Monthly Archive: February 2012

Morgellons: Real Skin Disease or Delusional Dermatology?

Morgellons Syndrome is described as a skin ‘infestation’ by small mites, or morgellons.  The ‘diagnosis’ is not accepted by mainstream medicine but has been widely publicized by media outlets and advocacy groups. Those who are believed to have morgellons complain of itchy skin, stinging and painful sensations, and the feeling of creeping and crawling underneath the skin. In many patients, there are persistent skin infections that do not heal properly. Some describe white plaques the form around chronic skin wounds. One of the unifying complaints, however, is the presence of small fibers erupting from the skin after the symptoms have been present for a few weeks.

Initial research into these complaints identified no unifying cause, no parasite, and no underlying cause. The lack of evidence for morgellons led most medical organizations, including the American Academy of Dermatology, to declare the the symptoms were not skin related at all, but were a delusion. The combination of symptoms, they say, follows a well known pattern that has been described in dermatology as Delusional Parasitosis: a disease that causes a healthy person to have a strong and incurable belief that their bodies are being overtaken by mites or bugs.  Interestingly, a PubMed search of all research that has been published on the subject (34 papers since 2006) identified no causative factor but did include titles with words such as: psychosis, hypnosis treatment, delusion, unexplained, antipsychotic-responsive, mysterious, web-based dissemination, contested, unknown etiology, and internet meme. [CLICK HERE TO SEE ALL 34 PAPERS]

Nevertheless, though the medical community has shunned the idea of morgellons, the diagnosis has lived on. A recent paper  published in PLoS One identified the epidemiology of 115 patients who were thought to have morgellons syndrome.  The paper found that 70% of these patients also complained of chronic fatigue, 59% had cognitive deficits, 50% tested positive for drugs, and 78% reported exposure to solvents. Quite the motley crew!  However, they did find some interesting results among this interesting group, see images below…

Microscopic image of a fiber taken from 'morgellons' patient

Skin lesions seen in patients enrolled in the PLoS One study

Something is certainly going on in those images.  Is it a delusion? Or is it a whole body infestation?

Pre-operative Clearance Checklist

A frequent question in the outpatient setting is whether or not a patient is optimized for surgery. There are a number of things that a physician must check in order to properly send a patient back to a surgeon with a gold star. I recently used the Johns Hopkins Internet Learning Center (HopkinsILC) to study the basic pre-operative evaluation and I highly recommend it (requires access from your school or hospital, many hospitals have access, ask your librarian).  There is a great review pdf available from HopkinsILC which details some of the highlights of the lesson.  Below I will summarize some points from the pdf. To learn more, you should ask for access to HopkinsILC, it is a great resource.


  1. If the patient has any active cardiac issues, surgery should be postponed.  This includes…
    1. Recent myocardial infarction (<30 days)
    2. Active cardiac disease (unstable angina or worse)
    3. An uncorrected arrhythmia
    4. Severe aortic stenosis


  1. The patient must be able to complete 4 or more ‘metabolic equivalents of task’ (METS).  This includes
    1. Climbing a flight of stairs
    2. Walk for 30 minutes
    3. Play tennis, bowling, or other more intense sports
    4. Able to vigorously clean a house (scrub floor, move furniture)


  1. There are a few medications that must be stopped prior to surgery. Some examples (not an exhaustive list) include…
    1. If the patient is on blood thinners (coumadin) or anti-platelet drugs (plavix, lovenox, etc) these may have to be stopped and the surgeon will have to be part of the discussion
    2. Diuretics, ACE-inhibitors, and ARBS are usually held
    3. Oral hypoglycemics are usually held for 1-2 days
    4. Insulin is usually decreased by 50%
    5. Sedatives are usually held


Again, here is the link to the pdf explaining the above points. And here is the link to the HopkinsILC website.



American College of Radiology: Appropriateness Criteria

Have you ever wondered what imaging test should be ordered for your patient? What radiologic test would be most beneficial in this situation? What imaging test should I order first? If a patient comes in with a painful knee, should I get an x-ray or go straight to MRI?  If a woman comes in with a non-tender breast mass should I get an ultrasound before the mammogram?  These are difficult questions; luckily The American College of Radiology (ACR) has our back! The ACR publishes a fantastic online resource they call the “Appropriateness Criteria” which details the best imaging tests for nearly every presentation.

They website allows the user to choose between a variety of organ systems (e.g. women’s health, urology, gastrointestinal).  In each organ system the user can then choose a specific complaint (e.g. breast mass, hematuria, dysphagia). For each complaint, the ACR then allows the user to choose what specific patient presentation is occuring (e.g. 35 year old woman with a new breast mass vs. 35 year old woman with a mass seen on mammogram vs. 70 year old woman with a new breast mass). In each circumstance, the ‘Appropriateness Criteria” explains what is the best radiologic test to help diagnose the patient’s problem.  They explain in detail the advantages and disadvantages of each test (MRI, CT scan, ultrasound, x-ray, etc) for each specific problem.

The criteria are updated every few years, the most recent data comes from 2009. One of the best parts about the ACR Appropriateness Criteria can be found at the end of each section. Not only do they make suggestions about which tests will be most useful in diagnosis, they also provide a literature review for EVERY SINGLE patient complaint which outlines what research and studies they are using when making their suggestions.

I HIGHLY RECOMMEND this website. In fact, there are few resources that I can recommend higher. I have used this many times and they intricacies and precision of the criteria still surprise me.  There is NO BETTER RESOURCE available to determine which imaging tests are indicated for a specific patient presentation.


EKG Basics PowerPoint

I recently started a rotation in cardiology. It has been nearly 2 years since I have worked on a heart service and I was looking for a quick refresher on EKGs. Luckily, I found a great powerpoint review on the Standford website. There are only 20 or so slides and they cover major topics such as: review of heart conduction system, EKG lead placement, determining the heart rate, and determining the QRS axis.  They review both the ‘quadrant’ approach to axis determination and the ‘equiphasic’ approach. If you are going to be starting a rotation in cardiology or if you just want to refresh yourself on EKG basics, I suggest you take a look.

You can click the link below to download the PowerPoint directly from this website or you can go to the Stanford website listed below.

EKG Basics – Long

Dealoz: Textbook Price Comparison

Throughout college and medical school I had to buy thousands of dollars worth of textbooks. During my first year of medical school I came across the world’s best textbook website:  DealOz allows you to search all available websites, auction sites, book stores, and online sites for the textbook you are looking for. All you need is a title or IBSN and DealOz will do the rest of the work.  If you have every used for flight tickets, DealOz works the same way by comparing all available options.

After inputting the book of choice, DealOz will compare all of these locations and report back to you the lowest price available. You can search for all available books, or you can choose to search only for ‘new’ books. DealOz will then link you to your seller of choice.  Try it, you will like it. I have saved hundreds of dollars using their website.

Again, here it is