Prescription drug abuse

This online documentary from 2009 covers the problem of prescription drug diversion and abuse, focussing on the dysfunctional regulatory environment in Florida, USA. The principles covered are relevant for all opioid prescribers.

Prevention of Pain on injection from Propofol

This meta-analysis assessed various methods to prevent pain on injection from propofol. This totalled 170 studies and 25,000 adult patients. The most effective methods were using the ante-cubital vein (RR 0.14) and injection of lignocaine combined with venous occlusion (RR 0.29). Interestingly the new MCT/LCT formulation were not very effective with a relative risk reduction of only 0.75. The article also scored an editorial. And it's in a general medical journal too.

No improvement in Hospital Safety

A study reported in the NY Times, and to be published in the NEJM next Thursday (Nov 2), finds no improvement in Hospital safety. The large long-term observational study in ten US hospitals found harm from medical care is still common (18% of patients) and most incidents are preventable. The commonest causes were related to medication and procedures.

Robotic Prostate Surgery: Marketing wins over data?

Despite no good short term data, or data on cancer control, the acceptance of robotic prostatectomy is continuing. This article in the NY Times gives insight into the problem of the introduction of new surgical techniques before adequate data shows it to be better, same or worse than established techniques. Robotic prostatectomy has a long learning curve, costs more and takes twice as long.

This difficulty of evaluating new technology in patient care is discussed in an editorial in the NEJM from August.

New CPR Guidelines 2010

The new CPR guidelines have just been published in Circulation and Resuscitation. They are open acces and can be read here

Reviving the lost art of the physical examination

Teaching medical students how to do a physical exam

The New York Times reports on the remarkable medical education breakthrough of teaching the ancient and mysterious art of the physical examination. Stanford Medical School has employed Dr. Abraham Verghese solely to teach this skill. This is in an era when the first step in a neurosurgical examination is an MRI scan. Importantly, undertaking a physical examination helps develop rapport with your patient and getting to know them as an actual person. This is something the anesthesiologist should embrace.

The last round for codeine?

Codeine has been an historically popular drug. This has been particularly due to its availability in many over-the-counter combination analgesic drugs such as Panadeine and cold-and-flu remedies. The problem is that codeine is a pro-drug for morphine which depends on the highly variable pharmacokinetics of individual patients. This editorial from the CMJ argues that it is better and safer for patients to avoid codeine and just use a predictable opioid such as morphine or oxycodone.

Maybe too much pain relief is bad?

NEJM Sept 29. This recent drug trial and editorial show the outcome of too much analgesia when treating osteoarthritis of the knee. The study drug was Tanezumab, a monoclonal antibody that blocks nerve growth factor which then produces pain relief. Unfortunately the drug was too effective, which caused some patients to wear out their knees so badly they needed knee replacements. Consequently the FDA has put a halt on the studies with Tanezumab.

Transfusion and the microcirculation

This astounding video of a patient's microcirculation shows what happens when a blood transfusion is given. The results are not pretty.

“Would I be surprised if this patient died within the next year?”

Palliative care is usually taken to mean death from cancer. Yet many of us will die from a slow progressive decline that is not due to cancer. It has been proposed that a positive answer to the question  “Would I be surprised if this patient died within the next year?” should prompt a discussion with the patient and family about dying to allow the best use of the time remaining. Read more in this series in the BMJ

US Government gets tough with recalcitrant drug companies

A Bitter Pill to Swallow

A BMJ special feature reports how the US government is moving beyond large fines to make Big Pharma behave legally and ethically. Despite imposing fines of up to $500 million dollars there has been no effective change in drug companies' unlawful behaviour. It is just seen as a cost of doing business. The next steps include confiscating drug patents to force drugs to become generic, holding executives responsible and investigating doctors who accept financial kickbacks. See the report here

The surgeon's pact with the patient - "Never give up"

This article in the NY Times delves into why surgeons don't call "enough is enough" when patients suffer postop complications and undergo repeated re-operations and protracted stays in ICU. Research indicates that during the consent process, the surgeon implicitly indicates to the patient he will undertake to do "what ever it takes". However patients don't see the consent having the same implied meaning.

Anesthesia v Orthopedics

Here we usually talk about research, data and other such topics. But I could not let this very funny video pass without mentioning. Watch for the condition that the orthopod has not seen before. This one is pure genius.

 

 

 

 

http://www.youtube.com/watch?v=q0S5EN7-RtI

 

iPad in Medical publishing

The editor of the BMJ ponders the impact of the global iPad launch tomorrow and how it will affect the future of medical journals. Overall she gives it a positive wrap. As the traditional print media looks at a downturn in circulation figures, the iPad maybe be a good fit for the information needs of doctors.
Update: BMJ Careers gives a good overview of the potential of tablet computers to improve medical care. Read more here.

Futile Surgery

Ever wondered why so much time and resources are spent on patients who are going to die? A new book by Ken Hillman "Vital Signs: Stories from Intensive Care" examines the problem that most of us, if we die in hospital, will die in intensive care. This happens even if we have irreversible illness. The treatment does not change the outcome, it just delays death by a short time. Meanwhile the patient is exposed to treatment that may be unpleasant and consume scarce health resources. In effect the ICU becomes the defacto palliative care unit. An extract from the book was published in the Sydney Morning Herald, and an interview with Ken was on ABC Radio National here. Both are well worth a look.