nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
See here for more discussion.

Monday, July 21, 2008



Almost one-third of patients who suffer cardiac arrests in hospitals may not receive timely defibrillator shocks, study suggests.

In a front-page article, the New York Times (1/3, A1, Grady) reports that approximately three out of ten hospitalized patients who go into cardiac arrest are not given an electrical shock from a defibrillator within two minutes, the time recommended by experts, according to a study published in the New England Journal of Medicine. Lead author Paul S. Chan, M.D., of Saint Luke's Mid-America Heart Institute in Kansas City, Mo., and colleagues, examined the "records of 6,789 patients at 369 hospitals whose hearts stopped because of conditions that could be reversed with" a shock from a defibrillator. The researchers found that when defibrillation did not occur within two minutes of cardiac arrest, just "22.2 percent of the patients survived long enough to be discharged from the hospital, as opposed to 39.3 percent when the shock was given on time."

Doc D: This is an observational study and has several problems. First, the health record is notoriously unreliable (even “code sheets” are not perfect): in all my years in emergency medicine, I’m not sure I ever got the times exactly right when I sat down later to record the event, mainly because I wasn’t watching the clock when I got called, or when I gave the shock. I was usually too engrossed in the patient…duh. Second, these are hospitalized patients: unless you want a cardiac team and resuscitation cart in every room, it’s going to take time to bring this all together. Lastly, the study didn’t say much about what happens after you shock somebody. Many times I’ve shocked a patient successfully (and rapidly), only to have them arrest again, and again, and again…or later in the ICU, and while it says that 22 percent survived to leave the hospital it doesn’t say much about what kind of shape they were in (paralyzed? couldn’t talk?). Studies like this are bothersome because it sounds like “three out of ten” got substandard care, and maybe that’s not true. In any case, hospitals should be good at reacting to arrests: I recommend practice, practice, practice.

Wall Street Journal cautions against panic in the face of medical risk.
The Wall Street Journal (1/2, A10) reported that the "Vioxx panic seems to have subsided, but the same kind of alarmism is beginning to wash over healthcare fields other than pharmaceuticals," such as "medical technology." One of the most pressing issues before Congress "is Medtronic, a major medical-device maker, and the controversy surrounding a component of its heart defibrillators." Last October, "in the face of escalating criticism over safety concerns, Medtronic voluntarily withdrew from the market a type of the complex wires -- called leads -- that connect a defibrillator to the heart muscle, and tell it when to deliver therapy." The Journal noted that "Medtronic's withdrawal may also have been driven by legal and political calculations." Since Vioxx was pulled from the market, "companies are under pressure to get out in front of even modest health risks." Treatments typically have some risk, and medical devices generally "undergo extensive laboratory 'bench tests' to simulate how they'll behave under the stresses of the human body." Still, the Journal concluded, "the real danger to public health is overreaction to medical risk."

Doc D: I agree with this. Frankly, I don’t think there is such a thing as a completely harmless medicine, especially when we get down to the “one-in-a-million” level of risk. Consider the case of polio vaccine: the “sugar cube” we all took is not as harmless as it sounds. Five to eight out of every million kids who took it…got polio from the vaccine. This is not something we learned just recently, we knew it all along. But, at the time there were 50-100,000 cases of polio a year that was the alternative. Now that polio is rare, we don’t give the oral vaccine at the earliest doses, to reduce the risk of vaccine-induced polio. It’s a matter of balancing risk, something we should always do…with every form of treatment. The media reports don’t discuss this. So, every time you read something about the risk of a drug or treatment, remember that somebody is trying to “scare you” into watching their show, or reading their article…and ask yourself, (1) how does this risk compare to other risks, and (2) what are the alternatives, if not this drug. If I had arthritis so bad that I could hardly walk, and Vioxx was the only thing available, I would take it and accept the very small risk of heart problems.

Survey finds that wealthier, insured patients receive most free medication samples.
USA Today (1/3, 7D, Szabo) reports that according to a survey published in the February issue of the American Journal of Public Health, the majority of "free medications...actually go to wealthier patients who have insurance." Study author Sarah Cutrona, M.D., a physician with Cambridge Health Alliance in the Boston area, and an instructor at Harvard Medical School, and colleagues, surveyed "nearly 33,000 Americans" in 2003, and found that just "28 percent of those who got samples were poor, whether insured or not." But, Ken Johnson of Pharmaceutical Research and Manufacturers of America argues that studies have "show[n] 75 percent of physicians frequently or sometimes give out samples to help patients with out-of-pocket costs." Still, "Cutrona says many poor and uninsured people never get to see a doctor, and more often visit public health clinics or emergency rooms, where samples may not be available, or go without care."

Doc D: Just so you know, when I worked at the county hospital, we tried to give away all we could to our poor patients. The problem is, as it was explained to me, there are some legal issues with trying to do this systematically. Also, most free samples are one-to-several days worth of medicine, and even if you had a handful of samples, this only postpones the cost, and risks discontinuity with those medicines where you don’t want the patient to stop it suddenly (you could even argue that giving samples is a “risky” thing to do, as above). And, if you were a pharmaceutical company, would you want a wealthy, or a poor, population to be trying out your latest whiz-bang, 3-dollars-a-pill drug? Related to that, we tried to use cost-effective drugs in public institutions, since this gave us more care for our dollars, which were limited. This study makes it sound like wealthy doctors are doing favors for wealthy patients. That happens, I guess, but it aint the only thing going on here.

Doc D

Opinions are entirely my own. Quotations from AMA Morning Rounds (© U S News Custom Briefings)

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