Test performance of celiac disease serologies

From JAMA:

Among adult patients presenting with abdominal symptoms in primary care or other unselected populations, IgA antitissue transglutaminase antibodies and IgA antiendomysial antibodies have high sensitivity and specificity for diagnosing celiac disease.

Should all patients with PE be checked for concomitant DVT?

According to a recent study:

Conclusions: In patients with a first episode of acute symptomatic PE, the presence of concomitant DVT is an independent predictor of death in the ensuing 3 months after diagnosis. Assessment of the thrombotic burden should assist with risk stratification of patients with acute PE.

AT A GLANCE COMMENTARY

Scientific Knowledge on the Subject
Risk stratification of patients with pulmonary embolism may identify patients at high risk of early death who may benefit from more intensive surveillance or aggressive therapy. Alternatively, patients deemed low risk for early complications might be considered for partial or complete outpatient treatment of their pulmonary embolism.

What This Study Adds to the Field
In patients with a first episode of acute symptomatic pulmonary embolism, the presence of concomitant deep vein thrombosis is an independent predictor of death in the ensuing 3 months after diagnosis. This study validates the use of the lower extremity venous compression ultrasonography for prognostication and risk stratification of patients with acute symptomatic pulmonary embolism.

Traditionally we assess risk by evaluating right ventricular function, via biomarkers and echocardiography. Assessment for concomitant DVT may have a complementary role.

The Society of Hospital Medicine urges the FDA not to approve generic Lovenox

Why??? I'm not sure I understand why, but SHM apparently does receive considerable support from Sanofi-Aventis, the maker of Lovenox.

In typical fashion, Roy Poses at Health Care Renewal is all over this. He quotes this from a recent WSJ article (my italics):

WASHINGTON—A medical researcher and two medical groups with financial ties to Sanofi-Aventis SA have asked federal regulators to hold off on approving generic forms of a Sanofi blood-thinner, the latest twist in a long running battle to market generic versions of a drug with annual sales topping $4 billion.

Citing potential patient safety issues, the head of the Society of Hospital Medicine and a medical researcher at Duke University last month sent letters to the Food and Drug Administration contending that Lovenox is too complex for any generic maker to copy fully.

Too complex to copy fully? I'm no expert in pharmacology but that's a novel argument to me. Yes, I'm sure the manufacturing process is complex. And yes, any variation in potency, particularly for an anticoagulant, especially one whose biological effect cannot be monitored readily in most hospitals, could be a critical patient safety issue. The issue of potency variation in generic drugs has been raised before, for drugs such as thyroxine. A generic drug does not have to prove efficacy and safety to get approved, only bioequivalence. For some drugs the FDA's bioequivalence standards permit variation in potency on the order of 25% form the brand name drug. This could be highly significant for drugs with a narrow therapeutic window, particularly those like Lovenox where the biologic effect cannot be easily monitored.

I don't know if that's the concern here, but it's plausible. As a member of SHM, I hope they explain.

Rapid response teams have not been convincingly shown to improve outcomes

---according to research quality data, but the effectiveness of such teams may be enhanced by using the Modified Early Warning Score (MEWS) to trigger calls.

Related post here.

What route of corticosteroids for AECOPD?

In his latest Medscape video update in pulmonary and critical care Andy Shorr discusses the ins and outs of the study I originally linked here.

Therapeutic inertia or appropriate skepticism?

Bob Morrow over at the Transparent Medical Practice blog always seems to come up with something provocative. The other day he was questioning the notion of therapeutic inertia. That's a construct that's been used to describe underutilization of evidence based therapies, often pharmacologic. Bob wonders if it's just a drug company pitch.

OK, look. It doesn't have to be either/or. It's been well documented that many life saving therapies (heart failure drugs and pharmacologic DVT prophylaxis to name a couple) are vastly underutilized, resulting in needless suffering and loss of life. Increase doctors' adherence to best practice, patients benefit and, yes, the drug companies are happy. Nothing inherently wrong there.

Was Elena Kagan a ghostwriter for ACOG?

Seems to me she all but admitted so in her confirmation hearings and here it is on You Tube. Watch and decide for yourself. The clip is a little long and you may want to skip over to 14:34 where Hatch's questioning about partial birth abortion begins. Her very round about admission to writing a document that was incorporated into ACOG's position statement on partial birth abortion, and which changed the meaning of the document, is the portion from 17:06 to 17:15.



Well, she's gonna be confirmed. But is there a prize for politicization of science? This tops anything I've seen.

The dizzies: ordinary vertigo or cerebellar infarction?

A recent review article is available here. Here's why this is important:

While most patients who present to emergency departments (ED) with isolated vertigo have benign disorders, approximately 0.7–3% have cerebellar infarction.1,2Because the symptoms of cerebellar infarction overlap substantially with benign conditions it is commonly overlooked, with a misdiagnosis rate estimated at 35%2. Patients with missed cerebellar infarction in general are at higher risk for complications, with a mortality rate possibly as high as 40%.3

Physical diagnosis is the most important diagnostic modality for cerebellar infarction. Resorting to computed tomography (CT) is insufficient because it is only 26% sensitive for acute stroke.4 In contrast, important physical signs are present in the majority of patients with cerebellar infarction.

Sodium azide toxicity

A discussion in Emergency Medicine news.

Beyond rapid response teams: track and trigger systems

Experience with RRTs has shown us that, by themselves, they don't do much good. More recent work has focused on various extensions of the concept, such as incorporating early warning scores, proactive rounds by RRTs, mandatory review of all RRT calls, etc.

Professional groups issue letter in support of Donald Berwick's nomination

It reads in part:

"Specifically, it has been suggested that Dr. Berwick is an advocate of health care rationing and that he in some way supports the government making health care decisions that should be made by patients and their doctors," the letter stated. "This misrepresentation does a disservice to Dr. Berwick, who has a long history of as a leader in promoting patient-centered care."

That paragraph, except for the part about patient-centered care, is itself a misrepresentation. Who are the signatories?

Signatories to the letter included the American Academy of Family Physicians, the American Osteopathic Association, the American College of Physicians, the National Business Coalition on Health, Wal-Mart Stores, Kaiser Foundation Health Plan, the AFL-CIO, Consumers Union, and the Alzheimer's Association.

That's simply amazing. They can't have read his article in Health Affairs or listened to his speech about the NHS. Or know about his statement that EBM may have to take a back seat. Or that he supports non-science based CAM.

But beyond all that, these supporters, as well as Berwick's detractors, miss the real point: Berwick's stand on health care is incoherent. He supports rationing, socialized medicine and radical consumerism all at the same time. Those elements are incompatible anywhere in the world, but especially in the U.S.

Twenty states so far have filed challenges to federal health care reform

Here's an update on Virginia's efforts.

More on Elena Kagan's alleged ghostwriting for ACOG

This from the corner:

The War on Science [Yuval Levin]
If you haven’t read Shannen Coffin’s piece on Elena Kagan and the partial-birth-abortion debate today, you really should. What he describes, based on newly released Clinton White House memos, is absolutely astonishing.

It seems that the most important statement in the famous position paper of the American College of Obstetricians and Gynecologists—a 1996 document that was central to the case of partial-birth-abortion defenders for the subsequent decade and played a major role in a number of court cases and political battles—was drafted not by an impartial committee of physicians, as both ACOG and the pro-abortion lobby claimed for years, but by Elena Kagan, who was then the deputy assistant to the president for domestic policy.

And Wesley J. Smith over at Secondhand Smoke reports that when confronted by Senator Hatch about it (either her ghostwriting or an associated memo):

Update: Today (7/1), Kagan was asked by Senator Hatch whether she “wrote” the memo in question. She tried to skate away, for example saying she was “aware” of it. When Hatch kept pressing, Kagan finally said, “It certainly is in my handwriting.”

I wonder what ACOG will have to say about this.

Were hundreds of St. Louis area vets exposed to HIV and other bloodborne pathogens?

That's what you'd think if you read this somewhat over-hyped report from CNN. The problem was a deviation from the protocol for cleaning dental instruments that took place for a little over a year, discovered recently in a routine inspection. It's hard to know what the risk to the affected dental patients is. It may be very low but, according to a VA spokesperson, “not zero.”

In a rare instance of responsible reporting of health issues by popular media, the local NBC affiliate KSDK offered a refreshing nuanced account, particularly in the video here.

Meanwhile congressman Russ Carnahan, seeing a great opportunity for a little political grandstanding, wrote, in letter posted at KSDK:

The men and women who have served this nation deserve the very best health care available - anything less is intolerable.

I wholeheartedly agree. But there's no evidence to support any claim that the VA has ever delivered the best care available. It's OK, good in some facilities, but it ain't the Mayo.

Stephen Barrett of Quackwatch is being sued

Read the update here. He plans to continue his work. You can contribute to his defense here.

It's that time of year again

Does the July phenomenon really exist in teaching hospitals? Studies through the years have been contradictory. A post at Kevin MD points to a new study that suggests it does. This is despite the fact that house staff are supposed to be much better supervised these days.

Octreotide for sulfonylurea induced hypoglycemia

This underutilized antidote is the subject of another fascinating toxicology essay by Dr. James R. Roberts.

Inconsistency in health care decisions at NHS---driven by politics?

It would seem so according to this post at Secondhand Smoke:

So, some seriously ill patients might get rationed out of a stay in hospital, or receive less than optimal care due to a nursing shortage, as money will be diverted to older women so they can give birth past their time? I’m sorry, but that is just nuts.

Marilyn Monroe's chest x-rays

---auctioned for $45,000.

Via Boing Boing.

What will health care reform mean?

Maybe this, according to David B. Nash:

Next, we can relinquish our slavish adherence to the notion of professional autonomy.

Not an ounce of skepticism here.