“It's a reflex that's built into the brain circuits,” she said in an interview. “At its core biological basis, it's unfair to criticize men for that initial unconscious circuitry.”
Leapfrog has released a study based on a simulation tool (fake patients, simulated inappropriate order entry) showing that, across many hospitals and many EMR brands, CPOE does a poor job of intercepting errors. For anyone who uses CPOE in the real world that's a no brainer---you don't need a study.
Margalit Gur-Arie, guest blogging at Kevin MD, explains the report and notes that the more complex the situation the more poorly CPOE performs:
For basic adverse events, such as drug-to-drug or drug-to-allergy, an average of 61% of events across all systems generated appropriate warnings. For more complex events, such as drug-to-diagnosis or dosing, appropriate alerts were generated less that 25% of the time.
And for the far more common and complex judgment errors, (eg dangerous drugs such as heparin given for weak and sloppy indications, antibiotic selections in sepsis that are too narrow based on patient attributes, local resistance patterns and clinical circumstances) CPOE doesn't do squat.
On the other side of the spectrum are the simple alert triggers which are often inappropriate, such as flagging the combination of antiplatelet agents and low molecular weight heparin for acute coronary syndrome as “duplicate therapy”, leading to alert fatigue.
We have a long way to go before CPOE is a patient safety tool.
A new cohort study from a large administrative database published in Archives of Internal Medicine found:
Results Of 269 866 patients in the cohort, 38.8% (n = 104 695) underwent consultation. Within the matched cohort (n = 191 852), consultationwas associated with increased 30-day mortality (relative risk [RR], 1.16; 95% confidence interval [CI], 1.07-1.25; number needed to harm, 516), 1-year mortality (1.08; 1.04-1.12; number needed to harm, 227), mean hospital stay (difference, 0.67 days; 0.59-0.76), preoperative testing, and preoperative pharmacologic interventions...
Conclusions Medical consultation before major elective noncardiac surgery is associated with increased mortality and hospital stay, as well as increases in preoperative pharmacologic interventions and testing. These findings highlight the need to better understand mechanisms by which consultation influences outcomes and to identify efficacious interventions to decrease perioperative risk.
So---the differences, while statistically significant, were small but everything---everything related to outcomes and utilization---was in the wrong direction.
There are many caveats. First, this was a Canadian study. Applicability to US systems of care cannot be taken for granted. Second, applicability to hospitalists is limited. Although hospitalists do a lot of comanagement (and it looks as though a lot of comanagement was done in this study, though impossible to say how much) they do hardly any preoperative evaluations, because the vast majority of patients are not admitted to the hospital in advance of their surgery. Third, since the study period, 1994-2004, we have worked out a lot of the nuances of perioperative medicine, particularly in areas relating to beta blockers, evaluation, management of patients with coronary stents and perioperative anticoagulation management. Finally, the study doesn't adequately address the value of postoperative consultation, the more likely scenario today.
Although we now have research quality data (and while it needs to be reproduced it's probably the highest quality we're likely to get) saying consultation may cause harm it's easy to imagine individual circumstances in which it's likely to be helpful. Who's going to make sure the right medications are held and the right ones are continued as seamlessly as possible (e.g. statins and beta blockers)? Will somebody pay attention to the patient's diabetes and keep their chemistries from getting messed up? Will the surgeons do these things? Some will and some may not (which is why I say individual circumstances).
What might have led to the harm? The consultation group received more beta blockers, which, in the manner they are likely to have been used from 1994 to 2004, may have been harmful. Increased testing in the consult patients may have delayed some surgeries, which could have led to harm.
As the authors pointed out, these results do not argue decisively against the use of consultation. They do suggest that we shouldn't do consultation and comanagement just because we can and that more research is needed do define which processes involved in consultation and comanagement are truly useful and in what circumstances.
Impedance cardiography (ICG) guided treatment was superior in getting patients to blood pressure goals in this meta-analysis:
Results: Significant benefit was found in both RCTs for ICG-guided BP treatment. The combined odds ratio for the two trials was 2.41 (95% CI = 1.44-4.05, p = 0.0008), in favor of ICG treatment, meaning that it was more than twice as likely to achieve BP success when using ICG than if ICG was not used. Success attainment of goal BP of less than 140/90 mmHg was 67% in the ICG-guided arms of the combined randomized trials. Overall success in the single-arm prospective trials of ICG-guided BP treatment was a similar 68%.
This little noticed paper interests me for a couple of reasons. First, it's one of several papers to come out in just a short time (see yesterday's post on renin profiling) on individualized treatment of hypertension. In hypertension as in many other fields the pendulum appears to be swinging back from one-size-fits-all to pathophysiologic rationale as a guide to treatment.
Second, I became very interested in ICG when I started attending this course in 1981 where I was exposed to the work of the late Robert S. Eliot. ICG was one of the methods Eliot, in collaboration with James C. Buell, MD, used to study the hemodynamic effects of emotional stress. Hemodynamic profiling of hypertension via ICG was a spin-off from this research.
Then in the mid 90s interest in ICG guided antihypertensive therapy fizzled out. ICG was not sexy enough and there was little commercial interest in its development. As the EBM movement gained traction pathophysiologic rationale was frowned upon and one-size-fits-all became the guiding principle. But now that we're on the cusp of a new era of individualized medicine ICG guided treatment may be poised for comeback.
Here's a publication from NCPA you should read. Forget the sound bite. Forget the government spin. This is the best source I've seen to find out what Obamacare will look like “on the ground” to the extent it's possible to say right now. I add that last qualifier because there's a lot we still don't know. Many provisions of the law are under the discretion of a handful of czars who could shift the landscape in any of several directions. Important provisions unfold over several years and in the meantime elections are coming up and challenges in over 30 states are in the works. So health care in the US is far from settled right now. Less settled, I dare say, than it was before passage of the bill.
When I was a resident in Internal Medicine in the late 70s the work of John Laragh was hot stuff. Renin profiling, although not practical in the real clinical world, was in vogue and frequently performed at the academic medical center where I trained and at other tertiary centers where it was available “in house.” It was based on the idea that pathophysiologic rationale should be used to guide treatment of hypertension. But this idea was frowned on by EBM, which gained traction in the 90s, so that renin profiling fell out of favor. Now, though, as the conversation turns increasingly toward individualized medicine, renin profiling may be making a comeback. A recent issue of the American Journal of Hypertension contains research articles and two editorials along with a podcast interview of the editorial writers calling for the adoption of renin-guided hypertension treatment. This resurgence of interest has occurred despite the fact that in the 30 plus years since Laragh's original work we still lack megatrials based on “hard” clinical endpoints to prove that the physiology based approach is superior. But, as one of the editorial writers points out, in other diseases endocrinologists have been relying on the physiologic approach for decades. Why not with hypertension?
I remember seeing this ad many times on LMT. Like many doctors during those years who were reeling from the MRFIT data I was reluctant to prescribe thiazides, even combined with potassium sparing diuretics.
The ad was kind of silly because it mainly dissed Dyazide but in a way it was prescient.
Before passage, the conversation on health care reform lacked a dimension of reality. Some important issues were discussed, to be sure, but all in all it was pretty nebulous. Since passage, though, the debate has taken on substance as the negative consequences become apparent. That's well illustrated in the video below.
As a corollary to what Nancy Pelosi said, we had to pass the bill so we could have a real debate.
A medical resident guest blogging at Kevin MD notes:
According to an article published in the Journal of General Internal Medicine, counties with teaching medical hospitals experienced a 10% increase in fatal medication errors as compared to counties without teaching medical hospitals.
Of course we've long suspected this. Apparently having better supervision, better hours, CPOE and UpToDate everywhere at the point of care hasn't solved the problem. In fact, CPOE could be making it worse. When new interns arrive, if they've come from another school, as likely as not they have to use an EMR they're not familiar with, having had only a brief orientation period and no secretarial training.
This is research information to change practice now. The effectiveness, however, may be limited by turnaround time. How is it important for hospitalists? Suppose you're planning an early discharge of a patient with DVT or low risk PE. Genotyping, if turnaround time is reasonable, could greatly simplify discharge planning and the transition to ambulatory care. Up to now it's been largely guesswork. What warfarin dose? When should they get their first post hospital INR? Will the PCP monitor it appropriately? What's the anticipated duration of low molecular weight heparin? How confident can I be that the patient will be therapeutic within so many days without overshoot? Genotyping may reduce the guesswork and make for a smoother transition.
Walmart is in my back yard. I live about 5 miles from the corporate headquarters. As the company has grown it has transformed my community. Here's a Flowing Data map which shows the growth of the chain since the first store opened here in 1962.
Visitors are greeted with Welcome to the internet's busiest one-person medical site. Dunno if that's true but there's a lot of good stuff here including all his pathology lecture handouts, lots of images and links, as well as ruminations on science, religion, culture and the humanities.
When I'm researching a disease the Internet trail often leads me back to his second year pathology lectures because I think a fundamental understanding of disease is important.
While family medicine and internal medicine represent overlapping Venn diagrams, they have major and important differences. They need not merge. We should learn from each other, but continue to celebrate our differences.
Commenter 8 gets to the root of the problem:
It would be nice to nail down what the differences are between IM and FP so we all have the same expectations.
But our professional societies, at least on the IM side, have made little effort to do this.
---because it distorts more than it informs. Regular readers of this blog know that I've been critical of the popular media for a long time. My favorite media outlet to pick on is the New York Times because it is purported to be the most reliable source for medical news. When they blow it, and they usually do, we really need to be concerned about the rest of the popular media.
A number of years ago I ran across Science Education in Preparation for the Ministry. The premise of the document, written by pathologist and teacher Ed Friedlander, MD, was that because members of the clergy are often called on to speak in areas where morality and ethics interface with science, they should have some prerequisite knowledge. Orac's latest example of credulous and sloppy medical reporting in the New York Times got me to thinking that maybe there should be similar learning objectives for journalists. So, borrowing some ideas from Dr. Friedlander, here were a few that came to mind:
Outline the scientific method.
Explain the hazards of examining scientific questions in the arena of public debate.
Explain how the 1918 influenza pandemic was fundamentally different from the 1957, 1968 and 2009 pandemics.
Define and distinguish: epidemic, pandemic, endemic.
Define and distinguish: enzyme, catalyst, protein.
Define and distinguish: antigen, antibody.
Define and distinguish: DNA, RNA.
Define and distinguish: axiom, postulate, hypothesis, theory, fact.
Define evidence based medicine.
Explain why consideration of biologic plausibility is important in the evaluation of health claims and why evidence based medicine often fails when biologic plausibility is not taken into account.
Define and distinguish: bacteria, fungus, virus.
Explain why scientific progress does not lend itself to sound bite reporting or “news of the day” journalism.
Describe Medicare’s prospective payment system and the financial conflict of interest it causes.
Define and distinguish: carbohydrate, protein, fat, vitamin, mineral.
Define and distinguish: heart failure, shock, heart attack, angina.
Define: relative risk reduction, absolute risk reduction, number needed to treat.
Explain the difference between clinical significance and statistical significance in clinical trial results.
Define and distinguish: accountable health organization, health maintenance organization, preferred provider organization, patient centered medical home, integrated delivery system.
Define and distinguish, in the context of health care: quality, patient safety, performance.
Describe Mendalian genetics and explain why common inherited conditions do not follow simple Mendalian patterns.
Define and distinguish: meta-analysis, systematic review, expert review.
Distinguish between a left ventricular assist device (LVAD) and an artificial heart.
Distinguish between pacemaker, implantable defibrillator and cardiac resynchronization device.
This list is the product of some initial brainstorming and is by no means comprehensive or even realistic, but I think you get the idea.
Some might argue it's just soft woo, but it's still woo. First there was Berman's promotional and unscientific article on acupuncture (see Orac's analysis here). Now, just a few weeks later, we are offered this “study” on the effects of Tai Chi in the treatment of fibromyalgia. Well, we know exercise helps patients with fibromyalgia. And, some compelling anecdotal experience suggests that, if started early in the course of the disease, it might mitigate the progressive spiral of polypharmacy and higher and higher doses of narcotics and all the bad consequences associated therewith. Since there are many different forms of exercise it makes sense to ask if some work better than others. So it's perfectly legitimate to compare specific forms of exercise. The problem with the NEJM study is that, because it studies not just a particular type of exercise but an entire package of Eastern woo it lacks scientific rigor. From the methods section of the paper it appears that the real woo behind Tai Chi was promoted to the study patients. Even worse, the paper and the accompanying editorial seem to be entirely uncritical, at least regarding the woo claims behind the treatment in question.
I use the weasel words appears and seem in the commentary above because I don't have access to the papers in their entirety. You see, recently my subscription to NEJM lapsed. Now that NEJM, like many journals preceding it, has become a platform not only for political propaganda but now for woo, I'm not sure I want to spend my own money or dip into my CME stipend to re-up. Fortunately Orac cited portions of the body of the paper which illustrate my concerns (my emphasis):
The tai chi intervention was described thusly: The tai chi intervention took place twice a week for 12 weeks, and each session lasted for 60 minutes. Classes were taught by a tai chi master with more than 20 years of teaching experience. In the first session, he explained the theory behind tai chi and its procedures and provided participants with printed materials on its principles and techniques. In subsequent sessions, participants practiced 10 forms from the classic Yang style of tai chi18 under his instruction. Each session included a warm-up and self-massage, followed by a review of principles, movements, breathing techniques, and relaxation in tai chi. Throughout the intervention period, participants were instructed to practice tai chi at home for at least 20 minutes each day. At the end of the 12-week intervention, participants were encouraged to maintain their tai chi practice, using an instructional DVD, up until the follow-up visit at 24 weeks.
The control intervention consisted of this: Our wellness education and stretching program similarly included 60-minute sessions held twice a week for 12 weeks.19 At each session, a variety of health professionals provided a 40-minute didactic lesson on a topic relating to fibromyalgia, including the diagnostic criteria; coping strategies and problem-solving techniques; diet and nutrition; sleep disorders and fibromyalgia; pain management, therapies, and medications; physical and mental health; exercise; and wellness and lifestyle management.20 For the final 20 minutes of each class, participants practiced stretching exercises supervised by the research staff. Stretches involved the upper body, trunk, and lower body and were held for 15 to 20 seconds.
The NEJM is a relative latecomer in the promotion of woo. I guess it shouldn't surprise me, since woo is metastasizing rapidly throughout mainstream medicine. If NEJM keeps this up it may soon earn a place alongside the BMJ on Steve Barrett's list of non-recommended publications.
---at least in the way they are now perceived and handled. Dr. Wes pointed out a blatant example of this in a just released Annals of Internal Medicine article about the health care reform package. It's largely a propaganda piece by health care czars in the Obama administration. The point is that, although it's patently obvious to all but the most credulous reader that what you have here are Obamacare czars tooting their own horns with unsubstantiated claims, those affiliations were not listed in the formal conflict of interest declarations. The principle that financial interests are the only relevant conflicts is too narrow.
The heated debate on CER is rife with logical fallacies: appeal to belief (it's something new, doctors have no research data with which to compare treatments), the straw man (so and so is opposed to CER), false dichotomy (you are either for us or against us in the debate on CER) and others. This is well illustrated in a recent exchange of blog posts and comments. DB accuses another blogger, guest blogging at Kevin MD, of being anti-CER. That goes beyond what the blogger was saying. DB is not alone. The straw man about people out there being against CER is pervasive. I gave additional examples here. Yeah, maybe there's some nut-job out there who really opposes the pure notion of CER, but I have yet to encounter such opposition among physicians or on either side of mainstream politics.
I've been watching the “debate” on CER for over a year now with some amusement. It conflates issues directly linked to comparative effectiveness research with other concerns about misguided government policy, conflicts of interest, perverse cost incentives, things that have nothing to do with whether doctors need research to help them compare treatments (which most everybody agrees they do) which, for the sake of clarity, might best be discussed separately.
At least DB did acknowledge in his post that CER is nothing new, citing research findings about antiarrhythmic drugs and mortality. That research, CAST, comparing flecainide, encainide and moricizine, and its companion pilot study CAPS, comparing those three drugs alongside procainamide and impiramine, was from the 1980s!
Just about the only thing everyone agrees on in the prevention of pigment induced renal failure is early aggressive volume resuscitation (don't just order half a liter saline bolus and call it a day).
Urinary alkalinization with bicarb and the use of mannitol have been advocated as “specific” measures for this syndrome but remain controversial. The Renal Fellow Network recently updated this topic. The controversy stems from inconclusive evidence (alkalinization and mannitol may benefit some patients, e.g. crush syndrome victims, more than others, and different populations were studied in different studies that showed varying outcomes) and possible harm (hypocalcemia from alkalinization and osmotic nephrosis from injudicious use of mannitol .
I don't generally post profanity here (be warned) but this Penn & Teller Bullshit episode is just too good not to post. The cynicism informed by stupidity of the anti-vaccination movement gets an in-your-face response. But despite being in-your-face the video captures the nuances of the controversy and gets the science right. Very effective.
These are mainly rhythm and conduction disturbances. I have a minor quibble with case 1. It is not classic Mobitz II AV block. The level of block here is probably in the common bundle of His. The prognosis and appropriate treatment are less well understood than that of classic Mobitz II, in which the lesion is in the bilateral bundle branches. Pattern recognition will not help you here. You must know basic electrophysiology and bring it to the bedside.
A fascinating Annals study examined the premise that contextual errors conspire with biomedical errors to cause poor decisions in clinical practice. The authors explain what contextual errors are:
A contextual error occurs when a physician overlooks elements of a patient's environment or behavior that are essential to planning appropriate care. In contrast to biomedical errors, which are not patient-specific, contextual errors represent a failure to individualize care.
The investigators used standardized (fake) patients to present scenarios containing biomedical red flags, contextual (psycho-social) red flags, both or neither and found:
Physicians probed fewer contextual red flags (51%) than biomedical red flags (63%). Probing for contextual or biomedical information in response to red flags was usually necessary but not sufficient for an error-free plan of care. Physicians provided error-free care in 73% of the uncomplicated encounters, 38% of the biomedically complicated encounters, 22% of the contextually complicated encounters, and 9% of the combined biomedically and contextually complicated encounters.
Although we didn't use the same terms, my Roundtable colleagues and I talked about this a couple of years ago. In that article I related this story:
I'm reminded of some experiences from my own practice. A patient (not a real one but a composite of several I've observed) with "resistant hypertension" was treated with sequential dosage increases and additions of several antihypertensive medications. When the patient entered the hospital with an unrelated illness, the nursing staff dutifully "reconciled" the patient's hospital medications (the Joint Commission would have been proud!) with his primary physician's list, which had been kept up to date during all the titrations. When progressive hypotension and renal insufficiency developed over the next several days, the hospital physicians were perplexed until a little detective work revealed that for months, the patient had been taking only a fraction of what his medication list reflected. The ever changing and increasingly complex medication instructions had proved overwhelming to the patient, who had limited cognitive function. At last, the complete version of the history explained not only the patient's hypotension and renal insufficiency, but also the resistant hypertension.Examples such as this teach us that although getting to know the patient takes time, the investment is cost effective.
A related Huffington Post piece makes the case that we need a shift in focus of training toward contextual medicine.
But this is not something new. As I began my third year Internal Medicine rotation in 1973 one of our faculty mentors, the late Thomas E. Brittingham, taught us the importance of context.
My father, an old fashioned GP, knew about contextual medicine although there was no formal training in his day. He didn't have the biomedical resources we have now. He had to rely on his context based instincts and knew that they were an extensions of basic clinical skills
So it's not that this is a new area of training. The problem we face today, as pointed out in the Huffington Post piece, is that the perfunctory “metrics” we are overwhelmed with are distractions to real quality.
If this video is any indication, though, the authors of the Annals piece take the wrong approach by making the art of context based medicine just another checklist that we can be measured against. Watch as the physician, going down the checklist and asking all the “right” questions, fails to encourage the patient to tell his uninterrupted story, hammering away on the keyboard the whole time as he follows the EMR template.
You'd think something that was created in 2500 B.C. would be in the public domain by now but that seems to be in dispute. Quackademicians and hospital administrators take note.
There’s an interesting discussion of this topic over at Nephron Power with links to important review articles. Mention is made of bolus therapy with 100 cc of 3% saline, which I have previously mentioned here and elsewhere, as well as the use of DDAVP to “apply the brakes” on over correction if need be, which I mentioned here.
Not much of immediate interest. The lawyers are getting busy but the wheels of justice, as everyone knows, turn slowly. I did find this recent piece:
The American Board of Internal Medicine's proposed sanctioning of 139 physicians by the ABIM for passing along and receiving exam questions from a test preparation company is getting messier.
Here's why. A lengthy appeals process is underway, with potentially 80 lawyers involved, which always means complexities and various paths toward getting to the truth. And questions are growing, at least in my mind, about whom exactly the ABIM is targeting.
Relaxation techniques and balance exercises are great. But promote it as Tai Chi, which is based on claims of the universal energy force Qi, and you drag in woo. I’d expect better from Mayo.
I don’t think anyone’s really saying that but it’s what’s implied in a recent post at Clinical Cases and Images. It was in reference to an older post by Bob Wachter about how house staff and medical students search the literature in the Internet era compared to back in the day. Bob suggests that students’ and residents’ use of resources like UpToDate democratizes teaching and learning on the wards. It’s an interesting trend, but as I’ve said before over-reliance on point of care references, even excellent resources like UpToDate, runs the risk of an overly formulaic approach to clinical medicine. That’s why a solid background in basic science, background reading on the mechanisms and categorizations of disease as well as the development of clinical skills are so important. These are, unfortunately, areas of de-emphasis in medical education today.
Residents were randomized to receive a one-page description of Medicare’s “no pay for errors” rule with pre-vignette reminders (intervention group) or no information (control group). Residents responded to five clinical vignettes in which “no pay for errors” conditions might be present on admission.
MAIN MEASURES Primary outcome was selection of the single most clinically appropriate option from three clinical practice choices presented for each clinical vignette.
KEY RESULTS Survey administered from December 2008 to March 2009. There were 119 responses (71%). In four of five vignettes, the intervention group was less likely to select the most clinically appropriate response. This was statistically significant in two of the cases. Most residents were aware of the rule but not its impact and specifics. Residents acknowledged responsibility to know Medicare documentation rules but felt poorly trained to do so. Residents educated about the Medicare’s “no pay for errors” were less likely to select the most clinically appropriate responses to clinical vignettes. Such choices, if implemented in practice, have the potential for causing patient harm through unnecessary tests, procedures, and other interventions.
We're not told in the body of the paper whether these were industry sponsored activities but most Internet offerings are, and after a look at the disclosures it's a pretty sure bet they were. Here's a related study which reached similar conclusions.
There have been several reviews of acute pancreatitis lately, all varying slightly in their focus. The latest is from The Journal of Hospital Medicine.
Points of interest:
Etiology Although the 20% or so of patients who do not have gallstones or a history of ethanol abuse are considered idiopathic they aren't really idiopathic. If a gallbladder is in tact a diagnosis of microlithiasis or sludge can be invoked, and that is supported by evidence. If the gallbladder has been removed Sphincter of Oddi dysfunction is plausible and evidence supported. Of the remainder of these 20% of patients drugs, hypercalcemia, hypertriglyceridemia, familial cause, anatomic abnormalities or autoimmune pancreatitis (which can also cause chronic pancreatitis or mimic pancreatic carcinoma) are known causes. The patient really has idiopathic pancreatitis if none of these are present.
Imaging CT is a useful imaging modality but not mandatory in all cases. CT scanning on day 1 is used principally to exclude other causes of abdominal pain if the diagnosis is not clear on clinical and laboratory grounds. CT scanning on day 2, 3 or 4 is more useful for assessment of complications or severity.
MRCP has the highest sensitivity for diagnosing common bile duct stones and can provide information on ductal anatomy that may clarify the cause of the pancreatitis, as well as select patients for ERCP.
Severity assessment This is critical as it impacts management in several ways. Several scoring systems are presented.
Initial management This consists mainly of general symptomatic and supportive care. Fluid resuscitation is believed to be critical but the optimal volume is controversial. High level data are lacking. Expert opinion and pathophysiologic rationale have led to recommendations for 250-300 ml/hr for the first 48 hrs if the patient's cardiopulmonary status permits.
Nutrition In mild cases the patient can be started on clear liquids with advancement as tolerated, as soon as pain is markedly improved. In severe cases artificial support is indicated. Enteral is favored over TPN. Jejunal feeding has been favored over NG feeding in the past although recent data challenge that tradition. NG feeding is acceptable in many cases.
Antibiotics Antibiotics are not indicated for pancreatitis per se although there are specific indications. Prophylactic antibiotics, to prevent infected pancreatic necrosis or other pancreatic infections, have been traditionally recommended for patients who are assessed as having severe pancreatitis or who have pancreatic necrosis. This is controversial, however, and current guidelines do not recommend them. A septic picture or other signs/symptoms of infection justify antibiotics as well as suspected cholangitis. Antibiotics are generally recommended for cholecystitis although the evidence is unclear. When antibiotics are used, “pancreatic coverage” generally consists of either a pemen or a quinolone combined with metronidazole.
ERCP ERCP has a role in gallstone pancreatitis. Timing depends on clinical circumstances and is urgent in cholangitis.
Cholecystectomy This is indicated in documented gallstone pancreatitis, that same admission if possible, but at least no later than 4 weeks, absent surgical contraindications, given the high rate of relapse of gallstone pancreatitis if not done.
An alternative approach, which we believe best incorporates live interaction and real-time learning while enhancing patient care and maintaining clinical applicability, is a modification of the standard SOAP (subjective, objective, assessment, and plan) case-presentation format. This option redefines the classic SOAP note to a SOAPS note, with the additional S standing for safety. This method directs providers, at the point of care, to identify potential safety issues during each encounter...
This makes sense, and I think many of us have already adopted something similar with the advent of the EMR, in the form of a check list at the end of our progress note templates, with reminders about DVT prophylaxis, pharmacovigilance, foley catheter removal and the like.
Multiple reviews of pancreatitis emphasize severity assessment because several management decisions hinge on it. Several severity scoring tools are available. Their use is somewhat cumbersome because different tools are applicable in different situations. Some are useful on day one while others cannot be used until 48 hours. Since each tool has advantages and disadvantages, multiple tools may be needed for most effective use so I thought it would be helpful to have links to the major ones here in one place.
Ranson's score. Pro---tried and true, and in my anecdotal experience uncannily predictive. Con---can't be completed until 48 hours.
APACHE II. Pro---well validated in pancreatitis, can be used daily. Con---a little cumbersome to use.
BISAP score. Pro---easy to use, can be used in the first 24 hours. Con---not as well validated as some of the other scores, needs further research.
CT scores (no Internet table or calculator found; resource here). Pro---clinically validated. Con---cumbersome; not generally available on day 1 or daily; IV contrast preferred.
Atlanta criteria (no Internet calculator found, but resource here). Pro---can be used any time during the patient's course; any single criterion on the list defines pancreatitis as severe. Con---relies on other scores and assessment tools.
---was accompanied by a higher rate of complications in this study. The increase was attributable to early (septic shock, death) rather than late complications.
Staphylococcal bacteruria accompanying bacteremia is generally due to hematogenous seeding of the urinary tract rather than the urinary tract as the primary source.
Boy I wish they had stuff like this when I was a med student:
These Web Pages are dedicated to all the students with whom I had the good fortune of teaching at Georgetown University. They are meant to be studied by the person who is just interested in learning a little about human anatomy, as a review of previous anatomy courses or for anyone else who might find the lessons helpful.
Today’s sessions featured stress and lifestyle management in cardiovascular disease which has always been a sub theme of this conference due to the legacy of the late Robert S. Eliot, MD, one of the founders of this meeting 36 years ago.
There were also updates on changing systems of health care delivery and cardiovascular genetics.
There are too many nuances on these subjects to discuss than time permits tonight. I plan more detailed posts when I return home.
Gordon Ewy, long time Chief of Cardiology at the University of Arizona and leading expert and pioneer in CPR, presented an update. He and his group in Arizona began advocating for compression only resuscitation for primary cardiac arrest in 1993. While Ewy’s protocol is the only change in resuscitation to make a dent in the mortality of out of hospital cardiac arrest, it took EBM over 15 years to catch up. Ewy’s recommendations encompass several changes around the importance of uninterrupted chest compressions and are now known as cardiocerebralresuscitation (CCR). Ewy presented the mounting and very compelling evidence of the superiority of CCR over traditional CPR as taught in the 2005 guidelines.
He also presented an update on the emerging post resuscitation bundle and the new mandate for regional centers for post resuscitation care.
These are exciting times for resuscitation science. It’s amazing that an editorial on CPR recently published in JAMA completely ignored this.
Spencer King is arguably the world’s leading expert on percutaneous coronary intervention. At Emory he did some of the pioneering work in the field. He is currently President of the Heart and Vascular Institute at Saint Joseph’s Hospital in Atlanta and Professor Emeritus at Emory. His topic, the role of PCI in stable coronary disease, was very timely because it took center stage in the health care reform debates.
In the spotlight were COURAGE and BARI 2D, two trials which were egregiously hyped by the popular media and some bloggers. It was purported that these studies compared PCI with medical therapy. That was not the case. In fact, COURAGE and BARI 2D (and even this is an oversimplification) compared, in patients on optimal medical therapy, PCI as an initial strategy versus a strategy of watchful waiting, with PCI deferred and reserved for patients with progressive symptoms or instability. It turned out that the deferred PCI strategy was acceptable, but keep in mind that many patients on optimal medical management, about one third in COURAGE, required PCI on clinical grounds. (BARI 2D was much more complex and had other arms, beyond the scope of this discussion).
---were recently reviewed in Current Opinion in Rheumatology.
Points of interest:
Virtually any cardiac tissue can be directly affected, usually by fibrosis.
The relationship to coronary disease is poorly defined. Rheumatic diseases in general are thought to be associated with accelerated atherosclerosis. Coronary vasospasm may be a complication of Ssc.
Pulmonary hypertension may occur with or without interstitial lung disease (ILD).
Special MR and nuclear imaging applications are discussed.
Echocardiography is helpful but has limitations.
BNP and proBNP have limited usefulness.
Specific antinuclear antibodies (anti-SCl 70, anti-centromere and anti-RNA polymerase III) may predict particular cardiovascular complications although the correlation is imperfect.
But it requires an exceptional degree of echocardiographic skill and close attention to detail, probably with the interpreting cardiologist in attendance while the study is done, or an extremely capable tech.
No one's been able to show that statins are protective in ESRD. This is probably due to the multitude of atherogenic factors in renal failure which statins don't address such as hypercoagulability, the metabolic syndrome, Lp(a) and the like. It's not that statins don't help any patients with ESRD but in the aggregate any beneficial effects are overshadowed.
Despite this fact nephrologists aren't stopping statins, possibly out of concern that events may be precipitated.
Purpose of review: Labeling osteoarthritis as a degenerative arthritis is a misnomer. It is now clear that an active genetic and proteomic profile suggests inflammation. The cytokine milieu is similarly inflammatory and neatly parallels that found in the metabolic syndrome.
Main results Three trials involving 387 patients were included and 14 deaths occurred. The pooled RR of death was 2.88 (95% CI 0.88 to 9.39) in an intention-to-treat analysis and 3.03 (95% CI 0.93 to 9.83) in patients with confirmed AMI. While suggestive of harm, the small number of deaths recorded meant that this could be a chance occurrence. Pain was measured by analgesic use. The pooled RR for the use of analgesics was 0.97 (95% CI 0.78 to 1.20).
Authors' conclusions There is no conclusive evidence from randomised controlled trials to support the routine use of inhaled oxygen in patients with acute AMI. A definitive randomised controlled trial is urgently required given the mismatch between trial evidence suggestive of possible harm from routine oxygen use and recommendations for its use in clinical practice guidelines.
Last year Richard Conti wrote a thoughtful editorial expressing similar concerns:
I must admit that when I see a patient with an uncomplicated myocardial infarction receiving supplemental oxygen whose oxygen saturation is 95%, I usually ask the housestaff and nurses why this patient is receiving oxygen. Most of the time the answer is, ‘‘Well, that’s the way it has always been done,’’ or the nursing staff thinks these patients need oxygen.
Another answer relates to guideline recommendations by the ACC that supplemental oxygen in the first 6 hours of an acute uncomplicated myocardial infarction is okay.5 The level of evidence for this recommendation is C (based on expert opinion, case studies, and ‘‘Standard of Care,’’ (ie, the ‘‘Book of Common Wisdom’’). As far as I am concerned, that is not good enough.
He points out that oxygen may cause coronary vasoconstriction and acknowledges that it should be used in hypoxemic patients.
---for some relaxation and CME. I’m on the road headed for this meeting.
I didn’t promote the meeting the way I did last year because, up until relatively late this summer, I didn’t know if I was going to be able to take the time off from work. I’ve only missed two years since I first attended in 1981.
This year’s topics will include updates in CPR, cardiovascular genetics and coronary revascularization by the some of the world’s experts in those fields, Gordon Ewy, Robert Superko and Spencer King respectively. As a special treat Timothy Flemming will lecture about health care in New Zealand, the ultimate example of government controlled, single payer health care. He spends half of the year teaching and practicing there and half the year in the US, so this should be an interesting perspective. He made some informal observations on the subject last year.
Through all the vicissitudes of changing sponsorship and threats to CME funding the leaders of this meeting have managed to keep it going for 36 years. In recent years they’ve cobbled together financial support from drug companies, genetics companies, device makers and non-profits to keep the pharmascolds from shutting them down.
If time permits I will blog some of the highlights following each day’s sessions.
The systemic capillary leak syndrome (SCLS) is a rare disease of reversible plasma extravasation and vascular collapse accompanied by hemoconcentration and hypoalbuminemia. Its cause is unknown, although it is believed to be a manifestation of transient endothelial dysfunction due to endothelial contraction, apoptosis, injury, or a combination of these. Fewer than 150 cases of SCLS have been reported, but the condition is probably underrecognized because of its nonspecific symptoms and signs and high mortality rate. Patients experience shock and massive edema, often after a nonspecific prodrome of weakness, fatigue, and myalgias, and are at risk for ischemia-induced organ failure, rhabdomyolysis and muscle compartment syndromes, and venous thromboembolism.
---published in the BJMP is available as free full text.
There is not a whole lot that’s new regarding ALI/ARDS but this review made some points that have not received much attention elsewhere:
Long term outcomes relate to neuromuscular, neurocognitive and psychological problems rather than pulmonary dysfunction (except in those patients who develop pulmonary fibrosis, sometimes accompanied by pulmonary hypertension).
For reporting purposes most cases are captured in the ICU. However, it is believed that there is a significant number of patients on the wards and in other settings who would meet criteria for ARDS/ALI but are not identified, reflecting the wide ranging severity and heterogeneity of the syndrome.
Some patients do not resolve their ARDS and progress to a fibrotic phase resulting in chronic PFT abnormalities and pulmonary hypertension.
The use of high levels of PEEP (above that called for by the ARDSnet PEEP scale) has not been validated conclusively although a recent meta-analysis suggests that it may be beneficial in a subset of patients with severe disease. However, the optimal level in such cases is not known.
ECMO deserves consideration as a rescue measure in patients with severe hypoxemia refractory to conventional measures.
Here's what a review in The Journal of Hospital Medicine says (my italics):
While administration of IV haloperidol can be associated with QTP/TdP, this complication most often took place in the setting of concomitant risk factors. Importantly, the available data suggest that a total cumulative dose of IV haloperidol of less than 2 mg can safely be administered without ongoing electrocardiographic monitoring in patients without concomitant risk factors.
Considering the number of patients who get hypokalemic, hypomagnesemic or get other QT prolonging drugs (can you say Levaquin?) that may be a pretty select group. And given that you never know when you might reach that threshold of 2 mg, well...
Hospital bouncebacks are in large part fueled by the Prospective Payment System, an ill conceived negative cost incentive put into effect in 1984. Now it looks like the health care czars are about to deal with this unintended consequence by tacking on even more negative cost incentives. Isn't that a bit like adding drugs to combat the side effects of other drugs?
---I'm having trouble keeping up with them. This one suffers the same flaw as most others, as it designates CTA as the diagnostic modality of choice. That claim, as I've demonstrated recently and multiple other times in the past, is not evidence based. The recommendations in this particular review, though, come with an interesting twist:
Ventilation perfusion (VQ) scanning remains an alternative method of imaging for PE, particularly in individuals without pre-existing lung disease in whom the incidence of nondiagnostic results is decreased.30 It has the advantage over CTPA of not requiring contrast exposure, and therefore is the investigation of choice in patients with renal impairment. Breast radiation exposure is also substantially reduced with VQ scanning in comparison to CTPA, and therefore it should be considered as a first line investigation for PE in women of reproductive age. A normal VQ scan can be used to exclude PE, while a high probability scan justifies anticoagulation. All other results are associated with an intermediate probability of PE (10–40%) and further imaging, normally CTPA, is therefore required .
To its credit this review makes no evidential claims as to which imaging modality is best. It merely says:
Computerized tomographic pulmonary angiography (CTPA) has become the most widely used radiological investigation for suspected PE.
All these recent reviews are remarkably consistent in their recommendation that the decision for imaging should be made on an initial pre-test assessment tool combined with D dimer testing.
Now that scleroderma renal crisis has declined as the cause of death in patients with systemic sclerosis, pulmonary complications, namely ILD and PAH, are increasingly important and have emerged as the leading causes of death. This study shows the wide practice variation in the evaluation and treatment of pulmonary manifestations. This may be due to varying perspectives among different specialties, lack of familiarity with pulmonary aspects of the disease or a lack of guidelines and evidence.
Results A total of 220 (65%) graduates had Facebook accounts; 138 (63%) of these had activated their privacy options, restricting their information to 'Friends'. Of the remaining 82 accounts that were more publicly available, 30 (37%) revealed users' sexual orientation, 13 (16%) revealed their religious views, 35 (43%) indicated their relationship status, 38 (46%) showed photographs of the users drinking alcohol, eight (10%) showed images of the users intoxicated and 37 (45%) showed photographs of the users engaged in healthy behaviours. A total of 54 (66%) members had used their accounts within the last week, indicating active use.
Conclusions Young doctors are active members of Facebook. A quarter of the doctors in our survey sample did not use the privacy options, rendering the information they revealed readily available to a wider public. This information, although it included some healthy behaviours, also revealed personal information that might cause distress to patients or alter the professional boundary between patient and practitioner, as well as information that could bring the profession into disrepute (e.g. belonging to groups like 'Perverts united'). Educators and regulators need to consider how best to advise students and doctors on societal changes in the concepts of what is public and what is private.
---had higher costs per case in this study. Hospitalists also had higher 30 day readmission rates at borderline statistical significance.
The 30 day readmission rate is intuitive, because patients cared for by hospitalists may not receive optimal out patient follow up compared to patients cared for in the hospital by their long term physicians.
Why the increased charge per case? My very biased explanation has to do with the fact that the gastroenterologist is in charge of the care of the patient. Hospitalists, compared to their non-hospitalist peers, may be more active in comanagement of these patients. This comanagement is redundant and may lead to inefficiencies.
---asks Kevin MD, quoting a recent JAMA article which reported that around a third of doctors would not report.
I was surprised that the number was only a third. There's been wide spread under-reporting among physicians for as long as I can remember. Contrast that with nurses, who seem to file incident reports and “write up” their colleagues frequently.
It's a cultural phenomenon that's hard to define. Maybe reporting of impaired colleagues will gain traction now that it's linked to the catch phrase “patient safety.”
I've linked to quite a few PE reviews, here, probably to most that have been published over the past few years. A disturbing non-evidence based trend I've noted in these reviews is an increasing emphasis on CT over V/Q scanning as the initial diagnostic strategy of choice. Some of the more recent reviews clearly state that CT scanning is the modality of choice. This latest one (an otherwise excellent review) doesn't even mention V/Q scanning. The trend is based solely on popular belief, there being no evidence to support it. These reviews are propagating a popular myth. I have not data to back this up, and I'd like to see it systematically studied, but I suspect this is keeping the nephrologists busy in hospitals.
---according to this Cochrane review. Med Page Today commentary here. The Cochrane reviewers were only able to find two studies that met their criteria: Randomised trials of augmentation therapy with alpha-1 antitrypsin compared with placebo or no treatment. Both looked at surrogate endpoints and neither addressed mortality. One surrogate endpoint (change in CT lung density) showed a statistically significant difference favoring treatment but the clinical significance is not known. There was no difference in exacerbations, quality of life of other endpoints.
I am not familiar with the primary literature on treatment of alpha-1 so this report raises more questions than answers for me. The medical press has hyped this somewhat but it's not as if it should be breaking news given that there were only two high level trials, both essentially negative, such that it wouldn't have taken a statistician to figure it out.
Professional societies endorse replacement therapies in their guidelines. Surely they were already aware of this literature. I have no idea whether this will change their recommendations for treatment. The important point is not that the treatment doesn't work (it seems to improve at least one surrogate endpoint and may ease the severity, although not the frequency, of exacerbations) but that we need a large RCT looking at mortality and other hard clinical endpoints, something like the National Emphysema Treatment Trial.
What about screening? Screening is widely advocated and has been widely believed to be underperformed. Although it will be interesting to see what the next round of guidelines say I will not change my approach that all patients with COPD or unremitting asthma should be screened. Screening is easy to do, is important for non-pulmonary disease associations and may still have treatment implications.
With about 70 percent of the vote counted late Tuesday, nearly three-quarters of voters had supported the measure.
Tuesday's vote approving the ballot measure, known as Proposition C, was seen as largely symbolic because federal law generally trumps state law. But it was also seen as a sign of growing voter disillusionment with federal policies and a show of strength by conservatives and the tea party movement.
No. It helps but the benefits are modest and the science is soft. Here's a semi-systematic-narrative-as-expert-as-anyone-else review at Science Based Medicine.
Half truths are sometimes more dangerous than lies:
"The unaided human mind, and the acts of the individual, cannot assure excellence. Health care is a system, and its performance is a systemic property."
"I would place a commitment to excellence—standardization to the best-known method—above clinician autonomy as a rule for care."
"Young doctors and nurses should emerge from training understanding the values of standardization and the risks of too great an emphasis on individual autonomy."
Results The study represents the first census of free clinics in 40 years and garnered a 75.9% response rate. Overall, 1007 free clinics operated in 49 states and the District of Columbia. Annually, these clinics provided care for 1.8 million individuals, accounting for 3.5 million medical and dental visits. The mean operating budget was $287 810. Overall, 58.7% received no government revenue. Clinics were open a mean of 18 hours per week and generally provided chronic disease management (73.2%), physical examinations (81.4%), urgent/acute care (62.3%), and medications (86.5%).
Conclusions Free clinics operate largely outside of the safety net system. However, they have become an established and meaningful contributor to it. Policymakers should consider integrating the free clinic network with other safety net providers or providing direct financial support.
The document is available on line here. Here are some excerpts from the summary:
Control of hyperglycemia is recommended to reduce microvascular complications; achievement of a hemoglobin A1c less than 7% without causing hypoglycemia may be particularly important, if accomplished early in the disease and maintained successfully.
This as well as other statements in the body of the paper seem to ignore recent evidence that the goal of less then 7% for HgbA1c may be too aggressive.
There is evidence that suggests a macrovascular benefit with metformin, especially for obese diabetic patients, and some inconclusive evidence of potential harm from rosiglitazone but not pioglitazone.
This statement, unfortunately, does not go far enough in acknowledging evidence for probable macrovascular benefit associated with the use of pioglitazone.
For most of the other glucose-lowering agents, there are few or no data to support either harm or benefit with regard to macrovascular disease.
That statement is simply wrong. There is ample evidence pointing to macrovascular harm associated with the use of sulfonylurea drugs, which carry a black box warning for that effect.
A related editorial in Circulation: Cardiovascular Quality and Outcomes is available here.
This is from the Association of American Physicians and Surgeons, in many ways the most libertarian of all our professional societies. I don't agree with everything these folks put out (they have been a little anti-vax in their leanings in the past) but AAPS has been uniquely courageous in its refusal to kowtow to the increasingly self-flagellating medical establishment and the “system” with all its intrusive regulations. Also unique among professional societies, AAPS refuses to buy into the cynical view that the interests of organized medicine and those of patients are inherently conflicted.
The Declaration presents an interesting time line of the intrusion of government into the doctor-patient relationship but leaves out two important events: the utter failure of Medicare's PSRO in the 70s and early 80s to stem its massive excesses and inefficiencies followed by the ill-conceived and capricious implementation of the Prospective Payment System in 1984.
Lifetime Network is the network for women. It was in the 80s and early 90s too, but back then they interrupted their regular fare on Sundays and devoted the entire day to programming for doctors. The schedule contained educational programs (non-accredited, mostly) in all the specialties. Although most presentations were balanced it was all clearly industry supported with a few of the offerings resembling infomercials for featured products. Commercial ads (directed to doctors, not consumers) were frequent. I've since been bombarded by all the non-evidence based propaganda about how this sort of stuff is harmful to patients but you know what? I found it to be a helpful learning experience.
I was getting on line even back then but the on line experience was very limited compared to what we have today. There were no blogs, multimedia presentations or web casts on demand. I lived in the hinterlands and didn't get away for CME all that often so I was hungry for something like this. I was addicted to LMT. It was my Monday Night Football. When I could I watched in real time. When I couldn't be home to watch I set my VCR.
In spite of all the web has to offer I kinda miss LMT. It's Sunday, time to reminisce. Here's a montage of promos and ads from 1991. (Most of this is from LMT although a couple of promos are from American Medical Television, a competing doctors' network on CNBC, which had a very brief run). Of note: at 4:00 to 4:25 a panel of master teachers including Jeremy Swann prepare to challenge three residents in a sort of medical Jeopardy on Med Quiz. At 4:30-5:25 a Vasotec ad highlights the landmark CONSESUS trial. At 5:25-6:23 is a very clever Feldine ad. At 7:00-7:44 on Physicians Journal Update discussants prepare to debate Washington's (failed) initiative 119 for assisted suicide.
