Myelodysplastic syndrome versus myeloproliferative disorder

I've seen fuzzy use of these terms and evidently the question came up at Emory morning report, hence a post at The Bottom Line:

Myeloproliferative diseases are characterized by large numbers of abnormal blood cells (red, white or platelets) growing and spreading in bone marrow and blood. On the other hand, myelodysplastic syndrome includes various clonal hemopathies characterized by decreased production of blood cells and are associated with a risk for development of acute leukemia.

Pancreatic neuroendocrine tumors

From a review in Gastroenterology.

Most are “malignant” with the exception of insulinomas. “Malignant” is quotes because clinical behavior in terms of tumor bulk and metastasis is generally indolent, and the major clinical impact is from the secretory products, though some tumors are nonfunctional.

Via The Bottom Line.

Prophylaxis against spontaneous bacterial peritonitis in cirrhotic patients---I'm confused

This was a recent topic of an evidence summary posted at The Bottom Line according to which the only universally accepted indication is for cirrhotic patients hospitalized with UGI bleeding while they're in the hospital (and maybe for a few days after). For non-bleeding ascitic patients with other risk factors, while a prior history of SBP seems to be a strong factor in favor of prophylaxis, the recommendations are all over the map, (and I checked Up to Date regarding this) reflecting the less than optimal quality of available evidence.

UpToDate versus Harrison's and other traditional text books---it's about apples and oranges

You wouldn't criticize an orange for not being a good apple. In terms of taste, texture and many other attributes an orange isn't supposed to be a good apple. So why in the world would you criticize Harrison's or Cecil's for not being good “look up” treatment references like UpToDate is? They're not supposed to be. They are mainly background references, not point-of-care references. So they have a different role.

An interesting exchange of tweets between Ves, the author of Clinical Cases and Images and Joel, who blogs at Precious Bodily Fluids seems to ignore this point:

@DrVes: UpToDate is likely the most read medical reference tool, at least in the U.S. - how did Harrison's, Cecil's, etc. manage to lose that war?

Thus a false dichotomy is set up between UpToDate and the traditional textbooks. It's both-and, not either-or. The resources should not be in competition. They are complementary. When I'm rounding and need a quick look up of the latest and best information on the treatment of interstitial lung disease complicating systemic sclerosis I go to UpToDate. At home that night I might want to review some background information on the pulmonary complications of systemic sclerosis---pathophysiology, radiographic patterns, disease characteristics, natural history and the like. For that, my best bet is Harrison's or Cecil's.

Don't get me wrong, I love UpToDate. It may even save lives. But UpToDate by itself is not enough. You need additional resources. If your Harrison's is serving primarily as a booster seat for one of your kids at the dinner table you could put it to better use. What do you think? (I'm opening up comments again in hopes the spammers will stay away).

Related post: How and why should we read?

Warfarin versus the new oral anticoagulants

This review belongs in the hospitalist's library. It covers the two new agents approved in the U.S. as well as those in the pipeline. It cites a lot of comparative effectiveness research. (Not that comparative effectiveness research is anything new, but that's what it's trendy to call it when there are two or more active treatment arms).

So is warfarin dead? No. This little appreciated perspective is offered:

Warfarin's long, effective half-life of approximately 40 hours, may work to the providers' advantage in a nonadherent patient, Therefore, a degree of nonadherence may have a negligible effect on anticoagulation levels, compared with an anticoagulant with a short half-life.

The lack of a requirement for monitoring may also deny the physician the opportunity for patient education and the earlier detection of problems. It denies the practitioner the ability to tailor the intensity of anticoagulant therapy for patient-specific factors, such as for patients on single or dual antiplatelet therapy, or for those patients with an increased bleeding risk. Lastly, it may make it difficult to determine if the specific therapy has failed. If a patient develops a thromboembolic event on warfarin, the INR is measured to determine if the event is truly a failure of therapy or whether the patient was subtherapeutic (due to noncompliance or other factors influencing the INR).

And, my suspicion is that the purported safety and ease of use of these new drugs could lead to complacency in heeding renal precautions and other labeling concerns.

The high osmolal gap---toxic alcohol poisoning and other disorders

This topic was reviewed as part of the acid-base teaching series of the American Journal of Kidney Diseases.

Concluding points from the article:

• Increased serum osmolal gap with or without high-anion-gap metabolic acidosis can be an important clue to toxic alcohol intoxications

• The presence and magnitude of serum osmolal gap depends on several factors, including molecular weight of the offending alcohol, baseline serum osmolal gap, and state of metabolism of the parent alcohol

• Patients with toxic alcohol intoxications can present with an increase in serum osmolality alone, increased serum osmolality and high-anion-gap acidosis, or increased-anion-gap acidosis alone. Rare cases in which both serum osmolality and anion gap are within reference ranges also might occur

• Kidney failure, lactic acidosis, and diabetic ketoacidosis also can cause high-anion-gap metabolic acidosis associated with a large serum osmolal gap

• Given the potential severity of all these disorders, they should be excluded in all individuals presenting with serum osmolal gap, serum osmolal gap and high-anion-gap metabolic acidosis, or high-anion-gap metabolic acidosis alone

Also remember this:

Osmolality must be measured by the method of freezing point depression. Other methods may not be reliable. Fortunately, freezing point depression is the method of most hospital labs.

In contrast to the other toxic alcohols, isopropyl alcohol is not metabolized to an acid (it is metabolized to acetone resulting in ketosis but not ketoacidosis because acetone cannot be carboxylated to produce a ketoacid). Thus isopropyl alcohol intoxications produce elevations in the osmolal gap but not the anion gap unless they produce sufficiently severe hypotension to cause lactic acidosis.

The other toxic alcohol ingestions start with only an elevated osmolal gap. As the parent compound is metabolized to acid metabolite(s) the osmolal gap goes down as the anion gap goes up. Late in the course only the anion gap is elevated.

The higher the molecular weight of the offending compound the less it will contribute to the osmolal gap.

An interesting situation exists with DKA. Ketoacids dissociate and the hydrogen ion is buffered. Sodium pairs with ketoacids to maintain electroneutrality. Because sodium figures in the calculated osmolality the ketoacids do not directly contribute to the osmolal gap. They contribute indirectly because acetoacetic acid is irreversibly and non-enzymatically converted to acetone, an osmotically active non ionic compound which is slowly excreted in breath and urine. Glycerol and some amino acids also contribute to the osmolal gap.

High school chemistry question: what's the difference between osmolality and osmolarity? We use the terms interchangeably but there is a difference. No fair googling.

Does thyrotoxic atrial fibrillation carry a higher thromboembolic risk than other forms of atrial fibrillation?

There's a long held belief that this is true. I first heard it from an old sage who said that when the thyrotoxic patient develops atrial fib, “run for the heparin!”

Thyrotoxicosis is not listed as one of the CHADs risks, so fact or myth?

All the evidence is examined in this review in the Texas Heart Institute Journal. It turns out that multiple studies show an alarmingly high rate of thromboembolism in thyrotoxic patients with a fib compared to rates reported in non-thyrotoxic patients. But these studies were small and had methodologic problems. At least one larger study questioned the association. A systematic comparison of thyrotoxic and non-thyrotoxic patients with a fib has not been done.

Guidelines differ. The AHA/ACC guidelines suggest that indeed thyrotoxicosis is a risk factor and is itself a reason for anticoagulation. The authors of this review conclude:

Given the lack of clear evidence, the ACC/AHA classification of thyrotoxicosis as a moderate thromboembolic risk factor seems to be reasonable, and the recommendation to initiate anticoagulation when there are no contraindications appears to be warranted. More evidence-based trials are necessary to clarify this issue.

Takotsubo cardiomyopathy versus anterior STEMI: is there an electrocardiographic differentiation?

TC can present with anterior ST elevation, in which case it resembles acute anterior STEMI. This paper demonstrates an electrocardiographic differentiation:

ST-segment elevation greater than or equal to 1 mm in greater than or equal to1 of leads V3 to V5 without ST-segment elevation greater than or equal to1 mm in lead V1 identified TC with sensitivity of 74.2% and specificity of 80.6%.

It is amazing to me how the power of electrocardiography continues to be discovered year after year. However, this finding is of limited practical value. At a specificity of 80% for TC you wouldn't want to rely on this pattern to exclude patients from reperfusion.

Sofia course gallery

Here.

Hospital Medicine Virtual Journal Club

From the Wash U Hospital Medicine section.

Quick reference on lead aVR

Reports in the last few years highlight the emerging importance of lead aVR, a long neglected electrocardiographic lead. I have written several posts on the important clues available from lead aVR in the detection of left main or multivessel coronary ischemia, the differential diagnosis of narrow complex tachycardias, the differentiation between VT and SVT with aberrancy, and pericarditis. All these and more are summarized in this quick reference guide, from the Paucis Verbis series at Academic Life in Emergency Medicine.

Televancin and HCAP

It has been approved for the indication in Europe based on two phase 3 trials showing non-inferiority to vanc. In the US it is approved only for complicated skin and skin structure infections.

Fluid resuscitation in acute pancreatitis: is less actually more?

Traditional teaching and guidelines held that we should pour the fluids early on in the treatment of acute pancreatitis. Nobody would say just how much, but a lot. The problem was, these recommendations were not driven by high level data. We had expert opinion, animal data, pathophysiologic rationale and low level studies in patients but nothing more.

A new study, representing the best evidence we have to date, challenges that teaching:

RESULTS:

A total of 247 patients were analyzed. Administration of greater than 4.1 l during the initial 24 h was significantly and independently associated with persistent OF, acute collections, respiratory insufficiency, and renal insufficiency. Administration of less than 3.1 l during the initial 24 h was not associated with OF, local complications, or mortality. Patients who received between 3.1 and 4.1 l during the initial 24 h had an excellent outcome.

CONCLUSIONS:

In our study, administration of a small amount of fluid during the initial 24 h was not associated with a poor outcome.

I don't have access to the full text of the paper to know how severity adjustment was done. The authors, when interviewed by Medscape, spoke strongly against the practice of massive fluid resuscitation for all patients with pancreatitis.

How might this study change practice? To me it challenges the dogma that patients with acute pancreatitis should undergo massive initial fluid resuscitation just because they have acute pancreatitis. The game changer may be that we'll have to adopt a more individualized approach to fluid management based on volume assessment. For patients who seem well perfused at presentation, a strategy like that suggested by the authors, aiming for 3-4 liters or so over the first 24 hours, may be reasonable with the caveat that frequent clinical and laboratory assessment over that time may be necessary to identify those patients who need to be switched to a more aggressive volume loading strategy. We'll need further study of this question to refine the approach.

A new challenge to Obamacare---the Interstate Health Care Compact

Interstate compacts are older than the Constitution itself although this effort just got going a few months ago. A few states have signed up with many more standing in line. These folks seem very determined and at a minimum they'll open a new front in the battle over health care.

GPs in the British National Health Service

Bob Wachter, on sabbatical in England, has been blogging about the National Health Service. In his latest post, noting Donald Berwick's romanticism about the NHS and the political consequences he reaped, Bob is not so romantic. While acknowledging many of the negatives of the NHS he finds a few things to like. Let's look at some of those and decide how likeable they really are.

A GP can make more than a surgeon, and brings home about 20% more than a subspecialist. (We aren't told how much that is and how it compares to primary care in the US). This is largely due to a big P4P incentive implemented by the NHS in 2004. The incentive, as Bob portrays it, is like our own system on steroids:

In 2004, the NHS negotiated a new contract with GPs, which included a “Quality and Outcomes Framework” (QOF), an unprecedentedly far-reaching pay-for-performance system in which GP practices could earn substantial sums based on performance on over 100 quality measures...

But the most prominent wall decoration is a large white board, located in the practice’s main thoroughfare, its grids filled with data on the group’s performance on the QOF measures. All the doctors, nurses and staff track these numbers daily because their livelihood, literally, depends on them. In addition to tracking process and outcome data via the white board, the practice’s sophisticated computer system allows caregivers to track their adherence to evidence-based quality measures and to see how the practice is doing against benchmarks and bonus thresholds.

Well, you can just imagine the distraction this creates away from real quality and clinical skill along with other unintended consequences. I have blogged many times before (and cited evidence) on the fallacy of performance as a surrogate for quality. (In the above quote I wish Bob had put the word quality in quotation marks). Beyond that, recent evidence suggests that even the effect on performance of P4P incentives is modest at best. The same was found to be true for the NHS incentive in particular in this NEJM study. More than that, under the British QOF incentives there was deterioration in adherence to uncompensated measures.

And there was this tidbit:

Moreover, the NHS limited GP practice hours to 8 am-6:30 pm, weekdays only, creating alternative ways (mostly through a series of urgent care clinics and, of course, through emergency rooms) for patients to receive after-hours care.

GPs in the NHS apparently like this, but can you imagine the US government setting your practice hours?

Finally this, speaking of the GP group Bob toured there:

..they review every case in which a patient goes to the ED, is admitted to the hospital, and is referred to a subspecialist.

Yes, the decision to refer even a single patient to a cardiologist or nephrologist needs to be defended. As far as I could tell, this is not because the costs of subspecialty consultation come out of the practice’s resources (although this may soon change, as the Cameron government’s plans to turn over most of the healthcare budget to GPs, called “commissioning,” are rolled out over the next few years). Rather, it seemed to me to be an issue of professional pride.

Can you imagine a US primary care practice reviewing every one of its subspecialty consults? They wouldn’t have any time left over to see any patients.

These reviews flow from the UK’s overall care model, which requires that all patients go through their GP in order to access subspecialty care and most sophisticated tests (one vivid example: a GP cannot order a CT scan or MRI—they need to be ordered by subspecialists). They don’t call this “gatekeeping” here, but that’s precisely what we would call it in the US.

Yes, gatekeeping. Remember the days of heavy managed care? Again, on steroids.

Tufts med school

Open courseware.

UC Irvine

Open courseware.

UMass Boston

Open courseware.

Med school course materials

University of Michigan.

U-Now

University of Nottingham open courseware.

Can the post resuscitation electrocardiogram distinguish between patients who do or do not need to go to the cath lab post resuscitation?

According to this paper it can help despite recent teaching which says it is unreliable:

ST-segment elevation predicted AMI with 88% sensitivity and 84% specificity. The criterion including ST-segment elevation and/or depression had 95% sensitivity and 62% specificity. The combined criterion including ST-segment elevation and/or depression, and/or non-specific wide QRS complex and/or left bundle branch block provided a sensitivity and negative predictive value of 100%, a specificity of 46% and a positive predictive value of 52%.

So reliance on classic STEMI criteria is not enough because it will miss at least 22% of patients who need to go to the lab. On the other hand the use of combined criteria (meaning the patient's EKG has to be nearly stone-cold normal to avoid a trip to the lab) has very high sensitivity.

Troponin measurement in heart failure

What does it mean when it’s elevated? Does it mean ACS or chronic elevation as a part of the heart failure syndrome? How does one distinguish? If the patient does not have ACS are measurements of value in risk stratification? These questions and more are answered in a review from last year in JACC, available here as free full text.

Hospitalization for adverse medication events in elders

67% in a new study were due to oral hypoglycemics, insulins and antithrombotics, none of which are on the Beers list.

The authors conclude that intensified outpatient vigilance targeting these classes of medications is warranted to reduce hospitalizations in the elderly.

EMRAP TV

Short videos on clinical emergency medicine and the intersection with critical care medicine.

Intraosseous access

---may be catching on in the ER but is still underutilized. It can serve as a bridge to a central line if you can't get a peripheral in in a reasonable amount of time. Study here, Medscape commentary here.

Gram positive bacteremia in hemodialysis patients

A review in the American Journal of Kidney Diseases. Free full text.

Celiac disease

It has a wide clinical spectrum with many atypical variations. A review in the Archives of Pathology and Laboratory Medicine.

Update on animal bite infections

This is a very comprehensive review. Article at journal site. Free full text from Medscape.

Open courseware from Yale

Multiple subjects covered here.

Vaccine news from IDSA

A Medscape video by Dr. William Schaffner.

Managing severe acute valvular regurgitation

Here is a review from the Texas Heart Institute Journal, focusing on left sided valvular regurg:

Although acute, severe valvular regurgitation can be a true surgical emergency, accurate diagnosis and subsequent treatment decisions require clinical acumen, appropriate imaging, and sound judgment. An accurate and timely diagnosis is essential for successful outcomes and requires appropriate expertise and a sufficiently high degree of suspicion in a variety of settings. Whereas cardiovascular collapse is the most obvious and common presentation of acute cardiac valvular regurgitation, findings may be subtle, and the clinical presentation can often be nonspecific.

Cerebral salt wasting vs SIADH

Via The Bottom Line:

Cerebral salt wasting is associated with hypovolemic hyponatremia in patients with intracranial disease, such as subarachnoid hemorrhage, traumatic brain injury, craniotomy, encephalitis, and meningitis. SIADH is a cause of euvolemic hyponatremia due to the excess secretion of vasopressin that may be attributed to malignancy, various CNS or pulmonary disorders or drugs, such as chlorpropamide and carbamazepine.

The treatments differ completely but the distinction between the two can be very difficult. Both conditions have CNS disease in common and are biochemically similar. The diagnosis my hinge on volume assessment and response to treatment.

Donald Berwick to step down as CMS leader

Berwick, who once said evidence based medicine may have to “take a back seat,” has decided to take a back seat himself rather than face confirmation hearings in the Senate as Republicans remain determined to block his nomination. For many of them the problem is their perception of Berwick as a Marxist. For me it was his incoherence---advocating for more central control on the one hand while favoring an agenda of radical consumerism on the other. The Fox News piece gives us a sample of the double talk (my emphasis):

"I abhor rationing. My entire life has been spent fighting rationing. There's no substance whatsoever to the substance of that," Berwick told the House Ways and Means Committee in February 2011…

The decision is not whether or not we will ration care ... the decision is whether we will ration with our eyes open.

Berwick had big and interesting ideas. If there was a unifying thread in them I couldn’t find it.

Bacteremia as a red flag for colon cancer---it’s not just Strep bovis

According to a poster presentation at the 51st Interscience Conference on Antimicrobial Agents and Chemotherapy other species, particularly anaerobic organisms, can be indicitative of increased risk.

Anti-Xa assays---ready for prime time on the wards?

The anti-Xa assay is becoming more readily available in community hospital labs. Its potential value in dosing low molecular weight heparins in special situations such as pregnancy, morbid obesity and renal disease is well known. Less well known is a potential role in monitoring unfractionated heparin. How does it compare with PTT monitoring and what are the practical aspects? These questions are answered in a recent review in Lab Medicine, available as free full text here.

The concluding paragraph of the paper summarizes the current controversy:

Anti-Xa assays represent an attractive alternative to the PTT for UH monitoring; however, minimal outcomes data and greater expense are limiting factors. While the cost of Anti-Xa assays might decrease with higher test volumes, prospective clinical outcomes data are not likely to be forthcoming because of the waning utilization of UH. Nonetheless, laboratories may elect to switch to anti-Xa heparin monitoring based on the outcomes data currently available.

What is HCAHPS?

Ever notice how a new acronym or buzzword gets introduced and no body bothers to tell you what it means? It may be that the people throwing it around don't know what it really means themselves. Such is the case with HCAHPS. At first I thought they were talking about health care associated pneumonia. Later I realized that it was a new survey method that will change the way the patient satisfaction game is played. But when I asked around nobody, it seemed, could tell me what those letters stand for. So I looked it up. It's Hospital Consumer Assessment of Healthcare Providers and Systems. There you are. Information here and here.

Physical fitness and brain aging

Physical fitness may be associated with slowed brain aging according to a presentation at the Society for Neuroscience. Via WSH Health Blog.

Does Up To Date save lives?

Maybe so according to this study in which hospital outcomes were compared based on use or non-use of Up To Date:

We found that patients admitted to hospitals using UpToDate had shorter lengths of stay than patients admitted to non-UpToDate hospitals overall (5.6 days vs 5.7 days; P less than 0.001) and among 6 prespecified conditions (range, −0.1 to −0.3 days; P less than 0.001 for each). Further, patients admitted to UpToDate hospitals had lower risk-adjusted mortality rate for 3 of the 6 conditions (range, −0.1% to −0.6% mortality reduction; P less than 0.05). Finally, hospitals with UpToDate had better quality performance for every condition on the Hospital Quality Alliance metrics. In subgroup analyses, we found that it was the smaller hospitals and the non-teaching hospitals where the benefits of the UpToDate seemed most pronounced, compared to the larger, teaching institutions where the benefits of UpToDate seemed small or nonexistent.

The study, by the way, according to the WSJ Health Blog, was funded by Up To Date. It passes the test of plausibility for me, and supports my long held contention that doctors need “tools not rules.” I hope we see more research in this exciting area.

Managing the patient with electrical storm

Very helpful article from the Texas Heart Institute Journal.

Do you need to interrupt single or dual antiplatelet therapy for dental extractions?

No, but a marked increase in bleeding in patients on uninterrupted dual antiplatelet therapy may require local hemostatic measures according to this study.

How are hospitals doing in the area of infection control?

Pretty well except for C diff. Here are the data from HHS and here is a related Medscape article.

But before you get all warm and fuzzy about the CMS no pay for adverse event policy, remember that the decline in nosocomial UTIs began long before the implementation of that policy in 2008. Likewise the central line bundle, credited with the decline in IV catheter infections, was introduced a decade ago.

More on abdominal compartment syndrome

Intra-abdominal hypertension (IAH) is a precursor to abdominal compartment syndrome (ACS). Awareness of ACS across a variety of medical settings is increasing. There is now a professional society devoted to IAH and ACS. ACS is a systemic disease which can lead to multi-organ failure. One of the better reviews on this topic was recently published. I previously blogged this topic here and here.

The microcirculation in sepsis

Here's a review from Seminars in Respiratory and Critical Care Medicine. Free full text from Medscape is available here.

A few key points:

The microcirculation has diverse homeostatic functions which become severely altered in sepsis.

The microcirculation is the site where systemic inflammation and hemodynamic disturbance translates into organ failure.

The microcirculation is the interface between the macrocirculation and the cells. Total body oxygen delivery (DO2) may be fine while things are failing at the microcirculatory level. Microthrombi may be present or altered cellular processes may impair utilization of O2.

According to the article this state is associated with so called pathologic oxygen supply dependency in which 1) oxygen consumption varies directly with delivery over a wide range from subnormal to supranormal delivery and 2) there is an elevated DO2 threshold below which oxygen consumption becomes critically reduced. This led to efforts to raise DO2 to supranormal levels in critically ill patients. However, the very existence of such pathologic supply dependency has been in dispute for many years. Moreover, trials in the 1980s demonstrated a lack of benefit and possible harm from treatment regimens aimed at supranormal oxygen delivery. Clinical protocols aiming for high DO2 have been confused with early goal directed therapy, but they are fundamentally different.

The effects of standard sepsis treatment interventions on microcirculatory function are poorly understood.

Cardiac dysfunction in severe sepsis

Current guidelines assume myocardial dysfunction if reduced central venous oxygen saturation persists after optimization of filling pressure, mean arterial pressure and hematocrit. In those instances dobutamine is recommended. The authors of this paper suggest a more refined approach utilizing cardiac biomarkers and echocardiography.

Free full text from Medscape.

Being a great doctor is not enough

---or even all that important anymore. This report from Medscape Business of Medicine discusses some of the new incentives that trump clinical skills.

ICD 10 is coming

The Medscape article implies this will address the obsolescence of ICD 9. That's pretty funny considering that the final version of ICD 10 was created around 1990.

Celiac disease review

---in American Family Physician. A bit dated but good.

Academic Earth

A large open courseware repository.

Churg-Strauss syndrome review

Journal site.

Free full text at Medscape.

Staphylococcus lugdunensis

It's coag negative but behaves like Staph aureus.

Free full text from Medscape.

The PROMETHEUS experiment in bundled payment

PROMETHEUS is a pilot project in bundled payments on the part of three health care systems. According to a report in Health Affairs the project lies dormant after three years of trying to get it off the ground. The abstract of the Health Affairs article euphemistically concludes:

Participants continue to see promise and value in the bundled payment model, but the pilot results suggest that the desired benefits of this and other payment reforms may take time and considerable effort to materialize.

A closer look at the project, according to this Medscape report, reveals the true magnitude of the problems. The Medscape piece opens:

November 10, 2011 — A new study published in the November issue of Health Affairs throws cold water on the notion that healthcare reform can quickly replace the fee-for-service (FFS) system...

Hold it right there. Much of the medicine we practice today is non-fee for service. Almost all hospital reimbursement for inpatient services is bundled and has been since the implementation of the Prospective Payment system in 1984. So the experiment in bundling is not new. We've already learned some hard lessons from the Prospective Payment system. With the implementation of DRGs in 1984 hospitals had some tough choices. They could cut corners, play games with Medicare, shift costs or fold. Reports in the medical literature from the beginning of that era suggested that as a result of the new incentives patients tended to be discharged prematurely and may have suffered bad outcomes as a result.

It was a negative cost incentive program with workarounds and loopholes. What's new in health care reform is that the negative cost incentives will now be on steroids. The bundling will be much more inclusive and the workarounds more difficult.

Continuing from the first paragraph of the Medscape piece:

and all its attendant problems, with new models of reimbursement that reward the quality of care..

Quality of care. We know what that means in the administrative world. It means performance. Performance that has nothing to do with real quality and has never been demonstrated to benefit patients.

Go ahead and read the rest of the Medscape piece and get an idea of what a nightmare this project is and consider in particular this statement:

They also note that many healthcare organizations that might start a bundled-payment system would be less prepared than the PROMETHEUS participants, which are sophisticated integrated delivery systems. As a consequence, their struggles might even be more prolonged.

Can we rectify medication reconciliation in the ER?

Med lists generated by the ER medication reconciliation process are inaccurate according to this study:

Results: There were 98 patients enrolled in the study; 56% (55/98, 95% confidence interval [CI] 46–66%) of the medication lists for these patients had an omission and 80% (78/98, 95% CI 70–87%) had a dosing or frequency error; 87% of ED medication lists had at least one error (85/98, 95% CI 78–93%).

These findings are not surprising. Medication reconciliation requires a great deal of attention to detail. Often multiple people must be questioned and phone calls made. Medication bottles must be examined when available. Information on medication bottles, medication lists and the available medical records must be compared and any discrepancies explained. Often the patient's physician changes the directions without issuing a new prescription. For each item on the medication list or for each bottle the patient and/or family must be asked whether that is the case. Patients sometimes unilaterally (without involvement of a physician) change the way they take certain medications. For each medication the patient must be asked whether that is the case. Discrepancies between intended and actual use must then be made clear in the medication reconciliation section.

This process usually takes more than just a few minutes. It could take an hour or more. No wonder accuracy is so low. It's easy to understand why under the time pressure of the ER environment, personnel do not feel it is their priority to attend to this much detail.

It's also no wonder that Joint Commission's medication reconciliation initiative, which I once thought was a wonderful idea, has flopped. Miserably. There are some lessons here. First, no “systems approach” is a substitute for sitting down and spending time with the patient. Second, as we've seen in example after example (remember rapid response teams?) many “systems approaches” which sound like great ideas are accepted uncritically. But by the time they are well entrenched research data tell another, often disappointing, story.

Viral arthritis review

Article at journal site. Free full text at Medscape.

Overview of catheter ablation for atrial fibrillation

A review in the Texas Heart Institute Journal.

Implantable cardioverter-defibrillators for non cardiologists

Troubleshooting tips from a review in the Texas Heart Institute Journal.

The human side of medicine

---is an essential ingredient of diagnostic skill as explained in this essay by the late J. Willis Hurst. A few choice quotes:

The history-taking period is when the doctor not only obtains vital clinical information, but also has the opportunity to know the patient as a person—as a human being. This is also when patients begin to know their doctor as a person. It is during the history-taking period that patients decide if the doctor is a robot with no feeling or a caring individual...

The doctor who asks questions like an interrogating lawyer and pays little attention to a patient's answers is doomed to being a poor diagnostician, because the patient's medical history is often the doctor's best diagnostic tool. Patients should know that the doctor cares about them as persons, after the history-taking period is over...

Finally, Hurst contrasts genuine caring with mere performance where we play for points on the patient satisfaction survey:

Every action and comment made by the doctor must be genuine. Doctors must not simply memorize their actions and comments like actors do when they act in a play. Remember, patients can identify the doctor who is not sincere.

I think I need to reread this article every week before returning to the inpatient service.

Physiologic consequences of sleep deprivation

As evidence accumulates we are gradually clarifying the links to immune, endocrine and metabolic dysregulation. Consequences include metabolic syndrome, insulin resistance, type 2 diabetes and cardiovascular disorders. Here is a recent review.

Allergic fungal rhinosinusitis

It is a condition beset with much confusion. This review should be helpful.

J wave disorders: a spectrum between early repolarization syndrome and Brugada syndrome

As I have blogged previously it is now known that there is both a benign and a malignant form of early repolarization. The latter is now known as early repolarization syndrome. In this review early repolarization syndrome is discussed alongside Brugada syndrome as a continuum of repolarization variants known as J wave disorders.

Under diagnosis of celiac disease

Delayed diagnosis was the rule in this study:

The mean delay to diagnosis from the first symptoms was 9.7 years, and from the first doctor visit it was 5.8 years. The delay has been reduced over time for some age groups, but is still quite long. The mean QALY score during the year prior to initiated treatment was 0.66; it improved after diagnosis and treatment to 0.86, and was then better than that of a general population (0.79).

How multiple MIs distort the electrocardiogram

When the Q wave vectors are, say, 90 degrees apart two separate MIs can be easy to spot and localize. If they are on opposite walls (180 degrees apart) things get a little tricky because of cancellation of forces. In such cases nothes and multiple baseline crossings may be observed, producing M and W waves. These electrocardiographic signs of multiple infarcts may predict reduced ejection fraction, according to this paper.

Non invasive diagnosis of mesenteric ishcemia

CT angiography had excellent test characteristics in this study.

Substitutes for evidence based (and science based) medicine

Appearance based medicine Performance measures; looking good on public report cards.  Never proven to help patients, often harmful, generally confused with quality.

Belief based medicine A form of medical decision making driven by the ad hominem fallacy in which one chooses to believe or disbelieve a guideline or scientific paper based on whether the authors have industry ties. Convenient, because no analysis and no scientific or clinical expertise needed.

Coding based medicine Ranks the clinician’s history taking and physical examination skills based on the number of bullet points they generate in the CPT coding system.

Committee based medicine Decisions made by central policy making committees removed from the patient. Promoted by Dartmouth Atlas aficionados. Claims to be evidence based but isn’t.

Consumer based medicine The patient wants it, the patient gets it no matter the evidence. CMS director Donald Berwick once spoke in favor of this type of medicine when he remarked that evidence based medicine may have to take a back seat.

Defense based medicine You know your ER patient doesn’t need that CT, but…

Media based medicine Increasingly utilized by medical thought leaders and policy makers. Why bother to check primary scientific sources when you can read it in the New York Times?

Population based medicine The red pill is cheaper than the blue pill and is just as good. Red pill approved, blue pill denied for all. Often confused with evidence based medicine because evidence based medicine is based on population studies. Not evidence based medicine because it denies consideration of individual patient attributes and clinician expertise.

Template based medicine Driven by pathways and order sets. Accelerated with the advent of the electronic medical record. Often a substitute for thought.

Why blog?

It’s a labor of love but is it worthwhile? Time to stop and reflect.

For me there are several reasons.

It keeps me interested in continued learning about medicine and the science behind it and makes me more disciplined in the way I read. 

It keeps me interested in the external issues that impact the practice of medicine. It forces me to think carefully and critically about them.

It provides me with an extensive on line filing system of articles of interest from the medical literature. If I am looking for this or that article I can go to the blog and find it fast.

It has introduced me to many wonderful cyber friends.

Besides, it’s fun.

How do we get medicines?

An article in Life Sciences Education delves into the various forms of research in drug development and the basic science surrounding it.

A genetics teaching resource

---from the University of Utah.

When it comes to the QT interval

---it's good to be average.

We're familiar with the long QT syndrome and, more recently, the short QT syndrome.

Now it appears that variations toward short or long term QT intervals even within the normal range are associated with increased mortality.

From Medpage Today commenting on the paper:

"As often happens in medicine, the first recognized cases of [long and short QT syndrome] had extreme QT prolongation or shortening, but it is now clear that considerable overlapping exists between the QTc [QT interval corrected by heart rate] values of the healthy population and those of the genetically impaired, so that no single QT value reliably separates 'normal' from 'short' or 'long'," wrote Sami Viskin, MD, from Tel-Aviv Sourasky Medical Center in Israel, and colleagues in an accompanying editorial.

Another ad hominem attack on guideline writers

This one, predictably, is from the New York Times. Typical of other ad hominem attacks on authors for their financial interests, this one is intellectually empty---devoid of any direct criticism of the science.

And here’s a choice quote from the piece:

“If you want the public to really believe in the guidelines, why not have a committee that is conflict-free?”

Does that ever miss the point. Guidelines are for the people making clinical decisions for individual patients---the health care professionals, not the public. Guideline development is not a popularity contest.

That quote also illustrates the intellectual laziness I alluded to earlier---the idea that guidelines are out there to be believed or not believed based on the litmus test of financial ties. Belief based medicine??? Whatever happened to critical appraisal and examination of primary evidence?

More from Tom Sullivan at the Policy and Medicine blog.

The American College of Physicians weighs in on VTE prophylaxis for hospitalized medical patients

---with a systematic review published in the Annals of Internal Medicine alongside a new set of guidelines. This has caused a bit of a stir, so is it anything really new? Yes and no.

First, the systematic review indicates that any benefits from prophylaxis are much, much more modest than popularly believed, particularly considering associated bleeding risks.

The guidelines themselves are being spun as a new and more restrictive approach to VTE prophylaxis. However, they are not fundamentally different from the Chest guidelines, which reserve prophylaxis in medical patients for those with increased VTE risk who do not have high bleeding risk. In contrast to the Chest guidelines, the ACP document is less specific as to what conditions constitute increased clotting or bleeding risk, and makes the statement that no risk assessment tools have been validated.

What is new in the ACP guidelines is the strong statement that recommendations for VTE prophylaxis should not be used as a performance measure. Many of these measures make pharmacologic prophylaxis the default option which may be embedded in order sets of electronic medical records. The point is that pharmacologic VTE prophylaxis should not be given by default, but for specific indications taking into account individual patient attributes.

I applaud this statement by the ACP. They recognize the toxic effects of performance measures, and how they can limit the effectiveness of evidence based care.

Save the date

The dates for the 2012 Tutorials in the Tetons, 38th Annual Update in Cardiovascular Disease, have been announced. Why not join me August 10-13 in the Grand Tetons for a time of learning and relaxation? I’ll provide more details about the meeting as they become available, and have in development some more posts on material presented at the 2011 meeting.

Subarachnoid hemorrhage presenting as out of hospital cardiac arrest

Are there clinical or electrocardiographic characteristics that help distinguish these patients? See here.

Telomeres, aging and clinical medicine

Reviewed here.

Smart phones, smart resuscitation

---in this study.

Changes in CPR protocols: the less emphasis on rescue breathing the better the outcome

---for adult arrest of suspected cardiac origin. Here is another study in support of the idea.

Brain-body relationships: science meets woo at the annual meeting of the Heart Failure Society of America

The scientific framework for the field of brain-body medicine is slowly but surely maturing. Yet the field remains mysterious enough that it carries a special attraction to the purveyors of unscientific complementary and alternative medicine otherwise known as woo. Recently Medscape reported on two well known speakers who addressed this topic at the annual session of the Heart Failure Society of America (note I didn't say scientific session). (“Brain-body medicine” seems to be a replacement for the old term “psychosomatic medicine” which nowadays is apparently too politically incorrect or not sexy enough).

Unfortunately the Heart Failure Society of America (HFSA) decided to offer a truly scientific treatment of the subject (Dr. Martin Samuels) alongside, in an apparent attempt to be “fair and balanced,” a woo based viewpoint (Dr. Deepak Chopra). If you're unfamiliar with these two speakers I have blogged about Dr. Samuels' work here. See here for a perspective on Dr. Chopra.

Dr. Samuels, whose major focus in this field is neurocardiology, has maintained the highest possible scientific standards for studying and teaching it. He has compiled extensive case studies (for obvious reasons population studies in this area are next to impossible and controlled experiments have ethical problems). Many of the lectures Dr. Samuels gives on this topic are entitled “Voodoo death.” I have heard him give this talk many times and from what I have observed Samuels' regard for scientific plausibility, thoroughness and rigorous scientific interpretation is impeccable.

To explain neurocardiology Samuels breaks the brain-body relationships down into their component parts. Some of these parts include the neuroanatomic circuitry, the neurochemistry, new information about the autonomic nervous system and even the unique histologic patterns in the heart. Some of these aspects have been characterized in exquisite detail.

Despite the fact that it would be impossible to understand brain-body relationships (or any other area of human biology for that matter) without examining component parts in detail, Dr. Chopra and other woosters dismissively swat this approach away, describing it by the simplistic use of the term reductionism.

Here's a sample of Dr. Chopra's remarks starting with the reductionism canard:

"The body is not a structure, but a process," he said. Second, "the mind is also a process." Last, the two are actually different aspects of one overarching system. "Your body's eating, breathing, digestion, metabolism, sensory experience, inner processing of thoughts, emotions, memories, and dreams--they are all a single process," according to Chopra. "As reductionist scientists, we try to separate these processes, but they are actually one...

"In Eastern wisdom traditions, unlike Western scientific reductionism, we look at the body as an integrated, holistic process, where everything is inseparably connected to everything else," he said.

This notion, that because medical science seeks to understand the human body at the level of its component parts it disregards patients as integrated organisms is one of the gigantic straw man arguments of modern medicine. The popularity of this patently absurd and empty position has always baffled me. I guess I shouldn't be surprised that the HFSA featured Dr. Chopra. It's just another example of how non-science based and implausible woo is metastasizing throughout medical schools, graduate medical education and the CME world, a trend now characterized by the term I originated a few years ago, quackademic medicine.

Important topics in ID for 2011

A Medscape Expert Review and Commentary from Dr. John Bartlett.

A few points of interest:

There's yet another new betalactamase causing resistance to multiple antibiotics including the penems. It's from India and Pakistan but has reached the US. It's very nasty and although tygecycline may show activity generally you have to use colistin. No new gram negative drugs are in the pipeline for the near future:

Two bills introduced in Congress (the GAIN bill in the House and the STARR Act in the Senate) include proposals for financial incentives for the pharmaceutical industry to produce new antibiotics. Nevertheless, no antibiotics currently in phase 3 development are likely to resolve the problem of gram-negative bacilli resistance, so it will continue to evolve with no anticipated deterrence until 2016 at the earliest, considering the snail speed of the regulatory process.

Antibiotic stewardship will need to rise to a new level.

New Hep C drugs here or in the pipeline. This section of the article is a nice perspective of the current status of Hep C evaluation and treatment.

The central line bundle and reduction in central catheter related infections. This is a remarkable story. Very soon after the bundle was rolled out came the ridiculous claim that central line infections would “go to zero.” Well, it's been a decade now. It didn't happen. Instead we have reductions in infections on the order of 50% to 70%. As laudable as that is there is no warrant for the claim that a central line infection is a “never event.”

What does this tell us about bundles in general? In the experience to date it appears that bundles can work. We're talking about the effectiveness of the central line bundle. We've seen the effectiveness of the sepsis bundle. The VAP bundle has had mixed results. As Dr. Bartlett pointed out the success of bundles is getting the attention of regulatory agencies, which means there may be a future push to turn them into performance measures. That is a concerning trend because in my view incorporating them into the performance measures will do little more than diminish their effectiveness for reasons I've stated previously here.

Rapid detection of MRSA in blood cultures by PCR. Sometimes fancy new technology really does reduce costs! Dr. Bartlett also discusses other molecular techniques along with some general principles of microbiologic diagnosis. Study question: name some pathogens that often colonize the airways of healthy individuals and some that should never be there.

Point of care testing for Hep C and other infections. Dr. Bartlett gives an update on this new test along with some background on the enormously successful track record of other point of care tests, such as HIV.

Anti-vaccination and the outbreak of measles and other pediatric infectious diseases. Some parents refuse vaccination for their children or surreptitiously avoid vaccination. This ignorant and nasty practice is not only child abuse; it has caused an enormous public health problem. Despite waning immunity we old farts, up until recently, were protected by herd immunity. Not so much anymore. Measles is a big deal. It can be fatal. Remember the case definition:

The standard case definition of measles is: fever (over 38.3ºC), a characteristic generalized maculopapular rash lasting more than 3 days, cough, coryza, and/or conjunctivitis. A patient with these symptoms needs prompt isolation and diagnostic testing.

So think of it in someone who has a really bad cold and a rash.

Vanc update. Dr. Bartlett references the vancomycin guidelines---a couple of years old but still very useful. Key points include the waxing and waning concerns surrounding vancomycin nephrotoxicity, to what extent it exists, a possible re-emergence due to newer more aggressive dosing recommendations, and its case definition. There's also the concern, as I've blogged before, about treatment failures with MRSA MICs in the higher range of “sensitivity.” Some higher MICs, despite being below the breakpoint, warrant switching to an alternative anti-MRSA agent. Vancomycin is the most frequently ordered antibiotic in hospitals today.

Looking back on the 2009-2010 flu pandemic.

This was not the highly feared (and probably much more lethal) H5N1 strain we were watching out for.

We were under a non-evidence based mandate to wear N-95 masks. Subsequent findings confirmed that surgical masks were just as good.

What causes respiratory deaths in pandemic flu? Is it viral or bacterial pneumonia? Although well known for some time that both exist, controversy dates all the way back to the 1918 pandemic when it was widely believed that a bacterium then known as Pfeiffer's bacillus (now known as Haemophilus influenzae) was the primary etiologic agent. During that pandemic Dr. Ernest Goodpasture, who probably later insisted that there's no such thing as Goodpasture syndrome, published a report of two autopsies on cases which had negative bacterial cultures, thus giving credence to a viral etiology of influenza pneumonia. One of the patients also had glomerular lesions, which later led to the inappropriate association of Goodpasture's name with pulmonary renal syndrome due to anti-GBM antibody. (You can view the first page of Goodpasture's paper here). All that being said, it is believed that then and in 2009-2010 bacterial superinfection was important. According to Dr. Bartlett:

Ambitious gumshoe detective work with historic reports and autopsy studies determined that the major cause of death was bacterial infection with the following pathogens: S pneumoniae, N meningitidis, H influenzae type B, S aureus, and group A streptococci.[48] Translated to the 2011 experience, the major bacterial superinfecting pathogens were S pneumoniae, group A streptococci, and S aureus, which proved prophetic in the subsequent CDC review.[49]

Unnecessary hospitalizations in nursing home residents

Due to the grandstanding in the 1980's skilled care of the elderly became a political football. There grew out of this an advocacy movement on behalf of the elderly and skilled elder care became the most regulated sector of American health care. Difficult and exceedingly complex regulations, draconian inspections by regulatory agencies and harsh penalties put nursing homes on the defensive. Nowadays, in order to avoid any perception of under treatment of the elderly, nursing homes have a very low threshold for transfer to hospitals of patients with acute symptoms.

Many advance directives specify that a patient is not to be transported to a hospital. However, families under pressure to make an urgent decision often contravene these documents at the last moment. At other times the directives are simply ignored. I suspect many of these directives are drafted and signed hastily without sufficient time for education and counseling of patients and their families.

These incredibly complex patients arrive in the ER where the pressure for a quick work up and rapid disposition may drive the decision for admission. Throw in pressure from families and return to the nursing facility becomes a lost cause.

This creates a tough discharge planning situation for hospitalists. Traditional discharge criteria do not easily apply because the baseline functional status of many of these patients is so poor. Treatment endpoints are often poorly defined and may be inflated by family expectations.

What can be done? Better education and counseling of families to clarify and align treatment expectations might be helpful in reducing both the number of hospital admissions and the length of stay. This is where I see an important role for palliative care teams in the nursing home and even the emergency department.

A Perspective piece in the September 29 issue of NEJM takes a different view. This article reads like a pitch for more government intrusion, as if that sector of health care is not already over-regulated. But now the incentives would be 180 degrees in the opposite direction, favoring under-treatment, as opposed to what we had in the 1980s. Indeed there are provisions of the Affordable Care Act that can be leveraged in that direction. The authors do acknowledge potential unintended consequences.

But what struck me most about the article was the case example used to launch the discussion. It concerns a 90 year old female with multiple complex problems:

She develops a nonproductive cough and a fever of 100.4°F. The night nurse calls an on-call physician who is unfamiliar with Ms. B. Told that she has a cough and fever, the physician says to send her to the emergency room, where she's found to have normal vital signs except for the low-grade fever, a normal basic-chemistry panel and white-cell count, but a possible infiltrate on chest x-ray. She is admitted to the hospital and treated with intravenous fluids and antibiotics. During her second night in the hospital, Ms. B. becomes confused and agitated, climbs out of bed, and falls, fracturing her hip.. The episode results in about $10,000 in Medicare expenditures...

There is an alternative scenario, however, in which, when the same symptoms develop, the night nurse evaluates Ms. B. using a standardized protocol and calls an on-call nurse practitioner (NP) who visits the nursing home daily. “Late this afternoon, the resident developed a nonproductive cough and a temperature of 100.4°F,” the nurse reports. “Her other vital signs are normal, and her lungs sound clear. She isn't complaining of shortness of breath or chest pain, and there is no leg edema. I think we can watch her and call back if something changes.” The NP agrees and says she'll see Ms. B. in the morning, at which point she finds a persistent low-grade fever and crackles in the right posterior lung field. After consulting with Ms. B.'s daughter, who serves as her health care proxy, the NP orders an oral antibiotic and increased oral fluid intake. Ms. B. recovers over the next several days. The episode costs Medicare about $200..

The patient had pneumonia. Based on her nursing home residency it was health care associated pneumonia (HCAP). Maybe you don't like the HCAP guidelines but it doesn't matter. You don't treat HCAP by waiting until the next morning then starting an oral antibiotic whether the patient is 90 or 50.

So here we have authors making policy recommendations in NEJM regarding acute care of complex frail elders who demonstrate a very poor understanding of such care. Concerning.