Tuesday, March 30, 2010

Post thrombotic syndrome

A very useful review was recently published in Blood, available as free full text.

Points of interest:

More than one third of patients with DVT will develop post thrombotic syndrome (PTS). 5-10% will develop severe PTS.

In patients who have had a DVT the differentiation between recurrent ipsilateral DVT and PTS is difficult. Venous duplex testing, D-dimer and clinical prediction tools can be helpful.

Which patients will develop PTS? Incomplete resolution of leg symptoms by 1 month is a strong predictor. Risk factors include age, obesity, common femoral or iliac (as opposed to distal femoral of popliteal) location, subtherapeutic INRs during the first three months of treatment and recurrent ipsilateral DVT are risk factors. Thrombophilia does not appear to be a risk.

Prevention is somewhat controversial. Fitted compression stockings (worn for 2 years) appear to cut the incidence in half although better quality data are needed. Thrombolytic therapy is controversial. Such therapy, particularly catheter directed thrombolytic therapy, can reduce the incidence of PTS but the supporting studies have limitations. Rigorous trials are underway. The Chest guidelines suggest that catheter directed thrombolytic therapy “may be considered” in cases of extensive DVT in otherwise appropriate patients (low bleeding risk, patient preference, etc).

The author recommends that risk assessment for PTS and counseling the patient concerning said risk be carried out.

Noninvasive ventilation for chest trauma related hypoxemia

---reduced the need for intubation in this study.

Pancreatitis review with emphasis on guideline adherence

This CCJM review emphasizes under appreciated points in the guidelines.

Among these are the need for daily severity assessment. Severity assessment using the Ranson score is of prognostic importance but not useful for daily assessment because the score requires 48 hours to complete. Other assessment tools are available and mentioned in the review. Surveys of guideline adherence indicate that this is often not done, whereas the practice of daily measurement of amylase and lipase is often done but not recommended.

Indications for and timing of CT are frequent sources of confusion.

The need for nutritional support depends on severity assessment.

Hematocrit should be repeated at 12 and 24 hours. A rise consistent with hemoconcentration predicts necrosis. Also, a fall at 48 hrs (Ranson score) is a marker of severity.

There being no high level studies, fluid resuscitation recommendations are supported only by animal data, expert opinion and pathophysiologic rationale. Nevertheless, it is the opinion of some experts that under-resuscitation is common in practice. Recommendations are vague, with statements calling for “tempering” volume resuscitation in the elderly. Volume needs should be assessed and reassessed frequently using vital signs, urine output and hematocrit.

Scoring systems for CT based severity assessment exist. If contrast is contraindicated due to renal dysfunction some assessment parameters can be recorded without contrast.

Absent cholecystectomy, relapse rate is very high in the early weeks following an episode of gallstone associated pancreatitis.

Among the risk factors for in-hospital mortality

---is high occupancy rate in this study.

Monday, March 29, 2010

All nerds are dweebs but not all dweebs are nerds

Terms and relationships defined here.

Via Grunt Doc.

Is low tidal volume ventilation beneficial for patients who do NOT have ARDS/ALI?

It is well known that low tidal volume ventilation is beneficial in patients with ARDS/ALI. The pathophysiologic rationale, that by avoiding over distension of alveoli low tidal volume ventilation mitigates lung injury and is associated with decreased cytokine production, is appealing for ventilated patients without ARDS/ALI. Up to now, for these latter patients, although RTC evidence was lacking, several papers suggested a beneficial effect.

This retrospective cohort study showed that for each ml (ml/kg predicted body weight?) above the ARDSnet standard of 6 ml/kg PBW the odds ratio for development of ALI increased by 1.3.

This study noted a similar effect.

In this study higher plateau pressures and tidal volumes (but not tidal volumes per unit predicted body weight!?) were risk factors. This combination of findings, which translates into taller individuals being at higher risk for ARDS, is an anomaly and not reproduced in other studies.

Now, just out, is a RCT of conventional vs low tidal volume ventilation for patients who do not have ALI or ARDS:

The trial was stopped prematurely for safety reasons because development of lung injury was higher in the conventional tidal volume group as compared to the lower tidal volume group (13.5% vs. 2.6%, P = 0.01). Univariate analysis showed statistical relations between baseline lung injury score, randomization group, level of positive end-expiratory pressure (PEEP), number of transfused blood products, presence of a risk factor for ALI and baseline IL-6 lavage fluid levels and development of lung injury. Multivariate analysis revealed randomization group and level of PEEP as independent predictors of the development of lung injury.

Conclusions
Mechanical ventilation with conventional tidal volumes is associated with sustained cytokine production as measured in plasma. Our data suggest mechanical ventilation with conventional tidal volumes contributes to development of lung injury in patients without ALI at onset of mechanical ventilation.

Higher sedation needs and more difficulty in maintaining oxygenation, cited as barriers to the evidence based implementation of low tidal volume ventilation in patients with ARDS, were not noted in the low tidal volume group in this study.

This is a very important paper which stands an excellent chance of making my top 10 list next December!

It's about time

Primary care in the U.S. suffers from inadequate time to spend with patients. The popular wisdom is that health care reform can fix that. Well---

Results: German, British, and American physicians were allocated (on average) 16/11/32 minutes for a new patient appointment, 6/10/18 minutes for a routine visit, and 12/20/36 minutes for a complete physical, but felt that they needed more time. Over half of German and American physicians felt that they always or usually had control over the hours they were required to be in their office or spending sufficient time with their patients while less than half of British physicians felt this way.

Conclusion: German physicians had the least time allocated and needed for most types of appointment. American physicians had the most time allocated and needed for each type of appointment. However, British physicians felt they had the least control over time in their office and spending sufficient time with patients.

Friday, March 26, 2010

Why IM trainees choose hospital medicine and subspecialties over primary care

Although available slots in IM, FP and Peds in the 2010 match far exceeded those who matched, there was a slim increase over 2009 in the number of graduates matching in all three specialties. While that may be regarded by some as good news, very few IM trainees are opting for primary care, choosing instead susbpecialty and hospitalist positions. DB asks why and suggests better job conditions for hospitalists as one of the reasons.

His analysis is only partially correct and ignores one of the key issues: General Internal Medicine is losing its identity as a unique specialty. Its distinction from Family Practice is diminishing. It has been proposed for dissolution by merger with FP and may no longer exist in a decade or two. The American College of Physicians, Internal Medicine's leading professional organization, has been complicit in this trend.

I hope DB takes advantage of his leadership position in the ACP to make a difference here.

Heart failure performance measures fail---again

Some time ago I blogged about the initial results of OPTIMIZE-HF which showed that at 60-90 day follow up the CMS core heart failure measures were found to be lacking in benefit. Now we have the results of the 1 year follow up. Again, no benefit:

Background: Recent efforts to improve care for patients hospitalized with heart failure have focused on process-based performance measures. Data supporting the link between current process measures and patient outcomes are sparse...

Conclusion: Hospital process performance for heart failure as judged by current CMS measures is not associated with patient outcomes within 1 year of discharge, calling into question whether existing CMS metrics can accurately discriminate hospital quality of care for heart failure.


I'll say it again: performance does not equal quality and by itself does not produce better outcomes.

Warfarin genotyping

---reduced hospitalizations, including those for bleeding and thromboembolism, in the Medco-Mayo Warfarin Effectiveness Study (MM-WES) presented at the American College of Cardiology (ACC) 2010 Scientific Sessions reported here via Medscape.

Thursday, March 25, 2010

Defensive medicine is practiced everywhere, everyday

From Medscape Family Medicine:

"I practice defensive medicine daily," says an internist, "and order excessive, costly, unnecessary laboratory tests and imaging studies because patients demand them.”


As cited in this article both anecdotes and data support the notion that defensive medicine due to the fear of being sued is a driver of health care costs.

Your guilt or your career

Over the past 10 years the culture of our profession has been leaning towards disclosure and apology for medical mistakes. Despite that, such disclosure is selective and inconsistently applied. This Medscape article explains why it doesn’t work in a culture of blame.

Palliative care---here we go again

Last week the Dinosaur wrote an insightful post of particular interest to me: Palliative Care: An Unnecessary Specialty. In reply Bob Centor at Medical Rants defended palliative care, but as a level of organization, not as a specialty.

Dinosaur's post reflected a lot of my concerns. I would be open to the notion of palliative care as a unique specialty if someone would tell me what it is, exactly. The trouble is, no one seems able to do that. Many folks talk around the issue. Some talk about palliative care as an end of life care modality. Others say just the opposite, that palliative care does not depend on prognosis and may be given right along with curative, life prolonging care. Most apologists for palliative care have at least this idea in common: that palliative care provides excellence in symptom relief, communication with patients and families, and coordination of care. But those are just basic tenets for all care, at the bottom of the pyramid of principles of good old fashioned doctoring! So why a specialty?

One of Dinosaur's commenters was R. Sean Morrison, MD, president of the American Academy of Hospice and Palliative Medicine. Even he couldn't seem to nail down a definition, merely characterizing palliative care as excellence in the care of very ill and complex patients.

Another commenter, Christian Sinclair, MD, author of the Pallimed blog, didn't define the specialty but gave an honest appraisal of why we need palliative care teams: severely ill and complex patients and their families need time and attention to detail. Economic and administrative barriers do not allow this to happen in ordinary primary and hospital care. Somebody has to be there to do it.

Wednesday, March 24, 2010

Which stent for STEMI?

According to two trials presented at the ACC national meeting it's too close to call between bare-metal and drug-eluting stents. Larger studies are needed, but it looks as though there may be a trade off between a substantial risk of revascularization due to in-stent restenosis (bare metal) and a smaller risk of cardiovascular catastrophe due to stent thrombosis (drug eluting). Will Prasugrel tip the balance in favor of DES?

If you care about your career and use social media

---clean it up.

Via Clinical Cases and Images.

Inpatient management of heart failure---can it be evidence based?

The guy who gave the heart failure talk at SHM 2009 said that hospitalists have no evidence to guide them in the inpatient management of heart failure. That was an overstatement. We have, for example, evidence about Neseritide (maybe marginally better than IV nitro but with safety concerns raised); IV inotropes (they increase mortality); what to do with patients' beta blockers when they come in with ADHF (don't hold them or reduce the dose unless they're in shock); and the use of non-invasive positive pressure ventilation. That said, it's true that the vast majority of high level clinical evidence to guide heart failure treatment is on the ambulatory side. While that evidence on long term treatments suggests things for hospitalists to do at discharge time, even the hospital performance measures based on that evidence proved to be a bust.

So, always looking to be evidence based in the management of common problems in hospitalized patients, I found this report from the ACC national meeting to be of interest. In an example of some of that comparative effectiveness research we've all been clamoring for researchers looked at several different loop diuretic regimens: high dose, low dose, continuous infusion and boluses. It turns out it doesn't really matter. All the folklore handed down about loop diuretics may be equally true and can be summarized thusly:

Lasix dose = age + BUN (Law # 7 of the House of God).

Rales heard only at peak inspiration are “20 mg Lasix rales.” (Pearl from visiting professor William J. Grace, M.D., St. Louis University Hospital, 1976).

40 mg IV Lasix “is a pretty good dose.” (One of my resident mentors in medical school).

Give the same dose IV lasix as the patient takes PO at home. (Another resident mentor).

Tuesday, March 23, 2010

The fight over health care reform

---is far from over.

New state laws which counter the reform package are mainly symbolic. The law suits may have more teeth.

Consequences of ObamaCare

Intended and unintended.

Via Grunt Doc.

Infectious disease pearls for hospitalists

---are provided in a recent review in the Journal of Hospital Medicine.

Points of interest:

Don't chase your tail with antibiotics or, as the authors put it, avoid spiraling empiricism. Although it may at times be necessary to escalate antibiotics in a non-responding patient don't do it willy-nilly. Think and, if clinically appropriate, re-evaluate before you do.

In bacteremic patients do serial blood cultures (every 24-48 hours until clear) especially in infections with staph, enterococcus and yeast. The results impact decisions on duration of treatment and source evaluation.

Remove lines from patients with candidemia to optimize the chance for a good outcome.

Candida colonization is common and usually dismissed but be suspicious if you grow it from multiple sites.

Don't treat asymptomatic bacturiuria except in pregnant patients and those about to undergo GU manipulation.

A similar open access article from The Hospitalist is dated but still relevant.

What is “meaningful use” of the EMR?

From Medscape Medical News:

Here's the plain-English translation: The federal government won't give you a bonus simply for buying an EHR. You qualify for the money only if you use the system in ways that improve the quality of care while lowering costs.


Hmm. How can that be when it's never been proven that EMRs are capable of achieving those objectives in the first place?

Some feel the regulations which define meaningful use are too onerous:

"If the regulations stay the way they are today, many physicians won't even attempt to be a meaningful user," said Dr. Waldren.


Dr. Waldren is director of the Center for Health Information Technology for the American Academy of Family Physicians (AAFP). CMS is expected to roll out the final version of the regs in a few months.

Monday, March 22, 2010

Statins and liver disease---how big a problem?

From Seminars in Liver Disease:

Despite their widespread use, acute liver failure and death have rarely been reported in patients with statin hepatotoxicity. Multiple retrospective studies as well as a large prospective randomized controlled trial demonstrate that statins can safely be given to hyperlipidemic patients with compensated chronic liver disease.

Varices and variceal hemorrhage

Very helpful and comprehensive review in NEJM.

Thursday, March 18, 2010

What rate control target for atrial fibrillation?

Lenient vs strict---

Methods: We randomly assigned 614 patients with permanent atrial fibrillation to undergo a lenient rate-control strategy (resting heart rate less than110 beats per minute) or a strict rate-control strategy (resting heart rate less than 80 beats per minute and heart rate during moderate exercise less than 110 beats per minute). The primary outcome was a composite of death from cardiovascular causes, hospitalization for heart failure, and stroke, systemic embolism, bleeding, and life-threatening arrhythmic events. The duration of follow-up was at least 2 years, with a maximum of 3 years.

Results: The estimated cumulative incidence of the primary outcome at 3 years was 12.9% in the lenient-control group and 14.9% in the strict-control group, with an absolute difference with respect to the lenient-control group of –2.0 percentage points (90% confidence interval, –7.6 to 3.5; P less than 0.001 for the prespecified noninferiority margin). The frequencies of the components of the primary outcome were similar in the two groups. More patients in the lenient-control group met the heart-rate target or targets (304 [97.7%], vs. 203 [67.0%] in the strict-control group; P less than 0.001) with fewer total visits (75 [median, 0], vs. 684 [median, 2]; P less than 0.001). The frequencies of symptoms and adverse events were similar in the two groups.

Conclusions: In patients with permanent atrial fibrillation, lenient rate control is as effective as strict rate control and is easier to achieve.

It was previously known that uncontrolled atrial fibrillation results in tachycardia mediated cardiomyopathy over time. The precise target for preventing this outcome was not known. This study did not report changes in ejection fraction in these patients but there was no difference in events between the two strategies. The average heart rates achieved were fairly similar. So this study does not refute the idea of aggressive rate control for prevention of tachycardia mediated cardiomyopathy.

Commentary from DB’s Med Rants here.

Elective coronary angiography

---had a low yield in this large data base:

Conclusions: In this study, slightly more than one third of patients without known disease who underwent elective cardiac catheterization had obstructive coronary artery disease. Better strategies for risk stratification are needed to inform decisions and to increase the diagnostic yield of cardiac catheterization in routine clinical practice.


So about a third of patients had potential revascularization targets. Of those, many were likely more appropriate for medical management.

Tuesday, March 16, 2010

Thursday, March 11, 2010

Is metformin's creatinine threshold too strict?

Review in the American Journal of Health-System Pharmacy.

Methadone responsible for a disproportionate number of deaths

--compared to the number of prescriptions written, according to a poster presentation at the American Academy of Pain Medicine 26th Annual Meeting.

Straight talk about hand washing

Vanderbilt University Medical Center (VUMC) recently reported a hand washing compliance rate of 78%, far better than has been reported elsewhere. Why? Well, as early as 35 years ago I remember folks there like William Schaffner harping on it. And nowadays they're addressing it as a system problem. The approach focuses on aggregate compliance rather than a punitive approach against individuals:

“Hand hygiene remains the single most important clinical safety practice that we can improve upon,” Kaiser said. “Now, to the credit of our overall health system, it's finally agreed that the only way to have success is to have observers routinely counting and reporting adherence with the standards.”


Good hand washing compliance should be the low hanging fruit in patient safety, yet the goal remains elusive. Kaiser is interim chair of Medicine and Chief of Staff of the hospital. He's an ID doc who's treated patients, taught and researched the field for nearly 30 years, and has written numerous articles and textbook chapters on prevention of infection in hospitalized patients. Recently his interests have morphed into administrative, safety and quality aspects of hospital medicine.

The systems approach at VUH involves over 100 monitors logging up to 2000 observations per month. Though somewhat artificial it's robust and perhaps the best that can be implemented with reasonable resource use:

“If you're not touching the patient and you're not touching anything in the patient's environment, there's nothing in the germ theory of disease that would require you to have washed your hands, so in that respect any rule for observation is going to be somewhat artificial,” said Kaiser, who is a founding member and past president of the Society for Healthcare Epidemiology of America, a health care safety group.

“But the only alternative to observation and reporting would be to ensure adherence directly by following every provider into every room.”


The importance of hand washing has been a no-brainer for a long time, so why have hand washing rates been so low? Its' not a careless disregard for the patient as some have suggested:

“We all believe the germ theory these days,” Kaiser added, “but in many patient care contexts, we still have trouble getting providers to predictably wash their hands. I think that has to do with there being no immediate complications for the patient from non-adherence. And it's to be acknowledged that in most cases there won't be a complication — most times it doesn't mean anything.

“However, in the event that a harmful pathogen is transmitted to a patient, the results can lead to unexpected morbidity and even mortality,” Kaiser said.


Doctors are inherently very vigilant about things that have direct, immediate consequences. Hand washing is not one of them. A new way of thinking is needed.

Wednesday, March 10, 2010

tPA treatment for ischemic stroke

This review from the Journal of Emergency Medicine (full text via Medscape) may be the best evidence synthesis available on the topic. It deals with all the studies and focuses both on the use of tPA in general as well as the new extended window. Concerning the latter question here's the author's bottom line:

The publication of the ECASS III trial has produced much excitement and discussion in the Stroke community. The Heart and Stroke Foundation of Canada and the European Stroke Organisation have both recommended treatment with IV tPA up to 4.5 h from symptom onset for appropriate patients. At this time, treatment with IV tPA for acute stroke beyond 3 h from symptom onset remains without FDA approval, but it has been endorsed by a Scientific Advisory from the American Heart Association Stroke Council.


The paper notes that many tPA associated head bleeds may be of little clinical importance, partly because those who suffer them tend to have large infarcts already destined for bad outcome. This was illustrated in a 2007 paper cited by the author:

Background and Purpose—A clinically relevant number needed to harm for tissue plasminogen activator (tPA)-related symptomatic intracerebral hemorrhage (SICH) would greatly assist therapeuticdecision-making.

Methods—A 15-variable prognostic model was derived from a placebo group enrolled in National Institute of Neurological Disorders and Stroke tPA Trials 1 and 2 and used to predict final global disability outcome for patients with tPA-related SICH had they been treated with placebo, rather than tPA, and not experienced SICH.

Conclusions—Most patients who experience SICH have severe baseline infarcts and already are destined for poor outcomes. For every 100 patients treated with tPA, approximately 1 will experience a severely disabled or fatal final outcome as a result of tPA-related SICH.


In other words the clinically relevant number need to harm is higher than one might expect.

But there's more than one way to interpret the NINDS data as illustrated by this recent analysis:

Methods
We used the original data from the NINDS trials to create graphs showing the effect of treatment on neurologic function in all 624 individual patients in the trial. Our goal was to show detailed graphics of the 90-day outcomes, stratified on relevant confounders and effect modifiers.

Results
Final outcomes were highly dependent on stroke severity. In many graphs, the small difference between groups favored tissue plasminogen activator, particularly when baseline NIHSS score was between roughly 5 and 22. These differences diminish or disappear when 90-day change in NIHSS is graphed. Our graphs fail to support the time-is-brain hypothesis.

Benefits of inhaled steroids in COPD

From a new paper in the Annals of Internal Medicine:

Conclusion: ICS therapy decreases inflammation and can attenuate decline in lung function in steroid-naive patients with moderate to severe COPD. Adding LABAs does not enhance these effects.

Tuesday, March 09, 2010

Inflammatory bowel disease and the risk of venous thromboembolism

I never really understood why IBD was such a high risk condition. Apparently it was known to be so because the Chest guidelines gave it special mention in their recommendations for VTE prophylaxis in medical patients.

Now a new Lancet paper reports this:

13756 patients with inflammatory bowel disease and 71672 matched controls were included in the analysis, and of these 139 patients and 165 controls developed venous thromboembolism. Overall, patients with inflammatory bowel disease had a higher risk of venous thromboembolism than did controls (hazard ratio 3·4, 95% CI 2·7–4·3; p less than 0·0001; absolute risk 2·6 per 1000 per person-years). At the time of a flare, however, this increase in risk was much more prominent (8·4, 5·5–12·8; p less than 0·0001; 9·0 per 1000 person-years). This relative risk at the time of a flare was higher during non-hospitalised periods (15·8, 9·8–25·5; p less than 0·0001; 6·4 per 1000 person-years) than during hospitalised periods (3·2, 1·7–6·3; p=0·0006; 37·5 per 1000 person-years).


So let's see if I understand this. IBD in general carries an increased risk of VTE. That risk is even higher during an active flare. But why was the difference between patients with and without a flare less in hospitalized patients? Perhaps because other VTE risk factors inherent in just being hospitalized may dilute out the difference.

IBD must be an under-appreciated VTE risk because it isn't talked about all that much. It deserves inclusion on the list of usual suspects such as hereditary thrombophilia, cancer, severe acute respiratory disease, etc. I also have to wonder how many patients are deprived of chemical prophylaxis because of a perceived risk of GI bleeding.

H/T to Clinical Cases and Images.

Friday, March 05, 2010

Diagnosis of lung cancer in patients hospitalized with pneumonia

From the Green Journal:

Results
Of 40,744 patients hospitalized with pneumonia, 3760 (9.2%) patients were diagnosed with pulmonary malignancy after their index pneumonia admission. Median time to diagnosis was 297 days, with only 27% diagnosed within 90 days of admission. Factors significantly associated with a new diagnosis of pulmonary malignancy included history of chronic pulmonary disease, any prior malignancy, white race, being married, and tobacco use. Increasing age, Hispanic ethnicity, need for intensive care unit admission, and a history of congestive heart failure, stroke, dementia, or diabetes with complications were associated with a lower incidence of pulmonary malignancy.

Conclusion
A small, but clinically important, proportion of patients are diagnosed with pulmonary malignancy posthospitalization for pneumonia. Additional research is needed to examine whether previously undiagnosed pulmonary malignancies might be detected at admission, or soon after, for those hospitalized with pneumonia.

This underscores the importance of out patient follow up after hospitalization for pneumonia. Patients should have their chest xrays followed to clearance.

Thursday, March 04, 2010

Mayo Clinic videos on You Tube

Here's one on essential thrombocythemia, with the others linked at the right side bar. The series doesn't define its audience very well. Some are clearly helpful to health care professionals while others seem more directed to consumers.

Via Clinical Cases and Images.

Hopkins respiratory physiology course

This may appear dated, but it deals with basic physiologic principles, unlikely to change much until the woosters re-write the basic science books.

Via Clinical Cases and Images.

Wednesday, March 03, 2010

New HIT review

This is one of many I've posted on this site and is similar to previous topic reviews. One important point not mentioned in some of the other reviews is that if the patient happens to be on warfarin at the time the HIT is discovered, it should be reversed with vitamin K due to the risk of skin necrosis, venous gangrene and other thrombotic complications. The role of fondaparinux remains uncertain and the authors are reserved in their comments.

Pulmonary Langerhans' Cell Histiocytosis

Here is a case description and brief review. This condition has also been known as histiocytosis X and eosinophilic granuloma.

Tuesday, March 02, 2010

One of the best reviews on DIC you'll ever find

It's by the same author who wrote this one and can be considered a companion paper.

Perioperative management of anticoagulant and antiplatelet therapy

This article from the Perioperative Medicine Summit brings together sections from the relevant guidelines and adds practical advice for real world implementation. The emphasis is on the practical aspects of bridging and the management of patients with stents.

Sedation trends in mechanically ventilated patients

cTrends vary widely, but in this systematic review it looks as though, on the whole, we're over doing it.

Monday, March 01, 2010

Perioperative beta blockers: do they “work” or not?

The answer, as it is for most questions in medicine, is “it depends.” The perioperative beta blocker controversy is a good example of the simplistic fallacy of categorizing treatments into those that “work” and those that “don't work.” As the pendulum continues to swing around this controversy we're beginning to see a pattern. Large fixed doses of beta blockers given to beta blocker na├»ve patients perioperatively are likely to carry risks that exceed benefits. On the other hand low starting doses gradually titrated to heart rate and blood pressure seem to produce better results. This was illustrated in the recently published DECREASE-IV looking at low dose bisoprolol in intermediate risk patients, which nudged the pendulum back toward beta blocker use.

An ACCF/AHA focused guideline update was released late last year. The recommendations differ very little from the previous focused update. The only class I recommendation is for continuation of beta blockers perioperatively in patients previously taking them for a class I guideline indication. Class IIa recommendations include certain high risk patients, mainly those undergoing vascular surgery, with emphasis on titration to pulse and blood pressure.

A recent article in Today's Hospitalist discusses the ins and outs.

Lean process improvement

Lean and Six Sigma are process improvement tools borrowed from industry, increasingly used in hospitals. Here is an example of lean methods used to improve efficiency in a in patient pharmacy.

Board certifications incorporate performance measures

--and Grunt Doc weighs in on the ABEM recert.

Imagine my surprise at ABEMs’ latest addition to hoops to jump through to maintain my Board Certification: the Assessment of Practice Performance. In a nutshell: show ABEM that 10 patients didn’t hate my medical performance, prove that on 10 hand-picked charts I’m keeping up with published treatment benchmarks (like aspirin for ACS, antibiotics in 6 hours for pneumonia, etc), and self-certify the same to ABEM.


My emphasis on the 6 hour pneumonia rule, BTW.

Artificial and perfunctory if you ask me.

What to do about asymptomatic funguria

In many cases it represents colonization and responds to simple measures such as removal of foley catheters, but there are exceptions. Here is a discussion in The Hospitalist.