Rheumination

MD Chat for Sale

As a  Canadian I have always been  a bit envious of Americans for their physician social networking sites like Sermo and Web MD.  Thousands of like-minded physicians in a confidential, doctor-only site who can exchange ideas without the prying eyes of government and  pharma and  with somewhat less worry about patient confidentiality.  A recent article in Newsweek (via DB's Medical Rants) has cast doubt on all of that.  It appears that these sites are now selling information gleaned from these sites to the pharmaceutical industry. I guess it's only normal in that these sites are businesses and have to find a way to make the whole endeavour profitable, but it sure takes away much of it's allure.

In Canada, I've discovered, the Canadian Medical Association has taken the lead on this issue.  They have started their own MD social network called Asklepios (Greek for: what was that name again?)  It is probably along the same lines but has so far not been hugely successful as far as I can tell. It has about 1400 members so far and the groups are fairly sparsely populated.  Book club- 11 members, I-Phone group-22 members. Of the fifty or so groups formed so far, ten are founded by the same guy.  Oh well, it's a start .  But most importantly, the site is hosted by the Canadian Medical Association and so I doubt it'll soon be selling off my comments to the highest bidder.

Lousy Studies on Monoarthritis: A Systematic Review

The CMAJ has come a long way.  This Canadian journal used to be tossed into the trash on arrival but lately I've found several interesting and important articles, even references from several international bloggers.  That reputation took a bit of a hit in my mind with the recent publication of an article on the causes of acute monoarthritis.  The article purported to do a systematic review of the differential diagnosis of acute monoarthritis.  What caught my eye was the first table where they list the most common causes of acute monoarthritis: gout, septic arthritis, and rheumatoid arthritis.  Rheumatoid arthritis?  In all my years I've never seen RA included among the common causes of this condition and so my curiousity was piqued.  

The reviewers did a MEDLINE search, yielding 1966 citations they hacked down to a mere four for their study.  The four studies included a total of 363 patients.  It was probably at this point they should have realized that they didn't really have a study.  But it gets worse.  In the first study of 129 patients, acute was defined as being within four weeks or less, hardly what most would consider acute.  Flare of a single joint in a chronic arthritis sufferer was also included.  Oddly, not a single case of pseudogout was diagnosed.  The second study included 59 patients seen in an emergency department.  Of course, any case of gout, pseudogout, reactive or other that was managed by the primary care physician would not make it to the ER.  They, not surprisingly, diagnosed a full 20% as septic arthritis.  Not a single case of RA.  The third study apparently worked backwards from synovial fluid received at the lab.  These results would select for easily aspirated joints and would reduce the number of gout cases which occur frequently in the always difficult to tap 1st MTP.  The lat 75 were for a study of suspected septic arthritis in the ER. Again perhaps not surprisingly, this study had the highest percentage of septic arthritis patients at 27%, the same percentage as gout.  Apparently none of the patients were hospitalized patients where acute arthritis is perhaps most common.  Psuedogout, one of the more common causes of acute arthritis was diagnosed in 2 of the 363 patients. (Although there may have been some included under crystal in the third study.)  

If you're going to write an article on acute monoarthritis and you plan on changing the classical textbook lists of differential diagnosis, you should really have the evidence to back you up .  A systematic review of a few crappy studies just doesn't cut it.

Four Steps of Osteoporosis

Normal Bone

Osteopenia

 

Osteoporosis

Osteoporosis with fracture

The Four Steps

Photos by yours truly

Reps. Even I Feel Sorry.

If you read this blog regularly, and I'm sure you do, you'll know that while I'm not anti-pharma, I do have ambivalent feelings towards these companies.  If it wasn't for their drugs, rheumatology would be a sad place to work today, but the near constant stream of reports of unethical/sleazy marketing by these firms leaves me feeling constantly uneasy.  The face of pharma, of course, is the drug rep.  These people are almost universally pleasant, the type of people you could get along with outside of work.  Of course, that's the plan.  I keep things pretty business-like.  No first names.  No golf.  I like to keep it that way, even though they must think that I'm quite the cold fish given that most MD-Rep interactions I see are definitely more cozy.  I just like to remember that the job of these guys is to get me to buy.  No more, no less.

These days though, I must admit that I feel a bit sorry for some of these people.  Along with many in these tough economic times, reps are starting to sweat.  It seems a week doesn't go by without new pharma job cuts.  I haven't seen anyone lose their jobs yet, but with the massive cuts around the world, it's likely a matter of time.

With Pfizer buying Wyeth, the Enbrel rep is looking a little uncomfortable.  Given that Pfizer is buying Wyeth for it's biologics though, I think maybe the Pfizer reps for Celebrex and Lyrica should be more worried.  I can foresee a day where we have one rep for the three meds.  

The Roche people aren't sweating the Roche-Genentech deal up here because both Rituxan and tocilizumab (Actemra) are marketed by Roche in Canada.  Weirdly, they have separate reps for the two drugs as I mentioned in a previous post.  This, of course, could change in the new belt-tightening environment.

The Schering Plough people didn't look too worried.  They seemed happy enough with their Remicade sales, probably because of  the GI indications, and seemed upbeat about the sooner than expected arrival of golimumab.  This of course was all before todays purchase of Schering-Plough by Merck.

Overall though, I think the importance of biologics in the bottom-line of these big companies may well save the jobs of many of the reps that rheumatologists see.  That's good because they  really are nice people.  Really, really nice.

Whiter House

White House  after this week's snowfall

Great.  I escape Canada's winter for one week in Washington and am met by one of the rare snowstorms to reach that far south.  I say snowstorm with reluctance, however, and only because that is what they called it down there.  I awoke to an announcement that there had been ten inches of snow and that there was a snow emergency declared.  Now ten inches, 25cm, of snow is a lot, a decent amount even for a Canadian  storm.  So I was more than surprised to see that the streets looked  like this:

This despite the fact there were no snow removal machinery to be seen.  It appears they measure snow differently down there.  Despite the rather unimpressive snow drifts, there was in fact a snow emergency declared.  We were told not to use our car because it would be towed.  The museums were understaffed and had to close sections because employees couldn't make it to work.

It's worrisome to think that the capitol of the world's most powerful nation could easily be taken by a well- coordinated snowball attack.

Off to Washington

  

Since Obama visited us here in Canada this week I thought I would return the favour and go visit him in Washington.  I'll be off for the week.