Not only do the kinetics exhibit a long half-life, the actual half life has been shown to be poorly characterized in clinical trials and even seems to vary over the course of treatment. There are also issues with drug-drug interactions with hepatic and intestinal CPY450 isoenzymes. Methadone is a drug that really needs to have regular clinician follow-up and extensive patient education about the nature of the drug and which drugs to avoid using concomitantly. It's a good (and cheap) drug, but it needs to be use intelligently or it loses that cheap characteristic -- death is not cheap as an outcome measure.
I don't know if this nurse was fired or not. I hope so, too. Criminal liability in healthcare is kind of tricky and really needs to be looked at on a case-by-case basis. Generally there are four levels of liability -- at the employer/employee level (fired, reprimanded, re-trained, suspended), at the regulatory body level (lose license, require re-education), criminal level (prosecution in a criminal court), and civil liability (getting sued by an individual).
For employers, the current trend within institutions is to consider all errors to be system errors and not individual errors (my observation, I don't have any data to support this). If someone made a mistake, you perform a root-cause analysis. Even if that comes down to the actions of one person, there can be reasons to push it back as a system error. Was the employee improperly trained? Was the environment too distracting? Was their workload to high? Can you reasonably expect a human to perform hundreds of actions a day without error? If you're coding all day and you make an error, there are layers of QA (hopefully!) to go through before it gets to market. And even after that, you can fix it in a bug report. You don't get all of those things when you're working a double shift in an understaffed nursing unit. That's why we try to make it as hard as possible to mess up.
I don't know that I agree with criminal liability in any but the most egregious cases. And I mean that there is criminal intent. An expectation of perfection is unreasonable. An expectation of perfection with the consequence of criminal prosecution isn't helping anybody at all. Sending a nurse to jail because she was distracted and grabbed the wrong drug doesn't seem just to me.
Nobody in healthcare likes making mistakes. I can honestly say I've made mistakes and luckily none of them have caused harm. It's changed the way I practice for sure, but I know that I am flawed and will make errors again. I work with other flawed people and I learn from them. Whenever I hear of a medical error harming a patient (and I think this can be generalized to all but the most sociopathic of healtcare workers), I get the sickest feeling in my stomach. In the same environment, with the same mindset, could I have done the same thing? Taping two tubes together because they don't fit? Probably not.
This does happen, and unfortunately the journalist either somehow did not discover this or failed to report it.
I work in a hospital -- in the pharmacy, not nursing. I can't be sure that this is generalizable to other hospital systems, but we already do have incompatible connections for almost every route. You can't connect an IV line to an oral syringe. You can't connect a gastric feeding tube to an IV line. They just don't fit.
In cases where injectable drugs have potentially dangerous routes, we have other safeguards -- if a drug is to be injected intrathecally (into the spinal fluid), there is a giant, black sticker on it that essentially says "Hold on. Take a second and review everything. This is serious business." If it is commonly given with another drug that is given intrathecally, it comes double-bagged with a giant label that says "DON'T GIVE THIS INTRATHECALLY OR SOMEBODY WILL DIE".
I don't know that these practices occur across the US, but I'm pretty sure that there are at least products on the market that do all of these things. Without the FDA making new laws.
In many cases it comes down to the resourcefulness of the nurse. I have heard of at least one case of a nurse who gave an enteral feeding intravenously. The connections were incompatible. Her solution was to attach the two ends together and keep them in place with surgical tape.
One exception that I know is a problem is in the neonatal arena. It is a specialized area without a whole lot of specialized equipment in some cases. For instance, the enteral feeding is sometimes so small and required to go so slowly that the only alternative may be to put it into an IV syringe and run it through a syringe pump. This is (and has been) a recipe for disasterous outcomes.
I think it's more like: failure of a science writer extrapolates results to make cute headline. I'm pretty sure the scientists who performed this study facepalmed pretty hard when they read that article. I know I did.
The stem cell transplants currently used for leukemias and lymphomas involves completely eradicating the host immune system through chemotherapy and/or radiation therapy. Then a donor stem cell is implanted and is used to replace the host immune system (which will hopefully be completely eradicated and not pumping out cancer cells). Dr Cui's research is a little different. He is keeping the host immune system intact, but is taking sample immune cells from donors with cancer resistance and injecting them into the host. The goal is that the donor cells will kill the cancer but not the rest of the host's cells which leads to GVHD. This seems to work for solid tumours in rats. A good summary of is research is here.
In the US, the usual FDA process for drug approval is to go through 3 phases of human trials (then a mandatory phase 4 during which adverse event data from the wild is gathered and analyzed). There is a Fast Track program at the FDA for serious diseases where there is a need for treatment options. This allows drugs to get approved faster by skipping steps and using surrogate end points instead of proving complete efficacy and safety.
I'd be interested to hear the reasons that grants were not given to continue this research. It might have something to do with there not being a specific mechanism of action identifiable in his experiments. In his interview he admits that he has no idea why it works, but it seems to work. Sciency people don't like things like that. They probably have a better reason than "it seems a little hokey", though.
When I was a child we lived in Trinidad for a few years. The Pitch Lake isn't really as bad as the article makes it sound. It doesn't smell. You won't die from noxious fumes by going near it. You can even take tours and walk out into the lake if you want. There are some areas that are solid pitch and other areas that you will sink into and die if you try to walk on them. There are guides who know (hopefully!) where it is safe to walk. It's a pretty cool place to visit if you get the chance.
I honestly don't understand this. Can someone explain this to me: If the analysts are concerned that their information is being disseminated before they can get it to their clients, why don't they just give the information their clients earlier? If someone else can aggregate all of their data and get it out at 0700, why is it so hard for the people who -made the data- get it out at 0630?
If someone is paying me big bucks to determine the probability that it's going to rain today I'm going to make sure they know what I know ASAP. I'm not going to figure it out then go grab a latte and do a few Sudoko puzzles first while someone else sells my leaked meteorological research to somebody else.
I don't think the assumption is bad -- money does influence outcome, historically. But I completely agree that it should be left to the voter to decide whether they want to continue to vote for the person who has the flashiest advertising. Perhaps in the future this assumption will turn bad. In a way, free flow of corporate money will give us a better indication of what a politician may do once elected. If by chance an individual feels that those interests are aligned with theirs, they can go on ahead and vote for the Google candidate or the Blackwater candidate. This also opens the possibility that a candidate may choose to not accept corporate money. Right now nobody accepts corporate money (nudge, wink). An "open source" candidate may choose to open their books and show voters that they have received no corporate donations and that all contributions have come from individuals -- or maybe they take no contributions at all and just accept campaign help. This may not be immediately practical for something like a presidential campaign, but currently it may be feasible for a senator of a smaller state. If enough people are actually concerned with corporate influence over politics (I'm not convinced enough people actually care right now) then they can vote for a candidate they feel is not (or is less) influenced by corporate backers.
I appreciate your optimism that people will not automatically vote for the best-funded candidate and I certainly hope that comes true some day.
I worked at a hospital with a pretty complicated series of tubes. Even after using it hundreds of times, I still thought it was totally sweet.
Yes, tubes DO get clogged, and pretty regularly. We fixed it by calling maintenance and saying "tube's down". I think they reversed the polarity or something. If something was extra-stuck it could be down for an hour or so, so they probably have access points or something if reversing didn't work.
If you use a damaged capsule it can end up clogging the tube, so it's not a good idea. Capsules will get stuck if it's not closed all the way (you try to squeeze stuff too much stuff into it). If you put something in wrapped in a plastic bag (always a good idea with IV bags and things that can break) and a bit of the bag is sticking out it can clog the tubes, too.
You don't generally put in things that can break easily -- you wouldn't generally send glass bottles, but vials are okay if you throw some padding around them. They don't stop gently, it's a pretty good thud even with whatever braking they use so you make sure the contents will survive impact before you send it. Usually you'll double-bag for biologic and chemo products. If a capsule gets contaminated with bio or chemo there are cleaning procedures. Generally it's just the capsule that gets contaminated. There are probably procedures for shutting down and cleaning the tube system after contamination. It was one of those things that you always think could happen and how much it would suck, but it didn't happen when I worked there.
If a critical sample gets stuck or destroyed, then tough cookies. There will always be noob mistakes.
True story: the tube system we used had a function to send tubes out if you had an excess of empty tubes. You push a code and it takes it -somewhere-. Then if you need a tube, you push a code and it sends you an empty one. I don't know how that works, but I always imagined that it involved monkeys.
New, more permissive laws provide police and government prosecutors with the opportunity to selectively pursue certain easy cases. The cases they choose to investigate will invariably be in line with their political or personal agendas. I don't know if I would consider this a burden.
Wow. I responded to parent as well regarding "alcohol-related". I was not aware they used passenger intoxication in their stats as well. I've been trying to curb my feelings of moral indignation lately because I don't think it is good for my health -- things like this make it so hard. Unfortunately I can't see the day when we start clawing back laws that burden society without providing a net positive benefit. Is there a Net Positive Benefit party?
Usually statistics from the NHTSA in the US reports uses a different definition of "alcohol-related":
Alcohol related fatalities are defined as fatalities that occur in crashes where at least one driver or
nonoccupant (pedestrian or pedalcyclist) involved in the crash has a positive Blood Alcohol Concentration
(BAC) value.
cite
If someone is looking at LOLcats on their iPhone and kills you in a car crash and they blow a 0.01 on a breathalizer because they were eating a bagel with their free hand that is considered an alcohol-related fatality. If you run over a a drunk guy on a bike that counts as an alcohol-related fatality. Furthermore, if there is no breathalizer done then they use "statistical modeling" to determine if alcohol is involved. I don't know what kind of modeling they use, but my guess is that they say there is a 33% chance alcohol was involved and list is as such. I'm not sure why their threshold for "alcohol-related" is so low, but it definitely gives us some big, scary numbers.
Yeah, it is pretty small by American standards. I roll with a Golf and it's not that bad. I've had to borrow pick-ups to help move stuff a few times, though.
[cool story] I don't know if it was a C2 or not, but once we crammed 9 people into a Citroen (including the unfortunate guy in the boot/hatch). Good times. [/cool story]
This is true for vehicles that are marketed in the US. The top 10 cars for fuel economy in the UK include a number of vehicles that aren't marketed in the US (made by Citroen and Renault). The Prius barely scrapes in with 10th place.
Slashdot Mirror
Not only do the kinetics exhibit a long half-life, the actual half life has been shown to be poorly characterized in clinical trials and even seems to vary over the course of treatment. There are also issues with drug-drug interactions with hepatic and intestinal CPY450 isoenzymes. Methadone is a drug that really needs to have regular clinician follow-up and extensive patient education about the nature of the drug and which drugs to avoid using concomitantly. It's a good (and cheap) drug, but it needs to be use intelligently or it loses that cheap characteristic -- death is not cheap as an outcome measure.
"Did you know that disco record sales were up 400% for the year ending 1976? If these trends continues... AAY!"
It's a bit early for a case of the Mondays, chap.
So the smiling officer standing right beside him with equal "danger" of getting hit by bubbles was taking the wrong course of action?
You, sir are the toughest guy on the Internets.
I don't know if this nurse was fired or not. I hope so, too. Criminal liability in healthcare is kind of tricky and really needs to be looked at on a case-by-case basis. Generally there are four levels of liability -- at the employer/employee level (fired, reprimanded, re-trained, suspended), at the regulatory body level (lose license, require re-education), criminal level (prosecution in a criminal court), and civil liability (getting sued by an individual).
For employers, the current trend within institutions is to consider all errors to be system errors and not individual errors (my observation, I don't have any data to support this). If someone made a mistake, you perform a root-cause analysis. Even if that comes down to the actions of one person, there can be reasons to push it back as a system error. Was the employee improperly trained? Was the environment too distracting? Was their workload to high? Can you reasonably expect a human to perform hundreds of actions a day without error? If you're coding all day and you make an error, there are layers of QA (hopefully!) to go through before it gets to market. And even after that, you can fix it in a bug report. You don't get all of those things when you're working a double shift in an understaffed nursing unit. That's why we try to make it as hard as possible to mess up.
I don't know that I agree with criminal liability in any but the most egregious cases. And I mean that there is criminal intent. An expectation of perfection is unreasonable. An expectation of perfection with the consequence of criminal prosecution isn't helping anybody at all. Sending a nurse to jail because she was distracted and grabbed the wrong drug doesn't seem just to me.
Nobody in healthcare likes making mistakes. I can honestly say I've made mistakes and luckily none of them have caused harm. It's changed the way I practice for sure, but I know that I am flawed and will make errors again. I work with other flawed people and I learn from them. Whenever I hear of a medical error harming a patient (and I think this can be generalized to all but the most sociopathic of healtcare workers), I get the sickest feeling in my stomach. In the same environment, with the same mindset, could I have done the same thing? Taping two tubes together because they don't fit? Probably not.
This does happen, and unfortunately the journalist either somehow did not discover this or failed to report it.
I work in a hospital -- in the pharmacy, not nursing. I can't be sure that this is generalizable to other hospital systems, but we already do have incompatible connections for almost every route. You can't connect an IV line to an oral syringe. You can't connect a gastric feeding tube to an IV line. They just don't fit.
In cases where injectable drugs have potentially dangerous routes, we have other safeguards -- if a drug is to be injected intrathecally (into the spinal fluid), there is a giant, black sticker on it that essentially says "Hold on. Take a second and review everything. This is serious business." If it is commonly given with another drug that is given intrathecally, it comes double-bagged with a giant label that says "DON'T GIVE THIS INTRATHECALLY OR SOMEBODY WILL DIE".
I don't know that these practices occur across the US, but I'm pretty sure that there are at least products on the market that do all of these things. Without the FDA making new laws.
In many cases it comes down to the resourcefulness of the nurse. I have heard of at least one case of a nurse who gave an enteral feeding intravenously. The connections were incompatible. Her solution was to attach the two ends together and keep them in place with surgical tape.
One exception that I know is a problem is in the neonatal arena. It is a specialized area without a whole lot of specialized equipment in some cases. For instance, the enteral feeding is sometimes so small and required to go so slowly that the only alternative may be to put it into an IV syringe and run it through a syringe pump. This is (and has been) a recipe for disasterous outcomes.
I think it's more like: failure of a science writer extrapolates results to make cute headline. I'm pretty sure the scientists who performed this study facepalmed pretty hard when they read that article. I know I did.
It most certainly did. The key word is "reportedly". Incidentally, I reportedly have a massive sex organ and 2 Ferraris.
Oh. I've been working on those in the wrong order.
The stem cell transplants currently used for leukemias and lymphomas involves completely eradicating the host immune system through chemotherapy and/or radiation therapy. Then a donor stem cell is implanted and is used to replace the host immune system (which will hopefully be completely eradicated and not pumping out cancer cells). Dr Cui's research is a little different. He is keeping the host immune system intact, but is taking sample immune cells from donors with cancer resistance and injecting them into the host. The goal is that the donor cells will kill the cancer but not the rest of the host's cells which leads to GVHD. This seems to work for solid tumours in rats. A good summary of is research is here.
In the US, the usual FDA process for drug approval is to go through 3 phases of human trials (then a mandatory phase 4 during which adverse event data from the wild is gathered and analyzed). There is a Fast Track program at the FDA for serious diseases where there is a need for treatment options. This allows drugs to get approved faster by skipping steps and using surrogate end points instead of proving complete efficacy and safety.
I'd be interested to hear the reasons that grants were not given to continue this research. It might have something to do with there not being a specific mechanism of action identifiable in his experiments. In his interview he admits that he has no idea why it works, but it seems to work. Sciency people don't like things like that. They probably have a better reason than "it seems a little hokey", though.
When I was a child we lived in Trinidad for a few years. The Pitch Lake isn't really as bad as the article makes it sound. It doesn't smell. You won't die from noxious fumes by going near it. You can even take tours and walk out into the lake if you want. There are some areas that are solid pitch and other areas that you will sink into and die if you try to walk on them. There are guides who know (hopefully!) where it is safe to walk. It's a pretty cool place to visit if you get the chance.
I honestly don't understand this. Can someone explain this to me: If the analysts are concerned that their information is being disseminated before they can get it to their clients, why don't they just give the information their clients earlier? If someone else can aggregate all of their data and get it out at 0700, why is it so hard for the people who -made the data- get it out at 0630?
If someone is paying me big bucks to determine the probability that it's going to rain today I'm going to make sure they know what I know ASAP. I'm not going to figure it out then go grab a latte and do a few Sudoko puzzles first while someone else sells my leaked meteorological research to somebody else.
I don't think the assumption is bad -- money does influence outcome, historically. But I completely agree that it should be left to the voter to decide whether they want to continue to vote for the person who has the flashiest advertising. Perhaps in the future this assumption will turn bad.
In a way, free flow of corporate money will give us a better indication of what a politician may do once elected. If by chance an individual feels that those interests are aligned with theirs, they can go on ahead and vote for the Google candidate or the Blackwater candidate. This also opens the possibility that a candidate may choose to not accept corporate money. Right now nobody accepts corporate money (nudge, wink). An "open source" candidate may choose to open their books and show voters that they have received no corporate donations and that all contributions have come from individuals -- or maybe they take no contributions at all and just accept campaign help. This may not be immediately practical for something like a presidential campaign, but currently it may be feasible for a senator of a smaller state. If enough people are actually concerned with corporate influence over politics (I'm not convinced enough people actually care right now) then they can vote for a candidate they feel is not (or is less) influenced by corporate backers.
I appreciate your optimism that people will not automatically vote for the best-funded candidate and I certainly hope that comes true some day.
I worked at a hospital with a pretty complicated series of tubes. Even after using it hundreds of times, I still thought it was totally sweet.
Yes, tubes DO get clogged, and pretty regularly. We fixed it by calling maintenance and saying "tube's down". I think they reversed the polarity or something. If something was extra-stuck it could be down for an hour or so, so they probably have access points or something if reversing didn't work.
If you use a damaged capsule it can end up clogging the tube, so it's not a good idea. Capsules will get stuck if it's not closed all the way (you try to squeeze stuff too much stuff into it). If you put something in wrapped in a plastic bag (always a good idea with IV bags and things that can break) and a bit of the bag is sticking out it can clog the tubes, too.
You don't generally put in things that can break easily -- you wouldn't generally send glass bottles, but vials are okay if you throw some padding around them. They don't stop gently, it's a pretty good thud even with whatever braking they use so you make sure the contents will survive impact before you send it. Usually you'll double-bag for biologic and chemo products. If a capsule gets contaminated with bio or chemo there are cleaning procedures. Generally it's just the capsule that gets contaminated. There are probably procedures for shutting down and cleaning the tube system after contamination. It was one of those things that you always think could happen and how much it would suck, but it didn't happen when I worked there.
If a critical sample gets stuck or destroyed, then tough cookies. There will always be noob mistakes.
True story: the tube system we used had a function to send tubes out if you had an excess of empty tubes. You push a code and it takes it -somewhere-. Then if you need a tube, you push a code and it sends you an empty one. I don't know how that works, but I always imagined that it involved monkeys.
Your allergy to noisy babies and children won't kill you.
I dunno. I'd prefer not to take any chances.
New, more permissive laws provide police and government prosecutors with the opportunity to selectively pursue certain easy cases. The cases they choose to investigate will invariably be in line with their political or personal agendas. I don't know if I would consider this a burden.
Balls. Back to grammar academy :(
The press were kicked out?
Wow. I responded to parent as well regarding "alcohol-related". I was not aware they used passenger intoxication in their stats as well. I've been trying to curb my feelings of moral indignation lately because I don't think it is good for my health -- things like this make it so hard. Unfortunately I can't see the day when we start clawing back laws that burden society without providing a net positive benefit. Is there a Net Positive Benefit party?
cite
If someone is looking at LOLcats on their iPhone and kills you in a car crash and they blow a 0.01 on a breathalizer because they were eating a bagel with their free hand that is considered an alcohol-related fatality. If you run over a a drunk guy on a bike that counts as an alcohol-related fatality. Furthermore, if there is no breathalizer done then they use "statistical modeling" to determine if alcohol is involved. I don't know what kind of modeling they use, but my guess is that they say there is a 33% chance alcohol was involved and list is as such. I'm not sure why their threshold for "alcohol-related" is so low, but it definitely gives us some big, scary numbers.
Yeah, it is pretty small by American standards. I roll with a Golf and it's not that bad. I've had to borrow pick-ups to help move stuff a few times, though.
[cool story] I don't know if it was a C2 or not, but once we crammed 9 people into a Citroen (including the unfortunate guy in the boot/hatch). Good times. [/cool story]
This is true for vehicles that are marketed in the US. The top 10 cars for fuel economy in the UK include a number of vehicles that aren't marketed in the US (made by Citroen and Renault). The Prius barely scrapes in with 10th place.
Good thing I don't have to worry about that. I use Linux!
How can this technology be leveraged to keep my children safe?