Conceptually, the matching procedure seems straightforward: assign medical students to residency programs in a way that streamlines the process and produces the best outcomes for all parties involved. Practically, however, it’s a bit more complicated. Fourth-year medical students apply to residency programs in the specialty (or specialties) of their choosing, usually via the Electronic Residency Application Service (ERAS) which is a standard computerized application form used by most residency programs across all specialties. The programs review these applications, select the candidates they’d like to meet and go through the standard interview process. The students then rank the programs in order of most desired to least desired and submit their lists electronically to the NRMP. The residency programs do a similar ranking of the students they’ve interviewed, and submit their lists as well. Through a complex computer program that possibly only its creators understand, the best “matches” are made in a manner that optimizes both the students’ and programs’ requests. Both students and programs are contractually bound to the outcomes of the match.

This would be a feat unto itself if it was that simple. The matching program also takes into consideration whether the students have registered as a couple, as in the case of married students who want to stay in the same location, whether the student has applied in two different specialties, and whether the specialty to which the student is applying needs a preliminary or transitional year (“internship”) following medical school before entering into their categorical program. The data processing required is mind-boggling.

And yet, somehow it works. So every March crowds of fourth year medical students anxiously await the envelope containing the program’s output that determines their destiny for the next three to seven years. Every March, dreams are realized or ruined with the opening of a single envelope. While it seems somewhat arbitrary that after years of difficult and expensive education the course of someone’s career comes in the form of a computer-generated assignment, for many it’s preferable to the vague and chaotic process of years past.

References

National Resident Matching Program.

Electronic Residency Application Service. Association of American Medical Colleges (AAMC).

The study, published in the British Medical Journal (BMJ), looked at close to twenty thousand patients who received anesthesia-related procedures while under the care of trainees starting work for the first time at a specific Australian hospital over a five year period.

What they found was a noticeable spike in medical errors in July, but not just for the rookies. Even seasoned anesthesia residents made significantly more errors in July, at a rate similar to the newbies.

The reason for the errors, the authors postulate, may not just be related to lack of technical expertise. Given that the error rate was similar across all levels of training, it may have had more to do with the unfamiliarity of the environment and the pitfalls associated with it. The facility may have used materials that were different than the ones trainees had used in the past, policies related to a given procedure may have been different, even the staff would have been different, which may have affected how comfortable a trainee would feel asking for help.

So while lack of technical expertise may contribute to medical errors in residents, there are clearly other factors at play. Perhaps the next focus of our efforts to reduce medical errors among physician trainees should be to better familiarize our residents with their environment, materials, and staff well before their work is to commence.

Reference

Haller, G., Myles, P., Taffe, P., Perneger, T., & Wu, C. (2009). Rate of undesirable events at beginning of academic year: retrospective cohort study BMJ, 339 (oct13 1) DOI: 10.1136/bmj.b3974

The so-called “baby blues” are common, affecting 30-75% of new mothers (fathers are affected too). True post-partum depression is less common, affecting 10%, while post-partum psychosis afflicts around 1 to 2 out of 1000 new mothers. Other than the precipitating event, post-partum depression differentiates itself from standard depression by having a somewhat lower age of onset and lower incidence of suicide, while having a higher degree of obsessional behavior and anxiety. For obvious reasons, wild swings in hormones are thought to play a role, although no consistent pattern of hormonal alterations leading to depression has yet been identified.

As opposed to post-partum depression, post-partum psychosis differentiates itself from standard psychosis primarily by its precipitating factor: childbirth. Personal or family history of bipolar disorder is perhaps the strongest risk factor for the development of post-partum psychosis. Women with bipolar disorder who also have a family history of post-partum psychosis are at highest risk, with an estimated 570 of 1,000 individuals with this profile developing the disorder in the post-partum period. Early age at parenthood is also a risk factor for obsessional problems in the post-partum period. Women with one episode of post-partum psychosis are also at risk of recurrent mental illness, with 51% developing an illness in a non-childbirth associated setting, and 38% having a recurrent episode of post-partum psychosis with subsequent deliveries. The rarity of this disorder has precluded thorough testing of treatment methods, although electroconvulsive therapy (ECT) has shown some promise. In patients with pre-existing bipolar disorder or a history of psychotic episodes in the post-partum period, mood stabilizers such as lithium may reduce the rate of relapse.

The question remains as to whether the tragedy of the dismembered infant could have been avoided. Although little is known at this time about the mother’s medical history or medication use, the best answer we can give at this time is: maybe.

References

Seyfried, L., & Marcus, S. (2003). Postpartum mood disorders International Review of Psychiatry, 15 (3), 231-242 DOI: 10.1080/0954026031000136857

FAIRBROTHER, N., & ABRAMOWITZ, J. (2007). New parenthood as a risk factor for the development of obsessional problems Behaviour Research and Therapy, 45 (9), 2155-2163 DOI: 10.1016/j.brat.2006.09.019

Tam, W., & Chung, T. (2007). Psychosomatic disorders in pregnancy Current Opinion in Obstetrics and Gynecology, 19 (2) DOI: 10.1097/GCO.0b013e3280825614

To the uninitiated, doses that high would be lethal. To someone who had developed a tolerance to the medication, however, doses in that range may be necessary to achieve the desired effect. It seems to defy physiology that what would kill one individual would merely mellow out another, but therein lies the enigma of drug tolerance.

Certain medications, such as narcotic painkillers and sedatives such as Xanax, are known to create tolerance. In the case of opiate narcotics, this occurs at several levels within the body. Chronic use of opiate medications causes partial loss of function of its neural receptors’ ability to signal within brain cell. It also causes adjustment of the signaling systems within the cell, leading to alterations in its excitability. These changes, in turn, can indirectly affect the excitability of nerve cells throughout the body, further contributing to overall tolerance. Interestingly, the signaling systems involving cAMP also play a role in synaptic plasticity, leading to potential consequences of opiates on learning and memory. Combined, these changes lead to a blunting of the body’s response to a given dose of an opiate over time, and therefore an ever-escalating need for higher doses of opiates in order to achieve the same effect.

The development of tolerance to sedatives such as Xanax is less well understood, but may involve down-regulation of the benzodiazepine and GABA receptors within the brain. Reduction in the number of chloride channels within the cells and the resultant changes in the GABA receptors may also play a role. Chronic use may alter the gene regulation of the receptor itself. However tolerance to sedative medications occurs, it is known to occur swiftly, particularly with respect to their depressant effects.

While the amount of medications that Jackson was taking may seem shocking, it is a well-known consequence of chronic use of these medications. Unfortunately, while tolerance to the sedative effects of these medications may occur, tolerance to some of their other effects may not, frequently leading to illness, and in some cases, death.

References

Christie, M. (2008). Cellular neuroadaptations to chronic opioids: tolerance, withdrawal and addiction British Journal of Pharmacology, 154 (2), 384-396 DOI: 10.1038/bjp.2008.100

Bateson, A. (2002). Basic Pharmacologic Mechanisms Involved in Benzodiazepine Tolerance and Withdrawal Current Pharmaceutical Design, 8 (1), 5-21 DOI: 10.2174/1381612023396681

Miller LG. Chronic benzodiazepine administration: from the patient to the gene. J Clin Pharmacol. 1991 Jun;31(6):492-5.

Hutchinson, M. (1996). The behavioural and neuronal effects of the chronic administration of benzodiazepine anxiolytic and hypnotic drugs Progress in Neurobiology, 49 (1), 73-97 DOI: 10.1016/0301-0082(96)00011-1

Gender reassignment was not something I had learned about in medical school. It was mentioned in passing, but there were no lectures about how to correctly dose estrogen for the male-to-female transsexual. I frankly had no idea what to do. I think my surprise and confusion were apparent, as the man blushed a little and suggested that I might want to refer him to a specialist.

Chastity Bono’s recent announcement that she will be transitioning from female to male reminded me anew what a deeply personal and difficult decision gender reassignment is. Medically, it’s complicated as well. Before even embarking on the anatomically-altering regimen, a great deal of therapy is recommended, as well as a “test run” living as the desired gender. Following that, hormones are begun. The regimen for a woman becoming a man is relatively straightforward: testosterone shots once every twelve weeks. Such a regimen produces increased facial hair, body mass index, a deeper voice, and enlargement of the clitoris, sometimes to the degree that intercourse is possible without surgery. It can have adverse effects on serum triglycerides and may cause acne.

A man wanting to become a woman faces a bit more complicated hormonal regimen, as not only does estrogen need to be added, but testosterone needs to be suppressed. Surgery to remove the testicles will obviate the latter, but is not a procedure that some are willing to undergo right away. This hormonal one-two punch will result in breast growth, increased subcutaneous fat, some decrease in upper body strength, and atrophy of both the testicles and prostate. Facial hair growth and voice depth will not change appreciably, however, and usually require additional procedures to mitigate.

The ultimate step in sexual reassignment is surgery. The most common type of surgery involves the removal of sex-specific organs; beyond that is genital reconstruction, which is significantly more complicated. After the entire process is completed, only 1 to 2 percent of postsurgical transsexuals experience regret.

As for my patient, I never saw him again after I referred him to another physician. Hopefully he is now a she, and is living a happy and fulfilling life.

References

Benjamin H. International Gender Dysphoria Association’s Standards of Care for Gender Identity Disorders, Sixth Version. February 2001.

Lawrence, A. (2003). Factors associated with satisfaction or regret following male-to-female sex reassignment surgery Archives of Sexual Behavior, 32 (4), 299-315 DOI: 10.1023/A:1024086814364

What these researchers and others before them have done is taken a representative swath of humanity and labeled them as “healthy.” The JUPITER trial, for example, looked at using a statin for so-called “healthy” individuals and found that it reduced their risk of cardiovascular events. However, these people weren’t healthy. Average, yes; representative of the United States population, yes. Healthy, no. Seventy-five percent of the subjects in the JUPITER trial were overweight or obese and also had a blood test abnormality. Similarly, in the TIPs study the subjects did not have pre-existing cardiovascular disease but did have type 2 diabetes, increased waist-to-hip ratio, abnormal lipids, high blood pressure, or a history of recent smoking. In other words, not “healthy.” Notable, too, is the fact that each and every one of the things that renders these individuals unhealthy is almost entirely preventable with lifestyle modifications.

The fact that legitimate research is being conducted on this “polypill” is a sad commentary on the faith that the healthcare industry has in people to save themselves. Although the researchers in the TIPS trial point out that their medication is not intended to be a substitute for diet and exercise, as Dr. Clyde Yancy, medical director of the Baylor Heart Institute in Dallas, was quoted in Clinical Endocrinology News, “There is nothing more effective than modifying lifestyle, but people may tend to dismiss that concept if they believe a pill is lowering their risk of heart disease.”

In a few years, we’ll get the final results on the TIPS trial. I predict that it will show a benefit. I also predict that the drug will be heavily marketed to people who have had the power to lower their risk of cardiovascular disease in their own hands all along. It is up to us to decide if we want our health to be determined by our own efforts or those of the pharmaceutical industry.

References

Xavier, D., Pais, P., Sigamani, A., Pogue, J., Afzal, R., & Yusuf, S. (2008). The need to test the theories behind the Polypill: rationale behind the Indian Polycap Study Nature Clinical Practice Cardiovascular Medicine, 6 (2), 96-97 DOI: 10.1038/ncpcardio1438

Ridker, P., Danielson, E., Fonseca, F., Genest, J., Gotto, A., Kastelein, J., Koenig, W., Libby, P., Lorenzatti, A., MacFadyen, J., Nordestgaard, B., Shepherd, J., Willerson, J., Glynn, R., & , . (2008). Rosuvastatin to Prevent Vascular Events in Men and Women with Elevated C-Reactive Protein New England Journal of Medicine, 359 (21), 2195-2207 DOI: 10.1056/NEJMoa0807646

Then came the Libby Zion case, in which a young woman died while under the care of overtired residents. Suddenly America realized that it probably wasn’t a good idea to have inexperienced doctors taking care of really sick people on less than three hours of sleep per night. Enter the Accreditation Council for Graduate Medical Education (ACGME) which is charged with accrediting residency programs nationwide. As of 2003, the ACGME limited the number of hours a resident could work per week to 80, 88 if you were training to be a surgeon and then only under extenuating circumstances. If you were listening carefully at that time, you may have heard the cries of outrage from practicing physicians across the country. How could residents possibly learn enough in 80 hours a week? And after all, if we had to do it, then so should they!

As it turns out, however, caps on resident working hours were nothing new, having been in place across the Atlantic for quite some time. In the United Kingdom, for example, the resident work week is capped at 56 hours per week. And as of August 1, 2009, it’s dropping to 48.

As a program director, I believe I can provide my residents with the training that they need in 80 hours per week over the course of three years. 56 hours per week would take some very creative scheduling. But if I were limited to 48 hours per week, I don’t think that adequate training would be possible, at least not in three years. The British Medical Association seems to realize that and has written a paper outlining several options to address this problem, including extended training. Most options, however, entail added staff and costs. Moreover, most practicing physicians work more than 48 hours per week, according to a 2003 JAMA article. Any resident trained in a 48 hour work week environment would be in for a rude awakening once released into the “real world”.

Fortunately, I don’t have to worry about a foreshortened resident work week just yet. But if the ACGME is taking any cues from the training of British physicians, I may be in for a rude awakening myself in a few years.

References

Maintaining the quality of training in the craft specialties: managing EWTD implementation. British Medical Association. 2009.

E. Ray Dorsey, David Jarjoura, & Gregory W. Rutecki (2003). Influence of Controllable Lifestyle on Recent Trends in Specialty Choice by US Medical Students. JAMA, 290 (9), 1173-1178

In the article, many of his fellow medical students expressed harsh criticism of the school for admitting this student, if not outrage. But one student openly wondered who had the right to say that this person may not turn out to be a great doctor, in spite of his past misdeeds.

Who, indeed? After all, there are reports that some congressmen have prior convictions. George W. Bush may have been the first U.S. president to enter office with a criminal record. Even Bill Gates has a rap sheet, and I think it’s fair to say he’s doing pretty well for himself. Moreover, our country is faced with an imminent shortage of physicians, and declining interest in primary care. In light of such shortages, should we keep people who are willing and able out of medical school due to past offenses? And if so, where do we draw the line? Murder seems to be a likely exclusion criterion. How about rape? Assault with a deadly weapon? DUIs? Parking tickets? Domestic abuse? Animal cruelty? Fraud?

As anyone schooled in behavioral interviewing can confirm, the best predictor of future behavior is past behavior. A 2008 article published in the Annals of Internal Medicine found that physicians who had poor professionalism behaviors during residency were much more likely to face disciplinary actions as practicing physicians. In addition, a 2005 article published in the New England Journal of Medicine found that disciplinary actions by state medical boards were strongly associated with prior unprofessional behavior in medical school.

So to the extent that having a criminal record can be considered “unprofessional,” it seems that a criminal record — any criminal record — would be sufficient reason to keep someone from becoming a doctor. And if the Swedes don’t want to look for a record of criminal activity prior to admitting people to medical school, they’re going to have to make sure their medical licensing boards, as well as their citizens, are ready to suffer the consequences.

References

Altman, Lawrence. A Quandary in Sweden: Criminals in Med School. The New York Times, March 23, 2009: D1.

Papadakis M, Arnold G et al. Performance during Internal Medicine Residency Training and Subsequent Disciplinary Action by State Licensing Boards. Annals of Internal Medicine, June 3 2008. Volume 148, Issue 11, pp 869-876.

Papadakis, M. (2005). Disciplinary Action by Medical Boards and Prior Behavior in Medical School New England Journal of Medicine, 353 (25), 2673-2682 DOI: 10.1056/NEJMsa052596

In spite of the disturbing mental image this conjures, it actually is possible for men to produce breast milk. As DeNiro’s character so comedically noted, men do indeed have nipples. They also have the rudimentary breast tissue and ductal structure that would make the production of milk, called lactation, possible. What they lack is the proper combination of hormones to plump up the breast tissue and stimulate the production of milk.

The formation and proliferation of breast tissue is dependent on the hormone estrogen. Though generally considered to be a “female” hormone, men do produce small amounts of estrogen, as well. In men, its effects are usually tempered by the large amount of testosterone that they produce. The actual production of milk by the breast tissue is dependent on the hormone prolactin, which is secreted by the pituitary gland in the brain. Following the birth of a child, the pituitary gland increases its secretion of prolactin, enabling the new mother to begin producing milk for her infant. Stimulation of the nipples by the nursing infant also causes a spike in prolactin production.

Most cases of male breast formation and lactation in humans are the result of disease or medication side effects and not the need to feed their offspring. The medical literature is replete with reports of men developing breast tissue due to medications or medical conditions. Fat cells are known to increase the production of estrogen, so it’s not uncommon for obese men to develop more prominent breast tissue, known as gynecomastia. In addition, steroid use, cirrhosis, certain medications and certain herbal formulations may cause gynecomastia. Reports of males producing milk are much less common, and are usually seen in infancy when the baby’s overall hormonal status is in quite a bit of flux. And although multiple causes of increased prolactin secretion exist, such as from a pituitary tumor or side effect of a medication, men rarely get galactorrhea as a result.

So while male lactation is possible, it’s very rare, and almost never physiologic. And for those of you who are fans of Meet the Parents, please don’t try this at home.

References

Devidayal (2005). A Male Infant with Gynecomastia-Galactorrhea The Journal of Pediatrics, 147 (5), 712-712 DOI: 10.1016/j.jpeds.2005.06.026

van der Steen M, Du Caju MV, Van Acker KJ. Gynecomastia in a male infant given domperidone. Lancet. 1982 Oct 16;2(8303):884-5.

A recent study published in the Annals of Behavioral Medicine found that smokers who received anti-tobacco messages via their PDAs were more likely to try to quit smoking. In this study, one group received frequent messages about the adverse health consequences of smoking, while the control group received frequent messages about general stress or money concerns. In the end, 53% of those receiving anti-tobacco messages attempted to quit smoking, versus 19% in the control group. In addition, those receiving the anti-tobacco messages expressed significantly more worry about their smoking habits than those who did not. The researchers concluded that in order to get an individual to quit smoking, the key was to get the smoker worried about the health consequences of tobacco use.

However, another recent study found that dieters were more likely to succeed with their weight loss if they had more frequent telephone contact with nutritionists. A study published in the Annals of Internal Medicine found that obese individuals who were trying to lose weight had more success with high-frequency telephone contact or high-frequency face to face visits with nutritionists than those who had neither. They did not include a group that had high-frequency contact with researchers regarding general stress or money concerns. The article does not mention what precisely was addressed during contact with the study participants other than “lifestyle counseling”, nor does it assess how concerned the study group was about the effect of obesity on their health. The researchers in this study concluded that the frequent contact may have played a key role in the study group’s success.

In both the smoking and the weight loss studies, success was due, at least in part, to frequent contact that addressed the behavior that needed changing. In the first study, the researchers concluded that it was “worry” that motivated the smokers to quit, and certainly those who received the anti-tobacco messages did indicate an increased level of concern about their habit. However, was it truly worry that motivated the change, or was it the frequent reminder about the behavior at issue? Would similar effects be seen in dieters if they received frequent reminders about the negative effects of obesity and a sedentary lifestyle on their overall health? Could it be that the frequent nudges about the undesired behavior, rather than “worry”, is the crucial factor to spur behavioral changes?

Given that between 50 and 75 percent of medical conditions are due to behavioral factors, learning how to motivate change could play a huge role in improving our health. I hope to see more studies that address precisely these issues.

References

Magnan, R., Köblitz, A., Zielke, D., & McCaul, K. (2009). The Effects of Warning Smokers on Perceived Risk, Worry, and Motivation to Quit Annals of Behavioral Medicine, 37 (1), 46-57 DOI: 10.1007/s12160-009-9085-8

Andres G. Digenio, James P. Mancuso, Robert A. Gerber, Roman V. Dvorak. Comparison of Methods for Delivering a Lifestyle Modification Program for Obese Patients: A Randomized Trial. Annals of Internal Medicine, Volume 150, Number 4 (February 2009), pp. 255-262.

But how exactly does carbon monoxide cause problems? In humans, oxygen is transported to the body by attaching to hemoglobin, a protein found in red blood cells. Carbon monoxide binds to hemoglobin more easily than oxygen, and therefore displaces the oxygen from the red blood cells. In addition, carbon monoxide makes it more difficult for any other oxygen molecules the red blood cell may be carrying to get delivered to the rest of the body. In short, carbon monoxide poisoning mimics oxygen deprivation. There is, however, a condition due to carbon monoxide poisoning known as delayed neurologic sequelae which can’t be explained by poor oxygen delivery, and may have more to do with enzymatic changes in the brain induced by the carbon monoxide molecule. Carbon monoxide can also cause damage to the heart and can cause accumulation of fluid in the lungs, a condition known as pulmonary edema.

Symptoms of carbon monoxide poisoning can be vague and nonspecific. Frequently patients will present with confusion or symptoms directly attributable to oxygen deprivation, such as chest pain. Headaches, nausea and vomiting may also occur.

The diagnosis of carbon monoxide poisoning is largely based on a suggestive history or clear evidence of exposure in addition to elevated levels of hemoglobin bound to carbon monoxide, otherwise known as carboxyhemoglobin. In cases of chronic carbon monoxide poisoning, however, carboxyhemoglobin levels can be inaccurate, making the diagnosis in such circumstances quite difficult.

Treatment of carbon monoxide poisoning is premised on getting enough oxygen into the patient’s system to wrestle the carbon monoxide off of the hemoglobin. This is accomplished with delivery of 100% oxygen into the patient’s lungs via a face mask, or in more severe cases, via a breathing tube connected to a respirator. Hyperbaric chambers can deliver 100% oxygen at high pressures, making delivery of oxygen into the patient’s system even more effective.

Carbon monoxide poisoning is entirely preventable with the use of inexpensive detectors that can be installed in your home. And if you already have carbon monoxide detectors in your home, be sure to check the batteries.

The push in medical education for several years has been towards more evidence-based medicine; that is, we should teach our young doctors to recommend to their patients what has been scientifically proven to be beneficial. However, a recent study published in the Journal of the American Medical Association (JAMA) found that, at least with regards to cardiovascular problems, the vast majority of the medical evidence supporting current recommendations is weak. Researchers examined the current recommendations of the American Heart Association and the American College of Cardiology on 22 different cardiovascular topics. They graded the strength of the evidence supporting these recommendations from A to C, with A being the best evidence, and C being very little or weak evidence. Only 12% of the recommendations were in the A category. A staggering 45% earned a C.

There are many potential reasons for this, not the least of which is simply the lack of powerful data. The ideal medical study is a large, multicenter, randomized, double-blind, controlled trial funded by an organization with no vested interest in the outcome. The closer a study comes to this ideal, the stronger the evidence is to support its findings. However, many studies fall short of this ideal on numerous fronts. They involve a small or restricted subgroup of patients. They’re performed at only one medical center. They’re funded by the company that makes the medication or device being studied. Any of these shortcomings call the results of the study into question and weakens the strength of the evidence. Can these findings be applied to a larger or less restricted population? Can the results be reproduced at a different hospital? Are the researchers biased towards finding a positive outcome for the company that funds their research?

So should you ignore the majority of what your doctor says for lack of strong evidence? Not necessarily. Most doctors are simply working with the best information they have, even if the data supporting it is weak. What studies like this highlight is the need for better research to ensure that our recommendations are based on sound scientific evidence.

References

P. Tricoci, J. M. Allen, J. M. Kramer, R. M. Califf, S. C. Smith (2009). Scientific Evidence Underlying the ACC/AHA Clinical Practice Guidelines JAMA: The Journal of the American Medical Association, 301 (8), 831-841 DOI: 10.1001/jama.2009.205

Search the literature for reasons why this is happening and you’re likely to stumble across an array of sources that point the finger at over-prescribing physicians and misbehaving patients who don’t take their antibiotics as prescribed. Certainly these two factors play a significant role. But what is frequently overlooked is how drug resistance may be fostered outside the hospital and doctor’s office.

Take, for example, factory farming. Each year in the United States, the farming industry uses 25 million pounds of antibiotics, representing 70% of America’s antibiotic usage, not just to treat infections, but also to prevent them so that their livestock can survive their feedlots long enough to get to slaughter. In 2001, the AMA issued a statement opposing this practice. In 2004, the FDA officially discouraged this practice but backed off from this position in July of 2008.

Then there’s the issue of lax oversight of production and disposal of antibiotics. There was a recent article documenting the presence of ciprofloxacin, a broad-spectrum antibiotic that was once one of the medical community’s “big guns”, in the effluvia of a medication production plant in India in concentrations high enough to treat 90,000 people. When the companies that utilized this plant were questioned about this finding, they stated that the issue of pollution in India was “not within the scope of the activities” of their group. And an Associated Press investigation last year found not only the antibiotic tetracycline, but also blood pressure medications, steroids, cholesterol medications, and antidepressants in Philadelphia’s drinking water, presumably due to the practice of flushing unused medications down the toilet.

Finally, the pharmaceutical industry shifted its attention elsewhere. Research and development funds began being diverted away from the realm of antibacterials in the 1980’s, focusing more on anti-retrovirals for the newly emerging HIV epidemic and higher-order cardiovascular medications. Only in recent years has the attention once again swung back to developing medications to attack the resilient bacteria that have rendered antibacterial efforts of previous decades obsolete.

So while both physicians and patients need to exercise caution in the prescription and consumption of antibiotics, a true attack on drug-resistant bacteria may require a more comprehensive approach addressing not only medical, but also environmental, societal, and industrial factors.

Reference

J. Stephenson (1998). Antibiotics and Livestock JAMA: The Journal of the American Medical Association, 280 (7), 594-594 DOI: 10.1001/jama.280.7.594-a

On the surface, this seems reasonable. When it became apparent that I was going to need a cesarean section after 12 hours of labor with my third child, I had serious misgivings about the fatigue of my physician, who had been awake with me the entire time, not to mention the twelve hours prior. I’m happy to report that all went well, but the fact that my physician had been in practice for over twenty years and could probably do c-sections in his sleep (and maybe even had) probably played largely into his success.

But what about residents? Fresh out of medical school and eager to please, these young physicians are often scheduled to be “on call” for up to thirty hours at a time. And studies have shown that with only 24 hours of sleeplessness, brain performance is equivalent to that of someone with a blood alcohol level of 0.10%. So in theory, at any given moment in the United States, there could be an inexperienced physician writing orders for life-altering medications with all the acumen of the town drunk.

This assumes that the resident has been awake continuously for that 30-hour shift, however. It’s important to note that even though residents are scheduled to be “on call” for extended periods of time, most nights they actually do get some sleep. So the question becomes: how much is enough? The National Sleep Foundation states that adults need seven to nine hours of sleep per night. How did the IOM come up with the idea that five would be just fine? Why not just say you can’t work longer than 16 hours, period? And who’s to say that given five interrupted hours residents will actually sleep?

I agree with the spirit of the IOM’s recommendations. Patients shouldn’t be subjected to inexperienced, overtired physicians. But I can’t help but wonder if the IOM’s new recommendations fall short of the goal that they are trying to achieve.

Cardiac arrest: Mild to moderate hypothermia has been shown to preserve neurologic function following a cardiac arrest, during which the heart stops pumping and the brain is deprived of oxygen. In addition, recent studies have shown that hypothermia may also help improve short-term survival and minimize damage to the heart following such an injury. There are multiple theories as to why this is the case, including alteration of inflammation, slowing of metabolism, and reduction in cell death. It is apparent, however, that hypothermia can be a major benefit to victims of cardiac arrest.

Traumatic brain injury in children: Although hypothermia has been studied in adults with traumatic brain injury, its benefit may be especially prominent in children. As children’s brains are developing rapidly, any significant injury has the potential to cause serious long-term effects. Therapeutic hypothermia has been shown to reduce neurologic dysfunction as well as improve mortality.

Neonatal ischemic encephalopathy: Newborn infants who experience decreased oxygen flow to their brains are at great risk of developing brain damage. Hypothermia has been shown to improve not only their brain function but also their survival.

Stroke: There are some promising studies indicating that hypothermia may help improve recovery in stroke victims. At present, these studies are simply promising, but if validated by larger studies, the use of hypothermia for stroke victims may become more widespread.

Typically hypothermia is induced by using cool intravenous fluids and cooling blankets, but if only local hypothermia is needed the body part of interest can be packed in ice. Patients treated with therapeutic hypothermia may experience electrolyte disorders and may be at higher risk for pneumonia. Overall, however, in specific situations hypothermia can be useful adjunct medical treatment.

References

Hsu CY, Huang CH, Chang WT, Chen HW, Cheng HJ, Tsai MS, Wang TD, Yen ZS, Lee CC, Chen SC, Chen WJ. Cardioprotective effect of therapeutic hypothermia for post-resuscitation myocardial dysfunction. Shock. 2008 Dec 4.

David B. Seder, Salam Jarrah (2008). Therapeutic hypothermia for cardiac arrest: A practical approach Current Neurology and Neuroscience Reports, 8 (6), 508-517 DOI: 10.1007/s11910-008-0081-3

Patrick D. Lyden, Derk Krieger, Midori Yenari, W. Dalton Dietrich (2006). Therapeutic hypothermia for acute stroke International Journal of Stroke, 1 (1), 9-19 DOI: 10.1111/j.1747-4949.2005.00011.x

T HOEHN, G HANSMANN, C BUHRER, G SIMBRUNER, A GUNN, J YAGER, M LEVENE, S HAMRICK, S SHANKARAN, M THORESEN (2008). Therapeutic hypothermia in neonates. Review of current clinical data, ILCOR recommendations and suggestions for implementation in neonatal intensive care units? Resuscitation, 78 (1), 7-12 DOI: 10.1016/j.resuscitation.2008.04.027

Sven M Schulzke, Shripada Rao, Sanjay K Patole (2007). A systematic review of cooling for neuroprotection in neonates with hypoxic ischemic encephalopathy – are we there yet? BMC Pediatrics, 7 (1) DOI: 10.1186/1471-2431-7-30

Nadeem I. Shafi, M Michele Mariscalco (2006). Considering the use of induced hypothermia in a pediatric patient with traumatic brain injury: A critical appraisal of two meta-analyses Pediatric Critical Care Medicine, 7 (5), 468-472 DOI: 10.1097/01.PCC.0000235258.79253.8C