Tuesday, March 6, 2012

Miserable Manure: More Ochoa

There has been a recent uptick in searches on this blog for one Dr. Jose Ochoa, traditionally referenced as "a turd."   In the past, when this has occurred, I figured Ochoa was engaged in some lonely, late-night hunt for himself.  We've all been there.

My emails, mostly impersonal notices of sales and political opinions, have piled up, mostly unread, during these surgeries and hospitalizations.  I've returned to blogging but unhappily, as what I most want to write about involves french-kissing forbidden loves.

Workhorse that I am, though, and desperate for undrugged sleep, I began going through the electronic backlog a few hours ago, with Buddy the Freakishly Large Kitten perched daintily on my lap, his bigass* claws inches from my PICC line. [Woo hoo!  Who do you know who is getting her last intravenous dose of daptomycin tonight at 18:00?  Who is having that same tape-gummy line removed tomorrow morning?  Yay!]

*My Google Spell Master/Composition Editor strongly suggests that "bigass" be replaced by "bigamous."

I subscribe to several feeds from MedWorm, "the Internet's medical router," thereby hoping to remain current about CRPS research publications.  Lately, there's not been much, and what there has been is sufficiently specialized that I was quite lost trying to understand it.  But when I opened MedWorm mail from March 1, 2012, I found something accessible and set out to do some reading.

In the Journal of Hand Surgery, a conversation about CRPS has popped up, in reaction to what seems a solid piece of work, though quite dated in some of its suppositions, published in Volume 36, Issue 9, Pages 1553-1562, back in September 2011.  I do wish researchers in the specialized surgical fields, especially, would avail themselves of the new work that largely debunks the insistence on all things "sympathetic," including rote prescription of sympatholytic drugs and sympathetic blocks -- for all that "SMP."

That I might have a problem with the proposal of surgery as "an appropriate alternative," well, I think that's understandable but concede that maybe it's a personal problem...

Here is the abstract of that article:

Complex Regional Pain Syndrome of the Upper Extremity

Ryan W. Patterson, MD, MPH, Zhongyu Li, MD, PhD, Beth P. Smith, PhD, Thomas L. Smith, PhD, L. Andrew Koman, MD
Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, NC

The diagnosis and management of complex regional pain syndrome is often challenging. Early diagnosis and intervention improve outcomes in most patients; however, some patients will progress regardless of intervention. Multidisciplinary management facilitates care in complex cases. The onset of signs and symptoms may be obvious or insidious; temporal delay is a frequent occurrence. Difficulty sleeping, pain unresponsive to narcotics, swelling, stiffness, and hypersensitivity are harbingers of onset. Multimodal treatment with hand therapy, sympatholytic drugs, and stress loading may be augmented with anesthesia blocks. If the dystrophic symptoms are controllable by medications and a nociceptive focus or nerve derangement is correctable, surgery is an appropriate alternative. Chronic sequelae of contracture may also be addressed surgically in patients with controllable sympathetically maintained pain.
Out of the blue, under the vague title, "Additional Considerations in Complex Regional Pain Syndrome," a letter to the editor, purportedly in response to the work just cited, was submitted by Peter J. Hayes, BA [Univ. of Louisville School of Medicine], Dean S. Louis, MD [Univ. of Michigan, Dept of Orthopedics], and Morton Kasdan, MD [Univ. of Louisville, Dept of Plastic Surgery].

To the Editor:

We applaud the efforts of Patterson et al1 to update and outline the definition, understanding, and treatment of complex regional pain syndrome (CRPS) in addition to the use of the 3-phase radionuclide bone scan proposed as an essential part of diagnosis. However, they neglect critical components of CRPS that have been well documented: the “nocebo effect” and psychogenic illness. Patterson et al state that CRPS should be suspected in any patient with unexplained or inappropriate pain; nevertheless, hand surgeons must be cautious not to rush into a diagnosis because of the nocebo effect. Specifically, a diagnosis without objective evidence can give the patient negative expectations and lead him to believe something is wrong before evidence for the pathological process is proven. As a result, the patient may not respond to any treatment given because he is preoccupied, trying to prove the legitimacy of his symptoms. Moreover, a misdiagnosis with CRPS can lead to “medicalization,” an avoidable process in which attempts are made to treat nonphysical ailments with invasive procedures. Not only does this have negative consequences for the patient, but it is also a preventable drain on the resources of the health care system. Finally, Patterson et al failed to mention that CRPS is often associated with psychogenic illness. Patients often have a diathesis personality disorder causing emotional insecurity and present as chronic complainers. Misdiagnosis of CRPS in patients with psychogenic illness allows these patients to justify their factitious disorder and reap the emotional and monetary benefits of being sick.Thus, it is essential for hand surgeons to take a multidisciplinary approach to the diagnosis of CRPS to avoid the nocebo effect, and to be wary of maligners.

First off, love the last word typo.  Let not the Hand Surgeon be maligned;  Get back, you maligner, you!

I read the letter, realized it contributed nothing to meaningful CRPS conversations, and prepared to move on, glad that someone got their name in print -- published, perhaps, so that he'd not perish.  But the tone was just strident and outdated enough as to be familiar.

[Published, perhaps, before he perished?  A last hurrah?]

To pass this opinion piece off as scientific work, the authors took pains to establish a few "references."

And there he was, the stinking turd:  Jose Ochoa.

  1. Patterson RW , Li Z , Smith BP , Smith TL , Koman LA 
  2. Complex regional pain syndrome of the upper extremity . J Hand Surg .2011;36A:1553–1562
  1. Mackinnon SE , Holder LE 
  2. The use of three-phase radionucleotide bone scanning in the diagnosis of reflex sympathetic dystrophy . J Hand Surg 1984;9A:556–563
  1. Stutts JT , Kasdan ML , Hicket SE , Bruner BA 
  2. Reflex Sympathetic Dystrophy: misdiagnosis in patients with dysfunctional postures of the upper extremity . J Hand Surg 2000;25A:1152–1156
  1. Louis DS , Lamp MK , Greene TL 
  2. The upper extremity and psychiatric illness . J Hand Surg 1985;10A:687–693
  1. Ochoa JL 
  2. Truths, errors, and lies around “reflex sympathetic dystrophy” and “complex regional pain syndrome.” . J Neurol 1999;246:875–879

I figure the recent increase in searches for Ochoa here at elle est belle la seine la seine elle est belle must be in relation to this unfortunate citation of his "work." That, or he is out and about again, testifying in worker's compensation hearings, spreading his miserable manure in the guise of expert opinion.  I doubt that, though, or doubt, rather, that his opinion continues to count as "expert" in any court.

What a tiresome man, tiresome mindset.

Let's give the last word to the authors of the September 2011 "original" article, since they responded to the Letter to the Editor by Hayes, Louis, and Kasdan -- and, in my opinion, responded well:

We appreciate the interesting commentary by Drs. Hayes, Kasdan, and Louis that highlights the difficulty of diagnosis of a medical condition without a pathognomonic marker. Unfortunately, medical conditions without absolute diagnostic markers are a common occurrence. For example, it is difficult to argue that the diagnosis of seronegative rheumatoid arthritis with synovitis, pain, and joint changes, but normal laboratory tests, portends a nocebo effect. We agree that objective measures are extremely important, and documentation of autonomic or vasomotor dysfunction, atrophy, and/or functional impairment is critical before a final diagnosis of chronic regional pain syndrome (CRPS). “Bone scan–positive” CRPS is a real entity and provides objective corroboration; however, “bone scan–negative” CRPS exists and has objective signs. In patients without classic findings, positive bone scans, and obvious autonomic dysfunction, care is needed to avoid misdiagnosis. Despite the desire by all of us, CRPS is not defined by bone scans.1 The authors are correct to emphasize the importance of a differential diagnosis. The commentators among others have warned of the symptoms and signs of malingering and factitious events (eg, “clenched fist”). In general, the patient with CRPS demonstrates metacarpophalangeal joint extension and mild proximal interphalangeal joint flexion.

A psychiatric or psychological causation of reflex sympathetic dystrophy or CRPS is not supported in the literature by primary articles or meta-analyses. This literature refutes the concept that CRPS—as manifested by pain, autonomic dysfunction, trophic changes, and functional impairment—is a psychiatric illness.2, 3 There is no argument that chronic pain affects wellbeing and can precipitate severe emotional responses in patients with personality disorders, including dependent, passive aggressive, and histrionic responses. We did not mention a “diathesis personality disorder” because this concept is not supported by data in any scientific literature. There may be genetic influences that contribute to the severity and chronicity of CRPS; however, these possibly genetic profiles are poorly delineated and not causative.

Clouding the issue with the concept of a nocebo is problematic. In 1961, Kennedy used the Latin term Nocebo (“I will do harm”).4 In pharmacology, a nocebo produces intentional unpleasant consequences; in anthropology, a nocebo ritual or intervention implies malicious intent. The misdiagnosis of CRPS in an already symptomatic patient may have unintended repercussions but should not be labeled as malicious; if based on a diagnosis, treatment is neither placebo nor nocebo.5 We agree that the diagnosis should be thoughtful, based on careful history, knowledgeable examination, and appropriate adjunctive testing. However, failure to diagnosis variant or partially treated CRPS can delay recovery and cause noteworthy harm.

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