Wednesday, November 29, 2006

FDA alert on methadone

They have an alert out concerning respiratory depression and QT prolongation. Via Journal Watch.

But, hey, this isn’t all that new. You read it here first! Let me add my bias here. I would go beyond what the FDA says, and consider methadone just as I would cardiac drugs known to prolong the QT interval and cause torsade. That is, I would get an ECG at the start of therapy and periodically thereafter. I would pay meticulous attention to interacting drugs and liver function. I would keep an eye on the patient’s potassium and magnesium. Is this overkill? Maybe. But don’t forget, as I mentioned in the post referenced above, that the Center for Education and Research on Therapeutics, a center of expertise on drug induced cardiac arrhythmias, has placed methadone in the highest risk category of QT prolonging drugs.

Libby Zion---the rest of the story

The recent Washington Post piece about the Libby Zion case (Via Kevin MD) might leave some readers on the edges of their seats! After mentioning all the speculations concerning some mysterious infection and the family’s rejection of that theory, the possible adverse drug effects and the disputed finding of cocaine in her system, what’s the final answer? What did the patient actually have? Is this one of those puzzlers? Do we get the answer next week?

Although not recognized or denoted as such in those days (rarely mentioned in the world’s literature before 1986 based on my quick Pub Med survey) Libby Zion had the serotonin syndrome.

Tuesday, November 28, 2006

Grand Rounds Vol. 3, No. 10

Welcome to Grand Rounds Vol. 3 No. 10! Many thanks to all who contributed, and special thanks to Nick for all the hard work organizing this event and for walking me, a first time host, through the process. Thanks also to blogger for sparing me one of their many unscheduled outages this particular day!

It’s trendy nowadays at traditional academic Grand Rounds for the speaker to disclose any potential conflicts of interest. Here are mine. I have no financial ties with drug or device companies. A Zithromax clock, a hand me down from National Nurses Day, graces one wall of my office. I have attended about four drug company lunches in the past year. That’s about the extent of any blandishments from Evil Pharma.

Although under appreciated, non-financial conflicts, perceived or real, are just as important as the financial kind. We all have them. I, for example, am a) a Christian, b) a member of the vast right wing conspiracy and c) a staunch adherent to the principles of science. (Note that a is not inexorably linked to b or in opposition to c). I’ve become opinionated and crotchety in middle age and have many biases. But not to worry, dear readers! I’ve done my darndest to keep those biases out of this edition of Grand Rounds. To that lofty end there will be no editor’s choice, best of the best, or best of the rest! Everything included here gets equal billing in hopes that this carnival will be a good time for all.

I’ve restricted my editorial prerogative to adding a running commentary, stream-of-consciousness style, to provide some structure to this incredibly diverse collection of links and perhaps liven things up a bit. I’ll sneak a few opinions in here and there, but you’ll know them when you see them. Well, enough of the preliminaries. There’s some heavy duty blogging to get to, so let’s rock and roll.

Mother Jones suffered through pandemic flu not long ago. Well, an inservice on pandemic flu, anyway. On her day off, no less.

Enjoying the eye candy on the wards? Dr. Derlet of Rural Pediatrics has some sobering advice for health care professionals on what not to wear. Strutting too much of your stuff may turn heads but it lowers patients’ confidence. And that’s evidence based! Worse yet, the credentialers are watching how you dress. Just ask our favorite credentialer Rita over at MSSPNexus blog! Yikes!

Are there moral absolutes? Is there a free lunch? Rohin, author or The Daily Rhino, finds himself in an existential crisis as he ponders these weighty questions after making the transition from student to doctor. It’s tough trying to balance medical student idealism against the allurement of Big Pharma freebies.

Wandering Visitor has some friendly infection control advice in Don’t Get Raunchy with Mr. Open Sores. Trouble is, Mr. Open Sores isn’t likely to tell you he has a problem. Nuff said. While we’re on the subject of taking medical advice, Dr. Nic at Shoe Money Tonight explains why it’s easier said than done.

I can remember being abused as a medical student and house officer, but I thought such abuse went out like the dark ages. Not so according to Anthony Rudine, blogging on the Medscape Med Students blog. In reading his post (recommended by Medscape editor Christine Wiebe) it appears that the grand tradition of med student abuse, like fraternity hazing, is alive and well. Isn’t it about time for a kinder, gentler medical curriculum?

Another Medscape student blogger (again, thanks for the tip, Christine) Ali Tabatabaey, reflects on one year of blogging on his first blogiversary (or is it blogoversary?). Congrats and keep up the good work, Ali!

A wise medical sage once told me that when it comes to being sued there are two types of doctors: those who have been and those who will be. It’s like the Sword of Damocles! Medical student Vitum Medicinus and his classmates are being lectured about the ever present threat. He shares his concerns here.

Ectopia what??? Ectopia cordis---a rare developmental anomaly in which the heart is situated outside the chest. Dr. Anonymous writes about a recent case.

NHS Blog Doctor speaks against physician assisted suicide and euthanasia, sparked by the recent story of another assisted suicide at Switzerland’s Dignitas institute.

RDoctor posts an interview with Emergiblog author Kim, exploring a wide range of nursing and blogging issues. Particularly interesting were her comments on arrogant physicians (they’re becoming an anomaly, she thinks), hospital case managers (nurses and social workers who facilitate discharge planning and troubleshoot financial, social and administrative problems in patient care) and the nurse’s role in facilitating ED patient flow.

And now that the kids have returned to school from Thanksgiving break The Fitness Fixer has some tips for ergonomically smart book carrying.

Now to reflect on matters of the psyche. Sigmund Freud started as a neuroanatomist, and maybe the behavioral sciences are coming full circle. Psychologist blogger Dr. Deborah Serani writes of a recently discovered gene (a variant of the serotonin transporter) which is associated with mental illness and enlargement of a group of thalamic nuclei known as the pulvinar, a deep region of the brain associated with emotions. Now there are those who might say this is all just pseudoscience. I’m waiting for them to demonstrate a neuroanatomic locus for engrams. But I digress. I think this discovery is pretty cool.

By the way, Dr. Serani has been a technical advisor for “Law and Order: Special Victims Unit.” (My wife is addicted to that show). I’ll be browsing her blog with interest in the near future. There’s a post on the psychological aspects of “If I Did It” and other interesting stuff.

Tempering our enthusiasm for bench-to-bedside correlation in the behavioral sciences, Health Business Blog reminds us that we have a ways to go, particularly in the area of pediatric psychiatric diagnosis.

Are we really what we eat? On some level, yes. The Wellness Tips blogger takes it literally and recommends organic food. Healthy? I’m sure, but rather spartan, it seems to me. I like the advice given in the poem Desiderata: Beyond a wholesome discipline, be gentle with yourself.

Oh, those perverse incentives! Everybody’s talking about conflicts of interest these days. The popular buzz in medicine is almost exclusively focused on the conflicts that arise from the influence of Big Pharma. But Number 1 Dinosaur has a thing or two to say about another conflict: ordering unnecessary tests to pad the bottom line. Dino’s insightful (or should I say inciteful---read what his commenters had to say!) and entertaining post and its update bemoan the decline of basic clinical skills and the use of technology as a substitute for clinical reasoning.

Now for your fix of hardcore clinical content---

Unbounded Medicine presents a case, along with some interesting images, of Tetralogy of Fallot.

Corpus Callosum cites a small study from the American Journal of Medicine suggesting that baclofen is as good as diazepam for the treatment of alcohol withdrawal. It’s not enough evidence to change current practice. At the risk of sounding trite, more studies are needed.

Inside Surgery has a nice series of posts on seizures in the ICU. Here’s Part 7, the most recent post. You can access the rest from the main page.

Dr. Kenneth Trofatter of Fruit of the Womb presents a case of cervical incompetence and discusses the possible role of insulin resistance syndromes.

And for patients and families---

Dr. Auerbach, blogger of Medicine for the Outdoors, offers some tips for the safe buying and handling of fresh produce and Cancer Treatment and Survivorship has some timely advice this holiday season on traveling with supplemental oxygen.

Now for some exciting news about the medical blogosphere. Dr. Ves Dimov, Clinical Assistant Professor at Cleveland Clinic Lerner College of Medicine and author of the Clinical Cases and Images blog reports back from the American Society of Nephrology’s Renal Week 2006 where one of his poster presentations (which you can view on the blog entry) dealt with medical blogging as an educational tool for students and house staff. The medical blog is emerging as an educational vehicle in no small part due to the efforts of Dr. Dimov. Nice work!

Second opinions come in many forms. Some patients go doctor hopping. Grunt Doc saw a patient the other night who went drugstore hopping.

Our “From Bench to Blogosphere” segment features docinthemachine with some original research he recently presented before the American Association of Gynecological Laparoscopists on a little appreciated variant of Asherman’s Syndrome along with discussion about potential applicability to the treatment of other gynecological disorders.

Kim at Emergiblog discusses the progression of signs and symptoms along the road to burnout and what to do about it. She’s been there and done that.

Tundra PA describes a case of steam bath boil. The culture came back MRSA. Given that it was sensitive to TMP-SMX it’s almost certainly one of the new community associated strains (CA-MRSA). Looks like it’s made its way up to the villages of Southwest Alaska!

When less is more: Insureblog comments on a study suggesting that more intense care doesn’t always help patients with chronic illness and wonders how patients would respond if the results were widely known.

Amy at Diabetes Mine writes about the bright future of continuous glucose monitoring systems. Unfortunately she missed out as a study subject for Abbott’s latest device because of skin sensitivity to the adhesive patch!

The folks at Anxiety, Addiction and Depression Treatments have posted some information on drug-grapefruit interactions. It’s not confined to psychiatry drugs, by the way. Felodipine, which I take for high blood pressure, is noted for the interaction. Although grapefruit might give me a bigger bang for my buck by exaggerating the effects of the medicine (it inhibits gut mucosal CYP34A, doubling systemic absorption) it’s too risky. Don’t try it. Always ask your doctor or pharmacist about food-drug interactions!

Susan Palwick, volunteer ED chaplain, describes a particularly difficult shift with several very ill children in Peds Night. A chaplain never knows what a distressed family might want---prayer, affirmation, maybe just someone who will listen.

Well, that’s about it for this edition of Grand Rounds. Don’t miss next week’s edition at The Antidote.

Friday, November 24, 2006

Medication adherence and mortality after MI

Patients with myocardial infarction frequently discontinue evidence based medications (aspirin, statins, beta blockers) soon after discharge. According to this study such patients have an increased mortality.

The current fragmentation of ambulatory care will only make this problem worse. Hospitalists are often the ones who start such medications, and therefore have a significant role in secondary prevention. This study suggests a need for more aggressive patient education and case management at discharge.

New antibiotics for gram positive infections

This CCJM review provides useful perspectives on the use of vancomycin and the newer antibiotics linezolid, quinupristin-dalfopristin, daptomycin and tygecycline. Note: since this paper’s publication daptomycin has been approved for S. aureus bacteremia including MRSA. Related post here.

Tuesday, November 21, 2006

Here we go again on ER crowding. It’s not us against them.

A while back I wrote a series of posts criticizing the Institute of Medicine’s proposals to remedy ER crowding, and their incredible statement that hospitals can fix the problem, and eliminate diversion and patient boarding just by being more efficient. I thought I made it clear that I was only criticizing the IOM, but then Grunt Doc weighed in with this:

Second, what's so magic about the ED? Only the ED and OB have rubber walls and are infinitely flexible, to try our best to care for every patient ho needs our help. Except, see, our walls really aren't made of magic rubber, we can't just snap our fingers and make more rooms, beds, monitors or nurses appear. Every patient who should be admitted to the hospital but isn't is a) not getting the specialized nursing care available on the ward where they belong and b) is taking up a bed in the ED we need to see then next 1-12 patients. The linked commenters in the first paragraph give a 'suck-it-up ED' subtext that rankles.

That wasn’t what was intended, so I clarified here. Grunt Doc graciously relented (in my comments). But the finger pointing by some of the ED types in his comments suggested an “us against them” attitude. My clarification post made these points:

Wait a minute---nobody’s blaming the ER here. This isn’t “us against them.” The emergency department is part of the hospital. Their problems are the hospital’s problems, and vice versa. If the ER is overtaxed the entire hospital feels the strain due to extensive overlap and sharing of resources. Concerning whether patients who needed boarding should be boarded in the ER or on the wards I said: There’s nothing written in stone in my mind that such boarding has to take place in the ER unless the patient needs cardiac monitoring.

Well, I figured I’d made that pretty clear until commenter Ryan (evidently an ED provider) weighed in with this straw man: My question to you is why are my halls better then your halls? And then: I ask again why floor nurses are different from the ED nurses.

Look, it’s not a matter of my nurses vs. your nurses, or my hallways vs. yours. I never said it was! Why do ED types seem to want to frame it in adversarial terms? Hospitalists are “on board” with this issue. We’re on the same side. Really. One of the thought leaders at the Southern regional hospitalist meeting in New Orleans a week or two ago said that the Society of Hospital Medicine is committed to helping improve ER throughput. (I wasn’t there but I browsed the syllabus one of my colleagues brought back. Sorry I missed you DB. We’ll hook up one of these days).

Compression only resuscitation triples survival

Data from Phoenix Emergency Medical Services presented at the American Heart Association meetings this month showed improved survival after implementation of the compression only method. Evidence favoring compression only has been mounting and the folks at the University of Arizona Sarver Heart Center have been beating this drum for quite a while. Although the 2005 AHA Guidelines moved in the right direction they didn’t go far enough---they’re years behind the science, and the science is compelling. Tuscon rescuers are using the same protocols. In 2006 if you’re going to have a cardiac arrest, your chances are best if you have it in Arizona.

You read it first on here over a year ago. I’ll repeat the caveats I posted then:

1) For witnessed VT or VF in the health care setting immediate defibrillation remains the initial modality (remember the electrical phase!).


2) This new thinking does NOT apply to pediatric codes or other arrests of suspected respiratory origin. Rescue breathing remains a higher priority in those situations.

Thursday, November 16, 2006

Acupuncture anatomy goes mainstream!

I figured they pretty well knew the layout of the human body when the classic edition of Gray’s Anatomy was published in 1918. Sure, there have been many subsequent editions with updates in terminology, embryology and cell biology but the depiction of “gross” features hasn’t really changed much. But after a tip from the Health Fraud List pointed me to this Georgetown University Medical Center site I began to wonder if they shouldn't rewrite the anatomy books. Georgetown apparently thinks the “anatomy of acupuncture” should be incorporated into gross anatomy.

Until recently complementary and alternative medicine (CAM) courses in medical school have been offered mainly as electives. Georgetown wants to take it a step further and “Aim CAM curriculum at all students through required courses.” Plans for integration of woo into the basic science courses read like fodder for late night infomercials: psychoneuroimmunology, stress hormone modulation through relaxation, imagery and breathing regulation and more.

Wednesday, November 15, 2006

More on Rate MDs

I posted a little over a week ago about Rate MDs, an open access, free for all consumer website where anyone can anonymously say just about anything about a physician. Then I heard via Clinical Cases and Images that the author of MSSP Nexus Blog opined thusly: “This site, or others like it that follow, will no doubt begin to be checked as part of a routine credentialing process, so the implications to healthcare providers are considerable.”

Well, that’s scary----opening up the credentialing process to last week’s disgruntled drug seeker or patients of this ilk. Heck, why not just invite ‘em to attend the credentials committee? By any reasonable standard the evidentiary quality of sites like this is somewhere below garbage in this blogger’s opinion.

Sunday, November 12, 2006

The latest hygienic measure for type 2 diabetes

We’ve long been aware of two important hygienic (non-pharmacologic) interventions for DM-2, those being diet and exercise. Now evidence is emerging for another: get enough sleep.

Thursday, November 09, 2006

Woo pitching med students say they’re evidence based

AMSA is kicking off its annual PharmFree Day with much fanfare and this statement: “AMSA members believe in providing the highest quality care through evidence-based medicine.”

Really? What about their belief that traditional Chinese medicine (TCM) has “proven helpful” for cancer, infectious disease, heart disease and AIDS (Complementary Therapies Primer, page 5)? Or that “By activating the electrical circuitry of the body which conduct qi along the meridians, qigong is able to harness the body’s own healing powers (page 7)? And does therapeutic touch really help asthma (page 9)?

While AMSA wants a rigorous evidentiary standard for the products of Evil Pharma the herbs seem to get a free pass (pp 12, 13). Thus cayenne is good for “strengthening metabolism” (were these kids sleeping through biochem?) and preventing colds. Echinacea is recommended for respiratory infections, connective tissue diseases and multiple sclerosis and ephedra “must be used with caution.” (How does one use ephedra with caution, exactly?).

And how about that four day fast? Seems it thins blood, leads to better oxygenation and improves immunity (page 18). Finally, don’t forget good old chelation for everything from cancer to spider bites (page 20).


So, on November 16, go PharmFree and consider the alternatives.

Wednesday, November 08, 2006

Patch Adams rants to Vanderbilt medical students against psychiatry, government

Adams declared to the students “Our government is worse than Hitler” and that today’s medical students would live to see the extinction of the human race. He advised them not to prescribe psychiatric drugs and said depression is a “selfish act.”

Read the rest and laugh. Via VUMC Reporter.

Friday, November 03, 2006

Is VA health care the best?

Time magazine thinks it is. Time writer Douglas Waller extols the VA’s electronic medical record, cites this study which showed lower mortality rates among VA patients, and hints that it may be an argument for government run health care.

The problem with such thinking is that the study, published in the April issue of Medical Care, is the comparison group: Medicare Advantage, another government run health plan loaded down with the added baggage of managed care.

Nevertheless it will be spun in opposition to the free market.

Thursday, November 02, 2006

Despite the brouhaha over drug company free lunches

A silent majority of health care professionals still favor them according to this Medscape poll.

Doctor rating with an attitude

Kevin MD points us to this article about doctors’ organizations upset over the increasingly popular web site Rate MDs. The organizations believe comments on the site are defamatory and are pressuring Rate MDs to remove them. Two comments have been removed from the site but other requests by doctors’ groups have been ignored.

Perhaps the best known and most reputable physician rating service is Health Grades, a no nonsense, “just the facts” site that requires paid access to view physician ratings. Rate MDs is different. It’s a free wheeling, let it all hang out message board style web site with open access to all. Although users have the option to create an account, it’s not necessary in order to post or view, and commenters do not have to give any identifying information.

According to the FAQ page although patient comments are reviewed for appropriateness they are posted “immediately.” The site owners imply they may delete inappropriate comments, but here’s a sampling of what did not get deleted:

does breast exam for no reason

this doctor is a bully

this man is a joke

I fully blame this doctor for my aunt’s death

--just a creep!

trained his staff to lie---------

Don’t go to ---------they will kill you in there


On a more positive note:
-----and he is cute!!!!

More FAQs----

If you’re a doctor and don’t like the ratings: “The fact of the matter is that this site is only going to get more popular as time goes by, so the best way of dealing with it is to use it rather than try to fight it.” (In other words, get over it).

I’m a doctor. How do I get my name removed from your site? “The short answer is, you don’t.”

And if you’re thinking about legal action against the web site, don’t bother, say the owners (FAQ # 18).

Have a look. Are you rated?