Thursday, October 29, 2009

Hospitalists and comanagement---the debate continues

But the debate, as illustrated by a point-counterpoint piece in the October issue of The Hospitalist, is not about whether collaboration among hospitalists, surgeons and subspecialists is good for patient care. It's about the importance of dealing with unintended consequences and defining the relationships.

There are strong arguments in favor of comanagement as a model which benefits patients. It it's not done carefully, though, the adverse consequences for patient care are many and it is a driver of career dissatisfaction. Eric Siegal, M.D., a co-author of the piece, described a situation all too familiar:

In the wee hours of a recent busy call night, the ED called me to admit a patient whose automatic implantable cardioverter cefibrillator (AICD) had fired repeatedly. The patient had no other active medical issues. When called, the electrophysiologist, who was on staff, demanded that I admit the patient for “medical comanagement.” The specialist agreed that I probably would have little to add to the care, but his firm expectation was that hospitalists admit his patients and he “consults” … especially at 2 a.m.

Tuesday, October 27, 2009

Management of ulcerative colitis in hospitalized patients

Steroid therapy is the mainstay in severe cases. How long should you wait for a response before resorting to surgery or rescue medical therapies? What rescue therapies are available? These issues are discussed in a recent review in Expert Review of Gastroenterology and Hepatology.

Mechanical ventilation strategy in ARDS/ALI

Nothing new according to the latest meta-analysis:

Conclusion: Available evidence from a limited number of RCTs shows better outcomes with routine use of low VT but not high PEEP ventilation in unselected patients with ARDS or acute lung injury. High PEEP may help to prevent life-threatening hypoxemia in selected patients.

Saturday, October 24, 2009

Type 2 diabetes cures

Generally I don’t like to be anecdotal but today I will. The testimonials in this LA Times piece are so compelling I’ll even overlook the Yoga references. These were obese folks with “bad” type 2 diabetes who used lifestyle changes to dispense with insulin and completely reverse their disease processes. It drives home the point that you treat insulin resistance with exercise and caloric reduction. These patients’ doctors were treating overeating with more and more insulin. Predictably, they got worse.

Of course these were exceptionally motivated people. For folks who can’t seem to diet and exercise we sometimes have to treat their overeating with insulin just to decrease microvascular disease, but it’s not physiologic.

Read the whole article but ignore the parts about Yoga.

The Senate Finance Committee’s proposed device tax

---is part of the Senate health care bill.

After explaining how it works Dick Morris notes:

The result will be that virtually every piece of advanced surgical equipment will be subject to a price increase to meet the levy from Washington. No matter that these devices often make the difference between life and death and that, in effect, taxing them raises the cost of vital treatments. The vengeful White House will have its pound of flesh from the medical device industry for daring to be independent and to refuse to knuckle down to administration pressure.

This tax, imposed in a spirit of haughty arrogance, falls on totally inappropriate objects. Valves, prosthetic limbs, pacemakers, hearing aids and such are essential therapies that make life longer, better and less painful. To tax them makes no sense. Except in the world of sharp elbows and interest group politics that grips this take-no-prisoners and show-no-mercy White House.

Dr. Wes adds:

Part of the reason the device industry did not capitulate on the price consessions was that hospitals are already pressuring device companies to lower their prices. Despite their best efforts, medical device companies will continue to feel the pinch from increasingly capitated payments to "Accountable Care Organizations" (aka, big lumbering hospital systems serving as HMO's), we'll see the gradual erosion of medical innovation in favor of business survival, especially for those who don't "play nice" with reform efforts underway.

Thursday, October 22, 2009

Options for nutritional support in acute pancreatitis

Enteral, parenteral, or none at all? According to this systematic review:

Enteral nutrition, when compared with no supplementary nutrition, was associated with no significant change in infectious complications: ratio of relative risks (RR) 0.56, 95% confidence interval (CI) 0.07–4.32, P=0.58, but a significant reduction in mortality: ratio of RR 0.22, 95% CI 0.07–0.70, P=0.01. Parenteral nutrition, when compared with no supplementary nutrition, was associated with no significant change in infectious complications: RR 1.36, 95% CI 0.18–10.40; P=0.77, but a significant reduction in mortality: RR 0.36, 95% CI 0.13–0.97, P=0.04. Enteral nutrition, when compared with parenteral nutrition, was associated with a significant reduction in infectious complications: RR 0.41, 95% CI 0.30–0.57, P less than 0.001, but no significant change in mortality: RR 0.60, 95% CI 0.32–1.14, P=0.12.

So enteral nutritional appears to be the way to go. What the paper (or at least the abstract) doesn't tell us is how soon to start, whether jejunal feedings are better, and the severity of pancreatitis as an indication for nutritional support.

Wednesday, October 21, 2009

Spontaneous bacterial peritonitis: what's new?

Although the long term prognosis of SBP is guarded the short term prognosis is no longer considered dismal, as it was when the condition was first reported.

A recent review in the World Journal of Gastroenterology (available as free full text here) makes the following points:

Suspect SBP in patients with large volume ascites due to liver disease. It seldom occurs in patients with small volume ascites or in those with ascites unrelated to liver disease.

Clinical manifestations may be vague and indolent. Thirteen percent of patients have no direct symptoms. So, paracentesis is recommended for all cirrhotic patients admitted to the hospital with large volume ascites.

In patients diagnosed with peritonitis as defined as a peritoneal fluid PMN count of 250 or above additional peritoneal fluid tests (LDH, total protein and glucose), along with the use of imaging studies as clinically appropriate, can help distinguish SBP from secondary bacterial peritonitis due to perforation or other abdominal catastrophe.

Applying a drop of ascites fluid to the leukocyte esterase square of a urine dipstick may enable rapid detection of SBP and immediate institution of antibiotics while waiting on laboratory confirmation.

Five days of antibiotics seems to be as effective as longer courses.

Albumin administration is recommended for most patients---those with renal deterioration and those who undergo large volume paracentesis. 1.5 g/kg on day 1 and 1 g/kg on day 3 has been recommended in patients with renal dysfunction. (Albumin is not only a volume expander but also a drug. It binds inflammatory mediators).

The role of antibiotic prophylaxis has been defined.

Tuesday, October 20, 2009

Citation bias and unfounded authority

Bias is omnipresent and operates at many levels. We're all familiar with publication bias but there's a less will appreciated form: citation distortion. This can occur by several means such as selectively citing papers that support a claim while ignoring those that refute it, or by citing papers in support of a claim but which have no original research data.

H/T to Secondhand Smoke.

Monday, October 19, 2009

When med students post unprofessional content on social networking sites

From a survey in the JAMA issue on medical education:

Results Sixty percent of US medical schools responded (78/130). Of these schools, 60% (47/78) reported incidents of students posting unprofessional online content. Violations of patient confidentiality were reported by 13% (6/46). Student use of profanity (52%; 22/42), frankly discriminatory language (48%; 19/40), depiction of intoxication (39%; 17/44), and sexually suggestive material (38%; 16/42) were commonly reported. Of 45 schools that reported an incident and responded to the question about disciplinary actions, 30 gave informal warning (67%) and 3 reported student dismissal (7%). Policies that cover student-posted online content were reported by 38% (28/73) of deans. Of schools without such policies, 11% (5/46) were actively developing new policies to cover online content. Deans reporting incidents were significantly more likely to report having such a policy (51% vs 18%; P = .006), believing these issues could be effectively addressed (91% vs 63%; P = .003), and having higher levels of concern (P = .02).

Monday, October 12, 2009

Ablation or drugs for atrial fibrillation?

Ablation is far from perfect but is getting better. Although preliminary data suggest it is more effective than drugs an upcoming large comparative trial may provide better answers.

A recent review in CCJM discusses current indications and complications. Complications, particularly pulmonary vein stenosis and atrioesophageal fistula, may appear relatively late and should be recognized by hospitalists.

Related editorial here.

Appropriateness criteria for stress nuclear cardiac imaging

A document written by the AHA, the ACC Foundation and other specialty organizations. The tables are good for quick reference, and those portions dealing with acute chest pain will be of particular interest to hospitalists.

A clinical prediction instrument to assess risk of tuberculosis in patients admitted with pneumonia

You admit a debilitated patient with pneumonia to the general medical ward. He does not respond well and has a long drawn out hospital course. Weeks later his sputum specimens reveal tuberculosis. Meanwhile several hospital nurses and respiratory therapists have converted their tuberculin skin tests. You're kicking yourself for not having isolated the patient. But how could you have known? You wanted to be a good steward of hospital resources and not utilize isolation rooms unnecessarily. Here's a clinical prediction instrument to help you decide which patients to isolate.

Friday, October 09, 2009

Causes of cardiac arrest in the absence of structural heart disease or ECG abnormalities

From a series in Circulation:

Sixty-three patients in 9 centers were enrolled (age 43.0±13.4 years, 29 women). A diagnosis was obtained in 35 patients (56%): Long-QT syndrome in 8, catecholaminergic polymorphic ventricular tachycardia in 8, arrhythmogenic right ventricular cardiomyopathy in 6, early repolarization in 5, coronary spasm in 4, Brugada syndrome in 3, and myocarditis in 1.

...28 patients (44%) were considered to have idiopathic ventricular fibrillation.

Thursday, October 08, 2009

The American Medical Student Association and the National Center for Complementary and Alternative Medicine

---may not want you to see this paper.

A few years ago the NIH and the NCCAM awarded a grant to the AMSA Foundation to help introduce CAM curricula at 14 MD and DO granting medical schools. The AMSA project was known as EDCAM.

Investigators in the department of Medicine at Baylor looked at the curricula and concluded, in September's issue of Academic Medicine (my emphasis):

The authors reviewed the educational material concerning four popular CAM therapies-herbal remedies, chiropractic, acupuncture, and homeopathy-posted on the integrative medicine Web sites of the grant recipients and compared it with the best evidence available. The curricula on the integrative medicine sites were strongly biased in favor of CAM, many of the references were to poor-quality clinical trials, and they were five to six years out of date. These “evidence-based CAM” curricula, which are used all over the country, fail to meet the generally accepted standards of evidence-based medicine. By tolerating this situation, health professions schools are not meeting their educational and ethical obligations to learners, patients, or society.

Well, we didn't need a formal survey to reach the conclusion in that last sentence. This is what Orac and I and a few other bloggers have been pointing out for some time. The background of this paper offers an insightful glimpse into the antecedents of quackademic medicine.

Wednesday, October 07, 2009

Non invasive ventilation after extubation in patients with hypercapnic respiratory failure

Via Lancet:

We aimed to assess prospectively the effectiveness of non-invasive ventilation after extubation in patients with hypercapnia and as rescue therapy when respiratory failure develops.


We undertook a randomised controlled trial in three intensive-care units in Spain. We enrolled 106 mechanically ventilated patients with chronic respiratory disorders and hypercapnia after a successful spontaneous breathing trial. We randomly allocated participants by computer to receive after extubation either non-invasive ventilation for 24 h (n=54) or conventional oxygen treatment (n=52).

……Respiratory failure after extubation was less frequent in patients assigned non-invasive ventilation than in those allocated conventional oxygen therapy (8 [15%] vs 25 [48%]; odds ratio 5·32 [95% CI 2·11—13·46]; p less than 0·0001). In patients with respiratory failure, non-invasive ventilation as rescue therapy avoided reintubation in 17 of 27 patients. Non-invasive ventilation was independently associated with a lower risk of respiratory failure after extubation (adjusted odds ratio 0·17 [95% CI 0·06—0·44]; p less than 0·0001). 90-day mortality was lower in patients assigned non-invasive ventilation than in those allocated conventional oxygen (p=0·0146).

I suspect these were patients with chronic hypercapnia and acute on chronic respiratory failure. The non invasive ventilation strategy was effective both as a routine measure and a rescue measure.

Medscape commentary here.

Tuesday, October 06, 2009

The competing ideas of accountability and no blame

A decade ago the Institute of Medicine (IOM) issued its landmark patient safety recommendations. Included was the statement that medicine should move away from a culture of individual blame toward a systems based approach of safety enhancements. Don Berwick, president of the Institute for Health Care Improvement, echoed this sentiment in his address at SHM 2008. He said that the onus for patient safety should shift away from individual doctors because they, most of them anyway, traditionally run at top speed. To continually ask overstressed doctors to do “just a little more” to fix safety problems, he argued, would be counterproductive. Among the benefits of a blame-free approach, many patient safety experts also agreed, would be a new culture of transparency.

Ironically, the IOM, with the issuance of its report, undermined its own aspirations for a culture of transparency right out of the gate! They did this by indiscriminately referring to a broad spectrum of adverse patient outcomes as “errors.” This unfortunate attribution, based on faulty analysis of a landmark study on adverse hospital events, I have argued, did much to sabotage the cause of patient safety in the decade that followed. (For the original investigator’s own criticism of the IOM’s interpretation see this editorial). Instead of an era of transparency we entered a heightened culture of blame and finger pointing. The most vivid example of this, of course, is Medicare’s never events policy, of which we are just beginning to realize the adverse consequences. According to a recent report by the Patient Safety Project we’ve effectively implemented virtually none of the IOM’s patient safety recommendations for system improvement and transparency. I argued that this should not be surprising given the heightened culture of blame fueled by faulty analysis of research findings, sloppy use of language and media hype.

So now we have Bob Wachter offering a little different take. He wonders whether we’ve taken the no-blame idea too far:

In this week’s New England Journal, Peter Pronovost and I make the case for striking a new balance between “no blame” and accountability. Come on folks, it’s time.

I agree with much of the substance of Bob’s argument although I have a problem with his tone and choice of terms. We can start with the premise that either of the two competing ideas, blame and no-blame, can be taken to an unhealthy extreme. We can also agree that if a health care worker repeatedly flouts safety rules there should be consequences.

Bob goes on to address the problem of hand washing compliance:

At most hospitals, hand hygiene rates hover between 30-70%, and it’s a near-miracle when they top 80%. When I ask people how they’re working to improve their rates, the invariable answer is “we’re trying to fix the system.”

Now, don’t get me wrong. I believe that our focus on dysfunctional systems is responsible for much of our progress in safety and quality over the past decade. We now understand that most errors are committed by good, well-intentioned caregivers, and that shaming, suing, or shooting them can’t fix the fallibility of the human condition.

But not washing hands? When I hear, “It’s a systems problem,” my BS detector goes a little bit haywire, particularly after I walk around the hospital and see alcohol gel dispensers every 2 feet and glossy photos of smiling clinical leaders cleaning their hands at every turn.

Well, if as many as 70% of hospital personnel are not washing their hands I’d say the problem is pretty systematic. At SHM 09 Bob mentioned a company that installs video surveillance equipment, monitors and gives real time feed back on hand washing compliance rates on individual wards. He’s been lobbying to get it installed at his institution, UCSF. It looks like a great idea and guess what? It’s a system enhancement!

Meanwhile our culture of blame devolves. The notion that “adverse event equals medical error” has been codified administratively by Medicare. The trial lawyers are watching.

We should learn from the failed IOM initiative that words like “error” mean things. We need to be more careful how we use them.

Monday, October 05, 2009

Selective skepticism

From time to time I’ve done battle with Daniel Carlat over CME and industry support. I’m repeatedly amazed by what seems to be his selective skepticism and outrage about bias in medical education, ranging from extreme cynicism about anything touched by pharma to utter credulity concerning non-industry supported sources (buried somewhere in one of our comment threads is an interesting exchange about NCCAM supported CME). It’s as if freedom from pharma influence is the litmus test for reliable information.

I’ve tried repeatedly to call out the inconsistency in this attitude but haven’t succeeded nearly as well as The Last Psychiatrist did in a recent post (H/T to Retired Doc):

It's excellent that Daniel Carlat thinks doctors like himself cannot be trusted to read and interpret their own studies, and that some other group of-- doctors? lawyers? what?-- with special bias-immunity rings need to be assembled to protect us. But those people are still people. This is why the NIH, with their incestuous grant reviewers, crazy politics and flavors of the decade philosophies is so dangerous-- they're just as biased as Pfizer except you think they are objective.

Although the post singled out Dr. Carlat concerning a piece he coauthored in Internal Medicine News all the pharmascolds are pretty much in lockstep with this view.

Quackademic medicine update

I haven’t posted anything on this topic in a while. Here’s a nice update from Science Based Medicine.

McAllen, Texas---another dubious distinction

Seems it’s also the allergy capital of the U.S.

Thursday, October 01, 2009

Noninvasive ventilation for COPD exacerbations

The results reported in the
latest paper are consistent with prior reports:


These results demonstrate that noninvasive positive pressure ventilation, in a pulmonary ward, reduces the need for endotracheal intubation, particularly in the more severe patients, and leads to a faster recovery in patients with acute exacerbation of chronic obstructive pulmonary disease.

Medscape commentary here.