Mark A. Graber

Effect of a patient's psychiatric history on physicians' estimation of probability of disease

A questionnaire was mailed to 300 Iowa family physicians to determine the influence of a prior psychiatric history on decision making. The response rate was 77%. Respondents were less likely to believe that a patient had serious illness when presenting with a severe headache or abdominal pain if the patient had a prior history of depression (P<.05) or prior history of somatic complaints (P<.05), compared with a patient with no past history. Respondents were less likely to report that they would order testing for a patient with headache or abdominal pain if the patient had a history of depression (P<.05, P=.08, respectively) or somatic complaints (P<.01). Differences in likelihood of ordering tests were not significant after adjusting for differences in estimated probability of disease. We conclude that physicians respond differently to patients with psychiatric illness because of their estimation of pretest probability of disease rather than bias. We conclude that past psychiatric history influences physicians’ estimation of disease presence and willingness to order tests.

Effective and evidence-based management strategies for rosacea: summary of a Cochrane systematic review

Rosacea is a common chronic skin disease affecting the face. There are numerous treatment options, but it is unclear which are the most effective. The aim of this review was to assess the evidence for the efficacy and safety of treatments for rosacea. Searches included the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index, and Ongoing Trials Registers (updated February 2011). Randomized controlled trials in people with moderate to severe rosacea were included. Fifty‐eight trials, including 27 from the original review, comprising 6633 participants were included in this updated review. Interventions included topical metronidazole, oral antibiotics, topical azelaic cream or gel, topical benzoyl peroxide and/or combined with topical antibiotics, sulphacetamide/sulphur, and others. There was some evidence that topical metronidazole and azelaic acid were more effective than placebo. Two trials indicated that doxycycline 40 mg was more effective than placebo. There was no statistically significant difference in effectiveness between doxycycline 40 mg and 100 mg but there were fewer adverse effects. One study reported that ciclosporin ophthalmic emulsion was significantly more effective than artificial tears for treating ocular rosacea. Although the majority of included studies were assessed as being at high or unclear risk of bias, there was some evidence to support the effectiveness of topical metronidazole, azelaic acid and doxycycline (40 mg) in the treatment of moderate to severe rosacea, and ciclosporin 0·05% ophthalmic emulsion for ocular rosacea. Further well‐designed, adequately powered randomized controlled trials are required.

Answering clinical questions in the ED

OBJECTIVES The objective of the study was to determine how many patient-related questions emergency medicine physicians have and how they answer them at the point of care. METHODS We conducted an observational study of 26 physicians at 2 institutions. All physicians were followed for at least 2 shifts. The number and type of questions were recorded. The percentage answered, resources used, and barriers to answering questions were also recorded. RESULTS Physicians had 235 questions or approximately 5 questions per 8-hour shift . They attempted to answer 81% of them and were successful 87% of the time. The 2 most commonly used information sources were drug information resources (Personal digital assistant [PDA], pocket pharmacopeia [37% of the time]) followed by electronic resources (Google, UpToDate [29% of the time]). The most common reason for not pursuing a question was lack of time and distractions or interruptions, followed by a belief that an answer would not be found. When an answer was not found to a pursued question, non-emergency department physicians were the most common resource consulted (28%). CONCLUSIONS Emergency department physicians in this study pursued and found answers for most questions posed at the point of care. Rapid access to electronic resources and drug-prescribing references were critical for answering questions at the point of care.

How well does decision support software perform in the emergency department

Objective: To determine how well general decision support systems perform given the data collected in an emergency department (ED). Methods: A convenience sample of 25 patients was selected from those patients having a diagnostic question on presentation to the ED. All interactions with the patients were audiotaped and abstracted into a structured data form. All other data such as written notes, laboratory, and EKG results were also abstracted. All data were entered into two general diagnostic decision support programs (Quick Medical Reference (QMR Version 3.82, Knowledge Base 10–07–1998 Copyright University of Pittsburgh and The Hearst Corporation) and Iliad (Version 4.5 Copyright 1996 Applied Medical Informatics)). The diagnoses generated by the computer programs were compared with the final diagnoses of the ED attending. Results: The final ED diagnosis was found in the differential diagnosis generated by Iliad and QMR 72% and 52% of the time respectively. The final ED diagnosis was found in the top 10 diagnoses 51% and 44% of the time and in the top five diagnoses 36% and 32% of the time for each program respectively. This approximates to the performance of these programs in other clinical settings. Conclusions: Diagnostic decision support software has the same success in finding the “correct” diagnosis in the ED as in other clinical settings where more extensive clinical data are available. The accuracy is not sufficiently high to permit the use of these programs as an arbiter in any individual case. However, they may be useful, prompting additional investigation in particularly difficult cases.

Sertraline-Phenelzine Drug Interaction: A Serotonin Syndrome Reaction

OBJECTIVE: To report a serious drug interaction possibly occurring with the monoamine oxidase inhibitor phenelzine and the selective serotonin reuptake inhibitor sertraline. CASE SUMMARY: A 61-year-old woman with treatment-refractory major depressive disorder was being treated unsuccessfully with lithium, phenelzine, thioridazine, and doxepin. Sertraline 100 mg/d was added to the patients therapy. Within three hours of ingesting the first dose, the patient experienced a dramatic increase in her temperature, pulse, and respirations along with labile blood pressure, and symptoms of rigidity, diaphoresis, shivering, and decreased sensorium. The patient was transported to the emergency room and treated with diazepam 10 mg iv, followed by midazolam 10 mg iv for control of rigidity. She was also intubated. The patient then experienced precipitous falls in her blood pressure and respiratory rate. Ice packs combined with a cooling blanket and dantrolene 80 mg iv were administered to control fever and rigidity, respectively. She had an initial working diagnosis of neuroleptic malignant syndrome, which was later changed to serotonin syndrome. Dantrolene was continued for 72 hours at which time the patient was extubated and transferred to a psychiatric unit. CONCLUSIONS: Selective serotonin reuptake inhibitor antidepressants should not be combined with monoamine oxidase inhibitor antidepressants because of the risk of serotonin syndrome.

Pharmaceutical Company Internet Sites As Sources of Information About Antidepressant Medications

AbstractAbstract Objective: To determine the informational content of nine pharmaceutical company websites about the antidepressant medication marketed by the company. Method: A structured, explicit review of materials found on pharmaceutical company websites about nine antidepressants for which no generic drug is available was conducted using eight popular search engines. The accessibility of these websites was also determined using these search engines. Results: Of 72 searches (one for each drug using each search engine), 46 yielded the pharmaceutical company website within the top 10 links. When outliers were removed, the company website was found in the top 10 links for 45 of 56 searches. All of the websites contain information of an advertising and emotive nature. Of the nine company websites, three contain anecdotal information; only two mention electroconvulsive therapy and four mention other types of drug therapy; and only one mentions the tradenames of other drugs. None of the websites mention drug costs, only one has efficacy statistics for the company’s drug and, although all of the websites mention at least one adverse effect of the company’s drug, only one lists percentages for adverse effects. Conclusion: The information about drugs for treating depression on pharmaceutical company websites aimed at consumers is limited and makes it difficult for consumers to compare drugs.

Internet-based crowdsourcing and research ethics: the case for IRB review

The recent success of Foldit in determining the structure of the Mason-Pfizer monkey virus (M-PMV) retroviral protease is suggestive of the power-solving potential of internet-facilitated game-like crowdsourcing. This research model is highly novel, however, and thus, deserves careful consideration of potential ethical issues. In this paper, we will demonstrate that the crowdsourcing model of research has the potential to cause harm to participants, manipulates the participant into continued participation, and uses participants as experimental subjects. We conclude that protocols relying on this model require institutional review board (IRB) scrutiny.

Defining the Scope of Implied Consent in the Emergency Department

Purpose: To determine the relative value that patients place on consent for procedures in the emergency department (ED) and to define a set of procedures that fall in the realm of implied consent. Methods: A questionnaire was administered to a convenience sample 134 of 174 patients who were seen in the ED of a Midwestern teaching hospital. The questionnaire asked how much time they believed was necessary to give consent for various procedures. Procedures ranged from simple (venipuncture) to complex (procedural sedation). Results: Participants valued a simple blood draw at a low mean of 1.02 minutes of extra time and a lumbar puncture at a high mean of 7.78 minutes. Of all participants 52% and 48% noted a time-value of “0” time on blood draw and intravenous line starts, respectively, indicating that they desire no additional consent for these procedures. Conclusion: Defining a set of ED procedures covered under implied consent will be difficult because many patients value formal consent for even the simplest procedure.

Patients’ views about physician participation in assisted suicide and euthanasia

OBJECTIVE: To elucidate the effect of physician participation in physician-assisted suicide and euthanasia on the physician-patient relationship.DESIGN: A questionnaire administered to 228 adult patients.SETTING: A university-based family practice training program.PATIENTS/PARTICIPANTS: We approached 230 individuals of at least 18 years of age who were patients in the study practice. These individuals were selected on the basis of age and gender to ensure a heterogeneous study population. Of these, 228 agreed to participate and completed the questionnaire.RESULTS: The majority of subjects felt that a physician who assists with suicide or performs euthanasia is capable of being a caring person (91% and 88%, respectively) and would still be able to offer emotional support to surviving family members (85% and 76%, respectively). Most also felt that a physician assisting in suicide or euthanasia would be as trustworthy as a nonparticipating physician to care for critically ill patients (90.5% and 84.6%, respectively). Five percent “likely would not” continue to see their physician if it was known that he or she assisted in suicide and 7.8% “likely would not” continue seeing their physician if it was known that this physician performed euthanasia. No individuals stated that they “definitely would not” continue seeing their doctor under either circumstance. Individuals who supported the ideas of physician-assisted suicide and euthanasia were more likely to think that a physician who assisted with suicide and euthanasia could perform well in the tasks noted above and would be more likely to continue seeing such a physician (p=.001)CONCLUSION: Participating in physician-assisted suicide and euthanasia does not markedly adversely affect the physician-patient relationship.

Methylxanthine Use in Anaphylaxis: What Does the Evidence Tell Us?

OBJECTIVE: To review the literature examining the use of methylxanthines in the treatment of anaphylaxis. DATA SOURCES: A MEDLINE search (January 1966–December 1998) was performed using the terms aminophylline, theophylline, and anaphylaxis. STUDY SELECTION AND DATA EXTRACTION: Articles discussing methylxanthine use in anaphylaxis were independently examined by each author. Additional information was obtained through the references of these articles. Articles not written in English were excluded. DATA SYNTHESIS: No human studies were identified. Limited published data were found in animal models of anaphylaxis. CONCLUSIONS: Safer agents with proven efficacy exist for the treatment of bronchoconstriction in anaphylaxis. Until data are available in humans, methylxanthines should not be recommended in the treatment of anaphylactic reactions.