Real physicians discuss recent healthcare headlines.
Muscle relaxants little help for low back pain
https://www.bmj.com/content/374/bmj.n1446
This was a meta-analysis of 31 trials and 6,500 patients which showed very low to low evidence of improvement in low back pain using non-benzodiazepine antispasmodics. I think most physicians already realize this. However, in patients with NSAID allergies who have tried over the counter remedies including lidocaine patches, there isn’t much left in the armamentarium that doesn’t require a DEA. Since a vast majority of back pain resolves spontaneously within two- to three-weeks, maybe these medications serve the purpose described by Voltaire: entertaining the patient while nature cures the problem.
– William Sullivan, DO, JD
So let me get this right…I am going to give you medication that has all the risk of dependency and misuse and potentially doesn’t help? Basically, my takeaway is don’t treat acute low back pain with non-benzodiazepine antispasmodics!
—Salim R. Rezaie, MD
I feel like this study validates something I’ve believed (and how I’ve practiced) for years. I’m reminded of a faculty member who always said “the only muscle relaxants are Sux and Rocuronium.” So, focus on things that have been shown to work in back pain; appropriate dosed NSAIDS, topical medications (Lidoderm, Lidocaine Jelly, Capsaicin), and moderate exercise with return to normal function as tolerated.
—Andy Little, DO
Forever ago, I threw my back out my last week of residency at a family reunion 500 miles from home. I ended up in a four bed ER where the doc prescribed me Percocet, Motrin, Valium and Flexeril. Nowadays, I would need a script for narcan — that would be bad medicine — you would get a call from the pharmacy, and the DEA may start tracking your prescribing habits. I spent the next 48 hours sleeping and could sit in the car so my wife could drive me home. A couple years ago a spine surgeon asked me to prescribe a muscle relaxant to one of his patients. I asked him his take on the med and said I thought they don’t work. He replied with “Correct, but they let patients sleep, and that allows them to heal.” There is still some art left in medicine when patients have used up a lot of the options, but I don’t prescribe this class of meds nearly as often as I used to.
—Mike Silverman, MD
This only serves to further support that non-benzodiazepines don’t work for acute low back pain. But I get the appeal, a large majority of the patients I treat for this complaint have already tried something, NSAIDS, heat/ice and maybe even lidoderm. So what else do we have to offer other than a pat on the back (gentle of course because we don’t want to exacerbate things)? Heck, a recent study cast doubt on the benefits of OMT for these patients (Nguyen C, et al. JAMA Intern Med. 2021). In the world of patient satisfaction, etc, it’s tempting to do more, but non-benzodiazepines are not the answer. I do on occasion give a dose of benzodiazepines to patients in the ED with significant palpable muscle spasm and then spend a lot of talking exercises, stretching and patience, you know that thing we seem to be seriously devoid of.
– Drew Kalnow, DO, FACEP
Amazon Alexa sued for HIPAA violations
https://www.newsweek.com/healthcare-workers-sue-amazon-over-potential-hipaa-violations-alexa-device-1606589
Complete disclosure, I love my Amazon Alexa. It has revolutionized how I shop, set reminders, track my kid’s device usage, communicate to my children (we use the intercom function a lot). But, I have to say it shows its “on” often when I don’t ask to be and I’ve feared for a long time my conversations are being recorded somewhere in the Amazon empire. So as with your phone, be sure your electronics are off if you want to have a conversation that includes HPI, or just don’t talk specifics outside of the clinical setting…
—Andy Little, DO
Why would these devices be in the patient care area? I realize that Amazon is everywhere, but come on, let’s all use a little commonsense and not have one of these devices on where active patient care is occurring. On a side note, someone should ask Andy Little about the need to turn off the ordering function on his Alexa devices, how much was that Lego your kid ordered?
– Drew Kalnow, DO, FACEP
My wife hasn’t “allowed” one of these in our house because they are always listening. I can’t imagine having one in a medical facility where it can listen to patients. I do love when I visit friends and they get the Alexa to play music with a command, but if you’re going to have an Alexa or other AI device in your house or office, I do think you have to assume it’s always listening.
—Mike Silverman, MD
I’m betting the HIPAA portion of this suit goes nowhere. I don’t think Amazon could be considered a covered entity under these situations and there isn’t a private right for patients to sue under HIPAA. Also, the healthcare workers may be implicating themselves for violating HIPAA if they discuss PHI near a device they know could record their conversations. I could care less how easy these things make anyone’s life. No way will there ever be an always-on microphone in my home. I still freak out when I talk about some medication over dinner with my wife and then ads for that medication start popping up on my phone. I’ll stick to using SwissCows search engine, thanks.
– William Sullivan, DO, JD
It’s creepy to think that smart speakers are recording our conversations much less patient encounters. My issue isn’t with the device recording conversations, but why is the device located where patient care is happening? Either A) Turn off the device or B) Don’t put the device in an area where you are caring for patients.
—Salim R. Rezaie, MD
Pathogens on children’s face masks:
https://rationalground.com/dangerous-pathogens-found-on-childrens-face-masks/
When will we stop arguing against masks? This is far from scientific and adds nothing to the conversation about masks. Masks work to prevent viral spread, they protect those around you and to a lesser extent protect the wearer. Interestingly there was no comment on any virus being detected but not only did school age children wearing masks in school prevent the spread of COVID in schools (recently released data and summary from NC: ABC Science Collaborative, Final Report, June 2021) but had a substantial impact on decreasing other common respiratory viruses too.
Honestly, all of the pathogens found on children’s masks raises the question of hand washing and surface cleaning much more so than the effectiveness of masks. Did any of those children get an infection related to the identified pathogens? I suspect not and maybe there is a case to be made that the masks help prevent those illnesses too. I wonder what would have been cultured if the children’s sheets were sent as the control sample instead? **Shudder**
Oh, and one more time, MASK WORK!
– Drew Kalnow, DO, FACEP
Contamination is not the same as infection. There is no evidence that I am aware of that links bacteria, fungi or viruses contaminating masks increases the chances of pneumonia, meningitis or any other infection. That being said, it is important to regularly clean non-medical facemasks to avoid contamination.
—Salim R. Rezaie, MD
This is a “yeah, we knew that” kind of piece. Having four kids I can tell you they are walking Petri dishes and that despite working in healthcare I can attribute most of the times I’ve gotten sick as a parent directly to my children. But, to me, that’s the point of having them mask up. If they wear a device that captures, these and they routinely change their mask (when they get wet, when they get home from school, daily), and I then clean that mask or just replace it, that’s fewer pathogens they are spreading to others and receiving from others.
—Andy Little, DO
A bunch of parents paid out of pocket to analyze their children’s face masks for pathogens. They even analyzed unused masks and a worn T-shirt as controls. Know what was found on the children’s masks? Neisseria meningitidis. Tularemia. Rickettsia. Acinetobacter. Multiple other dangerous pathogens. Know what wasn’t found on the masks? SARS-CoV-2. None.
In fact, only one mask had any virus at all. And if we think masks are good because they filter out all these pathogenic bacteria while apparently being freely permeable to viruses, consider the definition of a reservoir and then think about how often the masks are cleaned and how many times per hour school kids touch their masks and then touch other surfaces. This study (https://pubmed.ncbi.nlm.nih.gov/25637115/) showed medical students touched their faces an average of 23 times per hour. Does anyone think school children are going to do better? I guess that should be a rhetorical question since the critical analytical skills of the entire medical establishment have already been embarrassed by the intellectual curiosity of a few third-grade parents. SMH. For those who would like some divergent analysis on mask effectiveness, see https://b.link/masks01 and https://b.link/masks02.
– William Sullivan, DO, JD
Early in med school we had a lab where we swabbed our hands and grew bacteria on Petri dishes. We also swabbed our hands after washing them with soap and then again after sterilizing with alcohol and shocker, the Petri dishes grew less bacteria as our hands got cleaner. All of these bacteria sound really bad, but the reality is, we weren’t getting sick in med school from bacteria on our hands and the kids aren’t getting sick from these bacteria on the masks. Masks decrease virus transmission and protect these kids from COVID as well as other respiratory viruses.
—Mike Silverman, MD
Children faking COVID positivity with cola:
https://www.bbc.com/future/article/20210705-how-children-are-spoofing-covid-19-tests-with-soft-drinks
What ingenuity. Using soda to drop the pH of the COVID test to denature the proteins, which then causes a false positive result. Interestingly, you can spot a false positive result by using the correct buffer solution to make the pH normal again, which allows the proteins to regain their function, which then makes the test a true negative result. At least I know how to get out of work now.
—Salim R. Rezaie, MD
This is really very creative. We all know there are false positive tests and at least these kids are thinking about science.
—Mike Silverman, MD
Ironic that the method to create false positive COVID tests is allowed to spread faster on social media than are studies about vaccine efficacy and safety.
– William Sullivan, DO, JD
Shouldn’t these students at least get a passing grade in their science course?
– Drew Kalnow, DO, FACEP