Tuesday, May 31, 2011

Inhaled anticholinergics and acute urinary retention in COPD

Inhaled anticholinergics increased the risk of urinary retention in this study.

COPD in never smokers---not as rare as you might think

From a paper in Chest:

Results: Among 4,291 never smokers, 6.6% met criteria for mild (GOLD stage I) COPD, and 5.6% met criteria for moderate to very severe (GOLD stage II+) COPD. Although never smokers were less likely to have COPD and had less severe COPD than ever smokers, never smokers nonetheless comprised 23.3% (240/1,031) of those classified with GOLD stage II+ COPD. This proportion was similar, 20.5% (171/832), even when the LLN was used as a threshold for the FEV1/FVC ratio. Predictors of COPD in never smokers include age, education, occupational exposure, childhood respiratory diseases, and BMI alterations.
Conclusion: This multicenter international study confirms previous evidence that never smokers comprise a substantial proportion of individuals with COPD. Our data suggest that, in addition to increased age, a prior diagnosis of asthma and, among women, lower education levels are associated with an increased risk for COPD among never smokers.

Extensive infarction, subtle ECG changes

Would you have caught this?

Interpretation hinges on several factors, but largely on the very subtle (half a mm) reciprocal ST depression in AVL.

Sunday, May 29, 2011

Society of Hospital Medicine eyed in Senate Finance Committee Report

---along with others concerning their petition to the FDA to delay the approval of generic Lovenox. I first blogged and offered my opinions about the controversy here. Health Care Renewal has posted an update here. The full committee report is here.

As I said before, conflict of interest aside, I wish SHM would articulate the scientific rationale for their petition to the FDA. From reading the report I gather the thinking is that for complex molecules such as LMWHs, the copying and producing of bioidentical products is unreliable, such that clinical trials for generics are warranted, just as if they were entirely new drugs. I have no idea whether that claim is true.

Friday, May 27, 2011

Thursday, May 26, 2011

Antibiotic pharmacokinetics in critical illness---special considerations

From a review in Chest. The major points are that an increase in volume of distribution may lead to inappropriately low serum concentrations initially. Later in the course of treatment concentrations tend to rise due to decreased clearance, leading to the risk of toxicity.

A clinical risk score for aortic dissection

The aortic dissection detection score (ADD score) is a sensitive bedside tool for the evaluation of patients presenting with chest pain and other symptoms consistent with dissection. Read here for a description of the tool and its validation.

Wednesday, May 25, 2011

Diagnostic error---the sleeping dog of patient safety?

Yes, at least according to patient safety expert Robert L. Trowbridge, MD, interviewed in a recent issue of Today's Hospitalist. Diagnostic errors, at least so called cognitive diagnostic errors, reflect on the physician's clinical skill. As Trowbridge pointed out:

If I prescribe the wrong medication or the wrong dose, I can justify that by saying that we all make mistakes. But when it's a critique of your thinking as a diagnostician, that cuts to the core of who you are as a physician.

According to Trowbridge that is why diagnostic errors have received little attention in the patient safety movement despite the fact that they are believed to account for a large portion of adverse events. Patient safety leaders, as I've repeatedly observed before, have turned safety concerns into a culture of blame. This policy-level finger of blame, at least up to now, however, has pointed largely at system failures and unavoidable outcomes, areas for discussion well within the comfort zones of most docs. Not necessarily so when you move the conversation to misdiagnosis.

The problem of misdiagnosis is largely unexplored territory in the patient safety field. Transparency is essential if progress is to be made. To that end Trowbridge has helped set up an anonymous reporting system at his facility. It seems like a great idea to me although I would eliminate references to error partly for the reasons just stated, but also because of the difficulty on multiple levels of adjudicating misdiagnoses as to the presence or absence of error.

Solutions? Trobridge mentioned decision support, the effective use of basic clinical skills and an idea I particularly like, the “diagnostic time out.” It's exactly what DB was talking about here.

Tuesday, May 24, 2011

Comparative effectiveness research in action: dalteparin vs UFH in prevention of VTE

This is CER to be sure but it provided more questions than answers for clinicians wondering about the best treatment. The findings:

There was no significant between-group difference in the rate of proximal leg deep-vein thrombosis..


The proportion of patients with pulmonary emboli was significantly lower with dalteparin...
..fewer patients receiving dalteparin had heparin-induced thrombocytopenia (hazard ratio, 0.27; 95% CI, 0.08 to 0.98; P=0.046).

To really complicate matters the UFH group was treated with a dose (5000 U SQ bid) known to be inferior.

One of the investigators had multiple industry ties, including to the makers of dalteparin. So this trial had a design flaw, whether inadvertent or rigged, which put unfractionated heparin at a disadvantage. Two years ago I warned about the unique vulnerability of CER to design flaws of this type.

C. Thorpe Ray: master clinician and teacher

I'm adding some new posts about great mentors to honor and remember some of those master clinicians and teachers from the past who believed the stethoscope was more than a device to spread germs and enhance coding. This web site is devoted to the legacy of C. Thorpe Ray, who headed departments at Tulane, Oschner and the University of Missouri. I never knew Dr. Ray but was familiar with some of the C. Thorpe Ray stories circulating around among New Orleans and Mizzou alumni.

Monday, May 23, 2011

Guidelines for bipap and cpap in critical illness

As far as I know these are the first ever formal practice guidelines, published in CMAJ. Unfortunately, the document is closed access, and I don't know of any other publication where the guidelines are freely available. Medscape has published a commentary here, and although it lists many of the recommendations it lacks important nuances of the original document. It would be well worth the effort to get the full text. If you don't subscribe to CMAJ your medical librarian could help or you could access the full article via MD Consult.

Functional limitations 5 years after recovery from ARDS

In this NEJM study, although pulmonary function was nearly normal, multiple physical and cognitive impairments were noted at 5 years.

Friday, May 20, 2011

Can CME improve patient outcomes?

That's a question for which research quality evidence has not provided an answer. However, a recently published long term follow up of a Swedish CME intervention in lipid management showed reduced patient mortality in the intervention group.

Of note, this was an intense, multiphase intervention which included physician interaction over time.

Primary article.

Related editorial.

Commentary from the Policy and Medicine blog.

Thursday, May 19, 2011

Another view of the hospitalist movement at 15

---by Robert Centor MD (AKA DB) guest blogging at Kevin MD.

Fluid resuscitation in septic shock

The title of a recent paper in Critical Care Medicine is deceptive: Fluid resuscitation in septic shock: A positive fluid balance and elevated central venous pressure are associated with increased mortality. It would seem to run contrary to what we know about treating septic shock, from both clinical and animal data. But the study's actual findings were not so simple. Keep in mind that this was not an intervention trial. From the results:

After correcting for age and Acute Physiology and Chronic Health Evaluation II score, a more positive fluid balance at both at 12 hrs and day 4 correlated significantly with increased mortality...
At 12 hrs, patients with central venous pressure less than 8 mm Hg had the lowest mortality rate followed by those with central venous pressure 8–12 mm Hg. The highest mortality rate was observed in those with central venous pressure greater than 12 mm Hg.

The CVP target for early goal directed therapy (EGDT) is 8. Does this study refute EGDT? No. This study looked at CVP and fluid balance from 12 hours into presentation to 4 days. Early goal directed therapy (emphasis on the word early) is an intervention for the first 6 hours. The original EGDT trial was premised on knowledge from studies decades ago showing that when goal directed hemodynamic resuscitation commenced relatively late in the course of septic shock, after the patient had arrived in the ICU and had a right heart cath inserted, outcomes were not improved or made worse. The whole idea was to find out the results of hemodynamic resuscitation in the first 6 hours, in the ER. That's not what this study looked at.

Tele-ICU (aka eICU)---does it affect patient outcomes?

Up to now the data have been mixed at best. But a new study suggests a beneficial effect:

Results The hospital mortality rate was 13.6% (95% confidence interval [CI], 11.9%-15.4%) during the preintervention period compared with 11.8% (95% CI, 10.9%-12.8%) during the tele-ICU intervention period (adjusted odds ratio [OR], 0.40 [95% CI, 0.31-0.52]). The tele-ICU intervention period compared with the preintervention period was associated with higher rates of best clinical practice adherence for the prevention of deep vein thrombosis (99% vs 85%, respectively; OR, 15.4 [95% CI, 11.3-21.1]) and prevention of stress ulcers (96% vs 83%, respectively; OR, 4.57 [95% CI, 3.91-5.77], best practice adherence for cardiovascular protection (99% vs 80%, respectively; OR, 30.7 [95% CI, 19.3-49.2]), prevention of ventilator-associated pneumonia (52% vs 33%, respectively; OR, 2.20 [95% CI, 1.79-2.70]), lower rates of preventable complications (1.6% vs 13%, respectively, for ventilator-associated pneumonia [OR, 0.15; 95% CI, 0.09-0.23] and 0.6% vs 1.0%, respectively, for catheter-related bloodstream infection [OR, 0.50; 95% CI, 0.27-0.93]), and shorter hospital length of stay (9.8 vs 13.3 days, respectively; hazard ratio for discharge, 1.44 [95% CI, 1.33-1.56]). The results for medical, surgical, and cardiovascular ICUs were similar.

Medscape commentary here.

Prophylactic antibiotics for dental work in patients with joint replacements

Let's say you're doing comanagement for a patient on the orthopedic service who has undergone total knee arthroplasty. She asks you if she'll need prophylactic antibiotics for dental work. How do you advise her?

It turns out that despite the lack of convincing evidence two professional societies have issued statements. Neither makes the claim of being a “guideline” and the two statements vary substantially in their recommendations.

The American Dental Association (ADA) has issued an advisory statement and the American Academy of Orthopedic Surgeons (AAOS) had issued an information statement. The ADA statement recommends prophylaxis in patients with certain comorbidities and those whose joint replacements were within two years. The AAOS recommendations are broader and recommend that antibiotics be considered for all patients who have ever undergone joint replacement. The AAOS statement acknowledges the role of clinical judgment in making the final decision.


A recent study failed to support the administration of prophylactic antibiotics.

What should the clinician do? There's room for debate here. There is no strong evidence in support of antibiotics. The statements linked above, however, place a certain onus on the clinician. The administration of prophylactic antibiotics is simple and low risk. The ADA position may represent a reasonable compromise to some. There is no pat answer.

Wednesday, May 18, 2011

What are the triggers for rupture of brain aneurysms?

From a study in Stroke:

Eight triggers increased the risk for subarachnoid hemorrhage: coffee consumption (RR, 1.7; 95% CI, 1.2–2.4), cola consumption (RR, 3.4; 95% CI,1.5–7.9), anger (RR, 6.3; 95% CI, 4.6–25), startling (RR, 23.3; 95% CI, 4.2–128), straining for defecation (RR, 7.3; 95% CI, 2.9–19), sexual intercourse (RR, 11.2; 95% CI, 5.3–24), nose blowing (RR, 2.4; 95% CI, 1.3–4.5), and vigorous physical exercise (RR, 2.4; 95% CI, 1.2–4.2). The highest population-attributable risks were found for coffee consumption (10.6%) and vigorous physical exercise (7.9%).

Via Skeptical Scalpel.

Updated guidelines for IV catheter infection prevention

Primary source (CDC).

Medscape commentary.

The hospitalist movement at 15

That was the topic of Bob Wachter's keynote at the just finished SHM national meeting in Dallas. Recently he gave a synopsis of the talk in his blog. It's an interesting and lively read (as Bob's posts always are) although I disagree on a couple of points.

Concerning, for example,the efficiency of the hospitalist model:

Proving that we could cut costs without harming quality was central to gaining hospitals’ support and creating a viable economic model for hospitalists. The early research unambiguously supported this proposition, as I knew it would.

Whoa. Early research was mixed. In 2005 one of the largest and arguably best studies on the hospitalist model, presented at the national meeting, showed no cost saving attributable to the model. Unfortunately that study fell victim to publication bias. It never saw the light of day except for a brief splash in the blogs. Accordingly that important study was left out of every systematic review to be done since then. It was not until a very recent study was published that the balance of evidence tipped in favor of efficiency attributable to the hospitalist model. It's still not a slam dunk.

As Bob points out tough economic times produce tension, and not always healthy tension, in negotiations between hospitalist groups and their health systems. But he says this:

It will be critical that hospitalist groups produce measurable value. I worry about programs organized around the convenience or the income of the physicians. You know the ones – programs whose patients say, “Oh, the hospitalist just flies in and out of the room,” or “I saw a different hospitalist every day,” or ones in which every patient complaint and lab abnormality reflexively triggers another subspecialty consult or CT scan. Such programs are not likely to achieve the status of being indispensable.
And the opposite of indispensable is, of course, dispensable.

Don't get me wrong here. Hospitalists should strive to be efficient and provide superb service because it's part of their professionalism---just the right thing to do. But what makes them indispensable is the plain and simple fact that without hospitalists (and they're still in short supply) there's hardly anyone left to care for most patients in the hospital anymore. Look at Emergency Medicine. EM is indispensable not because of any claim of increased efficiency but because primary care docs left the department decades ago.

Tuesday, May 17, 2011

Concerning news about health care costs

The cost curve is yet to be bent and the Medicare trust fund is projected to be exhausted in 2024, years earlier than anticipated.

Via WSJ Health Blog.

Newt on health care

Individual mandates good, Repub plan to overhaul Medicare “right-wing social engineering.”

Via WSH Health Blog.

Daily blood work in hospitalized patients

According to a recent study published in the Archives of Surgery, merely giving doctors feedback on the hospital charges reduced costs:

Intervention  A weekly announcement to surgical house staff and attending physicians of the dollar amount charged to nonintensive care unit patients for laboratory services during the previous week.
Main Outcome Measure  Dollars charged per patient per day for routine blood work.
Results At baseline, the charges for daily phlebotomy were $147.73/patient/d. After 11 weeks of residents being made aware of the daily charges for phlebotomy, the charges dropped as low as $108.11/patient/d. This had a correlation coefficient of –0.76 and significance of P = .002. Over 11 weeks of intervention, the dollar amount saved was $54 967.

Of course that dollar amount is artificially inflated because it represents hospital charges rather than actual costs. All things being equal this means nothing to most patients and to Medicare and other payers that are based on DRGs. It's the hospital that's “out” the amount of money these extra tests cost.

But all things are not equal. There are other factors. A dropping hemoglobin picked up on the daily CBC enables the clin doc specialist to code “acute blood loss anemia” which might more than make up for the added cost. Similarly hyponatremia, hypokalemia or a rising creatinine on the daily chem profile might have the same effect.

Daily labs are necessary on some but not all patients. Most hospitalized patients on IV fluids need daily chemistries. There are probably multiple reasons why doctors do it to excess. CPOE may be a facilitator.

Via WSJ Health Blog

What are the pulmonary effects of marijuana?

From a review in Expert Reviews of Pulmonary Medicine, it’s not at all clear:

Unfortunately, it is difficult to accurately study the effects of marijuana on the respiratory system. This is related to the inconsistency in the method of administration between subjects,[7] the illegal nature of the substance leading to problems with nonbiased recruitment, the concurrent use of tobacco in many participants and the often relatively short duration of regular marijuana use compared with tobacco smoking.[12] Nevertheless, it is the opinion of the authors that cannabis smoking has a detrimental effect on the respiratory system in a number of ways, including symptoms, lung function, and possibly carcinogenesis and respiratory tract infections,[13] although the available evidence is conflicting.

Free full text via Medscape.

Monday, May 16, 2011

Another look back at Lifetime Medical Television

I've posted several of these before. Here are some more promos and openings from LMT, c. 1991.

Bernard Lown shows up at 7:25.

More on NSAIDs and cardiovascular risk

The latest study from Circulation is another of many to show the cardiovascular hazards of NSAIDs, and at least the second one to show that even short term use if dangerous.

This one looked at patients with prior MI although multiple studies have shown hazards in patients with and without prior cardiovascular disease.

In the conclusion the authors make the strongest statement yet:

Even short-term treatment with most NSAIDs was associated with increased risk of death and recurrent MI in patients with prior MI. Neither short- nor long-term treatment with NSAIDs is advised in this population..

I've harped on this before emphasizing that they're all dangerous, not just Vioxx.

Via Dr. John M.

Sunday, May 15, 2011

A progressive and a classical liberal discuss the Independent Payment Advisory Board

Shadowfax versus Dr. Rich. Read here here and here.

High tech hand hygiene---does it help patients?

The elaborate and cleverly designed system illustrated in the video below can increase compliance to virtually 100% but how much does it really serve patient safety? Note that none of the health care workers profiled in the video cleaned their stethoscopes.

Via Clinical Cases and Images.

Monday, May 09, 2011

Systemic capillary leak syndrome---recent Annals article

Interesting points from this small case series include the fact that IVIG and terbutaline may be effective preventive treatments, and that IgG monoclonal gammopathy was observed in 89%.

Friday, May 06, 2011

Conflict of interest in medicine: negative consequences of the inquisition

An opinion piece in Nature Medicine by Thomas Stossel and Lance Stell deals with the mounting public pressure and increasingly burdensome regulations against the medical profession's interaction with industry. They argue that the movement has gone too far and its proponents have no evidence to back up their claims. I don't have access to the full text but Thomas Sullivan parses it pretty well in a recent blog post. Concerning the lack of evidence he cites from the article thus:

Drs. Stell and Stossel assert that, “insinuations of corruption by those who call for increased oversight and regulation of the interaction between academia and industry require quantitative evidence—for a start, providing a denominator as well as a numerator.”...
While many critics can easily compose the numerator by mentioning “the same cases alleging corruption due to industry influence, many laced with hindsight wisdom, dredged up repeatedly and assembled into a narrative framework,” a denominator is almost always missing. In fact, “the storytelling suffers from serious ‘denominator neglect’—the non-nefarious, noncorrupt, beneficial collaborations, over decades that dwarf the comparatively few cases that populate the numerator.”
As the authors point out, “when attending to the numerator, the misconduct rate is negligible. The numerator of supposedly substantive adverse outcomes due to industry relationships (excluding relationship disclosure lapses discussed below) barely adds up to two digits. Surveys reporting that over 90% of physicians have some type of financial interaction with industry, with 18% of them engaged in consulting arrangements, indicate that the denominator is orders of magnitude greater.”

In the words of the authors the inquisitors' judgments lack “quantitative rigor.”

Thursday, May 05, 2011

Patient centered conversations about ICDs

Some wisdom from Dr. John M:

In selected patients, ICDs unequivocally provide statistical benefit, but there are risks, and alternatives—as in any invasive treatment. In this way, ICDs are akin to many other expensive and invasive therapies. Cancer chemotherapies like adriamycin, with its cardiac toxicity, come to mind, for example.

He ends with a reminder of the most pervasive conflict of interest to keep in mind when reading research reports:

Most smart doctors read journal articles with a critical eye. They (should) know that the writers are passionate and convinced of their positive findings. Such is human nature.

Wednesday, May 04, 2011

Is there a dark side of altruism?

Doing something for someone else
isn't really for someone else.
It does twice as much for you
as something you do
just for yourself.

Those lyrics from Reflections sung by Sally Kellerman in the campy remake of Lost Horizon pose the question: is there such a thing as true altruism or is altruism nothing more than a means for us to feel better about ourselves?

The fascinating PJTV interview by Dr. Helen linked here (can't seem to embed it) raises additional disturbing questions about altruism. Empathy is viewed as a right brained trait on the spectrum between emotion and logic as drivers of social interaction. A proper balance between the two poles is necessary. The extreme to the right is codependency. On the other extreme are Asperger traits. Altruism can have a dark side if not tempered by logic, and vice versa. Just what is the dark side of Altruism? Do physicians have to “tamp down” their empathy to be effective?

I haven't read Dr. Oakley's books but I'm adding them to my list.

Postural orthostatic tachycardia syndrome (POTs)

The above video from Mayo Clinic explains it well. (HT to Clinical Cases and Images).

Two free full text reviews are available (see here and here).

Points of interest:

POTS is a “pervasive” circulatory disease involving multiple autonomic and volume regulating mechanisms.

Ganglionic acetylcholine receptor antibodies are found in a small percentage of patients suggesting that it is an autoimmune disorder in some.

Although a genetic mechanism has been found in some patients (involving norepi re-uptake) environmental factors are suggested by the cases that follow viral illness and surgery.

In additional to circulatory symptoms a wide variety of non-circulatory symptoms (GI, constitutional) have been described as being frequent.

Tilt-table testing is the principal diagnostic modality. It can also test for vaso-vagal syncope and orthostatic hypotension, conditions which overlap considerably with POTS.

Many treatments are discussed in the review articles. The Mayo video emphasizes exercise, adequate fluid and salt intake and beta blockers as the principal therapeutic approaches. Beta blockers, however, are controversial, are down played in one of the above linked reviews and considered contraindicated in the other.

Tuesday, May 03, 2011

Do you want to be a Twitter star?

Dr. Ves, arguably THE expert on doctors' use of social media for education, shows you how.

I have been blogging for almost 6 years. I still don't Tweet. Why? A couple of observations. As Dr. Ves noted:

There is a flood of medical news that hits the wires every day. I want to know what YOU think is important. Share the 3-10 news items per day that you find interesting. I will subscribe to read them. Many will do the same.

That's precisely the problem with using Twitter in medicine. It's an aggregator of medical “news.” Despite the daily deluge of pieces of information from the popular media and scientific literature, true advances in medicine are only rarely to be found in the medical “news of the day.” Medical science progresses in small increments, one study building on another. As Steve Milloy wrote on page 46 of his book Junk Science Judo:

...keep the slow, steady ho-hum scientific method in mind. Boring? Sure. Tedious? You betcha. Slow and deliberative? Be grateful.

When medical research is presented in the sound bite fashion of the typical Tweet it is inevitably subject to distortion because there's neither time nor space to address important nuances and background information. (Due to the constraints of time many of the posts on my blog are brief link dumps but I try to provide more depth when I can).

So I'm not Tweeting right now. That's not to say I won't find a reason to Tweet in the future. But if your objective is to drive traffic to your blog with a series of rapid fire mini posts, why not just “Tweet” on your blog? After all the blogfather himself, Instapundit, does it to great effect!

The use of D-dimer and the Wells score improved utilization of CTA to diagnose PE

Via American Journal of Roentgenology.

Implementation for implementation's sake: meaningless use?

Provocative commentary at Health Care Renewal.