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.
Saturday, November 17, 2007
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!
H/T to the Mayo Hospital Medidine update!
Friday, November 16, 2007
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:
According to an article from Quackwatch, the purported acupuncture points were at one time 365 in number, corresponding to the days of the year!
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.
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.
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.
Thursday, November 15, 2007
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.
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.
Wednesday, November 14, 2007
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.
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:
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.
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.
Tuesday, November 13, 2007
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!
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!
Monday, November 12, 2007
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.
Sunday, November 11, 2007
Treatment of pulmonary embolism in critical illness
A very helpful review appeared recently in Chest. Key points follow:
Assessment
Get a bigger bang for the buck with CT by measuring RV and LV diameters. RV/LV diameter ratios over 0.9 are concerning for right ventricular dysfunction.
Echocardiography is useful in the assessment of RV function.
Biomarkers (troponin, BNP, ProBNP) are potentially useful indicators of RV damage and wall stress. Given the shorter half life of BNP and ProBNP these markers are more useful than troponin for assessment of patient progress in real time. Q 12 hour determinations are suggested by the authors.
Assessment of RV function by any means is useful for assessing risk. Negative predictive power exceeds positive predictive power.
Hemodynamic support
Judicious volume infusion can improve RV function. Theoretical adverse effects of RV over distension are cited.
Norepinephrine is favored for vasopressor support. However, this is based largely on animal data. High level comparative clinical studies are not available.
Antithrombotic and antiembolic strategies
Intravenous anticoagulants are favored over subcutaneously administered anticoagulants if the patient is critically ill.
Concerning contraindications the authors state: Only rarely is anticoagulant treatment flatly contraindicated (eg, active hemorrhage in the brain or another vital organ, uncontrolled bleeding threatening tissue perfusion); but in those situations, consideration of prompt placement of a vena cava filter (see below) and clot removal (see above) should be undertaken.
The established indication for intravenous thrombolytic therapy is PE causing shock. Potential indications are deterioration despite standard treatment and normotensive patients with RV dysfunction.
Assessment
Get a bigger bang for the buck with CT by measuring RV and LV diameters. RV/LV diameter ratios over 0.9 are concerning for right ventricular dysfunction.
Echocardiography is useful in the assessment of RV function.
Biomarkers (troponin, BNP, ProBNP) are potentially useful indicators of RV damage and wall stress. Given the shorter half life of BNP and ProBNP these markers are more useful than troponin for assessment of patient progress in real time. Q 12 hour determinations are suggested by the authors.
Assessment of RV function by any means is useful for assessing risk. Negative predictive power exceeds positive predictive power.
Hemodynamic support
Judicious volume infusion can improve RV function. Theoretical adverse effects of RV over distension are cited.
Norepinephrine is favored for vasopressor support. However, this is based largely on animal data. High level comparative clinical studies are not available.
Antithrombotic and antiembolic strategies
Intravenous anticoagulants are favored over subcutaneously administered anticoagulants if the patient is critically ill.
Concerning contraindications the authors state: Only rarely is anticoagulant treatment flatly contraindicated (eg, active hemorrhage in the brain or another vital organ, uncontrolled bleeding threatening tissue perfusion); but in those situations, consideration of prompt placement of a vena cava filter (see below) and clot removal (see above) should be undertaken.
The established indication for intravenous thrombolytic therapy is PE causing shock. Potential indications are deterioration despite standard treatment and normotensive patients with RV dysfunction.
Fondaparinux for HIT?
This pentasacharide anticoagulant (Arixtra) does not cross react with HIT antibodies. Early experience with its use in HIT patients is favorable. It’s not approved for such use at present, and not recommended in guidelines. I predict it will eventually emerge as a treatment for HIT. The topic is reviewed here. (Pharmacotherapy, via Medscape).
See update here!
See update here!
Saturday, November 10, 2007
November is CAM month
---over at Panda Bear. He responds to some of the tired arguments of his detractors in the latest installment.
Where medicine is headed
I laughed watching Homeopathic ER. For some in academic medicine, though, this is serious business. Orac said it well:
I don't think we're too far from this point, at least in some medical centers. If current trends continue, give it a decade or two. Something to look forward to when I get old and start to need more medical care.
Friday, November 09, 2007
Update on skin and soft tissue infections
An excellent and thorough review of this topic recently appeared in CCJM as part of its supplement on Infections in Hospitalized Patients. With the increasing severity of illness of hospitalized patients and the rise of community associated MRSA, clinicians must be vigilant for necrotizing infections and the need for surgical consultation. The review covers clinical assessment for necrotizing infections and cites this study from Critical Care Medicine describing a scoring system of laboratory parameters to assess for necrotizing fasciitis. Although the scoring system is not detailed in the abstract of the Critical Care Medicine paper it can be accessed in this open access full text paper from Current Opinion in Infectious Diseases.
Sepsis update
From Current Opinion in Infectious Diseases.
New and noteworthy:
If appropriate antibiotics are given within the first hour of hypotension the survival rate in one study was 79.9% and declined by 7.6% per hour of delay.
While elevated lactate levels may result from acceleration of glycolysis due to hypermetabolism rather than tissue hypoxia, levels of 4 meq/l or above are concerning and indicate need for aggressive hemodynamic support.
New data from the CORTICUS study were cited regarding the use of corticosteroids in patients with shock. No benefit was found. Corticosteroids can be considered in selected cases, but routine use is no longer warranted.
EGTD, activated protein C and other bundle components are discussed
New and noteworthy:
If appropriate antibiotics are given within the first hour of hypotension the survival rate in one study was 79.9% and declined by 7.6% per hour of delay.
While elevated lactate levels may result from acceleration of glycolysis due to hypermetabolism rather than tissue hypoxia, levels of 4 meq/l or above are concerning and indicate need for aggressive hemodynamic support.
New data from the CORTICUS study were cited regarding the use of corticosteroids in patients with shock. No benefit was found. Corticosteroids can be considered in selected cases, but routine use is no longer warranted.
EGTD, activated protein C and other bundle components are discussed
Thursday, November 08, 2007
Pioglitazone (Actose) vs rosiglitazone (Avandia)
Ever wonder why the two drugs seem to have opposite effects on macrovascular outcomes? Well, just look at what happened to lipid levels when patients were switched form one to the other. (Via Baylor University Medical Center Proceedings).
Real world experience with early goal directed therapy for sepsis
Here’s how they did it at the Carolinas Medical Center. Although the investigators observed a 33% RRR similar to that reported in the original study by Rivers, their study was time limited and not powered to reach statistical significance.
The Carolinas Medical Center protocol was an ER based protocol. That is, the initial assessment for patient eligibility, insertion of the central venous catheter, initial hemodynamic management and antibiotic initiation were done by ER personnel before admission to the ICU.
The Carolinas Medical Center protocol was an ER based protocol. That is, the initial assessment for patient eligibility, insertion of the central venous catheter, initial hemodynamic management and antibiotic initiation were done by ER personnel before admission to the ICU.
What kind of diabetes does Halle Berry have, anyway?
When I was lurking over at Diabetes Mine preparing for my post on diabetes technology I ran across this little rant on the controversy sparked by Halle Berry’s claim that she weaned herself off insulin thus transitioning from type 1 to type 2 diabetes. That’s some serious misinformation. The dangerous message this sends to anyone who really does have type 1 diabetes is obvious.But I think maybe Amy and other bloggers are being unfair to Berry. Maybe she doesn’t know any better. I fault the media. They should know better. If they don’t they have no business covering the story. Even the news reports that purported to debunk the idea were faulty.
So, what type of diabetes does Berry really have? Type 1? Can’t be. She’s alive. Is it type 2? Well, she doesn’t really fit the profile. According to reports the presenting manifestation of her diabetes was coma. Besides, look at her. Type 2 doesn’t immediately come to mind!
We don’t really have enough information, but given that Berry’s father is African American and that her diabetes appears to have transitioned from type 1 to “something else” she could have an under appreciated condition that I blogged about early last year which has gone by various names including Flatbush diabetes, diabetes 1.5 and, more recently, ketosis prone type 2 diabetes, something of a misnomer since it’s not really type 2 diabetes at all.
If this is the disease Berry has her days of taking insulin may not be over. Diabetes 1.5 is a form of intermittent, reversible beta cell failure that can cause the diabetes to appear to flip-flop like John Kerry from type 1 to type 2 and back.
Image source: U.S. Government Via Wikipedia.
Wednesday, November 07, 2007
Type 1 diabetes, gadgets, and evidence based medicine
A recent keynote speech by Richard Kahn, Chief Scientific Officer of the American Diabetes Association (ADA), seems to have raised the ire of Amy and numerous commenters over at Diabetes Mine. Kahn spoke about where we’ve been and where we’re going with technological advances in diabetes care. So what’s controversial about that, you ask?
The post and comments that followed covered several related issues---inappropriate lumping of type 1 and type 2 diabetes, failure to advocate for patients, not enough emphasis on a cure---but I will focus on one. It seems Dr. Kahn is being accused of “dissing” diabetes technology:
OK, so did Kahn really dis new technology? Here’s an excerpt from the speech:
Kahn suggests a healthy skepticism towards new technology. He raises questions of evidence. But he’s not dismissive, at least in my reading. He’s not even suggesting technologies be subjected to the same scrutiny we apply to new drugs. I can think of many gadgets, bells and whistles, both in and outside the field of diabetes, which have survived such scrutiny despite a lack of proof of improvement in clinical outcomes. The proliferation in the 1980s of programmable functions in cardiac pacemakers and new modes in mechanical ventilators are just two examples. Many of these advances, while never passing the rigorous tests of evidence based medicine, remain available today to the benefit of individual patients.
Amy goes on:
The ADA should follow the evidence. Although insulin pumps have no proven superiority over newer insulins they represent an alternative which should be available to patients with type 1 diabetes. I can understand patients’ concerns. I hope we never see the day when the patient has to wait a year after the doctor fills out a ream of paper in order to get a pump. That may happen if we go to a single payer system---not as a result of any influence of Richard Kahn or the ADA.
H/T to Kevin MD.
The post and comments that followed covered several related issues---inappropriate lumping of type 1 and type 2 diabetes, failure to advocate for patients, not enough emphasis on a cure---but I will focus on one. It seems Dr. Kahn is being accused of “dissing” diabetes technology:
It is frightening that someone like Kahn, who in his position with the ADA is arguably the most visible spokesperson for diabetes in this country, would deliver a speech essentially dissing the value of new diabetes technologies -- and at the country's top gathering of D-tech experts, no less!
OK, so did Kahn really dis new technology? Here’s an excerpt from the speech:
The ‘90s also gave birth to many other advances in technology without which we would have made little progress in controlling the ravages of the disease. Laser photocoagulation, insulin pumps, angioplasty and by-pass procedures, mono filaments for foot exams, sophisticated glucose meters, and many more technological advances, have given people with diabetes a far better life than was imagined even a decade or two earlier. They have certainly saved lives, improved many more lives, and made diabetes manageable for millions of people.
Kahn suggests a healthy skepticism towards new technology. He raises questions of evidence. But he’s not dismissive, at least in my reading. He’s not even suggesting technologies be subjected to the same scrutiny we apply to new drugs. I can think of many gadgets, bells and whistles, both in and outside the field of diabetes, which have survived such scrutiny despite a lack of proof of improvement in clinical outcomes. The proliferation in the 1980s of programmable functions in cardiac pacemakers and new modes in mechanical ventilators are just two examples. Many of these advances, while never passing the rigorous tests of evidence based medicine, remain available today to the benefit of individual patients.
Amy goes on:
Think of the ramifications. If the ADA comes out with an official position that there's no value in using an insulin pump, or a CGM system, or even a fingerstick meter if you're a Type 2 not on insulin, the Powers That Be will listen.
The ADA should follow the evidence. Although insulin pumps have no proven superiority over newer insulins they represent an alternative which should be available to patients with type 1 diabetes. I can understand patients’ concerns. I hope we never see the day when the patient has to wait a year after the doctor fills out a ream of paper in order to get a pump. That may happen if we go to a single payer system---not as a result of any influence of Richard Kahn or the ADA.
H/T to Kevin MD.
Frontotemporal dementias
This group of dementias was formerly called Pick’s disease. Some patients are mislabeled as Alzheimer’s disease. The topic is reviewed here in the Annals of General Psychiatry.
Emergency treatment of warfarin associated intracranial hemorrhage
This review in Emergency Medicine News is full of pearls. Given current controversies and the almost universally dismal outcome in patients presenting with warfarin associated ICH, no particular regimen for reversal can be held up as the standard of care. A practical approach taking into account recent guidelines and the relevant physiology and pharmacology is presented.
Tuesday, November 06, 2007
The Orphanet Journal of Rare Diseases
Don’t be deceived by the title. Some of the diseases covered in this journal, launched early last year, are not so rare. Others are rare in real world practice but not so rare on Internal Medicine boards. These high quality, thoroughly referenced expert reviews (the EBM Nazis are gasping) should prove useful for clinical reference, background reading and board review. I’ll be linking to some of the articles, which are available as free full text, in future posts.
Early goal directed therapy five years later
Five years after the seminal paper of Rivers, et al. establishing the efficacy of early goal directed therapy (EGDT) for severe sepsis and septic shock this review was published in the November 2006 issue of Chest. It reviews evidence on EGDT since the original paper and covers multiple theoretical and practical aspects of EGDT. The following points are noteworthy:
Experience accumulated since the Rivers study has confirmed the benefits of EGDT.
Treatment modalities for sepsis are time dependent. Goal directed therapy must be given in the first 6 hours. Older studies demonstrated that, when given later in the course of sepsis, goal directed therapy was not efficacious and possibly harmful.
Arrival to the ER of a patient with suspected sepsis carries the same urgency as does the arrival of a patient with suspected stroke, MI or trauma.
Each hospital must have its own plan for implementation. Three options were suggested for those patients presenting to the ER with sepsis: 1) EGDT is carried out entirely in the ER, by ER personnel. This is how it was done in the original study, in which ICU personnel were uninvolved in EGDT and were, in fact, blinded to the initial therapy. 2) Patients who meet criteria after an initial rapid assessment are taken directly to the ICU, and EGDT is initiated there. 3) As soon as assessment indicates severe sepsis, resources are mobilized by calling a rapid response sepsis team which could be assembled from multiple hospital departments. (Option 1 seems logical, but may not be appropriate for ERs that are burdened by overcrowding and understaffing. Option 2 would probably work only in ICUs staffed around the clock by dedicated intensivists. Option 3 might be best for many hospitals).
EGDT must not supplant or in any way diminish the importance of timely administration of appropriate antibiotics.
Experience accumulated since the Rivers study has confirmed the benefits of EGDT.
Treatment modalities for sepsis are time dependent. Goal directed therapy must be given in the first 6 hours. Older studies demonstrated that, when given later in the course of sepsis, goal directed therapy was not efficacious and possibly harmful.
Arrival to the ER of a patient with suspected sepsis carries the same urgency as does the arrival of a patient with suspected stroke, MI or trauma.
Each hospital must have its own plan for implementation. Three options were suggested for those patients presenting to the ER with sepsis: 1) EGDT is carried out entirely in the ER, by ER personnel. This is how it was done in the original study, in which ICU personnel were uninvolved in EGDT and were, in fact, blinded to the initial therapy. 2) Patients who meet criteria after an initial rapid assessment are taken directly to the ICU, and EGDT is initiated there. 3) As soon as assessment indicates severe sepsis, resources are mobilized by calling a rapid response sepsis team which could be assembled from multiple hospital departments. (Option 1 seems logical, but may not be appropriate for ERs that are burdened by overcrowding and understaffing. Option 2 would probably work only in ICUs staffed around the clock by dedicated intensivists. Option 3 might be best for many hospitals).
EGDT must not supplant or in any way diminish the importance of timely administration of appropriate antibiotics.
Applying different methods to the Avandia meta-analysis yields uncertainty
This paper is old news because of the media splash that resulted when it was released ahead of print, but it’s in the current print issue of Annals of Internal Medicine. Diamond et.al. point out one of the hazards of meta-analysis: conclusions may be sensitive to methodologic choices made by the authors. Based on their use of alternative methods of analysis: “We conclude that the risk for myocardial infarction and death from cardiovascular disease for diabetic patients taking rosiglitazone is uncertain: Neither increased nor decreased risk is established.”
Sepsis review from Hospital Physician
This review on the diagnosis and management of sepsis from the June 2007 issue of Hospital Physician covers multiple aspects of treatment including practical application of the Surviving Sepsis Guidelines.
Of special note, the section on early goal directed therapy (EGDT, the Rivers protocol) emphasizes the underappreciated point that EGDT is time dependent. As such it is an emergency department protocol which commences as soon as severe sepsis or septic shock is recognized, and is carried out during the first 6 hours. The article appropriately cautions that EGDT should not wait until arrival in the ICU.
This caveat is supported by largely forgotten evidence that goal directed therapy which commenced in the ICU (late goal directed therapy, when a pulmonary artery catheter could be inserted) was ineffective.
Of special note, the section on early goal directed therapy (EGDT, the Rivers protocol) emphasizes the underappreciated point that EGDT is time dependent. As such it is an emergency department protocol which commences as soon as severe sepsis or septic shock is recognized, and is carried out during the first 6 hours. The article appropriately cautions that EGDT should not wait until arrival in the ICU.
This caveat is supported by largely forgotten evidence that goal directed therapy which commenced in the ICU (late goal directed therapy, when a pulmonary artery catheter could be inserted) was ineffective.
Monday, November 05, 2007
None dare call it quackery
(With apologies to John A. Stormer). In yesterday’s edition of an ongoing series on alternative medicine Panda Bear compares and contrasts alternative and mainstream methods on several levels. Both traditions, for example, construct models to describe the how and why of biological processes. The difference, of course, is that conventional medicine refines its models over time to conform to new scientific observations while much of alternative medicine does not. As Panda Bear notes:
Is academic medicine listening? Almost a century ago Abraham Flexner urged medical education to get rid of the woo. Nowadays, though, the leaders (well, maybe there are two or three exceptions) in medical education seem unwilling to take a stand. The task is left to a few bloggers who choose to call quackery what it is at the risk of being labeled narrow minded fuddy-duddies or Pharma shills.
“Meridians” make sense when your knowledge of the body is based on religious superstition and mysticism. Once you discover the true function of blood vessels and nerves, however, it is time to put away your belief in qi, a spiritual construct that as a metaphor for disease has no basis in real physiology.
Is academic medicine listening? Almost a century ago Abraham Flexner urged medical education to get rid of the woo. Nowadays, though, the leaders (well, maybe there are two or three exceptions) in medical education seem unwilling to take a stand. The task is left to a few bloggers who choose to call quackery what it is at the risk of being labeled narrow minded fuddy-duddies or Pharma shills.
Friday, November 02, 2007
The up and coming Rush Limbaugh of medical talk?
Who knows? Listen to Dr. Anonymous Live! There are a few technical difficulties to iron out. Nice bumper music, though.
Via Clinical Cases and Images.
Via Clinical Cases and Images.
Panda Bear joins the chorus against quacky promotions by academic medicine
Not only that, he’s launching a month long series on the subject. Here are some excerpts from the inaugural post:
Actually, by the time I had finished the eighth grade I had a sufficient background in chemistry and biology to recognize that these things cannot possibly work.
This is literally third grade stuff and the fact that many prestigious medical centers lack the institutional courage to point it out should make you cringe in shame, either at their gullibility or their venality.
“Well, we’re just being open-minded,” is the formula used to justify spending large sums of money to investigate therapies that even my ten-year-old son could instantly recognize as not only impossible but also somewhat ridiculous.
Glucocorticoid replacement during surgery and acute illness
Hospital physicians frequently encounter patients with decreased adrenal reserve (iatrogenic adrenal insufficiency due to long term corticosteroid therapy or, rarely, adrenal or pituitary disease) who undergo invasive procedures or become acutely ill. The physician must be familiar with the indications for steroid replacement as well as the appropriate dosing schedule. A recent article in The Hospitalist (p. 12) discussed this issue and cited two important primary sources.
A JAMA Clinicians Corner piece published in the January 9, 2002 issue made these procedure specific recommendations:
Minor procedure (endoscopy, inguinal hernia repair): 25 mg hydrocortisone or its equivalent on day of procedure only.
Moderate procedure (abdominal surgery): 50-75mg hydrocortisone on day of procedure and taper quickly over 2-3 days to patient’s maintenance dose.
High risk procedure (cardiovascular surgery, extensive abdominal): 100-150 mg hydrocortisone initially, then taper over 1-2 days to patient’s maintenance dose.
Similar recommendations apply to mild, moderate or severe illness, respectively. For critical illness, 50-100 mg hydrocortisone every 6-8 hours for the duration of critical illness is recommended, along with mineralocorticoid replacement, with slower taper after critical period has resolved.
The above regimens may need to be modified according to the patient’s clinical response.
Superficial procedures under local anesthesia lasting one hour or less require continuation of the patients maintenance regimen but no additional supplementation.
Similar recommendations appeared in a review in Bulletin on the Rheumatic diseases, freely available in full text.
A JAMA Clinicians Corner piece published in the January 9, 2002 issue made these procedure specific recommendations:
Minor procedure (endoscopy, inguinal hernia repair): 25 mg hydrocortisone or its equivalent on day of procedure only.
Moderate procedure (abdominal surgery): 50-75mg hydrocortisone on day of procedure and taper quickly over 2-3 days to patient’s maintenance dose.
High risk procedure (cardiovascular surgery, extensive abdominal): 100-150 mg hydrocortisone initially, then taper over 1-2 days to patient’s maintenance dose.
Similar recommendations apply to mild, moderate or severe illness, respectively. For critical illness, 50-100 mg hydrocortisone every 6-8 hours for the duration of critical illness is recommended, along with mineralocorticoid replacement, with slower taper after critical period has resolved.
The above regimens may need to be modified according to the patient’s clinical response.
Superficial procedures under local anesthesia lasting one hour or less require continuation of the patients maintenance regimen but no additional supplementation.
Similar recommendations appeared in a review in Bulletin on the Rheumatic diseases, freely available in full text.
Wednesday, October 31, 2007
Postdischarge low molecular weight heparin for VTE prophylaxis
This is a common practice for surgical patients, but the experience in high risk medical patients has been limited. Now there’s evidence to support it from a randomized trial. Results were recently presented at the 21st Congress of the International Society on Thrombosis and Hemostasis.
Via Medscape.
Via Medscape.
Update on community associated MRSA
This review, part of the Cleveland Clinic Journal of Medicine supplement on infections in hospitalized patients, covers the genetics and epidemiology of CA-MRSA. CA-MRSA is increasingly acquired in hospitals and is no longer clearly defined by site of origin.
Monday, October 29, 2007
Peripheral blood cells and mortality in the ICU
Check for nucleated red cells in the peripheral blood. The authors of a study in the journal Critical Care recommended daily monitoring via a high sensitivity mechanized technique and not to transfer patients to the ward until NRBCs have cleared.
Sunday, October 28, 2007
Free ciprofloxacin
…and several other generic antibiotics are being offered to customers by a St. Louis supermarket chain. From the St. Louis Post Dispatch.
A repository of cool web sites
Worth book marking. Watch out for the woo, though. Via Family Medicine Notes.
Another new medical blog
The Happy Hospitalist on what’s to like about being a hospitalist and what’s not to like about primary care.
Hospitalists and primary care
The hectic pace of hospitalist duties last week brought blogging and blog reading to a screeching halt. Today afforded me a little catch up time to comment on some interesting items from the last few days. Bob Wachter and DB wrote three insightful posts about the sorry state of primary care, particularly internal medicine. Is the hospitalist movement to blame? No.
General internists are struggling with two increasing threats to their livelihood and professionalism. First, the existing payment system pressures them to spend inadequate time for quality care of individual patients. Second, various forces have redefined general internal medicine as “family practice minus ob and peds”.
Is anyone advocating for the general internist? Dr. Robert Centor (DB), past president of the Society of General Internal Medicine, has done his part. The American College of Physicians, on the other hand, seems uninterested in promoting internal medicine as a unique specialty, merely depicting general internists as “doctors for adults”.
Although the hospitalist movement didn’t cause these problems it provided internists an alternative career path with reasonable compensation and professional satisfaction, giving them an opportunity to vote with their feet. The resulting mass exodus from primary care will make internal medicine’s doldrums a hot public issue. For that reason the hospitalist movement may ultimately help rather than harm the cause of primary care.
Recommended reading:
Retired Doc asks: Is being a hospitalist the only way to still be an old time internist?
The Happy Hospitalist weighs in.
The American College of Physicians proposals don’t address what’s really wrong with internal medicine.
Med students and pre-meds chat on line and express confusion about the difference between FP and IM, and wonder if there’s any reason in the world to choose IM. (The answer seems to be NO unless you want to sub specialize or be a hospitalist).
General internists are struggling with two increasing threats to their livelihood and professionalism. First, the existing payment system pressures them to spend inadequate time for quality care of individual patients. Second, various forces have redefined general internal medicine as “family practice minus ob and peds”.
Is anyone advocating for the general internist? Dr. Robert Centor (DB), past president of the Society of General Internal Medicine, has done his part. The American College of Physicians, on the other hand, seems uninterested in promoting internal medicine as a unique specialty, merely depicting general internists as “doctors for adults”.
Although the hospitalist movement didn’t cause these problems it provided internists an alternative career path with reasonable compensation and professional satisfaction, giving them an opportunity to vote with their feet. The resulting mass exodus from primary care will make internal medicine’s doldrums a hot public issue. For that reason the hospitalist movement may ultimately help rather than harm the cause of primary care.
Recommended reading:
Retired Doc asks: Is being a hospitalist the only way to still be an old time internist?
The Happy Hospitalist weighs in.
The American College of Physicians proposals don’t address what’s really wrong with internal medicine.
Med students and pre-meds chat on line and express confusion about the difference between FP and IM, and wonder if there’s any reason in the world to choose IM. (The answer seems to be NO unless you want to sub specialize or be a hospitalist).
Wednesday, October 24, 2007
Let’s get grandma on some antibiotics before this goes into pneumonia
The guidelines and the experts tell doctors to say no. But just when it looks like they’re starting to listen (the rate of antibiotic prescriptions for respiratory infections seems to be going down) comes this study in BMJ. Although NNTs were very high for preventing mastoiditis and quincy after ototis and sore throat, respectively, they were low for preventing pneumonia after bronchitis, particular in the elderly (39!).
What is already known on this topic
Guidelines based on randomised controlled trials recommend that antibiotics should not be prescribed for upper respiratory tract infection, sore throat, or otitis media.
Chest infections are divided into acute bronchitis (antibiotics not recommended) and pneumonia (antibiotics recommended).
What this study adds
Antibiotics reduce the risk of mastoiditis after otitis media, quinsy after sore throat, and pneumonia after upper respiratory tract infection but over 4000 courses of antibiotics are needed to prevent one complication.
Conversely, the risk of pneumonia in those presenting with chest infection is high, particularly in elderly patients, and can be substantially reduced by the use of antibiotics.
Monday, October 22, 2007
Defensive medicine
Kevin has been exposing the malpractice crisis and how it leads to defensive medicine. His relentless blogging finally got the attention of the national media. Nice work!
Neurologic complications of critical illness
Critical illness polyneuropathy (CIP), critical illness myopathy (CIM) and septic encephalopathy are under recognized complications of sepsis, multiorgan failure and prolonged mechanical ventilation. A review in the May issue of Chest focuses on CIP and CIM (often overlapping and sometimes lumped as ICU associated weakness). An editorial in the same issue discusses CIP and CIM and mentions the related entity septic encephalopathy, a state of impaired consciousness and cognition associated with sepsis.
An algorithm for diagnosis and strategies for prevention are presented. Among preventive strategies limitation of corticosteroids and neuromuscular blocking agents are those best supported by evidence.
An algorithm for diagnosis and strategies for prevention are presented. Among preventive strategies limitation of corticosteroids and neuromuscular blocking agents are those best supported by evidence.
Multidrug resistant gram negative infections
This CCJM paper, part of the supplement on Infections in Hospitalized Patients, is one of the best reviews I’ve seen on the topic of rising antimicrobial resistance in gram negative infections.
Sunday, October 21, 2007
Confusion about MRSA reaching epidemic proportions
MRSA outbreaks are nothing compared to the outbreak of media distortion about MRSA. The latest barrage was sparked by the report of the MRSA related death of a Virginia high school student as well as this paper in JAMA which updates the epidemiology of MRSA.
In an attempt to parse what’s going on let’s start with the story of the Virginia high school student. The Associated Press report reads:
Although we have no information about the infecting strain, be it the “old MRSA” typified by the USA100 strain or the “new MRSA” typified by USA300 (although pulsed-field typing was probably not done in this case the strain could easily have been inferred from the sensitivity pattern for antibiotics other than methicillin as I explained here) it was most likely the former.
The significance of the JAMA article is that it is the most systematic analysis of the epidemiology of invasive MRSA in the U.S. to date and despite its limitations suggests that the infection is more widespread than had been appreciated. The paper is “busy” with data and somewhat confusing categorizations. (An editorial in the same issue provides clarity). Infections were classified on the basis of site of onset (health care or community) and on the basis of risk factor associations (health care or community). Pulsed field typing was available for a minority of isolates. Considerable overlap among all 3 methods of categorization suggests limitations on the popular designations “community associated” and “health care associated”. Nevertheless MRSA comprises at least two different beasts with important clinical associations, best typified by pulsed field types USA100 and USA300 and usually distinguishable to clinicians by characteristic antimicrobial sensitivity patterns. While I decry the media’s “killer superbug” hype I did point out, almost 2 years ago, that the “new” MRSA had unique potential for increased transmissibility and severe necrotizing infections.
Now let’s examine some of the media distortion. I did a Google News search for MRSA and had difficulty finding articles that provided appropriate perspective. This Q and A piece defines MRSA as “a type of staph bacterium that is resistant to common antibiotics such as penicillin.” Not quite. Penicillin sensitivity is rare even among non-MRSA isolates.
Many articles talked about schools closing for a good scrubbing down following the reports of MRSA infections in Aston Bonds and other students. However, given the importance of person to person spread of MRSA it’s unlikely that environmental sanitation measures would have much impact. This article implies that poor hospital cleaning was responsible for MRSA sepsis and death in a newborn. But almost a year ago I cited a lack of evidence of correlation between hospital cleanliness and MRSA bacteremia. In hospitals hand washing and proper use of isolation procedures, rather than environmental cleanliness, will make the most impact. Equally important are sanitation measures for infected patients to follow after hospital discharge, which I provided here.
This superbug article declares:
There may be good reasons for environmental disinfection, but such measures won’t contain MRSA. Kids bring these bugs form home and pass them to others via direct contact or sharing of items of personal hygiene, also brought from home in many cases. Utensils and items of athletic equipment are reasonable areas of focus for schools.
It’s simplistic to characterize the “new” MRSA, the one that’s getting all the attention in schools, as a problem of increasing antimicrobial resistance. For milder cases several antibiotics are effective, including a few old ones (Bactrim, tetracyclines). The problem is these are not the same old antibiotics (cephalexin, diclox) we’ve been used to using to treat community acquired skin infections. To make it a bit more challenging, the ones that work for the new MRSA aren’t effective against group A strep which is still a common cause of skin infections. The new MRSA happens to be susceptible to more antibiotics than the old MRSA that’s been quietly making the rounds in hospitals for years.
There’s plenty more hype, but I’ll stop there. I can imagine how the reporter felt as she researched her daughter’s ordeal with MRSA: “I became a mouse-click medical expert. The more I read, the more I feared”.
In an attempt to parse what’s going on let’s start with the story of the Virginia high school student. The Associated Press report reads:
BEDFORD, Va. (AP) — A high school student who was hospitalized for more than a week with an antibiotic-resistant staph infection has died. After a student protest, officials shut down 21 schools for cleaning to keep the illness from spreading.
Ashton Bonds, 17, a senior at Staunton River High School, died Monday after being diagnosed with Methicillin-resistant Staphylococcus aureus, or MRSA, his mother said.
Although we have no information about the infecting strain, be it the “old MRSA” typified by the USA100 strain or the “new MRSA” typified by USA300 (although pulsed-field typing was probably not done in this case the strain could easily have been inferred from the sensitivity pattern for antibiotics other than methicillin as I explained here) it was most likely the former.
The significance of the JAMA article is that it is the most systematic analysis of the epidemiology of invasive MRSA in the U.S. to date and despite its limitations suggests that the infection is more widespread than had been appreciated. The paper is “busy” with data and somewhat confusing categorizations. (An editorial in the same issue provides clarity). Infections were classified on the basis of site of onset (health care or community) and on the basis of risk factor associations (health care or community). Pulsed field typing was available for a minority of isolates. Considerable overlap among all 3 methods of categorization suggests limitations on the popular designations “community associated” and “health care associated”. Nevertheless MRSA comprises at least two different beasts with important clinical associations, best typified by pulsed field types USA100 and USA300 and usually distinguishable to clinicians by characteristic antimicrobial sensitivity patterns. While I decry the media’s “killer superbug” hype I did point out, almost 2 years ago, that the “new” MRSA had unique potential for increased transmissibility and severe necrotizing infections.
Now let’s examine some of the media distortion. I did a Google News search for MRSA and had difficulty finding articles that provided appropriate perspective. This Q and A piece defines MRSA as “a type of staph bacterium that is resistant to common antibiotics such as penicillin.” Not quite. Penicillin sensitivity is rare even among non-MRSA isolates.
Many articles talked about schools closing for a good scrubbing down following the reports of MRSA infections in Aston Bonds and other students. However, given the importance of person to person spread of MRSA it’s unlikely that environmental sanitation measures would have much impact. This article implies that poor hospital cleaning was responsible for MRSA sepsis and death in a newborn. But almost a year ago I cited a lack of evidence of correlation between hospital cleanliness and MRSA bacteremia. In hospitals hand washing and proper use of isolation procedures, rather than environmental cleanliness, will make the most impact. Equally important are sanitation measures for infected patients to follow after hospital discharge, which I provided here.
This superbug article declares:
All schools should be disinfected. Regularly. And we need to educate ourselves about this increasingly aggressive disease that few drugs can defeat.
There may be good reasons for environmental disinfection, but such measures won’t contain MRSA. Kids bring these bugs form home and pass them to others via direct contact or sharing of items of personal hygiene, also brought from home in many cases. Utensils and items of athletic equipment are reasonable areas of focus for schools.
It’s simplistic to characterize the “new” MRSA, the one that’s getting all the attention in schools, as a problem of increasing antimicrobial resistance. For milder cases several antibiotics are effective, including a few old ones (Bactrim, tetracyclines). The problem is these are not the same old antibiotics (cephalexin, diclox) we’ve been used to using to treat community acquired skin infections. To make it a bit more challenging, the ones that work for the new MRSA aren’t effective against group A strep which is still a common cause of skin infections. The new MRSA happens to be susceptible to more antibiotics than the old MRSA that’s been quietly making the rounds in hospitals for years.
There’s plenty more hype, but I’ll stop there. I can imagine how the reporter felt as she researched her daughter’s ordeal with MRSA: “I became a mouse-click medical expert. The more I read, the more I feared”.
Saturday, October 20, 2007
The emphasis on core quality measures is dumbing down the practice of medicine
That’s because “quality” measures as they are now promulgated reflect a simplistic view of clinical science, distract from things in medicine that really matter and encourage health care providers to “play for the test”.
Bob Wachter over at Wachter’s World sees some interesting parallels with the unintended consequences of outcome based education and the No Child Left Behind law. In primary and secondary education, emphasis on the core skills of math and reading has relegated the humanities and other important subjects to the status of “soft” content. (Wachter presents data from the San Diego schools!).
Whether in primary and secondary education or in medicine, one hazard of adopting core measures is that the achievement of minimum standards trumps the pursuit of excellence. One of the many consequences in medicine may be the demise of the master clinicians, the Proctor Harveys of the world. Wachter agrees and shares an anecdote about one of UCSF’s master diagnosticians, Gurpreet “Goop” Dhaliwal, concluding:
Bob Wachter over at Wachter’s World sees some interesting parallels with the unintended consequences of outcome based education and the No Child Left Behind law. In primary and secondary education, emphasis on the core skills of math and reading has relegated the humanities and other important subjects to the status of “soft” content. (Wachter presents data from the San Diego schools!).
Whether in primary and secondary education or in medicine, one hazard of adopting core measures is that the achievement of minimum standards trumps the pursuit of excellence. One of the many consequences in medicine may be the demise of the master clinicians, the Proctor Harveys of the world. Wachter agrees and shares an anecdote about one of UCSF’s master diagnosticians, Gurpreet “Goop” Dhaliwal, concluding:
I’m afraid that Goop’s diagnostic acumen might well be healthcare’s music class: extraordinarily impressive, really quite beautiful in a way, but way off the measurement radar screen. If our students get the message that Goop's kind of clinical intelligence and diagnostic ability are unimportant (after all, they don’t seem to be part of what we’re calling “quality”), I think you can guess what will happen over time. Clinical "artists and musicians" will become extinct.
Friday, October 19, 2007
Rapid response teams: promoted but not evidence based
Rapid response teams, though promoted by Joint Commission and IHI have not been supported by high level evidence. The latest analysis, a systematic review recently published in Critical Care Medicine, offers little more in the way of evidentiary support for RRTs.
RRTs were marginally effective in preventing cardiac arrest in the pooled analysis of observational studies but not in the only randomized controlled trial (RCT). RRTs had no impact on mortality in any level of study (neither in observational studies nor in the two RCTs). This is consistent with what was known before. Despite these negative findings Joint Commission urges hospitals to use “Rapid Response Systems to Save Lives” and the IHI declares that the use of RRTs is “perhaps the most dramatic of the six strategies at the heart of IHI’s 100,000 Lives Campaign”.
The authors of the systematic review conclude that “Large randomized controlled trials are needed to clarify the efficacy of rapid response systems before they should become standard of care.”
RRTs were marginally effective in preventing cardiac arrest in the pooled analysis of observational studies but not in the only randomized controlled trial (RCT). RRTs had no impact on mortality in any level of study (neither in observational studies nor in the two RCTs). This is consistent with what was known before. Despite these negative findings Joint Commission urges hospitals to use “Rapid Response Systems to Save Lives” and the IHI declares that the use of RRTs is “perhaps the most dramatic of the six strategies at the heart of IHI’s 100,000 Lives Campaign”.
The authors of the systematic review conclude that “Large randomized controlled trials are needed to clarify the efficacy of rapid response systems before they should become standard of care.”
Unreasonable expectations for new type 2 diabetes drugs
Physiology and clinical epidemiology give us no reason to expect that glycemic control with any drug should prevent heart attacks or strokes (macrovascular benefit). In fact, the most time tested and trusted class of oral agents for type 2 diabetes is associated with macrovascular harm. Had macrovascular benefit been the standard for approval of drugs for type 2 diabetes all along we would now have only two drugs available: metformin and pioglitazone.
Of course all this got started as a result of the Avandia bru-ha-ha. I‘ve ranted about this macrovascular issue here and elsewhere. Here’s an expert who seems to agree, commenting in a recent issue of DOC News:
Of course all this got started as a result of the Avandia bru-ha-ha. I‘ve ranted about this macrovascular issue here and elsewhere. Here’s an expert who seems to agree, commenting in a recent issue of DOC News:
But as a medical community, do we want to prove that our agents to treat type 2 diabetes improve heart attack and stroke risk before approval?
I think not.
Thursday, October 18, 2007
Deceptive promotion by hospitals and health care systems
---while commonplace, hasn’t gotten the criticism it deserves. Earlier this year I wondered why the outrage about direct to consumer advertising was so selective and quoted Dr. David Oxman’s article:
A survey of hospitals from the Archives of Internal Medicine a couple of years ago, referenced in Oxman’s article, uncovered conflicts of interest, non-evidence based promotions, disease promotion and “freebies”. Worse, these promotions were found in 16 of the 17 “America’s Best Hospitals”.
To me it’s a case of the pot calling the kettle black as physician leaders at these and other academic medical centers talk about “professionalism” and rail against pharmaceutical industry promotion while tolerating such ethical breaches by their own institutions.
That may be changing. In yesterday’s issue of JAMA, faculty from two medical centers addressed a novel aspect of self-promotion: hospitals, eager to take advantage of rising public interest in quality and transparency, are now couching their promotions in scientific terms by presenting them as “data”. The problem is they are doing this independently of any form of external validation, without appropriate statistical analysis and with bias.
Dr. Robert Wachter, one of the paper’s authors, talks about it on his blog.
By now Americans are accustomed to seeing advertisements for medical goods and services. The steady supply of direct-to-consumer TV advertisements by the pharmaceutical industry is probably the most high-profile example. But while much has been written about the negative effects of these advertisements, the impact of healthcare service advertising---by hospitals as well as by individual physicians---receives comparatively little attention and almost no debate.
A survey of hospitals from the Archives of Internal Medicine a couple of years ago, referenced in Oxman’s article, uncovered conflicts of interest, non-evidence based promotions, disease promotion and “freebies”. Worse, these promotions were found in 16 of the 17 “America’s Best Hospitals”.
To me it’s a case of the pot calling the kettle black as physician leaders at these and other academic medical centers talk about “professionalism” and rail against pharmaceutical industry promotion while tolerating such ethical breaches by their own institutions.
That may be changing. In yesterday’s issue of JAMA, faculty from two medical centers addressed a novel aspect of self-promotion: hospitals, eager to take advantage of rising public interest in quality and transparency, are now couching their promotions in scientific terms by presenting them as “data”. The problem is they are doing this independently of any form of external validation, without appropriate statistical analysis and with bias.
Dr. Robert Wachter, one of the paper’s authors, talks about it on his blog.
Mycosis fungoides
It’s a great mimicker. Be sure to think of it. A review appeared in the British Journal of Dermatology, via Medscape.
ITP---not always idiopathic
When clinical conditions warrant consider these underlying diseases:
SLE
Antipholpholipid syndrome
H. pylori infection---here the association is controversial, but some studies indicate a high rate of improvement or remission of thrombocytopenia following eradication.
Hepatitis C---screen all patients with chronic thrombocytopenia for hep C. Thrombocytopenia may improve with treatment of the underlying disease.
HIV
Via Current Opinion in Hematology
SLE
Antipholpholipid syndrome
H. pylori infection---here the association is controversial, but some studies indicate a high rate of improvement or remission of thrombocytopenia following eradication.
Hepatitis C---screen all patients with chronic thrombocytopenia for hep C. Thrombocytopenia may improve with treatment of the underlying disease.
HIV
Via Current Opinion in Hematology
Wednesday, October 17, 2007
Another hazard of systematic reviews
---is that they go out of date, as this paper in the Annals of Internal Medicine reminds us.
So what, you’re thinking to yourself. All medical literature goes out of date!
OK, here’s what: Some EBM mavens worship the systematic review. Most EBM resources rate systematic reviews at the top of the evidence hierarchy, thus encouraging clinicians to preferentially seek systematic reviews to answer clinical questions. Many contain links that search only systematic reviews
Search strategies which focus on systematic reviews ignore randomized controlled trials published since the latest review and thus may not yield the best and most current evidence.
A quick Google image search reveals that the vast majority (although not all) evidence pyramids rank the systematic review at the top.
So what, you’re thinking to yourself. All medical literature goes out of date!
OK, here’s what: Some EBM mavens worship the systematic review. Most EBM resources rate systematic reviews at the top of the evidence hierarchy, thus encouraging clinicians to preferentially seek systematic reviews to answer clinical questions. Many contain links that search only systematic reviews
Search strategies which focus on systematic reviews ignore randomized controlled trials published since the latest review and thus may not yield the best and most current evidence.
A quick Google image search reveals that the vast majority (although not all) evidence pyramids rank the systematic review at the top.
Tuesday, October 16, 2007
Why is tPA for stroke still so controversial 12 years after NINDS?
Because of all the screaming. Plenty of it on both sides.
On the affirmative side are false claims (“it saves lives”), egregious media spin and hyped up expert testimony.
On the negative side are knee jerk cries of “conflict of interest”.
What’s a doctor to do?
We need an objective analysis that cuts through all the noise and gives us a balanced perspective.
I think I’ve found such an analysis: Joseph Lex’s presentation at the FERNE 2007 Brain Illness and Injury Course.
Bottom line: Patient selection is difficult, therapeutic window is narrow and informed consent is crucial. Know how to inform patients and families. This presentation shows how.
On the affirmative side are false claims (“it saves lives”), egregious media spin and hyped up expert testimony.
On the negative side are knee jerk cries of “conflict of interest”.
What’s a doctor to do?
We need an objective analysis that cuts through all the noise and gives us a balanced perspective.
I think I’ve found such an analysis: Joseph Lex’s presentation at the FERNE 2007 Brain Illness and Injury Course.
Bottom line: Patient selection is difficult, therapeutic window is narrow and informed consent is crucial. Know how to inform patients and families. This presentation shows how.
Monday, October 15, 2007
Modest effects of pneumococcal vaccination in adults
Polysaccharide pneumococcal vaccination has been designated a core quality measure despite the fact that it does not prevent pneumonia and from the standpoint of absolute risk reduction its effects on the complications of pneumococcal infection are modest.
This study, reported in the Archives of Internal Medicine, compared vaccinated and unvaccinated patients hospitalized with community acquired pneumonia and found a reduction in a composite outcome of death or admission to the ICU in vaccinated patients. Buried in the body of the paper is the statement that the entire effect was due to the reduction in ICU admissions. There was no effect on mortality.
So, when you administer pneumococcal vaccine to your patients at discharge you won’t prevent pneumonia and probably won’t help them live longer, but you’ll decrease the likelihood of admission to ICU next episode.
The polysaccharide pneumococcal vaccine, which is the only kind approved for adults, is a weak sister compared to the conjugate vaccine approved for kids. We need a conjugate vaccine for adults. Is anybody out there working on it?
This study, reported in the Archives of Internal Medicine, compared vaccinated and unvaccinated patients hospitalized with community acquired pneumonia and found a reduction in a composite outcome of death or admission to the ICU in vaccinated patients. Buried in the body of the paper is the statement that the entire effect was due to the reduction in ICU admissions. There was no effect on mortality.
So, when you administer pneumococcal vaccine to your patients at discharge you won’t prevent pneumonia and probably won’t help them live longer, but you’ll decrease the likelihood of admission to ICU next episode.
The polysaccharide pneumococcal vaccine, which is the only kind approved for adults, is a weak sister compared to the conjugate vaccine approved for kids. We need a conjugate vaccine for adults. Is anybody out there working on it?
Saturday, October 13, 2007
Massive pulmonary embolism leading to cardiac arrest
Emergency surgery may be an option. (Texas Heart Institute Journal).
Is your medical reading getting too dry?
Try Striped Giraffe Press. “…a publishing company dedicated to teaching medical knowledge in an offbeat fashion.”
The site appears to be under construction. Not much there yet, but could be interesting.
The site appears to be under construction. Not much there yet, but could be interesting.
Friday, October 12, 2007
Core measures and P4P: rank-and-file doctors aren’t buying in
Bob Wachter used an electronic audience response system to poll over 500 attendees (mainly hospitalists) about this topic at his recent UCSF/SHM sponsored Hospital Medicine Course. Among physician groups, you’d think hospitalists would be the cheerleaders of the quality movement. But these doctors were overwhelmingly skeptical. Wachter presents the poll results here and euphemistically concludes: The bottom line: everybody’s got a lot of work to do if we’re going to get this thing right.
More discussion on intensive glycemic control in hospitalized patients
A review in Chest addressed the controversies on this topic and summarized results of clinical studies done up to the time of submission of the manuscript. Several tables display summaries of available data on the basis of duration of the intervention, types of outcomes and types of populations.
An accompanying editorial is linked here.
An accompanying editorial is linked here.
Early Goal Directed Therapy of sepsis
---from the perspective of an Emergency physician. Via Emergency Medicine News.
Remembering Proctor Harvey
W. Proctor Harvey, M.D., M.A.C.C., passed away on Sept. 26 at the age of 89. He was widely renowned as a master clinician and teacher of cardiac auscultation. His teaching sessions were legendary. I had the good fortune to attend a few of them at CME meetings through the years. Harvey taught, and demonstrated to his students repeatedly, that most cardiovascular disease could be diagnosed at the bedside.
Nowadays the abuse (wasteful, ineffective use, sometimes to the harm of patients) of sophisticated technology, especially in cardiovascular medicine, is common. That’s because medicine has lost the legacy of Proctor Harvey: the importance of basic clinical skills. Another master teacher, J. Willis Hurst, has said that unless one masters low technology (basic clinical skills) one is bound to abuse high technology. He said it here in this way:
During my training it seemed there was never quite enough time to teach basic skills properly. Today there is even less time, given the many new and competing demands of medical education, not to mention all the fluff and woo. Now as in years past practicing physicians must teach and reteach themselves these skills.
Dr. Harvey realized that fact and at one of his CME presentations announced a collaboration with engineer David C. Canfield and Roche pharmaceuticals to capture live recordings of heart sounds from hundreds of patients, put them on cassette tapes along with a set of booklets to be distributed as freebies by drug reps to interested physicians. (Dr. Harvey, true to his reputation for humility, didn’t think it beneath himself to collaborate with a drug company to make this wonderful educational resource available!).
A tribute to Dr. Harvey in the Texas Heart Institute Journal described the project:
I still have my set, pictured here.
Nowadays the abuse (wasteful, ineffective use, sometimes to the harm of patients) of sophisticated technology, especially in cardiovascular medicine, is common. That’s because medicine has lost the legacy of Proctor Harvey: the importance of basic clinical skills. Another master teacher, J. Willis Hurst, has said that unless one masters low technology (basic clinical skills) one is bound to abuse high technology. He said it here in this way:
When low technology, consisting of the history, physical examination, electrocardiogram, and chest x-ray film, is used poorly it is very likely that high technology will be used poorly. It is not possible to take a second step (high technology) without taking a well placed first step (low technology).
During my training it seemed there was never quite enough time to teach basic skills properly. Today there is even less time, given the many new and competing demands of medical education, not to mention all the fluff and woo. Now as in years past practicing physicians must teach and reteach themselves these skills.
Dr. Harvey realized that fact and at one of his CME presentations announced a collaboration with engineer David C. Canfield and Roche pharmaceuticals to capture live recordings of heart sounds from hundreds of patients, put them on cassette tapes along with a set of booklets to be distributed as freebies by drug reps to interested physicians. (Dr. Harvey, true to his reputation for humility, didn’t think it beneath himself to collaborate with a drug company to make this wonderful educational resource available!).
A tribute to Dr. Harvey in the Texas Heart Institute Journal described the project:
In recognition of the importance of his message, numerous educational grants have enabled the distribution of his writings to American medical students and physicians. Roche Pharmaceutical company alone is responsible for distributing 75,000 copies of Clinical Auscultation of the Cardiovascular System, a work that includes 10 high-fidelity audio cassettes of various heart sounds and murmurs, recorded from more than 450 patients, together with a text that describes the compendium of acoustic findings and their significance. Harvey's voice is heard throughout the cassettes as he sprinkles in his “cardiac pearls.”
I still have my set, pictured here.
Shamelessly and with no sense of “reciprocal obligation” I would like to express my thanks to Roche Laboratories for making this wonderful resource available.
For those who would like to feel morally superior by paying for this resource, last time I looked one was being sold on ebay.
Thursday, October 11, 2007
Meet the newest member of the trauma team: the reiki master!
I considered not writing about this because I’m a little late for the party. Orac has already covered it extensively and Kevin has posted a link. But the incredible story on the introduction of reiki to the University of Maryland’s Shock Trauma program deserves exposure, and the more we can give it the better. It represents infusion of pseudoscience into mainstream academic medicine (a trend I’ve followed on this blog for some time) taken to a new level. Not only is reiki among the wooiest of woo, it’s being introduced into the (up to now) pristine specialty area of emergency and trauma medicine!
Another reason for me to weigh in is that Orac, it seems, is beginning to feel a little lonely and frustrated in his battle to restore scientific integrity to academic medicine:
Yes, it must get a little lonesome. Out here in the hinterlands I can only wonder what’s going on in academic medicine these days. Is there anyone there for whom the standards of science mean anything at all? Well, there must be. There are plenty of people who teach and write about evidence based medicine. And how about the rising chorus of voices calling for the purging from academic medicine of the biased influence of drug companies? They claim to stand for scientific purity, so why do they (with the notable exception of Arnold Relman) remain silent about woo?
What conflicts of interest might be involved? It’s partly about money. Consumers demand woo and to an astonishing degree pay for it out of pocket. There’s also the ever more lucrative pipeline of government grants to promote and “research” woo. And, as Orac pointed out, there is the dinosaur phenomenon. Increasing pseudoscientific indoctrination of medical students over the last few years means changing priorities and values for the academic medical center as these students become faculty members. As the culture of the academic medical center becomes more and more steeped in woo it must be getting difficult to stand up for science. It takes courage to risk the dinosaur label.
So, for what it’s worth, I’m weighing in. As Orac points out, not only is reiki unsupported by evidence but, even worse, it’s utterly implausible. Its purported mechanisms involve a mysterious, undocumented energy which can traverse time and space provided the proper symbols are used. (That would be mighty handy if it worked. The reiki master wouldn’t even have to show up). Such credulity in academic medicine is astonishing. What’s going on?
At the University of Maryland, as well as, I suspect, other academic medical centers, there appears to be a new standard. Alternative medicine modalities, unlike pharmaceutical agents, no longer have to be evaluated with the measuring stick of science. A different standard has been adopted, one which was articulated by the University of Maryland’s own director of integrative medicine, Dr. Brian Berman, in his BMJ editorial from a few years ago. His statement is telling (emphasis mine):
The Baltimore Sun piece quotes Berman as saying patients’ reactions to reiki therapy make it “ripe for study”. And I had to laugh at this:
Well, I’ve got news for reporter Stephanie Desmon. It’ll take more than “a study” to quiet the skeptics and move reiki out of the category of extreme woo, especially considering the type of study that’s most likely to be conducted. In order to evaluate reiki’s energy based claims, and test whether it’s anything more than a relaxation technique it would have to be compared with those same techniques. It would require a control group of patients undergoing an equivalent form of relaxation, stripped of the name “reiki” and all its associated energy and religious woo. It might also be necessary to blind patients to the fact that there is a comparison group. (Suppose you told the control patients they were only receiving “reiki light” and being compared with patients getting the real thing. What would that do to the placebo effect?). Suppose reiki demonstrated a positive effect. What then? Well, reiki is an extraordinary claim. The results would need to be duplicated at other study centers, preferably those (if they exist) which have no interest in promoting woo. If a robust effect were observed repeatedly then the basic scientists would need to get to work in search of a mechanism.
Like Orac, I lament the fact that woo seems to be running rampant in academic medicine. I know there are leaders there who share my concerns. I hope they’ll comment here. I’d like to know why they remain largely silent and what, if anything, they are doing to stand against this trend in their own institutions.
Another reason for me to weigh in is that Orac, it seems, is beginning to feel a little lonely and frustrated in his battle to restore scientific integrity to academic medicine:
I'm beginning to wonder if I should just give up this quixotic battle to try to insist on evidence-based medicine in academic medical centers. I'm clearly losing the battle, and sooner or later I'll be relegated to the sidelines along with the other dinosaurs who advocate scientific medicine over unproven, non-evidence-based therapies. If I were to join the Dark Side, I could probably attract a bunch of grants to fund clinical trials to look at whatever the woo du jour is. I'd never do that, of course, if only because as a former skeptic I'd represent a truly valuable scalp for the world of non-evidence-based medicine, but I feel as though I'm increasingly alone in holding out.
Yes, it must get a little lonesome. Out here in the hinterlands I can only wonder what’s going on in academic medicine these days. Is there anyone there for whom the standards of science mean anything at all? Well, there must be. There are plenty of people who teach and write about evidence based medicine. And how about the rising chorus of voices calling for the purging from academic medicine of the biased influence of drug companies? They claim to stand for scientific purity, so why do they (with the notable exception of Arnold Relman) remain silent about woo?
What conflicts of interest might be involved? It’s partly about money. Consumers demand woo and to an astonishing degree pay for it out of pocket. There’s also the ever more lucrative pipeline of government grants to promote and “research” woo. And, as Orac pointed out, there is the dinosaur phenomenon. Increasing pseudoscientific indoctrination of medical students over the last few years means changing priorities and values for the academic medical center as these students become faculty members. As the culture of the academic medical center becomes more and more steeped in woo it must be getting difficult to stand up for science. It takes courage to risk the dinosaur label.
So, for what it’s worth, I’m weighing in. As Orac points out, not only is reiki unsupported by evidence but, even worse, it’s utterly implausible. Its purported mechanisms involve a mysterious, undocumented energy which can traverse time and space provided the proper symbols are used. (That would be mighty handy if it worked. The reiki master wouldn’t even have to show up). Such credulity in academic medicine is astonishing. What’s going on?
At the University of Maryland, as well as, I suspect, other academic medical centers, there appears to be a new standard. Alternative medicine modalities, unlike pharmaceutical agents, no longer have to be evaluated with the measuring stick of science. A different standard has been adopted, one which was articulated by the University of Maryland’s own director of integrative medicine, Dr. Brian Berman, in his BMJ editorial from a few years ago. His statement is telling (emphasis mine):
When in 1992 we developed a complementary and alternative therapy curriculum at the University of Maryland we thought it was important to present the therapies in the context of their own philosophies and models of health and illness.
The Baltimore Sun piece quotes Berman as saying patients’ reactions to reiki therapy make it “ripe for study”. And I had to laugh at this:
At Shock Trauma, a clinical research study is under way to look at the effectiveness of acupuncture on trauma patients, to see whether it lessens a patient's reliance on drugs. A reiki study could follow, which might quiet skeptics who still wonder whether its power is little more than one of suggestion.
Well, I’ve got news for reporter Stephanie Desmon. It’ll take more than “a study” to quiet the skeptics and move reiki out of the category of extreme woo, especially considering the type of study that’s most likely to be conducted. In order to evaluate reiki’s energy based claims, and test whether it’s anything more than a relaxation technique it would have to be compared with those same techniques. It would require a control group of patients undergoing an equivalent form of relaxation, stripped of the name “reiki” and all its associated energy and religious woo. It might also be necessary to blind patients to the fact that there is a comparison group. (Suppose you told the control patients they were only receiving “reiki light” and being compared with patients getting the real thing. What would that do to the placebo effect?). Suppose reiki demonstrated a positive effect. What then? Well, reiki is an extraordinary claim. The results would need to be duplicated at other study centers, preferably those (if they exist) which have no interest in promoting woo. If a robust effect were observed repeatedly then the basic scientists would need to get to work in search of a mechanism.
Like Orac, I lament the fact that woo seems to be running rampant in academic medicine. I know there are leaders there who share my concerns. I hope they’ll comment here. I’d like to know why they remain largely silent and what, if anything, they are doing to stand against this trend in their own institutions.
Wednesday, October 10, 2007
Does mainstream medicine treat the whole patient?
I have a certain hesitation in talking about the “whole patient”. As important as the notion is, in recent years it seems to have lost some of its meaning, at least in popular usage. That’s because it’s been hijacked by the boosters of alternative medicine who relentlessly accuse the mainstream of focusing on the disease and organ system at the expense of the person who has the disease. The American Medical Student Association, for example, in its promotional web page on Integrative, Complementary and Alternative Medicine, says this:
The above examples suggest that CAM fills a hole in conventional medicine. Michael Cohen describes the biomedical vs. holistic paradigms. Conventional medicine has almost perfected the biomedical approach. This system views the body as a machine and reduces the body to its components. The biomedical paradigm works well for emergency problems or diseases with one specific cause. The holistic paradigm, embraced by many CAM practitioners, sees the body as more than the sum of all of its parts. It emphasizes lifestyle changes, stress reduction and nutrition to enhance the patient's healing process. Biomedicine often falls short in treating chronic problems, while many patients with chronic problems find some relief with the holistic approach of CAM therapies.
Half truths and innuendo of this sort are pervasive in alternative medicine literature. Such “whole patient” promotions generally mislead and have the potential for great harm because they drive widespread uncritical acceptance of non-evidence based health claims.
But do they have a point? Has the mainstream become too reductionistic? The answer, in part, is that external barriers have caused a disconnect between real world practice and the teachings and ideals of mainstream medicine.
Mainstream medicine has always taught that doctors must treat the whole person. My favorite medical school mentor, the late Thomas E. Brittingham, pounded the notion into students’ heads. In his annual introductory letter to incoming third year students about to begin their medicine clerkship he wrote:
I expect you to spend time with each one of your patients after the initial workup in establishing rapport with him, obtaining an extensive personal history by indirect and easy means, and in showing the patient that you have a keen interest in him as a person and friend as well as a disease.
Dr. Brittingham wasn’t pushing some altie agenda. (There was no room for that in medical school in those days!). He was teaching the fundamentals of mainstream medicine. And despite the unfortunate fact that quackery is making its way into the curricula of MD granting schools today, the “mainstream” teachers in these schools still emphasize a comprehensive approach that treats the patient and not just the disease. One of our favorite “mainstream” bloggers, DB of DB’s Medical Rants, teaches this philosophy to students and house staff at the University of Alabama School of Medicine. For a sample of his writing on this subject check out his last two blog entries.
But, as I alluded to above, physicians encounter difficulty translating this principle into real world practice. Economic incentives force doctors to see too many patients in too little time. Perfunctory “quality” measures distract from things that really matter in patient care. The ever present threat of litigation makes the patient a potential adversary. These dehumanizing forces are significant obstacles to treating patients as whole persons.
There are no easy fixes, but at both the individual and the system level we in medicine must continually oppose these barriers to our professionalism. Without knowledge and skill in the humanistic dimensions of medicine we cannot be effective clinicians, but “integrative” medicine is not the answer. We can spend all the time in the world learning about the patient’s psychological make up, temperament and social interactions, but when we’re not grounded in the biomedical model we become incompetent.
We as doctors need to appreciate patients as people, but guess what? We also need to know about organs. And diseases. Our thought leaders do well to teach about the healing of whole persons. But they must also insist that the principles of Western science be rigorously applied to the healing of those persons.
Screening for coronary artery disease with CT calcium scoring and carotid intima media thickness: ready for prime time?
Prevention guidelines for cardiovascular disease have advocated treatment guided by the assessment of traditional risk factors. The Framingham risk score is often used for this purpose. Recently, interest has grown in the use of noninvasive imaging to assess risk in asymptomatic patients, particularly CT calcium scoring and ultrasound measurement of carotid intima media thickness (IMT), due to accumulating evidence of superior predictive power of these modalities. Risk assessment strategies have not been studied head to head for clinical outcomes. And, unfortunately, they’re not likely to be anytime soon:
This controversy bears careful examination for several reasons, not the least of which is the nagging question of how best to stem the epidemic of cardiovascular disease. It also impacts broader areas of guideline development relating to potential conflicts of interest and disagreement with other guidelines.
The new guidelines, known as the SHAPE guidelines, expand the recommendations for imaging modalities to screen patients, calling for the use of CT calcium scoring or ultrasound IMT measurement for all asymptomatic men ages 45-75 and women ages 55-75 except for those defined as very low risk. This represents a radical departure from the American College of Cardiology Foundation/American Heart Association expert consensus document, just updated this year to recommend screening only for those patients deemed to be at intermediate risk.
Publication of the guidelines in a supplement to the American Journal of Cardiology was supported by Pfizer pharmaceuticals, eliciting the usual knee-jerk cries of “conflict of interest”. (Joining the chorus were medical thought leaders Arnold Relman and Jerome Kassirer. Do those guys ever miss a chance to pounce on the drug companies?).
Dr. Steven Nissen, no stranger to controversy and hyperbole, also chimed in with:
That appears unlikely, at least for now, said Dr. Diane Bild, a medical officer at the National Heart, Lung, and Blood Institute, the logical agency to conduct such research. She said specialists there have already rejected the idea of a head-to-head study looking at how patients who received the high-tech screening fared long term, compared with those screened using more traditional methods.(Competing priorities indeed. Like the multimillion dollar promotion of quackery by the NCCAM which, like NHLBI, is also a subsidiary of the NIH. But I digress). Needless to say we won’t have the benefit of outcome based trials to guide in the assessment of patients. For the foreseeable future we must settle for lower level evidence. Does that mean we can’t make evidence based decisions? No. Evidence based medicine would have us apply clinical judgment and expertise to come up with the best synthesis of evidence we can, even when this evidence is “low level”. But when a group of experts with special interest in cardiac imaging attempted to do just that and promulgated their own guidelines a firestorm of controversy erupted.
The institute, Bild said, ``has a lot of competing priorities, and this type of study would be very expensive to conduct, and it just hasn't reached that level where we've gone forward with it."
This controversy bears careful examination for several reasons, not the least of which is the nagging question of how best to stem the epidemic of cardiovascular disease. It also impacts broader areas of guideline development relating to potential conflicts of interest and disagreement with other guidelines.
The new guidelines, known as the SHAPE guidelines, expand the recommendations for imaging modalities to screen patients, calling for the use of CT calcium scoring or ultrasound IMT measurement for all asymptomatic men ages 45-75 and women ages 55-75 except for those defined as very low risk. This represents a radical departure from the American College of Cardiology Foundation/American Heart Association expert consensus document, just updated this year to recommend screening only for those patients deemed to be at intermediate risk.
Publication of the guidelines in a supplement to the American Journal of Cardiology was supported by Pfizer pharmaceuticals, eliciting the usual knee-jerk cries of “conflict of interest”. (Joining the chorus were medical thought leaders Arnold Relman and Jerome Kassirer. Do those guys ever miss a chance to pounce on the drug companies?).
Dr. Steven Nissen, no stranger to controversy and hyperbole, also chimed in with:
This issue is not about the conservatism of the ACC and AHA, it’s about the practice of evidence-based medicine. The AEHA is a group of shameless self-promoters who have no scientific basis for their assertions.The controversy was nicely covered in a point counterpoint in the Cleveland Clinic Journal of Medicine. While I believe Nissen was wrong to say the guideline authors had no scientific basis for their assertions I have chosen not to take sides in this controversy. A reasonable clinician could take either view. All physicians involved in preventive medicine should familiarize themselves with both sides of this debate. These tests are being promoted to patients, who will come to their appointments with questions.
Monday, October 08, 2007
In defense of traditional lecture based CME
Right now I’m feeling a little morose as Bob Wachter over at Wachter’s World posts bittersweet reminders of the fact that I missed this year’s just completed UCSF Hospital Medicine Conference in San Francisco. It’s one of several high quality CME courses I repeat on a rotating basis, chock-full of updates and thoughtful presentations on this ever more complex field.
As I console myself thinking “maybe next year” I‘m a little concerned about an emerging threat to the existence of this type of meeting. There are people out there, people in high places, who would like nothing more than the end of traditional didactic CME conferences as we now know them. A rising chorus of voices calls for the end of pharmaceutical company support for CME activities, without which many conferences of the high caliber exemplified by the UCSF meeting would simply cease to exist. Others call for a virtual end of all traditional didactic CME, including Dr. Jordan Cohen, former president of the AAMC.
Wachter addresses these criticisms in the concluding paragraph of his post:
As far as "proof" of efficacy of CME goes, some critics of traditional programs insist that accreditation somehow be based on verification that each content element be correlated directly with a change in physician “behavior”. For a more lengthy rant of mine on what’s wrong with that thinking click here.
As I console myself thinking “maybe next year” I‘m a little concerned about an emerging threat to the existence of this type of meeting. There are people out there, people in high places, who would like nothing more than the end of traditional didactic CME conferences as we now know them. A rising chorus of voices calls for the end of pharmaceutical company support for CME activities, without which many conferences of the high caliber exemplified by the UCSF meeting would simply cease to exist. Others call for a virtual end of all traditional didactic CME, including Dr. Jordan Cohen, former president of the AAMC.
Wachter addresses these criticisms in the concluding paragraph of his post:
People wonder about whether CME does any good, either because content taught in big lectures tends not to stick or because many CME courses are golf-laden boondoggles. It is now Saturday morning, and 90% of our registrants are still here (and they’ve already received their CME certificates and it is gorgeous day in San Francisco – lots of excuses to play hookie). I admire their commitment, and, though I can’t prove it, I think we’re saving a few lives here in the Fairmont Hotel.No, he can’t prove it, but having attended a couple of Bob’s past conferences I suspect he’s right. I come home from courses like this, read and re-read the syllabus, look up related material and primary sources on the Internet, then return to work with batteries charged, newly inspired to try and make a difference.
As far as "proof" of efficacy of CME goes, some critics of traditional programs insist that accreditation somehow be based on verification that each content element be correlated directly with a change in physician “behavior”. For a more lengthy rant of mine on what’s wrong with that thinking click here.
New and noteworthy medical blog
One of the latest additions to the growing medical blogosphere is Wachter’s World, Robert Wachter’s new blog devoted to hospital medicine. The subtitle reads Lively and iconoclastic ruminations on hospitals, hospitalists, quality, safety and more… Having heard Wachter speak many times I have no doubt that he’ll deliver on that promise. Stop by for a dose of healthy skepticism on the hospitalist movement along with the latest buzz on hospital medicine. I’ll be linking from there often. It’ll be on my blog roll once I get around to the next update.
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