Wednesday, November 30, 2005

Medical students’ skulls being filled with mush

Student BMJ is a journal for medical students from the BMJ publishing group. In the November 2005 issue is an article on an alternative modality called Ayurvedic medicine. Ayruveda, the article says, is an ancient healing tradition with roots in India. It goes on to say that Ayruvedic tradition describes health and disease in terms of three fundamental constitutional principles called the doshas. Stephen Barrett’s expose on Ayruveda reports that “Ayurvedic proponents have claimed that the symptoms of disease are always related to the balance of the doshas, which can be determined by feeling the patient's wrist pulse or completing a questionnaire. Some proponents claim (incorrectly) that the pulse can be used to detect diabetes, cancer, musculoskeletal disease, asthma, and ‘imbalances at early stages when there may be no other clinical signs and when mild forms of intervention may suffice.’”
The BMJ publishing group, a division of the British Medical Association, says its mission is "To publish intellectually sound material that will serve the needs of doctors, members, other health professionals, the scientific community, and the public." Its premier journal, BMJ, is widely regarded as a champion of evidence based medicine. So why might a paper on an ancient healing art be published in Student BMJ? To increase students’ cultural awareness, or to alert them to the alternative treatments patients are seeking, perhaps? No. This article in SBMJ actually promotes Ayruveda. The article asks “Is scientific medicine the only way?” The author notes “Studying Ayurveda provided me with an alternative system for categorising and describing states of health and disease.”
So much for intellectually sound material.

Heparin induced thrombocytopenia and open heart surgery—news from Chest 2005

The annual meeting of the American College of Chest Physicians recently took place in Montreal. One of the presentations (reported in eMedicine news) concerned the prevalence of heparin-platelet factor 4 (HPF4) antibodies in patients about to undergo open heart surgery. HPF4 antibodies are found in patients with heparin induced thrombocytopenia (HIT) and are instrumental in its pathogenesis. The Milwaukee investigators screened patients before surgery and found antibodies in 5.4%. Antibody positivity was associated with longer ICU stays and a higher incidence of prolonged mechanical ventilation, limb ischemia, renal dialysis and gastrointestinal complications. These findings raise the question of whether all cardiac surgery candidates should be screened.

I’m anxious for some details not available in this sound bite version. What was the mechanism of the bad outcomes associated with antibody positivity? How many of those patients actually met criteria for HIT?

We previously knew that many cardiac surgery patients (up to 50 %!) treated with unfractionated heparin (UFH) test positive for antibodies during their perioperative course but of those only 2% develop HIT. In contrast, fewer orthopedic surgery patients treated with UFH develop antibodies but substantially more antibody positive patients in the orthopedic group develop HIT. Thus the presence of antibodies is more predictive in orthopedic patients than in cardiac surgery patients. [1]

An iceberg model has been proposed for HIT. [2] At the base of the iceberg is a relatively large number of patients who have antibodies. Toward the surface is a smaller number who develop a drop in the platelet count, and at the tip of the iceberg are those who develop thrombosis. The interacting risk factors are complex and the actual number of antibody positive patients who develop HIT seems to vary with the patient population, as the above data suggest.

Tuesday, November 29, 2005

A warning form the Infectious Disease Society of America

The Infectious Disease Society of America (IDSA) has written a white paper about the rising problem of antimicrobial resistance. Compounding the problem is an alarming trend: research and development for antibiotics is waning. After investigating the problem for over a year the IDSA concluded that antibiotic development is not profitable in today’s environment. The executive summary warns “The pipeline of new antibiotics is drying up. Major pharmaceutical companies are losing interest in the antibiotics market because these drugs simply are not as profitable as drugs that treat chronic (long-term) conditions and lifestyle issues. Drug R&D is expensive, risky, and time-consuming. An aggressive R&D program initiated today would likely require 10 or more years and an investment of $800 million to $1.7 billion to bring a new drug to market.”

The report recommends incentives such as patent extensions, liability protection, and relaxation of FDA requirements for clinical studies. It warns of emerging serious infections without effective treatments unless there is prompt action to promote antibiotic development.

Elevated troponin in non-cardiac critical illness---what does it mean?

This is a controversial situation that comes up frequently in the ICU, especially in patients with sepsis. It was the subject of a prospective study published September 28 in Critical Care. Earlier literature has suggested that elevated troponin in the setting of sepsis is associated with left ventricular dysfunction [1] [2] [3] [4] [5] and mortality [2] [6] [3] [4] [5]. These same studies demonstrate elevated troponin in close to half of sepsis patients.

In keeping with previous reports, the Critical Care paper found troponin elevation in almost half of their population of ICU patients. About half of those with elevated troponin were found to meet previously defined criteria for myocardial infarction. The new finding in this study was that among patients with elevated troponin only those meeting criteria for myocardial infarction had a worse outcome. Troponin elevation absent other criteria for MI was not associated with a worse prognosis.

Although the mechanism of elevated troponin is non-cardiac critical illness remains uncertain this study adds significantly to our understanding of the problem.

Monday, November 28, 2005

Another paper challenges metformin’s contraindications

This time it’s specifically in reference to heart failure, which is listed as a contraindication in the product labeling. As I recently blogged, the vast post marketing experience with metformin indicates that it is safe, and that lactic acidosis has been difficult to attribute to it despite widespread contraindicated prescribing.

This large observational study from Diabetes Care showed that heart failure patients treated with metformin, as monotherapy or in combination with sulfonylureas, had significantly lower rates of mortality and hospitalization than those treated with sulfonylurea monotherapy. The average follow up period was 2.5 years. The mechanism may be the alleviation of hyperinsulinemia.

The authors suggest that the strict labeling of metformin may represent unfounded concerns which have deprived patients of beneficial treatment, and challenge the precautionary principle with this statement: Although "patient safety" studies often seem to focus on finding and reducing the use of previously widely prescribed medications that are of unproven benefit or even harmful, our study should serve as a reminder that there is another side to the patient safety coin—some medications that are currently considered contraindicated may have been defined as such on the basis of little or no evidence beyond pathophysiological rationale. Since this rationale alone is considered insufficient evidence for efficacy, it should also be insufficient to declare harm. We believe that the onus in the patient safety literature should shift to acknowledge that both types of patient safety issues can lead to suboptimal prescribing practices.
Well said.

Hemostatic risk factors for arterial thrombosis

Although venous thrombophilic states have recently been well defined the hemostatic (non-atherosclerotic) risks for arterial clotting have been less clear. The topic is reviewed here in Atherosclerosis, Thrombosis and Vascular Biology. The review points out that homocysteine, fibrinogen, C-reactive protein, lupus anticoagulant and anticardiolipin antibody assays are justifiable tests. Somewhat surprisingly, in those patients with concomitant vascular risk factors, in those <55 years old, and in women, testing for factor V leiden and prothrombin mutation may be justifiable.

Saturday, November 26, 2005

More resources on CA-MRSA

[1] [2]

More evidence regarding panic disorder and heart disease

I recently posted this regarding myocardial perfusion changes during panic attacks. Now this study (Psychosomatic Medicine) suggests an epidemiologic association (almost two fold risk of coronary disease in patients with panic disorder) which is even worse if depression coexists.

Friday, November 25, 2005

The emerging threat of community acquired methicillin resistant Staphylococcus aureus

Methicillin resistant Staphylococcus aureus (MRSA) has been well known for decades as a nosocomial pathogen. More recently MRSA has been increasingly reported in the community. Community acquired MRSA (CA-MRSA) tends to present as a new strain with features which distinguish it from the more familiar nosocomial MRSA. I found this helpful review in September’s Mayo Clinic Proceedings. (The abstract is linked here. Full text open access will be available in March 2006).

Although some community isolates appear to have escaped from hospitals, the new strains (“true” CA-MRSA) arise de novo in the community. Here are some important distinctions pointed out in the review:

1) CA-MRSA has a unique genetic determinant of resistance---the type IV Staphylococcal cassette cartridge (SCC).
2) Unlike the “old” MRSA which has multiple drug resistance, CA-MRSA is typically sensitive to many non beta lactam antibiotics. Sensitivity patterns have regional variation and tend to show a typical pattern in a given region, which may be the clinician’s principal clue that CA-MRSA rather than the older strain is present.
3) CA-MRSA appears to be more virulent than other S. aureus strains, in part due to expression of the Panton-Valentine leukocidin.
4) CA-MRSA appears to have increased transmissibility and infectivity compared to other S. aureus strains.
5) Skin infections, soft tissue infections and necrotizing pneumonia are characteristic compared to other strains, and necrotizing fasciitis has been reported. Bacteremia and endocarditis are less characteristic.

Perhaps the most troubling aspect of CA-MRSA is its emergence as a cause of community acquired pneumonia. The authors state: “It is now prudent to consider CA-MRSA as an etiology of severe CAP in the correct clinical context. Severe necrotizing pneumonia with or without hemoptysis after an influenzalike illness in high-risk patients warrants therapy directed against MRSA.” The antibiotics of choice for pneumonia are vancomycin and linezolid.

Medical journals promote pseudoscience

Recently I picked on medical schools for promoting unscientific health claims [1] [2]. Today a medical journal got my attention and reminded me that the compromise of science by “mainstream” medicine is pervasive, and not confined to medical schools. What’s ironic is that the journal is BMJ, supposedly a champion of evidence based medicine. This week’s issue contains a review of the homeopathy promoting book “Passionate Medicine: Making the Transition from Conventional Medicine to Homeopathy.” Trouble is, the review is favorable to the book, giving it a four star (the highest) rating. Worse, four homeopathy promoting links are posted on the same page as the review.

BMJ has been taken to task for this sort of thing before and Quackwatch has BMJ on its list of nonrecommended periodicals.

Controversy in treatment of deep vein thrombosis

The treatment of deep vein thrombosis (DVT) has been controversial concerning prevention of the post thrombotic syndrome (PTS). Although systemic thrombolytic therapy is superior to conventional anticoagulation in restoring venous flow and preserving the function of the venous valves, it is associated with greater risk of hemorrhage and its effect on meaningful clinical outcomes has been disputed.

The hemorrhage risk of systemic thrombolysis has spurred interest in local interventional modalities including catheter directed local thrombolysis and catheter extraction techniques. This review from the American Journal of Medicine explores such techniques for the prevention of PTS and discusses the complication of venous gangrene (phlegmasia cerula dolens) which may be amenable to such strategies. It draws upon experience from the National Venous Thrombosis Registry suggesting improved health related quality of life outcomes for patients treated with interventional strategies as opposed to conventional anticoagulation alone.

The take home message is that physicians should be aware that such modalities are available and should familiarize themselves with the capabilities at their individual hospitals. Physicians should be prepared to resort to these strategies in the desperate situation of venous gangrene complicating massive DVT and consider offering the techniques to selected patients with DVT for the prevention of PTS.

The paper unfortunately did not mention that the widely accepted modality for prevention of PTS, compression stockings fitted to 30-40 mm Hg, work pretty well for this purpose.

Tuesday, November 22, 2005

More on the disruptive physician

Medscape General Medicine recently posted a provocative discussion on this topic, which I had blogged about November 5. There appears to be a burgeoning power struggle between hospital administrators (and their lawyers) and some rank and file physicians. It’s an unintended consequence of the Health Care Quality Improvement Act of 1986, which sought to protect hospital peer review. It provides immunities for hospitals in the peer review process, greatly enhancing their power to discipline physicians. Some physician groups are concerned that this has lead to abuses of peer review as hospitals, for a variety of reasons, increasingly seek to control doctors, setting increasingly narrow boundaries for behavior. A related development has been the emerging notion of the “disruptive physician.” Originally conceived with the good intention of addressing the genuine problems of incompetence and abusive physician behavior, the concept has come to be used as a pretext for stifling dissent, eliminating economic competition and abusing the peer review process.

This article and an accompanying editorial discuss the related issues of sham peer review and the abuse of the “disruptive physician” concept.

Monday, November 21, 2005

Hype versus evidence in patient safety

At last----a refreshingly sober assessment of medical errors and patient safety, here in CMAJ.

Don’t forget the thyroid in chronic urticaria

There is a high prevalence of thyroid autoimmunity in patients with chronic urticaria. The patient with urticaria and anti-thyroid antibodies may be euthyroid, hyperthyroid or hypothyroid. The mechanism of the association is poorly understood. The Thyroid and Urticaria is a review of the topic in the October issue of Current Opinion in Allergy and Clinical Immunology.

Some patients may achieve remission with L-thyroxine, which of course is indicated for those who are hypothyroid. Such treatment of euthyroid patients is not supported by high level evidence and is controversial.

Thyroid testing should be considered in patients with chronic urticaria. Knowledge of this association could help a patient and might come in handy some day on internal medicine boards.

Sunday, November 20, 2005

Irresponsible diet hype is being offered by the media

Don’t trust popular media for health information
The lay press lacks nuance and perspective in reporting on medicine and health, with the result that the consumer gets served an endless series of hyped up sound bites. These sound bites are often superficially contradictory, leading readers to wonder if medical science can make up its mind about much of anything. Nowhere is this better illustrated than in the popular coverage of diet trends.

The latest offering is this shocking headline: “Low-Carb Diet: An Alarming, New Danger.” Then, in bold type, the first sentence of the article reads “Low-carbohydrate diets may lead to dramatic weight loss, but dieters pay a big price for their thinner waistlines.” The article goes on to say that the diets lead to reduced myocardial energy storage and impaired cardiac relaxation. This is based on an Oxford University study that was apparently presented at the American Heart Association last week.

In attempting to dig deeper I was unable to find quality reporting on the study. The AHA will have some of the meeting presentations posted on the web later this month. I did find this from the British Heart Foundation, which sponsored the study. Their web page says that myocardial energy storage was measured by magnetic resonance spectroscopy. There were no clinical endpoints studied.

What’s irresponsible about the reporting is this study is far too preliminary and too low-level to warrant prime time. Specifically, the study period was all of two weeks, and the study population consisted of 19 subjects (the investigators themselves along with some of their friends and family!). Not exactly high level evidence. It’s hypothesis generating at best.

Next I did a Google news search and got this. Sure enough, the usual parade of contradictory sound bites appeared. The first few hits tell me low carb is bad (it reduces energy stores in the heart)---but, the next few headlines say it’s good for the heart (it helps improve the metabolic syndrome). So what’s the deal? Is low carb good for us? Yes and no, if you follow the popular press. Good last week, deadly today. What will it be tomorrow?

All this, of course, is rubbish. Science doesn’t move like the daily news. Its progress is gradual, with each new set of observations integrated cautiously with what was known before. There are no pat answers about low carb diets. They are probably good for some patients and bad for others. Basic research paints an enormously complex picture and suggests that it depends on one’s genetic makeup and associated risk factors.

If I were not such a passionate believer in open sharing and expression of ideas I’d be calling for a media ban at scientific sessions. I guess we shouldn’t blame them for being faithful to the interests of their stockholders. After all, hype sells.

The down and dirty on avian flu

Here’s some information from the infectious disease folks at Vanderbilt (Vanderbilt Reporter, November 4) which cuts through the hype and tells you the essentials.

Saturday, November 19, 2005

Hypertensive headache?

We were traditionally taught that hypertension is a silent killer, and that the notion of hypertensive headache is a myth. This meta-analysis in Circulation reports that antihypertensive treatment prevents headache, NNT=30, without regard to antihypertensive class. Four classes of medication with differing mechanisms of action were studied. Maybe our patients knew what they were talking about all along.

Community acquired methicillin-resistant staphylococcus aureus: what to tell the family

Many young and otherwise healthy patients are now being hospitalized with community acquired methicillin-resistant staphylococcus aureus (CA-MRSA) infections. Family members, taking notice when we place these patients on contact isolation, naturally want to know if they should take similar precautions when the patient goes home. Here’s a little blurb from Patient Care on how to counsel patients and family at discharge.

This is a big deal for a couple of reasons. First, as pointed out in the Patient Care article, CA-MRSA seems to be more transmissible than the “old” and more familiar MRSA. Worse, at least some CA-MRSA strains are hyper-virulent, associated with severe and rapidly progressive infections such as necrotizing pneumonia, due in part to the Panton-Valentine leukocidin. The issue of CA-MRSA pneumonia was reviewed in last April’s Current Opinion in Infectious Disease (subscription required).

This expose of the Canadian health care system

is anecdotal but compelling. The 25 minute film, available here, is preliminary to a full length documentary that will be out in 2006. Thanks to Dr. Helen for the link.

Friday, November 18, 2005

Giant cell arteritis

Here’s a review on a must not miss diagnosis, giant cell arteritis (GCA). Of particular interest to me are the following points:

1) GCA can have unexpected late extra-cranial manifestations such as aortic aneurysm.
2) Steroids must be started as soon as the diagnosis is suspected and need not await temporal artery (TA) biopsy. Biopsy results are not affected by several days of steroid treatment. (This comes in handy if the patient presents with signs and symptoms of GCA late on a Friday afternoon).
3) Bilateral TA biopsy is sometimes necessary.
4) Combining the erythrocyte sedimentation rate with the C-reactive protein is superior to either test alone. In a population of patients undergoing TA biopsy, combined abnormal results of both tests was associated with a specificity of 97%. *

Thursday, November 17, 2005

What is the supposed mechanism of homeopathy?

Where better to find out than from its supporters? Here’s a pro-homeopathy alt med blog found via the Health Fraud List. This post from the blog outlines the “mechanism.”
Concerning the dilution of the remedy it says “Once we reach the 12C potency, according to chemical science, there should be no more physical substance left in the dilution……..Potencies above 12C work very effectively as though there was still a material substance present. Even though there is nothing left of the original physical substance, the medicine acts as though there were.” Then how could there be any biological effect? Reading on----“the vital force in the water, which now holds the impression from the original substance, acts upon the vital force of whoever takes the medicine.”

So, let’s see. The original active ingredient, though diluted so many times that no molecules remain in the water, leaves an “impression.” That impression is held in the vital force of the water, which in turn acts upon some vital force in the patient. Got it? Aren’t you glad this is supported by your tax dollars?

Wednesday, November 16, 2005

Statin use in elderly patients

Here’s a review in Clinical Cardiology with some useful perspectives on statin use. It makes a case for the safety and effectiveness of aggressive lipid lowering across the spectrum of age and risk. Keep in mind one caveat: be cautious regarding choice and dose of statin in patients on clopidogrel to prevent stent thrombosis. (I previously blogged about that here).

Tuesday, November 15, 2005

How did pseudoscience get admitted to medical school?

My recent post (scroll down) entitled “What is happening to our medical schools” took medical education to task for promoting pseudoscience. A commenter (Retired Doc) asked how this was allowed to happen and suggested in his own insightful post that it may be a form of political correctness.

Several trends over the past 15 years are at play. In his book review of the Institute of Medicine Report on Complementary and Alternative Medicine Stephen Barrett points to a subsidiary of the NIH which has poured large sums of money into the promotion of bogus claims. This funding was paralleled by an explosion of consumer interest in Complementary and Alternative Medicine (CAM) driven by the Internet. These two forces created a substantial financial incentive for medical institutions to become involved in CAM.

And although to a large extent it’s about money, it’s not entirely about money. There is also an important philosophical shift towards postmodernism, in which political correctness plays an important part. The postmodern view has influenced not only art, literature and politics, but also science. It places the individual’s internal reality above any external truth. To the postmodernist it’s not THE truth but rather MY truth and YOUR truth. It asks “Who is to say one version of truth is more valid than any other.” One can begin to see how this might lead to an eclectic view of medicine.

The movement’s influence is described in this important paper in Lancet entitled Postmodern Medicine. Author JA Muir Gray notes in the introduction that “Postmodernism is characterised by relativism, namely that there are no such things as objective facts…..” Good news there for the alt med folks. It goes on to say “Postmodernism also challenges the objectivity that science has claimed is its defining characteristic as spurious and unsupportable, and although many different theories are encompassed by the term ‘postmodernism’, a suspicion of science lies at the core of such theories.” Gray points out that postmodern medicine is driven in part by increasing regard for patient values and preferences, the rise of consumerism over paternalism and increasing concern for the unintended adverse consequences of science. These are beneficial trends to be sure, but in his defense of postmodernism Gray doesn’t seem overly concerned about its disregard for science. Citing a striking parallel to my previous commentary on the mixing of science and pseudoscience in medical schools Gray notes “The relativism of the postmodern world can be seen in Blackwells, Oxford's most famous bookshop, where evidence-based texts on gastroenterology are sold alongside a book on colonic irrigation.”

I am reminded of a conversation with an acquaintance extolling the benefits of her favorite alternative modality. As I pressed for a scientific defense she finally relented and said “well, OK, I can’t explain how it works, but I just know it works for me.” On a larger scale such thinking is behind the fallacious attempt to justify pseudoscience by citing its rising popularity among consumers. Perception equals reality in postmodern thinking, no matter the science. Postmodernism is a dangerous trend in medicine and is a driving force behind the explosion of CAM.

Saturday, November 12, 2005

What is happening to our medical schools?

Abraham Flexner is turning over in his grave.Almost a century ago Abraham Flexner, a secondary school educator, was commissioned by the Carnage Foundation to study medical education in the United States and Canada. The conclusion of the Flexner Report was scathing. Medical education was a sorry state of affairs. (Download the original report here ---large pdf file).

As a result of the report medical schools closed, others merged, and those that survived instituted major reforms. Medical education for the twentieth century and beyond was to have scientific underpinnings. The Flexner Report has since been celebrated as a pivotal document in medical education.

But what would Abraham Flexner think of medical education at the dawn of the twenty first century? Have medical schools backslidden? Sadly, medical education has forgotten some of Flexner’s warnings, as evidenced over the past decade by the increasing uncritical acceptance of unscientific teaching in the medical curriculum. This conclusion is supported both by systematic research and examples such as this uncritical homeopathy promotion by the University of Maryland Medical Center. (Thanks to the Health Fraud List for this link).

I do not oppose the right to teach or practice alternative medicine, or patients’ rights to choose it. The problem is that much of alternative medicine is a separate realm, outside the biological model. Thus it can not “complement” science based practice nor can it be “integrated” with it. Yes, it’s a free market place of ideas. The homeopath, the colonic irrigator and the herbalist have every right to compete in this market and patients have a right to choose. I would submit, however, that their practices cannot be integrated with mine. And, although medical students need to be made aware that such practices exist, medical schools should not be promoting them.

Flexner asserts precisely this notion. Let’s examine a portion of the Flexner Report concerning science based medicine. (The portion of the Flexner Report discussed here has been reproduced on this page from Homeowatch). Referring to homeopathy and other unscientific methods as “dogma” the report notes “The ebbing vitality of homeopathic schools is a striking demonstration of the incompatibility of science and dogma. One may begin with science and work through the entire medical curriculum consistently, exposing everything to the same sort of test; or one may begin with a dogmatic assertion and resolutely refuse to entertain anything at variance with it. But one cannot do both. One cannot simultaneously assert science and dogma;”. So, from this passage in Chapter X of the report comes a strong message: institutions of medical education must decide what they’re all about. Choose science or choose another path. One or the other please, not both. Clearly Flexner’s mandate left no room for “complementary” or “integrative” solutions.

Another offering from the University of Maryland School of Medicine Center for Integrative Medicine is Reiki. The course description for Reiki level II says the student will learn to “send distant healing to others as well as to past or future events.” Maybe Harry Potter should apply. In the Advanced Reiki training course the student will “learn how to use crystals and stones with Reiki and create a Reiki grid that will continue to send Reiki to yourself and others after it is charged.”

This sort of thing is going on to an increasing degree at numerous medical schools. Here’s a sampling from the University of New Mexico Health Science Center. Or, just Google up any medical school and combine a search term for your favorite alternative modality.

I hope our medical schools don’t devolve into institutes for the eclectic healing arts. In 1910 Abraham Flexner cleaned house in American medical education. By 2010 we may need him back.

Medication discrepancies at the transitions of health care

Quality improvement efforts in medication safety have traditionally focused on errors during hospitalization. In contrast, medication errors at the transitions between hospital and home have received little attention. I pointed this out before. A recent issue of Archives of Internal Medicine contains this study which found medication discrepancies between home and hospital medication lists in about 14% of patients. Risk factors for discrepancies were the number of medications taken and the diagnosis of heart failure. Discrepancies were associated with an increased risk of readmission. The Joint Commission on Accreditation of Healthcare Organizations is now focusing on this problem. Attention to this aspect of quality and safety is long overdue.

Thursday, November 10, 2005

The Thrombosis Interest Group of Canada

This is an excellent open-access resource on clinical issues in thrombosis. It contains a series of evidence based topic reviews, a summary of the ACCP conference guidelines on antithrombotic therapy and more.

Tuesday, November 08, 2005

Guillain-Barré Syndrome

I think I’ll put this article from Archives of Neurology on the must read list for hospital medicine. This nuts-and-bolts review focuses on the supportive aspects of care (if you want the latest on IVIG or plasmapharesis you’ll want to look elsewhere). In the treatment of patients with Guillain-Barré Syndrome the devil’s in the details of such things as DVT prophylaxis, pain management, respiratory care, skin care and rehab. This review, while acknowledging a lack of high level evidence, covers them all nicely. I’ve linked to the abstract but the full text is worth having. It definitely belongs in your library if you’re a hospitalist or a critical care doc.

Sunday, November 06, 2005

Learning evidence based medicine by doing

I’ve commented before on the gap between the theory and practice of evidence based medicine. New York-Presbyterian Hospital/Columbia University has developed a unique method of teaching EBM to emergency medicine residents which may help bridge the gap. A series of two hour EBM exercises has been incorporated into the curriculum. The sessions, entitled “Evidence Detectives”, consist of a case presentation followed by a supervised exercise in all the steps of EBM, including question formulation (using the PICO format), “live” on line searching, critical appraisal and article selection, and finally discussion of applicability to the case at hand.

This project, in the early stages of development, impresses me as a wonderful way to teach the essential skills of EBM. I would like to see CME workshops of this type for practicing physicians.

In order to carve out time for the sessions some of the more traditional aspects of the curriculum were cut, with elimination of the traditional journal club and less time for didactics. (The elimination of the journal club concerns me. I’ve already blogged on the importance of “background reading”).

The project was reported in a recent issue of Academic Emergency Medicine.

Saturday, November 05, 2005

Are you a disruptive physician?

The phrase “disruptive physician” has been bandied about at medical staff meetings lately. Apparently, most hospital medical staffs have provisions in their bylaws for sanctioning physicians deemed to be disruptive irrespective of their clinical competence. I’ve always been a bit uneasy about this, since any behavior or opinion someone else (such as a nurse or an administrator) finds objectionable could be categorized as disruptive.

Of course there are occasional examples of physician behavior clearly detrimental to patient care such as intoxication, sexual impropriety and threatening or intimidating behavior so severe as to preclude an effective working relationship among staff. Such episodes require an organized, explicit institutional response. The notion of a disruptive physician policy to deal with these situations is sound. But how do you define disruptive behavior? Greg Piche in his Health Care Law Blog recently remarked “The definition of what constitutes disruptive behavior in most of these policies is left so inordinately broad and so diaphanously vague as to render them effective tools for silencing responsible criticism….” His examples of behaviors that could be considered disruptive are concerning; having a disagreeable personality or willingness to speak out against the administration could perhaps result in a disciplinary proceeding.

So this concerns me. Although the original notion of a disruptive physician policy may be valid it could have the unintended consequences of stifling original thought and dissent. This editorial from the Journal of American Physicians and Surgeons warns about abuse of the concept. Please read the whole article, particularly the little ditty at the end.

Disclosure: I have occasionally bumped heads by playing the medical staff curmudgeon role.

Friday, November 04, 2005

The list of drugs that prolong the QT interval and cause torsades de pointes

is growing so rapidly that clinicians need help in keeping up. Here’s a useful resource: The Center for Education and Research on Therapeutics at the University of Arizona Health Sciences Center, spearheaded by Raymond L. Woosley, MD, PhD Vice President for Health Sciences there. Dr. Woosley has an extensive background on the clinical pharmacology of antiarrhythmic drugs. The site is a frequently updated listing of drugs that cause or increase the risk of TDP. The lists are categorized according to degree of risk and strength of recommendation.

Thursday, November 03, 2005

Under diagnosis of alpha 1 antitrypsin deficiency

A survey in the September issue of Chest reminds us that we are under diagnosing alpha 1antitrypsin deficiency (AATD). The study of 1020 patients with AATD revealed an average of 8.3 years from symptom onset to diagnosis. 20% of patients went through four or more physicians before being diagnosed. Timeliness of diagnosis did not improve between 1968 and 2003.

AATD is easy to diagnose, so why are we doing so poorly? Clinicians under appreciate the fact that AATD can be present in any patient with COPD. It is not, as popularly believed, confined to the rare non-smoker with emphysema or to those patients with primarily lower lobe disease. Moreover, it may not be widely known that current guidelines cast a broad net for screening patients for AATD. In reviewing this topic I was surprised to learn that the World Health Organization, the American Thoracic Society and the European Respiratory Society recommend that ALL patients with COPD be tested for AATD.

The joint statement of the American Thoracic Society/European Respiratory Society was published in the American Journal of Respiratory and Critical Care Medicine in 2003. Here is a partial list of patients for whom screening was definitely recommended (type A recommendation):

1) Symptomatic patients with a diagnosis of emphysema or COPD
2) Patients with asthma whose pulmonary function does not completely normalize after aggressive treatment
3) Individuals with unexplained liver disease
4) Asymptomatic patients with persistent obstruction on pulmonary function tests with known risk factors
5) Adults with necrotizing panniculitis

Wednesday, November 02, 2005

Panic attacks---not so benign

They may be bad for your heart (American Journal of Cardiology).

COPD and cardiovascular disease

Two recent offerings from the medical literature suggest an association between COPD and cardiovascular disease that may be under-appreciated. In this study from Chest patients with COPD had twice the rate of hospitalization for a composite of cardiovascular outcomes, adjusted for pre-study cardiovascular risk factors. The follow up period was just under three years.

This paper from the European Heart Journal reports unrecognized heart failure in 20% of patients with stable COPD. Approximately half the heart failure cases had systolic left ventricular dysfunction and half had primarily diastolic dysfunction. Surprisingly, none had right sided heart failure. The authors suggest that right sided failure is characteristic of more advanced COPD than was represented in this study. The reasons for the association may be both physiologic (e.g. ventricular interdependence) and epidemiologic (overlapping risk factors, particularly smoking).