Vandy Med students get a lecture on alternative medicine

I have no information about the lecture content but from the picture it was more promotional than science based, I’d wager.

Increased hospital admissions with diagnosis of PE

Not surprising given the increased use of CT, which may be picking up insignificant filling defects in many patients. Graphic here.

CA-MRSA: From epidemic to endemic

With the flu season here it’s a good time to review CA-MRSA, particularly CA-MRSA pneumonia. Emergency Medicine News has a blurb on CA-MRSA pneumonia which references this review in Emergency Medicine Clinics of North America.

Here are a few points of interest from both articles:

CA-MRSA does not represent the old MRSA (HA-MRSA) having escaped to the community. It has distinct microbiologic, clinical and epidemiologic characteristics.

Risk factors for CA-MRSA pneumonia are colonization, prior infection including skin and soft tissue, exposure and recent influenza or influenza like illness (respiratory epithelium damage from antecedent viral infection facilitates bacterial attachment). CA-MRSA should be considered in any case of severe pneumonia.

The PVL toxin imparts unique pathogenicity.

In the initial antibiotic selection for pneumonia, the IDSA/ATS guidelines say that if CA-MRSA is suspected add vancomycin or linezolid. The Emergency Medicine Clinics article, however, suggests that linezolid is preferred if CA-MRSA pneumonia is suspected. It also points out that both linezolid and clindamycin decrease toxin production, and suggests that if vancomycin is used, clindamycin should be added for life threatening infections.

The Clinics article contains a wealth of information on infection control including the limited indications and regimens for decolonization.

Long time, no post

Just too dang tired to blog last week. Things should ramp up soon.

Intravascular catheter related infections

An article in Expert Review of Anti-Infective Therapy summarizes the latest evidence and recommendations.

Allergic to Wi-Fi?

Some are advocating for Wi-Fi free zones.

H/T to StL Media.net.

Coming soon---ceftobiprole

Via The Annals of Pharmacotherapy:

Ceftobiprole medocaril is an extended-spectrum cephalosporin with activity against methicillin-resistant Staphylococcus spp., vancomycin-resistant Staphylococcus aureus, penicillin-resistant Streptococcus pneumoniae, vancomycin-resistant Enterococcus faecalis, Enterobacteriaceae, and Pseudomonas aeruginosa.

The major hole in this 5th generation cephalosporin? Those pesky ESBLs.

Note: Many VREs are Enterococcus faecium. Ceftobiprole is apparently not active against E. faecium.

Bicarb no better than saline in preventing contrast nephropathy

---in this study. Via JAMA.

Henny Youngman doctor jokes

Here are a few of my favorites:

A doctor gave a man six months to live. The man couldn't pay his bill, so he gave him another six months.

The Doctor called Mrs. Cohen saying, "Mrs. Cohen, your check came back." Mrs. Cohen answered, "So did my arthritis!"

The Doctor says, "You'll live to be 60!" "I AM 60!" "See, what did I tell you?"

The patient says, "Doctor, it hurts when I do this." "Then don't do that!"

"Doctor, my leg hurts. What can I do?" The doctor says, "Limp!"

"Doctor, I have a ringing in my ears." "Don't answer!"

Hospitalist turnover

It’s widely said that a rolling stone gathers no moss. Try telling that to a hospitalist.

Putting evidence into practice: the Surviving Sepsis guidelines

Experts discuss the ins and outs in Today’s Hospitalist.

Disruptive behavior policies---they’re not just about doctors anymore

Today’s Hospitalist interviewed Alan H. Rosenstein, MD, MBA, a long time hospital based physician who has authored several papers on the subject. He notes:

“It’s not physician-bashing,” says Alan H. Rosenstein, MD, MBA, the lead author of the August 2008 study. “And it’s not just physicians who are doing this.”

Traditional discussions on the issue in past years have focused on doctors, but Joint Commission standards set to go into effect in January will now apply to all personnel in the hospital environment, where a zero tolerance policy is recommended.

Regarding hospitalists:

Where do hospitalists fit into this picture? According to Dr. Rosenstein, who began his career as a hospital-based physician before the term “hospitalist” existed, hospitalists tend to be more on the receiving end of bad behavior than on its delivery.

Is misguided policy driving the success of the hospitalist movement?

The Happy Hospitalist thinks so:

If not for the gross failures of the Medicare National Bank (MNB), hospitalist medicine would fail to exist. We are here ONLY as a financial necessity out of a payment system gone mad. As much as I rile on the MNB, I am forced to admit that my position as a hospitalist would be nonexistent if not for the incompetent clowns making policy decisions based on lobster dinners with lawyer lobbyists.

I’ll go half way on that premise. Maybe I’m naïve but it’s hard for me to stomach the thought that I am, first and foremost, part of a business solution. Medicare’s ill conceived and manifestly unfair Prospective Payment System and never events rules do put pressure on hospitals to limit utilization and hospitalists are perceived as a way to do that. And while perception may equal reality for many, the evidence that hospitalist care results in more efficient utilization is not robust.

On the other hand if the Medicare clowns implement the latest idea they’ve been tinkering with, the bundling of doctors’ rounding fees into hospital DRG payments, it will be the final finishing blow for traditional hospital care. The hospitalist model will be secure once and for all. Debates about our value will become moot. The demand for hospitalists will accelerate over the next decade and the future of inflating hospitalist salaries will be secure.

Make woo a never event

---by paying hospitals for real patient care.

One of my commenters said:

But we keep making it harder for hospitals to get paid with DRG undercoding, "never events", more uninsured and underinsured.We keep adding more unfunded mandates to hospitals.How else can they keep their doors open except by increasing revenue And how can they do that without the woo factor? Make it easier for the health care system (and docs, and nurses) to stay financially viable and the woo will fade out quickly.

POA is the new buzzword

---with Medicare’s never event policy and hospitals are gearing up. Let the games begin!

Subarachnoid hemorrhage

Initial evaluation and management.

Beth Israel Hospital takes woo to a new level

The New York Times recently posted an article about a huge new woo promotion launched at Beth Israel Medical Center. Mark Hoofnagle over at the Denialism Blog thought it was a good article. I thought it was just “so-so”---not really promotional but by no means appropriately critical. (Why the NYT doesn’t rip the quacks a good one the way they do the pharmaceutical industry is beyond me). At any rate it was eye opening. I had no idea how much woo was going on there. The Times piece did accomplish two things---it prompted Orac to update his Academic Woo Aggregator (I love it when Orac updates his AWA) and it coined a new slogan for academic woo: “Say ‘Om’, not ‘Ah’.”

It isn’t as though BI wasn’t already promoting woo as Orac pointed out well:

Of course, where there's one form of woo, there's other woo. After all, it's highly doubtful that Donna Karan would try to sell her yoga program to an institution not likely to be receptive to her woo, and, boy, oh, boy is Beth Israel open to woo. Just get a load of its Continuum Center for Health and Healing. Just peruse its webpage, and it's a veritable cornucopia of woo and unscientific medical modalities. It's all there. There's leech therapy for osteoarthritis, reiki, traditional indigenous healing therapies, acupuncture, even that woo of woo, that quackery to rule all quackeries, homeopathy…

You can read the NYT article and Orac’s post about the new project, in which an entire oncology service is being revamped to promote such treatments as Yoga, Urban Zen and aromatherapy. Yoga masters, Zen instructors and a feng shui master are being turned loose on the ward.
While the project is unashamedly promotional (they’ve got T shirts emblazoned with “The Unstoppable PATH/Patient Awareness Towards Healing”) the leaders make a weak claim of doing research. According to the Times article:

While other hospitals in New York and across the country have dabbled in yoga, the new Beth Israel project is broader, better financed and more integrated into the medical protocol, and because of Ms. Karan’s concern that it might be dismissed as touchy-feely nonsense, it includes a research component. Ms. Karan hopes to prove…

Stop. Red flag. This isn’t objective research. It’s somebody setting out to prove something they’re already promoting and are already convinced “works.” What form will the “research” take? Comments from one of the project leaders, according to the NYT piece, weren’t scientifically promising:

But Dr. Benjamin Kligler, the research director in integrative family medicine for the Beth Israel-affiliated Continuum Center for Health and Healing and the research project’s principal investigator, acknowledged that the experiment of yoga teachers and their interaction with patients did not lend itself to the random, double-blind placebo trials favored in the medical world.

“The truth is, from a very traditional research perspective, that’s a problem,” Dr. Kligler conceded, adding that it might be time for the medical establishment to consider a new research model for what he called “lifestyle interventions.”

The only rigorous way to study modalities like Yoga is in a single blinded fashion with comparable “sham” postures and mantras in the comparison group. But as I said before that type of research has never been done with modalities like Yoga and, judging from the comments of the boosters of this study, is unlikely to be done in this instance.

Doc, my device just went off

With more and more folks walking around with AICDs this complaint is not unusual anymore. For isolated occurrences without significant change in clinical status patients can go on about their business and see their EP in clinic in a day or so (although you’ll want to give the EP a call and let him/her know what’s going on). Other situations, such as electrical storm or repeated inappropriate discharges, are dire emergencies. You, the front line provider, will have to initiate action while waiting for the cardiologist to arrive. It usually falls on the ER physician. Because hospitalists are liable to get in the loop somewhere I thought it was worthwhile linking here. You need to have a systematic approach in mind. Your best friends in such an emergency (when used properly!) are amiodarone, beta blockers, a magnet, and the device company representative.

A JAMA article form 2006, available as free full text, provides clear explanations and an algorithm, and this recent piece from Emergency Medicine News discusses the approach from the perspective of the ER physician.

Alpha-1 antitrypsin deficiency

An open access full text review is available in the Orphanet Journal of Rare Diseases. The most underappreciated point in the article: all patients with COPD and asthma should be screened.

LQTS

Another review.