Wednesday, December 29, 2004

NEJM: Ten Years After Gastric Bypass

Too bad it's not free full text, but the NEJM has published a study showing that bariatric surgery results can be good:

" "Two- and 10-year rates of recovery from diabetes, hypertriglyceridemia, low levels of high-density lipoprotein cholesterol, hypertension, and hyperuricemia were more favorable in the surgery group than in the control group, whereas recovery from hypercholesterolemia did not differ between the groups. The surgery group had lower 2- and 10-year incidence rates of diabetes, hypertriglyceridemia, and hyperuricemia than the control group; differences between the groups in the incidence of hypercholesterolemia and hypertension were undetectable." "

Here's a nice graph of the weight loss over the course of the ten year follow up:

The same issue contained another article on obesity in women as it relates to increased risk of death:

" "We estimate that excess weight (defined as a body-mass index of 25 or higher) and physical inactivity (less than 3.5 hours of exercise per week) together could account for 31 percent of all premature deaths, 59 percent of deaths from cardiovascular disease, and 21 percent of deaths from cancer among nonsmoking women." "


[Click for larger image]

It would be interesting to know if weight loss from bariatric surgery confers the same benefit.

New Genetic Test May Prevent Drug Interaction

New Genetic Test May Prevent Drug Interaction:

A new DNA microarray test called the AmpliChip Cytochrome P450 Genotyping Test analyzes abnormalities in the gene coding for Cytochrome P450, the liver enzyme involved in metabolizing many drugs. The hope is that testing for the abnormality will allow better use/selection of drugs in these patients. As the list of cytochrome P450-metabolized drugs is long and includes NSAID's, inhaled anesthetics. Are we looking at a standard pre-op test? Perhaps. Polymorphism at this gene may explain some of the bell-shaped curve we see in responses not only to anesthetics, but to many commonly prescribed drugs. What we need now are outcome studies...and to be patient.

More information about genotyping in general is here (thanks, Google).

[Via WebMD Health Headlines]

Lessons learned from troubles with COX-2 inhibitors - JAMA

JAMA: Arthritis Medicines and Cardiovascular Events—"House of Coxibs" (free full text)

" "In the wake of the high density of new data on coxibs, several important issues now need to be confronted. First, is there any continuing role for coxibs? Only rofecoxib has been shown to reduce gastrointestinal complications compared with naproxen, but valdecoxib and celecoxib have never been definitively confirmed to protect against gastrointestinal complications. While coxib superiority over NSAIDs for relief of arthritic pain has not been shown, many individual patients report pain relief with a coxib but not an NSAID. With the considerably higher cost, marginal efficacy, and known cardiovascular risks of the remaining agents on the market, valdecoxib and celecoxib, it would seem prudent, at the least, to avoid using these agents as first-line therapy. A contraindication is appropriate for patients with established coronary or cerebrovascular disease." "

and the final sentence

" "The combination of mass promotion of a medicine with an unknown and suspect safety profile cannot be tolerated in the future. An aggressive position going forward is necessary not only for ensuring the safety of prescription medicines but also to restore a solid foundation of public trust." "

[Via UK Medical News Today]

Donate to Doctors Without Borders

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We've been talking about how best to donate to relief efforts after the tsunami. As I write this, the Doctors Without Borders web site is redirecting to a search page, but you can still reach the donation page directly.

Other choices for helping out are detailed here.



Sunday, December 26, 2004

Are Lawsuits Affecting Mammography Access in Florida?

Common Good points to the following article: Report: Lawsuits Limit Cancer Tests

" "In Florida, a governor-appointed task force reports that lawsuits are "discouraging radiologists from offering mammograms." Radiologists have good reason to be afraid. As many as 17 percent of tumors are "missed during at least one exam." And in 2002, a study of 25 insurance companies conducted by the Physicians Insurers Association of America found that "radiologists accounted for 33 percent of all claims and the most common allegation against radiologists was 'mammogram misread.'" Six seats are available in breast-imaging fellowship programs across the state of Florida, but none are filled. In fact, "a recent survey of 211 radiology residents showed that 63 percent of students wouldn't accept a fellowship in breast imaging." "Why would they jeopardize their lives and their careers if it's not absolutely necessary?" said Dr. Ada Patricia Romilly, a member of the Florida task force." "

I found the home page for the Workgroup on Mammogram Accessibility [thanks to Google] but see no final results. Those that are there indicate available data is inconclusive or invalid. So where does that leave us, exactly?

First cloned pet delivered by a US company

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First cloned pet delivered by a US company:

" "The first cloned-to-order pet has been delivered by a US company, reigniting debate over the ethics of commercial cloning.

The 9-week-old kitten, named Little Nicky, was cloned for a woman in Texas, to replace a 17-year-old pet cat called Nicky, which died in 2003. She paid for $50,000 for her new pet. " "

Fifty thousand dollars for a cat? For a dog, I could see it, but a cat?

[Via Medical News Today]

Sales Rep Pleads Guilty in Federal Court To Bribing Physicians

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Sales Rep Pleads Guilty in Federal Court To Bribing Physicians:

" "A former New York regional sales manager for Swiss biotechnology company Serono on Tuesday pleaded guilty to bribing doctors in New York City to write prescriptions for the company's AIDS-related drug Serostim, the Boston Globe reports." "

And what of the physicians he bribed?

[Via UK Medical News Today]

Charite Artificial Intervertebral Discs--ready for prime time?

DePuy Spine/J&J are marketing Charite artificial discs as an alternative to spinal fusion. A recent New York Times report, though pointing out that long term evidence is lacking, was basically positive and contained the following quote from a company representative:

" "Some of the anecdotal evidence for the Charité is impressive." "

Some of the anecdotal evidence? What? This device has been in use in Europe for two decades and that's the best they can do? The Charite web site with information for physicians has results but no references. None.

The one study I did find via PubMed concluded:

" "In this prospective randomized study, both surgical groups improved significantly. Complications of total disc replacement were similar to those encountered with anterior lumbar interbody fusion. Total disc replacement appears to be a viable alternative to fusion for the treatment of single-level symptomatic disc degeneration unresponsive to nonoperative management." "

It may be a 'viable alternative', but there's no data on long term results. Here's what I bet will happen. The FDA will approve the device and ask for long term followup, which is actually done by a company in fewer than half the cases where it is requested by the FDA. (I don't know J&J's record specifically, though.) Patients will read about it and find a surgeon that does the Charite procedure (even if it means going to someone who is not their normal orthopedic surgeon)...and resort to the legal system if their expectations are not met or their long term results are disappointing.

[Via Medgadget]

Radiologists Use iPod for Image Storage

Via Medgadget:

" "

Radiological Society of North America reports:

The iPod is not just for music any more. Radiologists from the University of California, Los Angeles (UCLA), and their colleagues at other institutions from as far away as Europe and Australia are now using iPod devices to store medical images.

'This is what we call using off the shelf, consumer market technology,' says Osman Ratib, M.D., Ph.D., professor and vice-chairman of radiologic services at UCLA. 'Technology coming from the consumer market is changing the way we do things in the radiology department.'

Dr. Ratib and Antoine Rosset, M.D., a radiologist in Geneva, Switzerland, recently developed OsiriX, Macintosh-based software for display and manipulation of complex medical image data.

Dr. Rosset set up the OsiriX software to automatically recognize and search for medical images on the iPod. When it detects the images, they automatically appear on the list of image data available - similar to the way music files are accessible by the iTune music application.

'It's easy to use and you don't have to worry about how to load and unload it from the iPod,' Dr. Ratib says. 'But the real beauty of it is that I can use the images directly on the iPod. I don't have to take the time to copy them to my computer. The iPod allows me to copy data from work to my laptop, but I don't have to do it if I don't want to.'

Dr. Ratib sees the iPod as a kind of giant memory stick, 'The performance is amazing.'

" "

Book Recommendation: Powerful Medicines

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I began reading Jerry Avorn's 'Powerful Medicines: The benefits, risks, and costs of prescription drugs' before Vioxx and Celebrex made headlines for their possible effects on cardiac risk. Though I'm only a third of the way through the book, I want to pass along my recommendation. So far, I've gained real insights into how drugs are tested, 'approved' by the FDA, and marketed using examples such as Fen-phen, Premarin, Rezulin and others. I'm embarrassed to say that I didn't know a tenth of what actually goes/went on (and I'm a medical doctor!). You'll be amazed, too.

PowerfulMedicine.gif



Friday, December 24, 2004

Online Posting of Med-Mal Payouts Is Seen as Chilling Settlements

Online Posting of Med-Mal Payouts Is Seen as Chilling Settlements:

" "Nearly five months after a [New Jersey] state government Web site began posting doctors' malpractice histories, the publicity may be having a chilling effect on settlements.

Lawyers on both sides of the aisle say that some doctors, faced with the reality that even a confidential settlement will end up on the Internet, are opting to take their chances in court.

They are exercising the right available under most medical malpractice policies to withhold their consent to settle, even when it goes against the wishes of their carriers and advice of counsel.

'Doctors do not want to settle at all now that it has to be reported to the databank for any payment whatsoever,' says defense lawyer Richard Amdur." "

[Via Point of Law]



Tuesday, December 21, 2004

New Web Resource: Consumer Reports Best Buy Drugs

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" "The mission of the Consumer Reports Best Buy Drugs project is to provide consumers and their doctors with information to help guide prescription drug choices–based on effectiveness, a drug's track record, safety and price.

The project aims to improve access to needed medicines for tens of millions of Americans—because they lack insurance coverage for prescription drugs, because the prices of many medicines today are so high, and because many consumers and physicians may not be aware of proven and affordable alternatives. " "

Washington Post: A Whole New Operation

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A Whole New Operation (washingtonpost.com)

The following quote from the article gives a hint as to what may be going on behind the scenes in Pennsylvania's recent change in posture toward laparoscopic procedures in ASC's:

" "The one major health care player that's not pleased is your community hospital. Ellen Pryga, policy director of the American Hospital Association, said ASCs tend to draw away just the kinds of patients that financially pressed hospitals need to stay in business: people with relatively simple medical problems and the ability to pay. 'If the community looked to you to be the provider for all the safety net services,' she asked, 'and your ability to generate the revenues to support these services was disappearing left and right, wouldn't you be nervous?'" "

One thing to remember, though, is that many hospitals are investors in ASC's and so do share in the revenue they generate.

Which Surgeries Are Suited for Off-Site Centers? (washingtonpost.com)

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Washington Post:Which Surgeries Are Suited for Off-Site Centers?

" "The Center for Medicare and Medicaid Services (CMS) authorizes reimbursement for some 2,500 procedures -- from cataract surgery to breast reduction -- at ASCs. Last month , it revised the list of approved procedures, adding 25, including knee arthroscopy, chin reconstruction and bladder repair, and deleting 105.

Among the items deleted as too risky: muscle and skin grafts, reconstructive cleft palate surgery, excision of the parotid gland, draining ovarian abscesses, repair of facial nerves and eardrum revision." "

The above references list of covered procedures was published at the Federal Register on November 26, 2004 (thank you, Google).

The WaPo article also makes reference to a paper by Fleisher titled: Inpatient Hospital Admission and Death After Outpatient Surgery in Elderly Patients. It concludes:

" "In multivariate models, more advanced age, prior inpatient hospital admission within 6 months, surgical performance at a physician's office or outpatient hospital, and invasiveness of surgery identified those patients who were at increased risk of inpatient hospital admission or death within 7 days of surgery at an outpatient facility." "

JCAHO Sentinel Event Alert: Patient controlled analgesia by proxy

Sentinel Event Alert Issue 33: Patient controlled analgesia by proxy

" "Patient controlled analgesia (PCA) is an effective and efficient method of controlling pain, and when it is used as prescribed and intended, the risk of oversedation is significantly reduced. However, serious adverse events can result when family members, caregivers or clinicians who are not authorized become involved in administering the analgesia for the patient "by proxy." " "

I had this happen during my training. Healthy patient, uncomplicated anesthetic, uneventful recovery. Three hours after arriving on the floor she had a respiratory arrest. Despite numerous attempts from every quarter to blame my anesthetic (I had used Sufenta, a new synthetic narcotic at that time), it turned out to be the family pressing the PCA button.



Monday, December 20, 2004

I'll have some wine, fish, dark chocolate, fruits and vegetables, almonds, and garlic, please

The Polymeal: a more natural, safer, and probably tastier (than the Polypill) strategy to reduce cardiovascular disease by more than 75% -- Franco et al. 329 (7480): 1447 -- BMJ:

" "What is already known on this topic

  • Prevention of cardiovascular disease is limited by high costs and low compliance
  • The concept of a combination pill (the Polypill) to reduce cardiovascular disease by more than 80% was introduced in 2003
  • Pharmacological interventions are not the only option for preventing heart disease; a healthy diet and an active lifestyle reduce cardiovascular disease as well
What this study adds
  • A combined meal of seven food components (the Polymeal) could reduce cardiovascular disease by more than 75%
  • Chocolate, wine, fish, nuts, garlic, fruit, and vegetables are all known to have a positive effect on cardiovascular disease, and have been enjoyed by humankind for centuries
  • Finding happiness in a frugal, active lifestyle can spare us a future of pills and hypochondria"
"

More On PA Surgery Centers and Laparoscopic Procedures

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A recent Pittsburgh Post-Gazette article contains a baffling statement from the spokesman for the PA Department of Health:

" "Surgery center operators say they have been performing laparoscopic procedures for years, but the state Department of Health became aware of the practice only this year, said spokesman Richard McGarvey." "

Laparoscopic surgery has been performed at surgery centers in Pennsylvania since 1985. Before a new center can open, it must be approved to perform certain procedures (such as laparoscopy). In their annual review if each center, the DOH inspects random charts, review lists of cases performed, looks at all event reports as well as QA minutes. In short, it is just not credible for the state to claim they did not 'become aware' until this year.

As far as I am aware, we have yet to see any evidence that laparoscopic surgery performed at a surgery center is any more risky to the patient. If I thought it was, I'd be the first to agree with the state's ruling. If patient safety were truly their motivation, the State would be looking at individual surgeons as risk factors, rather than the location of the procedure.

[Disclosure: I do not own a financial stake in any ASC, though my group does provide anesthesia for several. In other words, it's no loss to me because we provide anesthesia for the case either way.]



Sunday, December 19, 2004

Medicaid's fee-for-service drug expenditures increased 18% per annum

Medicaid’s Reimbursements to Pharmacies for Prescription Drugs (pdf)

This Congressional Budget Office report focuses on the markup paid to pharmacies by Medicaid for buying and dispensing drugs. For example, in 2002 medicaid reimbursed pharmacies an average of $46 per prescription. Of that amount, $14 was for purchase of the drug itself. The $32 difference constitutes the 'markup', which has been increasing at a rate of roughly 10% per year between 1997 and 2002.

" "Between fiscal years 1997 and 2002, Medicaid’s expenditures on prescription drugs in the fee-for-service part of the program increased from $10.2 billion to $23.4 billion. About one-quarter of those amounts went to wholesalers and pharmacies to compensate them for distributing and dispensing the drugs.

Prepared at the request of the House Committee on Energy and Commerce, this paper examines recent trends in that “markup”—or the difference between the total amount that state Medicaid agencies paid to pharmacies and the amount that pharmacies and wholesalers paid to purchase the drugs from manufacturers. In keeping with the Congressional Budget Office’s (CBO’s) mandate to provide objective, impartial analysis, the paper makes no recommendations. " "

and

" "Overall, the largest single factor contributing to the rapid increase in markups was the use of newer generic drugs, with their high markups. Another factor was the use of newer single-source brand-name drugs, which had somewhat higher average markups than did older brand-name drugs." "

Ambulatory Care, Procedures Requiring Surgical Site Marking

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JCAHO: Ambulatory Care, Procedures Requiring Surgical Site Marking:

" "marking the site is required for procedures involving right/left distinction, multiple structures (such as fingers and toes), or levels (as in spinal procedures). Site marking is not required (nor is it prohibited) for other procedures." "



Saturday, December 18, 2004

100 Years Ago....

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100 Years Ago....:

" "Maybe this will boggle your mind. I know it did mine! The year is 1904
...one hundred years ago. What a difference a century makes! Here are some of the US statistics for 1904:

The average life expectancy in the US was 47 years.

Only 14 percent of the homes in the US had a bathtub.

Only 8 percent of the homes had a telephone.

A three-minute call from Denver to New York City cost eleven dollars.

There were only 8,000 cars in the US, and only 144 miles of paved roads.

The maximum speed limit in most cities was 10 mph.

Alabama, Mississippi, Iowa, and Tennessee were each more heavily populated than California. With a mere 1.4 million residents, California was only the 21st most populous state in the Union.

The tallest structure in the world was the Eiffel Tower.

The average wage in the US was 22 cents an hour.

The average US worker made between $200 and $400 per year.

A competent accountant could expect to earn $2000 per year, a dentist
2,500 per year, a veterinarian between $1,500 and $4,000 per year, and a mechanical engineer about $5,000 per year.

More than 95 percent of all births in the US took place at home.

Ninety percent of all US physicians had no college education. Instead, they attended medical schools, many of which were condemned in the press and
by the government as 'substandard.'

Sugar cost four cents a pound. Eggs were fourteen cents a dozen. Coffee was fifteen cents a pound.

Most women only washed their hair once a month, and used borax or egg yolks for shampoo.

Canada passed a law prohibiting poor people from entering the country for any reason.

The five leading causes of death in the US were:
1. Pneumonia and influenza
2. Tuberculosis
3. Diarrhea
4. Heart disease
5. Stroke

The American flag had 45 stars. Arizona, Oklahoma, New Mexico, Hawaii, and Alaska hadn't been admitted to the Union yet.

The population of Las Vegas, Nevada, was 30!!!

Crossword puzzles, canned beer, and iced tea hadn't been invented.

There was no Mother's Day or Father's Day.

Two of 10 US adults couldn't read or write.

Only 6 percent of all Americans had graduated high school.

Marijuana, heroin, and morphine were all available over the counter at corner drugstores. According to one pharmacist, 'Heroin clears the complexion, gives buoyancy to the mind, regulates the stomach and bowels, and is, in fact, a perfect guardian of health.'

Eighteen percent of households in the U.S. had at least one full-time servant or domestic.

There were only about 230 reported murders in the entire U.S.

Where will we be in another 100 years? " "

[Via Aarmadillo]

Pennsylvania and Medical Courts

From Law.com: States Weigh Med-Mal Courts.

" "In Pennsylvania, a House bill was introduced in 2003 that would have created a Medical Professional Liability Court. The bill never made it out of committee.

"It was the source of a lot of discussions for the greater part of four or five months," said Mark Phenicie, the legislative counsel for the Pennsylvania Trial Lawyers Association. "But it hasn't happened ... .We have the additional impediment here that all of the judges are elected. If I'm a judge, I probably wouldn't want to have to run in a partisan statewide campaign just to be in a malpractice court." " "

Like other malpractice reform proposals, it never made it 'out of committee' because legislators from the Philadelphia area (who represent the trial lawyer lobby) prevented it from going to the floor for a vote.

[Via PointOfLaw Forum]



Thursday, December 16, 2004

BMJ: Magnetic bracelets may relieve hip and knee pain

" "Wearing a magnetic bracelet could reduce the pain arising from osteoarthritis of the hip and knee. After randomising 194 people aged 45-80 to wearing a standard strength static bipolar magnetic bracelet, a weak magnetic bracelet, or a non-magnetic (dummy) bracelet for 12 weeks, Harlow and colleagues found that mean pain scores were reduced significantly more in those in the standard magnet group than in the dummy group. Although a few participants allocated to the dummy group did notice the lack of magnetic force, further analysis showed that unblinding did not affect the results." "

The result table is here.

Very interesting results. Can one ever really be blinded as to whether a bracelet is magnetic or not? Wouldn't it just be too easy to 'check' to see if you're in the placebo group or not?



Wednesday, December 15, 2004

Health, United States, 2004 with Special Feature on Drugs

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Health, United States, 2004 with Special Feature on Drugs
""Health, United States, 2004, is the 28th annual report on the health status of the Nation and is submitted by the Secretary of the Department of Health and Human Services to the President and Congress. It assesses the Nation’s health by presenting trends and current information on selected determinants and measures of health status in a chartbook followed by 153 trend tables organized around four major subject areas: health status and determinants, health care utilization, health care resources, and health care expenditures.""

Medical Weblogs Grand Rounds

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12th Edition of Medical Blogosphere Grand Rounds

Guidelines: Coronary Artery Bypass Grafting

Guidelines updated for Coronary Artery Bypass Grafting (CABG):

" "Key Points

  1. Off-pump CABG, which avoids aortic cannulation and cardiopulmonary bypass, is now available in many hospitals. However, three randomized trials comparing neurologic outcomes after off-pump and on-pump CABG provide insufficient evidence to warrant the conclusion that the off-pump procedure is better for limiting neurologic complications.
  2. The authors note that long-term data from trials of angioplasty versus CABG (most notably the BARI trial) continue to show significant advantages with CABG for preventing death and repeat revascularization in diabetes patients.
  3. Since 1999, both stent use and left internal mammary-artery grafting have become more common. The most recent randomized trial data show that rates of death, MI, and stroke remain similar for CABG recipients compared with stent recipients. The authors also mention that CABG's advantage over stenting for preventing repeat revascularization has narrowed, but remains significant.
  4. In a class I recommendation, the authors write that aspirin is "the drug of choice" for prophylaxis against early saphenous-vein graft closure and should be continued indefinitely.
  5. There is a new class I recommendation for statin therapy in all CABG patients, unless contraindicated.
  6. Hormone replacement therapy should no longer be initiated in women after CABG.
  7. The new guidelines emphasize the importance of understanding how newer antithrombotic and antiplatelet therapies affect bleeding risk in acute coronary syndrome patients who undergo CABG. For example, the authors have made a class I recommendation that clopidogrel be withheld for 5 days before CABG, if clinical circumstances permit.
  8. Several new sections have been added, including those about off-pump techniques, robotic coronary bypass, and the value of clinical guidelines and pathways for guiding postoperative care and improving outcomes." "

[Via Medscape Headlines]

New Weblog: MedGadget

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MedGadget: Medgadget is an online journal of the latest medical gadgets and technologies (XML).

What Is the Rhythm?

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Medscape: What Is the Rhythm? Part of their ECG of the week series.

Safe Personal Computing--Lessons for Safe Hospital Computing?

Bruce Schneier has updated his list of a dozen things Internet users can do to protect themselves. There's no particular reason I can think of that these shouldn't also apply to hospital IT. Does your hospital still use Internet Explorer as its default web browser and Exchange for e-mail? Here are a few of his recommendation that I think should be applied in the hospital setting.

"

"Operating systems: If possible, don't use Microsoft Windows. Buy a Macintosh or use Linux. If you must use Windows, set up Automatic Update so that you automatically receive security patches. And delete the files 'command.com' and 'cmd.exe.'

Browsing: Don't use Microsoft Internet Explorer, period. Limit use of cookies and applets to those few sites that provide services you need. Set your browser to regularly delete cookies. Don't assume a Web site is what it claims to be, unless you've typed in the URL yourself. Make sure the address bar shows the exact address, not a near-miss.

Passwords: You can't memorize good enough passwords any more, so don't bother. For high-security Web sites such as banks, create long random passwords and write them down. Guard them as you would your cash: i.e., store them in your wallet, etc.

E-mail : Turn off HTML e-mail. Don't automatically assume that any e-mail is from the 'From' address.

Delete spam without reading it. Don't open messages with file attachments, unless you know what they contain; immediately delete them. Don't open cartoons, videos and similar 'good for a laugh' files forwarded by your well-meaning friends; again, immediately delete them.

Never click links in e-mail unless you're sure about the e-mail; copy and paste the link into your browser instead. Don't use Outlook or Outlook Express. If you must use Microsoft Office, enable macro virus protection; in Office 2000, turn the security level to 'high' and don't trust any received files unless you have to. If you're using Windows, turn off the 'hide file extensions for known file types' option; it lets Trojan horses masquerade as other types of files. Uninstall the Windows Scripting Host if you can get along without it. If you can't, at least change your file associations, so that script files aren't automatically sent to the Scripting Host if you double-click them.

Firewall : Spend $50 for a Network Address Translator firewall device; it's likely to be good enough in default mode. On your laptop, use personal firewall software. If you can, hide your IP address. There's no reason to allow any incoming connections from anybody.

Encryption: Install an e-mail and file encryptor (like PGP). Encrypting all your e-mail or your entire hard drive is unrealistic, but some mail is too sensitive to send in the clear. Similarly, some files on your hard drive are too sensitive to leave unencrypted."

"


Friday, December 10, 2004

Recent developments in non-invasive cardiology -- Prasad et al. 329 (7479): 1386 -- BMJ

Recent developments in non-invasive cardiology -- Prasad et al. 329 (7479): 1386 -- BMJ:

"Current clinical applications of cardiovascular magnetic resonance imaging
  • General--measurement of cardiac volume and function; if echocardiography is unsatisfactory
  • Great vessels--accurate sizing; detection of dissection, coarctation, stenosis; anomalous vessels
  • Congenital heart disease--check for concordance of atrioventricular or ventriculoarterial connections; check for great vessels connections; assessment of conduits; assessment of complex anatomy
  • Ischaemic heart disease--detection of regional wall motion abnormalities or infarction; assessment of viability
  • Cardiomyopathy--identification of hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy; detection of fibrosis or scarring; risk stratification; quantification of iron overload in thalassemia
  • Left ventricular mass--accurate assessment in hypertension; assessment of response to therapy
  • Valvular disease--quantification of regurgitation
  • Pericardium--assessment of thickening
  • Cardiac masses--characterisation of tissue; assessment of extent of tumour
"

Parenteral metoclopramide for acute migraine: meta-analysis of randomised controlled trials -- Colman et al. 329 (7479): 1369 -- BMJ

BMJ: Parenteral metoclopramide for acute migraine: meta-analysis of randomised controlled trials -- Colman et al. 329 (7479): 1369

""Conclusions: Metoclopramide is an effective treatment for migraine headache and may be effective when combined with other treatments. Given its non-narcotic and antiemetic properties, metoclopramide should be considered a primary agent in the treatment of acute migraines in emergency departments.""

This works well. I've been using metoclopramide (Reglan) for perioperative migraine for years, ever since learning about it from a Navy ER doc at Balboa. I don't use metoclopramide for post-operative nausea vomiting (prophylactic or treatment), but that's another blog post.



Thursday, December 9, 2004

Unreliable System Fails Doctors and Patients

" "The Washington Post takes a detailed look at a single medical malpractice case--one that began when Dr. Kevin Kearney of Maryland's Eastern Shore urged an 18-year-old mother to have her baby without a Caesarean section. What followed was a complicated delivery resulting in permanent injuries to the child, and a multi-year legal battle, filled with dramatic moments that illustrate how an unreliable system can fail both doctors and patients." "

[Via MedWatch]

NEJM -- The Genetic Archaeology of Influenza

NEJM -- The Genetic Archaeology of Influenza:

" "Different strains of influenzavirus have different pathologic effects. For example, infection by the so-called Spanish influenzavirus caused more than 20 million deaths in 1918 and 1919, many of which were due to hemorrhagic pneumonia. To identify the critical components of this virus, mouse-adapted influenza A viruses (Panel A) were modified by Kobasa et al. so that these viruses expressed the form of hemagglutinin encoded by the gene of the 1918 Spanish influenza strain (HAsp), alone (Panel C) or in combination (Panel B) with the form of neuraminidase encoded by the gene of the 1918 Spanish influenza strain (NAsp). They concluded that the HAsp protein is critical to the enhanced cytokine production, inflammation, and hemorrhagic pneumonia that characterized this virulent influenza." "

" "This new study has important clinical and epidemiologic implications. Assuming that the mouse model at least partially reflects the important factors in the virulence of influenza in humans, further dissection of the HAsp molecule is warranted to help identify the critical structural motifs that confer enhanced virulence. This can be accomplished by performing site-directed mutational analyses of the HAsp gene and investigating the effects of these mutations on infection in the mouse model. The identification of these motifs may provide a new epidemiologic tool for surveillance of circulating animal and human influenzaviruses that could be used to predict the emergence of a new, highly virulent pandemic strain. In addition, these detailed molecular studies could facilitate the identification of antigenic epitopes to include in vaccines in order to protect people against related pandemic strains." "

The above comments are in reference to a recent article in Nature titled Enhanced virulence of influenza A viruses with the haemagglutinin of the 1918 pandemic virus. This is exciting and excellent work which opens the way for more fundamental basic science animal research as well as clinical studies.

Military Medicine Is Making A Difference In Iraq

From NEJM: Casualties of War — Military Care for the Wounded from Iraq and Afghanistan

""Though firepower has increased, lethality has decreased. In World War II, 30 percent of the Americans injured in combat died.3 In Vietnam, the proportion dropped to 24 percent. In the war in Iraq and Afghanistan, about 10 percent of those injured have died. At least as many U.S. soldiers have been injured in combat in this war as in the Revolutionary War, the War of 1812, or the first five years of the Vietnam conflict, from 1961 through 1965 (see table). This can no longer be described as a small or contained conflict. But a far larger proportion of soldiers are surviving their injuries.

"It is too early to make a definitive pronouncement that medical care is responsible for this difference. With the war ongoing and still intense, data on the severity of injuries, the care provided, and the outcomes are necessarily fragmentary. But from the data made available for this report and discussions with surgical teams that have returned home, a suggestive picture has emerged. It depicts a military medical system that has made fundamental — and apparently effective — changes in the strategies and systems of battle care, even since the Persian Gulf War.""

And, near the end, this tidbit about updated contingency plans for registration of health care workers:

""Interest in joining the reserves has dropped precipitously. President George W. Bush has flatly declared that there will be no draft. However, the Selective Service, the U.S. agency that maintains draft preparations in case of a national emergency, has recently updated a plan to allow the rapid registration of 3.4 million health care workers 18 to 44 years of age. The Department of Defense has indicated that it will rely on improved financial incentives to attract more medical professionals. Whether this strategy can succeed remains unknown. The pay has never been competitive. One now faces a near-certain likelihood of leaving one's family for duty overseas. And without question, the work is dangerous.""

A former teacher and Army Reserve Anesthesiologist, Rod Calverley, suggested that since the military had become an instrument of foreign policy rather than being used just to protect the homeland, perhaps I should not join the reserves and tend to my young marriage and likely family instead. After 9/11, I think he'd be advising me otherwise...and to put my money where my mouth is.



Wednesday, December 8, 2004

Two NEJM Articles on the War

NEJM: Notes of a Surgeon: Casualties of War — Military Care for the Wounded from Iraq and Afghanistan (free full text)

NEJM: From the War Zone to the United States: Caring for the Wounded in Iraq — A Photo Essay (free full text)

Pentium 4 Causes Male Infertility!

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Yup. It's true. Working with a Pentium 4-based laptop computer can raise the temperature around the family jewels. Whether that has any effect on fertility is about four leaps of faith beyond that, however. Even if they can demonstrate an effect on fertility rates, it may just be because men that hold portable computers on their laps for 19 hours a day are hideous, fat, geeks with no social skills or appeal to the opposite sex! Hello?!

Clearly, these experiments need to be replicated with Apple Powerbooks because, well, women notice men with that glowing Apple logo on their machines...



Tuesday, December 7, 2004

Laparoscopy and Ambulatory Surgery Centers in PA

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The Pennsylvania Department of Health sent a letter to all Ambulatory Surgery Centers in Pennsylvania reminding them that they are not to perform laparoscopic surgeries which:

" 'require major or prolonged invasion of body cavities.' "

Noting that:

" 'the risk of injury to abdominal and other internal organs and structures is not lessened. In fact, there are some reports that the risk of injury may be increased. (Peter D. Jacobson, Medical Liability and the Culture of Technology, PEW Project on Medical Liability, released 9/22/04). ' "

My reading of the Pew report turns up no data implicating ambulatory surgery centers (ASC's) specifically in injuries from laparoscopic procedures. Nothing to suggest that eliminating most laparoscopic procedures from ASC's will improve patients safety. In an era when 'evidence based medicine' is the watchword for practitioners, this kind of blanket policy by the government is difficult for me to swallow.

I suspect (though cannot prove) that hospitals have brought political pressure to bear on the Governor and/or Department of Health to make this policy change in order to bring a very profitable class of surgery back to the hospital setting. The facility fees collected for laparoscopic surgery are considerable, and hospitals feel they've been missing out.

Another example to suggest hospitals have been active in this area is the requirement by some payors that orthopedic implant surgeries be performed in hospitals rather than free standing ASC's. For example, we used to perform rotator cuff repairs (which use an anchor suture) in the ASC, but they can no longer be done here because the insurance company will only pay for the anchors if placed in a hospital. There is just no reason I can think of for this requirement other than to force surgeries back into hospitals and away from ASC's.

12/8/04 update: it is on the state servers at: http://app2.health.state.pa.us/commonpoc/content/facilityweb/FacMsgBoardDetails.asp?msgid=819&msgindex=2&Selection=ALL



Friday, December 3, 2004

Pennsylvania Has Its First Influenza Case

Type A-Fujian influenza has been confirmed in a Philadelphia resident, the first laboratory-confirmed case of influenza in Pennsylvania. Of note, this strain was included in the vaccine.

Legalize It

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Froggy Ruminations an excellent argument for why we should Legalize It:

""I’m talking about completely legalizing it and selling it much in the same way as alcohol. I’m not going to trot out statistics about how alcohol is more harmful to the body than pot because you already know that. Besides, that’s not part of my argument either.

"The enforcement of marijuana smuggling is a massive distraction to the interdiction of really dangerous narcotics like cocaine, methamphetamine, and heroin. Smugglers do not care if a 100 lb. weed load is intercepted at a US Port of Entry. They don’t care because it’s the cost of doing business when your actual goal is to cross 5 lbs of heroin or 20kg of coke. The smugglers send some broke migrant farm worker with a green card across in a stolen car with the promise of $500 dollars if the poor sap actually makes it. But when the dope is spread out all around the car, the dogs are sure to catch it, and even if the dogs are taking a nap, any inspector that’s half awake can see the guy’s hand shaking and the beads of sweat forming on his brow. Right after that guy is sent to Secondary Inspection and all of the attention focused on a load car with unknown contents, 10 carloads of real dope crosses. In my two years working dope cases on the Southwest border, I caught a handful of dope loads containing anything but marijuana. Confidential Informants tell us the tactics that the smugglers use, and it is information from them that accounts for 90% of non-marijuana seizures at the Port.""

[Via Froggy Ruminations]

Ten troublesome trends in TV health news

Ten troublesome trends in TV health news:

  1. Too brief to matter
  2. No full time health journalists
  3. No data to back up sensational claims
  4. Hyperbole
  5. Commercialism
  6. Single source stories
  7. Baseless predictions from basic science
  8. FDA approval treated as a fait accompli
  9. Little coverage of health policy
  10. No time for enterprise

[Via bmj.com -- latest BMJ headline]

Simple steps nearly eliminate catheter-related blood infections

Eliminating catheter-related bloodstream infections in the intensive care unit :

""Intervention: To eliminate CR-BSIs, a quality improvement team implemented five interventions: educating the staff; creating a catheter insertion cart; asking providers daily whether catheters could be removed; implementing a checklist to ensure adherence to evidence-based guidelines for preventing CR-BSIs; and empowering nurses to stop the catheter insertion procedure if a violation of the guidelines was observed.""

Well, that last point right there explains the whole effect. In my experience, whenever I place a line in an ICU the nurse disappears. Poof. Gone. "Empowering nurses to stop the...procedure" is just a fancy way of saying "forcing them to stay in the room in case you need anything so you don't contaminate yourself by accident."

[Via Science Blog - Science News Stories]

Merriam-Webster's Word of the Year 2004: Blog

Blog noun [short for Weblog] (1999) : a Web site that contains an online personal journal with reflections, comments, and often hyperlinks provided by the writer

Just as interesting to me is number 10 on the list: defenestration: Etymology: de- + Latin fenestra window: a throwing of a person or thing out of a window. I believe its more popular use today is in reference to getting rid of the Microsoft Windows operating system, as described in this book

Perioperative Pacemaker Management

There's an editorial in A&A titled Pacemaker Misinformation in the Perioperative Period: Programming Around the Problem by Marc Rozner. The editorial makes an important point: slapping a magnet on a pacemaker is NOT universally indicated because not ALL pacemakers will switch to continuous asynchronous mode.

In the editorial, Rozner points to the American College of Cardiology perioperative guidelines (pdf) on perioperative cardiac management. The guideline contains a section on pacemakers and AICD's. These guidelines nicely summarize why we worry about using elecrocautery in patients with implanted pacemakers or AICD's:

""The electrical current generated by electrocautery can cause a variety of responses by the implanted device, including the following: (1) temporary or permanent resetting to a backup, reset, or noise-reversion pacing mode (i.e., a dual-chamber pacemaker may be reset to VVI pacing at a fixed rate); (2) temporary or permanent inhibition of pacemaker output; (3) an increase in pacing rate due to activation of the rate-responsive sensor; (4) ICD firing due to activation by electrical noise; or (5) myocardial injury at the lead tip that may cause failure to sense and/or capture. ""

And their recommendations are as follows:

""However, under optimal circumstances, several general recommendations can be made. Patients with implanted ICDs or pacemakers should have their device evaluated before and after surgical procedures. This evaluation should include determination of the patient’s underlying rhythm and interrogation of the device to determine its programmed settings and battery status. If the pacemaker is programmed in a rate-responsive mode, this feature should be inactivated during surgery. If a patient is pacemaker dependent, pacing thresholds should be determined if the patient has not been evaluated recently in a pacemaker clinic. ICD devices should be programmed off immediately before surgery and then onagain postoperatively to prevent unwanted discharge due to spurious signals that the device might interpret as ventricular tachycardia or fibrillation. If QRS complexes cannot be seen during electrocautery, other methods of determining heart rate should be monitored to be certain device inhibition is not present.""

Kudos to the American College of Cardiology for making these guidelines available free of charge. The more I think about this the more sense it makes to require a pacemaker check within, say, six months of elective surgery and call the supporting company for specifics about any given pacemaker



Wednesday, December 1, 2004

Despair.com "Greatest Hurts" Collections

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Looking for a gift for a doctor in your life? Many of us are pretty cynical, so why not consider a gift from Despair.com, creators of 'demotivators.' How about a mug that says:

"Ambition: The Journey of a Thousand Miles Sometimes Ends Very Very Badly "

or

"Meetings: None of Us Is As Dumb As All of Us"

or

"Procrastination: Hard Work Pays Off After Time, But Laziness Always Pays Off Now "

Big Red Palm

""The Big Red Book comes to your Palm with the release of AHFS DI (AHFS Drug Information) by Skyscape

First published in 1959, the 'Big Red Book,' as it's come to be known, has gone the extra mile for pharmacists and healthcare professionals seeking answers to the most detailed questions. It provides more extensive evidence-based data than any other drug reference and is now available for the PDA.
""

[Via The Palmdoc Chronicles]

I prefer this text for looking up drug information and find the information it contains much more useful. It seems as though the PDR contains every possible complication as a CYA for the drug maker. The AHFS book doesn't give me that impression.

Ambu Bag Simulation Online

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The Virtual Anesthesia Machine web site now has a simulation of a Self Inflating Resuscitation Bag (SIRB) a.k.a. "Ambu bag" during normal operation and how to check the bag as part of an anesthesia machine pre-use check at http://vam.anest.ufl.edu/pre-use-check.html.

How Much Midazolam Is Holding Someone's Hand Worth?

I provided anesthesia for cataract surgery today. For most of today's patients, it was their second eye and they tend to be more nervous the second time. I rediscovered how holding someone's hand is worth at least a milligram or two of midazolam (intravenous sedative).

That's Why We Call Them 'Donorcycles'

Picked from Trends in Motorcycle Fatalities Associated with Alcohol-Impaired Driving --- United States, 1983--2003 [CDC]

""Motorcycles are the most dangerous type of motor vehicle to drive. These vehicles are involved in fatal crashes at a rate of 35.0 per 100 million miles of travel, compared with a rate of 1.7 per 100 million miles of travel for passenger cars.""

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