Monthly Introduction to Tech Medicine

What's this blog all about?

My goal in Tech Medicine will be to explore the intersection of medicine, new technologies, and the Internet. This is a purposefully broad topic. Several times weekly I will post focused reviews of issues interesting to health professionals and nonprofessionals alike. Posts may include examinations of medical devices, pharmaceuticals, scientific advances, internet services, and other technologies involving health care and the practice of medicine. Mirroring as it does the nature of the Internet and the sometimes surprising nature of new technologies, the content may also include topics that are wonderful, unusual, hilarious, or strange.

What are some recent posts on Tech Medicine?

In the last month, posts have included a discussion of medical uses of the iPhone; an argument in favor of medical podcasts; an introduction to and review of the HydraCoach, an intelligent water bottle; a roundup of unusual medical news; and a two part discussion of aquapheresis, a new treatment for heart failure.

Who are you?

I'm trained as a nephrologist (a kidney and blood pressure specialist). For the last two years I've written Kidney Notes, a blog designed to filter and process medical news. Most recently, Kidney Notes has become a collection of links, commentary, and scraps of information -- a reference database of interesting things with the help of a popular social bookmarking service called del.icio.us. While I will continue posting to Kidney Notes, several friends have asked me to write longer posts of original content -- and this is what I will be writing on Tech Medicine. (Recently, I have also written a blog on personal productivity called The Efficient MD.)

There are many topics I plan to cover, but I'm also open to suggestions and tips. Please email them to techmedicine@gmail.com.

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The Web 2.0 Carnival is Up

Thanks to Science Roll for including my post on podcasts.

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Medical Uses of the iPhone

As I was walking to the dialysis unit today, I couldn't help thinking about the iPhone -- mostly because I had to walk through a crowd of people who were waiting outside an AT&T store to buy one.

The iPhone (in case you haven't watched any media for the last three months) is Apple's new phone, combining a video iPod, a touch screen phone, and an internet device with several other "breakthrough" features.

That's all well and good -- but how might the iPhone be helpful to doctors and patients?

MedGadget, back in January, had this to say:

Apple's iPhone has got a lot of people excited... including the Medgadget crew. Why? Well, among its other uses, it's a powerful medical device. For instance, you can use the iPhone to:

1. Watch medical podcasts [or videocasts; see an intro to medical podcasts here]
2. Dial 911

Sure, you could always do this before on a separate iPod and cell phone, but convergence is key. Later this year, we expect to hear about the first patients that diagnosed their MI via medical videos watched on their iPhone, and were able to alert EMS with the very same device.

Then, hopefully, Steve Jobs will add a defibrillator to the second-generation iPhone...

A portable device for watching medical videocasts and listening to podcasts would be helpful for medical education and displaying medical information for patients, but as MedGadget points out, you don't need an iPhone to do that -- you could use a regular video iPod.

One way to really leverage the special nature of the iPhone would be to use its integrated YouTube player. There's an increasingly large amount of medical education videos on YouTube -- for example, clinicalcases.org reviews pathology cases and echocardiogram teaching cases. There are many videos designed for patients as well.

Imagine a patient-physician encounter where the doctor pulled out an iPhone and punched up a video on YouTube that explained the patient's medical condition or the procedure about to be performed.

Or a physiology discussion where a process was illustrated by someone's iPhone playing a computer generated image like those seen in The Inner Life of the Cell.

If you have any more ideas for using the iPhone, please feel free to comment.

(I've posted a longer discussion on using the iPhone to improve productivity on The Efficient MD.)

Labels: iphone, medgadget, youtube

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Review of the HydraCoach

This is a brief review of the HydraCoach, an intelligent water bottle that measures how much you drink.

In my last post, I described the HydraCoach, which is marketed primarily to athletes and those concerned about maintain optimal hydration.

As a kidney specialist, my primary interest in the product was evaluating it for use in patients with kidney stones. In these patients, the recommended fluid intake is at least 24 - 30 oz three times daily, producing a urine output of at least 2.5 liters. Many people understandably have difficulty drinking this much water. I've reviewed many 24 hour urine collections which have shown urine outputs of less than 1.5 liters a day. This definitely increases the risk of future stones.

After using the Hydracoach for three days, I'd give it a thumbs up. After programming the digital display with your body weight, the program shows you your target fluid intake as well as the percentage of target achieved in either liters or ounces. Having it on my desk within easy reach definitely encouraged me to drink more. I gained a new appreciation for both how difficult it is for people to consume the goal fluid intake and how a digital readout could encourage people to achieve that goal.

A cardiologist who reads Tech Medicine nicknamed Huck also helpfully pointed out another possible use -- *restricting* fluid intake. In certain conditions (like SIADH), drinking too much water can lead to low blood sodium through dilution. These patients are usually restricted to 1 - 1.5 liters of fluid a day. The HydraCoach can also be programmed to a lower target level of fluid, allowing people on fluid restrictions to know when they've reached their target fluid intake. (Thanks, Huck.)

Labels: hydracoach

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Stop Going to Conferences for the Lectures. Listen to Podcasts Instead.

Going to medical conferences has many benefits -- but with up-to-the-minute reporting of breaking medical news from conferences, the wide availability of free podcasts, and the inexpensiveness of MP3 players -- listening to lectures is not one of them.

Consider the cost of a typical conference. Figure $250 for airfare, $300 (at least) for hotel, and another $300 (give or take) for the conference itself. That's at least $850 for a few days (not even counting potential lost revenue). In total, some conferences can cost $1500 or more.

Compare this to an alternative. The most inexpensive iPod, the shuffle, costs about $79. Using the specialty of nephrology and hypertension as an example, the site HDCN.com provides countless lectures from most major nephrology conferences for $85 a year. And other sites for other specialities also provide high-quality podcasts inexpensively or for free. (If you'd like to recommend sites with medical podcasts for other specialities, please leave a comment.)

When the cost of a single conference -- at $850 to $1500 -- is compared with the cost of listening to a year's worth of podcasts, anywhere, whenever you want to -- at roughly $79 to $170 -- it's easy to see that the primary benefit of conferences is not the lectures, but travel and socializing. And the benefit of face-to-face time is not trivial. I've spoken to a few veteran conference-goers who admit to skipping all the lectures (with the exception of one or two entertaining speakers) and spending the majority of time interacting with colleagues and friends.

I've posted a four part "Introduction to Medical Podcasts" on the Tech Medicine blog, here.

(Originally posted on The Efficient MD.)

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Grand Rounds is Up

Grand Rounds, this week's best posts of the medical blogosphere, is up at Revolution Health. Thanks for including my post on gadolinium and nephrogenic fibrosing dermopathy.

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HydraCoach: An Intelligent Water Bottle

Drinking enough water is difficult. Exactly how much water people need is debatable (here's a sample calculator), but most people probably aren't drinking enough. Typically, the usual recommendation is 8 ounces of water 8 times a day.

And for people in hot environments and with certain medical conditions, like kidney stones, drinking enough water is critical. To dilute their urine and prevent future stones from forming, people with kidney stones should drink enough water to produce at least 2.5 liters of urine a day -- at least 24-32 ounces three times a day. "You know those people who walk around with water bottles all day?" I tell my patients. "You should become one of those people."

But of course, it's tough to carry around water all the time, it's tough to know how much you've drank, and it's tough to remember to drink that much water.

The HydraCoach is a newly-created "intelligent water bottle" that is designed to calculate daily fluid requirements, monitor how much you drink, and encourage you to drink more water. It's such an obvious idea that I wondered why it hadn't been created before. From the website:

The HydraCoach hydration monitor functions by means of Generated Electronic Pulse technology. A magnetized impeller floating within a sealed cartridge is placed in-line with the path of fluid, and in close proximity to a sensor located within the head unit. When the flow of liquid comes in contact with the impeller, it begins to rotate, causing the equi-spaced magnetic elements embedded within to pass the sensor, generating a small electronic pulse. This pulse is transmitted to the microprocessor where a measurement of fluid volume is calculated. The volume of fluid is directly related to the rate at which the impeller spins and these pulses generated. The amount of fluid passing through the system is shown on the display. The interactive head unit features several buttons that allow the user to toggle between various informative function modes and to input customized settings.

I've not tried the Hydracoach personally, but considering the importance of hydration in preventing kidney stones, the next time someone complains that they can't remember to drink enough water, I'll be recommending this device. (It costs $29.95, and if it can help a person prevent even one kidney stone, I think it's worth it.)

Labels: hydracoach, kidney stones, nephrology

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Unusual Medical News: A Fatal Overdose of Bengay; A Patient Bleeds Green Blood

Two medical cases in the news recently caught my eye.

In the first, tragic case, a 17 year old track star from Staten Island was found dead. The detectives who found her noticed a faint minty smell. Laboratory tests eventually revealed a fatal overdose of methyl salicylate, also known as oil of wintergreen, the active ingredient in Bengay. (The teenagers blood reportedly had six times the safe level of methyl salicylate.) Apparently, she had been applying more than the recommended amount of Ultra Strength Bengay to relieve her muscular pain from training. In rare cases, sufficient methyl salicylate can be absorbed through the skin to lead to systemic toxicity. Overdoses of methyl salicylate can lead to ringing in the ears, difficulty breathing, nausea, seizures, and death.

In the second case, a patient required emergency surgery on his legs to relieve pressure and swelling after falling asleep in a sitting position. Surgeons stuck in an intravenous catheter and were startled to find that the patient bled green blood. (At this point, most news reports make some joke referencing Dr. Spock from Star Trek.) After some laboratory tests and detective work including a thorough review of the patient's medications, the surgeons realized he had been taking heavy doses of the migraine medication sumatriptan (Imitrex). Rarely, this types of medication can cause a sulfur atom to be incorporated into hemoglobin, the pigment in blood. The result, sulfhemoglobin, appears dark green-black, and the condition is called "sulfhemoglobinemia." Off sumatriptan, the patient completely recovered, and his blood turned from green to red.

Labels: bengay, lancet, medical news, sulfhemoglobin, sulfhemoglobinemia

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Aquapheresis: A New Treatment for Heart Failure (Part 2)

In Part 1, I introduced the problem of heart failure and the use of intravenous diuretics, the standard therapy to treat fluid overload in hospitalized patients.

Recently, the UNLOAD trial was published in the Journal of the American College of Cardiology. This study compared intravenous diuretics with aquapheresis, a new treatment for heart failure.

Aquapheresis -- also called ultrafiltration -- is a technique for removing excess fluid from the body. It involves the placement of an catheter in the bloodstream that continuously runs the patient's blood through a filter. Excess fluid is remove from the blood through this filter, and the blood is then returned to the patient. Up to half a liter an hour of extra fluid can be precisely removed from the body in this way. (This technique is different than dialysis, which also involves the removal of excess toxins from the body -- using the process of diffusion -- when the kidneys have failed.)

In the UNLOAD trial, two hundred patients with heart failure were randomized to receive either intravenous diuretics or aquapheresis/ultrafiltration. After 48 hours, patients receiving aquapheresis had the following results:

• 38 % greater weight loss over standard care
• 28 % greater net fluid loss over standard care
• Equal improvement in dyspnea score (breathing)

Ninety days after hospital discharge, patients receiving aquapheresis showed

• 43% reduction in patients requiring re-hospitalizations for heart failure over standard care
• 50% reduction in the total number of re-hospitalizations for heart failure over standard care
• 52% reduction in emergency department or clinic visits over standard care
• 63% total reduction in days re-hospitalized for heart failure over standard care

This study suggests that aquafiltration is an alternative therapy for hospitalized patients with heart failure that may be more effective than standard therapy.

Labels: aquadex flexflow, aquapheresis, cardiology, chf solutions, congestive heart failure, unload trial

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Aquapheresis: A New Treatment for Heart Failure (Part 1)

Congestive heart failure (CHF) is a condition where the heart's pumping of blood is inadequate and consequently, fluid builds up in the lungs. (As a nod to my readers who are cardiologists -- CHF has many causes and is much more complicated that this simple explanation.) Symptoms of heart failure can include shortness of breath, low blood pressure, and a lack of blood flow to other organs of the body, like the kidneys.

Ninety percent of hospitalizations for congestive heart failure are due to shortness of breath from fluid overload. In patients with CHF, the major treatment for fluid overload has classically been diuretics injected intravenously. There are many types of diuretics, but Lasix (furosemide), is the one most commonly used.

The use of diuretics, while often quite effective, has many potential problems. First, an inadequate dose may be given, which may require a longer course of hospitalization until titration to the proper dose is achieved. Second, the patient may respond too well to the diuretic (a condition called "overdiuresis"), which can lead to low blood pressure and decreased kidney function. Third, even if the proper dose is given, diuretics may occasionally still lead to decreased kidney function and other complications, like low potassium.

For patients with congestive failure who already have significantly decreased kidney function, an alternative to diuretics is a process called "ultrafiltration." During dialysis -- a way of cleaning and filtering the blood using a dialysis machine -- fluid may be removed from the blood directly. In patients with CHF, ultrafiltration of extra fluid, which is performed during dialysis, can relieve symptoms of shortness of breath the same way diuretics can. The downside is that ultrafiltration requires a dialysis machine and is usually only used in patients with decreased kidney function.

In an attempt to overcome the problems with diuretics and the requirement of a dialysis machine for ultrafiltration, a company called CHF solutions has designed a device for ultrafiltration -- which they call "aquapheresis" -- called the AquaDex FlexFlow Fluid Removal System. A recently published study called the UNLOAD trial has shown impressive results in using the machine to treat patients with heart failure.

More in Part 2.

Labels: aquadex, aquapheresis, cardiology, chf solutions, congestive heart failure, heart failure, nephrology

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Grand Rounds is Up

Grand rounds, this week's best posts of the medical blogosphere, is up at Medskool. Thanks for including my post on the Encyclopedia of Life.

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