Levamisole associated ANCA vasculitis

Here is an abstract from SHM 2014 containing a case presentation and brief discussion of ANCA positive vasculitis associated with levamisole-adulterated cocaine. Levamisole is one of several culprit drugs (see here). Once thought of as a drug induced “false positive ANCA” it is now widely recognized that the problem can involve a fully developed vasculitis, the management of which may require more than just stopping the offending drug, as illustrated in the abstract.

Agile MD

A collection of quick reference medical resources. Most are free after registration. It is optimized for smart phone use but you can also access it from a desktop or laptop.  

Abstract presentations, SHM 2014

The abstract presentations at the 2014 Society of Hospital Medicine annual meeting can be accessed here. I will blog individual presentations of interest in the near future. After my disappointment in the plenary sessions I was encouraged to see so many clinically focused abstracts. Though SHM as a whole has lost its clinical emphasis, clearly there are hospitalists on the ground who are still passionate about clinical medicine. The abstract  collection contains some of the gems of SHM 2014. It's too bad this type of content wasn't given center stage.

SHM 2014: scientific assembly or rally?

Being a clinician, as I sat in the plenary sessions of our 2014 national meeting I started to wonder. Was I in the right place? There was some clinical content at the conference (I'll blog a bit of that later) but, unless you paid extra to attend a precourse, it was largely relegated to the breakout and poster sessions.

I attended the plenary sessions in hopes I'd get a better idea of the vision of our leaders and where they are taking the field of hospital medicine. It wasn't encouraging. The highlights below centered around Ian Morrison's talk and some elaboration in a panel discussion.


Consolidation and increased centrality of care

Morrison said:

Doctors discretion in selection of specific technologies and clinical protocols
will be increasingly constrained by large motivated health systems that employ
them..

He might as well have said “prepare for the decimation of evidence based medicine.” I'll explain. EBM takes the external evidence and applies it to the individual patient's attributes, preferences and values, as directed by the judgment and expertise of the individual clinician. It's incompatible with medicine by central control. That point seems widely misunderstood about EBM but it was taught by the founders and still applies today.


The transitions of care

Morrison said:

Care coordination of transitions will be at a premium.

The hospitalist model is a deliberate disruption in the continuum of care. Hospitalists created these artificial transitions and have been trying, with little success, to undo the consequences ever since. Don't expect them to suddenly fix it now.


Renewed focus on primary care

What will that mean for patients? It will mean limited choice and limited access to specialists. We've been there before. With heavy managed care in the 90s patients found it very difficult to access specialty care. It backfired. It was a patient satisfaction disaster. Are we going to try again?


The second curve

By that he means, broadly, the future demands of the economic and regulatory environment of health care.

Components of the second curve, according to Morrison, include the following:

A shift toward population health.

As important as that is, what do hospitalists have to do with it?


A shift from volume to value as the compensation incentive .

Value based purchasing is the latest term for P4P, based on performance surrogates that do not equate to real quality and to date have had no proven beneficial impact. [1] [2] The principal effect of the incentive has been to drive elaborate charting and coding games to create the appearance of delivering quality care to very sick patients. It's difficult for me to see how any of that can be good.


Morrison ended with some remarks about how hospitalists can “lead the redesign of acute care” to achieve the triple aim. If inpatient medicine's place in health care is about to diminish precipitously (see Bob Wachter's post here and if you're still skeptical about the incredible shrinking hospital see here) why, of all people, would hospitalists emerge to be the reformers? We would do that by “reaching out beyond the walls” of the hospital according to Morrison. In other words we wouldn't be hospitalists anymore.

So Morrison is predicting the demise of EBM and the demise of the hospitalist model, at least as originally conceived. I'm not criticizing him. He's a health care futurist and is just the messenger. The disturbing thing is that the leadership of SHM doesn't seem to mind.

Rare and emerging viral infections in transplant recipients

Recent review.

Thyroid storm

The clinical approach to thyroid storm was well covered in a recent post at Academic Life in Emergency Medicine. Though it's a quick, concise read and just a click away I'll mention here a few points deserving emphasis, made by the peer reviewer:

Thyroid storm is a clinical diagnosis

Despite difficulty in the fact that many patients have vague and undifferentiated features the urgency of the situation may not allow time for laboratory confirmation. If you suspect it, treat it.


The presentation may be deceptive

The peer reviewer goes so far as to say:

The diagnosis of thyrotoxicosis can be subtle and will absolutely be missed by the clinician who has not considered it on his or her differential.

The Burch-Wartofsky score may be helpful

It's a clinical tool for evaluation of the probability of thyroid storm independent of lab results and can be accessed here.


Order and timing of medications

Wait at least an hour after giving the thionamide before giving iodine to avoid exacerbation of storm as a consequence of iodine.


Understand the relationship to infection

Infection is one of several known stressors that can convert ordinary thyrotoxicosis into storm. So in the patient presenting with storm evaluate for underlying infection and have a low threshold for starting antibiotics. It works in the other direction. Since the manifestations of sepsis and storm overlap considerably, avoid premature closure and consider the thyroid in patients presenting as sepsis.

The binary classification of ACS into STEMI and NSTEMI can be misleading

There, I said it again. I've said it here before in various ways and offered many examples [1] [2] [3] [4] [5] [6] [7], encountering a little resistance along the way.

This review makes the case again and provides some examples of why it's true, including hyperacute T waves, de Winter T waves and Wellen syndrome.

VTE and cancer

This review in Circulation compliments another review on this topic that I linked recently and makes the following additional points of interest:

Tissue factor expression and activation of the coagulation system by tumor cells facilitate tumor growth and metastasis.

Pulmonary embolism incidentally discovered on cancer imaging studies is not benign as was once thought.


The other points are similar to the review linked in the previous post. The Circulation review is available as free full text.

Weight reduction as a treatment modality in atrial fibrillation

Obesity has become increasingly recognized as a driver of atrial fibrillation. The topic was recently reviewed in this paper and I provided some background here. Now for the first time a study in JAMA suggests that weight reduction lowers the arrhythmia burden in obese patients who have atrial fibrillation:

Design, Setting, and Patients Single-center, partially blinded, randomized controlled study conducted between June 2010 and December 2011 in Adelaide, Australia, among overweight and obese ambulatory patients (N = 150) with symptomatic atrial fibrillation. Patients underwent a median of 15 months of follow-up.

Interventions Patients were randomized to weight management (intervention) or general lifestyle advice (control). Both groups underwent intensive management of cardiometabolic risk factors...

Results Of 248 patients screened, 150 were randomized (75 per group) and underwent follow-up. The intervention group showed a significantly greater reduction, compared with the control group, in weight (14.3 and 3.6 kg, respectively; P less than .001) and in atrial fibrillation symptom burden scores (11.8 and 2.6 points, P less than .001), symptom severity scores (8.4 and 1.7 points, P less than .001), number of episodes (2.5 and no change, P = .01), and cumulative duration (692-minute decline and 419-minute increase, P = .002). Additionally, there was a reduction in interventricular septal thickness in the intervention and control groups (1.1 and 0.6 mm, P = .02) and left atrial area (3.5 and 1.9 cm2, P = .02).

More about the study from Medscape Cardiology.

SHM 2014: What was all the excitement about?

To answer that question let’s take another look at Bob Wachter’s post about the conference. Bob, after all, is tuned in to the hospital medicine zeitgeist if anyone is. So what was Bob excited about? Well, the incredible growth of our field, hospitalists “taking over the world” of inpatient care, and the fact that the CMS Chief Medical Officer and the nominee for surgeon general are hospitalists. Wonderful. So where was the excitement about the latest in critical care, nephrology and cardiovascular disease? There’s been some real cool stuff that’s come out in the past year!

I’m not picking on Bob these days but chose to center my discussion points around his comments because I believe they reflect the overall focus of our professional society (which I think is misguided) and he articulates them well.

The problem illustrated here is that we're losing our clinical focus. If we want value why not focus on being the best clinicians available to care for these incredibly sick and complex patients? It’s not measurable in any meaningful way but something we could embrace.

SHM 2014: the prevailing winds of hospital medicine

This is my second post about the 2014 Society of Hospital Medicine national meeting in Las Vegas. I decided to use Bob Wachter's blog form April 14 as a starting point. I intended to review his entire post on Saturday but got stuck on the first paragraph. But Bob had a good deal more to say. My reactions were all over the map (agree, disagree, hope you're wrong, I told you so) so let's dive right in.

One of the big topics for discussion in the plenary sessions was the impact of the ever changing regulatory environment on hospital medicine. Bob predicts a major trend toward closure of hospitals in just the next few years as if it's something new. But we've seen this before, haven't we? In fact it's been going on ever since Medicare enacted the Prospective Payment System (DRGs) in 1983.

Consider this paper for example. According to the report many hospitals closed in the 1980s due at least in part to the advent of Medicare's Prospective Payment System:

Throughout the 1980s a tremendous number of rural hospitals closed their doors nationwide due to the impact of rural outmigration, shifting demographics and changes in Medicare payment methodologies.

This section of the report elaborates on the impact of DRGs:

Early on, Medicare and many other third party insurers simply paid what the hospital charged for the care received by the beneficiary. Then, in 1982, as a result of the TaxEquity and Fiscal Responsibility Act8 (TEFRA), Medicare started transitioning over to a new reimbursement methodology called the prospective payment system in an effort tocontrol costs. For inpatient services, Medicare would pay a set amount per diagnosis related group (DRG)9

As McGuire et al. (1993) point out, PPS was designed to reward efficiency. If a hospital could find a way to keep its costs below the rate of payment, the difference could be considered a profit. This concept was problematic for many rural hospitals because costs were usually well above these generally determined reimbursement rates. Fluctuations in the cost of providing care were not taken nto account by Medicare and were skewed toward urban providers. Medicare has saved a lot of money over the years but cost rural America a lot of hospitals as well.

A lot of hospitals did close and those that stayed open shifted inpatient beds to other lines of service. Things only got worse through the years as Medicare tightened its noose and private payers adopted the DRG model. We've been on a trajectory of more and more regulatory baggage ever since but it has been smooth. Obamacare means we'll progress along that continuum. It'll be disruptive but not nearly so much as with DRGs unless I miss my guess.

So what, says Bob, does this mean for hospitalists? Why, value! It's been Bob's mantra for years and it goes something like this: the hospitalist model has proven its value (in terms of resource utilization and outcomes) up to now and will have to work even harder to do so in order to thrive as a specialty in the future. I'm sure Bob would have some nuance to add but it's certainly the group think at SHM these days. So we have two ideas in need of critical examination.

First, have we proven our value by any measure? Bob says in his post:

The point here is that, just as hospitalists took over the world of hospital care because they demonstrated that they could provide high-quality care at a lower cost, the increasing financial pressures that hospitals are under will create, in turn, pressures on hospitalist programs to achieve quality, safety, patient satisfaction, and efficiency outcomes at the lowest possible cost to the hospital...

The reason the hospitalist field thrived was that it demonstrated that it delivered better value than traditional models.

Well, that's debatable. As I've blogged time and time again the evidence is mixed. I'll not rehash it all here other than to say that one of the best and largest studies ever to address this question showed no benefit of the model. It can be accessed on page 25 of this issue of The Hospitalist but as far as I know has never been published in a Medline indexed journal. So it's been tossed down the memory hole and has contributed to the publication bias that has plagued this literature ever since. I'm happy to listen to arguments on both sides of the question but you can't take it for granted that the hospitalist model has been proven superior to the traditional model. There's just not a clean evidential case to be made.

In terms of demonstrating our value to secure our future, how about just showing up? Outside of our ranks fewer and fewer doctors are willing to take care of hospitalized patients. There’s no reason to think the increasingly harsh regulatory environment will do anything other than drive the rest of the non-hospitalists out of the building.

Consider emergency medicine and its parallels with our specialty. Though under the same economic and regulatory pressures as we are you don’t find them crowing about their value. Their emphasis is clinical which is why I have so many of EM blogs linked here. They’re thriving quite well with that singular focus. There are lessons we can learn from them.

What's the optimal duration of antibiotic treatment for ventilator associated pneumonia?

Short duration of treatment was as good as long duration in this systematic review. Keep in mind though that short duration was defined as 7-8 days.

SHM 2014: visceral reactions

The 2014 national meeting of the Society of Hospital Medicine was held March 25-27. I've been busy since I got back and am just now getting around to “blogging the conference.” This, I hope, will be but one of a series of posts about the meeting.

Bob Wachter shared some of his thoughts the other day. I thought I'd read his post before starting. Bob can be a little provocative and sure enough his comments got me going.  In Bob's opening I was struck by this:

As Win Whitcomb, who co-founded SHM, wrote to me, the meeting is “a mix of love, deep sense of purpose, community, mission, changing-the world, and just plain sizzle,” and I completely agree.

Unfortunately that quote matches my own observations concerning what the sizzle was about: community, mission, changing the world. But what happened to the clinical care of the individual hospitalized patient? Sadly, there didn't seem to be a lot of energy focused on that aspect. Sure there were clinical break out sessions (yes, they were good and will be the subject of future posts here) but they seemed to be relegated to a lesser status. It was as if the clinical content was incidental. That seems to be the general direction of the organization.

It wasn't always that way. It was different when I first attended our national meeting about a decade ago (when we were known as NAIP, the National Association of Inpatient Physicians). The buzz as I remember it back then was about things like sepsis, pneumonia, mystery cases and complex cases of thromboembolic disease. The focus was clinical.

Not so much nowadays. In the plenary sessions I got the feeling this was a meeting for hospital administrators, policy makers and public health professionals rather than doctors. The “patients” they talked about were the hospitals, the health care systems and the larger communities, not the individuals populating the hospital wards.

We need the leaders of our field to go back to promoting hospitalists as clinicians. Unfortunately I didn't see that happening at SHM 14.

EM talks from Vanderbilt

By Corey Slovis and others.

Wiki Tox

An open source toxicology site. Lots of good resources here.

Update on serotonin syndrome

Free full text review.

Brain dysfunction in sepsis

A review.

The Z-drugs: zolpidem, zopiclone, and zaleplon

From a recent review:

The Z-drugs zolpidem, zopiclone, and zaleplon were hailed as the innovative hypnotics of the new millennium, an improvement to traditional benzodiazepines in the management of insomnia. Increasing reports of adverse events including bizarre behavior and falls in the elderly have prompted calls for caution and regulation..Z-drugs exert their effects through increased γ-aminobutyric acid (GABA) transmission at the same GABA-type A receptor as benzodiazepines..Poisoning with Z-drugs involves predominantly sedation and coma with supportive management being adequate in the majority. Flumazenil has been reported to reverse sedation from all three Z-drugs. Deaths from Z-drugs are rare and more likely to occur with polydrug overdose.

The Magic Eye method of ECG rhythm assessment

Magic Eye posters were quite the rage a couple of decades ago. I got pretty good at stereoviewing so I'll have to try this. It might come in handy if there are no calipers around.

Via RESUS ME

A simple clinical prediction rule for the presence of CAD in patients presenting with heart failure

Published here in AJC. This may help in selecting those patients who need coronary angiography. The new ACC heart failure guidelines do not make a strong statement on coronary angiography or non invasive imaging indications, leaving it to clinical assessment.