Monday, March 31, 2008

Why did this patient suffer a cardiac arrest in the hospital?

Common medications conspired with “borderline” electrolyte levels to produce this outcome.

Via Medscape.

Brand new medical school wants its inaugural class to be competitive

How does the University Of Central Florida College Of Medicine, scheduled to open next year, plan to do it? By making it free of charge!

Each of the first 40 students will receive a full tuition scholarship with living expenses for all four years. This is an unprecedented opportunity in the history of medical education.

Read the rest here.

Thursday, March 27, 2008

The adoption of electronic medical records

In an ars technica piece from yesterday Jonathan Gitlin discussed the ins and outs of electronic medical records. He opened with:

Doctors' poor handwriting might be a cliché, but being able to accurately read medical records can often be a matter of life and death. The ubiquity of the personal computer has allowed the clinic to enter the digital age, and given that computers excel at managing information, the development of electronic health records (EHR) has been a no-brainer.

That’s part of the problem. Maybe we’d all be better off if more thought was put into development and implementation. Read the rest here.

Via Kevin M.D.

Wednesday, March 26, 2008

How good is PubMed?

Around this time last year I wrote that while no search engine had a singular advantage in all situations PubMed was the most reliable. I still believe that’s true, at least for clinical medicine.

Last Saturday virologist PhD student and blogger Anna Kushnir expressed a different view:

For a site that is as vital to scientific progress as PubMed is, their search engine is shamefully bad. It’s embarrassingly, frustratingly, painfully bad.

She gave these examples:

I can hold a paper in my hands, search for two authors’ last names and have PubMed come up with nothing. My friend searched for microRNAs and her virus of interest. The search engine (can I even call it an engine? It’s more like a tricycle) came up with papers dating back to 1997. I am pretty sure no one knew about microRNAs in 1997. Yet another friend was only able to find publications about his compound of choice after empirically defining one of its functions in the cell… which is when he found out this information had been available all along. He couldn’t pull up the relevant papers without searching specifically for the compound and that one effect on the cell.

While the issues here may stem from limitations of PubMed they may also reflect a misunderstanding of search strategies.

She asks, for example:

How does it even work? Does it search only the abstract? Does it also search the body of the papers that are available online?

Those answers are readily available and there are two ways to know. You can tell PubMed exactly how to do the search through the use of Boolean operators and PubMed field tags or you can type in a simple free text search word or phrase and let PubMed decide the strategy. In the former case you know what PubMed did because you told it what to do. In the latter case you can find out by clicking the details tab on the results page to see the strategy. The information displayed there is extremely useful because it suggests ways to refine your search for better results.

The details display also reveals some of the hazards of simple free text searching. Here’s what PubMed did, for example, when I simply typed “diabetes” (click image to zoom):

It retrieved results for both diabetes mellitus and diabetes insipidus. Chances are I’d be looking for one or the other, not both. It also tells me it searched text words through the title and abstract in addition to applicable subject headings (MESH terms).

Sound complicated? You can always get help from your medical librarian but you don’t have to. You can learn to do it yourself. After some initial effort (take the tutorial) and a little practice it’s not that hard. If you can blog you can do PubMed. If you can navigate an electronic medical record you can do PubMed.

That said, I have little experience using PubMed for basic topics in molecular biology and the like, where its performance may not be as suitable as in clinical medicine.

Via White Coat Notes and Kevin M.D.

Tuesday, March 25, 2008

Antibiotics no good for sinusitis?

That’s what recent evidence suggests and it’s in keeping with all the latest buzz. Well, a jury didn’t buy it and it cost the docs $3 million bucks. (The fact that they didn’t follow their own procedures for supervising midlevels didn’t help).

Via Kevin.

ECG manifestations of pulmonary embolism

Lacking sensitivity and specificity, the ECG can not be the sole modality to diagnose or exclude pulmonary embolism. It can provide clues, however, which point to the diagnosis, as well as information on the physiologic state of the right ventricle. The topic is reviewed here in the American Journal of Emergency Medicine.

Monday, March 24, 2008

More on the triple rule out CT scan for evaluation of chest pain

New technology is promising but technical obstacles are substantial.

American Medical Student Association teams up with naturopathic medicine

Thanks to a link from one of Panda Bear’s commenters I found the naturopathic medicine page of AMSA’s web site, where we learn that the president of the American Association of Naturopathic Physicians recently spoke at AMSA’s national meeting. And take a look at the reading list and some of the links. Unbelievable.

Sunday, March 23, 2008

Dr. Anonymous returns

As many of you know, Dr. Anonymous recently put his blog on hiatus. Well, he’s back blogging now, expansive and upbeat as ever. Concerning his radio show, due to return March 27, he gives us this tease:

Boy, will I have lots to talk about. So much so, that I'm not even scheduling a guest. It will be me talking about stuff and you calling in and telling me what's been happening with you. First of all, I'll kind of talk about what happened for me to take the blog break in the first place.

That should be interesting. Anyway, glad you’re back, Dr. A.

Thursday, March 20, 2008

Don’t neglect lead aVR

Often relegated to the status of placeholder in the electrocardiogram, aVR may contain the critical data for the diagnosis of a number of conditions. A review in the American Journal of Emergency Medicine highlights pericarditis, left main coronary obstruction, orthodromic tachycardia and acute tricyclic antidepressant poisoning.

Additional references:

ST elevation in aVR as a sign of left main coronary artery obstruction.

Review of electrocardiographic clues obtainable from aVR (JACC).

Classic paper on the electrocardiographic changes of pericarditis.

The electrocardiogram in non cardiac conditions.

Wednesday, March 19, 2008

EBM in the ER

Can EBM be practiced in the real world? Investigators put this question to the test in the most difficult environment imaginable---the ER. Time pressed and constantly interrupted, ER physicians searched for the answer to 81% of clinical questions they encountered and were successful 87% of the time. Impressive indeed!

The 64 slice CT and the triple rule out for chest pain: ready for prime time?

Find out here in a review published in the American Journal of Emergency Medicine.

Tuesday, March 18, 2008

Orac on AMSA’s CAM leadership training program

As Orac pointed out so well, it’s about advocacy and promotion, not critical analysis. The American Medical Student Association (AMSA) is grooming the next generation of academic leaders to take medical school woo to a whole new level.

Orac also noticed AMSA’s double standard for scientific claims, something I’ve hammered at many times in reference to their PharmFree campaign:

This is, of course, ironic given the way that AMSA makes such a big deal of mentioning evidence-based approaches when it comes to dealing with the claims of big pharma while strongly promoting non-evidence-based approaches.

To say the least it leaves a credibility gap.

Monday, March 17, 2008

Should quality and safety measures be held to evidence based standards?

From time to time I and a few other bloggers have criticized the quality and safety enthusiasts for pushing measures that are not supported by evidence. Some instances involve truly evidence based therapies not shown to be effective when promulgated as ill conceived “core measures.” Most of the debates swirling around the field have appealed to evidence. At least until now.

In the latest issue of JAMA Donald M. Berwick, a leader at the Institute for Healthcare Improvement, writes that the prevailing standards of clinical evidence are too rigid for the evaluation of safety and quality practices. He cites what he believes to be the inadequacy of the randomized controlled trial and “injudicious assaults on bias.”

Although Berwick’s language is oblique to me he seems to be calling for less scientifically rigorous ways of evaluating quality and safety measures. Bob Wachter blogged about this last Saturday and described Berwick’s position more plainly:

He argues that traditional rules of evidence-based medicine should be suspended or relaxed when it comes to safety and quality practices, since the risks and costs of the practices are generally low (at least compared with drugs or devices), rigorous studies are difficult to do (since they deal with such complex settings), and the “evidence” from experience and theory is often sufficiently compelling to merit adoption.

Wow. It kind of reminds me of Andrew Weil arguing for a relaxed evidentiary standard for complementary and alternative medicine. Now don’t get me wrong. I’m not a stickler for evidence when it comes to simple common sense safety practices. I don’t need a systematic review to tell me I should wash my hands between patient encounters. But I do demand evidence when the measure in question is expensive (such as the IHI promoted universal screening measure for MRSA, debunked in the same JAMA issue) or mandated as a core quality measure without due regard for potential adverse consequences (four hour antibiotic rule, intensive glycemic control, the fifth vital sign---I could go on). I’m also concerned that our non-evidence based zeal for a zero defect health care environment unrealistically inflates public perceptions which could drive intrusive legislation and law suits. Wachter said it well:

On the other hand, in our zeal to “do something,” vigorously promoting or mandating practices with weak evidence risks squandering scarce resources, diverts us from better strategies, and subjects the safety field to the whims of opinions and biases. Berwick worries that our EBM pushback gives intellectual ammo to the dark forces of status quo. This is a reasonable concern. But given the public interest in quality and patient safety, I worry more that the distance between “this seems like a good idea” to “let’s include it as part of a campaign” to “let’s make it a new Joint Commission standard” to “let’s make it a state law” is perilously short. Accordingly, we should require awfully strong evidence that we’re doing the correct thing as we traverse that path, particularly when practices are complex and expensive.

Psychoanalyzing medical bloggers on NPR’s Morning Edition

The program featured Kevin MD, and Robert Wachter along with psychiatrist and psychoanalyst Deborah Peel. Dr. Peel thinks it’s inappropriate for medical bloggers to vent their frustrations on line. Here’s what Wachter had to say about her comments:

…personally I thought the psychiatrist went a bit overboard when she said,

"If you are unhappy with the people that you're supposed to be serving and taking care of, you probably need therapy," she says. "You don't need to be venting your frustrations in a public manner like that. That's very inappropriate and unprofessional."

Re-read my
last post on resuscitating 90-year-olds with metastatic cancer and dementia. Do I need a head shrinker?

No Bob, you don’t, but maybe Dr. Peel needs to work a few shifts in an ER or spend a few sleep deprived call nights on a busy medicine service.

Friday, March 14, 2008

More evidence in favor of “the new CPR”

Arizona investigators have been telling us for years that the CPR guidelines fall short. The latest evidence is found in this week's issue of JAMA. You read it first here.

John Ritter malpractice case decided in favor of defendant doctors

Read the Associated Press report here.

One of the defense attorneys, speaking on behalf of the two doctors, said "They were the only doctors with the courage to stand up and come to court in a celebrity case."

From what I have been able to glean from all the reports, no malpractice was committed at any level. Nevertheless other parties previously settled for $14 million.

Video from KNBC is here. “They were asking for an amount of money that no doctor anywhere in the United States unless his last name was Trump could afford to pay.”

Thursday, March 13, 2008

The hospitalist movement and what it means to PCPs

Medical Economics discusses the state of the movement from the viewpoint of the primary physician.

Cochrane collection podcasts

---are now on line.

Via Clinical Cases and Images blog.

Don’t miss Wellens syndrome

Wellens syndrome is a distinct electrocardiographic entity. It is highly predictive of proximal LAD stenosis and progression to myocardial infarction despite apparent response to medical management. The initial electrocardiographic manifestations may be subtle, presenting as biphasic T waves or a small “dimple” in the terminal portion of the T wave.

Abdominal involvement in giant cell arteritis

Reviewed in Medicine.

Tuesday, March 11, 2008

Fluid balance in ARDS/ALI

Findings presented at the Society of Critical Care Medicine 37th Critical Care Congress reinforced what we have already learned from the Fluid and Catheter Treatment Trial. Negative fluid balance was associated with better outcomes.

Via Medscape.

Thrombocytopenia in hospitalized patients receiving heparin

---be it low molecular weight or unfractionated heparin, in systemic anticoagulant doses, is common (36.4% of patients in the CATCH registry) and associated with increased mortality despite the fact that heparin induced thrombocytopenia (HIT) was not suspected or proven in the vast majority of patients.

The National Practitioner Data Bank: How does it work?

This is chilling. Via Medical Economics.

Monday, March 10, 2008

Hyperglycemia in acute coronary syndrome: the AHA statement

A just released American Heart Association scientific statement on the management of hyperglycemia in patients with ACS is refreshingly circumspect and free of dogma.

Strong pathophysiologic rationale supports aggressive glycemic control in patients with ACS but questions remain about the proper targets and the hazards of hypoglycemia.

The AHA report contains a nice evidence summary and concludes that while hyperglycemia should not be ignored the jury is still out concerning the appropriate glucose target. The report provides some “soft” recommendations with the disclaimer that they are for general reference only and points out that evidence does not support glycemic control as a quality measure during ACS hospitalization.

This is a must read, must bookmark document for physicians practicing hospital medicine.

New Framingham tool for estimating cardiovascular risk

Published in Circulation and discussed in Medscape.

Maybe this will motivate people to exercise

A large VA study found a robust inverse relationship between fitness level and all cause mortality.

More on hospital deaths at night and on weekends

Two studies were recently presented showing increased mortality in stroke when admission takes place at night or on the weekend. One of the investigators commented:

"I think it's a public health issue about why we find this acceptable, that hospitals can provide basically a different business model on the weekends," Dr. Reeves said.

Via Medscape’s coverage of the International Stroke Conference 2008.

Survival of cardiac arrest in relation to time of occurrence was discussed here.

Sunday, March 09, 2008

The latest woo from BMJ: acupuncture as an adjuvant for in vitro fertilization

Wallace Sampson, in a recent Science Based Medicine blog post, discusses “how to establish ineffectiveness in presence of conflicting information without submitting every nutty idea to infinite numbers of trials.” That, of course, is the problem with the National Center for Complementary and Alternative Medicine (NCCAM) which so far has spent about a billion dollars on such ideas. Its promotion of nutty ideas is often aided and abetted by the British Medical Journal (BMJ), earning it a place on Quackwatch’s list of nonrecommended periodicals under the category of “Journals, Excellent Except for Too Many Poorly Reasoned Articles on ‘Complementary’ and/or ‘Alternative" Medicine.’”

A systematic review and meta-analysis on acupuncture for in vitro fertilization (IVF) in this week’s BMJ suggests that the journal won’t be delisted any time soon. The review, which purported to demonstrate a favorable effect, included studies comparing acupuncture with sham acupuncture or no adjuvant treatment.

A commentary in the same issue concluded with:

So is this review by Manheimer and colleagues a well conducted review, worthy of consideration when making decisions about IVF? Yes. Is it perfect? No. However, several thousand systematic reviews are published each year in health care, and none of them is likely to be perfect. This one seems as good as many. Unless, of course, you know differently?

Well, yes, we know, or should know, differently. Questions abound. How, for example, can sham acupuncture points be defined when there’s no historic agreement or anatomic basis for the “real” ones? What conclusions would Bayesian analysis reach?

How would such an analysis be done? Sampson in his post suggests quantitative methods, but they are mostly applicable to individual trials. Bayes’ theorem evaluates data in light of prior knowledge and probability. BMJ makes only a nominal gesture at such an analysis:

What is already known on this topic:

In vitro fertilisation is lengthy, expensive, and stressful.

Safe, low cost, adjuvant treatments to improve success rates would benefit patients and reduce costs.

What this study adds:

Current evidence from methodologically sound trials showed an odds ratio of more than 1.6 for clinical pregnancy after in vitro fertilisation with adjuvant acupuncture.

On average, 10 women would need to be treated with acupuncture to bring about one additional clinical pregnancy. The magnitude of this effect depended on the baseline pregnancy rate.

The “analysis” is totally uncritical but is telling in that it implies no prior knowledge on the subject. There’s certainly no rationale on the basis of scientific principles.

I won’t attempt to do all the math, but here’s my semi-quantitative analysis.

P(AIB) = [P(BA) x P(A)] / P(B). P(AIB) (the probability of A given B) is the “bottom line” assessment after taking into account prior knowledge and the new evidence. P(A) is the “prior probability”, or the probability that the effect of acupuncture is true given prior knowledge and scientific plausibility. Since P(A) has to be infinitesimally small and occupies the numerator of the equation, the probability that acupuncture has a real effect on the success of IVF would have to be very small.

Saturday, March 08, 2008

Friday, March 07, 2008

Sorting out the causes of severe hypokalemia

Via the American Journal of Emergency Medicine.

The Brugada pattern can be dynamic and its significance is not always clear

Here’s a case report and literature discussion of Brugada pattern during febrile illness. Temperature sensitive genes are postulated.

I’m not ashamed of my CME

The hue and cry against pharmaceutical industry support for CME is growing louder. The latest salvo comes from Merrill Goozner in a post entitled The Shame of CME. (H/T to Kevin MD). Goozner cites a recent JAMA commentary critical of industry funding.

The JAMA piece notes increased commercial support for CME, jumping from $302 million to $1.2 billion between 1998 and 2006. But that’s not the whole story. According to a recent report in Medical Marketing and Media a downward trend began in 2003 along with a similar decline in the portion of educational monies spent on accredited activities, from 75% to 50%. It reflects increasingly onerous compliance standards that must be met for accredited CME funding. As detailed in the report, drug companies now have firewalls in place to help separate educational and marketing activities.

Nevertheless the JAMA opinion writer finds the current state of CME funding “at best very troubling” and Goozner believes states should ban accreditation of industry supported CME if the situation continues.

Why all the fuss? The argument goes something like this: Drug company support for CME is an extension of marketing and promotion. It has to be because the companies wouldn’t do it if it didn’t work. The drug companies influence the content of the CME, rendering it biased and unreliable. The only solution is for industry support to go away.

This popular and well worn argument seems appealing but on close examination is specious. Can drug companies spend large amounts of money on educational material and not influence content? Yes, they can and do. One of the best examples is MerckMedicus, a web site sponsored by Merck & Co., offering doctors free and unlimited access to the full text of dozens of journals and textbooks including Harrison’s, Cecil’s and Ferri’s Clinical Advisor. The site is pristine, with no advertising and no content other than that of the journals and textbooks in their original form. What’s in it for Merck if they don’t advertise on the site or influence its content? Good will, perhaps. Whatever the case, they’ve been offering it for years.

Critics of industry supported CME love to point to the free drug company lunches and evening speakers over dinner at expensive restaurants. I agree that type of activity is of little educational value, but it’s not at issue here because such events are seldom accredited. Those and other questionable sponsored activities may increase, though, if industry is banned from supporting accredited programs. According to the Medical Marketing and Media report cited above the trend may already be in that direction, with non-accredited funding jumping from 25% to 50%.

What about industry support of educational meetings sponsored by reputable professional societies such as the American College of Physicians, the American College of Cardiology and the Society of Hospital Medicine? While most of us believe those courses to be scientifically rigorous, a vocal minority seeks to ban their accreditation as long as they receive industry support. Their innuendo about such activities being only an extension of marketing appeals to public fear but not to evidence, because there isn’t any. Not a shred.

I had to chuckle at Robert Steinbrook’s conclusion in the JAMA piece: “Although eliminating support from pharmaceutical and medical device companies would involve more change than the alternatives, this approach will likely allow the medical profession to control its own continuing education.” Now how does he figure that? Cutting off industry funding would force many CME offerings out of existence and make others much more expensive, thus reducing doctors’ options. How is that supposed to give doctors more control? I don’t think this is what the rank and file of the medical profession want. They remain silent, perhaps because they don’t know what’s at stake. As the Medical Marketing and Media report pointed out, “For continuing education to continue, commercial funding must remain healthy. The future of CME depends on it.”

Thursday, March 06, 2008

Do bureaucratic delays in Canada’s prescription drug plan increase mortality after coronary stenting?

Possibly, according to a study recently published in the Canadian Medical Association Journal. The authors attributed it to the red tape patients had to go through to get their Plavix filled following coronary stenting. It’s been known for quite a while that even a minor delay in getting the Plavix filled is associated with worse outcomes.

I’m thankful that here in the U.S. I don’t have to send paperwork to Washington (or Little Rock) when I prescribe Plavix for patients.

When to suspect autoimmune insulin resistance

Autoimmune insulin resistance, also known as type B insulin resistance, is rare compared to the more common forms of insulin resistance related to obesity and acute illness in type 2 diabetes. Patients with type B insulin resistance tend to have other autoimmune diseases and may have insulin requirements of thousands of units daily. A case presentation and review was recently published in Nature Clinical Practice Endocrinology and Metabolism.

Tuesday, March 04, 2008

Dr. Rob’s handout on antibiotic myths

In general, says Dr. Rob, it is inappropriate to “call in” antibiotics for patients. I agree, although there are a few exceptions. Let’s look at some common patient misperceptions cited by Dr. Rob.

If mucous is green, it is time for antibiotics. Agree. That’s a myth.

When a fever starts, it is time for antibiotics. That’s not necessarily a myth. The best answer is “it depends.” What if the patient has a history of splenectomy or is neutropenic? Should you tell the patient to take two aspirin and call you in the morning? You may not get that call! Of course, calling in antibiotics would not be appropriate. That patient needs to go to the ER, pronto.

Sinus pain means you need antibiotics. Yeah, that’s a myth. The patient doesn’t necessarily need antibiotics, at least initially. He/she may ultimately need them, though.

“The last time I had this I needed antibiotics, so I wanted to catch it early this time.” That appeals to patients’ intuition but isn’t necessarily true.

Bronchitis requires antibiotics. NOT a myth, at least according to recent evidence. Popular dogma has taught that it’s inappropriate to treat bronchitis with antibiotics, then along came this study. It provided robust evidence that, at least in the elderly patient with bronchitis, a “preemptive strike” with antibiotics prevents pneumonia with a NNT of only 39. That’s way, way better than adult pneumococcal vaccine!

“I am immune to amoxicillin.” Whatever that means.

“Can I have antibiotics to be on the safe side?” Again, it depends.

“Can you call in an antibiotic?” Doctors in the middle of a busy day are often maneuvered into doing this. Stop and think first.

“When I got an antibiotic last time, I got better. That means the antibiotic made me better.” The post hoc ergo propter hoc fallacy.

Via Kevin M.D.

Dismissed from a frivolous shotgun malpractice suit

---this doctors troubles weren’t over. Via Medical Economics.

Carisoprodol abuse and withdrawal---a newly emerging problem

Case descriptions and topic review from Pharmacotherapy.