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Dr. Donald Berwick and “patient-centered” medicine: Letting the woo into the new health care law?

There’s been a bit of buzz in the health blogs over President Obama’s decision last week to use the mechanism of a recess appointment to be the director of the Centers for Medicare and Medicaid Services (CMS). Recess appointments, for those who may not be aware, allow a President to put a nominee in place when Congress is in recess in order to have him in place without the messy process of having him approved by the Senate. True, the Senate still has to approve a recess appointment by the end of its term, or the seat goes vacant again, but it’s an excellent way to avoid having nasty confirmation fights during election years. Of course, both parties do it, and the reaction of pundits, bloggers, and politicians tend to fall strictly along partisan lines. If you support the President, then a recess appointment is a way to get around the obstructionism of the other party. If you don’t support the President, it’s a horrific abuse of Presidential power. And so it goes. Either way, I don’t really care much about the politics of how such officials are appointed so much as who is being appointed.

The man who was appointed last week to head CMS is Donald Berwick, M.D., CEO of the Institute for Healthcare Improvement. His being placed in charge of CMS will likely have profound consequences not just for how the recent health care/insurance reform law is implemented but for how the government applies science-based medicine to the administration of the this massive bill. Most of the criticism of his views that I’ve seen thus far comes from conservatives, who do not like Berwick’s apparent penchant for health care systems like the British NHS. Ironically, it’s views held by Berwick that will likely come into direct conflict with his mandate to hold down costs that are the problem with Dr. Berwick, at least to me. It is in these views where there is much that is admirable. Unfortunately, I also fear that there is much about Berwick’s views that are very friendly to the possibility of allowing the infiltration of woo into the U.S. health care system as well, and these fears begin with what Berwick is most known for, a term he calls “patient empowerment.”

What a grand word! After all, who doesn’t want to be “empowered”? Certainly not me. Perhaps that’s the reason why it’s become the new buzzword in a movement known as “patient-centered” care. Old fart that I am, when I first encountered the term I was a bit puzzled by exactly what “patient empowerment” means. After all, I’ve always thought I have been practicing patient-centered care, ever since my first days in medical school. Apparently these days it means something different, at least if this article from about a year ago in the New York Times is any indication. It’s an interview with Dr. Donald Berwick, who advocates what he himself calls a “radical” patient-centered care, having at the time recently published an article in Health Affairs entitled What ‘Patient-Centered’ Should Mean: Confessions Of An Extremist. It was unclear to me then and it’s unclear to me now whether Berwick was being sarcastic or flippant in his characterization of himself as an “extremist.”
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Posted in: Politics and Regulation, Public Health, Science and the Media

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Natural is not innocuous: the case of Angel’s Trumpet and tropane alkaloid intoxication

With this post, I’m happy to return to Science-Based Medicine on a regular basis, at least monthly and perhaps more depending upon how often commentary is required on natural products, whether they be herbal medicines or single-agent pharmaceuticals derived from natural sources. Next week, I’ll be attending the 2010 Annual Meeting of the American Society of Pharmacognosy being held jointly with the Phytochemical Society of North America in St. Petersburg, Florida. I hope to bring back the latest on novel natural products in preclinical development.

But today, I bring recent news that revisits a timeworn folly of the young (and some older folks): recreational use of toxic plants for the purpose of hallucination.

Toxicity reports are re-emerging in southern California this week after a dozen hospitalizations of kids using teas made from a fragrant flowering plant called Angel’s Trumpet. The tea is used to produce hallucinations, but they can progress to extremely unpleasant experiences. Moreover, Angel’s Trumpet can be deadly, accelerating the heart rate and causing fatal cardiac rhythmic disturbances and bronchoconstriction that can trigger asthma attacks in sensitive individuals.

220px-Atropine.svg.pngAngel’s Trumpet is one of a series of plants in the Brugmansia genus that make a variety of muscarinic cholinergic antagonists such as atropine (dl-hyoscyamine, pictured to the right) and scopolamine (l-hyoscine). These compounds are also known chemically as tropane alkaloids or belladonna alkaloids, the latter derived from their classical isolation from Atropa belladonna. The belladonna name derives from the use of eye drops made from the plants that prevent constriction of the pupils (mydriasis), back when the size of a woman’s pupils was a sign of beauty and arousal.

The tropane alkaloids are ubiquitous in plants and fungi and act as classic hallucinogens when used in high doses. Their legend goes back to witches brews and beyond. A wonderfully colorful history of tropane alkaloids by Robert S. Holzman of Children’s Hospital and Harvard Medical School was offered in this free 1998 paper in the journal, Anesthesiology (1998; 89:241-249).

However, the aftermath of Angel’s Trumpet use is far from colorful. In cases like these, I like to turn to the Erowid site, a respected, user-supported site that offers non-judgmental information on plant-derived and synthetic psychoactive agents. The Erowid Experience Vault has several descriptions of the use of Angel’s Trumpet but this one is the most detailed and representative of the downsides of this plant. (Note that the colloquial term for Angel’s Trumpet in Australia is sometimes “Tree Datura,” although Brugmansia is a closely-related but distinct genus from Datura within the Solanaceae family.)

I also came across a poorly-documented 2003 news article cited a German teenager cutting off his penis and tongue with garden shears after using Angel’s Trumpet.

While I’m NOT a physician, emergency personnel stumbling upon this post would do well to note that physostigmine or pilocarpine are typical antidotes for anticholinergic poisonings with Angel’s Trumpet, Atropa, Datura, and other similar plants that cause dilated pupils with loss of accommodation, xerostomia (dry mouth), and tachycardia. Click on this paragraph to access the Medscape poisoning article with more details on when and where specific treatments should be employed.

From the eMedicine article linked to in the above paragraph:

Remember common signs and symptoms with the mnemonic, “red as a beet, dry as a bone, blind as a bat, mad as a hatter, and hot as a hare.” The mnemonic refers to the symptoms of flushing, dry skin and mucous membranes, mydriasis with loss of accommodation, altered mental status (AMS), and fever, respectively.

I encourage all clinicians to be vigilant about anticholinergic poisonings in the weeks to come. In some cases in the past, I have found that reports such as these from southern California will often give rise to attempts to use the hallucinatory plant elsewhere despite the risks detailed.

Posted in: Science and Medicine

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Sunscreen in a Pill?

Starr_050107-2831_Phlebodium_aureum

I’ve previously described the consequences of acute and chronic sun exposure, and the rationale for topical sunscreen products. But wouldn’t it be easier to just take a pill that can boost our skin’s resistance to to the harmful effects of the sun? Is it possible to get all the benefits of sunscreen without the bother of creams, or even clothing? (more…)

Posted in: Herbs & Supplements

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Acupuncture and Modern Bloodletting

Last year Ben Kavoussi published an interesting article on SBM called Astrology with Needles in which he purported a historical connection between acupuncture and bloodletting. I had previously thought that bloodletting was a uniquely Western cultural invention – part of Galenic medicine involving the balancing of the four humors, one of which being blood. (In the West bloodletting faded away with the advent of science-based medicine in the 19th century.) I was intrigued by this connection and have since been doing my own reading on the topic. It turns out that bloodletting was common throughout ancient cultures and not unique to the west.

In fact acupuncture was originally a form of bloodletting – the “needles” were really lances and the acupuncture points locations over veins to be opened. Chi, or the Chinese concept of the life force, was believed to be partly in the blood, and blood letting could be used to free the flow of chi. This was closely related to the Galenic concept of using bloodletting to free the flow of static blood in the tissue.

For example, in the ancient medical text of Suwen, we find:

When heaven is warm and when the sun is bright,
then the blood in man is rich in liquid
and the protective qi is at the surface
Hence the blood can be drained easily, and the qi can be made to move on easily…

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Posted in: Science and Medicine

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Shingles Vaccine (Zostavax) Confirmed Safe

Shingles (herpes zoster) is no fun. It usually begins with a couple of days of pain, then a painful rash breaks out and lasts a couple of weeks. The rash consists of blisters that eventually break open, crust over, and consolidate into an ugly plaque. It is localized to one side of the body and to a stripe of skin corresponding to the dermatomal distribution of a sensory nerve. Very rarely a shingles infection can lead to pneumonia, hearing problems, blindness, brain inflammation (encephalitis) or death. More commonly, patients develop postherpetic neuralgia (PHN) in the area where the rash was. The overall incidence of PHN is 20%; after the age of 60 this rises to 40%, and after age 70 it rises to 50%. It can be excruciatingly painful, resistant to treatment, and can last for years or even a lifetime.
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Posted in: Vaccines

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Doctor’s Data Sues Quackwatch

A few weeks ago I posted an article about bogus diagnostic tests. I cited Doctor’s Data, Inc. (DDI), as “a company with a long history of dubious offerings.” I also wrote:

You can’t help but have noticed that many of the links in this post are to articles on Quackwatch. That’s because the site is chock full of useful information about bogus tests, far more than can be found elsewhere. There you will find a more comprehensive list of bogus tests than I’ve mentioned here, and a larger list of laboratories peddling them. You’ll also find an article on “Dubious Genetic Testing” co-authored by the Quackwatch founder, Stephen Barrett, and our own Harriet Hall, and an article about bogus “biomedical treatments” for autism showing that—surprise!—Doctor’s Data and Genova Diagnostics are major players there, too.

I stand by all of those statements. It turns out that Doctor’s Data is not pleased that Dr. Barrett has so thoroughly blown the company’s cover.

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Posted in: Diagnostic tests & procedures, Health Fraud, Politics and Regulation, Science and the Media

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Homeopathy in the ICU?

ResearchBlogging.orgEditor’s note: It’s still a holiday weekend in the United States. I had considered simply taking the day off altogether, particularly since I’m busily working on my talk for TAM8–which (holy crap!) is in a mere three days–but then I figured today’s a good time to resurrect a “classic” (if you will) post that I wrote a few years ago, dust it off, and post it. I decided to do this mainly because I had been planning on bringing this post to SBM at some point right from the very beginning of SBM.

Regular readers of this blog are probably familiar with a certain homeopath named Dana Ullman. So persistent is he in his pseudoscientific arguments for the magic that is homeopathy that fellow SBM blogger Kimball Atwood once postulated a humorous law he dubbed the Dull-Man Law:

In any discussion involving science or medicine, being Dana Ullman loses you the argument immediately…and gets you laughed out of the room.

Kimball then pointed to a number of studies that Ullman likes to cite ad nauseam that supposedly “prove” the efficacy of homeopathy. One study Kimball didn’t mention, however, is a favorite of Ullman’s, one he likes to trot out time and time again. Specifically, it’s a study of homeopathy in the ICU that was published, in all places, in Chest, a respectable journal that, as you might expect, is dedicated to research on diseases of the chest, such as chronic obstructive pulmonary disease (COPD), cardiac disease, and basically any disease that manifests its pathology in the chest, although it primarily deals with critical care. I first learned of this study way back in 2007 from Dr. R. W., who at the time commented quite aptly that the article impressed him with just how far into the medical mainstream woo has penetrated, while retired doc also expressed his dismay.

Although I do feel a bit guilty not providing you with more original peerless prose pontificating on medical pseudoscience that you know and (hopefully) love, this article is constantly trotted out by homeopaths, even five years later, and that makes it worth updating an older post from another source. So here’s the abstract:
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Posted in: Clinical Trials, Homeopathy

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Not to worry! Chiropractic Board says stroke not a risk of cervical manipulation.

Back in January, the Connecticut Board of Chiropractic Examiners held a four-day hearing to decide whether chiropractors must, as a part of the informed consent process, (1)warn patients about the risk of cervical artery dissection and stroke following neck manipulation and (2) give patients a discharge summary listing the symptoms of stroke.1 On June 10th, the Board of issued a written opinion that stroke or cervical artery dissection is not a risk of cervical spine manipulation, so no warning is necessary. Presumably, although it is not specifically mentioned in the decision, no discharge summary is required because, if there is no risk of a stroke after neck manipulation, what would be the point?

Background

Janet Levy and Britt Harwe are two Connecticut women who suffered strokes resulting from neck manipulation by chiropractors. That’s not just their lay opinion, it’s the opinion of their respective treating physicians, right there in the medical records.

Each decided that some good should come of their unfortunate situations, so each formed a non-profit and began warning patients of the risk of stroke following manipulation. Victims of Chiropractic Abuse, Levy’s organization, put giant ads on the sides of busses in Bridgeport, CT., much to the chagrin of the folks at the University of Bridgeport. Within the hallowed halls of the University (Go Purple Knights!) is a College of Chiropractic, a College of Naturopathic Medicine, and the Acupuncture Institute. The chiropractors demanded that the ads be taken down, which got exactly nowhere.

Some chiropractors also began harassing Levy and Harwe, calling them Nazis and KKK members, for example, and threatening their personal safety and that of their families.(What is it with the pseudoscience crowd and calling people Nazis? Perhaps, having used up their entire supply of imagination creating their nostrums, they are reduced to these tired tropes.) The FBI recommended Levy and Harwe have one of the harassers arrested, which they did, and that calmed things down for a while. (more…)

Posted in: Chiropractic, Politics and Regulation

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Acupuncture CME

Some Universities have more cachet than others. On the West coast it is Stanford that has the reputation as the best. There is Oxford, Yale, MIT, and maybe Whatsamatta U. I would wager that in most people’s mind the crème de la crème is Harvard. Harvard is where you find the best of the best. If Harvard is involved, a project gains an extra gobbet of credibility. Brigham and Women’s Hospital also has a similar reputation in the US as one of the hospitals associated with only Harvard and the New England Journal of Medicine. Premier university, premier hospital, premier journal.

So if Brigham and Women’s Hospital and Harvard Medical School are offering continuing medical information (CME) for acupuncture, there must be something to it, right? A course called “Structural Acupuncture for Physicians” must have some validity.

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Posted in: Medical Academia, Science and Medicine

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It sounds so “nutritionous”

Dietitians are a critical part of modern medicine. In the hospital, dieticians not only educate patients on dietary treatment of diseases such as diabetes and heart disease; they also evaluate the nutritional status of critically ill patients and develop nutrition plans that may involve tube feeding or intravenous feeding. This is complicated, and takes into account a patient’s nutritional needs, medical conditions, etc. They are highly trained professionals.

If you want to see a dietitian lose it, call them a “nutritionist”. “Dietitian” is a specific profession governed by specific educational and licensing requirements. A dietitian can call themselves a nutritionist, but so can just about anyone else. As with other health care professions, dietitians have good reason to protect their profession. Protecting their profession protects their patients. Dietary fads are among the most prolific of medical scams and good information can be hard to find. Registered dietitians explicitly strive to utilize evidence to guide their practice. And critically, they have a published Code of Ethics.*

As is not uncommon, there are those who, in the name of “health freedom” (and profit), object to the dietitian “monopoly” on nutritional therapy.   One way they have done this is to claim the title “nutritionist” and set up a certification system. Once this structure is in place, it’s easier to get states to approve them as licensed professionals.  In this second area—state licensing—they are enlisting allies that comprise many of  ”the usual suspects”. (more…)

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