\-hope u pass!

3-11-15
Diet Nutrition and Chronic Disease - Dr. Hecht
Epidemiological Transition: used to die of infections, now die of chronic illness
Obesity, Diabetes and Cancer
Chronic disease is increasing because:
smoking (#1 cause of all chronic illness)
aging population
inactivity
drug usage
environmental carcinogens
diet
20-25% of kids are obese compared to ~5% in 1970s
once you gain weight, it is hard to lose predictor of poor
future health
Obesity related to fatty liver and major cause of cirrhosis
other problems: heart disease, malignancy, arthritis, etc.
Total population attributable fraction = If we removed obesity from population see
that there would be 15% less mortality from cancer in men and 20% less in women
Not just calories in and calories out for weight loss or weight gain
Homeostatic mechanisms keep our weight about the same,
making it difficult to gain or lose weight indefinitely
Most Americans have this energy imbalance: we consume more
than we expend. Losing weight is difficult. My advice to you: dont gain the weight
to begin with. -Hecht TRUE DAT SON
Obesity is a cultural problem (watching too much TV, not having healthy food
options, placing fast food restaurants near schools) - ironic that BK couldnt have been
placed closer to the med school.
[Obesity] is never the individuals fault. You can only be as
healthy as the society you live in. <- lolwut false
Without public health changes, there will not be an end to the
obesity epidemic. -Hecht true
we need changes on an industry level about what foods are being
offered to us, we need to get rid of food deserts, we need to eat more meals at
home. true
if were going to eliminate the obesity epidemic (which we have
to), there have to be big cultural shifts true
Several decades ago people looked at ecological studies and realized that they suffer from
ecological fallacy and a classic is fat intake and breast cancer, correlated by country but in
individuals it did not(this sentence brought to you by Wernickes aphasia hahaha).
< loled for real at this. lol medstudent jokes. i also LOLed still loling actually LOL
Animal fat is slightly more associated than vegetable fat
Forest plot shows meta analysis of relative risk and red meat is hazardous
Hazard ratio is RR but over time
Fish and vegetable eaters (pescatarians) ratio of colorectal cancer
was way lower
Red meat may have carcinogens, some believe Fe causes DNA damage
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 RCT best form of data, the rest suffer from confounding

Repeated studies have associated lifetime alcohol with breast cancer
Soy might actually be protective against breast cancer
Fruits and Veggies have antioxidant activity and all kinds of theories why it may
prevent against cancer
Cruciferous vegetables have sulfur moiety - broccoli, cauliflower, brussel
sprouts, and cabbage positive because generates glutathione which is bodies
antioxidant and Forest plot shows some protection from colorectal cancer from these.
In nursing health study cohort study which looked at exposure and outcomes no
benefit was found with fruits and vegetables, so data can be somewhat confusing in
regards to the relationship between cancer and diet
Pancreatic cancer and fruits/veggies - RR seemed < 1 but not statistically
significant because Confidence interval includes 1 the null
Eat food. Not too much. Mostly plants. - Michael Pollan
No benefit in RCT of multivitamin for cancer.
Vitamin D may have some protective effect, but when pool data not significant
Folate may have small protective effect
Green tea & black tea suggests protective but not sig < ??? english people
My dick bench pressed 350 Your dick couldn't shoplift at Thrifty <-- your dick is
broke bro. LOL. micky avalon hayyyy
Vitamin E and beta carotene on lung cancer no effect
Curcurmin = phytochemical in Indian food (yummy...more incentive to go to
bombay darbar<- theyre getting a new location) may be protective against cancer. <to
clarify, this is talking about turmeric not just indian food lolz
CV risk factors: dyslipidemia, HTN, smoking, diabetes (the big 4), BMI > 25,
physical inactivity and diet
So RCT with low fat diet had no benefit for cardiovascular disease
Mediterranean diet was very successful in showing decrease in MI reinfarction
Then showed Med diet vs low fat diet and med diet was significant affected. So
monounsaturated fats (fatty fish) with omega 3s were great.
Mediterranean diet: fish, olive oil, vegetables, less fatty cheeses reduction in CV disease and MI (compared to standard low fat diet)
Mono/polyunsaturated good (reduce LDL); saturated fat bad
(raise LDL)
Conclusions
Diets with low total fat, low saturated fat, and low cholesterol
reduce cholesterol levels & seem good for CV endpoints, but they did not
reduce the incidence of MI or CHD death
Replacement of animal fats with vegetable oil results in a dramatic
decrease in serum cholesterol in patients
Mediterranean-style diets (nuts, fish, olive oil) are effective in
preventing CHD even though they do not decrease total serum cholesterol
or LDL cholesterol
monounsaturated oils may have protective effect on
the heart.
BROSCO KNOWS YOURE HERE :O
3/18/15

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Immunizations Lecture - Dr. Brown

Successful attempts at eradicating disease (measles?)
Small pox- vesicles with erythematous base
30% mortality, 65-80% scarred forever
declared eradicated in 1980 by WHO due to
vaccine
Polio- mostly eradicated (still in Afghanistan, Pakistan, Nigeria)
fecal/oral or respiratory transmission
permanent paralysis of limbs (<1%)
paralysis of resp. muscles death (5-10%)
Unsuccessful attempts
yellow fever & malaria (animal reservoirs
difficult/impossible to eradicate)
Influenza/pneumonia: #9 cause of death in the U.S.
herd immunity- vaccinate everyone!-but...AUTISM!
seasonal and have to decide 8-9 months ahead of time so may
miss upcoming strain
decide in Feb what will be in vaccination, vaccinate
in Sept/Oct, flu season is Dec-Feb roughly
<5 and >65 most at risk populations for dying these are
preventable deaths!
Strep pneumoniae
most common cause of bacterial otitis media in kids
also bacteremia
meningitis
80% are viral
All adults >65 y/o get PCV 13
(formerly kids only)
another example
of herd immunity
Neisseria meningitidis
Can die within 24 hours! red
petechiae
H. flu
with vaccine, essentially 0%
TDaP vaccine: tetanus, pertussis & diphtheria
Diphtheria- pseudomembranes
(can lead to fatal airway obstruction)
Tetanus- lock jaw
Pertussis- whooping cough, 100
day cough
Need booster
MMR vaccine
Measles- vaccinate at age 1 &
receive booster at age 4
Mumps- parotitis, orchitis sterility
Rubella- congenital cataracts, blueberry muffin baby (purpuric
spots)
Side Effects: Autism < lol
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Varicella - chicken pox

Vesicles with erythematous base in various stages of healing
Chicken pox parties - dont do that anymore! Now theres a
vaccine.
Can die from pneumonia
Live vaccine, provides herd immunity
Gardasil for HPV
Quadrivalent vaccine: 6, 11 (warts) 16, 18 (cervical cancers)
Hep B (PS cured as of this week ->
http://www.pnas.org/content/early/2015/04/15/1502390112.full.pdf?sid=683e56b9-6a974370-9add-7a3df97f2f5d - HOray for science - sparknotes: cancer drug, Birinapant, with
current anti-virals lead to 2x quicker elimination in acute and a cure in chronic forms.
Induces apoptosis in infected cells. the fact that this drug has already undergone human
safety trials makes this really promising)
hepatocellular cancer
Vaccine incidence went down
Test for HEP B SURFACE ANTIGEN in MOTHER to confirm that
they do not have the disease and will not pass it perinatally
those who have been vaccinated are Hep B surface
Ab positive
Why do we immunize?
Eradication, prevention of chronic disease/cancer, prevention
mortality/morbidity, herd immunity
link to Jimmy Kimmels 5min video: A Message for the Anti-Vaccine Movement:
https://www.youtube.com/watch?v=QgpfNScEd3M
3/18/15
Quality of Health Care in the US - Dr. Dauer
How we compare to peer countries? (peer country = capitalist democracy)
Wealth vs. health
Americans live shorter lives and experience more injuries and illnesses than
people in other high-income countries (YOLO!!)
Spend the most money yet have the worst outcomes
Why?
1. We subsidize the pharmaceutical industry for development of new drugs
2. Futile care on end of life and premies
3. Other countries ration care (ex. dont do transplants after certain ages)
So formed a panel to do a study comparing to democratic capitalist countries (17) based on life
expectancy.
So we are summarizing report:
1. 1 of the highest infant mortality rates we have low prenatal care and
prenatal vitamins, cocaine babies, heroin babies. (sad)
2. Injuries & Homicides:
a. We have lots of motor vehicle accidents (MVA) and from drunk
driving
i.
we have more vehicles

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ii.
we tend to drive drunk
more often (its
called uber, people <- fuck uber and their
surge pricing.
7x the normal fare is unreasonable) <--yeah
we should just
drink and drive instead <- murica fuck yeah!
b. violence is a major problem
3. high rates of adolescent preg
4. HIV and AIDs
5. #1 Drug related deaths excluding DUI
a. more people died from narcotics (like oxycontin) than MVA
6. Obesity and diabetes highest here (& high prevalence in children)
7. Heart disease
8. Chronic lung disease
9. Disability
10. Skrew this list! USA is #1! --- only important thing to know
Life expectancy: 78.7 years
Mortality causes: #1 Heart dz, #2 Cancer
Infant mortality rate: 6.15 deaths per 1000 live births
unintentional injuries = #1 cause of death for ages 1-44
Once get to 75 in US you do better than in other countries, under 75 do worse
http://genius.com/Father-john-misty-bored-in-the-usa-lyrics
Why are Americans so unhealthy?
So we also have large uninsured population but this is less true now. So still lots
of access issues.
ACA- newly insured Americans only really have help for
catastrophic care; not for routine mammograms, etc. (b/c of the really high
deductible)
Health behaviors - we drink and smoke less, but really bad drug abuse problems
~ of MVAs that result in mortality can be linked to drugs &
alcohol
Social and economic
Income inequality - poor people dont get better education. Spend
the most money per student but produce stupidest (most stupid?) students.- LOL
-This is sad :(
Physical environment: designed around cars; less physical activity
more obesity
Firearms
we carry a lot more guns than most countries
Most of the time, shot by people you know
firearm death men:women = 6:1
Same level of SUICIDE rates as other countries
HIGHER level of HOMICIDE compared to other countries (off the wall)
Traumatic Brain Injury
#1 cause of death & disability among children & young adults in
US
#1 cause of TBI in elderly = fall
MVA = leading cause of TBI leading to hospitalization

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Can US health care disparities be fully explained by people who are uninsured or poor?
NO! Even advantaged Americans (college degree and make > 50K a year)
still had worse health than peer countries!
Diet & Obesity impacting/causing this!
Possible Explanations for US health disadvantage
US health care is highly fragmented
access to care issue, low rates of prenatal care
Americans less likely to smoke or drink but consume the most calories per
capita
So we smoke less and drink less but eat more! Also drink and
drive and do hard drugs.
We eat because we are unhappy we are unhappy because we
eat - Fat Bastard. hahahahah
Higher rates of poverty and income inequality
US does have a health advantage when compared to peer countries:
5 year survival regardless of stage for newly diagnosed cancer cases is much
better in the US - so in Canada delay diagnosis and colonoscopies have a long wait
Avastin (anti-VEGF) not covered by insurance in Canada
We also have greater control of BP and cholesterol
Americans who reach 75 will live longer in US than other countries
Sweet
We have lower stroke mortality
lower rates of current smoking
Higher average household income
Immigrants actually do better than native citizens in the US
Shorter lives and poorer health will harm the economy as health care costs rise.
3/25/15
Diabetes Education - Matheson
Type 1 diabetes (autoimmune) - can occur in adults, usually youth or early adult
Type 1 often presents with rapid onset with DKA
a lot of people at risk but dont acquire disease
environmental factor
only 30-40% of pts have family hx
higher in N European descent
Misdiagnosed all the time- especially young adults
focus on physiologic replacement of insulin
Need insulin!
A lot of misconceptions about high glucose food (bagels, cereal,
pineapple more so than chocolate or ice cream which contain more fat). The fat
in ice cream allows for slower transit time in the GIT, so the sugar doesnt
overload the blood supply as rapidly as bagels, for example.
Type 2 more common to have a family history (80% of pts have family hx)
metabolic syndrome
More common in Hispanic, American Indian, African American
descent

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focus on minimizing insulin resistance

Diet and exercise first line, then oral meds, then
may need insulin
Pump- rapid acting insulin and can be programmed to be given throughout the

day

fault

Continuous glucose monitoring- tells you glucose every 5 minutes

It is important to empower type II diabetics without making them feel it is their

Just encourage them to lose weight (30 min x 5 days = 150

min/week)

Dont look at it as defeat if need to go from oral agents to insulin

Adult learners need to be:
autonomous and self-directed
accumulated a foundation of experience and knowledge
they are goal oriented so explain the disorder pathophys and how
they can impact that
Make it relevant/practical
Be respectful
Child learners:
teach both parent and child
age-appropriate: developmental skills & milestones need to be
considered
9 year old should be able to inject on their own
Kids are concrete thinkers & cant synthesize all the info they need
to for exact planning of insulin doses (can get complicated)
From 15-17 can start to think non concrete
25% of adults cant think in a non-concrete way

4/7/2015
How to Take a Sexual History - Dr. Ricky Gervais
Ground Rules
Everyones opinion is honored
Mutual respect
confidentiality
Sexual Health- involves critical aspects of disease prevention and health promotion
Absence of disease
Control of fertility
Preservation of Function
Freedom of sexual expression
Freedom from sexual coercion and abuse
Enhanced self-esteem/self-worth
Personal and interpersonal intimacy
Sexual Health (good one)
Sex History: PLISSIT Model
Permission
Limited Information
Specific Suggestions

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 Intensive (Individualized) Treatment

(using 3rd person perspective can be less confronting)
Detailed Sex History:
1. Expression of sex and sexuality
2. Disease screening and prevention
3. Control of fertility

4/8/2015
Intimate Partner Violence and Human Trafficking - Dr. McNulty
Intimate partner violence can be physical, sexual, or psychological, also
controlling behaviors
its about power dynamics
It can go both ways, and it doesnt have to be a sexual
relationship
Could be between a married couple, to a man (women arent
always the victim), or can be between same sex relationships
Often situation complicated by economic and emotional
dependence
Health providers need to support patients wish to choose the best time for them
to leave
Women from 20-24 are at greatest risk of experiencing intimate partner violence
25% of women report having been in a relationship like this.
The men who are at risk of abusing their partners are often young, alcohol,
depression, low income home, low academic achievement, witnessing or experiencing
violence as a child
Sparks: marital conflict, economic stress, poverty, etc.
Social norms - some think maybe it is okay to hit wife if food was burned (or if
she thought lynyrd skynyrd was a person - forreal?), but we want to work toward a
society where no amount of violence is acceptable
Responses to abuse
Women are not passive victims and adopt active strategies to
maximize their safety and that of their children
Leaving an abusive relationship is difficult & violence often
escalates after a woman leaves her partner
(b/c now man lost his control over her, &
fundamentally it is an issue of power dynamics/control in the first place)
Homicide can happen if woman tries to leave, so it really needs to
be planned
We should look at victims as survivors and validating their strength is important
Health Consequences of IPV:
Physical: Chronic pain syndromes and fibromyalgia and
headaches/ stomach aches that wont go away, so somatic manifestations of
trauma possible, also to get opportunity to talk to someone.
Sexual: unwanted pregnancy, STD, PID, etc.
Psychological: Low self esteem, feelings of guilt and shame, drug
abuse, unsafe sexual behavior

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 Fatal: AIDS-related mortality, maternal mortality, homicide, suicide

USPSTF recommends screening for IPV- B grade and recommending that
health plans provide the service
So screening with a question like do you feel safe at home?
should be asked and definitely if anything suspicious like in ER for trauma
Response: Empathy and normalization and then validate them saying its
not their fault, and you dont deserve this and you must have been strong to be
able to ask for help
Practically- we can encourage and offer resources (legal aid, social welfare
services, shelters, community hotlines) and be a solid presence for them
Assess for safety in that moment
Ask what they think immediate & future safety needs are
We can call police or domestic violence shelter if you think its
really unsafe for them.
Also important to document injury because physical exam
notes - can be later used in court (Can also take pictures of injuries as
evidence not in the VA lol).
Mandatory reporting
State specific
Florida law: only have to report if the child or a vulnerable adult
is getting hurt (aka ppl who cant advocate for themselves)
Vulnerable adult: elder patients or those who cant
care for themselves
If life-threatening but not a vulnerable adult you can
call police but not mandated to as a provider
Children who were abused are most likely to become abusers so its good to treat
children and discuss with them and teach them about loving and healthy relationships
Human Trafficking- brought to care only as a last resort (ex: not useful sexually, needs to be
treated for STD or something) and often with a supervisor. :((((((
Get patient alone- say its policy (dont make supervisor suspicious - be sly about
it)
Identifying Factors:
No ID
Inconsistent/vague info
avoid eye contact
Dirty/improper clothing
Tattoo and branding (ex: creepy looking bar codes)
Younger than 18
Dont get into immigration status or trafficking, but ask about others around them.
listed some very direct screening questions like: (ask very direct questions)
Are you threatened at work
Has anyone threatened your family?
Do you have to ask permission to eat, sleep, or go to the
bathroom?
Is there a lock on your door or window so you cant get out?
*ask questions about OTHERS first - before asking them to tell
their own story

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 Again supportive response important and we say things like help make sure this
doesnt happen to other women
We are here to help you
We can help find you a safe place to stay.
You have rights and we can help you to rebuild your life safely.
She says we should focus on empathy and support for the quiz
4/8/2015
Patient Panel: Sexual Issues with Spinal Cord Injury
people with spinal cord injuries have & enjoy sex.
Idk what questions could be asked.
A large part of their arousal is psychological; they may feel most stimulated in areas other than
their genital - like their neck, etc.
Some may be able to ejaculate with intercourse- may regain ability years after disability
People with spinal cord injuries can still feel pain; they can have severe sympathetic spasms
Listen!
4/8/2015
Wrapping It Up - Dr. Mendez
RIME:
reporter
interpreter
manager
educator
Documenting patient interaction important for legal reasons, for us to return to
the case, for insurance companies, keep track of patient history and progress,
justifications for ordering procedures/meds, communications between doctors
Case 1: 56 yo chest pain and SOB, inverted T waves on ECG
PMH: CAD, DM
Problem List can be: sign/symptom complex, diagnosis, test result, anything
that is a problem
It is important to prioritize most active and significant first
cluster to make list more manageable
Be as specific as you can, like chest pain say unstable angina and if 80% sure just commit and call it that
Dont put r/o, possible, or questionable things in problem list
(means you arent sure enough for it to be on your problem list)
Temporality can be a reason to cluster two symptoms on problem
list
So we can cluster LLQ, fever, constipation h/o diverticulitis
recurrent diverticulitis
Assessment! 1
Start with case summary that includes highlights that support your
impression. So give a 1 line and should suggest at the diagnosis
This is a 56 y/o gentleman with a history of CAD
and DM who presents with a one day history of exertional CP with
associated SOB and found to have inverted T-waves on ECG.

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If diagnosis that is known assess the problem

Assess problem thinking about severity, control.
We should also include important issues in the patient, so if positive
family history and long truck driver putting at risk avoid these things in
future
In our assessment we can include that we are
thinking about something high risk but not likely
If diagnosis is unknown differential diagnosis
DDx should not be longer than 4 and dont
include unlikely ones unless high impact life threatening
Put most likely on top and tell why likely or not
only reason to keep unlikely ones is if they are
high impact (i.e. life-threatening) & you just wanna keep it in the back of
your mind
Assessment should cover every problem on your
problem list, so dont include irrelevant things on problem list
Plan- next step which is easy once have ddx.
Diagnostic- order tests to rule things out
Therapeutic (treatment) - especially if time-sensitive
Patient education
Social work and discharge planning
Written note: Goal is to eliminate unnecessary wording, and avoid redundancy, put thing in one
place if it is important
be precise, detail, thorough (aka clear, concise, complete) but
also succinct
avoid generalizations
avoid redundancy (put the info in the 1 place in the note where it
most belongs)
depends on service youre in
You will not present all this information! More of a reference.
Identifying data / CC:
3 things that must be in the first sentence: ID, significant PMH,
and CC
Mr NG is a 56 y/o married Nicaraguan, truck driver with a PMH
significant of CAD and DM who presents with a 1 day history of exertional CP
and SOB
HPI should be chronological and think about when problem started.
Try to sell attending on what you think dx is by including pertinent
positives and negatives of the diff dx
so ex. if pneumonia on diff dx possible but unlikely,
say no fever so we can rule it out.
HPI should be biased - leading attending to know what youre
probably going to say in the Assessment & Plan (but what if you get it completely
wrong lol)
OLD CARTS
HPI relates to why theyre here TODAY
PMH is other inactive problems unrelated to why they are here, otherwise in
HPI

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 Duration, severity, symptoms

ROS should be unimportant, if its important PMH or HPI
Broad, organ-system based
Symptoms not diagnoses
Memory tool to ask about associated symptoms
reminder for pt to tell you something that they may
have forgotten
reminder from med student/MD to ask pt about
these things
He likes to do it during physical
Follow-up Notes depend on service and surgery you will see post op days.
SOAP = Subjective (hx), objective (physical exam, lab, imaging),
assessment, and plan
Follow up notes should be focused on what has changed
Day #, problem list, medications
Focused physical exam
Oral Presentations:
They need to be shorter (50% of note) and focused on what is
pertinent to the case, while note is a detailed reference document.
For admission history we want it to be thorough and can take 10
minutes, then when calling for consult is very different (more like 10 seconds).
Dont do review of systems in here.
Try to do from memory and refer to paper if necessary. Youll
sound more like a human & not be as boring. use voice inflections.

4/14/15
Intubation Session? - no notes
dont break no teeth w/ that lil hinge gadget (laryngoscope) when intubating.
oh tru
4/15/15
Ethics Panel
Case 1: Patient is 15 and with her mom and told the nurse she is having sex with her boyfriend:
1. What do you do?
a. Ask if can speak with the daughter alone (without
presence of parents or relatives) and slowly bring up the subject & get
sexual history patients have a right to privacy, even if <18
b. Ask patients if comfortable getting pelvic exam with mother there
2. What do you do do if you find out she had unprotected sex?
a. Ask about protection, concern for abuse with older boyfriend
b. Can offer contraception
c. Boyfriend doesnt like condoms- If in the last 5 days, give
emergency contraception. Parents will find out
d. Have to be over 17 to buy over the counter. If less than 17- need
to write a prescription.
Case 2: 27 week pregnant and needs a C-section, but she says no she doesnt want scars.
1. What do you do?

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a. Explain that she might lose the baby & scare her.
b. You can also try to win her over saying you understand but the
scars are small.
Case 2 continued: Lifelong history of anorexia
1. Does this change your plan of action? Ask for psych consult, Its important that
they gain weight for the babys health
Case 2 continued more: Vaginal birth and based on psych eval she is competent. What do we
do now? We need to consult social worker to make sure she has the support she needs. Need
safe environment for mom and baby. Whos the father?
Case 3: 1 baby and 6 abortions and wants to terminate.
1. What do you tell the patient? Address contraception, ask what is going on that
is requiring this repetitive undesirable pregnancies- are these pregnancies voluntary?
What constitutes being ready in her mind? Give contraception options (IUD), she should
be aware of health risks involved with multiple abortions.
Case 4: A lesbian couple wants to have a child and ask about reproductive assistance
1. Can they become pregnant? So take on the case
2. Brings up the issue of how many parents can a child have? How many is
necessary? May not be biologically related at all. Can buy sperm & eggs on the internet!
3. What are their options? Does one want to become pregnant or want a surrogate,
adoption
Case 5: Business person wants to use embryos you are not using for research?
1. How do you respond? You want to make sure IRB and everyone consents.

4/16/2015
Interactions with Industry
A ton of money spent on advertising and it works on doctors, although we think
we wont be convinced.
Newly patented drugs may just be slightly different from an older generic drug
that works just as well but way more expensive
Direct to consumer marketing- TV
Never accept ANYTHING from a drug rep--even a pen can have consequences:
- Psychological implications of any gift subconsciously makes you
want to return the favor
- Can affect your prescribing habits
- Can make you look like a walking drug advertisement
- Drug companies can pull your prescribing history to learn your
habits and see if you are prescribing their drugs! They will come try to convince
you.
UMMSM has a policy that NOBODY involved with the school can participate with
any drug company sponsored event (even if they are the one lecturing).<-- if who is
the one lecturing? I think if youre a UM doc and are to give a lecture, you cant be
involved with the industry aspect of things

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 Non-academic medical community offices can accept meals and gifts but must
not be excessive or worth too much
Pharmaceutical companies can keep track of how much/how
many times you prescribe a drug and will try to convince you to prescribe more!
Drugs only produced by a few countries, including the US, Switzerland, UK,
Japan, France, Germany, Sweden.
Drugs not readily available in developing countries, and not much research and
development so that they can be readily available--mostly for developed countries.
9-10% of healthcare expenditures in USA is on drugs.
More than 2X spending on research and development of new drugs than the
amount of sales of all other industries.
Top 10 drugs account for top 10% of drug industry revenues.
4 of worlds top selling drugs are oncology drugs.
Leading therapeutic categories--Oncology, Asthma/COPD inhalers, Diabetes,
Cholesterol.
Kids take mostly-antibiotics and asthma meds
Young adults take mostly - anti-depressants and pain meds
Older folks > 60yo (use highest percentage of drugs)- blood pressure and
cholesterol drugs
65% of older folks are on 3 or more drugs. (37% on 5 or more)
17% of younger adults are on 3 or more drugs.
The US pharmaceutical industry is the most research intensive U.S. industry
Roughly 18% of pharmaceutical sales are reinvested back into research
From these research-and-development efforts has come a stream of new
therapeutic products,
The number of new chemical entities (or molecules) approved for marketing in
the United States averages 15 to 30 per year
Most offer modest variations on existing therapies but some providing
groundbreaking new approaches to the treatment of disease.
Drug companies sponsor Continuing Medical Education events, buy
advertisements in medical journals, and send representatives to talk to doctors in
person.
$3 billion in direct-to-consumer advertising, $5 billion on detailing efforts and
$11 billion of free samples.
Doctors get most of their drug info from biased sources.
Studies sponsored by the company owning the drug (even when peer reviewed
to be unbiased) are more likely to have positive results than studies sponsored by
companies with no stock in the drug.
AMSA PharmFree Scorecard for medical schools grades them on their ability to
be unbiased:
- No industry funded promotional speaking
- No pharm sales rep access to campus
- School does not accept scholarships from industry
- No industry funding of CME
- No accepting gifts or meals from industry reps`
- No attendance of industry sponsored events
UMMSM currently has a B rating on AMSAs PharmFree Scorecard
Used to have an A rating

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what happened Dr Goldman/!?!? :( - his name is Dr.

Goodman?
i dont know what is going on
No samples of any drug are allowed to be accepted on UMMSM campus

4/21/2015 - Ron McGill Sexual Practices of Animals

Who deleted the most quality information on the document?!!??!?!!? someone who has
their panties in a large bunch
The blue whale has the largest penis; the gorilla has a small penis (Gorilla = steroids)
Male Orangutans engage in oral sex (and utilize the hands at the same time for nipple
stimulation)- that was a sexy shot
Homosexuality is natural and found throughout the animal kingdom
Dont be awkward about sex.
Elephants have the largest penis of any terrestrial animal
The mammalian penile bone is called a baculum. The walrus has the largest baculum.
Pandas that cant figure out that they want to have intercourse can be shown panda porn and
then decide they want to have sex with the other panda.
Felines engage in intercourse every 20 minutes for three days. Upon penile withdrawal, the
females vagina is sheared, initiating ovulation. The female feline attacks the male but is ready
for more 20 minutes later.
Flamingos are rather monogamous but will only engage in intercourse if AT LEAST 30 other
flamingos are watching. Hence lots of mirrors put around flamingos in zoos (with less than 30)
when they want the flamingos to mate. Clever trick.
The male rhinoceros rides on the females back during penetration, which can persist for days
until the female begins to buckle. Only then is it time for penile withdrawal.
Rhino vulvae can snap shut though (isnt it a zebra vulvae-- Koala?) Yes, Koala, it is
the zebra vulva that snaps shut. Its like a strobe light. When the male zebras see
the flashing pink tissue of the vulva they really go wild. Guys thats
different...remember the photo where the rhino bro bent his peepee? Good point
Koala, I actually think there are a few different
Important distinction - high
yield stepanimals that have the capability to snap shut their vulvae. lol dafuq did i
just read.
Zebras can control the vulva, more importantly the labia around the introitus
Can separate dark skinned labia majora, exposing bright pink mucosa
Rhinos have really strong vice grip like vaginas, they prefer slow penetration
The blue whale has the largest penis; the gorilla has a small penis (Gorilla = steroids)

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Male Orangutans engage in oral sex (and utilize the hands at the same time for nipple
stimulation)- that was a sexy shot turned me on a little oh my
Homosexuality is natural and found throughout the animal kingdom
Elephants have the largest penis of any terrestrial animal
The mammalian penile bone is called a baculum. The walrus has the largest baculum.
Pandas that cant figure out that they want to have intercourse can be shown panda porn and
then decide they want to have sex with the other panda. LOL
Felines engage in intercourse every 20 minutes for three days. Upon penile withdrawal, the
females vagina is sheared, initiating ovulation. The female feline attacks the male but is ready
for more 20 minutes later.
Flamingos are rather monogamous but will only engage in intercourse unless AT LEAST 30
other flamingos are watching. Hence lots of mirrors put around flamingos in zoos (with less than
30) when they want the flamingos to mate. Clever trick.
The male rhinoceros rides on the females back during penetration, which can persist for days
until the female begins to buckle. Only then is it time for penile withdrawal. Rhino vulvae can o
they use their vagina clamps if penetration is too fast
The penis of the swine is shaped like a screw, hence the popular slang term, Screwing. Unlike
humans, who nail...I think theres a human vs animal sex table somewhere in Pathoma.
lol, definitely
Female primates mate only with the alpha male. Other male primates are welcome to inspect
the females inflamed vulva, watch the coitus, and/or masturbate. (sometimes they have sneaky
sex for like 5 seconds while the alpha male is not watching)
NOTE: Kangaroo testicles are anterior and superior to the penis and can be retracted as to not
present an allosteric hindrance during intercourse. I clearly dont know what allosteric means. (I
think changing the confirmation to prevent optimal binding into the vagina.)
Frog chicks love dogpiles...more like frogpiles :) The female frog is surrounded by multiple male
suitors. There is no penetration involved, yet her eggs are literally squeezed out of her vagina
by radial force.
Many animals need to be urinated on by the female in order to get the green light for sex. (so do
some people but hey, whatever floats your boat). Anonymous Mink-- were animals too arent
we?
Bottom line: Sex is natural, weird, and fun. Be open-minded to prevent judgments that may
interfere with optimal treatment of your patients.

4/21/2015
Access to Health Care in
...in what? the suspense is killing me!
dude what should i study

4/23/2015
PELM Access to Care

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TELOS-if anyone is afraid and scared and sick-all things being equal, its your moral duty to
care for your patients and try to make them better (your job is NOT to ration at that beside,
make decisions that are in best interest of your patients!)
what influences health?
-Genetics (30%)
-Environment, population around you, neighbors (30%)
-Individual behaviors (smoking, stress, diet) (30%)
-Doctors (10%) We spend 5000 dollars per person in healthcare in the US! ACA trying to eliminate this, but
depends on expansion of Medicaid (.. no the question is about guns - asking a gun question if
child had firearms in the house thats the big debate going in Tallahassee right now)
Lip=limited income pool
Latinos are the most likely to sign up for insurance under the ACA...Dade/Broward were off the
charts.
Physicians are not supposed to act as an extension of law enforcement.
Providing quality care from the beginning reduces costs; once the patients condition
deteriorates because of lack of pursuing health care, the patient will present extremely
deconditioned and require more expensive treatments/specialist interventions
Provide care!
Wow this google doc is outta control.
I love all these anon animals

ugh who deleted Brosco.

some serious damn sallys around here.
LIGHTEN UP
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