Takotsubo cardiomyopathy and acute coronary syndrome

---can have very similar clinical presentations. It may not be possible to make the distinction without cardiac catheterization according to this paper in the American Journal of Emergency Medicine.

The spectrum of aspergillus pulmonary infection

Reviewed in Clinical Pulmonary Medicine.

Oxford handbooks on just about everything

---medical and non-medical accessible at Google Books. The content appears to be available in its entirety, and the editions, many of them anyway, appear current.

Via Clinical Cases and Images blog.

Arkansas medical bloggers featured

Via Medical News of Arkansas:

Medical News of Arkansas spoke to or corresponded through email with four active Arkansas medical bloggers –R.W. Donnell, MD, a hospitalist in Rogers who publishes "Notes from Dr. RW" at doctorrw.blogspot.com; Elizabeth Schneider, MD, a Baptist Health pathologist in Little Rock who publishes "Methodical Madness" at www.gizabethshyder.blogspot.com; Ramona Bates, MD, a plastic surgeon in Little Rock who publishes "Suture for a Living" at rlbatesmd.blogspot.com; and Victoria Powell, RN, a nurse consultant in Benton who publishes a blog on her Web site, www.vp-medical.com.

Many thanks to Steve Brawner!

Candida endocarditis

From a Medicine review:

Candida IE should be classified as an emerging infectious disease, usually involving patients with intravascular prosthetic devices, and associated with substantial related morbidity and mortality. Candida PVE usually is a late-onset disease, which becomes clinically evident even several months after an initial episode of transient candidemia.

Acute Aortic Syndromes

---including aortic dissection, thoracic aortic aneurysm, penetrating atherosclerotic ulcer and intramural hematoma, reviewed in Mayo Clinic Proceedings.

Notable pearls:

The most important historical feature is pain maximal at onset.

The D-dimer has powerful negative predictive value.

Brugada---an electrocardiographic pattern you need to know

James Roberts, MD, gives another erudite discussion of an electrocardiographic pattern worth keeping in mind if you're an emergency physician or a hospitalist:

This month's EKG contender, Brugada syndrome (BS), is one of those findings that will elude many if not most EPs. This is a relatively new and rare entity, but one that is currently the object of much interest to the erudite cardiologists who study such things. This syndrome is not an expected pickup by ED clinicians, at least not yet, but if you're perceptive enough to spot it, you will certainly look like a star.

But it's easy to spot if you keep it in mind. It's a pattern every ED physician, PCP and hospitalist should know.

Despite the bad economy

---it's still a good time to be hospitalist job hunting. Via The Hospitalist.

Tylenol

Harriet Hall writing at Science based Medicine offers useful perspective about the current brouhaha and possible consequences of the FDA's proposed action.

The evidence is in: the Surviving Sepsis Campaign saves lives

I first reported outcome based evidence on the effects of the most maligned pharmaceutical industry campaign here. The campaign was associated with increased adherence to evidence based practice and reduction in mortality. Now a review in Clinics in Chest Medicine reports several additional studies confirming the mortality benefit attributable to the influence of the campaign.

For many years the pharmascolds made the completely non-evidence based claim that pharmaceutical industry marketing campaigns were harmful to patients. For almost three years on this blog I asked for evidence concerning the effect of industry campaigns on patient outcomes. Now the evidence is finally coming in, and so far it’s favorable to influence of industry.

More data on NSAIDs and cardiovascular risk

This time it’s on patients who have recently suffered a myocardial infarction. Once again, as in all the other studies, although the pharmascolds would have you believe differently, the older generation NSAIDs, with the exception of naprosyn, were at least as bad as the Cox 2s.

Linezolid as salvage therapy?

From Clinical Infectious Diseases:

All adult patients with persistent MRSA bacteremia for greater than or equal to 7 days…

The results of linezolid salvage therapy with or without carbapenem were compared with those of salvage therapy with vancomycin plus aminoglycosides or rifampicin.

Thirty-five patients with persistent MRSA bacteremia were studied. The early microbiological response (ie, negative results for follow-up blood culture within 72 hours) was significantly higher in the linezolid-based salvage therapy group than the comparison group (75% vs 17%; p=.006). Adding aminoglycosides or rifampicin to vancomycin was not successful in treating any of the patients, whereas linezolid-based therapy gave an 88% salvage success rate (p less than 0.001 ). The S. aureus–related mortality rate was lower for patients treated with a linezolid salvage regimen than for patients continually treated with a vancomycin-based regimen (13% vs 53%; p=.030).

This is interesting and has the potential to change practice. Linezolid (Zyvox) because of its avid tissue penetration tends to have low blood levels, which has been a theoretical concern regarding its use in bacteremia. Also, how many, if any, of these patients had endocarditis? Linezolid is not bactericidal for MRSA (or enterococci, although it is for most strep). Traditional teaching holds that bactericidal therapy is essential in treating endocarditis. Daptomycin might be a better option in those patients.

Via Hospital Medicine Quick Hits.

Drug induced hypersensitivity syndrome (DIHS)

---is another name for DRESS syndrome and is the topic of a review in Medicine. In contrast to other reviews I’ve linked on this topic the authors emphasize the possible role of vitamin D deficiency in the pathogenesis and some overlap with adult onset Still’s disease.

Quotes from Ezekiel Emanuel

Dr. Ezekiel Emanuel is head bioethicist at NIH, one of Obama’s comparative effectiveness mavens and brother of the White House chief of staff. I mentioned his Lancet paper and his views on rationing against elders here. Now here’s more from Secondhand Smoke, quoting from another of Emanuel’s papers (emphasis added):

Substantively, it suggests services that promote the continuation of the polity-those that ensure healthy future generations, ensure development of practical reasoning skills, and ensure full and active participation by citizens in public deliberations-are to be socially guaranteed as basic. Conversely, services provided to individuals who are irreversibly prevented from being or becoming participating citizens are not basic and should not be guaranteed. An obvious example is not guaranteeing health services to patients with dementia.

Wow.

HR 3200 end of life counseling provision: paid service or mandate?

That seems to be the question du jour concerning the health care reform bill. Although the notion (advanced by Betsy McCaughey and others) that the bill would require seniors to undergo counseling has been characterized as a wingnut lie, when I went and read the relevant section of the original bill (pages 425-430) things got really muddy. After reading and re-reading I just couldn't be sure who's lying, who's telling the truth and who's just plain confused. I'm nowhere near as smart as some folks on both sides of the issue who seem so sure so I thought I'd ask Fred Thompson. After all he's a former senator and a lawyer, and McCaughey made the claim on his show. I wrote to him, in part, concerning the bill:

The language is arcane. It amends and makes reference to portions of the Social Security act which I was unable to access. That said, to my reading it merely adds such counseling as a covered service but does not mandate it. Do you really believe it will force elders to engage in such counseling? Alternatively, is the language so vague that we really can't anticipate how it will be interpreted? I would appreciate it if you would help me and some of my blogging colleagues work through the legalese. Thanks!

In the meantime, while I waited for Fred's reply (and I'm still waiting) a commenter tipped me off to these posts by Wesley Smith at Secondhand Smoke. Concerning McCaughey's claim he wrote:

Is she right? It is very hard to tell. That section of the bill refers to existing law without quoting it.

And, a little further on:

Here’s the thing: I’m a lawyer and I couldn’t figure out what this section of the bill would actually require because it refers to existing laws, and to look up and cross reference those against the bill would require hours to figure out. That in itself should send up warning flares. From what I have seen, this bill is simply incomprehensible.

It is urgent that our representatives slow down, figure out what these bills really contain, and let the people weigh in before the legislation is finally decided upon. That the President of the United States, the Speaker of the House of Representatives and others in political leadership want to deny us that opportunity tells me this bill is toxic–and on that basis alone, it should be rejected unless sufficient time is allowed to permit the democratic process to operate in a proper fashion.

So Smith, a lawyer and an expert in bioethics no less, shares my confusion! At the very least we need time for the representatives and the American public, particularly seniors, to understand the provision. Maybe, as Smith suggests, the language of the bill needs some tweaks to make it abundantly clear that the counseling would be voluntary and without coercion:

Regardless, if mandatory counseling is not what the president and Congress really have in mind, it would be very easy to correct any confusion:

1. Add a provision stating that the counseling is entirely voluntary–both for the patient and the medical provider. In that way, the regulations–that will be thousands of more pages–promulgated by the agencies to further the purpose of the law won’t be able to require counseling.

2. Add a provision stating that the patient will not lose benefits if he/she refuses counseling or does not sign an advance directive.

3. Add a provision that no service provider will lose compensation for not providing counseling.

4. Add a provision prohibiting the counseling from being directed toward refusing or accepting care–along the same lines of the Kennedy/Brownback bill passed last year to prevent genetic counseling of pregnant women carrying a Down baby from being directed toward abortion.

All the ambiguity aside Smith did cite some concerning language in the provision (italics added):

Such consultation shall include the following:

and---

The Secretary shall limit the requirement for explanations under clause...

OK, maybe the imperative words here merely refer to coding requirements in order to get reimbursed for the counseling, but who knows?

I'm reading cocksure opinions, from folks on both sides of this debate, not wingnut lies. It's refreshing to see a nuanced analysis such as Smith's, and I hope he stays on top of the issue.

Letter to Fred Thompson

I just sent the following email to the Fred Thompson radio show:

Dear Fred,

I am a physician and a medical blogger. One of the hotly debated topics in my community of medical bloggers is the provision in the health care reform bill, HR 3200, concerning counseling on end of life issues.

In a recent interview on your show Betsy McCaughey, citing pages 425-430, claimed that the bill would require mandatory end of life counseling every five years. I read that portion of the original bill. The language is arcane. It amends and makes reference to portions of the Social Security act which I was unable to access. That said, to my reading it merely adds such counseling as a covered service but does not mandate it. Do you really believe it will force elders to engage in such counseling? Alternatively, is the language so vague that we really can't anticipate how it will be interpreted? I would appreciate it if you would help me and some of my blogging colleagues work through the legalese. Thanks!

Dr. Sanity: If it passes, I’m done

Read it here. Via Medpolitics.

What to do with upper extremity DVT

From The Hospitalist.

Systolic dysfunction, diastolic dysfunction and postoperative outcome

In this recent study diastolic dysfunction but not systolic dysfunction was associated with adverse outcome in patients undergoing surgery. This makes perfect physiologic sense but counters a widespread clinical misconception.

Via Hospital Medicine Quick Hits.

Hospitalists as utility players

Here's a nice little rant from The Refugee over at Hospitalist With A View.

Here are some dictionary definitions of utility:

Used, serving, or working in several capacities as needed, especially:

1. Prepared to play any of the smaller theatrical roles on short notice: a utility cast member.

2. Capable of playing as a substitute in any of several positions: a utility infielder.

1. Designed for various often heavy-duty practical uses: a utility knife; a utility vehicle.

2. Raised or kept for the production of a farm product rather than for show or as pets: utility livestock.

3. Of the lowest U.S. Government grade: utility beef.