Dr. Sanity: If it passes, I’m done

Read it here. Via Medpolitics.

What to do with upper extremity DVT

From The Hospitalist.

Systolic dysfunction, diastolic dysfunction and postoperative outcome

In this recent study diastolic dysfunction but not systolic dysfunction was associated with adverse outcome in patients undergoing surgery. This makes perfect physiologic sense but counters a widespread clinical misconception.

Via Hospital Medicine Quick Hits.

Hospitalists as utility players

Here's a nice little rant from The Refugee over at Hospitalist With A View.

Here are some dictionary definitions of utility:

Used, serving, or working in several capacities as needed, especially:

1. Prepared to play any of the smaller theatrical roles on short notice: a utility cast member.

2. Capable of playing as a substitute in any of several positions: a utility infielder.

1. Designed for various often heavy-duty practical uses: a utility knife; a utility vehicle.

2. Raised or kept for the production of a farm product rather than for show or as pets: utility livestock.

3. Of the lowest U.S. Government grade: utility beef.

Forget about heparin to treat ischemic stroke

That was the message of a session on stroke care at Internal Medicine 2009. That's pretty widely accepted by now, or should be. But what if the patient's stroke is believed to be of cardioembolic origin, say, in the setting of atrial fibrillation?

Evidence suggests that there is no rush to give heparin in most patients with a cardioembolic source of stroke, said Dr. Kasner. He recommended waiting 48 hours in patients with minor strokes and five to seven days for major strokes.

Paul Krugman polls Canadians in the audience

---on their health care and doesn't get the response he wanted. His reaction? “Bad move on my part.”

Via Instapundit

Severity adjusted data for McAllen, Texas

Maybe Gawande's analysis was wrong.

End of life care

One of the provisions in Obama's health care proposal is, apparently (I say apparently because I haven't read the provision in the original), that Medicare would pay for time spent in counseling patients on end of life decisions. Although I'm not sure why it's necessary to create a new CPT code, as there are already counseling codes that cover just about everything, on its face this is not a bad idea .

Wasteful interventions at the end of life are often driven by poor understanding of grandma's disease processes which leads to inflated treatment expectations. If given the appropriate information many patients and families would decide against expensive treatment options which carry little benefit.

In the current debate there's a misconception that the Obama plan would force all elders to undergo the counseling. DB called out that straw man in a post yesterday:

As I read the provision, physicians could charge for having these important conversations. Hopefully this provision will encourage physicians to address goals of treatment in patients facing the end of life.

Opponents have perverted this concept into claiming that the government will bully patients into forgoing “life saving” treatments. These opponents do not understand medicine or end of life care.

I agreed with pretty much everything in the post until DB dropped this bomb at the end:

So I say to the critics of this provision – shame on you. Any bill has much to criticize, but this provision stands beyond reproach.

Not so fast! Shouldn't we be thinking about all those unintended consequences, slippery slopes and conflicts of interest? While the pure notion of doctors counseling patients on end of life issues in a way that respects their wishes and values may be above reproach how does it play out in the real world of corrupt incentives? Perverse incentives to limit care have been with us for years in the form of the prospective payment system. Now we're going to pay very busy doctors to have these counseling sessions. Will they take the time to explain things in a way that the patient and family members will understand? Will values be respected? Will undue pressure be applied?

When looked at as a pay for performance measure the unintended consequences readily come to mind. I can see it now. Perfunctory conversations supplemented by pages of “smart text” in the EMR on end of life decisions. Opportunities for hospitalists to improve coding and limit hospital care all at the same time. A real win-win for administration.

Those considerations alone warrant debate on the provision. But it gets even more concerning when you consider that high level policy makers in the current administration are bent toward rationing directed against the elderly. I first pointed that out last May. More recently Retired Doc and Sandy Szwarc have weighed in and linked to this Lancet piece written by those policy makers. The double-talk below, in which the authors defend ageism in health policy, then explain why it's not really ageism, would be funny if it wasn't so chilling:

We consider several important objections to the complete lives system.

The complete lives system discriminates against older people. Age-based allocation is ageism. Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years. Treating 65-year-olds differently because of stereotypes or falsehoods would be ageist; treating them differently because they have already had more life-years is not.

So I'll conclude with this:

I do strongly agree that end of live discussions should be encouraged.
I do agree that palliative care teams play an important role.
I do not trust government policy makers and am concerned about the consequences, intended and unintended, of their actions.

More about floppy iris syndrome

The June 15 issue of American Family Physician has an update on tamsulosin (Flomax) and the intraoperative floppy iris syndrome (IFIS). Here, according to the article, is why the problem is practically unique to tamsulosin:

Of the three alpha-1 receptor subtypes (A, B, and D), the 1A receptor predominates in the iris dilator and prostatic smooth muscle. Among alpha-1 antagonists commonly used to treat benign prostatic hyperplasia (BPH), including terazosin (formerly Hytrin), doxazosin (Cardura), and alfuzosin (Uroxatral), only tamsulosin is subtype selective and demonstrates the highest affinity for the alpha-1A receptor.

And here's what's scary:

Another unexpected and remarkable finding is that IFIS can occur more than one year after tamsulosin has been discontinued. ^{[1] , [2]} Ninety-five percent of ASCRS survey respondents have experienced IFIS in patients with only a previous history of alpha-1 antagonist use.^[8] Histopathologic analysis of autopsy eyes from patients who were taking tamsulosin shows atrophy of the iris dilator muscle, which would be consistent with a semipermanent drug effect.

There are apparently some work-arounds in surgical technique that ophthalmologists can use to minimize operative complications.

Does the public want Obamacare?

While the Republicans are doing their homework on health care reform public support is waning.

House Republicans doing their homework on health care bill

GOP's teachable moment on the risks of Obamacare

"We learned from the stimulus, and the other side didn't," says one savvy GOP aide. "They pushed through a bill as fast as possible so that no one knew what was in it. Very early on, there was a clear goal that Republican members of Congress would know what was in this [health care] bill and what its impact would be."

House Republicans had six private health care seminars in May, two in June and three so far in July, with the ones this month dealing specifically with the Democratic proposal on the table. GOP officials estimate about three-quarters of the Republican members have gone through the sessions.

"This is not a bill you can skim," says Rep. Dave Camp, the ranking Republican on the House Ways and Means Committee. "You have to read it again and again and find new nuances. It's a big, complex piece of legislation."

According to David Camp, the ranking Republican member on the House Ways and Means Committee people's concerns are shifting from platitudes about health care to details, and they're beginning to understand that the devil's in those details.

Speaking by phone from the small town of Stanwood, Mich., where he was meeting with constituents, Camp told me voters are hungry for the details of the health care proposal; people come up to him in the grocery store and ask him how this or that measure would work.

The August recess will provide an opportunity to get information to voters. We need time to understand and debate what's in the bill. Health care has been in crisis for years. We can take a few weeks for debate. No one can make a rational argument that we have to pass something now.

This website provides updated information on the bill.

Via Instapundit.

Beta blocker titration in heart failure: base it on heart rate reduction

From a meta-analysis in Annals:

For every heart rate reduction of 5 beats/min with β-blocker treatment, a commensurate 18% reduction (CI, 6% to 29%) in the risk for death occurred. No significant relationship between all-cause mortality and β-blocker dosing was observed…

Conclusion: The magnitude of heart rate reduction is statistically significantly associated with the survival benefit of β-blockers in heart failure, whereas the dose of β-blocker is not.

This differs from guideline recommendations, which are based on the doses used in trials.

Via Hospital Medicine quick Hits.

Inpatient glycemic control after NICE-SUGAR

The American Association of Clinical Endocrinologists and the American Diabetes Association have come out with a new consensus statement. The document covers a variety of issues encountered with hospitalized patients and should be a useful reference. The authors seem a little doctrinaire, though, in areas where evidence is lacking.

For critically ill patients:

Insulin therapy should be initiated for treatment of persistent hyperglycemia, starting at a threshold of no greater than 180 mg/dl (10.0 mmol/l).

Once insulin therapy has been started, a glucose range of 140–180 mg/dl (7.8–10.0 mmol/l) is recommended for the majority of critically ill patients.

Intravenous insulin infusions are the preferred method for achieving and maintaining glycemic control in critically ill patients.

That reflects the state of our knowledge after NICE-SUGAR. The IV route is preferred in such patients because of the flexibility it affords in the constantly changing conditions of critical illness as well as the fact poor and fluctuating tissue perfusion makes sub Q absorption unreliable.

The recommendations for noncritical patients seem more problematic:

For the majority of noncritically ill patients treated with insulin, the premeal BG target should generally be less than140 mg/dl (less than 7.8 mmol/l) in conjunction with random BG values less than 180 mg/dl (less than 10.0 mmol/l), provided these targets can be safely achieved.

Although this recommendation seems perfectly reasonable it implies that less ill patients need a stricter glycemic target (which doesn't make a whole lot of sense) and has no high level evidence to back it up.

Concerning the means to get to those targets the statement says:

Scheduled subcutaneous administration of insulin, with basal, nutritional, and correction components, is the preferred method for achieving and maintaining glucose control.

Prolonged therapy with SSI as the sole regimen is discouraged.

The point about sliding scale insulin here is it shouldn't be the sole regimen. The patient needs some basal coverage to go with that. Note that when diabetologists do recommend sliding scale insulin as part of a regimen they use the more politically correct term correctional insulin.

And finally:

Noninsulin antihyperglycemic agents are not appropriate in most hospitalized patients who require therapy for hyperglycemia.

That doesn't quite address the question of whether patient's non-insulin diabetes medicines should always be withheld in the hospital although they often are. There's no evidence to support such a rule that I know of and factors such as anticipated NPO status (e.g. in the case of sulfonylureas) and changes in renal function (e.g. for sulfonylureas and metformin) should guide clinical judgment.

Lantus and cancer---what's going on?

Dr. Mintz has written a series of posts which provide the best perspective I've seen on this issue, which can be accessed here, here and here.

Key points:

According to the data Lantus seems to be associated with greater cancer risk than old fashioned human insulin but no comparison with the other long acting insulin analog, Levemir, has been made.

Since insulin is a growth factor, due at least in part due to its agonist effect on the IGF-1 receptor, it's plausible that any insulin might promote tumor growth. However, the affinity of Lantus for the IGF-1 receptor is uniquely high, higher than that of human insulin and much higher than Levemir.

This plausible mechanism, along with an apparent dose-response relationship for the effect, suggests that there really may be something to the association.

In patients with low cancer risk the absolute risk associated with Lantus is probably very low, and the association needs additional study.

My take:

Pushing insulin to very high doses in obese insulin resistant type 2 diabetics likely compounds the problem. Such an approach is irrational and needs serious re-examination as I recently pointed out here.

Although insulin analogs are appealing and relatively easy to use hard data that they offer advantages over older insulins in terms of clinical outcomes are lacking.

Current evidence does not give clinicians clear guidance about what to do but for now, in patients needing an insulin analog for basal coverage I'm tempted to go with Levemir.

Gratuitous comanagement

Happy Hospitalist ranted over at Hospitalist With A View on getting consulted by surgeons for “medical follow up”:

If there is an acute issue that needs to be addressed, elevated blood pressure, abnormal blood sugar, chest pain, fever I am more than happy the evaluate patients who need a physician specialist as my self to evaluate an acute issue. This is not general medicine. This is internal medicine.If you are asking me if I am happy to see post op surgical patients to write discharge orders, address home meds and field nuisance pages, then you must be mistaking me for someone you should be hiring to do your work for you.

Wait a minute, Happy, haven’t you heard of comanagement?

He went on:

Does consulting me make it medically necessary? Well, Medicare and their carriers seem to think so. No claim is ever rejected. So what am I to do? Do I say no to the physician's request? Or do I do it and submit a claim.

Well, you could see the patient, submit a claim for your initial visit and then, having determined that there is no acute problem in need of your expertise, sign off. That’ll get you out of the loop for those nuisance pages and the discharge planning which should really be the responsibility of the surgeons or their PAs. Keep up the clerical scut work and you won’t be a Happy Hospitalist much longer.

Cost effective wound management

Cranky Kong,MD over at Hospitalist With A View wrote:

Before ordering the damn MRI to "rule out osteomyelitis", please take apart the dressing and look at the effing wound first. Or read the wound care notes.

For a more formal discussion consult this resource.

CMV infections in non-immunocompromised critically ill patients

This subject has been getting lot of press. Here's the latest paper from Critical Care Medicine:

Conclusions: Active cytomegalovirus infection occurs frequently in nonimmunosuppressed patients in intensive care, especially in those with positive cytomegalovirus serology, intensive care unit stay ≥5 days, severe sepsis, and high disease severity, in whom the rate of cytomegalovirus infection is up to 36%. Mortality rate is significantly doubled with cytomegalovirus, but a cause-effect relationship cannot be established yet.

Alpha 1-antitrypsin deficiency review in NEJM

Key points from the review:

Current guidelines recommend testing for alpha 1 in all COPD patients without exception and in those asthma patients who do not normalize their PFTs with treatment.

Disease associations, in addition to emphysema, include bronchiectasis, asthma, liver disease, necrotizing panniculitis and Wegener's granulomatosis.

Replacement therapy is of modest benefit in affected individuals with COPD, may be dramatically effective in necrotizing paniculitis (anecdotal reports), and is ineffective against Wegener's granulomatosis and liver disease (for obvious reasons).

For patients with end stage liver disease transplantation reverses the syndrome of liver failure and comes with the added bonus of curing the alpha 1-antitrypsin deficiency!

As the NIH continues

---to promote unethical and dangerous quackery we have to ask:

Are these the clowns we want in charge a national research agenda?

Why is Obamacare losing steam?

Because Americans have gone beyond the mantra “We need change” and actually started thinking. From Peggy Noonan's WSJ piece:

I suspect voters, the past few weeks, have been giving themselves an internal Q-and-A that goes something like this:

Will whatever health care bill is produced by Congress increase the deficit? “Of course.” Will it mean tax increases? “Of course.” Will it mean new fees or fines? “Probably.” Can I afford it right now? “No, I’m already getting clobbered.” Will it make the marketplace freer and better? “Probably not.” Is our health care system in crisis? “Yeah, it has been for years.” Is it the most pressing crisis right now? “No, the economy is.” Will a health-care bill improve the economy? “I doubt it.”

and---

The final bill, with all its complexities, will probably be huge, a thousand pages or so. Americans don’t fear the devil’s in the details, they fear hell is. Do they want the same people running health care who gave us the Department of Motor Vehicles, the post office and the invasion of Iraq?

Or, might I ask, the NCCAM and TACT?

Via Dr. Helen.

Corticosteroids in severe sepsis and septic shock

Critical illness related corticosteroid insufficiency (CIRCI) is a well documented entity. Yet, controversy surrounds the question of when and when not to give steroids in critically ill patients, particularly septic patients. CORTICUS, the highest level study to date to address the issue, found no benefit from steroid therapy in patients with hypotension persisting after fluid resuscitation whether their cortrosyn stimulation test was normal or showed “relative” adrenal insufficiency. The Surviving Sepsis guidelines downgraded their steroid recommendation to patients refractory to pressors, and did not recommend adrenal testing.

More recently, this systematic review suggests benefit from low dose steroids (defined as 300 mg hydrocortisone or its equivalent/day) in a broader range of patients:

Corticosteroid therapy has been used in varied doses for sepsis and related syndromes for more than 50 years, with no clear benefit on mortality. Since 1998, studies have consistently used prolonged low-dose corticosteroid therapy, and analysis of this subgroup suggests a beneficial drug effect on short-term mortality.

Some, but not all of the studies in that review based steroid treatment on the cortrosyn stimulation test.

Not surprisingly, some studies showed increased hyperglycemia attributable to steroids, as well as hypernatremia, the latter particularly associated with hydrocortisone, which among corticosteroids has stronger mineralocorticoid effects.

This study adds to our uncertainty, as pointed out by the accompanying editorial:

The authors report that there have now been 12 randomized trials testing the more recent strategy of low-dose steroids for a week or more and suggest an impressive overall reduction in mortality (risk ratio, 0.84; 95% confidence interval, 0.72-0.97; P=.02), even when accounting for the CORTICUS study. They conclude that steroids are indicated for all patients in septic shock, despite the findings of this trial, and in contrast with the position articulated in the SSC guidelines.

So it seems that clinicians treating patients with sepsis have 3 choices regarding steroids: no use, limited use, or broad use. Steroid use could be abandoned if the largest and latest trial, CORTICUS, is thought to effectively trump all prior studies. Steroids could be used in a limited set of patients and initiated only after it has been demonstrated that these patients are not responding to conventional measures, based on the SSC guidelines. Or steroids could be used broadly in septic shock, and possibly even in all severe sepsis (ie, any infection complicated by acute organ dysfunction), based on the results of the meta-analysis by Annane et al.4

Putting it mildly, this is a messy situation.

The answer? Again, from the editorial:

...the major difference between the SSC guidelines and the current meta-analysis seems to be a difference of judgment and opinion in the face of inconclusive evidence. That means that the final decision rests squarely on those at the bedside.

Is the hospitalist movement going full circle?

The Hospitalist Refugee reflects on the SHM 2009 national meeting:

The discussion of readmission rates and post-hospitalization care was important, but I was quite disturbed at the murmurs of suggesting that hospitalists now take over some of those outpatient duties post-discharge. Hospitalist medicine emerged because primary care doctors could no longer effectively do clinic AND inpatient medicine. In our community, the primary care doctors that we started admitting for immediately boosted their clinic schedules. And that's fine... unless we can't get your damn inpatients to follow up with you. I think that this is an area where the onus does fall back on the primary care doctors. In our community, they used to be responsible for all the unassigned admissions AND their follow up. I just bristle at the suggestion that the job of the hospitalist needs to start morphing back into the very profession we all found so dissatisfying.

I guess the same lame-brained notion circulating around SHM 2008---that hospitalists are supposed to help fix everything that needs fixing---both in and outside the hospital---was making the rounds again at this year's meeting. The Society of Hospital Medicine is not representing its rank and file members in this important area. Its leadership needs to do a better job of defining and limiting the scope of the hospitalist's job description. There's a lot they could learn from our colleagues in emergency medicine.

Pulmonary hypertension in patients with systemic sclerosis and its variants

In patients with systemic sclerosis (SSc) pulmonary hypertension (PH) portends a poor prognosis, and even worse if it’s associated with interstitial lung disease (ILD) according to this study. According to this Medscape commentary on the study, the investigators suggest identifying such patients, as they may be candidates for early lung transplantation.

Background:

Traditional thinking holds that limited SSc such as CREST syndrome is associated more with PH while diffuse SSc is associated more with ILD. [1]

Such traditional clinical classifications are flawed, and serologic classifications based on autoantibodies (anti-topoisomerase, anti-centromere, anti-RNP, etc.) may be more useful. [2]

As noted in this review, PH may be idiopathic or have disease associations (connective tissue diseases, congenital heart diseases, portal hypertension, HIV infection, drugs) and be associated with pulmonary diseases including COPD, although it is sometimes unclear in the latter case whether it is due to hemodynamic effects of the lung disease itself or overlap with another disorder of the pulmonary vasculature.

Although the use of warfarin was not associated with improved survival in the above mentioned study, the guidelines suggest its use in patients with idiopathic PH.

Obama: Doctors are in it for the money

From his press conference:

We wanted to make sure that doctors are making decisions based on evidence, based on what works. That's not how it's happening right now. Doctors are forced to make decisions based on a fee payment schedule that's out there. So they're looking... if you come in with a sore throat or your child comes in with a sore throat, has repeated sore throats, a doctor may look at the reimbursement system and say to himself, "I'd make a lot more money if I took this kids tonsils out."

It’s hard to put a positive spin on what he just said though some have tried, pointing out that he said doctors are “forced” by the payment system to make non-evidence based decisions. Well, at the very least, then, he’s saying doctors are incapable of managing the conflicts of interest created by a fee for service system. That’s giving his remarks the benefit of the doubt. But that’s bad enough.

Well, never fear. Soon his panel of comparative effectiveness experts will free us all from our conflicts.

Additional blog reactions from Dr. Wes, Dinosaur and Buckeye Surgeon.

Update---Instapundit: "...a truly staggering degree of medical ignorance."

Will Obamacare be patient centered?

The two videos that follow are slightly different edits of the same conversation at a town hall type meeting in which Obama took audience questions about health care reform. Watch them and decide for yourself how patient centered his attitude is. I made some time marked comments below the respective clips. Italics mine.

0:00-0:59 The lady’s question was eloquent yet plain and clear. Under a formulaic “reformed” health care plan will there be room for humanism in medical decisions?

1:00-1:03 Obama dodges her question but dismissively blurts out “We’re not gonna solve every difficult problem in terms of end of life care…”

1:04-1:13 “…a lot of that is gonna have to be we as a culture and as a society starting to make better decisions within our own families and for ourselves…” This after the questioner had just movingly described her own decision making process. Maybe he really was responsive to her question.

1:14-1:24 “…but what we can do is make sure that at least some of the waste that exists in the system that’s not making anybody’s mom better…” All that comes to my mind in that category is the woo being pushed by the NCCAM but somehow I don’t think that’s what he’s talking about.

1:33-1:39 “…at least we can let doctors know and your mom know that, you know what, maybe this isn’t gonna help.” He just spoke volumes. He’s saying doctors can’t make rational clinical decisions. No, worse. Doctors can’t even determine what services are utterly wasteful.

1:41-1:47 “Maybe you’re better off not having the surgery but taking the pain killer.” Make of that what you will.

In this clip Obama says, in effect, that if the experts (those, as he puts it, “who are advising doctors across the board”) were to determine that a pacemaker would save money they would get it done faster.

H/T to Dr. Helen

Medical Justice founder tries to bring quality to on line physician rating web sites

According to this CMAJ piece he’s not trying to shut down sites like Rate MDs. He does want to increase public pressure to make these sites accurate and reliable.

He freely admits he’s swimming against a tide. "Our challenge is based on the premise that Internet ratings are here to stay — let’s do it right," he says. "What we’ve seen looks more like the wild wild West, Jerry Springer and The National Enquirer than a serious enterprise. We’re trying to provoke a discussion and get it done better."

Dr. Mintz on Avandia

Two years after the Avandia brouhaha Dr. Mintz has offered some needed perspective.

Backing up a bit, last year he noted VADT, which appeared to absolve Avandia of any role in promoting macrovascular disease.

Earlier this month he cited the RECORD study which also appeared to vindicate Avandia of any role in causing myocardial infarctions. In the body of that post and in the comments there is an interesting discussion about whether Nissen's meta-analysis and the way it was handled had political motivation. Dr. Mintz believes it did. I have believed so too ever since watching the Avandia hearings which I blogged about here.

In a more recent follow up post about the Avandia hype Dr. Mintz addressed possible patient harm. There's little doubt in my mind that irrational fears deprived many patients of potential benefits of TZD therapy. But what's irrefutable is that politics and the media hijacked the discussion with the result that reasoned, nuanced scientific debate over Avandia never had a chance.

Does passing laws make doctors more ethical?

Daniel Carlat apparently thinks so. In his latest post, in which he pokes fun of a new organization dedicated to opposing the backlash against medicine-industry collaboration, he writes (my italics):

Everybody’s buzzing about the new organization and website, ACRE, whose purpose is to stem the tide of legislation that is rehabilitating the ethics of physicians.

Legislation is rehabilitating our ethics? A credulous statement indeed from such a skeptic as he.

Point of care testing---does it improve ER throughput?

The results are mixed.

Living wills and DNRs are not enough---patients need a comprehensive advance care plan

This topic was nicely addressed in a recent article in CCJM. It’s an important reference for the hospitalist’s library because it contains many algorithms and assessment tools. Here are a few key points:

Planning is best done as a series of discussions and should therefore take place in the ambulatory setting. As a hospitalist your job will be a lot easier if that has already taken place. All too often it has not. In such cases you as the admitting physician have to ask unprepared family members, caught in the overwhelming stress of the moment, what their preferences are. The chances of you getting an informed and rational decision are somewhere between slim and none.

Discussions need to go beyond the usual DNR check list. Would dialysis be appropriate? What about PCI as opposed to non-invasive symptomatic treatment of acute coronary syndrome? Next time the patient deteriorates at the nursing home should s/he be transported to the hospital again?

Discussions need to address the big picture. Patients and families may be clueless about big picture issues despite superficial familiarity with all the medspeak of gramma’s disease processes. Big picture questions include: What are the expectations of treatment? Can we really “fix” anything? Is it really important to make precise etiologic diagnoses if we can otherwise maintain comfort and quality of life? What’s the prognosis?

An accompanying editorial disagrees with the authors on several points, including the degree to which algorithms are useful.

Evidence based practice in patients with combined atrial fibrillation and heart failure

---was very low in the Euro Heart Survey on Atrial Fibrillation:

…29% received the recommended drug therapy for both LVSD-HF and AF, consisting of the combination of a beta-blocker, either ACEI or angiotensin II receptor blocker, and oral anticoagulation. Rate control was insufficient with 40% of all HF patients with permanent AF having a heart rate of 80 beats/min.

The latter finding is particularly disturbing, since aggressive rate or rhythm control of atrial fibrillation is associated with improvement in ejection fraction.

A wooster selected to lead the lymphoma association

Orac writes:

Homeopathy is quackery, pure and simple, and hiring a quack apologist to run what should be a science-based organization sends a horrible message. At the very least, it makes me wonder if the BHA is about to go down the woo-hole of quackademic medicine. If so, British patients with lymphoma should be very, very afraid indeed.

Read the rest here.

Flatulence

Flatulence can have significant consequences.

In 1976 this paper reported a detailed set of investigations and unsuccessful therapeutic trials in a patient troubled with flatulence. It was a bit whimsical for the staid NEJM and offered no prospects for effective treatments.

Well, it looks like the science has matured since then. The June 15^th issue of American Family Physician offers an evidence based summary of treatment options. Notably, it appears that bismuth subsalicylate, good old Pepto, (used PRN before social outings) may have a role in odor management to help reduce the uncomfortable situations created by those pesky SBDs. Otherwise why bother?

Of course there are non-pharmacologic and behavioral approaches such as offered here:

Euthyroid sick syndrome

---is now apparently more correctly referred to as nonthyroidal illness syndrome (NTIS). Anyhow, in patients with respiratory failure its presence seems to be associated with longer duration of mechanical ventilation according to this study. There's nothing here to suggest changes in practice, as there's no evidence regarding whether thyroid replacement helps.

Watch those bounce backs

Out the door, out of mind. That's all too often the attitude of social workers, case managers, administrators and, yes, even doctors, when it comes to Medicare patients. If they bounce back tomorrow, well, hey, it's a new day, a new admitting team and, most importantly, a new DRG. As hospitalists under the perverse prospective payment system we're under pressure to discharge patients quicker and sicker.

All that may change. Medicare may penalize hospitals with high readmission rates or, worse, bundle episodes of care over 30 day periods. Here's Erik DeLue's analysis in Today's Hospitalist.

Fulminant C diff colitis---call the surgeons!

A retrospective study and editorial commentary in Archives of Surgery reviewed the topic of FCDC and cited risk factors for increased mortality. At the risk of cramping our comanagement style, I thought this point was interesting:

Survival rates are higher in patients who were cared for by surgical vs nonsurgical departments, possibly because of more frequent and earlier operations.

The editorial made these points:

Increased patient age, immunosuppression, hypoalbuminemia, significant leukocytosis, and increased serum lactate levels have all been shown, in this or other reviews, to correlate with the need for operation and with ultimate treatment outcome. Nevertheless, there is no absolute threshold in any of these categories and no finding on CT scan, short of pneumoperitoneum, that predicts the need for operation with certainty for an individual patient.

So when does the patient with C diff colitis have a surgical abdomen? When a good surgeon says they have one!

Dr. Wes on physician burnout

Having finished med school and residency---

Just then, we decide to launch a full scale attack on physicians and their patients with increased documentation requirements, call hours, larger geographic coverage of their specialties, reduced ancillary workforce, and shorter patient visits.

…At the same time that we expect our doctors to be devoted, available, enthusiastic, meticulous and at the top of their game with perfect "quality" and "perfect performance," while simultaneously cutting their pay, increasing documentation requirements and oversight, limiting independence, questioning their professional judgment, and extending their working hours.

I think he understands. Read the rest.

The guv'ment's proposed program for comparative effectiveness research

---is conflicted and agenda driven, and if you don't realize that you're profoundly naïve. I presented irrefutable evidence of the conflict of interest straight from Pete Stark, Peter Orzag and the Congressional Budget Office here.

Last week there was more from JAMA as Robert H. Brook, M.D., wrote about what we can expect from comparative effectiveness research. He sees a very biased and conflicted agenda, though apparently sees nothing wrong with it (my italics):

The comparative effectiveness funds should be allocated according to a framework designed to identify procedures, devices, and drugs that would reduce cost but not diminish health. This would help achieve the goal of making health care more affordable. Such a framework would have 2 new required features. First, a grant or contract to spend public money must include an initial analysis to establish a business case that implementing whatever is being proposed would reduce the cost of care by a certain percentage.

A business case? Imagine the howls of protest if a drug company advanced a business case to pitch for its research agenda!

The Trial to Assess Chelation Therapy

It’s a waste of tax money. It’s scientifically unsound. It’s driven by conflicting interests. It’s being conducted by incompetent investigators. It is biased, methodologically flawed and ethically compromised. It is the biggest and most disgraceful boondoggle in the recent history of clinical research. Yet the government, through the NIH, continues to fund it.

Read the updates here, here, here and here. Then explain to me how anyone could possibly think the United States Government, under the rubric of “comparative effectiveness research,” would be a reliable steward of our research dollars.

Peripartum cardiomyopathy

Reviewed in CCJM.

Peripartum cardiomyopathy occurs in the last trimester of pregnancy or up to 5 months after delivery. Treatment is, in general, similar to standard heart failure treatment although during pregnancy ACEIs and ARBs are supplanted by hydralazine and nitrates.

Novel treatment strategies were mentioned, including bromocriptine, which I blogged about here, supported at this time only by pathophysiologic rationale in a mouse model and dramatic anecdotal reports.

Red cell distribution width, morbidity and mortality

The red cell distribution width (RDW), one of the automated red cell indices, is a measure of variation in red cell size (anisocytosis). Its ubiquitous presence on the CBC report, though a useful troubleshooting tool in patients with anemia, is usually ignored by clinicians. Now there is evidence that it may predict morbidity and mortality in patients with heart failure and coronary artery disease as well as in the general population. The mechanism is not understood.

H/T to Retired Doc.

Rethinking the anti-antibiotic dogma

A while back I linked a study demonstrating that antibiotics, when prescribed for bronchitis, prevented pneumonia. Now comes this study in Chest showing that antibiotic treatment in the ambulatory setting for “lower respiratory tract infections” (essentially bronchitis) is associated with decreased mortality and decreased hospitalization rates. An accompanying editorial points out the methodologic problems, suggests alternative explanations for the findings and calls for more research.

What does it mean? That a rigid rule against antibiotics for bronchitis is simplistic. Consider the patient you’re dealing with. Some healthy patients at low risk can probably do without. On the other hand prior research has shown that when bronchitis is causing a COPD exacerbation antibiotics may be life saving. Think before you give antibiotics to patients with bronchitis. Equally important, think before you withhold them!

Update in Anesthesia---a virtual physiology text

Although posted as an educational reference for anesthesiologists this is an excellent resource for anyone involved in the care of critically ill patients.

ECMO for refractory respiratory failure?

It may be beneficial in selected adult patients according to this paper in the Archives of Surgery. It would be indicated and available in only a very select group of patients.

Accompanying editorial.

Medscape commentary.

Previous related post.

Diabetic retinopathy and cardiac dysfunction

---are associated, even when adjustment for other variables is made, thus lending credence to the notion of diabetic cardiomyopathy as a microvascular disease.

Lifetime Medical Television

Every Sunday in the late 1980s and early 1990s Lifetime Television, the network for women, became Lifetime Medical Television, the network for physicians. Back in the days before the Web this was the only option for viewing presentations on medical topics right from the comfort of home. I was glued to the set all day many Sundays. I took notes. When I couldn’t watch I set my VCR. There were few if any accredited CME offerings but the content was excellent. The pharma ads, directed to physicians, were attractive and clever, much better than the DTC ads of today. In the videos that follow is a montage of promos, openings and ads with shots of some of LMT’s all star cast. I spotted HJ Swann, Robert Rakel, Bernie Lown and Roger Bone, all of whom were frequent hosts.

Cardiologists---not so greedy after all?

After I challenged Doug Bremner for claiming that all angioplasty (by which he meant, primarily, coronary stenting) was useless and should be eliminated from future health care budgets he updated his post thusly:

[...Even so they are still estimated to be about 1/3 which is too many and some cardiologist lately have gone to jail for performing PCI on people with little or no heart disease. So my initial statement that 25 billion dollars could be saved is not correct. It is more like, um, 8 billion.]

So the question Dr. Bremner and I now have on the table is not whether to cut out all stent procedures, but whether one third could be slashed from the budget. We're getting closer but we need to examine a little more rigorously what the clinical trials said about that third. They are the folks who have stable coronary disease. Neither the BARI 2D nor the COURAGE trial showed a reduction in major events with stenting as compared to medical therapy. But what else was learned from the two studies? First, both trials addressed the lowest risk stable angina patients. If the patients were too high risk they simply were not included for study. Second, many medically managed patients in both groups crossed over to revascularization---around 30% in courage and around 40% in BARI 2D. In other words many patients failed medical therapy. That's not to say it was inferior to PCI, because many PCI patients had to have repeat revascularizations. It is to say that many stable CAD patients initially managed medically will develop legitimate indications for unblocking their arteries sooner or later. In fact, the authors of the very paper Dr. Bremner was referring to (the BARI 2D trial, or at least I think it was—Dr. Bremner didn't provide the citation) said this in their discussion section:

It is important to note that all the patients who were assigned to receive medical therapy underwent careful clinical monitoring, and 42.1% had changes in the clinical course that called for later revascularization during 5 years of follow-up. In clinical practice, the initial treatment strategy for a patient with diabetes and coronary disease rarely remains constant over a 5-year period.

In the real world these stable patients get stented for better angina relief, which study after study shows is a benefit of revascularization even if major events are not reduced. So when Dr. Bremner calls for a denial of PCI for these patients he can't base it on evidence. He has to make a value judgment about whether the better quality of life these patients would experience is worth it. Will Obama's “comparative effectiveness” panels make similar value judgments?

Now if Dr. Bremner will concede that some stable angina patients have a legitimate need for PCI for symptom relief not afforded by optimal medical therapy then we can reduce this discussion down to the real question: how many of those revascularizations are truly unnecessary? How many cardiologists yield to the oculostenotic reflex and stent lesions just because they're there and because they can, in stable minimally symptomatic patients? There's little doubt such non-evidence based stenting takes place, but we don't know how much, do we? Without such numbers how can Dr. Bremner begin to estimate they monies potentially saved by eliminating non-evidence based PCI?

Maybe Dr. Bremner's problem is that he uses the same EBM pyramid as Marcia Angell. He seems to have gotten his information from this article in Business Week. Lets hope the folks in the Obama administration who evaluate comparative effectiveness spend a little more time reading the NEJM.

The new evidence pyramid

Consensus Algorithm for medication choices and titrations in DM 2

This review is a convenient reference and follows the “mainstream” recommendations. Note that the A1C target of 7%, which the authors advocate, is controversial.

Bundle branch blocks and fascicle blocks

Classification, diagnosis and clinical implications reviewed in the American Journal of Emergency Medicine.

Another tool to help determine the duration of anticoagulation

---may be venous ultrasonography after a period of treatment. There are some caveats in this paper. I previously discussed D dimer testing here.

More on Salmonella and mycotic aneurysms

If my recent post on this subject seems a little dry go read the case report by Lisa Sanders in a recent issue of the New York Times magazine. Because Salmonella mycotic aneurysm is a very uncommon presentation of a not so common disease and presents with nonspecific symptoms it's likely to unfold as a mysterious case.

Dr. Sanders commented:

I published a similar case in a very different forum, the New York Times Magazine. I think the case gives a sense of how this might unfold in real time...

The patient presented with fever, back pain and confusion. The resolution of the case:

The radiologist called as soon as the scan was done. There was no abscess on the spinal cord, but the patient's aorta had weakened and the pressure of the blood flow had caused the tube to bulge like a worn garden hose. He was also concerned that this weak spot had sprung a leak....

...the patient was rushed to the operating room.

The left side of his abdominal cavity was filled with blood, and parts of the normally thick tube of the aorta were in tatters. The surgeon quickly replaced the shredded portion of the aorta and sent the dissected bits to the lab. Under the microscope, it became clear what had caused all of this man's symptoms. The tissue had been invaded by a bacterium -- an unusual type of salmonella, one usually found in uncooked pork. This bug -- salmonella choleraesuis...

So what is Salmonella choleraesuis? I have always been confused by the taxonomy of Salmonella. In my post I mistakenly said:

Species associations, according to the brief review, tend to be enteritidis and typhimurium.

Well, after a little digging it turns out that those aren't species. They're serotypes, also known as serovars. (I plan to make the correction). Salmonella choleraesuis is indeed a species. One popular classification denotes this species, which contains many serotypes and is also called Salmonella enterica, as the one which accounts for virtually all human Salmonella infections. The patient in the New York Times report apparently had an unusual organism acquired from uncooked pork, so maybe the name choleraesuis, referring to pigs, denotes something more specific in another classification. I've consulted Cecil, Robbins pathology and a micro textbook and am still more than a little confused.

That's all beside the point of Dr. Sanders's article but one distinction does bear emphasis. This situation, bacteremia causing vascular infection complicated by mycotic aneurysm, is not the same thing as enteric fever, aka typhoid fever.

Image: Salmonella invading cultured human cells. Public domain. Source Wikipedia.