Mark D. Fox

Commonly prescribed medications and potential false-positive urine drug screens.

PURPOSE The implications of potential false-positive urine drug screen (UDS) results for patients receiving commonly prescribed medications were evaluated. SUMMARY A comprehensive literature review was conducted to identify false-positive UDSs associated with all clinic formulary medications, as well as common nonprescription medications. The references of each report describing a medication whose use was associated with false-positive UDS results were also reviewed. If a class effect was suspected, additional agents in the category were searched. A total of 25 reports of false-positive UDS results were identified. Categories of medications included antihistamines, antidepressants, antibiotics, analgesics, antipsychotics, and nonprescription agents. Reports of false-positive results were found for the following formulary and nonprescription medications: brompheniramine, bupropion, chlorpromazine, clomipramine, dextromethorphan, diphenhydramine, doxylamine, ibuprofen, naproxen, promethazine, quetiapine, quinolones (ofloxacin and gatifloxacin), ranitidine, sertraline, thioridazine, trazodone, venlafaxine, verapamil, and a nonprescription nasal inhaler. False-positive results for amphetamine and methamphetamine were the most commonly reported. False-positive results for methadone, opioids, phencyclidine, barbiturates, cannabinoids, and benzodiazepines were also reported in patients taking commonly used medications. The most commonly used tests to screen urine for drugs of abuse are immunoassays, even though false-positive results for drugs of abuse have been reported with a number of these rapid-screening products. Results from such tests should be confirmed using additional analytical methods, including gas chromatography-mass spectrometry. CONCLUSION A number of routinely prescribed medications have been associated with triggering false-positive UDS results. Verification of the test results with a different screening test or additional analytical tests should be performed to avoid adverse consequences for the patients.

Changing the culture of a medical school by orienting students and faculty toward community medicine.

Oklahoma’s health status has been ranked among the worst in the country. In 1972, the University of Oklahoma established the Tulsa branch of its College of Medicine (COM) to expand the physician workforce for northeastern Oklahoma and to provide care for the uninsured patients of the area. In 2008, the Tulsa branch launched a distinct educational track, the University of Oklahoma COM’s School of Community Medicine (SCM), to prepare providers equipped and committed to addressing prevalent health disparities. The authors describe the Tulsa branch’s Summer Institute (SI), a signature program of the SCM, and how it is part of SCM’s process of institutional transformation to align its education, service, and research missions toward improving the health status of the entire region. The SI is a weeklong, prematriculation immersion experience in community medicine. It brings entering medical and physician assistant students together with students and faculty from other disciplines to develop a shared culture of community medicine. The SI uses an unconventional curriculum, based on Scharmer’s Theory U, which emphasizes appreciative inquiry, critical thinking, and collaborative problem solving. Also, the curriculum includes Professional Meaning conversations, small-group sessions to facilitate the integration of students’ observations into their professional identities and commitments. Development of prototypes of a better health care system enables participants to learn by doing and to bring community medicine to life. The authors describe these and other curricular elements of the SI, present early evaluation data, and discuss the curriculum’s incremental evolution. A longitudinal outcomes evaluation is under way.

Values, Policies, and the Public Trust

Let it not be so with Todd Krampitz. The tragedy of Todd Krampitz’s situation—his illness, his quest for a transplant, and ultimately his death—ought not be minimized. His media plea for a directed donation highlighted some of the ethical pitfalls in the current policies and practices related to organ donation and transplantation. At the same time, however, his story reached a broad audience and put a human face on the need for donor organs in a way that few other campaigns have rivaled. The Krampitz tragedy highlights the tension between the experience of individual patients and the demands of developing policies that serve the needs of the community as a whole. It is important to situate the development of transplant policy in its appropriate historical and political context. Further, it is necessary to tease out three distinct threads in transplant policy: issues related to organ donation, access to transplantation, and allocation. Finally, and perhaps most importantly, it is necessary to ask a fundamental question: What is the goal of transplantation? Zink et al, as well as the various commentators have raised a number of legitimate concerns—and demonstrated the range of opinions on these issues that exists, at least within the academic bioethics community. Not apparent in these discussions is an appreciation of the interplay between various forces that impact organ donation and transplantation policy and practice. Specifically, there are the preferences and behaviors of potential and actual donors (both living and deceased), of transplant candidates, of organ procurement organizations and transplant centers. In addition, there are legal constraints governing organ donation, while it is primarily (though not exclusively) transplant center and payor policies that affect access to transplantation. Ultimately, UNOS has far less actual power in regulating these practices than many commentators would have us believe; UNOS’s authority is primarily centered around the allocation of organs recovered from deceased donors,1 and secondarily on waiting list policies as they ultimately relate to allocation. It is interesting to note that most of the commentaries on Zink’s article focus on the issues of solicitation and directed donation; the issues related to access (specifically, the policy allowing patients to be on the waiting list at multi-

A case of seizure activity associated with a therapeutic dose of venlafaxine.

To the Editor: Seizures associated with venlafaxine overdoses1–4 and with therapeutic doses5 have been reported. Several factors may increase the risk of generalized seizure activity, including genetic,6 neurologic,7 psychiatric,7 and drug withdrawal8 effects and the use of agents that lower seizure threshold, such as antidepressants.9 We report a case of a patient on anticonvulsant pharmacotherapy who experienced a seizure following an increase in venlafaxine dose. Case report. Ms A, a 25-year-old white woman with juvenile myoclonic epilepsy, was recently diagnosed with DSM-IV-TR major depressive disorder and generalized anxiety disorder.10 Seizures were well controlled on treatment with lamotrigine (600 mg/d) and clonazepam (2 mg/d), with 1 episode of generalized tonic-clonic seizure reported 2 years prior, following nonadherence to anticonvulsant therapy. Ms A received fluoxetine 80 mg/d for 6 months before it was discontinued, at which time venlafaxine extended release (ER) 37.5 mg daily was started along with hydroxyzine 25–50 mg orally 3 times daily as needed for anxiety. Venlafaxine ER was titrated to 75 mg daily after 1 week and then increased to 150 mg daily after another 3 weeks with moderate mood improvement but minimal anxiety improvement. For anxiety, alprazolam was started 4 weeks after initiation of venlafaxine and hydroxyzine and was titrated to 1 mg twice daily with good adherence. After another 12 weeks, the patient’s mood symptoms worsened, and venlafaxine ER was titrated to 225 mg daily. Sixteen days following this dose titration, the patient experienced a generalized tonic-clonic seizure despite adherence to her anticonvulsant regimen and other medications. Venlafaxine-induced hyponatremia (serum sodium level less than 136 mEq/dL)11 was considered as a potential cause of seizure in our case, but our patient’s sodium level checked on the day of the seizure was 138 mEq/dL. On the basis of the time course of the generalized tonic-clonic seizure, the Naranjo Adverse Drug Reaction Probability Scale12 was applied and indicated a probable relationship between the adverse effect of a generalized tonic-clonic seizure and venlafaxine ER in this patient. Venlafaxine-associated seizure activity at a therapeutic dose has been reported. In the case report identified,5 a patient demographically similar (25-year-old white woman with chronic depression) to ours experienced a generalized tonic-clonic seizure 11 days following an increase in trimipramine from 50 mg to 100 mg daily; her venlafaxine dose was 150 mg daily. No further seizure episodes were reported (12 months of monitoring) following antidepressant discontinuation. The authors theorized that a pharmacokinetic or pharmacodynamic interaction between the antidepressants may have induced the episode. This potential was not identified in our patient. Concurrent medication use and the potential for seizure activity were evaluated. The patient in our case report also received benzodiazepines, ie, clonazepam and alprazolam. The potential for benzodiazepine-mediated seizures was deemed noncontributory. Venlafaxine doses up to 225 mg are included in the recommended dosage range for patients with seizure disorders.7 However, clinicians should be aware of the epileptogenic effects of venlafaxine even at therapeutic doses, particularly in patients with a previous history of seizure activity. For these patients, clinicians should consider using antiepileptics also indicated for psychiatric disorders, avoiding, if possible, agents known to lower the seizure threshold, starting with low doses, proceeding cautiously, and using the lowest effective dose for maintenance therapy.13

Electronic Fences Make Good Neighbors: The Importance of Medical Records Managers to Protecting Autonomy

not perfectly reliable; they contain random measurement error. For example, suppose it is known that the mean on some variable is 100 for the consenting population whereas it is 80 for the population that does not consent. The researcher wishes to avoid bias and chooses people from the consenting population in such a way that the sample mean is 80 to match the mean of those who do not consent. It might seem that the researcher has avoided bias by ensuring that the mean of the consenting sample matches the mean of people who do not consent. The fly in the ointment, however, is that the researcher has not matched on the variable of interest, but rather on the measure of that variable. This might seem to be a trivial distinction, but I shall show that it is not. Let us ask ourselves why a consenter might score below the mean for his or her population (e.g., scoring 80 when the mean consenter is 100). There are two reasons. First, the person really might be lower than the mean for his or her group on the variable of interest. Second, the person might have scored below the mean because of random measurement error. To the extent that the second reason is responsible for the person’s score, we would expect the person to score higher if tested a second time. Put more generally, we have a “regression to the mean” issue; the mean true score of the consenting sample is larger (closer to the mean of 100) than the sample’s mean observed score of 80. The exact number depends on the reliability of the test and can be determined by equations provided by Trafimow (2012). The important general point, however, is that matching on observed scores does not imply that there is a true score match. The simple fact of statistical regression guarantees that the mean true score of a sample of specially selected consenters will be closer to their population mean than will the sample observed score mean. In turn, this guarantees that matching on observed scores will cause a bias with respect to true scores. The reader might wonder why the same effect does not happen for a hypothetical sample of people who do not consent that could, in principle, be chosen to participate if researchers did not worry about obtaining consent. The reason is that in the example, the consenters were chosen to match those who did not consent rather than the other way around. So if those who did not consent were chosen to have a sample mean of 80, that sample mean equals their population mean of 80, and thus random measurement error would not have the systematic effect that I demonstrated in the earlier paragraph. Regression to the mean in this context merely indicates that the mean true score is similar to the mean observed score for that sample. In summary, I agree with Rothstein and Shoben that researchers should continue to obtain informed consent from their research participants. However, there are potential sources of bias that these authors did not cover and that researchers who are concerned with consent bias should consider addressing. Two of them result from the interaction of having two groups (those who consent and those do not) and the statistical fact of random measurement error.

Critical Conversations When the Bedside Clinician Calls for Clinical Ethics

VignetteBackground: Sharon is a 56-year-old woman who has been complaining of bloating and discomfort for years. While descending steps from her hillside home, she recently fell and fractured her pelvis. A CT of the pelvis revealed a large ovarian mass with smaller masses in the peritoneum, and studies of the chest and upper abdomen revealed masses in the liver and lung. A recent biopsy confirmed poorly differentiated cells. She was diagnosed with metastatic ovarian carcinoma and managed conservatively for the pelvic fracture. Until last month Sharon ran a preschool, but she has been homebound for weeks.Presentation: Now, a month after the fracture, Sharon has developed increasing shortness of breath and has been admitted to the hospital with fever and pulmonary infiltrates bilaterally. She appears weak and delirious and has a raspy cough and signs on examination of extensive lung consolidation. She has lost a substantial amount of weight since last month. She is receiving high-flow oxygen 100% in the ICU...

Adverse childhood experiences and posttraumatic stress as an antecedent of anxiety and lower hope.

It is well established in literature that hope is an important psychological strength associated with resilience and overall psychological well-being. Early research also indicates that both posttraumatic stress disorder (PTSD) and anxiety have a negative relationship with hope. To better understand the potential mechanisms of the relationship between childhood trauma, PTSD, anxiety, and hope, we conducted a cross-sectional study of homeless individuals residing in the south central United States (N = 180). The study measured individual differences in the experience of childhood trauma, PTSD symptoms, anxiety, and hope. Based on the hope theory by C.R. Snyder, we hypothesized that PTSD has a negative relationship with hope because trauma memories can be “attention robbers” that take one’s focus off developing pathways toward future goals. The result is greater anxiety and lower hope. To test this theory, covariance-based structural equation modeling was used to evaluate a model of the variables in the sequential order as follows: (a) adverse childhood experiences, (b) PTSD symptoms, (c) increased anxiety, and (d) lower hope. The results indicated that the observed data produced a “good fit” to a model based on Snyder’s theory (&khgr;2 = 419.38; df = 247; p = < 001; root mean square error of approximation = .06 [90% confidence interval: .05, .07]; comparative fit index = .93; standardized root mean square residual = .06). Such a result suggests that future research is needed with survivors of childhood trauma to further explore mechanisms, such as “attention robbing,” that may link PTSD to greater anxiety and less hope.

CPR as Golden Calf

Rosoff and Schneiderman (2017) rightly contend that cardiopulmonary resuscitation (CPR) is an overutilized medical intervention that often offers little potential for benefit and risks great harm, including devastating neurologic injury (Rosoff and Schneiderman 2017). The utilization of CPR is a socially enforced norm that, unlike other medical procedures, requires permission not to perform. Lacking clear evidence to the contrary, we assume that patients and families desire CPR, both in and out of the hospital. Rosoff and Schneiderman correctly object to this situation, including recent, uncritical efforts by the Institute of Medicine and the American Heart Association to expand out-of-hospital CPR. Rosoff and Schneiderman suggest instead that we need to evaluate CPR with the same cost–benefit analysis that we would apply to any other medical intervention and that the medical profession is duty bound to initiate a public education campaign about the procedure’s limitations and the narrow clinical indicators for a satisfactory outcome. Rosoff and Schneiderman note in passing that calls to address this situation “have been made for decades to little effect.” Why does CPR have this unique, oversized role in health care and beyond? And why do calls for change go unheeded? Part of the answer likely rests in Rosoff and Schneiderman’s provocative description of CPR as a fetish. Unfortunately, they do not develop this insight beyond noting that health care practitioners and the public alike view CPR with an irrational reverence, a kind of mythic awe, perhaps driven by how CPR is portrayed in television dramas. “Fetish” is often invoked as a way of dismissing another culture’s religious beliefs as superstition. Conversely, religious studies and sociology have fruitfully turned the notion of fetish toward our own society. Besides Freudian and Marxist uses, the idea of “fetish” offers insight into phenomena as different as Coca-Cola, sports memorabilia, and intragroup power dynamics (e.g., Chidester 1996; Johnson 2000). When combined with religious studies’ increasing attention to the embodied character of religion—that is, religion is necessarily mediated in concrete, embodied ways, including specialized language, architectural spaces, sensory experiences, bodily performances, rituals, and so on (e.g., Strijdom 2014)—the notion of CPR as fetish is illuminating. A plausible account of CPR as a religious fetish would likely include several key elements. A fetish is only intelligible within its complex religious context. Removed from that context, the fetish appears superstitious or irrational or even silly. Fetishes are necessarily tactile/bodily; they can be touched and used. Fetishes impart power, but the fetish must be often repeated to maintain its power. The fetish makes something (whether otherworldly or a historical moment) visible and tangible in the world. Taking these elements together, a credible case could be made that CPR is a religious fetish. Considering CPR as a fetish necessarily brings into view the often-missed reality that medicine functions as a religion in our society. We tend to think of medicine as a type of applied science. When considering religion, we often ask about the relationship between two separate realities: medicine and religion. Consequently, we develop different models for how medicine and religion might relate to each other as separate but vital human practices (e.g., Balboni, Puchalski, and Peteet 2014). But the insight that CPR might be a fetish requires interrogating the complex religious background that makes that fetish intelligible. Medicine as one of our society’s religions is that background (cf. Branson 1973). A religion embodies a distinct set of beliefs and values. Medicine entails a complex set of beliefs about the nature of the world (including unseen forces like viruses and bacteria) and values about how practitioners and patients should act toward each other. Like the priest, the physician has unique attire—liturgical vestments—usually white. Like the priest, the physician makes judgments about when someone has deviated from the social norm. Indeed, medicine determines when you must be quarantined from the social group and when your sins (illness) are sufficiently atoned for, for you to return to the group. Like the parishioner or supplicant, the patient makes extensive confession (the medical history) and is carefully examined. The physician, like the priest, determines your guilt—your diet or smoking or lack of exercise or sexual practices contributed to your illness—or absolves you from guilt—the bad luck of a random virus. As in most religions, medicine includes rituals of purification and anointing. Further, practitioners use specialized language that is opaque to the supplicants. Medicine has its own churches or temples, to which supplicants often travel great distances. Finally,

The Pediatrician's Dilemma: Respecting Parental Autonomy Versus Protecting Vulnerable Children

The Pediatricians Dilemma: Respecting Parental Autonomy Versus Protecting Vulnerable Children Michael R. Gomez, Kyle J. Bielefeld, Michelle K. Escala, Ric T. Munoz & Mark D. Fox To cite this article: Michael R. Gomez, Kyle J. Bielefeld, Michelle K. Escala, Ric T. Munoz & Mark D. Fox (2016) The Pediatricians Dilemma: Respecting Parental Autonomy Versus Protecting Vulnerable Children, The American Journal of Bioethics, 16:1, 22-23, DOI: 10.1080/15265161.2015.1115148 To link to this article: http://dx.doi.org/10.1080/15265161.2015.1115148

Hazard Warning! The Perils of Extending Moral Hazard Analysis Only to Contrarian Parents

Hazard Warning! The Perils of Extending Moral Hazard Analysis Only to Contrarian Parents Michael R. Gomez, Rebecca Moran, Ricky T. Munoz & Mark D. Fox To cite this article: Michael R. Gomez, Rebecca Moran, Ricky T. Munoz & Mark D. Fox (2016) Hazard Warning! The Perils of Extending Moral Hazard Analysis Only to Contrarian Parents, The American Journal of Bioethics, 16:7, 50-52, DOI: 10.1080/15265161.2016.1180459 To link to this article: http://dx.doi.org/10.1080/15265161.2016.1180459