When med students post unprofessional content on social networking sites

From a survey in the JAMA issue on medical education:

Results Sixty percent of US medical schools responded (78/130). Of these schools, 60% (47/78) reported incidents of students posting unprofessional online content. Violations of patient confidentiality were reported by 13% (6/46). Student use of profanity (52%; 22/42), frankly discriminatory language (48%; 19/40), depiction of intoxication (39%; 17/44), and sexually suggestive material (38%; 16/42) were commonly reported. Of 45 schools that reported an incident and responded to the question about disciplinary actions, 30 gave informal warning (67%) and 3 reported student dismissal (7%). Policies that cover student-posted online content were reported by 38% (28/73) of deans. Of schools without such policies, 11% (5/46) were actively developing new policies to cover online content. Deans reporting incidents were significantly more likely to report having such a policy (51% vs 18%; P = .006), believing these issues could be effectively addressed (91% vs 63%; P = .003), and having higher levels of concern (P = .02).

Therapeutic hypothermia after cardiac arrest

Cost effective in this new analysis.

Exercise may reverse non-alcoholic fatty liver disease

---and the effect was independent of weight loss.

Medscape CME.

Primary source.

Practical overview of noninvasive ventilation

This is the best paper I'm aware of on the subject. It covers a variety of indications.

IV and PO antibiotic options for cellulitis

From The Hospitalist.

Guideline concordant treatment of community acquired pneumonia

---improved outcomes and reduced resource utilization in this study.

Electrocardiographic findings in arrhythmogenic right ventricular dysplasia

Via Circulation.

ER throughput in the U.S.

We’re still not doing a very good job.

Cutaneous manifestations of liver disease

Some of these apply to liver disease in general while others are associated with specific etiologies (e.g. Hep C, hemochromatosis).

Via CCJM.

Ablation or drugs for atrial fibrillation?

Ablation is far from perfect but is getting better. Although preliminary data suggest it is more effective than drugs an upcoming large comparative trial may provide better answers.

A recent review in CCJM discusses current indications and complications. Complications, particularly pulmonary vein stenosis and atrioesophageal fistula, may appear relatively late and should be recognized by hospitalists.

Related editorial here.

Appropriateness criteria for stress nuclear cardiac imaging

A document written by the AHA, the ACC Foundation and other specialty organizations. The tables are good for quick reference, and those portions dealing with acute chest pain will be of particular interest to hospitalists.

A clinical prediction instrument to assess risk of tuberculosis in patients admitted with pneumonia

You admit a debilitated patient with pneumonia to the general medical ward. He does not respond well and has a long drawn out hospital course. Weeks later his sputum specimens reveal tuberculosis. Meanwhile several hospital nurses and respiratory therapists have converted their tuberculin skin tests. You're kicking yourself for not having isolated the patient. But how could you have known? You wanted to be a good steward of hospital resources and not utilize isolation rooms unnecessarily. Here's a clinical prediction instrument to help you decide which patients to isolate.

Causes of cardiac arrest in the absence of structural heart disease or ECG abnormalities

From a series in Circulation:

Sixty-three patients in 9 centers were enrolled (age 43.0±13.4 years, 29 women). A diagnosis was obtained in 35 patients (56%): Long-QT syndrome in 8, catecholaminergic polymorphic ventricular tachycardia in 8, arrhythmogenic right ventricular cardiomyopathy in 6, early repolarization in 5, coronary spasm in 4, Brugada syndrome in 3, and myocarditis in 1.

...28 patients (44%) were considered to have idiopathic ventricular fibrillation.

The American Medical Student Association and the National Center for Complementary and Alternative Medicine

---may not want you to see this paper.

A few years ago the NIH and the NCCAM awarded a grant to the AMSA Foundation to help introduce CAM curricula at 14 MD and DO granting medical schools. The AMSA project was known as EDCAM.

Investigators in the department of Medicine at Baylor looked at the curricula and concluded, in September's issue of Academic Medicine (my emphasis):

The authors reviewed the educational material concerning four popular CAM therapies-herbal remedies, chiropractic, acupuncture, and homeopathy-posted on the integrative medicine Web sites of the grant recipients and compared it with the best evidence available. The curricula on the integrative medicine sites were strongly biased in favor of CAM, many of the references were to poor-quality clinical trials, and they were five to six years out of date. These “evidence-based CAM” curricula, which are used all over the country, fail to meet the generally accepted standards of evidence-based medicine. By tolerating this situation, health professions schools are not meeting their educational and ethical obligations to learners, patients, or society.

Well, we didn't need a formal survey to reach the conclusion in that last sentence. This is what Orac and I and a few other bloggers have been pointing out for some time. The background of this paper offers an insightful glimpse into the antecedents of quackademic medicine.

Non invasive ventilation after extubation in patients with hypercapnic respiratory failure

Via Lancet:

We aimed to assess prospectively the effectiveness of non-invasive ventilation after extubation in patients with hypercapnia and as rescue therapy when respiratory failure develops.

Methods

We undertook a randomised controlled trial in three intensive-care units in Spain. We enrolled 106 mechanically ventilated patients with chronic respiratory disorders and hypercapnia after a successful spontaneous breathing trial. We randomly allocated participants by computer to receive after extubation either non-invasive ventilation for 24 h (n=54) or conventional oxygen treatment (n=52).

……Respiratory failure after extubation was less frequent in patients assigned non-invasive ventilation than in those allocated conventional oxygen therapy (8 [15%] vs 25 [48%]; odds ratio 5·32 [95% CI 2·11—13·46]; p less than 0·0001). In patients with respiratory failure, non-invasive ventilation as rescue therapy avoided reintubation in 17 of 27 patients. Non-invasive ventilation was independently associated with a lower risk of respiratory failure after extubation (adjusted odds ratio 0·17 [95% CI 0·06—0·44]; p less than 0·0001). 90-day mortality was lower in patients assigned non-invasive ventilation than in those allocated conventional oxygen (p=0·0146).

I suspect these were patients with chronic hypercapnia and acute on chronic respiratory failure. The non invasive ventilation strategy was effective both as a routine measure and a rescue measure.

Medscape commentary here.

The competing ideas of accountability and no blame

A decade ago the Institute of Medicine (IOM) issued its landmark patient safety recommendations. Included was the statement that medicine should move away from a culture of individual blame toward a systems based approach of safety enhancements. Don Berwick, president of the Institute for Health Care Improvement, echoed this sentiment in his address at SHM 2008. He said that the onus for patient safety should shift away from individual doctors because they, most of them anyway, traditionally run at top speed. To continually ask overstressed doctors to do “just a little more” to fix safety problems, he argued, would be counterproductive. Among the benefits of a blame-free approach, many patient safety experts also agreed, would be a new culture of transparency.

Ironically, the IOM, with the issuance of its report, undermined its own aspirations for a culture of transparency right out of the gate! They did this by indiscriminately referring to a broad spectrum of adverse patient outcomes as “errors.” This unfortunate attribution, based on faulty analysis of a landmark study on adverse hospital events, I have argued, did much to sabotage the cause of patient safety in the decade that followed. (For the original investigator’s own criticism of the IOM’s interpretation see this editorial). Instead of an era of transparency we entered a heightened culture of blame and finger pointing. The most vivid example of this, of course, is Medicare’s never events policy, of which we are just beginning to realize the adverse consequences. According to a recent report by the Patient Safety Project we’ve effectively implemented virtually none of the IOM’s patient safety recommendations for system improvement and transparency. I argued that this should not be surprising given the heightened culture of blame fueled by faulty analysis of research findings, sloppy use of language and media hype.

So now we have Bob Wachter offering a little different take. He wonders whether we’ve taken the no-blame idea too far:

In this week’s New England Journal, Peter Pronovost and I make the case for striking a new balance between “no blame” and accountability. Come on folks, it’s time.

I agree with much of the substance of Bob’s argument although I have a problem with his tone and choice of terms. We can start with the premise that either of the two competing ideas, blame and no-blame, can be taken to an unhealthy extreme. We can also agree that if a health care worker repeatedly flouts safety rules there should be consequences.

Bob goes on to address the problem of hand washing compliance:

At most hospitals, hand hygiene rates hover between 30-70%, and it’s a near-miracle when they top 80%. When I ask people how they’re working to improve their rates, the invariable answer is “we’re trying to fix the system.”

Now, don’t get me wrong. I believe that our focus on dysfunctional systems is responsible for much of our progress in safety and quality over the past decade. We now understand that most errors are committed by good, well-intentioned caregivers, and that shaming, suing, or shooting them can’t fix the fallibility of the human condition.

But not washing hands? When I hear, “It’s a systems problem,” my BS detector goes a little bit haywire, particularly after I walk around the hospital and see alcohol gel dispensers every 2 feet and glossy photos of smiling clinical leaders cleaning their hands at every turn.

Well, if as many as 70% of hospital personnel are not washing their hands I’d say the problem is pretty systematic. At SHM 09 Bob mentioned a company that installs video surveillance equipment, monitors and gives real time feed back on hand washing compliance rates on individual wards. He’s been lobbying to get it installed at his institution, UCSF. It looks like a great idea and guess what? It’s a system enhancement!

Meanwhile our culture of blame devolves. The notion that “adverse event equals medical error” has been codified administratively by Medicare. The trial lawyers are watching.

We should learn from the failed IOM initiative that words like “error” mean things. We need to be more careful how we use them.

Selective skepticism

From time to time I’ve done battle with Daniel Carlat over CME and industry support. I’m repeatedly amazed by what seems to be his selective skepticism and outrage about bias in medical education, ranging from extreme cynicism about anything touched by pharma to utter credulity concerning non-industry supported sources (buried somewhere in one of our comment threads is an interesting exchange about NCCAM supported CME). It’s as if freedom from pharma influence is the litmus test for reliable information.

I’ve tried repeatedly to call out the inconsistency in this attitude but haven’t succeeded nearly as well as The Last Psychiatrist did in a recent post (H/T to Retired Doc):

It's excellent that Daniel Carlat thinks doctors like himself cannot be trusted to read and interpret their own studies, and that some other group of-- doctors? lawyers? what?-- with special bias-immunity rings need to be assembled to protect us. But those people are still people. This is why the NIH, with their incestuous grant reviewers, crazy politics and flavors of the decade philosophies is so dangerous-- they're just as biased as Pfizer except you think they are objective.

Although the post singled out Dr. Carlat concerning a piece he coauthored in Internal Medicine News all the pharmascolds are pretty much in lockstep with this view.

Quackademic medicine update

I haven’t posted anything on this topic in a while. Here’s a nice update from Science Based Medicine.

McAllen, Texas---another dubious distinction

Seems it’s also the allergy capital of the U.S.

Noninvasive ventilation for COPD exacerbations

The results reported in the latest paper are consistent with prior reports:

Conclusions

These results demonstrate that noninvasive positive pressure ventilation, in a pulmonary ward, reduces the need for endotracheal intubation, particularly in the more severe patients, and leads to a faster recovery in patients with acute exacerbation of chronic obstructive pulmonary disease.

Medscape commentary here.

Disruptive physicians

Despite the fact that Joint Commission’s disruptive behavior standards now apply equally across all disciplines in the health care environment, in common usage the discussions usually focus on doctors. Even more so these days the attention seems to be shifting to hospitalists. As Bob Wachter noted in a recent blog post, hospitalists are now expected to be the “best behaved doctors in the building.” In part this is because, as Bob pointed out, hospitalists’ and hospitals’ incentives and accountabilities are aligned, like never before. Or so we would hope.

I’m thinking back to my pre-hospitalist days of traditional internal medicine practice. My medical group was one entity and the hospital was another. My accountability was to meet the requirements of medical staff membership. That was it. On a couple of occasions I and some of my colleagues did battle with the hospital. Back then we believed we were just advocating for better patient care, but things have since changed. I wonder if some of those actions would now be considered disruptive behavior.

How well aligned are those incentives, really? Every day I see competing agendas between the hospital and physicians, and within the hospital. These tensions can range from healthy to counterproductive. As hospitalists, the hospital is now one of the patients we must treat. That being said, our most important patients are the human beings that occupy the beds. The best I can do as a hospitalist is to advocate for those individual patients above all else. Occasionally that will conflict with the business incentives of the hospital. Will I be perceived as disruptive?

Neurologic prognosis after cardiac arrest

Updated in NEJM.

Key points:

…patients whose pupillary reactions were absent at day 3 after cardiac arrest had poor outcomes (false positive rate, 0%; 95% confidence interval [CI], 0 to 3).

...the absence of a corneal reflex at 72 hours was associated with no false positives for a poor outcome (95% CI, 0 to 14 in one study¹⁸ and 0 to 41 in the other).

If the patient received a therapeutic hypothermia protocol I assume time zero would be at completion of the protocol rather than the time of the arrest but the review is not clear on that point. It does mention therapeutic hypothermia as a potential confounder in assessing for these neurologic signs over time.

The motor response to noxious stimuli also provides useful prognostic information. Several prospective studies, including one multicenter study involving more than 400 patients with cardiac arrest, showed that a motor response to noxious stimuli that was no better than extensor posturing (i.e., a decerebrate response or no response) at 72 hours was associated with no false positives for a poor outcome …

The author cautions that if the patient received therapeutic hypothermia this sign may not be reliable until day 6 or beyond.

In a prospective study involving 407 patients, myoclonic status epilepticus at 24 hours after arrest was associated with no false positives...

The caution here is that this syndrome must be differentiated from other seizure like syndromes, which means you'll want to get an EEG and some help from a neurologist.

Theophylline to help wean patients from mechanical ventilation

Few patients require weaning from mechanical ventilation. Theophylline has largely been discarded from day to day pulmonary medicine. Interest in the use of theophylline as a stimulant to help in difficult weaning situations, however, persists. Pathophysiologic rationale, animal studies and low level clinical data indicate that theophylline improves respiratory muscle function. High level clinical studies simply have not been done.

This topic was recently reviewed in Clinical Pulmonary Medicine. The authors of the review were cautiously favorable towards the use of theophylline:

Overall, available data and experience suggest a role for methylxanthines in facilitating liberation from mechanical ventilation of adult patients, though the paucity of available studies invites further research regarding this specific application.

The authors suggest that when used, frequent monitoring of serum levels is advised, aiming for levels slightly below the usual therapeutic range.

Alcoholic hepatitis review in NEJM

In this update the use of corticosteroids with patient selection based on severity scores and the use of pentoxifylline were discussed.

Neutropenic precautions

There’s a nice post on this topic in the Clinical Correlations blog titled Neutorpenic Precautions Demystified. It should have been titled Neutropenic Precautions Debunked because it’s one of the most non-evidence based things we do in medicine. Save for a few notable exceptions these patients get infected from within rather than from without.

Should this well entrenched procedure be abandoned? I don’t know. I’d hate to foster a casual attitude in the care of these patients. As with the care of all patients hand washing is essential.

Spinning negative RCTs

---is very common, according to a presentation at the 2009 International Congress on Peer Review and Biomedical Publication. Comments from the presenter:

"We should be really careful about the way people present and conclude their articles. And for academics, they should be very careful about the way they write articles. I often work with principle investigators in writing their articles, and I always need to calm them down, because they believe that their treatments work and they try to frame the results in a specific way."

Considering all the negative studies that are buried as a result of publication bias this may be the tip of the iceberg, and it’s about much more than industry influence. Academic careers and reputations are at stake, and, besides, investigators just want to believe their treatments work.

Board certification for hospitalists

Recognition of focused practice is the more correct term. According to Bob Wachter it’s cleared the final hurdle of approval by the American Board of Medical Specialties and will be rolled out in about a year. I wonder if there are any board review resources available or in development. Stay tuned.

Probiotics to treat C diff?

Not helpful according to this brief update from CCJM.

Profiles in heart failure: clinical predictors of heart failure with preserved or reduced EF

From a new paper in Circulation:

Multivariable predictors of HFPEF (versus HFREF) included elevated systolic blood pressure (odds ratio [OR]=1.13 per 10 mm Hg; 95% confidence interval [CI], 1.04 to 1.22), atrial fibrillation (OR=4.23; 95% CI, 2.38 to 7.52), and female sex (OR=2.29; 95% CI, 1.35 to 3.90). Conversely, prior myocardial infarction (OR=0.32; 95% CI, 0.19 to 0.53) and left bundle-branch block QRS morphology (OR=0.21; 95% CI, 0.10 to 0.46) reduced the odds of HFPEF. Long-term prognosis was grim, with a median survival of 2.1 years (5-year mortality rate, 74%), and was equally poor in men and women with HFREF or HFPEF.

So if grandma has hypertension and a-fib her heart failure is probably associated with preserved EF. Male gender, prior MI and LBBB are associated with reduced EF.

Background: ECG predictors of dilated cardiomyopathy here and here.

The American Academy of Family Physicians promotes acupuncture

The best scientific critique of acupuncture I ever heard was by Wallace Sampson:

The other mistake people make about acupuncture, Sampson says, is that it offers specific cures. "It is nonspecific," Sampson says. "If it has the effect of, say, releasing endorphins through the application of needles, well, many things release endorphins -- a walk in the woods, a 5-mile run, a pinch on the butt."

Somewhat more pretentious (and promotional) articles on acupuncture have recently appeared in the journal American Family Physician. What’s ironic is that American Family Physician has a reputation as being a champion of evidence based medicine.

Health benefits of coffee

Works wonders for your cyclic AMP, too!

Comparative effectiveness research and the medical home

---was the focus of the latest Medscape Roundtable Discussion. This Roundtable, really a series of “cerebral burps” by a larger number of participants, was more of true panel discussion than its predecessors. I weighed in with predictable skepticism.

Obama on malpractice caps

There, he said it.

"You know, what I would be willing to do is to consider any ideas out there that would actually work in terms of reducing costs, improving the quality of patient care," Obama said in an interview with the CBS-TV show "60 Minutes."

"So far, the evidence I've seen is that caps will not do that," Obama added.

Nurses charged with felony for reporting woo pushing doctor to Texas medical board

I know I’m late with this. In fact, I’m woefully behind on blogging in general thanks to a couple of weeks on the road and a busy work schedule when I returned home. But, better to weigh in late than never. This is the case of Vicki Galle, RN, and Anne Mitchell, RN. I won’t cover the details---Orac has done that---but I have a few questions and points to raise which have not, as far as I can tell, been covered by others.

This episode raised issues on so many levels it’s hard to talk about it without conflating them. On one level it’s about abuse of prosecutorial discretion (not much to discuss there---it’s patently clear, and all seem to agree, this was excessive). On other levels it’s about whistleblower protection, cronyism and ill conceived hospital policies and procedures. Then there are the legal questions. The nurses, in referencing patient records in reporting Dr. Rolando Arafiles to the Texas medical board, were exempt from HIPAA penalties but is there some Texas statute that regulates release of information from public hospitals? It’s a stretch, but who knows? One of Orac’s commenters even raised the “nurses get no respect” issue which, in my view, is not what this is really about.

And what are the issues before the Texas medical board concerning Dr. Arafiles? That he endangered patients by pushing herbs? Most herbal woo is harmless. Was if fraud? Although I strongly believe herbal woo is fraud it is not considered so in the general public perception, or even as it is being taught in academic medical centers. Is it a violation of Stark rules prohibiting self-referral and, if so, is that in the jurisdiction of the medical board? I don’t know.

What hasn’t been discussed enough is that this is a story of incorporation of woo into conventional medicine and two individuals who called it out. Galle and Mitchell were not just a couple of RNs working at Winkler County Memorial Hospital; they had significant roles in quality review and credentialing according to their civil complaint. As they tried to go through the proper administrative channels they were stonewalled---concerns were ignored and meetings to discuss the matter were repeatedly canceled. The abuse here was not only on the part of the sheriff and prosecutor but also on the part of hospital administrators who, no doubt, considered Galle and Mitchell guilty of “disruptive behavior.”

Although there were issues surrounding Dr. Arafiles besides the herbs clearly the herbal woo was a major focus of the complaint to the medical board, falling under the category of “non-therapeutic prescribing or treatment” according to exhibit B.

Given the increasing acceptance and promotion of quackery in hospitals and academic medical centers, the reporting of a doctor for promoting woo is a novel and courageous act. But it took place at a 25 bed hospital in Podunk USA. Can you imagine someone doing this at Yale or the University of Arizona?

Wake up and breathe

A summary of the protocol and the supporting evidence is provided here.

Emergency medicine's push-back on TPA for ischemic stroke continues

---but new evidence may be making a dent.

Emergency physicians have long been among the most vociferously opposed to tPA for stroke, but some are now reconsidering that stance. Most notable in that group is the Society of Academic Emergency Medicine, whose Board of Directors officially retired its policy questioning the use of thrombolytics in patients with acute ischemic stroke in January....

It is a stunning turnaround from the tumult surrounding the use of the clot-buster in stroke just six years ago when all of the major professional emergency medicine organizations - the American College of Emergency Physicians, the American Academy of Emergency Medicine, and SAEM - passed similar policies of no confidence in the emergency use of thrombolytics for stroke. ACEP is now reviewing its policy statement to determine if revisions are needed...

AAEM has not changed its policy, said the group's former president Robert McNamara, MD. He said the issue remains controversial, and will become more so as information emerges.

So where do emergency medicine physicians in the trenches stand?

In a study presented in May 2008 at SAEM's annual meeting, Dr. Scott and his colleagues found that 83 percent of the 199 emergency physicians who completed the survey would use tPA in an ideal setting. Seventy-two percent said its use in eligible patients represented ideal care but was not a legal standard of care while 27 percent said its use was ideal care and the legal standard. Forty-nine percent said existing data on the use of tPA in stroke are convincing, but 65 percent said they were uncomfortable treating without consultation. Sixty-six percent said a telephone consult was sufficient. Fifty-nine percent said they were concerned about the liability of not using tPA. On a 15-item test of knowledge about tPA, the median score was eight correct answers.

Another electrocardiographic pattern you need to know

Emergency Medicine professor James Roberts, MD is writing a series of articles on electrocardiographic patterns likely to be dismissed as nonspecific but which, in the appropriate clinical context, portend disaster. The latest is a discussion of Wellens syndrome.

Read it here.

A couple of important points about Wellens syndrome: It is highly predictive of proximal LAD disease. The electrocardiographic pattern evolves after pain resolution and apparent “response” of the patient to medical management, yet these patients are in need of early revascularization.

What Ezekiel Emanuel and his supporters don’t seem to understand

---is this:

Patients, especially when they are sick and least able to fend for themselves, are in dire need of an advocate, a professional who will take their part and protect their individual interests against the often competing interests of a hostile and complex healthcare system, whose only concern is reducing costs. Patients abandoned in such a system without their rightful advocate are in a very dangerous position indeed. This is why the classic doctor-patient relationship is so critically important. And this is why Emanuel’s position is wrong. If we are to control healthcare costs, we need to find some way of doing it other than to expect (or, more likely, coerce) physicians to place the needs of society ahead of the needs of their individual patients.

On the whole, Dr. Rich’s post offers a nuanced and respectful view of Emanuel’s writings. I’ve have a post in preparation in an attempt at a similarly nuanced view in response to a challenge from Orac, but Dr. Rich is a hard act to follow.

No one can fix health care on a grand scale

---but maybe your hospitalist program can create a little slice of Mayo in your own corner of the world. If enough of us do this, who knows?

Discharge summaries “grossly inadequate”

---according to this study.

Discharge summaries were available for 99.2% of 668 patients whose data were analyzed. These summaries mentioned only 16% of tests with pending results (482 of 2,927). Even though all study patients had tests with pending results, only 25% of discharge summaries mentioned any pending tests, with 13% documenting all pending tests. The documentation rate for pending tests was not associated with level of experience of the provider preparing the summary, patient’s age or race, length of hospitalization, or duration it took for results to return. Follow-up providers’ information was documented in 67% of summaries.

These were academic medical centers which should have been exemplars of quality documentation!

In today’s push for “efficient use” of hospital resources we see more and more patients shoved out the door with pending test results. This is a huge problem.

Most discharge summaries nowadays are generated by templates. Popular templates that I’ve seen, whether paper-based or generated by the EMR, tend to lack sections devoted to pending test results and follow up needs.

Via Hospital Medicine Quick Hits.

Perioperative statin use: a randomized controlled trial

Myocardial ischemic events at 30 days in these statin naïve patients undergoing vascular surgery were cut in half. Fluvastatin, the only available statin with an extended release form, was used. That’s an important property in patients who may be NPO for several days following their surgical procedure.

Via Hospital Medicine Quick Hits.

Helping launch an EMR go-live

I spent most of last week as part of the physician support team at our flagship hospital. It was more of a learning than a teaching experience for me. Here are a few observations:

The hospitalist group, 30 members strong, seem well organized and happy. The nurses and ancillary staff love them.

Although I was there primarily to support the hospitalists it was the non-hospitalist docs, generally an older bunch, who needed the most help. Many of the hospitalists had trained on CPOE. It was nothing new to them. Push back form the non-hospitalist docs, it seemed to me, was not against technology but against the unintended consequences of the new culture that inevitably results from implementation of an EMR. Their concerns are well founded. Although there are advantages of the EMR there are disadvantages too, and it has yet to be demonstrated that the advantages outweigh the disadvantages in a way that translates into meaningful improvements in patient safety. Some of the docs were angry but their basic attitude was one of healthy skepticism. There was no Luddite mentality that I observed.

Members of the support staff were dedicated and eager to help but some of them, the non-physician ones anyway, seemed unaware of unintended consequences and how the new EMR, initially, will adversely affect physicians' work flows. These are the folks who really push some doctors' buttons. I encountered a number of angry docs---docs who had already spent 30 minutes on something that should have taken 5. The best approach, I found, was to validate their concerns (because their concerns really are valid), get them unstuck so they could go on with their work, and try and encourage them that things will get better. Almost invariably their tone softened and they thanked me.

As an aside, while there I had the opportunity to visit the EICU which monitors all our system hospitals and gained a new appreciation for how those folks can be a real enhancement to patient care.

When it comes to tort reform Obama doesn’t get it

In his speech the other night President Obama made passing mention of tort reform. His solution? Bolster the patient safety movement! Concerning that, Dr. Wes said:

That was it. Medical malpractice reform by putting patient safety first. You could see the members of Congress sitting there somewhat stunned and with puzzled looks on their faces. They weren't sure if they should clap or not.

Quoting the NEJM perspective piece on patient safety by Obama and Hilary Clinton, Dr. Wes noted:

So there you have it. It will be medical liability reform through more safety supervisors, hand soap dispensers, operative "time outs" and hall monitors. No unseemly caps on financial damages. Boy, the Bar Association members must be giving each other "high fives" for how well the President handled that part of his speech, don't you think?

Patient safety is a laudable objective but to think that the patient safety movement will help solve the malpractice crisis is patently absurd. As I noted before, the patient safety movement has been a failure precisely because it furthers rather than mitigates the culture of blame and threatens to bring the malpractice crisis to a new level.

Procalcitonin based antibiotic use for lower respiratory tract infections more efficient than traditional guidelines

---in this study. Problem is it’s not available at the point of care in many hospitals.

Via Clinical Cases and Images blog.

Influenza

Time for another flu post, I guess. One of the better updates I’ve seen lately is this post form Science Based Medicine. I would only add that the folks responsible for naming this pandemic virus have done a very poor job. First they called it Swine Flu, misleading because it confused this strain with the one responsible for the 1976 scare and because it is really a re-assortment of avian, swine and human strains. Now they’re calling it H1N1, true but confusing as it implies nothing special or specific: H1N1 isolates have been involved in many ordinary seasonal outbreaks since 1977, and is in one of the ordinary seasonal strains this year.

Practical aspects of managing feeding tubes

This Medscape linked review covers a variety of aspects but focuses primarily on medication delivery.

Guidelines for nutritional support in critically ill patients

Via Critical Care Medicine.

How fast should we titrate statin drugs?

From a paper in the American Journal of Cardiovascular Drugs:

The average time to titration to maximum dose of statin therapy was longer for patients who experienced a cardiac event than for those who did not (3.5 +/- 2.2 vs 2.1 +/- 1.8 years; p = 0.0004). After accounting for other risk factors, the titration period was still significantly related to the presence of a cardiac event (p = 0.0060, odds ratio per month increase in the titration period 1.3, 95% CI 1.08, 1.58).

Conclusions: Despite potential limitations, the results of our study show that an excessive delay in titrating statin therapy to the optimal dose may lead to an increased risk of atherosclerosis-related events in high-risk patients.

In high risk patients maybe we should start high and back down later.

Insulin initiation in DM 2---early rather than late?

Maybe in some patients according to this review in Clinical Diabetes. I’ve argued before that over aggressive use of insulin in DM 2 promotes weight gain, fuels the metabolic syndrome and may cause macrovascular harm. When the initial presentation is one of marked hyperglycemia, however, the use of insulin as part of the regimen may be the only way to get that patient anywhere near goal. Early aggressive control with insulin may ameliorate beta cell fatigue, improve pancreatic function and enable reduction or even withdrawal of insulin later.

In patients with respiratory failure

---consider hypothyroidism.

Mourning the loss of basic clinical skills

In his recent essay in the Texas Heart Institute Journal Herbert L. Fred, MD points out another cause of excessive medical costs: the loss of basic clinical skills.

For nearly 4 decades now, I have watched with sorrow the progressive demise of bedside medicine. Admittedly, the advent of ultrasonography, echocardiography, computed tomography (CT), and magnetic resonance imaging has enabled us to establish diagnoses with speed, accuracy, and safety never before imagined. At the same time, however, overreliance on these technologic marvels has crippled physicians' use of the mind and the 5 sensory faculties to make diagnoses. Jumping from the patient's chief complaint to a host of tests and procedures has become virtually routine. And when that approach fails, the physician typically orders more tests and seeks numerous consultations.

This new way of practicing medicine has made the skilled clinical diagnostician a vanishing species, a true “dinosaur.” It has also taken most of the fun and challenge out of medicine. It has depersonalized the patient–doctor relationship and has essentially eliminated the individuality of patient care. I call this malady of practice “technologic tenesmus”: the uncontrollable urge to rely on the lastest medical gadgetry for diagnoses.

The article is well worth reading in its entirety.

Pancreatic neuroendocrine tumors

Gatrinomas, insulinomas, etc. Which ones are more often malignant? Which are associated with MEN and other hereditary tumor syndromes? Which are more commonly extrapancreatic? Get the answers here in a review from The Oncologist.

Non-typhoidal salmonella bacteremia

A review in Annals of Clinical Microbiology and Antimicrobials.

Mechanical ventilation terminology---words mean things

And if you don't understand what the words mean you can't understand the things the ventilator is doing to your patient. Understanding the words is no small task given the increasing complexity of mechanical ventilators and the inconsistency of terminology among manufacturers. Presented here is the closest thing we have to a standardized nomenclature.

The fragmented wide QRS---another important electrocardiographic sign

It is increasingly recognized that not all bundle branch blocks are alike. Designations such as complicated and uncomplicated bundle branch blocks have recently been suggested. A recent paper in Circulation: Arrhythmia and Electrophysiology reports that the finding of greater than 2 notches in the R or S wave of a wide QRS is of prognostic import:

f-wQRS was defined by the presence of greater than 2 notches on the R wave or the S wave and had to be present in greater than or equal to 2 contiguous inferior (II, III, aVF), lateral (I, aVL, V₆) or anterior (V₁ to V₅) leads. ECG analyses of 879 patients (age, 66.7±11.4 years; male, 97%; mean follow-up, 29±18 months) with bundle branch block (n=310), premature ventricular complex (n=301), and pQRS (n=268) revealed f-wQRS in 415 (47.2%) patients. Myocardial scar was present in 440 (50%) patients. The sensitivity, specificity, positive predictive value, and negative predictive value of f-wQRS for myocardial scar were 86.8%, 92.5%, 92.0%, and 87.5%, respectively. The sensitivity and specificity for diagnosing myocardial scar were 88.6% and 94.4%, 81.4% and 88.4%, and 89.8% and 95.7% for f-bundle branch block, f-premature ventricular complex, and f-pQRS, respectively. f-wQRS was associated with mortality after adjusting for age, ejection fraction, and diabetes (P=0.017).

In addition to bundle branch block, paced ventricular complexes and ventricular ectopic beats lend themselves to this analysis.

Early goal directed therapy update

This review was written by the Detroit group that originated the protocol. As a subset of the larger array of interventions recommended in the Surviving Sepsis Guidelines EGDT can viewed as a “bundle within a bundle.”

Controversy about EGDT broke out last year. Since EGDT was studied as a package of interventions questions have arisen as to the value of the individual components (e.g. do all patients need a central line and a hct target of 30?). An NIH study in early stages of development plans to address this. Arms of the study will include “Rivers protocol minus the central line” and “usual care.” (How ethical is it to have a usual care group given all the studies that show improved outcomes with protocol driven therapy---see below?).

Delivery of the entire package of EGDT as opposed to individual components had a great deal of prior evidence and pathophysiologic rationale to recommend it according to the paper:

Comprehensive resuscitation is a way to optimize systemic oxygen delivery (preload, afterload, arterial oxygen content, contractility), balance oxygen delivery with systemic oxygen demands, optimize the microcirculation, and use metabolic end points to verify efficient cellular oxygen use. Although there is much discussion about the components required to accomplish a comprehensive resuscitation, no single component dictates the overall intent of the resuscitation. These components are interrelated and should be considered as a continuum of care and not as isolated variables.

The paper reviews the data that have accumulated since the original Rivers paper, overwhelmingly supporting the EGDT protocol:

Eleven peer-reviewed publications (1569 patients) and 28 abstracts (4429 patients) after the original EGDT study have been identified from academic, community, and international settings. These publications total 5998 patients (3042 before and 2956 after EGDT). The mean age, sex, Acute Physiology and Chronic Health Evaluation II scores, and mortality were similar across all studies. The mean relative and absolute risk reduction was 46% (±26%) and 20.3% (±12.7%), respectively. These findings are superior to those from the original EGDT trial, which showed figures of 34% and 16%, respectively. When peer-reviewed publications are compared, the relative risk reduction exceeded 25% and absolute risk reduction exceeds 9% in all studies. This evidence shows effectiveness across a broad range of mortality risks.[9]

Finally, EGDT is cost effective:

Hospital costs for severe sepsis and septic shock account for over $54 billion of the Medicare and Medicaid budget. Reports in the literature have noted reductions in ICU length of stay, hospital length of stay, duration of mechanical ventilation, renal replacement therapy, vasopressor therapy, and pulmonary artery catheterization with early hemodynamic optimization. [68] , [69] These studies have shown that sepsis-related hospital costs can be reduced up to 20%. [70] , [71]

DNA explained to school kids---1960

From The Thread of Life.

The new cardiac resuscitation

Here’s more supporting evidence. This is Dr. Gordon Ewy’s “cardiocerebral resuscitation” protocol. I’ll have more about what Dr. Ewy had to say about it at my recent Wyoming CME soon.

ER performance measures

This is a list generated by the National Quality Forum. Although it goes beyond the current CMS and JC “core measures” it suffers many of the same weaknesses of today’s performance movement: low hanging fruit items (things we’re already doing well) become documentation games; some listed items are not supported by high level evidence and items are listed that may compete with more important areas of best practice.

I did find it interesting that the list specifies two conditions (VTE and sepsis) for which it implies treatment should be underway before the patient leaves the ER.

Colchicine toxicity

Brief review and lessons from the courtroom.

A list of quality and patient safety organizations

Via Wikipedia.

Open courseware galore

Happy learning.

Via Instapundit.

UBC medical podcast wiki

The quality of this collection is variable and the intended audience is not always specified, so you may have to do some poking around.

Via Clinical Cases and Images blog.

Blogging success stories

Who knows where it might lead?

Via Clinical Cases and Images blog.

Did JFK have Schmidt’s syndrome?

Fascinating stuff here:

At the age of 43, he was the youngest man ever elected president. During his campaign and presidency, the media portrayed him as the epitome of youth and vigor. However, a recent review of his medical records reveals that Kennedy had the most complex medical history of any U.S. president.

The post from the Clinical Cases and Images blog also includes information on polyendocrine syndrome.

Back from Wyoming

---and all charged up about some of the topics presented at the meeting. Although a difficult schedule at work the rest of this week and then more travel will make blogging difficult I intend to post a few more topics from the meeting, as well as some final thoughts and information about next year, as time permits.

Guideline adherence in the treatment of dyspepsia

I’m fascinated by studies of this type. Why is adherence to evidence so low? According to this survey published in Alimentary Pharmacology and Therapeutics regarding to adherence to best practice in dyspepsia treatment:

Results The expert, community gastroenterologist and PCP groups endorsed 75%, 73% and 57% of best practices respectively. Gastroenterologists were more likely to adhere with guidelines than PCPs (P less than 0.0001). PCPs were more likely to define dyspepsia incorrectly, overuse radiographic testing, delay endoscopy, treat empirically for Helciobacter pylori without confirmatory testing and avoid first-line proton pump inhibitors (PPIs). PCPs had more concerns about adverse events with PPIs [e.g. osteoporosis (P = 0.04), community-acquired pneumonia (P = 0.01)] and higher level of concern predicted lower guideline adherence (P = 0.04).

Conclusions Gastroenterologists are more likely than PCPs to comply with best practices in dyspepsia, although compliance remains incomplete in both groups. PCPs harbour more concerns regarding long-term PPI use and these concerns may affect therapeutic decision making. This suggests that best practices have not been uniformly adopted and persistent guideline-practice disconnects should be addressed.

As revealed by the study, one of the causes of guideline-practice disconnects is concern over adverse effects. What may be less clear is whether this is appropriate concern or over reaction to hype. Of course PPIs have long term adverse effects but what does the best evidence say about the benefits in comparison to the risks when used appropriately? Put another way: If use of PPIs was more evidence based appropriate use would increase and inappropriate use would decrease. Then wouldn’t patients be better off?

The media put adverse effects in the public spotlight, but not the benefits of guideline based use. Your gramma probably knows about the hip fracture risks of PPIs but how many people, even physicians, are familiar with the guidelines?

Diabetic foot ulcers

A review in Clinical Diabetes.

More from CME in the Tetons: updates in the treatment of cardiac arrest

Gordon A. Ewy, MD, professor of Cardiology at the University of Arizona Health Sciences Center, presented an update on this exciting and evolving field. As I have noted, first here and then in multiple subsequent posts, Ewy and his group have been years ahead of the AHA resuscitation guidelines. The 2005 guidelines, influenced by his work, made new recommendations emphasizing the importance of chest compressions. These recommendations, however only went half way towards full implementation of changes in the treatment of out of hospital cardiac arrest Ewy and his group have been advocating and implementing in some communities since 2003. In those communities, notably areas of Arizona, Wisconsin and greater Kansas City Missouri neurologically intact survival increased to an unprecedented degree.

Here is the paper from Kansas City, the latest community to benefit by a departure from the “evidence based” AHA guidelines. In a related editorial Ewy summarizes recent evidence and suggests a failing of evidence based medicine:

It is always scientifically correct to say that we must wait for randomized controlled trials in humans, but is it always morally correct?

I previously cited the slow progress in resuscitation as a failing of EBM here.