//////////////////LOST BLOG=12-18/09/07-GGL
////////////////Today is Nov 4, 2007.Nostalgia is a seductive liar.~George W. Ball~
///////////////Open policy debate on euthanasia: Ottawa doctorRising health-care costs will play a factorMohammed AdamCanWest News Service. November 02, 2007OTTAWA -- A national debate on balancing the right to life with skyrocketing health care costs could endanger services for the elderly and fuel demands to legalize euthanasia, some experts say.Dr. Robert Cushman, CEO of the Champlain Local Health Integration Network in eastern Ontario stirred a hornet's nest this week with a call for a serious debate on the right to die with dignity as a matter of public policy.He said seniors deserve independence and dignity in the twilight of their lives and the debate should take place in the context of ballooning health costs.His comments drew swift condemnation from Physicians for Life, which accused him of promoting euthanasia. The group says "dying with dignity" is often a code for allowing frail, elderly and often helpless people to take their own lives, or get strangers to do it for them.The doctors' group says Dr. Cushman is playing into the hands of right-to-die advocates who want to legalize euthanasia, which Canadians have already rejected. And tying the issue to the rising cost of health care is a rather ingenious way of broadening its appeal."Those who say people have a right to die with dignity are saying you have the right to demand death at a time of your choosing," Dr. Will Johnston, president of Physicians for Life, said from Vancouver. "Dr. Cushman seems to be hinting at a personal bias towards legalized suicide and he is trying to open the debate. He is softening public opinion by raising a false issue of costs. Our health care costs are not high because of a lack of assisted suicide. He is doing the work of the extremists."But others say with seniors now consuming about a third of health care resources, a healthy debate is needed to get a grip on all the possible ramifications of ballooning health costs."It is clear that the cost of health care is not sustainable for our society and the society is going to have to make some tough decisions. Dr. Cushman is right to open up the debate," said Dr. Andrew Falconer, deputy chief of staff at Ottawa's Queensway-Carleton Hospital. "I would assume that a debate like that is going to lead us in the direction of caps on some services but quite frankly, it is a debate that ought to go on."Ottawa Hospital chief of staff Dr. Chris Carruthers acknowledges that a debate on the health needs of seniors could veer into taboo subjects such as right to die and caps on some treatments. But it is necessary to have such a debate to provide a clear road map on what choices and consequences lie ahead.Dr. Carruthers points out that because of limited resources, a U.S. state such as Oregon ranks health services in order of what is important enough to treat. Other countries have faced the issue and devised different solutions and Canada must follow the same path."If you come to our hospital and say 'don't put me on a ventilator' we won't put you on one even if we know it will save your life," Dr. Carruthers said. "But on the other side of the coin, if you are very sick and elderly and you continue to want all the care, no holds barred, what should happen? At the present time we will treat people. But with limited resources how do you manage that? We have not had that discussion and Dr. Cushman is only asking for that debate."Ottawa Citizen
//////////////////////CREDIT-ACEP-
Focus On: Ultrasound-Guided Lumbar Puncture
ACEP NewsSeptember 2007
By Michael Murphy, MDand Arun Nagdev, MD
Learning Objectives
After reading this article, the physician should be able to:
Teach basic ultrasound imaging techniques (probe selection, patient positioning, etc.) and obtain spinal images for accurate pre-puncture localization.
Correctly identify pertinent spinal anatomy by ultrasound.
Learn the various ways to label the pre-puncture location.
Heinrich Quincke first developed the traditional landmark-guided lumbar puncture procedure in 1891. The landmark-guided technique is performed by palpating important anatomical landmarks (i.e., the iliac crests and the lumbar spinous processes) to determine the site of optimal spinal needle introduction. Certain patient variables, such as pregnancy, obesity, or generalized edema are predictive of difficulty localizing landmarks and performing the lumbar puncture.1-3 Even in patients with clearly palpable lumbar landmarks, studies have demonstrated clinician error in correctly identifying vertebral and interspace level by palpation technique.4,5
In the emergency department, lumbar punctures are most commonly performed to determine the presence of an infectious process (meningitis, encephalitis, sepsis, etc.) or subarachnoid hemorrhage. In cases in which the procedure is unsuccessful, the emergency physician must often utilize other services, specifically fluoroscopic guidance, to obtain cerebrospinal fluid (CSF). Unfortunately, during nighttime or weekend hours, reliance on other services can be problematic, possibly leading to compromised patient care. For example, in treating a patient with a suspected central nervous system infectious process, the emergency physician may be forced to use empiric antibiotic therapy without appropriate CSF cultures.
Also, transportation of a potentially critically ill patient from the ED can be troublesome because it requires multiple personnel and places the patient at risk for clinical deterioration in the radiological suite. An immediately accessible bedside procedure facilitating lumbar puncture performed by the treating emergency physician would be ideal in these situations.
Ultrasound-guided lumbar puncture was first described in the Russian anesthesia literature in 1971.6 Subsequent evidence from the anesthesia literature demonstrates that there is a reduction in the number of attempts and interspaces accessed and in repositioning of the needle in patients with pre-procedural ultrasound visualization as compared to traditional landmark identification for spinal and epidural anesthesia.7-11
Recent pediatric literature demonstrates efficacy of ultrasound guidance for introduction of a spinal needle in neonates, with some recognizing it as the preferred method of "rescue" in cases of failed landmark-guided lumbar punctures.12 With the increasing availability of bedside ultrasound equipment and training over the past decade, emergency physicians have incorporated bedside ultrasound visualization during various emergent procedures (central venous access, pericardiocentesis, thoracentesis, etc.).
In 2005 the first published emergency medicine case series described the utility of bedside ultrasound in pre-puncture localization in three emergency department patients in whom an experienced provider was unable to obtain CSF.13 Recently, two observational studies demonstrated the ability of trained emergency physicians to identify accurately the pertinent lumbar landmarks by ultrasound.1,2 Further, in patients with poorly palpable or non-palpable spinal landmarks, ultrasound was found to identify relevant structures that could help guide a lumbar puncture in 76% of these patients.2 Currently no prospective, randomized trials exist demonstrating the efficacy of bedside ultrasound for procedural guidance either before or during lumbar puncture in the emergent setting.
Key Basic Principles of Ultrasound
Reflection occurs when sound waves encounter tissues with different acoustic impedance. Impedance, in simple terms, is resistance to propagation of ultrasound waves. Bone has very high tissue impedance and reflects a hyperechoic (white) image back to the transducer, with an area of anechoic (black) "shadowing" directly behind the reflective image. In spinal imaging the identification of bony landmarks is imperative in locating the interspinous space. The specifics of performing a pre-procedure ultrasound-guided lumbar puncture will be detailed in the following sections.
The Procedure: Ultrasound-Guided Lumbar Puncture
View video of procedure
Patient Positioning: A recent observational trial demonstrates increased interspinous distance by placing the patient in a sitting position with feet supported, which may yield an improved success rate for lumbar puncture.14 However, patient positioning should be determined by patient tolerance and comfort.
Probe selection: Linear (high frequency) probes allow for higher resolution of superficial structures, making these the most commonly used transducers for imaging of spinal anatomy. In patients with large body mass and correspondingly deep spinal structures, changing to a curvilinear (low frequency) probe to delineate the vertebral spinous processes may be a prudent alternative (pic1).
Probe orientation: In lumbar spinal imaging, two main probe orientations are used: the transverse and the longitudinal views. The goal of the transverse view is to determine an accurate anatomic midline by identification of the hyperechoic spinous process. This view is obtained by placing the probe perpendicular to the long axis of the spine (pic2). The purpose of this cross-sectional image is to identify the lumbar spinous process and center it on the image display. The bony spinous process will appear as a "hyperechoic" white convex rim with an anechoic shadow. We recommend looking for a solitary anechoic shadow if the hyperechoic rim is not seen, as this may be the only landmark visualized.
Often, paired hyperechoic structures (transverse processes, facet joints, or laminae) may be visualized surrounding the spinous process, adding support for midline confirmation (pic3). Once the midline is localized, it should be marked and labeled as described in the next section.
Once the midline landmarks are identified, the longitudinal view should be obtained, always maintaining reference to the midline located in the transverse view. The goal of the longitudinal view is to determine the spinal interspace while placing the probe's long axis parallel to the long axis of the spine (pic4). Again, the key structure to identify is the spinous process, which will appear as a hyperechoic convexity with a deep anechoic shadow (pic5). The spinous process should be the most superficial hyperechoic structure, and we recommend moving the probe in a lateral direction in an attempt to confirm that the structure is, in fact, the superficial spinous process and not a similar-appearing deeper and lateral structure.
Once the spinous process is identified, the probe should be moved cephalad and caudad, always maintaining the previously identified midline. If midline position is not maintained, inadvertent imaging of the similar-appearing lateral transverse processes may occur, leading to improper pre-puncture localization. The goal is to identify a contiguous spinous process and then center the probe and image between the contiguous spinous processes over the hypoechoic grey interspace (pic5). This interspace is the optimal location for needle insertion for lumbar puncture.
Physicians more experienced with identification of spinal anatomy may be able to locate deeper structures through this visualized interspace, such as the ligamentum flavum, which is the fibrous structure that lies just superficial to the epidural space, dura, and subarachnoid space. Ultrasound imaging can be used to measure the depth from the skin to this ligament and can be an accurate adjunct to guide spinal needle introduction.10 Once the interspace is identified, it should be marked and labeled as described below.
Pre-procedural Labeling: Pre-procedural ultrasound guidance is useful only if accurate skin markings are made of the optimal lumbar puncture location. In the transverse view the probe and resultant image should be centered over the spinous process with a physical marking made on the patient's skin adjacent to both sides of the probe.
In the longitudinal view the probe and image are centered over the desired interspace with another physical mark made adjacent to the probe, corresponding to interspace level. We recommend using a surgical tissue marking pen because standard aseptic skin cleansing technique can remove common pen markings. Of note, removal of the excess gel from the edges of the probe before skin marking can increase adherence of the ink to skin (pic6).
Another simple tool that may be used to promote accurate labeling is described by Lin et al in February's ACEP News.15 One slides a straightened paper clip between the transducer and the patient's skin, creating a reverberation artifact on the monitor. In the transverse view, the paper clip artifact should be centered over the spinous process and marked, indicating anatomic midline. The probe is then placed in a longitudinal view, and the paper clip and resultant reverberation artifact should be centered and marked over the spinous interspace. The intersection of these two points is the optimal pre-puncture location.
After labeling has been accomplished, the standard aseptic preparation may be performed. The lumbar puncture may be carried out utilizing the labeled landmarks with "X marking the spot" for needle introduction, remembering to introduce the needle with slight cephalad angulation to follow the contours of the spinous processes. Lastly, it is very important that patients maintain their positioning between ultrasound guided labeling and performance of the lumbar puncture, because patient movement may change the relationship between the labeled surface marks and the underlying spinal structures.
Bibliography
Ferre RM, Sweeney TW. Emergency physicians can easily obtain ultrasound images of anatomical landmarks relevant to lumbar puncture. Am J Emerg Med 2007;25(3):291-6.
Stiffler KA, Jwayyed S, Wilber ST, Robinson A. The use of ultrasound to identify pertinent landmarks for lumbar puncture. Am J Emerg Med 2007;25(3):331-4.
Grau T, Bartusseck E, Conradi R, Martin E, Motsch J. Ultrasound imaging improves learning curves in obstetric epidural anesthesia: a preliminary study. Can J Anaesth 2003;50(10):1047-50.
Broadbent CR, Maxwell WB, Ferrie R, Wilson DJ, Gawne-Cain M, Russell R. Ability of anaesthetists to identify a marked lumbar interspace. Anaesthesia 2000;55(11):1122-6.
Furness G ea. An evaluation of ultrasound imaging for identification of lumbar intervertebral level. Anesthesia 2002;57:277-80.
Bogin IN, Stulin ID. [Application of the method of 2-dimensional echospondylography for determining landmarks in lumbar punctures]. Zh Nevropatol Psikhiatr Im S S Korsakova 1971;71(12):1810-1.
Cork RC, Kryc JJ, Vaughan RW. Ultrasonic localization of the lumbar epidural space. Anesthesiology 1980;52(6):513-6.
Currie JM. Measurement of the depth to the extradural space using ultrasound. Br J Anaesth 1984;56(4):345-7.
Grau T, Leipold, Conradi, R, Martin, E, Motsch, J. Efficacy of Ultrasound imaging in Obstetric Epidural Anesthesia. Journal of Clinical Anesthesia 2002;14:169-75.
Grau T, Leipold RW, Conradi R, Martin E, Motsch J. Ultrasound imaging facilitates localization of the epidural space during combined spinal and epidural anesthesia. Reg Anesth Pain Med 2001;26(1):64-7.
Grau T, Leipold RW, Fatehi S, Martin E, Motsch J. Real-time ultrasonic observation of combined spinal-epidural anaesthesia. Eur J Anaesthesiol 2004;21(1):25-31.
Coley BD, Shiels WE, 2nd, Hogan MJ. Diagnostic and interventional ultrasonography in neonatal and infant lumbar puncture. Pediatr Radiol 2001;31(6):399-402.
Peterson MA, Abele J. Bedside ultrasound for difficult lumbar puncture. J Emerg Med 2005;28(2):197-200.
Sandoval M, Shestak W, Sturmann K, Hsu C. Optimal patient position for lumbar puncture, measured by ultrasonography. Emerg Radiol 2004;10(4):179-81.
Lin M, Washington C. Tricks of the Trade: Ultrasound-Guided Lumbar Puncture. ACEP News 2007 2007(February):23.
Contributors
Dr. Michael Murphy is an attending physician, department of emergency medicine, at the Warren Alpert School of Medicine of Brown University. Dr. Arun Nagdev is an assistant professor, department of emergency medicine, the Warren Alpert School of Medicine of Brown University. Medical Editor Dr. Robert C. Solomon is an attending emergency physician at Trinity Health System in Steubenville, Ohio, and clinical assistant professor of emergency medicine at the West Virginia School of Osteopathic Medicine.
Disclosures
In accordance with the Accreditation Council for Continuing Medical Education (ACCME) Standards and American College of Emergency Physicians policy, contributors and editors must disclose to the program audience the existence of significant financial interests in or relationships with manufacturers of commercial products that might have a direct interest in the subject matter.
Dr. Murphy, Dr. Nagdev, and Dr. Solomon have disclosed that they have no significant relationships with or financial interests in any commercial companies that pertain to this educational activity.
"Focus On: Ultrasound-Guided Lumbar Puncture" has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME).
ACEP is accredited by the ACCME to provide continuing medical education for physicians. ACEP designates this educational activity for a maximum of one Category 1 credit toward the AMA Physician's Recognition Award. Each physician should claim only those credits that he or she actually spent in the educational activity.
"Focus On: Ultrasound-Guided Lumbar Puncture" is approved by ACEP for one ACEP Category 1 credit.
Disclaimer
ACEP makes every effort to ensure that contributors to College-sponsored programs are knowledgeable authorities in their fields. Participants are nevertheless advised that the statements and opinions expressed in this article are provided as guidelines and should not be construed as College policy.
The material contained herein is not intended to establish policy, procedure, or a standard of care. The views expressed in this article are those of the contributors and not necessarily the opinion or recommendation of ACEP. The College disclaims any liability or responsibility for the consequences of any actions taken in reliance on those statements or opinions.
Ultrasound-Guided Lumbar Puncture CME Quiz
Focus On: Ultrasound-Guided Lumbar Puncture
ACEP NewsSeptember 2007
By Michael Murphy, MDand Arun Nagdev, MD
Learning Objectives
After reading this article, the physician should be able to:
Teach basic ultrasound imaging techniques (probe selection, patient positioning, etc.) and obtain spinal images for accurate pre-puncture localization.
Correctly identify pertinent spinal anatomy by ultrasound.
Learn the various ways to label the pre-puncture location.
Heinrich Quincke first developed the traditional landmark-guided lumbar puncture procedure in 1891. The landmark-guided technique is performed by palpating important anatomical landmarks (i.e., the iliac crests and the lumbar spinous processes) to determine the site of optimal spinal needle introduction. Certain patient variables, such as pregnancy, obesity, or generalized edema are predictive of difficulty localizing landmarks and performing the lumbar puncture.1-3 Even in patients with clearly palpable lumbar landmarks, studies have demonstrated clinician error in correctly identifying vertebral and interspace level by palpation technique.4,5
In the emergency department, lumbar punctures are most commonly performed to determine the presence of an infectious process (meningitis, encephalitis, sepsis, etc.) or subarachnoid hemorrhage. In cases in which the procedure is unsuccessful, the emergency physician must often utilize other services, specifically fluoroscopic guidance, to obtain cerebrospinal fluid (CSF). Unfortunately, during nighttime or weekend hours, reliance on other services can be problematic, possibly leading to compromised patient care. For example, in treating a patient with a suspected central nervous system infectious process, the emergency physician may be forced to use empiric antibiotic therapy without appropriate CSF cultures.
Also, transportation of a potentially critically ill patient from the ED can be troublesome because it requires multiple personnel and places the patient at risk for clinical deterioration in the radiological suite. An immediately accessible bedside procedure facilitating lumbar puncture performed by the treating emergency physician would be ideal in these situations.
Ultrasound-guided lumbar puncture was first described in the Russian anesthesia literature in 1971.6 Subsequent evidence from the anesthesia literature demonstrates that there is a reduction in the number of attempts and interspaces accessed and in repositioning of the needle in patients with pre-procedural ultrasound visualization as compared to traditional landmark identification for spinal and epidural anesthesia.7-11
Recent pediatric literature demonstrates efficacy of ultrasound guidance for introduction of a spinal needle in neonates, with some recognizing it as the preferred method of "rescue" in cases of failed landmark-guided lumbar punctures.12 With the increasing availability of bedside ultrasound equipment and training over the past decade, emergency physicians have incorporated bedside ultrasound visualization during various emergent procedures (central venous access, pericardiocentesis, thoracentesis, etc.).
In 2005 the first published emergency medicine case series described the utility of bedside ultrasound in pre-puncture localization in three emergency department patients in whom an experienced provider was unable to obtain CSF.13 Recently, two observational studies demonstrated the ability of trained emergency physicians to identify accurately the pertinent lumbar landmarks by ultrasound.1,2 Further, in patients with poorly palpable or non-palpable spinal landmarks, ultrasound was found to identify relevant structures that could help guide a lumbar puncture in 76% of these patients.2 Currently no prospective, randomized trials exist demonstrating the efficacy of bedside ultrasound for procedural guidance either before or during lumbar puncture in the emergent setting.
Key Basic Principles of Ultrasound
Reflection occurs when sound waves encounter tissues with different acoustic impedance. Impedance, in simple terms, is resistance to propagation of ultrasound waves. Bone has very high tissue impedance and reflects a hyperechoic (white) image back to the transducer, with an area of anechoic (black) "shadowing" directly behind the reflective image. In spinal imaging the identification of bony landmarks is imperative in locating the interspinous space. The specifics of performing a pre-procedure ultrasound-guided lumbar puncture will be detailed in the following sections.
The Procedure: Ultrasound-Guided Lumbar Puncture
View video of procedure
Patient Positioning: A recent observational trial demonstrates increased interspinous distance by placing the patient in a sitting position with feet supported, which may yield an improved success rate for lumbar puncture.14 However, patient positioning should be determined by patient tolerance and comfort.
Probe selection: Linear (high frequency) probes allow for higher resolution of superficial structures, making these the most commonly used transducers for imaging of spinal anatomy. In patients with large body mass and correspondingly deep spinal structures, changing to a curvilinear (low frequency) probe to delineate the vertebral spinous processes may be a prudent alternative (pic1).
Probe orientation: In lumbar spinal imaging, two main probe orientations are used: the transverse and the longitudinal views. The goal of the transverse view is to determine an accurate anatomic midline by identification of the hyperechoic spinous process. This view is obtained by placing the probe perpendicular to the long axis of the spine (pic2). The purpose of this cross-sectional image is to identify the lumbar spinous process and center it on the image display. The bony spinous process will appear as a "hyperechoic" white convex rim with an anechoic shadow. We recommend looking for a solitary anechoic shadow if the hyperechoic rim is not seen, as this may be the only landmark visualized.
Often, paired hyperechoic structures (transverse processes, facet joints, or laminae) may be visualized surrounding the spinous process, adding support for midline confirmation (pic3). Once the midline is localized, it should be marked and labeled as described in the next section.
Once the midline landmarks are identified, the longitudinal view should be obtained, always maintaining reference to the midline located in the transverse view. The goal of the longitudinal view is to determine the spinal interspace while placing the probe's long axis parallel to the long axis of the spine (pic4). Again, the key structure to identify is the spinous process, which will appear as a hyperechoic convexity with a deep anechoic shadow (pic5). The spinous process should be the most superficial hyperechoic structure, and we recommend moving the probe in a lateral direction in an attempt to confirm that the structure is, in fact, the superficial spinous process and not a similar-appearing deeper and lateral structure.
Once the spinous process is identified, the probe should be moved cephalad and caudad, always maintaining the previously identified midline. If midline position is not maintained, inadvertent imaging of the similar-appearing lateral transverse processes may occur, leading to improper pre-puncture localization. The goal is to identify a contiguous spinous process and then center the probe and image between the contiguous spinous processes over the hypoechoic grey interspace (pic5). This interspace is the optimal location for needle insertion for lumbar puncture.
Physicians more experienced with identification of spinal anatomy may be able to locate deeper structures through this visualized interspace, such as the ligamentum flavum, which is the fibrous structure that lies just superficial to the epidural space, dura, and subarachnoid space. Ultrasound imaging can be used to measure the depth from the skin to this ligament and can be an accurate adjunct to guide spinal needle introduction.10 Once the interspace is identified, it should be marked and labeled as described below.
Pre-procedural Labeling: Pre-procedural ultrasound guidance is useful only if accurate skin markings are made of the optimal lumbar puncture location. In the transverse view the probe and resultant image should be centered over the spinous process with a physical marking made on the patient's skin adjacent to both sides of the probe.
In the longitudinal view the probe and image are centered over the desired interspace with another physical mark made adjacent to the probe, corresponding to interspace level. We recommend using a surgical tissue marking pen because standard aseptic skin cleansing technique can remove common pen markings. Of note, removal of the excess gel from the edges of the probe before skin marking can increase adherence of the ink to skin (pic6).
Another simple tool that may be used to promote accurate labeling is described by Lin et al in February's ACEP News.15 One slides a straightened paper clip between the transducer and the patient's skin, creating a reverberation artifact on the monitor. In the transverse view, the paper clip artifact should be centered over the spinous process and marked, indicating anatomic midline. The probe is then placed in a longitudinal view, and the paper clip and resultant reverberation artifact should be centered and marked over the spinous interspace. The intersection of these two points is the optimal pre-puncture location.
After labeling has been accomplished, the standard aseptic preparation may be performed. The lumbar puncture may be carried out utilizing the labeled landmarks with "X marking the spot" for needle introduction, remembering to introduce the needle with slight cephalad angulation to follow the contours of the spinous processes. Lastly, it is very important that patients maintain their positioning between ultrasound guided labeling and performance of the lumbar puncture, because patient movement may change the relationship between the labeled surface marks and the underlying spinal structures.
Bibliography
Ferre RM, Sweeney TW. Emergency physicians can easily obtain ultrasound images of anatomical landmarks relevant to lumbar puncture. Am J Emerg Med 2007;25(3):291-6.
Stiffler KA, Jwayyed S, Wilber ST, Robinson A. The use of ultrasound to identify pertinent landmarks for lumbar puncture. Am J Emerg Med 2007;25(3):331-4.
Grau T, Bartusseck E, Conradi R, Martin E, Motsch J. Ultrasound imaging improves learning curves in obstetric epidural anesthesia: a preliminary study. Can J Anaesth 2003;50(10):1047-50.
Broadbent CR, Maxwell WB, Ferrie R, Wilson DJ, Gawne-Cain M, Russell R. Ability of anaesthetists to identify a marked lumbar interspace. Anaesthesia 2000;55(11):1122-6.
Furness G ea. An evaluation of ultrasound imaging for identification of lumbar intervertebral level. Anesthesia 2002;57:277-80.
Bogin IN, Stulin ID. [Application of the method of 2-dimensional echospondylography for determining landmarks in lumbar punctures]. Zh Nevropatol Psikhiatr Im S S Korsakova 1971;71(12):1810-1.
Cork RC, Kryc JJ, Vaughan RW. Ultrasonic localization of the lumbar epidural space. Anesthesiology 1980;52(6):513-6.
Currie JM. Measurement of the depth to the extradural space using ultrasound. Br J Anaesth 1984;56(4):345-7.
Grau T, Leipold, Conradi, R, Martin, E, Motsch, J. Efficacy of Ultrasound imaging in Obstetric Epidural Anesthesia. Journal of Clinical Anesthesia 2002;14:169-75.
Grau T, Leipold RW, Conradi R, Martin E, Motsch J. Ultrasound imaging facilitates localization of the epidural space during combined spinal and epidural anesthesia. Reg Anesth Pain Med 2001;26(1):64-7.
Grau T, Leipold RW, Fatehi S, Martin E, Motsch J. Real-time ultrasonic observation of combined spinal-epidural anaesthesia. Eur J Anaesthesiol 2004;21(1):25-31.
Coley BD, Shiels WE, 2nd, Hogan MJ. Diagnostic and interventional ultrasonography in neonatal and infant lumbar puncture. Pediatr Radiol 2001;31(6):399-402.
Peterson MA, Abele J. Bedside ultrasound for difficult lumbar puncture. J Emerg Med 2005;28(2):197-200.
Sandoval M, Shestak W, Sturmann K, Hsu C. Optimal patient position for lumbar puncture, measured by ultrasonography. Emerg Radiol 2004;10(4):179-81.
Lin M, Washington C. Tricks of the Trade: Ultrasound-Guided Lumbar Puncture. ACEP News 2007 2007(February):23.
Contributors
Dr. Michael Murphy is an attending physician, department of emergency medicine, at the Warren Alpert School of Medicine of Brown University. Dr. Arun Nagdev is an assistant professor, department of emergency medicine, the Warren Alpert School of Medicine of Brown University. Medical Editor Dr. Robert C. Solomon is an attending emergency physician at Trinity Health System in Steubenville, Ohio, and clinical assistant professor of emergency medicine at the West Virginia School of Osteopathic Medicine.
Disclosures
In accordance with the Accreditation Council for Continuing Medical Education (ACCME) Standards and American College of Emergency Physicians policy, contributors and editors must disclose to the program audience the existence of significant financial interests in or relationships with manufacturers of commercial products that might have a direct interest in the subject matter.
Dr. Murphy, Dr. Nagdev, and Dr. Solomon have disclosed that they have no significant relationships with or financial interests in any commercial companies that pertain to this educational activity.
"Focus On: Ultrasound-Guided Lumbar Puncture" has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME).
ACEP is accredited by the ACCME to provide continuing medical education for physicians. ACEP designates this educational activity for a maximum of one Category 1 credit toward the AMA Physician's Recognition Award. Each physician should claim only those credits that he or she actually spent in the educational activity.
"Focus On: Ultrasound-Guided Lumbar Puncture" is approved by ACEP for one ACEP Category 1 credit.
Disclaimer
ACEP makes every effort to ensure that contributors to College-sponsored programs are knowledgeable authorities in their fields. Participants are nevertheless advised that the statements and opinions expressed in this article are provided as guidelines and should not be construed as College policy.
The material contained herein is not intended to establish policy, procedure, or a standard of care. The views expressed in this article are those of the contributors and not necessarily the opinion or recommendation of ACEP. The College disclaims any liability or responsibility for the consequences of any actions taken in reliance on those statements or opinions.
Ultrasound-Guided Lumbar Puncture CME Quiz
///////////////////////////A PATCH OF BLUE-1965
////////////////////From Chapter V: The Yoga of Renunciation of ActionV.8. NAIVA KINCHIT KAROMEETI YUKTO MANYETA TATTWAVIT;PASHYAN SHRUNVAN SPRISHAN JIGHRAN NASHNAN GACCHAN SWAPAN SHWASAN.(Krishna speaking to Arjuna)"I do nothing at all"-thus will the harmonised knower ofTruth think-seeing, hearing, touching, smelling, eating, going,sleeping, breathing,V.9. PRALAPAN VISRIJAN GRIHNAN NUNMISHAN NIMISHANNAPI;INDRIYAANEENDRIYAARTHESHU VARTANTA ITI DHAARAYAN.Speaking, letting go, seizing, opening and closing the eyes-convinced that the senses move among the sense-objects.COMMENTARY: The liberated sage always remains as a witnessof the activities of the senses as he identifies himself withthe Self.
ULTIMATELY CBNAD STONE TO DUST
/////////////////////A Patch of Blue (1965) CREDIT IMDB=
Accidentally blinded by her prostitute mother Rose-Ann (Oscar winner Shelley Winters) at the age of five, Selena D'Arcy spends the next 13 years confined in the tiny Los Angeles apartment that they share with "Ole Pa" (Wallace Ford), Selena's grandfather. One afternoon at the local park, Selena meets Gordon Ralfe (Sidney Poitier), a thoughtful young office worker whose kind-hearted treatment of her results in her falling in love with him, unaware that he is black. They continue to meet in the park every afternoon and he teaches her how to get along in the city. But when the cruel, domineering Rose-Ann learns of their relationship, she forbids her to have anything more to do with him because he is black. Selena continues to meet Gordon despite Rose-Ann's fury, who is determined to end the relationship for good. Written by alfiehitchie
Accidentally blinded by her prostitute mother Rose-Ann (Oscar winner Shelley Winters) at the age of five, Selena D'Arcy spends the next 13 years confined in the tiny Los Angeles apartment that they share with "Ole Pa" (Wallace Ford), Selena's grandfather. One afternoon at the local park, Selena meets Gordon Ralfe (Sidney Poitier), a thoughtful young office worker whose kind-hearted treatment of her results in her falling in love with him, unaware that he is black. They continue to meet in the park every afternoon and he teaches her how to get along in the city. But when the cruel, domineering Rose-Ann learns of their relationship, she forbids her to have anything more to do with him because he is black. Selena continues to meet Gordon despite Rose-Ann's fury, who is determined to end the relationship for good. Written by alfiehitchie
///////////////////////A MESSAGE FROM HOLLY-CARE OF CNACER PTS YOUNG OFFSPRING
/////////////////////DIRTY DOZEN-WAR ADVENTURE
////////////////////BHOOT JOLOKIA
NMSU is home to the world’s hottest chile pepper
When Paul Bosland exhaled after taking a bite of the world’s hottest chile pepper, it felt like he was breathing fire.
“Got milk?” he thought.
The next thing Bosland thought, after gulping down a soda, was, “That chile has got to be some kind of record.”
He was right.
In fall of 2006, the Guinness Book of Records confirmed that New Mexico State University Regent’s Professor Paul Bosland had indeed discovered the world’s hottest chile pepper, Bhut Jolokia.
Bhut Jolokia, at 1,001,304 Scoville Heat Units (SHU), is nearly twice as hot as Red Savina, the chile pepper variety it replaces as the world’s hottest. A New Mexico green chile contains about 1,500 SHUs and an average jalapeno measures at about 10,000 SHUs.
“The name Bhut Jolokia translates as ‘ghost chile,’” Bosland said, “we’re not sure why they call it that, but I think it’s because the chile is so hot, you give up the ghost when you eat it!”
When Paul Bosland exhaled after taking a bite of the world’s hottest chile pepper, it felt like he was breathing fire.
“Got milk?” he thought.
The next thing Bosland thought, after gulping down a soda, was, “That chile has got to be some kind of record.”
He was right.
In fall of 2006, the Guinness Book of Records confirmed that New Mexico State University Regent’s Professor Paul Bosland had indeed discovered the world’s hottest chile pepper, Bhut Jolokia.
Bhut Jolokia, at 1,001,304 Scoville Heat Units (SHU), is nearly twice as hot as Red Savina, the chile pepper variety it replaces as the world’s hottest. A New Mexico green chile contains about 1,500 SHUs and an average jalapeno measures at about 10,000 SHUs.
“The name Bhut Jolokia translates as ‘ghost chile,’” Bosland said, “we’re not sure why they call it that, but I think it’s because the chile is so hot, you give up the ghost when you eat it!”
//////////////////The Egnor Challenge: Tooth Decay and Human Origins
Category: Bioarchaeology • Paleoanthropology • PaleopathologyPosted on: March 18, 2007 12:33 PM, by afarensis, FCD
Bioarchaeologists frequently study the distribution of dental caries in populations in order to try and understand subsistence, diet, and status. Rarely, however, does one hear about the study of dental caries aiding paleoanthropology. A recent study mentioned on Science Daily is an exception. Before going further let's look at what dental caries are.
Your mouth is full of bacteria. Before you freak out and start washing your mouth with the nearest antibacterial soap, I should point out this is a good thing. The bacteria in your mouth help break down the food you have just eaten. A byproduct of this breakdown is a sticky biofilm that forms plaque. Plaque is acidic and eventually starts dissolving the enamel outer layer of a tooth. The picture below should help:
[1] Early stages : acids dissolve the enamel in the crown of the tooth[2] Moderate tooth decay : here the dentin is attacked by acids and bacteria invade the cavity.[3] Advanced tooth decay : inflammation of the pulp.[4] Necrosis (death) of the pulp tissue.[5] Periapical abcess forms at the apex of the root
One of the bacteria in your mouth is Streptoccocus mutans. Streptoccocus mutans has evolved receptors to help them stick to your teeth and produce lactic acid as a byproduct of sugar digestion. S. mutans is also transmitted from mother to offspring.
Enter Dr. Page Caufield. Dr. Caufield is Professor of Cariology and Comprehensive Care at the New York University College of Dentistry. He is interested in three areas. First:
The first area concerns the delineation of the natural history of oral bacteria responsible for dental caries, including genetic and environmental events that influence the acquisition and transmission of bacteria indigenous to humans. More specifically, our present focus is in three areas: 1) windows of infectivity for acquisition of indigenous bacteria, 2) fidelity of genotypic transmission and 3) clonality of caries-associated strains of Streptococcus mutans. We are looking at what biological rules govern the opening and closing of this window in infants; infants who do not become infected with S. mutans during this window may remain free of these organisms and do not manifest disease, i.e., caries. The recent development of a DNA fingerprinting techniques allows us to study transmission /acquisition as well as describe polymorphic behavior inherent to indigenous bacteria that are vertically transmitted. The conservation of S. mutans within both racial and familial lines suggests a pattern of co-evolution between host and parasite. Because S. mutans is transmitted vertically, i.e., mother to child, clonal types are confined within racial and familial cohorts. If clonality proves to be true for all strains of S. mutans, then virulence factors can be traced based on commonality of certain clones among children with severe caries. It follows that diagnostic tools can then be developed capable of predicting risk before the initiation of caries.
In other words, he is trying to use an understanding of the evolutionary history of S. mutans to develop clinical applications for prevention and treatment of dental carries. Second:
Our second major interest is developing techniques for characterizing diversity of bacteria within plaque biofilms associated with dental caries. To do this, we have developed two systems of DNA profiling - one using gradient gels (DGGE) to separate distinct 16S rDNA moieties representing individual species of bacteria from biofilm and the second subtraction DNA hybridization of genetic fragments. Both approaches are culture-independent, hence we should be able to expand our knowledge of the cariogenic biota to include the non-cultivable, and majority portion of the dental biofilm. These studies give us clues as to why some strains are more virulent than others.
Basically, you carry - in your oral cavity - your very own experiment in natural selection and evolution. As one example, there are a wide variety of bacteria in your mouth and each one competes for the resources present. Natural selection applies and the bacteria evolve various strategies to out reproduce their competitors. As I mentioned above, when S. mutans digests most sugars it produces lactic acid as a byproduct. When it digests sucrose, however, it produces a sticky substance that allows S. mutans to bind together forming plaque.
Dr. Caufield's third area of interest is:
Our third area of research is in the population structure of Streptococcus mutans and its co-evolution with its human host. Comparing phylogenies of different strains with and without plasmids reveal separate evolutionary pathways between plasmid and chromosomal frames. As humans migrated out of Africa, they carried their intraoral commensal biota, including S. mutans. These migrations parallel S. mutans phylogeny.
To that end he has published an interesting paper in the February issue of the Journal of Bacteriology. According to Science Daily (I don't have access to the Journal of Bacteriology) Dr. Caufield gathered over 600 samples of S. mutans covering six continents. From Science Daily:
His final analysis focused on over 60 strains of S. mutans collected from Chinese and Japanese; Africans; African-Americans and Hispanics in the United States; Caucasians in the United States, Sweden, and Australia; and Amazon Indians in Brazil and Guyana.
"By tracing the DNA lineages of these strains," Caufield said, "We have constructed an evolutionary family tree with its roots in Africa and its main branch extending to Asia. A second branch, extending from Asia back to Europe, traces the migration of a small group of Asians who founded at least one group of modern-day Caucasians."
Additional branches, tracing the coevolution of humans and bacteria from Asia into North and South America, will be drawn in the next phase of Caufield's analysis.
The bottom line is that his research on S. mutans provides some support to the Out-of-Africa theory of human origins.
So, let's summarize. Dr Egnor first claimed that:
Doctors don't study evolution. Doctors never study it in medical school, and they never use evolutionary biology in their practice. There are no courses in medical school on evolution. There are no 'professors of evolution' in medical schools. There are no departments of evolutionary biology in medical schools.
When this was shown to be incorrect he changed his story to:
In addition, a common Darwinist argument is that the presence on medical school faculties of scientists who study some aspects of evolutionary biology is evidence that evolutionary biology is indispensable to medicine. That argument is flawed, but it does raise an important issue. I'll address that issue here, and I'll address the other issues, one by one, in ensuing posts.
Many, even most, scientists whose work includes evolutionary biology are fine scientists. They have been my teachers, and many are now my colleagues and friends. They contribute to medical education in major ways. They contribute as anatomists, or as physiologists, or as microbiologists, or as molecular biologists. I hold them in high regard, and I am indebted to them for much of my own education.
These fine scientists do not, however, contribute to medicine by studying or teaching evolutionary biology. They contribute to medicine by their work in anatomy, or physiology, or microbiology, or molecular biology. The central assertion of Darwinism--that all biological complexity arises by random heritable variation and natural selection--is of interest to evolutionary biologists (and to those of us who disagree with it), but the assertion that randomness is the raw material for all biological complexity plays no role in medical education or research.
Yet, as the example above illustrates, the medical community does use evolutionary theory to guide research and to create clinical applications based on the results of that research. Not only that, in the above example we an example of a member of the medical community making an interesting and significant contribution to the study of human origins.
So, my challenge to Dr. Egnor is threefold:
1) If, as you say, evolutionary biologists contribute to medical education in major ways, and if you are indebted to them for much of your own education, then why did you start out saying:
There are no courses in medical school on evolution. There are no 'professors of evolution' in medical schools. There are no departments of evolutionary biology in medical schools.?
I ask because it looks like you are not being truthful about the question.
2) Dr. Caufield is studying the co-evolution of various bacteria with each other and their human host and is coming up with clinical applications. How do you reconcile that with your claim that evolutionary theory contributes nothing to medicine? How could "design theory" do better?
3) The practice of medicine, like evolutionary biology and other sciences, is grounded in a materialist, empirical paradigm. Yet the Discovery Institute, which you are affiliated with, is dedicated to overthrowing materialistic based science and, hence, medicine. Do you think this is a good thing for medicine? Do you think medical professionals should be studying non-material causes for disease and non-material cures?
You can find Orac's challenge here.
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Comments(Subscribe to this post's comment feed: )-->
He's just yanking your chain.
He's making this stuff up. He pretends to believe it because advancing this nonsense is his way of getting people like you to jump through hoops.
Get him deposed and see how he'll weasel out of it.
Posted by: Roy March 18, 2007 02:34 PM
I commented briefly on that ScienceDaily article as well (nowhere near your depth, I just pointed out that it existed), and while I did think it might be of interest to people like you, I didn't think of it in relationship to Egnor's nonsense.
Posted by: Kristjan Wager March 18, 2007 05:26 PM
Antibiotic resistance is a pretty powerful rebuttal to the claim that evolution is irrelevant to medicine.
Posted by: Tabitha Powledge March 19, 2007 10:59 AM
I love dental caries, as any dental anthropologist would, but I had not heard of that study. Very very cool to see that Out of Africa has dental pathology evidence!
Posted by: Jason Fox March 20, 2007 10:59 AM
Jason - one version of the paper is available here.
Posted by: afarensis, FCD March 20, 2007 06:23 PM
I have the paper, thanks! I have access to the Journal of Bacteriology through my university, but thanks for the link.
Category: Bioarchaeology • Paleoanthropology • PaleopathologyPosted on: March 18, 2007 12:33 PM, by afarensis, FCD
Bioarchaeologists frequently study the distribution of dental caries in populations in order to try and understand subsistence, diet, and status. Rarely, however, does one hear about the study of dental caries aiding paleoanthropology. A recent study mentioned on Science Daily is an exception. Before going further let's look at what dental caries are.
Your mouth is full of bacteria. Before you freak out and start washing your mouth with the nearest antibacterial soap, I should point out this is a good thing. The bacteria in your mouth help break down the food you have just eaten. A byproduct of this breakdown is a sticky biofilm that forms plaque. Plaque is acidic and eventually starts dissolving the enamel outer layer of a tooth. The picture below should help:
[1] Early stages : acids dissolve the enamel in the crown of the tooth[2] Moderate tooth decay : here the dentin is attacked by acids and bacteria invade the cavity.[3] Advanced tooth decay : inflammation of the pulp.[4] Necrosis (death) of the pulp tissue.[5] Periapical abcess forms at the apex of the root
One of the bacteria in your mouth is Streptoccocus mutans. Streptoccocus mutans has evolved receptors to help them stick to your teeth and produce lactic acid as a byproduct of sugar digestion. S. mutans is also transmitted from mother to offspring.
Enter Dr. Page Caufield. Dr. Caufield is Professor of Cariology and Comprehensive Care at the New York University College of Dentistry. He is interested in three areas. First:
The first area concerns the delineation of the natural history of oral bacteria responsible for dental caries, including genetic and environmental events that influence the acquisition and transmission of bacteria indigenous to humans. More specifically, our present focus is in three areas: 1) windows of infectivity for acquisition of indigenous bacteria, 2) fidelity of genotypic transmission and 3) clonality of caries-associated strains of Streptococcus mutans. We are looking at what biological rules govern the opening and closing of this window in infants; infants who do not become infected with S. mutans during this window may remain free of these organisms and do not manifest disease, i.e., caries. The recent development of a DNA fingerprinting techniques allows us to study transmission /acquisition as well as describe polymorphic behavior inherent to indigenous bacteria that are vertically transmitted. The conservation of S. mutans within both racial and familial lines suggests a pattern of co-evolution between host and parasite. Because S. mutans is transmitted vertically, i.e., mother to child, clonal types are confined within racial and familial cohorts. If clonality proves to be true for all strains of S. mutans, then virulence factors can be traced based on commonality of certain clones among children with severe caries. It follows that diagnostic tools can then be developed capable of predicting risk before the initiation of caries.
In other words, he is trying to use an understanding of the evolutionary history of S. mutans to develop clinical applications for prevention and treatment of dental carries. Second:
Our second major interest is developing techniques for characterizing diversity of bacteria within plaque biofilms associated with dental caries. To do this, we have developed two systems of DNA profiling - one using gradient gels (DGGE) to separate distinct 16S rDNA moieties representing individual species of bacteria from biofilm and the second subtraction DNA hybridization of genetic fragments. Both approaches are culture-independent, hence we should be able to expand our knowledge of the cariogenic biota to include the non-cultivable, and majority portion of the dental biofilm. These studies give us clues as to why some strains are more virulent than others.
Basically, you carry - in your oral cavity - your very own experiment in natural selection and evolution. As one example, there are a wide variety of bacteria in your mouth and each one competes for the resources present. Natural selection applies and the bacteria evolve various strategies to out reproduce their competitors. As I mentioned above, when S. mutans digests most sugars it produces lactic acid as a byproduct. When it digests sucrose, however, it produces a sticky substance that allows S. mutans to bind together forming plaque.
Dr. Caufield's third area of interest is:
Our third area of research is in the population structure of Streptococcus mutans and its co-evolution with its human host. Comparing phylogenies of different strains with and without plasmids reveal separate evolutionary pathways between plasmid and chromosomal frames. As humans migrated out of Africa, they carried their intraoral commensal biota, including S. mutans. These migrations parallel S. mutans phylogeny.
To that end he has published an interesting paper in the February issue of the Journal of Bacteriology. According to Science Daily (I don't have access to the Journal of Bacteriology) Dr. Caufield gathered over 600 samples of S. mutans covering six continents. From Science Daily:
His final analysis focused on over 60 strains of S. mutans collected from Chinese and Japanese; Africans; African-Americans and Hispanics in the United States; Caucasians in the United States, Sweden, and Australia; and Amazon Indians in Brazil and Guyana.
"By tracing the DNA lineages of these strains," Caufield said, "We have constructed an evolutionary family tree with its roots in Africa and its main branch extending to Asia. A second branch, extending from Asia back to Europe, traces the migration of a small group of Asians who founded at least one group of modern-day Caucasians."
Additional branches, tracing the coevolution of humans and bacteria from Asia into North and South America, will be drawn in the next phase of Caufield's analysis.
The bottom line is that his research on S. mutans provides some support to the Out-of-Africa theory of human origins.
So, let's summarize. Dr Egnor first claimed that:
Doctors don't study evolution. Doctors never study it in medical school, and they never use evolutionary biology in their practice. There are no courses in medical school on evolution. There are no 'professors of evolution' in medical schools. There are no departments of evolutionary biology in medical schools.
When this was shown to be incorrect he changed his story to:
In addition, a common Darwinist argument is that the presence on medical school faculties of scientists who study some aspects of evolutionary biology is evidence that evolutionary biology is indispensable to medicine. That argument is flawed, but it does raise an important issue. I'll address that issue here, and I'll address the other issues, one by one, in ensuing posts.
Many, even most, scientists whose work includes evolutionary biology are fine scientists. They have been my teachers, and many are now my colleagues and friends. They contribute to medical education in major ways. They contribute as anatomists, or as physiologists, or as microbiologists, or as molecular biologists. I hold them in high regard, and I am indebted to them for much of my own education.
These fine scientists do not, however, contribute to medicine by studying or teaching evolutionary biology. They contribute to medicine by their work in anatomy, or physiology, or microbiology, or molecular biology. The central assertion of Darwinism--that all biological complexity arises by random heritable variation and natural selection--is of interest to evolutionary biologists (and to those of us who disagree with it), but the assertion that randomness is the raw material for all biological complexity plays no role in medical education or research.
Yet, as the example above illustrates, the medical community does use evolutionary theory to guide research and to create clinical applications based on the results of that research. Not only that, in the above example we an example of a member of the medical community making an interesting and significant contribution to the study of human origins.
So, my challenge to Dr. Egnor is threefold:
1) If, as you say, evolutionary biologists contribute to medical education in major ways, and if you are indebted to them for much of your own education, then why did you start out saying:
There are no courses in medical school on evolution. There are no 'professors of evolution' in medical schools. There are no departments of evolutionary biology in medical schools.?
I ask because it looks like you are not being truthful about the question.
2) Dr. Caufield is studying the co-evolution of various bacteria with each other and their human host and is coming up with clinical applications. How do you reconcile that with your claim that evolutionary theory contributes nothing to medicine? How could "design theory" do better?
3) The practice of medicine, like evolutionary biology and other sciences, is grounded in a materialist, empirical paradigm. Yet the Discovery Institute, which you are affiliated with, is dedicated to overthrowing materialistic based science and, hence, medicine. Do you think this is a good thing for medicine? Do you think medical professionals should be studying non-material causes for disease and non-material cures?
You can find Orac's challenge here.
Send this entry to:
Email this entry to a friend View the Technorati Link Cosmos for this entry
Comments(Subscribe to this post's comment feed: )-->
He's just yanking your chain.
He's making this stuff up. He pretends to believe it because advancing this nonsense is his way of getting people like you to jump through hoops.
Get him deposed and see how he'll weasel out of it.
Posted by: Roy March 18, 2007 02:34 PM
I commented briefly on that ScienceDaily article as well (nowhere near your depth, I just pointed out that it existed), and while I did think it might be of interest to people like you, I didn't think of it in relationship to Egnor's nonsense.
Posted by: Kristjan Wager March 18, 2007 05:26 PM
Antibiotic resistance is a pretty powerful rebuttal to the claim that evolution is irrelevant to medicine.
Posted by: Tabitha Powledge March 19, 2007 10:59 AM
I love dental caries, as any dental anthropologist would, but I had not heard of that study. Very very cool to see that Out of Africa has dental pathology evidence!
Posted by: Jason Fox March 20, 2007 10:59 AM
Jason - one version of the paper is available here.
Posted by: afarensis, FCD March 20, 2007 06:23 PM
I have the paper, thanks! I have access to the Journal of Bacteriology through my university, but thanks for the link.
/////////////////////ME-ENTEROVIRUS CNXN?
///////////////////////
/////////////////////MORE YOUNG ADULTS ON STATINS
Use of cholesterol and blood pressure medicines by young adults appears to be rising rapidly -- at a faster pace than among senior citizens, according to an industry report being released Tuesday.
Experts point to higher rates of obesity, high blood pressure and high cholesterol problems among young people. Also, doctors are getting more aggressive with preventive treatments.
Experts point to higher rates of obesity, high blood pressure and high cholesterol problems among young people. Also, doctors are getting more aggressive with preventive treatments.
/////////////////////
///////////////////
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