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Hocus Pocus
by Mary Barry, MD
Or hokey-pokey? That is the question. Recently, a group of doctors at the University of Calgary divined that the Payne formula – used for correcting a low serum calcium level when the serum albumin is also low – no longer is valid. It turns out that this formula was based on all of 200 patients’ data and was set forth in 1973. I remember learning about it on teaching rounds at Grady when the nephrology fellow( holding court for his absent boss) asked me to define it and my first words were a befuddled,“ Pain? You mean like on a scale of 1 to 10?” This did not go over well.
My resident, wincing, explained that half of circulating calcium is bound to albumin, and if the measured calcium and the albumin are both low, you gotta correlate them to know when to worry( or when to panic). I had heretofore only really worried about high calciums, but I did know that you could get all twitchy and crampy and tingly on intensive diuretics, and therefore, we checked calciums and magnesiums and potassiums, a bunch. The fellow looked meaningfully at my resident and said,“ Your work is not done here,” and we carried on to the next person. But I got extra homework, for real.
Dr. Desgagnes et al in Alberta 1 looked at over 22,000 people with a median age of 60, over a six-year span. They found that for both men and women, using the plain old Chem-18 calcium level, unadjusted, was more trustable than using the Payne formula(“ Hah!” said a mean small voice in my head). Using the formula overestimated and misclassified 41 % of patients, while simply accepting the measured level misclassified only 29 %. If you are worried about someone’ s low calcium level, you should check the ionized calcium level and leave the
formulas on the shelf.
I am eternally grateful to actual scientists. What they do seems magical, but it starts with nosiness. You gotta be a curious, skeptical, noticing, kinda driven sort of person. You want to KNOW. But if you want a grant? You gotta get your name out there. You have to have the right patients, who inspire you to ask the right questions. The inspiration comes with noticing differences, then wondering about them, then talking about them, then researching them. Lab and clinical doctors alike must make exacting observations, talk to interested peers and seek counsel from their professors. This is followed by a whole bunch of messy applications for grants, and mistakes, and trying again, and starting over, and even messier pressure to publish. You gotta network with the device-making and drug-making industry. Yet now, this wealth of highly motivated, dedicated U. S. doctors face the specter of having such a castrated NIH that no one will materialize to review and approve their work.
Keeping track of the dizzying round of DOGE’ s massive withdrawal of grant approvals is an exercise in controlling one’ s temper. People in clinical trials for lifesaving drugs, people with newly implanted medical devices of a hopefully-improved design: they have been abandoned on the ice floe. Their connections to research nurses and specialists may have been completely severed. They have pinned their hopes on something new and improved and only with the intervention of enough appeals reaching the appropriate courts, may they possibly be granted reprieves. They may lose out entirely, and so will their doctors and lab staff. It’ s hard to keep all those lab refrigerators humming when just your salary is now supporting everything and everyone related to your life’ s work,
32 LOUISVILLE MEDICINE OPINION