Sad Story -“Tumors and Transformations”

From NEJM: Tumors and Transformations

“It Happened 21 years ago…”

My take: Most physicians I know all have sad stories that stick with them.


Choosing the Right Intravenous Fluids

A recent “SALT-ED” study (WH Self et al. NEJM 2018; 378: 819-28) with more than 13,000 noncritically-ill adults indicated that patients who received normal saline had increased incidence of major adverse kidney events compared to those who received more balanced fluids like lactated Ringers’ or Plasma-Lyte A.

A 2 min quick take summary:Comparison of Crystalloids and Saline for Noncritically Ill

In a separate “SMART” study (MW Semler et al. NEJM 2018; 378: 829-39), investigators looked at balanced crystalloids versus saline in critically-ill adults (n=15,802).  The use of balanced crystalloids (compared to saline) resulted in a lower rate of mortality (10.3% vs 11.1%, P=.06) and fewer major adverse kidney events (14.3% vs. 15.4%, P=.04).


Assault Weapon Trauma and Measles Outbreak


Exorbitant Medicine Costs -Generics Discounts Often Minimal

A recent story in the NY Times (Patients Eagerly Awaited a Generic Drug. Then They Saw The Price. ) shows that the availability of a generic drug does not guarantee that exorbitant pricing will be remedied.

An excerpt:

Syprine, which treats a rare condition known as Wilson disease, gained notoriety after Valeant Pharmaceuticals International raised the price of the drug to $21,267 in 2015 from $652 just five years earlier…

In promoting its “lower-cost” alternative to Syprine, a Teva executive boasted in a news release that the product “illustrates Teva’s commitment to serving patient populations in need.”

What the release didn’t mention was the price: Teva’s new generic will cost $18,375 for a bottle of 100 pills, according to Elsevier’s Gold Standard Drug Database. That’s 28 times what Syprine cost in 2010, and hardly the discount many patients were waiting for.

Nearly three years after Valeant’s egregious price increases ignited public outrage, the story of Syprine highlights just how hard it can be to bring down drug prices once they’ve been set at stratospheric levels.

My take: This type of excessive drug cost is why critics demand additional regulation be placed over the entire pharmaceutical industry; it can occur only in a system which has limited competition and indirectly shares the cost across the entire system by having insurance companies foot most of the bill.

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What Does Richard Thaler’s Work Mean for Medicine?

A recent commentary (J Avorn. NEJM 2018; 378: 689-91) addresses a huge problem in medicine: “medicine’s ongoing assumption that clinicians and patients are, in general, rational decision makers.”

He points out that just as Albert Einstein upended Newtonian physics with the much more complex theory of relativity, Richard Thaler’s work in economics “explained that people often don’t make choices by acting as the rational balancers of risk and reward assumed by classic economics.” (More information about his work at Wikipedia post on Nudge).

Key points:

  • “We are disproportionately influenced by the most salient and digestible information” rather than the totality of information.  This “helps explain the power of simplistic pharmaceutical promotional materials, often delivered..with a tasty lunch.”
  • “Our beliefs are shaped by recent experiences…(Last-case bias).”
  • “We often overestimate small probabilities (such as uncommon drug risks).”  Another example would be fear of dying in a plane crash which is far less likely than dying in an auto accident.

The potential remedies to flawed decision-making include the following:

  • “Academic detailing” which is a process attempting to integrate more information to counter biases
  • Nudge concept. This is a strategy of “making a preferred alternative the default choice when several options exist.”  Order entry systems in computers could default to preferred drugs (ie. best drug in class)
  • Cost constraints can affect decision-making which could include targeting copayments for payments.  For physicians/administrators, looking at what drives revenue is crucial.  “As Upton Sinclair once noted, ‘It is difficult to get a man to understand something when his salary depends on his not understanding it.'”

My take: Addressing these ideas could help reduce unnecessary surgeries, increase  high value care, and improve outcomes.  This is why Richard Thaler’s work is important for medicine.

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Physician Age and Patient Outcomes

Tsugawa Y, Newhouse JP, MacArthur JD, et al. Physician age and outcomes in elderly patients in hospital in the US: observational study. BMJ. 2017;357 doi:

Thanks to Ben Gold for this reference. Slides from Patient Care newsletter.


Researchers used nationally representative data on Medicare beneficiaries admitted to hospital with a medical condition during 2011-14. They wanted to find out the association between age of the treating physician and 30 day patient mortality after admission; whether this association varied with the volume of patients a physician treats; and whether physician age is associated with readmissions and costs of care. Their study included 736 537 admissions managed by 18 854 hospitalist physicians (median age 41).

Key findings


PFAPA Conference Report

A conference report on periodic fever, aphthous stomatitis, pharyngitis, adenitis syndrome (PFAPA): L Harel et al. J Pediatr 2018; 193: 265-74

This report reviews PFAPA along with other fever syndromes.

Table II reviews several published criteria.  Most of these include abrupt onset of fever, duration of symptoms <5 days, presence of constitutional symptoms, exclusion of cyclic neutropenia, presence of  aphthous stomatitis, pharyngitis, cervical adenitis, presence of asymptomatic intervals, normal growth.

  • The authors note that ~25% of patients are >5 years of age.
  • They note that it is important to exclude exudative tonsillitis.
  • They suggest NOT testing for familial Mediterranean fever (FMF) in the absence of clinical suspicion. The pain symptoms with FMF are much more intense and  consistent with a peritonitis.
  • They recommend checking acute phase reactants between attacks to assure normalization
  • Corticosteroids (single dose) have been shown to shorter course.  “The recommended full dose is 2 mg/kg prednisone or 0.3 mg/kg betamethasone.”
  • “It is our practice to conclude the following: 1. Fever recurring the next day [after steroids]–not a PFAPA episode, 2. fever recurring withing 2-4 days –the corticosteroid dose is too low, and 2. attack recurs >1 week –new episode.”
  • Any of the following should exclude PFAPA: “neutropenia, cough, coryza, severe abdominal pain, significant diarrhea, rash, arthritis, or neurologic abnormalities; elevated acute phase reactants between attacks”

Differential diagnosis and characteristics are reviewed in Figure 5, with emphasis on mevalonate kinase deficiency, FMF, cryopyrin-associated periodic syndromes (CAPS), and tumor necrosis factor receptor-associated periodic syndrome (TRAPS).

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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

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