Saturday, June 11, 2011

The Trouble with Wikipedia as a Source for Medical Information « Laika's MedLibLog

Do you ever use Wikipedia? I do and so do many other people. It is for free, easy to use, and covers many subjects.

But do you ever use Wikipedia to look up scientific or medical information? Probably everyone does so once in a while. Dave Munger (Researchblogging) concluded a discussion on Twitter as follows:

"Wikipedia's information quality is better than any encyclopedia, online or off. And, yes, it's also easy to use".

Wikipedia is an admirable initiative. It is a large online collaborative, multilingual encyclopedia written by contributors around the world.
But the key question is whether you can rely on Wikipedia as the sole source for medical, scientific or even popular information.

Well, you simply can't and here are a few examples/findings to substantiate this point.

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Friday, June 10, 2011

Doctor and Patient: Burning the Midnight Oil -

A few years ago during a visit home, my mother interrupted me as I was recounting the details of a transplant operation I'd done a week earlier. For as long as I've been a doctor, my mother, who owns a small business, has queried me about my long work hours, usually punctuating her questions with sympathetic clucks and gentle exhortations to eat more of the Taiwanese food she has prepared.

This time, however, there was no softness to her voice. She wanted to know exactly when I had begun the operation. When I finally told her that the start time had been well past midnight after a full day's work, she pushed away the vegetables she had been chopping and put her hands on her hips.

"Why do you surgeons start operations at those kinds of hours?" she asked. "How can that be good for patients?"

For well over a decade now, patient safety has dominated many of the national discussions regarding health care. While research has shown that most errors and complications are rooted in multiple factors, only one — fatigue stemming from work performed at night — has inspired the kind of widespread debate that results in policy changes. Since 2003, for example, doctors-in-training in the United States have not been allowed to work more than 80 hours each week; and more and more hospitals, practices and individual doctors have shifted away from a culture of long hours and overriding devotion to work, instead emphasizing moderation and concern for lifestyle.

But one specialty has held out. Transplant surgeons continue to work at all hours, the timing of their operations determined by the time of death of the donor and the viability of the organs to be transplanted. Two recent small studies have raised serious concerns about what had been accepted as simply the "distinctive nature" of the specialty. The studies — one on kidney transplants and the other on liver transplants — revealed that patients tended to fare worse if their operations took place in the middle of the night.

This week, The Journal of the American Medical Association published a third study on the topic. Unlike the other two studies, which examined the outcomes of abdominal transplants, this one focused on transplant operations performed in the chest. And rather than reviewing the results of a single institution, as the previous investigators did, this most recent study took into account all of the almost 30,000 heart and lung transplants performed in the United States over 10 years.

The results surprised the researchers. Patients fared essentially the same whether the transplants were performed during the day or at night. Contrary to conventional wisdom, patient outcomes had little to do with the time of the operation or the fatigue of the surgeon. Rather, they seemed to hinge on the reliability of the surgical team.

"We all think the risks are higher at night," said Dr. Ashish S. Shah, assistant professor of surgery at the Johns Hopkins University School of Medicine. "But across the country, it appears that we have figured how to do heart and lung transplants safely."

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Lives Cut Short by Depression -

There is something about a first friend that is irreplaceable. No matter how disparately your lives travel, the first friend you ever had occupies a special place in your heart. I was lucky that Michael was considerate enough to be born four months before me, waiting next door, ready to join me in elaborate childhood games of hide-and-seek, multilevel couch forts and family camping trips in the Catskills.

Michael was quirky and inquisitive, equally adept at dismantling the innards of a telephone, figuring out how to sing "Hey Jude" backward, and testing the physics of fire escape ladders. We both became vegetarians at sleep-away camp — I because I thought it was cool, Michael because he literally couldn't hurt a fly, protesting the flypaper strips that dangled from the ceilings and carrying spiders out of the cabin to set them free in a thicket of blackberry bushes.

When Michael killed himself during his sophomore year of college, it was a horrible shock. I'd known he'd been depressed, but we'd lost touch, so I hadn't known the extent of it. But it was the fact the he'd shot himself in the face, in his childhood bedroom, while his parents and brother were watching TV downstairs that caused the most intense pain. How could someone who defended flies against the barbarity of flypaper find in himself the capacity for such violence?

As a physician, I know that suicide is the third leading cause of death for Michael's cohort — 15- to 24-year-olds. Every year an estimated million people worldwide take their lives. It's not just one million lives, but millions of families, friends and neighbors left with thorns in their hearts, black holes that may scab over but will never disappear.

Despite all the advances in depression treatment, mors voluntaria, or voluntary death, the Latin term for suicide, remains stubbornly persistent. I had always thought of suicide as what lay at the tarry depths of the funnel of mental illness. Then I came across an essay that offered a slightly different take.

In The Bellevue Literary Review, in an essay called "By My Own Hand," Anita Darcel Taylor writes about her bipolar illness and depression:

I have no grand wish for death. I do not view suicide as a desire to end life or a dramatic way to go down in flames. Rather, it is a tool in my possession — the only one, really — that offers a permanent end to my pain. When I have lost enough of myself to this disease as to become unrecognizable even to me, I will stop. I will go no further. That, I tell myself, is my earned choice.

I have pondered these words many times. The clinician in me wants to insist that with the right tools — therapy, medications, support systems — most depressions can be treated. But the reality is that our tools are often no match for the fury.

Depression screening is now standard. Along with a blood pressure check, all my patients get a depression questionnaire. One question is: "Have you ever had thoughts that you would be better off dead?"

A surprising number of patients say they have, and I find myself in frequent existential conversations about life and death, hunting for pragmatic clues about actual risks for suicide. There are clinical guidelines for assessing risk, but it is an imperfect science.

Two weeks ago, I called one of my patients to reschedule an appointment. A family member answered and told me that my patient had been found dead in his apartment, most likely a suicide. This robust and healthy 54-year-old had screened "negative" for depression at every visit, despite having risk factors: being unemployed, living alone, caring for an ill relative.

I'm not ready to give up hope. I will continue to assiduously treat my patients' depression, but I remain humbled by the fact that even with the best of medical science, we will be successful only in part. And of course there is — as Ms. Taylor points out — the voluntary aspect of mors voluntaria. For some people it might be a rationally used tool. For others, it is a tsunami without possibility of escape. It is precarious, from the outside, to judge.

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Assisted Living or a Nursing Home? -

Like so many adult children, Catherine Hawes confronted The Promise. You may have experienced this fraught conversation, too: Your elderly parent grasps your hand and pleads, "Promise me you'll never put me in a nursing home."

Dr. Hawes, a professor of health policy and management at the Texas A&M Health Science Center, happens to be one of the nation's leading experts on long-term care. "I've been in this business for 35 years," she told me in an interview. "But when my mother said, 'I'd rather die than go to a nursing home — promise me you'll never put me in a nursing home,' I felt like every other child feels. It's a knife to the heart."

Remind me, in 20 years or so, not to try extracting The Promise from my daughter, because it's not a vow that can be kept without a crystal ball. With great effort, Dr. Hawes and her husband, who's also a long-term care expert, managed to keep her mother in their home for eight years. But not everyone can make that happen.

The great interest in assisted living over the past 20 years stems, in part, from families making The Promise. Assisted living — a term encompassing a bewildering variety of facilities, from small family-operated homes to 100-unit complexes -– has advantages and disadvantages, but chief among its attractions is that it's not a nursing home.

When families can no longer keep an older adult in his own home (the almost universal preference) and are investigating congregate living, "that's everyone's first thought," said Lisa Gwyther, the veteran social worker who directs the Duke Family Support Program in Durham, N.C. "Everyone says, 'My mom doesn't belong in a nursing home,' so they think assisted living, regardless of her medical needs or prognosis."

But assisted living won't work for everyone, either. I consulted Ms. Gwyther and Dr. Hawes for guidance on which older people are likely to do well there and which will need the greater supervision and higher staff ratios a good nursing home can offer.
"Good nursing home" is not a contradiction, by the way, despite the industry's longstanding and well-documented problems. "Nursing homes have gotten a bad rap," Ms. Gwyther said. There are good ones, and there are seniors who need them.

For instance, "anyone with moderate to severe cognitive impairment and problem behaviors like resisting care or becoming alarmed if someone tries to help them shower generally belongs in either a dementia unit with well-trained staff or in a nursing home," Dr. Hawes said. In standard assisted living, "there's not enough staff to help."

Ditto for seniors with complicated medical conditions that require regular monitoring — for instance, those whose use of blood thinners involves regular testing to adjust the dosage. Assisted living doesn't provide much health care, so residents risk becoming what Ms. Gwyther calls "frequent fliers — they're going in and out of hospitals for conditions that could perhaps be treated in a nursing home."

Medication management — a program to provide the right dose at the right time — can take place in either type of facility, but Dr. Hawes points out that in most states assisted living staff cannot legally administer medication, and may only hand it to a resident. So someone who stuffs pills into her purse, or whose dementia means that moments later she won't remember to swallow them, may easily fall off her drug regimen.

Assisted living can pose a problem for seniors with incontinence, too. Frequently, the marketing director says an assisted living facility can accept someone who's incontinent. But, Dr. Hawes cautioned, "she means, 'As long as she can change her own briefs.' What you mean is, 'She needs help getting changed four times a day and needs the sheets changed every other day.'" Housekeeping staff in assisted living typically change linens weekly.

Further, federal regulation provides greater protection for nursing home residents. State regulations govern assisted living, and they vary widely. "Assisted living facilities can ask you to leave, and they do," Ms. Gwyther said. "Nursing homes can, too, but you have more rights."

Nevertheless, assisted living can work well for people with mild cognitive problems, who particularly cherish privacy (private apartments being more common), who are sociable and alert.

Years ago, Dr. Hawes told me that the ideal candidate for assisted living was Miss Daisy, the character in the play and the film starring Jessica Tandy. Miss Daisy, lucid and opinionated, didn't need extensive nursing or personal care, just transportation, light housekeeping and meals, and the attention of the courtly Morgan Freeman. If that's your mother, she may not need a nursing home.

At least, not yet. Families shopping for facilities hear a lot about "aging in place." Marketing directors may imply, or even say, that this will be your parent's last home. But however suitable assisted living may be when a resident moves in, the average stay is a little over two years, and the most common reason for moving out is needing more care than it can provide.

Despite The Promise, then, "this is probably a temporary solution," Dr. Hawes said. The most frequent destination when residents leave assisted living: nursing homes.

Tuesday, June 7, 2011

What I Learned from My Cancer Scare - Dr. Mehmet Oz - TIME

At some level, I knew I was standing in the middle of New York City traffic, but my mind was in another dimension entirely. Reminders of your mortality will do that.

The day hadn't started off so strangely and scarily, but it hadn't started off to be much fun either. I was going to my doctor's office for a colonoscopy, my second in nine months. Colonoscopies aren't supposed to happen nine months apart, of course, unless the first one turns up something worrisome — and mine had. Back in August, my doctor discovered a suspicious polyp that needed to be removed. It turned out to be precancerous, and while a large majority of such growths do not eventually become cancer, colon cancer usually starts with just that sort of polyp. So did I have the 40-some years left to me that I had been more or less counting on — or just a year or two? You ask a lot of existential questions like that when you get the kind of news I had gotten. And you do a lot of hoping that when you return for a follow-up exam, all will be well — and the problem will simply go away.

Now I was going in for that follow-up. Surely I would get the all clear, and life would go back to being what it had been. I didn't, and it didn't. My doctor found another polyp, higher up in the colon — a more dangerous location.

I left the doctor's office and stood out on the street wrestling with the news. Pedestrians bustled by — all of them, I felt, untroubled by the kinds of things I was feeling. But of course, I wasn't alone. Indeed, I had something in common with millions of people across the U.S. I was a medical statistic, one of many, many patients who receive the kind of diagnosis I did every day of every year. The very fact that I was joining so large a population meant that this was by definition a routine story. But that's the case only if the story isn't about you.

When it is about you, your mind races. Am I at fault? Could I have done something differently? What do I tell my children and wife? What if I actually get cancer? Have I done everything I set out to do in life? I am a physician who gives advice for a living. I have spent much of my professional life extolling the value of healthy eating and regular exercise, and I practice both. So how in the world did this happen to me?

Part of the answer to that last question is luck of the draw. A healthy lifestyle can dramatically lower your risk of cancer, but it's no guarantee of anything. But there was more at work too — at least in terms of how and when I learned of my condition. I take pride in being a good doctor and a good family man, but the fact is, I had been a pretty bad patient. Living my life on television, dispensing medical advice every day leaves me with a solemn obligation and moral imperative to be honest and to own up to mistakes — and I made some. They may not have been big, but they were more than enough to threaten my health, my future and the well-being of my family. The experience transformed me from Dr. Oz to just plain Mr. Oz, and it taught me a lot, both about myself and about my patients.

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Sunday, June 5, 2011

Side Effects? These Drugs Have a Few -

Dr. Jon Duke of Indiana University was trying to figure out why his patient's blood platelets were abnormal. Could it be a side effect of one of the dozen drugs the man was taking, a number that is not uncommon among elderly people?

He began reading the label of each and every drug. "I was just overwhelmed," Dr. Duke said. The lists of possible adverse reactions went on and on.

Now he knows why. In a new paper in the Archives of Internal Medicine, Dr. Duke and two colleagues report that the average drug label lists 70 possible side effects and some drugs list more than 500. "This was beyond even what I'd expected," he said.

For anyone who has ever had to watch an entire Flomax commercial, the listing of a drug's side effects is almost a joke. But the question is, why does the list continue to grow?

It's not as if the problem hasn't been addressed. In 2006, troubled by the ever-expanding lists of side effects, Dr. Jerry Avorn and Dr. William Shrank of Harvard Medical School wrote a paper in The New England Journal of Medicine calling it "linguistic toxicity."

That same year, the Food and Drug Administration suggested making labels clearer with a new format and advised drug makers: "Exhaustive lists of every reported adverse event, including those that are infrequent and minor, commonly observed in the absence of drug therapy or not plausibly related to drug therapy should be avoided."

 But, Dr. Duke found, instead of decreasing in the years after the agency issued guidelines, the average number of side effects rose to 94, as compared to 67 for those whose labels predated the new format. Some potential complications are weird, like "compulsive gambling." Others, like "nausea" are so common — it's listed on 75 percent of drug labels — that they almost seem like a universal issue.

Some were adverse reactions that showed up in clinical trials before a drug was marketed. Others were conditions patients reported when they were taking the drugs that may — or may not — have been caused by the drugs. Often there is no way to know why or how a side effect got reported.

Listing every inkling of an adverse reaction can help drug companies in lawsuits, Dr. Duke said. If someone sues about a side effect that is listed in the drug's package insert, the company can say patients had been warned.

The Pharmaceutical Research and Manufacturers Association says the companies are just complying with the F.D.A.'s requirement that they reveal all of a drug's risks, "even if a clear causal connection between the medicine and the observed adverse event cannot be fully established," a spokesperson for the group wrote in an e-mail.

But, said Dr. Christine Cheng, a doctor of pharmacy at the University of California in San Francisco, what is happening is a case of "information overload." Dr. Cheng wrote an invited commentaryto accompany Dr. Duke's paper.

And the F.D.A., in an e-mail, said "extensive lists of rare and minor adverse events for which there are no data to support a causal relationship" are not useful.

 Patients agree.

Jim Murrell, a 54-year-old telecommunications consultant who lives in the Atlanta suburbs, says he wants to know all about adverse drug reactions but he has decided the labels are not helpful; he looks for better sources on the Internet.

"I took a medication that had the side effect of drowsiness," he said. "I read a little further and saw it had another side effect. Insomnia. One medication had diarrhea as a side effect and it also had constipation."

"It makes no sense," Mr. Murrell said.

"What I need to know is probably buried somewhere in there," he added. "But what I don't need is all the information that is probably in there because, I don't know, maybe there's a lawsuit somewhere."