Friday, January 30, 2009

Heparin for septic shock???

Activated protein C decreases mortality in patients with sepsis and a high risk of death due to its anticoagulant and anti-inflammatory properties. Why not something cheaper that does the same thing? In this study unfractionated heparin decreased mortality in the most severely ill patients (APACHE II 29-53) with septic shock. It’s not ready for prime time and the findings need more validation. It was not a RCT, but rather a propensity matched retrospective study. Although patients with an admitting diagnosis of acute coronary syndrome or pulmonary embolism were excluded, many patients in the treatment group had their heparin started because of an elevated troponin level or clinical suspicion or VTE.

Editorial comment here.

Recruitment maneuvers in ARDS/ALI---ready for prime time?

Not for routine use according to this systematic review although they may be considered in patients with life threatening hypoxemia.

Background: My previous literature review here.

There’s exceptional blogging about hospital medicine going on

---at The Ether Way. It’ll show up on my blog roll when I get around to updating it.

Thursday, January 29, 2009

Should all medical journals be considered “throw-away” journals?

That’s what you might conclude after reading Dr. Marcia Angell’s recent JAMA commentary. (H/T to Retired Doc for alerting me to the article). Angell is concerned about the corrupting influence of the drug industry on research reporting in peer reviewed medical journals. Citing the conflicts of interest that plague present day clinical research, she too is conflicted. She discloses this at the end of the article:

Dr Angell reported receiving royalties from her book The Truth About the Drug Companies: How They Deceive Us and What to Do About It.

In fact, Angell seems to have devoted a great deal of her career over the past decade to criticizing the pharmaceutical industry.

In the first several paragraphs she goes through the usual litany of concerns: conflicts of interest, publication bias, rigged designs and spinning of results. These are valid concerns, but Angell, simplistically putting almost all the blame on industry, wants a government solution:

I have proposed that an Institute for Prescription Drug Trials be established within the NIH to administer clinical trials of prescription drugs, including the premarketing trials that will be submitted to the FDA as a part of new drug applications.

The implied premise, that taking clinical trials out of the hands of the pharmaceutical industry would solve the problems, is faulty. The problems Angell cites permeate non-industry supported research and the government is no exception. Examples abound. I have noted just a few in previous posts: [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14]

But this is over the top:

Physicians can no longer rely on the medical literature for valid and reliable information. This is the conclusion I reluctantly reached toward the end of my 2 decades as an editor of the New England Journal of Medicine, and it has been reinforced in subsequent years.

Does Angell think simplistic readers’ acceptance of this alarmist statement will rally support for more government control? Complete government control of the performance of clinical trials and their publication is not likely to happen soon and, for the reasons I stated, would not solve the problem.

What then are practicing doctors to do? Angell’s statement above suggests that in the current environment the practice of evidence based medicine and science based medicine are impossible. Nonsense. EBM is premised on the fact that all research reports have weaknesses and are to be viewed with skepticism. SBM, recognizing that EBM lacks the tools to examine all claims, goes a step further by evaluating reports in light of prior research and scientific plausibility. In short, doctors have the tools to critically appraise the medical literature. It’s hard to believe Dr. Angell wants to abandon EBM altogether. More likely she would revise EBM’s evidence pyramid to look something like this: (Click image to zoom).

Wednesday, January 28, 2009

Before you use the D dimer to rule out VTE

---do a clinical assessment first, using a tool such as the Wells score:

From the paper in Chest:

In the patients with an unlikely probability of PE (n = 477), VTE was confirmed in 1.1% of the patients with a normal d-dimer concentration (95% CI, 0.4 to 2.4%). In those patients with a likely clinical probability of PE (n = 86), VTE was confirmed in 9.3% of the patients with a normal d-dimer concentration (95% CI, 4.8 to 17.3%). The difference in VTE incidence between patients with unlikely and likely clinical probabilities of PE was significant (p less than 0.001).

A regimen for MRSA decolonization

The use of topical mupirocin as monotherapy for decolonization of hospitalized patients has been disappointing. Here is a paper detailing the effectiveness of a multi-agent topical and systemic regimen.

The indications for decolonization are not well defined but this regimen can be considered for patients who have repeated presentations with MRSA infection.

Clinical trial enrollment suspended

---amidst concerns about ethics breeches, conflicts of interest, safety, and investigator qualifications. The latest Pharma funded study, you’re thinking. No, it’s funded by a branch of the NIH. It’s none other than the Trial to Asses Chelation Therapy (TACT). The NIH is keeping mum about this---no announcement has been issued. In fact, the guvment’s official web site says the study is still recruiting participants!

Although I smelled the rat and started agitating about this over two years ago I’ve been a little remiss in keeping up with recent developments and missed this Science Based Medicine post last fall concerning the suspended enrollment. What finally tipped me off was an article from the International Journal of Clinical Practice posted January 22 in Medscape. It reads, in part:

A comprehensive review of the TACT trial by Atwood et al.[2] calls into question the safety of the study and highlights deficiencies in the NIH application process, economy with detailing the adverse effect potential, inappropriate political pressure to undertake the study and failure to provide complete data on conflicts of interest, especially investigator financial gain. The authors concluded in May 2008:

"... TACT is unethical, dangerous, pointless and wasteful. It should be abandoned."

That review, a powerful expose of the corruption associated with the trial, was published in the Medscape Journal of Medicine and may have had something to do with the suspension of enrollment.

Among the allegations swirling around TACT is that it violates provisions of the Declaration of Helsinki. I can think of a number principles being violated, one of which is that:

Medical research involving human subjects must conform to generally accepted scientific principles, be based on a thorough knowledge of the scientific literature, other relevant sources of information, and adequate laboratory and, as appropriate, animal experimentation.

That principle, that research be based on “generally accepted scientific principles,” proscribes (or ought to) many forms of woo based research currently being supported by NCCAM, the Consortium of Academic Health Centers for Integrative Medicine and the Bravewell Collaborative.

Tuesday, January 27, 2009

Narcotic use associated with delayed diagnosis and more severe C diff.

Via Hospitalist News.

If some one makes malicious or blatantly false statements about you on Rate MDs

---there’s not much you can do according to this Medical Economics article.

Here’s a sampling from the article:


"I feel like I was just another number at the office."

Incidence and predictors of post-thrombotic syndrome

Via Annals of Internal Medicine:

At all study intervals, about 30% of patients had mild (score, 5 to 9), 10% had moderate (score, 10 to 14), and 3% had severe (score greater than14 or ulcer) postthrombotic syndrome. Greater postthrombotic severity category at the 1-month visit strongly predicted higher mean postthrombotic scores throughout 24 months of follow-up (1.97, 5.03, and 7.00 increase in Villalta score for mild, moderate, and severe 1-month severity categories, respectively, vs. none; P less than 0.001). Additional predictors of higher scores over time were venous thrombosis of the common femoral or iliac vein (2.23 increase in score vs. distal [calf] venous thrombosis; P less than 0.001), higher body mass index (0.14 increase in score per kg/m2; P less than 0.001), previous ipsilateral venous thrombosis (1.78 increase in score; P = 0.001), older age (0.30 increase in score per 10-year age increase; P = 0.011), and female sex (0.79 increase in score; P = 0.020).

Friday, January 23, 2009

Low tidal volume ventilation for ALI and ARDS---read the fine print

The care of patients with ALI/ARDS was revolutionized several years ago with publication of the ARDSnet trial of low tidal volume ventilation (LTVV). Recently investigators reporting in Critical Care Medicine looked at an underappreciated complication of LTTV: breath stacking. Breath stacking refers to patient triggering of machine breaths in rapid succession. When two or more breaths occur in sufficiently close proximity they behave as a single breath with higher tidal volume.

The low tidal volumes recommended following publication of the ARDSnet trial are insufficient to satisfy the dyspnea of many mechanically ventilated patients, leading to more frequent inspiratory efforts and, consequently, breath stacking. The resulting high tidal volume (which is easily determined as the area under the curve of the flow-time graph) counters the beneficial effects of the LTTV strategy.

According to the Critical Care Medicine paper breath stacking occurs frequently, is often unrecognized and is more frequent with lower set tidal volumes. Although breath stacking can be mitigated by increasing the tidal volume or via sedation (both of which are allowed for in the ARDSnet protocol) breath stacking in this patient series was frequent despite deep sedation.

An editorial in the same issue of the journal suggested that slavish adherence to the protocol may have served as a substitute for clinical judgment, leading to failure to recognize and address the unintended consequences. There’s a larger lesson to be learned here regarding the application of EBM.


Practical aspects of LTVV via NEJM.

ARDSnet resource page containing the LTVV protocol, determination of dosing body weight for tidal volume, the PEEP scale and more.

Ventilator graphics made easy.

Thursday, January 22, 2009

(±)-1-(Isopropylamino)-3-[ p-(2-methoxyethyl)phenoxy]-2-propanol L-(+)- tartrate, 5mg IV STAT!

That’s how you’d be writing for IV metoprolol if a proposal from a few years ago had taken hold. It made sense. Many eschew brand names because they’re too commercial. But all too often forgotten is the fact that official (i.e. generic) drug names are also chosen by the companies during development. Who knows, they may contain subliminal messages. Then there’s the issue of sound alike generic names that lead to medication errors. Why not play it safe and use scientific nomenclature?

DM 2 update

Since publication of guidelines for type 2 diabetes a number of negative trials and cardiovascular safety issues have surfaced. A new evidence synthesis was needed, and authors of a review published in the January 1 issue of American Family Physician took a stab at it. AFP is no longer open access so I can’t link to the full article, but this Medscape CME activity provides a summary. (The CME content is non-industry supported).

Wednesday, January 21, 2009

Problems with VA’s EMR

A tip of the Dr. RW hat goes to Retired Doc (glad he’s back from his blogging hiatus, by the way) for reporting this story:

The top Republican on the House Veterans Affairs Committee
demanded Wednesday that the VA explain how it allowed software glitches to put the medical care of patients at its health centers nationwide at risk.

Reading between the lines of this report it appears there were two issues, one of which, patient data showing up under the wrong name, was indeed a glitch. The other issue, inappropriate medication stop times, may be more complex and illustrative of a more pervasive problem in how we use EMRs.

Disclaimer: I have never used the VA EMR but I have received electronically generated records from the VA and talked to some users. The print outs have a lot of electronic clutter. Frustrated users describe multiple mouse clicks for simple tasks. I can easily imagine the resulting user fatigue making it difficult to follow order trails. A more general problem with hospital EMRs that feature CPOE is that secretaries and nurses are disengaged from their traditional roles in order processing. Consequently an important safety net is removed. That’s a problem with the culture around implementation of the EMR rather than the EMR itself.

Specifying the duration of medications by directly entering start and stop dates is counterintuitive to how we did it in the paper days not to mention distracting to the traditional clinical train of thought. In the paper environment I could order a tapering course of steroids by writing “Solumedrol 80mg IV Q 6 hours x 4 doses then 40mg IV Q 6 hours x 4 doses then 20mg IV Q 6 hours x 4 doses then D/C.” Although it was clear to me and others exactly what I wanted clinically the order processing was, for me, a black box---not what I was trained to do. The secretary and nurses, knowing my clinical intent, took care of all the entry and processing stuff, and all the checking and double checking to make sure it happened as intended. Not fail safe, but worked well. All those layers of safety are gone in the electronic environment, where entry and processing are in the doctor’s lap. So I can imagine a gazillion ways infusion times got messed up in the VA system by virtue of design, not necessarily a glitch.

Drug reps will be able to give out off-label info

---with certain restrictions. The new guidelines were opposed, predictably, by Rep Henry Waxman (D-CA).

Diabetic cardiomyopathy

Reviewed in the American Journal of Medicine.

Tuesday, January 20, 2009

Economic pressures are destroying the doctor-patient relationship

---and Retired Doc has some compelling anecdotes:

My brother-in-law has coronary angiography following an episode of chest pain and an EKG that "showed some problem." After the cath, he was seen by someone in a white coat that he had not seen before . The white coated,scrub suited man explained the procedure very briefly ( there were " no significant blockages"),gave him several prescriptions and told him to call the office for a followup visit in 6 weeks. My sister said that somehow he didn't seem like a doctor.I told her he wasn't, he was a PA ( I looked him up on the state board's web site).He was later seen by the PA for the office visit.

He relates a few more stories like this, and in no case did the patient get to spend any time with the doctor.

Early in my career I began to notice that in talking with patients about their encounters with other doctors and hospitals they would often relate “they never told us anything.” I knew that wasn’t literally true but was astonished at how often medicalese, lack of time and bad listening could conspire to give patients the perception that they were not told anything. I naively vowed that it would never be said of me. I would make mistakes, my bedside manner was not perfect and not all patients would like me, but to the best of my ability I would give no one cause to say “he never told us anything”.

I developed a particular style of talking with patients. During interviews I would note concerns and questions and at the end would give a “summation.” Then I would ask, repeatedly if necessary, if there were any questions. While most patients left their encounter satisfied they’d had their questions answered sometimes I failed. Occasionally I’d get this call from a hospital nurse: “The family’s upset because Mr. Jones has been in here for a week and no one has told them anything.” Determined to fix the problem then and there I would, unless in the middle of an emergency, drop what I was doing, present to the patient’s room and talk with the patient and family for however long it took to de-fuse the crisis. Too bad if I got home late that night.

Spending this extra time with patients meant I was often behind schedule and could see fewer patients. For the first few years my medical group, appreciative of my unique way of relating to patients, and of my role as consultant-generalist, understood. Over time, though, the economic realities of Stark rules and managed care weighed in and my income tanked. The hospitalist job came to the rescue. As a hospitalist I still try to go the extra mile in answering questions, but time constraints often interfere.

Nowadays after a typical encounter patients are likely to find themselves overwhelmed. Presented with a ream of paper generated by the electronic medical record covering everything from the importance of smoking cessation to the use of seatbelts, patients still often don’t feel they have had their questions answered.

Can single payer health care be patient centered (or evidence based)?

Dr. Wes had this conversation at the Boston Atrial Fibrillation Symposium:

At lunch the last day, I sat with some nice nurse practitioners from Canada and asked them about how things work at their hospital in the electrophysiology department - after all they worked for a big regional hospital outside a major metropolitan city like mine. I asked how many electrophysiologists they had there: three - two of whom do afib procedures and one who does more device rather than ablation work. I asked how many defibrillators performed a year and asked who paid for them, and she said the
government. "But we got authorization to do five more devices next year," she said.

"Only five?" I asked in disbelief."

Yep, and we were lucky. Other centers got fewer. They're expensive, you know. We have to be very careful about who we select to get one of those. It's not like America - people here are used to waiting."

"But what about SCD-HeFT and MADIT-II and the other trials?"

She smiled and looked down at her plate. "We have no choice, people up here don't have to pay for their care, so we have to choose who we think the best candidates are and do the best we can."

Those of you advocating for patient centered health care and single payer health care have some serious ‘splainin’ to do!

(For that matter, can you even practice EBM under single payer)?

Monday, January 19, 2009

Even the Wall Street Journal is promoting woo!

Straw man arguments (mainstream medicine eschews preventive lifestyle modifications), appeals to fear (the economy’s tanking so we better change our medical thinking), the false dilemma (science based medicine often fails, so alternative treatments must be the answer) and assorted other logical fallacies combine to produce this masterpiece of obfuscation in the Wall Street Journal. And, inside the trojan horse of evidence based “natural” medicine---

Heart disease, diabetes, prostate cancer, breast cancer and obesity account for 75% of health-care costs, and yet these are largely preventable and even reversible by changing diet and lifestyle

comes a serving of some of the wooiest of woo:

When you eat a healthier diet, quit smoking, exercise, meditate and have more love in your life, then your brain receives more blood and oxygen, so you think more clearly, have more energy, need less sleep. Your brain may grow so many new neurons that it could get measurably bigger in only a few months. Your face gets more blood flow, so your skin glows more and wrinkles less. Your heart gets more blood flow, so you have more stamina and can even begin to reverse heart disease. Your sexual organs receive more blood flow, so you may become more potent -- similar to the way that circulation-increasing drugs like Viagra work.

About the only thing that’s believable in this article is that this sort of woo is endorsed by the Institute of Medicine:

In mid-February, the Institute of Medicine of the National Academy of Sciences and the Bravewell Collaborative are convening a "Summit on Integrative Medicine and the Health of the Public." This is a watershed in the evolution of integrative medicine, a holistic approach to health care that uses the best of conventional and alternative therapies such as meditation, yoga, acupuncture and herbal remedies.

That statement would have shocked me before I learned of the massive Kool-Aid party going on at IOM.

The article calls for an increase in the funding of woo and might be seen as a counterpoint to the call of Orac and others to stop taking money out of our pockets to promote quackery.

Dr. Wes weighs in here and concludes with:

These guys know the government is looking to cut costs, and (fortunately and correctly) their workshop will be first to suffer the fall of the axe.

Let’s hope so.

Sunday, January 18, 2009

Pulmonary infiltrates in HIV patients in the HAART era

Pneumocystis jirovecii pneumonia (formerly PCP) is no longer the most common presentation. Now it’s bacterial pneumonia. The topic is reviewed in Clinical Pulmonary Medicine.

Xray of PJC pneumonia. Image source: Wikipedia

Really cute puppy dog video

Like the little old ant, this kid had high hopes.

Via StL Media

Friday, January 16, 2009

Important grassroots effort for concerned bloggers

Let’s quit spending tax payers’ money on the promotion of quackery! Defund the NCCAM! Orac explains.

Need a champion for your next quality improvement project? Try your local fire chief!

Although strong evidence favoring therapeutic hypothermia to improve neurologic outcomes after cardiac arrest has been out there for over six years hospitals in the U.S. have been appallingly slow to adopt it, all but ignoring the data. Among the reasons is the fact that hospitals, motivated by money, pride and shame, are focused, to a distraction from matters of real import, on publicly reported core performance measures.

Any quality maven will tell you that if you really want to go beyond the core measures with your project you need a champion. Enter the fire chief. From a piece last month in the New York Times:

Starting on Jan. 1, New York City ambulances will take many cardiac arrest patients only to hospitals that use a delicate cooling therapy believed to reduce the chances of brain damage and increase the chances of survival, even if it means bypassing closer emergency rooms.

The move by the city’s Fire Department and Emergency Medical Service, after a year
of preparation, indicates a shift away from the prevailing view among emergency workers and the public that how fast critically ill patients reach the hospital is more important than which hospital treats them.

That’s right---ambulances transporting cardiac arrest patients will be diverted away from hospitals that don’t have a therapeutic hypothermia protocol in place! Predictably the public attention and real money at stake has New York City hospitals, few of which were providing therapeutic hypothermia, scrambling:

Since the Fire Department sent letters to hospital chief executives this week informing them of the impending change, about 20 of the 59 hospitals with emergency rooms have said they will have cooling operations ready by the Jan. 1 deadline.

The fire chief, who has no money at stake and isn’t a slave to public core measures, is the perfect champion. According to the New York Times piece this fire chief as champion strategy has been tried in a few other cities but we’re a long way from widespread adoption. If it takes hold nation wide the cooling protocol may finally get the attention it deserves.

By the way, although it requires institutional commitment, organization and staffing you don't need a lot of expensive equipment. I previously reviewed the practical aspects here and here.

Image source Wikipedia.

Whither industry supported CME?

That’s the question we addressed in the latest Medscape Roundtable Discussion. Dr. Bradley Fox and I favored continued industry support. Drs. Pennie Marchetti and Robert Centor (DB) favored a ban.

Some key points of my argument:

Proponents of a ban on industry support of CME should provide evidence to sustain their burden of proof that the benefits of such a ban would outweigh the inevitable unintended consequences.

Because no such evidence exists the proponents of a ban have appealed to a system of beliefs.

A ban on industry support of accredited CME would do nothing to stop industry from providing non-accredited offerings which, like direct-to-consumer advertising, would increase as industry diverts its resources. Doctors would then be bombarded with even more industry material much of which would, absent the accreditation requirements, be purely promotional. This would degrade the overall quality of content doctors are exposed to.

Space constraints prevented me from making one additional point. Interested parties in this debate have an inflated view of the importance of accredited CME. Think about it. What’s 30 hours, the typical state requirement, compared to the total time doctors spend reading and attending lectures?

A mainstream media article finally got it right about Medicare’s never events policy

---but only because it was written by our very own Kevin M.D. Check it out here.

Thursday, January 15, 2009

Sidney Wolfe appointed to the FDA!?

When I first stumbled across this on a Medscape discussion thread I couldn’t quite believe it, but apparently it’s true. Any of you who follow the controversies about Pharma marketing and drug safety know about Dr. Wolfe, the controversial consumer activist who heads the Public Citizen Health Research Group.

Dr. Wolfe and his group have accomplished some good things in the field of drug safety. They called for a ban of several dangerous drugs, traced an epidemic of gram negative sepsis to contaminated IV fluids and have raised awareness of many adverse drug effects. In the minds of many, though, these accomplishments have been overshadowed by consumer fear mongering, questionable research and reporting methods and an agenda against organized medicine and the pharmaceutical industry.

Consider, for example, their black list of drugs concerning which they warn consumers “do not use”. Actose, Avandia, Singulair and Tricor are on that list and at one time so was metformin. UCSF, UCSD and the University of Massachusetts are on this list of Questionable Hospitals. Public Citizen also publishes a list of Questionable Doctors. Read here about the damaged reputation of one doctor who landed on the list as a result of sloppy fact checking.

The Wall Street Journal article says of Dr. Wolfe:

He has been so hostile to the FDA under President George W. Bush that he decried its 100th-anniversary celebration in 2006 as a "propaganda campaign" to hide its "unprecedented assault on the American public."

Now I know why I caught a bad cold last week

I had been working a greater than usual number of shifts back to back to pay for some extra time off during the holidays. Today I found this study:

Results There was a graded association with average sleep duration: participants with less than 7 hours of sleep were 2.94 times (95% confidence interval [CI], 1.18-7.30) more likely to develop a cold than those with 8 hours or more of sleep. The association with sleep efficiency was also graded: participants with less than 92% efficiency were 5.50 times (95% CI, 2.08-14.48) more likely to develop a cold than those with 98% or more efficiency. These relationships could not be explained by differences in prechallenge virus-specific antibody titers, demographics, season of the year, body mass, socioeconomic status, psychological variables, or health practices. The percentage of days feeling rested was not associated with colds.

Conclusion Poorer sleep efficiency and shorter sleep duration in the weeks preceding exposure to a rhinovirus were associated with lower resistance to illness.

I think my mom always knew this, and now it’s evidence based.

Via Medscape.

Topic review: acute liver failure

Key points from this Chest review:

Classification of acute liver failure (ALF) based on its time course (hyperacute, acute, subacute) is useful in anticipating the etiology, prognosis and expected complications.

APAP is the most common etiologic factor.

The APAP toxicity nomogram is unreliable in many circumstances.

Infection is common in ALF and may precipitate cerebral edema. Daily surveillance cultures are recommended and empiric broad spectrum antibiotics are recommended in some subgroups.

The risk or cerebral edema rises in proportion to the rapidity of development of ALF due to the time required for cerebral adaptive mechanisms.

There is a relative lack of high level evidence to guide treatment. A summary is provided.

Wednesday, January 14, 2009

On being sued for malpractice

An Emergency Medicine professor vents his spleen:

It felt very personal when they questioned my honesty, morals, and intelligence. It felt personal when they didn't miss a chance to accuse me of recklessness, stupidity, arrogance, and laziness. It felt very personal when they asked for an award far more than my policy limits, and I, as the sole defendant, had to imagine the possibility of losing my house, retirement savings, and kids' college fund. Through a stroke of luck, the jury returned a decision for the defense. No one will convince me that on another day, a different group of 12 people could not have found me guilty, and awarded my future to the plaintiff.

It was simply luck that saved me. I sincerely believe that. It is of little significance that I felt and still feel that I cared for the patient as well as any good emergency physician, but the patient died, and his death demanded that someone pay. With a lottery mentality, the plaintiff's attorney put expectations in the plaintiff's minds of a fair compensation. That fair compensation was totally removed from the real world finances in which we all live.

The medical facts of the case mattered very little.

This is a must read.

What’s the best test for PE in 2009? V/Q scan or CT?

The evidence based answer is that neither one is better than the other, although it’s not always a coin toss. Clinical circumstances dictate the choice of modalities. V/Q scanning might be preferable if the patient is at risk for contrast induced renal failure. In the evaluation of chest pain if cardiac catheterization is planned V/Q scanning may be preferable to avoid a double contrast load. If stress nuclear myocardial perfusion is planned CT may be preferable, since the nuclear medicine myocardial perfusion scan will have to be delayed following V/Q scanning. An abnormal chest xray or COPD lessens the likelihood of a diagnostic V/Q scan.

A recent concern is that, because nuclear medicine scanning is being abandoned in favor of CT, the radiologists may be losing their interpretive skills.

Tuesday, January 13, 2009

Neurocognitive sequelae in ARDS survivors

This problem is gaining increasing recognition and was recently reviewed in Clinical Pulmonary Medicine. The etiology is probably multifactorial. Relative contributions of hypotension, hyperglycemia, hypoglycemia, hypoxemia, duration and depth of sedation and psychiatric factors need further study.

BNP, pro-BNP and PE outcomes

Elevations in BNP or pro-BNP in patients with acute PE are predictive of complications and mortality according to this meta-analysis. Implications for clinical practice, particularly how this marker complements the information gained from troponin testing and echocardiography, are not clear. But according to the At a Glance Commentary accompanying the article: Normal (NT-pro)BNP levels might be an indication for outpatient treatment. Or at least early discharge.

Monday, January 12, 2009

Early goal directed therapy for sepsis---does the concept work?

Yes, according to this meta-analysis. Late goal directed therapy was no better than conventional strategies. This confirms what we already knew.

Old thinking is sepsis resuscitation: just give ‘em “lots” of fluids.

New thinking: treat to pre-defined hemodynamic goals, but do it early (starting in the ER).

Another electrocardiographic clue to dilated cardiomyopathy

---is the voltage paradox. High in the precordial leads, low in the limb leads. I’ve seen this paradox several times. Expecting to find a hypertrophic cardiomyopathy, I have repeatedly ended up surprised when the echo reveals dilated cardiomyopathy. Imagine my ah-ha moment when I read this case report from the Baylor University Medical Center Proceedings! Those interested in a quantitative treatment of the relationship between the voltages in the precordial and limb leads as a predictor of DCM should check out this paper.

Related: LBBB + RAD as a predictor of DCM.

Friday, January 09, 2009

How often do docs review med lists on rounds?

Not as often as they should according to this study in BMC Clinical Pharmacology:

The physicians did not review medication charts on all ward rounds and there was considerable variation in how often they did this. There is some evidence that the frequency with which charts are reviewed decreases as the number of patients seen increases. More efforts should be made to encourage regular review of medication charts.

If there is a bright spot in tight inpatient glycemic control

---it may be in the early perioperative period (OR through ICU discharge) for cardiac surgical patients:

In non-diabetics, strict perioperative blood glucose control was associated with a reduced incidence of renal impairment (P=0.01) and failure (P=0.02) scoring according to RIFLE criteria, as well as a reduced incidence of acute postoperative dialysis (from 3.9% in Control to 0.7% in Insulin; P<0.01). Thirty-day mortality was lower in the Insulin than in the Control group (1.2 vs. 3.6%; P=0.02), representing a 70% decrease in non-diabetics (P<0.05) and 56.1% in diabetics (NS).

Via Critical Care.

If you’re the smartest doctor in the world

---it covers a multitude of sins, at least according to one survey. More respondents would choose House as their doctor than any other.

Thursday, January 08, 2009

Medical relicensing may get tougher

The Federation of State Medical Boards is considering a policy in which doctors would have to jump through more hoops for license renewal:

Under the draft policy, relicensure would become more comprehensive and require that physicians demonstrate continuing skills and knowledge in their area of practice. As proposed, the maintenance of licensure process would closely mirror the requirements that the American Board of Medical Specialties has in place for maintenance of certification.

But at this point it’s only a proposal. If adopted by FSMB it would be up to individual states to enact it, or some modification.

Via Dr. Bobbs.

Telemetry monitoring overutilized

The overuse of telemetry monitoring in step-down units may create bed control problems for hospitals, congesting the ICU and the ER. There are some high yield situations in which telemetry monitoring is indispensable. Other uses of telemetry, like rapid response teams, are popular but lacking in terms of evidence of effectiveness.

A literature review in the November issue of the American Journal of Emergency Medicine helps sort out the evidence based from the non-evidence based uses.

A realistic view of the hospitalist movement

A post from The Hospitalist Leader is titled Will the last traditionalist leaving the hospital please turn in your parking pass. It refers, of course, to the mass exodus of traditional practitioners (even specialists!) from hospitals. After describing how the exodus is accelerating the post says this:

Just to make this interesting, let’s assume for a minute that no one believes that a practice focused on a site of care, such as hospitalists, ER doctors, and intensivists, offers no [sic] improvement in quality or efficiency. Would ER doctors and hospitalists have still been “invented?”

I’m confident the answer is yes.

ER doctors appeared in the 60’s and 70’s largely because existing specialties on the medical staff were less willing to treat emergency patients, especially if the patient was “unassigned.” And hospitalists began appearing in the ‘90s because PCPs were less willing to provide hospital care.

OK, this is exactly what I said a while back. Like emergency medicine, the value of the hospitalist model is the large and ever expanding niche. And the statement above regarding no improvement in quality or efficiency is not merely hypothetical in my view of the evidence, as I’ve said time and again.

Wednesday, January 07, 2009

H pylori testing for patients with ITP?

Why not? It may spare your patient from the hazards of immunosuppressant therapy.

Background: ITP is not always idiopathic.

Bisphosphonates and osteonecrosis of the jaw

A couple of years ago everyone was blogging about it. The association is real, but it was overhyped. Here’s a sober assessment.

What’s the best way to withdraw life support?

In this study gradual withdrawal was common and was associated with greater family satisfaction than abrupt withdrawal.

Tuesday, January 06, 2009

Hospitals cutting back services, many closing

The current recession was merely the final finishing blow for many hospitals hanging by a thread for years under Medicare’s provider tax.

Adrenal Incidentalomas---what to do?

Here are the follow up data on adrenal incidentalomas from one study:

In our study group, nonfunctioning adenomas were the most frequent cause of AI (42%), followed by cortisol-secreting adenomas (15%), metastatic disease (10%), pheochromocytomas (8%), myelolipomas (6%), cysts (6%), carcinomas (4%), lymphomas (4%), tuberculosis (4%), and aldosteronoma (2%). Only 13 lesions (25%)
were functioning (8 cortisol-secreting adenomas, 4 pheochromocytomas, and 1 aldosteronoma). Carcinomas were the largest adrenal masses (mean diameter, 11.7
± 1.3 cm). With the exception of 1 pheochromocytoma, 1 cyst, and 1 myelolipoma, all AI larger than 6 cm were carcinomas. During follow-up of 21 patients with nonsurgically treated AI for 6 to 36 months (mean, 24.8 ± 8.9), no patient had tumor reduction or disappearance. After 12 months of follow-up, however, a 45-year-old woman had adrenal mass enlargement from 3.2 cm to 4.4 cm; the excised lesion proved to be an adenoma. Moreover, evidence of cortisol hypersecretion developed after 24 months of follow-up in a 30-year-old man with a 3.5-cm adenoma in the left adrenal gland.

Why is this important to hospitalists? Because hospitalized patients have a large number of CT scans for other reasons. Due to the severity and complexity of illness in hospitalized patients these incidentalomas may be more likely to be ignored than in the ambulatory setting. Those that are acknowledged may not be communicated to the PCP.

Abdominal visceral fat

---was reduced by high intensity but not low intensity exercise in this study.

Monday, January 05, 2009

Should we do head CT in patients resuscitated from cardiac arrest?

The yield was high in this study:

Seventy-eight (79%) patients demonstrated 111 CT abnormalities: edema, 35 (32%); atrophy, 24 (22%); extra-axial hemorrhage, 14 (13%); old infarct, 12 (11%); new infarct, 11 (10%); intraparenchymal hemorrhage, 6 (5%); skull fracture, 5 (4%); mass, 3 (2%); and foreign body, 1 (1%). Therapeutic and diagnostic alterations in care were made in 38 (39%) patients—35 abnormal and 3 normal CTs.

High technology and declining clinical skills

Over at Bob Wachter’s blog there’s a fascinating discussion on this topic, prompted by a NEJM perspective piece written by Dr. Abraham Verghese. Verghese laments the declining emphasis on the teaching of basic clinical skills, particularly physical examination, in today’s technological environment.

Please read the whole thing, but it seems to me that Wachter, though concerned about the threats to the human dimension of the doctor-patient relationship, has his reservations on the practical value of basic clinical skills today. Acknowledging the poor skills of today’s trainees---

(Let’s be honest – many of our physical exams are now perfunctory performances in a Theater of the Absurd whose audience is comprised of coders and insurers.) That can’t be good.

---he says this:

It seems to me that with everything today’s residents and students need to do and learn, the chances that we can revive the painstaking Oslerian physical exam are zilch, akin to the chance that we can resurrect the study of Latin in medical school.

Even if we could create a new generation of expert physical examiners, would it be worth the time and trouble? I doubt it.

Wow. He goes on to cite examples of poor performance characteristics of some aspects of physical examination.

Two questions are being raised here. First: Is basic clinical examination of practical value apart from the human dimension of “laying on of hands?” I would submit that in this era of runaway medical costs it may be more important than ever! J. Willis Hurst of Emory once said that if you don’t master low technology (history and physical exam) you are bound to abuse high technology, citing untold unnecessary echos, CT scans and nuclear studies. (Occasionally evidence wins out over the abuse of technology. For one of the best examples of that in all of medicine consider the rise and fall of the PA catheter).

Second, given that some feel the ancient clinical skills are irretrievably lost, can we afford the effort it would take to revive them? I would submit that we can’t afford not to. While we can’t turn the clock back to Oslerian days we can maintain a reasonable degree of basic clinical skill if we make it a priority in our quest of life long learning. I believe it’s part of the learning curve of high level clinical expertise that should characterize the hospitalist career.

Another new hospitalist blog

The Hospitalist Leader plans to focus on hospitalist group management issues including:

Staffing & Scheduling
Billing, Coding & Documentation
Career Satisfaction
Negotiating Contracts

Friday, January 02, 2009

Does EMR adoption decrease malpractice payouts?

Boy, wouldn’t that be something! Well, if you believe this report from AAFP News you might just think it was true:

Physicians who say they can't afford to purchase an electronic health record, or EHR, system may want to evaluate new research that suggests physician practices that use EHRs have fewer paid malpractice claims.

The report cites this study from Archives of Internal Medicine which shows that, yes, EMR adopters seem to pay out less in malpractice claims. It goes on to spin the study as something that might “tip the scale” toward a decision to adopt the EMR.

So, does this study prove that EMRs decrease payouts? All things being equal, no. It seems AAFP news left out this little detail from the paper:

In logistic regression analysis controlling for sex, race, year of medical school graduation, specialty, and practice size, the relationship between EHR adoption and paid malpractice settlements was of smaller magnitude and no longer statistically significant (adjusted odds ratio, 0.69; 95% confidence interval, 0.40-1.20; P = .18).

It’s a good thing EMRs don’t have to meet the same evidentiary standard that new drugs do! Despite the cheerleading for EMRs there’s still not a shred of evidence they have a beneficial impact on outcomes that matter.

As a user of the EMR I believe we have a long, long way to go before the benefits outweigh the unintended consequences.

Via RangelMD.

Accredited woo from Mayo Clinic

It should come as no shock that Mayo is offering a course on complementary and alternative medicine (CAM). After all Mayo, for some time now, has been listed on Orac’s Academic Woo Aggregator. What’s interesting about this is the fact that Mayo is not only offering but teaching woo as accredited CME (the fact that the offering would pass the Pharma free litmus test notwithstanding). I also learned from the brochure that Mayo is not only on Orac’s Aggregator but also a member of the Consortium of Academic Health Centers for Integrative Medicine.

The course appears to be an exercise in promotion and experiential learning. If the CAM topics presented at Mayo’s otherwise excellent hospital medicine course are any indication it will not be a science based critique of CAM.

The topics range from soft woo to some of the wooiest woo. The course claims to be evidence based. Papers on various CAM modalities will be dutifully cited. (“Research” in support of CAM is hopelessly flawed as I have pointed out here and elsewhere).