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.

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.

Post-discharge problems faced by elderly patients

---are more likely to occur when the PCP is not aware that the patient was hospitalized according to this study. Current guidelines recommend that the ED physician contact the patient's PCP if the patient is to be admitted.

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.

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.

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..

BUT:

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.

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.

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.

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.


BUT---


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.

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.