RCT Autopsy:  The Differential Diagnosis of a “Negative” Trial

At many institutions, Journal Clubs meet to dissect a trial after its results are published to look for flaws, biases, shortcomings, limitations.  Beyond the dissemination of the informational content of the articles that are reviewed, Journal Clubs serve as a reiteration and extension of the limitations part of the article discussion.  Unless they result in a letter to the editor, or a new peer-reviewed article about the limitations of the trial that was discussed, the debates of Journal Club begin a headlong recession into obscurity soon after the meeting adjourns.

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SCIENCE, BELIEF, INTUITION

The intuitive mind is a sacred gift

The rational mind is a faithful  servant 

We honor the servant 

And have forgotten the gift. 

– A. Einstein

SCIENCE: During a 50 year career in Academic Medicine, I used the scientific method of inquiry to investigate the pathophysiology and treatment of disease. Science is the evidence based generation of knowledge. Using reproducible accurate measurements,  scientists formulate hypothetical explanations of phenomena, and then we conduct experiments to falsify each hypothesis. Those explanations that could not be falsified are the truth. We go to this trouble to avoid the errors arising from people’s tendencies to observe what they expect. But the scientific method is slow and tedious, has little to say about subjective phenomena of great interest, and the requisite controls for each intervention can obscure the question under study 1,2.

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Scientism and Spiritual Disbelief – by LDH Wood, MD PhD

If a higher power wants to tell us how the Cosmos works, scientists would be wise to learn how to listen to god’s voice. In my memoir Science, Belief, Intuition1, I describe how a person can pursue a productive career as a clinician scientist while cultivating a spiritual relationship. Yet many scientists act as if science and spirituality are antagonistic, so they must choose between them². Some of those choosing science feel the need to discredit spirituality as if it’s existence threatens science or reason, when what it threatens is materialism as a doctrinal world view3.

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My 2 Cents – The 2016 Election and Medical Cultures

We on the two coasts of the U.S. were thumped last week by what is sure to be the ugliest national election of our life-time.  Politicians will perform “autopsies” to examine how/why a great country has chosen a President whose behavior throughout the election was decidedly (probably purposely) un-presidential.  Aside from the extraordinary intuitions and showmanship of this modern PT Barnum, there may be interesting and relevant parallels in Medicine.

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QUASIPOTENT: A TALE OF THREE HYPOTHESES

Like many starry-eyed medical students, I was drawn to critical care because of the high stakes, its physiological underpinnings, and the apparent fact that you could take control of that physiology and make it serve your goals for the patient.  On my first MICU rotation in 1997, I was so swept away by critical care that I voluntarily stayed on through the Christmas holiday and signed up for another elective MICU rotation at the end of my 4th year.  On the last night of that first rotation, wistful about leaving, I sauntered through the unit a few times thinking how I would miss the smell of the MICU and the distinctive noise of the Puritan Bennett 7200s delivering their [too high] tidal volumes.  By then I could even tell you whether the patient’s peak pressures were high (they often were) by the sound the 7200 made after the exhalation valve released.  I was hooked, irretrievably.  Continue reading “QUASIPOTENT: A TALE OF THREE HYPOTHESES”

The Rule of Rescue and the Standard of Abandonment

The patient in bed 11, 20-something years old, usually leaves AMA (against medical advice).  She has gone AMA three times in as many months after being treated, sometimes partially, sometimes completely, for DKA (diabetic ketoacidosis).  This time, she has stayed for a complete course of therapy and I am about to go formally discharge her.  As I approach the room, I can hear her sobbing and I pause outside the doorway.  I had heard from the nurses that, in addition to using methamphetamine, she has been living on the streets.  I wonder how anybody can manage type I diabetes while living on the streets.  This is not going to be an easy discharge.

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Rivaroxaban Treatment Failure in a Patient with Metastatic Lung Cancer

Rivaroxaban is an oral factor Xa inhibitor that was recently approved by the FDA as an oral anticoagulation agent. The FDA approved indications for the use of rivaroxaban include anticoagulation and stroke reduction in nonvalvular atrial fibrillation, treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), for reduction in risk of developing DVT and PE, and for prophylaxis against DVT in patients who recently underwent hip or knee replacement.  The approval of rivaroxaban was based on two non-inferiority studies, the EINSTEIN-DVT study and the EINSTEIN-PE study, which evaluated the use of oral rivaroxaban against the current standard therapy comprised of enoxaparin bridging to vitamin K antagonist (VKA) in patients with known venous thromboembolism (VTE). Both studies (found here and here) found that rivaroxaban was non­inferior to the current therapy for the prevention of symptomatic recurrent VTE or PE without significantly increased rates of bleeding.

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More than Just 140 Characters: Why you Should Join the Annals of the American Thoracic Society on Twitter

When the editors of the Annals of the American Thoracic Society launched the new journal in 2013, they issued a mission statement that the journal was “To publish the highest quality research, commentaries, reviews, and education content of direct interest to practicing adult and pediatric clinicians in pulmonary, critical care, and sleep medicine.”

This statement is near and dear to me, and not just for its use of the Oxford comma. As clinicians, we are looking for data to help us improve the care of those lives entrusted to us. At the same time, we seek content that keeps us engaged in our craft and sharpens our minds, to make us the best practitioners possible. If you’re reading this on the blog, I am likely already preaching to the choir. But were you to print this and hand it to a colleague that reads journal content only, I’d make an argument for social media in the era of widely disseminated and easily accessible peer reviewed publications.

We all enjoy discussing topics in clinical medicine, just as this blog does. Twitter is an opportunity to catch up with a terrific array of clinicians, researchers, policy-makers, pundits, patients, and families.  If you’re already on Twitter, I hope you’ll join us at @AnnalsATSEditors. If you’re not on Twitter, I hope you’ll get an account and join the party. Twitter is a chance to stay abreast of the latest published manuscripts, to see what your peers are reading, hear what others are thinking, and, sometimes, have a nice (and civil) exchange of ideas. All in 140 characters. Our Twitter account is dedicated to not only bringing you the latest published Annals content but also to bring you Tweets from other sources that might pique your interest as an Annals reader. And soon, you’ll be engaging Annals authors directly in Twitter chats.

I hope you’ll follow us @AnnalsATSEditors, and that you’ll also Tweet us your thoughts, suggestions, feedback, and tidbits of interest. See you in the Twittersphere!