thigh. They are more likely to occur if you are inactive for long periods, smoke, or take medication that increases risk for clots. If you suspect a blood clot, go to your doctor or emergency room right away. Pieces of blood clots can travel to lungs and other organs. Medications and support stockings are two types of treatment.

Varicose veins. Weak valves and vein walls can cause twisted dark blue or purple veins near the surface of the skin (varicose veins). Varicose veins may cause a dull ache, especially after prolonged standing. Support stockings can be helpful. Throughout the day, alternate between standing and sitting. If your varicose veins are very painful, see your doctor about other types of treatment.

Infection. A skin or soft tissue infection can appear as red, tender, swollen, and warm. Warm soaks can help soothe discomfort. Your doctor may also recommend the use of antibiotics. If symptoms worsen or you develop a fever, call your doctor.

Lower extremity peripheral arterial disease. Just as with the heart, the lining of arteries in your legs may become damaged and hardened (atherosclerosis). Arteries narrow or become blocked, which decreases blood flow circulation. This can cause lower leg pain or cramping when walking, climbing stairs, or other kinds of exercise (called claudication) because muscles aren't getting an adequate blood supply. Resting may bring relief. If arteries become severely narrowed or blocked, pain may persist, even when you're at rest. Also, wounds may not heal well. If not treated, this disease can cause tissue to die (gangrene). People at high risk for PAD include: people with diabetes, high blood pressure, and/or high cholesterol and people who smoke.

Treatment includes lifestyle changes such as:

• Quitting smoking
• Reducing intake of foods high in cholesterol or saturated fats
• Managing weight
• Exercising, gradually increasing walking distance over time

Other treatment includes medications to control cholesterol, diabetes, and/or hypertension, to help with walking distance, and to help prevent blood clots. Surgery may be needed to improve blood flow to the area.

Lower Leg Pain: Nerves

These are some of the more common sources of lower leg pain brought on by problems in nerves:

Narrowed spinal canal (stenosis) and sciatica. A common cause of a narrowed spinal canal is arthritis of the spine.  Sometimes a herniated disc puts pressure on nearby nerve roots, which can lead to symptoms of sciatica such as:

• Burning, cramping leg pain when standing or sitting
• Numbness
• Tingling
• Fatigue
• Weakness

Pain may begin in your back and hip, then later extend down into your leg. Sciatica often doesn't get better with brief periods of rest. Treatment may involve resting for a few days, along with taking anti-inflammatories and pain medications, as needed. Cold and heat can help with some symptoms. Physical therapy and stretching exercises are often useful. Gradually increase movement over time. Your doctor may also recommend other therapies or surgery if pain is not resolved.

Diabetic neuropathy . With diabetes, nerves can be damaged from high blood sugar levels. This is a common complication of diabetes. It can cause pain in both legs along with numbness and less sensation in lower legs. Treatment includes controlling pain with oral medications and managing blood glucose levels.

If You Have Diabetes, Metabolic Syndrome, or Insulin Resistance Take Your Folic Acid

Recent study published in Obesity ((23 September 2010) | doi:10.1038/oby.2010.210) reveals exciting information about protecting the blood vessels of patients with diabetes, metabolic syndrome and insulin resistance.

It is a well known fact that excessive small blood vessel damage in these patients leads quickly to renal failure, macular degeneration (damage to the retina of the eye), and painful numbness and neuropathy in the hands and feet.  Patients with metabolic syndrome and diabetes have been shown to have increased levels of nitric oxide in their small blood vessels. This is thought to be one of the major causes of the damage that occurs in these patients. Much attention and monitoring is given to these patient in attempts to protect their blood vessels from ongoing damage.
Recent data showed that in just four weeks folic acid decreased the amount of nitric oxide present in the blood vessels of  patients with metabolic syndrome thereby implying significant vascular protection and health.  Further study is needed to determine the degree of protection folic acid renders in these patients, but until then, I'm taking my folic acid!!

Social Rejection Really Does "Brake" Your Heart

A fascinating study reported in the Journal of Psychological Science was completed in the Netherlands on social experiences and their effect on the heart. Participant's vital signs and heart rate were closely monitored throughout a period of socially emotional experiences. Participants were asked to look at a number of pictures of people they did not know and asked to predict whether or not the participant thought that each individual in the picture liked them or did not like them. The participants were then given feedback about whether the person they viewed accepted or rejected them. Heart rate and responses were closely monitored.
What is fascinating is that the participant's heart rate notably slowed when unexpected social rejection was observed, and significant delay in return to normal heart rate was also observed.
What does this all mean?

It means that experiences of social rejection have significant physical effects upon the heart and other vital organs of the body. There is a strong chemical signal from the brain on the parasympatheic nervous system slowing the heart rate when emotional rejection is experienced. The study noted that repeated episodes of rejection further lowered the rate and suppressed the time of recovery from that lowered rate even longer. This explains repeated rejection's physical symptoms and many of the physical symptoms that I often see in patient's suffering from emotional abuse. This explains the physical changes associated with depression and anxiety.
This may also be why hobbies or experiences that lend positive influence on our emotions lend to our overall physical health.

Waist Size in Childhood Predicts Risk for Adult Metabolic Syndrome

A recent study published in the Journal of Obesity begun in 1985 shows that your waist size as a child is a very strong and independent risk factor in your forming metabolic syndrome later in life.  Metabolic syndrome is a precursor stage to type II diabetes mellitus that puts you at significant risk for heart disease and stroke. The study was conducted in 2188 boys and these boys were followed and evaluated at age seven, fifteen, and twenty-seven years old (twenty years later).
Results show that as your waist circumference increases as a child, your risk for metabolic syndrome notably increases and is unrelated to waist changes between childhood and adulthood.  This means that emphasis on childhood weight is significant and must be a factor in evaluation of the child's overall health and risk for disease later in life.

Shadows of the Gallows

(Post taken in entirety from Musings of a Distractible Mind by Dr. Rob.  It was just too good not to, as this is exactly how I feel.  Thanks Dr. Rob for putting in prose my feelings for the last year. . . )

“It will never happen.”
“They know better than to do it.”
“They realize the disaster it would be if they let it pass.”
That’s what I hear.  I hear that the upcoming SGR adjustment, the one that will cut Medicare reimbursement by 23%, won’t go through.  In case you missed it, the SGR is a formula coming from the Balanced Budget Act of 1997 that does automatic cuts to Medicare reimbursement.  This year we witnessed a legislative game of chicken in congress, with both sides agreeing that it was a bad idea to screw physicians in a time that they are trying to fix healthcare.  Here’s what happened:

On March 3, 2010, Congress delayed the enforcement of the conversion factor until April 1, 2010.^[5][6] On April 15, 2010, Congress voted to again delay the implementation and extended the 2009 rate to June 1, 2010.^[7] On June 25, 2010, President Obama signed legislation that not only delayed implementation of the conversion factor until December 1, 2010 but also increased reimbursements by 2.2%.^[4] The 2.2% increase is retroactive to June 1, 2010, and will expire on November 30, 2010. Barring any further congressional legislation, this will result in a 23.5% decrease in Medicare reimbursements on December 1, 2010. (Wikipedia)

So we are t minus 65 days until we face another congressional battle.  The thing that makes it scary: November 2.  On November 2, our current congress changes its members, making the current congress lame-ducks.  Lame duck, impotent, worthless.  They are the ones who are supposed to fix this once and for all?  They are the ones who aren’t going to play political sabotage on the other side?
I was talking with some of my colleagues last week, and the “it won’t happen” line didn’t work.  They were all depressed, and all making plans to deal with a systemic melt-down.  They talked like men living in the shadow of the gallows.  Plan for the future?  The only way to do that is to stop accepting Medicare, which will be hard to do when 40% of the practice is Medicare patients.  There were a lot of downcast eyes, a lot of frustration.  There was not much comfort to give when the dark clouds are gathering.
Things are about to get worse.
Oh wait!  I forgot!  It will never happen.
Now I feel happy.