Saturday, February 19, 2005
MayoClinic.com Anesthesia Information
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James T. Li, M.D. has written two 'Ask a Specialist' pieces at MayoClinic.com that are relevant to patients having anesthesia. I've read them both and do hereby confer upon them the WakingUpCosts seal of approval:
- Anesthesia: Options and considerations
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- Anesthesia: Safe for people with asthma?
Wisconsin Hospital Association Launches Web Site Detailing Retail Prices of Procedures
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"The Wisconsin Hospital Association on Thursday launched a Web site that allows consumers to compare prices at hospitals statewide for more than 60 'common medical problems,' the Milwaukee Journal Sentinel reports. The site does not list actual prices charged to insurers but rather the 'retail,' or list prices, as well as the overall discount insurers collectively receive off a facility's retail rates for all procedures combined."
The site also contains links to quality information for each facility (example).
[Via Kaisernetwork.org]
COX-2 Prescriptions Fell 43% Since Last Year
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"The number of COX-2 inhibitor prescriptions decreased by 43% between December 2003 and December 2004, according to a study released on Monday by the pharmaceutical information and consulting company IMS Health, the AP/Seattle Post-Intelligencer reports"
[Via Kaisernetwork.org]
Wednesday, February 16, 2005
New Manifestations of Avian Influenza A (H5N1)
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NEJM--Fatal Avian Influenza A (H5N1) in a Child Presenting with Diarrhea Followed by Coma:
" In southern Vietnam, a four-year-old boy presented with severe diarrhea, followed by seizures, coma, and death. The cerebrospinal fluid contained 1 white cell per cubic millimeter, normal glucose levels, and increased levels of protein (0.81 g per liter). The diagnosis of avian influenza A (H5N1) was established by isolation of the virus from cerebrospinal fluid, fecal, throat, and serum specimens. The patient's nine-year-old sister had died from a similar syndrome two weeks earlier. In both siblings, the clinical diagnosis was acute encephalitis. Neither patient had respiratory symptoms at presentation. These cases suggest that the spectrum of influenza H5N1 is wider than previously thought. "
NEJM -- The Risk of Cesarean Delivery with Neuraxial Analgesia Given Early versus Late in Labor
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NEJM --The Risk of Cesarean Delivery with Neuraxial Analgesia Given Early versus Late in Labor
" Analgesia was initiated in the intrathecal group by a combined spinal–epidural technique. Intrathecal fentanyl (25 µg) was injected, an epidural catheter placed, and an epidural test dose administered. At the second request for analgesia, the cervix was again examined. Epidural analgesia was then initiated as follows: if the cervix was less than 4.0 cm in diameter, a 15-ml epidural bolus of bupivacaine (0.625 mg per milliliter) with fentanyl (2 µg per milliliter) was given, and if the cervix was 4.0 cm or greater in diameter, a 15-ml epidural bolus of bupivacaine (1.25 mg per milliliter) was given (Figure 1). In both instances, patient-controlled epidural analgesia was then begun. "
Bottom Line: Intrathecal fentanyl in women not yet at 4 cm cervical dilation does not increase C-section rate when compared to systemic opioids. Lots of great information to digest over the next several days...
Monday, February 14, 2005
Truth in Advertising
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The availability of references and the sponsorship of original research cited in pharmaceutical advertisements (free full text):
" Results: In the 438 ads with medical claims, 126 contained no references and 312 contained 721 unique references. Of these ad references, 55% (396/721) cited journal articles and 19% (135/721) cited data on file. In contrast, in the sample of research article references, 88% (351/400) cited journal articles and 8% (33/400) cited books. Overall, 84% of the citations from the ads were available: 98% of journal articles, 86% of books, 71% of meeting abstracts or presentations and 20% of data-on-file references. In all, 99% of the sample of research article references were available. We determined that 58% of the original research cited in the pharmaceutical ads was sponsored by or had an author affiliated with the product's manufacturer, as compared with 8% of the articles cited in the research articles. "
[Via UK Medical News Today]
We shouldn't be surprised at these findings. It is just marketing, after all.
Grand Rounds XXI At Sumer's Radiology Site
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Sumer's Radiology Site: Grand Rounds XXI
Sunday, February 13, 2005
Using Passwords? Switch to Pass-phrases, Instead.
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Slashdot points to a very interesting blog entry by a Microsoft engineer in which he makes it perfectly clear how single
passwords are not secure any longer:
" So with all of these highly successful, highly effective attacks on passwords (dictionary attacks, brute-force attacks, pre-computation attacks) I've come to the conclusion that there is simply too much risk associated with passwords and that users of Windows should simply stop using them to avoid this risk. "
Instead, he recommends pass-phrases:
" Pass-phrase LENGTH, not complexity defeats these attacks. Short, but complex passwords should be shunned as they are not truly secure anymore and you are deceiving yourself if you think they are. Long pass-phrases (14 characters or more) are the future (along with 2-factor or more authN, but that's another blog for another day) and are the only way to go if you want to ensure that you won't get hacked via any type of password based attack of any kind. "
Think CPAP Mask After Major Abdominal Surgery
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JAMA just published Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial and those of us giving anesthesia for open major abdominal surgery should take note. Here's the abstract:
" Results Patients who received oxygen plus continuous positive airway pressure had a lower intubation rate (1% vs 10%; P = .005; relative risk [RR], 0.099; 95% confidence interval [CI], 0.01-0.76) and had a lower occurrence rate of pneumonia (2% vs 10%, RR, 0.19; 95% CI, 0.04-0.88; P = .02), infection (3% vs 10%, RR, 0.27; 95% CI, 0.07-0.94; P = .03), and sepsis (2% vs 9%; RR, 0.22; 95% CI, 0.04-0.99; P = .03) than did patients treated with oxygen alone. Patients who received oxygen plus continuous positive airway pressure also spent fewer mean (SD) days in the intensive care unit (1.4 [1.6] vs 2.6 [4.2], P = .09) than patients treated with oxygen alone. The treatments did not affect the mean (SD) days that patients spent in the hospital (15 [13] vs 17 [15], respectively; P = .10). None of those treated with oxygen plus continuous positive airway pressure died in the hospital while 3 deaths occurred among those treated with oxygen alone (P = .12). "
I remember the first time someone suggested using CPAP for the struggling patient in the recovery room after major abdominal surgery. I snorted and mumbled something under my breath about how the patient needed an endotracheal tube and should have taken the offered thoracic epidural. I went back to bed, convinced that I'd be called in an hour or two to intubate the patient who would by then certainly be in extremis. You know what? They never called me that night and this paper helps me understand why.
I think I need to modify my internal algorithm for post-anesthesia management of these often difficult cases to reflect the option of CPAP as a middle ground between mask oxygen and endotracheal intubation.
Screening for AAA Recommended for Smokers Aged 65-75
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The U.S. Preventive Services Task Force (part of AHRQ) now 'recommends one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65 to 75 who have ever smoked.'
" Rationale: The USPSTF found good evidence that screening for AAA and surgical repair of large AAAs (5.5 cm or more) in men aged 65 to 75 who have ever smoked (current and former smokers) leads to decreased AAA-specific mortality. There is good evidence that abdominal ultrasonography, performed in a setting with adequate quality assurance (i.e., in an accredited facility with credentialed technologists), is an accurate screening test for AAA. There is also good evidence of important harms of screening and early treatment, including an increased number of surgeries with associated clinically-significant morbidity and mortality, and short-term psychological harms. Based on the moderate magnitude of net benefit, the USPSTF concluded that the benefits of screening for AAA in men aged 65 to 75 who have ever smoked outweigh the harms. "
Patients should also be made aware that there is an alternative to open AAA repairs known as 'endovascular repair.' NEJM recently published A Randomized Trial Comparing Conventional and Endovascular Repair of Abdominal Aortic Aneurysms which concluded:
" On the basis of the overall results of this trial, endovascular repair is preferable to open repair in patients who have an abdominal aortic aneurysm that is at least 5 cm in diameter. Long-term follow-up is needed to determine whether this advantage is sustained. "
As an aside, wouldn't it be nice to be able to query our electronic medical record for all patients in our primary care practice who meet this criteria? Oh wait. We don't have EMR's (for the most part).
Saturday, February 12, 2005
Citation Classics in Anesthetic Journals
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I was listening to some friends talk about taking a large set of information and making it more useful to the user when I thought about a project I helped with to try to remedy this with regard to the body of published literature in medicine. PubMed is the National Library of Medicine's big online database of medical articles (no, I didn't help with that). Searching for a term on PubMed usually gets lots of results but doesn't necessarily get you any closer to finding that key reference that people consider the classic or definitive paper in the field.
As a teacher in academic anesthesia, I saw residents (note the past tense) had little hope of finding the 'right' paper to read unless I gave it to them. If I said 'read about airway management' they would no doubt find some things about airway management, but probably not the paper on airway management. Unless of course they were able to search a subset of articles in PubMed defined in advance to be especially relevant to their field of study. That's how we conceived of the idea of 'Key References'--make it easy to assemble a list of references for whatever purpose. To make it easy, we used a unique identifier for each article called the PubMed ID Number (PMID). Seth Dillingham then wrote a plugin for Conversant that could take that PMID and go to the PubMed system and (politely) request information about the reference such as title, authors, citation, and even the abstract.
'Citation classics in anesthetic journals' by Baltussen and Kindler is comprised of 'seminal advances in anesthesia' which give 'a historic perspective on the scientific progress of this specialty'. The advantage of having them available online as a compilation lies in the fact that they 1) are searchable and 2) linked to related articles in PubMed (something which even the online version of the original article even does not do).
See for yourself: Citation Classics in Anesthetic Journals
After looking up all 100 PMID's for these articles I wrote to the journal editors and suggested they require authors to include PMID's for references they cite in each article but (apparently) failed to make a convincing enough case. Sort of like in, oh, 1995 when I suggested to the editors of another journal that they could put their articles online using Highwire Press and was told that they had their hands full putting back issues on CD.
Thursday, February 10, 2005
Coming To A School Near You: Super Size Me
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" What happens when a man eats nothing but McDonald's food for 30 days? It's a lesson that schoolchildren across the country are about to find out.
Morgan Spurlock, director and star of "Super Size Me: A film of epic proportions," is releasing an edited version of the film for classrooms. The school version of the Academy-Award nominated film is scheduled to be released after the Feb. 27 Oscars (news - web sites) ceremony. "
Um. Can we show it in hospital waiting rooms?
[via Yahoo News]
"What the Doctor Saw"
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Published in the Fulton County (Georgia) Daily Report: What the Doctor Saw:--The court system through the eyes of a surgeon sued for malpractice (PDF--432k)
" Outstandingly reported account of a surgeon's professional liability trial from the standpoint of the defendant and his family as well as the lawyers on both sides. "
[Via Overlawyered]
Does it really cost 800 million dollars to develop a new pill?
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Estimating the Costs of New Drug Development: Is it really $802m?:
" Abstract:
This paper replicates DiMasi et al (2003) drug development cost estimates using their published survey cost estimates along with information from a publicly available data set. The results suggest that the expected cost of developing the average drug is even higher than the DiMasi et al (2003) estimate of $802m (in 2000 dollars). The paper estimates the capitalized out-of-pocket cost per new drug to be between $839m and $868m (in 2000 dollars). The paper similarly estimates the expected cost of the average new drug with certain characteristics such as primary indication. It is shown that the expected cost of developing the average HIV/AIDS drug is $479m, while the expected cost of developing the average rheumatoid arthritis drug is twice that, at $936m.
...[continues]..." "
PDF (184k)
[Via Marginal Revolution]
Tuesday, February 8, 2005
I want a Bluetooth pre-tracheal stethoscope
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During my anesthesiology training, attendings encouraged me to use a pre-tracheal stethoscope--basically a metal bell that rested on the base of the patient's neck over the trachea which could be used to listen to breath sounds during general anesthesia. This usually involved a hollow tube running from the stethoscope to an earpiece in the anesthetists ear. FM transmitter were available for wireless monitoring.
I still think this is usefull, especially for cases using a laryngeal mask airway (LMA). Trouble with an LMA is usually preceded by 'crowing'--a high pitched noise caused by the passage of air over partially closed vocal cords. This can progress to frank laryngospasm, airway obstruction, and the generation of very large negative intra-thoracic pressures and negative pressure pulmonary edema.
What would the modern equivalent be like? Bluetooth transmitter. Wireless ear phone. I wonder if I can do this with my PowerBook somehow? I'd need a box to convert the sound from the stethoscope to a digital signal (and amplify it), then run it into the PowerBook. On a PowerBook with built-in bluetooth, can I send the sound-in signal out via bluetooth? Sounds like a weekend project, to me...
medmusings: Grand Rounds XX
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All the way from Singapore......medmusings: Grand Rounds XX
Monday, February 7, 2005
More than 80 Prominent Leaders Endorse Special Health Courts
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Common Good has kicked off a national education campaign about special health care courts with a brochure titled An Urgent Call for Special Health Courts: America needs a reliable system of medical justice. (pdf also available).
I've posted about special health courts before here and support them in principle We have special courts for workman's compensation--we need special courts for malpractice issues. The proposal includes:
- Full-time judges
- Neutral experts
- Speedy processing at lower cost
- Schedule for non-economic damages
- Liberalized standard for patient recovery
Wired Magazine: Pain Management in Iraq
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The Painful Truth: The Iraq war is a new kind of hell, with more survivors - but more maimed, shattered limbs - than ever. A revolution in battlefield medicine is helping them conquer the pain.
" For soldiers evacuated from the battlefield, the advantages of nerve blocks over traditional methods of pain control are clear. The wounded troops flying in and out of Landstuhl are often in misery or a narcotized stupor, while those treated with blocks remain awake and pain-free despite massive injuries. "
A great story about how military anesthesiologists are making a big difference for our wounded.
Kaiser Daily Health Policy Report Highlights News of State Medical Malpractice Developments
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Summarizes recent developments in tort reform in Georgia, Maryland, Missouri, Nevada, North and South Carolina, and Wyoming.
[Via UK Medical News Today]
Friday, February 4, 2005
Site Update: Trackbacks Are Live
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My content management system, Conversant, now fully support Trackback as detailed here. To see the trackbacks, you'll have to look at the 'discuss' link that follows each post.
Thursday, February 3, 2005
PA State Medical Society Frivolous Lawsuit Project
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In 2004, the Pennsylvania State Medical Society began a project to support physicians who chose to countersue lawyers who brought frivolous malpractice lawsuits under the Frivolous Lawsuit Project. A recent newsletter gave the following update:
" In May of 2004, the Society settled its first frivolous case, resulting in an apology from the offending attorney and an agreement to make an undisclosed monetary payment.
The countersuit was brought by Charles Dunton, MD—a gynecological oncologist from Delaware County—against Diane Rice, Esq., of Bucks County.
Ms. Rice had filed a medical malpractice action on behalf of her client in which she accused Dr. Dunton of providing inadequate care. That action was eventually resolved in Dr. Dunton’s favor when Ms. Rice was unable to produce an expert to support her allegations.
In her apology, Ms. Rice admitted she did not obtain an opinion from a qualified medical expert prior to filing the suit... "
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