Sunday, December 31, 2006

Evidence based medicine to the rescue

This is from last year’s BMJ but it’s timely. Somebody finally applied an evidentiary standard to all those hangover remedies. The final answer: none of ‘em work. Moderation is the key.

Top 10 issues in hospital medicine for 2006---issue 3: emergency department crowding

ER crowding seems to have reached a crisis level this year, attracting the attention of the Institute of Medicine and the medical blogosphere. The problem is well illustrated in a recent newspaper article from Arizona linked by Grunt Doc.

What’s the solution? The late medical humorist and author Robert Eliot, M.D. was fond of telling the joke about a man who cut his finger with a kitchen knife and went to the ER. After going through the main entrance he came upon two doors. The sign over one door said “critical” and over the other door “stable.” He went through the door marked “stable” and down a long corridor before coming to another set of doors, one of which was marked “illness” and the other “injury.” After going through the “injury” door he came to another set of doors, one of which was marked “blow” and the other “cut.” He examined at his finger, decided that the injury was indeed a cut and went through the appropriate door. The next pair of doors was marked “extremity” and “torso.” He opened the door marked “extremity”, walked down a corridor and found two doors marked “bleeding” and “not bleeding.” Because the bleeding had stopped by this time he went through the door marked “not bleeding” and found himself in the parking lot. Good case management?

Equally humorous was the Institute of Medicine’s solution recently published in the New England Journal of Medicine which said, in effect, “hospitals: cease patient boarding and ambulance diversion by just being efficient.” What’s humorous and patently absurd about this mandate is that hospitals have been under maximum pressure to improve efficiency and patient flow for 23 years. Thanks to the prospective payment system (DRGs) implemented in 1983 their very survival already depends on efficient patient flow. My previous post criticizing the Institute of Medicine is here. More critical commentary on the IOM recommendation can be found at DB’s Med Rants and Kevin M.D.

Hospitals can cut down on ambulance diversion with aggressive bed control strategies, but busy hospitals have not been able to eliminate it. St. Louis University, for example, despite intensive process changes geared specifically toward the problem, still diverts ambulances on average between 30 and 60 minutes a day.

Hospital administrators, reluctant to divert ambulances, sometimes allow their ERs to accept patients even when all inpatient beds are occupied. This results in worsening of crowded conditions since patients in need of admission have no place to go and must be “boarded” until an inpatient bed becomes available. Such boarding can take place wherever space happens to be available such as hallways, one day surgery or observation units or the ER itself with the location determined in many cases by staffing. In some states, however, regulations may dictate where patients can be placed.

Dealing with such conditions requires a spirit of cooperation and a seamless relationship between the ER and the rest of the hospital. Unfortunately, if some of Grunt Doc’s commenters or a recent thread over at the UCSF Emergency Medicine Listserve are any indication there is a culture of finger pointing, an “us against them” mentality which will prove counter productive to any solutions for ER crowding. I commented about this culture of blame here.

Saturday, December 30, 2006

Top 10 issues in hospital medicine for 2006---issue 4: the new Clostridium difficile strain

Clostridium difficile continued to emerge as an important hospital pathogen in 2006 and was the subject of a number of important review articles. I linked to them here, here and here.

What’s different about the new strain? It has a mutation which causes it to produce markedly increased quantities of toxin. This has resulted in an increase in treatment failure, relapse and mortality. The latest review on this hospital scourge was published in the November 21 issue of Annals of Internal Medicine.

Top 10 issues in hospital medicine for 2006---issue 5: perioperative medicine

The relationship between medical and surgical hospital services was adversarial in The House of God, representative of the hospital of a few decades ago. The epitome of good case management was to turf your patient to a competing specialty service whenever the opportunity presented itself. Nowadays that relationship is changing. A model of collaboration between hospitalists and surgeons is emerging.

The year 2006 saw the publication of three new resources in perioperative medicine which merit inclusion in this year’s top ten list:

The proceedings of the second annual Cleveland Clinic Perioperative Medicine Summit appeared in a September supplement to CCJM. There’s a world of helpful stuff there.

Guidelines for perioperative pulmonary risk assessment and management were developed by the American College of Physicians and appeared in the April 18 issue of Annals of Internal Medicine.

After a frustrating back-and-forth on just which patients should receive perioperative beta blockers the American College of Cardiology helped settle the issue, at least for now, with new guidelines.

Top 10 issues in hospital medicine for 2006---issue 6: outsourcing of hospital services

In a February 16 NEJM Perspective piece and an accompanying podcast interview Dr. Robert Wachter discusses new forms of outsourcing now made possible by electronic means including image interpretation, transcription and the electronic ICU (eICU). Outsourcing has been driven primarily by economic considerations and the need for night call relief for physicians. New ideas and wider forms of implementation, however, are likely to bring unanticipated benefits as well as unintended consequences and are sure to spark controversy.

Perhaps the best known forms of outsourcing are remote transcription services and remote interpretation of images. A more novel and ambitious form of outsourcing is the eICU. It is believed that the first eICU in the United States was started several years ago at Sentara Health Systems in the Hampton Roads area of Southeastern Virginia. Evidence suggests that mortality and length of stay in ICUs are improved with a dedicated intensivist model in which there is mandatory care of all patients by a critical care specialist. The Leapfrog Group and others which set standards for quality in health care recommend the dedicated intensivist model. The major problem in implementation is the shortage of critical care specialists. It is estimated that there may be fewer than half as many critical care specialists as there are hospitalists. The eICU may be a way to close this gap in implementation. Evidence that eICUs improve mortality and utilization is beginning to accumulate. This study in the journal Critical Care demonstrated that improvements in outcomes derived from the use of an eICU were similar to those reported for the dedicated intensivist model of on site critical care specialists.

How does it work? This description of the eICU at Sutter Health seems fairly representative. Critical care physicians and ancillary staff monitor electrocardiographic and physiologic data in real time, as well as laboratory data via direct computer interface from a remote location, perhaps hundreds of miles away. The eICU staff communicates with on site physicians and nurses via direct audio and video links, telephone hotlines and computer text messages. High resolution cameras zoom in to check patients’ pupils, examine the skin and read labels on infusion bags. Thanks to real time interface with the lab, the remote team will be aware of critical results before anyone else and when the contractual arrangement with the on site physicians allows, they can give orders directly to the on site nurses. Because the eICU control room is manned “24/7” by staff who are free of the competing demands of hospital rounds and the distractions of pagers the response time to abnormal lab tests and hemodynamic disturbances is shortened.

There are limitless possibilities. The eICU doctors can access physician orders, medication records and progress notes and thus can make daily reviews for compliance with evidence based quality “bundles.” Prompts from the eICU staff to the on site doctors thus have the potential to enhance compliance with DVT prophylaxis and other underutilized quality measures.

The skeptic in me realizes that bright ideas tend to be implemented, sometimes with irrational exuberance, ahead of evidence. The early promise of the eICU needs validation by more studies. In the meantime will it be viewed as a welcome practice enhancement or as something Orwellian? It all depends on your attitude.

Friday, December 29, 2006

Top 10 issues in hospital medicine for 2006---issue 7: medication reconciliation

For years hospitals’ efforts to curb medication errors ignored one of the most important aspects of medication safety: errors which occur at the transitions of care including admission, discharge and transfer from one facility to another. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO, which, by the way, in a week or so will no longer be JCAHO) set out to remedy the problem in an initiative known as medication reconciliation across the continuum of care. Although this, one of their more laudable efforts in some time in my opinion, was announced in 2005 it really got into high gear this year thus deserving mention as one of the top issues of 2006.

Although the concept is simple, implementation seems to have proven difficult judging from some of the forums I read. For many initiatives on patient safety big ideas tend to precede evidence, but in the case of medication reconciliation evidence is already trickling in that the process can save lives.

Top 10 issues in hospital medicine for 2006---issue 8: two debates put to rest concerning ALI and ARDS

The ARDS net sponsored Fluid and Catheter Treatment Trial (FACTT) released in May refuted the role of the PA catheter and supported a conservative fluid administration strategy thus helping settle the decades long wet-dry debate.

Top 10 issues on hospital medicine for 2006---issue 9: surviving sepsis guidelines under fire

Judge guidelines by the company they keep and not by the evidence. That seems to be the conclusion of the authors of a NEJM Perspective piece this year which was anything but evidence based. I blogged about it here and here.

There have been other responses to the Perspective article. Dr. Mitchell Levy, FCCM, responding to the criticisms in a recent interview which can be accessed from the Society of Critical Care Medicine podcast page, welcomes the Perspective piece as a starting point for discussion, but believes the authors’ criticisms of the sepsis guidelines are based on innuendo more than evidence. He also cites factual error in the article and wonders if the Perspective authors, whose publishing record seems to be slanted toward criticism of industry, have biases of their own.

He points out that the interests of Eli Lilly actually “dovetail” with the interests of patients because the use of their product activated protein C is supported by high level evidence. “Conflict of interest” is the knee jerk mantra invoked any time industry collaborates with science. But where is the conflict when industry’s role is in line with evidence and facilitates the adoption of best practice?

In another response entitled “Surviving Skeptics” Sean Townsend, M.D. addresses some FAQs about the Perspective piece.

Thursday, December 28, 2006

Top 10 issues in hospital medicine for 2006---issue 10: state of the hospitalist movement

As 2006 draws to a close it’s time again to reflect on important issues in the field of hospital medicine for the past year. As was the case last year the selections are confined to adult hospital medicine and reflect the opinions of a biased committee of one: me.

I ranked the state of the hospitalist movement first last year. I’m ranking it number 10 this time because 2006 saw no movement-defining developments.

Economic pressures a decade ago created a niche for the movement in areas of heavy managed care penetration. The pressures of managed care relented, but a new niche was created as more and more primary care physicians chose to increase their efficiency by dropping hospital practice. These physicians can more easily stay on schedule in their offices, a patient satisfaction advantage counterbalanced by some patients’ frustration with receiving in patient care from strangers.

Some feel that hospitalist medicine is opposed to the agenda of primary care. Robert Wachter, M.D., a leader in hospital medicine, disagreed in a recent interview in Internal Medicine World Report: “Rather than feeling that hospitalists are another nail in the coffin of primary care, I hear from many primary care doctors that hospitalists have helped them tremendously. They realized long ago that they simply could not take care of sick hospitalized patients and manage their office practice simultaneously, and hospitalists have helped them make their jobs more survivable.”

Professional satisfaction seems to be shifting in favor of hospital medicine. It’s at an all time low in traditional primary care practice leading more and more internal medicine trainees to choose hospital medicine. According to Wachter, Society of Hospital Medicine surveys show a high rate of professional satisfaction among hospitalists. Wachter also predicted that the number of hospitalists needed may reach 50,000, a higher estimate than those made previously.

A few decades ago the hospital was a jungle, a combat zone inhabited by people with competing agendas and a culture of blame. Booby traps posed dangers to patients at every turn requiring the vigilance of the “superdoc” to head them off. The dream for the hospital of tomorrow is that of a safe place where a nurturing spirit of teamwork pervades the facility and computer enhanced system improvements all but eliminate errors. Movement along this path may gradually shift the role of the hospitalist from superdoc to systems management team member. But we’re not there yet. It’s a slow journey and in 2006 we’re somewhere between The House of God and the safe place. Systems improvement is too early in its development to solve the problem of patient safety. There will be a role for vigilance on the part of the individual hospital physician for years to come.

Wednesday, December 27, 2006

A master teacher discusses the importance of the electrocardiographic P wave

David Spodick, M.D., professor of Medicine and Cardiology at the University of Massachusetts, comments on under appreciation of the electrocardiographic P wave in Internal Medicine World Report, making the following points:

  • Analysis of the P wave is often neglected in discussions on electrocardiography.
  • Most P wave abnormalities are defined by P wave duration, the upper limit of which is 100ms.
  • P wave duration in excess of 100ms constitutes atrial conduction block, specifically intra-atrial or, more likely, inter-atrial block.
  • Atrial conduction blocks indicate increased risk of atrial fibrillation and stroke, and may reflect left ventricular dysfunction.

Background:

Review by Spodick in Mayo Clinic Proceedings on this subject.

Previous notes from Dr. RW on this subject.

Thursday, December 21, 2006

Woo invades Music City USA

This isn’t the West coast. It’s Nashville, Tennessee, the buckle of the Bible Belt. A recent article in the Tennessean profiles the Nima Holistic Wellness clinic in Nashville and the Center for Integrative Health at Vanderbilt University Medical Center just a few blocks away. Dainia Baugh, M.D., medical director of the Nima clinic, practices Reiki in order to “move energy through the body” according to the article.

What caught my eye was the picture of the pendulum used during the Reiki treatment which, according to the caption, swings in accordance with the flow of the patient’s life-force energy. Now if the body’s energy field moves a pendulum that energy can be harnessed. Use the pendulum’s motion to turn a small generator and store the electricity thus produced. We’re not talking about a large quantity of energy in one Reiki session---maybe enough to charge a patient’s hearing aid battery.

Dr. Baugh’s credentials are impressive. She’s a diplomat of the American Board of Internal Medicine and a former assistant professor of Medicine at Vandy. What do such mainstream credentials bring to the world of woo? According to Dr. Baugh “….our approach to alternative medicine is a little different because it's more scientific.”

Well, if they want to be scientific I suggest they make some controlled observations on the motion of that pendulum. They could start by suspending it over a patient from an inanimate structure rather than the hand of the practitioner. Suspend another pendulum over an unoccupied exam table to control for ambient air currents. Repeat the experiment in other settings with independent observers. It wouldn’t be rocket science. It might make a nice junior high school science project, but it this stuff really works there’s a Nobel Prize in it for someone along with a million bucks in the Randi Challenge.

It’s mysterious to how the energy works. As the Reiki practitioner’s hands move this way and that over the patient how does one keep track of where the energy goes? The Tennessean article offers us hard data on the energy flow of Dr. Baugh’s patient. She lost 20 pounds. If stored as fat that translates into 81,720 Kcal or 34,183,280 joules of energy which left her body. That’s 9.5 kilowatt-hours---not bad if you can harness it.

But I digress. I won’t be convinced until I see that pendulum experiment. I confess I’m not optimistic. I think it’s all woo. The launch of the Vanderbilt center is disturbing. Vanderbilt is on the cutting edge of science yet very traditional. I thought it would be the last bastion of scientific integrity, the last place on the planet where you’d find woo. Is there any hope?

Wednesday, December 20, 2006

Who needs medical knowledge, anyway?

In a recent MedGenMed Video Editorial Dr. Hampton Roy, Assistant Clinical Professor of Ophthalmology at the University of Arkansas for Medical Sciences said: “As physicians, we do not need to carry information about lab tests, medications, or dosages in our heads. We need a reliable ready source of information to consult……” With apologies to Rush Limbaugh, stop the tape! What does he mean, we don’t have to carry information in our heads? Sure, we make no pretense of knowing it all, but don’t we need to know anything? I guess not, in the minds of some. After all, we can just “go look it up.”

And what would that mean for the medical school curriculum? Just turn students loose with lap tops, subscriptions to Up To Date and lots of patients, I guess. Don’t laugh. It’s not far from a proposal in BMJ a few years ago in which the medical school of the future would train doctors primarily to be information hunters, eliminating lectures and exams in anatomy, biochemistry and physiology.

Dr. Roy believes patients can help close the resulting knowledge gap. Referring to the “reams of paper” patients often bring for their appointments he says: “Since we are now ‘partners’ with the patient in terms of diagnosis and treatment, we need to honor the patient's book of knowledge and provide our best guidance system.” But many patients, 44% in this study, have no desire to seek out medical information for themselves. Of those who do, few have the skills in literature searching and critical appraisal needed to apply the principles of evidence based medicine (EBM), without which clinical decision making becomes flawed. The task of making patient decisions evidence based is onerous, as I once blogged here. Although patients often bring their homework to the clinical encounter I’ve yet to be presented with a rigorous, critically appraised summary of the best evidence. If only it were so! More often I’m presented with a drug ad or the latest New York Times article---hardly evidence based.

Sunday, December 17, 2006

Frequently asked questions on woo and mainstream medicine

“Woo” is a term for certain implausible and outlandish claims of complementary and alternative medicine (CAM). The term has recently been popularized on the blogosphere by Orac and others and has been a subject of several recent posts of mine which have drawn numerous criticisms and questions. Rather than address them piecemeal in my comment threads I decided a more effective way to answer my detractors would be in the form of a frequently asked questions (FAQ) post, so here goes.

Many of mainstream medicine’s conventional treatments are not evidence based. Aren’t they a form of woo?
No. Although some conventional methods fail to measure up to best evidence they are at least based on known anatomy and physiology. They have some plausibility in the observable biophysical model in contrast to the “vital forces”, nebulous “energy fields” and “non-local powers of the mind” which are characteristic of woo.

You seem to focus a lot of your criticism on woo. Isn’t non-evidence based conventional medicine harmful too?
Yes, of course. Moreover, there are harmless forms of woo just as there are harmless conventional breaches of EBM. All departures from best evidence are problematic and need to be addressed, whether woo-based or not.

Then why make a distinction?
Because of important differences in the ways the problems manifest themselves. Mainstream medicine applies a double standard and that’s what I’m trying to expose. People in the mainstream are appropriately critical of conventional deviations from best evidence and are trying to correct the situation. But due to the nature of the problem---a complex interplay of system and cognitive failures---the fix is not easy. In contrast (and here’s where the real hypocrisy comes in) mainstream medicine uncritically embraces woo, applying to it a much easier evidentiary standard and often no standard at all. The remedy for the problem of woo would be much simpler, too. Mainstream medicine could simply say no. Woo, by definition patently implausible, is easy to spot. There’s nothing complicated about it. It’s not a system problem. It’s there in mainstream medicine purely by choice. That fact raises another important distinction. If mainstream departure from EBM is a complex system problem and woo is there by choice then woo constitutes a more serious ethical problem.

But if patients want woo shouldn’t we let them seek it out?
By all means. We must respect our patients’ right to choose, and there are plenty of woo facilities outside the mainstream which can accommodate them. It’s quite another thing, though, if we misinform patients by putting our mainstream reputations and credentials behind false promotions. It’s just plain dishonest.

I’ve been reading all these statistics about the increasingly large numbers of patients who are seeking alternative medicine, or “woo” as you call it. They’re even paying for it out of their own pockets. Shouldn’t we in mainstream medicine accommodate them?
Not unless we decide all we’re interested in is taking their money, or in basing best practice on a popularity contest. These don’t strike me as good reasons.

Some woo based methods seem to be little more than relaxation and exercise techniques. What’s wrong with that?
Nothing, as long as you don’t make false claims. Go ahead and recommend relaxation and exercise, but if you promote it, for example, as Qigong you’re promoting all the paranormal theories of “vital energy healing” that go with the package. If you’re a mainstream medical practitioner and put your good name and credentials behind such false claims you’re being unethical.

Now, will this settle the misunderstandings once and for all (as Dr. RW braces for the next salvo)?

Wednesday, December 13, 2006

Pseudoscientific indoctrination of social workers

Pseudoscience may wage a full frontal attack on your hospital or clinic, or it may sneak in through the ancillary services. Here’s some of the woo being taught at the University of Michigan School of Social Work.

If you note strange goings on when the social worker pays your patient a visit you might want to read this.

Recombinant factor VIIa: who, when and how

Recombinant factor VIIa is approved for bleeding episodes in hemophilia A and B patients who have circulating inhibitors to factor VIII and IX, respectively. Most of its use, however, is probably for a variety of off label indications including life threatening bleeding in patients on warfarin or with liver failure. The 2004 ACCP guidelines on antithrombotic therapy, for example, support its use in patients on warfarin with life threatening bleeding.

These off label uses, at times controversial, have created challenges for hospitals at the institutional level due to cost concerns. This paper from the American Journal of Health System Pharmacy describes how one academic institution, the University of Virginia Health System, addressed the problem. Evidence for various off label uses is cited and proposed guidelines for on and off label uses are provided.

Wednesday, December 06, 2006

When woo overlaps mainstream medicine can patients sort it out?

Emily in the latest Grand Rounds says this about my post on alternative medicine: Dr. R.W. Donnell, in Notes from Dr. RW, urges readers to beware of "woo" - scientifically unsupported alternative medicine - particularly when it's combined with allopathic offerings. Dr. RW, and others, I'd like your thoughts. Not to plug alternative medicine - ANY modalities used on patients should be tested if possible in randomized studies - but how can patients be sure that "standard" procedures and treatments are evidence-based? What about that full-body scan, or the drug that's been around so long no one's ever tested its safety in an RCT? Is that not, in effect, a form of woo, too?

How can patients be sure if a treatment is valid? In many cases they can’t----they have to trust us. That’s the whole point about fiduciary duty. Many of the woo providers of the world are easy to spot because they make no pretense about being based on Western science. What the patient sees is what the patient gets. The ethical problem, the real deception, comes from the mainstream’s more subtle promotion, hiding the woo behind its reputations and scientific credentials. It’s one thing when the shaman down the street tells patients they need a colon cleanse. It’s quite another thing, and far more concerning when Vanderbilt----Vanderbilt, mind you---promotes Qigong or UCSF promotes herbal tea to “boost the immune system.”

Emily correctly points out that conventional medical treatments aren’t always evidence based. She asks “Is that not, in effect, a form of woo, too?” The breach between evidence and practice to which she refers, let’s call it the quality chasm, while every bit as serious as woo, is not in fact woo in most cases. The quality chasm is not a result of outlandish or implausible claims, (e.g. that water has memory) and that’s what distinguishes it from woo. The quality chasm results from an extremely complex interplay of cognitive and system barriers to the consistent application of best evidence in practice. Mainstream medicine recognizes the need for widespread system change and promotion of evidence based medicine. Although there’s no simple fix to the quality chasm, many in mainstream medicine are trying, which is in ironic contrast to the fact that mainstream medicine also increasingly promotes woo. For the mainstream, especially academic medicine, to promote woo is to engage in unethical scientific pretense and active deception of patients. It seems to me that the solution to woo in the mainstream is much simpler than the quality chasm: Mainstream medicine just needs to say NO.

Monday, December 04, 2006

Metformin is associated with vitamin B12 deficiency

The mechanism is unknown. Via Archives of Internal Medicine

And it’s been scientifically proven----

---that your support of George W. Bush is inversely proportional to your sanity. The “study” in question, appearing as a press release ahead of publication, is being lapped up by the credulous liberal blogosphere. Orac on the other hand, himself not a big fan of George W., applies his usual dose of hard nosed skepticism, citing data mining, poor design and failure to consider alternate hypotheses, concluding that this study “…sucks. And sucks hard.”

To that I’ll just add that there might be a wee bit of a conflict of interest here---“science” with an agenda, perhaps. At least it was disclosed. Although the author describes himself as a “Reagan revolution fanatic” he believes George W. is “beyond the pale.”

Sunday, December 03, 2006

Atorvastatin and clopidogrel---continued concerns

A while back I reviewed the literature on the interaction between clopidogrel and statins, particularly atorvastatin. Although there were conflicting opinions the prevailing consensus was that the drugs could safely be used in combination. Now comes this study published in the American Heart Journal suggesting that the interaction is clinically significant. This retrospective study using administrative databases from Quebec was restricted to patients prescribed clopidogrel after undergoing coronary stenting. Patients receiving atorvastatin had an increase (!) in a composite outcome for vascular events at 30 days (adjusted OR 1.65, 95% CI 1.07-2.54). A delay in getting the clopidogrel prescription filled was also significantly associated with increased events.

The authors, acknowledging weaknesses in this study, were cautious in their conclusions and called for further studies, but this really concerns me. My take home messages are 1) in the early months following coronary stenting consider using a statin that is not a substrate for CYP3A4 and 2) upon discharge after coronary stenting send your patient straight to the drug store and consider dispensing a couple of clopidogrel tablets!

Saturday, December 02, 2006

Lyme disease activism versus science

It seems some Lyme disease activists are unhappy (via My Left Nutmeg) with the new IDSA guidelines on Lyme disease because of the guidelines’ recommendation for specific objective diagnostic criteria, the non-recommendation of months to years of antibiotic treatment and the non-recommendation of “alternative” nutritional supplements. Armed for battle, they even have the Connecticut Attorney General involved.

Lyme disease has been quack-fodder for too long and guidelines such as these are badly needed.

Friday, December 01, 2006

Auto repairs, alternative medicine and fiduciary duty

I went and got my car winterized the other day, just in time for the impending meteorological catastrophe. They told me I needed, among other things, a radiator flush. They took me through the steps in making the “diagnosis”, dutifully showing me their findings, but it didn’t really matter. Mechanically disinclined not-so-smart consumer that I am I ultimately had to take their word for it. It was one of those reputable quick-lube chains, trusted by housewives and little old ladies, with mechanics who were certified. I didn’t know exactly what that meant, but I figured it was something significant. It probably meant they had a certain level of expertise and could reasonably be expected to apply that expertise honestly to my service needs. In other words I had reason to trust them. I was entitled to certain assumptions about the service I would get, assumptions I couldn’t make if I had taken my car to, for example, the Griner Brothers’ Garage, where it’s strictly caveat emptor.

And so it is with medicine. I know it’s dangerous to compare medicine with auto repair, but there may be a useful analogy here concerning the responsibility of a person in a position of trust (and we’ll restrict the comparison to just that). In medicine we sometimes call it fiduciary duty. Our particular fiduciary duty to patients is to be and do what all those certifications and accreditations lead them to expect. They expect expertise, and for that expertise to be applied honestly. Moreover, the general public perception of that expertise, at least for us in mainstream medicine, is that it’s based on science. Most patients, when offered a particular treatment, believe that. Lacking any desire or ability to verify it independently they simply trust that it’s so. This presents an ethical problem when unscientific treatment methods are offered to patients (call it alternative medicine, call it what you will; I think Orac’s term “woo” should serve our purpose here as well as any other).

Now, in order to really parse the ethics of woo I would propose two broad contextual categories: stand-alone woo and integrated woo. Here are my definitions. Stand alone woo: woo which is offered by a clinic or institution as its major method of treatment. Integrated woo: woo which is promoted by “mainstream medicine”, accounts for a relatively small fraction of total treatment offerings and is more likely to be disguised as science.

This definition is somewhat imprecise and there are fuzzy areas. Some stand-alone woo providers, for example, have “MD” after their names and purport to “integrate” the best of woo with the best of conventional medicine. Nevertheless I place such institutions in the category of stand-alone woo because they major in woo, and that fact is usually patently clear to patient-shoppers. The average consumers know it when they see it.

Integrated woo presents the more serious ethical problem because the mainstream institutions (like, I’m embarrassed to say, my beloved medical alma mater Vanderbilt) are putting their good names, their certifications and accreditations, behind the woo they promote. Patients come, most of them anyway, expecting scientifically based treatment, and may be none the wiser when offered woo. After all, mainstream science-based providers wouldn’t promote something unscientific, would they? Why should patients expect them to? When they receive treatment based on an eclectic, mystical world view it's disguised, implicitly or explicitly, as science. The woo is more insidious, more subtle, which is why it’s all the more egregious. Patients are flat out being deceived unless, as recently suggested by anti-pseudoscience warrior Wallace Sampson, they receive explicit informed consent about the nature of the method being offered.

I have less of an ethical problem with the stand-alone woo providers. For one thing, maybe they don’t know any better. I’m convinced that they (many of them anyway) truly believe in what they do, are trying to make an honest living and have a heart for helping patients. (This is in contrast to the mainstream hospitals and medical schools which know better, or should know better). Secondly, the stand-alones, many of whom are openly dismissive about western science, aren’t nearly as pretentious about any scientific underpinnings as are the mainstream folks. As a consumer you know what you’re getting with the stand-alones. It’s caveat emptor, like going to the Griner brothers’ garage.

So, I say let the stand-alones compete in the open market place of ideas. To those in the mainstream for whom this shoe of integrated woo fits, clean it up. To medical school faculty who remain silent while the largest and most influential activist group of medical students on your campus promotes chelation for everything under the sun that ails a person, wake up. To physicians who care about evidence based medicine, if you see woo creeping into your hospital or clinic, speak out. To those in the mainstream who lend your good name to the promotion of quackery in your institutions, STOP IT! It’s unethical. It’s a violation of fiduciary duty.

Sleep deprivation and obesity

Add this study form rural Iowa to the mounting evidence for a link. Low self reported sleep duration correlated with high BMI. The study didn’t answer the question of causality. Does obesity cause poor sleep or does sleep deprivation contribute to obesity? Increasing evidence points to the latter. I suspect it’s a little of both.

From across the pond

NHS Blog Doctor, in linking to my Grand Rounds, inflated my civic pride by adding a plug for Northwest Arkansas and an image of an Arkansas Sunset. This must have taken some serious Googling! Although I still consider myself a resident of the hinterlands that’s changing rapidly. The NHS Blog Doctor correctly points out that Northwest Arkansas is one of the six fastest growing areas of the United States.

A cluster of sleepy little towns not so long ago, we’re morphing into a major commercial center due in large part to Walmart, whose corporate headquarters are here. The resulting business travel has spawned a thriving service industry, and the population growth has outpaced the influx of doctors. So, if you’re looking for a place to hang your shingle, give us a look.

Wednesday, November 29, 2006

FDA alert on methadone

They have an alert out concerning respiratory depression and QT prolongation. Via Journal Watch.

But, hey, this isn’t all that new. You read it here first! Let me add my bias here. I would go beyond what the FDA says, and consider methadone just as I would cardiac drugs known to prolong the QT interval and cause torsade. That is, I would get an ECG at the start of therapy and periodically thereafter. I would pay meticulous attention to interacting drugs and liver function. I would keep an eye on the patient’s potassium and magnesium. Is this overkill? Maybe. But don’t forget, as I mentioned in the post referenced above, that the Center for Education and Research on Therapeutics, a center of expertise on drug induced cardiac arrhythmias, has placed methadone in the highest risk category of QT prolonging drugs.

Libby Zion---the rest of the story

The recent Washington Post piece about the Libby Zion case (Via Kevin MD) might leave some readers on the edges of their seats! After mentioning all the speculations concerning some mysterious infection and the family’s rejection of that theory, the possible adverse drug effects and the disputed finding of cocaine in her system, what’s the final answer? What did the patient actually have? Is this one of those puzzlers? Do we get the answer next week?

Although not recognized or denoted as such in those days (rarely mentioned in the world’s literature before 1986 based on my quick Pub Med survey) Libby Zion had the serotonin syndrome.

Tuesday, November 28, 2006

Grand Rounds Vol. 3, No. 10

Welcome to Grand Rounds Vol. 3 No. 10! Many thanks to all who contributed, and special thanks to Nick for all the hard work organizing this event and for walking me, a first time host, through the process. Thanks also to blogger for sparing me one of their many unscheduled outages this particular day!

It’s trendy nowadays at traditional academic Grand Rounds for the speaker to disclose any potential conflicts of interest. Here are mine. I have no financial ties with drug or device companies. A Zithromax clock, a hand me down from National Nurses Day, graces one wall of my office. I have attended about four drug company lunches in the past year. That’s about the extent of any blandishments from Evil Pharma.

Although under appreciated, non-financial conflicts, perceived or real, are just as important as the financial kind. We all have them. I, for example, am a) a Christian, b) a member of the vast right wing conspiracy and c) a staunch adherent to the principles of science. (Note that a is not inexorably linked to b or in opposition to c). I’ve become opinionated and crotchety in middle age and have many biases. But not to worry, dear readers! I’ve done my darndest to keep those biases out of this edition of Grand Rounds. To that lofty end there will be no editor’s choice, best of the best, or best of the rest! Everything included here gets equal billing in hopes that this carnival will be a good time for all.

I’ve restricted my editorial prerogative to adding a running commentary, stream-of-consciousness style, to provide some structure to this incredibly diverse collection of links and perhaps liven things up a bit. I’ll sneak a few opinions in here and there, but you’ll know them when you see them. Well, enough of the preliminaries. There’s some heavy duty blogging to get to, so let’s rock and roll.

Mother Jones suffered through pandemic flu not long ago. Well, an inservice on pandemic flu, anyway. On her day off, no less.

Enjoying the eye candy on the wards? Dr. Derlet of Rural Pediatrics has some sobering advice for health care professionals on what not to wear. Strutting too much of your stuff may turn heads but it lowers patients’ confidence. And that’s evidence based! Worse yet, the credentialers are watching how you dress. Just ask our favorite credentialer Rita over at MSSPNexus blog! Yikes!

Are there moral absolutes? Is there a free lunch? Rohin, author or The Daily Rhino, finds himself in an existential crisis as he ponders these weighty questions after making the transition from student to doctor. It’s tough trying to balance medical student idealism against the allurement of Big Pharma freebies.

Wandering Visitor has some friendly infection control advice in Don’t Get Raunchy with Mr. Open Sores. Trouble is, Mr. Open Sores isn’t likely to tell you he has a problem. Nuff said. While we’re on the subject of taking medical advice, Dr. Nic at Shoe Money Tonight explains why it’s easier said than done.

I can remember being abused as a medical student and house officer, but I thought such abuse went out like the dark ages. Not so according to Anthony Rudine, blogging on the Medscape Med Students blog. In reading his post (recommended by Medscape editor Christine Wiebe) it appears that the grand tradition of med student abuse, like fraternity hazing, is alive and well. Isn’t it about time for a kinder, gentler medical curriculum?

Another Medscape student blogger (again, thanks for the tip, Christine) Ali Tabatabaey, reflects on one year of blogging on his first blogiversary (or is it blogoversary?). Congrats and keep up the good work, Ali!

A wise medical sage once told me that when it comes to being sued there are two types of doctors: those who have been and those who will be. It’s like the Sword of Damocles! Medical student Vitum Medicinus and his classmates are being lectured about the ever present threat. He shares his concerns here.

Ectopia what??? Ectopia cordis---a rare developmental anomaly in which the heart is situated outside the chest. Dr. Anonymous writes about a recent case.

NHS Blog Doctor speaks against physician assisted suicide and euthanasia, sparked by the recent story of another assisted suicide at Switzerland’s Dignitas institute.

RDoctor posts an interview with Emergiblog author Kim, exploring a wide range of nursing and blogging issues. Particularly interesting were her comments on arrogant physicians (they’re becoming an anomaly, she thinks), hospital case managers (nurses and social workers who facilitate discharge planning and troubleshoot financial, social and administrative problems in patient care) and the nurse’s role in facilitating ED patient flow.

And now that the kids have returned to school from Thanksgiving break The Fitness Fixer has some tips for ergonomically smart book carrying.

Now to reflect on matters of the psyche. Sigmund Freud started as a neuroanatomist, and maybe the behavioral sciences are coming full circle. Psychologist blogger Dr. Deborah Serani writes of a recently discovered gene (a variant of the serotonin transporter) which is associated with mental illness and enlargement of a group of thalamic nuclei known as the pulvinar, a deep region of the brain associated with emotions. Now there are those who might say this is all just pseudoscience. I’m waiting for them to demonstrate a neuroanatomic locus for engrams. But I digress. I think this discovery is pretty cool.

By the way, Dr. Serani has been a technical advisor for “Law and Order: Special Victims Unit.” (My wife is addicted to that show). I’ll be browsing her blog with interest in the near future. There’s a post on the psychological aspects of “If I Did It” and other interesting stuff.

Tempering our enthusiasm for bench-to-bedside correlation in the behavioral sciences, Health Business Blog reminds us that we have a ways to go, particularly in the area of pediatric psychiatric diagnosis.

Are we really what we eat? On some level, yes. The Wellness Tips blogger takes it literally and recommends organic food. Healthy? I’m sure, but rather spartan, it seems to me. I like the advice given in the poem Desiderata: Beyond a wholesome discipline, be gentle with yourself.

Oh, those perverse incentives! Everybody’s talking about conflicts of interest these days. The popular buzz in medicine is almost exclusively focused on the conflicts that arise from the influence of Big Pharma. But Number 1 Dinosaur has a thing or two to say about another conflict: ordering unnecessary tests to pad the bottom line. Dino’s insightful (or should I say inciteful---read what his commenters had to say!) and entertaining post and its update bemoan the decline of basic clinical skills and the use of technology as a substitute for clinical reasoning.

Now for your fix of hardcore clinical content---

Unbounded Medicine presents a case, along with some interesting images, of Tetralogy of Fallot.

Corpus Callosum cites a small study from the American Journal of Medicine suggesting that baclofen is as good as diazepam for the treatment of alcohol withdrawal. It’s not enough evidence to change current practice. At the risk of sounding trite, more studies are needed.

Inside Surgery has a nice series of posts on seizures in the ICU. Here’s Part 7, the most recent post. You can access the rest from the main page.

Dr. Kenneth Trofatter of Fruit of the Womb presents a case of cervical incompetence and discusses the possible role of insulin resistance syndromes.

And for patients and families---

Dr. Auerbach, blogger of Medicine for the Outdoors, offers some tips for the safe buying and handling of fresh produce and Cancer Treatment and Survivorship has some timely advice this holiday season on traveling with supplemental oxygen.

Now for some exciting news about the medical blogosphere. Dr. Ves Dimov, Clinical Assistant Professor at Cleveland Clinic Lerner College of Medicine and author of the Clinical Cases and Images blog reports back from the American Society of Nephrology’s Renal Week 2006 where one of his poster presentations (which you can view on the blog entry) dealt with medical blogging as an educational tool for students and house staff. The medical blog is emerging as an educational vehicle in no small part due to the efforts of Dr. Dimov. Nice work!

Second opinions come in many forms. Some patients go doctor hopping. Grunt Doc saw a patient the other night who went drugstore hopping.

Our “From Bench to Blogosphere” segment features docinthemachine with some original research he recently presented before the American Association of Gynecological Laparoscopists on a little appreciated variant of Asherman’s Syndrome along with discussion about potential applicability to the treatment of other gynecological disorders.

Kim at Emergiblog discusses the progression of signs and symptoms along the road to burnout and what to do about it. She’s been there and done that.

Tundra PA describes a case of steam bath boil. The culture came back MRSA. Given that it was sensitive to TMP-SMX it’s almost certainly one of the new community associated strains (CA-MRSA). Looks like it’s made its way up to the villages of Southwest Alaska!

When less is more: Insureblog comments on a study suggesting that more intense care doesn’t always help patients with chronic illness and wonders how patients would respond if the results were widely known.

Amy at Diabetes Mine writes about the bright future of continuous glucose monitoring systems. Unfortunately she missed out as a study subject for Abbott’s latest device because of skin sensitivity to the adhesive patch!

The folks at Anxiety, Addiction and Depression Treatments have posted some information on drug-grapefruit interactions. It’s not confined to psychiatry drugs, by the way. Felodipine, which I take for high blood pressure, is noted for the interaction. Although grapefruit might give me a bigger bang for my buck by exaggerating the effects of the medicine (it inhibits gut mucosal CYP34A, doubling systemic absorption) it’s too risky. Don’t try it. Always ask your doctor or pharmacist about food-drug interactions!

Susan Palwick, volunteer ED chaplain, describes a particularly difficult shift with several very ill children in Peds Night. A chaplain never knows what a distressed family might want---prayer, affirmation, maybe just someone who will listen.

Well, that’s about it for this edition of Grand Rounds. Don’t miss next week’s edition at The Antidote.

Friday, November 24, 2006

Medication adherence and mortality after MI

Patients with myocardial infarction frequently discontinue evidence based medications (aspirin, statins, beta blockers) soon after discharge. According to this study such patients have an increased mortality.

The current fragmentation of ambulatory care will only make this problem worse. Hospitalists are often the ones who start such medications, and therefore have a significant role in secondary prevention. This study suggests a need for more aggressive patient education and case management at discharge.

New antibiotics for gram positive infections

This CCJM review provides useful perspectives on the use of vancomycin and the newer antibiotics linezolid, quinupristin-dalfopristin, daptomycin and tygecycline. Note: since this paper’s publication daptomycin has been approved for S. aureus bacteremia including MRSA. Related post here.

Tuesday, November 21, 2006

Here we go again on ER crowding. It’s not us against them.

A while back I wrote a series of posts criticizing the Institute of Medicine’s proposals to remedy ER crowding, and their incredible statement that hospitals can fix the problem, and eliminate diversion and patient boarding just by being more efficient. I thought I made it clear that I was only criticizing the IOM, but then Grunt Doc weighed in with this:

Second, what's so magic about the ED? Only the ED and OB have rubber walls and are infinitely flexible, to try our best to care for every patient ho needs our help. Except, see, our walls really aren't made of magic rubber, we can't just snap our fingers and make more rooms, beds, monitors or nurses appear. Every patient who should be admitted to the hospital but isn't is a) not getting the specialized nursing care available on the ward where they belong and b) is taking up a bed in the ED we need to see then next 1-12 patients. The linked commenters in the first paragraph give a 'suck-it-up ED' subtext that rankles.

That wasn’t what was intended, so I clarified here. Grunt Doc graciously relented (in my comments). But the finger pointing by some of the ED types in his comments suggested an “us against them” attitude. My clarification post made these points:

Wait a minute---nobody’s blaming the ER here. This isn’t “us against them.” The emergency department is part of the hospital. Their problems are the hospital’s problems, and vice versa. If the ER is overtaxed the entire hospital feels the strain due to extensive overlap and sharing of resources. Concerning whether patients who needed boarding should be boarded in the ER or on the wards I said: There’s nothing written in stone in my mind that such boarding has to take place in the ER unless the patient needs cardiac monitoring.

Well, I figured I’d made that pretty clear until commenter Ryan (evidently an ED provider) weighed in with this straw man: My question to you is why are my halls better then your halls? And then: I ask again why floor nurses are different from the ED nurses.

Look, it’s not a matter of my nurses vs. your nurses, or my hallways vs. yours. I never said it was! Why do ED types seem to want to frame it in adversarial terms? Hospitalists are “on board” with this issue. We’re on the same side. Really. One of the thought leaders at the Southern regional hospitalist meeting in New Orleans a week or two ago said that the Society of Hospital Medicine is committed to helping improve ER throughput. (I wasn’t there but I browsed the syllabus one of my colleagues brought back. Sorry I missed you DB. We’ll hook up one of these days).

Compression only resuscitation triples survival

Data from Phoenix Emergency Medical Services presented at the American Heart Association meetings this month showed improved survival after implementation of the compression only method. Evidence favoring compression only has been mounting and the folks at the University of Arizona Sarver Heart Center have been beating this drum for quite a while. Although the 2005 AHA Guidelines moved in the right direction they didn’t go far enough---they’re years behind the science, and the science is compelling. Tuscon rescuers are using the same protocols. In 2006 if you’re going to have a cardiac arrest, your chances are best if you have it in Arizona.

You read it first on here over a year ago. I’ll repeat the caveats I posted then:

1) For witnessed VT or VF in the health care setting immediate defibrillation remains the initial modality (remember the electrical phase!).


2) This new thinking does NOT apply to pediatric codes or other arrests of suspected respiratory origin. Rescue breathing remains a higher priority in those situations.

Thursday, November 16, 2006

Acupuncture anatomy goes mainstream!

I figured they pretty well knew the layout of the human body when the classic edition of Gray’s Anatomy was published in 1918. Sure, there have been many subsequent editions with updates in terminology, embryology and cell biology but the depiction of “gross” features hasn’t really changed much. But after a tip from the Health Fraud List pointed me to this Georgetown University Medical Center site I began to wonder if they shouldn't rewrite the anatomy books. Georgetown apparently thinks the “anatomy of acupuncture” should be incorporated into gross anatomy.

Until recently complementary and alternative medicine (CAM) courses in medical school have been offered mainly as electives. Georgetown wants to take it a step further and “Aim CAM curriculum at all students through required courses.” Plans for integration of woo into the basic science courses read like fodder for late night infomercials: psychoneuroimmunology, stress hormone modulation through relaxation, imagery and breathing regulation and more.

Wednesday, November 15, 2006

More on Rate MDs

I posted a little over a week ago about Rate MDs, an open access, free for all consumer website where anyone can anonymously say just about anything about a physician. Then I heard via Clinical Cases and Images that the author of MSSP Nexus Blog opined thusly: “This site, or others like it that follow, will no doubt begin to be checked as part of a routine credentialing process, so the implications to healthcare providers are considerable.”

Well, that’s scary----opening up the credentialing process to last week’s disgruntled drug seeker or patients of this ilk. Heck, why not just invite ‘em to attend the credentials committee? By any reasonable standard the evidentiary quality of sites like this is somewhere below garbage in this blogger’s opinion.

Sunday, November 12, 2006

The latest hygienic measure for type 2 diabetes

We’ve long been aware of two important hygienic (non-pharmacologic) interventions for DM-2, those being diet and exercise. Now evidence is emerging for another: get enough sleep.

Thursday, November 09, 2006

Woo pitching med students say they’re evidence based

AMSA is kicking off its annual PharmFree Day with much fanfare and this statement: “AMSA members believe in providing the highest quality care through evidence-based medicine.”

Really? What about their belief that traditional Chinese medicine (TCM) has “proven helpful” for cancer, infectious disease, heart disease and AIDS (Complementary Therapies Primer, page 5)? Or that “By activating the electrical circuitry of the body which conduct qi along the meridians, qigong is able to harness the body’s own healing powers (page 7)? And does therapeutic touch really help asthma (page 9)?

While AMSA wants a rigorous evidentiary standard for the products of Evil Pharma the herbs seem to get a free pass (pp 12, 13). Thus cayenne is good for “strengthening metabolism” (were these kids sleeping through biochem?) and preventing colds. Echinacea is recommended for respiratory infections, connective tissue diseases and multiple sclerosis and ephedra “must be used with caution.” (How does one use ephedra with caution, exactly?).

And how about that four day fast? Seems it thins blood, leads to better oxygenation and improves immunity (page 18). Finally, don’t forget good old chelation for everything from cancer to spider bites (page 20).


So, on November 16, go PharmFree and consider the alternatives.

Wednesday, November 08, 2006

Patch Adams rants to Vanderbilt medical students against psychiatry, government

Adams declared to the students “Our government is worse than Hitler” and that today’s medical students would live to see the extinction of the human race. He advised them not to prescribe psychiatric drugs and said depression is a “selfish act.”

Read the rest and laugh. Via VUMC Reporter.

Friday, November 03, 2006

Is VA health care the best?

Time magazine thinks it is. Time writer Douglas Waller extols the VA’s electronic medical record, cites this study which showed lower mortality rates among VA patients, and hints that it may be an argument for government run health care.

The problem with such thinking is that the study, published in the April issue of Medical Care, is the comparison group: Medicare Advantage, another government run health plan loaded down with the added baggage of managed care.

Nevertheless it will be spun in opposition to the free market.

Thursday, November 02, 2006

Despite the brouhaha over drug company free lunches

A silent majority of health care professionals still favor them according to this Medscape poll.

Doctor rating with an attitude

Kevin MD points us to this article about doctors’ organizations upset over the increasingly popular web site Rate MDs. The organizations believe comments on the site are defamatory and are pressuring Rate MDs to remove them. Two comments have been removed from the site but other requests by doctors’ groups have been ignored.

Perhaps the best known and most reputable physician rating service is Health Grades, a no nonsense, “just the facts” site that requires paid access to view physician ratings. Rate MDs is different. It’s a free wheeling, let it all hang out message board style web site with open access to all. Although users have the option to create an account, it’s not necessary in order to post or view, and commenters do not have to give any identifying information.

According to the FAQ page although patient comments are reviewed for appropriateness they are posted “immediately.” The site owners imply they may delete inappropriate comments, but here’s a sampling of what did not get deleted:

does breast exam for no reason

this doctor is a bully

this man is a joke

I fully blame this doctor for my aunt’s death

--just a creep!

trained his staff to lie---------

Don’t go to ---------they will kill you in there


On a more positive note:
-----and he is cute!!!!

More FAQs----

If you’re a doctor and don’t like the ratings: “The fact of the matter is that this site is only going to get more popular as time goes by, so the best way of dealing with it is to use it rather than try to fight it.” (In other words, get over it).

I’m a doctor. How do I get my name removed from your site? “The short answer is, you don’t.”

And if you’re thinking about legal action against the web site, don’t bother, say the owners (FAQ # 18).

Have a look. Are you rated?

Tuesday, October 31, 2006

How do you prepare pre meds for the woo they’ll be taught in med school?

Teach it in undergrad, of course! Call it Project Head Start. Pre med students, it seems, are taking Boston University’s Chinese Medicine class:

There are also premed students looking for another perspective. Western doctors may generally be skeptical of the field, Kohn says, but she notices more of them are sending patients to classes in yoga and Qigong (posture and breathing exercises).
"You've got a new generation of doctors who've grown up with the idea that some self-practice, self-awareness is really helpful," she says.

Next thing you know, med schools will be adding it to their list of prerequisites, right alongside biology, organic chemistry, etc.

Pulmonary embolism and chronic pulmonary hypertension

A while back I cited a study which showed a 3.8% rate of development of chronic thromboembolic pulmonary hypertension after PE. This was surprisingly high to me. The September issue of Medicine reports this study of patients with PE which looks at outcomes in relation to the degree of pulmonary vascular obstruction. The rate of chronic pulmonary hypertension was much lower, on the order of 1%. The study reported nearly complete resolution of emboli in most patients. I previously linked to this study reporting a high rate of persistence of perfusion defects long term.

Saturday, October 28, 2006

Just got through watching the CBS documentary on the Jeremy Perkins case---

Jeremy was a paranoid schizophrenic. He and his parents were Scientologists. They refused psychiatric help because it was against their beliefs. Jeremy was treated with vitamins and sent to a Scientologist physician who recommended an intravenous treatment to remove toxic metals, possibly chelation therapy. Jeremy’s condition worsened, as did his delusions that his mother was “evil”, and he fatally stabbed her.

The show featured an interview with an official from the anti-psychiatry and Scientology front organization Citizens Commission on Human Rights which maintains that the drug industry has conspired to medicalize non-medical aspects of life by inventing mental illnesses.

Background:

The Lisa McPherson case
CCHR

Friday, October 27, 2006

Sports media bias

If you’re a St. Louis Cardinal fan you know it’s there. Palpable. So thick you could cut it with a knife.

Could you hear the disappointment in the voices of the announcers when the Cards eliminated the Mets? So much for “fair and balanced Fox.”

I’m told one columnist said something like “Detroit in three if the Tigers don’t die laughing.”

Bernie Miklasz of the St. Louis Post Dispatch, relieved that we don’t have to suffer a “subway series”, comments here.

Thursday, October 26, 2006

The Surviving Sepsis Guidelines: guilt by association?

The Surviving Sepsis Guidelines have been under fire for the role of Eli Lilly in their development and promotion. In a recent blog post I argued that much of the criticism of the guidelines is irresponsible because it ignores the evidence and relies solely on the fallacious argument of “guilt by association” or, as one of my commenters put it, “corruption.”

Two of my favorite bloggers who recently weighed in on the controversy took a somewhat more negative view of the guidelines than I. Dr. Roy Poses of Health Care Renewal cites the guidelines as the latest example of “stealth marketing” and concludes with “Maybe with increasing realization how pervasive conflicts of interest fuel deceptive marketing and promotion will come some increased skepticism and a will to address this problem.” I’m all for more skepticism, but what was it that was deceptive about Lilly’s promotion, exactly?

Retired Doc’s response was more scathing. (Retired Doc sees eye to eye with me on many issues, but we may have to agree to disagree on this one!). He’s concerned about how drug companies use EBM for promotional purposes and wonders whether their spin of evidence puts patients’ lives at risk. He cites the NEJM Perspective authors’ concerns that information on the risks of bleeding due to Xigris was suppressed, and feels the jury is still out concerning Xigris.

Let’s examine these questions. Did the guideline authors spin the evidence on Xigris? The guideline section on activated protein C is on page 863 of volume 32, issue 3 of Critical Care Medicine. Looks pretty straightforward to me. Right out of the PROWESS article. Where is the spin here?

Although the guideline authors appropriately emphasize that Xigris is to be used in patients assessed to be at high risk of death, some might criticize their failure to be more explicit in how the APACHE II score and the number of failing organs should determine candidacy for the drug. The results of ADDRESS later suggested restricting Xigris to patients with two or more failing organs or an APACHE II score above 25, but those results were not announced until 7 months following the guideline publication and were not published until 18 months after the guidelines. That fact didn’t stop the NEJM Perspective authors from trying to hold the guideline authors accountable. They state: “Although the results of the ADDRESS study were reported at the October 2004 ESICM meeting, no mention of the study was included in a supplement to the Surviving Sepsis Campaign Guidelines published the following month in Critical Care Medicine.”

But, digging deeper, the ESICM meeting in question was held October 10-13 2004. The November supplement to Critical Care Medicine was certainly already posted and printed during the month of October and probably in press by the time the ADDRESS results were announced. The Perspective authors left out those little details. Now who’s being deceptive?

Was the risk of bleeding suppressed? The body of the report mentions bleeding risk and refers the reader to an appendix which explicitly states this risk and cites product labeling containing the actual data on bleeding from clinical trials. I’m still looking for the smoking gun.

What about the evidence favoring activated protein C in severe sepsis? Critics of the guidelines talk around this issue but seem to come short of any direct criticism. Retired Doc correctly notes that the jury is still out. That’s often the case, to one degree or another, in clinical research, but at any given time we have to go by the best evidence we have. Is PROWESS so hopelessly flawed that we should throw it out? Nothing in the subsequent analysis or research on this topic suggests that we should. The NEJM Perspective authors acknowledge that the Surviving Sepsis Guidelines are supported by randomized controlled trials but make this astounding statement: “Although such trials represent the gold standard of medical evidence, overreliance on them in the construction of guidelines has a tendency to favor new drugs and devices, which typically undergo at least one such trial in order to obtain government approval.” Overreliance on randomized controlled trials? Do the authors want to turn evidence based medicine upside down?

I should mention the XPRESS study comparing outcomes in patients receiving Xigris with and without heparin in DVT prophylactic doses, showing a mortality rate comparable to the treatment arm of PROWESS. Although presented last January at the Society of Critical Care Medicine meeting the NEJM perspective authors did not mention it. The results indicate that DVT prophylaxis using low molecular weight or unfractionated heparin need not be withheld during treatment with activated protein C.

Most of the critics of drug company marketing, up until now, have complained that doctors are influenced to prescribe counter to the best evidence. The NEJM Perspective authors have taken the novel tack of complaining that a drug company promotes in line with evidence. The drug companies can’t seem to win for loosing!

Imaging studies in acute pancreatitis

Who, when and how, from CCJM.

Wednesday, October 25, 2006

Authors’ conflicts of interest----selective outrage

Allan Detsky, guest editorialist in the October 24 issue of CMAJ, writes about conflicts of interest in writing guidelines. Financial conflicts of interest due to drug company ties are generally mentioned while other types of conflicts are ignored, Detsky notes. Underappreciated conflicts include a personal stake (reputation, academic career) as well as incentives to promote one’s specialty.

If conflicts of interest invalidate the development of guidelines perhaps we should question how the American College of Gastroenterology writes guidelines pertaining to endoscopy or whether the American College of Cardiology should write guidelines for coronary interventions. Such conflicts, though less tangible, are no less powerful than those involving drug company money. The journals tend to ignore them, as Detsky notes in this example: “A recent review article in the New England Journal of Medicine promoted positron-emission tomography (PET) scans for cancer assessment; of the 2 coauthors, 1 was a radiologist (who, I assume, reads PET scans). The article contained a statement that ‘No potential conflict of interest relevant to this article was reported.’ Really?”

Political agendas create powerful conflicts of interest as I have noted here, here and here. I first wrote about the “other” conflicts of interest over a year ago here.

In Detsky’s concluding paragraph he states “Although these other influences may be even more difficult to document and quantify than financial ties, they are no less important.”

Thanks to DB for pointing me to the editorial.

Wachter on the state of the hospitalist movement

I’m always interested in what Robert Wachter, hospitalist thought leader, has to say on the state of the field. He was recently interviewed by Internal Medicine World Report. Points of interest:

Rise of hospitalists and decline of primary care: true, true and unrelated in Wachter’s opinion. Not sure I agree.

How many hospitalists are needed? 30,000 to 50,000, perhaps, more than previously estimated.

What makes the difference between a good program and a bad one? Communication---with families and primary care docs.

Tuesday, October 24, 2006

NCCAM chelation study site tour---Part VII

The Marino Center for Progressive Health in Cambridge, Massachusetts is one of the NCCAM chelation therapy study sites. The clinic features the usual array of alternative methods including acupuncture, chelation and chiropractic. Their IV therapy program offers intravenous therapy for multiple ailments including the common cold. One of the major components of the IV program is magnesium therapy. According to the web site magnesium “plays a critical role in a vast array of acute and chronic diseases” and “studies strongly suggest that when it comes to magnesium, most of us may be running on less than a full tank.”

At the Magaziner Center for Wellness, another chelation study site in Cherry Hill, New Jersey, patients are offered a variety of alternative treatments including hyperbaric oxygen therapy for neurologic diseases. The Center promotes this vast array of herbal products for everything from faulty immune systems to stress.

The Gables Natural Medicines Center and Day Spa is another NCCAM study site located in Mayville, New York, offering chelation and naturopathic medicine.

The Rhinebeck Health Center in Rhinebeck New York, another study site, advocates chelation therapy and a variety of other CAM modalities. The site contains a number of articles, one of which advances the theory that mercury containing vaccines help cause autism, and defends the work of the Geiers in this area.

Background: part VI here; part V here.

Monday, October 23, 2006

The Surviving Sepsis Campaign guidelines: evidence based or not???

An exhaustive review on sepsis in the October 19 issue of the New England Journal of Medicine (NEJM) covers nomenclature, pathophysiology and treatment, including a discussion of the Surviving Sepsis Campaign guidelines. But in what could be viewed as a strange attempt on the part of the Journal to appear “fair and balanced” the same issue’s Perspective piece entitled Surviving Sepsis---Practice Guidelines, Marketing Campaigns, and Eli Lilly dismisses the guidelines as little more than a marketing strategy disguised as evidence based medicine. The authors base their criticism entirely on the role of Eli Lilly in the development and promotion of the guidelines, which endorse its drug Xigris (activated protein C) for restricted indications in patients with severe sepsis. (When I wrote about this controversy 5 months ago I took the more moderate position that the Eli Lilly ties deserved exposure and these guidelines, like any guidelines should be viewed with healthy skepticism. I also took the position that any responsible criticism of the guidelines should appeal to the primary sources of evidence and not be based solely on arguments concerning industry affiliation).

Guidelines, though useful, are imperfect. This can have unintended consequences when they are promulgated by agencies like IHI and JCAHO or become the focus of pay-for-performance initiatives. Even greater harm can result when they are hijacked by the trial lawyers and their hired guns under the rubric of “standard of care.”

Although the authors correctly point this out their criticism of the sepsis guidelines is misdirected and at times defies logic. Proper criticism of the guidelines should be based on the measuring stick of evidence. Portions of the Surviving Sepsis Guidelines indeed depart from high level evidence. The Perspective piece authors, however, don’t seem to care about evidence and disregard the fact that the only examples of the guidelines’ departure from evidence are unrelated to influence by Eli Lilly.

So let’s look at how each recommendation in the guidelines stacks up:

Early goal directed therapy----supported by high level evidence.
Diagnostic studies to ascertain source and microbiology---supported by low level evidence.*
Antibiotic therapy---supported by low level evidence.*
Source control---supported by low level evidence.*
Fluid therapy recommendations---supported by low level evidence.
Vasopressor recommendations---supported by low level evidence.
Inotropic agents---supported by low level evidence (high level evidence if used as part of early goal directed therapy).
Corticosteroids---conflicting evidence; use is controversial.
Activated protein C---supported by high level evidence.
Low tidal volumes for patients requiring mechanical ventilation---supported by high level evidence.
Sedation protocols and avoidance of neuromuscular blocking agents in mechanically ventilated patients---supported by high level evidence.
Intensive glycemic control---not supported.
Renal replacement therapy recommendations---supported by high level evidence.
Non-recommendation of bicarbonate therapy for most cases of hypoxic lactic acidosis---supported.
DVT prophylaxis---supported by high level evidence.
Stress ulcer prophylaxis---supported by high level evidence.

*Although diagnostic studies, antibiotic therapy and source control recommendations are based on “weak” evidence the guideline authors unequivocally recommend these measures. The ethical problems in demanding high level evidence for these modalities are obvious.

From the synopsis above it is readily apparent that any evidence based criticism of the Surviving Sepsis Guidelines would have to question intensive glucose control and the use of corticosteroids. The Perspective authors were conspicuously silent about these, the two weakest recommendations in the document. Why? Because they can’t blame it on the drug companies! Cheap, generic, plain ole insulin and hydrocortisone, the only non-evidence based drugs supported by the guidelines, are of no financial interest to the drug companies.

Gotta ask this question: is this ad hominem attack on the sepsis guidelines anything more than gratuitous bashing of the drug companies?

Friday, October 20, 2006

Harry Potter would be right at home in today’s medical schools

Orac, dangit, you beat me to it.

Homeopathy: Holmes, Hogwarts, and the Prince of Wales. This piece in the FASEB Journal isn’t just about homeopathy. It takes on many forms of pseudoscience currently promoted by NIH, NHS and U.S. medical schools. It concludes: Hogwarts is certainly on the move! If the trend persists, perhaps MIT or Cal Tech will march in step with the medical schools and offer prizes for integrative alchemy or alternative engineering.

Wednesday, October 18, 2006

More evidence of under-utilization of VTE prophylaxis

Presented at the American Heart Association’s 7th Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke.

Via Internal Medicine News and World Report.

Tuesday, October 17, 2006

A boost for open access

Five major UK research funders now require open access publishing of all their supported research. We can expect more and more studies to be published in open access journals. Read the rest from Biomed Central.

Wednesday, October 11, 2006

Biphosphonates and osteonecrosis

Two brief items appeared in September’s Internal Medicine World Report.

General update on the problem.
New guidelines with focus on prevention of osteonecrosis

Monday, October 09, 2006

Avoiding ambulance diversion: how does it work in the real world?

Recent blog discussions [1] [2] [3] [4] [5] about ambulance diversion have been generally critical of the Institute of Medicine’s unrealistic mandate for hospitals to avoid diversion and patient “boarding” by improving the efficiency of patient flow.

St. Louis area hospitals, feeling the crunch, offer a picture of what can realistically be achieved by the most aggressive bed management conceivable, as reported in today’s Post Dispatch. It’s an impressive effort---arguably the best hospitals could be expected to make. These folks are organized, and they’re trying everything in the book, from more efficient room cleaning to electronic tracking systems. The results? Although diversion lessened it still occurs at a rate of one to two hours per day in spite of some patient boarding.

When there’s no room there’s no room, and there’s only so much you can do.