Save Antibiotic Strength (SAS-NY) is a very good website if you're looking for materials on careful antibiotic prescribing.
It's a VERY poorly designed website, though .. and this detracts from the message. Too bad. Just in time for Jakob's Top Ten Web Design Mistakes of 2003. I agree with most of them.
BMJ Learning: Learning resources
Want a fast, evidence based update? Here are the essentials on everyday conditions.
BMJ has learning resources that seem to fit my short attention span. I just did the hypertension module in about 8 minutes.
Good: It's a good, quick overview of common problems with a short quiz and references. It has a well done user interfact with a nice feature that tells you what your answer was on a given item and how other people answered. So if you're MUCH smarter or much stupider than everyone else .. you know.
Bad: I didn't learn anything new. I'll have to try another module when I have 8 minutes free sometime.
I'm cleaning off my desk today
Items in the pile:
a) Junk mail from Life Line Screening Radiology. It's targeted to our zip code -- not just physicians. Like the Bookmibile ... they'll be in the area next week. It looks like they set up shop in the parking lot of a local church. I can get a carotid u/s for $45 ... Screen for an AAA for another $45 .. etc .. or a "complete package" for $99.
I'm not sure what to think about this. It's certainly not indicated in young people. I wonder who shows up at such events.
b) Another version of treatment guidelines for community acquired pneumonia. As usual, this one suggests that we use:
When I was in training, I recall wondering what the "right" answer was. I thought I was stupid because I didn't get it .. that somewhere in the guts of the guideline was the right answer hiding from me. Instead .. it seemed elusive. "You CAN do this ... you could choose one of these .. " It all seemed so ambiguos.
Now that I'm a jaded mid-career 40 year old physician .. I see that these things are vague because no one has the right answer, and they are fearful in such a guideline to dictate what the physician shoudl do.
This is odd. We need more clarity .. not more ambiguity. We all end up at an answer when we reach for the prescription pad. Are some answers better than others? Yes. Why? ... ooh .. we're getting closer.
So the guidelines need to help physicians parse out the distinctions.
Why is azithromycin NOT my first choice for community acquired pneumonia?
Enoch's post on medmusings makes a good point about avoiding antibiotics in the context of a prolonged fever in his child. I think that those of us with kids have an advantage over physicians without kids. We've been there. We've worried about the fever that won't go away. We've been up all night with the crying baby (?Is it the ear? Is it teething .. or is it just ... behavior?)
Working with patients in a similar predicament - we have much more credibility than even the most knowledgable, thoughtful, compassionate physician in the world.
It's that time of year again ... and we're seeing kids in the office with otitis media. With each pasing year, more parents seem to understand that antibiotics for acute otitis media in children are largely unnecessary.
Several years ago, I developed a guideline that was part of a regional effort to reduce antibiotic overuse. I still print out the patient information that we developed as part of this project, but these days I find that parents already know much of the contents.
When making the decision of how to treat a child with otitis these days, I find myself sharing the decision with the parents.
JMR: "Well .. 80% of kids in this situation will get better by themselves."
Mom: "Yes .. it seemed to work last time. Johnny got better in 2 days .. but the time before that, he needed the antibiotics."
JMR: "Well, that's the problem .. we don't yet have a way to twll which kids are going to be that 20%"
Mom: "Let's wait and see. I'll call you in 2 days if he's not better."
On Fridays and before holidays, I usually write the prescription, and ask the parents to hold on to it for a day or two. It's not uncommon that they bring it back to demonstrate proudly all was well without the antibiotics.
In this process, I always focus on the concept that otitis media, like sinusitis, is a problem with obstruction .. rather than one of infection. There's a nice monograph on this topic. Te bugs are there anyway. A little H. flu, S. Pneumo and Moraxella are components of the normal flora of the nasopharynx and therefore the eustacian tube.
But as the mucosa thickens in the context of a cold, the bugs are trapped. A system that is usually dynamic and flushed on an ongoping basis .. is now stagnant. Warm, moist place with bacteria. Infection? Duh. But as with any abcess .. we need to enhance drainage FIRST .. not necessarily treat with antibiotics.
Too bad we can't just pop open the eustacian tubes with a remote control. Hmm ... maybe I'm not the only one with this idea.
Reviewing the last 20 cases of otitis media that I saw in the office .. I wrote prescriptions for antibiotics in 6 of them within 48 hours of the visit. Many of these prescriptions were on Fridays .. so I don't really know how many kids actually got the antibiotics. I wonder how Chris Bradley or Enoch or Bhavesh handle this in urgent care settings.
In our area .. urgent care and ERs have been the biggest problems for us in curbing antibiotic oversue. Patients seem to get what they ask for in such settings .. which then builds the expectation that antibiotics are indicated for sinusitis, otitis or bronchitis ... and of course, this is a concept that I don't agree with.
In the context of the recent flu scares .. and a rather persistent "flu-like-illness" that has been quite prevalent in the past 2 weeks (though waning now, it seems) ... I spoke on the phone with a friend in the ER the other day:
JMR: "How are you guys dealing with this high-fever/cough viral thing going around?"
ERDOC: "Man .. it's bad. Clearly not flu .. but most people think it is ... which is just semantics, I guess. The worst part is that many of the urgent care docs are prescribing Azithromycin for it ... so the patients come here 3 days later because the z-pak isn't working and they want us to give them a stronger antibiotic"
JMR: "yikes."
It's been a very long week or two.
The boy I saw last week with hip pain turned out to have Slipped Capital Femoral Epiphysis. This is a diagnosis that is easy to miss .. and I didn't know that he had it when I saw him. The x-ray didn't show anything .. which was reassuring .. though his pain persisted .. which prompted a referral to orthopaedics.
The orthopod ordered more views of the hip .. one of which showed the SCFE .. prompting surgery.
Randy Daniels Fiddles While Baby Burns
It's been two and a half years since New York passed fire-safe cigarette legislation. To be implemented, however, the law requires Secretary of State Randy Daniels to issue fire-safe standards. While Daniels delays, a series of fatal cigarette-caused fires have occurred. The following story describes the plight of a family whose baby was severely burned in a recent cigarette-caused fire.
This compelling story of how a family is struggling with the consequences of cigarette smoking. I often counsel parents about the dangers of cigaterette smoking, but this story may provide a different image of some of the health risks
From the fresnobee.com | Local News:
One of the most passionate and persistent of critics to visit City Hall was Dr. David Pepper. In 1997, street racers welcomed him to the Tower District. Two drivers charged down Van Ness Avenue at 90 mph.
One car jumped a curb and crashed into Pepper's new home. He paid $19,000 for repairs. His car was next. It was totaled a year later when two trucks careened down his street. He persuaded neighbors and other doctors to speak to the City Council, "and tell them that speeding is a huge problem in this area."
They asked for more stop signs, crosswalks and traffic officers. Stop signs eventually were added to Pepper's neighborhood, but his crusade against bad drivers continued. Van Ness Avenue is often dotted with homemade signs demanding that drivers slow down to obey the 30 mph speed limit.
Pepper decided in 1999 that speeding problems extended far beyond his neighborhood. Drivers whizzed throughout the city, he says, because police were not writing tickets. The results were deadly. During a five-year period beginning in 1997, 186 people died in Fresno collisions, more than any other California city with a similar population size. Fresno's fatalities topped those of Long Beach (142 from 1997 through 2001), Sacramento (178) and Oakland (181), according to the California Highway Patrol.
Dave Pepper is a family physician who has clearly had an impact on the health of his community. Nice going, Dave.
ToySafety.net is a project of the National Association of State Public Interest Research Groups (PIRGs). The information contained on this site was researched and compiled by state PIRG staff across the country and published in the state PIRGs' 18th annual Trouble In Toyland report.
Boring technology topic:
Dave Winer points to Jason Shellen's proposal for using a CSS to make XML look nicer in Atom.
No reason not to do this in RSS too ... here it is.
How I did it:
I had to modify my MovableType 2.0 template (view source if your browser tries to open it) to make it look better. Now my feed may even look "un funky" to Dave.
I copied Jason's CSS example and modified it some to work on the RSS format.
Then I found Eric Kidd's dormant weblog. He did this about a year ago. His CSS is better than Jason's.
I can't get rid of the spaces .. (NBSP) ugh ..
From the Adam Smith Institute Weblog - Private health: bigger than NHS!
This week, BBC Radio 4 asked me to do an interview on the origins and growth of the non-state healthcare market. Boning up for it, I was reminded just how significant the independent sector is. It provides 85 percent of the UK's residential care beds, for example, and 20% of all acute elective surgery - that's the stuff like hip replacements that isn't exactly life-threatening, but which you want to get done fast anyway. Indeed, the independent sector has more beds than the NHS and local-authority care homes put together! It employs almost as many people - roughly 750,000 of them - and it accounts for a quarter of UK health and social care spending. In addition to the 15,000 nursing and residential care homes that the sector provides, private agencies care for more than 200,000 people in their own homes.
Of course, the other (unanswered) question is whether this is good. If the NHS needs so much supplementation for those who can afford it, what happens to those who can't afford it? This makes for a very compelling case that a two-tier healtchare system doesn't ration healthcare resources.
huh? yes .. I said ration. With limited resources, and infinite need, we need to RATIONALLY deliver the limited resource. This is rationing, and despite the negative connotation usually assocated with it .. this is not a four-letter word.
Bottom line is well summarized in The Onion this week.
Flu-shot shortage may aid MedImmune
This is a no-brainer. We're out of vaccine, and only one local pharmacy carries the stuff.
Who killed JFK?
Is the Flu crisis of 2003-2004 real?
Another Oliver Stone Movie?
New York Times: A Conversation With | Steffie Woolhandler: Heal Health Care System? Start Anew
Steffie is one of my heroes. It's now been 14 years since The original paper appeared in the New England Journal of Medicine. Yikes. I was applying for medical school at the time, and a friend of mine sent me a copy of a draft version of the article.
In medical school, I helped start an Albany chapter for the Physicians for A National Health Program .. and when this new thing called the Internet came along, I built the organization a website and hosted it on a server I managed in 1995.
These days I don't have enough time to work on PNHP stuff very much, but this doesn't mean I'm not still passionate about it. Tha huge administrative overhead that the US insurance industry adds to the cost of healtcare in this country is terrible. Read the Woolhandler article -- it's very compelling.
Today's unrelated tidbits:
The last one is the best of many calculators out on the web. Here's why - it combines the calculations of likelihood ratios with the calculation of PPV and NPV. Huh? Terms for normal humans:
a) How good is the test that I'm doing for this disease? (sensitivity) let's take one that is VERY common: the "rapid strep" test. It's pretty good, but not perfect. Let's say it's 85% sensitive. This means that 15% of the time it will miss strep throat. So ... does a patient in my office with a sore throat and a negative "rapid strep" have a 15% chance of having strep throat? Nope. Read on.
b) How accurate is the test? (specificity). If I get a positive result - how sure can I be that the patient really has it? In the case of the rapid strep - darn sure. Let's say 99%.
c) How likely is THIS patient to have this disease given their symptoms? Long story - Kids are more likely to have it than adults. Let's say an adult has a 10% chance of having a sore throat caused by strep - and a kids have a 25% chance.
So now we can use the calculator. Enter a prevalence of 25% (it's a kid with a sore throat) and a sensitivty of 80% and a specificty of 99%.
PTL- .. The post-test likelihood of a negative test = .048 So a kid with a negative rapid strep has only a 5% chance of having strep throat - not 15% like we thought above.
But we can play with this plot even more. We know from the long story above (click it - it's a very good article) that the kid with a cough and no adenopathy is much less likely to have strep than the kid with no cough and positive anterior adenopathy. So let's say our patient has a cough and runny nose and not much of a fever. Hmm .. doesn't sound much like strep. But he does have a sore throat. Let's move his "prevalence" score to 10%.
Yikes. Now the PTL- is .01 -- not very likely that this kid has strep.
So now you see why I'm not compelled to send a follow-up culture (with sensitivity of 90% rather than 85%) if I get a negative rapid strep.
