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Avoiding a bad death requires preparation Print E-mail
Written by Dr. John M   
Tuesday, 18 August 2015 00:00

If there was a hashtag for sub-specialty healthcare and ICU medicine in the United States it would be:
 
#WeCanButShouldWe
 
A recent study led by Dr. Harlan Krumholz (Yale University) showed that we have become more efficient at keeping elders alive. This is not surprising. And it's good news in the sense that technology-if used wisely-can enhance both quality and quantity of life.
 
The key phrase above is...if used wisely.
 
The obvious fact remains: Human beings don't live forever. The same medical technology that can extend life can also prolong death.
 
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Last Updated on Wednesday, 19 August 2015 16:54
 
Can FDA tell a drug company to stop talking about research? Print E-mail
Written by Nicholas Bagley | The Incidental Economist   
Friday, 14 August 2015 18:05

A long-running dispute over the First Amendment flared up this past Friday, when a federal judge in New York told FDA that it couldn't prevent a drug manufacturer from discussing research supporting an off-label use of its drug.

The drug at issue is Vascepa, the active ingredient of which is an omega-3 fatty acid. It's similar to fish oil, so let's just call it "fishy oil." In 2012, FDA approved the fishy oil for use in people with very high triglyceride levels (above 500 mg/dL). Turns out that taking fishy oil reduced their triglyceride levels, which are associated with heart disease.

The manufacturer of the fishy oil, Amarin, thought that people who had persistently high, but not very high, triglyceride levels (between 200 and 499 mg/dL for those already on statins) might benefit, too. So, with FDA's blessing, Amarin came up with a study to see if they did. And it turns out their triglyceride levels also dropped.

The thing is, though, that the ultimate goal of the fishy oil isn't to reduce triglycerides. It's to prevent heart disease. And what if reducing triglycerides doesn't help with that, as some recent studies have suggested?

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Last Updated on Tuesday, 25 August 2015 17:40
 
Storytelling in Medicine: the Passion and the Peril Print E-mail
Written by Dr. Danielle Ofri   
Wednesday, 05 August 2015 00:00

Some years back, we admitted a middle-aged French woman with advanced lung cancer who was in acute respiratory distress. It was not clear from her x-ray whether this was from her cancer progressing or from severe pneumonia. Whichever the case, she needed to be intubated, and soon.
 
Before we could put the tube down her throat, however, she insisted on dictating her last will and testament. Between wispy gasps of breath, she told us who should get her linens and her artwork, and where exactly in Paris she wanted to be buried.

I scribbled this down as fast as I could as the anesthesiologist hovered over us, endotracheal tube in hand.
 
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The Layman's Diagnosis Print E-mail
Written by Dr. Jordan Grumet   
Friday, 31 July 2015 00:00

Jim almost convinced me. The burning in his chest, after all, could have just been gastroesophageal reflux. He assured me that the sensation was nothing new; that he got it from time to time after a large meal and took Tums. I couldn't, however, ignore that it seemed to worsen with activity... 
 
...Jim and I argued over the EKG. He wanted to take his prescription and go home. No hospitalization, no blood tests, no diagnostic studies. I grabbed his shoulder, and did my best to convince him to reconsider. He slowly turned back toward the exam room. A few minutes later, I gulped as I looked down at the electrocardiogram. He was having a heart attack.

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Last Updated on Saturday, 01 August 2015 16:10
 
Big Data Is Not Big Enough Print E-mail
Written by Skeptical Scalpel, MD   
Wednesday, 22 July 2015 00:00

<On 7.14.15> ProPublica released its "Surgeon Scorecard" touting it as the best way to pick the right surgeon.
 
It took me less than a minute to discover some interesting omissions from the application.
 
For laparoscopic cholecystectomy, the only general surgery procedure listed, the app omits approximately one-third of the hospitals in my state including two where I have practiced.
 
It looks like the problem is that using Medicare fee-for-service data does not yield enough surgeons performing 20 or more cases in some categories such as laparoscopic cholecystectomy for the five years included in the database.

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Last Updated on Thursday, 23 July 2015 12:50
 
Are You Proud of Your Patients? Print E-mail
Written by Jordan Grumet, MD   
Thursday, 16 July 2015 00:00

It was only afterwards that I wondered if I had been condescending. The words had come out so naturally. We were sitting across from each other in the nursing home. It didn't take a doctor to recognize that his leg was visibly less swollen. I had seen him walking down the hallway with the physical therapist. His face a mix of pain, concentration and triumph.
 
Each day had brought improvements. The range of motion was returning. His strength was growing. His body balanced now with only the most minimal of assistive devices. What had once been disability had transformed to normal physiologic functioning.

In medicine we often talk in the most passive of manners.

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The PCSK9 Drugs - Epic success or epic failure? Print E-mail
Written by Dr. John M   
Wednesday, 24 June 2015 17:17

Earlier this month an FDA advisory committee recommended approval for the potent cholesterol-lowering drugs, evolocumab and alirocumab. The funny-sounding medications are called PCSK-9 inhibitor drugs.
 
Advisory committee members felt the benefits of the drugs outweighed the potential risks, especially in high-risk patients, such as those with Familial Hypercholesterolemia (FH).
 
The FDA usually-but not always-follows the recommendation of the advisory committee. A final decision from FDA will come later this summer.
 
In reading this piece, keep in mind that the goal of cholesterol drugs is to reduce the risk of heart attacks, strokes and death. It's easy to get side-tracked into thinking a drug is good if it lowers cholesterol. Changing lab values is worthless unless those changes result in better outcomes in the future.

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Last Updated on Thursday, 09 July 2015 07:34
 
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