MEN type 2

Reviewed in the Orphanet Journal of Rare Diseases.

Docs don’t know stats?

Dr. Helen and California Medicine Man tipped me off to this fascinating paper in JAMA. House staff, fellows and faculty with research backgrounds were given a basic skills test on biostatistics and quantitative interpretation of medical research articles. Test performance was surprisingly poor:

The overall mean percentage correct on statistical knowledge and interpretation of results was 41.4% (95% confidence interval [CI], 39.7%-43.3%) vs 71.5% (95% CI, 57.5%-85.5%) for fellows and general medicine faculty with research training (P < .001).

Read Dr. Helen’s and California Medicine Man’s commentaries on the study. I’ll offer a few random observations here.

According to the study author:

In her own teaching, Windish had seen that trainees often read only the abstracts, or "ignored the statistics and skipped right to the results." This practice turns out to be common throughout the medical profession -- and potentially troubling.

Heck, if you think that’s bad, how many docs settle for the New York Times?

You can take the test here. It was eye opening for me. I don’t know as much as I thought I did although I scored substantially better than the residents. It’s been a self teaching exercise for me through the years and I’m still on the learning curve.

This dovetails with the concerns of the No Free Lunchers, who never have given docs much credit for their ability to critically appraise the medical literature. What’s the answer? For me it’s an ongoing self study (there are plenty of free on line resources) of EBM and medical literature analysis as part of one’s commitment to lifelong learning.

Additional thoughts on chelation death

Here are a couple of additional points I should have made in last night's rant on the chelation related death of Abubakar Tariq Nadama.

1) It is alleged that the chelation mixture was given IV push. The labeling for Endrate, the drug which was apparently used, indicates that such rapid injection increases the possibility of fatal toxicity due to a precipitous fall in the serum calcium. Although rapid injection of Endrate, if it occurred, would be relevant to the case, it remains my considered opinion that the emphasis of the CDC, the prosecution and the prosecution’s expert witness sends the implicit message that it’s OK to use chelation therapy for everything under the sun so long as you don’t give the “wrong” drug or administer it “inappropriately”. It would be foolish for me to suggest how the prosecution should spin their arguments but I’d personally rather see wording to the effect that Dr. Kerry “engaged in scientifically unfounded treatment and, moreover, administered such treatment in a manner which enhanced its toxicity”.

2) I noted that Endrate is indicated for the treatment of hypercalcemia and digitalis toxic ventricular ectopy. However, it deserves mention that newer and safer treatments for these conditions have been available for decades, effectively rendering Endrate obsolete.

Death by chelation

Orac recently posted an update on the story of Abubakar Tariq Nadama and noted that the wheels of justice are finally turning as Dr. Roy Kerry faces charges in the death of the 5 year old autistic boy. I join Orac and others in the hope that justice prevails. But, while lacking any legal training, I am bothered about this case. One of the roles of the execution of criminal justice is to set examples and thereby send appropriate messages to society. If this case plays out as it has so far the wrong message will be sent. Dr. Kerry may “go down” but justice will not have been fully served.

What’s wrong with the case? From The Washington Post (italics mine):

A doctor was ordered on Thursday to stand trial on charges he caused the death of a 5-year-old autistic boy by incorrectly administering a controversial chemical treatment.

Dr. Roy Kerry, 69, used the wrong drug and administered it incorrectly while trying to use chelation therapy on Abubakar Tariq Nadama…

As I pointed out in some detail over a year ago, this is not a case of the wrong drug or the wrong method of administration. No, it’s a case of total woo. In that post I called it a matter of “wrong indication”, implying merely off label use, but it’s really much worse than that. Most off label use is evidence based to some degree. The use of chelation as a treatment for autism is even worse than non-evidence based---it isn’t based on anything.

If chelation for the treatment of autism is baseless in the first place how can you talk about the wrong drug or even the wrong method of administration? There has to be a right alternative before you can talk about a wrong drug. Logically, at least, the prosecution appears to be on thin ice in pursuing this line.

The Nadama family’s attorney in praising the judge’s decision to order Kerry to stand trial displays his misunderstanding of the issue in stating “He did something no doctor in the world would do”. But, truth is, the non-indicated non-evidence based non-anything based use of chelation is widespread, and it’s apparently done without rhyme or reason as to the choice of chelation agent.

A little background on the two chelation agents--- Endrate, the drug apparently used by Dr. Kerry, has two indications: hypercalcemia and digitalis toxic ventricular ectopy. Versenate, the other available chelation agent, has one indication: lead poisoning. Although the prosecution’s expert witness seems to be following the CDC’s faulty analysis of the case in implying that Versenate would have been the “right” drug, neither drug can be applied to the treatment of autism on any basis other than absolute and total woo.

Endrate, the purported “wrong drug”, is frequently administered by chelation practitioners for the bogus indication of atherosclerosis and is in fact the agent being used in the NCCAM sponsored Trial to Assess Chelation Therapy. In a recent post to the Health Fraud List, quackbuster Robert S. Baratz, MD, PhD, DDS noted that “Chelationists regularly conflate Endrate (R) (disodium EDTA) and Verseanate (R)”. Something “no doctor in the world would do”? Uh huh. And if the indoctrination of current medical students is any indication, the woo based use of chelation may become more widespread. Here’s what the American Medical Student Association’s Complementary Therapies Primer says on page 20 about chelation:

Since it improves blood flow, it is also helpful in gangrene, intermittent claudication caused by peripheral vascular disease, and poor memory due in part to insufficient cerebral blood flow. Reduction in metal ions reduces inflammation caused by free radicals, and makes chelation therapy helpful in arthritis, scleroderma, and lupus. Chelation therapy has also been used to normalize cardiac arrhythmias, improve vasculogenic vision loss, reduce cancer mortality, protect against iron poisoning and detoxification of snake and spider bites.

Chronic eosinophilic pneumonia

It was reviewed in the Orphanet Journal of Rare Diseases. The review distinguishes it from other eosinophilic diseases with pulmonary manifestations. A couple of points are of particular interest. Chronic eosinophilic pneumonia responds dramatically well to corticosteroids. Its characteristic chest radiographic pattern (the “photographic negative” of pulmonary edema), though not entirely sensitive or specific, may at times enable a “look see” diagnosis (making it potential fodder for board exams).

An evidence based medicine toolkit

---is now on line at American Family Physician.

Hospital medicine CME conference: final reflections

The 4th annual Mayo Clinic Update in Hospital Medicine was completed today. It was my first time to attend this particular conference and the first hospital medicine course I’ve attended that was not affiliated with the Society of Hospital Medicine. I had high expectations for the course (after all it’s Mayo Clinic, right?) and was not disappointed. This course was comparable in quality to Bob Wachter’s excellent and very popular course in San Francisco and I would recommend it highly to hospitalists and other health care professionals interested in hospital medicine.

There is currently a groundswell of sentiment which seeks to ban this type of lecture based CME (a subject many of you probably think I’ve already beaten to death in the pages of this blog). The naysayers seem to occupy one of two camps. One maintains that lecture based CME is worthless, and wants all future CME to consist of case based interactive programs with built in mechanisms to measure how much the activity resulted in changed physician “behavior”. The other camp seeks to block the accreditation of all programs that receive support from the pharmaceutical industry. That would mean the end of the program I attended this week, the end of Bob Wachter’s program and the end of CME as we now know it.

To the agitators I say rubbish. What makes them think they know my learning style and educational needs better than I do? And I’m more than a bit rankled by the paternalistic arrogance of those who want to tell me what medical literature I should and should not read. I’m an adult. I graduated from medical school quite some time ago. The responsibility for life long learning lies with me and I take it very seriously.

Yes, I need occasional feedback about the strengths and weaknesses of my fund of knowledge. For that purpose there are plenty of self assessment tools (e.g. MKSAP) I can choose and on which I have spent hundreds of dollars through the years. For most physicians the external requirements for maintenance of licensure and certification are already onerous enough.

Trips to lecture based CME activities, although they constitute just one of several types of CME I participate in, have helped me to be a more effective physician though often in intangible ways which can’t be “measured”. Many important content areas such as basic clinical skills, pathophysiology and certain abstract concepts (one of today’s sessions dealt with heuristics and other cognitive traps in medical decision making) could never reasonably be expected to result in direct, measurable changes in physician behavior because they impact intangible attributes such as judgment and skill.

But those who want some form of verification of the educational impact of my activities this week can read my last few posts about some of the content areas. Moreover, rest assured that for the next several weeks while pouring over the course syllabus I’ll be looking up primary sources of information and background material. And I’ll be reflecting and thinking extensively on ways to put the information to the most appropriate use for the benefit of hospitalized patients.

More clinical pearls from the hospital medicine CME conference

Continuing from my last post---


How should doctors decide whether to administer corticosteroids to patients with septic shock in the wake of the surprising findings of CORTICUS, which failed to show benefits from such therapy? This and related questions were discussed by Dr. Charles Abboud of the endocrinology section at Mayo Clinic. First it must be remembered that CORTICUS did not address “classic” adrenal failure which can occur in critical illness as a result of bilateral adrenal hemorrhage, bilateral adrenal infarction or, most commonly, suppression of the HPA axis as a result of prior corticosteroid therapy. Instead, CORTICUS applies to the concept of relative adrenal insufficiency, also known as “adrenal exhaustion” more recently termed “critical illness related corticosteroid insufficiency” (CIRCI). There is no dispute about the need to identify and treat classic adrenal insufficiency, either primary or secondary, in acutely ill patients. But in view of the recent CORTICUS results the treatment of CIRCI has become controversial.

CORTICUS was recently reviewed at the 72nd Annual International Scientific Assembly of the American College of Chest Physicians and at the Society of Critical Care Medicine 36th Critical Care Congress. The CORTICUS patients were less ill than those in other studies showing benefits of corticosteroid treatment. Also the study was halted before its enrollment target was met. From the Medscape report of the ACCP presentations:

Clinicians, nonetheless, must choose if and how to utilize corticosteroids. Hence, restricting their employment to persons who resemble those studied by Annane and colleagues might be the most prudent course as there are clinical trial findings to support this. Broad, routine administration of corticosteroids in severe sepsis and shock seems unwarranted at present.

Acknowledging the controversy raised by CORTICUS, Dr. Abboud believes that over 60% of patients with septic shock have CIRCI and recommends treating with corticosteroids if appropriate testing indicates its presence. His testing criteria seem to me more rigorous than other recommendations I’ve seen for evaluating CIRCI (any cortical value over 20 rules it out; subtract 5 from this cutoff value to account for decreased cortical binding if the serum albumin is below 2.5) and may select more severely ill patients, and hence those more likely to benefit. Dr. Abboud advises clinicians to closely follow the evidence in this evolving controversy.



Although guidelines now exist to help determine the duration of warfarin treatment following VTE there are controversies and gray areas. For such patients, measurement of D dimer levels 3-4 weeks following discontinuation of warfarin can help determine the risk of recurrent VTE. This enables a quantitative estimate which can be weighed against the estimated bleeding risk.



In a single center study of patients admitted with unexplained severe COPD exacerbation, with no initial suspicion of PE, PE was found in 25%.

Random observations from the hospital medicine CME conference

Before heading down for the final day of sessions I thought I’d mention a few noteworthy items from the course content that particularly impressed me (now that we’ve gotten the woo out of the way). These were little ah ha moments for me and are not necessarily representative of the best of the course content:

In its checkered history hospital medicine has gone through many transformations but three lessons seem to have endured the test of time: Wash your hands. Seek the evidence. Examine the patient.

Acute phosphate nephropathy, thought to be rare, is now an emerging issue in hospital medicine. Associated with sodium phosphate based bowel cleansing products, it can result in permanent renal failure.

Enoxaparin dosing guidelines do not call for renal adjustment until the creatinine clearance drops below 30ml/min. However, bleeding complications with enoxaparin begin to rise precipitously as GFR falls below 80ml/min/1.73m2.

The colloid/crystalloid debate is still unresolved. We lack high level evidence to favor colloid over crystalloid.

Almost every hospital medicine conference contains a talk on in patient pain management, including this one. Having listened to many such lectures and noting the widely varying opinions and biases of the speakers it is my considered opinion that current recommendations regarding pain management are based 45% on the art of medicine, 45% on dogma and 10% on science.

Enough for now. I’ll post additional impressions and a wrap up, time permitting, after today’s sessions.

Fondaparinux and HIT---the bubble has burst

It only takes one counter-example to disprove an absolute statement like “fondaparinux (Arixtra) never causes HIT”. We now have a counter-example in the form of a letter to the editor of NEJM which documents a case of HIT due to fondaparinux. So much for its emergence as a treatment for HIT!

H/T to the Mayo Hospital Medidine update!

Alternative medicine promoted to hospitalists attending CME course

I revealed in last night’s post that the Mayo Clinic CME conference in hospital medicine I’m attending had “integrated” some woo into an otherwise excellent assemblage of “hard core” scientific content. I decided to reserve judgment until after the two lectures in question were delivered today. My verdict? Mixed. Some valid points and eye opening statements were made. But much of the content, from where I sat, consisted of uncritical promotion of non-evidence treatments, suggestions of biologically implausible mechanisms and a certain amount of bobbing and weaving. Let me explain.


There were two speakers. The first one discussed general issues of CAM in hospital medicine. He opened his talk declaring that, like it or not, CAM is now very much a part of our health care system and went on to present data on the recent “CAMbrian explosion” (my words) in hospital medicine. Some interesting data on the demographics of CAM use were presented (it’s really high, as one would expect, in cancer patients) along with some discussion of the hazards of herbal medicine (St. John’s wort is a big inducer of metabolism of many drugs---watch those antiretrovirals, antirejection meds and warfarin!).


He also touched on stress medicine. The study of stress and its effects on health (brain-body medicine) is not total woo although it is plagued by methodologic obstacles. From the point of view of scientific validation brain-body medicine is not ready for prime time. On the other hand do we really need a study (the speaker dutifully cited many) to know that if music or a nice massage relaxes you it probably does some good in some way?


The second speaker, who focused on acupuncture, was more problematic. When pinned down he allowed that we don’t really know how acupuncture “works”, although spoke of the existence of the vital energy Qi and the meridians through which it flows as undisputed facts. It’s the blockage of Qi, he said, that causes illness and pain.


He made the claim that the body’s 400 and some odd acupuncture points can be verified by changes in electrical resistivity and are reproducible in location from one person to another. The history of how the locations of these points were determined, however, leads me to suspect that the science behind such a claim is dubious. According to Dr. Wallace Sampson, professor emeritus of medicine at Stanford:

First, most people assume that it's an ancient Chinese cure that has existed, unchanging, for centuries. Not so, says Sampson, noting that "acupuncture was formalized in a complex way over the past 100 years, mostly in Europe and France and after the Communist takeover in China. Before that time there was no consistent formalization of acupuncture points or what each place was supposed to do. It was largely regional, and the thinking varied from city to city."

According to an article from Quackwatch, the purported acupuncture points were at one time 365 in number, corresponding to the days of the year!

Treatment is applied to "acupuncture points," which are said to be located throughout the body. Originally there were 365 such points, corresponding to the days of the year, but the number identified by proponents during the past 2,000 years has increased gradually to about 2,000 [1].

With such confusion about where the “real” acupuncture points are supposed to be the claims of “sham acupuncture”, the new and sexy standard for research reports, become meaningless. Sham acupuncture studies are blinded to the patient but not the therapist. What’s the actual difference, then, between sham and “real” acupuncture? Do the sham therapy sessions apply the same personal touches and TLC as the real ones?


This speaker, in my view, was inappropriately and uncritically promotional of acupuncture.


Attendance at these lectures afforded me a unique opportunity. My knowledge of the woo invasion of mainstream medicine, up to now, was based on reading---reading of medical journals, medical school web sites and a few blogs. Today, by experiencing it first hand, I came to appreciate the problem on several new levels. I was amazed, for example, at the utter lack of audience reaction, even during the presentation of the worst of the woo---no snickers, groans or shaking heads and no skeptical audience questions (except for mine!).


Most eye opening for me was my interaction with the faculty during Q&A. Remember, these are Mayo Clinic faculty members, not woomeisters from the community. As such, their responses represent the official academic “party line” on CAM. I asked the acupuncture speaker if the energy flowing through the meridians could be measured, and in what form it was transported (e.g. as heat, phosphate bonds, etc.). He answered, without explanation or elaboration, merely that yes it had been measured, and smoothly deflected the question of how or in what form the energy was transferred.


The other presenter had mentioned Yoga and I asked him, in effect, what the placebo should be. In other words, to what extent has Yoga research employed comparison groups using sham postures and mantras with reasonably equivalent relaxation and conditioning value. The speaker, who is the director of Mayo’s complementary and integrative medicine program, indicated that little if any of the Yoga research has been conducted according to this rigorous standard. In fact, control groups in Yoga research have consisted of patients on waiting lists for Yoga classes!


The responses of these faculty members, the best and brightest in the field of CAM who are trying to put the best foot forward, convinced me more than ever before how faulty present day “research” in CAM actually is.


And I shouldn’t be surprised that Mayo is promoting this sort of thing. After all, they’re on Orac’s list.

Thoughts and impressions on hospital medicine CME

When scheduling conflicts prevented me from attending Bob Wachter’s Hospital Medicine Conference I consoled myself by signing up for Mayo Clinic’s Update in Hospital Medicine which I have been attending in Tucson for the last few days. Although it’s my first time at this course (the 4th annual) I’ve had prior experience with other Mayo CME and found that they have a knack putting together quality activities, exceptional in every detail. From my experience so far this meeting (but for one possible concern which I’ll explain below) is no exception.

Although singular in quality this program is like a lot of others. It has the traditional didactic lecture format and receives support from the pharmaceutical industry. Recently some extreme critics have called for the end of such programs. For me, though, this type of activity (parade of stars faculty, relaxed setting away from distractions) provides a uniquely effective learning experience.

And my concern about this meeting? It appears they’ve thrown in a little woo! I’ll reserve judgment at this point---the woo based content will be presented tomorrow. For all I know the lectures will be appropriately critical. If not, the course directors will get a piece of my mind on the evaluation form.

Time permitting I’ll post my observations tomorrow.

Panic attacks and heart disease

I read with interest this post from the Clinical Cases and Images blog which points to a paper in the Archives of General Psychiatry demonstrating a link between panic attacks and cardiovascular disease in postmenopausal women. But Dr. Wes in a blistering attack cites the study’s flaws and asks whether these women were in fact exhibiting heart disease symptoms misdiagnosed as panic attacks.

So what’s going on? From where I sit the study makes a contribution (albeit a weak one) to the growing body of evidence of a relation between panic disorder and heart disease. I previously posted evidence that myocardial perfusion abnormalities occur during panic attacks and cited an epidemiologic association.

A question remains. How many of the episodes of heart disease cited in the paper were actually examples of takotsubo cardiomyopathy, an under appreciated entity with a demonstrated preponderance in postmenopausal females strongly suspected to be a brain-heart disorder?
For a broader view of brain-heart disorders see my post here.

Orac’s med school woo aggregator

Over the last couple of years Orac and I along with a few other bloggers have posted innumerable examples of uncritical promotion and teaching of non-evidence based woo in medical schools. Although we’ve marshaled plenty of evidence of the encroachment of woo into med school curricula, up to now it’s been fragmented, widely scattered and buried in archives of our blogs. This, of course, is not conducive to quick reference. Today Orac has remedied the problem by compiling a list of links to academic medical woo all in one post! (I had thought about doing something similar but had not yet found the time or energy).

I knew such a list would be large, but seeing it all in one post was overwhelming. As the list grows it will need updating frequently to keep it current and near the top of our blogs, an effort to which I hope to contribute from time to time.

Panda Bear continues his series of posts on CAM

In today’s post Panda Bear likens the patient to a person seeking automotive repairs:

And yet I am not so confident in my intelligence that I don’t think I can be fooled. Because, for example, I having nothing but a polite interest in automotive technology I am pretty much at the mercy of my mechanic when he describes the repairs needed by our aging pair of automobiles. I trust the guy because nothing he has ever suggested sounds too outrageous and on a couple of occasions he replaced a three-dollar fuse when he could have taken me for an alternator. I am however at his mercy unless I want to study car repair or haul the thing to more than one mechanic.

That is, the consumer’s only real option is to accept the findings and recommendations of the professional since he/she lacks the expertise needed to independently verify the professional’s findings. The analogy between auto repairs and medical treatment, as Panda Bear points out, isn’t perfect because medicine is far more complex. It comes down to a level of trust, to which the patient has no viable alternative. In other words there’s no caveat emptor in medicine. This puts doctors in the position of fiduciary duty. I used this same analogy to raise the principle of fiduciary duty last year.


The ethical questions posed by this analysis may differ between proponents of non-evidence based CAM within and outside of mainstream medicine. Many CAM practitioners outside of conventional medicine honestly believe in their methods. By contrast, mainstream practitioners purport to adhere to scientific principles and evidence based medicine and know, or should know, that water does not possess memory and that acupuncture meridians have not been documented to exist. Their credentials attest to scientific integrity and are the basis for public expectations. Thus, for mainstream medical institutions or their representatives to promote non-evidence based and biologically implausible claims is a violation of fiduciary duty. It’s the most egregious form of woo.

Grand Rounds 4.8 hosted by Dr. Anonymous

Dr. Anonymous hosts for the second time. (His first hosting was about this time last year and can be found here).

That’s not all! Dr. Anonymous and Grand Rounds custodian Nick Genes recently took turns interviewing each other. To get a double fix of musings and ruminations about blogging listen to Dr. Anonymous interview Nick Genes on Dr. Anonymous Live then check out Nick Genes’s Medscape Pre-Rounds interview of Dr. Anonymous.

This week’s edition was special because Dr. A performed the finishing touches and launched GR 4.8 live during the performance of his Internet radio show.

I’ve followed Dr. A’s activities with interest the last few days because he’s been in Tucson. I’m there now to attend the Mayo Clinic Hospital Medicine course and wondered if Dr. A was attending the same meeting. Listening to last night’s show, it turns out not to be. He left for home about the same time I arrived.

Anyhow, I’ll be blogging from Tucson for the next few days and sharing my impressions of the meeting as time permits.

Sorry I missed you, Dr. A!

Stress echocardiography review

Published in the British Journal of Cardiology, via Medscape. The free access full text article (made possible with the help of your friendly pharmaceutical companies) discusses indications, contraindications and comparison with other stress imaging modalities.

Don’t forget primary aldosteronism

---in your patient with resistant hypertension. It’s more common than formerly believed. (Via Medscape).

More evidence on erythropoietin agonists in critical illness

A meta-analysis published in CMAJ. I recently posted similar evidence here.

Palliative care

This web site from Medical College of Wisconsin is THE resource for palliative care. Some subsections, such as the one on patient controlled analgesia, have broader applicability.