Monday, January 31, 2011

More evidence regarding the impact of industry supported CME on treatment choices

According to a report in The Journal of Clinical Hypertension, physicians participating in the STOP Hypertension NOW! CME program were more likely than non-participants to select appropriate treatment regimens in various case scenarios. The literature about the impact of industry support of CME on the appropriateness of practice is relatively new. Research reports that have come out so far are favorable.

More at Policy and Medicine.

Look alike, sound alike diagnoses

Here's an interesting post at Academic Life in Emergency Medicine suggesting the potential for cognitive errors due to imprecision in our use of terminology.

New MRSA guidelines

The first ever from IDSA. Here's the free full text guideline.

The guideline nails down some of the specifics on questions we might equivocate on or defer to our ID consultants, such as when and how to use adjunctive antibiotics, vancomycin versus daptomycin versus linezolid versus telavancin, and when and how to decolonize.

Of special note, the recommendation for MRSA pneumonia states:

For hospitalized patients with severe community-acquired pneumonia defined by any one of the following: (1) a requirement for intensive care unit (ICU) admission, (2) necrotizing or cavitary infiltrates, or (3) empyema, empirical therapy for MRSA is recommended pending sputum and/or blood culture results (A-III).

That makes perfect sense, but calls for a change in the CAP guidelines which, for patients admitted to ICU, recommend double coverage e.g. with a third generation cephalosporin and a respiratory fluoroquinolone. With the new MRSA guidelines incorporated, a respiratory MRSA drug such as vancomycin will be added to the mix. (Would this result in triple therapy or would it supplant the beta lactam?).

Is the EMR slowing you down? Hire a scribe!

More and more health care systems are hiring scribes to help deal with the unintended consequences of the EMR. From the St. Louis Post Dispatch:

After the switch to computer records, emergency departments have reported a loss in productivity. At DePaul, patient wait times initially increased 28 percent and patient satisfaction declined 40 percent despite additional staffing, said Dr. Stephen Larson, director of the hospital's emergency department. St. John's Mercy also reported a peak in wait times.
While both hospitals have seen wait times drop as doctors get past the learning curve, the emergency physicians group at DePaul decided to begin the scribe program in December "to allow us to continue to add to our gains," Larson said.

Related content from Health Care Renewal.

Sunday, January 30, 2011

Impressionist David Frye dead at 76

David Frye was perhaps was best known for his impersonations of Richard Nixon. His Watergate satire LP “Richard Nixon: A Fantasy” is available in full as free streaming audio at the Internet Archive.

Friday, January 28, 2011

Blood ammonia and lactate levels after cardiac arrest as predictors of outcome

Therapeutic hypothermia has rendered neurologic examination virtually useless for the determination of prognosis in the first 72 hours after cardiac arrest. Can biomarkers help? Here's a paper describing high predictive value for lactate and ammonia levels. Not something to change practice yet, but definitely something to watch.

Catamenial pneumothorax

Catamenial pneumothorax has become increasingly recognized. Here is an update.

Imbalance in reporting about the pharmaceutical industry

Just as some attorneys specialize in suing doctors some journalists and many bloggers (you know who they are) major in digging up dirt on the pharmaceutical industry.

A recent opinion piece in the American Journal of Gastroenterology calls for fairness. The piece was, I do believe, written by our very own MD Whistleblower.

More on the piece from Policy and Medicine.

We have doctors in the House

---and more of them as a result of the 2010 elections. Doctors who have experienced the realities of patient care appreciate the complexities if individual clinical decision making and have a heightened skepticism of models based on “central planning.”

Here's a rundown on the new doctors joining the House and Senate.

Thursday, January 27, 2011

Cardiologist who presented data on misread echos fired by her institution

Here's the report on her presentation.

Here's the report on her firing.

Officials at the hospital where she was fired said it was unrelated. Uh huh.

Myositis review

This review is organized around the various clinical and serologic phenotypes of myositis.

Small troponin bumps within the normal range

---are associated with increased odds of ACS:

Of 17 713 patient visits, 2162 met inclusion and exclusion criteria. There were 1872 patient visits with 2 troponin results and 1312 with 2 CK-MB results. Patient visits with increasing troponin had increased odds of ACS compared with those with stable troponin levels (odds ratio, 3.6; 95% confidence interval, 1.4-9.2). Changing CK-MB and decreasing troponin were not associated with increased odds of ACS.

Wednesday, January 26, 2011

Colistin resistance in carbapenem resistant Klebsiella shows up in Detroit

Colistin has been our go to drug for carbapenem resistant bacteria, so this is very concerning.

Should red cell transfusion be unbundled from the sepsis resuscitation bundle?

The sepsis resuscitation bundle consists of those interventions recommended in the Surviving Sepsis Campaign guidelines which are applicable to the first six hours of treatment. They include timely administration of appropriate antibiotics and early goal directed therapy. The early goal directed therapy protocol calls for a transfusion target of 30% hematocrit if the SVC oxygen saturation is below 70% after the initial CVP and blood pressure goals are met.

Controversy surrounding EGDT is based on the fact that, although it has been well validated as a bundle of interventions, the individual components have not been well studied separately. A recent paper in the Indian Journal of Critical Care Medicine addresses (or, I should say, purports to address) whether RBC transfusion belongs in the bundle:

Background: The optimal hemoglobin level and transfusion threshold in patients with septic shock treated with an early, goal oriented approach to resuscitation remains unknown. Aims: To assess the impact of packed red blood cell (PRBC) transfusion on clinically relevant outcomes in patients with septic shock treated with early goal directed therapy (EGDT).

The study found a non-statistically significant trend toward increased mortality in the transfusion group, and a statistically significant increase in length of ICU stay, ventilator time and hospital stay in the transfusion group.

Conclusions: In this retrospective cohort study, transfusion of PRBCs was associated with worsened clinical outcomes in patients with septic shock treated with EGDT.

What that language implies is that transfusion as part of EGDT is associated with bad outcomes. That's not what the study showed at all, but it takes a close look at the body of the paper to realize that. The authors were not explicit about it, but what the study actually looked at was the effect of transfusion over the first 24 hours of treatment. But EGDT, as anyone familiar with the concept knows, ends in 6 hours. Long before the landmark Rivers trial which established the value of goal directed hemodynamic resuscitation in the first 6 hours, we knew, from several studies in the 1980s, that later implementation of such resuscitation was not helpful, in fact potentially harmful.

What this study did demonstrate, really all it demonstrated, was something else we've known for a long time---for almost 12 years in fact---which is that a liberal transfusion trigger (HCT 30) in critically ill patients is in general (without respect to time) not beneficial.

So at what time points did the patients in the Indian Journal of Critical Care Medicine study get their transfusions? Again, the authors aren't explicit but from the details of the paper you can glean that most of the transfusion was not in the six hours of EGDT. How can we know that? First of all, according to the EGDT protocol, transfusion does not even begin until after fluid resuscitation titrated to a CVP of 8, followed by pressor administration to a MAP of 65 and subsequent measurement of the SVC O2 saturation. This figure from the paper says it all. Note that in the transfusion group it took, on average, over 9 hours to achieve the CVP goal of 8! That means that for most patients, transfusion was given either outside the 6 hour period that defines EGDT or in violation of the EGDT protocol.

Finally, even though baseline characteristics of the two groups were similar the transfusion group is defined by the EGDT protocol as a group of patients doing poorly during the course of resuscitation.

In short, while this study addresses the general issue of transfusion in critically ill patients, it proves nothing about transfusion as a component of EGDT.

Tuesday, January 25, 2011

Estimation of jugular venous pressure and examination of jugular venous pulse

Three recent posts at Renal Fellow Network deal with this topic.

This one deals with some of the basics and focuses on measurement of jugular venous pressure.

This one reviews the literature and concludes that the test characteristics of jugular venous examination are poor (keeping in mind, of course that test characteristics can never be better than the skill of the examiner).

Speaking of which, this post shows four fascinating videos from 1957 which show us how far our skills have devolved.

The growing attitude that old fashioned physical examination is becoming useless is a self fulfilling prophecy: as clinical skills devolve the test characteristics of physical exam maneuvers will get worse.

It's a sad state of affairs when not even internists know what Internal Medicine is

Retired Doc with more on “What is Internal Medicine?”

Status epilepticus

Nice summary at Academic Life in Emergency Medicine.

Primary source here.

Money and medicine---a lecture by Thomas Stossel

HT to Policy and Medicine.

Monday, January 24, 2011

Is deviation from practice guidelines a crime?

Well, maybe in the minds of the “central planners.”

Dr. Wes points out the stupidity here.

See related posts from me and Dr. Rich.

Jack LaLanne dead at 96

The video below must have been from the 50s or 60s. Jack was decades ahead of the rest of us.

So the guvment's getting into drug R&D?

I'm not at all optimistic about this.

Via Gateway Pundit.

HCAP guideline adherence associated with increased mortality?

Apparently according to recent findings. A Tweet from DB, a hard-nosed guideline skeptic, alerted me to this paper in Lancet Infectious Diseases:

The American Thoracic Society and Infectious Diseases Society of America provide guidelines for management of hospital-acquired, ventilator-associated, and health-care-associated pneumonias, consisting of empirical antibiotic regimens for patients at risk for multidrug-resistant pathogens. We aimed to improve compliance with these guidelines and assess outcomes...
303 patients at risk for multidrug-resistant pneumonia were treated empirically, and prescribed treatment was guideline compliant in 129 patients and non-compliant in 174 patients. 44 (34%) patients died before 28 days in the compliance group and 35 (20%) died in the non-compliance group...
Kaplan-Meier estimated survival to 28 days was 65% in the compliance group and 79% in the non-compliance group (p=0·0042). This difference persisted after adjustment for severity of illness...
Compliance failures included non-use of dual treatment for Gram-negative pathogens in 154 patients and absence of meticillin-resistant Staphylococcus aureus coverage in 24 patients. For patients in whom pathogens were subsequently identified, empirical treatment was active in 79 (81%) of 97 of patients receiving compliant therapy compared with 109 (85%) of 128 of patients receiving non-compliant therapy.

According to this commentary in Medscape the main difference between the adherent and the non-adherent regimens was the use of double gram-negative coverage in the former. This often involved the use of an aminoglycoside as the secondary gram negative drug. Since the study findings showed little difference in pathogen coverage between the two groups, the difference in outcomes must have been driven by adverse effects of treatment. Aminoglycoside toxicity is well known and may have been a driving factor.

Why do the IDSA HCAP guidelines advocate double gram-negative coverage for patients deemed to be at high risk for drug resistant pathogens? In looking at the primary sources cited in the guidelines it appears that it was based on these two papers. They were not comparative antibiotic trials, so this is not high level evidence. Both papers involved VAP patients at large academic medical centers---the sickest of the sick. What the guideline authors drew from these studies were antimicrobial sensitivity patterns, from which it was determined that double gram-negative coverage was needed to cover the spectrum. In one study it was a carbapenem plus a quinolone; in the other it was a carbapenem plus amikacin. It would appear that the rationale was spectrum coverage rather than synergy or concerns about emerging resistance. The spectrum may not need to be so broad in patients with HCAP in community hospitals. To the guideline authors' credit, they emphasize that antibiotic selection must be guided by local antibiograms.

So are the guidelines flawed? It's possible that the evidence they draw on is not generalizable, as it comes from a sicker population of patients than those encountered in many community hospitals. The HCAP guidelines are around 6 years old. An update is due to be published about a year from now. What should clinicians do in the meantime? First I think we have to acknowledge, based on multiple lines of evidence, that the underlying principle behind the guidelines is valid: the initial therapy needs to be sufficiently broad to cover the likely spectrum. In other words get it right, with sufficiently broad spectrum antibiotics, from the get go (ie, in the ER). That said, clinical judgment and knowledge of the local antibiogram may alter the treatment regimen. How so? I wouldn't venture to make a definitive statement but in some cases a regimen of single agent gram-negative coverage alongside single agent MRSA coverage might be considered. At the very least the clinician should ask, given the local resistance pattern, what if anything a quinolone or and aminoglycoside would add to the spectrum already covered by a carbapenem.

Are there lessons here concerning guidelines in general? Yes and no. This study is a reminder that guidelines are not mandates, nor are they a measuring stick for EBM. Moreover, although guidelines aim to adhere to the EBM principle of “best evidence”, that evidence is often of low quality as has recently been demonstrated for the IDSA guidelines. On the other hand this study is an anomaly, going against the overwhelming body of other evidence showing that guideline adherence leads to improved outcomes. Maybe the HCAP guideline is an exception. For example, regarding the guidelines for community acquired pneumonia (CAP) every study I know of links adherence to better outcomes [1] [2] [3] [4] [5] [6] [7].

Tuberculous pleural disease

Here's a nice review from Current Opinion in Pulmonary Medicine.

A few key points and pearls:

...a complex septated pattern on sonography in lymphocyte-rich exudative pleural effusions was 96% specific and had a positive predictive value (PPV) of 94% for a tubercular cause.
A study by Kim et al. [23] of 106 patients with tuberculous pleuritis revealed that lung parenchymal lesions were detected in 91 cases (i.e. 86%) using chest CT scan...
Usually 90–95% of the pleural fluid cells are T-lymphocytes, the remainder being B-lymphocytes...
Eosinophilia more than 10% and mesothelial cells more than 5% in the pleural fluid are also traditionally felt to make TB an unlikely diagnosis...

Adenosine deaminase levels in the pleural fluid play a major role in diagnosis. Adenosine deaminase was not discussed in this review, as there was another article in the same issue devoted to that, which I will post separately.

Pleural biopsy and thoracoscopy were discussed.

What about nucleic acid amplification tests? Currently available test has been approved by the FDA for diagnostic testing of pleural fluid. There is considerable experience with the tests, however. They can be useful because they have high specificity. They are not recommended for ruling out tuberculous pleural disease, however, because of low sensititivity.

Scoring systems combining clinical and pleural fluid data have shown promise.

Saturday, January 22, 2011

Will my dogs make me sick?

The article from Emerging Infectious Diseases is not on line yet, but I ran across this from Bloomberg Business Week:

You might want to think twice before snuggling in bed at night with Fido or Fluffy.
According to a report published in the February issue of the public health journal Emerging Infectious Diseases, seemingly healthy pets can carry parasites, bacteria or viruses that cause mild to life-threatening illness in people...
Even though disease transmission is low in comparison to how many people sleep with their pets -- more than half of all U.S. pet owners -- Chomel said the risks are still there.
"Having a pet in the bed is not a good idea," he said.

Stop. I don't wanna hear it.

Does test taking facilitate more effective learning?

The New York Times reports research suggesting that it does, and is more effective than the concept maps (elaborative learning) currently in vogue:

...students who read a passage, then took a test asking them to recall what they had read, retained about 50 percent more of the information a week later than students who used two other methods.

The tests, it's important to note, were old fashioned essay tests. The investigators called it retrieval practice.

When I was a third year medical student one of our resident mentors understood this. He told us we would have no trouble passing the upcoming exam if for each clinical topic encountered we would write the material down in our own words and study as if preparing to give a mini-lecture on the topic.

Primary source from Science.

HT to Instapundit.

Friday, January 21, 2011

Those dumb, greedy bone crunchers

My orthopedic surgery colleagues sometimes facetiously say to me “You're the real doctor. I'm just a dumb bone cruncher.” We know that isn't really true. Well, most of us. Billy Rubin, an ID doc and part time hospitalist, rants:

One of the central ironies of American medicine is that several of these very fine students, whom many a prestigious Internal Medicine or General Surgery program would be delighted to train, will have spent an inordinate amount of time and energy learning medicine only to forget the vast majority of it during their residencies. You see, the orthopedic surgery residency takes people who have doctorates in medicine and turn them into doctors of bones! They spend their residency years un-learning all the medicine that their expensive education gave them in the first place. My experience is that most orthopods can't even deal with the simplest postoperative medical issue for their patients, and they tend to punt problems to a medical consult that even a third-year medical student could handle competently.

He goes on about how much money they make and how greedy they are, assuring the reader all the while that he bears no economic envy.

Happy Hospitalist largely agrees with him. He noted:

There is no reason for a hospitalist to follow a patient with stable medical issues any more than there is for an orthoapedic patient [sic] to follow my CHF patient for stable osteoarthritis.

That's clever, but I would offer this caution. Many patients on the ortho service are there for elective surgery, eg knee replacement. Our medico-legal culture these days tends to be very unforgiving when nasty post-operative complications such as MI and PE follow elective surgery. So it's not hard for me to understand why the orthopedic surgeon would want to have a hospitalist “on board.” Now, that must be distinguished from having the hospitalist take over the details of post-operative care as I'll explain below.

But back to Dr. Rubin's post. He relates a story of a lady who was not seen by her attending surgeon for eleven days in the hospital following a joint replacement.

Although his rant will contain a ring of truth for many hospitalists (especially his illustration of the “I've done my procedure, I'm outta here” mentality) I take issue in part. First, to borrow a popular saying today, he might have turned down the vitriol. His post is titled “Billy Rubin To Orthopods: Man Up or Drop Dead.”

Second, from what I have observed Dr. Rubin's criticisms might apply equally to many specialties, at least the procedural specialties. I see no reason to single out the orthopods. (Or could it be that I'm just very lucky to work with a uniquely good group of orthopedic surgeons?).

Yes, it's true that in the procedural specialties there's too great a focus on the procedure and not enough attention to general patient care. But I've been in practice a long time and I don't think it's always been that way. In fact, it was once the opposite. Post operative care with all its little details, from the TPN to the pain management to the discharge instructions, was once a source of great professional pride for the surgeons. This has changed in recent years and I think I know one of the reasons. I think (OK, I'm about to drop a bomb here) the hospitlaist movement is largely to blame. We, thanks in part to our very presence in the hospital and to our poorly defined and ill conceived comanagement initiatives, have been the enablers.

Let's look for a moment at comanagement. Bob Wachter, writing in his Google Knol (yeah, remember those things?) about hospital medicine, had this to say about comanagement:

Post-operatively, in addition to obvious issues like wound care and pain control, patients often need their diabetes or blood pressure managed, their infections treated, and a variety of strategies implemented to increase their probability of recovery (for example, prevention of post-operative blood clots).
Just as the primary care doctor’s busy office practice meant that he or she could not be physically present to coordinate hospital care, so to [sic] does the surgeon’s busy operating room schedule. Moreover, although surgeons have superb training in the technical aspects of their trade and the pre- and postoperative surgical aspects of care, their training (and often their interests) are less focused on medical management. So once hospitalists were present in the majority of U.S. hospitals, the stage was set for hospitalists to expand their patient population to “co-management” of surgical patients.

Yes, and the stage was also set for the procedural specialties to become disengaged from the details of patient care. It's the law of unintended consequences. Having hospitalists hang around the wards so surgeons can spend more time in the OR (one of the original selling points for comanagement) just made economic sense to some. To the more skeptical among us it opened the door to a whole host of problems in patient care. And to the really cynical folks like Dr. Rubin it just fueled the surgeons' greed.

Hospitalist leader Eric Siegal, interviewed in The Hospitalist, took the contrarian view and noted this about comanagement (my emphasis):

So, little by little, co-management evolved from a strategy for managing only the most complicated cases to a routine practice at many institutions—even when hospitalists actually added little to a patient’s care. For example, a “patient with a stable GI bleed who needs little more than an endoscopy I would argue does not need co-management,” Dr. Siegal says. In fact, he points out in his paper, inserting the hospitalist into the situation above might work against the patient if it delays the gastroenterologist’s involvement and the endoscopy. A gastroenterologist who assumes a hospitalist is running the show may pay insufficient attention to the patient, Dr. Siegal writes.

Back in the day the surgeons proudly took ownership of perioperative care. When I was a medical student I recall a surgical house officer telling me “I may not be the world's greatest diagnostician but I know how to take care of post-operative patients.” When I first showed up in town to begin a traditional IM practice many years ago I was given a tour of the hospital. We arrived on the surgical floor and I was introduced to one of the surgeons. This is my floor, he informed me.

The orthopods are not dumb. They haven't forgotten what they learned in medical school any more than the rest of us. Hospitalist leaders came along and promoted this new idea of comanagement. “We'll look after the patients on the surgical wards so you guys can spend more time in the OR doing what you do best,” we told them. And, guess what? They bought it. Under today's economic pressures how else would you expect them to respond? Is is any surprise things have deteriorated to where they are now?

Drug induced hyponatremia

Discussion at Renal Fellow Network with link to a review.

Should you hold or continue ACEIs and ARBs prior to surgery?

It turns out that evidence is mixed and opinion is divided. Discussion at Renal Fellow Network.

Transcutaneous pacing and the problem of false capture

I believe this problem is under appreciated in the use of the external (transcutaneous) pacer. Ineffective pacemaker discharges create an electrical artifact. As the deflection returns to baseline it resembles a QRS complex (false capture). To complicate things further, the skeletal muscle twitch caused by the pacer's impulse may be mistaken for a pulse. Here's a post from EMS 12-Lead which illustrates a case of false capture and provides some troubleshooting tips. Here's another post (from the 12-Lead ECG blog) which adds another troubleshooting tip: using capnography!

The EMR dogma

---holds that the electronic medical record improves patient safety and facilitates quality. This has been shoved down doctor's throats despite the lack of supporting evidence. Here's an insightful post from MD Whistleblower who nails it with these comments:

Clearly, EMR is in transition. I place it on the 40 yard line, a long way from a touch down or field goal position...
I am not a Luddite who opposes EMR on ideological grounds. I believe, and have written, that once perfected, it will accomplish its mission. My quarrel is with those who already claim that the goal line has been reached, or is in sight. I also believe that many of these systems were designed by folks who don’t practice medicine or understand physicians’ needs. What’s good for billers and coders may not help physicians in exam rooms with living, breathing patients.

Yes, we're on the 40 yard line. We have a long, long way to go before we overcome the unintended consequences and develop robust quality and safety tools.

Thursday, January 20, 2011

What's the level of evidence behind the IDSA practice guidelines?

Unfortunately not as good as you might think:

Results In the 41 analyzed guidelines, 4218 individual recommendations were found and tabulated. Fourteen percent of the recommendations were classified as level I, 31% as level II, and 55% as level III evidence. Among class A recommendations (good evidence for support), 23% were level I (greater than or equal to 1 randomized controlled trial) and 37% were based on expert opinion only (level III). Updated guidelines expanded the absolute number of individual recommendations substantially. However, few were due to a sizable increase in level I evidence; most additional recommendations had level II and III evidence.

But EBM doesn't insist on RCTs. It only calls for the best available evidence. In a field like ID RCTs are often unavailable and may not be ethical.

Conclusions More than half of the current recommendations of the IDSA are based on level III evidence only. Until more data from well-designed controlled clinical trials become available, physicians should remain cautious when using current guidelines as the sole source guiding patient care decisions.

Via Hospital Medicine Quick Hits.

Wednesday, January 19, 2011


Via Health Care Renewal.

Whither Obamacare?

From around the blogosphere:

A majority of states now have suits against it.

65% of doctors think health care would deteriorate under Obamacare according to the latest poll.

Other polls show support for repeal.

200 economists sent a letter supporting repeal.

Now that it has been repealed in the House will it even make it to the Senate floor? There are rules that could be invoked.

ER work up for first time seizure

There's a nice summary posted at Academic Life in Emergency Medicine. It is based on guidelines and a very recent review out of Emergency Medicine Clinics of North America. The post accurately covers the main points of the review.

Post bariatric surgery suicide

---reflects a long suspected association but has been poorly studied. From a new study in the American Journal of Medicine:

Medical data following bariatric operations performed on Pennsylvania residents between January 1, 1995 and December 31, 2004 were obtained from the Pennsylvania Health Care Cost and Containment Council. Matching mortality data from suicides between September 1, 1996 and December 28, 2006 were obtained from the Division of Vital Records, Pennsylvania State Department of Health.

There were 31 suicides (16,683 operations), for an overall rate of 6.6/10,000; 13.7 per 10,000 among men and 5.2 per 10,000 among women. About 30% of suicides occurred within the first 2 years following surgery, with almost 70% occurring within 3 years. For every age category except the youngest, suicide rates were higher among men than women. Age- and sex-matched suicide rates in the US population (ages 35-64 years) were 2.4/10,000 (men) and 0.7/10,000 (women).

Compared with age and sex-matched suicide rates in the US, there was a substantial excess of suicides among all patients who had bariatric surgery in Pennsylvania during a 10-year period. These data document a need to develop more comprehensive longer-term surveillance and follow-up methods in order to evaluate factors associated with postbariatric surgery suicide.

Medical apps for smart phones

Check out this entry at Academic Life in Emergency Medicine. Several are listed in the body of the post and plenty more in the comment thread.

Emergency treatment of hyponatremia

This post and podcast from the EMCrit blog aims to make emergency decision making simple. Simple maybe, but solid. Well worth a listen.

The devaluation of the internist---from specialist to primary care provider

No one I can recall from my training days went into Internal Medicine to “do primary care.” You went into Internal Medicine because you wanted to be a specialist. The field has devolved considerably since then. DB and Carolyn Poplin opine.

Tuesday, January 18, 2011

Why the profession's adherence to evidence based medicine can never be measured

In today's conversation about health care reform evidence based medicine (sometimes referred to by popular synonyms such as “best practice” or “what works versus what doesn't work”) is a hot topic. Politicians and policy experts believe doctors' adherence to this ideal is poor. Some advocate for policy measures designed to improve on this situation. Such thinking is based on the faulty premise that adherence to EBM can be measured. Experts cite guideline usage or, worse yet, performance metrics as measurable processes to assess EBM adherence.

Such thinking is profoundly simplistic and naïve.

EBM adherence cannot be measured. Why? The answer is to be found in the definition of EBM as put forth by its founders. They wrote it here. David Sackett said it again here. Read and listen carefully. EBM has three key elements. If any of these three is missing, it's not EBM:

The individual patient
The patient's unique attributes, biological, social, psychological. This includes attitudes, preferences and external circumstances.

Individual clinical expertise
That means the expertise, in diagnosis and treatment, of the individual doc who's delivering the care.

The best external evidence

The first two elements are not measurable. The third element seems measurable in concept but in actual practice is inscrutably hard. Sometimes it's elusive. Guidelines and performance measures are not valid surrogates for best external evidence.

It's way, way more complicated.

More on not so benign early repolarization

Recall that I blogged on this topic here. Recently Clinical Correlations posted this discussion. It appears that early repolarization changes in the inferior leads carry the highest risk of sudden cardiac death. The association between cardiac death and anterolateral lead early repolarization is weaker. There is no consensus or guideline as to how to manage asymptomatic individuals with the inferior lead early repolarization pattern.

Surgeons are not pilots and patients are not airplanes

“Please let the analogy end” says Skeptical Scalpel in posts here and here.

Monday, January 17, 2011

Who's your employer?

Here's an interesting quote appearing at the bottom of a post from Life in the Fast Lane:

“You are the patient’s advocate. You work for no one else.”
Clifton K. Meador

Dr. Meador is a Professor of Medicine at Vanderbilt University. I'm not sure but I suspect it came from this book which he wrote years ago. Even more relevant today than it was back then!

Non-guideline based ICD implantation

---occurred at a rate of about 25% in this study. Deviations had to do largely with timing: not waiting as long post MI as the guidelines recommend, and not waiting to see if patients still met criteria after a period of optimal medical therapy.

Acute liver failure associated with dronedarone (Multaq)

The “Dear Doctor” letter.

More details from the drug company.

FDA warning, Steve Nissen weighs in.

Friday, January 14, 2011

Poor R wave progression in the electrocardiogram in diabetes

---may be an early indication of diabetic cardiomyopathy.

Can we prevent ventilator associated pneumonia?

Ventilator associated pneumonia has been characterized by some policy experts as a “never event.” But despite the popularity of “VAP bundles” their effectiveness in preventing ventilator associated pneumonia is not clear. New data from a study in Clinical Infectious Diseases may shed some light. The study looked at the ling-term effect of a bundle of eight interventions:

Results. Baseline and intervention VAP rates were 22.6 and 13.1 total VAP episodes over total mechanical ventilation duration per 1000 ventilation-days, respectively, and 26.1 and 14.9 first VAP episodes over mechanical ventilation duration at VAP or hospital discharge per 1000 procedure-days, respectively (P less than .001). VAP rates decreased by 43% in both statistical analyses and remained significant after adjustment for confounders (Cox adjusted hazard ratio, 0.58; 95% confidence interval, 0.46–0.72; P less than .001). Daily VAP hazard rates on ventilation days 5, 10, and 15 were 2.6%, 3.5%, and 3.4%, respectively, during the baseline period and 1.4%, 2.3%, and 2%, respectively, during the intervention period.
Conclusion. Our preventive program produced sustained VAP rate decreases in the long term. However, VAP rates remained substantial despite high compliance with preventive measures, suggesting that eliminating VAP in the intensive care unit may be an unrealistic goal.

An earlier paper describing the pilot study listed the interventions:

1) comply with hand-hygiene; 2) comply with correct glove-and-gown use; 3) maintain adequate endotracheal cuff pressure; 4) ensure bed backrest elevation less than30° (in the absence of medical contraindication); 5) avoid ventilator-circuit disconnection and perform tracheal aspiration only when necessary; 6) provide good oral hygiene; 7) use an orogastric rather than a nasogastric tube; and 8) avoid gastric overdistension.

What are the lessons from this and previous studies on VAP? First, although VAP can be reduced, a substantial incidence remains despite aggressive measures. Based on the evidence we have so far there is no warrant for classifying VAP as a medical error or a never event. Second, there are multiple combinations of interventions which could be bundled. Since evidence for individual interventions is limited, the optimal bundle is not known.

Thursday, January 13, 2011

The number of states suing to stop Obamacare

---is now up to 25.

Via Instapundit.

What is the effectiveness of the AED in hospitalized patients?

A recent study in JAMA found:

Results Of 11 695 patients, 9616 (82.2%) had nonshockable rhythms (asystole and pulseless electrical activity) and 2079 (17.8%) had shockable rhythms (ventricular fibrillation and pulseless ventricular tachycardia). AEDs were used in 4515 patients (38.6%). Overall, 2117 patients (18.1%) survived to hospital discharge. Within the entire study population, AED use was associated with a lower rate of survival after in-hospital cardiac arrest compared with no AED use (16.3% vs 19.3%; adjusted rate ratio [RR], 0.85; 95% confidence interval [CI], 0.78-0.92; P less than .001).

This result was driven by patients with non-shockable rhythms. For patients with shockable rhythms there was no difference between AED and non-AED use.

An editorial in the same issue cited prior research with similar results and also noted studies showing more and longer interruptions of compressions when the AED is used as opposed to a manual defibrillator and concluded:

As the authors suggest, it appears that routine AED use cannot be recommended in the in-hospital setting...


---web atlas resource.

Another cause of pseudohyperkalemia

Making a fist during phlebotomy.

Wednesday, January 12, 2011

Time to take the American Medical Student Association (AMSA) to task again

I've blogged many times about the AMSA and its promotion of quackery in medical education. I did so with the thought that the best way I could fight quackademic medicine was to expose it. The extreme woo promoted by AMSA made great fodder for ridicule with little elaboration or work required on my part. It pretty well spoke for itself. I gave it a rest a year or so ago though because I thought I had covered most everything and, after they redesigned their web site the woo became much harder to find. They've either toned it down or buried it deep, deep within their site, I thought. Whatever the case I even wondered if I deserved a little credit for AMSA's woo assuming a lower profile.

After reading Orac's recent update and doing a little digging of my own it turns out that AMSA's still pushing the same old woo; they've just adopted a smoother approach and made it a little more palatable. I thought this would be a good time to post my own update.

First a look at Orac's post. It was prompted by AMSA's upcoming International Integrative Medicine Day (the link is from last year's event). Here's a sample from this year's event:

During the Happy Hour, clinical services to be offered include: Acupuncture, Massage, Chiropractic, Energy Healing, and more.
Classes from 4:15 - 11PM include Ambient Music, Yoga, Meditation and Qi Gong, Community Drumming for Wellness, and Salsa Class & Dancing.

This page documents AMSA's role as a partner in the event, alongside a virtual parade of stars of woo.

Now for a recap on some of the material I've posted before and what I dug up today. It seems that the promotion of woo on the AMSA web site is organized around four campaigns: ICAM, EDCAM, HUMED (I'll explain about those three in a moment) and, more recently, a strong and rising interest in naturopathic medicine.

ICAM stands for AMSA's initiative for integrative, complementary and alternative medicine. In its present form it's basically a repository for various woo promoting documents and links. There you'll find, for example, the CAM Pocket Handbook. It contains promotional, credulous statements about acupuncture, Ayurvedic Medicine and, yes, that woo of all woo, homeopathy, describing it as “very cost effective over the long term.” Polarity therapy, Reiki, reflexology get similar credulous treatment.

HUMED stands for humanistic medicine. The old HUMED page redirects here. A current focus seems to be student wellness and self care but again, it's another repository of woo. For example, there's the Complementary Therapies Primer which contains the same old woo, including a particularly non-critical view of reflexology, along with several types of woo I had never heard of. It also claims that large doses of vitamin E are useful in Parkinson's disease. You'll also find the claim that fasting eliminates pesticides and other toxins from the body. Finally, it says chelation therapy (no, I'm not making this up) is beneficial for arthritis, scleroderma, lupus and spider bites.

EDCAM, which stands for Educational Development for Complementary and Alternative Medicine, is a completed project in which the AMSA Foundation, with funding from the NIH and the NCCAM, introduced and developed CAM, including a lot of woo, in the curricula of 14 medical schools. In an article published in the journal Academic Medicine (which none of the aforementioned organizations will likely want you to read) reviewers from Baylor found the teaching material to be devoid of supporting evidence and concluded:

By tolerating this situation, health professions schools are not meeting their educational and ethical obligations to learners, patients, or society.

I blogged about the whole thing here.

Finally there's the Naturopathic Medicine page, which says that the AMSA aims for collaboration with naturopathic medical students. This page has lots of dubious links and a recommended reading list of promotional material for all sorts of woo. I won't go to the trouble of fisking it here. This post is getting long and the list speaks for itself.

In my blogging career I've gotten into many discussions about the rise of quackademic medicine. A common theme is speculation as to why, and it seems inscrutably hard to determine for some. Sure, the money behind it is one element. But after following quackademic medicine closely for several years (although it was a few years later that I coined the term, my first post about it was here) I am of the opinion that the AMSA has been a major driver, perhaps the major driver of this trend.

Eleanor Roosevelt's tuberculosis

This Medscape article chronicles Eleanor Roosevelt's illness. Eleanor Roosevelt carried a diagnosis of aplastic anemia for two years, for which she received multiple transfusions and was given prednisone. It was not until two weeks before her death that her final bone marrow specimen grew out tuberculosis.

When I was a medical student the story was circulating around that Eleanor Roosevelt had died of miliary Tb that had long been misdiagnosed as aplastic anemia, but I didn't know if it was really true. The Medscape piece, which draws on information from Roosevelt's medical record, is the best account I've found.

This was a popular topic when I was a medical student. One of our most esteemed and feared Internal Medicine mentors, Thomas E. Brittingham, always encouraged skepticism toward accepting any diagnosis of an incurable disease, particularly if an infectious cause could be sought. He was particularly negative about diagnosing patients with idiopathic inflammatory diseases and treating them with immunosuppressives and was fond of presenting patients long diagnosed with such diseases as systemic lupus, Wegener's granulomatosis or inflammatory bowel disease and ultimately discovered to have tuberculosis or a fungal disease.

Renal manifestations or rheumatoid arthritis

Via Renal Fellow Network.

Tuesday, January 11, 2011

JAMA commentary proposes adding emotion and passion to scientific articles

Some medical journals such as JAMA and the Annals of Internal Medicine occasionally publish emotional articles that convey the human side of medicine. Many journals, NEJM notable among them, also weigh in on political issues. Appropriately, the emotional and political content is clearly compartmentalized from the scientific content. A commentary writer in the December 8 issue of JAMA seems to think that may not be a good thing:

What if science were presented in the same passionate, emotional style as in those accounts of personal experiences that moved the physician who wrote them? Instead of requiring a science article to have the standard introductory, methods, results, and discussion sections with a certain number of words and a certain number of tables, science articles should perhaps include cartoons, pictures, or emotional images that contain meaning and require the use of both the right and left brain. Perhaps permitting the personal would not degrade the scientific process but rather increase the likelihood that the information contained in the journals would actually be read, absorbed, and used.

Apparently the author, Robert H. Brook, MD, of the Rand Corporation, thinks the dispassionate language of scientific papers is too dry to be useful. Earlier in the paper he wrote:

...scientific articles are written in a manner that, in many instances, adopts a bland, somnolent tone. The language has no passion, conveys no emotion. The words stimulate no visual image. Physicians have been taught to present their science in what is called a “flat manner”: let the facts speak for themselves.

That's what Dr. Brook thinks is wrong with scientific articles. What nonsense. Steve Milloy, in his book Junk Science Judo, wrote, on page 46:

...keep the slow, steady ho-hum scientific method in mind. Boring? Sure. Tedious? You betcha. Slow and deliberative? Be grateful.

Dr. Brook seems to start with a faulty premise: that the purpose of a research article is to persuade. Wrong. Persuasion is an art which almost by definition introduces fallacies. That's what Aristotle laid out in his textbook on Rhetoric. He described the three elements of persuasion: ethos, pathos and logos. Scientific papers confine themselves to logos. Bring in the other two elements and you introduce all sorts of emotionally driven fallacies such as appeals to fear, passion and belief. More than that, allowing an author's emotions and passions in a scientific paper would deliberately permit and even introduce bias.

It's true that doctors need to be persuaded to incorporate the best evidence into practice. But please, not in original scientific papers. There are other appropriate places and methods to accomplish that. Imagine if clinical investigators passionately spun the results right in their own research articles! It would make a joke of scientific journals.

As an aside I note this little gem of an observation Brook makes midway through the paper:

However, the world of communication has changed. Today, the Internet, Facebook, LinkedIn, and all sorts of connected devices allow humans to immediately share photographs, emotions, thoughts, and passions. It is difficult to imagine a young physician growing up in this communication environment, trying to focus his or her brain on science studies that seem to be written in a language as foreign as medieval English would be to modern inhabitants of the British Isles.

Here Brook comes dangerously close to saying that social media has dumbed down science education for a whole generation of students! Could it be? I'm not sayin'. U r free 2 read n 2 that what u want 2 LOL.

Rescue therapy for refractory hypoxemia in ARDS

I recently highlighted this as one of the top issues in hospital medicine for last year. Although I missed this review in JAMA from December 8 when preparing that post, many of the same points were made. The review is in a Johns Hopkins Grand Rounds format and the full text (which is unfortunately behind access control) is worth reading in its entirety. It provides a nice overview of ARDS.

ARDS is hypoxemic respiratory failure. Despite this, as is pointed out in the article, only a small minority, on the order of 10-15%, of the mortality is attributable to refractory hypoxemia. The remainder is due to failure of other organs.

General supportive care is the mainstay of management of ARDS with only one specific modality known from research evidence to decrease mortality: low tidal volume ventilation. Multiple other modalities which in studies have not been shown to decrease overall mortality but can improve oxygenation are considered rescue therapies, examples of which are prone positioning, heavy sedation with paralysis, high frequency modalities, high peep and recruitment maneuvers. Rescue therapies, while not “evidence based” in the strict sense, may offer the patient's only chance for survival in desperate situations involving refractory hypoxemia.

Which rescue therapies to implement depend in part on local expertise. Provision of rescue therapy will require some preparation, particularly if the patient requires transfer to another facility. This underscores the importance of early severity assessment which facilitates planning for possible rescue therapy.

The decline effect

---refers to a waning of the magnitude of positive research findings over time. In other words while initial research may lead to a slam dunk conclusion subsequent attempts to replicate it, though sometimes positive, are often less robust. Other times, of course, they don't stand up at all. Such was the topic of a recent piece in The New Yorker.

Aside from a few flaws in the article (its implication that early popularity of HRT was bolstered by randomized controlled trials, credulity towards acupuncture and a statement that research on cardiac stents suffered from the decline effect) it did a fair job of illustrating some of the booby traps of conducting and reporting research.

The article explored several explanations for the effect including regression to the mean. No single one is adequate. There are probably many contributing factors. Initial research findings may be more likely to suffer from investigator and publication bias than those of subsequent investigations, which may bring more skepticism to the picture. Sometimes initial studies have design issues that make them unsuitable for generalization or widespread change in practice such as small size or anomalies in the sample that was studied. Early studies on glycemic control in hospitalized patients and perioperative beta blockers come to mind.

So do we throw evidence based medicine (EBM) and science based medicine (SBM) out the window? Not at all. This is just a reminder that though some science is for practical purposes settled, much of it is tentative. That's why EBM regards the most current evidence as an important attribute of best evidence.

Related content at DB's Medical Rants.

Monday, January 10, 2011

Megyn Kelly handles Sheriff Dupnick

---and exposes his foolishness. Deferentially and with respect.

OK, back to regular blogging, punctuated if the need arises by updates on this topic.

After Arizona shootings the political vultures swoop

I've tried to make it a rule to confine political blogging to issues of health policy. Today I'm breaking that rule. I don't want to, I have to. I simply can't contain my outrage. So let's start with this piece from NRO:

Very few Americans are fans of both The Communist Manifesto and Mein Kamp, as the Tucson killer, 22-year-old Jared Lee Loughner, apparently was. Fewer still post on the Internet fears about “brain washing,” “mind control,” and “conscience dreaming”; have a long record of public disruption and aberrant behavior; were expelled from community college; or were summarily rejected for military service.
No matter. Almost immediately following Loughner’s cowardly murdering of six and wounding of 14 including Rep. Gabrielle Giffords, pundits and some public figures rushed to locate his rampage, together with his paranoid rantings about government control, within the larger landscape of right-wing politics — especially the rhetoric of the Tea Party and Sarah Palin.

And rush they did. Almost immediately after it happened Paul Krugman, admitting he didn't know if the shooting was political, blamed the Right anyway.

Upon first learning of this tragic shooting I suspected something like this would happen but I had no idea of the degree of political opportunism that would follow. Disgusting.