And this is what I first landed up with:

It looked fine with me, after all I didn’t want to spend too much time on a silly logo. But my wife couldn’t stand it. What does it mean?? It looks funny, that’s what she said. So I modified it a little bit more:

trying my best to convince myself that it couldn’t get better than this. I even got a favicon working.

I was using drupal for my site, another open source CMS. It just didn’t match the drupal icon.

I noticed how the icon was small and yet so large. Being spherical in size it seemed to occupy all the 64×64 icon space. So I changed my mind to work on a spherical model. I had been working on the crooked tree picture

sometime back and had saved it in png image format. Gave it a try and this is what I came up with.

But then the site background was also green, and there seemed to be no contrast between the two. It just didn’t stand out! So I played around with the background and finally settled for lemon yellow.

The icon was finally beginning to shape up. I enlarged the central image to fill up my icon. I was also having trouble adjusting my site name. It seemed too long to be a title. So I decided to include it in the logo. Wanted the title to be more clear so added shadow and made it bold to improve its appearance. And this is what I finally came up with:

It still doesn’t look perfect to me. For one the title is crowded and secondly it seems to be going beyond the equator. But for the moment I am going to use this logo. My site has got an identity now! Hooray!!

Tags: Logo, Orthodoc, drupal

The field of Orthopaedic Surgery is exploding!!

There is so much to learn today. All that we learnt during our post graduation is so out dated that sometimes I get frustrated. Constantly whenever I browse the net I keep my eyes open for material worthy of notice. Most of the material is of two main types: either a busy surgeon with a webpage that is loaded with information which is more of a web page filler rather than being informative or it is a big-notch company that is trying to sell its equally big-notch product. The latter are heavily biased in their delivery of information towards the product they sell. In other words, both the types are grossly inadequate. Of course there are exceptions, but they are rare or out dated.There is a need for more informative material for both the student and the patient. Someplace where the person can visit to collect reliable info. Something on the lines of an OKO or the emedicine portals. While the former is a paid site, the latter is very limited. There were a few learning materials available in the NEJM site but then this requires a subscription.

I have been looking at Wikibooks for quite some time now. A book on Orthopaedic Surgery is also listed but contribution is scanty and the book has lain empty. Wikiversity could be the ideal ground for development of some teaching material. Teaching today, goes beyond books. With the availabilty of digital cameras and excellent presentation software it should not be hard to create materials like slide presentations or even instructional videos. And once we have some material then we can have some basic courses set up as well.

But am pretty unsure about how to get collaborators onto the projects. The fact that there are so many open-source projects with community contribution in other subjects, it makes me wonder when we will have the same situation in Orthopaedic Surgery.

You may say I am a dreamer,
But I’m not the only one.
I hope some day you will join us,
And the world would live as one…
John Lennon.

Technorati Tags: Orthopaedic, Online learning, Wikiversity

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For Patients

You get to see more or less what your doc would be doing if you are planning to have a particular surgery done in the near future. Most of the surgical videos have a moderator who in conversation with the operating surgeon reveals the premise of the surgery. You get to know the details of an operative procedure as you keep watching it being performed. You can even mail in your questions for the moderator to answer live! This is not for the weak-hearted who feel queasy on seeing blood. But nevertheless you can switch off the screen when you like and listen to the commentary instead. A schedule is put up by about a month’s advance. Fear not, if you are busy or missed one. They have most of the surgeries archived …they call it OR-Replay. They even have a search box provided and you can pull out the surgical video if you know the surgery by its name. You need a Windows Media Player to run all the videos. Since it is a streaming video a net connection with decent speeds is necessary. Those with ordinary dial-ups can wait for the entire video to load before playing it. Otherwise they will have to watch it in bits. Mind you, the surgeries are quite long, more than an hour at least, so be prepared and keep yourself free. All of these surgeries are performed in the US so the intended audience is per se Americans.

For Surgeons

Most of the conferences these days have a live demo by a senior, experienced and trained surgeon. OR-Live is nothing but an extension of the same demo. The intended audience is world wide. This is most likely to appeal to juniors and students very well. Senior surgeons will always remain skeptical! For example, the two-incision MIS Hip replacement is yet to pick up in India. Seeing the surgery being performed live is a good introduction to the subject in question. But in no way is it sufficient enough to learn and start doing it on your own.

Pros and Cons

This is the age of information and any information is always welcome, especially about surgeries that have always been performed behind closed doors. Seeing it with your own eyes will beat any description of it. Is it informative? Yes it is, you have a moderator to make the sessions interactive. You also have a slide display by the side with diagrammatic representations of the surgery in progress. What I found disturbing is that most of the procedures web cast are relatively new procedures …the ones that involve new or difficult instrumentation. Ideally the site should be web casting the most commonly done procedures. It is not difficult to understand the reason behind this. Most of these procedures are sponsored by the companies involved. And the industry’s concern about selling a new product is only well known. But then on the other hand I can’t help appreciating their involvement in the educative process. Ultimately from the patients’ standpoint we benefit from the surgery more than anyone else. Surgeons require a more serious debate centered around the procedure in question. Such a web site is unlikely to provide the necessary platform. They are best served by conferences involving members of their own fraternity. Certain online journals, particularly New England Journal of Medicine, have attempted to host videos of procedures. But these are of the most basic nature and concern routine ward procedures. Others like Wikiversity have expressed intentions and hold a lot of promise to produce quality learning tools, but are still a long way from bearing any fruit. Until then surgeons have to do with sites like OR-Live.

Update: Those familiar with youtube.com can look out for the user ORLIVEDOTCOM. You will find most of their videos you want at You Tube. Good Luck.

Tags: Live Surgery, Orthodoc, Orthopedic Surgery

"What is it Tom? I am here at the OP. What happened?"

"Nothing sir. I want to meet you."

He was there in a minute. He looked tired. In the OR, he was a restless creature full of energy. Anytime I looked at him he was rushing to some place or busy at work. As a scrub nurse he was ready with the scalpel. But he was a little too quick for anybody’s comfort. I had noticed his unsteady and shaky hands at times, but he managed to mask them well with his agility and quickness. It was evident that at the moment he had been busy the whole day. He was not his usual self, though. The smile was not there for one thing and then his restlessness.

"Sir, I need your help. I don’t know how to say it."

"What is it? Go ahead and tell me." The impatience was becoming evident.

"I need money, sir." Then there was a pause. "They are suddenly asking for money. All these days it was fine …and now last moment. You know, I am leaving to Gulf. My visa is ready. It came in yesterday, so I am leaving. They are not paying …they are cutting." It all came out in a rush.

"The hospital is not paying you last month’s stipend?" It took me a while to understand.

 Most, almost all of the nurses, are working for the hospital under a contract. They get to work in the hospital, earn a stipend, stay in a hostel free of cost, have subsidized food. In turn they are educated in nursing. They have all completed their required courses but are still not competent. So they often, for practical on-the-spot exposure, work for less at some big hospital like ours. In return at completion of the two years of bonded work they are released with a certificate stating their work experience. Most of the nurses manage to get certificates of recommendations form the senior consultants with whom they worked. They also spend quite a bit on English courses. Then they apply to work in hospitals abroad. The most preferred places are USA, UK and the middle east countries like Saudi Arabia, UAE and so on.

"I completed my two year bond many months ago. I was applying here and there. I was not sure. Suddenly I got call. Visa is ready. I went to Delhi to collect it. I have to go there. Now the personnel dept. wants money." The words became less distinct. He stood crestfallen. "They are not giving my completion certificate." When he looked up to see my response, I could see tears in his eyes.

"How much money are they asking for, Tom?" I couldn’t take it anymore. "Don’t cry, Tom."

"Sir, all the hard work I did. I worked overtime so many times. I did so many duties. But last moment…." He broke off. "I don’t like asking for money like this. Its very difficult. I thought I could ask only ask Dr Pathak , he is not in his room. Then I thought about you. Please don’t think anything, sir" He was pleading hard.

"Tom!" I was searching for words to say myself. "The world is not fair at all times. Sometimes, we learn the hard way. probably they wanted a month’s notice. But they could have considered your past work. Does the Nursing Supdt. know about this?"

"But she won’t do anything. She said you settle with personnel dept."

"So you need 4000. I don’t have so much in my purse. I have to check in the bank. Come we will go and check in the ATM."

"Sorry sir! I don’t like doing this at all."

"Come on, Tom. Stop sobbing like this." I patted him on his back.

I managed to get 2000 from the ATM. I explained my inability to get the rest. Lets see if I can get it from Sandy or Rajesh. So I left him downstairs and hurried to the Men’s room to see if I could get some more. I knew they would be reluctant. I was wondering if I should put it to them as if I required the money. I decided to tell them the truth.

"Sandy, are you free? I need to ask you something."

"What?" His brows furrowed deep and he shook his head querying.

"Well …Tom is in a spot. You know he’s leaving for Saudi. He’s quitting. He needs money. They are not giving him the completion certificate unless he pays them a fine for leaving without notice. I was wondering if you could spare some money."

"I don’t have money on me, buddy. "He relaxed immediately. "But I will give you a word of advice. By the way how much is he asking you for?"

"4000. I managed some for him but not all of it." I deliberately hid the amount I had managed form the ATM. "I thought I will ask you and Rajesh for something. Can you…"

"I will tell you something. These people cannot be trusted." His tone was grave. "If you are giving him money then don’t expect it back. He will fly away for ever and never return. If at all you want to give him some money, give him a small amount and forget about it. I mean, explain to him nicely!"

"How much can you give?" I was livid and I wanted to be direct. But I didn’t show it. I didn’t come here for advice. I didn’t come to ask whether I should or not. I was in the mood for arguing, but then, Tom was waiting. I decided to give up.

"I don’t have any money on me, boss."

So that’s it. I scrambled down to meet Tom. I wondered if he had managed to find more.

"Sir, I met Dr Pathak. He returned. I explained my situation to him. He asked me to wait here. He said he will get the money for me. So I can return your 2000. I am happy sir. Thanks a lot." He returned my money.

"Ok Tom!" I took the money back. A small pause. I fished out a 500 and thrust it into his pocket. "Here Tom,. keep this. Buy  a new pair of shoes or a pair of trousers."

" No sir. I don’t want it." He was beaming. He had his problem solved. "Sir I won’t forget what you did for me. Give me your number."

That was about two months ago. There was a call yesterday from Tom. He was in Dubai. He was back to his same restless self eager to go to work. It was tough work but he said he was enjoying. We talked for  a while and then he hung up. I felt a warm feeling come over me.

Trust! I could not help feeling right about having trusted Tom.

Tags: Trust, orthodoc

In the home page this is what they have to say

Edheads brings you high quality, free educational activities for your classroom.

At the moment they have four different activities listed. Among them, two of them concerned replacement surgeries. For a freshman in Orthopaedic Surgery the two virtual surgeries will help understand hip and knee replacement surgery better. The major steps are displayed. There are also accompanying real surgery photos available. Personally, I am not sure they will make sense to young school students, though those with a special interest in medicine may find them interesting.

From a patient point of view the flash movies may help someone to understand what exactly goes into replacement surgery. However some of the questions make it apparent that the movies are intended for the student community.

The movie quality is excellent! The voiceover and the subtitles make it easy to understand. The steps are remarkably accurate. It seems to me that the site came up last year, however they have managed only four activities until now. Hope the site lasts for a long time and comes up with more educational videos.

Tags: Educational Movies, Virtual Surgery, Hip Replacement, Knee Replacement

But PubMed Central beats them all. I became aware of its existence only recently. Initially I thought I had been blind. But when a friend and a colleague claimed ignorance, I knew we may not have been the only ones!

PubMed Central is a digital archive of life sciences journal literature at the US National Institutes of Health (NIH), developed and managed by NIH’s National Center for Biotechnology Information (NCBI) in the National Library of Medicine (NLM). With PubMed Central, NLM is taking the lead in preserving and maintaining unrestricted access to the electronic literature, just as it has done for decades with the printed biomedical literature.

It is not a journal publisher. NLM believes that giving all users free and unrestricted access to the material in PubMed Central is the best way to ensure the durability and utility of the archive as technology changes over time.

In addition to Highwire Press, here is another important source of articles for Orthopods. In simple words PubMed central maintains a database of all articles that are available free of cost (free access).

Tags: Pubmed, pubmed central, Free access

But anyway, today after a long time I felt like talking. We have quite a few patients who undergo hip surgery at our hospital. We leave a drain tube in the wound and connect it to a bellow unit so as to prevent collection of blood at the wound site. We remove the drain tube at 48 hrs. By 48 hrs the blood is clotted, and the bellow cannot drain it out anymore. Secondly, it is the only connection to the exterior from what otherwise is a closed wound, and so we do not want to risk any infection. We do not, as a routine, anchor the drain to the skin with a stitch so that we can just pull the tube off.

The patient was a 63 years old lady with a hip surgery. She had had it two days ago. She had a change in the pain medication to Fentanyl infusion as the previous drug (Tramadol) did not bring her pain down at all. With this background in mind, my consultant asked me to be careful with the drain removal and take a decision to mobilize her. Ok boss, done! Ok Miss J, shall we go ahead with the change in dressing? As I peeled the tapes off her skin she jumped in pain. I apologized and went about gently removing her dressing. I tried to take her mind off the dressing ritual. She glanced at the tube and asked me if pulling it out was going to hurt. I replied in the affirmative saying it is going to sting a little. I cleaned up her wound with betadine and covered it with a piece of gauze. I then proceeded to remover the tube. I let her know that I was going to pull it out. I asked her to inhale deeply and suddenly yanked it out at one go. She screamed and tears rolled down her eyes. She was crying in pain. I apologized for the pain I had caused her, and went on to tape down the rest of the wound. I tried to talk her through it but did not quite succeed. She felt the pain was like nothing she had ever felt before. It was the worst pain in her life. I felt miserable. I helped her get into a comfortable position. I made attempts to ease her pain …but they were not good enough. She kept repeating that her pain was horrible. It was another thing that she went through her physio and she even went onto walk. I walked out of the room dejected wondering if I should have been more gentle in pulling out the drain.

The other day I was removing the drain of another patient who had undergone surgery on a previous occasion, and he urged me to yank the dressing off in one single go, rather than tug at it slowly. He could not bear the slow torture. I could not agree with him more. If I was in his position I would want it to be yanked off rather than have it removed gently. I suppose with that notion I had pulled the drain out of this lady’s wound hoping I would keep the painful period short. But I was wrong! Sometime the intensity of pain is more unbearable than anything else. Maybe I should have pulled it out carefully. The way I pull the drain out, or give an injection should depend upon the patient. A small discussion with the patient about how he/she would want it out should go a long way in gaining the patient’s confidence. Doing that is, I believe, the best way of tackling the patient’s painful state.

What do you think?

Tags: Pain, Drain tube, Pain threshold

One of my neighbors’ father in a close by flat had back pain troubling him for a week. Apparently he had slipped in the bathroom and was now refusing to get up from bed. His son was worried and had called me in to check if anything was wrong. I made a courtesy call …anxious to prove my competence. I declared that there was nothing serious and rest should be enough. I thought that would suffice but soon the specifics were enquired into, and I knew I couldn’t get away so easily. Clinically he seemed to be comfortable with no weakness in his limbs. This time around I announced that there could be a fracture in one of the several back bones (vertebrae). Knowing how worried they could get, I added that this is quite common at his age, 75 years, and it requires an x-ray for confirmation. Out came the x-ray!! He had it all along!

I held it up against the tube, furrowed my brows and made a note of the compression fracture of the D12 vertebrae. So there you are, he has a fracture. No, but his doctor told him that there was a scratch in the bone. Did he really have a fracture, enquired his wife, her eyes about to fall of her sockets! Of course there was one. I struggled to explain. This is not like the usual fracture where the bone breaks into two or more pieces. Here the height of the bone decreases as the walls of the square-shaped bone collapses making it look wedge-shaped. This is because …the bone is weak, interjected the son. I nodded my head in agreement. The doctor prescribed some painkillers and …he also asked us to take this. He handed over a packet with a vial inside it. Salmon Calcitonin was the name of the drug. He said this will make his bones stronger in a week but I do not know the dosage. He mentioned 200 but there’s so little of it …and how do we give it to him. Well, well …this is administered as nasal puffs and each puff is metered to deliver 200 units. Oh! Ok.

There are so many drugs introduced in the market these days that makes keeping up with all the information very difficult. So what did we have about Osteoporosis and its treatment in the web? I decided to do a Google search. And this is what I came up with.

Osteoporosis

In simple words, osteoporosis refers to loss of density of bones. What that means is that the bones become weak and break easily from minor falls, necessitating a visit to the doctor. It is commonly seen in the elderly and women in particular after menopause. Bones also become less dense and weak after prolonged immobilization as in fractured bones treated in plaster casts or in paralyzed limbs. But the medical term for this is osteopenia. Osteoporosis refers to the specific disease process rather than the mechanical condition or radiological appearance of bone. In other words it is a quantitative and not a qualitative defect.

There are several web sites dedicated to Osteoporosis. But there’s one that took my breath away. Osteoporosis and Bone Physiology is a site maintained by Susan Ott, who is an Associate Professor in the Department of Medicine at University of Washington. The site details every aspect of osteoporosis. Overall the site looks old-fashioned, but hides a lot of information, if you cared to look for it. Some excellent images and animations supplement the information available. The language is lucid and clear. This would be a one stop reference for everything on Osteoporosis. There is also information available for Patients and a corner for kids. To top it all she manages to keep it updated.

Salmon Calcitonin

Susan Ott does mention calcitonin as one of the many drugs available to treat osteoporosis. Calcitonin can be administered as an injection or as a nasal spray. As a nasal spray, salmon calcitonin was first used to treat Paget’s disease. Its ease of use as a nasal spray was then exploited for treatment of osteoporosis. Its use significantly reduces the occurrence of spinal fractures and there is a modest improvement in vertebral bone density. Calcitonin is a hormone produced normally in the human body by the thyroid gland. Salmon calcitonin is a synthetic form that has the same amino acid sequence as in the calcitonin of salmon origin. The drug is not of salmon origin. This is marketed as Miacalcin by Novartis. Emisphere technologies has developed an oral form of Salmon Calcitonin in conjunction with Novartis and the drug is yet to complete its phase III clinical trials.

The Facts

The presence of a vertebral fracture is more an evidence than an indication for osteoporosis. Vertebrae can have micro fractures invisible to the naked eye that are probably the cause of back pain in an elderly with osteoporosis. They do not suffer from any kind of scratches!! Vertebrae also collapse in the center when they are referred to as codfish vertebrae. Fractures in the elderly around the hip, spine and wrist in a low-energy trauma situation indicate the presence of osteoporosis, and necessarily require to be treated for the same.

Each puff of the calcitonin spray, indeed delivers 200 IU of the drug (0.09 ml to be exact) and it doesn’t have to be inhaled. Each bottle contains 3.7 ml and that usually lasts for a month. Opened bottles need to be stored in temperatures not exceeding 25 ºC. And unused bottles need to be stored in the refrigerator but not in the freezer. The drug has no gastric side effects but can, in a few patients, irritate the nasal lining. In addition to using the spray a patient also needs to use calcium and Vitamin D supplements.

Other drugs available for treating osteoporosis are:

Anabolic (Bone forming) agents

• Intermittent Parathormone (PTH) injection. Low doses of parathormone helps build bone mass. Abnormally high secretions of the hormone, on the contrary, causes bone resorption.

Anti-resorptive agents

• Hormone Replacement therapy (HRT) in the form of estrogen. There have been concerns of increased risks of breast and endometrial cancer, strokes, pulmonary embolism and coronary heart disease. Low dose therapy may be appropriate.
• Selective Estrogen Receptor Modulators (SERM) – Raloxifene (Ralista, Evista). These drugs bind to estrogen receptors and have estrogen-like and anti-estrogen actions depending on the tissue of action. Though they help control osteoporosis like estrogens, they do not carry the same risk factors as HRT is normally associated with. The effect on the cardiovascular system, whether desirable or undesirable is still under debate. Along with HRT, SERMs are best considered for post-menopausal osteoporosis.
• Biphosphonates are Alendronate (Fosamax, Restofos) , Rrisedronate (Actonel) and Ibandronate (Boniva). They are known to reduce the incidence of fractures. Of late there have been reports about Osteonecrosis (bone death) of the jaw bone in the literature, and so the drug needs to be used with caution.
• Calcitonin.

Further reading

1. Pharmaceutical Treatment of Osteoporosis by Susan Ott.
2. Osteoporois – Preventiion and Treatment at Endotext.com
3. Pharmacotherapeutic Implications of Osteoblast and Osteocyte Apoptosis at Endojournals .org
4. Alendronate for treatment of Osteoporosis in men at NEJM.
5. Article on Salmon Calcitonin in American Journal of Medicine (pdf format).
6. Miacalcin at novartis website.
7. Diseases of Bone and Calcium Metabolism at Endotext.

Tags: osteoprorosis, salmon calcitonin, treatment of osteoporosis, vertebral fractures

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In their own words

HighWire Press is the largest archive of free full-text science on Earth! As of 4/28/06, we are assisting in the online publication of 1,333,054 free full-text articles and 3,446,917 total articles. There are 26 sites with free trial periods, and 33 completely free sites. 219 sites have free back issues, and 825 sites have pay per view!

Click on the following link HIGHWIRE PRESS to find a full list of journals and the type of access they allow. For example the Journal of Bone and Joint Surgery, British volume has all the full-text versions of articles from Jan 1, 1948 to Dec 31, 2000 available. Curiously there is no mention of the American version, which in fact led me here!! maybe it is listed on another page.

One warning:

List limited to journals published online with the assistance of HighWire Press.

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Open- access (Full text available)

Ortho related:

• Journal of Orthopaedic Surgery – Official publication of Asia Pacific Orthopaedic Association.
• The Iowa Orthopaedic journal – Official journal form the Dept. of Orthopaedics, University of Iowa, USA.
• Journal of Orthopaedics – Official journal published by the Dept of Orthopaedics, Calicut Medical College, Kerala, India.
• The Internet Journal of Orthopaedic Surgery – Peer reviewed journal from Internet Scientific Publications.
• BMC Muskuloskeletal Disorders – From Biomedcentral.
• Acta Orthopaedica – Articles from issues one year from the present month available online.
• Journal of Bone and Joint Surgery (Br) – British edition of the prestigious journal with articles appearing in issues 5 years agon are available online.

Other Repositories:

• PLOS MEdicine – Peer reviewed open access journal.
• Free Medical Journals – For promotion of free access to medical journals over the inernet.
• Directory of Open Access Journals – Extensive but not complete and up to date.
• Find Articles – Free article search available.
• Medbioworld – large medical and bioscience directory.

Anyone else is welcome to add to the list.

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