GlassHospital

Demystifying Medicine One Week at a Time

Category: patient safety (page 1 of 5)

Mushrooms: Magic?

3/22/2013--Shelton, WA, USA Pioppini mushrooms (Agrocybe aegerita) from Fungi Perfecti. Paul Stamets, 57, is an American mycologist, author, and advocate of bioremediation and medicinal mushrooms and owner of Fungi Perfecti, a family run business that specializes in making gourmet and medicinal mushrooms. ©2013 Stuart Isett. All rights reserved.

©2013 Stuart Isett.

In ‘study of the week’ news, major media outlets reported on two small studies looking at the possible benefits of the chemical psilocybin, the ingredient found in psychedelic mushrooms.

Both studies were conducted in volunteers with cancer, who also had concomitant depression and anxiety–assumed related to their cancer.

The interesting headline-grabbing finding was that after a single dose (“trip”) with psilocybin, a majority of patients in both trials reported improved mood, decreases in mental health symptoms, and positive experiences with the drug (i.e. good trips).

Here’s the kicker: 6 months after their trips, without additional drug, many of the study participants still reported improved mental health.

Study 1 was conducted at NYU and involved 29 patients. The study found that at 6.5 months, “60-80% of the participants continued with clinical significant reductions in depression or anxiety.”

The second study was conducted at Johns Hopkins, involved 51 patients, and had similar findings. Note how the second study describes the orchestration of its sessions:

Psilocybin sessions

Drug sessions were conducted in an aesthetic living-room-like environment with two monitors present. Participants were instructed to consume a low-fat breakfast before coming to the research unit. A urine sample was taken to verify abstinence from common drugs of abuse (cocaine, benzodiazepines, and opioids including methadone)….

For most of the time during the session, participants were encouraged to lie down on the couch, use an eye mask to block external visual distraction, and use headphones through which a music program was played. The same music program was played for all participants in both sessions. Participants were encouraged to focus their attention on their inner experiences throughout the session. Thus, there was no explicit instruction for participants to focus on their attitudes, ideas, or emotions related to their cancer.

Both studies appeared in the Journal of Psychopharmacology. While I agree this news is of general interest, I think the media reporting on the studies is overly sensational. Many doubts remain about the safety of psilocybin. Cancer patients–and indeed the lay public–are vulnerable to this sort of unchecked hype. Issues unaddressed:

  • Negative effects of psilocybin (i.e. no reporting on any adverse effects)–which were listed in the studies
  • Cost
  • Alternatives
  • Small sample sizes in the studies

Overall, I’m glad that researchers are reconsidering ideas long thought too risky or out of bounds. But more science needs to be done before psilocybin is ready for mainstream use.

We Used To Sell Cigarettes in Hospitals

nurse_1471846fNice article in STAT, a relatively new Boston Globe-affiliated publication devoted entirely to health care. Melissa Bailey reminds us that ‘candystripers’ used to sell cigarettes to patients to comfort them while hospitalized.

How quaint.

She goes on to point out 5 practices that will seem just as antiquated. Soon, we hope.

  1. Advising doctors NOT to say, “I’m sorry.” Hospitals still do this. It can be seen as an admission of guilt, the thinking goes.
  2. Have prescription labels that don’t indicate what the medicine is for. How smart. And not even close to standard at present.
  3. Not washing our hands in front of you every time. ‘Nuff said.
  4. Spending more time typing than talking and listening to you. We can hope, can’t we?
  5. Easily getting your medical records, without your having to pay, wait, fill out forms, or just be hassled like you’re asking for state secrets.

I think this is an excellent list. There are no doubt dozens more. (Why do we awaken people in the hospital so often?) What are your ideas for health care pet peeves you’d like to see abolished?

The Evolution of Hospitals

I-love-Lucy-assembly-line-300x223Once upon a time, a hospital was a place you went if you were sick. Doctors would (ideally) figure out what was wrong, offer treatment, and you would convalesce.

The longer you stayed in a hospital, the more the hospital could charge you (your insurance, really — if you had it).

This all changed in 1983, with the advent of the DRG system (it stands for Diagnosis-Related Group). Almost overnight, the incentives for hospitals changed. With DRG payment, the hospital would get one ‘bundled’ payment for the whole hospitalization based on the patient’s diagnosis. Average length of stay for hospitalized patients went from thirty days (imagine: a month(!) in a hospital). Hospital executives saw the need to minimize length of stay — depending on the payment for each diagnosis, there would be an inflection point when a patient staying beyond a certain number of days would result in financial loss.

‘Throughput’ became the term of art. (Like widgets on an assembly line.)

Now the average time someone spends in a hospital is a little more than four days. (Of course, for mothers with normal births, this is even less — about 2 days. Many surgeries that used to necessitate several days in the hospital are now done on an outpatient basis. Length of stay in those situations: zero.)

A recent essay on this topic in the New York Times by Dr. Abigail Zuger brought back memories for me. I once had a teacher tell me, “No one should ever need to be in a hospital. Except for some cardiac conditions that require immediate care, the only people winding up in hospitals are frail elders, and those with social problems and no place to go — the mentally ill, the destitute, the homeless.” I remember feeling a bit shocked by this, but as I reflected on it, I realized he had a point. I should start with the assumption, he told me, “that almost no one really needs to be there and they’re better off at home.”

The modern condition leads us to keep people in hospitals for as short a duration as possible. But something is clearly lost. As Dr. Zuger writes:

Hospitals were where you stayed when you were too sick to survive at home; now you go home anyway, cobbling together your own nursing services from friends, relatives and drop-in professionals.

Patients often go home feeling brutalized by all the blood draws, hospital food, and lack of sleep. Rare is the patient who says, “I feel better now — can I go home?” Often we send them home before they feel ready.

It sounds a bit cruel, and like there’s a perverse incentive at play. But keeping people in the hospital is also inherently risky. Hospitalization can cause infections, loss of muscle and coordination (especially in older folks), falls, and delirium. So getting people out as quickly as possible is in many ways the right thing to do.

The truth, however, probably lies somewhere in the middle.

Stomach Draining?

FDARecently the US Food & Drug Administration (FDA) approved a device for market called “AspireAssist.”

The device is hooked up to an incision in your abdominal wall after each meal that allows you to drain 30% of your stomach contents directly into the toilet.

Harder to gain weight (and easier to lose it!) when you’re diverting a third of caloric intake from your body into the sewer system.

It works like a “G-tube” in reverse — the kind of tube that puts liquid calories INTO your stomach in the event you can’t swallow (i.e. you’ve had a stroke or some kind of oral surgical issue that won’t let you chew and swallow). Therefore it was deemed ‘safe enough’ because SO FAR it has a low complication rate.

But keep in mind to get FDA approval the manufacturers only had to show efficacy and safety in two small trials totaling less than 200 patients. This is a lower barrier to market than would occur if the new product were a medication. [Devices and medications are held to different approval standards at the FDA.]

As for whether AspireAssist is ‘ready for prime time,’ I share the healthy skepticism of my friends over at “Updates in Slow Medicine,” who wrote:

From the Slow Medicine perspective, removing food after eating directly from the stomach using an A-tube remains an experimental approach to weight loss, and we would only recommend an AspireAssist device to a patient of ours enrolled in an appropriate clinical trial.

With more clinical experience it’s possible this could be a solution for many folks struggling with obesity. But only when we know more.

Column Laurel

Good news dept:

2016-Column-Contest-560x469Dear loyal GlassHospital readers–

GlassHospital was recently recognized by the National Society of Newspaper Columnists as a finalist for columnist of the year in the Online, Blog, and Multimedia Category with >100,000 readers. This is for work published on the world’s best health care site, NPR’s Shots blog [to which I attribute such high readership — you loyalists on this site are in much more select company].

I was awarded third place, behind a Reuters columnist who works to bring broader understanding of Islam to a large general readership, and a columnist from The Street who writes frequently to expose scams and complicated investment schemes that over-promise and under-deliver. Given all that’s going on in the news cycles of late, I think this makes perfect cosmic sense.

I do my best to share NPR work on this site to attract you over there, but if you’re interested in the columns for which I won the award, links to them are below.

  1. From August 2015 — Suicide: not a natural cause of death
  2. From April 2015 — How should we educate 21st century doctors?
  3. From September 2015 — For older folks, pruning back prescriptions can bring better health

Thanks for reading!

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