Some case examples with pointers on how to differentiate from ischemic ST depressions of “NSTEMI” from Dr. Smith's blog.
Wednesday, December 22, 2010
Tuesday, December 21, 2010
Another SVT mimic
I recently mentioned 1:2 AV conduction. Here's another one: interpolated junctional extrasystoles. The authors considered 1:2 conduction in each case but it turned out to be junctional firing interpolated between sinus beats, leaving the sinus mechanism undisturbed, behaving as a parasystolic focus. An abrupt, exact doubling of the ventricular rate provides a clue.
Why do hospitalists and IM house staff order PPIs?
Often for the wrong reasons in this study:
Sixty-nine percent of physicians reported prescribing SUP to greater than or equal to 25% of patients. In multivariable analyses, the following factors were associated with higher level of prescribing (greater than or equal to 25%) of SUP: fear of gastrointestinal bleeding (OR = 2.7, 95% CI 1.07, 7.28) and of the legal repercussions of not prescribing SUP (OR = 3.02, 95% CI 1.07, 8.56), whereas knowledge of SUP indications (OR = 0.39, 95% CI 0.20, 0.74) and concern about side effects (OR = 0.24, 95% CI 0.09, 0.61) were associated with low prescribing behavior. Level of training was not associated with prescribing rate. Less than half of respondents were able to identify a single side effect of proton pump inhibitor therapy.
Monday, December 20, 2010
ER-hopping drives up costs
I'm getting tired of going to Regional. Let's try St. Joe's tonight!
For many patients hospitals are like restaurants.
A new study in the Archives of Internal Medicine showed that such hospital-hopping is common and it drives up costs. And there's reason to believe it's unsafe. You can take for granted that medication errors will increase, and in this study patients who went to multiple ERs were more likely to be hospitalized overnight.
Occasionally a trip to a different hospital is unavoidable but in general, if you want to do your part for the medical commons and make your hospital visit a safer experience don't hospital-hop!
Via Grunt Doc.
For many patients hospitals are like restaurants.
A new study in the Archives of Internal Medicine showed that such hospital-hopping is common and it drives up costs. And there's reason to believe it's unsafe. You can take for granted that medication errors will increase, and in this study patients who went to multiple ERs were more likely to be hospitalized overnight.
Occasionally a trip to a different hospital is unavoidable but in general, if you want to do your part for the medical commons and make your hospital visit a safer experience don't hospital-hop!
Via Grunt Doc.
Pharmacovigilance
Acute RV failure understudied and underappreciated
Here's a review from JACC. Full text available via Medscape here. We usually think of pulmonary embolism and RV infarct but there are many other causes. Management is not as straightforward as you might think, and goals of therapy may conflict with those of coexisting disease processes in the critically ill patient.
Update on short QT syndrome
This condition has gotten a lot of attention in the last few years, but as far as we know it's rare.
Friday, December 17, 2010
Interview with David Sackett, one of the EBM movement's founders
Although EBM (at least in its popular application) cannot evaluate the unscientific claims of CAM (you need SBM to do that) it is useful for evaluation of most of the clinical questions that arise in mainstream practice. And I wonder what David Sackett would say if asked about EBM's blind spot. Right off the bat in the interview below he swats away some of the concerns of EBM's detractors by saying that first and foremost it's about the patient and clinical expertise. It's these elements that must be combined with the “best external evidence.”
His review of EBM's history is interesting. The movement had its antecedents in the 1960s with the birth of the discipline of clinical epidemiology at McMaster University.
His review of EBM's history is interesting. The movement had its antecedents in the 1960s with the birth of the discipline of clinical epidemiology at McMaster University.
What do docs in the rank and file think of health care reform?
Here are some survey results released by the Physicians' Foundation:
Via Drugwonks.
• The majority of physicians (60%) said health reform will compel them to close or significantly restrict their practices to certain categories of patients. Of these, 93% said they will be forced to close or significantly restrict their practices to Medicaid patients, while 87% said they would be forced to close or significantly restrict their practices to Medicare patients.
• 40% of physicians said they would drop out of patient care in the next one to three years, either by retiring, seeking a non-clinical job within healthcare, or by seeking a non-healthcare related job.
• The majority of physicians (59%) said health reform will cause them to spend less time with patients.
• While over half of physicians said health reform will cause patient volumes in their practices to increase, 69% said they no longer have the time or resources to see additional patients in their practices while still maintaining quality of care.
Via Drugwonks.
Thursday, December 16, 2010
EBM's blind spot
The Cochrane Collaboration, arguably the exemplar of EBM, is a good place to illustrate EBM's blind spot, a phrase used by Kimball Atwood at Science Based Medicine in his description of EBM's inability to evaluate implausible health claims in the arena of complementary and alternative medicine (CAM).
Here's the listing of Cochrane CAM reviews. Few if any of the treatments covered in these reviews have enough scientific plausibility or prior evidence to warrant a share of our research funds, let alone a systematic review. But the Cochrane reviewers refuse to call a nutty idea a nutty idea. Submit the wackiest fairy dust treatment you can think of to the folks at Cochrane for review. The worst they're liable to say about it is that there's not enough evidence out there to know whether or not it's a valid treatment, so research (or more research) is warranted.
So here are a few examples.
Homeopathic treatment for influenza. Promising, say the reviewers, although more research needed.
Homeopathic treatment for asthma. RCTs needed, of course.
Acupuncture to enhance in vitro fertilization. It works, declare the Cochrane reviewers. But, they say, more research is needed.
Acupuncture for acute stroke (and the mechanism doesn't seem to matter to the reviewers, evidenced by the fact that they lumped hemorrhagic and ischemic strokes, conditions with entirely different mechanisms, together). The reviewers are not sure whether it works and recommend larger and more “methodologically sound” studies.
Acupuncture for vascular dementia. RCTs are urgently needed, say the reviewers!
EBM has become an enabler of pseudoscience, and that's its grand failure. Atwood explains why in the above link and multiple other posts linked there, and I summarize the reasons briefly here. That's the fatal flaw Richard Smith and DB didn't mention in their otherwise informative and accurate criticisms of EBM.
Here's the listing of Cochrane CAM reviews. Few if any of the treatments covered in these reviews have enough scientific plausibility or prior evidence to warrant a share of our research funds, let alone a systematic review. But the Cochrane reviewers refuse to call a nutty idea a nutty idea. Submit the wackiest fairy dust treatment you can think of to the folks at Cochrane for review. The worst they're liable to say about it is that there's not enough evidence out there to know whether or not it's a valid treatment, so research (or more research) is warranted.
So here are a few examples.
Homeopathic treatment for influenza. Promising, say the reviewers, although more research needed.
Homeopathic treatment for asthma. RCTs needed, of course.
Acupuncture to enhance in vitro fertilization. It works, declare the Cochrane reviewers. But, they say, more research is needed.
Acupuncture for acute stroke (and the mechanism doesn't seem to matter to the reviewers, evidenced by the fact that they lumped hemorrhagic and ischemic strokes, conditions with entirely different mechanisms, together). The reviewers are not sure whether it works and recommend larger and more “methodologically sound” studies.
Acupuncture for vascular dementia. RCTs are urgently needed, say the reviewers!
EBM has become an enabler of pseudoscience, and that's its grand failure. Atwood explains why in the above link and multiple other posts linked there, and I summarize the reasons briefly here. That's the fatal flaw Richard Smith and DB didn't mention in their otherwise informative and accurate criticisms of EBM.
Rabies Milwaukee protocol
The protocol and related resources can be accessed here. The protocol is complicated and counterintuitive. It relies on principles which differ from those of general critical illness. If faced with a potential case, familiarity with the protocol will help in deciding whether you have the resources to implement it in your own hospital or whether the patient should be shipped.
And here's a recent report in MMWR of a case reported in Virginia, following international travel.
And here's a recent report in MMWR of a case reported in Virginia, following international travel.
Ictal asystole---when the brain stops the heart
It's an experiment of nature in the field of brain-heart medicine. It can result from a seizure in a patient with normal heart function. Via PACE.
Wednesday, December 15, 2010
Work hour limits shouldn't be just for residents
Old farts need rest too, says Bob Wachter in a guest post at Kevin MD, citing a recent study of radiologists (both residents and attendings) showing deteriorating accuracy with increased fatigue.
Resident fatigue was the initial focus of the patient safety movement and even predated the IOM report by over a decade, as a result of the Libby Zion case. Have initiatives to address physician fatigue improved patient outcomes? Although we can't answer that question with data I'm sure the anecdotal evidence would be impressive, as any of us who trained in the pre-Zion era could attest.
I trained in the days of every third and every other night call when night float was not part of the lexicon. On your call day you went to work early and worked 36 hours straight. Maybe longer. You got home late on your post call day so your spouse could watch you sleep. You occasionally fell asleep while interviewing your patient---typically your sixth admission of the night, at 3 AM. The next day a malignant attending might chide you on the sloppy appearance of your hand written H and P. You didn't dare point out that you were just too tired. Too tired? they might ask incredulously. These anecdotes are comical. But what about mistakes with consequences for patients? How many of us really want to know?
Well, for residents, at least, things have changed. We've gone to the opposite extreme, perhaps even too far. The latest proposal is to require naps. It seemed silly to me in the first grade. I would welcome it now.
If efforts to reduce resident fatigue haven't meaningfully impacted patient safety maybe it's because of the unintended consequences or because no attempt has been made to address the equally important issue of fatigue on the part of practicing physicians. But as Bob points out this would be next to impossible to implement for those who practice in the eat-what-you-kill world of fee for service reimbursement.
So (and my conflict of interest here should be obvious) maybe hospitalists should be the next group to target. After all, many of them are treated as advanced residents anyway, and most are not paid by RVUs. For that to gain traction organized hospital medicine would need to set a standard. This might be a worthwhile project for the Society of Hospital Medicine.
Resident fatigue was the initial focus of the patient safety movement and even predated the IOM report by over a decade, as a result of the Libby Zion case. Have initiatives to address physician fatigue improved patient outcomes? Although we can't answer that question with data I'm sure the anecdotal evidence would be impressive, as any of us who trained in the pre-Zion era could attest.
I trained in the days of every third and every other night call when night float was not part of the lexicon. On your call day you went to work early and worked 36 hours straight. Maybe longer. You got home late on your post call day so your spouse could watch you sleep. You occasionally fell asleep while interviewing your patient---typically your sixth admission of the night, at 3 AM. The next day a malignant attending might chide you on the sloppy appearance of your hand written H and P. You didn't dare point out that you were just too tired. Too tired? they might ask incredulously. These anecdotes are comical. But what about mistakes with consequences for patients? How many of us really want to know?
Well, for residents, at least, things have changed. We've gone to the opposite extreme, perhaps even too far. The latest proposal is to require naps. It seemed silly to me in the first grade. I would welcome it now.
If efforts to reduce resident fatigue haven't meaningfully impacted patient safety maybe it's because of the unintended consequences or because no attempt has been made to address the equally important issue of fatigue on the part of practicing physicians. But as Bob points out this would be next to impossible to implement for those who practice in the eat-what-you-kill world of fee for service reimbursement.
So (and my conflict of interest here should be obvious) maybe hospitalists should be the next group to target. After all, many of them are treated as advanced residents anyway, and most are not paid by RVUs. For that to gain traction organized hospital medicine would need to set a standard. This might be a worthwhile project for the Society of Hospital Medicine.
Whither evidence based medicine?
It's been 18 years now since evidence based medicine (EBM) became a catch phrase. Richard Smith, a former editor for BMJ, reflects on the distortions and unintended consequences of EBM as a “movement” in this month's The Scientist.
David Sackett and others once tried, in their classic BMJ editorial, to explain what EBM is and what it isn't. But, 18 years later, among academics, policy makers and practicing physicians alike it seems anything but clear what it is and what it isn't. There is a pure notion of EBM out there somewhere, perhaps best stated in the opening sentence of the Sackett editorial---“It's about integrating individual clinical expertise and the best external evidence.” But in real world application it's all over the place as Smith explains.
That's why it's folly to suppose that some central authority can dictate “what works and what doesn't work” for every patient and somehow homogenize the Dartmouth Atlas maps by bringing doctors into “compliance with EBM.”
More from DB's Med Rants.
David Sackett and others once tried, in their classic BMJ editorial, to explain what EBM is and what it isn't. But, 18 years later, among academics, policy makers and practicing physicians alike it seems anything but clear what it is and what it isn't. There is a pure notion of EBM out there somewhere, perhaps best stated in the opening sentence of the Sackett editorial---“It's about integrating individual clinical expertise and the best external evidence.” But in real world application it's all over the place as Smith explains.
That's why it's folly to suppose that some central authority can dictate “what works and what doesn't work” for every patient and somehow homogenize the Dartmouth Atlas maps by bringing doctors into “compliance with EBM.”
More from DB's Med Rants.
Hand washing compliance: real quality or just another performance metric?
First a disclaimer. I am a strong proponent of hand hygiene. I strive to be 100% compliant where I work. But the skeptical side of me sees flaws in the hand hygiene dogma. Tracking hand cleaning rates as a performance metric (not a JC or CMS measure yet but being done at many institutions) may have unintended consequences. Moreover, the claim that hand washing keeps hospitalized patients safe from infections is simply not true. Allow me to explain. But first watch this video on hand hygiene at Vanderbilt, a leader in quality and safety.
It's clear the folks at Vanderbilt are passionate about hand hygiene but how effective is the measure, really? Watch the video closely and keep in mind evidence cited by the CDC in its guidelines that a 15 second hand wash is needed, as well as evidence that pathogens can be transmitted via the stethoscope. The stethoscope, perhaps more than the hands, is a major point of physical contact with the patient.
None of the people seen on this video cleaned their stethoscopes. And while it was difficult to tell how long they took to wash their hands it appeared to be well under 15 seconds in most instances.
Making the rate of hand washing the sole metric (91% at Vandy as reported in this video) may distract attention from equally or more important measures such as the length of the hand washing activity and the rate of stethoscope cleaning.
It's clear the folks at Vanderbilt are passionate about hand hygiene but how effective is the measure, really? Watch the video closely and keep in mind evidence cited by the CDC in its guidelines that a 15 second hand wash is needed, as well as evidence that pathogens can be transmitted via the stethoscope. The stethoscope, perhaps more than the hands, is a major point of physical contact with the patient.
None of the people seen on this video cleaned their stethoscopes. And while it was difficult to tell how long they took to wash their hands it appeared to be well under 15 seconds in most instances.
Making the rate of hand washing the sole metric (91% at Vandy as reported in this video) may distract attention from equally or more important measures such as the length of the hand washing activity and the rate of stethoscope cleaning.
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