The new "SARS"?

Supposedly this is a coronavirus, but unlike SARS is not spreading to medical personnel.

The editorial puts those findings into context. It recounts four recent viral public health emergencies — Nipah virus in 1998, West Nile virus in 1999, SARS in 2003 and the pandemic H1N1 flu in 2009 — to demonstrate that the time from identification, to analysis with increasingly sophisticated tools, and then to public health response, is shortening....

This is somewhat reassuring — but it also raises so many questions. What happens, on the one hand, if recognition doesn’t take place, or communication is not swift? (Recall that, though the Saudi hospital contacted the Erasmus lab quickly, most of public health did not learn of the case until 3 months had gone by.) And what happens if, on the other hand, all those communications work well enough to raise public alarm — and then nothing further happens? (Recall that, in 2009, public reaction to the generally mild presentation of pandemic H1N1 was generally that authorities were crying wolf.)

The real problem with experts and "Guidelines"

Let's talk about “evidence,” a term that is thrown around far too loosely. The USPSTF's technique of question development followed by a detailed, standardized analysis of the literature to answer a specific question is “best in class.” Far too often, recommendations that are purported as evidence-based are nothing more than a consensus recommendation from a group of experts without any well-defined data to support it. Case in point: A 2009 review of 14 American Heart Association/American College of Cardiology (AHA/ACC) guidelines revealed that only 11 percent were based on multiple randomized trials or meta-analyses (AHA/ACC level A evidence), whereas nearly one-half were based on consensus (AHA/ACC level C evidence).4 Simply put, a group of experts expressing their views is not evidence.

Andrea: And just who are these experts involved with guideline development? The USPSTF dismisses experts with conflicts of interest, and so does the United Kingdom's National Institute for Health and Clinical Excellence. This is a no-brainer in my book. However, a review of 17 ACC/AHA guidelines involving 498 contributors revealed that 56 percent of the guidelines had an author with a conflict of interest.5 And this ethical dilemma is not limited to ACC/AHA guidelines. A 2011 review of 14 U.S. and Canadian clinical practice guidelines on diabetes mellitus and hyperlipidemia revealed that there was no conflict-of-interest documentation in five of the guidelines (this does not mean there were no conflicts of interest), and of the nine with documentation, 48 percent had authors who disclosed conflicts of interest.6 Digging deeper, specialty society guidelines in particular seem to have strong ties to pharmaceutical manufacturers. A 2002 survey of 100 specialty society guidelines revealed that 87 percent had ties to the pharmaceutical industry.7

Bob: One has to wonder why an organization that is creating a guideline does not seek conflict-of-interest disclosure or recuse authors that have a conflict of interest. Perhaps the truth is that specialty society organizations themselves may sometimes have a conflict of interest (e.g., receiving income from pharmaceutical companies). This can lead to the organization consciously or unconsciously predetermining the outcome of a guideline. Don't believe this can happen? A British Medical Journal report revealed that a prominent “nonprofit” organization that received a total of $11 million from a pharmaceutical company subsequently placed six members with ties to this company on a nine-person committee that was to determine the role of the company's drug in a guideline.8

Many have called for transparency in the clinical practice guideline development process. Currently, final recommendations often appear as if there was unanimity among the contributors' recommendations. This is not always the case. It would be more appropriate to disclose how the committee members voted on the final recommendation, similar to Supreme Court rulings. Wouldn't a five-to-four decision reflect a level of concern (or conflict) that clinicians should be aware of?

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summary:

Main Points

• There are no controlled trials demonstrating that lipid screening in children improves long-term health outcomes.

• Many guidelines are dominated by recommendations from experts and are not based on sound clinical studies. The development of clinical practice guidelines needs to be transparent and devoid of commercial, financial, and political influences.

• Be wary of outdated guidelines.

EBM Points

• Primary care guidelines tend to be more methodologically sound than specialty society guidelines.

• The level of evidence of clinical practice guidelines should be reviewed before widespread implementation.

waste in health care

The American medical system squanders 30 cents of every dollar spent on health care,

The Institute of Medicine report — its research led by 18 best-of-class clinicians, policy experts and business leaders —

the American medical system wastes an estimated $750 billion a year while failing to deliver reliable, top-notch care.

The institute’s analysis of 2009 data shows $210 billion spent on unnecessary services, like repeated tests,

$130 billion spent on inefficiently delivered services, like a scan performed in a hospital rather than an outpatient center.

It also shows the health care system wasting $75 billion a year on fraud,

$55 billion on missed prevention opportunities

a whopping $190 billion on paperwork and unnecessary administrative costs.

Headlines of the day

ScienceDaily (Sep. 10, 2012) — A novel human liver-chimeric mouse model developed at Oregon Health & Science University and Yecuris Corporation has made possible a research breakthrough at Seattle Biomedical Research Institute that will greatly accelerate studies of the most lethal forms of human malaria.,,,

The liver-to-blood stage of P. falciparum is the focus of this research because the parasite is virtually harmless, causing no disease symptoms, prior to its transition to the blood stage.

In this study, researchers at Seattle Biomedical Research Institute, Yecuris Corporation, Oregon Health & Science University and The Rockefeller University have demonstrated that a complete liver-to-blood stage infection of P. falciparum is possible using a unique immunocompromised mouse model engrafted with human liver-chimeric cells.

The Placebo effect is probably subconscious.

As PiPS Director and study coauthor Ted Kaptchuk notes, "It's not what patients think will happen [that influences outcomes] it's what the nonconscious mind anticipates despite any conscious thoughts. This mechanism is automatic, fast and powerful, and does not depend on deliberation and judgment. These findings open an entirely new door towards understanding placebos and the ritual of medicine."

. The group of students who reported musical training in childhood had more robust responses — their brains were better able to pick out essential elements, like pitch, in the complex sounds when they were tested. And this was true even if the lessons had ended years ago.

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