Systemic lupus

This not so rare disease has been reviewed in the Orphanet Journal of Rare Diseases.

Staying out of trouble with iodinated contrast

A recent review in CCJM covers anaphylactoid reactions, nephrotoxicity and high risk situations.

Selective estrogen receptor modulators (SERMs) and surgery

Should they be stopped before surgery? Caseblog addresses the question here and links to additional perioperative medicine case discussions here.

Rapid response teams in perspective

I don’t have anything against rapid response teams (RRTs) although I’ve long suspected that they are promoted way beyond what the evidence supports. Yesterday saw some thoughtful blogging on the subject. Bob Wachter, though somewhat of a skeptic on RRTs, notes that the appeal is undeniable:

Don’t get me wrong. The concept of a Rapid Response Team is attractive. It isn’t hard to find patients who die in hospitals or require emergent transfer to the ICU in whom evidence of deterioration was present for hours – sometimes days – before the crash.

Indeed. Wachter goes on to mention Joint Commission’s 2008 National Patient Safety Goals number 16 of which states:

The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening. [Critical Access Hospital, Hospital]

This is rather vague, to Joint Commission’s credit, in that it allows individual institutions to fashion a method that meets their individual needs in this area. Wachter’s interpretation is that each hospital have a system in place to identify deteriorating patients and intervene. Such a system may or may not take the form of a RRT in the usual sense.

California Medicine Man, acknowledging the scarcity of data in support of RRTs, notes that some of the things such teams can do, such as administration of fluid boluses and respiratory treatments, just make sense. Moreover, the nurses feel more confident when such teams are available.

If RRTs are such a good idea who cares if they aren’t “evidence based?” If a RRT suits your hospital’s needs maybe you don’t need a study to justify it. It’s all well and good up to a point. It becomes problematic when unsupported claims are made (“we’re saving lives”) or rigid mandates are promulgated. That’s when I’ll say “show me the evidence.”

So, what does the evidence say? I’ve previously noted the lack of evidence in support of RRTs. Last month I blogged about a more recent systematic review which again failed to support RRTs. Wachter cited some more recent studies. Just out in JAMA is a paper showing a reduction in mortality associated with a RRT in a children’s hospital. Can such results be extrapolated to adult hospital medicine? Probably not. Things move faster in pediatrics. Compared to adult medicine everything in pediatrics is stat.

Perhaps the most interesting study Wachter mentioned was this one which demonstrated a remarkable reduction in mortality. In fact, the authors estimated that by the end of the study period the NNT to save one life was 3! Astounding! But take a closer look at what they really did. It wasn’t a RRT as we generally think of it. It was really early goal directed therapy.

So it all depends on what we really mean when we speak of RRTs. I suspect for many hospitals RRTs meet an important need. For others they may be no more than a promotional gimmick, an exercise in symbol over substance.

Coronary slow flow phenomenon (CSFP): an emerging cause of chest pain with “normal” coronary arteries

A case report and review of the literature appeared in Clinical Cardiology.

Key points:

This poorly understood disorder is not cardiac syndrome X and is not always a benign disorder.

Abnormal QT interval dispersion and life threatening cardiac arrhythmias may be associated.

Dipyridamole is a potential treatment.

Cooley and DeBakey make amends

A 40 year clash of surgeons’ egos apparently ends. Fascinating stuff.

Via Kevin M.D.

Pulmonary edema: Is it cardiogenic or non-cardiogenic?

Mesurement of BNP can help differentiate. From Chest.

New findings on VTE prophylaxis in hospitalized patients

A meta-analysis published in Archives of Internal Medicine found that both UFH and LMWH reduced VTE but neither agent reduced mortality. LMWH was superior to UFH with respect to prevention of DVT and occurrence of injection site hematoma.

Myasthenia gravis

This is one of the better reviews I’ve seen on the topic. From the Orphanet Journal or Rare Diseases.

D-dimer testing in pregnancy: helpful if normal

Since pregnancy is associated with elevated D-dimer levels clinicians have been hesitant to use the test in pregnant patients. Its usefulness in the diagnostic evaluation of pregnant patients for VTE had not been systematically reported, however, until publication of this study in Annals of Internal Medicine.

It turns out that the test is helpful when normal, and is normal often enough to make it worth while.

Avoiding geriatric medication nightmares

This article in Internal Medicine World Report, featuring Peter A. Boling, MD, director of the MCV Campus Geriatric Section at Virginia Commonwealth University, has several excellent clinical pearls on polypharmacy in geriatric patients.

Trying to be fair and balanced

Lest I come across as always defending the pharmaceutical companies I’ll note here a couple of industry shenanigans reported last week which are---well, indefensible.

First a ghost writing offer. Now I’ve been a little skeptical of all these claims about journal articles ghost written by pharmaceutical companies. I’ve never seen a specific article cited and verified as ghost written. (I’m from Missouri and would still like for some one to “show me” by citing a ghost written article!). But now the WSJ Health Blog reports on an offer by a pharmaceutical consulting firm to ghost write an abstract for a big name in hypertension, Jean Shealey. She declined. One of the Health Blog commenters wrote:

So, this is some new revelation for the WSJ?
There are plenty of studies in the medical literature which have been ghost written by an industry-sponsored medical writer, that was then submitted under the name of a highly-recognizable leader in the field–always at a steep price.

To which I say: documentation, please!

H/T to Kevin M.D.

Then there’s this update (via Medscape/Heartwire) on GlaxoSmithKline (GSK) applying pressure to silence Dr. John Buse, a diabetes expert who raised early concerns about the cardiovascular safety of rosiglitazone (Avandia). California Medicine Man discusses it here. The full report of the Senate Committee on Finance is here. Suppression of debate does not serve the cause of science.

The pharmaceutical industry has interests in common with those of the medical profession, but abuses exist. Our profession can collaborate with industry to the benefit of patients, but doctors need to aware of the possibility of abuse, and to be skeptical.

Chantix and suicide---what’s going on?

The news about a possible link between Chantix (varenicline) and suicide has started making its way around the blogosphere. Chantix binds to a4b2 nicotinic receptors in the brain providing weak agonism while at the same time blocking nicotine. Although this prevents complete nicotine (and consequently dopamine) withdrawal by providing a low level of receptor stimulation it blocks those dopamine rushes people get from cigarettes. That may not only take the fun out of smoking but it may also take away your patient’s antidepressant. In some hard core smokers those dopamine surges have powerful antidepressant and anxiolytic effects.

Taking advantage of patient complaints to reduce malpractice risk and enhance professionalism

Dr. Gerald Hickson, director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center, has conducted extensive research on why people sue doctors. His findings? Patient and family perception, not medical error, drives most malpractice suits:

He has found that 85 percent of malpractice claims are invalid, and that neither technical competence nor patient severity is a significant determinant of the risk of malpractice suit. “All doctors have patients who experience adverse events,” Hickson said. “What sends people to lawyers are perceptions, not necessarily medical facts.”

His research also suggests a correlation between the number of complaints from patients and the physician’s risk of being sued. Physicians with high numbers of complaints account for a disproportionate share of lawsuits and may benefit from intervention. Everybody wins if identification of patterns of patient complaints and timely intervention promotes professionalism and loss prevention.

Hickson is the lead author of a paper in the current issue of Academic Medicine which describes Vanderbilt’s non-punitive system for identifying and correcting patterns of unprofessional behavior based on analysis of patterns of patient complaints.

Must read DIC review

I recently ran across this review of DIC (via CCJM). Though a bit dated it’s the best review of the topic I’ve seen for its elucidation of basic concepts and clinical pearls.

This review is important for another reason: it illustrates that expert narrative reviews, decried by some EBM enthusiasts, are still useful.

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).