A recently published study in the Lancet examined this question:
We undertook an open-label, randomised non-inferiority trial at 19 emergency departments in Switzerland, France, Belgium, and the USA. We randomly assigned patients with acute, symptomatic pulmonary embolism and a low risk of death (pulmonary embolism severity index risk classes I or II) with a computer-generated randomisation sequence (blocks of 2–4) in a 1:1 ratio to initial outpatient (ie, discharged from hospital greater than or equal to 24 h after randomisation) or inpatient treatment with subcutaneous enoxaparin (greater than or equal to 5 days)...
So in the outpatient arm the entirety of treatment was not really outpatient. Evidently patients remained in the ER or in an observation unit for up to 24 hours. More from the article:
...one (0·6%) of 171 outpatients developed recurrent venous thromboembolism within 90 days compared with none of 168 inpatients (95% upper confidence limit [UCL] 2·7%; p=0·011). Only one (0·6%) patient in each treatment group died within 90 days (95% UCL 2·1%; p=0·005), and two (1·2%) of 171 outpatients and no inpatients had major bleeding within 14 days (95% UCL 3·6%; p=0·031). By 90 days, three (1·8%) outpatients but no inpatients had developed major bleeding (95% UCL 4·5%; p=0·086).
So while there was no difference in mortality there was a small increase in recurrent VTE and bleeding with outpatient treatment. Despite this the authors concluded that outpatient treatment was safe in selected low risk patients. How did they define low risk? Using the the pulmonary embolism severity index (PESI). I discussed the PESI previously here. As I cited in that post, an older study had suggested that the PESI could help select patients for outpatient treatment. The original study on the PESI is here.
Biomarkers and echocardiography are the traditional tools for acute risk assessment in PE, but clinical scores like the PESI are emerging as comparable means.
Clinicians have long relied on the ABCD 2 score to help determine which patients who present to the ER with TIA can be sent home for completion of their work up as an out patient. But the tool had never been prospectively validated. A new study in CMAJ tried to do just that. The result? If you use the traditional cut off of a score of 5 the sensitivity is lousy. If you use AHA's recommended score of 2 the sensitivity improves considerably but the specificity is poor.
A related Medscape piece offers some insightful comments from one of the study authors and new perspectives on today's stroke care:
The investigators found that an ABCD2 score of more than 5 had low sensitivity (31.6%; 95% confidence interval [CI], 19.1% – 47.5%) for predicting subsequent stroke at 7 days. For predicting stroke at 90 days, its sensitivity was 29.2% (95% CI, 19.6% – 41.2%). "These sensitivities are too low to be clinically acceptable," Dr. Perry said...
"The proposed threshold by the American Heart Association, which is a score greater than 2 to indicate high risk, was very sensitive; however, it classified all but a few patients as high risk, so it is not very discriminating for early stroke," Dr. Perry noted.
Which means you might as well admit just about everybody, if not to the hospital to a stroke obs unit, if you have one, or hold them in the ER long enough to do more extensive imaging, more than just a CT scan.
How would the score perform if integrated with aggressive imaging in the ER? That's a question for further study.
Here's a really interesting study that looked at serum potassium levels after cardiac arrest:
The mean potassium level was 3.9±0.9mmol/l and thus within the reference range of 3.5–5.0mmol/l, but the overall prevalence of hypokalaemia was high (31.0%). Moderate rather than severe hypokalaemia was typically observed..
Among those six patients with extreme hypokalaemia defined as a potassium levels below the 2.5 percentile, two adult females were identified to suffer from previously untreated body scheme disorder with furosemide abuse (potassium 1.1 and 1.4mmol/l). Another patient (potassium 2.1mmol/l) suffered from poorly controlled bulimia nervosa and acute diarrhoea due to GI infection and one (potassium 2.4mmol/l) from untreated bulimic anorexia...
Conclusions
In contrast to moderately reduced potassium which is a frequent finding in adult patients at the time of admission for non-traumatic cardiac arrest, severe hypokalaemia is uncommon. The high prevalence of patients with body dysmorphophobic eating disorders in this group underscores accidental self-induced hypokalaemia may evolve as an important differential diagnosis in cardiac arrest in young female patients.
Mild to moderate hypokalemia after cardiac arrest may be redistributional, due either to endogenous catecholamines associated with the cardiac event or to administered epinephrine and therefore may not reflect pre-arrest potassium levels. In this study severe hypokalemia was associated with eating disorders and extreme dieting.
Upon admission to the hospital, her serum potassium level was noted to be very low, at 2.0 mEq/L...
Her medical chart contained a note that "she apparently has been trying to keep her weight down with dieting by herself, drinking liquids most of the time during the day and drinking about 10–15 glasses of iced tea”...
Terri's husband, Michael, later filed and won a malpractice suit against her obstetrician, Dr. Stephen Igel, who was treating her for infertility, on the basis that he failed to diagnose bulimia as the cause of her infertility.
Postmortem examination, including a molecular autopsy, found no evidence of structural heart disease or channelopathy.
Here's a New York Times piece profiling one psychiatrist who made the switch for economic reasons:
Like many of the nation’s 48,000 psychiatrists, Dr. Levin, in large part because of changes in how much insurance will pay, no longer provides talk therapy, the form of psychiatry popularized by Sigmund Freud that dominated the profession for decades. Instead, he prescribes medication, usually after a brief consultation with each patient.
Long sessions with psychiatrists doing talk therapy may seem foreign to young readers, except in old movies and novels. A psychiatrist colleague of mine who has psychoanalytic training misses the old tradition. He prescribes pills in his practice and does psychoanalysis as a hobby in his off time.
Intervention team physicians were prompted to address six parameters from a daily rounding checklist if overlooked during morning work rounds. The second team (control) used the identical checklist without prompting...
Compared to control, prompting increased median ventilator-free duration, decreased empirical antibiotic and central venous catheter duration, and increased rates of DVT and stress ulcer prophylaxis. Prompted group patients had lower risk-adjusted ICU mortality compared to the control group (OR 0.36, 95% CI 0.13-0.96, P=0.041), and lower hospital mortality compared to the control group (10.0% vs. 20.8%, P=0.014), which remained significant after risk adjustment (odds ratio 0.34, 95% CI, 0.15-0.76, P=0.008). Observed-to-predicted ICU length of stay was lower in the prompted group compared to control (0.59 vs. 0.87, P=0.02). Checklist availability alone did not improve mortality or LOS compared to pre-intervention patients.
The lesson? It's one thing to have checklists and another to use them for all they're worth.
---has been talked about for years. This piece from Medpage Today is a little dated but is the best summary I could find about it:
Although the group boasts close to 240,000 members, 29% are students or residents, who pay sharply discounted dues. Still more of the members are retirees, whose dues are also cut...
Of those members, 20.5% are medical students, 9% are residents, and 36.5% are 56 or older. As one delegate put it, "we have a lot of students and a lot of old docs, but not a lot of practicing physicians."
Declining membership and diminishing relevance. Most in the rank-and-file, I suspect, would tell you AMA no longer represents their professional interests. Why? According to theseposts the AMA repeatedly capitulates to increased government intrusion because they are conflicted: beholden to the government for their coding business. How so? AMA holds the copyright to the codes and CMS mandates them. There you go.
The topic was recently reviewed in Critical Care Medicine. These are now considered overlapping conditions with distinctions based on the percentage skin involvement.
One of the main pro Obamacare talking points was the lack of integration of medical care and the inefficiencies reflected in marked regional variation of services provided. The Obamacare answer is the HMO on steroids known as the accountable care organization (ACO). In these discussions Mayo Clinic has been repeatedly cited as the ideal of integration. But it seems Mayo rejects the recent CMS proposal for ACOs.
A study on in-the-field point of care lactate testing was discussed in a recent article in JEMS. Though the original study was a couple of years old it bears emphasis today given the poor rate of usage of the technique in the US. From the article:
The investigators conducted chart reviews on patients who had lactate levels measured prospectively, categorizing them into two groups: non-shock (lactate levels less than 4 mmol/L), and shock (lactate levels at least 4 mmol/L)...
The most staggering statistic was in-hospital mortality: the shock group had a 26.7% mortality rate compared with 1.2% for the non-shock group.
Staggering indeed. The benefit for patients is that the ER can be alerted from the field when a patient has a high lactate level and thereby get a head start in assembling the resources for EGDT (central line set up, etc), for which time is of the essence. In this respect it is analogous to the prehospital ECG in STEMI patients.
There are regulatory barriers in the US, well illustrative of the negative consequences of government intrusion, though they are not insurmountable. These are discussed in the article.
The medical news services have been running with this story, a study of a large database in California which looked at the effect of ambulance diversion, finding an association with increased MI mortality.
A few caveats. The association only held up for the more extreme scenario of 12 or more hours of diversion. In this era of reperfusion, AMI is one of the most time sensitive conditions presenting to emergency departments. So no conclusions can be drawn about ambulance diversion overall. For other populations of patients it is not known whether the risk of diversion outweighs the risk of hospital crowding and ED or hallway boarding.
The CDC is working on this although I cannot find anything about it on their website. I did find this story from JEMS, an EMS news service:
In the aftermath of the Joplin tornado, some people injured in the storm developed a rare and sometimes fatal fungal infection so aggressive that it turned their tissue black and caused mold to grow inside their wounds.
Scientists say the unusually aggressive infection occurs when dirt or vegetation becomes embedded under the skin. In some cases, injuries that had been stitched up had to be reopened to clean out the contamination...
"To my knowledge, a cluster like this has not been reported before," said Dr. Benjamin Park, head of the CDC team that investigates fungal diseases. "This is a very rare fungus. And for people who do get the disease, it can be extremely severe."
Of the several patients reported, three have died. Since they had multiple injuries and medical problems it is not known the degree to which the mortality is attributable to the infections.
A few observations. Zygomycosis is a term which describes infections with a group of closely related molds. The terminology can be confusing, and despite changes in the taxonomic classification the older term has persisted. It is also known as mucormycosis, a term which clinicians usually think of as a life threatening necrotizing infection of the oropharynx and neighboring structures in patients with DKA (always be mindful of the nasopharynx in your H and P when you admit a patient with DKA!).
Even nasopharyngeal mucor is rare and wound infection is virtually unheard of though not unprecedented. And it's not just the mucor group. Other molds can cause necrotizing skin and soft tissue infections. I recall a critical care CME meeting years ago where we were given an unusual presentation by a mycologist. He presented case after case of these infections involving species of molds I had never heard of. A huge variety of species inhabit trees, grass and other plants. Many cases did not involve known trauma. In the typical case the supposedly immunocompetent patient presented with a funny “dermatitis” and was shuffled around among the ER, the PCP and a dermatologist. Many patients were treated with antibiotics and referral to a surgeon was too late. In virtually all cases the outcome was bad, with loss of life or limb. (Did these patients have some not yet described immune deficiency or were they just unlucky?). The speaker, not a clinician himself, thoroughly scolded doctors for not “thinking fungus.” I can't remember the names of any of the species but the adage “think fungus” was indelibly emblazoned in my hippocampus. These are very aggressive infections requiring prompt antifungal therapy and surgical debridement with an urgency not unlike that of necrotizing fasciitis.
I agree with the premise of Diana Hsieh's video over at Black Ribbon Project: that Obamacare and other external forces are driving us closer and closer to central control and what she calls “cookie cutter medicine” (CCM), a bad thing for patients and the profession. Unfortunately she confuses CCM with evidence based medicine (EBM). Understanding that it was her personal and emotionally very compelling story, she used one of the worst possible examples: the treatment of hypothyroidism. Specifically it has to do with the question about whether triiodothyronine (T3) should be supplemented, alongside L-thyroxine (the standard replacement monotherapy), in some patients who say they still don't feel back to normal after laboratory monitoring indicates adequate replacement with L-thyroxine.
The widely accepted recommendation for monotherapy with L-thyroxine and against the use of products containing T3 is not cookie cutter medicine. Neither is it some guideline writer's opinion. Rather, it's in conformity with best evidence, and the evidence is extensive. The most definitive literature review is here. It concludes:
Conclusions: Until clear advantages of levothyroxine plus liothyronine are demonstrated, the administration of levothyroxine alone should remain the treatment of choice for replacement therapy of hypothyroidism.
There has been nothing additional published since that paper to indicate benefits of the use of T3. Careful analysis of the published studies indicates that those patients who indicated they felt better with the addition of T3 tended to lose weight and be over-replaced. Over-replacement is bad because it increases the risk of atrial fibrillation and osteoporosis. In at least one study the subjective benefits were transient. That makes perfect sense. T4, the inactive prohormone, is only very gradually converted to T3. The gradual onset of effect may blunt subjective awareness. T3 given directly is rapidly absorbed and its relatively short half life results in an initial “buzz” with maximal effect achieved in days as opposed to weeks. As far as I know there are no comparative studies which followed patients long enough to assess how the potentially devastating effects of osteoporosis, atrial fibrillation and loss of muscle mass (all consequences of over-replacement) ultimately impacted quality of life!
It is claimed in the video that some patients lack the ability to convert T4 to T3. That claim is unsupported as far as I know. A related claim is that TSH monitoring is not enough to assess the adequacy of therapy. I won't belabor the evidence and rationale here except to say that God and the patient's pituitary (assuming the patient has primary rather than secondary hypothyroidism) know better than anyone else how much and what kind of replacement the patient needs.
There may be occasional patients, rare exceptions, who benefit from combined therapy. If this is done it should be with the appropriate expertise and great caution against the hazards of osteoporosis and atrial fibrillation. Unfortunately, though, it sometimes falls into the realm of quackery.
Like Diana Hsieh I am concerned about a coming era of cookie cutter medicine, but this was a bad example. Her policy points are great. Unfortunately the bad science used in this case to back them up weakened the credibility. We can have evidence based medicine without cookie cutter medicine.
The external environment is driving it the other way according to Beth Haynes, MD. Go read the article and note the choice Berwick quote. HT to the Black Ribbon Project.
Which brings us to the third skill that you must have but haven’t been taught—the ability to implement at scale, the ability to get colleagues along the entire chain of care functioning like pit crews for patients. There is resistance, sometimes vehement resistance, to the efforts that make it possible.
Vehement resistance???? Talk about assuming facts not in evidence. Is Gawande projecting from his early career as a surgeon?
More:
Partly, it is because the work is rooted in different values than the ones we’ve had. They include humility, an understanding that no matter who you are, how experienced or smart, you will fail. They include discipline, the belief that standardization, doing certain things the same way every time, can reduce your failures. And they include teamwork, the recognition that others can save you from failure, no matter who they are in the hierarchy.
Gawande is flat out wrong to imply we've not had these values before. My earliest mentors taught the value of humility. Multidisciplinary was a buzzword early in my career.
Teamwork is important, but as DB points out we must be careful not to devalue individual expertise and judgment.
Results 277 (81%) of the 340 patients randomised were men; the patients had a mean age of 52.4 (SD 10.5) years, a body mass index of 31.9 (5.7), an Epworth sleepiness scale score of 10.1 (4.3), an apnoea-hypopnoea index of 43.5 (24.5). No differences between groups were seen at baseline. Compared with placebo and analysed by intention to treat, the mean 24 hour ambulatory blood pressure of the CPAP group decreased by 1.5 (95% confidence interval: 0.4 to 2.7) mm Hg (P=0.01). The mean 24 hour ambulatory blood pressure monitoring measures decreased by 2.1 mm Hg (0.4 to 3.7) mm Hg (P=0.01) for systolic pressure and 1.3 (0.2 to 2.3) mm Hg (P=0.02) for diastolic blood pressure. Mean nocturnal blood pressure decreased by 2.1 (0.5 to 3.6) mm Hg (P=0.01).
Though statistically significant the magnitude of the effect was small and the authors were circumspect about the clinical significance. Patients with more severe symptoms, which were excluded from this study, may derive greater antihypertensive effect.
---are out from the American College of Physicians. They recommend against intensive glycemic control for any patients, ICU or ward, with the exception of post surgical patients in the SICU. I've listened to plenty of speakers from the diabetes mafia at hospitalist meetings over the last several years and this turns everything they've said upside down.
Reviewed in NEJM. It's surprisingly common, often misdiagnosed as major depression or bipolar disorder, and carries a surprisingly high suicide rate. The prognosis with psychotherapy is not as grim as once thought.
Bronchoconstriction (even absent inflammatory stimuli) caused airway remodeling in this study. Airway remodeling took the form of increased mucus glands and an increased thickness of subepithelial collagen bands.
What if you substitute serial lactate measurements for ScvO2 and IVC assessment via bedside ultrasound for CVP? The ins and outs are discussed at the Academic Life in Emergency Medicine blog.
I've never met Dr. Herb Fred but sometimes I feel as though I'm on teaching rounds with him when I read his articles in the Texas Heart Institute Journal. Now there's a new book, reviewed here, which is a collection of Herb Fred sayings. From the review:
In person, Dr. Fred is the curmudgeon who will always ask the question that you forgot, point out the physical finding that you overlooked, or note the subtle deficiencies in your clinical approach that differentiate between merely good medical care and excellent medical care. He is the angel on your shoulder who elicits guilt when you allow technology to make a diagnosis in your stead, and he is the talented teacher who bestows the skills that make that technology less necessary.
The loss of physicians of this kind is slowly creating an intellectual anemia in the profession. For this reason, a collection of his aphorisms is of value. The Best of Herb Fred, MD: His Insights, Observations, and Everyday Reminders offers a return to real “doctoring,” for it emphasizes professionalism, duty to your patient, and bedside diagnosis. This concise assemblage of advice will serve physicians in any field of medicine.
It might make a nice gift for a graduating student or resident.
The American Medical Student Association (AMSA) is the largest and most influential medical student organization. In 2002 AMSA launched PharmFree, a campaign to limit interaction between the medical profession and the pharmaceutical industry. The leaders of the campaign purport to be advocates for evidence based medicine. From the website:
AMSA promotes the conscientious, explicit and judicious use of the current best evidence in clinical care.
Sounds great. Straight out of David Sackett's landmark paper on EBM! But the credibility of the campaign is weakened by the fact that AMSA also has a long history of promoting non-evidence based alternative medicine. I was, as far as I know, the first to point out this hypocrisy in 2005. Other bloggers have since takennotice. Now Thomas Sullivan at Policy and Medicine has taken notice and writes:
AMSA sold the Association of Accredited Naturopathic Medical Colleges a booth at the 2011 convention. As the author pointed out, AMSA will not take money from pharmaceutical companies, but they have no problem with taking money from “pseudoscience.” Perhaps a conflict of interest?
Consequently, the author described how he went up to the booth to find out what naturopathy is. He was told that they are “primary care physicians” who treat the “whole patient in a holistic way.” In addition, one of the table reps told the author that naturopathy subscribes to the use of homeopathy, herbalism, acupuncture, therapeutic touch, and “all sorts of other nonsense.” The author also pointed out that their “written materials were more straightforward about their quackishness.” Ultimately, while AMSA “professes to support evidence-based medicine,” the author was disturbed by the fact that AMSA would legitimize “quackery of this sort.”
Wild armadillos and many patients with leprosy in the southern United States are infected with the same strain of M. leprae. Armadillos are a large natural reservoir for M. leprae, and leprosy may be a zoonosis in the region.
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.
---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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
According to a recent study published in the Archives of Surgery, merely giving doctors feedback on the hospital charges reduced costs:
Intervention A weekly announcement to surgical house staff and attending physicians of the dollar amount charged to nonintensive care unit patients for laboratory services during the previous week.
Main Outcome Measure Dollars charged per patient per day for routine blood work.
Results At baseline, the charges for daily phlebotomy were $147.73/patient/d. After 11 weeks of residents being made aware of the daily charges for phlebotomy, the charges dropped as low as $108.11/patient/d. This had a correlation coefficient of –0.76 and significance of P = .002. Over 11 weeks of intervention, the dollar amount saved was $54 967.
Of course that dollar amount is artificially inflated because it represents hospital charges rather than actual costs. All things being equal this means nothing to most patients and to Medicare and other payers that are based on DRGs. It's the hospital that's “out” the amount of money these extra tests cost.
But all things are not equal. There are other factors. A dropping hemoglobin picked up on the daily CBC enables the clin doc specialist to code “acute blood loss anemia” which might more than make up for the added cost. Similarly hyponatremia, hypokalemia or a rising creatinine on the daily chem profile might have the same effect.
Daily labs are necessary on some but not all patients. Most hospitalized patients on IV fluids need daily chemistries. There are probably multiple reasons why doctors do it to excess. CPOE may be a facilitator.
From a review in Expert Reviews of Pulmonary Medicine, it’s not at all clear:
Unfortunately, it is difficult to accurately study the effects of marijuana on the respiratory system. This is related to the inconsistency in the method of administration between subjects,[7] the illegal nature of the substance leading to problems with nonbiased recruitment, the concurrent use of tobacco in many participants and the often relatively short duration of regular marijuana use compared with tobacco smoking.[12] Nevertheless, it is the opinion of the authors that cannabis smoking has a detrimental effect on the respiratory system in a number of ways, including symptoms, lung function, and possibly carcinogenesis and respiratory tract infections,[13] although the available evidence is conflicting.
The latest study from Circulation is another of many to show the cardiovascular hazards of NSAIDs, and at least the second one to show that even short term use if dangerous.
This one looked at patients with prior MI although multiple studies have shown hazards in patients with and without prior cardiovascular disease.
In the conclusion the authors make the strongest statement yet:
Even short-term treatment with most NSAIDs was associated with increased risk of death and recurrent MI in patients with prior MI. Neither short- nor long-term treatment with NSAIDs is advised in this population..
I've harped on this before emphasizing that they're all dangerous, not just Vioxx.
The elaborate and cleverly designed system illustrated in the video below can increase compliance to virtually 100% but how much does it really serve patient safety? Note that none of the health care workers profiled in the video cleaned their stethoscopes.
Interesting points from this small case series include the fact that IVIG and terbutaline may be effective preventive treatments, and that IgG monoclonal gammopathy was observed in 89%.
An opinion piece in Nature Medicine by Thomas Stossel and Lance Stell deals with the mounting public pressure and increasingly burdensome regulations against the medical profession's interaction with industry. They argue that the movement has gone too far and its proponents have no evidence to back up their claims. I don't have access to the full text but Thomas Sullivan parses it pretty well in a recent blog post. Concerning the lack of evidence he cites from the article thus:
Drs. Stell and Stossel assert that, “insinuations of corruption by those who call for increased oversight and regulation of the interaction between academia and industry require quantitative evidence—for a start, providing a denominator as well as a numerator.”...
While many critics can easily compose the numerator by mentioning “the same cases alleging corruption due to industry influence, many laced with hindsight wisdom, dredged up repeatedly and assembled into a narrative framework,” a denominator is almost always missing. In fact, “the storytelling suffers from serious ‘denominator neglect’—the non-nefarious, noncorrupt, beneficial collaborations, over decades that dwarf the comparatively few cases that populate the numerator.”
As the authors point out, “when attending to the numerator, the misconduct rate is negligible. The numerator of supposedly substantive adverse outcomes due to industry relationships (excluding relationship disclosure lapses discussed below) barely adds up to two digits. Surveys reporting that over 90% of physicians have some type of financial interaction with industry, with 18% of them engaged in consulting arrangements, indicate that the denominator is orders of magnitude greater.”
In the words of the authors the inquisitors' judgments lack “quantitative rigor.”
In selected patients, ICDs unequivocally provide statistical benefit, but there are risks, and alternatives—as in any invasive treatment. In this way, ICDs are akin to many other expensive and invasive therapies. Cancer chemotherapies like adriamycin, with its cardiac toxicity, come to mind, for example.
He ends with a reminder of the most pervasive conflict of interest to keep in mind when reading research reports:
Most smart doctors read journal articles with a critical eye. They (should) know that the writers are passionate and convinced of their positive findings. Such is human nature.
Doing something for someone else isn't really for someone else. It does twice as much for you as something you do just for yourself.
Those lyrics from Reflections sung by Sally Kellerman in the campy remake of Lost Horizon pose the question: is there such a thing as true altruism or is altruism nothing more than a means for us to feel better about ourselves?
The fascinating PJTV interview by Dr. Helen linked here (can't seem to embed it) raises additional disturbing questions about altruism. Empathy is viewed as a right brained trait on the spectrum between emotion and logic as drivers of social interaction. A proper balance between the two poles is necessary. The extreme to the right is codependency. On the other extreme are Asperger traits. Altruism can have a dark side if not tempered by logic, and vice versa. Just what is the dark side of Altruism? Do physicians have to “tamp down” their empathy to be effective?
I haven't read Dr. Oakley's books but I'm adding them to my list.
Two free full text reviews are available (see here and here).
Points of interest:
POTS is a “pervasive” circulatory disease involving multiple autonomic and volume regulating mechanisms.
Ganglionic acetylcholine receptor antibodies are found in a small percentage of patients suggesting that it is an autoimmune disorder in some.
Although a genetic mechanism has been found in some patients (involving norepi re-uptake) environmental factors are suggested by the cases that follow viral illness and surgery.
In additional to circulatory symptoms a wide variety of non-circulatory symptoms (GI, constitutional) have been described as being frequent.
Tilt-table testing is the principal diagnostic modality. It can also test for vaso-vagal syncope and orthostatic hypotension, conditions which overlap considerably with POTS.
Many treatments are discussed in the review articles. The Mayo video emphasizes exercise, adequate fluid and salt intake and beta blockers as the principal therapeutic approaches. Beta blockers, however, are controversial, are down played in one of the above linked reviews and considered contraindicated in the other.
Dr. Ves, arguably THE expert on doctors' use of social media for education, shows you how.
I have been blogging for almost 6 years. I still don't Tweet. Why? A couple of observations. As Dr. Ves noted:
There is a flood of medical news that hits the wires every day. I want to know what YOU think is important. Share the 3-10 news items per day that you find interesting. I will subscribe to read them. Many will do the same.
That's precisely the problem with using Twitter in medicine. It's an aggregator of medical “news.” Despite the daily deluge of pieces of information from the popular media and scientific literature, true advances in medicine are only rarely to be found in the medical “news of the day.” Medical science progresses in small increments, one study building on another. As Steve Milloy wrote on page 46 of his book Junk Science Judo:
...keep the slow, steady ho-hum scientific method in mind. Boring? Sure. Tedious? You betcha. Slow and deliberative? Be grateful.
When medical research is presented in the sound bite fashion of the typical Tweet it is inevitably subject to distortion because there's neither time nor space to address important nuances and background information. (Due to the constraints of time many of the posts on my blog are brief link dumps but I try to provide more depth when I can).
So I'm not Tweeting right now. That's not to say I won't find a reason to Tweet in the future. But if your objective is to drive traffic to your blog with a series of rapid fire mini posts, why not just “Tweet” on your blog? After all the blogfather himself, Instapundit, does it to great effect!
