Pain Reduction by Distraction

Here’s the paper (“The Effectiveness of Distraction as Procedural Pain Management Technique in Pediatric Oncology Patients: A Meta-analysis and Systematic Review”) that we talked about regarding gate theory and distraction in pain reduction.

In the beginning of our discussion we watched a video of a pediatrician with amazing kiddo-distracting skills. Here’s a short article on him — he runs a solo practice outside DC. It’s a quick and worthwhile read to get a sense of a practice model that might appeal to some of y’all. We didn’t watch this video, but it’s also another great one along the same lines.

We also talked about a commercial-slash-consumer device that goes on the appendage of a kiddo and uses buzzing and temperature sensations to reduce injection pain. Here’s the YouTube video we watched of a young person named Tenley who is super brave and has some pretty admirable injection skills.

News Article

Bernie Sanders was in the news recently, drawing attention to the $375,000 cost of a medicine that used to be free. How was it free? Well that’s an interesting and capitalistically-heartwarming story of a small pharmaceutical company.

Early Childhood Radiation (and Later Cognition)

We looked at this 2004 Swedish study in the BMJ → “Effect of low doses of ionising radiation in infancy on cognitive function in adulthood: Swedish population based cohort study” → This is a really interesting paper for several reasons. First, it has some pretty remarkable (and scary) findings, particularly given how often CT scans are performed on young children. The design of the study looks reasonably good to us, but at the same time, it is retrospective. Given the nature of what it’s investigating, as well as the timeline involved and many other logistics, it would be incredibly difficult to undertake a prospective study of this sort. Sometimes retrospective looks at natural experiments are the best we can get for certain situations. Which is the second really interesting aspect: the total lack of attention paid to this study. I spent some time poking around in other scholarly works that cited this one (there are 349 citations for it, so I skipped plenty that seemed irrelevant). It’s cited in several textbooks, but merely as an afterthought (it’s used to support some brief statement, like “radiation can have insidious effects on later life cognitive abilities” with no additional discussion of its veracity). I was hoping to find something, anything really, that took a serious look at its findings — whether in support or opposing. The almost total silence is in itself interesting, particularly because this was published in the BMJ, which is not exactly an obscure journal.

The Swedish radiation study is the most modern of any study like this that I’m aware of. The only studies that even kind of fit into the same category are this one from 1982, two 1966 and 1978 (follow up) studies, and finally a number of studies of radiation effects from survivors of the atomic bombings in Japan. The data I have seen suggest that fetuses exposed to that radiation did not show the same effects the Swedish study suggested. While it’s possible that being in utero would lead to different effects than being an infant, one might expect these effects to be magnified, not reduced. We also briefly touched on the idea of cross validation in model/hypothesis testing.

We also talked about the long history of unethical medical experimentation that has taken place in the United States. The Plutonium Files was mentioned (here’s a story on its writing that gives a synopsis), as well as Acres of Skin and Medical Apartheid. A few books not solely devoted to medical experimentation, but worth mentioning are Dying While Black, Killing the Black Body, and An American Health Dilemma. Here’s the JAMA review of An American Health Dilemma. Here’s a recent PBS Newshour segment with Dorothy Roberts, author of Killing The Black Body:

I also mentioned a video on avoiding sexual assault that is shown to new inmates (as part of PREA, the Prison Rape Elimination Act). I recalled this being a Pennsylvania prison system video, but it turns out it was Alabama. That said, Pennsylvania has its own PREA program, but the videos that might be used (their policy gives detention centers the option of using videos) are not available online that I can find. Anyway, here is the link to the Alabama video, which I should warn you is likely to leave your heart feeling heavy, no matter how much you brace yourself for its subject matter.

Vocab

Our vocab word for the week was, ‘ditzel’ → your guess is as good as ours on this one.

Clinical Pearl

We talked about Virchow’s node, as well as the test-taking strategy of interpreting painless lymphadenopathy different from painful (the former being a hint at malignancy). Getting away from test taking and entering the real world, this paper [pdf] looked at the ability of family physicians to refer (within 4 weeks) malignant cases [aka: sensitivity]. It found sensitivity was 80-90%. Meanwhile, specificity [not referring benign cases] was 91-98%. Posterior probability (ie having malignancy if referred) was 11%. Another study found 17.5% of patients referred would have a malignancy. Lymphadenopathy of Virchow’s node (supraclavicular node) increased the likelihood of malignancy by 50 percent [see: pdf link].

EBM

As a bit of foreshadowing to the Great Belated DOAC Discussion that we’ve delayed for a couple of episodes now but finally tackled (see below!) we discussed the 2014 Annals of Internal Medicine article, “Reporting discrepancies between the ClinicalTrials.gov results database and peer-reviewed publications.” The results from the abstract speak for themselves,

“Of 110 trials with results, most were industry-sponsored, parallel-design drug studies. The most common inconsistency was the number of secondary outcome measures reported (80%). Sixteen trials (15%) reported the primary outcome description inconsistently, and 22 (20%) reported the primary outcome value inconsistently. Thirty-eight trials inconsistently reported the number of individuals with a serious adverse event (SAE); of these, 33 (87%) reported more SAEs in ClinicalTrials.gov. Among the 84 trials that reported SAEs in ClinicalTrials.gov, 11 publications did not mention SAEs, 5 reported them as zero or not occurring, and 21 reported a different number of SAEs. Among 29 trials that reported deaths in ClinicalTrials.gov, 28% differed from the matched publication.”

As mentioned in the podcast, this is hugely problematic because journals supposedly require trials to be registered and to follow best practices as a precondition for publication … but it seems they often don’t follow through on enforcing these requirements. And shifting the burden of enforcing to the peer reviewers (who are unpaid volunteers) is not a solution that is likely to work. Having sifted the clinical trials database results for the 5 studies we’ll discuss below in the DOAC write-up, I can tell you that it is actually a fair amount of work to correlate what is said in the publication to what is in the various historical records. Each of the studies below had 5 or 10 records, each many pages long, that had to be looked at carefully and then compared to each other. And in the end, some of those studies broke NEJM rules that have been in place since 2005, yet were still published. Top journals like NEJM make a lot of money publishing work completed by others and reviewed by volunteers. Running the journal isn’t easy, and has