Friday, February 22, 2019

Why are patients not forthcoming? Is it because we’re addressed as “Doctor”?

Importance Patient failure to disclose medically relevant information to clinicians can undermine patient care or even lead to patient harm.

Objective To examine the frequency of patients failing to disclose to their clinicians information that is relevant to their care and their reasons for doing so.

Design, Setting, and Participants Two national nonprobability samples were recruited to participate in an online survey, one using Amazon’s Mechanical Turk (MTurk) from March 16 to 30, 2015 (2096 respondents), followed by one using Survey Sampling International (SSI) from November 6 to 17, 2015 (3011 respondents). Data analysis was conducted from September 28 to October 8, 2018. After dropping respondents meeting the exclusion criteria, the final sample sizes were 2011 (MTurk) and 2499 (SSI).

Main Outcomes and Measures The primary outcome measures were self-reported nondisclosure of 7 types of information to their clinician (eg, did not understand instructions, medication use) and reasons for nondisclosure (eg, embarrassment, not wanting to be judged).

Results There was a total of 4510 overall respondents. Of 2096 respondents, 2013 completed the MTurk survey (96.0% completion rate) and 2011 were included in the analysis. Of 3011 respondents, 2685 completed the SSI survey (89.2% completion rate) and 2499 were included in the analysis. The mean (SD) age of the participants was 36 (12.4) years for MTurk and 61 (7.59) years for SSI. Both samples were predominantly white (MTurk: 1696 [84.3%]; SSI: 1968 [78.8%]). A total of 1630 MTurk participants (81.1%) and 1535 SSI participants (61.4%) avoided disclosing at least 1 type of information. Disagreeing with the clinician’s recommendation (MTurk: 918 of 2010 respondents [45.7%]; SSI: 785 of 2497 respondents [31.4%]) and not understanding the clinician’s instructions (MTurk: 638 of 2009 respondents [31.8%]; SSI: 607 of 2497 respondents [24.3%]) were the most common occurrences. The most commonly reported reasons for nondisclosure included not wanting to be judged or lectured (MTurk: 81.8% [95% CI, 79.8%-83.9%]; SSI: 64.1% [95% CI, 61.5%-66.7%]), not wanting to hear how harmful the behavior is (MTurk: 75.7% [95% CI, 73.5%-78.0%]; SSI: 61.1% [95% CI, 58.5%-63.8%]), and being embarrassed (MTurk: 60.9% [95% CI, 58.9%-62.9%]; SSI: 49.9% [95% CI, 47.8%-52.1%]). In both samples, participants who were women (MTurk: odds ratio [OR], 1.88 [95% CI, 1.49-2.37]; SSI: OR, 1.38 [95% CI, 1.17-1.64]), younger (MTurk: OR, 0.98 [95% CI, 0.97-0.99]; SSI: OR, 0.98 [95% CI, 0.97-0.99]), and with worse self-rated health (MTurk: OR, 0.87 [95% CI, 0.76-0.99]; SSI: OR, 0.80 [95% CI, 0.72-0.88]) were more likely to report withholding information.

Conclusions and Relevance Many respondents in these surveys intentionally withhold important information from their clinicians and were most likely to do so when they disagreed with or misunderstood their clinician’s instructions. A better understanding of how to increase patients’ comfort with reporting this information may improve the clinician-patient relationship and patient care.

At only one point in the body of the entire paper is the word “doctor” used, which is in the methods section where the authors described the survey instrument:

The survey defined “health care provider” as “any medical care giver, such as a doctor, physician's assistant, or nurse.”

Nevertheless Ron Harman King, writing a piece for Medpage Today, says the findings of this study “jolted” him into the idea that we should drop the title “doctor.” The piece is wrong on so many levels I don’t know where to start. Here’s my attempt to triage my reactions into a reasonably coherent post.

King starts with theatrical language to introduce his premise:

A recent study published in JAMA1 has jolted me into considering a crazy, radical idea. The article's title is, and I quote, "Prevalence of and Factors Associated With Patient Nondisclosure of Medically Relevant Information to Clinicians." Whew, can't wait to see the TV mini-series…

Even more chilling were the common reasons respondents gave for keeping secrets, in descending order: Patients didn't want to be judged or lectured. They didn't want to hear how harmful their behavior is. They feared embarrassment. They didn't want the clinician to think they're difficult patients. And they didn't want to take up more of the clinician's time.

No one I know of who is in touch with real medicine would feel jolted or regard as chilling the findings of this paper. It’s been well known throughout the history of medicine that patients lie, withhold information and withhold their feelings.

Then comes the non sequitur:

Which provoked my crazy, radical idea. Maybe it's time to take a long-standing healthcare tradition, wrap it up into a 40-gallon contractor-grade trash bag, and cart it out to the dumpster in the alley. That is, perhaps it's time patients stop addressing physicians as "Dr. So-and-So."

What does it mean if you drop the title “doctor”? It’s a pretense. It means pretending you don’t have superior knowledge and judgment that might help the patient. It’s part of a broader movement in medicine which was driven for years mainly by consumerism but is more recently gaining traction within the profession itself. It seeks to abandon all notions of expertise and completely democratize the transactions among patients, families and all members of the healthcare team. Is this a good thing?

Sep 1: thumbs up or thumbs down?

A piece in Today's Hospitalist covers some of the ins and outs of CMS's most complicated core measure yet. we’ve yet to realize the unintended consequences. It’s based on data from a survey (and the subjects were “quality officers” and others predisposed to drink the performance kool aid) the results of which suggested that the measure is perceived to be beneficial. But it restricts clinical judgment and is based on ideas deemed out of date by many.

After going through a long list of flaws and potential harms of the measure here's how the Today’s Hospitalist piece concludes (emphasis mine):

“While some people’s instinct is to just reject” the measure, Dr. Barbash says he draws a different conclusion from his research. “We have a professional obligation to try to make it better in ways that ultimately help us provide the best care for patients.” While SEP-1 “has gotten us to start paying attention to the most important killer of hospitalized patients,” he believes a revised sepsis measure could do better.

He's asserting that it took a CMS core measure to even get us to start paying attention to sepsis. Where has he been the last 15 years?

Thursday, February 21, 2019

STEMI treated with PCI: very low incidence of LV thrombus compared with historical data

Statins may reduce lung related and all cause mortality in COPD


Patients with COPD are often prescribed statin drugs due to the increased prevalence of cardiovascular disease. There is considerable debate about the benefits conferred by statin drugs in patients with COPD. This study evaluates the association of statin drug use with all-cause and lung-related mortality in patients with COPD.


This study uses population-based administrative data for the province of British Columbia, Canada. A cohort of patients with COPD was identified based on individual patient prescription records. Statin drug exposure was ascertained in the 1-year period after the COPD diagnosis. The primary and secondary outcomes, all-cause and lung-related mortality, respectively, were evaluated in the 1-year period thereafter using multivariate Cox proportional hazards models and several definitions of medication exposure.


There were 39,678 patients with COPD that met the study inclusion criteria. Of them, 7,775 (19.6%) had received at least one statin drug dispensed in the exposure ascertainment window. There were 1,446 all-cause deaths recorded in the cohort in the 1-year period after exposure ascertainment. In multivariate analysis, the estimated hazard ratio (HR) for statin drug exposure was 0.79 (95% CI, 0.68-0.92; P = .0016), suggesting a 21% reduction in the risk from statin drug use on all-cause mortality. For lung-related mortality, there was also a considerable reduction in the risk for all-cause mortality from statin drug use (HR, 0.55; 95% CI, 0.32-0.93; P = .0254). These results were robust to different specifications of the exposure ascertainment window.


This study shows that statin drug use in a population-based cohort of patients with COPD may confer benefits regarding reduced lung-related and all-cause mortality.

Livedo reticularis versus livedo racemosa

Reticularis can be primary (benign) or secondary (bad).

Racemosa is always secondary and always bad.

Secondary sclerosing cholangitis in critically ill patients (SSC-CIP)

From a review of this increasingly recognized entity:


SSC-CIP is a rather newly recognized condition that has been gaining more attention in recent years due to rise in ICU treatment-related diseases with improved ICU treatment. SSC-CIP is usually a progressive disease with an aggressive nature leading to liver cirrhosis and hepatic failure without LT.42 During the initial stages of the disease, the clinical symptoms and biochemical profile are not specific and do not differentiate much from endotoxin-associated jaundice, which is a common condition in critically ill patients. Thus, increased awareness and early detection of SSC-CIP and its complications are believed to be crucial to improve the poor prognosis. Biliary casts formation may be considered pathognomonic for SSC-CIP since most patients have them in early stages of the disease and these casts have not been described in the literature in either PSC or IgG4 cholangiopathy.18

Friday, February 15, 2019

Limitations of clinical trials with surrogate endpoints


Background Surrogate endpoint trials test strategies more efficiently but are accompanied by uncertainty about the relationship between changes in surrogate markers and clinical outcomes.

Methods and Results We identified cardiovascular trials with primary surrogate endpoints published in the New England Journal of Medicine, Lancet, and JAMA: Journal of the American Medical Association from 1990 to 2011 and determined the trends in publication of surrogate endpoint trials and the success of the trials in meeting their primary endpoints. We tracked for publication of clinical outcome trials on the interventions tested in surrogate trials. We screened 3016 articles and identified 220 surrogate endpoint trials. From the total of 220 surrogate trials, 157 (71.4%) were positive for their primary endpoint. Only 59 (26.8%) surrogate trials had a subsequent clinical outcomes trial. Among these 59 trials, 24 outcomes trial results validated the positive surrogates, whereas 20 subsequent outcome trials were negative following positive results on a surrogate. We identified only 3 examples in which the surrogate trial was negative but a subsequent outcomes trial was conducted and showed benefit. Findings were consistent in a sample cohort of 383 screened articles inclusive of 37 surrogate endpoint trials from 6 other high‐impact journals.

Conclusions Although cardiovascular surrogate outcomes trials frequently show superiority of the tested intervention, they are infrequently followed by a prominent outcomes trial. When there was a high‐profile clinical outcomes study, nearly half of the positive surrogate trials were not validated. Cardiovascular surrogate outcome trials may be more appropriate for excluding benefit from the patient perspective than for identifying it.

Thursday, February 14, 2019

A prediction tool for early recognition of spinal epidural abscess

Psychological benefits of a single exercise session

Systematic review here.

Smart Mat technology can detect diabetic foot ulcers a month in advance

From a report in Diabetes Care. There were a lot of false positives.

Wednesday, February 13, 2019

The yield of sputum cultures in hospital acquired pneumonia

Despite the fact that the new guidelines advocate for sputum cultures, the yield was low:

The clinical predictors of positive sputum culture have not been previously reported in hospital-acquired pneumonia (HAP), and data on yield of sputum culture in this setting are scant. Current Infectious Disease Society of America guidelines for HAP recommend noninvasive sputum sampling, though the data for this practice are limited. We assessed the yield of sputum culture in HAP cases at an academic medical center from January 2007 to July 2013. HAP cases were identified by International Classification of Diseases, Ninth Revision-Clinical Modification codes for bacterial pneumonia and all cases were validated by chart review. Our cohort had 1172 hospitalizations with a HAP diagnosis. At least 1 sputum specimen was collected noninvasively and sent for bacterial culture after hospital day 2 and within 7 days of HAP diagnosis in 344 of these hospitalizations (29.4%), with a total of 478 sputum specimens, yielding 63 (13.2%) positive, 109 (22.8%) negative, and 306 (64.0%) contaminated cultures..

Spontaneous bacterial peritonitis

Severe carisoprodol withdrawal

Monday, February 11, 2019

Stool PCR panels

The stool PCR panel can detect a wide variety of pathogens. Here is some info from Mayo Clinic Labs with algorithms for appropriate use.

Saturday, February 09, 2019

Spinal epidural abscess and diagnostic errors



With this study, we set out to identify missed opportunities in diagnosis of spinal epidural abscesses to outline areas for process improvement.


Using a large national clinical data repository, we identified all patients with a new diagnosis of spinal epidural abscess in the Department of Veterans Affairs (VA) during 2013. Two physicians independently conducted retrospective chart reviews on 250 randomly selected patients and evaluated their records for red flags (eg, unexplained weight loss, neurological deficits, and fever) 90 days prior to diagnosis. Diagnostic errors were defined as missed opportunities to evaluate red flags in a timely or appropriate manner. Reviewers gathered information about process breakdowns related to patient factors, the patient–provider encounter, test performance and interpretation, test follow-up and tracking, and the referral process. Reviewers also determined harm and time lag between red flags and definitive diagnoses.


Of 250 patients, 119 had a new diagnosis of spinal epidural abscess, 66 (55.5%) of which experienced diagnostic error. Median time to diagnosis in error cases was 12 days, compared with 4 days in cases without error (P less than .01). Red flags that were frequently not evaluated in error cases included unexplained fever (n = 57; 86.4%), focal neurological deficits with progressive or disabling symptoms (n = 54; 81.8%), and active infection (n = 54; 81.8%). Most errors involved breakdowns during the patient–provider encounter (n = 60; 90.1%), including failures in information gathering/integration, and were associated with temporary harm (n = 43; 65.2%).


Despite wide availability of clinical data, errors in diagnosis of spinal epidural abscesses are common and involve inadequate history, physical examination, and test ordering. Solutions should include renewed attention to basic clinical skills.

If the patient’s using a smart phone on rounds they may be close to discharge

File this one under “tell me something I don’t already know.”

Sleep apnea update

This topic was reviewed in JACC. The full text is only available to subscribers but the audio summary is open access.

Here are a few points of interest:

Obstructive sleep apnea (OSA) is common in the general population.

Central sleep apnea (CSA) is largely confined to patients who already have cardiovascular disease, largely heart failure. It is particularly associated with heart failure with reduced ejection fraction. It is also associated with stroke and atrial fibrillation.

OSA is a cause of multiple cardiovascular disorders. CSA, though a result of certain cardiovascular disorders, can in turn contribute to further cardiovascular dysfunction, resulting in a vicious cycle of reciprocal cause and effect.

Although OSA is largely a disorder of obesity, in which fatty deposits in the upper airway are contributory, 20-30% of OSA is in non-obese individuals. In such cases upper airway dilator muscle dysfunction is believed to be at play.

Among the many consequences of sleep apnea are the metabolic effects of hypoxemia, increased sympathetic output, cytokine activation, endothelial dysfunction, insulin resistance, systemic and pulmonary hypertension and atrial fibrillation.

Friday, February 08, 2019

Fighting C diff: the case for gastric acid suppressant stewardship

Postural tachycardia syndrome (POTS), inappropriate sinus tachycardia (IST) and vasovagal syncope (VVS)

Regional thrombolysis with adjunctive mechanical interventions and post thrombotic syndrome



The post-thrombotic syndrome frequently develops in patients with proximal deep-vein thrombosis despite treatment with anticoagulant therapy. Pharmacomechanical catheter-directed thrombolysis (hereafter "pharmacomechanical thrombolysis") rapidly removes thrombus and is hypothesized to reduce the risk of the post-thrombotic syndrome.


We randomly assigned 692 patients with acute proximal deep-vein thrombosis to receive either anticoagulation alone (control group) or anticoagulation plus pharmacomechanical thrombolysis (catheter-mediated or device-mediated intrathrombus delivery of recombinant tissue plasminogen activator and thrombus aspiration or maceration, with or without stenting). The primary outcome was development of the post-thrombotic syndrome between 6 and 24 months of follow-up.


Between 6 and 24 months, there was no significant between-group difference in the percentage of patients with the post-thrombotic syndrome (47% in the pharmacomechanical-thrombolysis group and 48% in the control group; risk ratio, 0.96; 95% confidence interval [CI], 0.82 to 1.11; P=0.56). Pharmacomechanical thrombolysis led to more major bleeding events within 10 days (1.7% vs. 0.3% of patients, P=0.049), but no significant difference in recurrent venous thromboembolism was seen over the 24-month follow-up period (12% in the pharmacomechanical-thrombolysis group and 8% in the control group, P=0.09). Moderate-to-severe post-thrombotic syndrome occurred in 18% of patients in the pharmacomechanical-thrombolysis group versus 24% of those in the control group (risk ratio, 0.73; 95% CI, 0.54 to 0.98; P=0.04). Severity scores for the post-thrombotic syndrome were lower in the pharmacomechanical-thrombolysis group than in the control group at 6, 12, 18, and 24 months of follow-up (P less than 0.01 for the comparison of the Villalta scores at each time point), but the improvement in quality of life from baseline to 24 months did not differ significantly between the treatment groups.


Among patients with acute proximal deep-vein thrombosis, the addition of pharmacomechanical catheter-directed thrombolysis to anticoagulation did not result in a lower risk of the post-thrombotic syndrome but did result in a higher risk of major bleeding. (Funded by the National Heart, Lung, and Blood Institute and others; ATTRACT number, NCT00790335 .).

The conclusion sentence is simplistic. You were equally likely to get ANY degree of post-thrombotic syndrome no matter what treatment you got. But moderate to severe post-thrombotic syndrome was less likely with intervention. Quality of life was equal across the board but that’s going to differ from one patient to another and becomes a matter of preference and value.

First, second and third generation cephalosporins cause delirium while cefepime and quinolones do not. Really?