Yesterday I linked to the latest Newsweek piece on the ABIM and MOC. It was a follow up to an earlier Newsweek piece which you can access here for a little background. Though like much written on this subject it makes some simplistic assumptions about how doctors keep up in their specialties it is generally spot on. Though not new to this discussion I found the article added clarity. It is an important read.
I found this of particular interest:
Then, something strange happened, doctors say. The tests started including questions about problems that had nothing to do with how doctors did their jobs. For example, endocrinologists who worked exclusively with adults said they were forced to answer questions about endocrinology for children, even though the pediatric information was irrelevant to their practices. Heart specialists who do not perform transplants – and even those at hospitals with no heart transplant programs – said they had to study techniques for reading transplant tissue slides and how best to evaluate these patients so they could answer questions on the tests. But that knowledge was unrelated to the care they provide to their real patients, they said, and took time that they could have spent learning the latest medical findings about the cardiology work they actually perform.Videos and study sessions sold to help doctors prepare for re-certification exams often featured instructors saying physicians would never see a particular condition or use a certain diagnostic technique, but they needed to review it because it would be on the test.
This rings true to my own experience in attending board review courses sponsored by academic institutions. Speakers would say "you may never see this but it always seems to show up on boards.". Although this brand of teaching for the test is pervasive even among the most reputable board prep resources, the ABIM called it "cheating", took legal action and drove at least one board review company out of business --- one which, it appeared to me, was in competition with board prep activities ABIM had "partnered" with. Curiously, this particular ethical question has received scant attention in the discussion though I blogged it extensively a while back.
And citing the progressive decline in board exam pass rates the author asks these questions:
Wow. Was it Obamacare? Ebola? A sign of the end times? What was turning so many American doctors so stupid all of sudden? Not to worry, the ABIM declares—the board could help doctors keep their certification. All they had to do was pay to take the tests again. Making doctors appear ignorant became big business, worth millions of dollars, and the ABIM went from being a genial organization celebrated by the medical profession to something more akin to a protection racket.
The ABIM disputes that characterization. Lorie B. Slass, a spokesperson for the ABIM, says “there have been and always will be” fluctuations in test results, since different groups of doctors are taking the exam each year. But in each of the categories cited above, there are no statistically significant fluctuations—the passing rate keeps going down. So the point remains: Either doctors are getting dumber each year, or the test that helps determine who gets to practice medicine has less and less to do with the actual practice of medicine.
Indeed.
It goes on to describe the lavish salaries of ABIM's leaders. By contrast, according to the piece, the leaders of Teirstein's newly formed National Board of Physicians and Surgeons will work for free.
CKD is emerging as a risk factor for hypoglycemia in diabetic patients. Here's a nice discussion at Mayo Clinic Proceedings.
This one is shocking. Worse than even I thought.
More from Dr. Wes.
A big part of this whole discussion has been whether doctors, once certified, should even have to "maintain" this certification by jumping through more hoops in the first place. One of Dr. Wes's commenters effectively ridicules the notion by extending it to its logical conclusion:
Just got a letter from my alma mater saying that my BS in engineering would be revoked if I didn't come back to college and prove proficiency in calculus and heat transfer. They are charging me a large sum for this remediation and claim that it is best for society. The dean said that my diploma was 'rented' and not granted unconditionally.
Funny, my medical school said the same thing. I need to enroll in a weekend course to brush up on anatomy and biochemistry. The dean said that the Krebs cycle is making a come back.
Finally, if this wasn't bad enough. My residency program and fellowship directors left messages on my phone saying that I will have to round one weekend every six months or I will no longer be certified by their programs.
I am very thankful, though. It could always be worse with the elementary school, junior high and high school requiring proficiency. Wait, the phone is ringing...
---were not associated with harms in this study.
A recent review on this topic is available as free full text here.
Here are some key points that emerge from this review:
With a few notable exceptions aggressive decongestion in ADHF improves rather than degrades renal function.
There are several mechanisms for this, described in the review.
Aggressive use of loop diuretics, traditionally considered non-evidence based, has recently been shown to be associated with improvement in important outcomes.
These outcomes include readmissions, progression of chronic heart failure and mortality. Once considered necessary for symptom relief but non-evidence based, loop diuretics are joining the ranks of the neurohumeral antagonists as evidence based for important clinical outcomes.
Some cases of “cardiorenal syndrome” may instead be due to unrecognized other causes.
Examples include ATN, interstitial nephritis, obstruction and intra-abdominal hypertension.
A diminishing role of inotropes for diuretic resistance and cardiorenal syndrome, even in the short term.
From the review:
.. inotropic agents may worsen survival over the long term, even when used temporarily; therefore, they should be avoided if possible.[37] In the OPTIME-CHF (Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure) trial, the short-term use of milrinone increased in-hospital death and the 60-day risk of death or rehospitalization in ischemic HF, and increased arrhythmias in all HF.[38-40] Exogenous cardiac stimulation, at a time when the myocardium is significantly energy depleted, may result in further ischemic and apoptotic damage, and lead to the poor outcomes associated with these agents despite immediate short-term hemodynamic improvement. An inotrope, typically dobutamine, is still indicated temporarily in: (1) wet and cold HF with systolic blood pressure less than 85 to 90 mm Hg, or (2) wet and cold HF not responding to diuretic therapy.[41]
The treatment approach to this problem continues to evolve. This is from a recent update:
Recent findings: Retrospective and prospective (nonrandomized noncontrolled) studies provide data regarding the management of infections due to carbapenem-resistant Enterobacteriaceae. The combination of a carbapenem with colistin or high-dose tigecycline or aminoglycoside or even triple carbapenem-containing combinations if the minimum inhibitory concentration (MIC) range of carbapenem (meropenem and imipenem) resistance is 8 mg/l or less seems to have an advantage over monotherapy with either colistin or tigecycline or fosfomycin. For Enterobacteriaceae with MIC for carbapenems over 8 mg/l, combination regimens involve colistin, tigecycline usually administered in a double dose than that suggested by its manufacturer, fosfomycin and aminoglycosides in various combinations.
Summary: Suggestions based on the limited literature cannot be made safely. Combination regimens involving carbapenems for Enterobacteriaceae with MICs 8 mg/l or less for carbapenems (in dual combination with colistin or high-dose tigecycline or aminoglycoside or even triple combinations) seem to confer some therapeutic advantage over monotherapy. For Enterobacteriaceae with higher than the above-mentioned MICs, a combination of two or even three antibiotics among colistin, high-dose tigecycline, aminoglycoside and fosfomycin seems to confer decreased mortality.
Conclusions from a recent article in ACP Hospitalist:
Hypertension has not been clearly defined in the hospital setting. The current definition of hypertension pertains to patients with chronic hypertension in an ambulatory setting.
Hypertensive emergencies should initially be treated with parenteral antihypertensive medications.
There is no benefit to acutely decreasing BP in patients who have elevated BP but no hypertension-related target organ damage.
Reflexive treatment of hypertension based only on BP readings should be avoided, and potential harms of an acute drop in BP should be considered.
Recognition of new or undertreated hypertension might be an opportunity to educate patients about the risks of hypertension and to introduce strategies to achieve better control.
Hypertensive emergencies are defined by the presence of target organ damage, not a number.
It's been known for quite a while that BNP and proBNP levels tend to be low in obese patients, even in heart failure. It is also well known that the natriuretic peptides help maintain sodium balance by facilitating excretion in response to a sodium load and that their activities are antagonistic to the renin angiotensin system.
This all leads to the notion that reduced BNP is a mechanism by which obesity drives hypertension and other cardiovascular events. In an elegant piece of clinical research investigators at Vanderbilt University marshaled evidence in support of that mechanism and also demonstrated reversal of the abnormal BNP setpoint after weight loss surgery.
The American Journal of Cardiology recently published these findings from a large database:
A total of 665,804 procedures were analyzed, which were representative of 3,277,884 procedures in the United States. Use of bare-metal stents (BMS) was associated with greater occurrence of in-hospital mortality compared with that of drug-eluting stents (DES; 1.4% vs 0.5%, p less than 0.001). The association stayed significant after adjustment of various possible confounding factors (odds ratio for DES versus BMS 0.59 [0.54 to 0.64, p less than 0.001]) and also in propensity matched cohorts (1.2% vs 0.7%, p less than 0.001). The results continued to be similar in the following high-risk subgroups: diabetes (0.57 [0.50 to 0.64, less than 0.001]), acute myocardial infarction and/or shock (0.53 [0.49 to 0.57, less than 0.001]), age greater than 80 (0.66 [0.58 to 0.74, less than 0.001]), and multivessel PCI (0.55 [0.46 to 0.66, less than 0.001]). In conclusion, DES use was associated with lesser in-hospital mortality compared with BMS. This outcome benefit was seen across subgroups in various subgroups including elderly, diabetics, and acute myocardial infarction as well as multivessel interventions.
This study suffers from the weakness of using an administrative database but was very large. Though it was previously known that the use of DES was associated with less lumen loss and restenosis over weeks it is not intuitive that it would reduce immediate term mortality. The authors do not offer a mechanism.
Early criticism of DES concerned costs compared with BMS, with hospitals under prospective payment wondering if they could afford to offer them. In this database the cost excess of DES, though statistically significant, was minimal and would be of questionable impact.
From a recent update in Current Opinion in Rheumatology:
Purpose of review Pulmonary artery involvement (PAI) due to Behçet's syndrome, although rare, has always been a focus of interest not only in endemic areas but also in many parts of the world. This interest is shared by many disciplines other than internal medicine, such as radiology, cardiothoracic surgery, cardiology and respiratory medicine. Most importantly, our understanding of PAI has significantly changed in recent years.
Recent findings Recent work found the following: pulmonary artery aneurysms are not the only form of PAI. Solo ‘in-situ’ pulmonary artery thrombosis (PAT) can be found in up to one-third of the patients at presentation. Both pulmonary artery aneurysms and PAT present with similar clinical symptoms, whereas abundant hemoptysis is less frequent in PAT. PAI is strongly associated with thrombosis in the lower-extremity deep veins and right side of the heart. Varying and multiple pulmonary parenchymal lesions such as nodules, consolidations and cavities are part of this involvement as well. While either aneurysms or thrombosis could disappear successfully with immunosuppressives in up to 70% of the patients, the condition can be fatal still in one-fourth. Large aneurysms and high pulmonary artery pressures are associated with a poor prognosis.
From a review in the American Journal of Cardiology:
Considerable progress has been made over the last few decades in the management of clinically stable coronary heart disease (SCHD), including improvements in interventions (e.g., percutaneous revascularization), pharmacological management, and risk factor control (e.g., smoking, diet, activity level, hypercholesterolemia, hypertension). Although β blockers have long been used for the treatment of SCHD, their efficacy was established in the era before widespread use of reperfusion interventions, modern medical therapy (e.g., angiotensin-converting enzyme inhibitors, angiotensin receptor blockers), or preventive treatments (e.g., aspirin, statins). On the basis of these older data, β blockers are assumed beneficial, and their use has been extrapolated beyond patients with heart failure and previous myocardial infarction, which provided the best evidence for efficacy. However, there are no randomized clinical trials demonstrating that β blockers decrease clinical events in patients with SCHD in the modern era. Furthermore, these agents are associated with weight gain, problems with glycemic control, fatigue, and bronchospasm, underscoring the fact that their use is not without risk. In conclusion, data are currently lacking to support the widespread use of β blockers for all SCHD patients, but contemporary data suggest that they be reserved for a well-defined high-risk group of patients with evidence of ongoing ischemia, left ventricular dysfunction, heart failure, and perhaps some arrhythmias.
From Current Opinion in Pulmonary Medicine:
Recent findings
Clinical and epidemiological studies indicate that obese patients with asthma may represent a unique phenotype, which is more difficult to control, less responsive to asthma medications and by that may have higher healthcare utilization. A number of common comorbidities have been linked to both obesity and asthma, and may, therefore, contribute to the obese–asthma phenotype. Furthermore, recently published studies indicate that even a modest weight reduction can improve clinical manifestations and outcome of asthma.
Summary
Compared with normal-weight patients, obese and overweight patients with asthma have poorer asthma control and respond less to corticosteroid therapy.
Via Hospital Medicine Virtual Journal Club.
From a recently published analysis:
Background Community screening to guide preventive interventions for acute aortic disease has been recommended in high‐risk individuals. We sought to prospectively assess risk factors in the general population for aortic dissection (AD) and severe aneurysmal disease in the thoracic and abdominal aorta.
Methods and Results We studied the incidence of AD and ruptured or surgically treated aneurysms in the abdominal (AAA) or thoracic aorta (TAA) in 30 412 individuals without diagnosis of aortic disease at baseline from a contemporary, prospective cohort of middle‐aged individuals, the Malmö Diet and Cancer study. During up to 20 years of follow‐up (median 16 years), the incidence rate per 100 000 patient‐years at risk was 15 (95% CI 11.7 to 18.9) for AD, 27 (95% CI 22.5 to 32.1) for AAA, and 9 (95% CI 6.8 to 12.6) for TAA. The acute and in‐hospital mortality was 39% for AD, 34% for ruptured AAA, and 41% for ruptured TAA. Hypertension was present in 86% of individuals who subsequently developed AD, was strongly associated with incident AD (hazard ratio [HR] 2.64, 95% CI 1.33 to 5.25), and conferred a population‐attributable risk of 54%. Hypertension was also a risk factor for AAA with a smaller effect. Smoking (HR 5.07, 95% CI 3.52 to 7.29) and high apolipoprotein B/A1 ratio (HR 2.48, 95% CI 1.73 to 3.54) were strongly associated with AAA and conferred a population‐attributable risk of 47% and 25%, respectively. Smoking was also a risk factor for AD and TAA with smaller effects.
From a recent study:
Methods and Results In a randomized, 2‐period (6 week/period), crossover, controlled‐feeding study of 48 individuals with elevated LDL‐C (149±3 mg/dL), a cholesterol‐lowering diet with almonds (1.5 oz. of almonds/day) was compared to an identical diet with an isocaloric muffin substitution (no almonds/day). Differences in the nutrient profiles of the control (58% CHO, 15% PRO, 26% total fat) and almond (51% CHO, 16% PRO, 32% total fat) diets were due to nutrients inherent to each snack; diets did not differ in saturated fat or cholesterol. The almond diet, compared with the control diet, decreased non‐HDL‐C (−6.9±2.4 mg/dL; P=0.01) and LDL‐C (−5.3±1.9 mg/dL; P=0.01); furthermore, the control diet decreased HDL‐C (−1.7±0.6 mg/dL; P less than 0.01). Almond consumption also reduced abdominal fat (−0.07±0.03 kg; P=0.02) and leg fat (−0.12±0.05 kg; P=0.02), despite no differences in total body weight.
Conclusions Almonds reduced non‐HDL‐C, LDL‐C, and central adiposity, important risk factors for cardiometabolic dysfunction, while maintaining HDL‐C concentrations.
This article in CCJM reviews the evidence, with a focus on the transcutaneous devices. The evidence from clinical trials is somewhat mixed and preliminary. As with any device, improvements in the technology far outpace clinical trials. The bottom line for now is that it is an emerging option for certain patients unable to take oral anticoagulants.
The pattern and timing of T wave inversion can also be helpful as discussed here and here at the EMS 12 Lead blog.
As Henry J. L. (Barney) Marriott used to say, when you see T wave abnormality suggestive of simultaneous anterior AND inferior ischemia think acute cor pulmonale, as in massive or submassive PE.
Why would a hospitalist need to know about ECMO? The applications are expanding rapidly. Hospitalists are increasingly likely to be involved in the care of patients who need the procedure and may be involved, at least indirectly, in determining a patient's candidacy. Here is a very helpful free full text review.
In this large propensity-matched cohort analysis no mortality benefit was seen.
