Friday, June 17, 2005

Review: Chronic Stable Angina

The NEJM has a very nice review article titled Chronic Stable Angina.
"It is useful to classify therapeutic drugs into two categories: antianginal (anti-ischemic) agents and vasculoprotective agents. Although medications for angina are widely used, therapy to slow the progression of coronary artery disease, to induce the stabilization of plaque, or to do both is a newer concept and these forms of treatment are underprescribed."

Medical Simulation Weblog

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I found a neat new weblog called SimBlog. Associated with the Society for Medical Simulation, it appears to be edited by Jeff Taekman, formerly of Penn State and the person I came to Hershey to work with. Jeff had moved to Duke by the time I arrived, and is now the Associate Dean for Technology in Education there.



Saturday, June 11, 2005

NEJM -- Two-Years after Endovascular Repair of Abdominal Aortic Aneurysms

Very interesting Dutch study on Two-Year Outcomes after Conventional or Endovascular Repair of Abdominal Aortic Aneurysms in the NEJM. This is the first study to look at prolonged survival (2 years) after placing a tube stent into a dilated abdominal aorta (aneurysm) to prevent rupture. We know that early survival is better with the stent vs. open repair. But what about after the first month? This study shows that after two years, the survival is about the same:

" The cumulative rates of aneurysm-related death were 5.7 percent for open repair and 2.1 percent for endovascular repair. This advantage of endovascular repair over open repair was entirely accounted for by events occurring in the perioperative period, with no significant difference in subsequent aneurysm-related mortality. "

To try to explain this, the authors discuss the following possibilities:

"There may be two possible explanations for the convergence of survival curves in our study. One is that patients who have survived the stress of open repair may be somewhat less likely to die in the first few months after surgery than patients who have undergone endovascular repair, since the latter group has not been subjected to a conventional surgical procedure.
...[snip]...
Another possible explanation for the convergence of survival curves is the failure of endovascular repair to prevent rupture of the aneurysm."

I wonder about a third possibility: did patients having an open repair make lifestyle change that those having the less stressful endovascular repair did not? I ask because one of the frustrations in taking care of patients with vascular disease is the extent to which they do NOT change their eating or smoking habits and so need to come back for yet another procedure at yet another time. The study lists baseline characteristics (55% smoked in the open group and 64% smoked in the endovascular repair group. Half in each group had hyperlipidemia), but no characteristics are given at the two year point. Can the lack of survival advantage after endovascular repair be explained by differences in rates of smoking, hyperlipidemia, and other risk factors at two years?

And thanks to the power of Google, I've sent the lead author an e-mail with just this question!

8: 00 A.M., the lead author writes back:

"We haven't studied that in this 2-year analysis but it is part of our long-term study."

Malpractice Insurance for Bariatric Surgeons Increasing

Other Perils of Overweight - New York Times:

" But after several years in which the surgery was seen as the last best hope by many obese people, a growing array of scientific data shows that the risks are greater than patients realized. One new study reported that almost one in 5 patients had complications after surgery. For one in 20 patients, the complications were serious, including heart attacks and strokes. Another recent study said the mortality rate for the most common type of bariatric surgery, gastric bypass, was one in 200 - a rate higher than for coronary angioplasty, which opens blocked heart vessels.

For thousands of patients, the weight-loss surgery has eliminated debilitating diseases and improved the quality of life. But the threat of malpractice lawsuits against doctors and hospitals, as well as the reluctance of health plans to cover the surgery costs, is creating difficulties for people now seeking treatment. "

The article points to an Annals of Internal Medicine article titled Meta-Analysis: Surgical Treatment of Obesity (Annals is another one of those nice free full-text journals).

[Via Common Good]



Friday, May 27, 2005

Medical Malpractice Law in the United States - Kaiser Family Foundation

Medical Malpractice Law in the United States - Kaiser Family Foundation:

" The Kaiser Family Foundation today issued a new report that explains how medical malpractice law in the United States works and provides an overview of recent trends and reform approaches. The Foundation also posted state-specific data on medical malpractice claim payments on statehealthfacts.org, the free online source of current health and health policy data for all 50 states. "

Average U.S. Family of 4 Will Use $12,214 in Medical Products, Services in 2005

Kaisernetwork.org--Average U.S. Family of 4 Will Use $12,214 in Medical Products, Services in 2005, Study Says - :

" The average U.S. family of four will use $12,214 worth of medical products and services in 2005, up 45% from $8,414 in 2001, according to a new report by Milliman, the Washington Times reports (Higgins, Washington Times, 5/26). The report -- the first on consumer health care costs culled from the new Milliman Medical Index -- was based on health insurance information for more than 15 million insured U.S. residents (Whitehouse, Dow Jones/Wall Street Journal, 5/26). The report examined medical costs for a family with two adults and two children under age 10 who were covered by a PPO. It focused solely on costs for medical care at the point of service and did not include health insurance premiums (Washington Times, 5/26). The report also did not examine over-the-counter drug spending and the cost of medical treatments not covered by health insurance (Croghan, New York Daily News, 5/26).

The report found that the average family will pay about 17% -- or $2,035 -- of its total health care costs in 2005, with a health plan paying the remainder. "

The whole report is available here pdf.



Thursday, May 26, 2005

Face-Lift Played Major Part in Woman's Death

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Face-Lift Played Major Part in Woman's Death, City Finds - New York Times:

You may remember the story several weeks ago about an Irish citizen who died the morning after a face lift in a plastic surgeon's office in New York. I've kept a Google Alert on this subject and this popped up today:

" An investigation by the New York City Medical Examiner's Office has concluded that the death of a 42-year-old Irish woman earlier this year was caused in significant part by face-lift surgery she underwent in the Manhattan office of a doctor who has repeatedly been sued for malpractice. "
Not much (any) detail. Maybe more will come out soon.

[Via ]



Thursday, May 19, 2005

Neuromuscular blocker binders around the corner?

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Organon is working on the first of a new class of drugs called selective relaxant binding agents (SRBA). The first drug, called Org 25969, is about to enter phase three trials in the US. These drugs can supposedly reverse neuromuscular blockade at any depth of neuromuscular block by binding the neuromuscular blocker.

Though this news release and the Organon website are short on details, this site has the scoop:

"The novel concept of using a ring-shaped cyclodextrin to engulf a neuromuscular blocking drug is fascinating.2 Cyclodextrins are cyclic oligosaccharides which are recognised to encapsulate lipophilic molecules such as steroids. They are water soluble and well tolerated biologically. Org 25969 consists of eight such sugar molecules in a ring, the outside of which is hydrophilic, and the inside, hydrophobic. The size and shape of the ring is designed to produce a cavity into which a neuromuscular blocking drug such as rocuronium will tightly fit. Org 25969 is capable of forming a binary host – guest complex of high affinity with rocuronium, for two of its externally charged side-chains react with the quaternary nitrogen groups of the muscle relaxant. It is able to encapsulate all four steroidal rings of rocuronium within its lipophilic cavity. This encapsulation or chelation reverses the effect of rocuronium, by preventing its access to the nicotinic receptor and promoting its dissociation from it."

[via Medical News Today]



Saturday, May 7, 2005

25 Years and a 1288% Increase in Malpractice Premiums

"...losses paid out per doctor rose much faster than premiums paid per doctor (1288% vs. 312%), or medical care inflation (480%), from 1975-2001 (see this graph). After 2001, when med-mal insurers were exiting the market in response to this reality, insurance regulators permitted substantial premium price increases that began to correct for these imbalances (though far from fully -- really returning medical malpractice paid-loss ratios to 1995 levels, which were still 150% higher than they were in 1975). It is an unavoidable fact that the exceptional growth in losses paid per doctor over time explains medical malpractice premium growth..."

[via PointofLaw.com]



Wednesday, April 27, 2005

IBM To Launch Electronic Medical-Record-Sharing Project

InformationWeek: IBM To Launch Electronic Medical-Record-Sharing Project > April 27, 2005:

"IBM wants to help pave the way for the free exchange of electronic health-care records that today are trapped in hundreds of disparate hospital, physician, and health insurance systems.

By the end of the year, IBM will launch a pilot system, the Interoperable Health Information Infrastructure, that will link IBM sites in San Jose, Calif.; Rochester, Minn. (home of the Mayo Clinic); and Haifa, Israel, to demonstrate how electronic medical records based on open standards could move from one health-care provider to another and follow a patient around the world. "



Saturday, April 23, 2005

When can nursing mothers resume breastfeeding after surgery?

When can nursing mothers resume breastfeeding after surgery?:

" the very small amount of propofol eliminated in breast milk within the first 24 hours after induction of anesthesia represents such minimal infant exposure to the drug that it provides insufficient justification for interruption of breastfeeding, Avram said. "

Studies are under way by the same group for other commonly used drugs. My advice to nursing patients is to pump and discard once, then resume normal breast feeding.

An Anesthesiologists Thoughts on the Early Epidural 'News'

The New England Journal of Medicine just published The Risk of Cesarean Delivery with Neuraxial Analgesia Given Early versus Late in Labor and it has gotten national attention, including a segment on the Today show on NBC on February 17th. There's nothing here which was not known before. It's a nice study nonetheless, but readers should be aware of several other issues.

There's really nothing here that's new or that we haven't known before. I've been using neuraxial narcotic in women not yet sufficiently dilated for local anesthetic for ten years. I don't like doing it because I find the incidence of prolonged decelerations in the fetal heart rate trace that sometimes occurs makes people very, very nervous. By 'people' I mean patient, family, nurses, obstetricians,......and yours truly. This study in fact confirms that tendency:

" There was a higher incidence of prolonged and late decelerations in heart rate in the intrathecal group after the initiation of analgesia. "

To be specific, the incidence of prolonged decels was 3.9% vs. 0.6% (p < 0.003). I'm not saying this is a reason to avoid the technique, only that the obstetrical service needs to be prepared for it when it happens and know how to deal with it.



Wednesday, April 20, 2005

House Bill Would Fund Special Health Courts

"Known as the Medical Liability Procedural Reform Act of 2005, HR 1546 would authorize grants to as many as seven states to establish special health courts to restore reliability to medical justice. The hallmark of the courts would be full-time judges with health care expertise, whose sole focus would be on addressing medical malpractice cases. Each participating state would be required to report on the effectiveness of the health courts, and the U.S. Attorney General would be required to hire a research organization to evaluate them."

Via [Common Good]


Sunday, April 17, 2005

Malpractice Insurance Summary for PA

The Coalition for Affordable and Reliable Health Care, an advocacy group supporting medical liability reform, has a has an accurate summary of the malpractice insurance situation in Pennsylvania (and other states in the Union).
"A full 80% of medical students who come to Pennsylvania for a world-class education ultimately choose to practice elsewhere, according to the Pennsylvania Medical Society. (PA Medical Society, June 17, 2003)"

[Via PointOfLaw Forum]

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