Should you admit that TIA?

Practices vary greatly from one community to another with regional variations in malpractice risk guiding decisions. Evidence based medicine has now come to the rescue. The ABCD-squared stroke risk score can help stratify patients presenting with or soon after TIA into high, intermediate and low risk categories. The score takes into account clinical features, blood pressure, history of diabetes and duration of symptoms. This should help standardize decision making when patients present with TIA. The validation study was published in Lancet and is linked here via Medscape.

Bet you didn’t know

That direct to consumer drug ads are deceptive. Wow. Who'da thunk it.

Unintended consequences of a “quality” measure

The “four hour antibiotic rule” for patients presenting to the hospital with pneumonia has become a mandate from JCAHO and CMS as well as a pay-for-performance initiative. This has caused hospital case managers and administrators to put pressure on ER physicians to jump to a diagnosis of pneumonia. A study presented as a poster abstract (poster 211) at the 2006 IDSA annual meeting demonstrated that the four hour rule is associated with over-diagnosis of pneumonia, evidenced by more diagnoses of pneumonia in patients with negative chest x-rays and a lower percentage of patients initially given antibiotics for pneumonia having the diagnosis confirmed at discharge.

The overuse of antibiotics as a result of the four hour mandate has been demonstrated before as I posted here. The implications concerning breeding antibiotic resistance are obvious.

American medical schools: slouching toward Hogwarts

Harry Potter would thrive in some medical schools today. I’ve been beating the drum about medical education’s egregious uncritical incorporation of non-evidence based woo for some time, starting with this post.

Science blogger Orac weighed in again yesterday with Medical schools going the wrong way in which he mentions a new wrinkle, the incorporation of woo into graduate medical education. Not surprisingly, it’s being promoted by the American Medical Student Association.

Yes, medical schools are going the wrong way. Does anyone in academic medicine care about the integrity of medical education? Who are you, and why aren’t you raising a stink? Medschool woo needs to be exposed. Maybe it’s time somebody wrote a book.

What malpractice crisis?

Public Citizen thinks it’s a hoax. Why then the four-fold variation in malpractice coverage rates between California and states without damage caps?

Via Kevin M.D.

Another risk factor for atrial fibrillation

Corticosteroids, equivalent to 7.5 mg prednisone daily or more, received in the previous month. Via Archives Internal Medicine.

Anaphylaxis

This review of anaphylaxis, though a little dated, is useful enough to be linked here. (Via Seminars in Respiratory and Critical Care Medicine).

Proposals by the American College of Physicians to improve health care quality and reimbursement---is the devil in the details?

Last year the American College of Physicians (ACP) warned of the collapse of primary care. This year they have proposed a series of reforms to help solve the problem, which they say will improve reimbursement and quality.

I have more than a few concerns about the proposals. They’re supposed to shift compensation incentives from procedures to comprehensive care. But haven’t we heard this before? The resource based relative value scale, conceived in the 1980s, was supposed to improve compensation for “cognitive” services. It wasn’t long, though, before physicians realized that RBRVS stood for “real bad reimbursement very soon.”

Worse yet, the proposals are another failure of the ACP to reclaim the identity of internal medicine. In defining the way internists fill the primary care role the proposals make no distinction from family practice. Is it any wonder there is a growing perception that the only way to be an internist is to be a hospitalist? Laurence Wellikson, M.D., CEO of the Society of Hospital Medicine, said it well: “General internal medicine had a chance to define itself as physicians who are master diagnosticians—the only doctors capable of handling the complexities of comorbidties, especially in the aging population. Instead of seizing terrain that was so uniquely geared to internal medicine training and experience, internists decided to compete with family practitioners and nurse practitioners to be the traffic cop for resource use and burgeoning specialization.” I have expressed this same view, though not as eloquently, here, here and here.

To me the proposals read like a mixture of physician DRGs, capitation, discounted fee for service, gate keeping, P4P and quality gamesmanship. They don’t make general internal medicine look very appealing.

Review of Echinocandins

The echinocandins comprise a new class of antifungal agents which act by inhibiting fungal cell wall synthesis. They tend to be fungicidal against yeasts (although inactive against cryptococci), fungistatic against molds and inactive against dimorphic fungi.

A two part review was recently published in the American Journal of Health-System Pharmacy, available in full text via Medscape. Part 1 addresses chemistry, pharmacokinetics and pharmacodynamics. Part 2 deals with clinical usage and role of echinocandins in the relative to other antifungal agents.

Naturopathic medicine topics at the American Medical Student Association’s Annual National Convention

From the talks listed it looks like they’re taking a promotional rather than a critical approach.

Joint Commission wants to set standards for how hospitals deal with disruptive behavior

I’ve posted about the concept of the “disruptive physician” here, here, here, here and here. Joint Commission’s latest proposal defines the problem this way (italics mine): “Disruptive behavior is conduct displayed by a health care professional that negatively impacts the quality or safety of care or has the potential to do so. Disruptive behavior may also intimidate staff, affect staff morale, and lead to staff turnover. Disruptive behavior may be verbal or non-verbal, and often involves the use of rude language, facial expressions, threatening manners, or even physical abuse.” Well, that’s kind of scary. Any behavior somebody else doesn’t like could be interpreted as disruptive and result in corrective measures (counseling, sensitivity training, psychiatric evaluation or worse) for the “offender.” It could also provide leverage to shove somebody out whose thinking happens to be a bit too original.

There’s one aspect of the proposal that I like. It doesn’t single out physicians. There’s a uniform standard that applies to all---physicians, administrators, nurses, etc.

(Via MSSPNexus blog)

Sniffing out C. diff

Lately I’ve been getting this call from nurses: “Mrs. so-and-so just had a liquid stool that smells like C. diff. Shall I send it down to the lab?” An informal poll revealed that many nurses are convinced they can detect the infection by smell. Is there anything to this?

Apparently, in the micro lab, blood agar colonies of Clostridium difficile have “a barnyard odor that is unmistakable” due to elaboration of P-cresol. But what are the test characteristics of olfaction at the bedside?

Observations of an ER nurse on how conflicts of interest trump evidence based medicine

Mention conflict of interest in medicine and the knee jerk response, nearly always, is to raise the issue of the pharmaceutical companies and their influence on doctors. Other conflicts, seldom appreciated, may play a larger role. ER nurse blogger girlvet mentions some of them in ER medicine is a free for all. The wide variations in practice she sees in her ER are anything but evidence based and, in her view, are driven by liability concerns, payer source and coding (the patient comes in with a tummy ache, but find 5 other diagnoses to document and you can code higher).

She warns doctors who may be reading: “you may not like what’s ahead….” Hey, I thought it was pretty good.

Via Kevin MD.

Medical Economics readers polled about doctor bashing web sites

If trashed on a doctor rating web site what would you do? In early results of a Medical Economics poll 50% of readers would ignore it, 35% would ask to post a rebuttal and 15% would threaten legal action.

Public Citizen: The medical liability crisis is a hoax

They “prove” it here. Point of Law offers this expose of the Public Citizen report. (Via Kevin MD).

Tygecycline for community acquired pneumonia

In a phase 3 double blind multicenter RCT presented as a poster abstract at the IDSA 2006 annual meeting (poster 171) Tygecycline was as safe and effective as Levofloxacin in patients with community acquired pneumonia (CAP).

Tygecycline is off label at present for CAP. I expect this study will be submitted to the FDA to approve the indication.

Propylene glycol toxicity due to high dose lorazepam infusions

Propylene glycol is a diluent for parenteral preparations of lorazepam and other drugs. Toxicity may occur with high or escalating intravenous doses of lorazepam and may be manifested by wide anion gap metabolic acidosis, renal failure and increasing osmolar gap. A brief review in ISMP Medication Safety Alert contains recommendations for minimizing the risk of toxicity, including daily chemistries and calculation of the osmolar gap in patients receiving high doses. An osmolar gap exceeding 20 may herald impending toxicity.

Vasoactive drugs in septic shock

A review was recently published in Seminars in Respiratory and Critical Care Medicine.

Brugada syndrome review

Brugada syndrome has been recognized with increasing frequency and in increasingly diverse populations since it was originally established as a distinct clinical entity in 1992. Recognition of the Brugada electrocardiographic patterns can be lifesaving and is thus an essential skill for emergency physicians, hospitalists and primary care physicians.

Although initial recognition of telltale electrocardiographic signs is straightforward, recent understanding of certain diagnostic nuances has been in a state of flux. In addition, new concepts regarding epidemiology, environmental factors, acquired patterns and mimics have rapidly accumulated. For these reasons a recent review in the journal PACE is timely and merits mention here.

Pertussis---not just for kids

Think of it when that cough won’t go away. (Patient Care).


Audio files of the characteristic cough, with and without the whoop. (Texas Health Department).