TB Rx= quadruple therapy plus liver and onions

Actually, you can hold the onions. The February 2005 issue of Chest published an article taking a very old observation(low cholesterol in tb patients) and decided to do something about it.What they did was a clinical trial involving giving cholesterol rich diet to see if a metric of improvement would occur quicker.Actually a couple of indicators did.By week 2, 8/10 in the treatment group achieved a negative culture while only 1/11 in the control group was negative.The authors also reported that sputum production decreased faster in the treatment group.Since 90% plus of tb patients are sputum negative by 6 mos anyway it is not likely that high fat diet diets for a couple of weeks will add much to the final outcome(and this is the era of outcome research)

WHI Strikes Again, A RCT trumps a systematic review and we learn estrogen does not help urinary incontinence

Once again we see a RCT provide a conclusion opposite to that supplied by a systematic review even one done by the legendary Cochrane Group. A 2003 Cochrane review (Moehrer B ,Jextall A, Jackson S, Oestrogens for urinary incontinence in women. Cochrane Data Base Sys rev.2003:(2) CD001405) concluded that oral estrogen treatment could improve or cure incontinence but ,of course, in appropriately cautious tones, recommended further study.
The further study is found in the February 23, 2005 issue of JAMA. Data from the Women's Health Initiative (WHI) showed that estrogen alone and estrogen plus MPA increased the risk of urinary incontinence in continent women and worsened the incontinence in symptomatic women after one year. In a related editorial Dr. Catherine DuBeau attempts to unravel the knotty aspects of biological plausibility and the ins and outs of methodological issues involved in part to try and understand why oral estrogen would worsen incontinence and why progestin seemed to mitigate the effect of estrogen on urge incontinence in the WHI data. The relative risks, though statistically significant,were generally less than 2 and maybe the play of chance is at work in some of the subgroup data. But the bottom line is doctors will likely not be prescribing oral estrogen for urinary incontinence after reading the WHI paper. We await further investigation on the use of topical estrogen.

Prophylactic antibiotics in Surgical Patients

A large survey published in the February 2005 Archives of Surgery reported that 99% of Medicare patients undergoing any of the five surgical procedures they reviewed received prophylactic antibiotics.1% developed wound infections. 92 % received antibiotics in compliance with published guidelines. Areas that the authors suggested could be problem areas were : possibly as many as 60 % received antibiotics for periods longer that some would say is optimal, possible overuse of vancomycin, and not all received the antibiotics within the usually recommended one hour of incision (Although, the exact time of incisions was frequently not recorded so this data is a bit soft) . The authors admited that their vancomycin-use analysis was limited by the fact they had no information about the frequency of MRSA in the various hospitals. These criticisms notwithstanding the apparent bottom line is there seems to be a very low incidence of sugical site infections. Duration of antibiotic therapy continues to be an area with more opinion that data. Critics of health care won't find much about which to express alarm but they will find something.

The Perfect Country and Western Song-The perfect Medical article

In the David Allan Coe song, "You never even called me by my name" we are told some of the essential components of the " perfect" country song. Things that should be mentioned are: trains, trucks, mama,prison and getting drunk.
There are also essential components of the perfect medical article and should appear in the introduction and/or the discussion and summary sections. They include: mention of evidence based medicine (this is required even if the article has little if any evidence actually presented), mention of the disease at issue being "a public health problem"(saying it is common is not enough), a word about "quality" and perhaps most importantly stating that "we must be good stewards in this era of scarity of medical resources ". Unlike the essential elements of C&W music, which are timeless, the medical article sine qua nons are of recent vintage.
Non C&W fans may claim that tired cliches populate some country songs. It could be claimed that "floating abstractions" and politically correct comments are the fluffy fillers of the perfect medical articles.

Likelihood ratios and Evidence Based Medicine, what does the evidence show?

Part of the teachings of EMB is the use of the likelihood ratio. It is defined as the likelihood that a given test result would be expected in a patient with the disease of interest compared to the likelihood that the same result would be expected in someone without that disease. To use one , you have to "estimate" the pretest probability of a disease in a given setting. It has always appeared to me that this means- much of the time- you simply make up a number.If that is true, a group of doctors given the same clinical scenario would make up different numbers. Now there is evidence that this is exactly what happens. Drs. Phelps and Levitt (Acad. Emerg. Med,2004 June:11 (6) 691-694) gave clinical vignettes to a group of IM and ER trainees and attendings and asked them to estimate the likelihood of several illnesses. The numbers varied widely.The smallest difference in the pretest probability was 70%. If you think about "making up" a number as opposed to "estimating" a number, the validity of the whole process is perceived differently. Here, at least, the "evidence" that a particular element of Evidence Based Medicine is valid in a simulated real world setting is lacking and in fact suggests that it is not. The Ontario EMB experts in their book "Evidence Based Medicine" indicate there are several ways to estimate the pretest probability besides the physician using her experience including national and regional data bases. But in the real world it seems that the most common way of estimating pretest probability is to use one's own experience because such data is either non existent or you cannot access it. In this regard perhaps older, more experienced doctors would have the edge.

EMB dogma states that the likelihood ratio is the best way to judge how much a test result help to make the diagnosis. In theory this is clearly the case but the scheme does not work very well if the pretest probability value is is so nebulous.

Do older physicians not use guidelines? Are Internal Medicine Residents not taught ventilator use?

In the Feb.15, 2005 issue of the Annals of Internal Medicine, one article paints a worrisome picture of older physicians while another article is quoted in a pulmonary disease review showing that internal medicine trainees do not seem to know much about ventilator use.

The paper (The Relationship between Clinical Experience and Quality of Health Care,Choudhry et al) casting a bad light on older doctors does not appear to represent the highest level of evidence. It is a review article of many articles whose methods and metrics differ widely and at least two of which are too old to have much current relevance.(These are two articles from the 1970s that show older doctors prescibed more chloromycetin than younger doctors). Many of the articles used questionnaires with variable response rates. While some of the articles reviewed used a "general knowledge assessment", many of the negative-to-older-doctors papers claimed older docs adhered to guidelines less frequently than younger one . Should quality be equated with adhering to guidelines? The accompanying editorial, rather than offering a scholarly critique of the methods, accepts all at face value and states "The profession cannot ignore this striking finding and its implications" More commonly an editorial would state the obvious need for more data and analyze the data critically rather than adopting a "its time to do something about it" attitude. I believe the editorial is overreaching-the article itself is more cautious in its conclusions- and since two of the authors are members of the American Board of Internal Medicine should it be considered self serving as the ABIM would have justification for more action items (testing re-certification etc) if in fact a problem exists with older internists. The editorial states "The message is clear for certifying boards." The "Summaries for Patients" section takes a much more cautious view saying in part " these findings do not apply to all older doctors and must be confirmed by more specific research" .
More solid was the data quoted in the "Update in Pulmonary Diseases" section. 259 residents in internal medicine took a 19 item question examinations. Almost half did not know how to set the tidal volume in ARDS. And only 46% of program directors thought residents had adequate knowledge of ventilators. If the ABIM is worried about what it should do about older doctors, they should be at least as concerned about current trainee's apparent knowledge gaps over which they exert more control .

Coarse Grain,Fine Grain distinctions in Medicine.

Jacob Bronowski in his "The Origins of Knowledge and Imagination" speaks of a basic problem in the brain's mechanism in terms of achieving fine discrimination with a coarse apparatus.Further, he says that in many ways "about all" human problems..in science or in literature..center around the same problem.How do you refine the detail with an apparatus which remains at bottom coarse and grainy?"
Consider the randomized clinical trial(RCT) currently thought to be at the apex of the mechanisms we have to find the medical truth.We are left with aggregate data, groups numbers that are relevant , strictly speaking, to patients having the characteristics of those in the trial but is freqently extrapolated to include many other patients.
Compare this grainy-ness with the progress made in the following example.
Consider the use of MRI in a patient with the clinical picture of optic neuritis.
The finding of white matter abnormalities of a cetain type provide valuable information regarding likelihood of progression to multiple sclerosis. The coarse grain category of optic neuritis has been fine grained a bit by sorting out those patients with a high risk of subsequent development of multiple sclerosis.
But fine tuning cannot occur with the RCT. We can break the aggregate data into sub groups but we loose power to see differences and at the same time we increase the likelihood of Type I errors by cranking out many comparisons. So basically the RCT is a coarse grain apparatus and cannot get any finer, remaining coarse and grainy.
To fine tune the aggregate data seems to take determining the relevant pathophysiology.The example of TPMT deficiency comes to mind. Before the details of this deficiency were mapped out, we could only say that a certain percentage of children treated with a thiopurine type drug developed serious bone marrow failure. Once we learned what the pathophysiology was , testing could be done to see who comprised that percentage and the coarse grain became fine.

Cosmic Justice as a medical ethical imperative

Thomas Sowell speaks of "Cosmic Justice". Is the" justice" appended to the ethical precepts of medicine this type of justice.Sowell in his book " The Quest for Cosmic Justice" argues that the traditional American justice is basically applying the same rules and standards to everyone. This is in contrast to "Social Justice" which involves redressing those inequalities that proponents characterize as the fault of society.Sowell argues further that social justice proponents seek not to just correct the sins of man (or society) but "the oversights of God or the accidents of history" as they bring about inequalities.So social justice is really cosmic justice.

The "big four" medical moral principles are respect for autonomy,beneficence,non-malficence and justice. ( Beauchamp, T;& Childress, J. (2001) Principles of Biomedical Ethics. 5 th ed. Oxford Univeristy Press, Oxford) Justice is the most recent on the ethics scene and the one , I believe, most difficult for physicians to wrap their minds around. Some would argue for a big three leaving out justice as it may conflict with the beneficence clause. But the establishment's party line includes it and is increasing being emphasized. And the justice that is proposed is "social justice". (Medical Professionalism in the New Millenium. A Physician charter. Annl Int Med 5 Feb 2002. VOl 136, pg 243-246)
Executing the first three may be difficult in a individual case but conceptually seem easier.Do no harm, respect the autonomy of the patient and act to benefit the patient. These resonate with what happens most of the time in a doctor patient encounter. But Justice is less clear. In the world of social justice it has to do with "allocation of [scarce] medical resources"How does one make that operational? It can only be made operational through population based assessments and recommendations .The individual practioner and his patient -concerned as they are-with their localized points of view cannot see the big picture and have to be told what to do by the guideline writers and the cost benefits analysis experts. To value the good of the group-as impossible as that is to delineate-above the good of the individual patient is not to start on a slippery slope , it is to go off the cliff.

The last gulp of "Sodi water" ? Once again a large RCT trumps a meta-analysis

As early as the mid 1960's an infusion of glucose, insulin and potassium was being used to treat myocardial infarctions having been introduced by Dr Demetri Sodi-Pollares.Over the years a number of small clinical trials seem to indicate the value of this "polarizing solution" that-at least when I was a house office- was known as sodi water.Also a meta-analysis indicated its efficacy. Now a very large (n=20,201)RCT has shown it to be of no value some 40 years after its introduction.
The CREATE-ECLA RCT was conducted in 470 centers through out the world and showed no difference in mortality,cardiac arrest or shock in patients with STEMI treated with the GIK solution.
Once again a large RCT provided results contrary to an earlier meta-analysis.Why does this happen? The usual suspects are: publication bias and poor methodology in some of the trials included in the meta-analysis.Adding up a number of questionable trials does not equal one large well done trial.

Two underwhelming articles from this week and Kudos to the Cleveland Clinic

Carratala et al from Barcelona writing in The Feb. 1, 2005 issue of the Annals of Internal Medicine offer rather weak data suporting the predictive value of the PSI (Pneumonia Severity Index). Patients in PSI categories II and III were randomized to outpatient treatment with oral levofloxacin or in patient treatment with I.V. levofloxacin. The results were about the same in terms of complications, etc but the outpatients were more satisfied with their care. It seemed fairly obvious prior to this article that if patients are not too sick with community acquired pneumonia outpatient oral antibiotic therapy is adequate and patients would generally rather not go to the hospital.
Even more obvious and expected were the results of an article by Smith et al in the February 2, 2005 issue of JAMA.A survey was done on 32 private clinics in Colorado. Questionanaires were completed and the data showed that in 13.6 % of visits there was missing clinical information, eg lab reports, xray reports etc.Further the data showed that some finite amount of time was spent in searching for the records and that in the opinion of the responding physicians this might result in patient delays or additional services.So it seems that sometimes items are missing from charts and time will be spent trying to find them. Could not any physician who has ever worked any where have predicted these findings ?
To end on a more positive note,Cleveland Clinic's EMR performed impressively in notifying patients about the Vioxx issue. In less than 24 hours 11,699 letters were sent to patients regarding the rofecoxib recall. Details of their activites are found in an article by Jain et al in the Feb. 1, 2005 Annals of Internal Medicine.

Internists as "the doctors for adults"

The American College of Physicians published results of surveys that indicated that around half of those iterviewed said they did not know what an internist was and some of the other half had it wrong.The College has had a "Doctors for Adults" slogan for a number of years and uses it in its advertising,an effort whose aim, at least in part is to correct this ignorance.
One wonders how this slogan differentiates internists from family physicians who also see adults with the same range of medical problems as an internists.Actually,the typical family practice doctor sees and treats more adult problems because of their training in and presumably comfort in managing office orthopedic and office gynecology problems.
At least some in the American College of Physicians want internists to be more like family practioners if the content of some of the recent ACP meetings is any indication.The offerings have including reviews of office gynecology, and woman's health issues and even a mini course in how to do skin biopsies. If an internist is concerned with a nevus on his arm,how likely is it he will say "I think I need to go to an internist to get a biopsy"? Will an internist with irregular periods likely consult with an another internist rather than a gynecologist?
Surveys show the average incomes from family practice doctors and general internists are about the same. So the third payer distorted "market place" does not seem to value internists services more than FPs and surveys indicate many patients do not know the differences anway- if there are any.
As there is more and more pressure to treat hypertension, diabetes etc with guidelines,what extra can the internists offer as any physician presumably can read and carry out the guides? As an internist,I want to believe there are "extras".
The medical landscape has changed so much since I received my internist credentials over thirty years ago that it is hard to rationalize a career choice in general inernal medicine today.There is mananged care pressure from one side and competition from family practice-not to mention nurse practioners and physicians assistants- from the other side.The American College of Physicians offers only a lame slogan,courses in how to be more like a family practice doctor,and exhorts its members to somehow help achieve "social justice" i.e. a "fair" distribution of "scarce" health care resources.