Big Pharma- Betrayal of Trust

Not too long ago I blogged about dodgy antimalarials as a public health risk. Here is a disturbing news report published in The Guardian about GlaxoSmithKline (GSK) pharmaceuticals. 


GSK was recently reprimanded for the promotion of anti-depressants for unapproved indications, concealing critical safety evidence from the FDA and offering lavish entertainment and incentives to doctors for endorsing their products. They were hit with a $3 billion fine, which in light of their massive profits, really will have little impact on their bottom line. 


This is Big Pharma at its worst.This is a betrayal of the public's trust in medicine and science.

Invasive Streptococcus- a Lethal Pathogen

Here is an New York Times newspaper article on the virulence and danger of invasive streptococcal disease. The newspaper article features a quote from VCU's own Dr. Michael Edmond.


The story is a strong reminder of the difficulty in making an early diagnosis as the clinical findings may be subtle. Sadly, as chronicled in the article, a delay in diagnosis and treatment can be fatal.

The Coffin-Maker as an HIV Benchmark

Source: NY Times

For those of you interested in the HIV epidemic, here is a good read in the Sunday New York Times. Improvements in HIV care and expanded access to retrovirals, particularly in resource poor settings, are having an adverse effect on the business of coffin-makers. This is a good thing.


Thanks to programs such as Pepfar, deaths from HIV/AIDS are decreasing significantly in Africa.


This is US Foreign aid put to excellent use. 

Vitamin D and Hospital Acquired Infections

I read an intriguing paper (full text online) on the vitamin D and its potential role in preventing hospital acquired infections.

The authors believe that vitamin D supplementation in vitamin D deficient, hospitalized patients could improve health outcomes. Vitamin D is inexpensive and supplementation is generally safe. They cite numerous publications on the immunomodulatory effects of vitamin D and its potential impact on both bacterial and viral infections. The paper references various associations (not causation) between low vitamin D levels and healthcare associated infections including pneumonia,Clostridium difficile and surgical site infections. 


Compelling, however, before we launch into mass vitamin D screening and supplementation of hospitalized patients, further data is needed to define target vitamin D levels for maximal immunologic benefit and optimal repletion strategies. Last, prospective clinical studies are needed to definitively confirm the infection prevention benefit of vitamin D. Until then, vitamin D supplementation to reduce the risk of hospital-acquired infections will likely not be the standard of care.  

At-Home HIV Tests- Likely a Good Thing

Source: NY Times

Last week the FDA approved an at-home HIV test, OraQuick. An informative read on the matter is found in the New York Times. The test is highly sensitive and positive results must be confirmed in a medical office.

As an infectious diseases specialist, I fully support at-home HIV testing. Alarmists have predicted a wave of suicides if home tests are made available. I think that these concerns may now be unfounded. Although there is still a stigma associated with HIV,  the disease can now be managed very well and is no longer a death sentence. 

Timely diagnosis is urgently needed. Diagnosis is treatment and treatment is prevention.

Clinical and Diagnostic Reasoning of Senior Medical Students

The public trusts the medical education system to graduate clinically competent physicians. The clinical reasoning skills of medical students are not systematically and uniformly examined during the clinical years of training. Traditional assessments such as ward evaluations, written examinations and even simulated patient encounters (using patient-actors) do not robustly measure clinical reasoning and diagnostic skills.  This was quite evident to me after nearly 7 years in charge of medical student training in internal medicine at the Virginia Commonwealth University School of Medicine.

Here is an article published in Academic Medicine exploring the diagnostic justification (DXJ) abilities (clinical reasoning) of senior medical students. All senior medical students in the classes of 2011 (n = 67) and 2012 (n = 70) at a Midwestern university were required to take and pass a 14-case, standardized patient examination prior to graduation. For nine cases, students were required to write a free-text response indicating how they used patient data to move from their differential to their final diagnosis. The DXJ scores were compared with traditional standardized patient examination (SCCX) scores.

Although using SCCX and DXJ scores led to the same pass-fail decision in the majority of cases, discrepancies occurred.  In discrepant cases, students would fail using the DXJ score but pass using the SCCX score, suggesting that deficiencies in diagnostic reasoning may go unnoticed. 

We are exploring the use of simulated technologies to simultaneously assess patient care and clinical management skills in a standardized, uniform fashion.  We are using newer simulation tools, e.g. high-fidelity mannequins (iSTAN), for the assessment of student diagnostic and management skills in real time based on response to changes in mannequin-patient clinical signs, data, and pathophysiologic state. Think of it as a flight simulator for medical trainees.

Stay tuned.

Medicare and Medical Education- Open Your Eyes

Every now and then I hear a medical resident grumble about government intrusion into medicine. To me, this is much a like a 'keep your government hands off my medicare' moment. 


Here is a letter published in Academic Medicine underscoring the importance of knowing that all ACGME clinical residency training programs are (and have been) funded by Medicare.  This important fact is frequently not known by residents (shocking) and by the public (not so shocking).


That is right. Medicare (i.e. the Federal Government) funds the training of doctors in the USA.  So, the next time you hear a doctor espouse outrage about government intrusion into health  care, keep in mind that his or her residency training was paid for by the US taxpayer.


Knowledge can be enlightening.