As I have mentioned in the past, almost all of my practice is inpatient medicine, doing infectious disease consults in acute care hospitals. I only spend three hours a week in the outpatient clinic, so I have a skewed perception of medicine and disease. The patients I see are sick, really sick, often trying to die and are a complicated collection of abnormal labs and deranged physiology.
I remember finishing residency thinking that a potassium of 2.8, a hemoglobin of 9.8 or a bilirubin of 4.5 wasn’t all that bad, losing track of normal physiology amongst all the medical pathology. I never did lose track of normal vital signs (VS): pulse, respiration, blood pressure and temperature. Like trying to be the fifth Beatle, over the years other values have vied to become the fifth vital sign: pain level or O2 saturation, but none have the importance of the fab four. I can live without pain*, but I can’t live long if the other vital signs are abnormal for extended periods of time. Watching the vital signs return to normal is often an important variable that signifies the patient is improving. (more…)
Disclaimer: I am a paid Medscape blogger and writer, and since they are in part supported by advertisements from the Pharmaceutical companies, indirectly I am in the thrall of Big Pharma.
I found Harriet’s post on the Medscape Connect topic of How do you feel about Evidence-Based Medicine? interesting.
I wondered about the breakdown of the comments by both specialty and opinions about SBM. So I read the 226 comments and classified them by field and response. I classified each response as disapprove, approve or nuanced. It is not, obviously, a legitimate survey and there was more than a little subjective interpretation in deciding how to classify the responses. I have no doubt that others would get different results; it is not methodologically sound analysis. The discussion was in the Family Medicine & Primary Care section, so it is unlikely to be representative of any population, including that of Family Practitioners and Primary Care Physicians. I would bet, as in alternative medicine and most topics, Shruggies predominate and are the silent majority.
Even though I belong to what a commentator referred to as the not so silent “militant wing” of SBM, I was surprised at my results: (more…)
There is no shortage of technology in my household: computers, smart phones and tablets of one kind or another. The nice thing about being a blogger and an app developer is I can justify it all. Well, mostly. The “It’s probably tax deductible” gambit can only be used so many times. It is remarkable how much of my life is filtered through the digital lens. I think if google glasses ever become a reality, my kids and I will be the first up to be permanently wired into the world. To my way of thinking, the Daemon haunted world looks like hog heaven.
There is an app for just about anything, many of which feed into my OCD. I keep track of my daily walk and I have walked over 1500 miles since July 1, 2011. When I developed my middle aged bloat I had the option of medications to control the metabolic results or lose some damn weight. Losing weight is simple in concept, hard in execution. Take in fewer calories than you expend and the weight will slowly, ever so maple bar free slowly, come off. It took 9 months to drop the 45 pounds needed, and I must say I feel just as old and creaky as I did before, but my labs are better. The opposite of the placebo effect: I am subjectively the same but am objectively better. I’ll take it. One of the cool features of the app I used, and still use, for calorie management is that it will take a picture of the bar code of food and give you the nutritional information for entry in the program. Amazing.
A fellow bugdoc sent me a link to story about Chinese Tongue diagnosis. The journal article has been accepted for publication as Automated Tongue Feature Extraction for ZHENG Classification in Traditional Chinese Medicine
It is as fine a piece of tooth fairy science and tooth fairy engineering as I have ever encountered. (more…)
For all the goofiness that is SCAM, I never thought I would have a post with Cannibalism in the title. The ability for humans to find imaginary healing properties in everything from duck liver and heart diluted 1:100 200 times, rhinoceroses horns, and waving hands over people to adjust energy fields that do not exist is remarkable. Somehow I never thought Jeffrey Dahmer would be at the forefront of alternative therapies.
Wednesday evening while my wife was reading me the paper (it is how I usually consume the local newspaper, my wife reads stories she finds of interest out loud. Otherwise I do not think I would bother with anything beyond the comics and sports page) she let it be known that Korean officials has confiscated medications containing aborted fetuses and stillborn babies. Instead of the usual distracted, uh huh, that’s interesting, this caught my attention. Say what?
I usually rely on the Secret. Every two weeks or so the Universe offers up some bit of wacky whimsey and I have a topic for an SBM blog entry. This week the Universe has failed me. Nothing has crossed my LCD so I have no studies to evaluate and I have been unusually busy at work preventing my browsing the Interwebs for material. But try telling that to the Managing Editor. I write half to amuse myself, half to learn about the topic, and half to clarify in my own mind the topics at hand (1). So this week is content free idle thoughts for my own benefit.
I have been reading 13 Things That Don’t Make Sense by Michael Brooks. The book concerns topics in science that are unexplained by the current understanding of the laws of the universe or contradict the dominant paradigm. Well, almost. His final topic is homeopathy, and it is the one topic whose conclusions, while qualified, belong on Failblog. The first chapter concerns dark matter and dark energy and how what we can see makes up only a small fraction of the content of the universe. (more…)
Although I write the definitive entries on topics in this blog, new information trickles in after publication. The new studies are often not worth an entire entry, recapitulating prior essays, but the new information is still worth a mention. What follows are updates on topics covered in prior SBM posts.
In Oregon we are having a small outbreak of infections from consumption of raw milk. Not a surprise, since milk is a wonderful culture media and the udder is just down the gravity well from the cows anus. Raw milk violates the classic dictum “Don’t shit where you eat” although I understand the saying concerned dating in its original conception.
Although the sale of raw milk is illegal in muchof the US, the law can be bypassed by owning the cow rather than buying the milk, a reverse of dating advice. Such is the case in Oregon, where 48 people are time sharing the cows responsible for the current outbreak. There has been the spread of pathogenic E. coli to at least 5 people, mostly children, and has lead to the hospitalization of at least 3 children.
Of course, it is hard to get infected. Humans have lived in Filth and Squalor (like Minneapolis and St. Paul or Buda and Pest) for centuries, drinking and eating contaminated food and enough survived perpetuate the species. Most infections in the past would have been from consuming contaminated food and drink. I have wondered if the reason fevers are often associated with diarrhea and/or vomiting is that it an evolved response for removing infected material as soon as possible.
I spend most of my time taking care of hospitalized patients with acute infections and issues of public health are, outside of infection control, not a high priority. Vaccinations in training were always like clean water and fresh food: their benefit was a given and I never needed to consider the benefits and subtleties of vaccination. There is just so much time in a day and I was more concerned with AIDS, endocarditis and meningitis to worry about the ins and outs of vaccination.
One of the many benefits of writing for SBM, and being the Chair of Infection Control, is it is a stimulus to keep up on aspects of medicine that I might not otherwise pay close attention to, like vaccines. I have been far more interested in vaccines, especially influenza vaccines, since starting practice in 1990 than I ever was in the decade I spend in training.
Vaccination and the efficacy of vaccines is not as straightforward as I would have thought 30 years ago. It was give a vaccine, generate an antibody, and, viola, the patient is protected. The vagaries of the flu vaccine are even more pronounced, since response to the vaccine is variable and the population has never been vaccinated at levels, more than 90%, where herd immunity would likely kick in.
My ideal flu vaccine study, which would be both impossible and unethical, would be to vaccinate everyone West of the Mississippi and no one to the East (no coincidence that me and mine live in the West) and study the short and long term effects. Until that day, I am stuck with the hodgepodge of medical studies that look at the results of influenza vaccination and add insights into the disease.
I thought this week it would be fun to mention some interesting studies about influenza, the vaccine and flu immunity that have come out in the last 2 years. This is not meant to be anything more than a compilation of articles I thought were interesting, and the only purpose is to give a hint as to the complexities of influenza and vaccination. (more…)
It has been tough in Portland this year. The Trailblazers, our NBA, and only professional team, started out on a tear, then went right down the toilet. It is painful to see such promise dribbled away. Sigh. Why is elation always followed by disappointment? Everyone and everything has feet of clay. Except Cassius Marcellus.
At the beginning of March the NEJM had a wonderful essay, What’s the Alternative? The Worldwide Web of Integrative Medicine by Ranjana Srivastava. The essay concerns a patient who is ‘diagnosed’ with cancer at an integrative medicine exhibition and the resultant diagnostic and therapeutic debacles that follow.
I do not understand the interest many appear to have in their bowels and the movement there of. But then, I pay little attention to most of my body functions as long they are functioning within reasonable parameters, and as I get older the definition of reasonable is increasingly flexible.
The elderly especially seem to obsess about their bowels. My theory is that since they have often lost taste, smell, hearing and are alone with little direct human touch, a good BM is the only remaining physical joy left, and when it is compromised they are understandably upset.
Still, the concept of colonics for ‘detoxification’ strikes me as more humorous than repellent, despite the lack of efficacy and documented complications of the procedure. Under normal circumstances, when it comes to the colon it is probably better to be removing substances than to be introducing them. (more…)
It all seemed so easy
In 2010 an article was published in the New England Journal of Medicine, Preventing Surgical-Site Infections in Nasal Carriers of Staphylococcus aureus . Patients were screened for Staphylcoccus aureus ( including MRSA, methicillin resistant Staphylococcus aureus) and those that were positive underwent a 5 day perioperative decontamination procedure with chlorhexidine baths and an antibiotic, mupirocin, in the nose. The results were impressive. Before the intervention the infection rates were 7.7 % and after the intervention it was 3.4 %. That is an impressive drop in surgical infections.
One of the orthopedic groups approached us (us being the hospital administration, pharmacy, nursing and infection control, of which I am Chair) to implement the protocol in their patients, citing a similar study on an orthopedic population. Great. It should be an easy enough intervention. I should have known better, of course, long experience has continually demonstrated that what appears to be simple never is.
First was the question as to whether the study was applicable to our patients. Resources were going to be devoted to an intervention, so going forward we had to demonstrate that the bang would be worth the buck. These are financially lean times, with cutbacks and declining reimbursement, so every expenditure of time and money needs to be justified. In the bizarro accounting of health care, not every hospital administration will include money saved in the evaluation of interventions, only the money spent. I work in a hospital system with a remarkably strong commitment to patient safety and quality, so there was little worry on that point. (more…)