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Category: Medical Practice

Why “Radiopharmaceutical” Should be Part of your Healthcare Vocabulary

By JAY T. RIPTON

Not to sound too alarmist, but the radiopharmaceutical industry is on the verge of an explosion. But don’t worry; it’s not the type of explosion one often associates with nuclear materials… I love those movies too! It’s the beginning of a new wave of innovation for the diagnosis and treatment of certain cancers and other diseases.

This new radiopharmaceutical boom quite literally has the life sciences industry in a nuclear arms race of sorts, as companies like Y-mAbs, Novartis and others are pushing through clinical trials for the next blockbuster for the treatment and detection of hard-to-treat diseases like medulloblastoma and metastatic castration-resistant prostate cancer. But all this excitement has many wondering, “what are radiopharmaceuticals anyway?”   

Radiopharmaceuticals are simply a group of pharmaceutical drugs containing radioactive isotopes. They are being used primarily for the treatment and detection of certain types of cancers, but they are also being developed for cardiac disease as well. And what makes radiopharmaceuticals so unique is that they can be targeted to extremely precise areas in the human body.

Although gaining ground with more precision today, this type of therapy actually began in the 1940s with I-131 – which has become an important agent for the treatment of benign and malignant thyroid disease. The development of radiolabeled antibodies began in the 1970s, and Radium-223 dichloride was approved by the FDA in 2013 for the treatment of castrate-resistant metastatic prostate cancer. Lu-177 PSMA is one of several recent developments that are making their way through FDA approvals.

“The radiopharmaceutical industry has actually been around for some time, but today it is at a tipping point,” says SpectonRx president Anwer Rizvi. “Over the next few years, it is estimated that our industry will triple. With more radiopharmaceuticals making their way through clinical trials and FDA approval, we are starting to see more data that highlight their effectiveness. This is why we are now starting to see more life sciences organizations committing real resources to radiopharmaceuticals.”  

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Why is a 1980 Drill in my 2020 Brain?

By SHVETALI THATTE

Late one evening, a trauma patient, a mother of three, comes through on an ambulance. She’s having trouble breathing, despite the breathing tube lodged in her throat. Dr. Nikhil K. Murthy, the neurosurgeon on the case, assesses the situation and orders a CT, which reveals a ruptured aneurysm, or a burst blood vessel. Excess fluid in the brain is fatal, as the increased pressure deprives the brain of vital oxygen. A sense of immediacy surges through Dr. Murthy as he calls for the necessary supplies to perform a ventriculostomy to drain the blood. He rushes to connect the drill bit, brace the manual drill against his body, and drill a hole in the right place, at the precise angle and depth. With the urgency of the situation blaring in his mind, Dr. Murthy has only his experience, training, and intuition to ensure that he does not drill past the skull and into the brain. The stakes are high, and a woman’s life is on the table. 

Bedside ventriculostomies, like the one described above, are common in the emergency department, as the surgery is often performed in life-or-death situations to immediately relieve fluid build-up in the brain. Dr. Murthy’s experience does not stand alone: countless neurosurgeons have stood in his exact shoes. While Dr. Murthy successfully performed the ventriculostomy, saving the woman’s life, not everyone is as lucky: the complication rate for bedside ventriculostomies in the U.S. stands at an egregious 50 percent. 

“When that woman was lying on the table, a drill braced against her skull, what she and I both needed was a safer, more reliable tool to perform the surgery.” – Dr. Nikhil K. Murthy 

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Equipoise and Its Problems

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By MICHEL ACCAD, MD

I recently participated in a debate opposing me to Professor Adam Cifu on the topic of “Evidence-based medicine in the age of COVID.” The debate took place on an episode of Dr. Chadi Nabhan’s Outspoken Oncology podcast. Dr. Saurabh Jha was the moderator and he did a great job keeping us on point and asking for important clarifications when needed. It was a fun and cordial moment and I found it intellectually fruitful. You can listen to it here or on any podcast platform. The discussion strengthened my conviction that the central issue about EBM is the conflation of the role of the physician with that of the clinical scientist.

That conflation was quite apparent in a recent online editorial published by Robert Yeh and colleagues on the topic of equipoise during the COVID-19 pandemic. Yeh at al. are accomplished academic cardiologists and outcomes researchers (Yeh was a guest on The Accad and Koka Report a couple of years ago).

I’ll get to their editorial in a moment, but equipoise is a term that I became aware of only in the last few years, mainly from mentions on MedTwitter. From those mentions I developed an intuitive sense of what equipoise must mean: a mental state of uncertainty about a treatment that prompts the medical community to seek a more definitive answer by way of a randomized controlled trial. For example, one might say “I’m not sure if hydroxychloroquine works to prevent or treat COVID-19.  Based on the existing collective experience, there is equipoise about it.  We need a clinical trial.”

That seems reasonably straightforward, but the editorial by Yeh et al. piqued my curiosity so I decided to look into the origin of the term and its introduction in the medical literature.

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Quantum Theory of Health

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By KIM BELLARD

We’re pretty proud of modern medicine.  We’ve accumulated a very intricate understanding of how our body works, what can go wrong with it, and what are options are for tinkering with it to improve its health.  We’ve got all sorts of tests, treatments, and pills for it, with more on the way all the time.

However, there has been increasing awareness of the impact our microbiota has on our health, and I think modern medicine is reaching the point classical physics did when quantum physics came along.  

Image credit: E. Edwards/JQI

Classical physics pictured the atom as kind of a miniature solar system, with well-defined particles revolving in definite orbits around the solid nucleus.  In quantum physics, though, particles don’t have specific positions or exact orbits, combine/recombine, get entangled, and pop in and out of existence.  At the quantum level everything is kind of fuzzy, but quantum theory itself is astoundingly predictive.  We’re fooled into thinking our macro view of the universe is true, but our perceptions are wrong.   

So it may be with modern medicine.  Our microbiota (including both the microbiome and mycobiome) both provide the fuzziness and dictate a significant portion of our health.   

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2020: Entering the Year of the Midwife

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By MICHELLE COLLINS, PhD, CNM, FACNM, FAAN

The World Health Organization has named 2020 the Year of the Nurse and Midwife. However, most Americans have never experienced a midwife’s care. In my over 30 years working in maternal-child health, I’ve heard plenty of reasons why. Families are understandably nervous about that with which they are unfamiliar, and nervous about pregnancy and birth in general, with good reason. The cesarean birth rate in the US has more than quadrupled since the early 1970’s, yet we aren’t seeing healthier mothers and babies as a result. In fact, compared to the prior generation, women in this country are 50% more likely to die in childbirth, and for women of color (particularly black women) that risk is three to four times higher than white women, regardless of the woman’s education level or socioeconomic status. For those expecting a baby in the new year, let me set the record straight about midwifery care.

Today’s certified nurse-midwives (CNM) and certified midwives (CM) have earned a minimum of a Master’s degree, as well as have passed a rigorous certification exam. A third category, certified professional midwives, are not required to have an academic degree, but they must also must pass a certification exam “based on demonstrated competency in specified areas of knowledge and skills.” Midwives are intensely educated both in normal, as well as in complications of, pregnancy and childbirth, and are well-prepared to address emergencies as they arise.

Midwives generally care for women with low-risk pregnancies; however, most pregnancies are low-risk. And in those instances when a patient’s pregnancy or birth becomes high-risk, the midwife collaborates with physician colleagues to provide comprehensive team care to result in the best outcome for mother and baby.

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The Liability of Outside Provider Orders and What Could be Done About It

By HANS DUVEFELT, MD

As a family doctor I receive a lot of reports from emergency room visits, consultations and hospitalizations. Many such reports include a dozen or more blood tests, several x-rays and several prescriptions.

Ideally I would read all these reports in some detail and be more than casually familiar with what happens to my patients.

But how possible is it really to do a good job with that task?

How much time would I need to spend on this to do it well?

Is there any time at all set aside in the typical primary care provider’s schedule for this task?

I think the answers to these questions are obvious and discouraging, if not at least a little bit frightening.

10 years ago I wrote a post titled “If You Find It, You Own It” and that phrase constantly echoes in my mind. You would hope that an emergency room doctor who sees an incidental abnormal finding during a physical exam or in a lab or imaging report would either deal with it or reach out to someone else, like the primary care provider, to pass the baton – making sure the patient doesn’t get lost to followup.

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Maternal Mortality – Separating Signal from Noise

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By AMEYA KULKARNI, MD

When Samuel Morse left his New Haven home to paint a portrait of the Maquis du Lafayette in Washington DC, it was the last time he would see his pregnant wife. Shortly after his arrival in Washington, his wife developed complications during childbirth. A messenger took several days on horseback to relay the message to Mr Morse. Because the trip back to New Haven took several more, his wife had died by the time he arrived at their home.  So moved was he by the tragedy of lost time that he dedicated the majority of the rest of his life to make sure that this would never happen to anyone again. His subsequent work on the telegraph and in particular the mechanism of communication for the telegraph resulted in Morse code – the first instantaneous messaging system in the world.

Mr Morse’s pain is not foreign to us in the 21st century. We feel the loss of new mothers so deeply that, when earlier this year new statistics on the rate of maternal death were released and suggested that American women died at three times the rate of other developed countries during child birth, doctors, patient advocates, and even Congress seemed willing to move heaven and earth to fix the problem. As someone who cares for expectant mothers at high risk for cardiovascular complications, I too was moved. But beyond the certainty of the headlines lay the nuance of the data, which seemed to tell a murkier story.

First at issue was the presentation of the data. Certainly, as a rate per live births, it would seem that the United States lagged behind other OECD countries – our maternal mortality rate was between 17.2 and 26.4 deaths per 100,000 live births, compared to 6.6 in the UK or 3.7 in Spain. But this translated to approximately 700 maternal deaths per year across the United States (among approximately 2.7 million annual births). While we would all agree that one avoidable maternal death is one too many, the low incidence means that small rates of error could have weighty implications on the reported results. For instance, an error rate of 0.01% would put the United States in line with other developed countries.

Surely, the error rate could not account for half the reported deaths, right? Unfortunately, it is difficult to estimate how close to reality the CDC reported data is, primarily because the main source data for maternal mortality is a single question asked on the application for death certificates. The question asks whether the deceased was pregnant at the time of death, within 42 days of death, or in the 43 to 365 days prior to death. While pregnancy at the time of death may be easy to assess, the latter two categories are subject to significantly more error.

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Indigenous Medicine– From Illegal to Integral

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Brooke Warren
Phuoc Le

By PHUOC LE, MD and BROOKE WARREN

In the 2020 Summer Olympics, we will undoubtedly see large, red circles down the arms and backs of many Olympians. These spots are a side-effect of cupping, a treatment originating from traditional Chinese medicine (TCM) to reduce pain. TCM is a globally used Complementary and Alternative Medicine (CAM), but it still battles its critics who think it is only a belief system, rather than a legitimate medical practice. Even so, the usage of TCM continues to grow. This led the National Institute of Health (NIH) to sponsor a meeting in 1997 to determine the efficacy of acupuncture, paving the way in CAM research. Today, there are now over 50 schools dedicated to teaching Chinese acupuncture in the US under the Accreditation Commission for Acupuncture & Oriental Medicine.

Image of Michael Phelps swimming in 2016 Rio Olympics after using TCM cupping. (Al Bello/Getty Images)

While TCM has seen immense growth and integration around the globe throughout the last twenty years, other forms of CAM continue to struggle for acceptance in the U.S. In this article we will focus on Native American/Indigenous traditional medical practices. Indigenous and non-Indigenous patients should not have to choose between traditional and allopathic medicine, but rather have them working harmoniously from prevention to diagnosis to treatment plan.

It was not until August of 1978 that federally recognized tribal members were officially able to openly practice their Indigenous traditional medicine (the knowledge and practices of Indigenous people that prevent or eliminate physical, mental and social diseases) when the American Indian Religious Freedom Act (AIRFA) was passed. Prior to 1978, the federal government’s Department of Interior could convict a medicine man to a minimum of 10 days in prison if he encouraged others to follow traditional practices.

It is difficult to comprehend that tribes throughout the U.S. were only given the ability to openly exercise their medicinal practices 41 years ago when the “healing traditions of indigenous Native Americans have been practiced on this continent for 12,000 years ago and possibly for more than 40,000 years.”[1]

Since the passage of AIRFA, many tribally run clinics and hospitals are finding ways to incorporate Indigenous traditional healing into their treatment plans, when requested by patients.

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Sexism vs. Cultural Imperialism

By SARAH HEARNE

As I was getting ready for bed last night a friend shared a tweet that immediately caught my attention.

https://twitter.com/sbattrawden/status/1143465003409915905

The tweet was of a paper that has just been published online, titled “Does physician gender have a significant impact on first-pass success rate of emergency endotracheal intubation?” and showed the abstract which began,

It is unknown whether female physicians can perform equivalently to male physicians with respect to emergency procedures.

Understandably, this got the backs up of a lot of people, myself included. Who on earth thinks that’s a valid question to be researching in this day and age? Are we really still having to battle assumptions of female inferiority when it comes to things like this? Who on earth gave this ethics approval, let alone got it though peer review?

I then took a deep breath and asked myself why a respected journal, The American Journal of Emergency Medicine, would publish such idiocy. Maybe there was something else going on. The best way to find out is to read the paper so I got a copy and started reading. The first thing that struck me was the author affiliations – both are associated with hospitals in Seoul, South Korea. The second author had an online profile, he is a Clinical Professor of Emergency Medicine. I couldn’t find the first author anywhere which made me think they are probably quite early in their career. The subject matter wasn’t something I could imagine a male early career researcher being interested in so figured they are probably female (not knowing Korean names I couldn’t work out if the name was feminine or masculine).

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What’s Wrong With American Doctors?

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By BRIANNA GRAFF

It is February of 2005, and my grandpa is lying in an Intensive Care Unit bed at Beth Israel Deaconess Medical Center in Boston, critically ill from a renal artery rupture that planted him face-first in his parlor. As a functioning alcoholic who has already been in the hospital for a day, he is beginning to shake periodically, a sign of his withdrawals.

Still, it will take another twelve hours and exasperations from both my mother and grandmother (both nurses themselves) before the physicians get him the Ativan he needs to combat this symptom, which is small potatoes compared to his emergent reason for admission.

While he would eventually make a full recovery, in those few hours my grandpa had tremors he was also the unintended victim of “tunnel vision” exhibited by many physicians: they see the most prominent problem and address it, often losing grasp of a holistic view of the patient and neglecting his humanity in their attempt to treat him. In short, they see the medical problem as opposed to the entire person.

Of course, this doesn’t mean that doctors are heartless: the number one reason doctors choose the profession is to help people, and the grueling work it takes to become an MD is clear evidence of their devotion to their career. So how did we end up here, with doctors overlooking the humanistic nature of their work?

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