In general it's true that being on a ventilator for two weeks carries a high mortality, but that's largely due to being sick enough to require ventilation for that duration. Presumably without effective oxygenation or airway protection, these people would have died before the two week mark. COVID pneumonia presents a special case. Early on the thinking was that noninvasive ventilation with bipap etc would promote spread of the virus, so the recommendation was to proceed earlier to intubation. In retrospect this did appear to lead to higher mortality, likely related to ventilator associated pneumonia and sedation and paralytic drugs. So we've returned to a more ordinary stance where intubation is a last resort. So, intubation is bad, but for most circumstances, it beats a trip to the morgue.
I have to say, this sounds to me like trying to market an expert system for experienced woodworkers to choose the best chisel for a particular task based on the type of wood, size of the cut, etc. Practitioners have strong opinions regarding the implements they use; they use them in concert with other implements and modalities; and the small differences that may emerge from this kind of analysis are likely to be swallowed up by differences in copay or other things besides pure efficacy.
I was reading this as a licensed professional in a different field, and trying to imagine someone without my licensure trying to sell me an app that made my decisions for me. Let’s just say this was always going to be a tough sell, no matter how good the economics looked.
I’ll take you up on the bypass statement. :) This is an 80 yo woman, that alone would probably make me not want to put her under for bypass. Also, she had a history of paroxysmal afib and prior pulmonary embolism (they don’t state if it wad provoked or not) but is not on anticoagulation. By CHADS2-Vasc criteria she should have been on AC alone, but isn’t. She’s clearly intelligent and has no issues with access to care (engineer, has an Apple Watch) which further makes me think that her underlying health warrants a more conservative approach.
Plus, I don’t want to risk giving the house a stroke or cognitive injury from the risks of the operation and general anesthesia when a comparable or better outcome could be done with PCI. It’s all about risks and benefits for her.
In three vessel disease, PCI is decidedly worse than CABG [1], but the latest evidence is, AFAIK, equivocal for CABG over PCI in one and two vessel disease [2].
I've personally often thought that this is due to the degree of collatoralisation that goes on in the ischaemic myocardium, even when we are convinced that the reduced FFR is all the story: stenosis does not happen overnight and metabolic adaption to, e.g., decreased O2 starts to begin. In three vessel disease you've burnt your reserves and are desperate for O2. In two vessel disease you're (mal)adapted.
Incidentally, this is why my scientific research is focused on using a slightly crazy CMR technique to directly image glycolysis and beta-oxidation in the ischaemic myocardium. We can make PCI kill fewer people if the interventionalists can be told "This region is ischaemic and has shifted towards anaerobic glycolysis due to this branch of (LCx/whatever) artery. Go revascularise".
Eh, I think the data is controversial and case-dependent in two-vessel disease. If this were three vessel disease, the data is far more in favor of CABG. The fluoroscopy doesn't look convincing to me of major stenosis, so a PCI/stent could certainly be placed for symptomatic relief without a CABG.
Additionally, the patient definitely did not need emergency CABG. My understanding is that CABG could be completed after stenting, and may very well have happened for this patient without our knowledge.
Drug reps in the US quit giving away pens and coffee mugs in the US in 2008, in accord with PhRMA rules (that's the drug manufacturers' association/lobby). They got to say it was improved ethics, but it was also a mutual disarmament agreement of sorts. "We'll stop giving out sticky pads if you will."
Headline is imprecise. The study is saying that higher doses of vit D do not strengthen bone more than lower doses, not that they don't strengthen bone at all, which is suggested by this headline.
As usual, the headline ought to be taken from the publication. Bone strength was virtually unchanged for every group in the study; no participant had osteoporosis. Mean BMD went down a hair for all groups, but estimated failure load was considered statistically the same:
> At trial end[...]
> mean percent change in [radial] volumetric BMD of −1.2% (400 IU group), −2.4% (4000 IU group), and −3.5% (10 000 IU group).
> mean percent change [...in tibial volumetric BMD] of −0.4% (400 IU), −1.0% (4000 IU), and −1.7% (10 000 IU).
> There were no significant differences for changes in failure load (radius, P = .06; tibia, P = .12).
Agreed the differences look small but find a copy of the full article (I would link but I saw a hard copy). The time curve will convince you this effect is real. All participants start at the same place and you see the dose curves move apart over time and very consistently. What definitely isn’t clear is whether vitamin D supplementation is benefiting the participants at all, thanks to their lack of a proper control.
The bone density decreases may look minor on paper but look at it this way: it’s quite possible that a very large cohort of elderly and middle aged people concerned about their bone health (potentially because they were told they have reason to be concerned) have been paying a lot of money annually to actually worsen their situation. That sucks.
I'd trust EPIC series more, even though it's not RCD. They showed J-curve for all cause mortality and morbidity with best inflection point around 1500-2000 IU. The curve is somewhat flat above this.
>Interventions: Daily doses of vitamin D3 for 3 years at 400 IU (n = 109), 4000 IU (n = 100), or 10 000 IU (n = 102). Calcium supplementation was provided to participants with dietary intake of less than 1200 mg per day.
>Main Outcomes and Measures: Co-primary outcomes were total volumetric BMD at radius and tibia, assessed with high resolution peripheral quantitative computed tomography, and bone strength (failure load) at radius and tibia estimated by finite element analysis.
>Conclusions and Relevance: Among healthy adults, treatment with vitamin D for 3 years at a dose of 4000 IU per day or 10 000 IU per day, compared with 400 IU per day, resulted in statistically significant lower radial BMD; tibial BMD was significantly lower only with the 10 000 IU per day dose. There were no significant differences in bone strength at either the radius or tibia. These findings do not support a benefit of high-dose vitamin D supplementation for bone health; further research would be needed to determine whether it is harmful.
Headline is not imprecise according to above-cited Conclusions and Relevance.
> Headline is not imprecise according to above-cited Conclusions and Relevance.
No, aladoc99 is right, because the study doesn't compare against 0. So you don't know if 4000 and 10000 improve strength compared to 0, only that they don't compared to 400. It's not a hill that someone should die on, though.
If you avoid animal foods the only dietary vitamin D really is from fortified products. However we also synthesize it, albeit poorly as adults, particularly with lower exposure to the sun.
My experience with such a system has been that it would quote ridiculously high prices for generic medications, so I'd simply tell patients their drug is on the $4 list at WalMart. An information source that's unreliable is worse than no information at all, since it poisons the well for competing systems.
Not a risk, a certainty. Until this ruling, not having a physician-patient relationship was an absolute safe harbor against professional liability. It was understood that the clinician seeing the patient had the ultimate responsibility. Now we can program Alexa to say "Send the patient to the ER" and save ourselves a great deal of time.
The ruling is that when you make a medical decision about a patient you have a physician/patient relationship. You no longer get to say “I was not present so that fact that I provided incorrect treatment instructions is irrelevant”.
If the doctors involved weren’t the ones responsible for allowing a patient to be transferred to the hospital maybe you could more reasonably claim you were giving advice.
But by denying the transfer to the hospital and misdiagnosing them, they were making (and effectively enforcing) those decisions.
If the doc had merely advised, instead of overriding the examine docs opinion, there wouldn’t even be a case because this woman would still be alive. Looks like doctors are free to consult, but are on the hook when they make an overriding decision.
Sorry for being obtuse. The point is that it doesn't take a physician to tell EVERY clinician calling with a patient for possible admission to send them to the ER. If the hospitalist is going to be liable for advice given on patients never seen, he can only err on the side of maximum treatment, since he hasn't had the benefit of seeing the patient and can't necessarily rely on the referring clinician's assessment.
Whether or not Merck "did some fraudulent science," I'd need a better source than RFKJr to believe it. Preferably a scientific source.
Here's some scientific sources on Gardasil, mostly after its introduction to the US market:
https://scholar.google.com/scholar?q=safety+efficacy+quadriv...
It's worth pointing out that CT is extremely sensitive for calcium and hence bone, so that bones could be scanned at a lower Xray dose than soft tissue. 30 seconds of Googling showed a study where a whole body CT bone survey was carried out using 4.1 mSv, or about 200 chest xrays. If you're not looking for fine detail in the bones, an even lower dose might suffice.
