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…)
I’m not here to convince people that we are right, although it would be nice if it turned out that way. I’m here to tell the truth and let readers decide for themselves.“
I had been too inarticulate to formulate what is essentially my approach to this blog: to tell the truth. That would appear to be simple enough. Of course it gets down to what constitutes the truth, and whether you can handle the truth.
What is truth, small ’t’? Truth with a big ’T’ is provided by belief systems that originate in a personal epiphany and you suddenly understand the meaning of life, the universe and everything. Or conjure up reiki or chiropractic. I suspect I was either born without the part of the brain that allows me to appreciate the mystical/spiritual aspects of human existence, or perhaps it was my upbringing. Probably a bit of both, although having raised two kids in the eternal nurture/nature debate has swayed me heavily towards the nature side of the fence. I bet I was born that way. But I am totally tone deaf to issues of spirituality and the surrounding issues of big ’T’ Truths, so I am going to stick to the little ’t’ truths. (more…)
I start these entries about a week before their due date, and when I saw Dr Hall’s Applied Kinesiology (AK) post from Tuesday, I thought the heck, there goes my post for Friday. After reading Harriet’s post, I think mine will be both complementary and alternative, and perhaps even integrative, to her entry. I do have one quibble with her post. She said
“we skeptics don’t dismiss AK just because it sounds silly.”
AK doesn’t just sound silly, it is silly. I have found over the years writing for SBM that I have developed an increasing bias around the concept of prior probability. As best I can tell there is a well described reality, and that reality constrains what is not only probable, but what is possible. Within the limitations of our current understanding of reality, some processes are impossible, i.e. have zero prior probability. AK’s prior probability is exactly zero. I sometimes think the blog should be called Reality Based Medicine. Science gives us understanding of reality and AK, like many a SCAM (Supplements, Complementary and Alternative Medicine) discussed in this blog, parted company with reality from the beginning.
This blog has two often overlapping purposes. Blogs offer timely commentary on contemporary issues, and this blog certainly fills that role. More than other blogs, SBM also has the opportunity to be a reference source on various SCAM’s . I have had the recent opportunity to reread the entire oeuvre of SBM, and it is impressive in the breadth and depth of topics covered in its three plus years. It is not yet encyclopedic and there are many topics not yet reviewed in the blog, such as Applied Kinesiology. So many many SCAM’s, so little time. (more…)
Medicine is simultaneously both easy and hard. As an Infectious Disease doctor, my day can be summed up with the phrase “me find bug, me kill bug, me go home.” Sometimes it is just that simple. A lot of the time it isn’t. I may not be certain what the infection is, or even if the patient has an infection, or allergies and/or antibiotic resistance limit therapeutic options, the host has co-morbidities that limit effectiveness, and the patient has no financial resources for the needed treatment.
I am lucky, since most infections are acute, make people feel terrible, and require a relatively short course of therapy during which the patient feels better. I rarely have to worry about compliance with the treatment plan; it is the rare patient, usually a heroin user or a particularly irascible old man, who will not follow through with their antibiotic course. I do not have to worry about chronic or symptomless diseases like diabetes or hypertension or the complications of obesity where long term compliance often limit therapeutic success. Long term it is difficult for many people to stick with their therapeutic plan, much less their diet and exercise resolutions.
It is hard to Sokalize alternative medicine. The closest has been buttock reflexology/acupuncture, but that is a tame example. Given the propensity for projections of the human body to appear on the iris, hand, foot, tongue, and ear, postulating a similar pattern on the buttocks are simple variations on a common SCAM (Supplements, Complementary and Alternative Medicine) theme. The buttocks? Not really different from any of the other focal acupunctures. Most of SCAM does not concern itself with application of reality and physiology, anatomy, biochemistry, etc can all be expected to be ignored with virtually all SCAM modalities.
Every time I think the heights (or depths) of absurdity has been reached, I discover a Braco the Starer or Himalayan Salt Inhalers. This blog is not affiliated with the British Medical Journal in any way, and although this is being published near Christmas, I want no one think that what follows is a hoax. I am not, I repeat not, making up what follows. It is not fiction. Well, it is fiction, but not written by me and believed and practiced by some who really should know better.
I have never belonged to the American Medical Association. As a student I didn’t want to pay the dues. As a practicing physician I am of the opinion that the AMA has two often mutually exclusive goals (promoting physician income and patient care) and they are doing both badly.
In the 1990’s the AMA entered into a contract with Sunbeam to get an AMA seal of approval for Sunbeam products, but due to objections the AMA backed out of the deal, in the end costing them almost 10 million dollars.
As was noted at the time:
“I think if we’d gone to trial,” Dr. Relman said on Saturday, ”probably a lot more relevant information would have been uncovered and made available to the membership. As a result of this settlement, we will never know the truth of what happened. It does not let the sun shine in.”
Yeah AMA. It is probably for good reason that only around 29% f of US physicians belong to the AMA; I have never seen them as representing me or my patients. Whether the AMA or physicians, I am automatically suspicious of any person or institution who puts their seal of approval on a product. I figure they are only doing it for the money. Not that there is anything wrong for that; I am for sale if anyone can meet my price. Trusting endorsements is like George Carlin’s (I think) observation that he did not like doing standup for stoners since you never know if was the act or the dope that lead to the laughter. I know celebrities are paid for their endorsements; it is not conflict of interest when it is your job to sell a product. At least actors say they only play a doctor on TV. But when professionals use their authority to recommend products, I would love to see a conflict of interest statement in the recommendation.
When I give a lecture I have to mention my conflicts of interest (COI)* and I have to specifically confirm or deny that I will mention products in which I have a financial interest^. The COI rules are nice, so you know, sort of, who has an interest in pleasing their corporate masters, although I suspect most doctors do not take COI statements seriously. At IDSA this year most of the speakers gave their COI statements with a short, dismissive sneer and a roll of the eyes. Me? Potentially Biased? Puh-please. (more…)
There have not been a lot of topics of late that warrant extensive analysis and discussion. But there are a number of little topics of interest, each worthy of a few paragraphs of discussion, archetypes of issues in medicine, science based and otherwise.
Xigirs. No, it is not whale vomit, but close.
Last month Xigris was pulled from the market by Lilly. Yes, I understand the shock. Xigris, we hardly knew ye. Xigris is the brand name for drotrecogin alfa, or activated protein C. It is an enzyme in the clotting cascade that is/was given for the treatment of sepsis. (more…)
I normally write the first draft of this blog the weekend before it is due, and this is no exception. However, I am ill this weekend. Headache, myalgias., painful cough, but only mildly ill. The worst part is the interferon induced brain fog; my thoughts flow with all the speed of pudding and I was not appreciably better as the week progressed, although no cracks about how you can’t any difference in my writing over baseline.
I doubt the cause of my symptoms is influenza. According to the CDC site and Google flu trends there is little influenza activity in the US at the moment, so it is probably one of the innumerable viruses that can cause a flu-like illness. I am also not ill enough to think I have influenza, but I could be having a modified course as I was vaccinated a month ago. Of course, the doctor who treats herself has a fool for a patient and an idiot for a doctor. Flu season approaches, so from my interferon addled brains, flu thoughts.
Evidently the 7 billionth human is going to be born on October 31. Happy birthday and welcome to the Earth. If you were unfortunate enough to be born into a developing country or a affluent California family, you may not receive your vaccinations, and may join one the
57 million who die each year of vaccine preventable diseases (VPD).
I totally misread the table. It’s about 4,320,000 who die of VPD. Well, I said I was no damn good at stats.
And if you are doubly unlucky, you may be exposed to illness from an unvaccinated friend, family or health care worker before you can get your vaccines, and join the ranks of the ‘only’s.’ The ‘only’s’ are those who die of vaccine preventable diseases and are mentioned in anti-vaccine literature in a sentence like ‘VPD X is a mild illness in most children and only kills Y% of cases ’. As I have said before the anti-vaxers do not care for whom the bell tolls.
I am no good at statistics. I signed up for, and dropped, statistics at least 4 times in college. Once they got past the bell shaped curve, it was one incomprehensible huh? Part of the problem with statistical concepts such as risks, both relative and absolute, is that it is often impossible to get a feel from what they represent. For me it is like metric measurements. I know what a 8 mile hike represents, but not an 8 kilometer hike. Same with centigrade and liters. I have been unable to internalize what metric means in my daily life. (more…)
I seem to be writing a lot about the urinary tract this month. Just coincidence, I assure you. As I slide into old age, medical issues that were once only of cursory interest for a young whippersnapper have increasing potential to be directly applicable to grumpy old geezers. Like benign prostatic hypertrophy (BPH). I am heading into an age where I may have to start paying attention to my prostate (not prostrate, as it is so often pronounced, although an infection of the former certainly can make you the latter), so articles that in former days I would have ignored, I read. JAMA this month has what should be the nail in the coffin of saw palmetto, demonstrating that the herb has no efficacy in the treatment of symptoms of BPH: Effect of increasing doses of saw palmetto extract on lower urinary tract symptoms: a randomized trial.
It demonstrated that compared to placebo, saw palmetto did nothing. There have been multiple studies in the past with the more or less the usual arc of clinical studies of CAM products: better designed trials showing decreasing efficacy, until excellent studies show no effect. There is the usual meta analysis or two, where all the suboptimal studies are lumped together, the authors bemoan the quality of the data, and proceed to draw conclusions from the garbage anyway. GIGO.
The NEJM study from 2006 demonstrated that saw palmetto was no better than placebo but it was suggested that perhaps the dose of saw palmetto was not high enough or that the patients were not treated long enough to demonstrate an effect, and the JAMA study hoped to remedy that defect. (more…)