A very useful review was recently published in Blood, available as free full text.
Points of interest:
More than one third of patients with DVT will develop post thrombotic syndrome (PTS). 5-10% will develop severe PTS.
In patients who have had a DVT the differentiation between recurrent ipsilateral DVT and PTS is difficult. Venous duplex testing, D-dimer and clinical prediction tools can be helpful.
Which patients will develop PTS? Incomplete resolution of leg symptoms by 1 month is a strong predictor. Risk factors include age, obesity, common femoral or iliac (as opposed to distal femoral of popliteal) location, subtherapeutic INRs during the first three months of treatment and recurrent ipsilateral DVT are risk factors. Thrombophilia does not appear to be a risk.
Prevention is somewhat controversial. Fitted compression stockings (worn for 2 years) appear to cut the incidence in half although better quality data are needed. Thrombolytic therapy is controversial. Such therapy, particularly catheter directed thrombolytic therapy, can reduce the incidence of PTS but the supporting studies have limitations. Rigorous trials are underway. The Chest guidelines suggest that catheter directed thrombolytic therapy “may be considered” in cases of extensive DVT in otherwise appropriate patients (low bleeding risk, patient preference, etc).
The author recommends that risk assessment for PTS and counseling the patient concerning said risk be carried out.
Tuesday, March 30, 2010
Noninvasive ventilation for chest trauma related hypoxemia
---reduced the need for intubation in this study.
Pancreatitis review with emphasis on guideline adherence
This CCJM review emphasizes under appreciated points in the guidelines.
Among these are the need for daily severity assessment. Severity assessment using the Ranson score is of prognostic importance but not useful for daily assessment because the score requires 48 hours to complete. Other assessment tools are available and mentioned in the review. Surveys of guideline adherence indicate that this is often not done, whereas the practice of daily measurement of amylase and lipase is often done but not recommended.
Indications for and timing of CT are frequent sources of confusion.
The need for nutritional support depends on severity assessment.
Hematocrit should be repeated at 12 and 24 hours. A rise consistent with hemoconcentration predicts necrosis. Also, a fall at 48 hrs (Ranson score) is a marker of severity.
There being no high level studies, fluid resuscitation recommendations are supported only by animal data, expert opinion and pathophysiologic rationale. Nevertheless, it is the opinion of some experts that under-resuscitation is common in practice. Recommendations are vague, with statements calling for “tempering” volume resuscitation in the elderly. Volume needs should be assessed and reassessed frequently using vital signs, urine output and hematocrit.
Scoring systems for CT based severity assessment exist. If contrast is contraindicated due to renal dysfunction some assessment parameters can be recorded without contrast.
Absent cholecystectomy, relapse rate is very high in the early weeks following an episode of gallstone associated pancreatitis.
Among these are the need for daily severity assessment. Severity assessment using the Ranson score is of prognostic importance but not useful for daily assessment because the score requires 48 hours to complete. Other assessment tools are available and mentioned in the review. Surveys of guideline adherence indicate that this is often not done, whereas the practice of daily measurement of amylase and lipase is often done but not recommended.
Indications for and timing of CT are frequent sources of confusion.
The need for nutritional support depends on severity assessment.
Hematocrit should be repeated at 12 and 24 hours. A rise consistent with hemoconcentration predicts necrosis. Also, a fall at 48 hrs (Ranson score) is a marker of severity.
There being no high level studies, fluid resuscitation recommendations are supported only by animal data, expert opinion and pathophysiologic rationale. Nevertheless, it is the opinion of some experts that under-resuscitation is common in practice. Recommendations are vague, with statements calling for “tempering” volume resuscitation in the elderly. Volume needs should be assessed and reassessed frequently using vital signs, urine output and hematocrit.
Scoring systems for CT based severity assessment exist. If contrast is contraindicated due to renal dysfunction some assessment parameters can be recorded without contrast.
Absent cholecystectomy, relapse rate is very high in the early weeks following an episode of gallstone associated pancreatitis.
Monday, March 29, 2010
Is low tidal volume ventilation beneficial for patients who do NOT have ARDS/ALI?
It is well known that low tidal volume ventilation is beneficial in patients with ARDS/ALI. The pathophysiologic rationale, that by avoiding over distension of alveoli low tidal volume ventilation mitigates lung injury and is associated with decreased cytokine production, is appealing for ventilated patients without ARDS/ALI. Up to now, for these latter patients, although RTC evidence was lacking, several papers suggested a beneficial effect.
This retrospective cohort study showed that for each ml (ml/kg predicted body weight?) above the ARDSnet standard of 6 ml/kg PBW the odds ratio for development of ALI increased by 1.3.
This study noted a similar effect.
In this study higher plateau pressures and tidal volumes (but not tidal volumes per unit predicted body weight!?) were risk factors. This combination of findings, which translates into taller individuals being at higher risk for ARDS, is an anomaly and not reproduced in other studies.
Now, just out, is a RCT of conventional vs low tidal volume ventilation for patients who do not have ALI or ARDS:
Higher sedation needs and more difficulty in maintaining oxygenation, cited as barriers to the evidence based implementation of low tidal volume ventilation in patients with ARDS, were not noted in the low tidal volume group in this study.
This is a very important paper which stands an excellent chance of making my top 10 list next December!
This retrospective cohort study showed that for each ml (ml/kg predicted body weight?) above the ARDSnet standard of 6 ml/kg PBW the odds ratio for development of ALI increased by 1.3.
This study noted a similar effect.
In this study higher plateau pressures and tidal volumes (but not tidal volumes per unit predicted body weight!?) were risk factors. This combination of findings, which translates into taller individuals being at higher risk for ARDS, is an anomaly and not reproduced in other studies.
Now, just out, is a RCT of conventional vs low tidal volume ventilation for patients who do not have ALI or ARDS:
The trial was stopped prematurely for safety reasons because development of lung injury was higher in the conventional tidal volume group as compared to the lower tidal volume group (13.5% vs. 2.6%, P = 0.01). Univariate analysis showed statistical relations between baseline lung injury score, randomization group, level of positive end-expiratory pressure (PEEP), number of transfused blood products, presence of a risk factor for ALI and baseline IL-6 lavage fluid levels and development of lung injury. Multivariate analysis revealed randomization group and level of PEEP as independent predictors of the development of lung injury.
Conclusions
Mechanical ventilation with conventional tidal volumes is associated with sustained cytokine production as measured in plasma. Our data suggest mechanical ventilation with conventional tidal volumes contributes to development of lung injury in patients without ALI at onset of mechanical ventilation.
Higher sedation needs and more difficulty in maintaining oxygenation, cited as barriers to the evidence based implementation of low tidal volume ventilation in patients with ARDS, were not noted in the low tidal volume group in this study.
This is a very important paper which stands an excellent chance of making my top 10 list next December!
It's about time
Primary care in the U.S. suffers from inadequate time to spend with patients. The popular wisdom is that health care reform can fix that. Well---
Results: German, British, and American physicians were allocated (on average) 16/11/32 minutes for a new patient appointment, 6/10/18 minutes for a routine visit, and 12/20/36 minutes for a complete physical, but felt that they needed more time. Over half of German and American physicians felt that they always or usually had control over the hours they were required to be in their office or spending sufficient time with their patients while less than half of British physicians felt this way.
Conclusion: German physicians had the least time allocated and needed for most types of appointment. American physicians had the most time allocated and needed for each type of appointment. However, British physicians felt they had the least control over time in their office and spending sufficient time with patients.
Friday, March 26, 2010
Why IM trainees choose hospital medicine and subspecialties over primary care
Although available slots in IM, FP and Peds in the 2010 match far exceeded those who matched, there was a slim increase over 2009 in the number of graduates matching in all three specialties. While that may be regarded by some as good news, very few IM trainees are opting for primary care, choosing instead susbpecialty and hospitalist positions. DB asks why and suggests better job conditions for hospitalists as one of the reasons.
His analysis is only partially correct and ignores one of the key issues: General Internal Medicine is losing its identity as a unique specialty. Its distinction from Family Practice is diminishing. It has been proposed for dissolution by merger with FP and may no longer exist in a decade or two. The American College of Physicians, Internal Medicine's leading professional organization, has been complicit in this trend.
I hope DB takes advantage of his leadership position in the ACP to make a difference here.
His analysis is only partially correct and ignores one of the key issues: General Internal Medicine is losing its identity as a unique specialty. Its distinction from Family Practice is diminishing. It has been proposed for dissolution by merger with FP and may no longer exist in a decade or two. The American College of Physicians, Internal Medicine's leading professional organization, has been complicit in this trend.
I hope DB takes advantage of his leadership position in the ACP to make a difference here.
Heart failure performance measures fail---again
Some time ago I blogged about the initial results of OPTIMIZE-HF which showed that at 60-90 day follow up the CMS core heart failure measures were found to be lacking in benefit. Now we have the results of the 1 year follow up. Again, no benefit:
I'll say it again: performance does not equal quality and by itself does not produce better outcomes.
Background: Recent efforts to improve care for patients hospitalized with heart failure have focused on process-based performance measures. Data supporting the link between current process measures and patient outcomes are sparse...
Conclusion: Hospital process performance for heart failure as judged by current CMS measures is not associated with patient outcomes within 1 year of discharge, calling into question whether existing CMS metrics can accurately discriminate hospital quality of care for heart failure.
I'll say it again: performance does not equal quality and by itself does not produce better outcomes.
Warfarin genotyping
---reduced hospitalizations, including those for bleeding and thromboembolism, in the Medco-Mayo Warfarin Effectiveness Study (MM-WES) presented at the American College of Cardiology (ACC) 2010 Scientific Sessions reported here via Medscape.
Thursday, March 25, 2010
Defensive medicine is practiced everywhere, everyday
From Medscape Family Medicine:
As cited in this article both anecdotes and data support the notion that defensive medicine due to the fear of being sued is a driver of health care costs.
"I practice defensive medicine daily," says an internist, "and order excessive, costly, unnecessary laboratory tests and imaging studies because patients demand them.”
As cited in this article both anecdotes and data support the notion that defensive medicine due to the fear of being sued is a driver of health care costs.
Your guilt or your career
Over the past 10 years the culture of our profession has been leaning towards disclosure and apology for medical mistakes. Despite that, such disclosure is selective and inconsistently applied. This Medscape article explains why it doesn’t work in a culture of blame.
Palliative care---here we go again
Last week the Dinosaur wrote an insightful post of particular interest to me: Palliative Care: An Unnecessary Specialty. In reply Bob Centor at Medical Rants defended palliative care, but as a level of organization, not as a specialty.
Dinosaur's post reflected a lot of my concerns. I would be open to the notion of palliative care as a unique specialty if someone would tell me what it is, exactly. The trouble is, no one seems able to do that. Many folks talk around the issue. Some talk about palliative care as an end of life care modality. Others say just the opposite, that palliative care does not depend on prognosis and may be given right along with curative, life prolonging care. Most apologists for palliative care have at least this idea in common: that palliative care provides excellence in symptom relief, communication with patients and families, and coordination of care. But those are just basic tenets for all care, at the bottom of the pyramid of principles of good old fashioned doctoring! So why a specialty?
One of Dinosaur's commenters was R. Sean Morrison, MD, president of the American Academy of Hospice and Palliative Medicine. Even he couldn't seem to nail down a definition, merely characterizing palliative care as excellence in the care of very ill and complex patients.
Another commenter, Christian Sinclair, MD, author of the Pallimed blog, didn't define the specialty but gave an honest appraisal of why we need palliative care teams: severely ill and complex patients and their families need time and attention to detail. Economic and administrative barriers do not allow this to happen in ordinary primary and hospital care. Somebody has to be there to do it.
Dinosaur's post reflected a lot of my concerns. I would be open to the notion of palliative care as a unique specialty if someone would tell me what it is, exactly. The trouble is, no one seems able to do that. Many folks talk around the issue. Some talk about palliative care as an end of life care modality. Others say just the opposite, that palliative care does not depend on prognosis and may be given right along with curative, life prolonging care. Most apologists for palliative care have at least this idea in common: that palliative care provides excellence in symptom relief, communication with patients and families, and coordination of care. But those are just basic tenets for all care, at the bottom of the pyramid of principles of good old fashioned doctoring! So why a specialty?
One of Dinosaur's commenters was R. Sean Morrison, MD, president of the American Academy of Hospice and Palliative Medicine. Even he couldn't seem to nail down a definition, merely characterizing palliative care as excellence in the care of very ill and complex patients.
Another commenter, Christian Sinclair, MD, author of the Pallimed blog, didn't define the specialty but gave an honest appraisal of why we need palliative care teams: severely ill and complex patients and their families need time and attention to detail. Economic and administrative barriers do not allow this to happen in ordinary primary and hospital care. Somebody has to be there to do it.
Wednesday, March 24, 2010
Which stent for STEMI?
Inpatient management of heart failure---can it be evidence based?
The guy who gave the heart failure talk at SHM 2009 said that hospitalists have no evidence to guide them in the inpatient management of heart failure. That was an overstatement. We have, for example, evidence about Neseritide (maybe marginally better than IV nitro but with safety concerns raised); IV inotropes (they increase mortality); what to do with patients' beta blockers when they come in with ADHF (don't hold them or reduce the dose unless they're in shock); and the use of non-invasive positive pressure ventilation. That said, it's true that the vast majority of high level clinical evidence to guide heart failure treatment is on the ambulatory side. While that evidence on long term treatments suggests things for hospitalists to do at discharge time, even the hospital performance measures based on that evidence proved to be a bust.
So, always looking to be evidence based in the management of common problems in hospitalized patients, I found this report from the ACC national meeting to be of interest. In an example of some of that comparative effectiveness research we've all been clamoring for researchers looked at several different loop diuretic regimens: high dose, low dose, continuous infusion and boluses. It turns out it doesn't really matter. All the folklore handed down about loop diuretics may be equally true and can be summarized thusly:
Lasix dose = age + BUN (Law # 7 of the House of God).
Rales heard only at peak inspiration are “20 mg Lasix rales.” (Pearl from visiting professor William J. Grace, M.D., St. Louis University Hospital, 1976).
40 mg IV Lasix “is a pretty good dose.” (One of my resident mentors in medical school).
Give the same dose IV lasix as the patient takes PO at home. (Another resident mentor).
So, always looking to be evidence based in the management of common problems in hospitalized patients, I found this report from the ACC national meeting to be of interest. In an example of some of that comparative effectiveness research we've all been clamoring for researchers looked at several different loop diuretic regimens: high dose, low dose, continuous infusion and boluses. It turns out it doesn't really matter. All the folklore handed down about loop diuretics may be equally true and can be summarized thusly:
Lasix dose = age + BUN (Law # 7 of the House of God).
Rales heard only at peak inspiration are “20 mg Lasix rales.” (Pearl from visiting professor William J. Grace, M.D., St. Louis University Hospital, 1976).
40 mg IV Lasix “is a pretty good dose.” (One of my resident mentors in medical school).
Give the same dose IV lasix as the patient takes PO at home. (Another resident mentor).
Tuesday, March 23, 2010
The fight over health care reform
---is far from over.
New state laws which counter the reform package are mainly symbolic. The law suits may have more teeth.
New state laws which counter the reform package are mainly symbolic. The law suits may have more teeth.
Infectious disease pearls for hospitalists
---are provided in a recent review in the Journal of Hospital Medicine.
Points of interest:
Don't chase your tail with antibiotics or, as the authors put it, avoid spiraling empiricism. Although it may at times be necessary to escalate antibiotics in a non-responding patient don't do it willy-nilly. Think and, if clinically appropriate, re-evaluate before you do.
In bacteremic patients do serial blood cultures (every 24-48 hours until clear) especially in infections with staph, enterococcus and yeast. The results impact decisions on duration of treatment and source evaluation.
Remove lines from patients with candidemia to optimize the chance for a good outcome.
Candida colonization is common and usually dismissed but be suspicious if you grow it from multiple sites.
Don't treat asymptomatic bacturiuria except in pregnant patients and those about to undergo GU manipulation.
A similar open access article from The Hospitalist is dated but still relevant.
Points of interest:
Don't chase your tail with antibiotics or, as the authors put it, avoid spiraling empiricism. Although it may at times be necessary to escalate antibiotics in a non-responding patient don't do it willy-nilly. Think and, if clinically appropriate, re-evaluate before you do.
In bacteremic patients do serial blood cultures (every 24-48 hours until clear) especially in infections with staph, enterococcus and yeast. The results impact decisions on duration of treatment and source evaluation.
Remove lines from patients with candidemia to optimize the chance for a good outcome.
Candida colonization is common and usually dismissed but be suspicious if you grow it from multiple sites.
Don't treat asymptomatic bacturiuria except in pregnant patients and those about to undergo GU manipulation.
A similar open access article from The Hospitalist is dated but still relevant.
What is “meaningful use” of the EMR?
From Medscape Medical News:
Hmm. How can that be when it's never been proven that EMRs are capable of achieving those objectives in the first place?
Some feel the regulations which define meaningful use are too onerous:
Dr. Waldren is director of the Center for Health Information Technology for the American Academy of Family Physicians (AAFP). CMS is expected to roll out the final version of the regs in a few months.
Here's the plain-English translation: The federal government won't give you a bonus simply for buying an EHR. You qualify for the money only if you use the system in ways that improve the quality of care while lowering costs.
Hmm. How can that be when it's never been proven that EMRs are capable of achieving those objectives in the first place?
Some feel the regulations which define meaningful use are too onerous:
"If the regulations stay the way they are today, many physicians won't even attempt to be a meaningful user," said Dr. Waldren.
Dr. Waldren is director of the Center for Health Information Technology for the American Academy of Family Physicians (AAFP). CMS is expected to roll out the final version of the regs in a few months.
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