,, May 16, 2011, by John Moore  —  About a year ago we posted a piece that basically summed up Google Health as on its death bed. Google, of course was quick to defend itself saying that Google Health was very much alive and well. We even had a long conversation with the senior leadership of Google Health who told us they were taking Google Health in a new direction, had been doing a significant rebuild of the underlying architecture which culminated in a “new” Google Health which had far greater focus on health and wellness. They even went so far, in very uncharacteristic fashion to give adoption numbers. Granted, those adoption numbers were only those from users of the Android App CardioNet, but hey, it was something.

Beginning in late March 2011, we started hearing the rumors of the impending demise of Google Health once again (is this becoming some sort of annual thing with Google Health?). We waited a few weeks to see if the rumors would die down, they did not. We put a call into Google Health to set up a briefing, get an update. Response back was slow (one yellow flag). When they did get back to us, they said it will be at least a couple of weeks (two yellow flags). Next, our Google contact told us by email that they were going to hand Chilmark’s inquiry off to Google’s PR department (screaming dark orange flag). And now today, we received an email from one of Google Health’s most visible spokespersons, Missy Krasner that she is leaving Google.

There is now no doubt in our mind that the Google Health development team has been dis-banded and Google Health has been placed in a cryogenic state until the moribund consumer adoption of such tools comes to life. It would be far to big a PR nightmare for Google to completely pull the plug on Google Health as they have done in the past with other less then stellar launches. No, they’ll put an engineer or two on Google Health to keep it up and running but don’t expect anything new out of Google Health for at least the next 5 years. This baby is frozen




Microsoft HSG Bets Future on Amalga

May 3, 2011 by John Moore  —  Microsoft’s Health Solutions Group (HSG), which has straddled the fence with consumer-facing (HealthVault) and corporate-facing (Amalga), is increasingly moving to the corporate side of the fence. Not that surprising considering that the consumer market continues to struggle (Google Health is in virtual mothball state, consumer adoption of HealthVault is nothing to write home about) and that HSG has now moved out of R&D and is now under the business solutions group, Dynamics. At the end of the day, HSG head Peter Neupert has to show that he can deliver the goods and Amalga is the horse he’s betting on (Note: Sentillion is there as well, but think of Sentillion as the gate-keeper to accessing Amalga).

Yet Amalga has gone through its share of birthing pains with some in the industry beginning to question its value.

Amalga has suffered from two significant problems, both inter-related. The first is that Amalga is an extremely powerful set of data aggregation and analytical tools, but it is more of a toolset then a product and this leads to long implementation time-frames and subsequently an inability to extract value quickly (ROI for Amalga is measured in years). For example, in 2009 Golden Living signed on to adopt Amalga and HealthVault. At last week’s Connected Health Conference, (CHC) Golden Living presented some remarkable results of how they are transforming long-term care through the use of Amalga. But in their presentation, Golden Living also stated that they knew full well when signing on to Amalga that this was going to be a multi-year effort and their implementation team has been given 5 years to put Amalga in place. Five years to fully implement a software solution is a very long-time and similar to the installs of the largest EHR systems. Unfortunately, many early Amalga customers did not have the foresight of Golden Living. In recent conversations with Microsoft, Chilmark has been told that significant resources are now being dedicated to improving time to value for Amalga. We’ll have to wait and see as the CHC sessions we attended on Amalga and HealthVault Community Connect, did not make this readily apparent.

Secondly, the flexibility of Amalga led Microsoft to pursue a number of different strategies and markets. One apparently aborted strategy was for Amalga to become a Platform as a Service (PaaS) when it announced at the 2010 HIMSS its partnership with Eclipsys wherein specific Eclipsys modules would run on top of the Amalga platform. Well a platform is not a platform if it does not support an ecosystem of third party applications. To date, Microsoft has announced no additional partnerships similar to that of Eclipsys for Amalga so this strategy has stalled.

This was also looking to be the case for Microsoft’s HIE strategy. In the profile we did of Microsoft for the HIE Market Report we questioned whether or not Microsoft would stick with this market as they had not had a significant HIE win in nearly a year. In a conversation with a CIO of a large academic medical center at CHC, he also brought up the question of whether or not Microsoft was committed to supporting HIE functionality within Amalga, so clearly we were not alone in our opinion. Those fears were put to rest last week when Microsoft announced the Chicago HIE contract win, which is a monster representing some 70% of the healthcare facilities and a population of 9.5 million in the Chicago metro area. The Chicago HIE is a very visible win for Microsoft and a clear signal that they intend to be a major player in the HIE market.

It was also clear at CHC that Microsoft HSG is very focused on Amalga. The majority of sessions were dedicated to various aspects of leveraging Amalga (clinical decision support, care transitions support, comparative effectiveness, etc.). Virtually all users we spoke to at CHC were there to learn more about Amalga. And maybe the most telling sign was the list of exhibitors. Unlike CHCs of the past, there was not one EHR company, very few third party software vendors (~14%), and only a couple of exhibitors with clear connections to HealthVault.  Consulting and service firms, however, were there in force representing over 50% of exhibitors.

While the Chicago HIE win is a strong vote of confidence in Amalga sending a clear signal to the broader HIT market, Amalga is not out of the woods yet. Broader adoption of Amalga will be highly dependent on Microsoft’s ability to further “productize” Amalga to insure faster installs and accelerate time to value. In today’s market, where senior IT executives of healthcare organizations are literally swamped in various initiatives (e.g., 5010, ICD-10, EHR/meaningful use), the last thing most want to adopt is an Amalga toolset. Developing Amalga to address specific use cases will go a long way towards seeing broader adoption of this potentially powerful solution.

Back in the Fall of 2010, here’s what was going on with Google………………



Google Health Unbound: Can It Overcome Indifference to Personal Health Records?, By Ken Terry | September 15, 2010



Ken Terry, a former senior editor at Medical Economics Magazine, is the author of the book Rx For Health Care Reform.




One of Google’s biggest stumbles in recent years has been Google Health, which has failed to gain traction and has fallen way behind Microsoft HealthVault in terms of partnerships. Google Health has just been relaunched with some interesting new features. But it hasn’t reinvented itself — and perhaps it can’t.

There was a lot of excitement two and a half years ago when Microsoft (MSFT) and Google (GOOG) unveiled their web platforms for personal health records (PHRs). Some observers even speculated that this could be the beginning of a new era in which patients would control their own healthcare data and PHRs would break down the information silos that impede health data exchange.

None of that has happened, of course. While the latest data indicates that 7 percent of consumers are using some form of PHR, that’s still a small fraction of the public, and one that seems to consist largely of younger, more highly educated people. Nobody has yet found the key to persuading most consumers that they need to track their own health indicators online.

Google Health’s new approach is to go beyond merely providing a repository for standard health data such as medications, problems and allergies, and focus on helping consumers enter and track data that’s important to them. That might include efforts to reduce weight, stop smoking, or get more exercise. A consumer who wants to lower his or her blood pressure, for instance, can enter readings in a preconfigured template that graphs progress over time. People can also create their own health trackers for specific purposes. And Google enables users to upload data from health-related devices such as FitBit, a belt clip-on that measures distance walked and calories burned; CardioTrainer, a feature of Google’s Android smartphone; and the Withings wi-fi digital scale.

All of this has won plaudits from observers like Dr. Dean Ornish and Chilmark Research. But let’s be clear here: Ornish was formerly head of the Google Health Advisory Council, so he’s somewhat invested in the success of the platform. Chilmark does not appear to have a similar tie to Google, but its author states that he has been disappointed that there’s no viable competitor to HealthVault.

HealthVault, meanwhile, has continued to strike deals that enhance the value of its website, ranging from the Mayo Clinic for educational content to Quest Diagnostics for lab results to Surescripts and several national health plans for medication data. And, while HealthVault offers to upload clinical data from healthcare providers in the dominant Continuity of Care Document (CCD) format, Google continues to cling to the little-used Continuity of Care Record (CCR).

Google did announce partnerships with a few significant providers, including Lucille Packard Children’s Hospital at Stanford University, the University of Pittsburgh Medical Center, and Sharp Healthcare. But, like HealthVault, it’s able to obtain only a small trickle of clinical data. Until patients demand that doctors and hospitals upload their records to PHRs, it’s not going to happen.

Meanwhile, it’s hard to understand why Google Health believes that people will enter their blood pressure, cholesterol or blood glucose data unless they’re very motivated. And if they’re that motivated, they’re people who already have serious health problems — a small percentage of the population at any given time.

As for tracking exercise or eating habits, the inconvenient truth is that most people are lazy. A 2009 National Business Group on Health survey of firms that have wellness programs discovered that it’s very difficult to motivate employees to participate, even with cash incentives. Only 1 to 2 percent of their respondents got 20 to 50 percent of their relevant employees involved in smoking cessation or weight reduction programs. Only a quarter of companies that offered health risk appraisals report persuaded the majority of their employees to take them.

So, while Google Health has taken a step forward with its new PHR, the jury is still out on the whole genre. Whether it will ever be a viable business remains unclear.


and back in the Fall of 2010………………Google said……………..



Google Hits Reset Button on Google Health

September 15, 2010,, by John Moore  —  Google Health has seemingly been stuck in neutral almost from the start.  Despite the fanfare of Google’s Eric Schmidt speaking at the big industry confab, HIMSS a couple of years back, an initial beta release with healthcare partner Cleveland Clinic and a host of partners announced once the service was opened to the public in May 2008, Google Health just has not seemed to live up to its promise. Chilmark has looked on with dismay as follow-on announcements and updates from Google Health were modest at best and not nearly as compelling as Google’s chief competitor in this market, Microsoft and its corresponding HealthVault.  Most recently we began to hear rumors that Google had all but given up on Google Health, something that did not come as a surprise, but was not a welcomed rumor here at Chilmark for markets need competitors to drive innovation.  If Google pulled out, what was to become of HealthVault or any other such service?

Thus, when Google contacted Chilmark last week to schedule a briefing in advance of a major announcement, we were somewhat surprised and welcomed the opportunity.  Yesterday, we had that thorough briefing and Chilmark is delighted to report that Google Health is still in the game having made a number of significant changes to its platform.

Moving to Health & Wellness

Today, Google is announcing a complete rebuild of Google Health with a new user interface (UI) a refocusing on health & wellness and signing on additional partners and data providers.  Google told Chilmark that the new UI is based upon significant user feedback and a number of usability studies that they have performed over the last several months. Rather than a fairly static UI (the previous version), the new UI takes advantage of common portal technologies that allow the consumer to create a personalized dashboard presenting information that is most pertinent to a consumer’s specific health and wellness interests and needs.  So rather then focusing on common, basic PHR-type functions, e.g., view immunization records, med lists, procedures and the like, the new UI focuses on the tracking of  health and wellness metrics. This is not unlike what Microsoft is attempting to do with MSN Health and their health widgets that subsequently link into a consumer’s HealthVault account, though first impressions lead us to give a slight edge to Google Health’s new UI for tracking health metrics.



A particularly nice feature in the new Google Health is the consumer’s ability to choose from a number of pre-configured wellness tracking metrics such as blood pressure, caloric intake, exercise, weight, etc.  Once a given metric is chosen, the user can set personal goals and track and trend results over time.  There is also the ability to add notes to particular readings, thereby keeping a personal journal of what may have led to specific results. And if one cannot find a specific health metric they would like to track, the new platform provides one the ability to create their own, for example the one in the figure below to measure coffee consumption. Nice touch Google.



On the partnership front, Google is also announcing partnerships with healthcare organizations Lucille Packard Children’s Hospital, UPMC and Sharp Healthcare and has added some additional pharmacy chains such as Hannaford and Food Lion among others.  On the device side, Google has the young Massachusetts start-up fitbit (novel pedometer that can also monitor sleep patterns) and the WiFi scale company, Withings.  On the mobile front, Google has added what they say is the most popular personal trainer Android app, CardioTrainer and mPHR solution provider ZipHealth (full disclosure, I’m an advisor to the creators of ZipHealth, Applied Research Works) which has one of the better mPHR apps in the market.

If any metric is a sign of pent-up consumer demand for what Google Health will now offer it may be CardioTrainer. In our call yesterday, the new head of Google Health, Aaron Brown stated that they did a soft launch of CardioTrainer on Google Health by just putting a simple upload button in CardioTrainer that would move exercise data to a Google Health account.  In two weeks, over 50K users have uploaded their data to Google Health. Pretty incredible.

Challenges Remain

Chilmark is delighted with what Google has done with Google Health.  The new interface and focus takes Google Health in a new direction, one that focuses on the far larger segment of the market, those that are not sick and want to keep it that way through health and wellness activities.  Today, within the employer market, there is a major transition occurring with employers focusing less on disease management and looking towards health and wellness solutions that keep their employees healthy, productive and out of the hospital. Google may be able to capitalize on this trend provided it strikes the right partnership deals with those entities that currently serve the employer market (payers and third party administrators).  Chilmark will not be holding its breath though as to date, Google has not had much success in the enterprise market for virtually any of its services.

And that is one of many challenges Google will continue to face in this market.

First, how will Google readily engage the broad populace to use Google Health?  Google has struggled in the enterprise market, regardless of sector, and will likewise struggle in health as well, be it payers, providers or employers. Without these entities encouraging consumers to use Google Health (especially providers as consumers have the greatest trust in them), Google Health will continue to face significant challenges in gaining broad adoption and use of its platform.  But as the previous example of CardioTrainer points out, Google may have a card up its sleeve in gaining traction by going directly to the consumer through its partners, but it will need far more partners than it has today to make this happen.

Second, the work that Google has done to re-architect the interface and focus on wellness, particularly the tracking and trending of biometric or self-entered data is a step in the right direction, but Google has not been aggressive enough in signing on device manufacturers that can automatically dump biometric data into a consumer’s Google health account.  Yes, Google is a member of the Continua Alliance but Continua and its members have been moving painfully slow in bringing consumer-centric devices to market. HealthVault, with its Connection Center, is leaps and bounds beyond where Google is today and where Google needs to be to truly support its new health and wellness tracking capabilities.  Google’s ability to attract and retain new partners across the spectrum of health and wellness will be pivotal to long-term success.

Third, Google has chosen not to update its support of standards and remains dedicated to its modified version of CCR.  While CCR is indeed a standard that has seen some uptake in the market, Chilmark is seeing most large healthcare enterprises devoting their energies to the support of the CCD standard.  In our conversation with Google yesterday we mentioned this issue and Google stated that they are hoping the VA/CMS Blue Button initiative will take hold and provide a new mechanism by which consumers retrieve their healthcare data and upload it to Google Health.  The Blue Button is far from a done deal and has its fair share of challenges as well. Google is taking quite a risk here and would be better off swallowing the CCD pill.

In closing, Chilmark is quite excited to see what Google has done with their floundering Google Health.  They have truly hit the reset button, have a new team in place and are refocusing their efforts on a broader spectrum of the market.  These are welcomed changes and it is our hope that with this new focus, this new energy, Google will begin to show the promise that we at Chilmark have always had for this company to help consumers better manage their health.

9/24/10 – Earlier this week, I was interviewed by They have created a podcast of that interview that provides further “color” to the Google Health Reset story.

John Moore discusses the future of Google Health, (Duke University School of Medicine) Venous disease refers to all conditions related to or caused by veins that become diseased or abnormal. Venous disease is quite common — about 15 percent of the adult population is affected. Mild venous disease is usually not a problem for patients, but as venous disease worsens, it can become crippling chronic venous insufficiency.



In the normal circulation, arteries carry oxygen rich blood from your heart to the body, and veins return the blood to your heart. Veins have one-way valves along their length to keep the blood flowing to the heart. As muscles contract, the blood is squeezed forward in the veins. When muscles relax, the valves shut to prevent blood from flowing backward.

There are three types of veins in your legs: superficial veins, communicating veins, and deep veins. Superficial veins lie just under the skin and carry about 10 to 15 percent of the blood in your legs. Superficial veins drain into communicating veins, which drain into deep veins. Deep veins lie inside the muscles (remember muscles are responsible for pumping) and carry 85 to 90 percent of the blood back to the heart.



Great saphenous vein and its tributaries

If the vein walls become weak or damaged, or if the valves are stretched or injured, the system stops working normally and the blood begins to flow backward when the muscles relax. This creates unusually high pressure in the veins, resulting in even more stretching, twisting, and swelling of veins. The abnormal veins with their sluggish blood flow create disorders known as venous disease.

Venous diseases include:

Spider veins

Varicose veins

Leg Swelling and Leg Pain

Chronic venous insufficiency

Leg skin changes

Leg ulcers


Vascular Malformations

Venous Malformations


Risk factors for venous disease include:

Family history



Prolonged standing

Prior history of blood clot formation in the veins






Spider Veins (Telangectasias)



Spider veins are clusters of small, unsightly veins that may appear red, purple, or blue. Spider veins are the smallest type of varicose vein and are usually only a cosmetic concern since they are generally medically insignificant. But in some people, they may be painful. They most commonly appear on the thigh, calf, and ankle. They lie very close to the surface of the skin. Although they are connected to the larger venous system they are not essential to it. It is estimated that about 50 percent of adult females are affected with spider veins. Spider veins can be treated with injections called sclerotherapy.

Varicose Veins



Varicose veins are larger than spider veins. The word “varicose” comes from the latin word “varix,” which means twisted. Varicose veins are usually blue and tend to bulge. As they enlarge, they may even become twisted, tortuous, gnarled, or even cord-like. They can occur anywhere in your leg from your groin to your ankle. Any vein can become a varicose vein, but they most commonly occur in your legs and feet.

Many people with varicose veins do not experience discomfort. In some cases, as more and more blood flows backward in the abnormal vein, the vein can become leaky causing symptoms of leg swelling and leg aches. Occasionally burning and throbbing occurs in your muscles as blood pools or backs up in your legs. Symptomatic varicose veins usually require treatment. In some patients sclerotherapy can be used to treat smaller varicose veins, but larger varicose veins many need endovenous laser ablation, radio frequency ablation, cutaneous laser, or microphlebectomy.

Leg Swelling and Leg Pain




Leg swelling occurs as the varicose vein and the vein valves become more abnormal. The poorly functioning valves allow blood to flow backward, which causes pooling in the veins. Symptoms can include: aching, cramping, tired legs, swelling, heaviness, restless legs, and itching. The pooling causes increased pressure inside the veins. This increased pressure causes the veins to distend and become “leaky,” allowing fluid inside the veins to leak outside the vein into surrounding tissue causing swelling. The swelling can cause the legs to ache and feel heavy. Leg pain is caused not only from the effects of swelling, but also from the effects of congestion or pooling in the muscles. The discomfort of both leg swelling and leg pain can be improved with compression stockings or possibly treated with endovenous laser ablation.

Chronic Venous Insufficiency

When venous disease is long standing, it can become chronic venous insufficiency (CVI). CVI occurs from chronic pooling and congestion caused by leaky varicose veins, from chronic obstruction in veins due to repeated clots (thrombosis), or from repeated inflammation of the veins (phlebitis). As this condition worsens and become severe, skin changes and leg ulcerations can occur. Treatment is aimed at relieving the swelling in the legs. This can be achieved with compression stockings or with endovenous laser ablation.

Leg Skin Changes



The skin changes associated with chronic venous insufficiency are sometimes called venous stasis dermatitis and are the result of long-standing swelling and increased pressure in the veins.

Eventually the constant swelling, decreased blood flow to the area, and increased pressure result in decreased movement of oxygen and nutrients to the skin. The tissue becomes damaged and the skin becomes inflamed (cellulitis). The skin eventually becomes reddish brown, hard, thick, leathery dry, and itchy.

Although treatment will probably not reverse the skin changes, treatment aimed at relieving the swelling and decreasing the pressure in the veins will improve symptoms and prevent progressions to skin ulcerations. Treatments aimed at reducing the swelling may involve a combination of treatments such as prescription drugs, compression stockings, and endovenous laser ablation.



Leg Ulcers


When venous disease and blood pooling becomes severe, venous stasis ulcers can occur in the skin. These ulcers usually occur around the ankles and are thought to be caused from long-standing “water logging” or pooling from blood congestion in the affected leg.

Long standing congestion is suspected to cause obstruction in the blood flow, which then causes changes in the skin pressure. These changes cause the oxygen levels in that area to become decreased. With the blood flow obstruction and the decreased oxygen levels, skin ulcers begin to form. These venous ulcers can be painful, and treatment can be lengthy and frustrating.

In many cases, if a varicose vein is diagnosed and considered a cause for the venous ulcer, treating the varicose vein with endovenous laser ablation will help redirect the blood flow, relieve the venous congestion, and improve the leg ulcer.


Phlebitis means inflammation of the vein. It can affect the superficial veins or the deep veins. Thrombus means clot. Because thrombus is almost always associated with phlebitis, some doctors use the terms thrombosis, phlebitis, and thrombophlebitis interchangeably. If a clot is in a vein, it causes stretching and inflammation of the vein. If a clot is in one of the superficial veins it is called superficial thrombophlebitis and if a clot is in one of the deep veins it is called deep vein thrombosis (DVT).



Superficial thrombophlebitis (ST) often develops in a varicose vein where the blood flow has become sluggish. Although ST does occur in people who have varicose veins, most people with varicose veins do not develop ST. ST can also occur after surgery, injury, intense exercise, in response to a medical or surgical disease, or from genetic blood clotting disorders. The symptoms include a tender, cord-like vein that is sensitive to pressure, redness, and warmth in the area from the inflammation and swelling around the affected vein.

Even a slight injury can cause a varicose vein to become inflamed. This sudden (acute) inflammation causes a small clot to adhere to the vein wall. Unlike deep veins, the superficial veins do not have surrounding muscles to squeeze and dislodge the clot (thrombus). For this reason, ST rarely causes an embolism, a sometimes serious condition when the clot is dislodged to other parts of the body.

An ultrasound may be able to detect a clot in the vein. Treatment may include taking anti-inflammatory drugs such as aspirin or ibuprofen; warm, moist compresses to the area (be careful to avoid burning the skin); and elevation of the leg. Occasionally the clot may be removed and compression stockings are worn. With proper treatment, ST usually resolves in one to two weeks. If you have varicose veins that predisposed you to ST, treating the varicose vein with endovenous ablation can help prevent recurrent ST.



Deep vein thrombosis (DVT) occurs when a clot develops in a deep vein. Unlike ST, in deep veins little inflammation occurs with the clot formation. Therefore, the clot is less likely to adhere to the vein wall and more likely to break loose, travel downstream, become lodged in an artery, and block blood flow (an embolus) – which is a serious condition. In addition, deep veins are surrounded by muscles. The squeezing action of the muscle can cause the clot to break loose and become an embolus. Therefore, DVT can be a potentially serious situation. Because blood from the legs drains directly into the heart and lungs, an embolus from the legs could become a pulmonary embolism.

There are many causes of DVT: injury to the vein (which may occur during surgery), decreased blood flow, or a genetic tendency to form clots, certain medical conditions, certain medications, dehydration, prolonged bedrest, prolonged sitting, smoking and more.

Because DVT usually causes little inflammation, pain and redness over the skin is usually minimal. 50% of the people with DVT have no symptoms at all. However, when the DVT blocks a large leg vein, swelling may occur in the foot, calf, leg or thigh, depending on where the blockage occurs. The area may become painful, tender to the touch and warm.



DVT can be difficult for doctors to diagnose, however an ultrasound can frequently detect a clot. Treatment is aimed at preventing the clot from enlarging and from becoming an embolus. Occasionally people need to be hospitalized, but some can be treated at home. Swelling of the leg can be helped with bedrest, leg elevation and sometime compressions bandages. Medications to prevent clot formation and sometimes medications to dissolve the clot may also be used. In more complicated cases, filters may be placed inside the large veins to prevent the vein from dislodging to the heart or lungs.

Vascular Malformations

Most vascular malformations are genetic — meaning you are born with them. Although these lesions/conditions are present at birth, they may not be visible until weeks or even years after birth. While they sometimes seem to grow quite rapidly, their growth is usually gradual and steady during the first year of life.

There are several sub-types of vascular malformation: capillary malformations, venous malformations, lymphatic malformations, arteriovenous malformations, and combined malformations. The severity varies greatly both within and among each group. Also, because these malformations are made up of vessels, and blood flows through these vessels, they are sometimes categorized as either slow or fast flow.

Venous Malformations

Venous malformations (VM) are superficial or deep veins (or both) that are either abnormally formed or unusually dilated. VMs can be genetic or acquired. Although most VMs are always present at birth, they may not show up until years later. Some VMs may be acquired, but the causes are not well understood. VMs usually are slow growing and usually grow as the body grows. However, certain situations such as surgery, trauma, infection, hormonal changes (like puberty, pregnancy, menopause) may cause a more rapid growth. VMs are most common in the legs, but may be found in anywhere in the body.

There is a wide variation of VMs and their appearance depends on their location, whether they are superficial or deep and whether they are localized or diffuse. If they are located in the skin, they may be visible as maroonish-red to purplish-blue, depending on how deep they are. Usually the closer they are located to the skin, the darker the color. A deeper lesion may not show color and only reveal itself as a protruding mass.

The symptoms of VMs vary greatly. Most VMs are benign and never cause a problem. Depending on their nature, size and location others can be very problematic causing swelling and pain. Treatment also depends on the nature, size, and location. VMs close to the skin can be treated with sclerotherapy, cutaneous laser, or surgical excision.




Insufficient venous return results in increased pressure in the capillaries with. Signs and Symptoms Stasis dermatitis can begin so slowly that it is barely. Information about Venous Stasis Dermatitis and Venous Ulcers and other common conditions of the foot. In severe cases of long-standing venous stasis, the skin. Stasis dermatitis (also known as “Congestion eczema,” “Gravitational dermatitis,. Types of Stasis dermatitis including their causes, diagnosis, and related symptoms from a list of total causes of symptom Stasis dermatitis. Stasis dermatitis causes a red, itchy rash on the lower legs. List of disease causes of Stasis dermatitis, patient stories, diagnostic guides.

Stasis dermatitis is a red itchy rash on the lower legs. Poor circulation in the veins (venous insufficiency) can lead to stasis dermatitis and ulcers (craters) in the. Diagnosis and medical treatment of stasis dermatitis Stasis dermatitis is inflammation of the skin of the lower legs caused by chronic venous insufficiency. Symptoms may be minimized if the underlying condition and swelling. Diagnostic checklist, medical tests, doctor questions, and related signs or symptoms. Overview, Causes, & Risk Factors; Symptoms & Signs; Diagnosis & Tests; Prevention & Expectations; Treatment & Monitoring These symptoms are worse with standing, and are relieved when the legs are elevated. The rash can be dry and scaly or can weep and form crusts. Stasis dermatitis is a skin condition due to the buildup of fluid.




A World-Class Academic and Health Care System

Duke Medicine conceptually integrates the Duke University Health System, the Duke University School of Medicine, and the Duke University School of Nursing.

It is the combination of research, clinical care, and education that takes place through the efforts of our faculty, staff, students, and trainees at many different sites throughout our region and worldwide.

As a world-class academic and health care system, Duke Medicine strives to transform medicine and health locally and globally through innovative scientific research, rapid translation of breakthrough discoveries, educating future clinical and scientific leaders, advocating and practicing evidence-based medicine to improve community health, and leading efforts to eliminate health inequalities.

iPhone App Improves Hand Hygiene, May 16, 2011, by Jim Kling, (Dallas, Texas) — The iScrub application for the iPhone and iPod Touch records and analyzes hand-hygiene observations, and provides near real-time feedback without the need for transcription. The application improves hand-hygiene compliance in healthcare workers, according to a study presented here at the Society for Healthcare Epidemiology of America 20th Annual Scientific Meeting.

Hand-hygiene compliance is often tracked using observation, and feedback can take days or longer to reach healthcare workers. “For healthcare facilities, this task not only requires an additional investment of staffing, but more importantly, it means that compliance rates are already out of date when presented back to healthcare workers. Rates might be from the week or month previous, for example,” said Jason Alan Fries, a PhD graduate student in computer science at the University of Iowa, in Iowa City, who presented the research, in an interview with Medscape Medical News.

To standardize the recording and collection of such data, the researchers developed iScrub and combined it with a Web site that rapidly generates reports.

To determine the efficacy of iScrub, the researchers tested it with a 34-week deployment at a single unit at the University of Iowa Hospitals and Clinics. Observation data were transferred to a rotating screen saver that displayed summary statistics, which were updated each time new observations were added. Nursing leadership was supplied with 2 iPod Touches loaded with iScrub. They were given no instructions about when or how many observations should be made.

Users who had no experience with iPhones were comfortable using the application with little instruction. In all, 8982 observations were made with iScrub (264.18 per week; standard deviation, 169.55). The researchers noted an overall statistically significant increase in hand-hygiene compliance rates among 11 types of healthcare workers during the study period (trend estimate, 0.0260; model-based standard error, 0.0096; P = .0065).

“I think [it illustrates] the importance of near real-time feedback when it comes to hand-hygiene compliance. Hospital employees know that, in the aggregate, compliance is less than it should be, but how many healthcare workers actually know what their own unit or job-class level of compliance is on any given day? When rates are presented to healthcare workers in the form of week-old averages aggregated across many different roles within a hospital, it is easy to dissociate that compliance rate from an individual’s current performance,” said Mr. Fries.

The real-time nature of the feedback was also emphasized by Steven Gordon, MD, chair of the Department of Infectious Disease at the Cleveland Clinic in Ohio. “I think that’s what’s most interesting. It provides real-time feedback to the ward. When they put this in place over a half-year period, compliance increased. Hopefully, that’s cause and effect,” Dr. Gordon told Medscape Medical News.

The study did not receive commercial support. Mr. Fries and Dr. Gordon have disclosed no relevant financial relationships.

Society for Healthcare Epidemiology of America (SHEA) 20th Annual Scientific Meeting: Abstract 69. Presented April 2, 2011




Parakeets arrived to roost for the night in Ashford.  Volunteers with Project Parakeet watched the arrival of the birds at a park in the suburbs of London. Andrew Testa for The New York Times





The New York Times, May 16, 2011, by Elisabeth Rosenthal, STANWELL, England — The evening started peacefully enough at Long Lane Recreation Park in the western suburbs of London, disturbed only by the occasional rumble of a distant jet landing at Heathrow Airport. But just before sunset, five bright green missiles streaked through the air toward a row of poplars at the park’s edge.

Within minutes, hundreds more of the squawking birds — in formations 10, 20, 30 strong — had passed above the tidy homes and a cricket club, whizzing toward their nightly roost.

Individually, any of the rose-ringed parakeets could be the star of a DreamWorks film, electric green with bright pink beaks and the voluble personalities that have long made the tropical species a popular household pet. But for people who frequent the park or live nearby, the visceral experience is more like “The Birds” — albeit with more color and a much noisier soundtrack than the Hitchcock film.

Native to the Indian subcontinent and sub-Saharan Africa, the rose-ringed parakeet is enjoying a population explosion in many London suburbs, turning a once-exotic bird into a notorious pest that awakens children, monopolizes garden bird feeders and might even threaten British crops.

One rough estimate put the population in Britain at 30,000 a few years ago, up from only 1,500 in 1995. Researchers at Imperial College London are now trying a more scientific census through its Project Parakeet, which enlisted volunteer birders around the country for simultaneous counts on a recent Sunday evening.

“I was delighted when I first saw one in my yard, but when you have a flock of 300, it’s a different matter,” said Dick Hayden, a retiree who was volunteering at Long Lane Park. “They eat all the berries. They ate all the food from my feeder in one day; it was ludicrous. I had to stop putting it out because it got too expensive.”

There is wide agreement that the Adams and Eves behind the current population boom did not fly here from Asia or Africa but escaped from British pet cages or were intentionally released by their owners. The great mystery is what allowed the parakeets to procreate with such phenomenal success just in the past decade.

Throughout much of the 20th century, there have been occasional sightings around Britain of escaped parakeets, which are hardy enough to survive the foothills of the Himalayas. But their numbers remained low, and most scientists assumed that they were not adapted well enough to breed readily.

Theories abound. Is it that gardeners are planting more exotic ornamental plants, effectively providing imported food to match an imported bird species? That suburbanites are installing more feeders and putting out more seed? The booming British gardening industry guards sales figures and has provided little guidance.

Alternatively, some scientists suggest that a slightly warmer climate has indeed helped tip the balance, perhaps increasing the parakeet’s metabolism during its February breeding season, bolstering the growth of some of its favored food or killing off a predator.

“Being tropical, they’re used to a milder climate, and they’ve arrived here during a long spell of warm years,” Grahame Madge, a spokesman for the Royal Society for the Protection of Birds, noted. Yet the parakeets also did fine over the past two winters, which were uncommonly cold.

“The jury’s out,” Mr. Madge said. “I’m not aware of any predators being removed. I’m not aware of any environmental trigger that set this off. I’m not convinced that climate is playing into it.”

Perhaps the answer lies in the numbers game that prevails in any dating venue: once the population passed a certain threshold, it was more likely that each parakeet could find a mate and make a home in the suburbs.

The new bird census may help shed some light on the trend. Scientists, birders and policymakers are “waiting with bated breath for these latest numbers,” said David Leech, senior research ecologist at the British Trust for Ornithology. “It’s absolutely fascinating to have a species come in and proliferate like this; we’ve never seen that before. But we need to know a lot more so we can understand how they’ll spread.”

British officials are watching trends closely since the parakeets have proved major agricultural pests elsewhere, ravaging crops in places like India. So far, they have shown little predilection for leaving Europe’s cities and suburbs for agricultural areas. (Far smaller flocks of rose-necked parakeets have also arrived in other European cities like Brussels and Amsterdam.)

There is also concern that the wily parakeet will out-compete more restrained British birds like the nuthatch, since both species nest in holes in old trees.

So far British scientists have not documented either problem, said Hannah Peck, a graduate student with Project Parakeet, but they remain watchful.

“I saw one have it in with a jackdaw,” she said, referring to a British crow that is itself no shrinking violet. “The jackdaw lost.”



Male shows black bib, narrow black and pink collar, extending from the bib, around the cheeks, to the nape sides where it tapers into a fine point. This half collar is bordered behind by narrow pink line extending across the nape, below an indistinct bluish crescent on the hind crown.

Flight feathers are darker green above than below where they are mostly grey. The tail has bluish-green central rectrices, and ochraceous undertail feathers.

Female has only a dull emerald-green collar, and lacks blue, pink and black on the head.

Juvenile resembles adult female, but it shows yellower plumage, tail is shorter and the pink bill is pale-tipped.

The Rose-ringed Parakeet’s typical call is a loud shrill, “kii-a” or “kii-ak” while flying, or when perched on a tree. Other loud calls may be heard, such as “kyik-kyik-kyik”.
In captivity, it is a very good imitator for home noises, and it is able to produce some words.

Rose-ringed Parakeet is common in cultivated areas, urban parks and gardens, open countryside with trees, palm-trees thickets, dry and open forest. It also may be found in semi-desert areas and second grow open jungles, mainly in lowlands. It frequents semi-desert savannahs with short grass, open bushy areas, wooded valleys and evergreen forests.
This species is now common in the large urban parks.



Rose-ringed Parakeet ranges from Central Africa to Uganda, southern Asia, India and Sri Lanka.
It has been introduced in Middle and Far East, North America, England, the Netherlands, Belgium and Germany. It is very cosmopolitan.



Rose-ringed Parakeet is a foolhardy and opportunistic bird. It has been introduced as cage-bird, but this species is able to adapt very well. It lives in more or less large groups in most of the big cities.



In their native areas, they gather in order to invade grain and fruit crops, and they also may be found in granaries where they open the grain sacks with their hooked bills. They often quarrel around these food sources.



During the breeding season, the groups disperse. Some courtship displays show the female rolling the eyes while twittering, and drawing semi-circles with the head while she moves the wings. At the same time, the male struts. They touch their beaks, and the male performs courtship feeding to the female while it raises one leg. At this moment, both birds utter soft sounds.
The Rose-ringed Parakeet is monogamous.



Rose-ringed Parakeet performs fast and direct flight, with rapid wing beats. In flight, the dark flight feathers are conspicuous.



The Rose-ringed Parakeet’s nest is a hole in tree. But when they live in towns, they can nest in any available high cavity, such as a crevice in a wall, under a roof, an old magpie nest… The nest is lined with rotten wood.



Female lays 3 to 4 eggs. Incubation lasts about 22 to 24 days, by both parents, but mainly by female. She raises the young too, sometimes helped by the male.

The young fledge about 40-45 days after hatching. They reach the adult plumage at 18 months, and complete adult plumage at 32 months of age.

The Rose-ringed Parakeet feeds on seeds, berries, flowers and nectar. After the breeding season, in some places, they arrive in groups and feed on grain, rice and maize in cultivated areas, but they also devastate orchards and coffee plantations. In California, they consume pecan nuts, buds and varied fruits.



Rose-ringed Parakeet is relatively common, and now, it may be found in the large urban parks in the world.

Before you make plans to travel for business or pleasure, you might want to refer to this world map