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Archive for November, 2011

Thursday, November 10th 2011

Circumventricular Organs

What is the only paired circumventricular organ?

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Thursday, November 10th 2011

Video Anatomy

The American Association of Neurological Surgeons has a great new YouTube channel hosting videos on surgical anatomy, including some Rhoton lectures. Even some videos in 3D if you have a computer capable of playing such. I hope they keep updating it but it’s a great resource as is.

Wednesday, November 9th 2011

Neurotransmitter Within Pre-Synaptic Vesciles

Name the only neurotransmitter made within the synaptic vesicles.

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Wednesday, November 9th 2011

Dr. Walmart

NPR and Kaiser Health broke some news this morning about Walmart looking to dramatically expand their in-store healthcare services. And I do mean dramatically, with a goal of,

becoming the largest provider of primary healthcare services in the nation.

Retail primary care physician directed care is nothing new. The first one opened in 2000. But their promise has been largely unfulfilled and, while they may have found a nitch market, the idea of them redefining primary care or supplanting the traditional internist office appears at present as a pipe dream. I know consultants and the industry say differently but I’m of the opinion the retail clinic industry promoted itself as having grown further and achieved more than it has to date. But then again maybe Walmart can do differentially.

I’m not sure I’m convinced of the feasability of some of their goals. For instance, I’m not sure there’s major cost savings to be had in this model. Whatever this model turns out to be.

What it may do, and what I think everyone should be on board with, is expand access to care.

“It’s a really big deal,” says Bob Kocher, a former health policy adviser to President Obama. “We have a shortage of primary care and of access. If Wal-Mart comes in, that creates a lot more access in areas where it’s been hard to find a doctor. This could bring low prices and relaible quality in a way that we don’t really see right now.”

The population attracted to retail clinics, in stores like Walmart, is a population already largely underserved. Even if the cost of health care becomes less of a hurdle as the ACA is implemented, a serious venture into primary care services by a major player like Walmart, if played right, could really expand care to a population that would benefit from it.

Tuesday, November 8th 2011

Segments of the Facial Nerve

List the segments of the facial nerve.

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Tuesday, November 8th 2011

A Critical Review of Recombinant Human Bone Morphogenetic Protein-2 Trials in Spinal Surgery


  • Although the specifics of assessment and technique in fusion remain for debate spinal fusion for pain with spinal instability has become a generally accepted treatment
  • Surgery for fusion attempts to promote new boney growth between the unstable vertebral segments
  • Early last decade saw the rise in the clinical use of a naturally occurring cytokine, bone morphogenic protein-2, which serves to promote osteoblast differentiation and new bone formation in the body
  • Initial studies demonstrated great success, as compared to bone grafts alone, in promoting boney fusion between unstable segments when BMP was used during surgery
  • The Spine Journal June 2011 issue is dedicated to editorials and studies reviewing the growing evidence that BMP use has a number of risks that were underreported as adverse events in the initial studies which trumpted its use. Amongst these studies is a literature review by Carragee et al which criticizes the lack of reported adverse events in the initial industry sponsored BMP studies

Carragee, Eugene, Eric Hurwitz, and Bradley Weiner. “A Critical Review of Recombinant Human Bone Morphogenetic Protein-2 Trials in Spinal Surgery: Emerging Safety Concerns and Lessons Learned.” The Spine Journal 11 (2011): 471-91.


  • Systemic review looking at adverse events reported in original 13 industry sponsored publications looking at rhBMP-2 use in spinal use representing 780 patients versus adverse events reported in subsequent publications and FDA data sets


  • 13 original studies of BMP
  • All first authors had significant financial ties to Medtronic, the industry manufacturer of BMP
  • Meta-analysis of the 13 studies shows 0 complications associated with BMP
  • Review of subsequent studies, unpublished data from the original studies submitted to the FDA leads the authors to conclude that BMP has a true adverse event rate of 10-50%. Newer studies may also associate the product with a cancer risk
  • Dr. Carragee’s group proposes that the financial ties of the authors of the original 13 studies may help explain the lack of reported complications with BMP

Spine surgery is facing a real scandal with BMP. The association with cancer and the implication that financial considerations influenced the studies which led to its approval as a device by the FDA and to its widespread use is a big enough story that it has crept out of the pages of Spine and into the mainstream media. Reuters, the AP have both reported on it, as have major papers like the San Francisco Chronicle and the New York Times and the Wall Street Journal.

Infuse and other BMP based products are likely rightly dead and recalls are in the future. As for what this plays into the long going debate about the association between researchers and industry remains to be seen. But this is a big deal.

I’m going to be less than reactionary here. I think severing the ties between academic medicine and industry is impossible without hurting the common good. This country is the leader in advancing medical science partly because of funding from industry. I think the oversight is going to have to come from the academic institutions themselves. That’s a tough thing and there are major obstacles to people policing their colleagues. I’m not sure exactly what form that might take. But certainly I don’t think the government is not in a position to police it all. And the alternative is severing all ties to industry funded research.