ECHINACEA & UPPER RESPIRATORY INFECTIONS IN CHILDREN

Echinacea is a widely used non-prescription herbal remedy that is often used to treat upper respiratory infections. However, there is little scientific data to support the effectiveness of this herb for such uses, particularly in children. A new study in the Journal of the American Medical Association looked at the effects of Echinacea on over 700 cases of upper respiratory infection (URI) in more than 400 children (ages 2 to 11 years). The study was performed as a double-blinded placebo-controlled trial, which means that neither the patients nor their pediatricians knew if they were receiving Echinacea or placebo sugar pills. Treatment was started at the time of onset of URI symptoms, and was continued throughout the course of the URI, for up to a maximum of 10 days.

After 4 months of monitoring, the results of this study showed no significant differences between Echinacea and placebo treatments in terms of the duration or severity of URIs. However, approximately 7% of the patients who received Echinacea developed skin rashes, compared to fewer than 3% of the patients who received the placebo pills. In summary, this study found no benefit in reducing the severity or duration of URIs in children with Echinacea, although its use was associated with an increased risk of skin rash.

EFFECTIVENESS OF MORBIDITY & MORTALITY CONFERENCES

The practice of medicine, like all human endeavors, is subject to at least occasional error. All physicians, no matter how well trained or how diligent, will inevitably err in judgment in such a way that a patient will be harmed. Medical training, continuing medical education, and physician credentialing are, by design, intended to minimize the occurrence of mistakes that might lead to adverse patient outcomes. However, such mistakes will likely always occur at some level.

Another method of error reduction used by physicians is the morbidity and mortality conference, or "M&M" conference. During M&M conferences, patients who have experienced complications during their treatment, including death, are anonymously discussed by attending surgeons, residents and interns. The patients' courses are presented, the complications are listed, and then a discussion about the cause, or causes, of the complications ensues. Fundamentally, a consensus must be reached as to whether or not the complication was caused by an error in physician judgment, rather than by the nature of the patient's disease. A second decision that must be made is the "standard of care" assessment. The care of the patient, including any mistakes made, must be compared with the "reasonable standards of care" within the community. Moreover, this standard of care assessment is arrived at relative to the standards expected of other physicians in the community with comparable training, and who are working at hospitals with comparable capabilities. For surgeons, specifically, potential errors in both judgment and surgical technique are considered, and usually in great detail. For most other specialties, errors primarily in clinical judgment are considered in addition to the standard of care consideration.

Among most surgeons, the M&M conference is taken very seriously, and every attempt is made to objectively identify any causative errors that might be avoided in the future. In my own experience over the past 15 years, the majority of surgeons actually tend to err on the side of personally accepting responsibility for complications and deaths, even when outside peer reviewers conclude that no significant errors in judgment or technique were actually made.

Surgeons tend to take M&M conferences very seriously, given the invasive and often injurious nature of our practices. Surgery basically involves the creation of traumatic injuries to other human beings, resecting or repairing anatomic abnormalities, and then making the best possible attempt to repair the consequences of these surgically induced injuries. Surgeons must also, of course, be good physicians in general, as they must manage non-surgical diseases in their patients before, during and following surgery.

A new study in the Journal of the American Medical Association this week evaluated 332 individual M&M conferences at 4 major university hospitals in the US. A total of 232 surgical M&M conferences were observed, in addition to 100 internal medicine M&M conferences. All of these conferences were conducted by surgery and internal medicine departments involved in teaching young residents to be surgeons or internists. As a surgeon, I found the observations presented in this study to be very intriguing.

The study compared the M&M conferences of the two specialties, and found the surgeons to be significantly more forthcoming in their presentation and discussion of patient complications when compared to the internists. The case presentations and discussions lasted 3 times longer in the surgeons' M&M conferences when compared to the internists' conferences. The internists spent 43% of their conference time listening to invited speakers, while the surgeons spent 0% of their time listening to guest lecturers. Instead, the surgeons spent 37% of their conferences discussing complications among the conference audience members, as compared to 15% of the internists. The presentation of cases also differed between the two specialties. Only 37% of the internal medicine M&M conference case presentations were actually related to adverse patient events, as compared to 72% of the surgery case presentations. Only 18% of the internal medicine cases discussed went on to attribute adverse events to specific errors in patient management, as opposed to 42% of the surgical cases. Errors were attributed to a particular cause in 8 of 21 (38%) cases for medical patients versus 88 of 112 (79%) surgery errors. Both the surgeons and the internists, however, tended to avoid explicit references to errors during their conferences, and tended to be reluctant to acknowledge having directly made an error that resulted in an adverse patient outcome.

>From these results, the authors of this study concluded that internal medicine training programs may not be routinely or adequately discussing adverse patient events, and the errors that might have caused them. At the same time, it appeared that both surgery and internal medicine teaching programs were remiss in failing to use explicit language to discuss errors in diagnosis or treatment, and to assign direct and individual accountability for such errors. Over the past 15 years, however, I can honestly say that most of the surgeons who I have worked with have not been shy about stepping up to the plate and assuming responsibility for any complications and deaths experienced by their patients.

VIRTUAL COLONOSCOPY

Endoscopic colonoscopy, using a flexible fiberoptic scope that is inserted into the rectum, is currently the gold standard examination used to rule out abnormalities in the colon. In most cases, the patient who is to undergo colonoscopy must spend the day before the test flushing their bowels out at home. On the day of the procedure, most patients are sedated with intravenous medications, and the entire length of the colon is inspected with the colonoscope. Small polyps or other tumors can often be completely removed during colonoscopy, while lesions too large to remove with the scope can usually be biopsied in order to obtain a diagnosis. There is some discomfort associated with this procedure, although adequate sedation and pain medication during the procedure make it quite tolerable for the majority of patients. Another more recent method of examining the interior of the large intestine, virtual colonoscopy, is currently being evaluated as a potential alternative to endoscopic colonoscopy.

Patients undergoing virtual colonoscopy must still cleanse their GI tract before undergoing the procedure, but generally do not require sedation for the procedure. The procedure is performed using a CT scanner, with software that reconstructs the interior of the colon in a three dimensional format. The colon is filled with a liquid radiographic contrast material, similar to that used for upper GI series, and the patient's abdomen is scanned in the CT machine. One past argument against virtual colonoscopy has been that it appears to be less sensitive in detecting small polyps when compared to endoscopic colonoscopy. A second criticism revolves around a major difference in capabilities between the two procedures, irrespective of how sensitive virtual colonoscopy becomes. If a polyp or mass is found inside of the colon by virtual colonoscopy, then the patient will still require a conventional endoscopic colonoscopy in order to remove or biopsy that lesion. Also, earlier applications of virtual colonoscopy lacked a high level of specificity for small polyps or colon masses, often mistaking small bits of feces for polyps.

A new study in the New England Journal of Medicine updates us on the current state-of-the-art for virtual colonoscopy. A total of 1,233 asymptomatic adults (average age was about 58 years) underwent both conventional endoscopic and virtual CT colonoscopy on a single day, and the results of the two tests were then compared. Neither the gastroenterologists nor the radiologists were privy to the results of virtual colonoscopy or endoscopic colonoscopy, respectively. For polyps at least 6 mm in diameter, virtual colonoscopy detected these small lesions 80% of the time, while endoscopic colonoscopy detected 89% of these tiny polyps. Polyps at least 8 mm in diameter were detected in 94% of cases with virtual colonoscopy, and in 92% of cases with endoscopic colonoscopy. Interestingly, when polyps 10 mm (1 cm) in diameter were found, virtual colonoscopy detected such polyps in 94% of cases, while endoscopic colonoscopy found 88% of such polyps in this study. The specificity of virtual colonoscopy also appears to have vastly improved, recently. The specificity of a test refers to its ability to detect an "abnormality" that turns out to actually be an abnormality, and not a "false positive" finding. In this study, virtual colonoscopy was more than 90% specific for polyps 8 mm in diameter or greater, and was about 80% specific for polyps up to 6 mm in diameter.

The principle finding of this study is that virtual colonoscopy now appears to be as accurate as conventional endoscopic colonoscopy in detecting polyps and other abnormal growths within the colon. At this time, it is not clear that virtual colonoscopy is inherently superior to endoscopic colonoscopy, and as already mentioned, any abnormalities that are identified by virtual colonoscopy will necessitate a subsequent endoscopic colonoscopy. The distention of the colon necessary to perform virtual colonoscopy may also disagree with some patients because, although unlikely to be severe, no sedation is generally used (unlike endoscopic colonoscopy). CT virtual endoscopy also subjects the patient to radiation exposure on par with other CT scan studies, and is not currently reimbursed by insurance companies and Medicare. Still, this is an interesting and important study, and it points out the considerable recent improvement in three-dimensional CT scanning technology. The future role of CT virtual colonoscopy is, however, unclear at this time. The current American Cancer Society guidelines for endoscopic colonoscopy are that people without a strong family history of colorectal cancer (and without any diseases that predispose to developing colorectal cancer) should undergo their first colonoscopy at age 50. If the study is normal, recent research suggests that subsequent colonoscopies should follow approximately every 10 years. In patients who are found to have precancerous polyps, repeat colonoscopy is generally recommended 1 to 2 years later. Other combinations of colorectal screening exams have also been proposed, including various combinations of fecal occult blood testing, flexible proctosigmoidoscopy, and air contrast barium enema. However, endoscopic colonoscopy is far more sensitive and specific than any combination of these alternative screening tests.

Dr. Robert A. Wascher