If you’re experiencing STEMI-----

Do not pass go, do not collect $200.00 and do not stop in the ER. Go straight to the CCU or cath lab. That’s the message of an observational study published in the October issue of Heart. Patients with ST segment elevation MI who were shipped directly to the CCU or cath lab were admitted earlier (by 48 min) and had a lower mortality than those who were admitted via the ER.

Mortality for ER patients was 8.6% for ER patients and 4.9% for those directly transported to the cath lab or CCU. By my math that means that the benefits of direct transport are RRR 43%, ARR 3.7%, NNT 27. In terms of relative risk, mortality rose by 0.9% per minute of delay, translating into 54% per hour.

This is one more piece of evidence that ER delays are lethal (see this recent post citing evidence that, across the board wait time is associated with 20% mortality per hour for all patients admitted) and that by some folks’ definition there are lots of emergency department homicides out there.

So how do you know if you’re having a STEMI (as opposed to NSTEMI or non cardiac chest pain)? Well, you don’t, initially. But the paramedics can tell from their pre-hospital ECG.

That raises another point. If you experience chest pain DO NOT come to the ER in a private car. Call an ambulance. Transport by private car was the first mistake in the Illinois heart attack death recently ruled a homicide.

Neuropathic pain management

Tricks of the trade reviewed in CCJM.

Abraham Flexner’s legacy---NEJM authors miss the point

The New England Journal of Medicine (NEJM) launched a series of articles on medical education with this piece on the legacy of Abraham Flexner. The 1910 Flexner Report, a comprehensive and highly critical evaluation of medical schools in the United States and Canada, helped spur a revolution in medical education, setting a blueprint for the twentieth century.

The authors, discussing how medical schools today might measure up in Flexner’s view, cite poor training in procedural skills, compromised teaching due to competing research and economic agendas and a lack of attention to professionalism and ethics. These are valid concerns. But conspicuously absent form the discussion was mention of a major problem plaguing medical training today about which we were warned in the Flexner Report: the rampant teaching and promotion of quackery and pseudoscience in medical school. Almost a year ago I pointed out that medical schools had backslidden from the recommendations of the Flexner Report as evidenced by their promotion of homeopathy, Reiki, Ayurvedic medicine and innumerable other unscientific claims.

As I reviewed the Flexner Report in its entirety this weekend I caught myself wondering whether the NEJM authors even read it at all. Flexner’s concern for the sanctity of science, practically an obsession, is evident throughout. If the authors read the report they must have skipped chapter 10 which warns strongly against what medical educators today call “integrative medicine.” The chapter is titled “The Medical Sects”, in reference to groups of teachers and practitioners who advocated for various non-scientific claims, referred to by Flexner as “dogmas.” Chapter 10 opens questioning the integration of dogma with science thusly: “Is it essential that we should now conclude a treaty of peace, by which the reduced number of medical schools should be pro-rated as to recognize dissenters on an equitable basis? The proposition raises at once as to whether in this era of scientific medicine, sectarian medicine is logically defensible; as to whether, while it exists, separate standards, fixed by the conditions under which it can survive, are justifiable.” Flexner’s emphatic answer, bolstered by eloquent arguments in the succeeding pages, is no.

Medical schools are showing increasing disregard for the principles of science. If the NEJM in its forthcoming series of reviews on medical education ignores this pernicious trend it will have done the profession a great disservice.

Orac exposes the “pharma shill” gambit

It’s a favorite fallacy for the alt-med crowd. It’s been used on me a time or two.

NCCAM study site tour---Part VI

The Wellness and Longevity Center of Louisiana is one of the NCCAM chelation study sites. According to the web page the Center’s vision is “…to prevent and treat chronic disabilitating diseases such as obesity, high blood pressure, Parkinson and Alzheimer’s disease, chronic fatigue, fibromyalgia, heart attack and stroke by integrative medicine which combines standard medical practice with alternative and complementary medicine…” (That’s right, it really says disabilitating).

The chelation therapy information page states “Every single study of the use of Chelation Therapy for Atherosclerosis that has ever been published, without exception, has demonstrated an improvement in blood flow and symptoms.” What journals have these folks been reading? And this: “Adverse editorial comment to the contrary lacks evidence and stems primarily from physicians with a vested interest in catheterization and surgery.” Yeah. I’m reminded of a guy I saw one time on TV promoting his perpetual motion machine, claiming that the fuel industry was suppressing the science behind his invention. Then there’s this claim: “Scientific studies have proven that blood flow increases after Chelation Therapy.” Too bad they left out the citation. I’d like to look that one up.

Aren’t researchers supposed to be unbiased?

Obesity state by state; process and outcome in Arkansas

Report cards are out. They contain no real surprises but there was a curious finding in my state. Although Arkansas, as expected, is one of our more obese states (13th in the nation) it received one of the best report cards----one of only two states to earn a B (no state got an A). Why this gap between process and outcome? Arkansas’s vigorous anti-obesity initiatives (and its good report card) can be attributed largely to the efforts of Gov. Mike Huckabee, who believes the measures will just take time.

But the battle of the bulge in Arkansas may be difficult. Arkansas clearly is in the obesity belt. It’s a culture war. It may not be as bad here in my neck of the woods, the culturally transformed rapidly emerging retail capital of the world, as it is in more rural pockets of the state as suggested in this county by county analysis.

Huckabee’s personal story is noteworthy. A few years ago our morbidly obese governor, barely able to make it to the top of the capitol building stairs, lived in fear that he would be met there, breathless, by media, and be unable to give an interview. When he turned up with type 2 diabetes his doctors said, in effect, “diet or die.” Thereupon the former Baptist minister “got religion” about his health and embarked on a comprehensive program of nutrition and exercise, shedding over 100 pounds. Later he decided to share his success and put his state on a diet.

That may strike some people as ironic. Huckabee’s a Republican. He’s a conservative. But he doesn’t fit the mold of libertarian conservatives who complain about the “fat police.” In the minds of some who think his health initiatives too intrusive Huckabee is chief of the fat police. A Little Rock restaurant owner told the New York Times concerning Huckabee’s weight loss “it’s fine for him….But he ain’t got to make the whole state lose weight.”

According to the New York Times the Arkansas anti-obesity measures, some of which exceed federal requirements, include exercise breaks for state employees, strict guidelines for school lunches, and the reporting of BMI on school report cards. But perhaps more remarkable than all that is the example set by the governor. His speaking engagements and writings (such as Quit Digging Your Grave With A Knife And Fork) recount many testimonials, and he has completed the Little Rock marathon.

It’s nice to see my state get a good grade in something. Will it translate into better health outcomes? I remain to be convinced.

House takes on the antivaccination crowd

And Orac provides the transcript. This is too funny.

Cardiac pacemakers demystified

A review in Clinical Cardiology.

E. coli in perspective

Folks in the popular media don’t seem to know, or care, that the often fatal E. coli (E. coli 0157:H7) causing the current outbreak of hemorrhagic diarrhea, sometimes complicated by hemolytic uremic syndrome, is completely different from the ubiquitous E. coli that inhabits the colon of each of us and commonly causes infection when it winds up someplace is shouldn’t (urinary tract or bloodstream).

If you don’t think this is confusing to people try telling your patient (when 0157:H7 is hot news) with a mild UTI “Oh, it’s just E. coli” and note the reaction. This pathogen should be referred to in media reports as “E. coli 0157:H7”, not “E. coli.”

The ubiquitous form of E. coli is not an intestinal pathogen. Six less common forms do not normally inhabit the human GI tract and are in fact enteric pathogens. These latter forms have little in common except for a propensity to cause intestinal disease, with distinctly different pathogenic mechanisms. Only one of these six forms, enterohemorrhagic E. coli, causes extraintestinal disease (hemolytic uremic syndrome). These are principally of the 0157:H7 variety, the subject of the current news stories.

The only other one of the six forms of enterovirulent E. coli of importance in the developed world is enterotoxigenic E. coli, believed to be the principal etiologic agent of traveler’s diarrhea. The toxin elaborated by this organism increases the production of cyclic AMP and GMP resulting in a secretory (non-inflammatory) diarrhea.

The other forms of enterovirulent E.coli are enteropathogenic E. coli, enteroinvasive E. coli, enteroaggregative E. coli and diffusely adherent E. coli.

Summary and update on the E. coli 0157:H7 outbreak

Today’s issue of Morbidity and Mortality Weekly Report has the latest info as well as links to CDC and FDA updates. This should be a helpful resource.

As an aside, I wish the popular media would bother to distinguish between E. coli 0157:H7 and the common and not so deadly forms of E. coli. Very confusing to the lay public.

Medscape Roundtable Discussion concerning pharmacists on the health care team

For the latest Medscape Roundtable Discussion we were asked “How Can Physicians Stay Current on Prescription Drugs?” Surprisingly the readers’ responses were overwhelmingly “Why didn’t anyone mention the role of pharmacists?” True enough we didn’t mention it. I can only speak for myself here. I regard pharmacists as an important part of the team, and a resource I utilize extensively. But we weren’t asked that. We were asked how we keep up with information in pharmacology, not how we delegate to other team members. Clinical pharmacists perform important tasks, safeguard against inappropriate orders and intercept errors. That doesn’t absolve physicians of the responsibility to expand and update their knowledge, utilizing the most authoritative primary sources available.

On the healthcare team the buck stops with me, the physician. If I’m doing my job I should know the “whole picture” of my patient’s problem better than anyone else including the pharmacist. If the pharmacist makes a recommendation on drug therapy I must understand the rationale. If the pharmacist happens to be wrong I must know how to proceed. The pharmacist has an essential role in patient care. At the same time physicians must independently stay knowledgeable in the field by regularly reviewing authoritative sources of information in prescribing as well as related information in physiology and evidence based medicine.

NCCAM chelation study site tour---Part V

Innovative Medicine in Lafayette, IN is a chelation study site. The clinic offers chelation therapy, hyperbaric oxygen, “advanced thyroid replacement”, chiropractic, acupuncture and “multiple powerful intravenous therapies.” Concerning thyroid treatment, the clinic claims to “easily help people who suspect that they are hypothyroid but have been told their thyroid test is normal.” They also claim that chronic neurologic diseases of any type usually respond to hyperbaric oxygen.

Well, it’s innovative all right. A little too innovative for me, but apparently not for government funded “research.”



Background: part I, part II, part III, part IV

Emergency department homicide???

A patient’s death in a Lake County Illinois emergency room was recently ruled a homicide by a coroner’s jury, finding “gross deviations from the standard of care” which prolonged the patient’s wait time. If a death related to ER wait time is a homicide then how many other undocumented emergency department homicides are occurring on a regular basis? Quite a few, perhaps, according to this study from the Medical Journal of Australia. The death rate went up 20% per hour of wait time in this study, independent of diagnosis or urgency of the patient’s presentation.

Medication safety resource

Institute for Safe Medication Practices.

Features safety alerts, news letters, a message board and more.

The TRIP database

Here’s some good news for EBM enthusiasts. I was a frequent user of this resource until it went paid access a few years ago. Today I’m pleased to learn, via Sumer’s Radiology Site, that TRIP is once again free. It looks as though, in the interim, they’ve made substantial improvements to an already useful site. The search engine is more precise and they’ve added a medical images section. Very nice.

Tygecycline

Reviewed in Baylor University Medical Center Proceedings.

I previously reviewed it here.

Controversies in the treatment of hypothyroidism

Although it ought to be straightforward, several controversies regarding treatment of hypothyroidism have arisen in the past decade. These are covered in a review in the July/August 2006 issue of The Endocrinologist.

What is the optimal TSH target during treatment? 0.4 to 2.5 mIU/L.

Is T4 + T3 replacement superior to T4 replacement alone? No.

Is brand L-thyroxine superior to generic? Not according to the best available evidence.

Should subclinical hypothyroidism be treated? Probably not if the TSH is less than 10 mIU/L.

Geriatric rounding tips

Some rules for geriatric patient safety from Today’s Hospitalist.


Review medications regularly. Watch out for such hospital booby traps as automatic stops, omissions in transfer from ICU to ward, changing renal function requiring dose adjustments, etc. Assess gait, fall risk, functional status and skin problems early and regularly. Get physical therapy involved early.

The tobacco industry helped launch television’s golden age

This week free Camels go to Veterans Hospitals North Little Rock Arkansas and Omaha Nebraska……….

That bit of irony was spoken by Anne Jeffries hawking Camel cigarettes at the close of a 1950s episode of Topper. Video files of this and other cigarette commercials (including John Wayne shilling Camels, and years later urging viewers to fight cancer) are archived at TV Party.

Television was dependent on the tobacco industry in the early years. A blockbuster network show typically had only one or two sponsors, and the sponsor was often a tobacco product. As the medium matured it became less dependent, and tobacco commercials were finally banned on January 2 1971.

Clostridium difficile update

This review in Baylor University Medical Center Proceedings focuses on the history of our experience with this pathogen, pathophysiology, diagnosis and treatment. Newly appreciated risk factors are profiled including proton pump inhibitors, chemotherapy and post pyloric tube feeding.