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ER Medicine: Fantasy, Meet Reality

EM at its finest:

Ending a shift with a bang.
I write a nice note trying to capture the essence of what I did and why I did it. Can’t write “decided to go big or go home” so I wrap it up in that nice, sterile and intentionally understated medicalese which makes it seem like the decisions were clear cut, and based on solid information, when the truth is that they were largerly judgement calls based upon spotty and/or inaccurate information.

I sign out and then I punch out.

In EM we often don’t get to wait for the test result, or for a period of observation. Curse, and beauty, of the job.

*This blog post was originally published at GruntDoc*

Re-evaluating Home Monitoring for Diabetes: Science-Based Medicine at Work

There is no question that patients on insulin benefit from home monitoring. They need to adjust their insulin dose based on their blood glucose readings to avoid ketoacidosis or insulin shock. But what about patients with non-insulin dependent diabetes, those who are being treated with diet and lifestyle changes or oral medication? Do they benefit from home monitoring? Does it improve their blood glucose levels? Does it make them feel more in control of their disease?

This has been an area of considerable controversy. Various studies have given conflicting results. Those studies have been criticized for various flaws: some were retrospective, non-randomized, not designed to rule out confounding factors, high drop-out rate, subjects already had well-controlled diabetes, etc. A systematic review showed no benefit from monitoring. So a new prospective, randomized, controlled, community based study was designed to help resolve the conflict.

O’Kane et al studied 184 newly diagnosed patients with type 2 diabetes who had never used insulin or had any previous experience with blood glucose monitoring. They were under the age of 70 and recruited from community referrals to hospital outpatient clinics, so they were likely representative of patients commonly seen in practice. They were randomized to monitoring or no monitoring. Patients in the monitoring group were given glucose meters and were instructed in their use and in appropriate responses to high or low readings, such as dietary review or exercise. They were asked to take four fasting and four postprandial readings every week for a year. Patients in the no monitoring group were specifically asked NOT to acquire a glucose monitor or do any kind of self-testing. Otherwise, the two groups were treated alike with diabetes education and an identical treatment algorithm based on HgbA1C levels.

Their findings:

We were unable to identify any significant effect of self monitoring over one year on HbA1c, BMI, use of oral hypoglycaemic drugs, or reported incidence of hypoglycaemia. Furthermore, monitoring was associated with a 6% higher score on the well-being depression subscale.

So home monitoring not only did no good but it made patients feel worse. Why? Perhaps because they were constantly reminded that they had a disease and worried when blood glucose levels rose, especially when the recommended responses of dietary review and exercise didn’t rapidly lead to lower readings.

We would not accept the results of one isolated study without replication, but in this case the new study adds significantly to the weight of previous evidence and arguably tips the balance enough to justify a change in practice.

The American Diabetes Association still says “Experts feel that anyone with diabetes can benefit from checking their blood glucose.” But they only recommend blood glucose checks if you have diabetes and are:
• taking insulin or diabetes pills
• on intensive insulin therapy
• pregnant
• having a hard time controlling your blood glucose levels
• having severe low blood glucose levels or ketones from high blood glucose levels
• having low blood glucose levels without the usual warning signs

Diabetes experts see the severe, complicated cases and have a different perspective from that of the family physician seeing mostly mild and uncomplicated cases. An article in American Family Physician said

Except in patients taking multiple insulin injections, home monitoring of blood glucose levels has questionable utility, especially in relatively well-controlled patients. Its use should be tailored to the needs of the individual patient.

An editorial in the BMJ pointed out that

Home blood glucose monitoring is a big business. The main profit for the manufacturing industry comes from the blood glucose testing strips. Some £90m was spent on testing strips in the United Kingdom in 2001, 40% more than was spent on oral hypoglycaemic agents.2 New types of meters are usually not subject to the same rigorous evaluation of cost effectiveness, compared with existing models, as new pharmaceutical agents are.
If the scientific evidence supporting the role of home blood glucose monitoring in type 2 diabetes was subject to the same critical evaluation that is applied to new pharmaceutical agents, then it would perhaps not have been approved for use by patients.

Conclusion

Home glucose monitoring in type 2 diabetes is not justified by the evidence. It does not improve outcome, it is expensive, and it may decrease the quality of life of patients.

Common sense suggested monitoring should improve outcome. We had assumed it would work. Scientists thought to question that assumption. They found a way to test that assumption. New evidence showed that it was a false assumption. In response to that evidence, the practice is now being abandoned. This is how science is supposed to work. Another small triumph for science-based medicine.

*This blog post was originally published at Science-Based Medicine*

It’s Not A Tumor: Dr. Val Lacks Veterinary Savvy

onaoncomputerAs some of my Twitter friends already know, I had a bit of a scare a few days ago with my cat. I know that I more-or-less promised not to let this blog degenerate into cat talk (and for the record I love dogs too), but please indulge me because I think there’s a larger lesson to be learned.

A few days ago I was emailing away on my computer when I heard an odd thud behind me. I turned around to find my cat lying on her back with one leg fully extended, her pupils dilated, and a fine tremor in all four legs. This lasted for about 10 seconds and then she jumped back onto her feet and walked away as if nothing had happened.

My husband denied giving her any catnip, and since I hadn’t seen this odd behavior in her before I decided to keep a close eye on her. About an hour later she was walking across the floor when she suddenly raised her back rear leg, hopped a few steps, flopped onto her back and did the same weird leg extension, trembling, and let out a bizarre yowl.

That buys her a trip to the vet – and I started running my differential diagnosis through my head. It seemed to me that she was having some kind of focal seizures – and I wondered if she could be in renal failure (she had had a UTI earlier in the year) with metabolic encephalopathy, or perhaps a small tumor that had started to trigger some seizure activity. The episodes seemed to resolve completely in between episodes so I didn’t think she was having a stroke, she also wasn’t continuing to limp and when I pressed on her bones she didn’t flinch so I didn’t think she had broken anything. I called the vet and when asked for the “chief complaint” I was just as helpful as many ER patients:

Dr. Val: My cat’s ‘acting weird.

Receptionist: Could you be more specific?

Dr. Val: Well, she’s acting like she’s had catnip, but she hasn’t.

Receptionist: Uh huh… And what do you mean by that?

Dr. Val: She keeps falling on the floor and stiffening her rear leg. Then she gets up as if everything’s fine. This seems to be happening every hour or so.

Receptionist: I see. And is it possible that she could have eaten something toxic? Do you have poison lying around the house?

Dr. Val: Not that I’m aware of.

Receptionist: Well it sounds like you should bring her in. Can you be here in 15 minutes?

Dr. Val: Wow, that’s not much time. But I can try! I think she might be having seizures…

And so with the vet’s office being 15 minutes away, you can imagine the frenzied efforts that ensued – I managed (single handedly) to put together a cat carrier and stuff the “seizing” feline into it and hoist her onto a cart and push her down the city sidewalks, much to the amusement of onlookers, who probably fully believed that I was a cat-abuser, hearing the pitiful cries coming from inside the cage.

To make a long story short, I explained to the vet-on-call what I’d witnessed, and suggested that my cat might have a brain tumor. Luckily for me, the vet did not blindly take my diagnosis for granted, but performed her own physical exam.

The conclusion?

Vet: Dr. Jones I don’t believe your cat is having seizures. She has a subluxing patella.

Dr. Val: Um, so you’re saying that her knee cap popped out of place?

Vet: Pretty much, yes. That’s why she flops on the floor and stiffens her leg. She’s trying to get the knee cap to slide back into place. It’s a grade 3 subluxation, which means it pops out easily, but still goes back into place on its own.

Dr. Val: How do we fix it?

Vet: She’s a surgical candidate. We can create a divot in her femur to help keep the knee cap in the right groove.

Dr. Val: Wow, we don’t do that for humans. Are you sure that will work?

Vet: Well, you can try glucosamine. It will reduce the inflammation.

Dr. Val: Glucosamine doesn’t reduce inflammation in humans – and there’s no conclusive evidence that it improves joint health either. Isn’t this more of a mechanical problem that needs a mechanical solution?

Vet: [Becoming irritated] Yes, well you can see our orthopedic specialist. She’s not board certified though – but she has a lot of experience with these kinds of things.

Dr. Val: Well, is there a board-certified orthopedic veterinary surgeon that we could consult with? How much do you think that would cost?

Vet: There’s an animal hospital in Friendship Heights. I’m sure their surgeons are all equally well qualified. I guess the procedure would cost around $2000.

Dr. Val: Wow, $2000 to put a divot in a cat’s femur? Gee… I don’t know…

Vet: You should also know that your cat needs her rabies shot.

Dr. Val: She needs another one?

Vet: Yes, they need one every year.

Dr. Val: How likely is a house cat to get rabies? Are there rabid mice that could get into our condo?

Vet: [Scowling] It’s the law. All cats must get a rabies shot every year. There is one rabies shot that can be given every three years, but it’s been associated with osteosarcomas in cats. Would you like to give her that vaccine?

Dr. Val: Uh, no. But seriously, where is my cat going to catch rabies?

Vet: Maybe she’ll catch it from the other pets at the animal hospital when she goes for surgery?

Dr. Val: [Visions of Cujo dancing in her head] Well, that doesn’t sound like a very safe place to take her.

Vet: Would you like to buy some glucosamine?

Dr. Val: No thanks, I think I’ll go now.

***

I learned a few things from this amusing interaction:

1. People should try not to make diagnoses beyond their level of expertise. (Brain tumor versus subluxing patella? Yikes.)

2. Vets do not necessarily practice evidence-based medicine. (Glucosamine for a subluxing patella?)

3. There’s a lot of money in cat vaccines.

4. Cash-only practices are quite lucrative. My little visit cost $300.

What do you think I should do with/for my poor cat?

Bad Science: How To Mislead, Misinform, and Make Mistakes in Medicine

Photo of Bad Science Book

I just finished reading Dr. Ben Goldacre’s new book, Bad Science. It received a very favorable review by the British Medical Journal, and so I thought I’d take a look for myself. After all, I am passionate about patient empowerment and worry sincerely for their safety as healthcare is becoming more and more of a “do-it-yourself” proposition.

Ben is a talented writer – his style is straightforward, accessible, and witty. The premise of the book is to expose the underbelly of science – how it’s miscommunicated to the public (via media, PR, and representatives from the snake oil community) and how research is often poorly designed (by uneducated scientists and government agencies, for-profit pharmaceutical companies, and biased physicians).

The case studies presented in Bad Science are especially poignant. Ben has selected a few shining examples of self-promoting figures who have risen to the highest rank of “expert” in the eyes of the media – all the while referring to themselves as “doctor” and yet only having a Ph.D. from an online correspondence school. Their legal bully tactics, fabrication of data to support their proprietary health gimmick, and extreme narcicism – are excellent studies in poor character triumphing over common sense. It is painful to see how successful snake oil salesmen can be, even in these modern and “enlightened” times.

Bad Science carefully dismantles the pseudoscience that underlies many of the claims of alternative medicine. He clearly demonstrates how research can be manipulated to demonstrate a positive effect for any therapeutic intervention, and explains why cosmetic and nutrition research are particularly rife with false positive results.

Ben also explores the role of the human psyche in misunderstanding science. Our deep desire to find a 1:1 correlation between every cause and effect is difficult to overcome. We want 1) to bring artificial simplicity out of complexity, 2) a quick fix in a pill form, 3) to believe in “breakthrough therapies,”4) to read sensational or scintillating news headlines. Unfortunately, science is often coopted to pander to these wants, rather than illuminate the truth.

Finally, Bad Science explores the many ways that statistics can be manipulated to support any claim. In fact, human intuition about math in general is quite flawed, which works against us as we try to understand the data collected by researchers.

I finished the book feeling enlightened but somewhat despairing – yearning to read a sequel, “Good Science” if only to restore my hope in the idea that wise people will have the courage to seek truth over sensationalism, and value objectivity over subjectivity for the greater good of all.

What does Ben Goldacre think we can do to combat the tidal wave of bad science on the Internet? He suggests that people of sound mind blog about the subject as frequently as possible, so that those who are searching for a voice of reason may find one. I blog here and at sciencebasedmedicine.org for that very purpose.

In my next post, I’ll summarize some tips from Bad Science that will help you to recognize when a health message is likely to be inaccurate.

Science Based Medicine – Your Best Shot At Truth

Regular readers of my blog will know that health fraud, misleading product and treatment claims, and deception of vulnerable populations (snake oil for cancer patients, for example) really get under my skin. For this reason, I’ve teamed up with a group of scientists and physicians to create a blog devoted to medical accuracy, transparency, and integrity in health reporting. It’s called Science Based Medicine, and we offer daily exposés of misleading health claims and practices. It’s a great way to learn about how to think critically – and to apply a scientific approach (rather than subjective and anecdotal) to discerning truth from error.

My contribution to the blogging team is to highlight online health fraud, scams, deception and misguided attempts to help consumers “live healthier lives.” I post once a week, every Thursday morning. Please head on over and check it out. It’s a great team of bloggers – and they’re looking out for you!

Here is a list of my recent posts:

A Shruggie Awakening: One Physician’s Journey Toward Scientific Enlightenment

Disintegrating Integrative Medicine: Lessons From Baking

When Further Research Is Not Warranted: The Wisdom of Crowds Fallacy

Knowledge Vs. Expertise: The View From Consumer Land



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