Tuesday, August 21, 2018

Redo Recommendations Now: Vitamin D, Fake Data, and Hype

We all need Vitamin D, a hormone, but the challenge is in how to measure levels of Vitamin D, how to determine how much a person needs, and when necessary how to supplement it. Over the years it was difficult for me to reconcile how practically everyone I knew had a Vitamin D deficiency. Since we are not all part of one cohort and we are certainly a group that is diverse in many ways it seemed very odd that we all had the same deficiency.

An answer came in two recent articles. First and most concerning was the August 17, 2018 issue of Science article,"Tide of Lies— The researcher at the center of an epic scientific fraud remains an enigma to the scientists who exposed him."(DOI: 10.1126/science.361.6403.636). This analysis detailed that much of what we know about Vitamin D was based on Dr. Sato's fabricated studies. According to the article his work was "referenced more than 1,000 times, and 23 systematic reviews or meta-analyses have included one or more of the 12 trials." Second, on August 18, 2018 A Kaiser Health News investigation for The New York Times, "Vitamin D, the Sunshine Supplement, Has Shadowy Money Behind It," revealed the effect of one person on an entire field of practice.

Both are disturbing commentary on the state of our knowledge...and our sense of responsibility to one another. How fast will clinical practice change to take this fake data and hype into account? How long will it take to change the Recommendations for Vitamin D Supplementation, the Algorithms in medical decision making and AI, and all the other information that we give and have been giving. Given this evidence how do we answer the question, "Do I stop taking my Vitamin D?"

Friday, August 3, 2018

How Can We Do Better...

This has been a year of field research that evidenced that too often efforts to create a better situation ends up compromising a person's health and well-being. Here are three cases to consider.

Heathcare-associated Infections (HAIs)
Frank entered the hospital with pneumonia but upon returning home it seemed that while in the hospital he had contracted an infection of his foot. Several weeks later the infection was much worse and Frank was taken back to the hospital to determine how much of his leg would have to be amputated. There were no plans for rehab. 

In 2011 75,000 patients with HAIs died during their hospitalizations.

Best Practice
After Rosa’s stroke she was told that in order to prevent another stroke she needed to have the blockage in her artery cleared, i.e., carotid endarterectomy (CEA). Rosa knew the risks of the procedure but went through with it. Much to her disappointment, a few months later the blockage had reappeared. One year later she still has the blockage but no stroke.

Translational research is a step in the right direction but the continued lag from the bench (research) to the bedside (clinical practice) is unacceptable. At the same time evidence based medicine (EBM) continues to be undermined by the lack of inclusion and analysis by individual characteristics as well as the tendency of clinicians and insurers to apply a rigid set of procedures that are not nuanced to the person in front of you.

Defining Comfort
Agnes was having difficulty breathing and was taken to the hospital. Her initial diagnosis was pneumonia and a UTI; then, suddenly while at the hospital she had two heart attacks. Her family was told that (1) her heart had stopped working and was severely damaged, (2) there were no treatments available, and (3) diagnostic procedures that were invasive were not possible given her age and fragility. Agnes' family was also told that she would die that night in the ICU. Agnes's family decided that given the damage to her heart that "palliative or comfort" care was the best option for her. Somehow Agnes got through the night and after two more nights in the ICU Agnes was moved to a private room. The family was told she could not go home because the levels of oxygen given were higher than allowed in a home setting.

Comfort care what does that mean? How do we know?