dras knowledge

Wednesday, August 18, 2004

Lancet. 2001 Jan 27;357(9252):251-6. Long-term effects of glucosamine sulphate on osteoarthritis progression: a randomised, placebo-controlled clinical trial.Reginster JY, Deroisy R, Rovati LC, Lee RL, Lejeune E, Bruyere O, Giacovelli G, Henrotin Y, Dacre JE, Gossett C.Bone and Cartilage Metabolism Research Unit (WHO Collaborating Center for Public Aspects of Osteoarticular Disorders), University of Liege, Belgium. jyreginster@ulg.ac.beBACKGROUND: Treatment of osteoarthritis is usually limited to short-term symptom control. We assessed the effects of the specific drug glucosamine sulphate on the long-term progression of osteoarthritis joint structure changes and symptoms. METHODS: We did a randomised, double-blind placebo controlled trial, in which 212 patients with knee osteoarthritis were randomly assigned 1500 mg sulphate oral glucosamine or placebo once daily for 3 years. Weightbearing, anteroposterior radiographs of each knee in full extension were taken at enrolment and after 1 and 3 years. Mean joint-space width of the medial compartment of the tibiofemoral joint was assessed by digital image analysis, whereas minimum joint-space width--ie, at the narrowest point--was measured by visual inspection with a magnifying lens. Symptoms were scored by the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index. FINDINGS: The 106 patients on placebo had a progressive joint-space narrowing, with a mean joint-space loss after 3 years of -0.31 mm (95% CI -0.48 to -0.13). There was no significant joint-space loss in the 106 patients on glucosamine sulphate: -0.06 mm (-0.22 to 0.09). Similar results were reported with minimum joint-space narrowing. As assessed by WOMAC scores, symptoms worsened slightly in patients on placebo compared with the improvement observed after treatment with glucosamine sulphate. There were no differences in safety or reasons for early withdrawal between the treatment and placebo groups. INTERPRETATION: The long-term combined structure-modifying and symptom-modifying effects of gluosamine sulphate suggest that it could be a disease modifying agent in osteoarthritis

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This 2001 WHO sponsored report in Lancet is relatively ancient history, and just one of several equally good[?] studies on glucosamine. Run a MEDLINE search, and don't leave out the reviews and comments. Might need to visit a local university medical library, but one could generate a really good argument for glucosamine or against it's routine use, using just study reports. It may depend on whether your approach is "Use it 'till it's proved worthless" or "Back off 'till we have demonstrated a basic population and dosing protocols where we can predict an effective outcome."

Among the original 5 supplements, glucosamine may be the most promising as far as clinical impact. But one good one will not not raise the credibility of all supplements. One thing that will always seem to pop up in medical commentary is the lack of regulation in the supplement industry. There is a huge fear, maybe more real than imagined, that actual contents of similarly labeled supplements will be dramatically different from manufacturer to manufacturer, and even from lot to lot.

Friday, August 13, 2004

Medical errors are sixth leading cause of death

http://www.healthgrades.com/media/english/pdf/HG_Patient_Safety_Study_Final.pdf

A summary of our findings follows:
1. Approximately 1.14 million total patient safety incidents occurred among the 37 million hospitalizations in the Medicare population from 2000 through 2002.
2. The PSIs with the highest incident rates per 1,000 hospitalizations at risk were Failure to Rescue, Decubitus Ulcer, and Post-operative Sepsis. These three patient safety incidents accounted for almost 60% of all patient safety incidents among Medicare patients hospitalized from 2000 through 2002.
3. Of the total of 323,993 deaths among patient s who experienced one or more PSIs from 2000 through 2002, 263,864, or 81%, of these deaths were potentially attributable to the patient safety incident(s).
4. Failure to Rescue (i.e., failure to diagnose and treat in time) and Death in Low Mortality Diagnostic Related Groups (i.e., unexpected death in a low risk hospitalization) accounted for almost 75% of all mortality attributable to patient safety incidents.
5. Of the remaining 65,972 deaths attributable to the other 14 patient safety indicators (excluding Failure to Rescue and Death in Low Mortality DRGs), almost 75% were in patients with decubitus Ulcer (34,320), Post-operative Pulmonary Embolism or Deep Vein Thrombosis (8,445) or Post-operative Respiratory Failure (6,320).
6. There were small variations in PSI incident rates across hospitals and regions.
7. Overall, the Central and Western regions of the U.S. performed better than the Northeast and Sunbelt.
8. Teaching hospitals and larger hospitals (>200 beds) had slightly higher patient safety incident rates per 1,000 as compared to non-teaching hospitals across most PSIs.
9. Patient safety incidents were more prevalent among medical admissions compared to surgical admissions.
10. Overall, the best performing hospitals (hospitals that had the lowest overall PSI incident rates of all hospitals studied, defined as the top 7.5% of all hospitals studied) had five fewer deaths per 1,000 hospitalizations compared to the bottom 10th percentile of hospitals. This significant mortality difference is attributable to fewer patient safety incidents at the best performing hospitals. Fewer patient safety incidents in the best performing hospitals resulted in a lower cost of $740,337 per 1,000 hospitalizations as compared to the bottom 10th percentile of hospitals.
11. The 16 PSIs studied accounted for $8.54 billion in excess inpatient cost to the Medicare system over 3 years, or roughly $2.85 billion annually. Decubitus Ulcer ($2.57 billion), Post-operative Pulmonary Embolism or Deep Vein Thrombosis ($1.40 billion), and Selected Infections due to Medical Care ($1.71 billion) were the most costly and accounted for 66% of all excess attributable costs from 2000 through 2002.
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Taken in context, this HealthGrades analysis and report seems very reliable. Problem is, too many will make and report assumptions about the findings, and use misleading statements like the one I put in the subject line.

The biggest concern has to do with the reports analysis of "failure to rescue" - the biggest contributer to mortality. Numbers attributed in this category will have to be based on ambiguity. For example, any analysis of circumstances associated with an unexpected death will return recommendations for reducing future incidents, or assign preventable potentially contributing factors. That does not necessarily mean the death was preventable, or a direct result of omission of action. Plus, reporting in this regard is not standardized, and probably not easily converted to a statistical analysis. Still, for the purposes of the Healthgrades report, these numbers are important.

The CDC will not rate medical errors as the 6th leading cause of death. (The subject statement above was my own making based on the CDC list.) Remember folks, the intent of the study was to identify ways to promote better, safer care, it cannot be used to blame the medical establishment for epic amounts of untoward irresponsible death in our society. Our medical establishment should be commended for devising ways to analyze and report causes of death, and to state and address responsibility for things that could have turned out differently. We should count ourselves privileged that hospitals are not widely regarded as places where people go to die - as they were, and are, in much of the world. We should be glad that a scientific method of reporting and accountability even exists.

I've been to hospitals, doctors and clinics several times in my life and haven't been killed once. In fact, I'd probably be dead had I not gone on some occasions.

Friday, August 06, 2004

More synergistic effects of alternative therapies

Hypothesis #1: Therapies/remedies work beyond placebo only if taken together (all 30 of them), they work in synergy
Hypothesis #2: Therapies/remedies don't work beyond placebo if applied one by one.
Hypothesis #3: You can't patent any of the therapies/remedies, it all exists in nature, or have been used before
Questions: How do you design one placebo controlled, randomized, double blind study, that will evaluate this "integrative approach", and how do you prove it working?
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From the way I understand the application, hypothesis #1 is not scientifically derived. There is no evidence to have us suspect that 30 benign natural processes can somehow magically come together to produce an epic effect. The example that air, water, nourishment etc all come together to sustain human existence is not correlative because it does not conform to Hypothesis #2, we can observe the individual effects of each. Like ingredients in making a cake. If a rooster crows 3 times in the morning at precisely 6am, walks twice around the henhouse, ruffles his feathers every 49 minutes and retires at exactly 7pm how can it be suggested (outside the occult, e.g. "One two buckle my shoe....") that this exact protocol kept the fox out of the henhouse?

Valid hypotheses about the additive effects of different interventions are tested, compared, and/or analyzed all the time, and seldom does it take a prospective RCT (fancy study.) For example, there was a recent report declaring the 10 best hospitals in the nation. There are obviously several (at least 30) factors that made the difference for those 10. Now it is up to researches to find and compare all of what the top 10 hospitals are doing right, that the sub-par hospitals are not. The test comes when a thorough analysis becomes recommendations that are applied back to the hospitals

Thursday, August 05, 2004

Synergistic effects of multiple aternative therapies

Now, hypothetically, in your personal practice you achieve great results by combining 10 or 30 different approaches.Out of 500 patients, you have a success with 150. hypothetically.
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This type of "shotgun" treatment approach will likely greatly enhance the placebo effect. Let's say I want to quit smoking. I chewed nicotine gum following directions on the box and still smoke. Let's say now I try chewing the gum, and start tennis lessons, but in 8 weeks I still give in to the cravings. Now, I go into an alt-med clinic. They have me chew the gum, continue tennis lessons, do 3 enemas per day, eat only organic foods, take $17.50 in a handful of herbal products per day, burn aromatherapy candles in my home, and whenever I get the craving, peer into a crystal while focusing my mind to purify my blood until the craving goes away. And, behold, I'm now 8 months smoke-free!

Can I attribute my success to the synergistic effects of the alternative medicine modalities? No, it is likely that by doing all of this, I've so drastically changed my life and daily routine, and my consciousness was so keyed into the effort, that I gained the edge or new lease on life to defeat smoking.

The amazing thing about this is that you can expect the same approach to improve reported symptoms related to all kinds of medical complaints. Wouldn't it have been nice to figure out that I only really needed to chew the gum, change the parts of my daily routine that centered of smoking, alter my diet, change my home surroundings, and find a distraction during cravings - like calling a friend who agreed to help me quit, in order to get the same results? Would have been alot cheaper.

"Shotgun" treatment is great when wisely dictated, it's used all the time in mainstream medicine to great effect. In research, many scientific clinical studies biggest bane is failing to develop an adequate control to account for little extra things that occur to only the active treatment group. You often end up with a very impressive study that can only conclude that doing more is better than doing less.
-dras

Wednesday, August 04, 2004

You're ignorant if you don't understand Chiropractic philosophy

After watching for a few weeks I see more response from disgruntled chiropractors than anyone else.

I am sure that there are those out there that will never agree with what I say, but that is just due to ignorance on their part, (I don't mean that in a mean way) that is just human nature and that doesn'thave an affect me.

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I know nurses who have become disgruntled or leave because most of Nursing didn't turn out to be like the many preconceptions they had when applying to nursing school. Seldom do they turn on the profession. However, seems those leaving a religion will often turn on it. That might be a discussion for another time.

Is it ignorance, or a conscious decision to focus from a different point of view?
I understand that a placebo effect may be influential in even the majority of remedies. Placebo effect is often attributed to very strong psychological, sociological, and spiritual factors keyed into the conscious and subconscious that will have huge impacts on health and well-being. Since I cannot in surety or accurately control these factors, I simply attempt to account for them in an analysis of the treatment of wellness or disease. In doing so, and despite this placebo effect, I can expect to reasonably be able to predict health outcomes of any given intervention. Or, at least predict it well enough to establish an idea as to whether or not the intervention is worthwhile compared to other alternatives.

In my mind, being able to predict that something is going to benefit is important, not only for ethical and quality-of-care reasons but for financial reasons as well. Now, I'm sure there is much in medical practice that has not proven itself "scientfically" this way, but in most cases these interventions seem to be comparatively worthwhile based on what is understood, and they are widely accepted practice.

Many of the specific interventions (outside adjustments) that I am used to seeing chiropractors practice fall well short of being predictably worthwhile. Before I can agree that adjustments/protocols are worthwhile, I need to know how such treatment might compare to anything else we might try. Since I cannot understand Chiropractic philosophy and subluxation empirically, I am almost obligated to consider adjustments/protocols to be in a realm associated with the placebo effect. In making that association, it may become essential to make study comparisons with not only other medical interventions, but perhaps psychological interventions, psychosocial interventions, and/or spiritual counseling.

I agree that sometimes it is better when we do not attempt to compartmentalize separate treatment of the body, from the mind, from the soul. Yet, this understanding does not validate Chiropractic philosophy within medicine. That is because Chiropractic does not have the corner on the market in the respect that it's adjustment based modalities contribute to health and well-beng. I do not doubt the contributions a devoted chiropractor makes in the community, nor the positive impacts in the lives of individuals through the practice of chiropractic. The same way I do not doubt the similar contributions and individual positive influences a dedicated Pastor or Priest might have. Or, how about a massage therapist, physical therapist, a compassionate hairdresser, a spa membership, a stress reduction course, or any of these in combination?

One obvious empasse has to do with socialized healthcare coverage that our society uses. If we collectively pay Chiropractors for the good they do for someone's health, we must also consider payments for Pasters, Priests, massage, hairdressers or anyone or any idea that proves it benefits someone's health. We attempt to gauge which proposition for health or wellness has better predictability and will be more worthwhile, and then limit payment accordingly, not only to preserve resources for true medical emergencies, but to prevent abuse of the payment system by those who would engage in fraud.

-dras

Monday, August 02, 2004

Chiro cyrstal ball

I see chiropractic services continuing indefinitely as a part of our healthcare system, regardless of what these services are or become.

Healthcare payment in our society is headed for more government regulation/intervention. I don't see any way that the "democracy" associated with a healthcare coverage bureaucracy would ever tolerate exclusion of payment toward chiropractic services. Science and the scientific method will never carry as much weight in the influence of popular opinion as will a passionate, feel-good testimonial followed by a plee to preserve freedom-of-choice and fairness among all healthcare practitioners.

After all, any association with a freedom-of-choice or fairness will touch an emotional nerve and promote action long before we realize any logical need for a more altruistic and somewhat utilitarianism-based approach to healthcare coverage that is perhaps demanded by the economics of what our society can afford. -dras

Hydrogen Peroxide in Natural Medicine

Am I misunderstanding some messages here, or is use of Hydrogen Peroxide considered health fraud by some people on this list?

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No, the uses of hydrogen peroxide (H2O2) in health as a dental rinse, externally in the care of some wounds, or as an antiseptic in not health fraud. To provide or promote the treatment or sale of H2O2 for ingestion or intravenous use may very well be health fraud. There is not good data or well designed clinical trials identified on MEDLINE (includes foreign text journals) to support the oral or IV use of hydrogen peroxide for treatment of any medical condition. H2O2 is not manufactured, packaged or classified for these purposes.
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…Abstract from The Journal of Integrative Medicine Volume 3 Number 1Majid Ali, M.D., Judy Juco, M.D., Alfred O. Fayemi, M.D., Omar Ali, M.D., Mahboob Baig, M.B.,B.S.;Marta Babol, M.D., Karimullah Zirvi, Ph.D., Carol Grieder-Bradenberger, R.N., Mary Ann Carroll, R.N….
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I could not locate this abstract on MEDLINE. Perhaps this is not a recognized peer-reviewed scientific journal. Very little practical information can be summarized from the abstract. Among the many obvious or suspected shortcomings of this study, it draws no conclusions about the singular impact of hydrogen peroxide effects on health outcomes.

Other references provided in the post do not support a clinical reason to use intravenous H2O2 in the treatment of disease. I could not find Dr. Farr referenced on MEDLINE, or the "five thousand studies" or "2,500 or more references" unless they are exclusive to antisepsis, wound care or oral hygiene.

The FDA has just repeated a 1997 warning about unapproved AIDS therapies including H2O2:

"…Recognizing the special needs of people with HIV infection and AIDS, FDA uses its discretion to allow them to import for their personal use unapproved but promising drugs for HIV and HIV-related life-threatening diseases. At the same time, the agency vigorously campaigns against AIDS health scams that have bilked their victims of as much as $ 10 billion a year.

As a result of FDA investigations, federal and state authorities have taken legal actions against individuals involved in hundreds of fraudulent cures for AIDS such as "energized" water, "ozone therapy," and hydrogen peroxide "treatment."…" http://www.fda.gov/fdac/features/1997/197_aids.html

The FDA doesn't seem to be worried that people are using "unapproved therapies" as much as the concern that people are being bilked out of money for treatments done with the intent to victimize.

As counterpoint, the following is from a popular integrative medicine site:

http://www.medical-library.net Ron Kennedy, M.D.
"…Those who refuse to educate themselves, never read, never try anything out of the mainstream of thought and insist on thoughtlessly following the "expert's advice," will pay through the nose for therapies which drain their resources and deliver half-baked results. It may be there is a segment of the population which is capable of nothing more. God bless those folks. Here is this doctor's advice: think for yourself.
"If hydrogen peroxide is so effective, why is it not made use of in "modern" medicine? The reason is simple. Hydrogen peroxide cannot be patented. It is present in the ocean, it is present in rainwater, it is present in vegetables, it is present in every cell of your body right now. It must be classified as a food, because it is part of all fresh food of plant origin. Because it is produced in the human body, it is undeniably safe. Since it is a food and cannot be patented, there is no big profit to be made on it…"