Saturday, September 30, 2006

NCCAM study site tour---Part VI

The Wellness and Longevity Center of Louisiana is one of the NCCAM chelation study sites. According to the web page the Center’s vision is “…to prevent and treat chronic disabilitating diseases such as obesity, high blood pressure, Parkinson and Alzheimer’s disease, chronic fatigue, fibromyalgia, heart attack and stroke by integrative medicine which combines standard medical practice with alternative and complementary medicine…” (That’s right, it really says disabilitating).

The chelation therapy information page states “Every single study of the use of Chelation Therapy for Atherosclerosis that has ever been published, without exception, has demonstrated an improvement in blood flow and symptoms.” What journals have these folks been reading? And this: “Adverse editorial comment to the contrary lacks evidence and stems primarily from physicians with a vested interest in catheterization and surgery.” Yeah. I’m reminded of a guy I saw one time on TV promoting his perpetual motion machine, claiming that the fuel industry was suppressing the science behind his invention. Then there’s this claim: “Scientific studies have proven that blood flow increases after Chelation Therapy.” Too bad they left out the citation. I’d like to look that one up.

Aren’t researchers supposed to be unbiased?

Friday, September 29, 2006

Obesity state by state; process and outcome in Arkansas

Report cards are out. They contain no real surprises but there was a curious finding in my state. Although Arkansas, as expected, is one of our more obese states (13th in the nation) it received one of the best report cards----one of only two states to earn a B (no state got an A). Why this gap between process and outcome? Arkansas’s vigorous anti-obesity initiatives (and its good report card) can be attributed largely to the efforts of Gov. Mike Huckabee, who believes the measures will just take time.

But the battle of the bulge in Arkansas may be difficult. Arkansas clearly is in the obesity belt. It’s a culture war. It may not be as bad here in my neck of the woods, the culturally transformed rapidly emerging retail capital of the world, as it is in more rural pockets of the state as suggested in this county by county analysis.

Huckabee’s personal story is noteworthy. A few years ago our morbidly obese governor, barely able to make it to the top of the capitol building stairs, lived in fear that he would be met there, breathless, by media, and be unable to give an interview. When he turned up with type 2 diabetes his doctors said, in effect, “diet or die.” Thereupon the former Baptist minister “got religion” about his health and embarked on a comprehensive program of nutrition and exercise, shedding over 100 pounds. Later he decided to share his success and put his state on a diet.

That may strike some people as ironic. Huckabee’s a Republican. He’s a conservative. But he doesn’t fit the mold of libertarian conservatives who complain about the “fat police.” In the minds of some who think his health initiatives too intrusive Huckabee is chief of the fat police. A Little Rock restaurant owner told the New York Times concerning Huckabee’s weight loss “it’s fine for him….But he ain’t got to make the whole state lose weight.”

According to the New York Times the Arkansas anti-obesity measures, some of which exceed federal requirements, include exercise breaks for state employees, strict guidelines for school lunches, and the reporting of BMI on school report cards. But perhaps more remarkable than all that is the example set by the governor. His speaking engagements and writings (such as Quit Digging Your Grave With A Knife And Fork) recount many testimonials, and he has completed the Little Rock marathon.

It’s nice to see my state get a good grade in something. Will it translate into better health outcomes? I remain to be convinced.

Wednesday, September 27, 2006

E. coli in perspective

Folks in the popular media don’t seem to know, or care, that the often fatal E. coli (E. coli 0157:H7) causing the current outbreak of hemorrhagic diarrhea, sometimes complicated by hemolytic uremic syndrome, is completely different from the ubiquitous E. coli that inhabits the colon of each of us and commonly causes infection when it winds up someplace is shouldn’t (urinary tract or bloodstream).

If you don’t think this is confusing to people try telling your patient (when 0157:H7 is hot news) with a mild UTI “Oh, it’s just E. coli” and note the reaction. This pathogen should be referred to in media reports as “E. coli 0157:H7”, not “E. coli.”

The ubiquitous form of E. coli is not an intestinal pathogen. Six less common forms do not normally inhabit the human GI tract and are in fact enteric pathogens. These latter forms have little in common except for a propensity to cause intestinal disease, with distinctly different pathogenic mechanisms. Only one of these six forms, enterohemorrhagic E. coli, causes extraintestinal disease (hemolytic uremic syndrome). These are principally of the 0157:H7 variety, the subject of the current news stories.

The only other one of the six forms of enterovirulent E. coli of importance in the developed world is enterotoxigenic E. coli, believed to be the principal etiologic agent of traveler’s diarrhea. The toxin elaborated by this organism increases the production of cyclic AMP and GMP resulting in a secretory (non-inflammatory) diarrhea.

The other forms of enterovirulent E.coli are enteropathogenic E. coli, enteroinvasive E. coli, enteroaggregative E. coli and diffusely adherent E. coli.

Tuesday, September 26, 2006

Summary and update on the E. coli 0157:H7 outbreak

Today’s issue of Morbidity and Mortality Weekly Report has the latest info as well as links to CDC and FDA updates. This should be a helpful resource.

As an aside, I wish the popular media would bother to distinguish between E. coli 0157:H7 and the common and not so deadly forms of E. coli. Very confusing to the lay public.

Medscape Roundtable Discussion concerning pharmacists on the health care team

For the latest Medscape Roundtable Discussion we were asked “How Can Physicians Stay Current on Prescription Drugs?” Surprisingly the readers’ responses were overwhelmingly “Why didn’t anyone mention the role of pharmacists?” True enough we didn’t mention it. I can only speak for myself here. I regard pharmacists as an important part of the team, and a resource I utilize extensively. But we weren’t asked that. We were asked how we keep up with information in pharmacology, not how we delegate to other team members. Clinical pharmacists perform important tasks, safeguard against inappropriate orders and intercept errors. That doesn’t absolve physicians of the responsibility to expand and update their knowledge, utilizing the most authoritative primary sources available.

On the healthcare team the buck stops with me, the physician. If I’m doing my job I should know the “whole picture” of my patient’s problem better than anyone else including the pharmacist. If the pharmacist makes a recommendation on drug therapy I must understand the rationale. If the pharmacist happens to be wrong I must know how to proceed. The pharmacist has an essential role in patient care. At the same time physicians must independently stay knowledgeable in the field by regularly reviewing authoritative sources of information in prescribing as well as related information in physiology and evidence based medicine.

Thursday, September 21, 2006

NCCAM chelation study site tour---Part V

Innovative Medicine in Lafayette, IN is a chelation study site. The clinic offers chelation therapy, hyperbaric oxygen, “advanced thyroid replacement”, chiropractic, acupuncture and “multiple powerful intravenous therapies.” Concerning thyroid treatment, the clinic claims to “easily help people who suspect that they are hypothyroid but have been told their thyroid test is normal.” They also claim that chronic neurologic diseases of any type usually respond to hyperbaric oxygen.

Well, it’s innovative all right. A little too innovative for me, but apparently not for government funded “research.”

Background: part I, part II, part III, part IV

Wednesday, September 20, 2006

Emergency department homicide???

A patient’s death in a Lake County Illinois emergency room was recently ruled a homicide by a coroner’s jury, finding “gross deviations from the standard of care” which prolonged the patient’s wait time. If a death related to ER wait time is a homicide then how many other undocumented emergency department homicides are occurring on a regular basis? Quite a few, perhaps, according to this study from the Medical Journal of Australia. The death rate went up 20% per hour of wait time in this study, independent of diagnosis or urgency of the patient’s presentation.

Medication safety resource

Institute for Safe Medication Practices.

Features safety alerts, news letters, a message board and more.

Tuesday, September 19, 2006

The TRIP database

Here’s some good news for EBM enthusiasts. I was a frequent user of this resource until it went paid access a few years ago. Today I’m pleased to learn, via Sumer’s Radiology Site, that TRIP is once again free. It looks as though, in the interim, they’ve made substantial improvements to an already useful site. The search engine is more precise and they’ve added a medical images section. Very nice.

Sunday, September 10, 2006

Saturday, September 09, 2006

Controversies in the treatment of hypothyroidism

Although it ought to be straightforward, several controversies regarding treatment of hypothyroidism have arisen in the past decade. These are covered in a review in the July/August 2006 issue of The Endocrinologist.

What is the optimal TSH target during treatment? 0.4 to 2.5 mIU/L.

Is T4 + T3 replacement superior to T4 replacement alone? No.

Is brand L-thyroxine superior to generic? Not according to the best available evidence.

Should subclinical hypothyroidism be treated? Probably not if the TSH is less than 10 mIU/L.

Geriatric rounding tips

Some rules for geriatric patient safety from Today’s Hospitalist.

Review medications regularly. Watch out for such hospital booby traps as automatic stops, omissions in transfer from ICU to ward, changing renal function requiring dose adjustments, etc. Assess gait, fall risk, functional status and skin problems early and regularly. Get physical therapy involved early.

Friday, September 08, 2006

The tobacco industry helped launch television’s golden age

This week free Camels go to Veterans Hospitals North Little Rock Arkansas and Omaha Nebraska……….

That bit of irony was spoken by Anne Jeffries hawking Camel cigarettes at the close of a 1950s episode of Topper. Video files of this and other cigarette commercials (including John Wayne shilling Camels, and years later urging viewers to fight cancer) are archived at TV Party.

Television was dependent on the tobacco industry in the early years. A blockbuster network show typically had only one or two sponsors, and the sponsor was often a tobacco product. As the medium matured it became less dependent, and tobacco commercials were finally banned on January 2 1971.

Wednesday, September 06, 2006

Clostridium difficile update

This review in Baylor University Medical Center Proceedings focuses on the history of our experience with this pathogen, pathophysiology, diagnosis and treatment. Newly appreciated risk factors are profiled including proton pump inhibitors, chemotherapy and post pyloric tube feeding.

An idiot’s guide to AICDs

Here’s what the non electrophysiologist needs to know.

Tuesday, September 05, 2006

And speaking of useful medical records---

As implied in the post below, the problem oriented medical record has been hijacked by coders and auditors. In contrast, here’s a report from the field in the Journal of Clinical Outcomes Management about a new concept in medical record keeping for patients with complex chronic problems.

First a disclosure. The author is a local colleague, and I reviewed and commented on an early draft of the manuscript. I’ve also seen this system in use.

Potentially adaptable to both electronic and paper based records, the system expands the traditional problem list into a comprehensive treatment summary. The use of symbols enables the summary to be contained in a single page. The summary itself is meant to be updated with key information in real time, freeing up the traditional progress note to depict clinical concerns in a meaningful narrative form without redundancy. You’ll need to get the full text article (which I can’t link here) to really see how it works.

While this tool will facilitate clinically meaningful charting it may not make the coders happy, which is why the author concludes the abstract with: “Feedback and guidance from Medicare audit will be crucial prior to widespread application of the system.”

Buffing the chart

While I was away Retired Doc linked to this article in the Annals of Internal Medicine, fueling more skepticism about pay for performance (P4P). The results of P4P programs, according to this systematic review, may be more cosmetic than real. Providers seem to be gaming the system and treating the chart rather than the patient.

This isn’t new. We’ve been playing chart games ever since reimbursement was tied to E and M coding, leading to the popularity of template generated progress notes. As a hospitalist who cares for a large number of “unassigned” patients I depend a great deal on outside records. From the vantage point of patient care the template generated notes (of which I’m seeing more and more) are the least helpful. Templates force all the “right” questions to make the coders happy, but produce little meaningful clinical information. P4P will fuel even more cosmetic charting and make the problem worse.

Sunday, September 03, 2006

Musings on continuing medical education

I’ve just returned home from a CME course, combined with a little vacation. It was one of those traditional CME activities centering on didactic presentations and workshops, held at a nice relaxing location. It was co-sponsored by a major professional organization and received financial support from several drug and device companies.

In my 28 year obsession with career learning I’ve availed myself of multiple methods---didactic, case based and Internet based to name a few. I’ve also become convinced that individual doctors have differing learning styles. I find that the different learning methods offer multiple dimensions, serving my educational needs in different and uniquely important ways.

Learning at the point of care about a specific clinical question (e.g., foreground reading) often directly impacts clinical decision making and sharpens my focus on diagnosis and treatment. Equally important is background learning, focusing on more general clinical features, treatment principles and pathophysiology. Background learning may employ textbooks, narrative reviews and didactic presentations. Although such learning has little immediate impact on my prescribing behavior it strengthens my conceptual framework for understanding medicine.

These two examples may represent opposite poles of a spectrum of learning styles. Both are essential. Without foreground learning we miss the best and most current evidence applicable to patient care. Without background learning we lose the underpinnings of medicine and resort to formulaic practice based on rote memorization and slavish adherence to algorithms. (See How and why do doctors read?).

For me the traditional didactic meeting offers a unique educational experience. The occasional retreat to a relaxed setting in a remote location, away from the time pressures and constant interruptions of the “point of care” helps me to maintain a receptive and enthusiastic frame of mind. Without these getaways I would miss an important aspect of lifelong learning.

Lately I’ve been troubled. In recent years these meetings have struggled for attendance and sponsorship. They’ve come under attack by naysayers from various camps. Some are unhappy with pharmaceutical company sponsorship. Others, like thought police, believe they know what type of continuing educational activity is best for me.

This salvo comes from a Medscape General Medicine video editorial by Dr. Jordan Cohen, president of the Association of American Medical Colleges. Dr. Cohen, describing “A New Vision for Continuing Medical Education”, wants to overhaul our CME system and thinks the didactic format should be used “only for appropriate issues, such as a basic science breakthrough.” Then there’s this astounding statement: “Research shows that the lecture-based format of CME does not change physician behavior or, more important, change the health outcomes for patients.” What’s the level of evidence for that claim? Moreover, the whole premise is wrong. A litmus test for CME that requires activity A to be measurably associated with behavior B is faulty because it ignores important intangibles. Under such a standard there would be no place for activities that teach pathophysiology, clinical diagnostic skills, general principles of evidence based medicine, or ethics. All are useful educational endeavors to be sure, but would change physician “behavior” mainly in intangible, and not readily measurable, ways.

Then there’s this curious statement (italics mine): “The vast majority of CME should employ self-directed, interactive, and relevant learning experiences that enable physicians to acquire the knowledge and skills necessary to exceed minimum expectations.” Well, that’s some vision. What if some doctors want to strive for excellence? If this is the latest theory on “outcome based” education applied to CME I’m underwhelmed.

As I’m often fond of doing I’ll invoke the memory of one of my favorite medical school mentors, Thomas Brittingham. His letter to third year students embarking on their Medicine clerkship concluded with “….for each one of us the primary teaching responsibility now and for the rest of his life lies within himself.”

Acupuncture, a walk in the woods, a pinch on the butt

And speaking of Dr. Wallace Sampson (see post below), check out this piece in the San Francisco Chronicle, Healthy Doubts in which Sampson takes on acupuncture.

"It is nonspecific," Sampson says. "If it has the effect of, say, releasing endorphins through the application of needles, well, many things release endorphins -- a walk in the woods, a 5-mile run, a pinch on the butt."

Via DB’s Med Rants.

Government bias toward pseudoscience

We’ve heard the tired canard: industry sponsored health information is suspect, government sponsored sources are trustworthy. Is that really true? Not according to Dr. Wallace Sampson, Clinical Professor of Medicine (Emeritus), Stanford University. In a Medscape General Medicine video editorial he exposes an alarming and pervasive bias in favor of complementary and alternative medicine by the NIH, the National Library of Medicine and other agencies.

Saturday, September 02, 2006

Medication reconciliation may save lives

In a chart review of diabetic patients admitted with MI, patients who did not resume pre-hospital anti-diabetic medications at discharge (13% of the sample) had a 24% increase in mortality at 1 year.

I wish I knew more of what went on here than was contained in this sound bite version (Internal Medicine News) of a poster presentation at the American Diabetes Association annual scientific sessions. When diabetic patients are admitted to the hospital with acute illness their oral anti-diabetic medications are often supplanted by hospital insulin protocols. Although it is usually the intention to resume pre-hospital medications at discharge such instructions may not always be effectively communicated.