Epidemiology of chronic pancreatitis changing

More non-alcoholic etiologies, including idiopathic CP, are emerging according to a recent study. Smoking is a risk factor for idiopathic CP. Commentary in Hospitalist News.

Vitamin D, the heart and cancer

Here's an update from CCJM. Promising, but clinical trials are needed to define its role.

Blood pressure management in intracranial hemorrhage

In a recent issue of Emergency Medicine news Dr. James Roberts parses the portion of the 2010 ICH guidelines devoted to BP management.


Evidence to guide clinicians is slim, nevertheless the guideline authors managed to come up with some recommendations, based in part on clinical assessment as to whether the patient has elevated ICP, a very difficult assessment but one for which the guidelines offer suggestions.


What's changed and what hasn't changed are summarized in the article.

Would mandatory palliative care screening work for your hospital?

It can save big bucks according to a presentation at the American Academy of Hospice and Palliative Care Medicine.

Derm pearls for hospitalists

From Lindy Fox's talk at Bob Wachter's UCSF Hospital Medicine conference last fall. Via Today's Hospitalist.

Interview with Dr. Cathleen Ammann, on the experience of taking the MOC exam for focused practice in hospital medicine

Via The Hospitalist.

Timely post-hospital PCP follow up means everything

In this study it meant a much lower readmission rate and a trend toward a lower length of stay.


HT to The Hospitalist.

More on DRESS syndrome

An interesting case report and review appeared recently in Pharmacotherapy. (Free full text). The case illustrates DRESS syndrome as a mimicker of a variety of systemic diseases. The case under discussion presented as severe sepsis, then evolved into a picture resembling TTP.

I have linked to several articles on this syndrome previously.

One of the most important principles of patient safety

---is all too often ignored by organized hospital medicine. This was illustrated in a recent post by DB about gathering and processing clinical data:

As time goes on, I become more skeptical of any information that I do not collect myself.

People I do not trust:

The ER physician 

The outpatient record

The outside hospital

The resident

The intern

The student

My colleagues

Myself!

I trust no one. Too often patients are "billed" as having a certain diagnosis, but the true diagnosis is quite difference. All the people I listed are honorable and doing their best. But patients change over time. The attending physician ALWAYS gets a more accurate history the next day. The physical exam changes and becomes more clear.

The worst thing I can do is to accept everything at face value.

This is nothing more than healthy skepticism but it takes time. A lot of time. Maybe even a diagnostic time-out for all but the most straightforward patient.


This is a key element of patient safety. Unfortunately it is all but ignored by the leadership of hospital medicine, where patient safety is addressed primarily at the system level. Reducing diagnostic error is all about the individual patient.


But, in a way, diagnostic error is a system problem because of the element of time. The major performance incentives for hospitalists today---rapid ER throughput, shorter lengths of stay, early discharge time and the generation of RVUs---run counter to the objective of spending more time on the individual patient.

Dr. Rich on the CMS never events policy

As a driver of quality and safety it's a failure. On the other hand, CMS may know what it's doing. Read here.

Blog note

Just a word about the decrease in posts. You see, I've been sick. As sick as I've ever been in my life. I'm sure it was a viral illness, but it didn't want to let go for over a week. Flu? Don't know. I was vaccinated. Whatever it was it took away interest in blogging and kept me in bed for several days. I expect blogging to resume apace now that the cytokine storm has nearly passed.

Do government payers follow the latest guidelines?

Nope, these folks, to whom last year we gave even more power over our health care decisions, are a little out of date as illustrated by Dr. Wes.

Comanagement gone bad

This is what can happen if you don't write out your comanagement agreement in stone.

Oral antibiotic therapy for cellulitis

HT to The Hospitalist for pointing me to this study in the American Journal of Medicine:

Treatment success rates for empiric therapy were compared among commonly prescribed antibiotics in our clinic: cephalexin, trimethoprim-sulfamethoxazole, and clindamycin...

The overall treatment success rate of trimethoprim-sulfamethoxazole was significantly higher than the rate of cephalexin (91% vs 74%; P<.001), whereas clindamycin success rates were higher than those of cephalexin in patients who had subsequently culture-confirmed MRSA infections (P=.01), had moderately severe cellulitis (P=.03), and were obese (P=.04). Methicillin-resistant S. aureus was recovered in 72 of 117 positive culture specimens (62%)...  

Conclusion 

Antibiotics with activity against community-associated MRSA, such as trimethoprim-sulfamethoxazole and clindamycin, are preferred empiric therapy for outpatients with cellulitis in the community-associated MRSA-prevalent setting. 

It's concerning that these docs used bactrim monotherapy as one of the alternatives for treatment. That's against current recommendations because streptococci are still important pathogens and bactrim is not reliable against them. It there is a take home message form this study it's that you need to cover for Ca-MRSA also, at least in areas where it's prevalent. These days I don't know of any place where it's not.

The atherogenic lipid phenotype (ALP)

---is a major cause of residual cardiovascular risk after statin treatment “to goal.” Treatment options are discussed in this review:

Large outcome trials designed to assess the value of combining statins with other agents to target HDL cholesterol and non-HDL cholesterol will not be completed for a few years, but there is ample evidence for the clinician to consider combination therapy. The choices for therapies to supplement statins include niacin, fibrates, and omega-3 fatty acids.

Nonhepatic hyperammonemias

---may be underappreciated causes of encephalopathy in hospitalized patients. I recently blogged one example of a nonhepatic hyperammonemia here. Today I found a review in the American Journal of Medicine on the topic. Among the several causes valproic acid, either in therapeutic or excessive levels of use, is the best known. Other causes include infection or GI colonization with urea-splitting bacteria and hyperalimentation. The role of previously undetected metabolic errors such as urea cycle defects is discussed as a susceptibility factor.

Guidelines for IVC filters differ

Hospitalist News reports on a poster presentation:

The current, published guidelines of the American College of Chest Physicians (ACCP) and the Society of Interventional Radiology (SIR) lack agreement on the indications for placement of inferior vena cava filters during routine practice. And the implications of the contradictory guidelines are growing because use of inferior vena cava filters has risen significantly in recent years, Dr. Amanjit S. Baadh and his associates said in a poster they presented at ISET 2011, an international symposium on endovascular therapy.

Actually there are three sets of guidelines, and the one they didn't mention, from the Thrombosis Interest Group of Canada, is the most strict of all. According to that guideline the only proven indication for an IVC filter is acute proximal DVT with an absolute contraindication to anticoagulants. The SIR guidelines are much more liberal, listing as “relative indications” (things the TIGC regards as controversial and not supported by evidence) such things as free floating thrombus, massive PE and various prophylactic uses.


The problems here are the dearth of high level evidence (forcing guideline authors to consider lower level evidence and rely on their expertise) and the obvious conflict of interest of the Society of Interventional Radiology.

How is organized hospital medicine coping with the problem of post hospital transitions? By gradually dismantling the hospitalist model!

Yes, I said it. It won't sound so absurd after you read this article in a recent issue of The Hospitalist, especially the concluding paragraph:

The blurring of lines between outpatient and inpatient providers has created questions for hospitalists, too. For example, at what point does a hospitalist working much of the time in an outpatient clinic or skilled nursing facility no longer fit the traditional definition of a hospitalist? Does that detract from the doctor’s hospital duties?

Wachter and Goldman in their classic NEJM paper in 1996 coined the term hospitalist to describe a new practice model which was springing up out of the economic necessities of managed care. Economic advantages continued even after the pressures of managed care waned as ambulatory providers realized the added efficiency of avoiding the competing demands of the hospital. Now there are new economic realities. Will the new pressures for accountability across the transition from hospital to ambulatory care make the hospitalist model obsolete? That increasingly seems to be the opinion of many hospitalist leaders. I was surprised at the degree to which this idea was promoted at HM 2010 and it seems to be gaining traction.


Discontinuity between the hospital and the ambulatory side has always been the principal weakness of the hospitalitst model. It's so inherent in the model (in fact Bob Wachter has often said that it was deliberately designed into it) that in the minds of some it can't be addressed without altering the model.


The idea of a post discharge clinic run by hospitalists never made sense to me. Having the hospitalist see the recently discharged patient in clinic for one or two visits will not eliminate the hand off. It will only delay it by those one or two visits. The patients who are at greatest risk for readmission are those who are on a continuous, long term trajectory with their complex medical illnesses. The need for intensive follow up is ongoing, and one or two post hospital visits will not address the problem. The real fix needs to be on the ambulatory side.


As pressure to address the problem of readmissions increases the leadership of the Society of Hospital Medicine will have to take a more definitive stand on this issue. Will they support the preservation of the hospitalist model or allow it to unravel?

Pressure ulcers not a “never event”

According to a study presented at the annual congress of the Society of Critical Care Medicine intrinsic patient factors related to severity of illness rather than preventive measures determine the incidence of pressure ulcers. Via Hospitalist News.

Long term PPI use may cause hyponagnesemia

---according to an FDA report.


Via Hospitalist News.

Which transition and continuity measures improve post discharge outcomes?

According to this study in the Journal of Hospital Medicine:

After adjusting for important covariates and other continuity scores, increased preadmission physician continuity was independently associated with a decreased risk of urgent readmission (adjusted hazard ratio 0.94 [95% CI, 0.91-0.98] for each absolute increase in continuity of 0.1). Other continuity measures—including hospital physician continuity—were not associated with either outcome.

CONCLUSIONS:

After discharge from the hospital, increased continuity with physicians who routinely treated the patient prior to the admission was significantly and independently associated with a decreased risk of urgent readmission. These data suggest that continuity with the hospital physician after discharge did not independently influence the risk of patient death or urgent readmission.

The results of this study support the guideline recommendation that the ED physician contact the patient's PCP if admission to a hospitalist is being considered. These results do not support the increasingly popular practice of hospitalists seeing patients in an ambulatory setting for one or two visits post discharge.

Fake-notes-real-docs update

Via Unlikely Hospitalist.

Where are people moving in the US?

Interesting.


HT Instapundit.

New Zealand as an example of socialized medicine

Although Obamacare threatens to increase the size and intrusiveness of government it's not pure socialized medicine. Despite this fact, the idea of socialized medicine frequently makes its way into today's health care debates. Many would prefer a single payer system. There may be lessons to learn from arguably the free world's purest example of socialized medicine: New Zealand. That's why I found this article of interest.


The author claims that New Zealand's system delivers “High-quality Patient Care at a Fraction of U.S. Costs.” Read the article and it's easy to understand the reduced cost. High-quality? Well, New Zealand's life expectancy does exceed that of the US by 1.9 years. Proponents of single payer health care are fond of invoking such statistics which, of course, are not adjusted for homicide, alcohol, drug related fatalities, etc. But as for quality, it may depend on whom you ask. In New Zealand you might wait two years for an echo. Door to balloon time for STEMI, depending on where you practice, might be hours to days according to the article.


The article, written by a hospitalist, dovetails with remarks by Dr. Timothy Flemming who often talks about New Zealand health care at this meeting. Dr. Flemming, who practices six months out of the year in New Zealand and six months in the US, paints a very similar picture of restricted options and long wait times, but notes that the Kiwis, who tend to value the commons over the individual, accept it quite well. The system would never fly in the individualistic culture of the US.

Is CAM fraudulent?

According to Jann Bellamy, blogging at Science Based Medicine, much of the CAM practiced today is actionable as fraud. There's a lot to parse here. Briefly, Bellamy goes into some legal principles of fraud, provides examples of how these definitions fit many popular CAM methods, then examines the idea of privilege as a defense against charges of fraud. For example, if your unscientific claims are sanctioned by law because you are licensed as a chiropractor or ND, there is a certain scope of privilege within which you can offer treatment based on those claims. But what if you're an MD or an MD granting institution? You're on shakier legal ground. After reading Bellamy's post I'm convinced that actionable fraud is rampant in today's medical schools. Somebody needs to test those legal waters.

Thomas Stossel comments in the Denver Post

---on CU Medical School's revisit of its conflict of interest policy.


Via Policy and Medicine.

Congressman Paul Brown on the impact of the health care law

---and the Republican response. Via Drug Wonks.

Nasojejunal feeding in severe pancreatitis

A study published last year in the journal Pancreas on jejunal feeding of patients with severe pancreatitis was recently given a rating of 8 by the Faculty of 1000 Medicine as a study worthy of changing practice. Fairly dramatic improvements in outcomes were noted with jejunal feeding as compared to TPN.


While this was an important study it only addressed jejunal feeding versus TPN. It did not address other controversial issues such as when to artificially feed pancreatitis patients at all, and the role of nasogastric feeding versus jejunal feeding.


Medscape commentary here.

Buzzword bingo

For those really boring committee meetings. Available only in paper now, but sooner or later someone will develop an app.

Accountability, shared incentives and integration: a look at some unintended consequences

These buzzwords of health care reform worked their way into our lexicon even before passage and are gaining traction with Obamacare barely off the runway. Health care systems are scrambling to make the most of the new incentives. One result is that more and more doctors are becoming employees of hospitals and integrated delivery systems. This has led to some negative consequences which Roy Poses, blogging at Health Care Renewal, discusses here. It all boils down to loss of professional control. It's equally concerning whether at the hands of government central planners or corporate entities.

New street drugs

Popping up faster than lawmakers can ban them and docs can learn them:

When these products appear, they are often so new that legislatures and regulatory bodies have not yet gotten around to banning them. When one of these drugs is outlawed, a new, related but chemically distinct and therefore legal substance takes it place. This means emergency physicians must struggle to keep up with a constantly changing situation, and treat based on clinical presentation rather than precise knowledge of specific drugs involved. It also means that patients who use these drugs are playing a toxicological version of Russian roulette.

Obamacare likened to the 55 mile an hour limit and prohibition

Dunno about that, but it may be on its way to suffering the same fate.


Via the Washington Examiner, Instapundit.

Socialized medicine has its own quality chasm

The one between theory and practice. This is a great article. HT to PJ Tatler and Instapundit.

Update:  The link to the original article does not appear to work here.  You can access it from the PJ Tatler link above. 

Do white coats promote medical errors?

A bit of a stretch to me.


HT Secondhand Smoke.

Intracranial hemorrhage guidelines---a critical look

James Roberts, MD offers insightful and, as always, colorful commentary on the new ICH guidelines in Emergency Medicine News. Original guideline document here.

NPR exposed

One of many updates here. I want it defunded. It'll survive. (I do like the Prairie Home Companion).

What's the University of Wisconsin department of Family Medicine doing about fake-notes-real-docs?

Here's an update and an interesting comment thread.


Via Instapundit.

Supporters call a rapid response for deteriorating Obamacare vitals

Via Washington Times and We Stand Firm.

Will stethoscopes be banned?

Happy Hospitalist, no doubt aware that stethoscopes transmit germs just as much as our hands, observes:

Maybe the Joint Commission should work on banning stethoscopes from hospitals, next. Or better yet, mandate hospitals supply cheap stethoscopes dedicated to each patient room.

Don't expect much push back from your colleagues, Happy. Those cheap, clinically useless stethoscopes enhance coding just as well as the real ones.

Should hospitalists be the admitting docs for pregnant patients?

As the slippery slope of hospitalist mission creep continues tension and confusion are building, with pregnant patients apparently representing the next frontier according to an article in Today's Hospitalist:

The debate over whether hospitalists should admit pregnant patients is splitting some medical staffs and hospitalist groups, and not just in St. Cloud. Across the country, mission creep has meant that hospitalists are being asked to admit patients they may never have seen before, from hip fractures to cerebral hemorrhages. Pregnancy, in many hospitals, is the next frontier.

When confronted with these patients—usually from the emergency department in the middle of the night when in-house hospitalists are the easiest physicians to reach—hospitalist groups are reacting differently. Some are concluding that they can't admit pregnant patients for any reason. Others are negotiating policies with obstetricians and administrators to admit some pregnant patients, but not all. But in other hospitals, like Dr. McFarling's, compromise remains elusive, with both hospitalists and obstetricians standing pat—and feeling unfairly put upon.

Hospitalists are increasingly asked to be attending physicians for patients who are beyond their comfort level and the scope of their training. This is a confusing situation because there are no guidelines or standards hospitalist programs can invoke to just say no. How much longer will the Society of Hospital Medicine stand aside and allow this mission creep to continue?

Private practice: dead in the era of health care reform?

At the plenary sessions of HM 2010 one of the members of a panel discussing the implications of Obamacare declared “private practice is dead.” The new emphasis on accountability through shared incentives is driving the trend of individual practices being swallowed up by hospitals. This article from Smart Money examines the many unintended consequences.


Roy Poses, offering skeptical view over at Health Care Renewal, put it bluntly. Accountable care organizations may end up being little more than large corporate entities buying up independent practices:

The name of these supposedly collaborative organizations, which are turning out to simply be hospital systems which have purchased physicians' practices and now employ physicians, is "accountable care organizations," which now appears ironic at least.

The article detailed some of the adverse effects to be expected when accountable care organizations become hospital systems with employed physicians providing patient care.

Malpractice risk and the EMR

So far, surprisingly little has been written about malpractice in the world of paperless medical records. Health Care Renewal has this post about a preemie who suffered complications following PICC insertion:

Within 48 hours, the PICC insertion site began to show evidence of compromise. The attending physician gave a verbal order to monitor the arm, but the order was never reduced to writing and no monitoring of the site was thereafter documented in the chart. Indeed, a comparison of the IV site care notes with the nursing notes revealed the use of an automated entry feature, confirmed by the defendants in discovery, which permitted the nursing staff to simply re-enter prior descriptions of a patient’s condition...

As a result, the nursing notes continued to describe the condition of the affected arm as normal when in fact it was continuing to visibly deteriorate. Thereafter, despite swelling and seepage at the PICC insertion site and discoloration of the hand, the PICC was not removed for an additional 48 hours. The decedent was flown to another facility where the right arm was amputated after becoming necrotic and gangrenous. The infant died after 36 days of life. Plaintiffs sued the nurses, hospital and neonatal specialists charged with the decedent’s care.

It's not clear whether this misled the doctors and directly contributed to the outcome, but it sure would have looked bad to a jury.


The post links to this article which discusses some of the liabilities of the EMR such as auto-generated entries and copy-and-paste functions.

Disruptive behavior

From a Today's Hospitalist interview (my emphasis):

The Joint Commission has a zero tolerance standard for behavior that is considered disruptive. The definition of bad behavior is broad and open to interpretation by the institution, but disruptive behavior is increasingly defined by the beholder. If it is perceived as disruptive and hostile, then we have an obligation to address it as such.

That's a problem with many disruptive behavior policies. If there's someone on the medical staff you don't happen to like, well...


I was a little disappointed that the article focused on disruptive physicians. Although many hospitals' policies may target physicians the Joint Commission standard makes no distinction among all levels of the work force, right up to the CEO. BIDMC may have learned a lesson there from Paul Levy.

Would someone please figure out a way to rectify med rec?

Happy says patients need to own it, but they won't.


Early in my blogging career, naïve about the law of unintended consequences, I thought Joint Commission's med rec initiative was a great idea. Turns out it hasn't worked. When it comes to medication safety across transitions of care we're no better off, maybe even worse off, than before the initiative.


Decades ago docs had their own simple version of med rec. Admission orders might read “give home meds, home dosage, home schedule except D/C digoxin.” Discharge orders might read “home meds same as pre-admission except change digoxin to every other day, increase lasix to bid, increase Ktabs to bid.” I remember one time as a resident discharging a patient from the “private” service. I asked the attending what to order in the way of discharge medications. He said “just tell the patient to take his bottles to his druggist and have the druggist call me.” And you know what? It wasn't perfect but it worked. One reason it worked as well as it did was that the patient did have to own it, along with the nursing staff. But through the years, every so often someone would get the bright idea to turn it into a “process,” which usually meant a new form or a new template. And with each new process, and its accompanying forms or templates, came another opportunity to mess stuff up.  With Joint Commission's med rec process the paper form and the electronic template became a substitute for someone sitting down with the patient and really addressing the details.

Remember those clunky cell phones?

HT to Nashville Blotter.

Mary and Peter in the rain

Who's right?

Ever happen to you?

Happy dropped his pager in the toilet.

Berwick nomination in trouble

After 42 Republican senators drafted a letter opposing the nomination it appears the Democrats have done the math and given up. If not confirmed his term would be over at the end of 2011.


It's difficult to know how to react because nobody can really know were Berwick stands on important health care issues although it's clear that he entertains some dangerous ideas about central planning.


HT to Health Care BS.

The Newspeak of comparative effectiveness research (CER)

Few topics lately have suffered more obfuscation in the use of words than CER. Concerning the idea that in today's health care debate there exist persons who oppose the pure notion of CER I have, as readers know, screamed straw man. Though the claim of such opposition is popular no one has yet to provide me with an example. Today I ran across a post at Drug Wonks which, according to some, might qualify. And while it contains some very strong warnings about the unintended consequences of the government's financially conflicted agenda and its manipulation of the use of words concerning CER (many Orwellian references therein) it comes short, way short, of opposition to the pure notion of conducting research to compare one treatment with another.


With that out of the way let's look at what the post says (and there's a lot to parse here). First, after a little background on the Orwellian notion of “Newspeak,” the blog author Peter Pitts seems to imply that a proper rendering of the language of the CER provision of APRA (the stimulus bill) calls for a focus on individualized medicine rather than population based research:

The Recovery Act of 2010 (aka – “the stimulus package”) gave the Agency for Healthcare Research and Quality (AHRQ) $1.1 billion to conduct (according to the HHS press release) “comparative effectiveness research” into various “healthcare interventions.”

Except that’s not what Congress funded. Per the Recovery Act, that $1.1 billion was earmarked for clinical comparative effectiveness not comparative effectiveness research. And this is not splitting hairs. Enter cost-think.

Those in favor of comparative effectiveness research favor large scale trials to "compare" drugs and other healthcare “technologies, striving to show which medicines are most effective for any given disease state. Is there a “more effective” statin? A “more effective” treatment for depression?

But how do you compare two molecules (or three or more) that have different mechanisms of action for patients that respond differently to different medicine based on their personal genetic make-up?

That's a bit of a stretch for me. Was individualized medicine what the politicians originally had in mind? Who knows what the thought process actually was. According to a post over at Science Based Medicine by Val Jones the original bill didn't really define what the research was supposed to be, leaving it instead to AHRQ and the Institute of Medicine (little comfort that is!) to define the agenda.


Pitts goes on to elaborate on the difference between the population based one-size-fits-all approach and individualized medicine:

..even well-funded comparative effectiveness trials are swiftly superseded by trial designs based on better mechanistic understanding of disease pathways and pharmacogenomics. And, since most comparative effectiveness studies are underpowered, they don’t capture the genetic variations that explain differences in response to medicines by different patients. Comparative effectiveness in its current form leads to a “one-size-fits-all” approach to healthcare, which means that it doesn’t fit anyone all that well.

Clinical effectiveness, on the other hand, measures outcomes on an individual patient level. Clinical effectiveness studies help us to understand how to design treatments based on patient variation rather than cost. The very definition of personalized medicine.

Here Pitts seems to be speaking more to the appropriate design for comparative effectiveness rather than the value of CER itself. As knowledge of genomics and disease mechanisms grows so will the tension between population based and individualized medicine. Ultimately, in some areas, individualized medicine will win out. Population based CER simply (and sometimes simplistically) asks how treatment A compares with treatment B for condition X. The potential weakness of population based CER could be illustrated by an absurd example. Imagine a comparative trial that asks the question: How does vancomycin compare with ceftazidime in the treatment of infection? Here's one that illustrates the point equally well but is not so absurd because it's a clinical question often asked today: What's more heart-healthy, low fat or low carb? When the diet question is asked in so simplistic a manner what one gets is liable to resemble a series of scientific flip-flops. As it turns out it depends greatly on your genetic makeup. (Even this is at the risk of oversimplification, but if you happen to have a certain APO E genotype you're probably better off with low fat. If you're genetically predisposed to small dense LDL particles you might do better with low carb).


Some of the tension between individual and population based medicine in comparative effectiveness may be artificial. Just about everyone would agree that CER must of necessity follow the principles of evidence based medicine (EBM). But population based research is only part of EBM. In its classic definition EBM has two other components, starting with the individual patient and incorporating clinical expertise. If CER really is part of EBM, then, it should never lend itself to a series of one-size-fits-all mandates.


Nevertheless that may be just what some policy makers have in mind. One of the mandates of APRA is that comparative effectiveness be disseminated. There have been varying opinions about what that means. Bob Wachter, for example, once said comparative effectiveness research will form the basis for a revolution in health care that will “drag the self-interested laggards along, kicking and screaming if need be...” into, presumably, some type of conformity. You can form your own conclusions about what dissemination might be. Pitts says in his post, as has been noted before, that the AHRQ has funding under APRA to become the promotional vehicle for government health care recommendations. That raises questions about how such promotions might be leveraged:

Will physicians be “academically detailed?” And if so, will they be required to be detailed? Will physicians be given incentives to spend time with AHRQ’s comparative effectiveness angels (i.e., CME credits) and punished if they do not (via Medicare and Medicaid restrictions)?

And how scientifically rigorous will such “academic detailing” be?

Asked another way – how can an “academic detailing” program funded by our nation’s largest payer (Uncle Sam) be considered neutral? Just like detailing programs run by pharmaceutical companies, there is an inherent “interest.” And that’s okay – as long as that “interest” is transparent. Who will be the arbiters of transparency?

Who will decide what these detailers can say or not say? Will these government “reps” have to play by the same rules as their pharmaceutical counterparts? And, importantly, what is the oversight mechanism? If academic detailers stray into off-label conversations, to whom does DDMAC send a letter? Whom does the Department of Justice investigate? Who pays the fine?

Interesting questions, those.

Hyponatremia update

This review from CCJM covers the diagnosis and treatment of both acute and chronic forms as well as special considerations in the treatment of specific etiologies and associated disorders. An update on the new vasopressin antagonists is included.

Health Grades list of America's top 50 hospitals

This is a joke. Via Skeptical Scalpel:

Let’s say I live in New York City and get sick. No hospitals in the states of New York or Connecticut made the top 50 list. My choices for hospital care are either the aforementioned Hackensack University Medical Center or the Community Medical Center of Tom’s River, both in New Jersey. I have never set foot in either place. They might be great hospitals. But I think I’ll take my chances at Columbia Presbyterian, Cornell or NYU.

Do you live in St. Louis? Sorry, no top 50 hospitals there. But you can go to the only hospital in Missouri on the list, St. Luke’s Hospital in Chesterfield. Pennsylvania? Sorry, no top 50 hospitals in Pittsburgh or Philadelphia but there are four in the Allentown-Bethlehem-Scranton area. Boston? Too bad. No Massachusetts hospital is good enough to be included in the HealthGrades Top 50 list. I hope Mass General, Deaconess and the Brigham don’t have to shut down.

Health Grades claims the ranking is based on severity adjusted outcome data. That severity adjustment, as many know, depends on how creative a coder you are.

What are Internal Medicine program directors worried about these days?

From survey data:


Key Points


* Internal medicine residency program directors are concerned about declining interest in internal medicine among medical students, and in primary care among residency graduates.


* Program directors are concerned about burdensome regulatory oversight of graduate medical education and medical practice, economic pressures affecting medical education and career choice, the eighty-hour work week, and fragmentation within internal medicine.


* The findings related to declining interest in internal medicine careers have implications for health policy reform.

Myositis associated interstitial lung disease (MA-ILD)

This topic was recently reviewed in Chest. Points of interest:


Estimates are that 35-40% of patients with idiopathic inflammatory myopathy (IIM) will be affected by interstitial lung disease (ILD, named as such for convenience, though perhaps better characterized as diffuse parenchymal lung disease) at some point in their course.


Antisynthetase syndrome is a particular entity characterized by positivity for an antisynthetase antibody (ASA) plus one or more of ILD, myositis, or any of several other rheumatologic manifestations mentioned in the article.


Patients with MA-ILD are generally but not always ASA positive. That is, MA-ILD overlaps considerably with, but does not equal, antisynthetase syndrome.


The principal ASA is Jo-1. There's a miscellaneous group of others seen in lower frequency, listed in the article.


Raynaud's and mechanic's hands are the principal derm manifestations of antisynthetase syndrome.


Derm, pulmonary and muscle manifestations of MA-ILD can occur in any combination, simultaneously or sequentially, and in any order.


Not all pulmonary manifestations of myositis are due to ILD. Muscle weakness itself may contribute to pulmonary complications.


A variety of histologic patterns are seen in MA-ILD the most common of which is NSIP. The prognostic value of histologic types is uncertain.

Pradaxa pearls

Via Dr. John M.

Mendelian cardiovascular disorders

This review focuses on HCM, ARVC and Marfan syndrome. Critical management decisions include when to place an AICD for primary prevention (HCM and ARVC) and when to electively replace the arotic root (Marfan).

High resolution CT to evaluate diffuse parenchymal and interstitial lung disease

This topic was reviewed in a recent issue of Current Opinion in Pulmonary Medicine. In addition to identifying diffuse parenchymal and interstitial lung disease (DPILD) HRCT may also be useful in determining the etiology or histology, obviating the need for biopsy in some cases. Finally, HRCT can be useful in estimating prognosis.

The latest on carotid artery stenting versus surgery

Review in CCJM.

Constitutional challenges to PPACA

Here's a place to keep up to date.

MRI contrast and nephrogenic systemic fibrosis

This free full text update is written for cardiologists but it has general applicability.

When patients with Parkinson's disease are hospitalized

---special clinical issues surface. Here is a review in the journal Movement Disorders.

Web resources in epigenetics

From Life Sciences Education.

Airway pressure release ventilation: another promising “rescue therapy” for severe ARDS

In the past year I've seen a surge of interest in rescue therapies for ARDS. This renewed interest may have been driven by the extensive experience with severe hypoxemia during the 2009 flu pandemic. Rescue therapies for ARDS are those which, though not “evidence based” according to population based studies may, in individual patients with severe hypoxemia at risk of dying directly from respiratory failure, offer the best hope for survival. I recently blogged a summary post on this topic here.


Here is a new CCJM review on airway pressure release ventilation (APRV). Though around for many years it is infrequently used and has not been subject to high level clinical studies. Because it has the potential to recruit alveoli and improve oxygenation over conventional modes, and because it has not been validated as a standard modality of care for ARDS in population based studies, it can be considered a rescue mode.


The article does an excellent job of explaining APRV and is worth reading in full, although I have to disagree with one statement (my emphasis):

Based on these studies, the use of low tidal volumes with appropriate levels of PEEP to ensure lung recruitment is the current standard of care in mechanical ventilation of patients with ARDS.

Again, while recruitment level PEEP may be life saving in cases of ARDS with unusually refractory hypoxemia, it proved to be no better overall than standard PEEP (minimum needed to oxygenate patients using non-toxic fractions of inspired oxygen) in the second ARDSnet trial.