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October 2004 Archives
I Found the Information, But is it
Good Information? Well, there's the HON
(Health on the Net) Seal of Approval. You've seen it. You can also look at a health site's "advisory board", which gives you an idea of the site's status in scheme of things (are these "big-time" names at important institutions?) For example, the vast majority of cardiologists on the board of HeartCenterOnline hail from St. Francis Hospital in Roslyn, Long Island or nearby centers, so you know "where they're coming from" (i.e. Exit 36 off the Long Island Expressway). It's considered a good hospital, one of the best on the Island. But how does that impact the information you're reading? What I've found true on many of the encyclopedic patient sites (WebMD, HeartCenterOnline, A.D.A.M.) is that they are one part health information and two parts business model. Let's say a good article got written back in 1999 by someone on the advisory board, or a hired "writer-physician" (my favorite is WebMD writer Robert Kloner, MD, cardiologist-turned-hospital-thriller-novelist, see medicalthrillers.com). In any case, maybe the original article gets "reviewed" in 2003 (usually the date is changed, only the text remains the same). And these articles get sold ($$$) in bulk packages, syndicated ($$$) to physicians' practice sites, to other health sites, and the same exact texts are distributed all over the net, unchanged. Actually, some of the most accurate and timely information can be found on company sites -- while the FDA has no control over health sites, it does regulate medical device manufacturers and pharmaceutical firms -- so their claims and info have to, by law, be accurate. For example, the ONLY places I found on the net where drug-eluting stent patients were given the extremely important information about continuing antiplatelet therapy for three or more months (other than our site) were the Johnson & Johnson and Boston Scientific corporate stent sites. Finally there are, what we might call, the fringe sites, or the "quack" sites -- sites that promote unproven therapies that may just be a waste of money (chelation therapy is one in particular that has come under scrutiny). Want to see if a fringe-y site is in any way legit? Run them through QuackWatch.org. Although I would caution here -- I can still remember that not long ago, the term "quack" was thrown at quite a few doctors in this country who were starting to do this strange procedure they had learned in Switzerland -- called "coronary angioplasty". A good rule of thumb to judging information is to paraphrase what "Deep Throat" whispered to Woodward and Bernstein in the parking garage -- "Follow the Mission". What is the purpose of these site, why were they started and who founded them -- were they conceived of as for-profit businesses or as non-profits supported by grants? What might their agenda be, if it's not you? This whole question of "dot.com" vs. "dot.org" vs. "dot.gov" and more is a complex subject and will be the subject of an upcoming entry. So if health information on the net is a mish-mash and each information source has its own particular agenda, how do you get what seems to be a full picture? Here's my recommendation. It's a metaphoric suggestion from my co-editor, who is an excellent chef. When venturing into unknown territory with a new recipe, she consults several cookbooks and a few online sources as well. She tries to see where the recipes conjoin and agree, and where they differ. Her confidence level increases and she synthesizes a good three-dimensional picture of how all the ingredients work together (she does the same thing with traveling -- get several guidebooks and cross-reference them). Likewise, I would suggest to patients that they take some time, peruse several sites and see where they agree (make sure to visit ours) -- you'll have a richer understanding of the particular procedure or therapy.
Medical Misinformation on the Net --
Part Two American Heart Association -- Their article on "Stent Procedure" is brief and pretty accurate, except that they tell patients blood-thinning drugs, such as ticlopidine or clopidogrel, should be used for two to four weeks after the stent procedure. Again, try three to six months! The shorter period is what used to be recommended for bare metal stents, but since around 70-90% of stents placed today are of the drug-eluting type, a minimum of three months, and preferably, six months to a year is what is considered safe. In fact, there is great concern in the medical community over the possibility of blood clotting, even a year after placement. In the words of Dr. Andrew Ong of Erasmus University, Rotterdam:
CardiologyChannel -- This multi-page coverage is pretty good. A few additions I would make: yes, catheterization, angioplasty and stenting are usually performed from the femoral artery in the groin or, less often, from the brachial artery in the elbow, but more and more cardiologists are using the radial artery in the wrist when possible -- good for patients because of shortened hospital stay, less complications and not having to lie flat on a hospital bed for 6-8 hours afterwards. Also, they mention only the Cypher™ drug-eluting stent, ignoring Boston Scientific's Taxus™, which was approved in March 2004 (and there will be more...). Oh yeah, throughout the article, the very important antiplatelet drug Clopidogrel (brand name = Plavix) is referred to as "Clopedigrol". Now you know why they call it "Plavix". And finally, I tested their MDLocator feature which doctors pay $25 a month to be listed on. I got no cardiologists in New York or Massachusetts, only 3 practices in California and 1 in Florida. Heart1.com -- This site is just one (no pun intended) of the many Body1 health sites, which include Knee1, Reflux1, Uterus1, Fibroids1, Back1, Shoulder1 -- you get the idea. Anyway, Heart1.com's article on Angioplasty is not only very brief, about a dozen lines, but, well let's say, oddly phrased. It states that the patient "is placed under local anesthesia" -- did I say odd? --I think they meant to say that a local anesthetic is injected, kind of like the dentist does when filling your tooth. Teacher's next check mark: "a catheter is inserted into a coronary artery in the groin or, less frequently, the arm" -- maybe this isn't important, but the last time I looked, the coronary arteries were in the heart. And, "More recently, a stent has been used in place of a balloon." -- not only have stents been used for over a decade, but most stents are manufactured and delivered mounted on balloons, which is how they expand -- additionally, balloons are usually used first to open up the artery. Finally, the article states that:
True, many patients consider having to lie still very uncomfortable, but there are a number of physical sensations that occur during the procedure itself that patients should be aware of and prepared for (see our article Angioplasty 101). Also -- no mention of vascular closure devices or alternative approaches (radial) that can minimize the 6-8 hours of immobilization. Oh well, what should one expect? Their article on the most widely-used treatment for CAD is shorter than this critique. Oh yeah, Heart1.com's article states that it was last updated on May 31, 2004 (Happy Memorial Day!) but the exact same text appears on the Body1.com site, with a date of January 1, 2000 (Happy New Year!). Really guys, working on holidays??!!?? Heartdisease.About.Com -- The About.com sites are all hosted by a "guide" who does it for love and a little money -- guides are compensated by About.com by the number of page views they generate. But the main draw is that the guides enjoy building a community of readers. The heart disease site is hosted by a semi-retired EP (electrophysiology) cardiologist from Pennsylvania, known as DrRich. He's got a number of articles he's written and links to other sites, as well as many sponsored links and ads, all part of the standard About.com package. There's alot of good info on his site, but I'll only briefly discuss his coverage of the most current development, drug-eluting stents. When the Cypher ran into very negative news headlines in Fall of 2003 (e.g. "Deaths prompt warning on stents") he posted an article. A month later he posted an follow up "Never Mind!" basically saying that the FDA took back its concern over the sub-acute thrombosis problem -- it was no problem! Not exactly. I would never use the phrase "no problem" when 60 deaths had been reported. I wrote an editorial at the same time to put the information into perspective, but I'm just a bit more cautious -- besides, valuable information was learned from this crisis, namely that physicians needed to be careful about sizing the stent correctly, and that patients needed to be in compliance with their post-stent antiplatelet medications. When Boston Scientific voluntarily recalled its Taxus stent, DrRich pondered whether the recall was really the end of the Taxus problems and implied that many cardiologists were switching to the Cypher. End of coverage. No follow up. That was four months ago and in the interim, the Taxus has regained 70% of the market and there have been no reports of major problems with either the Taxus or Cypher. So how does a patient get accurate and up-to-date information on the Net? The subject of tomorrow's entry.
Medical Misinformation on the Net --
Part One In the past two years this whole field has undergone nothing less than a revolution, but you wouldn't know it because most of these web sites are partying like it's 1999. Mostly, drug-eluting stents get short shrift, which is too bad, because, as noted cardiologist Gregg Stone, MD predicts, the volume of open heart bypass surgery will continue to drop. He thinks that right now over 90% of patients with coronary artery disease could be managed with drug-eluting stents.That's like...almost everyone! So outdated information becomes incorrect and misleading information, especially if you're a patient considering your options...and your future. For example: WebMD -- WebMD is one of the most popular sites on the net. But its main article on stenting begins: "For certain people, coronary artery disease can be treated without surgery." "Certain people" sure sounds like a "select" group, but even in 2002 that group would have been over half of all CAD patients -- as for today, if you listen to Dr. Stone and the interventional evangelists, 9 out of 10. Outdated=Misleading? One of the problems with WebMD is that it is so big that you can navigate to one of several articles on angioplasty or stents, and each have a slightly different skew, depending on when they were written or, more appropriately, purchased (more on this another day). One of their major articles states that:
Duh! They are being used everywhere. Patients are asking for them by name. Also, WebMD concedes that angioplasty is at least as effective (and possibly superior) to clot-dissolving drugs in treating heart attacks. In fact, there are studies saying that not only is angioplasty superior, but that a person having a heart attack should go to a hospital that performs emergency angioplasty, even if it takes up to 2 hours longer. This is a very important recommendation for patients! (See our feature on the topic.) HeartCenterOnline's Stent Center -- From the health site that recently sent me an email, sending me to Dr. Sinatra's Secret Nutrient web site, we get 3 articles, one on stenting, one on carotid artery stenting and one on intravascular radiotherapy (or intracoronary brachytherapy). This latter article is quite detailed and states that, while this technique is still experimental, it:
This would be news to prominent cardiologist and TCT organizer Martin Leon, MD, who stated last month,
So that would be a promising technique? (note: HeartCenter is not alone -- WebMD also lists brachytherapy as an important therapy for treating restenosis.) HeartCenter's stent article is interesting -- the information is relatively accurate, as far as it goes, and it does go -- for eight single-spaced detailed printed pages. Yet only four lines even mention drug-eluting stents, clearly the most important recent development in all of interventional cardiology. Patients are informed that they should expect to take antiplatelet medications for one month (instead of three, six or more -- mandatory for drug-eluting stent patients), and there are more references to intracoronary radiation as a new development. I remember that when HeartCenterOnline first posted its "Stent Center", it was sponsored by Guidant Corporation, which at that time was marketing a radiotherapy device (recently discontinued) and did not -- and still does not -- manufacture a successful drug-eluting stent of its own. As for carotid stenting, I will deal with the whole subject of less invasive therapy outside of the heart at a later date, but it is an exciting development that crosses over the medical specialties of vascular surgery, radiology and cardiology. Okay, I'm just plugging our documentary, Vascular Pioneers: Evolution of a Specialty. More sites tomorrow.
The Voice in the Ear For better or worse, here it is. I'm calling it "The Voice in the Ear" -- referencing my many years as a TV director of live medical demonstration courses, such as the ones viewed at meetings like the TCT. At the risk of becoming too "topical" (I'm referring here, of course, to the so-called controversy about whether George Bush had a wired earpiece during the 2004 debates) I readily admit that I was, in fact, the "voice in the ear" for many interventional cardiologists during the scores of procedures that I broadcast to professional audiences in the first two decades of coronary angioplasty. Our mission was to teach other cardiologists how to do procedures. And when you're in "live broadcast" mode, you must have a means of communicating with the operating physician. So the cardiologist had a wireless earpiece, called an IFB (internal feedback) in his ear, and I could communicate directly (and privately) with him while he was operating on a patient. Obviously, I used this power judiciously, but it was usually to convey such important information as "the next case isn't ready yet, so stretch your discussion to fill time" or "it's getting late and the audience needs to go to lunch, so wrap it up" or "can you tilt the pressure gauge slightly to your right, so the camera can see how many atmospheres the balloon is being inflated to?" In any case, I was the voice in the ear to many of the pioneering interventional cardiologists, so I thought it would be a fitting title for my ramblings.... |
