Saturday, December 28, 2013

Sunday, November 17, 2013

Extra Spicy Foods May be Harmful

Super spicy snack foods may cause harm to children (and adult) by causing or exacerbating gastritis.

Saturday, November 16, 2013

Journal of Cardiology and Therapy

I have just been added to the Editorial Board for the Journal of Cardiology and Therapy

Friday, November 15, 2013

Testosterone Supplementation and Increased Mortality

This study in JAMA found that the use of testosterone replacement therapy was associated with a 29% increased risk of adverse outcomes (all-cause mortality, MI, or ischemic stroke.)

COMMENT: there are several issues driving an increased use of testosterone replacement therapy. First is the assumption that a below average testosterone level is unhealthy. The decline in testosterone with age likely is just as normal as gray hair, balding, or arthritis in me. Attempting to "correct" what is essentially a normal change with age may lead to harm, and earlier death rather than prolong youth. 

The second major driver of increased testosterone therapy likely is profit. Turning a normal process (aging) into a disease ( "low" testosterone) is a common tactic of some pharmaceutical makers. 

JAMA Network | JAMA | Association of Testosterone Therapy With Mortality, Myocardial Infarction, and Stroke in Men With Low Testosterone Levels

Monday, October 21, 2013

Medical App Resources for the Android

ePocrates - “More than 1 million active members, including 50% of U.S. physicians, rely on Epocrates to enable better patient care by delivering the right information, right when it's needed.” - 4.3 stars (10/3/2013). Comment: This is the app I use the most. Good resource for both medications and for disease management.

UpToDate -  “Find clinical answers at the point of care or anywhere you need them! Now you can access current, synthesized clinical information from UpToDate® — including evidence-based recommendations — quickly and easily on your Android phone or tablet” - 3.9 stars (10/21/2013). Comment: I use this more on my laptop due to the navigation system which is a bit cumbersome on a tablet. Highly authoritative.

Medscape - “Medscape is the leading medical resource most used by physicians, medical students, nurses and other healthcare professionals for clinical information. Our mobile app is used by over 2 million registered users. Medscape app for Android is available free.” - 4.4 stars (10/3/2013). Comment: I use this significantly less often than ePocrates. Nevertheless, it is an essential app for two reasons: a) often it has content not covered by ePocrates, and b) it provides a good 2nd opinion to the recommendations in ePocrates. Like ePocrates, it is updated frequently, and contains both a good resource for medications and for disease management. Free.

WikEM - “WikEM is a database of concise emergency medicine notes to assist physicians with their daily practice. Via wiki notes on, WikEM features a continually available updated set of notes and checklists that allow for rapid reference of key information. WikEM is intended for clinicians only and not directly for patients. “ - 4.6 stars (10/3/2013). Comment: I use this with caution, because it is a wiki,  and therefore less secure than most other apps. Nevertheless, this wiki, initially put together by the Harbor-UCLA emergency medicine residency program, is well organized and succinct. I use this on an occasional basis, but do not let it be the final word on any management issue but rather use it to help guide my investigation in other apps and resources such as ePocrates, Medscape, and Uptodate. Free.


Johns Hopkins Antibiotic Guide - “The official Johns Hopkins ABX (Antibiotic) Guide from the Johns Hopkins Medicine features up-to-date, authoritative, evidenced-based information on the treatment of infectious diseases to help you make decisions at the point of care. This comprehensive resource organizes details into easily accessible, quick-read entries.” - 4.5 stars (10/3/2013). Comment: I use this app frequently in order to guide antibiotic therapy. Easy and quick navigation system. Highly authoritative. A good value for the money.

Sanford Guide - The Sanford Guide to Antimicrobial Therapy is the leading reference for health care professionals engaged in the treatment of infectious diseases. Subscribe for access to comprehensive, treatment-focused coverage of bacterial, fungal, mycobacterial, parasitic, viral infections, and HIV/AIDS; anti-infective drug information, prevention and useful tables and tools, including activity spectra for antibacterial, antifungal and antiviral agents, and calculators to assist with dosing.” - 3.2 stars (10/21/2013).

Nelson’s Pediatric Antimicrobial Therapy - “Pediatric Antimicrobial Therapy, optimized for mobile devices. Intelligent search based on drug and condition keywords takes you to the best answer. Drug dosage tables have been reformatted with an intuitive display for smaller screens. Includes a Body Surface Area Calculator for dosing.” - 3.0 stars (10/21/2013).  

CDC STD Treatment Guide - “The app is the result of collaboration between CDC's Division of STD Prevention and the Public Health Surveillance and Informatics Program Office's Informatics Research & Development Activity. The information in this mobile application is based on the CDC’s 2010 Sexually Transmitted Diseases Treatment Guidelines (MMWR 2010;59(No. RR-12) and the 2012 MMWR Update to CDC's Sexually Transmitted Diseases Treatment Guidelines, 2010: Oral Cephalosporins No Longer a Recommended Treatment for Gonococcal Infections (MMWR 2012; 61 (31): 590-594).” - 4.6 stars (10/31/2013).


Qx Calculate - “Essential tools in General Practice, Internal Medicine, Cardiology, Surgery, Obstetrics, Nephrology, Hematology, Orthopedics, Pediatrics, Gastroenterology, Neurology, Neurosurgery, Respirology, and more.” - 4.6 stars (10/3/2013). Comment: This is the fastest and most organized medical calculator that I’ve found. Not as complete as MedCalc 3000 Complete but easier to use and to navigate. Since just about everything necessary is found on Qx Calculate, this is the medical calculator I end up using most frequently. Free.

RSI Calculator - This app is designed to be stepped through rapidly - patient class (Adult, Pediatric, or Geriatric); patient weight in pounds or kgs, or Broselow tape if pediatric; finally, patient health considerations - does this patient have an intracranial bleed? Is this patient hypotensive? Should hyperkalemia be suspected? - finally, here are your drugs and dosages.” - 4.0 stars (10/21/2013).

MedCalc 3000 Complete -MedCalc 3000 is the most popular and comprehensive Medical Calculator system on the web. MedCalc 3000 has been highly acclaimed, reviewed and tested over the last 11 years. As a trusted resource it has been integrated into many prestigious websites for Medical Education, Medical Literature, Pharmacology, Nursing and more. Now you can put this invaluable resource in the palm of your hand!” - 3.4 stars (10/21/2013).  Comment: I only rarely use this app, and prefer instead QxCalculate due to the navigation system.

Mediquations - The most comprehensive medical calculator for the iPhone is now available on Android! Mediquations makes getting the answers you need quick and painless. With 232 formulas and scoring tools and a intuitive interface, Mediquations is the smart choice for anyone looking for a medical calculator for Android.” - 4.3 stars (10/21/2013).


palmEM - “palmEM is an all-in-one, rapid and succinct, evidence based emergency medicine quick reference. Internal medicine, critical care, family practice and urgent care clinicians will also find palmEM useful. The app is continually updated and expanded. Unlike several other references, updates are free and there are no yearly subscription fees. “  - 4.5 stars (10/3/2013). Comment: I use this on occasion. Less complete than ePocrates but sometimes gets to the relevant information more succinctly.


MyATLS - The medical care of trauma patients demands fast thinking and accurate, up-to-date resources. And there is no more reliable resource for trauma information than the American College of Surgeons (ACS). This app was developed alongside their seminal course, Advanced Trauma Life Support (ATLS). ATLS has trained more than 1.5 million participants in more than 75,000 courses around the world.” - 3.9 stars. Comment: an excellent complement to your ATLS course. Works well on Android apps.


CDC News - “The CDC mobile tablet application puts health information at your fingertips. It features important health articles, Disease of the Week, popular journals, timely updates, and access to social media. Wherever you go, you’ll have 24/7 access to important and timely health information that you can use to protect yourself and your loved ones.”  - 4.8 stars (10/21/2013).



Not Available on Android as of 10/21/2013
  • Difficult Airway App
  • RSI App by
  • IDIC Antibiotics
  • Vasopressors by EMRA
  • EM Rashes
  • Arrhythmia
  • ACOG App
  • CDC Field Triage
  • Neuro Toolkit
  • MD Consult

Saturday, October 19, 2013

Straight From the Heart

Once again this year, I had the great privilege of participating in the Straight From the Heart program which is designed to help increase awareness of heart disease in young adults, and to help screen young adults for cardiovascular disease. Special thanks goes to Heart Clinics Northwest. They supplied the echo machines, and the several echo techs and cardiologists from their group volunteered.

Straight From the Heart, Post Falls, Idaho

Thursday, October 3, 2013

Peace Health

Here's my Peace Health / St. Josephs Medical Center physician listing:


Wednesday, September 18, 2013

Navy Yard Shooter: Do Prescription Drugs Cause Violence?

Here's an article that looks at the rate of reports of violence associated with prescription drugs. The methodology is really iffy, and several authors are paid consultants for litigation. Bias from financial conflicts of interest is highly probable, especially given their unusual methodology for the determination of an association. Furthermore, the authors seem to intentionally blur the line between association and causation in their discussion and conclusions. Still, it is an interesting hypothesis (unproven by their research) that is worthy of further investigation.

The major flaw in this study is that we don't know whether or not a person with severe psychiatric problems is more, or less likely to commit violence when on or off the medication. It's possible that these are the medications prescribed to people with such tendencies, and that the overall effect of the medications is positive (i.e. reduces violence).

Let's look at this another way by hypothesizing that diabetic medications cause high blood sugar. We look at people on the diabetic medications, and compare them to people on blood pressure medications, and subsequently find that people on diabetic medications have higher blood sugar levels than people on blood pressure medications. In this situation, it is clearly wrong to conclude that the diabetic medications actually cause high blood sugar levels. However, there is an association because diabetic medications are only prescribed to diabetics, who because of their disease have high blood sugars. The medications may reduce blood sugar levels, but not down to the level of non-diabetics.

Just like it is really absurd to state that diabetic medications *cause* high blood sugar levels, it is wrong to conclude that psychiatric medications *cause* violence. Yes, there is an association, but perhaps the problem is that not enough diabetics are not on diabetic medications, and perhaps not enough people with psychiatric problems are on psychiatric medications.

Association does not equal causation, it's as simple as that.

PLOS ONE: Prescription Drugs Associated with Reports of Violence Towards Others

Tuesday, September 17, 2013

Tuesday, September 3, 2013

What's wrong with this?

I just read this online...

"Dysuria, or painful urination, is usually the chief complaint in men with urethritis, and is reported in the majority of men with gonorrhea and over half of patients with nongonococcal urethritis."


The majority of men with gonorrhea have dysuria.


Over half of patients with nongonococcal urethritis have dysuria.

Sunday, July 28, 2013

Medscape Reference Article: Bone Scan

Medscape recently published an article I wrote on nuclear bone scanning. You can view it here:

Bone Scan

Heston TF. Bone Scan. Medscape Reference. Updated July 15, 2013. Available at:

Thursday, May 30, 2013

High Doses of Common Painkillers Hike Heart Risks

Ibuprofen and diclofenac increase risk, but my favorite, naproxen, is not associated with increased risk.

High Doses of Common Painkillers Hike Heart Risks

Wednesday, May 22, 2013

Straight From the Heart

I had the great pleasure of participating in this program last month in Coeur d'Alene to help prevent cardiac deaths in teens and young adults. Please check out their website at

Saturday, May 18, 2013

Advanced Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Algorithms: 2010 Update

Benzodiazepine use and risk of dementia: prospective population based study | BMJ

This study found that the use of benzodiazepines appears to increase the risk of developing dementia. Common benzodiazepines are alprazolam (Xanax), diazepam (Valium), and lorazepam (Ativan).

Benzodiazepine use and risk of dementia: prospective population based study | BMJ

COMMENT: short term use appears to be safer; long term use may increase the risk of side-effects. Some medical conditions are best treated by benzodiazepines, and in these situations, early screening and taking measures to prevent dementia may be helpful.

Thursday, April 18, 2013

Leading Clinicians and Clinicians Leading — NEJM

This is a good article on the importance of including physicians in leadership positions at all levels of clinical and business management on the delivery of high quality, cost-effective medical care.

Leading Clinicians and Clinicians Leading — NEJM

Thursday, April 11, 2013

How to Improve Doctor-Patient Communication

This article from the Wall Street Journal asks several experts how to improve doctor-patient communication. One response I particularly like is the recommendation for the doctor to ask 3 questions:

  • What do you think is going on?
  • What are you most worried about?
  • What do you think I can do for you?
I like this because patients often know exactly what is going on with them. They have thought about their condition, and lived with it from the very start. Even if their ideas end up being wrong, it is important to address the issues.

Wednesday, April 3, 2013

Smokers have worse colon cancer prognosis

Here's a landmark study (or maybe not):  in patients with colon cancer, smokers don't do as well as non-smokers. Really? Guess that proving the point might be helpful but we already know smoking isn't good for you, it increases your risk of cancer and delays healing after surgery or infections. 

Sunday, March 31, 2013

The 5 pillars of successful aging

Research from the McArthur Foundation has found that there are 5 pillars of healthy aging: physical, mental, social, spiritual, and stewardship. This is really not revolutionary, but rather wisdom handed down about a hundred years ago or so by William Danforth, the founder of the Ralston Purina company and explained extensively in his book I Dare You. If you consider "stewardship" to be a part of your social and spiritual life, like many of us do, then this research is not new nor very interesting, it is simply confirmatory. Living what Danforth calls a "four square life" not only increases the years of life, but the life in our years. It's time to get back to basics.