Paxil (Paroxetine,Seroxat)

bmj.comLawyers may seek judicial review of panel reviewing paroxetine.

This is the latest volly in a conflict between patients and pharmaceutical manufacturers over what happens when the medication is withdrawn.

It's been well described that Paroxetine is associated with more symptoms of withdrawal than other SSRI's.  I've seen this so often that I no longer prescribe Paroxetine.  I also do my very best to switch patients to another SSRI if they were prescribed it by a previous physician.  Most patients are happy to switch.  It's a 1:1 switch .. so there is no need to taper OFF Paroxetine when starting another SSRI:

ParoxetineFluoxetineSertralineCitalopram
20 mg20 mg50 mg20 mg
40 mg40 mg100 mg40 mg
half-lifeup to 21 hrs4 – 15 days22-36 hrs36 hrs

While the short half-life may account for some of this effect, I think that there is also something unique about this drug that causes trouble when people discontinue it.  

IMKI

IMKI:

  • IMKI'S MISSION
     
    Create the tools for development, dissemination and implementation of high quality decision support rules.
     
    Increase the availability and use of computerized decision support rules in clinical medicine.
     
    Catalyze the development of a robust community of clinical decision support rule writers and rule implementers. 
      
  • IMKI'S INITIATIVES
     
    IMKI's program areas bring the best medical evidence to the point of care. The organization has received a grant from The Robert Wood Johnson Foundation to develop the following initiatives:

 

    • An Internet-based, searchable Rules Library of evidence-based rules for inclusion in point-of-care clinical decision support (CDS) systems.
       
      An Internet-based rule-authoring tool that allows clinicians to write new rules and includes a system for disseminating the Public Library.
       
      An Implementation Support Network, a facilitated forum for delivery systems implementing
      CDS systems. 

Their board is full of well-placed representatives from many of the more important software vendors (Siemens and GE for example) – so one could presume that the rules engines in the products of those vendors would be compatible with the end-products of the IMKI initiatives.

The web resources page and the articles page also provide excellent background documents for those considering physician-order-entry projects.

 

SARS

One of my partners saw a patient on Friday who may have SARS. The patient had recently been to Toronto, and had many of the symptoms consistent with the disease. Now that there is emerging concensus that this is a viral illness.

“Go to the ER”

   ER.jpg    Richard  and Allen talk (tongue-in-cheek) about sending patients to the ER.  Unlike Craig who just closed his practice … I deftected from the academic medical center's "primary care network" (6 months before it imploded) about 18 months ago. nbsp; So my practice is building.  Wo do our very best to keep our patients out of the emergency departments.  The patients we have the most trouble with are those who are accustomed to the "Go to the ER" mantra from their previous physicians .. and just show up without even calling us .. for minimal problems.

We'll happily stitch up the finger from a Sunday Morning Bagel-cutting accident — or check an ear in a child with a fever. 

It's better care than the ER … where the Mantra is "meet-em, treat-em and street-em."   ;-)

Eipdural Anesthesia

A Comment from Dr Bradley last week on my comment about the epidural analgesia issue.

He's right.  The authors did not conclude that their findings supported a rationale for witholding or even re-thinking epidural analgesia. 

That's not quite what I'm saying though … and I suppose that my non-intervention bias is revelaing itself here.

My preference — in my practice of maternity care — as in my practice of medicine in general — is to avoid any intervention unless it's clear that such intervention is necessary and appropriate.

Is an antibiotic intervention appropriate for the treatment of a cold?  Of course not .. but many physicians still do.

When I am involved in maternity care, I always make decisions with my patients — not for them.  The decision to have an epidural is not necessarily risk free.  A few references:

  • Pro-Con forum on epidural analgesia from the Society of Obstetric Anesthesia and Perinatology
  • A Boston University Study demonstrates that children born to mothers who had epidurals  showed poorer performance on the orientation and motor clusters on the Neonatal Behavioral Assessment Scale (NBAS) during the first month of life.  The authors also found that there epidurals were associated with longer labors, greater amounts of oxytocin used, and more instrumentation.
  • This study from Austria which demonstrated  that "The use of EA was associated with a decreased spontaneous delivery rate (50.0 vs. 79.2%), increased forceps delivery rate (30.7 vs. 4.0%) and increased vacuum extraction rate (3.5 vs. 0.7%). The caesarean section rate was not significantly changed in patients with EA (14.4 vs. 13.0%). Fever greater than 38 degrees C during labour and intrapartum haemorrhage exceeding 500 ml were associated with the use of EA."

… but …

These studies don't account for all off the possible confounding variabes (especially the Viennese study .. in which a minority or patients received epidurals.  One could easily argue that the more troublesome deliveries were associated with epidurals.)

We must remind ourselves of the basic rule of correlation: no causality can be inferred.  Does Tick cause Tock?  of course not.  But the r value is 1.

So .. I think that there is enough data to support the concept that there may be increased risk from epidural analgesia.   And this is really all I was saying in my commentary. We should think twice (or thrice!) before intervening in what is usually a normal healthy event.  A "routine" epidural may very well be a component of the obstetric practice of many physicians.  I would argue that this isn't good care, and that the epidural should be presented as an option – with risks, benefits and alternatives carefully presented – just as with all interventions.

Family Medicine Match

2003 Match Results Unwelcome, But Not Unexpected — American Academy of Family Physicians:

Despite diligent efforts by the Academy and other family medicine organizations, preliminary results released March 20 by the National Resident Matching Program show that family practice continues to struggle to position itself as the specialty of choice among medical students deciding on a career path.

It's hard to explain the shift away from family medicine over the last 3 years.  Our residency actually filled this year – with all US graduates.  And of 130 medical students – 16 went in to family medicine.  This is down from a few years ago, when we were routinely graduating 20 – 25 students into the speciality.

I had an advisee whe struggled with her choice a great deal this year — hmm .. I think I always have one ot two who struggle a bit .. but this one didn't know until "match day" whether she would be a family physician or go into medicine-pediatrics.

In my mind, the differences are vast, but she seemed to give some thought to the fp-bashing coming from ofther physicians – especially (primarily?) other generalists: pediatricians and internists. 

Weblog Fixed – HIT

I've got the weblog completely migrated from Radio to MovableType. Hardest parts were the archives and images. Radio saves archives as YYYY/MM/DD.html .. and MT doesn't .. but I was able to get it tow work by using a daily archive template with "<$MTArchiveDate format="%Y/%m/%d.html"$>" … The images were harder to do v.. but I ended up just moving the directories to the new server .. so my post on Heparin-Induced Thrombocytopenia one again has the images intact.

I still need to figure out how to post images in MT.