In positive: an example to follow, by José Luis Díaz

Hola a tod@s, my dear friends.

After more than 8 months, after suffering an infarction and return to tell the story, José wanted to continue telling us his experience during the subsequent follow-upAs many of you are fans of José, I asked him to write a post a few days ago, because he is at last to be discharged. Here it is:

The past day 6-current I was discharged by the Cardiac Rehabilitation Unit of the Cardiology Service of the Hospital General Universitario Gregorio Marañón in Madrid, after having suffered the night of December 24 an acute myocardial infarction.

On this occasion, although it may seem paradoxical, I would like to place on record my wonderful experience for the professionalism, the exquisite treatment and the immense affection that received me and other patients. All of us live at all times with our enormous vulnerability after the various cardiac events that we had suffered.

Proof of that, despite the high number of patients that make up each of the four groups every day following this programme, the healthcare providers always refered calling by our respective names and every day that lasted the program, they were interested in our physical and emotional state, giving us permanently  words of encouragement, without which we could never notice a bad gesture in any of the team members, despite the critical situation which is going through the Spanish public health system.

Finally, the toughest program part was the fact that I would accept that it had played to the end.

My most sincere and deep gratitude to the staff of such unit and particularly to María Ángeles, Teresa, Almudena and Silvia for their excellent work and for the immense love that carried out,  and congratulate all those who with their initiatives, their dedication and their efforts struggle every day for progress in the humanization of health in all areas, particularly in the intensive care.

Our particular idiosyncrasy frequently leads us to harshly criticize everything which, in our opinion, is not happening as it should be or how we had hoped or we would like it to take place and for this reason I consider opportune to highlight the excellent work carried out by many professionals, which certainly include the 'girls' dealing in the Centro de Especialidades de Peña Prieta "Hermanos Sangro " in the cardiac rehabilitation program.

A rehabilitated and grateful heart.
José Luis Díaz.

Oxycodone Hydrochloride

Download PDF

Download this Thunderbox Paper:

Oxycodone Hydrochloride


A Thunderbox is Australian slang for an old style outside toilet that was little more than a drafty wooden shed over a hole in the ground.

They also used a wad of papers (usually out of a magazine or newspaper) stuck on an old piece of wire for toilet paper. Life was rough back then. Hardcore.

These pdf files are a one page overview of a particular topic that you can print out and stick on the door of your toilet (hence thunderbox).

  • They will always be only one page.
  • Sometimes it will be VERY short (just a few lines).

The trick is to make it ONE thing for you to remember before the next paper is published.

To make this work you must commit to posting on your toilet door (you could even consider posting on the toilet door at work) and taking a moment to read over each time you………well, you know. Business.

The goal is to commit each paper to your long-term memory before the end of the week. So repetition is essential (as is business regularity).

Print it, stick it, study it.

Review of scorpion envenomation

Asian forest scorpion

Asian forest scorpion

3 out of 5 stars

Scorpion Envenomation. Isbister GK, Bawaskar HS. N Engl J Med 2014 Jul 31;371:457-463.


“O! full of scorpions is my mind, dear wife!”

With over 1700 species of scorpions found all over the world, this brief review article is much too short and unfocused to provide more than a superficial overview of its topic.

The authors point out that most scorpion stings cause, at most, minor toxicity with pain and other local effects only. Most serious envenomations are associated with the Buthidae family, which include the genus Centruroidesseveral of which are found in North America and commonly cause neuromuscular excitation.

Major toxicity is associated with α-toxins, which inhibit deactivation of voltage-gated sodium channels causing sympathetic and parasympathetic autonomic excitation, as well as the release of catecholamines epinephrine and norepinephrine. This can result in:

  • hypertension
  • myocardial injury
  • cardiogenic shock
  • impaired left ventricular function
  • hypotension
  • cardiac conduction abnormalities
  • pulmonary edema

Features of the sympathomimetic or cholinergic toxidromes can be prominent.

Use of antivenom in cases of scorpion stings is controversial, and this article really doesn’t provide much enlightenment regarding the pros and cons. The authors do note that although antivenom would seem to be more useful in cases of clinically severe envenomation, by the time clinical severity is apparent it may be rather late in the game — although antivenom can bind toxins and prevent progression, it does not reverse established injury. (A list of scorpion antivenoms available worldwide, as well as a summary of the effects of envenomation, can be found here.)

This fascinating video, featuring Dr. Leslie Boyer from the University of Arizona, makes the case for use of antivenom in stings by the Arizona bark scorpion (Centruroides sculpturatus):