tag:blogger.com,1999:blog-147430012012-01-26T22:33:08.087-06:00Hospitalist resources and more.R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comBlogger38101100tag:blogger.com,1999:blog-14743001.post-28785025227550503822012-01-23T12:23:00.000-06:002012-01-23T12:23:51.026-06:00

It's not often I see a good article in the lay press on health and medicine. This one from the Chicago Tribune is an exception. It goes like this: Many childhood diseases, thanks to vaccines, disappeared from the scene. A generation of doctors went through training without seeing a single case. They “learned” about these diseases once in med school from lectures and textbooks but never

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-59899301506528147412012-01-21T17:27:00.000-06:002012-01-21T17:27:49.687-06:00

---according to a CBO study as reported in this Medscape piece: Most Medicare demonstration projects aiming to reduce costs and improve the quality of care — prime goals of healthcare reform — miss their mark, according to a new study from the Congressional Budget Office (CBO) published online Wednesday. The projects consisted of numerous P4P schemes, disease management programs and bundled

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-76506524987806230802012-01-21T14:51:00.003-06:002012-01-23T00:07:45.713-06:00

---according to a recent announcement. Before getting into the report this might be a good time to compare some attributes of the four “penem” antibiotics approved in the U.S. Imipenem (Primaxin)---from rxlist: Approved for:Lower respiratory tract infections. Staphylococcus aureus (penicillinase-producing strains), Acinetobacter species, Enterobacter species, Escherichia coli, Haemophilus

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-88296369530552079982012-01-16T05:20:00.001-06:002012-01-16T05:20:00.605-06:00

---with a phase delay of several months. It appears to be related to the pandemic itself, not the vaccination. The mechanism of narcolepsy is believed to be autoimmune destruction of certain hypothalamic neurons. Via Medscape Neurology Minute.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-9702405821456391182012-01-12T06:00:00.011-06:002012-01-12T06:00:10.862-06:00

In this study much of the inappropriate use was driven by “prophylaxis” and it was associated with an increased rate of C diff. The authors conclude: Proton pump inhibitors are frequently inappropriately prescribed to Medicine inpatients who do not have a valid indication and this practice is associated with an increase in C. difficile infection. Interventions are needed to curtail this

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-38612230365418809842012-01-11T05:34:00.008-06:002012-01-11T05:34:00.133-06:00

We've known for a while that it reduces VTE but there's never been a basis for a claim that it saves lives. According to this first ever high level study it doesn't. And these were sick patients, the type we consider high risk. Once again the “quality” movement jumped the gun. I guess even if there isn't a mortality benefit preventing the occasional VTE means something to the patient. For

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-82037171569812302012012-01-10T05:53:00.001-06:002012-01-10T05:53:00.625-06:00

This study in the Journal of Emergency Medicine retrospectively reviewed patients with severe sepsis and septic shock who had positive blood cultures, and compared the antimicrobial sensitivities of the isolates with the initial ER therapy: Effective antibiotic coverage was prescribed by emergency physicians in 82% (95% confidence interval [CI] .74–.88) of cases. Of the 25 patients who received

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-65986302106114878742012-01-09T05:20:00.006-06:002012-01-09T05:20:01.572-06:00

From Medscape Ask the Experts. Among the possible benefits of metformin for DM 1 the article talks a lot about weight control. Which makes me wonder if all the subjects in the clinical studies cited really had DM 1 as opposed to DM 1.5 or DM 2 but requiring insulin for glycemic control.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-66000328668257181122012-01-06T05:35:00.002-06:002012-01-06T05:35:00.863-06:00

So the sixth edition of the manual has just come out. You can go here to access a link to download the entire manual for free. For the most part the language is pretty standard, similar to other codes of ethics we're familiar with, such as that put out by the AMA. Here I will comment on some new areas of content and other aspects of the document that got my attention. The readability and

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-71494451790966431422012-01-05T09:16:00.000-06:002012-01-05T09:16:00.825-06:00

---as a step toward possible vaccine development, just in case.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-8826204277421450162012-01-04T04:19:00.001-06:002012-01-04T04:19:00.540-06:00

This open-label randomized controlled trial reported a reduction in PTS attributable to local thrombolytic therapy in patients with iliofemoral DVT. The NNT was 7 and there was a downside of bleeding. The authors recommend the treatment, on top of conventional anticoagulant therapy, for patients with upper thigh DVT extending into the iliac, if appropriate expertise is available at the treating

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-11402461952846281212012-01-03T11:34:00.000-06:002012-01-03T11:34:59.510-06:00

Last fall the CDC reported two cases of infection with this novel influenza strain in children in Indiana and Pennsylvania. By the end of 2011 that number had increased to 12, involving 5 states. So what's up with this? What is it? It's a hybrid of a swine H3N2 known for several years, containing a genetic segment from the 2009 novel H1N1 strain. Human to human transmission capability? If so

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-47632570479370304822012-01-01T14:51:00.001-06:002012-01-01T15:01:44.083-06:00

I've been looking back over my posts for the year 2011. There was a lot of published research over the past year that should be of interest to hospitalists but I found little that was revolutionary, what I would call game changing. There were some articles with practice changing potential, either because of new information or reminders of under-appreciated clinical points, which I have linked

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com1tag:blogger.com,1999:blog-14743001.post-66987787778345638162011-12-23T06:31:00.000-06:002011-12-23T06:31:00.612-06:00

I've seen fuzzy use of these terms and evidently the question came up at Emory morning report, hence a post at The Bottom Line: Myeloproliferative diseases are characterized by large numbers of abnormal blood cells (red, white or platelets) growing and spreading in bone marrow and blood. On the other hand, myelodysplastic syndrome includes various clonal hemopathies characterized by decreased

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-20596984391818303812011-12-22T19:06:00.000-06:002011-12-22T19:06:20.636-06:00

From a review in Gastroenterology. Most are “malignant” with the exception of insulinomas. “Malignant” is quotes because clinical behavior in terms of tumor bulk and metastasis is generally indolent, and the major clinical impact is from the secretory products, though some tumors are nonfunctional. Via The Bottom Line.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-35273836519328813752011-12-22T18:39:00.000-06:002011-12-22T18:39:58.744-06:00

This was a recent topic of an evidence summary posted at The Bottom Line according to which the only universally accepted indication is for cirrhotic patients hospitalized with UGI bleeding while they're in the hospital (and maybe for a few days after). For non-bleeding ascitic patients with other risk factors, while a prior history of SBP seems to be a strong factor in favor of prophylaxis, the

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-82322885879081198232011-12-21T14:32:00.000-06:002011-12-21T14:32:30.745-06:00

You wouldn't criticize an orange for not being a good apple. In terms of taste, texture and many other attributes an orange isn't supposed to be a good apple. So why in the world would you criticize Harrison's or Cecil's for not being good “look up” treatment references like UpToDate is? They're not supposed to be. They are mainly background references, not point-of-care references. So they

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-19061654169108677622011-12-21T10:25:00.000-06:002011-12-21T10:25:49.213-06:00

This review belongs in the hospitalist's library. It covers the two new agents approved in the U.S. as well as those in the pipeline. It cites a lot of comparative effectiveness research. (Not that comparative effectiveness research is anything new, but that's what it's trendy to call it when there are two or more active treatment arms). So is warfarin dead? No. This little appreciated

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-72019918658776654472011-12-19T11:02:00.000-06:002011-12-19T11:02:25.791-06:00

This topic was reviewed as part of the acid-base teaching series of the American Journal of Kidney Diseases. Concluding points from the article: • Increased serum osmolal gap with or without high-anion-gap metabolic acidosis can be an important clue to toxic alcohol intoxications• The presence and magnitude of serum osmolal gap depends on several factors, including molecular weight of the

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-5554149439334325592011-12-12T07:17:00.000-06:002011-12-12T07:17:41.657-06:00

There's a long held belief that this is true. I first heard it from an old sage who said that when the thyrotoxic patient develops atrial fib, “run for the heparin!” Thyrotoxicosis is not listed as one of the CHADs risks, so fact or myth? All the evidence is examined in this review in the Texas Heart Institute Journal. It turns out that multiple studies show an alarmingly high rate of

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-13445834011898720082011-12-08T12:28:00.000-06:002011-12-08T12:28:45.824-06:00

TC can present with anterior ST elevation, in which case it resembles acute anterior STEMI. This paper demonstrates an electrocardiographic differentiation: ST-segment elevation greater than or equal to 1 mm in greater than or equal to1 of leads V3 to V5 without ST-segment elevation greater than or equal to1 mm in lead V1 identified TC with sensitivity of 74.2% and specificity of 80.6%. It is

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-35520880292026148732011-12-07T09:42:00.001-06:002011-12-07T09:43:56.735-06:00

Here.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-19352409370368345352011-12-07T09:41:00.000-06:002011-12-07T09:41:07.632-06:00

From the Wash U Hospital Medicine section.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-73146231633348464372011-12-06T10:43:00.000-06:002011-12-06T10:43:17.922-06:00

Reports in the last few years highlight the emerging importance of lead aVR, a long neglected electrocardiographic lead. I have written several posts on the important clues available from lead aVR in the detection of left main or multivessel coronary ischemia, the differential diagnosis of narrow complex tachycardias, the differentiation between VT and SVT with aberrancy, and pericarditis. All

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-46220862766711113912011-12-06T10:34:00.000-06:002011-12-06T10:34:16.838-06:00

It has been approved for the indication in Europe based on two phase 3 trials showing non-inferiority to vanc. In the US it is approved only for complicated skin and skin structure infections.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-68341337458523747302011-12-05T10:15:00.000-06:002011-12-05T10:15:22.106-06:00

Traditional teaching and guidelines held that we should pour the fluids early on in the treatment of acute pancreatitis. Nobody would say just how much, but a lot. The problem was, these recommendations were not driven by high level data. We had expert opinion, animal data, pathophysiologic rationale and low level studies in patients but nothing more. A new study, representing the best

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-81993998884610756242011-12-05T05:54:00.001-06:002011-12-05T05:54:00.130-06:00

Interstate compacts are older than the Constitution itself although this effort just got going a few months ago. A few states have signed up with many more standing in line. These folks seem very determined and at a minimum they'll open a new front in the battle over health care.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-60161810029119267502011-12-02T05:57:00.002-06:002011-12-02T05:57:00.324-06:00

Bob Wachter, on sabbatical in England, has been blogging about the National Health Service. In his latest post, noting Donald Berwick's romanticism about the NHS and the political consequences he reaped, Bob is not so romantic. While acknowledging many of the negatives of the NHS he finds a few things to like. Let's look at some of those and decide how likeable they really are. A GP can make

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-13962439769880059932011-12-01T06:33:00.001-06:002011-12-01T06:33:00.517-06:00

Open courseware.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-63759845280313121222011-12-01T06:30:00.002-06:002011-12-01T06:30:03.532-06:00

Open courseware.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-73101993745810565522011-12-01T06:28:00.000-06:002011-12-01T06:28:00.255-06:00

Open courseware.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-69318870810022194222011-12-01T06:27:00.000-06:002011-12-01T06:27:00.844-06:00

University of Michigan.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-3077448371768593442011-12-01T06:25:00.000-06:002011-12-01T06:25:00.116-06:00

University of Nottingham open courseware.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-43507043282041411262011-11-30T06:21:00.001-06:002011-11-30T06:21:00.080-06:00

According to this paper it can help despite recent teaching which says it is unreliable: ST-segment elevation predicted AMI with 88% sensitivity and 84% specificity. The criterion including ST-segment elevation and/or depression had 95% sensitivity and 62% specificity. The combined criterion including ST-segment elevation and/or depression, and/or non-specific wide QRS complex and/or left bundle

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-5189118115162652042011-11-30T06:19:00.001-06:002011-11-30T06:19:00.088-06:00

What does it mean when it’s elevated? Does it mean ACS or chronic elevation as a part of the heart failure syndrome? How does one distinguish? If the patient does not have ACS are measurements of value in risk stratification? These questions and more are answered in a review from last year in JACC, available here as free full text.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-59650005891144744462011-11-30T06:14:00.002-06:002011-11-30T06:14:00.389-06:00

67% in a new study were due to oral hypoglycemics, insulins and antithrombotics, none of which are on the Beers list. The authors conclude that intensified outpatient vigilance targeting these classes of medications is warranted to reduce hospitalizations in the elderly.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-5899587987848158312011-11-29T06:13:00.000-06:002011-11-29T06:13:00.176-06:00

Short videos on clinical emergency medicine and the intersection with critical care medicine.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-70789675293187000622011-11-29T06:09:00.001-06:002011-11-29T06:09:00.043-06:00

---may be catching on in the ER but is still underutilized. It can serve as a bridge to a central line if you can't get a peripheral in in a reasonable amount of time. Study here, Medscape commentary here.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-76367410296370228482011-11-29T06:06:00.001-06:002011-11-29T06:06:00.371-06:00

A review in the American Journal of Kidney Diseases. Free full text.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-67557362221765063592011-11-29T06:04:00.001-06:002011-11-29T06:04:00.087-06:00

It has a wide clinical spectrum with many atypical variations. A review in the Archives of Pathology and Laboratory Medicine.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-266440745909701442011-11-29T06:01:00.002-06:002011-11-29T06:01:00.270-06:00

This is a very comprehensive review. Article at journal site. Free full text from Medscape.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-43540997279157295012011-11-28T06:13:00.001-06:002011-11-28T06:13:00.462-06:00

Multiple subjects covered here.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-53129542132448107402011-11-28T06:11:00.001-06:002011-11-28T06:11:00.459-06:00

A Medscape video by Dr. William Schaffner.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-19169245419227800402011-11-28T06:08:00.001-06:002011-11-28T06:08:00.336-06:00

Here is a review from the Texas Heart Institute Journal, focusing on left sided valvular regurg: Although acute, severe valvular regurgitation can be a true surgical emergency, accurate diagnosis and subsequent treatment decisions require clinical acumen, appropriate imaging, and sound judgment. An accurate and timely diagnosis is essential for successful outcomes and requires appropriate

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-71223386490892784082011-11-28T05:04:00.001-06:002011-11-28T05:04:00.193-06:00

Via The Bottom Line: Cerebral salt wasting is associated with hypovolemic hyponatremia in patients with intracranial disease, such as subarachnoid hemorrhage, traumatic brain injury, craniotomy, encephalitis, and meningitis. SIADH is a cause of euvolemic hyponatremia due to the excess secretion of vasopressin that may be attributed to malignancy, various CNS or pulmonary disorders or drugs, such

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-64435038281930332392011-11-25T14:42:00.000-06:002011-11-25T14:42:34.870-06:00

Berwick, who once said evidence based medicine may have to “take a back seat,” has decided to take a back seat himself rather than face confirmation hearings in the Senate as Republicans remain determined to block his nomination. For many of them the problem is their perception of Berwick as a Marxist. For me it was his incoherence---advocating for more central control on the one hand while

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-51238583662944037952011-11-23T07:32:00.000-06:002011-11-23T07:32:17.526-06:00

According to a poster presentation at the 51st Interscience Conference on Antimicrobial Agents and Chemotherapy other species, particularly anaerobic organisms, can be indicitative of increased risk.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-18797153016835014092011-11-23T07:29:00.000-06:002011-11-23T07:29:32.784-06:00

The anti-Xa assay is becoming more readily available in community hospital labs. Its potential value in dosing low molecular weight heparins in special situations such as pregnancy, morbid obesity and renal disease is well known. Less well known is a potential role in monitoring unfractionated heparin. How does it compare with PTT monitoring and what are the practical aspects? These questions

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-8842224949535177202011-11-22T06:08:00.000-06:002011-11-22T06:08:00.390-06:00

Ever notice how a new acronym or buzzword gets introduced and no body bothers to tell you what it means? It may be that the people throwing it around don't know what it really means themselves. Such is the case with HCAHPS. At first I thought they were talking about health care associated pneumonia. Later I realized that it was a new survey method that will change the way the patient

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-5457462436105761222011-11-22T05:11:00.000-06:002011-11-22T05:11:00.309-06:00

Physical fitness may be associated with slowed brain aging according to a presentation at the Society for Neuroscience. Via WSH Health Blog.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-61908496401623823372011-11-22T04:48:00.001-06:002011-11-22T04:48:00.262-06:00

Maybe so according to this study in which hospital outcomes were compared based on use or non-use of Up To Date: We found that patients admitted to hospitals using UpToDate had shorter lengths of stay than patients admitted to non-UpToDate hospitals overall (5.6 days vs 5.7 days; P less than 0.001) and among 6 prespecified conditions (range, −0.1 to −0.3 days; P less than 0.001 for each). Further

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-49950762890568906102011-11-21T07:58:00.000-06:002011-11-21T07:58:35.739-06:00

Very helpful article from the Texas Heart Institute Journal.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-32674376467097909532011-11-21T07:56:00.000-06:002011-11-21T07:56:07.362-06:00

No, but a marked increase in bleeding in patients on uninterrupted dual antiplatelet therapy may require local hemostatic measures according to this study.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-73320459023074543332011-11-21T07:53:00.000-06:002011-11-21T07:53:45.426-06:00

Pretty well except for C diff. Here are the data from HHS and here is a related Medscape article. But before you get all warm and fuzzy about the CMS no pay for adverse event policy, remember that the decline in nosocomial UTIs began long before the implementation of that policy in 2008. Likewise the central line bundle, credited with the decline in IV catheter infections, was introduced a

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-11185358917217479292011-11-21T07:50:00.000-06:002011-11-21T07:50:24.160-06:00

Intra-abdominal hypertension (IAH) is a precursor to abdominal compartment syndrome (ACS). Awareness of ACS across a variety of medical settings is increasing. There is now a professional society devoted to IAH and ACS. ACS is a systemic disease which can lead to multi-organ failure. One of the better reviews on this topic was recently published. I previously blogged this topic here and here

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-76991850793077756872011-11-18T07:35:00.002-06:002011-11-18T07:35:01.194-06:00

Here's a review from Seminars in Respiratory and Critical Care Medicine. Free full text from Medscape is available here. A few key points: The microcirculation has diverse homeostatic functions which become severely altered in sepsis. The microcirculation is the site where systemic inflammation and hemodynamic disturbance translates into organ failure. The microcirculation is the interface

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-63759600209976739352011-11-18T05:38:00.002-06:002011-11-18T05:38:00.425-06:00

Current guidelines assume myocardial dysfunction if reduced central venous oxygen saturation persists after optimization of filling pressure, mean arterial pressure and hematocrit. In those instances dobutamine is recommended. The authors of this paper suggest a more refined approach utilizing cardiac biomarkers and echocardiography. Free full text from Medscape.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-39487609541826114892011-11-18T05:19:00.000-06:002011-11-18T05:19:00.109-06:00

---or even all that important anymore. This report from Medscape Business of Medicine discusses some of the new incentives that trump clinical skills.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-70150115213490253042011-11-17T08:15:00.000-06:002011-11-17T08:15:15.037-06:00

The Medscape article implies this will address the obsolescence of ICD 9. That's pretty funny considering that the final version of ICD 10 was created around 1990.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-44631814900415008932011-11-17T08:12:00.000-06:002011-11-17T08:12:24.205-06:00

---in American Family Physician. A bit dated but good.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-68561467328656692102011-11-17T08:09:00.000-06:002011-11-17T08:09:34.477-06:00

A large open courseware repository.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-47585397531175687052011-11-17T05:44:00.000-06:002011-11-17T05:44:00.772-06:00

Journal site. Free full text at Medscape.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-6739931973217103182011-11-16T05:34:00.001-06:002011-11-16T05:34:00.100-06:00

It's coag negative but behaves like Staph aureus. Free full text from Medscape.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-9216431725898036902011-11-16T04:20:00.000-06:002011-11-16T04:20:00.233-06:00

PROMETHEUS is a pilot project in bundled payments on the part of three health care systems. According to a report in Health Affairs the project lies dormant after three years of trying to get it off the ground. The abstract of the Health Affairs article euphemistically concludes: Participants continue to see promise and value in the bundled payment model, but the pilot results suggest that the

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-20061112827482951102011-11-15T11:56:00.002-06:002011-11-15T11:56:00.141-06:00

Med lists generated by the ER medication reconciliation process are inaccurate according to this study: Results: There were 98 patients enrolled in the study; 56% (55/98, 95% confidence interval [CI] 46–66%) of the medication lists for these patients had an omission and 80% (78/98, 95% CI 70–87%) had a dosing or frequency error; 87% of ED medication lists had at least one error (85/98, 95% CI 78–

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-59560418315862119762011-11-15T09:25:00.002-06:002011-11-15T09:25:00.065-06:00

Article at journal site. Free full text at Medscape.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-11660709675003862622011-11-15T06:53:00.003-06:002011-11-15T06:53:00.409-06:00

A review in the Texas Heart Institute Journal.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-55768044863166015752011-11-15T04:51:00.000-06:002011-11-15T04:51:00.284-06:00

Troubleshooting tips from a review in the Texas Heart Institute Journal.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-41526020952588991752011-11-14T08:13:00.001-06:002011-11-14T08:13:00.528-06:00

---is an essential ingredient of diagnostic skill as explained in this essay by the late J. Willis Hurst. A few choice quotes: The history-taking period is when the doctor not only obtains vital clinical information, but also has the opportunity to know the patient as a person—as a human being. This is also when patients begin to know their doctor as a person. It is during the history-taking

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-65633241674608974192011-11-14T07:15:00.000-06:002011-11-14T07:15:00.483-06:00

As evidence accumulates we are gradually clarifying the links to immune, endocrine and metabolic dysregulation. Consequences include metabolic syndrome, insulin resistance, type 2 diabetes and cardiovascular disorders. Here is a recent review.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-15920646599049377922011-11-14T05:41:00.000-06:002011-11-14T05:41:00.047-06:00

It is a condition beset with much confusion. This review should be helpful.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-51505909130063642222011-11-11T10:39:00.000-06:002011-11-11T10:39:39.732-06:00

As I have blogged previously it is now known that there is both a benign and a malignant form of early repolarization. The latter is now known as early repolarization syndrome. In this review early repolarization syndrome is discussed alongside Brugada syndrome as a continuum of repolarization variants known as J wave disorders.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-6280377599694468262011-11-11T07:06:00.001-06:002011-11-11T07:06:00.806-06:00

Delayed diagnosis was the rule in this study: The mean delay to diagnosis from the first symptoms was 9.7 years, and from the first doctor visit it was 5.8 years. The delay has been reduced over time for some age groups, but is still quite long. The mean QALY score during the year prior to initiated treatment was 0.66; it improved after diagnosis and treatment to 0.86, and was then better than

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-74029041402437896432011-11-11T06:02:00.002-06:002011-11-11T06:02:01.936-06:00

When the Q wave vectors are, say, 90 degrees apart two separate MIs can be easy to spot and localize. If they are on opposite walls (180 degrees apart) things get a little tricky because of cancellation of forces. In such cases nothes and multiple baseline crossings may be observed, producing M and W waves. These electrocardiographic signs of multiple infarcts may predict reduced ejection

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-58176975124140577602011-11-11T05:30:00.003-06:002011-11-11T05:30:00.760-06:00

CT angiography had excellent test characteristics in this study.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-43391272984934198342011-11-10T05:16:00.001-06:002011-11-10T05:16:00.217-06:00

Appearance based medicine Performance measures; looking good on public report cards.  Never proven to help patients, often harmful, generally confused with quality. Belief based medicine A form of medical decision making driven by the ad hominem fallacy in which one chooses to believe or disbelieve a guideline or scientific paper based on whether the authors have industry ties. Convenient,

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-68434433844576374392011-11-09T07:32:00.000-06:002011-11-09T07:32:32.425-06:00

It’s a labor of love but is it worthwhile? Time to stop and reflect. For me there are several reasons. It keeps me interested in continued learning about medicine and the science behind it and makes me more disciplined in the way I read.  It keeps me interested in the external issues that impact the practice of medicine. It forces me to think carefully and critically about them. It provides me

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-41646334737826436662011-11-09T06:02:00.001-06:002011-11-09T06:05:01.728-06:00

An article in Life Sciences Education delves into the various forms of research in drug development and the basic science surrounding it.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-62791971747753453192011-11-09T05:51:00.000-06:002011-11-09T05:51:17.134-06:00

---from the University of Utah.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-51959724204324737142011-11-09T05:08:00.001-06:002011-11-09T05:08:00.414-06:00

---it's good to be average. We're familiar with the long QT syndrome and, more recently, the short QT syndrome. Now it appears that variations toward short or long term QT intervals even within the normal range are associated with increased mortality. From Medpage Today commenting on the paper: "As often happens in medicine, the first recognized cases of [long and short QT syndrome] had extreme

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-38379788770304501072011-11-08T06:12:00.001-06:002011-11-08T06:12:00.092-06:00

This one, predictably, is from the New York Times. Typical of other ad hominem attacks on authors for their financial interests, this one is intellectually empty---devoid of any direct criticism of the science. And here’s a choice quote from the piece: “If you want the public to really believe in the guidelines, why not have a committee that is conflict-free?” Does that ever miss the point.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-29456241893037673692011-11-08T05:54:00.003-06:002011-11-08T05:54:00.476-06:00

---with a systematic review published in the Annals of Internal Medicine alongside a new set of guidelines. This has caused a bit of a stir, so is it anything really new? Yes and no. First, the systematic review indicates that any benefits from prophylaxis are much, much more modest than popularly believed, particularly considering associated bleeding risks. The guidelines themselves are being

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-53107472983704657652011-11-07T21:38:00.000-06:002011-11-07T21:38:37.661-06:00

The dates for the 2012 Tutorials in the Tetons, 38th Annual Update in Cardiovascular Disease, have been announced. Why not join me August 10-13 in the Grand Tetons for a time of learning and relaxation? I’ll provide more details about the meeting as they become available, and have in development some more posts on material presented at the 2011 meeting.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-14670546296332006762011-11-07T07:54:00.000-06:002011-11-07T07:54:50.193-06:00

Are there clinical or electrocardiographic characteristics that help distinguish these patients? See here.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-2056619345483759332011-11-07T07:53:00.000-06:002011-11-07T07:53:03.728-06:00

Reviewed here.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-61163686230986820112011-11-07T07:51:00.000-06:002011-11-07T07:51:18.014-06:00

---in this study.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-42558118358448946312011-11-07T07:49:00.000-06:002011-11-07T07:49:37.510-06:00

---for adult arrest of suspected cardiac origin. Here is another study in support of the idea.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-77564283103272961532011-11-04T05:45:00.003-05:002011-11-05T21:09:43.270-05:00

The scientific framework for the field of brain-body medicine is slowly but surely maturing. Yet the field remains mysterious enough that it carries a special attraction to the purveyors of unscientific complementary and alternative medicine otherwise known as woo. Recently Medscape reported on two well known speakers who addressed this topic at the annual session of the Heart Failure Society

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-20823991921509244332011-11-03T11:22:00.000-05:002011-11-03T11:22:13.691-05:00

A Medscape Expert Review and Commentary from Dr. John Bartlett. A few points of interest: There's yet another new betalactamase causing resistance to multiple antibiotics including the penems. It's from India and Pakistan but has reached the US. It's very nasty and although tygecycline may show activity generally you have to use colistin. No new gram negative drugs are in the pipeline for the

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-8254031832860447662011-11-02T07:39:00.001-05:002011-11-02T07:40:28.864-05:00

Due to the grandstanding in the 1980's skilled care of the elderly became a political football. There grew out of this an advocacy movement on behalf of the elderly and skilled elder care became the most regulated sector of American health care. Difficult and exceedingly complex regulations, draconian inspections by regulatory agencies and harsh penalties put nursing homes on the defensive.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-41672016601164943602011-11-02T05:54:00.000-05:002011-11-02T05:54:00.062-05:00

696 pages of them. CMS press release here. Medscape report here. Kool aid from Dr. Berwick here.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-44583604306245002832011-11-01T09:50:00.000-05:002011-11-01T09:50:06.102-05:00

I had not read this report when I blogged the topic yesterday. But it appears some of the folks at ACCP agreed with me that the robust improvements in various processes of sepsis care resulting from Lilly's promotional campaign may have helped do its sepsis drug in: Dr. Simpson and other physicians who spoke to Reuters Health said that this time around, Xigris was more hard-pressed to beat the

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-38106308402403633752011-11-01T08:07:00.001-05:002011-11-01T08:07:00.137-05:00

This review is available as free full text in Emergency Medicine. Here are some key points: The definitions for massive hemoptysis (MH) in terms of volume vary widely and are not useful because of difficulty in estimating volume. A more practical definition of MH is any degree of hemoptysis sufficient to threaten respiratory function. The most common causes of MH parallel the causes of all

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-46965427651093717402011-11-01T05:03:00.000-05:002011-11-01T05:03:00.159-05:00

RV MI is important to recognize because its hemodynamic management is different. Consider it in any patient with ECG changes of inferior STEMI. Recording from right precordial leads is confirmatory, but strong clues of RV infarction are usually present on the standard 12 lead. Those I've used include ST elevation in V1 and lead III showing greater magnitude of ST elevation than the other

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-21353762362398997052011-10-31T13:59:00.000-05:002011-10-31T13:59:38.031-05:00

Just over a week ago I posted an update on Xigris, concluding that the results of PROWESS-SHOCK would give us answers to help resolve some of the controversy surrounding the drug. Little did I know that the results would be announced so soon. For those who haven't heard, there was no significant difference attributable to Xigris, neither benefit nor harm, so Lilly has pulled it from the market.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.comtag:blogger.com,1999:blog-14743001.post-55978181196911814712011-10-31T05:42:00.002-05:002011-10-31T05:42:00.141-05:00

That is, they represent acute epicardial coronary occlusion nonetheless. These tricky situations have deprived many patients of a timely trip to the cath lab, even though the infarcts can be just as serious as STEMIs meeting the generally accepted criteria. Many of these infarcts are termed electrocardiographically silent although in most cases, under the careful scrutiny of an experienced

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-11024821363658931232011-10-28T18:34:00.001-05:002011-10-28T18:34:00.501-05:00

This entity was recently featured at Renal Fellow Network. From a review in Cardiology in Review: Glucocorticoid remediable aldosteronism (GRA) appears to be the most common monogenic form of human hypertension. As a result of chimeric gene duplication, aldosterone is ectopically synthesized in the zona fasciculata of the adrenal gland under the control of adrenocorticotropin (ACTH). Affected

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-36734278011634903832011-10-28T05:32:00.000-05:002011-10-28T05:32:00.211-05:00

A two part series from Emergency Medicine. Free full text.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-50553330371275242982011-10-28T05:27:00.001-05:002011-10-28T05:27:00.743-05:00

A great post at The Kidney Doctor talks about NSAID risks and asks why doctors don't get it. It summarizes the adverse renal effects of NSAIDs and links to an article documenting the degree of NSAID use among CKD patients, both over the counter and by prescription. I would take the discussion a step further and ask why the FDA doesn't get it. Their inconsistency is remarkable. After all for

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0tag:blogger.com,1999:blog-14743001.post-8820365553662837982011-10-27T07:19:00.001-05:002011-10-27T07:19:00.643-05:00

Via Renal Fellow Network. I had heard this mentioned at a talk but had not seen much written about it.

R. W. Donnellhttp://www.blogger.com/profile/16944231400440786271noreply@blogger.com0