Community associated methicillin resistant staphylococcus aureus---it’s not the old MRSA exported to the community

Community associated methicillin resistant staphylococcus aureus (CA-MRSA), as I blogged before, is a newly emerging pathogen, distinct form the formerly more familiar hospital associated MRSA. It now increasingly arises from within health care facilities and thus should no longer be defined by the setting in which it is acquired. Its distinguishing characteristics include unique drug sensitivity and virulence patterns.

A review in Seminars in Respiratory and Critical Care Medicine discusses CA-MRSA infection with an emphasis on pneumonia, which can occasionally manifest as a severe necrotizing infection in younger patients.

Anna Nicole Smith case raises questions about doctors treating celebrities

According to this article about famous patients, treating a celebrity could be hazardous to your profession by luring you away from evidence based medicine.

More physics majors getting into med school?

Apparently so. Maybe it’s a good thing given the rising credulity toward bogus “energy” theories in medical school these days. I wonder how many of these physics majors join AMSA?

Via Kevin M.D.

Anna Nicole Smith---the plot thickens

The medical blogosphere’s response to the death of Anna Nicole Smith is beginning to read like a virtual CPC. So far myocarditis, serotonin syndrome, cardiomyopathy, congenital heart disease, heritable disorders of connective tissue, pulmonary embolism, WPW, ischemic heart disease, Brugada syndrome and drug overdose and/or interaction have been posited.

Methadone garnered more attention in the last few days following reports that it was found in her refrigerator. As I posted here methadone could have caused an arrhythmic death. It causes prolongation of the QT interval and torsade de pointes, effects which would not be mitigated by narcotic tolerance or the use of Narcan. These electrophysiologic effects are under appreciated and may be responsible for many of the deaths recently reported in association with abuse of methadone.

Deep into woo

The American Medical Student Association recently sponsored its 2007 Circle of Healers Retreat. I knew there was woo at these gatherings but had no idea of the depths. This blogger says the event featured workshops on therapeutic drumming and shamanistic journeying.

Leukotriene inhibitors

Leukotriene inhibitors are popular agents in the treatment of asthma and allergic rhinitis. Although their use has outpaced evidence there are well defined roles. Here’s a summary of what’s evidence based and what’s not from American Family Physician.

The hospitalist movement: where is it headed?

Niraj L. Sehgal, MD, MPH and Robert M. Wachter, MD reviewed the hospitalist field in the January 2007 issue of Resident and Staff Physician. It’s on a roll and there are plenty of opportunities. The authors offer tips for trainees considering a hospitalist career.

There is controversy over whether hospitalists improve outcomes. The authors briefly address that question by citing this review appearing in 2005 which concluded that “most evaluations” found hospitalist care to be associated with reduced charges and lengths of stay with no significant difference in quality of care or patient satisfaction. The analysis was compromised by lack of randomization in many of the cited studies. Sehgal and Wachter failed to cite this very large multicenter study presented the same year at the Society of Hospital Medicine which showed no difference in outcomes or utilization between hospitalists and non hospitalist peers. Do hospitalists provide better or more efficient care? Although we’d like to think they do we don’t have an evidence based answer.

Noninvasive ventilation following extubation

Noninvasive ventilation following extubation has not been shown to be beneficial in unselected patients. This study, reviewed in Critical Care, suggested that it is useful in selected patients with high risk, the characteristics of which are outlined in the article.

Distortions about disease-mongering

The excerpt of the documentary Big Bucks, Big Pharma: Marketing Disease and Pushing Drugs opens with accusations that experts, influenced by the pharmaceutical industry, are re-defining sickness. In response to Thursday’s post on this subject a commenter said “In my understanding, the accusations disease-mongering usually apply to primary prevention i.e. labeling people who were considered ‘healthy’ yesterday as ‘sick’ today because of the lowered guidelines and thus increasing the number of people who are considered to have a disease.” That’s a widespread misconception. The video does accuse industry of redefining sickness through direct to consumer ads and influence on guideline writers, but where’s the evidence to back up that assertion?

Let’s look at cholesterol recommendations. The current guideline and a frequent target for accusations of disease-mongering is the NCEP Adult Treatment Panel-3. What are its recommendations for healthy persons? For individuals with no history of atherosclerosis and 0-1 risk factors it calls for consideration of drug treatment for patients with an LDL cholesterol of 190. This is hardly an aggressive target, and hardly a level a reasonable person would regard as healthy. But note the word consideration. That means that, as explained in the text of the full report, drug therapy should be recommended for such patients only after documented failure of a trial of hygienic measures such as diet and exercise.

It is only for patients with atherosclerosis, diabetes or a constellation of conditions defining very high risk that the guidelines recommend aggressive treatment to low targets. But that isn’t disease mongering. Such patients, especially those with atherosclerosis, already are sick.

Anna Nicole and Daniel Wayne Smith

Amid speculation on the causes of the deaths of Anna Nicole Smith and her son Daniel there has been mention of methadone. Daniel Wayne Smith was taking methadone. The conclusion of pathologist Cyril Wecht who performed a second autopsy on Daniel was that methadone in combination with Zoloft and Lexapro resulted in death due to cardiac arrhythmia. Moreover, the investigation concluded that there was no evidence of foul play or “suicidal overdose.” If all that’s true it’s possible that the methadone in his system caused torsade de pointes which progressed to ventricular fibrillation. It is doubtful that Zoloft or Lexapro played a significant role, as they are not arrhythmogenic in therapeutic doses, and their pharmacokinetic interactions with methadone are of minimal clinical significance. But as I blogged here the proarrhythmic effect of methadone does not require overdose or drug interaction. It appears in moderate therapeutic doses.

This morning Kevin M.D. cited a report that Anna Nicole Smith “kept passing out” before her death, a presentation typical of torsade. In various news reports multiple drugs including methadone have been mentioned in connection with her death.

I blogged here about the recent FDA alert and suggested precautions to be followed in the care of patients taking methadone. Better yet perhaps methadone, like meperidine, should disappear from clinical use as a pain reliever.

Accusations of disease-mongering and medicalization---are they evidence based?

The pharmaceutical industry has been under fire for its marketing practices. The latest barrage of accusations is about disease-mongering and medicalization. The idea is that the pharmaceutical industry carves out new markets for its products by inventing diseases and inflating the public perception of diseases.

Some of the more shrill industry critics are featured in the documentary “Big Bucks, Big Pharma: Marketing Disease & Pushing Drugs”, which can be viewed from this blogpost by Big Red Pill. The video deals mainly with direct to consumer (DTC) advertising, a major focus of the purported disease-mongering.

I don’t like DTC ads. But drug companies are going to market their products one way or the other. Public pressure may change how they market their drugs, but it isn’t likely to change the amount they spend on marketing. The constant hammering against physician marketing has been effective. It’s led to an increase in DTC advertising. But I digress.

Near the beginning of the video Marcia Angell, author of The Truth About the Drug Companies: How They Deceive Us and What to Do About It accuses drug companies of re-defining what it means to have hypertension and high cholesterol. Wrong, Dr. Angell. Although treatment targets have been lowered no one has “re-defined” hypertension. Hypertension is and always has been defined as blood pressure which exceeds a threshold for cardiovascular risk. Recent evidence suggests that that threshold is much lower than previously believed. An analysis of one million adults in 61 prospective studies demonstrated that the threshold is at least as low as 115/75. These data, rather than any “re-definition of hypertension” by the drug companies, are the basis for the lowering of blood pressure goals in recent guidelines. Over the years we’ve gradually become more aggressive in treating hypertension and data cited in the JNC-7 report suggest that this effort has reduced stroke, coronary events and heart failure. So what are you saying, exactly, Dr. Angell? What fault do you find with these data? You evidently believe we should go back to older, higher BP targets, right? What BP target do you feel would be appropriate and how would such higher targets help patients?

And what about cholesterol? I don’t see anyone defining high cholesterol or making it into a disease. The disease is atherosclerosis. We moved beyond worrying about what’s defined as high or low years ago in favor of setting treatment targets appropriate for the patient’s risk. These treatment targets have been lowered not because of any re-definition of high cholesterol by industry, but because it’s supported by evidence. So, again, Dr. Angell, let’s play fair. You evidently don’t agree with the new treatment targets. What’s wrong with the evidence I’ve cited? What targets do you think would be appropriate and what evidence do you have to support your proposed targets?

The narrator goes on to state that “Big Pharma normalizes even the most obscure health disorders and presents them as common.” Then, as if to illustrate that point, the video cuts to an ad about restless leg syndrome (RLS) which says that nearly 1 in 10 people have the problem. So how does this ad present an obscure health disorder as common? In fact evidence supports the statement in the ad. The figure of 1 in 10 individuals is not in dispute if one checks published research, something the producers of the video didn’t seem to bother to do.

Then Dr. Bob Goodman of No Free Lunch fame weighs in and accuses industry of taking common everyday maladies and “medicalizing” them. He asserts that of all the things they do this is the one thing he would label as “evil.” But he doesn’t really define what he means by medicalization. And while he points out that such “medicalization” might make a person realize that he or she is not healthy or (gasp) end up taking a prescription medication he doesn’t explain what’s really wrong with that. I wish I could pin him down. Is medicalization anything more than defining a problem? The idea that common everyday miseries are defined and characterized is nothing new. Constipation has its own ICD-9 code as does headache. Medicalization?

The video is unconvincing. If accusations of medicalization and disease-mongering are to amount to anything more than half truth and innuendo some questions such as those I have posed here need to be answered.

Homeopathy fails the test again

Mayo Clinic Proceedings reports this systematic review. But as I said before I see little point in this sort of exercise. Research and meta-analyze homeopathy ‘till you’re blue in the face and you’ll settle nothing. It’s not going to stop the woo-pushers. Medpundit quotes a spokesperson for the Society of Homeopaths as saying: It has been established beyond doubt and accepted by many researchers, that the placebo-controlled randomised controlled trial is not a fitting research tool with which to test homeopathy.

Despite the findings of a systematic review in Lancet a year and a half ago that homeopathy is useless it continues to be promoted uncritically by medical schools and the American Medical Student Association.

Some mainstream woo-pushers, not wanting to seem totally shameless, try to give woo the trappings of evidence based medicine. Here’s the recipe: test an implausible claim and throw in a little chance variation. Combine that with a massive dose of publication bias and voilà!—evidence based woo!

I’d pay more attention to some of those “positive” woo studies if either there was a plausible mechanism or the empiric evidence was strong. For me the strength of the proof required is inversely proportional to the plausibility of the claim. I’d be much more interested in these clinical “studies” on homeopathy if the folks at MIT would come up with a mechanism by which water has memory.

Need an alternative income? Try alternative medicine!

Alt med is one of several ways doctors, faced with declining fees, supplement their incomes according to this Time report. Concerning a pathologist who began selling “magnetized water” to folks, a friend says “I trust little about him since he started with the magnetic water because I know he knows better: he passed physics to get into med school. But now he can finally afford that Range Rover he's had his eye on.”

Acid-base resources

Here’s a collection of links compiled by Clinical Cases and Images.

The ethics of complementary and alternative medicine: where the rubber meets the road

I’ve gone on and on about how the promotion of pseudoscience by us in mainstream medicine is unethical. But how are those ethics applied in the real world? It’s a safe bet there are woo consumers in your practice, since 34% of patients in one survey reported using alternative medicine, and the vast majority of patients who use alternative medicine also use conventional medicine. (Doctor, have you looked in your spouse’s medicine cabinet lately?)

There may be risks in telling such patients the uncompromised scientific truth about their treatment choices. They may become offended and leave your practice. If you come across as dismissive about herbs they’ll feel uncomfortable discussing them and may even conceal their use. What’s a doctor to do?

I can recall patients so deep into woo it was a way of life. It had become a major part of their world view, holding together their precariously balanced psychological defenses. In such cases a debunking from me might have caused psychological trauma. I saw no point in driving those patients away. Although likely to reject much of my advice they often needed my services. I usually felt I could help them in some way. How could I be honest without harming them?

A common justification by mainstreamers for their pseudoscience promotion is that doctors must respect patients’ beliefs and choices. Implicit in that argument is the tired canard that telling the truth about unproven methods and respecting patients’ choices are mutually exclusive. My own experience with patients is different. It is possible to tell the truth with respect and agree to disagree. If the patient is deeply steeped in woo I simply acknowledge our opposing world views and explain that in order to maintain a sense of professionalism I must remain true to the world view I believe in and was trained in and in which is western science. In this manner it is possible to respect patients’ beliefs without agreeing with them. It is not necessary to promote quackery, even implicitly, to treat patients with respect. I’ve found that even patients who are extremely into woo accept this approach.

The November 17 issue of Medical Economics addresses this problem in What would you do? Alternative Medicine. Doctors were asked how they would handle a patient who, after two unpleasant rounds of chemotherapy for colon cancer with metastasis to regional lymph nodes, sought treatment at an alternative medicine center. 8% said they would agree to collaborate with the alternative medicine center, no questions asked. 71% indicated they would “work with” the alternative medicine center even though they could not support its methods. 21% said they would refuse to collaborate with the center and urge the patient to continue with conventional treatments. I would have difficulty answering this survey. How does one “collaborate” with an alternative medicine center? One respondent put it well: "Patients may choose their treatment, but my collaboration implies my endorsement, and I can only endorse treatments that have some likelihood of success. Even if patients don't demand some scientific basis for treatments, it's my duty to require it for anything I recommend."

New guidelines address controversies in diagnosis and treatment of venous thromboembolism

Two companion papers, one in the Annals of Family Medicine and one in the Annals of Internal Medicine provide new guidelines for the diagnosis and treatment of VTE. Here are some highlights of the guidelines, which are available via the links above as open access full text.

The Wells prediction rules (provided in tables 1 and 2 of the diagnosis guideline) are validated by evidence. They do not perform as well in patients with co morbid conditions or prior VTE, in which cases clinical judgment becomes more important.

D-dimer testing is useful in selected patients with low probability Wells scores to exclude VTE and obviate further testing.

Between V/Q scanning and CT pulmonary angiography, available evidence suggests that clinical circumstances and judgment should dictate the initial selection of tests, neither of which is supported as the initial test of choice over the other. There is a popular misconception that CT is the clear method of choice. I addressed that misconception here and here.

Low molecular weight heparin (LMWH) is superior to unfractionated heparin (UFH) for treatment of DVT to decrease risk of mortality and major bleeding. (Editorial note: morbid obesity and kidney disease alter the pharmacokinetics of LMWH making laboratory monitoring necessary. Such monitoring requires special tests such as anti-Xa activity which are not available in real time in many hospitals. In such situations UFH should be used).

LMWH is acceptable, though not established as the clear choice over UFH, for initial treatment of PE. Published experience with LMWH for PE is limited.

Outpatient treatment of DVT with LMWH has been validated. The guideline stipulates that the necessary support system must be in place. (Editorial note: What’s an adequate support system? The devil’s in the details. If you’re a hospitalist or an ER physician considering outpatient treatment ask these questions: Does the patient have a payer source for the LMWH? Who will administer the shots--patient, family, home health nurse? Who will be responsible for following the INR during the transition from LMWH to warfarin?).

Compression stockings should be routinely used, to prevent post thrombotic syndrome (a point I made previously here).

Duration of warfarin therapy: 3 to 6 months if VTE is due to transient risk factors; at least 12 months (indefinitely) in cases of spontaneous recurrent VTE; consider “extended duration” treatment for initial spontaneous VTE. (“Extended duration” is poorly defined, but follow up periods in studies were as long as 4 years).

Long term treatment with LMWH “may be preferable” to warfarin in selected patients such as those with cancer and those whose INR is difficult to control.

For all the nuances and caveats, read both articles in their entirety.

(Hat tip to Physician’s First Watch and Retired Doc.

Code what?

Here’s an indispensable resource in hospital medicine: Wikipedia’s listing of hospital emergency color codes.

And, if you’re hanging out in the ER listening to incoming ambulance calls here are the 10-codes.

Concise ACLS review

June 2006 Mayo Clinic Proceedings, now available as open access full text.

Medical student blogger: Why all the fuss about medschool woo?

Orac, Kevin and I were taken to task for “whining” about the increasingly pervasive uncritical promotion of pseudoscientific fluff in medical school curricula. The author of Over my med body sets up this straw man: “They’re whining as if this is the most scandalous thing to have happened to American Medicine” and goes on to cite mainstream medicine’s questionable ties with drug and device companies.

The promotion of pseudoscience by academic medicine is unethical to be sure, but no one’s taking the position that it’s “the most scandalous thing to have happened to American Medicine.” Let’s get one thing straight. I acknowledge that there’s plenty of questionable promotion in medicine outside the field of woo. If my outrage about woo seems selective it isn’t because I don’t share the concerns about other types of ethical breaches.

I focus on the problem of woo for a number of reasons, one being that it’s under appreciated. The ethical problem of medicine’s ties to drug and device companies is on everyone’s radar screen. There are books, web sites and a documentary movie devoted to the problem. They cite legitimate issues, but I choose not to join the chorus because it’s being beaten to death while the problem with woo is largely ignored. Moreover there are organizations such as the American Medical Student Association whose concern about the drug companies undermining evidence based medicine seems disingenuous when they invoke chakras and promote therapeutic touch (pp43-46, Between Heaven and Earth) and promote chelation therapy for arthritis, lupus and spider bites (p 20, Complementary Therapies Primer).

Over my med body goes on with “Either way, many patients use CAM, whether I think it’s a good idea or not–and honestly, I’d much rather have some sort of idea about what CAM is and what I need to know about it than be ignorant of it completely. Some herbs affect medication dosages, for instance.” Fair enough. Medical students need to know what’s out there in the world of CAM so they can be aware of drug interactions and other consequences of alternative modalities. That’s not the type of teaching I object to. But as I’ve documented here, here, here, here, here and here, and has been systematically reviewed here, the “teaching” of medical students concerning CAM is largely promotional, unscientific and uncritical. That’s a big problem. Maybe it’s not the worst problem facing medicine, but it’s a problem that needs to be exposed because it’s not being addressed.

Update: Orac beats me to it, and weighs in here.

Should you admit that TIA?

Practices vary greatly from one community to another with regional variations in malpractice risk guiding decisions. Evidence based medicine has now come to the rescue. The ABCD-squared stroke risk score can help stratify patients presenting with or soon after TIA into high, intermediate and low risk categories. The score takes into account clinical features, blood pressure, history of diabetes and duration of symptoms. This should help standardize decision making when patients present with TIA. The validation study was published in Lancet and is linked here via Medscape.

Bet you didn’t know

That direct to consumer drug ads are deceptive. Wow. Who'da thunk it.

Unintended consequences of a “quality” measure

The “four hour antibiotic rule” for patients presenting to the hospital with pneumonia has become a mandate from JCAHO and CMS as well as a pay-for-performance initiative. This has caused hospital case managers and administrators to put pressure on ER physicians to jump to a diagnosis of pneumonia. A study presented as a poster abstract (poster 211) at the 2006 IDSA annual meeting demonstrated that the four hour rule is associated with over-diagnosis of pneumonia, evidenced by more diagnoses of pneumonia in patients with negative chest x-rays and a lower percentage of patients initially given antibiotics for pneumonia having the diagnosis confirmed at discharge.

The overuse of antibiotics as a result of the four hour mandate has been demonstrated before as I posted here. The implications concerning breeding antibiotic resistance are obvious.

American medical schools: slouching toward Hogwarts

Harry Potter would thrive in some medical schools today. I’ve been beating the drum about medical education’s egregious uncritical incorporation of non-evidence based woo for some time, starting with this post.

Science blogger Orac weighed in again yesterday with Medical schools going the wrong way in which he mentions a new wrinkle, the incorporation of woo into graduate medical education. Not surprisingly, it’s being promoted by the American Medical Student Association.

Yes, medical schools are going the wrong way. Does anyone in academic medicine care about the integrity of medical education? Who are you, and why aren’t you raising a stink? Medschool woo needs to be exposed. Maybe it’s time somebody wrote a book.

What malpractice crisis?

Public Citizen thinks it’s a hoax. Why then the four-fold variation in malpractice coverage rates between California and states without damage caps?

Via Kevin M.D.

Another risk factor for atrial fibrillation

Corticosteroids, equivalent to 7.5 mg prednisone daily or more, received in the previous month. Via Archives Internal Medicine.

Anaphylaxis

This review of anaphylaxis, though a little dated, is useful enough to be linked here. (Via Seminars in Respiratory and Critical Care Medicine).

Proposals by the American College of Physicians to improve health care quality and reimbursement---is the devil in the details?

Last year the American College of Physicians (ACP) warned of the collapse of primary care. This year they have proposed a series of reforms to help solve the problem, which they say will improve reimbursement and quality.

I have more than a few concerns about the proposals. They’re supposed to shift compensation incentives from procedures to comprehensive care. But haven’t we heard this before? The resource based relative value scale, conceived in the 1980s, was supposed to improve compensation for “cognitive” services. It wasn’t long, though, before physicians realized that RBRVS stood for “real bad reimbursement very soon.”

Worse yet, the proposals are another failure of the ACP to reclaim the identity of internal medicine. In defining the way internists fill the primary care role the proposals make no distinction from family practice. Is it any wonder there is a growing perception that the only way to be an internist is to be a hospitalist? Laurence Wellikson, M.D., CEO of the Society of Hospital Medicine, said it well: “General internal medicine had a chance to define itself as physicians who are master diagnosticians—the only doctors capable of handling the complexities of comorbidties, especially in the aging population. Instead of seizing terrain that was so uniquely geared to internal medicine training and experience, internists decided to compete with family practitioners and nurse practitioners to be the traffic cop for resource use and burgeoning specialization.” I have expressed this same view, though not as eloquently, here, here and here.

To me the proposals read like a mixture of physician DRGs, capitation, discounted fee for service, gate keeping, P4P and quality gamesmanship. They don’t make general internal medicine look very appealing.

Review of Echinocandins

The echinocandins comprise a new class of antifungal agents which act by inhibiting fungal cell wall synthesis. They tend to be fungicidal against yeasts (although inactive against cryptococci), fungistatic against molds and inactive against dimorphic fungi.

A two part review was recently published in the American Journal of Health-System Pharmacy, available in full text via Medscape. Part 1 addresses chemistry, pharmacokinetics and pharmacodynamics. Part 2 deals with clinical usage and role of echinocandins in the relative to other antifungal agents.

Naturopathic medicine topics at the American Medical Student Association’s Annual National Convention

From the talks listed it looks like they’re taking a promotional rather than a critical approach.

Joint Commission wants to set standards for how hospitals deal with disruptive behavior

I’ve posted about the concept of the “disruptive physician” here, here, here, here and here. Joint Commission’s latest proposal defines the problem this way (italics mine): “Disruptive behavior is conduct displayed by a health care professional that negatively impacts the quality or safety of care or has the potential to do so. Disruptive behavior may also intimidate staff, affect staff morale, and lead to staff turnover. Disruptive behavior may be verbal or non-verbal, and often involves the use of rude language, facial expressions, threatening manners, or even physical abuse.” Well, that’s kind of scary. Any behavior somebody else doesn’t like could be interpreted as disruptive and result in corrective measures (counseling, sensitivity training, psychiatric evaluation or worse) for the “offender.” It could also provide leverage to shove somebody out whose thinking happens to be a bit too original.

There’s one aspect of the proposal that I like. It doesn’t single out physicians. There’s a uniform standard that applies to all---physicians, administrators, nurses, etc.

(Via MSSPNexus blog)

Sniffing out C. diff

Lately I’ve been getting this call from nurses: “Mrs. so-and-so just had a liquid stool that smells like C. diff. Shall I send it down to the lab?” An informal poll revealed that many nurses are convinced they can detect the infection by smell. Is there anything to this?

Apparently, in the micro lab, blood agar colonies of Clostridium difficile have “a barnyard odor that is unmistakable” due to elaboration of P-cresol. But what are the test characteristics of olfaction at the bedside?

Observations of an ER nurse on how conflicts of interest trump evidence based medicine

Mention conflict of interest in medicine and the knee jerk response, nearly always, is to raise the issue of the pharmaceutical companies and their influence on doctors. Other conflicts, seldom appreciated, may play a larger role. ER nurse blogger girlvet mentions some of them in ER medicine is a free for all. The wide variations in practice she sees in her ER are anything but evidence based and, in her view, are driven by liability concerns, payer source and coding (the patient comes in with a tummy ache, but find 5 other diagnoses to document and you can code higher).

She warns doctors who may be reading: “you may not like what’s ahead….” Hey, I thought it was pretty good.

Via Kevin MD.

Medical Economics readers polled about doctor bashing web sites

If trashed on a doctor rating web site what would you do? In early results of a Medical Economics poll 50% of readers would ignore it, 35% would ask to post a rebuttal and 15% would threaten legal action.

Public Citizen: The medical liability crisis is a hoax

They “prove” it here. Point of Law offers this expose of the Public Citizen report. (Via Kevin MD).

Tygecycline for community acquired pneumonia

In a phase 3 double blind multicenter RCT presented as a poster abstract at the IDSA 2006 annual meeting (poster 171) Tygecycline was as safe and effective as Levofloxacin in patients with community acquired pneumonia (CAP).

Tygecycline is off label at present for CAP. I expect this study will be submitted to the FDA to approve the indication.

Propylene glycol toxicity due to high dose lorazepam infusions

Propylene glycol is a diluent for parenteral preparations of lorazepam and other drugs. Toxicity may occur with high or escalating intravenous doses of lorazepam and may be manifested by wide anion gap metabolic acidosis, renal failure and increasing osmolar gap. A brief review in ISMP Medication Safety Alert contains recommendations for minimizing the risk of toxicity, including daily chemistries and calculation of the osmolar gap in patients receiving high doses. An osmolar gap exceeding 20 may herald impending toxicity.

Vasoactive drugs in septic shock

A review was recently published in Seminars in Respiratory and Critical Care Medicine.

Brugada syndrome review

Brugada syndrome has been recognized with increasing frequency and in increasingly diverse populations since it was originally established as a distinct clinical entity in 1992. Recognition of the Brugada electrocardiographic patterns can be lifesaving and is thus an essential skill for emergency physicians, hospitalists and primary care physicians.

Although initial recognition of telltale electrocardiographic signs is straightforward, recent understanding of certain diagnostic nuances has been in a state of flux. In addition, new concepts regarding epidemiology, environmental factors, acquired patterns and mimics have rapidly accumulated. For these reasons a recent review in the journal PACE is timely and merits mention here.

Pertussis---not just for kids

Think of it when that cough won’t go away. (Patient Care).


Audio files of the characteristic cough, with and without the whoop. (Texas Health Department).

Why is EBM controversial?

Four bloggers (myself included) try to parse that question in the latest Medscape Roundtable Discussion. You can access the article here. The Roundtable Discussion archives can be found here.

Web based doctor bashing---Medical Economics weighs in

Rate MDs and several other web sites provide an open access, anonymous free-for-all where patients can rant and vent their frustrations about their doctors. This has been discussed recently by several medical bloggers and now Medical Economics profiles Rate MDs and other similar sites.

Though this sort of trash isn’t deserving of serious attention doctors are upset and wonder what legal recourse can be taken. Site owners are defiant, saying in effect “just try”. An expert quoted by Medical Economics says legal remedies, while difficult and expensive, are available, and several strategies are discussed.

Background:
Doctor rating with an attitude
More on Rate MDs
Rate MDs suggested as a tool for doctor credentialing

The OPTIMIZE-HF database: heart failure core quality measures disappoint

An analysis of clinical outcomes in the OPTIMIZE-HF registry appeared in the January 3 issue of JAMA. An attempt to relate compliance with “core quality” measures for heart failure to clinical outcomes was somewhat disappointing, with most measures showing no effect. Angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) were associated with no improvement in mortality through 90 days although a decrease in the composite endpoint of re-hospitalization and mortality did reach statistical significance. The most robust improvement in outcomes was associated with one evidence based treatment which was not one of the core measures: beta blockers.

DB has already ranted on this issue, stating “Perhaps the concept of performance measures has flaws.” (I would strike the word perhaps). He correctly points out “Medical care has greater complexity than simple rules would suggest.”

There are many reasons not to be surprised at these findings. The web based reporting system for the registry depended on chart documentation and was of questionable accuracy regarding eligibility for various interventions. The rush by hospitals to get a good report card may have diverted attention from other life saving therapies such as devices and aldosterone receptor antagonists.

The first quality measure was the provision of discharge instructions on medications, diet and other aspects of heart failure care. In one study on which this recommendation was based the instructions included a full hour of one-on-one verbal counseling. The intervention was associated with improved outcomes. The “core quality” measure, in contrast, required only that written instructions be given to the patient. It’s one thing to hand patients a ream of paper as they are rushed out the door and quite another to provide detailed counseling. Nominal compliance may earn the hospital a perfect report card while doing little of substance to help patients.

The second measure was documentation of left ventricular systolic function. This is important in the identification of patients who are candidates for certain therapies. I’m reminded of a recent anecdote (unconfirmed but believable) about a nurse-case manager who wouldn’t allow a heart failure patient to be discharged until an echocardiogram was done whether the patient needed one at that time or not.

The third measure was the prescription of an ACEI or ARB for patients with left ventricular systolic dysfunction. These medications have been proven to increase heart failure outcomes. The disappointing results in the OPTIMIZE-HF registry may be due to the short follow up period. The same reason may apply to the negative findings concerning the other two measures, smoking cessation counseling and anticoagulant use for patients with atrial fibrillation.

Can we make sense of the findings? It would be wrong to conclude that the measures are not worthwhile. On the other hand the findings add to growing skepticism of “quality” mandates as they are now implemented.

Nephrogenic systemic fibrosis

This is a newly emerging entity (resource links here) occurring in patients with varying degrees of renal impairment. The more severe the renal disease the greater the risk, irrespective of the type of renal disease. Recently it has been associated with the use of gadolinium based magnetic resonance imaging contrast agents in patients with renal disease as described in this Medscape alert.

New age fluff at Wake Forest University Medical Center

Read about their promotions of Therapeutic Touch here. Here is their Grand Rounds schedule for Holistic and Integrative Medicine. They even have a conceptual model of how all this is supposed to fit together.

Top 10 issues in hospital medicine for 2006---issue 1: enthusiasm versus skepticism in quality and patient safety

With great fanfare, and with the help of the media, the Institute for Healthcare Improvement (IHI) this year announced the “success” of its campaign to save 100,000 lives. But a more sober assessment of the campaign cited methodological flaws and problems with the analysis of “lives saved” with the conclusion that the true impact of the campaign is unknown. This point-counterpoint illustrates the growing tension between the enthusiasts and the skeptics, and at the end of 2006 the skeptics are winning. The debate was nicely framed in a recent JAMA commentary by Robert Wachter, M.D.

Let’s look at some recent evidence.

Measured against Medicare’s performance measures, the difference in mortality between the top and bottom performing hospitals was of statistical, but questionable clinical significance. (JAMA editorial comment here).

Rapid response teams, recommended by the IHI and being considered for a Joint Commission initiative, are not supported by high level evidence. [1] [2]

Computerized Physician Order Entry was associated with an increase in mortality in a pediatric hospital population.

The four hour antibiotic mandate for pneumonia, a widely promulgated quality measure, is associated with unnecessary antibiotic use and has not been proven to improve outcomes.

Pneumococcal vaccination, another core quality and P4P measure, does not prevent pneumonia and is not cost effective with the preparation now licensed for use in adults.

What does it all mean? It means the quality and patient safety movements should move forward but individual measures should withstand scientific scrutiny before they are mandated by federal agencies and advocacy groups.

Top 10 issues in hospital medicine for 2006---issue 2: electronic medical records and computerized physician order entry

I elevated this topic from number 6 last year to number 2 due to increasing controversy and pressure for implementation. I sounded a cautionary note in last year's post, citing difficulties in physician acceptance and the potential for computerized physician order entry (CPOE) to increase certain types of errors.

Much more has been published this year including an insightful Medscape General Medicine Video Editorial by hospitalist thought leader and patient safety advocate Robert Wachter, M.D. Wachter sets out to temper irrational enthusiasm, pointing out that early studies which drove this enthusiasm took place in a select group of top notch institutions and looked only at “process” improvements. Until recently we had no data on patient outcomes. Wachter’s editorial reminds us of more recent papers showing a 3 fold increase in mortality in a pediatric hospital population following the implementation of a commercially available CPOE system and a powerful anecdote about a fatal insulin error related to bar code technology.

Issues regarding implementation are controversial. In another Medscape General Medicine Video Editorial AHRQ director Carolyn Clancy, M.D. thinks we should move full speed ahead and implies we should take advantage of readily available “off the shelf” systems. But Wachter warns that the systems that really seem to work are home grown and developed over years.

With the disasters in implementation and adverse patient consequences we’ve seen it would seem wise to move slowly.

Evidence based medicine to the rescue

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A master teacher discusses the importance of the electrocardiographic P wave

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

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

Background:

Review by Spodick in Mayo Clinic Proceedings on this subject.

Previous notes from Dr. RW on this subject.

Woo invades Music City USA

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

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

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

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

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

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

Who needs medical knowledge, anyway?

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

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

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

Frequently asked questions on woo and mainstream medicine

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

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

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

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

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

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

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

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

Pseudoscientific indoctrination of social workers

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

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

Recombinant factor VIIa: who, when and how

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

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

Got a brain tumor in Ontario?

Get Buffalo’d. Ah, the compassion of single payer health.

Update: Kevin MD has this.

When woo overlaps mainstream medicine can patients sort it out?

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

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

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

Metformin is associated with vitamin B12 deficiency

The mechanism is unknown. Via Archives of Internal Medicine

And it’s been scientifically proven----

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

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

Atorvastatin and clopidogrel---continued concerns

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

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

Lyme disease activism versus science

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

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

Auto repairs, alternative medicine and fiduciary duty

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

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

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

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

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

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

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

Sleep deprivation and obesity

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

From across the pond

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

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

FDA alert on methadone

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

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

Libby Zion---the rest of the story

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

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