Friday, July 30, 2010

The most unintentionally funny movie ever made---part 7

Local celebrity Nick Nixon is featured in the opening scene, “as himself.”

Missouri Prop C

This should be interesting to watch on August 3. Here's a little background. H/T to Gateway Pundit.

Grassley questions Berwick

---and some insightful comments by Dr. Wes.

Do you really need hard core basic science in premed?

It may not be necessary according to this very small single institution study. Kids who majored in the humanities and skipped organic chem, physics, calculus and the MCAT did just about as well at Mount Sinai medical school as those who took the traditional path.

I have problems with this study, methodologically and philosophically. It was anything but a controlled study. The non-traditional students received a summer “boot camp” in basic sciences to meet state requirements. Baseline characteristics between the two groups were not compared, but it appears that the non-traditional students may have been a very select group on some measures. According to a New York Times report on the project the mean SAT score for the non-traditional students was 1444 (wow!) and “elite” undergraduate schools were heavily represented.

I have questions at a more basic level. I don't think anyone knows how much basic science preparation is optimal in either medical school or undergrad. Maybe we could do with a little less. Moreover, a better background in the humanities can only be a good thing. (You can still major in the humanities and meet traditional med school basic science requirements, by the way. Generations of med students have done it under the “old” pathway). On the other hand, and this is a purely subjective observation, I wonder whether we are seeing a dumbing down of medical education attributable to a gradual de-emphasis on basic science over the past two decades.

Organic chemistry was a pivotal course for premeds at my undergraduate school. It's one of those courses, at least when taught properly, where you can't get by with rote memorization. Basic concepts and patterns had to be understood and built upon. My professor was passionate in his belief that a fundamental understanding of the human body and the natural world was important for success as a physician.

When I see the pervasive move toward promotion and teaching of quackery in academic medicine these days I can't help but think we need more, not less, basic science.

More from DB.

How much does public reporting tell about real quality?

Little if anything. H/T to Med Rants.

Hepatorenal syndrome

Nice update from the Renal Fellow Network.

For good outcomes in CPR

---it takes a village.

Another flawed PE review

---again making the non-evidence based recommendation that CTA is the preferred initial strategy for diagnosis. This time from NEJM.

Thursday, July 29, 2010

More on the dosage and route of corticosteroids for acute exacerbation of COPD

A recent feature on Med Page Today prompted me to revisit this study which showed equivalence of lower dose oral steroids and high dose IV steroids in treatment of AECOPD. The Med Page feature, which interviewed one of the study authors, made a stronger case for lower dose oral steroids than was apparent from the original study and pointed out that the oral route is associated with lower costs and a day or so reduction in length of stay. That makes intuitive sense. Traditionally when we admit a patient with AECOPD and use IV steroids we observe them, after taper to PO, for a day or so on PO treatment before discharge. Starting with PO from the beginning eliminates that step as well as the two or three days of IV steroid taper.

As for the doses compared in the JAMA study:

We excluded patients whose initial daily dose of corticosteroids fell outside a conventional range of treatment. This included patients who received less than 20 mg or more than 80 mg of oral prednisone and those treated intravenously at doses lower than 120 mg or higher than 800 mg of prednisone equivalents each day.

I was a little bit surprised at the claim that the guidelines recommend lower dose oral therapy, so I checked the primary sources. Sure enough, ATS, Global Initiative and ICSI guidelines all recommend oral therapy for patients who can tolerate PO, in the range of 40 mg or so of prednisone per day.

This will probably change my practice but I'm not sure how, just yet. The fact that 22% of patients started on PO crossed over into the IV group bothers me a little bit.

Med Page Today's video interview with one of the authors is shown here.

Berwick preparing a point-by-point rebuttal

---for his eventual hearings according to this article. Will he be asked the right questions?

Conventional CPR no better than compression only in two just published trials

Just out in NEJM, two RCTs. No difference in this study and a trend toward better outcomes for compression only in patients with primary cardiac arrest or shockable rhythm in this study.

The newspeak dictionary of assisted suicide and euthanasia

Via Secondhand Smoke.

ICU sedation is a risk factor for infection

---in this review.

Noncontrast CT to exclude appendicitis

---was just fine in this systematic review.

Adherence to heart failure guidelines

---is still abysmally low.

Wednesday, July 28, 2010

I forgot my own fifth blogiversary!

I just realized it today, a few days late. Ordinarily I would have let it pass, but this is a milestone. It's a good time to reflect and reminisce, so here goes.

Med Rants, Medpundit and Rangel MD were the first medical blogs I recall. Med Rants was the first blog to link to me, that I know of. Retired Doc was also an early supporter (thanks guys!).

In order to justify blogging in my own mind I had to find a niche, something not too many other medical bloggers were doing. Many medical blogs were news aggregators. I didn't want to do that because I believed then, as I do now, that scientific advances in medicine shouldn't be treated as “news” in the ordinary sense. Then there were the bloggers who related personal stories from their practices. There was plenty of that out there, and it was not where I felt I could make a unique contribution. Then there were the consumer information blogs, far too many for me to feel like starting a new one. Finally I realized that there was only a handful of blogs doing what really interested me---hardcore clinical blogging directed towards medical professionals in practice and training. That would be my focus, especially in the area of hospital medicine.

Before long I realized that public policy issues increasingly caught my blogging attention. That has seen a precipitous increase in this the most interesting political season in my memory. Despite that, the main focus remains clinical.

From the first I felt it very important to define my audience. I knew I couldn't write clinical content with any nuance or precision for professionals and consumers at the same time. It takes a special talent to do both. I realize that decision has cost me significantly in terms of blog traffic.

I will keep this endeavor going as long as it's still fun. Y'all will have to put up with me a while longer.

Center for Medicare and Medicaid Innovation pilot projects

---are in effect research on human subjects. What about the ethics of this research? asks Dr. Wes.

The UK's reality check about the National Health Service

Apparently they're not as romantic about their own health care system as Berwick is according to this government white paper (H/T to Dr. Wes). Arguments that the NHS is a model health care system are falling apart at the seams as is, apparently, the NHS itself.

Unraveling the enigma of Donald Berwick

In several earlier posts I said that Berwick's detractors as well as his supporters take a simplistic approach about his positions. A nuanced view of Berwick would be that his statements on health care are,at least on the surface, incoherent. How, for example, does he reconcile his contradictory positions, favoring rationing and central control on the one hand while at the same time espousing individual patient choice and consumerism?

A recent post at the Drug Wonks blog points to a primary source that may offer some insight. It's a document from the IHI entitled Best Health Care Results for Populations: The “Triple Aim.” The document isn't signed by Berwick but it is Berwickian. Berwick was head of the IHI and the document contains the substance of remarks he made in his keynote address at HM 2008. The subtitle lists the three incompatible aims and hints at Berwick's incoherency: Achieving the optimal balance of good health, positive patient experience of care, and low per capita cost for a population. So, if the document could explain away the incompatibility of these goals it could reconcile the inconsistency of Berwick's statements.

After the usual claims that the U.S. has the most expensive health care in the world with anything but the best quality the reader is offered this:

“Health care systems have evolved around the concept of infectious disease, and they perform best when addressing patients’ episodic and urgent concerns. However, the acute care paradigm is no longer adequate for the changing health problems in today’s world. Both high- and low-income countries spend billions of dollars on unnecessary hospital admissions, expensive technologies, and the collection of useless clinical information. As long as the acute care model dominates health care systems, health care expenditures will continue to escalate, but improvements in populations’ health status will not.”3

Is what's hinted here that we'll have to slash billions for hospital admissions, technology and diagnostic tests, but that's OK because we'll make it up in savings resulting from more basic care and prevention? Could this be the magical thinking that reconciles Berwick's positions?

A little later on in the document:

The recent Dartmouth Atlas work reveals waste in resources for care at the end of life, but the financial incentives are misaligned to produce change. Per capita US health care costs continue to rise, spurred by increasing use of technology as well as increasing prevalence of various medical conditions.5

No doubt referring to those conditions prevalent at the end of life. I guess there's a sense here in which reduced care for the “episodic and urgent concerns” of the very ill and the very old, and improvement in the population's health, are compatible. If you know what I mean.

For the positive patient experience aim the IHI model would include a measure such as “They give me exactly the help I want and need exactly when I want and need it.” (Likert Scale: strongly disagree to strongly agree) . There's Berwick's extreme consumerism. Left unanswered is how that aim would be accomplished alongside central control and slashing services to the very ill and very old.

Another measure in the IHI triple aim model is how many people have a BMI of over 30. Think of the money we could save if we could solve problem! After all most of our health care expenditures arise from diseases of choice, not chance. So does Berwick intend to appoint an obesity czar equipped with all the legal muscle he can squeeze out of the Constitution? Would it work? If the grand experiment in my home state of Arkansas is any indication, no. Former Arkansas Governor Mike Huckabee was an obesity czar. After an epiphany concerning his own obesity he put the entire state on a diet. But despite being in the top two states for anti-obesity public initiatives Arkansas remains among the most obese states in the U.S.

The ultimate solution to reconciling these conflicting aims, according to the report, lies in the integrator. In its pure notion the integrator could consist of just about anything---a health care system, an insurance company, a group of leaders. Berwick even suggested at SHM 2008 that it could be the hospitalist movement (go figure). Ultimately, though, the discussion focuses on the British National Health Service and its Primary Care Trusts as the best model for the grand integrator:

Primary Care Trusts are the center of the National Health Service (NHS) in England and control over 80 percent of the NHS budget. There are over 100 Primary Care Trusts in England, each of which is responsible for the health of the population they serve. Each Primary Care Trust serves approximately 600,000 individuals. Trusts receive funding through the NHS based on a weighted capitation scheme that corrects for deprivation, age, and market forces.

How would it all work? The grand integrator would be given lots of power and charged with lofty goals. For example:

Identify the needs of the population.

Manage a population-based budget for the health care needs of a defined

Help align the financial payment structure so that population health outcome is
rewarded. ..

Design standards for primary and acute care services.

Evaluate the effectiveness of new technologies and treatments.

Provide a mechanism for “remembering” each patient (could be an integrated
medical record). ..

Measure performance in new ways, including developing assessments that
measure health experience down to the patient level. ..

Connect individual health with public health.

Form partnerships with local communities.

Grandiose, nebulous and intrusive are adjectives that come to mind.

So that's Berwick's thinking. You can decide whether it's merely outside the box or beyond the pale. Whatever IHI's Triple Aim document may tell us about Berwick's thinking it fails to articulate a coherent stance on effective health care. Only the credulous among us would be convinced that it does.

What’s the most non-evidence based trend in all of hospital medicine these days?

It’s CT angiography as the default diagnostic test for pulmonary embolism, in my humble opinion. I’ve pointed it out before, here, here and other places. But despite the fact that the evidence has repeatedly shown V/Q scanning to be as accurate as CTA the latter test, despite being more hazardous, has emerged as the knee-jerk test. Even the so called evidence based reviews are declaring CTA the modality of choice. It is becoming a self-fulfilling prophecy. As fewer doctors order V/Q scans radiologists are losing their skills and imaging departments are increasingly finding the isotopes in short supply. (If no docs are ordering V/Q why bother to have it on hand?).

And it’s not as though we needed more research to prove that V/Q was a better initial strategy than CT, but this paper just came out in The Journal of Nuclear Medicine:

Results: A total of 81 simultaneous studies were available for analysis, of which 38% were from patients with PE. V/Q SPECT had a sensitivity of 97% and a specificity of 88%. When low-dose CT was added, the sensitivity was still 97% and the specificity increased to 100%. Perfusion SPECT with low-dose CT had a sensitivity of 93% and a specificity of 51%. MDCT angiography alone had a sensitivity of 68% and a specificity of 100%. Conclusion: We conclude that V/Q SPECT in combination with low-dose CT without contrast enhancement has an excellent diagnostic performance and should therefore probably be considered first-line imaging in the work-up of PE in most cases.

This is a little complicated. The key points are that V/Q scanning is more sensitive (much more sensitive) than CTA. That had already been established in the POIPED trials. Although V/Q scanning is moderately less specific than CTA, when combined with non-contrast low dose CT the specificity improved to 100%.

I don’t think it has ever been systematically studied but I strongly suspect there has been a spike in contrast-induced renal failure in hospitalized patients due to this non-evidence based trend.

Medscape commentary here.

Early goal directed therapy for sepsis---fatally flawed???

That’s what these guys, writing in the American Journal of Emergency Medicine, think. The basis for their objections? Essentially two fold: theoretical (e.g. CVP is not a good surrogate for assessing volume resuscitation) and the fact that while this “bundle within the sepsis bundle” has been shown to save lives, its individual components have not been evaluated separately. That issue is being addressed, at least partially, in three currently ongoing clinical trials.

The value of old farts in the young field of hospital medicine

Via Today’s Hospitalist:

Dr. Hodges—who joined the group in 2001 after 12 years in private practice—says that having so many team members with a deep background in primary care offers many advantages.

ECG manifestations of pericarditis, myocarditis, myopericarditis and endocarditis

The first three of these conditions can be difficult to distinguish from each other and from STEMI. Aside from the occasional classic ECG pattern of pericarditis, the diagnosis is based on a combination of ECG analysis (including serial tracings), clinical assessment and cardiac biomarkers. Sometimes nothing short of cardiac catheterization will reveal the answer. The ECG manifestations of endocarditis can be virtually anything. Conduction delays are characteristic although nonspecific, and are important only in predicting outcomes, not in making the diagnosis. According to a recent review in the American Journal of Emergency Medicine which covers the pathophysiology and provides illustrative tracings, some electrocardiographic patterns, although not specific, offer clues.

Perioperative management of Parkinson’s disease

Managing the medications can get tricky. Here are some tips from The Hospitalist.

Tuesday, July 27, 2010

Boozman vs Lincoln---ObamaCare revisited

In the aftermath of ObamaCare I find myself increasingly amazed at the prescience of Nancy Pelosi. She said we had to pass the bill in order to find out what it contained. That's why the real debate has to take place after passage, occasioned by such things as the Berwick appointment and, soon, the midterm elections. During the presidential campaign the health care debate centered on platitudes. Now it's about issues of substance, fact and real consequences.

One race to watch closely this year will be the election for U.S. Senator from Arkansas. Blanche Lincoln, the historically very popular Democratic incumbent, finds herself challenged by John Boozman, Republican Representative from the third congressional district (my neck of the woods). The health care reform debate will undoubtedly be played out in this election, as it will in many others this year, and Lincoln is in trouble because of her support of the bill.

The CMPI recently interviewed Boozman about the impact of ObamaCare on the upcoming elections.

Congressman John Boozman (R,AR) from CMPI on Vimeo.

ObamaCare---magical thinking vs evidence

Via American Thinker.

Impact of delayed admission from the ER

Longer hospital LOS and higher charges in this study:

Approximately 11.6% (n=1558) of admitted patients experienced admission delay. In multivariate analysis we found that admission delay was associated with 12.4% longer IP LOS (95 % CI 6.6% - 18.5%) and 11.0% greater total IP cost (6.0% - 16.4%). We estimated the cumulative impact of delay on all delayed patients as an additional 2,183 inpatient days and an increase in IP cost of $2,109,173 at the study institution.

The poison review

A toxicology blog.

Unraveling the safety concerns about cefepime

Unexpectedly poor outcomes in patients on cefepime have been noted previously although the mechanisms were unclear. Investigators in Switzerland monitored PK and PD parameters in a group of ICU patients receiving cefepime. The results suggested treatment failure due to inability to attain PD target in infections with MICs in the upper part of the sensitive range, as well as neurotoxicity in patients with creatinine clearances below 50. Authors suggested measuring plasma levels in patients with creatinine clearances below 50 or with infections by organisms with MICs above 4.

Removal of point of care occult blood testing

---decreases the performance of rectal exams in patients who need them.

It’s a Joint Commission thing, I think.

No one wins in an AMA discharge

Insightful and lively commentary from James Roberts, M.D.

Monday, July 26, 2010

Cost effective evaluation of syncope

From The Hospitalist. Some key points:

Among diagnostic tests, orthostatic blood pressure measurement (performed in about one-third of cases) is both the highest-yield test and the least expensive….

Cardiac enzymes, electroencephalography, CT scan of the head, and carotid ultrasonography contribute to diagnosis in less than 1% of cases. Echo is helpful about 2% of cases. Even inpatient telemetry, a routine part of standard evaluation, is helpful only 5% of the time.

Patients can be reassured that, in the absence of underlying cardiac disease, syncope itself is not associated with increased mortality.

The San Francisco Syncope Rule was mentioned.

An algorithmic approach to the ECG differentiation of narrow QRS tachycardias

In contrast to some previously published approaches this one asks the clinician to choose among three algorithms, depending on how much information is available. The algorithms lead the clinician through the same diagnostic steps that the ordinary logical and common sense thought process of a reasonably experienced clinician would take, but provide them in a more systematic form and in a series of binary decision points which may add clarity in difficult presentations.

ICD 9 and 10 codes not clinically relevant

This paper in Chest questions their value in describing chronic respiratory disease:

When the codes that relate to COPD and asthma are examined, the clinical relevance of the categories in International Classification of Disease coding must be questioned. In the future, a more simplified terminology that is consistent with clinical usage could improve accuracy and ease of coding.

Oh, the stupidity of administrative documentation. Aside from the inherent stupidity of the ICD codes, they are out of date. ICD 10, soon to be our “new” system, was conceived in the 1980's and completed in 1992. ICD 9 is decades out of date.

Diffuse parenchymal lung disease (DPLD)

This review uses the term DPLD to describe what is popularly though inappropriately termed interstitial lung disease (ILD) and focuses on IPF, NSIP, connective tissue disease, lymphangioleiomyomatosis and pulmonary hypertension. Open access.

Unintentional fatal drug overdoses

It's official, according to the CDC. It's an epidemic and the main cause is opiates. The spike in deaths started around 1999 when pain treatment activism was getting into high gear.

Sunday, July 25, 2010

Generic Lovenox approved

This was reported by Med Page Today Friday. The Society of Hospital Medicine recently urged the FDA to delay the approval. SHM claimed a patient safety issue. The FDA apparently didn’t buy it. I hope generic enoxaparin is safe. It will sure make it easier to arrange home VTE treatment.

The report says generic enoxaparin was approved "
for the prevention of deep vein thrombosis." I don't know if this means it isn't approved for therapeutic anticoagulation, for VTE and ACS, but I'm sure the generic will be used for those purposes.

Doctors didn’t put all that money in Berwick’s coffers so who did?

A great question by Dr. Wes.

Friday, July 23, 2010

The recent JAMA editorial on CPR

---doesn’t get it right. The authors conclude:

Improving the speed with which CPR and defibrillation are delivered will undoubtedly save more lives. But the fact remains that the fundamental knowledge of how to treat cardiac arrest has not changed appreciably in the past 5 decades. High survival rates and return of normal neurological function remain elusive. Perhaps a significant improvement in survival will require a multidisciplinary approach to the causes of ventricular fibrillation and a better understanding of cardiac arrest pathophysiology. Until then, it is important to redouble efforts to ensure better delivery of what is known can help.

Hmm. What about therapeutic hypothermia, the post-resuscitation bundle, regional centers for post arrest care and Ewy’s cardiocerebral resuscitation?

What they say

---and what they really mean. How to read between the lines. A few examples:

“I don’t kiss up to anybody.” — Translation: I’m a tactless jerk.

“It’s not you, it’s me.” — Translation: Let’s not kid ourselves, you’re definitely the reason we’re breaking up.

“I’m just crazy like that.” — Translation: I’m so clueless that I think other people are actually impressed by my goofy behavior.

“What do you do for a living?” — Translation: What socio-economic category can I place you in so that I may judge your value as a human being.

“I prefer a guy with a sense of humor”
— Translation: I prefer a guy who can make me laugh as long as he is also rich and good-looking.

“I’m know I’m high-maintenance” —Translation: I’m not going to apologize for being obnoxiously impossible to please.

“I’m always honest. If you don’t want the truth, don’t ask me.” — I will say anything I want and if it hurts your feelings, you’re the one with the problem.

Trimethoprim-sulfamethoxazole and hyperkalemia

The trimethoprim component is the culprit due to a triamterene like effect. The problem is particularly serious in elders taking ACEIs or ARBs according to this study:

Results During the 14-year study period, we identified 4148 admissions involving hyperkalemia, 371 of which occurred within 14 days of antibiotic exposure. Compared with amoxicillin, the use of trimethoprim-sulfamethoxazole was associated with a nearly 7-fold increased risk of hyperkalemia-associated hospitalization (adjusted odds ratio, 6.7; 95% confidence interval, 4.5-10.0). No such risk was found with the use of comparator antibiotics.

Conclusions Among older patients treated with ACEIs or ARBs, the use of trimethoprim-sulfamethoxazole is associated with a major increase in the risk of hyperkalemia-associated hospitalization relative to other antibiotics. Alternate antibiotic therapy should be considered in these patients when clinically appropriate.

Pneumonia---an old man’s best friend?

From a recent study:

Results Residents experienced 225 suspected pneumonia episodes, which were treated with antimicrobial agents as follows: none, 8.9%; oral only, 55.1%, intramuscular, 15.6%, and intravenous (or hospitalization), 20.4%. After multivariable adjustment, all antimicrobial treatments improved survival after pneumonia compared with no treatment: oral (adjusted hazard ratio [AHR], 0.20; 95% confidence interval [CI], 0.10-0.37), intramuscular (AHR, 0.26; 95% CI, 0.12-0.57), and intravenous (or hospitalization) (AHR, 0.20; 95% CI, 0.09-0.42). After multivariable adjustment, residents receiving any form of antimicrobial treatment for pneumonia had lower scores on the Symptom Management at End-of-Life in Dementia scale (worse comfort) compared with untreated residents.

Conclusion Antimicrobial treatment of suspected pneumonia episodes is associated with prolonged survival but not with improved comfort in nursing home residents with advanced dementia.

Clevidipine: a new parenteral antihypertensive agent

It's a dihydropyridine calcium channel blocker, different from nicardipine in its ultra short duration of action. Review here.

Should you worry about that rash?

Here's another derm show and tell from Medscape.

Thursday, July 22, 2010

Urologic emergencies in men

Priapism, testicular torsion, paraphimosis and Fournier's gangrene are reviewed.


Artificial elevation of the serum creatinine can occur due to interfering substances. An under-appreciated cause is DKA, in which acetone and acetoacetate cause overestimation of the creatinine concentration. The typical finding is a mild elevation of serum creatinine on presentation with DKA which clears within a matter of hours. This is often mistaken for mild acute renal insufficiency which quickly resolves with fluid resuscitation.

Via Renal Fellow Network.

Toward an understanding of septic encephalopathy

From Critical Care:

To date, we are far from fully understanding the neuropathology that develops as a secondary remote organ injury as a consequence of sepsis. However, recent studies suggest that bacterial proteins may readily cross the functional BBB and trigger an inflammatory response in the subarachnoid space, in absence of a bacterial invasion.

Poor guideline adherence for HCAP

---was the finding in this study which looked at nursing home acquired pneumonia, a form of HCAP. The default position seemed to be “hang some levaquin and call it a day.”

Why there are so many heart failure readmissions

What should happen:

Hospitalized patient started on evidence based heart failure medications.
Patient's record reviewed for contraindicated medications.
Patient diuresed to predefined goals based on daily physical exam, chest xray and maybe BNP.
Patient kept in the hospital until said goals achieved.
Heart failure educator sits down with patient and family for detailed teaching (requires at least an hour face-to-face).
Long term treatment goals (medications, dosage goals, device therapy needs if applicable) based on ventricular function, functional status and heart failure guidelines discussed explicitly in the medical record at or before discharge.
Explicit plans for post discharge follow up with PCP, home health or a heart failure clinic arranged before discharge.
Early post discharge follow up.
Repeated and frequent outpatient encounters during which evidence based medications are sequentially added with each one titrated to goal.
Once goals reached, reassessment of ventricular function and prognosis to assess candidacy for device therapy.

What really happens:

Patient placed on a little dab of ACEI or ARB, or comment made in record as to why not started. Performance measure satisfied.
Patient discharged as soon as she is comfortable at rest, the vitals are stable and the labs are not too messed up.
Boiler plate heart failure instructions printed off the EMR and handed to patient as she exits the building. Performance measure satisfied.
Ambulatory PCP (if the patient is fortunate enough to have one) sees the patient on her little dab of ACEI or ARB and thinks: “She's doing well. Now's not the time to mess with her medications.”

OK, this is a caricature but you get the idea.

Wednesday, July 21, 2010

Dix-Hallpike and Eply Maneuvers

These maneuvers were cited in the recently posted review on cerebellar infarction versus ordinary vertigo.

Evaluating diagnostic approaches to hyponatremia

This paper, which presents a systematic evaluation of popular approaches to the causal diagnosis of hyponatremia, is complex and has many clinical lessons. It should be read in the original if you can access it. Some key points in the paper (and key impressions on my part after reading it):

Inexperienced clinicians guided by an algorithm performed better than seasoned clinicians (“senior attendings”). (There are two ways you might interpret that finding. Some might be tempted to think cookbook medicine trumps clinical judgment. I think it means a systematic approach beats flying by the seat of your pants!).

Clinical volume assessment tends to be unreliable.

The diagnostic approach is confounded in patients with comorbidities and various external factors, particularly the use of diuretics.

Assessment of the fractional excretion of urate may add to the diagnostic power of the algorithm.

SIADH was said to be over diagnosed in this study. It must be acknowledged, however, that while many hospitalized patients had an identifiable non-SIADH etiology for their hyponatremia many hospitalized patients, and most if not all of those with complex illnesses, have elevated vasopressin levels. Those patients may not be labeled as SIADH in the usual sense but the elevated vasopressin level contributes to hyponatremia. SIADH is often said to be a diagnosis of exclusion, nevertheless many patients with non-SIADH etiologies for hyponatremia likely have elevated vasopressin levels as a contributing factor. This is why the construct of SIADH is confusing and needs better definition.

Patients with primary polydipsia may not maximally dilute their urine, and the urine osmolality threshold for excluding primary polydipsia should be raised to greater then 200. This makes sense, because compulsive water drinkers who have normal diluting capacity shouldn't get hyponatremic unless their water intake is enormous. Normal kidneys can dump a lot of free water.

Don't overlook adrenal insufficiency.

(By the way, I think there may be an error in the algorithm in the figure. A urine osmolality of greater than 100 indicates impaired renal dilution, not concentration.

More commentary from DB here.

In hospital initiation of lipid lowering therapy in patients with TIA and stroke

We already knew that initiation of statins was associated with better outcomes for ACS. We also knew that continuation of statins in patients already taking them was associated with better stroke outcomes. This study looked at initiation of lipid lowering drugs (presumably usually statins) in patients hospitalized with stroke or TIA:

On multivariate Cox regression analysis, after adjustment for the potential confounders, LLT use at discharge was associated with a lower rate of the composite end point at 6 months (hazard ratio 0.78, 95% confidence interval 0.61 to 0.98, p = 0.013). In conclusion, our data have indicated that LLT has been underused in patients with stroke. In-hospital initiation of LLT was associated with a better clinical outcome in patients with ischemic stroke or transient ischemic attack.

Prevention of central venous catheter infections

Review in Critical Care.

Platelet disorders in the ICU

Very helpful Chest review.

Clinic follow up within 7 days after heart failure discharge

---reduces 30 day readmission rates.

Tuesday, July 20, 2010

Gluttony at the ball park

Looks like the fat police are writing for Sports Illustrated now.

Obama resubmits Berwick's nomination to the Senate

Significant development or just a formality?

Survivors of methanol poisoning often have long term sequellae

Based on a six year follow-up study after the large methanol outbreak in Estonia in September 2001.

Via BMC Clinical Pharmacology.

Non-evidence based use of device therapy in heart failure

It's widely held that device therapy is underutilized in heart failure patients. But, according to this new study, when it is used it is often in a non-evidence based manner. Guidelines for device therapy require a period of optimal medical therapy before evaluating patients for device therapy, but in the study population a third of the patients were not on beta blockers.

ER visits from prescription opiates

---have spiked dramatically.

Another risk assessment tool for PE

Via Radiology:

Results: Overall, CT angiograms were negative for PE in 1806 (90.16%) of 2003 patients. CT angiograms were positive for PE in 197 (9.84%) of 2003 patients; 6.36% were Emergency Department patients, and 13.46% were inpatients. Of the 197 patients with CT angiograms positive for PE, 192 (97.46%) had one or more risk factors, of which age of 65 years or older (69.04%) was the most common. Of the 1806 patients with CT angiograms negative for PE, 520 (28.79%) had no risk factors. The sensitivity and negative predictive value of risk factor assessment in all patients were 97.46% and 99.05%, respectively. All risk factors, except sex, were significant in the multivariate logistic regression (P less than .031).

Conclusion: In the setting of no risk factors, it is extraordinarily unlikely (0.95% chance) to have a CT angiogram positive for PE. This selectivity and triage step should help reduce current costs and radiation exposure to patients.

You can safely avoid an imaging study if none of the risk factors are present. You have to be female to qualify, it seems.

CME at Medscape.

Monday, July 19, 2010

Mark Crislip on drug reps and industry supported CME

Mark Crislip, writing for Science Based Medicine, declares his biases about pharmaceutical industry promotion right up front: he’s a crank. True to form, in the screed which follows he offers impassioned opinions based on popular belief but little in the way of evidence to support his self described absolutist position regarding drug companies and their interactions with physicians. So let’s parse his arguments and try and apply a sober assessment.

He opens (italics mine):

Drug companies are somewhat schizophrenic. They have amazing scientists who invent drugs that treat an astounding array of diseases. Then, they take these drugs and turn them over to marketing, to be sold with all the enthusiasm and truthiness of a late night infomercial.

Although drug company promotions are biased and unbalanced they are required by FDA regs to be factually correct. He goes on:

As an Infectious Diseases fellow I was the on call physician for the hospitals antibiotic stewardship program where expensive or problematic drugs had to be approved before they could be released from pharmacy. It was curious how there would be spikes in approval requests, often for drugs that the surgical resident couldn’t pronounce correctly. Ain’t no drug called ciprofloxacillin, although there should be. Investigation revealed that these spikes often occurred shortly after a service was treated to a good dinner by the drug rep. Hmm. Funny thing, that.

Although that story might shock the consumer public I know of no one close to this debate who would deny that industry promotions influence prescribing. The staunchest defenders of drug rep promotions would acknowledge that.

In the next paragraph of his rant things get a little tricky:

Over the years it has been rare to find a physician as extremist as I am. It is curious, since the literature supports the concept that interaction with pharmaceutical reps is detrimental to patient care: docs who interact with reps are more likely to prescribe expensive and/or inappropriate drugs after being detailed.

That deserves careful scrutiny. Let’s save the part about “detrimental to patient care” for later. But are docs who interact with reps more likely to prescribe expensive and/or inappropriate drugs after being detailed? Expensive, probably yes. Inappropriate? Some published literature suggests so, but that literature is imbalanced. As I said in our Medscape Roundtable piece on this subject a couple of years ago (italics added here):

Studies in support of this argument do not give a balanced view. Surveys of the effects of drug detailing on doctors' prescribing have focused selectively on areas of overuse, such as antibiotics in the ambulatory setting and new expensive drugs compared with equally effective generics. Although some promotions undermine evidence-based practice, others may enhance it. Because promotional literature is a mix of good and bad information, the net effect on patient care is not known. Many heavily promoted treatments are evidence-based and known to be underutilized by doctors. A good example is the inadequate use of low-molecular-weight heparin for thromboembolism prophylaxis.[11] The promotion of statin drugs[12-14] and angiotensin-converting enzyme inhibitors for appropriate patients[15-17] is another example. Such a promotion toward best practice has been ignored in published studies. Research in a broader range of clinical situations is needed before conclusions can be made about the overall effect on evidence-based practice.

Dr. Crislip goes on to cite the literature on this topic (my italics):

Most of the literature on the topic is collected at, which appears to be under construction. It all may be publication bias, but I know of no reference that demonstrates improved patient care as a result of physicians interacting with drug companies. (More on the italicized part below).

Nofreelunch, rather than being under construction, appears no longer to be maintained. Their original focus was fighting the promotional gifts from drug reps. They won their inquisition when the drug companies ceased dispensing the gifts a year or so ago. Mission accomplished. But I digress. They still have links posted to a large repository of the literature referred to by Dr. Crislip, especially this one which, until very recently, contained just about everything that had been published on the topic. I’ve gone over that literature with a fine toothed comb. I participated on the nofreelunch listserv for several years and I know the arguments based on that literature inside out. The short version of what that body of literature says is as follows:

Drug company promotional activities influence doctors’ attitudes and actual prescribing.

Docs underestimate the degree to which they as individuals are influenced.

Studies which focused selectively on areas of previously suspected overutilization show that promotional activities sway doctors away from best evidence.

None of these studies looked at how promotions influenced areas of known underutilization of evidence based therapies and until very recently (more on that in a minute) there had been no studies, not a shred of evidence, contrary to the popular belief Dr. Crislip and others like to appeal to, of how this influence on prescribing affected patient outcomes. After all, that’s what matters, right?

Well, something happened recently to change all that. Finally a study was done on the effects of a pharmaceutical industry promotion on patient outcomes. And it wasn’t just any promotion. It was arguably the most maligned pharmaceutical industry promotion in all of medicine----maligned as a gigantic marketing campaign disguised as evidence based medicine. I’m talking about the Surviving Sepsis Campaign. The study was presented at SCCM in 2009 and published in Critical Care Medicine about a year later. Following implementation of the promotion there was improved adherence to evidence based sepsis care and reduced sepsis mortality.

Dr. Crislip seems to favor a ban on industry funding of CME, which seems strange in light of this paragraph:

Of course, I don’t know how I manage to keep up in my field with no pharmaceutical support. I can’t read journals, can’t use websites like Medscape (I am a paid blogger for Medscape, so of course I suggest them), can’t go to conferences, can’t listen to podcasts, can’t attend meetings, can’t do the MKSAP. There is such a wealth of educational opportunities in medicine to keep up you have to be either lazy or stupid not to find them. It does takes discipline and time to keep up. I spend a minimum of 24 hours a month on CME.

What’s strange about that is that many of those conferences and meetings, as well as those Medscape offerings, are industry supported. Dr. Crislip is an ID guy. Does he go the IDSA national meeting? It’s awash in industry support.

It’s not hard to imagine the unintended consequences of an industry ban. Given such consequences, those who call for a ban have a burden of proof that industry supported CME is inferior or leads to patient harm. The ban proponents are unable to sustain that burden because they lack evidence. Dr. Crislip has an interesting anecdote about Neurontin, but it’s more about one on one promotion than CME. There are other disturbing anecdotes out there, but a collection of anecdotes does not equal evidence. Occasional egregious cases are dealt with individually. They don’t form the basis for rules. All CME is biased but the evidence suggests that, in the aggregate, industry supported CME is no more biased than non-supported CME. I recently reviewed that body of evidence here.

Toward the end Dr. Crislip throws in the well worn social justice argument:

In the end, our patients pay for it. The price of drugs, in part, takes into account the cost of advertisement. Maybe you feel it is fine for the underinsured to pay $1500 out of pocket for a 10-day course of linezolid, but I can’t justify my patients indirectly subsidizing my pizza and education.

There’s a huge flaw there. The drug companies are going to spend whatever they want on advertising regardless of whether they help support my CME. Ban the industry support for CME and the funds will be diverted to other avenues of promotion such as direct-to-consumer advertising.

Finally Dr. Crislip points out that we doctors should be responsible for our own continuing education. I agree. But we will be less in charge of our education if a ban is put in place because such a ban will restrict our choices.

So ya think you're pretty smart about HCAP?

Surveyed docs weren't as smart as they thought in this study:

Surveys were sent to 1313 physicians with a response rate of 65% (n=855). Respondents included physicians in the following categories: hospital medicine/internal medicine, 60%; emergency medicine, 25%; and critical care, 13%. Respondents selected guideline‐concordant antibiotic regimens 78% of the time for CAP, but only 9% of the time for HCAP. Because mean scores for HCAP questions were extremely low (mean, 0.63 correct answers out of 7), differences in performance between groups were too small to be meaningful. Despite their poor performance, 71% of the respondents stated that they are aware of published guidelines for HCAP, and 79% stated that they agree with and practice according to the guidelines.

A related piece in ACP Hospitalist has a very helpful discussion of the nuances of conforming to the guidelines for HCAP. Important issues are patient categorization and appropriate de-escalation. Cultures are often not helpful in de-escalation, so the decision is a judgment call. The trend is to narrow coverage at 24-48 hours in patients who improve rapidly, but the question always nags: when patients get better rapidly is it because of or in spite of the broad spectrum antibiotics?

Lactate guided therapy in critically ill patients

A recent study in JAMA had shown that you could substitute serial lactate levels for measurement of ScvO2 in EGDT and do just as well.

Now a paper in the American Journal of Respiratory and Critical Care Medicine has looked at lactate guided therapy in a little different way. Here are the main points:

Overall, for patients with lactate levels greater than 3 meq/l, lactate guided therapy in the first 8 hours improved mortality.

In this study, in contrast to the JAMA study, lactate monitoring was an adjunct to ScvO2 monitoring rather than a substitute.

Treatment differences driven by the lactate monitoring consisted of more fluids and vasodilators.

Despite lower mortality in the lactate group, lactate clearance didn't differ between the groups. At first glance that's odd. It may merely mean that investigators caring for patients in the lactate group had one more “vital sign” to alert them to provide more aggressive and physiologically appropriate therapy.

The investigators interviewed in Medscape, noting some patients who met ScvO2 goals yet still had elevated lactates, posited a microcirculatory defect and gave vasodilators such as nitroglycerine. (Remember, though, in such patients, the non-hypoxic causes of hyperlactatemia such as drugs, e.g. metformin, and liver disease).

As pharma funding for CME goes down attendance at non-accredited industry offerings goes up

Docs will go for supported educational offerings no matter what, but not as many will be vetted for CME thanks to the efforts of the pharmascolds. Many of these are the increasingly popular branded med-ed offerings, often piggybacked onto large accredited meetings.

The importance of accredited CME is inflated in public perception. State licensing requirements for CME can be met with little effort or learning. Doctors' attendance at meetings and reading choices are driven by their professional educational needs, not by CME requirements.

Sunday, July 18, 2010

Why the obsession with Berwick?

---asked a loyal reader in a recent comment, concerned that maybe I'd lost my original focus on clinical hospital medicine.

Worry not. The raison d'être of this blog is and always has been to discuss and link to current literature on hospital medicine.

But this Berwick thing is just too interesting to ignore---on many levels. Besides, last week I had a little extra time on my hands to surf Google news and the political blogs. I can't help but be distracted by politics now and then. Clinical blogging will resume apace this week.

The vestibular ocular reflex

This maneuver was cited in the review on cerebellar infarcts and ordinary vertigo.

Saturday, July 17, 2010

The most unintentionally funny movie ever made---part 6

Brad is still on the run. Meanwhile back at the Karate school---

Donald Berwick on the job---remarks about EMRs

From the Boston Globe:

Berwick opened his brief speech with forward-looking remarks, reminding the audience of President Obama's goal to have electronic health care records available to all Americans by 2014. “What we have at stake is the future of health care itself,” said Berwick. “The benefits of a modernized health information technology help everyone. It’s a win-win, right across the board.”

“It’s going to be less costly in exactly the ways that we all want to reduce cost, by taking out barriers and complexity,” said Berwick.

Well, maybe so eventually, but not for a long, long time. You can tell Berwick hasn’t worked in the trenches of patient care in a while.

Elena Kagan’s ghostwriting for ACOG

More details have emerged.

Friday, July 16, 2010

Berwick: "He loved Big Brother"

That sums a lot of it up:

Dr. Berwick's passion eerily evokes the final four words of George Orwell's 1984, a short sentence dubbed by some the epitaph for our western world founded on individual autonomy, freedom of association and capitalism: "He loved Big Brother." For President Obama, at least, Berwick is just the right choice to carry out his leftist agenda.

Free lectures

---on just about everything.

Medical power point presentations and lecture notes

There's a huge collection here. I can't vouch for all the content but after a preliminary survey it looks as though there's some good stuff here. Readers will have to summon their critical skills and compare content with other sources.


“A digital library of authoritative medical information for the medical student and all students of medicine” according to the web site. Although last revised July 2 2010 this site looks old and contains some dead links. That said there's enough useful stuff to include it in my list of stuff.

Lectures on physiology and related topics

---on YouTube.

I can't vouch for all of the content here but it looks promising.

Repository of medical web sites

Some good material here but the quality varies. Use at your own risk.

Thursday, July 15, 2010

Remember the Winkler County doc and the two whistle-blowing nurses?

The Texas Medical Board has issued a ruling.

An after the fact hearing for Berwick in the works?

Maybe we'll get our summer TV special on C-SPAN after all.

Berwick: not just any recess appointment

Wha da ya mean, it's common, and Republicans do it too! Here's what, from the WSJ:

Barack Obama's incredible "recess appointment" of Dr. Donald Berwick to head the Centers for Medicare and Medicaid Services (CMS) is probably the most significant domestic-policy personnel decision in a generation. It is more important to the direction of the country than Elena Kagan's nomination to the Supreme Court.

The court's decisions are subject to the tempering influence of nine competing minds. Dr. Berwick would direct an agency that has a budget bigger than the Pentagon. Decisions by the CMS shape American medicine.

Medical textbooks free on line

These books cannot be downloaded but can be read on line, powered by Google books. Selected pages are missing but there's enough of each book available to make this a worthwhile reference site. All seem to be recent editions and some are brand new.


---has been in the news lately. There's this case from Indiana reported in Medscape and the one from Missouri last fall reported in the video below.

In both cases the exposure was contact with a bat that was dismissed as trivial. Think of it in any case of acute progressive encephalitis of unknown etiology.

Review of alcoholic liver disease

Via Continuing Education in Anesthesia, Critical Care and Pain.

Free full text at Medscape.

Nonpartisan concerns about Donald Berwick: extreme consumerism and quackery

As I think about it I become increasingly amazed at the credulous support of Don Berwick's appointment from the professional community. I have concluded that very few among our ranks have taken more than a superficial look at what Berwick is all about. Most of my colleagues know that he headed up the IHI, a sort of medical think tank that produced a lot of sound-good, feel-good ideas. But that's about as far as the analysis seems to go. As Berwick is romantic about the NHS so are many docs about Berwick, it seems.

At a place like IHI a leader can test the waters with flaky, over the top ideas to relatively little harm. Consider that person for a powerful government position and important questions arise. Those questions were never adequately addressed.

I've been a Berwick watcher for quite a while (because he's always been a hot topic at the Society of Hospital Medicine) and posted some concerns (here and here) long before any talk of his nomination for head of CMS. And while many of my recent postings about Berwick have focused on the well known Republican objections I have written several other posts (here, here, here, here and here) which, because they would be cause for concern on both sides of the political aisle, could have derailed his confirmation if he had been given a hearing. I'm talking, of course, about his extreme views on medical consumerism and his tendency to support non-evidence based and implausible complementary and alternative medicine (CAM).

Unfortunately, due to the relatively small reach of this blog, I did a poor job of getting the word out. That's why I am pleased today to provide links on this very subject from two of the big guys in the blogging world. David Gorski at Science Based Medicine wrote Dr. Donald Berwick and “patient-centered” medicine: Letting the woo into the new health care law? and Kimball Atwood at Health Care Renewal wrote New CMS Chief Donald Berwick: a Trojan Horse for Quackery?

These posts are worth reading in their entirety. You'll find that Berwick is romantic about a lot more than the NHS.

Wednesday, July 14, 2010

Lipid emulsion as a novel antidote

In the December issue of Emergency Medicine News James R. Roberts, MD began a series of articles on extreme toxicological emergencies and novel antidotes:

Occasionally, EMS can save someone in the field who has arrested or is about to, buying the EP some precious time. If the hapless individual simply needs naloxone, EMS has almost finished the resuscitation endeavor. Unfortunately, those who die outside the hospital from a drug overdose have essentially no chance of survival. And some toxins, such a colchicine, exotic hydrocarbons, or paraquat, can't be reversed by anyone on the planet.

This one was on lipid emulsions. The disclaimer:

There are also a few specific massive pharmaceutical overdoses, however, that are essentially a death sentence even when the patient arrives awake and talking. If one takes enough calcium channel blockers, beta blockers, or tricyclic antidepressants, the scene is often set for a lethal outcome once the bolus of toxin is swallowed, regardless of physician intervention.

This month's column begins a discussion of some novel antidotes that hold promise for reversing previously lethal overdoses. While the miraculous effects of naloxone and digifab are well referenced in the literature, the heroic antidotes described in my discussions lack scientific rigor, and are based mainly on theory and promising albeit scattered and anecdotal case reports. Nonetheless, the reputed antidotes appear to be helpful in otherwise desperate situations, and can be considered even when the specific offending pharmaceutical is unknown.

The use of lipid emulsion is generally accepted, though off label, for local anesthetic toxicity. Dr. Roberts discussed other uses including overdoses with TCAs, calcium blockers and beta blockers. There is limited experience with others and it can be considered when the offending drug is unknown. When to use it? The ideal circumstance would be in a patient deteriorating despite the use of conventional antidotal and supportive measures, but before they arrest. Much of the experience is as a last ditch measure in a patient already in arrest, and some dramatic results have been reported.

Two case registries exist and links are provided in the article.

Industry supported CME has the dwindles

From Medical Marketing and Media:

Total commercial support of accredited CME fell 17% to $856 million in 2009, according to ACCME's annual report—marking its second straight year of double-digit declines on a percentage basis.

For 2007, ACCME data showed commercial support increasing 1%. Sandwiched between 2008, when industry grants slid 14% to $1 billion, and a decade of sizable gains before it, 2007 proved to be the peak. The 2009 total also marks the first time since 2003 that industry funding dipped below $1 billion.

High frequency oscillation in patients with ARDS/ALI

---may be superior to conventional ventilation in this study. Multicenter randomized trials are under way.

Tuesday, July 13, 2010

The Berwick recess appointment---so much for accountability and transparency

Barrasso on Berwick.

More concerns about the Society of Hospital Medicine

---and their position on generic approval for Lovenox.

Happy Hospitalist is not happy.

DB at Medrants says that while he's no expert on LMWH this doesn't pass the smell test.

I'm not opposed to the support from Pharma companies. Commercial support enhances the organization's ability to deliver educational resources. What does concern me is the lack of transparency about their position on the Lovenox approval. Maybe there's a good reason. The members need to be given the rationale. Something more than vague claims about patient safety. How about some scientific arguments based on pharmacologic principles and evidence?

This isn't the only thing that's miffed me about SHM. They make biased and non-evidence based claims about the value of the hospitalist model; their credulity regarding the IOM, patient safety and performance measures is naïve; they could be doing a better job of promoting hospitalist career satisfaction; and the plenary sessions at SHM 2010 were like a rally for Obamacare.

What's going on here? It has a lot to do with the fact that the Society of Hospital Medicine is in he unique position of being the only professional society representing the fastest growing and now one of the largest specialties in medicine. Bias and professional arrogance are bound to creep in. It's only natural. It's how the world turns. Hardly any other specialty of comparable size is represented by only one organization. This is an anomaly. We're big enough for a second one. Both could thrive and help us really mature as a specialty. It would provide checks and balances. It would be a win-win. It's time.

Hedonism your thing?

There's an app for that.


Repeal of Massachusetts pharma gift ban in the works

Via Policy and Medicine.

Monday, July 12, 2010

The Paper Chase

Instapundit and Ann Althouse took me for a trip down memory lane. I've never read the novel or seen the movie but I loved the TV series. John Houseman's best known line (as Professor Kingsfield) was

You teach yourselves the law. I train your minds. You come in here with a skull full of mush, and if you survive, you'll leave thinking like a lawyer.

Maybe we need a few Kingsfield types (without the abuse) in med school. Nowadays med students, entering school with skulls full of mush, are at risk to leave with skulls full of woo.

Donald Berwick's conflicts of interest

---are numerous according to this report which concludes:

If a Republican president nominated a managed care executive to run CMS and rammed him through in a recess appointment, allegations about conflicts of interests would abound. Berwick made millions working with for-profit firms that will make money off Obamacare. But because he believes in central planning he gets a recess appointment. That's why elections, including the upcoming mid-term elections, matter.

These concerns might have been settled in a Senate hearing. But Obama cheated us out of that. Sure, recess appointments are common, but this wasn't just any recess appointment. Berwick represented issues of special importance to policy makers and the American people. Those issues needed exposure in the light of public debate.

H/T to Retired Doc.

Berwick: America is best at “audacious” health care interventions

Don Berwick #1: "Is American Healthcare the Best in the World?" from Century Foundation on Vimeo.

H/T to Dr. Wes.

Anti-aspartame nonsense at Huffington Post

Aspartame toxicity is a myth that's been around for decades.

Celiac disease associated malignancies

Reviewed here.

When COPD exacerbation leads to hospitalization

---it's a sentinel event.

Via Seminars in Respiratory and Critical Care Medicine.

Full test via Medscape.

Saturday, July 10, 2010

Friday, July 09, 2010

More on the Berwick recess appointment

From the WSJ:

White House respect for the public's health-care views dropped another notch yesterday, if that's possible, with its recess appointment of Donald Berwick. Circumventing Senate confirmation to appoint the new Medicare chief is part of the same political willfulness that inflicted ObamaCare on the country despite the objections of most voters.

And why?

Mr. Obama's real calculation was to dodge a debate in election season over Dr. Berwick's frequent praise for European health systems that ration care. The last thing most Democrats want now is to reprise the ObamaCare controversy.

Quackademic medicine at Harvard and the Brigham

Pure woo.

But wait, the CME offering is pharm free. I guess that makes it OK?

Sedation-free mechanical ventilation

---is associated with benefits in this Lancet study:

27 patients died or were successfully extubated within 48 h, and, as per our study design, were excluded from the study and statistical analysis. Patients receiving no sedation had significantly more days without ventilation (n=55; mean 13·8 days, SD 11·0) than did those receiving interrupted sedation (n=58; mean 9·6 days, SD 10·0; mean difference 4·2 days, 95% CI 0·3–8·1; p=0·0191). No sedation was also associated with a shorter stay in the intensive care unit (HR 1·86, 95% CI 1·05–3·23; p=0·0316), and, for the first 30 days studied, in hospital (3·57, 1·52–9·09; p=0·0039), than was interrupted sedation. No difference was recorded in the occurrences of accidental extubations, the need for CT or MRI brain scans, or ventilator-associated pneumonia. Agitated delirium was more frequent in the intervention group than in the control group (n=11, 20% vs n=4, 7%; p=0·0400).

No sedation of critically ill patients receiving mechanical ventilation is associated with an increase in days without ventilation. A multicentre study is needed to establish whether this effect can be reproduced in other facilities.

Medscape commentary here.

Statins, fibrates and the risk of VTE

From the European Heart Journal:

Conclusion This meta-analysis of available literature suggests that statins may lower the risk of VTE, whereas fibrates may increase this risk. Due to several methodological limitations, this conclusion should be considered with caution, and additional, specifically designed RCTs are warranted.

Free full text via Medscape.

Culture of blame creates new challenges for medical malpractice defendants

From Medscape Business of Medicine:

The best way to defend a case arising out of a "never event" is for your attorney to move the court for an order precluding references to the phrase "never event" at trial.

What a can of worms the IOM and this patient “safety” movement has opened.

Thursday, July 08, 2010

Reactions to Donald Berwick's appointment

---as reported in Medscape:

Under normal circumstances, the Senate Finance Committee would have held a hearing on the nomination, with Dr. Berwick fielding questions from both supporters and critics. Then the committee would have voted on whether to report the nomination to the full Senate for its approval.

President Obama sidestepped that process — which Senate Republicans could have derailed with a filibuster — by taking advantage of a Constitutional provision that allows the president to make appointments while Congress is between legislative sessions or in recess during a session. Congress recessed for the Fourth of July holiday and will not reconvene until Monday, July 12.

So what's the hurry?

The president issued a statement today saying that he was making a recess appointment in the case of Dr. Berwick and 2 other nominees for federal office because "many in Congress have decided to delay critical nominations for political purposes."

Political purposes? Yes, of course. The political process is for the public good. By circumventing it Obama cheated us of an important debate.

Lori Heim, MD, the president of the American Academy of Family Physicians, told Medscape Medical News that the recess appointment "serves CMS, physicians, and the public very well" because the Obama administration could not afford to wait any longer to fill the post...

"With healthcare reform legislation comes a renewed need to have a strong CMS administrator because of all the implementation that will fall to CMS," said Dr. Heim, whose medical association supported Dr. Berwick's nomination.
“All the implementation that will fall to CMS” is a big part of the problem with Obamacare. It puts enormous power into the hands of health care czars to implement things that would, in the pre-Obamacare world, have required legislative approval. I guess it's another reason why, as Nancy Pelosi said, we needed to pass this bill in order to find out what was in it.

Dr. McClellan, as well as Thomas Scully, another former CMS administrator appointed by George W. Bush, have both declared their support for Dr. Berwick. Such endorsements, taken together with Republican opposition to Dr. Berwick, demonstrate that "political debate is not about somebody's qualifications," Dr. Heim said. "It is strictly on a partisan basis."

She's right, it's not so much about qualifications. It's about ideas. Berwick's supporters have not critically examined his ideas.

Wednesday, July 07, 2010

Obama makes an end run around the legislative process to appoint Donald Berwick

From the New York Times:

WASHINGTON — President Obama will bypass Congress and appoint Dr. Donald M. Berwick, a health policy expert, to run Medicare and Medicaid, the White House said Tuesday.

Dan Pfeiffer, the White House communications director, said the “recess appointment” was needed to carry out the new health care law. The law calls for huge changes in the two programs, which together insure nearly one-third of all Americans.

Mr. Pfeiffer said the president would appoint Dr. Berwick on Wednesday. Mr. Obama decided to act because “many Republicans in Congress have made it clear in recent weeks that they were going to stall the nomination as long as they could, solely to score political points,” Mr. Pfeiffer said.

As a recess appointee, Dr. Berwick will have all the powers of a permanent appointee. But under the Constitution, his appointment will expire at the end of the next session of Congress, in late 2011.

Which means he'll be in a big hurry to impose who knows what. Great.

Well, rats. He was gonna be confirmed anyway, but now we won't have the opportunity to watch him try and defend his incoherent positions under Senate questioning.

WSJ Health Blog comments about the Arora-ABIM case

---are really heating up. Many among the 2700 docs who got letters of reprimand just for attending the Arora course and not “blowing the whistle” are seeking legal help. Many more are no doubt frightened. As a matter of conscience many will feel compelled to disclose the letter on future applications. This, they feel, will only lead to more questions, credentialing headaches and potential damage to their professional reputations. Here are a few excerpts:

I one of the recipients of a letter of reprimand from the ABIM. I had attended the course in 2006 and it was made clear throughout that the ABIM was well aware of how the course operated and that the course was approved by the AMA for CME credit. Why would one report that which was already known? I never for a minute believed that any of the questions discussed would appear on my exam and considered them only as learning tools...

I would not let this sit on your file without contesting it. It will be something that you will have to explain in every application you make for work anywhere in the USA and it is really uncalled for.

I too received this reprimand letter; I’m now going to have to explain this for the rest of my professional career when applying for privileges. I went to the Arora course 6 years ago.

I’m a resident, and I got packets of questions from my seniors and friends in other programs. Aren’t these publicly available - how can you sue somebody for compiling the questions and then teaching the answers?

This kind of thing, along with crazy lawsuits, makes me scared to pursue medicine.
If the ABIM can do this to the people who teach the course, and to those for just attending, is it even worth becoming an Internist.

I’ve taken very few review Board courses in my 30+ years of practice. I recall almost every course advertisement highlighted that it got REAL QUESTIONS from previous exams. I was offered $7 per question by the Stanley Kaplan group. Later, a friend who runs a popular review course asked me for neurology board questions. The rationale was that the questions are useful only as exemplars once they’ve been used. That was the same answer I got when I asked my specialty Board why my maintenance of certification exam cost $1800 for a computer-administered test which is easier to generate than the SAT’s - ‘it costs us a lot to make up new questions b/c they’re useless one they’ve been published’.

Information wants to be free. Nothing that has been used once is reusable to the same effect. So, what’s the big issue here when the doctors have been told over and over that each exam has new questions?

I have attended many review courses throughout my career. Fellow physicians, beware we are next!!!! ARORA was a CME approved course by the AMA. Thanks ABIM for discouraging even more physicians into primary care! Spending our life’s energy, taking care of obesity, diabetes, abd pain, alcoholism, hypertension, hyperlipidemia, non-compliance, and depression just got even more rewarding! ABIM reinstate my brothers and sisters who are on the front-lines caring for America’s sick or AM I NEXT?

There are many nuances in this dispute. It is clearly not just a case of “docs caught cheating on board exam.”