How Effective is the Influenza Vaccine? How About Tamiflu?

One of the greatest concepts I have run across since I finished school is the Number Needed to Treat (abbreviated NNT). NNT was never taught back when I went to medical school (we had barely given up The Four Humors!). Instead, we were taught “the p-value.” Does anyone else remember the p-value? The p-value of a study, it turns out, is a relatively poor measure of study validity, partly because it implies an “all-or-nothing” kind of understanding of studies: either the study is “valid” (meaning a p-value of >95%) or it is not. Either the treatment being studied works or it does not. And if a treatment works, it must work for all people.

Of course, in real life, this is not the case. No drug is universally good or bad. All drugs help some people, harm some people (with adverse side effects) and make no difference one way or another in some people. These numbers can be derived from any study’s data. There is even a fabulous website devoted to this where you can look up the NNT and its corollary, the Number Needed to Harm (NNH) for all sorts of drugs and treatments (found here).

Since it is influenza season and time for us to get our flu shots (I got mine yesterday), I thought it would be a great time to see how beneficial the flu vaccine is.  What is the NNT for the flu vaccine?  And while we are at it, why don’t we also look at the data on oseltamivir (Tamiflu) while we’re at it?

Influenza Ward, Great Pandemic 1919

Influenza Ward, Great Pandemic 1919

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Ammonia Capsules Are a Great Tool for Assessing Pseudoseizures

The question of whether a seizure-like event is a true epileptic seizure or some type of pseudoseizure is often very hard to sort out. Oftentimes (in fact, most of the time) these events do not happen in front of us. We just hear reports from the deputies of “something happening–looked like a seizure.” Or perhaps the patient himself will tell us that he had an seizure, like the patient I saw recently who told me “I’ve had four seizures this week.” Of course all of them were un-witnessed by anyone else.

Even though you might suspect that these un-witnessed seizure-like events are pseudoseizures, you should be very cautious about labeling such events “fake.” The absolute worst mistake that you as a medical provider can make in these cases is to declare an event “fake”—and be wrong. Until you are very sure, it is better to assume that un-witnessed events are real–or at least keep that possibility in the forefront of your mind. Until you have more evidence, you just don’t know for sure.

That is why it is so valuable when a patient has one of these seizure-like events right in front of you. This is the one opportunity to use objective findings to distinguish a true epileptic seizure from a pseudoseizure. I discussed in my last post the various differences in presentation between epileptic seizures and pseudoseizures, such as the nature of the shaking, eye deviation and a post-ictal period. Unfortunately, however, none of these findings are perfect.040 Continue reading

Changes in Hypertension Treatment? Why Yes! The Recommendations of JNC 8

As we all know from long experience, hypertension is the single most commonly seen and treated condition in primary care medicine. It is an important risk factor for strokes, heart attacks, kidney failure and overall death. It has been exhaustively studied. And yet there is still significant controversy over hypertension, including how to define it and what the best agents for treatment are.
Against this background, The 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults was released last December in JAMA. It was written by the 8th Joint National Committee, and so, of course, is referred to as JNC 8.

JNC 8 has a couple of important and surprising changes from JNC 7. One of these, at least, is controversial enough that some members of the committee rebelled and released a dissenting “Minority Report” (apologies to Tom Cruise). Today’s JailMedicine post is a summary of JNC 8 recommendations and changes to JNC 7.20140430 Continue reading

Skeletal Muscle Relaxers Do Not Relax Skeletal Muscles!

Today’s post is an opinion piece. Personally, I think that skeletal muscle relaxers like cyclobenzaprine, methocarbamol and chlorzoxazone are over prescribed for acute and chronic musculoskeletal pain, both in the outside world but especially in corrections. The main reason for this, I think, is that prescribers misunderstand what muscle relaxers do. Contrary to their name, muscle relaxers do not relax muscles, at least as they are commonly prescribed. Muscle relaxers are sedatives, pure and simple, and should be prescribed with that fact in mind. Instead of telling patients (and ourselves) that “I am prescribing a muscle relaxer for you,” in the interest of full disclosure, we should be saying “I am prescribing a sedative for you.”  Continue reading

Hepatitis C: Between a Rock and a Hard Place

As you probably know, Sovaldi (sofosbuvir) is an important new treatment for Hepatitis C infection that was released this last December and has been aggressively marketed by its maker, Gilead, ever since. The problem is that Gilead is charging an unheard of, jaw-dropping, $1,000.00 per pill for Sovaldi. This translates into a MINIMUM of $84,000.00 for Sovaldi alone for the simplest course of Hep C treatment. Add on the other necessary drugs and take into consideration more complicated cases, and a single course of therapy for Hepatitis C will cost between $100,000.00 and $250,000.00.

This price has placed prison systems in a no-win situation–and not just prisons, but also Medicaid, insurance companies, and HMOs. On one hand, Sovaldi is a good drug that, in fact, represents a significant advance in Hepatitis C treatment. Lots of Hepatitis C patients could potentially benefit from Sovaldi. On the other hand, no one can afford Sovaldi. Treating every potential Hep C patient using Sovaldi would bankrupt everyone. There is no good way out of this dilemma. 20120321 Continue reading

Price Check! Genital Herpes. How Much is Nursing Time Worth?

It is worthwhile to check drug prices now and then (once a quarter seems about right) to see what is happening in the pharmaceutical world.  When you do this, you will find some drugs that have inexplicably shot up in price.  One recent example was doxycycline, which went from around ten cents a tablet to over two dollars a tablet in a couple of months.

On the other hand, drugs that we think of as expensive in the back of our minds sometimes are no longer expensive.  Olanzapine (Zyprexa) is now cheaper than haloperidol.  Risperidone is cheaper still.

And sometimes, a drug that is a bit more expensive than its alternative is still the most cost-effective treatment based on “the hassle factor,” meaning frequency of dosing, ease of administration, potential for diversion–that sort of thing. Drugs prescribed for outbreaks of genital herpes are like that, in my opinion.  Valacyclovir can be more cost-effective than acyclovir for the treatment of recurrent genital herpes.herpes1 Continue reading

Reader Question: Xanax Withdrawal

I am looking for a withdrawal protocol for benzos. I have patients that have been on Xanax 2mg for 3-5 years and now I need to detox them. We all know how difficult this is with people in the community let alone in the correctional setting. PLEASE HELP !!!!
Thank You, Doris

Well, Doris, you have come to the right place! I, and many other JailMedicine readers, are happy to share our strategies for dealing with benzodiazepine withdrawal. And this is a common dilemma in county jails. Believe it or not, Xanax is the single most-prescribed psychiatric drug in the United States. My experience is that Xanax is highly addictive and yet handed out like candy by some community practitioners. Some community prescribers I have talked to do not even realize that Xanax is addictive!  Strange but true.GABA-Production Continue reading

Do Not Use Hydroxyzine for Alcohol Withdrawal!

We correctional practitioners get to see a wide range of medical practice as we review the medical histories of inmates arriving at our facilities. I myself have seen many prescribing practices that make me scratch my head. One example I have run into repeatedly is the practice at many jails of using hydroxyzine to treat alcohol withdrawal.  It turns out that many jails do this.  I am not talking about hydroxyzine as an adjunct or an add-on to the primary agent. I am talking about hydroxyzine being used as the primary treatment agent itself.

In my opinion, this is a mistake, and should be stopped.

Now I admit that there is room for dissention in medicine. Not all practitioners practice in the same way and there are many, many areas of medicine where there is no right answer. And it is true that hydroxyzine was used in the 1960’s to treat alcohol withdrawal. However, since then, medicine has discovered superior agents to treat this condition: the benzodiazepines. Today, hydroxyzine is the wrong agent for alcohol withdrawal. If your facility uses hydroxyzine as the primary treatment for alcohol withdrawal, you should change your protocol. There is no legitimate basis for this practice.images Continue reading

Antibiotic Over-prescribing and The Looming Threat of Resistance

I ran across a couple of interesting articles about antibiotics recently.

In the first article, entitled We Will Soon Be in a Post-Antibiotic Era, CDC researchers predict that the end of the antibiotic era is coming quickly. Antibiotic resistance is developing so rapidly now, that it is only a matter of time until antibiotics just don’t work anymore. This actually is not surprising when you think about it. If we kill all of the microbes that can be killed by our antibiotics, then of course the only ones left will be those that cannot be killed by antibiotics, in other words, that are resistant. The fact that this will happen eventually is a no-brainer.imgres Continue reading

Beware of Lithium Toxicity!

If you have read the title of today’s blog post, you already know the answer to today’s case.  The answer is “Lithium Toxicity.”  I could have instead presented a “Can you figure this case out?” type of format.  But I did not want to do that because, really, what was causing this particular patient’s symptoms is not obvious, especially early on.  This is an introspective learning case.  I want you to read the case knowing the answer.  The answer is “Lithium Toxicity.”  As you read this case presentation, I want you to ask yourself when the possibility of lithium toxicity would have first entered your head and when you would have stopped this patient’s lithium?lithium1 Continue reading