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.

Hospital cleanliness and MRSA bacteremia

There’s no correlation according to this large study in the Journal of Hospital Infection.

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.

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.

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.

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.

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.

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.

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.

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.

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?

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.

The scientific method

Lots of good web resources linked here. Via Life Sciences Education.

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

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.

Imaging studies in acute pancreatitis

Who, when and how, from CCJM.

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.

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.

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?

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.

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.

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.

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

New web resources for hospital medicine

Aggravated DocSurg stopped by the virtual doctor’s lounge and shared a couple of interesting new web sites presented at ACS.

The venous disease resource center.

UCSF perioperative beta blocker and clonidine protocols.

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.

More criticism of the Institute of Medicine

A recent commenter on ER crowding and the IOM said----

“The IOM is basically a government agency whose aim seems to be to find fault with and criticize health care professionals without having to find the means to properly fund their mandates. They make headlines and take the public's attention away from the real issues of healthcare economics. Our various professional organizations are afraid to refute their findings because we don't want to sound like we're whining. Yet we had better do so or all we're going to see is continued finger pointing and no real change.” I certainly agree with that. If the professional organizations won’t do it maybe the bloggers will!

As long as we’re picking on the IOM, NEJM recently reported on the IOM’s assessment of pay for performance. As we know, P4P is merely “playing for the test” and has little if any impact on real quality. Not to my surprise I found the IOM recommendations a little naïve. You can listen to the interview here or access a free transcript here.

The interview raises a few questions. They want to expand the P4P concept to reward not just quality, but also efficiency and “patient centered” care. Well, we already have a very powerful negative efficiency incentive----that hidden provider tax known as DRG. We also began a massive experiment in efficiency incentives almost a decade ago known as managed care.

And what is meant by “patient centered care”? It sounds great, but I thought all medical care was basically patient centered. It must mean something extra special----so what is it, exactly? Those folks at the IOM must be mighty smart if they can measure something as nebulous and subjective as patient centeredness. For phase two of their initiative they might consider measuring compassion, honesty, and empathy.

Although those are pretty lofty goals they’re going to start with the basics: reward providers “just for reporting data, at least initially.”

Bloggers respond on ER overcrowding

In response to my post on ER overcrowding DB notes that the Institute of Medicine (IOM) is unrealistic on many issues and points out the relationship of ER overcrowding to under compensation of general ambulatory care. Increasing utilization of the ER as a “clinic” by patients without access to primary physicians overtaxes emergency care. Worse, some ER patients require hospital admission largely due to the shortage of clinic doctors and inordinate wait times which preclude expeditious out patient work ups.

Today Grunt Doc offered a dissenting view and said (referring to DB, Kevin and myself): “The linked commenters in the first paragraph give a 'suck-it-up ED' subtext that rankles. We're doing that.” I guess I pushed the wrong button here, but no such subtext was intended. I was being critical of the IOM, not emergency departments. I have no doubt they’re doing the best they can.

He made this comment over at DB’s blog: “I think there’s a lot of arrogance in absolving the hospital of any responsibility to ease ED overcrowding. Overcrowding isn’t a result of ED inefficiencies, it’s a lack of hospital ownership of the patients admitted to the hospital through their own ED.” 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.

What’s Grunt Doc’s solution? Hallway beds. Fine. It seems to work at his institution. I’m not exactly sure what the hallway protocol entails, but I suppose it means that if all regular beds are occupied (hospital “full”) you put the patients where ever there’s physical space, initiate care and hold them there until a regular bed opens up. To me that’s a form of boarding, but you do what you have to do. 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.

But hallway boarding has its problems too. If the hospital has reached the capacity of its licensed beds (presumably the case if its wards are really full) might those hallway admissions run afoul of the law? In many cases it’s about more than licensed beds and physical space----it’s about staffing. That’s a patient safety issue. There’s plenty of evidence that higher patient to nurse ratios are associated with increased mortality. In this study, for example, 30 day mortality rose 7% for each patient added per nurse.

I’ll say it again. My whole point was directed at the IOM. They say hospitals wouldn’t have to divert or “board” if they’d just be more efficient. That is simplistic. Hospital administrators, physicians and case managers have been working their fannies off to make hospitals more efficient under draconian negative cost incentives (AKA DRGs) that have been in place for 23 years. That is not the answer to ER crowding.

Related criticisms of IOM:

The hyping of medical errors.

The promotion of pseudoscience.

Wish I’d said that

A commenter (Okulus) over at Kevin MD’s link to my post on the Institute of Medicine’s recommendations concerning ER overcrowding wrote:

Now the IOM will become the deserving target of the AHA. Given the abstracted and unrealistic ideas that seem to come with great regularity from the IOM, perhaps it is time government funds were spent elsewhere.
It seems wasteful to fund the production of so-called analysis that produces such wasteful and stupid results.

So right.

Speaking of ER delays and overcrowding---

In view of all that’s been written lately on the hazards of ER delays, this Perspective piece in NEJM is timely. The author, Arthur Kellermann, M.D., M.P.H., reports findings and recommendations from an Institute of Medicine (IOM) committee on emergency care. Due to increased utilization and shrinking resources, according to the article, ER care has reached a point of crisis. It points out that EMTALA, intended to improve ER access has in fact diminished it by giving emergency rooms an unfunded mandate.

As I read the article everything seemed reasonable until I got to the discussion of ambulance diversion and emergency department boarding. Briefly, when no inpatient beds are available for hospital admission the emergency department may commence care of the patients and keep (“board”) them in the department until an inpatient bed becomes available. In extreme situations ambulances are diverted to other area hospitals. These practices have become quite common due to overcrowding. But now the IOM is recommending these practices cease, except in disaster conditions. That’s all well and good, but what’s the hospital to do when there’s no room in the inn? Dr. Kellermann writes that the IOM decrees “Hospitals can achieve this goal by adopting operations-management techniques and related strategies to enhance efficiency and improve patient flow.” Huh? Isn't that what hospitals have been struggling to do for their very survival ever since DRGs were enacted in 1983? This is supposed to solve the problem of ER overcrowding, suddenly? It strikes me as naïve. The full IOM report is here.

If you’re experiencing STEMI-----

Do not pass go, do not collect $200.00 and do not stop in the ER. Go straight to the CCU or cath lab. That’s the message of an observational study published in the October issue of Heart. Patients with ST segment elevation MI who were shipped directly to the CCU or cath lab were admitted earlier (by 48 min) and had a lower mortality than those who were admitted via the ER.

Mortality for ER patients was 8.6% for ER patients and 4.9% for those directly transported to the cath lab or CCU. By my math that means that the benefits of direct transport are RRR 43%, ARR 3.7%, NNT 27. In terms of relative risk, mortality rose by 0.9% per minute of delay, translating into 54% per hour.

This is one more piece of evidence that ER delays are lethal (see this recent post citing evidence that, across the board wait time is associated with 20% mortality per hour for all patients admitted) and that by some folks’ definition there are lots of emergency department homicides out there.

So how do you know if you’re having a STEMI (as opposed to NSTEMI or non cardiac chest pain)? Well, you don’t, initially. But the paramedics can tell from their pre-hospital ECG.

That raises another point. If you experience chest pain DO NOT come to the ER in a private car. Call an ambulance. Transport by private car was the first mistake in the Illinois heart attack death recently ruled a homicide.

Neuropathic pain management

Tricks of the trade reviewed in CCJM.

Abraham Flexner’s legacy---NEJM authors miss the point

The New England Journal of Medicine (NEJM) launched a series of articles on medical education with this piece on the legacy of Abraham Flexner. The 1910 Flexner Report, a comprehensive and highly critical evaluation of medical schools in the United States and Canada, helped spur a revolution in medical education, setting a blueprint for the twentieth century.

The authors, discussing how medical schools today might measure up in Flexner’s view, cite poor training in procedural skills, compromised teaching due to competing research and economic agendas and a lack of attention to professionalism and ethics. These are valid concerns. But conspicuously absent form the discussion was mention of a major problem plaguing medical training today about which we were warned in the Flexner Report: the rampant teaching and promotion of quackery and pseudoscience in medical school. Almost a year ago I pointed out that medical schools had backslidden from the recommendations of the Flexner Report as evidenced by their promotion of homeopathy, Reiki, Ayurvedic medicine and innumerable other unscientific claims.

As I reviewed the Flexner Report in its entirety this weekend I caught myself wondering whether the NEJM authors even read it at all. Flexner’s concern for the sanctity of science, practically an obsession, is evident throughout. If the authors read the report they must have skipped chapter 10 which warns strongly against what medical educators today call “integrative medicine.” The chapter is titled “The Medical Sects”, in reference to groups of teachers and practitioners who advocated for various non-scientific claims, referred to by Flexner as “dogmas.” Chapter 10 opens questioning the integration of dogma with science thusly: “Is it essential that we should now conclude a treaty of peace, by which the reduced number of medical schools should be pro-rated as to recognize dissenters on an equitable basis? The proposition raises at once as to whether in this era of scientific medicine, sectarian medicine is logically defensible; as to whether, while it exists, separate standards, fixed by the conditions under which it can survive, are justifiable.” Flexner’s emphatic answer, bolstered by eloquent arguments in the succeeding pages, is no.

Medical schools are showing increasing disregard for the principles of science. If the NEJM in its forthcoming series of reviews on medical education ignores this pernicious trend it will have done the profession a great disservice.

Orac exposes the “pharma shill” gambit

It’s a favorite fallacy for the alt-med crowd. It’s been used on me a time or two.

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?

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.

House takes on the antivaccination crowd

And Orac provides the transcript. This is too funny.

Cardiac pacemakers demystified

A review in Clinical Cardiology.

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.

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.

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

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.

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.

Tygecycline

Reviewed in Baylor University Medical Center Proceedings.

I previously reviewed it here.

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.

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.

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.

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.

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.

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.

New developments in staphylococcal infections

This week’s NEJM reports a study from the S. aureus Endocarditis and Bacteremia Study Group showing non-inferiority of daptomycin (Cubicin) compared with “standard” therapy (vancomycin or an antistaphylococcal penicillin for MRSA or MSSA, respectively, both initially combined with low dose gentamicin) in patients with Staphylococcus aureus bacteremia and right sided endocarditis. Acquired resistance to daptomycin occurred leading to treatment failure, counterbalanced by increased renal toxicity causing treatment interruption in the standard therapy group, also contributing to treatment failure.

In the same issue is a report from Moran and colleagues on the microbiology and clinical characteristics of skin and soft tissue infections (classified as abscess, wound infection or cellulitis) presenting to emergency departments across a wide swath of the U.S. The majority of isolates were MRSA which possessed characteristics unique to community associated MRSA (CA-MRSA) including expression of the Panton-Valentine leukocidin toxin (PVL) and the characteristic sensitivity pattern.

An editorial in the same issue makes these points about the two studies:

1) When oral antibiotic therapy is indicated, trimethoprim-sulfamethoxazole (TMP-SMX) may be a reasonable choice for CA-MRSA but it is not effective against streptococci. Clindamycin is effective against streptococci but CA-MRSA may exhibit inducible clindamycin resistance. (This Mayo Clinic Proceedings review suggests combining TMP-SMX or a tetracycline with a beta lactam such as cephalexin to get around the problem).
2) Abscesses should be incised and drained and, given somewhat variable sensitivity patterns, culture data should guide therapy.
3) Daptomycin is an alternative to older standard therapy for bacteremia. Emergence of resistance during treatment is a problem. Patients who appear to fail treatment should be evaluated for acquired resistance to daptomycin in addition to sequestered foci of infection. (Daptomycin is not recommended for treatment of pneumonia).

DB weighs in with a discussion of how the problem is handled at his institution.

The restructuring of an embattled medical journal

In the wake of the fracas a few months ago over its leadership, the Canadian Medical Association Journal (CMAJ) is reorganizing. Changes include a strengthening of the Joint Oversight Committee responsible for mediating disputes between the editors and the journal owners. It remains to be seen how the changes will play out but contrary to popular speculation, and no doubt to the disappointment of some, the sky hasn’t fallen at CMAJ.

As debate unfolded in the weeks following the dispute at CMAJ “editorial independence” became a tired mantra. Dr. Jerome Kassirer, a member of the CMAJ editorial board and a critic of the publisher during the dispute, is quoted in the August 15 CMAJ article: "You want an editor who is not intimidated by anything. ... It's critical to have an editor who is beholden to nobody." My translation: an editor who is accountable to nobody. Editorial independence is not an absolute value. There must be a healthy tension between independence and accountability, which is what the people screaming about editorial independence don’t seem to get.

Background: previous notes from Dr. RW on this topic here and here.

Cool neurology sites

Educational web sites covering everything from molecular mechanisms to optical illusions are linked and reviewed here. Via Life Sciences Education.

Changing trends in hospital acquired bacteremia

According to this report form Archives of Internal Medicine the pendulum is beginning to swing back toward gram negatives.

NCCAM chelation study site tour—part IV

The Born Preventive Health Care Clinic in Grand Rapids Michigan and its Crossroad Healing Arts branch in Goshen Indiana are NCCAM chelation study sites. The clinics feature craniosacral therapy for autism, chelation, and Nambudripad’s Allergy Elimination Technique. The clinics offer lecithin infusions in combination with chelation which they claim have been shown to reduce plaques that cause various forms of vascular disease.

In explaining the Nambudripad’s Allergy Elimination Technique the web page offers an interesting theory of allergic diseases: “… blocked energy flow is the first step in a chain of events which can develop into an allergic response.” The section on autism and related developmental disorders attributes the increased incidence as to “excessive vaccination in infants.”

How close are we to an influenza pandemic?

This review from Baylor University Medical Center Proceedings discusses the World Health Organization’s statement: we’re at stage 3 of 6 along the progression.

Complementary and alternative medicine viewed from the perspective of medical ethics

Present day promotion and research on complementary and alternative medicine (CAM) is often unethical. Dr. Wallace Sampson, Clinical Professor of Medicine (Emeritus), Stanford University, in a Medscape General Medicine video editorial focuses on two little discussed issues relating to CAM: informed consent and the ethics of clinical research.

Physicians have a duty to inform the patient if a treatment under discussion is not scientifically validated. Dr. Sampson points out: An ethical dilemma occurs when patients have unrealistic expectations for an ineffective remedy. The practitioner who fails to inform realistically, or leads the patient on, compounds the dilemma. Failure to inform realistically is sometimes rationalized as either choosing not to remove hope or as nonjudgmental patient support.
However, uncritical support amounts to abetting ill-informed, counterproductive, and harmful decisions.

Concerning clinical trials Dr. Sampson points out that subjecting research participants to methods of “negligible plausibility” violates the Belmont and Helsinki declarations. By this standard much of current NCCAM sponsored research would be unethical.

Are statins beneficial in heart failure?

Although the body of evidence is small it suggests numerous beneficial effects and no harm, according to a review in American Heart Journal.

Type 1.5 diabetes---a clinical vignette

In the summer 2006 edition of Clinical Diabetes is a case study of atypical diabetes along with a brief topic review. I previously posted on type 1.5 diabetes here.

What test for suspected aortic dissection?

Transesophageal echocardiography, computerized tomography and magnetic resonance imaging performed equally well in the evaluation of patients with suspected aortic dissection in this meta-analysis published in Archives of Internal Medicine.

Pulling old antibiotics off the shelf

Gram negative infections in hospitalized patients are re-emerging, along with multiple antibiotic resistance. Options for dealing with such infections are limited because, with the exception of tygecycline the antibiotic pipeline is running dry. Tygecycline is a welcome addition to the formulary and may be an option for some, but certainly not all multiply resistant gram negative infections.

The June issue of Clinical Medicine and Research contains a review of the use of polymyxins for such multiply resistant gram negative infections. Polymyxins are polypeptide cationic antibiotics. The commercially available parenteral polymyxins, colistin (polymyxin E) and polymyxin B, were used extensively for a number of years before falling out of favor in the 1960s due to concerns about toxicity and the emergence of newer agents. The toxicity is primarily renal and neuromuscular (similar to aminoglycosides) and, the article cites more recent literature to suggest that this toxicity is less severe, or more manageable than reported decades ago.

We’ve been there before with polymyxins. This paper provides a memory jog back to my days as a Vanderbilt medical student. When I was doing my senior elective in infectious disease the VA hospital was in the throes of a severe epidemic of Serratia marcescens resistant to all commercially available antibiotics. It was 1974. Our big guns for gram negative infections were gentamicin and carbenicillin. The ID folks were able to get amikacin for some patients but it was investigational (then known as BBK8) and difficult to obtain. The polymyxins, which had already fallen into disuse by that time, were not effective against Serratia. Synergy against Serratia, however, was known to occur between the polymyxins and sulfamethoxazole/trimethoprim. The combination of sulfamethoxazole, trimethoprim and polymyxin E (STP) proved clinically effective against the infection. The Serratia epidemic and the use of STP were reported here in Antimicrob. Agents and Chemother. in 1976.

NCCAM chelation study site tour part III

This is the third in a series of posts in which I will examine some of the study sites for the National Center for Complementary and Alternative Medicine (NCCAM) sponsored Trail to Assess Chelation Therapy (TACT). The purpose is to address questions about the quality of the research based on conditions at the study sites. The vast majority of sites are private clinics at remote locations across the U.S., raising questions about supervision, and many are alternative or holistic medicine clinics, raising questions about scientific qualifications and investigator bias.

The next study site we will examine on our tour is Wellness Works in Brandon Florida. The mission of Wellness Works is, in part, “to offer our patients an evaluation, treatment, and education based on the holistic model of body-mind-spirit.” Services offered include the assessment of hormone status via saliva testing, intravenous vitamin therapy to treat neurologic dysfunction and immune deficiency, and chelation therapy for atherosclerosis.

The chelation page of the Wellness Works web site describes chelation thusly: “Chelation therapy is also thought by many doctors to be effective in reducing plaque in the arteries. By softening ‘hardening’ of the arteries, this process makes them capable of carrying much more oxygen and nutrients to all the organs of the body.”

Because this seems to be a recurring misconception among TACT investigators, a comment on the pathophysiology of atherosclerosis is in order here. Although reducing the lipid content of atherosclerotic plaques would be expected to reduce the risk of coronary events, reduction of plaque size to enable more blood flow would not. In fact, highly stenotic plaques appear to be an uncommon cause of acute coronary syndrome compared to plaques producing milder degrees of stenosis. Moreover, softening of plaques is not beneficial, as softer plaques are more prone to rupture and cause acute coronary syndrome (Ayala TH-Cardiol. Clin.-1-Feb-2006;24(1):19-35).


Background: Part I; Part II.

Medscape Roundtable

The first installment of Roundtable Discussion is posted at Medscape. The topic is physician obesity. Be sure to stop by the discussion page and “weigh in” with your opinion!

The fox is guarding the henhouse of science and public trust

And the National Council for Complementary and Alternative Medicine (NCCAM) doesn’t seem to mind. In researching for my posts on the NCCAM chelation study sites (Trial for the Assessment of Chelation Therapy, TACT) I’m becoming convinced that the NCCAM is entrusting chelation research to promoters of unscientific health claims who have a vested interest in the results. This is particularly concerning because the blinding of the investigators is faulty. According to the study protocol the chelation solution must be mixed at the individual study sites. Patients randomized to the EDTA arm have ascorbic acid injected into the chelation solution at the local study site. Those assigned to placebo have placebo ascorbic acid injected into the mixture. The problem is, the ascorbic acid solution is yellow, while the placebo ascorbic acid is colorless. The work around for this problem is to wrap the ascorbic acid and placebo syringes in tinted translucent tape. It is claimed that the ascorbic acid does not cause a yellow puff when injected into the infusion bag. It would seem easy enough, though, to waste and inspect a few drops of solution before or after injecting the infusion bag.

For insightful and humorous commentary on chelation and the NCCAM check out this week’s Friday dose of woo by Orac.

NCCAM chelation study site tour part II

The Trial to Assess Chelation Therapy (TACT) is a National Center for Complementary and Alternative Medicine (NCCAM) sponsored study to evaluate chelation therapy for patients with coronary artery disease. The study is conducted at multiple sites across the U.S., almost 100 of which are private clinics, with only 12 academic medical centers participating. Although this selection of study sites facilitates enrollment of large numbers of patients and has the purported advantage of simulating “real world” conditions, the approach has problems. Some authorities have expressed the view that investigation of chelation therapy should be restricted to academic centers. Supervision and credentialing of investigators at multiple non-academic sites is compromised and leaves research vulnerable to fraud, fabrication and faulty methodology, as illustrated recently by the Aventis sponsored Ketek trial.

After perusal of the TACT web site I became concerned that many of the study sites are clinics which are engaged in the practice and promotion of unscientific methods. Disclaimer: The profiles of NCCAM study sites in this and subsequent posts are not intended as criticisms of the clinics in question or their staffs. Although I disagree with the health claims to be discussed here I do not question the sincerity of the providers and respect their right to compete in the marketplace of ideas. The observations made are with the sole intention of raising questions about the quality of the research.

The first stop on our tour is Tequesta Family Practice, Tequesta Florida. Among the alternative practices featured there are heavy metal analysis for chronic fatigue, intravenous infusion of vitamins and minerals for chronic fatigue, evaluation and treatment of “dysbiosis”, evaluation of colonic “ecology” by various culturing techniques, intravenous colchicine infusion for spinal disk herniation and, of course, chelation therapy.

The clinic’s uncritical promotion of chelation raises questions about the objectivity and scientific qualification of the investigators. Chelation therapy is touted by the clinic as “one of the premier anti-aging therapies” and as useful for scleroderma, Alzheimer’s disease, rheumatoid arthritis, multiple sclerosis and porphyria.

Worse, the comments about how chelation therapy “works” reflect a misunderstanding of the pathophysiology of coronary heart disease: “…..to literally strip calcium out of the artery plaques that cause the clogging of the blood vessels that cause heart attacks and strokes. It can ‘soften’ the ‘hardening’ of the arteries caused by atherosclerosis, reversing the disease process.” I won’t go into a detailed explanation of the mechanisms of coronary atherosclerosis---look it up in any standard text or review---just suffice it to say that “soft” coronary plaques are much more rupture prone than “hard” plaques, and that a treatment to “soften” atherosclerotic plaques would be the wrong treatment. From the promotional comments about chelation therapy it is clear that the investigator(s) there believe that its effectiveness has already been proven.

In summary, consider these questions: Are the site investigators biased in favor of the treatment? Could such bias compromise the scientific integrity of the study, particularly given that the blinding of the investigators is faulty? Do the site investigators understand the pathophysiology of coronary heart disease and is such an understanding important for research on a treatment modality?

Background:
Part I
General criticisms of NCCAM here, here, and here.