Synapse

A common presentation, and a perennial short-case favourite in surgery, is the groin lump, which in all probability allows a platform for the distinction, specifically, of the inguinal hernia, from the femoral hernia. This subject allows for an exploration of the anatomy from a clinical, surgical, or somewhat theoretical level, and as such will serve well for a brief yet important discussion here.

A hernia, for those with a perchant for definitions, is the protrusion of any organ or tissue though an opening in its surrounding walls.  First, some basic anatomical distinctions:

The Inguinal Hernia

A great Powerpoint Presentation on Inguinal Hernias, from St Barnabas Hospital NY (site), can be found here.

It is important, when discussing inguinal hernias, to distinguish between direct and indirect hernias. The former will pass through Hesselbach’s Triangle, the latter will pass lateral to it.

Rather than to profess an intimate knowledge of the exact anatomy of said hernia, I must admit that i possess no such knowledge, but really should. Hence I will make an addendum to this posting within the week, once I myself are comfortable with the anatomy of the hernia. Unless someone wants to comment, and beat me to it.

The Femoral Hernia

Occur within the femoral triangle, bordered by the inguinal ligament superiorly, the medial border of adductor longus medially, and the medial border of sartorius laterally.

It contains the femoral nerve, artery and vein (laterally to medially). The femoral canal (wiki) is the point at which a protrusion of bowel or associated tissues may occur, creating a femoral hernia. This herniation hence sits between the lacunar ligament (medial) and the femoral vein (lateral).

This position also means that the hernia is occuring inferolaterally to the pubic tubercle.

Demographics

Males are more likely to develop inguinal hernias than females (9:1), with a lifetime risk of up to 27%. Females, particularly elderly, are more likely than males to develop femoral hernias (3:1).

A brief yet mildly useful summary of the hernia examination, can be found here. Perhaps not very complete, but the links contained within the page give some nice mnemonics for remembering the anatomy.

De Garangeot’s Hernia

I mention this simply because I was fortunate enough to come across one (though I cannot take credit for diagnosing it!). I discussed this in SynapseBlog late last year (Conversation Starter, 27Nov08). This is a rare complication of femoral hernia, when the appendix becomes incarcerated within the hernia, and hence develops appendicitis.

Perforated Appendix within a Femoral Hernia (AJR Online, 2006)

A brief yet interesting case study of this rare occurence, complete with some spectacular CT imagery.

1. Local physician: HIV/AIDS cure getting little publicity (BaldwinCountyNow.com, 27May09)

Sensationalism aside, this title basically sums up the subject material:  Dr. Awadhesh K. Gupta, reported a patient who, after receiving 4 years of conventional HAART (wiki) treatment, developed a leukaemia, prompting the performance of a bone marrow transplant.

The donor identified as suitable for the transplant was specifically selected for the presence of a gene-mutation known as “CCR-5 Delta-32″. This was on the background of observational research in San Francisco in 1996, that apparently found some sort of correlation between said mutation, and males engaging in unsafe homosexual practices.

At any rate, it is reported that following two stem cell transplants, the patient has remained off HAART for over two years. The original paper in the NEJM (12Feb09) can be found here. I have not read the actual paper, so have no justification for comment at this stage, though if the findings are as dramatic as rather simplistically portrayed here, it is a surprise that the paper was not more widely publicised at the time.

The research was performed at the Charite Hospital, Berlin, where I had the honour of studying in 2008.

2. Obama Gets Tested for HIV (Whitehouse.gov, 27Jun09)

In a bold move from a moderately good president, and one who is unequivocally the public-relations master, Barack Obama announced three years ago that he was being tested for HIV/AIDS, stating that “Because if you know your status, you can prevent illness“.

The speech sent a shiver down my spine - and the fact that the media clip has been reutilised as part of a bold public health campaign, is commendable.  http://www.hivtest.org/

3. Comment on reports of HIV man who may have “cured” himself (GlobalChange.com)

This posting would have have been complete without mentioning the British man who allegedly “cured himself” of HIV. This article provides a nice neat dissection of the sketchy facts in this overhyped case.

4. The Family Guy AIDS Song (here)

If you thought the content of this posting has gradually deteriorated, you were right. Unfortunately only the audio is present in this clip, but you get an idea of the brilliant yet cras innappropriateness that is bold even by Family Guy Standards. I’m not sure whether I feel uneasy about this song. What do others think?

After an inexcusable absence of more that two months duration, it is with great pleasure that i announce the return of Synapse.

While citing no single reason as to why I have been unresponsive for a period, which, in the time scale of the internet is tantamount to an eon, it should perhaps be mentioned that my internet access was somewhat limited due to rural placement for work. While this specific placement was indeed incredibly educationally and culturally rewarding, it must be stated that medicine on such a relative micro-scale (ie. a 50 bed hospital) lends itself even less to the deidentification that should be intrinsic to any medical journalism.

It is also worthy of note that retrospective analyses of the material so far blogged shows great fluctuance: medical data juxtaposed with the rantings of the most notorious of the internet digi-razzi.

The blog will indeed continue to oscillate from educational resource to voyeuristic tabloidism, with all the superfluous verbosity and laconic commentary that I have, albeit somewhat briefly, seem to have become known for.

It is also perhaps prudent to mention (and pertinent, given the gravity of many of the issues discussed herein), that this blog provides a chronological introspective direct from intern year: and as such, should be read with all the subjectivity and naivety associated with such self-indulgent introspection.

On a more technical note, this blog will soon be migrating to a new domain, as well as new back-end architecture: Updates on which I will make public as they become apparent.

So, enough redundant reintroduction - on with the blog.
Stew

Healing Yourself Via YouTube: The Amazing and Frightening Future of Health Care (FastCompany, 22Apr09)

FaceBook-Like Medical Platform (FastCompany, 22Apr09)

The Macophiles amongst us will appreciate the implications that iPhone Software 3.0 will have, not only in relation to the iPhone itself, but also because it perhaps alludes to the next generation of products from our friends at Apple.

My last rant that rather tenously connected Apple and medicine, by discussing Steve Jobs, can be found here.

The new software, to be released to the general user in June (it is currently available if one purchases the SDK), allows limited background process functionality (i.e. like a computer, being able to run more than one program at once), copy+paste (a far overdue addition), and the opening up of the iPhone interface (i.e. the ‘plug’) to allow more flexibility for developers creating, or interfacing with, external devices.

this will never happen.

While this allows for far greater flexibility for the iPhone itself, the allusion here is far greater: The question now, is when, not whether, Apple will release a Tablet.

Apple prefer to maintain a moderately pretentious, undeniably elitist, culture, that the global economic downturn seems not to have blunted at all. They won’t release a smaller, $99 US version of the iPhone, nor will they seemingly relent and release a sub-$700 MacBook Air: market suicide given the speed at which the NetBook market is growing.

What if the method to their madness, then, was a planned ueberPhone, a Tablet-based Maclet, that ran a similar version of OSX to the iPhone (feasible, now that greater flexibility has been built into this OS), but rather than being released as an el-cheapo MacBook, was announced as a new generation of device - a device as revolutionary as the iPhone, and the iPod before it.

Enter, our article of the week.

Mac Tablet - The Ultimate Device for EMRs (SoftwareAdvice 20Apr09)

I was tipped off about this article by a rather polite email, and I am eternally greatful, because it seamlessly melds relevant medical issues with the brilliance of modern technology with an informative eloquence that this blog can only ever dream of.

A summary won’t do the article justice, so far as to say it proposes a  solution for combining the interactivity of the practice of medicine with a device, that, for possibly the first time in IT history, would have the technical and ergonomic ability to cope. Gone would be the days of bad handwriting, crappy pens, and clunky software solutions that present more problems than they solve.

“Using iPhone speech recognition technology, physicians could dictate directly into an EMR to create notes, draft narrative reports or generate custom patient instructions. Mac design programs could be repurposed to make a really slick tablet drawing tool for anatomical diagrams that illustrate procedures and diagnoses.”

(the EMR link directs to a part of the site detailing all the EMR software currently available)

While I admonish that the idea of any health infrastructure being rebuilt on an Apple Platform is ludicrous, one can only begin to wonder what would happen if every doctor was as nerdy as I.

1995 lives on, through my current slower-than-dial-up internet access. How b-grade.

So, that’s my excuse for a decided lack of blog recently, will endevour to get a heap up as soon as my access is restored. In the interim, check out the ones in my blogroll (to the right), and I will try and throw some simple stuff up as I see fit.

Came across a great new blog from a fellow first year intern.

http://juniormedico.blogspot.com/

Check it out.

Minister Orders Hospital Audits After Dud Figures (TheAge, 1Apr09)

Losing Patients (TheAge, 2Apr09)

Audit Slams Phantom Wards Scam (TheAge, 2Apr09)

More scandal pertaining to the latest string of questionable data collection and intepretation in the Victoriam Public Health System. We already saw The Age’s series on the Royal Women’s Hospital (Synapse, 31Mar09).

So, hospitals are exploiting clear loopholes in funding criteria. To get more funds. To use at the hospital. To spend. To spend, most likely, on patient care.

So, let me get this straight: Hospitals who were being penalised for poor performance, were circumventing these penalties, so that they could get more funding to fill the deficits that were leading to the poor performance in the first place? How dare they.

Has anyone considered being more critical of the bodies that set up the flawed criteria in the first place, bearing in mind that the same parties are now promising “Independent Auditing” and are “determined to stamp these practices out”.

Dutch doctors tout ultrasound for appendicitis in children, caution against CT overuse (RadRounds, 30Mar09)

“differences that exist between, for example, a neonate of 4 kg with congenital problems or a 14-year-old transplantee weighing 80 kg”

Nice piece on the risks posed by CT scans to children, and the ultrasound examination as choice for diagnosing appendicitis. Interesting points also made about the need for more specialised protocols with regards to MR and CT studies of children, due to physiological variation, to allow for better image quality of the area of interest, and hence more accurate studies.

Doctors Prescribing More Drugs, and Ignoring Guidelines (MedNewsToday, 15Mar09)

Holistic is the buzz word-de-jour these days for Medical Schools, health ministers, and medical practitioners alike, however recent evidence from the EUROASPIRE Survey show that guidelines and actual lifestyles are showing increasing dissonance, in almost all classes of cardiovascular risk factors: be it obesity, diabetes, hypertension, or hypercholesterolaemia.

The Original EUROASPIRE trial was published in 1997,  ambitiously analysing 4863 medical records and interviewed 3569 patients, and can be found here. Essential reading, even if it is moderately dated.

This specific report pertains to a more recent publication from the same body, which you need to login in order to view.

Patient Figure Scam Sparks Surgery Delay Claims (TheAge, 21Mar09), then,

Hospital Lied Over Waiting Lists (TheAge, 31Mar09)

Ten days ago:

“may have been exaggerating its true elective surgery performance for at least five years,  data suggests“

And now:

“systematically lying about its surgery waiting list for almost a decade, says a damning report that has forced the Government to overhaul Victoria’s hospital funding system”

Things seem to be going from bad to worse, either in terms of actual revelations, or the media’s audacity in beefing up a story. Essentially, these two sentences say exactly the same thing, but the language used to deliver the second is far more inflammatory.

The second story also refers to Health Minister Daniel Andrew’s response to the matter, and one has to wonder: Was this dramatically labelled “health system overhaul”, a response to the original report, or the fact that it had begun to surface in the media?

Let’s not single out a single case: Hospitals are great targets for these emotive, “beauracracy vs your health”-style stories: Here are recent ones from  Sydney’s Morning Herald, and another from the Telegraph in the UK.

As a disclaimer, I am simply reporting these articles. I do not condone or endorse the content, and as with an internet or journalistic content, it should be read with a healthy degree of critique and cynicism.

Drug Firm Knew of Heart Attack Risk (TheAge, 31Mar09)

Refecoxib (wiki), marketed as Vioxx, as one of the first COX-2 specific NSAIDS, was hailed as a breakthrough for arthritis sufferers when it was released in 1999. Just 5 years later, the product was voluntarily withdrawn by its manufacurer, Merck, casting a shadow over this new generation of medications, while bringing to light the sinister way in which drug companies seem to operate.

This article from TheAge reveals that the company may have known about the adverse cardiac effects of the medication, even before it was first released on the market.