Welcome to Grand Rounds 8! I am delighted to host this week. Kudos to Nick who started it all. Grand Rounds was an idea waiting to happen.

I use this link as my permanent link to archived Grand Rounds – Undisclosed Location

Shrinkette will host next week’s Grand Rounds. For a daily aggregator of Medical Blogging check out – Medlogs

Race based medications

Kevin, M.D. reports on the The dawn of race-based medication.

Today, it was reported that a trial has shown that BiDil, a combination of hydralazine and isosorbide dinitrate, improved survival in blacks with congestive heart failure (CHF):

db (yours truly) also blogged on this issue – Race and CHF

We really need to better understand the underlying genetic predispositions that identify patients who benefit from this combination pill. Self-designated race gives only a modest clue to a patient’s genetics.

I applaud investigators, but caution all scientists to invest the effort to better understand the genetics and physiology suggested by these results.

Vitamin E

The antifaust discusses the vitamin E study –

I’m with DB on this one. The statement that high dose Vitamin E increases your risk of dying is indeed an overreaction. I think we should tell our patients that they should avoid taking supplemental Vitamin E because there is no proven benefit and it could be a waste of their hard-earned money. To say that they should stop because it could kill them is taking it too far.

A mentor once told us that we should give medicine not because they should work, but because they do work. Being an antioxidant, Vitamin E should help prevent death from cardiovascular disease, but according to the data, it doesn’t. I’m not going to scare my patients with this latest bit of medical doomsaying but I’m not going to defend Vitamin E supplementation either. I think it’s a practice no self-respecting physician should endorse.

A poignant story

Dr. Charles writes eloguently about a patient – 1982

I saw a black male patient last week who had just been released from jail. He was about 45 years-old, with thinning hair and thickening glasses. Despite his gentle voice and calm demeanor, I felt slightly uncomfortable in the room not knowing why he had been incarcerated.

The year was 1982. The Unabomber set off his first bomb. Rambo: First Blood was released to the delight of blood-thirsty masses everywhere. 241 United States Marines were killed in a bomb explosion at Beirut International Airport. The Soviets invaded Afghanistan. The Vietnam Veterans Memorial was dedicated in Washington, D.C.

My patient was convicted of grand theft auto.

A resident’s lament

From the Vertical Mattress – Sedation

Back in the old days (which in medicine are referred to in halcyon terms as “the Days of the Giants”) you didn’t need to fill out a dozen consent and privacy forms for studies (which, in the case of the infamous Tuskegee study where syphilitic men were studied for years without the treatment that was readily available in order to look at the long-term effects of the disease in a systematic way, was just plain unethical). Yes, it’s not particularly justifiable to get informed consent to randomize a patient to one of two different surgeries when the patient is drugged. But shit, it made for a bad day. I got bitched out in a paternal sort of way by my boss – as kind as he was trying to be, it stung when he brought out the “do I have to look over your shoulder? This is your study. If you want the responsibility and the accolades, you’ve got to be on the ball” argument. Man, I’m trying. A difference of two minutes… But he’s absolutely right: there’s no blaming anyone else. It’s all on my shoulders, and if I drop the ball, no one else will pick it up.

Overmedicated

James Baker, MD discusses – Are Children Overmedicated?

More typically, a harried physician has bowed to pressure from an exasperated case worker or teacher or parent to do a trial of medication in an attempt to manage behavior problems that have everyone feeling miserable. It takes time (and a tolerance for angry glares) to say “no,” and to insist that underlying causes of the behavior — undiagnosed learning disorders, marital conflict in the home, poverty — be addressed first.

Disease management

Matthew Holt writes a long, detailed rant on disease management – and why it may not be a panacea – QUALITY: DSM– Convincing anyone? Maybe. Improving health? Probably. Saving money? Probably not.

There’s a lot to chew on here, but the obvious conclusion is that while DSM is good for patients, it’s hard to get some patients into it and once you get past the really low hanging fruit, it may not be that good for the bank balances of the sponsoring plan/payer. That plans have been reluctant to do DSM is no new news. Don’t forget that most Americans will move from their health plan in less than two years. So the incentive to put these programs out there remains cloudy for most private plans because even if they do pay back, the money will be saved by the next plan, not them. So we shouldn’t be surprised that DSM is not storming the world.

But it’s a bit of a shock to find that DSM might potentially hurt the bottom line of a plan like Kaiser that tends to keep its patients around. (Although the Kaiser top brass apparently don’t think that it is hurting them, other health plan execs might not be so sanguine). As Medicare is starting to lumber towards DSM this is going to be a big discussion issue, and it would be very nice to know what’s really going on.

Bioterrorism preparedness

Our progenitor – Dr. Sydney Smith – the Medpundit – often writes about bioterrorism. Here is her latest – Preparedness Watch

Looks like a job for a leader with a “mandate.” We’ve grown far too complacent since 9/11 and the anthrax attacks about the very real threat of bioterrorism. It’s time to take them seriously again. And with the abysmal performance of the CDC in the wake of the flu vaccine shortage (see the post below), it’s time to re-examine that agency’s role in the preparedness equation. Wouldn’t plans for bioterrorism defense be better placed in the Defense Department or Homeland Security? (Certainly better placed than with a bunch of epidemiologists!)

Whodunnit?

I play in a fantasy baseball league with a bunch of lawyers (and a judge) and a few regular people. One of the teams is named Some Dudes. This rant from GruntDoc explains why – “Some Dude”: Public Health Menace

I have no idea how “Some Dude” is everywhere at once. I suspect he’s an evil superhero, though in the current times I cannot completely exclude an AlQuaeda conspiracy.

I advocate a vigorous police and public-health effort to locate and confine “Some Dude” due to the clear and present danger he represents to the health and welfare of our republic.

Fighting Back

Jacob Montgomery writes – Panel Sees A Gloomy Future For American Health Care

No lawsuit reform, reduced prescription drug benefits, massive cost increases, and cuts in benefits. It’s a bleak picture.

ProCare’s goal is that when the health care crisis comes – when things get so bad that the public demands political solutions – that doctors and patients will have a strong voice. Join ProCare today and help build our coalition.

IC

The famous Mad House Madman tells a patient tale – A Natural Catastrophe

It’s 1 am in my CCU. I’ve barely had time to put on my jacket when the charge nurse called me with the news that one of my patients, a young lady, is in Ventricular Tachycardia (V-Tach). She also told me to “relax, as this happens to her all the time”. The words “Relax” and “Ventricular Tachycardia” sound funny to a novice when used in combination. Naturally, I panicked!

Rimonabant

A medical student blog discusses – Obesity/smoking Pill May Help the Heart

Rimonabant (marketed as Acomplia), a new drug from the French pharmaceutical company Sanofi-aventis, was designed to attack pleasure centers in the brain diminishing appetite and other addictive desires such as smoking. One study has already revealed the weight-loss potential for those on the drug, but recent reports indicate that it might have cardiovascular benefits as well.

Treating lung cancer

Dr. Hildreth writes – New Treatment for Lung Cancer: A Hint of Good News?

This is the background I took with me to New York last week, where I attended a lecture describing a pilot study for the second-line therapy of NSCLC. In this trial patients were treated with the esoterically named agents erlotinib and bevacizumab, given simultaneously. The results were eye-opening for me, as this new combination produced a 20% response rate, a median survival of 12.6 months, and a one year survival of 52%. Why are these data provocative to a medical oncologist? They appear to be an improvement, but what’s all the hubbub over these agents with the tongue-twister names?

The answer is: erlotinib and bevacizumab are not chemotherapy drugs!

Bloggercon

Medmusings reports – Bloggercon III Medblogger session preview

Why do medical providers, patients, and policy pundits make good bloggers?
– medicine touches us all, if not personally, our families & friends
– storytellers who enjoy an audience (e.g. ER, CSI) or want to persuade a specific audience (pundits)
– providers:
o job is to advocate that their patients engage in a care plan leveraging the trust based on provider’s relationship with patients
o teach one do one: increase their own knowledge by sharing with peers
– patients: authentic voice of the suffering overcomer
– either elated that they’re getting better or angry about being sick or about the state of health economics & the provision of healthcare

Prediabetes

Dr. Emer writes an informative piece on prediabetes – ARE YOU A PRE-DIABETIC?

You can prevent pre-diabetes and diabetes by adapting a healthy lifestyle consisting of proper nutrition — making the right food choices — and injecting a healthy amount of physical activity or exercise into your daily routine.

Holding patients against their will

Trent McBride writes – 72-Hour Hell

Graham correctly notes that this is only one side to the story. 72-hour hold are commonly used in psychiatry as a means to keep people who may be a danger to themselves or others in protective custody. Primarily, it is used to hold people who are at risk for suicide.

Arafat’s death

Leave it to Rangel to examine Arafat’s death in depth – Death of a Terrorist – The monster.

We still don’t know what killed him. CodeBlueBlog disputes my guess that Arafat was dieing from cirrhotic liver disease.

And that ends this week’s Grand Rounds. Thanks for attending!