Influenza, COPD and statin use

Statin use is associated with reduced mortality in these conditions according to a study published in Chest.

Hyponatremia and the brain

CCJM review.

Hereditary thrombophilia review

Via Thrombosis Journal.

Hepatocellular cancer

This topic was recently reviewed in the American Journal of Medicine. Cirrhosis of any cause is the principal risk factor, particularly related to hepatitis B and C infections, chronic alcohol abuse and non-alcoholic steatohepatitis in the settings of obesity and type 2 diabetes.

Associated paraneoplastic syndromes may occur due to the elaboration of erythropoietin, insulin-like growth factor and parathyroid related protein.

Screening for HCC is controversial although some organizations recommend ultrasound every 6 months in high risk patients.

Diagnostic and treatment strategies are presented.

COPD update

An update, summarizing key papers for 2006, was published in the American Journal of Respiratory and Critical Care Medicine. The article is open access full text.

Cardiovascular update ‘07

Highlights of a recent Cleveland Clinic Grand Rounds covering perioperative cardiovascular medicine, drug eluting stents, statins and cerebrovascular disease. (Via CCJM).

No woo is beyond the pale

---for the National Center for the Promotion of Pseudoscience (NCPP) or, if you prefer, the National Center for Complementary and Alternative Medicine (NCCAM). It’s been a while, at least a few weeks, since I’ve picked on the NCPP. Maybe I had grown weary and needed to give it a rest. But today Orac stoked the flames with this exposé in the wake of their 2008 budget announcement.

He makes this point that I’ve hammered on many times before:

Indeed, there appears to be no woo so implausible, so without basis in science, that NCCAM won't take it seriously. Homeopathy? Check. Qi gong? Check. Craniosacral manipulations? Check. In children, yet! Shamanic healing? Check! Distant healing? Check!

And this:

Here's the problem. Negative studies don't matter. If a study shows that a particular CAM "remedy" does no better than placebo, CAM practitioners don't believe it. Can anyone point me in the direction of a single "alternative" remedy that, after multiple negative studies, has been abandoned?

The Orac challenge! But worse yet not only do the practicing woomeisters not abandon debunked woo, neither does the NCCAM! Take chelation. (Please!). In spite of high level evidence against the use of chelation in the treatment of cardiovascular disease the NCCAM is funding a large multi-center trial (one which, as I demonstrated before, is riddled with conflicts of interest and methodological flaws). And, of course, there’s echinacea.

The NCCAM just won’t give up on anything. In this editorial they, in effect, rationalize away all their negative studies and explain why they have to do them all over again. They even propose to fund omics analysis on previous negative studies of CAM modalities.

And on and on it goes.

HIT antibody positivity as a vascular risk factor

The presence of HIT antibodies (antibodies to heparin-platelet factor four complex) has been found in multiple studies to confer risk of arterial and venous thrombosis even in the absence of overt thrombocytopenia. Results of these studies along with pathophysiologic mechanisms are discussed in this review in American Heart Journal.

I previously cited a study showing a relationship between antibody positivity and a variety of adverse outcomes in patients undergoing cardiac surgery. Data such as these beg the question of whether patients (those with previous heparin exposure) should be screened for antibodies on a wide scale. The review authors suggest patient selection for antibody testing, but do not believe widespread testing is cost effective.

Yes, there is free lunch at Mayo Clinic Medicine Grand Rounds

And it improved attendance by 38.4% in a recent study published in BMC Medical Education. Pharmaceutical industry support was used to help defray the costs. The authors felt they addressed any ethical concerns about industry support:

Industry support of MGR raises the ethical concern of industry influence over MGR organizers, content, speakers, and attendees (1-3,17,18). This concern can be addressed by using the following guidelines: 1) industry support should be unrestricted; 2) MGR speakers should disclose to attendees any conflicts of interest; 3) industry representatives should not determine MGR content; and 4) presentations at MGR should be unbiased, especially when the industry sponsor’s products are discussed (3,19,20). These guidelines are rigorously followed at our institution.

They concluded:

Providing free food may be an effective strategy for increasing attendance at medical grand rounds.

Thought Police update

You should not say the U.S. has the best health care. You should not even think the U.S. has the best health care. So says Dr. Christopher Murray, head of the Institute for Health Metrics and Evaluation at the University of Washington:

“The starting point is the recognition that the U.S. does not have the best health care system. There are still an awful lot of people who think it does.”

But the information he’s basing that statement on, statistics indicating that the U.S. longevity ranking has slipped to 42nd in recent years, offers no proof of that assertion. It comes from this piece of spin at MSNBC which, in typical sloppy popular media style, didn’t bother to cite the primary source. (I did some poking around, and I think it’s here).

Via Dr. Helen.

Clinical Cases and Images weighs in here.

Are you guilty of medical thought crime?

You may be if you hold to certain political views. I’m not talking about extreme positions and ideas that most decent human beings, regardless of political affiliation, know are morally outrageous. But our professional culture is becoming increasingly Orwellian as an ideologically correct medical thought police, expressing itself through journals, the web and other media, increasingly defines what is acceptable in the realm of speech and ideas.

Though I’ve observed the trend for a long time several recent examples have emboldened me to challenge the prevailing orthodoxy. Recently I linked to this Kevin post about the Lucidicus Project and suggested that medical students check it out as an alternative to the popular dogma concerning single payer health care. This was met with indignant and morally superior comments from two anonymous readers. One, apparently in academic medicine, implied that conservative thinking equals greed:

This philosophy starts at the top with our president who feels tax cuts for his friends the uber rich are clearly more important than health care for children.The best definition I've heard for compassionate conservatism is I feel your pain,I just don't plan to to a damn thing about it. So be greedy, and selfish, but don't complain when some calls you that.

The other commenter was outraged at the mere suggestion that medical students read material supporting capitalism:

So RW the champion of critical thought & skepticism is championing a site that suggests medical students need to read ayn rand and propaganda material about how capitalism is good for medicine? Give me a break.

Of course I wasn’t championing anything. The commenter was clearly rankled. Does he/she believe that medical students should be banned from reading politically conservative literature?

More examples:

Not long ago we were told that if we didn’t feel guilt and shame about global warming we need psychiatric help to increase our anxiety.

And there’s this JAMA commentary that tells us what we may and may not say about health care in the U.S.

More recently Retired Doc dropped a bomb with this post about a JAMA piece which appears to redefine medical ethics in terms of a sociopolitical agenda which favors increased government intrusion into our profession and implies that failure to support such an agenda is a betrayal of ethical principles to which physicians are honor bound.

If you want to promote your political agenda I’m willing to be convinced with evidence or logic. Engage me in a collegial discussion, but don’t try to shame me or impugn my character if I happen to disagree.

Background reading: PC, M.D.: How Political Correctness Is Corrupting Medicine. (Hurry, before it’s banned).

Web 2.0 review

It’s the best explanation of Web 2.0 I’ve seen yet, complete with a historical time line, glossary and examples (including, of course, the Clinical Cases and Images blog).

Via eMJA.

How should scientific findings be presented to the public?

The Scientist has an article (h/t to Medpundit) examining this controversial issue. If the raw facts are too complex or boring for the general public how should scientists present information in a way that informs? One commenter, Greg Van Citters, comes close:

We need to approach communication for the masses at an entry level that assumes perhaps exposure to one high school course in biology. This in no way implies we should "spin" the facts or omit anything important. To the contrary, we need to provide the basic story anyone can understand, and also provide resources for more in-depth investigation. This tiered approach to communication allows the outsider to understand the basics and the more experienced to go beyond, all the way to the original research articles if they so desire.

The best scientists can do is to present the facts in plain language and direct the audience to primary sources. But Professor Matthew Nisbet and author Chris Mooney, writing in Science and the Washington Post apparently don’t think presenting the facts is enough. Their Washington Post piece is titled “Thanks for the Facts. Now Sell Them”. They write:

We're not saying that scientists and their allies should "spin" information; doing that would only harm their credibility. But discussing issues in new ways and with new messengers can be accomplished without distorting the underlying science. Good communication is by its very nature informative rather than misleading. Making complicated issues personally meaningful will activate public support much more effectively than blinding people with science.

Well, it sounds like spin to me. How, for example, can an issue of science be made “personally meaningful”? What can that possibly mean, other than the presentation of an issue in such a way as to play on public fear or special interest? And what does it mean to “activate public support” if not to advance an agenda?

Science should have nothing to sell. Science must remain objective. Scientific discussions at their best are sterile and boring. When such discussions enter the arena of public debate great caution is needed.

How PICO proficient are you?

With all the recent discussion of UpToDate and how it compares with other resources let’s not forget Pub Med. It’s the ultimate site for evidence based medicine. After all, it’s precise and gets you to the primary sources.

A comment to a recent blog post said UpToDate is not as evidence based as Dynamed. It’s even been claimed that only about 10% of UpToDate’s content is evidence based. I don’t know what that means or how it was derived. UpToDate bases some recommendations on expert opinion but when it does, usually because no higher level of evidence exists, it clearly points that out. Other potential downsides are relatively infrequent revisions of content (every 3 months or so) and imprecise searching (partially made up for by ease of navigation and extensive linking).

Other popular EBM “filtered” resources such as Bandolier, Dare and Trip are useful but suffer from limited depth of content and imprecise searching. That brings me back to Pub Med. But Pub Med has a major hurdle. It requires skill which comes only with training and practice. That’s where PICO comes in. The first step in using Pub Med for evidence based searching is to formulate a focused clinical question which can be converted into Pub Med search terms. PICO is an acronym that lists the essential components of a focused clinical question: Patient population, Intervention in question, Comparison group or treatment and Outcome of interest. And that’s only the first step.

Medical schools are supposed to be teaching the skills of Pub Med searching, but given the widespread dependence of students and house staff on UpToDate trainees may not be getting the necessary practice. In fact, easy resources such as UpToDate and Google may have produced a dumbing down of formal searching skills, as I said here:

The medical Internet has grown and information retrieval is much better now, but there may be a downside. As is true in clinical practice, the ease and convenience that comes with new technology can lead to a decline in basic skills. Though the formal discipline of Boolean searching is as necessary now as it was 20 years ago for precise and comprehensive searching, today’s new and more user friendly resources don’t require the skill and many don’t even support it.

That brings me to this interesting study involving medical house staff at Duke, (via BMC Medical Informatics and Decision Making) which looked at residents’ Pub Med skills and the effectiveness of a software tool to enhance searching. The tool was a user friendly PICO template which served as a Pub Med interface installed on a hand held device. The findings, though inconclusive, (it was a pilot study with small numbers) suggested that residents’ skills were lacking, as evidenced by the number of ineffective searches, and improvement with the use of the template. The article is worth the read as much for its excellent general discussion of Pub Med searching as it is for the study results.

Medical students, think for yourselves

With all the propaganda you’re bombarded with, you may need a little help. Check out the The Medical Intellectual's Self-Defense Kit and other resources from the Lucidicus Project.

Via Kevin M.D.

Obesity disease mongering?

Obesity concerns may be just another example of medicalization according to Dr Hamish Meldrum, head of the British Medical Association. According to This is London:

Obese people are often simply greedy and should not always be treated with pills, the head of the British Medical Association has said. Dr Hamish Meldrum believes an obsession with medical labels may be stopping overweight people addressing their own problems. He said the obesity epidemic is being mistakenly targeted with medical treatments and doctors' appointments.

Drug induced QT interval prolongation

This topic was reviewed in a recent issue of American Heart Journal. QT prolongation and associated torsade de pointes (TdP) are the most common reasons for drug restriction in the U.S. market. Although the advent of preclinical molecular testing during drug development lessens the likelihood of new arrhythmogenic drugs unexpectedly entering the U.S. market the list of drugs causing QT prolongation and TdP continues to grow, with the most notable recent addition being an old medication, long believed to be safe, which is methadone.

The review discusses electrophysiologic mechanisms, guidelines for QT interval measurement and QTc determination and points the reader to web resources on drugs which prolong the QT interval, all of which I have previously provided here.

Most patients who develop drug induced TdP have at least one additional risk factor, including female sex, interacting drugs, electrolyte disturbances and genetic polymorphisms. This latter risk factor raises the issue of interaction between genetic susceptibility and drug effects with some patients having a forme fruste of congenital LQTS.

Another tigecycline review

I have linked to several tigecycline reviews in recent months. This one from the Annals of Pharmacotherapy (via Medscape) is more comprehensive than most and warrants inclusion here.

Attention to the fifth vital sign may adversely affect the other four!

The DocSurg is aggravated by the fifth vital sign. So am I. In his July 23 post DocSurg recounts the rise of pain management dogma this decade, focusing on Joint Commission’s mandate and the notion of the fifth vital sign. (By the way, check out his 2005 rant about Joint Commission!). He notes:

And that, my friends, is how we have gotten into the pickle of potentially overmedicating, overnarcotizing, and oversedating patients sometimes to dangerous levels. That doesn't just lead to sleepy patients......it can lead to death.

He then goes on to cite this paper from the Journal of the American College of Surgeons. The investigators set out to test the premise that present day use of unscientific pain scales causes injury and death from overmedication by comparing adverse events in time periods before and after the promulgation of pain rating scales and other pain management dogmas (1994-1998 and 2000-2004, respectively). The study showed an increase in the rate of deaths due to overmedication in the 2000-2004 period and concluded:

The current assessment of pain by computer-stored pain scales is in a state of imbalance, with excessive emphasis on undermedication at the same time ignoring overmedication. This imbalance reflects pain-service attempts to comply with external accrediting agencies. This preventable cause of death and disability in trauma patients is also occurring in noninjured patients. Surgeons must correct this problem by insisting on a balanced assessment of overmedication versus undermedication.

These unintended consequences were not unanticipated. But as the pain management initiatives were rolled out 8 years ago practicing doctors’ safety concerns were largely ignored.

The diabetes mafia needs to refine its arguments

We get a lot of preaching these days about glycemic control in hospitalized patients and the evils of the sliding scale. A recent article in the American Journal of Medicine, Sliding Scale Insulin Use: Myth or Insanity?, illustrates what’s wrong with this preaching.

The authors make two important points: 1) hyperglycemia is under treated in hospitalized patients and 2) inpatients with uncontrolled hyperglycemia need basal coverage, usually with long acting insulin. Unfortunately, their arguments suffer from confusion about the term “sliding scale” and from assertions that go beyond what the evidence supports. As is the case with much of the preaching about glycemic control heard today, these defects in their arguments detract from the message.

Although the authors condemn sliding scale insulin, their examples of adverse effects of sliding scale treatment are primarily those in which sliding scale short acting insulin was the sole modality of treatment of hyperglycemia. In the real world, when patients enter the hospital with pre-existing diabetes on pharmacologic treatment, sliding scale insulin is usually given as an adjunct to such treatment.

While experts (including the authors) roundly condemn sliding scale insulin the basal-bolus regimens they recommend are in fact modified sliding scales. This is because the pre-prandial insulin doses, like traditional sliding scales, are subject to modification based on the prevailing capillary blood glucose. Unlike traditional sliding scales a portion of each pre-prandial dose is fixed. Moreover, currently recommended insulin drip protocols for critically ill patients are, conceptually, sliding scales since infusion rates are adjusted up and down based on the capillary blood glucose concentration. In this case the sliding scale, though modified by route of administration (intravenous), blood glucose target (more aggressive) and frequency of checkpoints (hourly) is a sliding scale none the less.

This tends to be confusing to clinicians. When experts categorically denounce sliding scales while recommending modified sliding scales what do they really mean? Physician buy in might improve if experts were more explicit about how current practice should change.

A second weakness of the article is that its recommendations go beyond current evidence. The authors state:

In view of this evidence, a recent position statement by the American Association of Clinical Endocrinologists recommended glycemic targets for hospitalized patients in the intensive care unit between 80 and 110 mg/dL, and in noncritical care settings a preprandial glucose goal less than 110 mg/dL and a random glucose less than 180 mg/dL. The Joint Commission on Accreditation of Healthcare Organization recently proposed tight glucose control for the critically ill as a core quality of care measure for all US hospitals that participate in the Medicare program.

These generalizations are not warranted by current evidence. Preliminary evidence suggests certain aggressive glycemic targets benefit specific subsets of patients, but these data do not warrant broad recommendations. The specific circumstances in which aggressive glycemic control is beneficial, as well as the optimal targets for various subsets of patients are far from settled.

Background: Review from Diabetes Care on inpatient management of hyperglycemia. Although somewhat dated, this review is timely and thorough in its coverage of multiple practical aspects of management.