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- August 30, 2010
- 08:15 PM
- 40 views
Cannabis for chronic pain: Are we there yet?
by PalMD in White Coat Underground
Marijuana is pretty popular stuff, and for good reason. It is a potent drug, capable of both making someone feel good and of reinforcing dependence pathways in the brain. Cannabis has been lauded for its ability to treat nearly any unpleasant symptom (except perhaps dry mouth), but so far evidence other than the anecdotal has [...]... Read more »
Mark A. Ware MBBS, Tongtong Wang PhD, Stan Shapiro PhD, Ann Robinson RN, Thierry Ducruet MSc,, & Thao Huynh MD, Ann Gamsa PhD, Gary J. Bennett PhD, Jean-Paul Collet MD PhD. (2010) Smoked cannabis for chronic neuropathic pain: a randomized controlled trial (Early e-release). Canadian Medical Association Journal. info:/10.1503/cmaj.091414
- August 25, 2010
- 05:15 PM
- 42 views
You gotta have heart—Just ask PZ
by PalMD in White Coat Underground
About a year and a half ago I injured my back fairly severely. I was relatively immobile for several days (although I continued to work), and one night the pain became so unbearable that I took a (appropriately-prescribed) narcotic pain reliever. A short while later I was able to move around a bit better, but [...]... Read more »
Hlatky, M., Boothroyd, D., Bravata, D., Boersma, E., Booth, J., Brooks, M., Carrié, D., Clayton, T., Danchin, N., & Flather, M. (2009) Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials. The Lancet, 373(9670), 1190-1197. DOI: 10.1016/S0140-6736(09)60552-3
Hansson, G. (2005) Inflammation, Atherosclerosis, and Coronary Artery Disease. New England Journal of Medicine, 352(16), 1685-1695. DOI: 10.1056/NEJMra043430
Serruys, P., Morice, M., Kappetein, A., Colombo, A., Holmes, D., Mack, M., Ståhle, E., Feldman, T., van den Brand, M., Bass, E.... (2009) Percutaneous Coronary Intervention versus Coronary-Artery Bypass Grafting for Severe Coronary Artery Disease. New England Journal of Medicine, 360(10), 961-972. DOI: 10.1056/NEJMoa0804626
- August 24, 2010
- 03:33 PM
- 56 views
Every patient is an experiment
by PalMD in White Coat Underground
Mrs. Charbin’s blood pressure just kept going up. She felt fine—no chest pain, no shortness of breath, no headaches—but the numbers put her at risk. At 55, her risk of developing heart disease at some point in her life is high, and is made even higher by her hypertension. For each 20 mm Hg rise [...]... Read more »
Aram V. Chobanian, MD; George L. Bakris, MD; Henry R. Black, MD; William C. Cushman, MD; Lee A. Green, MD, MPH; Joseph L. Izzo, Jr, MD; Daniel W. Jones, MD; Barry J. Materson, MD, MBA; Suzanne Oparil, MD; Jackson T. Wright, Jr, MD, PhD; Edward J. Roccella. (2003) The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 Report--Correction. JAMA: The Journal of the American Medical Association, 290(2), 197-197. DOI: 10.1001/jama.290.2.197
The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group, . (2002) Major Outcomes in High-Risk Hypertensive Patients Randomized to Angiotensin-Converting Enzyme Inhibitor or Calcium Channel Blocker vs Diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA: The Journal of the American Medical Association, 288(23), 2981-2997. DOI: 10.1001/jama.288.23.2981
- August 22, 2010
- 11:31 AM
- 57 views
Sinus infections: what we do and don’t know
by PalMD in White Coat Underground
Acute sinusitis—a “sinus infection”—is one of the most common problems seen by primary care physicians. The current preferred terminology is “acute rhinosinusitis”, a term which is more descriptive of how the disease works (its “etiology”). In most cases, a patient will first develop cold or allergy symptoms including a runny, congested nose (“rhinitis”). The swelling [...]... Read more »
Hickner JM, Bartlett JG, Besser RE, Gonzales R, Hoffman JR, Sande MA, American Academy of Family Physicians, American College of Physicians-American Society of Internal Mediciine, Centers for Disease Control, & Infectious Diseases Society of America. (2001) Principles of appropriate antibiotic use for acute rhinosinusitis in adults: background. Annals of internal medicine, 134(6), 498-505. PMID: 11255528
Snow V, Mottur-Pilson C, Hickner JM, American Academy of Family Physicians, American College of Physicians-American Society of Internal Medicine, Centers for Disease Control, & Infectious Diseases Society of America. (2001) Principles of appropriate antibiotic use for acute sinusitis in adults. Annals of internal medicine, 134(6), 495-7. PMID: 11255527
ZABOLOTNYI, D., KNEIS, K., RICHARDSON, A., RETTENBERGER, R., HEGER, M., KASZKINBETTAG, M., & HEGER, P. (2007) Efficacy of a Complex Homeopathic Medication (Sinfrontal) in Patients with Acute Maxillary Sinusitis: A Prospective, Randomized, Double-Blind, Placebo-Controlled, Multicenter Clinical Trial. EXPLORE: The Journal of Science and Healing, 3(2), 98-109. DOI: 10.1016/j.explore.2006.12.007
- August 18, 2010
- 11:22 AM
- 66 views
Vitamin D
by PalMD in White Coat Underground
Vitamin D is a fascinating molecule with a fascinating story. Historically, “vitamins” were defined as chemicals that humans required from their environment that were “vital” to human health. These chemicals were needed only in very small amounts to prevent disease; an absence of a particular vitamin in the diet led to a specific deficiency disease: [...]... Read more »
Holick, M. (2007) Vitamin D Deficiency. New England Journal of Medicine, 357(3), 266-281. DOI: 10.1056/NEJMra070553
Rajakumar, K. (2003) Vitamin D, Cod-Liver Oil, Sunlight, and Rickets: A Historical Perspective. PEDIATRICS, 112(2). DOI: 10.1542/peds.112.2.e132
Brannon PM, Yetley EA, Bailey RL, & Picciano MF. (2008) Overview of the conference "Vitamin D and Health in the 21st Century: an Update". The American journal of clinical nutrition, 88(2). PMID: 18689388
- August 13, 2010
- 04:07 PM
- 80 views
To live deep and suck out all the marrow of life
by PalMD in White Coat Underground
There are few procedures in medicine more complex, dangerous, and remarkable than stem cell transplantation. This procedure has enabled us to successfully treat cancers that were previously uniformly fatal. For certain types of acute myeloid leukemia, for example, stem cell transplant increases 5-year survival from less than 15% to about 44%. But the full story [...]... Read more »
Hsieh, M., Kang, E., Fitzhugh, C., Link, M., Bolan, C., Kurlander, R., Childs, R., Rodgers, G., Powell, J., & Tisdale, J. (2009) Allogeneic Hematopoietic Stem-Cell Transplantation for Sickle Cell Disease. New England Journal of Medicine, 361(24), 2309-2317. DOI: 10.1056/NEJMoa0904971
- August 12, 2010
- 03:00 AM
- 22 views
Homeoprophylaxis: An idea whose time has come—and gone
by Peter Lipson in Science-Based Medicine
One of the strengths of modern medical education is its emphasis on basic science. Conversely, the basic weakness of so-called alternative medicine is its profound ignorance of science and its reliance on magical thinking. Nowhere is this more apparent than in the attempts of altmed cults to conduct and publish research. From “quantum water memory” [...]... Read more »
Bracho, G., Varela, E., Fernández, R., Ordaz, B., Marzoa, N., Menéndez, J., García, L., Gilling, E., Leyva, R., & Rufín, R. (2010) Large-scale application of highly-diluted bacteria for Leptospirosis epidemic control. Homeopathy, 99(3), 156-166. DOI: 10.1016/j.homp.2010.05.009
- July 8, 2010
- 03:13 PM
- 88 views
Confound it!
by PalMD in White Coat Underground
This article is going to be about sex. I promise. But first, some reflections.
Well, Pepsipocalypse continues. The Management pulled the ill-conceived PepsiCo nutrition blog, which is a Good Thing. This doesn't change my misgivings about what has happened. As many other bloggers have already stated, the Pepsi fiasco is a single, highly-public event, but there are non-public problems that are important to some bloggers, including me.
Removing the "advertorial" blog was the right thing for SEED to do. It removes a clear ethical conflict (remember, this isn't about PepsiCo, it's about ScienceBlogs). But significant damage has been done. That being said, I write because I like to write, and whether I stay at Sb or move on to another venue, I'm going to keep doing this. If I move, you'll be nearly the first to know.
Anyway, it turns out that having sex predisposes you to sexually transmitted infections (STIs). What, you don't believe me? It's science!
A study published this week in the Annals of Internal Medicine looked at (male) users of erectile dysfunction drugs and rates STIs both before and after having them prescribed.
It should come as no surprise that men who have sex more are more at risk for STIs. The interesting twist here is that we generally think of STIs as being diseases of young people, and erectile dysfunction as being a disease of older people.
A recent article for the BMJ journal Sexually Transmitted Infections found that older people who "swing" have a high rate of STIs. This is also not surprising, but what was surprising was that so many older people swing. (The study was done in the Netherlands, and maybe they do things differently there, but I'm probably just naive.)
Studies have suggested that older folks have a lot more sex than their kids would like to imagine, and our ability to keep people relatively healthy as they age makes this plausible and possible. This gives us a lot to chew on. I write prescriptions for ED drugs all the time, but do I counsel all of these patients properly? The Annals article pointed out that:
Although middle-aged and older adults generally take fewer risks with their health, their decreased need for contraception may imply less-than-optimal safe sexual practices compared with younger populations.One interesting tidbit from this study was that HIV was one of the most common STIs. I certainly have counseled older folks who are "back on the market" about safe sex, but this article certainly drives home the need to be even more vigilant.
References
Dukers-Muijrers, N., Niekamp, A., Brouwers, E., & Hoebe, C. (2010). Older and swinging; need to identify hidden and emerging risk groups at STI clinics Sexually Transmitted Infections DOI: 10.1136/sti.2009.041954
Anupam B. Jena, MD, PhD; Dana P. Goldman, PhD; Amee Kamdar, PhD; Darius N. Lakdawalla, PhD; and Yang Lu, PhD (2010). Sexually Transmitted Diseases Among Users of Erectile Dysfunction Drugs: Analysis of Claims Data
Annals of Internal Medicine, 153 (1), 1-7... Read more »
Dukers-Muijrers, N., Niekamp, A., Brouwers, E., & Hoebe, C. (2010) Older and swinging; need to identify hidden and emerging risk groups at STI clinics. Sexually Transmitted Infections. DOI: 10.1136/sti.2009.041954
Anupam B. Jena, MD, PhD; Dana P. Goldman, PhD; Amee Kamdar, PhD; Darius N. Lakdawalla, PhD; and Yang Lu, PhD. (2010) Sexually Transmitted Diseases Among Users of Erectile Dysfunction Drugs: Analysis of Claims Data . Annals of Internal Medicine, 153(1), 1-7. info:/
- June 29, 2010
- 03:32 AM
- 103 views
"A state of institutional denialism"
by PalMD in White Coat Underground
Over a quarter century ago, a young woman was admitted to a New York hospital with fever and agitation. She never walked out. Libby Zion died while under the care of he primary care doctor and two medical residents. The exact cause of death was never identified, but the case led to a forced examination of medical residents' work hours. This was driven largely by Zion's father who felt that his daughter had been killed by inexperienced, poorly supervised, and overworked resident physicians.
"You don't need kindergarten," he wrote in a New York Times op-ed piece, "to know that a resident working a 36-hour shift is in no condition to make any kind of judgment call -- forget about life-and-death."
It was largely thanks to Zion's tireless work that in 1989 a bill was passed in New York State limiting resident work hours and requiring senior physicians to be physically present in the hospital. But though you might not need kindergarten to recognize this problem, you do need data. That came later.
Medical residents have traditionally worked long hours, especially in their first ("intern") year. In fact, they used to "reside" in the hospital, and were universally young, male, and single. Now, graduating medical students are about 48% female, compared to just over 26% in 1982 (although age hasn't changed much, which sort of surprised me). The Libby Zion law limited resident work hours to 80 hours per week and 24 hour shifts. During my internship in Chicago, we would typically work about 32 hours in a row on call and post-call, and call took place every fourth night, which has long been typical for internal medicine residencies. In 2003, the Accreditation Council on Graduate Medical Education (ACGME) instituted the first national work hour limitations for residents. These limitations looked very similar to those imposed by NY state. These work hour limitations required significant changes to how hospitals and residencies were run. Hospitals can only support a certain number of residents, and they count on these residents and the care they provide. Hospitals have had to reduce the number of patients cared for by residents, and has led to an increase in so-called mid-level providers (physician assistants and nurse practitioners). And residencies had to find ways to accomplish the same or similar amount of work with the same personnel but with significant time constraints. Many of these changes involved a more toward "shift work" and night float systems, where residents worked shifts of limited hours throughout a 24 hour day, handing off patients to the next shift. This creates its own problems for both patients and residents. There are concerns that shift work may lead to a disruption in continuity of care, since patients are being "handed off" potentially several times a day. Also, residents are not supposed to be performing functions that are primarily "service" rather than educational. During the day, residents can break away from clinical duties for educational conferences, but a 11pm-7am shift is all service.These, and the urgent questions about the safety of both patients and residents were addressed in a comprehensive report released in 2009 by the Institute of Medicine, part of the National Academies. While it makes sense that long sleep-free work hours might be dangerous to both patients and residents, knowing the data allows us to make proper, evidence-based decisions about these potential problems.Resident SafetyAs medical educators, we have a duty to our residents to ensure not only their education, but their well-being, at least as it relates to work. It is conceivable that long, sleepless work hours may have adverse health effects. The 2009 IOM report summarizes some of the evidence for fatigue-related injury. Much of this evidence is readily available through PubMed. Needle stick injuries, for example, are a relatively common problem and there is evidence that these are related to fatigue. There is also good evidence that medical residents have an elevated risk for falling asleep at traffic lights and being involved in motor vehicle accidents. And these data are not new.Patient SafetyData on patient safety isn't new either. A name that pops up again and again in this research is Charles A. Czeisler. He published a study in the New England Journal of Medicine in 2004 showing fairly convincingly that first-year residents in the ICU are at risk of committing significantly more medical errors when working extended shift vs. less onerous ones. That's just one good study of many.Individual errors are inevitable, but as a phenomenon, errors can be reduced significantly, often through simple systems fixes. One of these fixes is the implementation of reasonable resident work hours.Denialism?Responses in the literature and in doctors' lounges have been tangential and almost intentionally obtuse. A colleague of mine at another institution has opined that the medical profession is in a state of "institutional denialism" about the effect of long hours on safety and performance. I don't think that is unfair. The evidence on this has existed for years, yet we've made only cosmetic adjustments to our training programs. Even the latest ACGME rules (which take effect in July 2011) fail to address the most significant implications of the problem. The work hour limitations they mandate will very likely help, but there is a larger systemic problem. Medical training is lengthy and expensive. If we're going to cut back on hours, we need to re-evaluate whether the new hours are sufficient to meet educational needs. If not, we are going to have to find a way to fund longer training programs and to fund the debt-ridden trainees who will spend extra years not paying their educational debt. Quick fixes, even smart ones, aren't going to do the trick. The Libby Zion case that eventually led to the new work rules was over a quarter century ago. How long will it take us to create real, comprehensive solutions? References
Fisman, D., Harris, A., Rubin, M., Sorock, G., & Mittleman, M. (2007). Fatigue Increases the Risk of Injury From Sharp Devices in Medical Trainees: Results From a Case‐Crossover Study• Infection Control and Hospital Epidemiology, 28 (1), 10-17 DOI: 10.1086/510569 Trinkoff, A., Le, R., Geiger‐Brown, J., & Lipscomb, J. (2007). Work Schedule, Needle Use, and Needlestick Injuries Among Registered Nurses • Infection Control and Hospital Epidemiology, 28 (2), 156-164 DOI: 10.1086/510785
... Read more »
Fisman, D., Harris, A., Rubin, M., Sorock, G., & Mittleman, M. (2007) Fatigue Increases the Risk of Injury From Sharp Devices in Medical Trainees: Results From a Case‐Crossover Study • . Infection Control and Hospital Epidemiology, 28(1), 10-17. DOI: 10.1086/510569
Trinkoff, A., Le, R., Geiger‐Brown, J., & Lipscomb, J. (2007) Work Schedule, Needle Use, and Needlestick Injuries Among Registered Nurses • . Infection Control and Hospital Epidemiology, 28(2), 156-164. DOI: 10.1086/510785
Steele, M., Ma, O., Watson, W., Thomas, H., & Muelleman, R. (1999) The Occupational Risk of Motor Vehicle Collisions for Emergency Medicine Residents. Academic Emergency Medicine, 6(10), 1050-1053. DOI: 10.1111/j.1553-2712.1999.tb01191.x
Barger LK, Cade BE, Ayas NT, Cronin JW, Rosner B, Speizer FE, Czeisler CA, & Harvard Work Hours, Health, and Safety Group. (2005) Extended work shifts and the risk of motor vehicle crashes among interns. The New England journal of medicine, 352(2), 125-34. PMID: 15647575
Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, Lilly CM, Stone PH, Lockley SW, Bates DW.... (2004) Effect of reducing interns' work hours on serious medical errors in intensive care units. The New England journal of medicine, 351(18), 1838-48. PMID: 15509817
Gaba DM, & Howard SK. (2002) Patient safety: fatigue among clinicians and the safety of patients. The New England journal of medicine, 347(16), 1249-55. PMID: 12393823
Nuckols TK, Bhattacharya J, Wolman DM, Ulmer C, & Escarce JJ. (2009) Cost implications of reduced work hours and workloads for resident physicians. The New England journal of medicine, 360(21), 2202-15. PMID: 19458365
- June 14, 2010
- 05:33 PM
- 136 views
Plumbing the depth of quackery at HuffPo
by PalMD in White Coat Underground
One of the questions addressed in this space is, "what makes a particular condition susceptible to quackery?" Some of the common features we've seen over time are: Diverse and protean symptoms: fatigue, "brain fog", diffuse pain, and other vague symptoms are often used as diagnostic criteria for controversial entities such as morgellons and chronic Lyme disease. Lack of diagnostic certainty: there are no definitive tests to make the diagnosis of chronic Lyme disease or morgellons (or fibromyalgia for that matter) making objective diagnosis difficult. Children affected: autism affects children (and of course their parents) and our natural desire to protect children makes us vulnerable. There are a number of ways that quacks can churn out their product using just these three trends. When a patient suffers from generalized fatigue or malaise but a good work up fails to reveal a specific problem, a real doctor will listen carefully and take a cautious wait-and-see approach. A quack will rush into action, applying unproven treatments and even making up their own diseases. Making up a disease may sound easy but if you want people to really buy it, you need to follow a few principles. You have to make it sound plausible to lay people, and you have to create the best kind of lie---the one based on a nidus of truth. It helps if you have tests---everyone loves tests. Diagnostic testing is a complex field. Tests need to be validated in several different ways so that any test's characteristics are well understood. For example, if I want to use a hemoglobin A1C level to diagnose and follow diabetes, I need to know how results are distributed across the population of interest, I need to know how well the test itself technically works, and I need to know how well it works statistically. Without this information, the test result is meaningless. Quacks get around this in a few different ways: they make up their own tests; they misinterpret tests by, for example, re-define the normal range in proven tests or giving a result meaning that it does not have; they send tests to labs with less "stringent" quality controls; they use tests that have not been proven to show what they claim.All this is by way of introduction to another crappy piece in the Huffington Post. The piece, "Why Lead Poisoning May Be Causing Your Health Problems," is by Mark Hyman, a doctor and non-toxicologist. The title seems to imply that lead poisoning is common and causes just about everything. Hyman claims that "[n]early 40 percent of us have toxic levels of lead in our bodies." If this is true, this is potentially one of the greatest public health problems we have ever faced. Lead exposure affects children and adults unequally. The reason so much effort is focused on young children and lead is that lead has a devastating affect on a growing, developing child. Lead intoxication in kids leads to all sorts of serious problems including anemia and abnormal cognitive development. Although childhood lead levels in the U.S. are declining, there is still reason to be concerned. In the last reporting period (1999-2004) about 1.4% of American children had lead levels above 10 mcg/dL, the level usually considered problematic. Recent research is giving us reason to be less sanguine about lower lead levels as well (see references). Even blood levels below 7.5 mcg/dL are correlated with decreased intellectual function, although the data are a bit murky. In adults, the effects are less clear. Leaving aside occupational lead exposures, there is some evidence that environmental lead exposures cause cognitive problems in adults and may also contribute to hypertension and other common problems, but it's hard to draw conclusions about causation. Differentiating chronic and acute lead exposure and its effects is a significant problem in adults. States are responsible for collecting data and use different cut-offs but according to the data that are available (2005), the average rate of elevated blood lead levels in U.S. adults is about 8.7/100,000. To get a more complete picture, we would have to use other measurements for adults in addition to blood. But even a worst-case scenario of adults plus children brings us nowhere near the 40% figure cited by asserted by Hyman. While Hyman's alarmist statistics may not be anywhere near accurate, one of his basic premises is: lead is dangerous to children and too adults, even at levels lower than traditionally measured. After that, he flies right off the rails.He describes very much overplays the state of the research into adult lead toxicity. It appears to be correlated with a number of common health problems, but that's where it ends for now. There is not yet convincing data to show a strong causal relationship between low lead levels and common health problems. The data is certainly concerning enough to continue reducing human lead exposure, but beyond that, things are murky. For some reason, after describing the potential damage caused by lead exposure he states seemingly out of nowhere:Wow! Take a moment to digest that. Chelation therapy saves lives and billions of dollars. But your doctor probably isn't offering this as standard treatment, because, as I have said many times, doctors don't learn two of the most important things in medical school: How to help people improve their nutrition and how to deal with environmental toxins.Chelation for lead poisoning is indicated only when lead levels are very high. At lower levels, avoiding the source of the lead is the treatment of choice. There is no evidence that chelating adults or children with low lead levels leads to positive outcomes. With avoidance alone, children with elevated lead levels get better. There is no ev... Read more »
Jusko, T., Henderson, C., Lanphear, B., Cory-Slechta, D., Parsons, P., & Canfield, R. (2007) Blood Lead Concentrations . Environmental Health Perspectives, 116(2), 243-248. DOI: 10.1289/ehp.10424
Lanphear BP, Hornung R, Khoury J, Yolton K, Baghurst P, Bellinger DC, Canfield RL, Dietrich KN, Bornschein R, Greene T.... (2005) Low-level environmental lead exposure and children's intellectual function: an international pooled analysis. Environmental health perspectives, 113(7), 894-9. PMID: 16002379
Hu, H., Shih, R., Rothenberg, S., & Schwartz, B. (2006) The Epidemiology of Lead Toxicity in Adults: Measuring Dose and Consideration of Other Methodologic Issues. Environmental Health Perspectives, 115(3), 455-462. DOI: 10.1289/ehp.9783
Shih, R., Glass, T., Bandeen-Roche, K., Carlson, M., Bolla, K., Todd, A., & Schwartz, B. (2006) Environmental lead exposure and cognitive function in community-dwelling older adults. Neurology, 67(9), 1556-1562. DOI: 10.1212/01.wnl.0000239836.26142.c5
Liu X, Dietrich KN, Radcliffe J, Ragan NB, Rhoads GG, & Rogan WJ. (2002) Do children with falling blood lead levels have improved cognition?. Pediatrics, 110(4), 787-91. PMID: 12359796
- June 3, 2010
- 03:00 AM
- 155 views
Narcotic treatment contracts and the state of the evidence
by Peter Lipson in Science-Based Medicine
Opium derivatives—and later, synthetic opioids—have probably been used for millennia for the relief of pain. Given human biology, they’ve probably been abused for just as long. Opiate use disorders are a daily fact for primary care physicians; the use of these drugs has become more and more common for chronic non-cancer pain. [...]... Read more »
Starrels JL, Becker WC, Alford DP, Kapoor A, Williams AR, & Turner BJ. (2010) Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Annals of internal medicine, 152(11), 712-20. PMID: 20513829
- June 2, 2010
- 07:03 PM
- 115 views
Narcotic treatment contracts and the state of the evidence
by PalMD in White Coat Underground
Not an opium poppy
I took this picture a couple of days ago. This poppy popped up as a volunteer in my front bed. It's about four feet tall and the flower is about 5 cm in diameter. It's not an opium poppy, but it could pass, and I've been looking for an excuse to use the picture.
Opium derivatives---and later, synthetic opioids---have probably been used for millennia for the relief of pain. Given human biology, they've probably been abused for just as long. Opiate use disorders are a daily fact for primary care physicians; the use of these drugs has become more and more common for chronic non-cancer pain. These medications are very effective in the treatment of pain, but come with a lot of undesired effects, not least among them the potential of developing a substance use disorder. They also have considerable street value, with Vicodin selling for $5-$10 per tablet on the illicit market.
But our options for the treatment of pain are not unlimited. Non-steroidal anti-inflammatory medications such as ibuprofen are not safe in all patients, and are not always effective. A multi-modal approach to the treatment of chronic pain can be very helpful, but many patients do not have access to this expensive treatment, and many more simply want instant relief, something which opiates can provide, but with a price.
The abuse of prescription opiates is on the rise. Continuing with Vicodin as an example, 9.3% of American 12th graders reported using Vicodin illicitly in a recent survey. From 1994 to 2002, the mention of hydrocodone---the narcotic in vicodin--in emergency center charts increased 170%. This is a big problem.
So we have two big problems: chronic pain, and narcotic abuse. How can we treat chronic pain and avoid contributing to substance use disorders and drug diversion? One strategy has been the use of so-called narcotic contracts, which we've discussed at length. But absent from that discussion was the evidence.
Before we look at this evidence, we must re-examine our reasons for using these contracts. In my own practice, we generally use them to protect ourselves from becoming involuntary drug dealers, and to prevent patients from abusing the narcotics we prescribe. So how are we doing with that? I can't answer the first question, but the second was subjected to a systematic review published in the current issue of Annals of Internal Medicine. One of the primary findings of this review was that this question has not been well-studied. The few studies that are out there do not measure some of the most important end-points, such as abuse, dependence, overdose, and death. They also don't focus on primary care offices, the setting in which these drugs are often prescribed. The limited data available point toward a reduction in narcotic misuse with the use of treatment contracts. They conclude:
Our systematic review reveals that weak evidence supports the use of opioid treatment agreements and urine drug testing to reduce opioid misuse, despite the theoretical benefits of these strategies. This lack of evidence may explain in part why they have not been widely adopted in primary care.
I'm not as optimistic as the authors that it is the lack of evidence driving practice here. Leaving that aside, they make some interesting points regarding plausibility, attitudes, and the use of evidence. With regard to narcotic treatment contracts and urine drug testing they write:
Even in the absence of strong evidence, several compelling reasons for physicians to consider implementing these strategies exist. First, primary care providers who use opioid treatment agreements report improved satisfaction, comfort, and sense of mastery in managing chronic pain. Second, management strategies that include treatment agreements have been associated with reductions in emergency department visits in observational studies. Third, cross-sectional studies and a case series have demonstrated that urine drug testing is a valuable tool to detect use of nonprescribed drugs and confirm adherence to prescribed medications beyond that identified by patient self-report or impression of the treating physician. Finally, implementing routine urine drug testing may improve the provider-patient relationship and clinic morale, as suggested in a letter to the editor.
This is a clearly written and subtle approach to the use of a plausible but not-yet-proved modality, and is a nice example of one way to approach the dark zones of data in science-based medicine. They give a rationale for pursuing further research (the importance and scale of the problem of narcotic misuse, and the dearth of good evidence for current practices). And they give some plausible reasons why we might continue to use this as-yet unproved modality. But they do not overplay the current state of research, or make hyperbolic conclusions.
Science-based medicine does not always give us clear guidelines to care, but often leaves us with more questions to answer. This is one way to approach a difficult problem with incomplete data.
References
Starrels JL, Becker WC, Alford DP, Kapoor A, Williams AR, & Turner BJ (2010). Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Annals of internal medicine, 152 (11), 712-20 PMID: 20513829... Read more »
Starrels JL, Becker WC, Alford DP, Kapoor A, Williams AR, & Turner BJ. (2010) Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Annals of internal medicine, 152(11), 712-20. PMID: 20513829
- May 24, 2010
- 10:03 PM
- 139 views
Too many too soon?
by PalMD in White Coat Underground
Too many too soon: that's Jenny McCarthy's rallying cry. The disingenuous activists of the antivaccine movement use this motto as a foot in the door, claiming that they are not truly "anti-vaccine", just pro-"safe vaccines". This is despite the fact that vaccines have proved themselves to be one of the safest and most effective medical interventions in human history. Pediatricians in the community are struggling with the fallout of the antivaccine propaganda, having to spend their finite patient-care hours trying to explain to parents why they should vaccinate their children properly. While they are fighting this difficult but good fight, popular celebrity doctors such as Dr. Bob Sears and Dr. Jay Gordon are shouting about the horrors of evidence-based vaccination and offering their own made-up alternatives.In addition to promoting the resurgence of several infectious diseases, these "activists" have forced the medical and scientific community to waste valuable resources studying the same questions again and again. And when the question is answered, the infectious disease promoters yank up the goalposts and start running. There is no data set that will ever convince Jay Gordon, Jenny McCarthy, or Bob Sears that current vaccine recommendations are safe and effective. There is also no external evidence that will cause them to alter their own recommendations for "alternative schedules". But given the public health importance of vaccination, we are forced to counter the propaganda. A new study in the journal Pediatrics does just that. This study appears to have been designed to answer the questions frequently raised by antivaccine activists. When thimerosal was proved to be innocuous they moved on to "toxins". When this gambit failed, they moved on to "too many too soon". As this argument has unraveled, they have called for "vaccinated vs. unvaccinated" studies, prospective studies which follow children who are and are not vaccinated and look at different rates of autism. Epidemiologists have been all over the question of causation, but not surprisingly, the antivax crowd hasn't been satisfied with them to date. The new study adds another layer of evidence to what we already know: vaccines do not cause autism. But this study goes one step further and asks the question, "is it really 'too many too soon?'" The study's conclusion is in its title: "On-time Vaccine Receipt in the First Year Does Not Adversely Affect Neuropsychological Outcomes." The authors used vaccine data from several thousand children. They compared children who followed the recommended vaccination schedule in the first year of life vs. those who did not, and compared neurological outcomes 7-10 years later. The data were unequivocal: there were no significant neurologic problems present in the "off-schedule" group compared to the on-time group. This very strongly argues against "too many too soon". There are two rational complaints likely to be raised by the antivaccination crowd. One is potential conflicts of interests in the authors. Both authors have disclosed various types of financial support from drug companies in either research funding or speaking fees. This does not mean the data are tainted, but it does mean the data require close scrutiny. Neither the data nor conclusions in this study seem to suffer from undue influence, as far as I can tell from my reading. There is always the possibility of outright fraud, something that would be hard to detect in reading a study, but I see no reason to suspect this. Also, their data and conclusions track very closely with what we know from previous studies on vaccination and neurologic problems.The second question likely to be raised is whether this study captured the correct populations. The data make clear that when the recommended vaccination schedule is followed in the first year of life, there are no significant neurological sequelae in later childhood. But the study did not specifically look at "alternative vaccine schedules" such as those proposed by alternative doctors. It also did not specifically look at vaccination outside the first year of life. It did however divide the children into "most timely" and "least timely" groups too look for effects that might be missed in aggregate.This is a strong study. It seems likely that if vaccines given according to the recommended schedule during infancy were to lead to autism or other severe neurologic disorders, this study would have found an effect. Since autism usually manifests by age 2, it is unlikely that an exposure in the second or third year of life would contribute significantly to the development of autism. There is no such thing as "too many too soon"; it is simply another evidence-free attack on one of our safest and most effective public health measures. ReferencesMichael J. Smith, & Charles R. Woods (2010). On-time Vaccine Receipt in the First Year Does Not Adversely Affect Neuropsychological Outcomes Pediatrics, 125 (6), 1134-1141 : 10.1542/peds.2009-2489... Read more »
Michael J. Smith, & Charles R. Woods. (2010) On-time Vaccine Receipt in the First Year Does Not Adversely Affect Neuropsychological Outcomes. Pediatrics, 125(6), 1134-1141. info:/10.1542/peds.2009-2489
- May 6, 2010
- 03:00 AM
- 183 views
How do religious-based hospitals affect physician behavior?
by Peter Lipson in Science-Based Medicine
Science-based medicine is, among other things, a tool. Science helps us sequester our biases so that we may better understand reality. Of course, there is no way to avoid being human; our biases and our intuition still betray us, and when they do, we use other tools. Ethics help us think through situations using an [...]... Read more »
Stulberg, D., Lawrence, R., Shattuck, J., & Curlin, F. (2010) Religious Hospitals and Primary Care Physicians: Conflicts over Policies for Patient Care. Journal of General Internal Medicine. DOI: 10.1007/s11606-010-1329-6
- April 1, 2010
- 03:00 AM
- 242 views
Less salt: it’s that simple
by Peter Lipson in Science-Based Medicine
It has been known for decades that dietary sodium is significantly associated with hypertension and coronary heart disease. Despite this knowledge, Americans continue to consume more sodium, most of it coming from processed foods. Various approaches have been used to help individuals modify their behavior, one of the most popular of which is the DASH [...]... Read more »
Bibbins-Domingo K, Chertow GM, Coxson PG, Moran A, Lightwood JM, Pletcher MJ, & Goldman L. (2010) Projected effect of dietary salt reductions on future cardiovascular disease. The New England journal of medicine, 362(7), 590-9. PMID: 20089957
- February 23, 2010
- 03:35 PM
- 252 views
Platelet rich plasma
by PalMD in White Coat Underground
Several months ago, Dr. Val Jones wrote about a growing fad in the treatment of musculoskeletal disorders. The therapy, called platelet rich plasma (PRP) injection, involves taking a small amount of blood from a patient, spinning it down in a centrifuge, and then injecting the plasma component into...somewhere. This treatment is becoming increasingly popular, and can be very lucrative for doctors. But does it work?
Blood platelets are very biologically active particles and plasma is not a bland fluid. Platelets and plasma contain many biologically active molecules, some of which may be implicated in "healing". This gives PRP at least a veneer of plausibility, but like any other treatment, plausibility is only the first step.
There have been a few human studies of PRP. A recent article in the Journal of the American Medical Association (JAMA) showed no difference between PRP and saline injections for chronic Achilles tendon problems.
A small pilot study looked at PRP for the treatment of a particular periodontal disease, and found some possible benefit.
Another interesting study looked at PRPs affect on the healing of anterior cruciate ligament (ACL) grafts in the knee. This study included long term (two year) follow up, and found no benefit.
And that's really about it. There is little evidence to support platelet rich plasma for the treatment of anything. And yet it is being hyped and sold everywhere as a miracle cure for musculoskeletal injuries. Perhaps more studies will enlighten the issue further, but at this point, PRP is nothing but expensive snake oil, and those who promote and use it should re-examine the data and their ethics. References
de Vos RJ, Weir A, van Schie HT, Bierma-Zeinstra SM, Verhaar JA, Weinans H, & Tol JL (2010). Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. JAMA : the journal of the American Medical Association, 303 (2), 144-9 PMID: 20068208
Markou N, Pepelassi E, Vavouraki H, Stamatakis HC, Nikolopoulos G, Vrotsos I, & Tsiklakis K (2009). Treatment of periodontal endosseous defects with platelet-rich plasma alone or in combination with demineralized freeze-dried bone allograft: a comparative clinical trial. Journal of periodontology, 80 (12), 1911-9 PMID: 19961374
Nin JR, Gasque GM, Azcárate AV, Beola JD, & Gonzalez MH (2009). Has platelet-rich plasma any role in anterior cruciate ligament allograft healing? Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association, 25 (11), 1206-13 PMID: 19896041... Read more »
de Vos RJ, Weir A, van Schie HT, Bierma-Zeinstra SM, Verhaar JA, Weinans H, & Tol JL. (2010) Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial. JAMA : the journal of the American Medical Association, 303(2), 144-9. PMID: 20068208
Markou N, Pepelassi E, Vavouraki H, Stamatakis HC, Nikolopoulos G, Vrotsos I, & Tsiklakis K. (2009) Treatment of periodontal endosseous defects with platelet-rich plasma alone or in combination with demineralized freeze-dried bone allograft: a comparative clinical trial. Journal of periodontology, 80(12), 1911-9. PMID: 19961374
Nin JR, Gasque GM, Azcárate AV, Beola JD, & Gonzalez MH. (2009) Has platelet-rich plasma any role in anterior cruciate ligament allograft healing?. Arthroscopy : the journal of arthroscopic , 25(11), 1206-13. PMID: 19896041
- February 22, 2010
- 02:28 PM
- 265 views
Clinical Marijuana Research Update
by PalMD in White Coat Underground
Human beings are fundamentally narcissistic, and this narcissism can be antithetical to good science and good medicine. We place far too much confidence in our individual abilities to understand what happens to us, and we place far too much importance on our own experiences, inappropriately generalizing them. That's why science is so important in medicine---to avoid basing life-or-death decisions on something some guy thinks he might have heard once.
In my recent piece on medical marijuana in Forbes, commenters took me to task for what they perceived to be a host of errors in my reasoning. Some of these deserve to be specifically addressed, but not before a summary of the topic.
Marijuana's legal status is a political issue, not a scientific one. I will leave the politics to those cursed with such things. But I'm responsible for medical decisions, and as much as is possible, I have to look at data dispassionately. I have no doubt the individuals find marijuana beneficial for a wide range of problems---this may be a basis for study, but is not adequate data to prescribe a powerful pharmacologic agent.
In 2000, the University of California established the Center for Medicinal Cannabis Research. This month, they released a summary of results to date. The federal government has historically made it very difficult to study marijuana. The state of California, though specific legislation, was able to encourage a significant amount of research into the clinical use of marijuana, and this month's report is a summary of their work to date. So far CMCR has produced four published clinical studies and one poster/abstract.
The first study, by Abrams, et al, deals with painful HIV-associated sensory neuropathy (HIV-SN). This is a painful condition that can be caused by HIV infection or by certain treatments for HIV. This is a good place to start, as current treatments are disappointing. The study enrolled 55 patients with HIV-SN, and randomly assigned some to smoke real joints, and other to smoke joints with the cannabanoids extracted. Fifty patients completed the five-day study, with some encouraging results, but there are a few problems. First, it's unlikely that patients remained truly blinded to their assignment (unless they though the treatment group was given Grade F ditch weed). The authors recognized that unblinding might have been a problem. The authors also made an attempt to compare their data to studies of other drugs for this condition, but they did not compare cannabis directly to any other drug, including opioids.
This is a small study, and since the number needed to treat (NNT) found in this study and studies of other drugs was not dramatically different, head-to-head studies of marijuana, opioids, and standard drugs for this condition would be very useful. Given the benefits of opioids in a variety of pain conditions, including neuropathic pain, it would be important to compare the benefits and negative effects of opioids vs. marijuana. Finally, the authors concluded that the drug was generally safe during the five day study, as there were no major adverse events requiring subjects to drop out. I'm not certain this is a fair interpretation:
No patient withdrew from the study because of adverse events. One episode
of grade 3 dizziness related to study medication occurred in the cannabis group. One case of transient grade 3 anxiety possibly related to study medication was reported in each group. Both patients received a one-time dose of lorazepam.
These patients required a second medication to treat the symptoms of the drug. This may or may not be significant when compared to the level of pain relief or when compared to other drugs, but it cannot be concluded that the drug was entirely safe and well-tolerated, especially given what may be observed when there is more than 125 person-days of exposure.
A second study by Ellis, et al, also looked at painful HIV-related neuropathy, and addressed some of the issues with the Abrams study. This was also a small pilot study, but used a crossover design. The authors actually surveyed the subjects to see if they remained blinded, and by the end of the study, many subjects "knew" which toke was placebo and which was the good stuff. They also explicitly addressed one of the interesting questions that comes up in relation to marijuana research.
Because of funding mandates, these studies used smoked marijuana. Given the likely harm of long term smoking of anything, Ellis brought up the need to study non-smoked cannabis. Boosters often promote smoked cannabis as having "special" properties not available in extracts and derivatives, something these two studies, which each contained de-THC'd fatties, argue against this.
More important is that while these results are encouraging, they are not enough to make a clear medical recommendation. Two small pilot studies are not sufficient to make significant clinical recommendations. They may give us good reason to study the use of marijuana or its derivatives for the treatment of HIV-related painful sensory neuropathy. Hopefully future studies will include comparisons to standard therapy, and clearer evaluation of long-term effects of marijuana ingestion in these patients.
References
Abrams DI, Jay CA, Shade SB, Vizoso H, Reda H, Press S, Kelly ME, Rowbotham MC, & Petersen KL (2007). Cannabis in painful HIV-associated sensory neuropathy: a randomized placebo-controlled trial. Neurology, 68 (7), 515-21 PMID: 17296917
Ellis, R., Toperoff, W., Vaida, F., van den Brande, G., Gonzales, J., Gouaux, B., Bentley, H., & Atkinson, J. (2008). Smoked Medicinal Cannabis for Neuropathic Pain in HIV: A Randomized, Crossover Clinical Trial Neuropsychopharmacology, 34 (3), 672-680 DOI: 10.1038/npp.2008.120... Read more »
Abrams DI, Jay CA, Shade SB, Vizoso H, Reda H, Press S, Kelly ME, Rowbotham MC, & Petersen KL. (2007) Cannabis in painful HIV-associated sensory neuropathy: a randomized placebo-controlled trial. Neurology, 68(7), 515-21. PMID: 17296917
Ellis, R., Toperoff, W., Vaida, F., van den Brande, G., Gonzales, J., Gouaux, B., Bentley, H., & Atkinson, J. (2008) Smoked Medicinal Cannabis for Neuropathic Pain in HIV: A Randomized, Crossover Clinical Trial. Neuropsychopharmacology, 34(3), 672-680. DOI: 10.1038/npp.2008.120
- February 12, 2010
- 11:58 AM
- 160 views
A lurker in the forest
by PalMD in White Coat Underground
Human papillomavirus (HPV) is a fascinating little bugger. Certain strains can interfere with tumor suppressor genes leading to cancer, especially cervical, anal, and some mouth cancers. Other strains cause genital warts. The vaccine offered in the U.S. (Gardasil) protects against the two strains that cause most cancers and against two strains causing warts. The vaccine has the potential to change the way our population is affected by these diseases.
But we are still learning more about this virus. We know that HPV can be transmitted even without visible lesions. But where are these viruses hiding? A recent study in the Journal of Infectious Disease may have found one reservoir.
Researchers in Slovenia looked at some of the old data on HPV which suggested that pubic hair follicles might contain HPV. To investigate this further, they rounded up 53 Slovenian males with genital warts, and 53 males without warts to serve as controls. They then sampled the warts and plucked hairs from the scrotum, pubic area, and from around the anus. They used PCR to find and identify HPV DNA from the samples. HPV infections and HPV-related cancers are sexually transmitted, and are strongly affected by the immune system, and HPV-related cancers are particularly common in people with HIV, so the study subjects were screened for the presence of HIV and other immune diseases. The researches found significant differences between the two groups studied. Nearly 70% of subjects with warts had HPV isolated from hair samples, compared to about 13% of controls. Strains in the hair matched the strains from the warts present.
Now before you sign up for an expensive and uncomfortable series of sessions with the laser, there are some limitations to this study. The test group were people with warts, meaning they had active HPV disease. This means that while it is plausible that pubic hair serves as a reservoir for HPV, it is not clear if it actually does serve as a reservoir for transmission of the virus---it could be that hair follicles are only infected when there are other active lesions. Also, PCR is remarkably sensitive, so it's possible that the hair samples were contaminated by the warts (although the authors note that "a disposable pair of sterile tweezers and gloves were used for each individual." Comforting, that.).The results from this small study are intriguing, but simply reinforce the need for prevention of transmission via safer sexual practices and immunization. ReferencesPoljak, M., Kocjan, B., Potočnik, M., & Seme, K. (2009). Anogenital Hairs Are an Important Reservoir of Alpha‐Papillomaviruses in Patients with Genital Warts The Journal of Infectious Diseases, 199 (9), 1270-1274 DOI: 10.1086/597619... Read more »
Poljak, M., Kocjan, B., Potočnik, M., & Seme, K. (2009) Anogenital Hairs Are an Important Reservoir of Alpha‐Papillomaviruses in Patients with Genital Warts. The Journal of Infectious Diseases, 199(9), 1270-1274. DOI: 10.1086/597619
- February 1, 2010
- 03:01 PM
- 335 views
Success in the fight against childhood diarrhea
by Peter Lipson in Science-Based Medicine
Rotavirus is the world’s most common cause of severe childhood diarrhea. In the U.S. alone, rotavirus disease leads to around 70,000 hospitalizations, 3/4 million ER visits, and nearly half-a-million doctor office visits yearly. But it rarely causes death.
The same is not true for the developing world. Rotavirus disease is estimated to kill around a half-million [...]... Read more »
Madhi, S., Cunliffe, N., Steele, D., Witte, D., Kirsten, M., Louw, C., Ngwira, B., Victor, J., Gillard, P., Cheuvart, B.... (2010) Effect of Human Rotavirus Vaccine on Severe Diarrhea in African Infants. New England Journal of Medicine, 362(4), 289-298. DOI: 10.1056/NEJMoa0904797
Richardson, V., Hernandez-Pichardo, J., Quintanar-Solares, M., Esparza-Aguilar, M., Johnson, B., Gomez-Altamirano, C., Parashar, U., & Patel, M. (2010) Effect of Rotavirus Vaccination on Death from Childhood Diarrhea in Mexico. New England Journal of Medicine, 362(4), 299-305. DOI: 10.1056/NEJMoa0905211
Patel, N., Hertel, P., Estes, M., de la Morena, M., Petru, A., Noroski, L., Revell, P., Hanson, I., Paul, M., Rosenblatt, H.... (2010) Vaccine-Acquired Rotavirus in Infants with Severe Combined Immunodeficiency. New England Journal of Medicine, 362(4), 314-319. DOI: 10.1056/NEJMoa0904485
- January 27, 2010
- 07:00 PM
- 197 views
Whose demons?
by PalMD in White Coat Underground
"...It never was our guise To slight the poor, or aught humane despise: For Jove unfold our hospitable door, 'Tis Jove that sends the stranger and the poor..."---Homer: The Odyssey, Translation by Alexander PopeA few weeks ago, Drugmonkey wrote a piece about perceptions of drug users. Specifically, the study looked at how mental health providers perceive people with substance use disorders depending on whether the patients were referred to being a "substance abuser" vs. having "a substance use disorder." These data revealed something interesting. Among the mental health professionals:...those assigned the "substance abuser" term ... were significantly more in agreement with the notion that the character was personally culpable for his condition and more likely to agree that punitive measures be taken...[...][they were more likely]...to convey internal causal attribution and personal culpability, a moral vs. medical solution, suggesting the character has volitional control and might be viewed as a "perpetrator"who is willfully engaging in the behavior and thus more deserving of punishment.... Read more »
Kelly, J., & Westerhoff, C. (2009) Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms☆. International Journal of Drug Policy. DOI: 10.1016/j.drugpo.2009.10.010
Baldacchino A, Gilchrist G, Fleming R, & Bannister J. (2009) Guilty until proven innocent: A qualitative study of the management of chronic non-cancer pain among patients with a history of substance abuse. Addictive behaviors. PMID: 19897313
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