Saturday, November 20, 2004

Brain imaging study of drunk drivers pinpoints neurological changes

Alcohol Intoxication Effects on Simulated Driving: Exploring Alcohol-Dose Effects on Brain Activation Using Functional MRI

""The areas most profoundly affected by alcohol were the orbital frontal and anterior cingulate areas, which help control motor functions. The medial frontal regions of the brain involved in making decisions, and working memory, were not affected until the person was beyond the legal limit of intoxication. A function of working memory might be to find one's way home, the researchers said.

Impairment of the cerebellum area of the brain, which related strongly to speeding, was clearly correlated with the alcohol dose. Changes in the frontal and parietal cortex, which govern alertness and attention, were correlated with weaving while driving. ""

[Via Medical News Today]

Thursday, November 18, 2004

Prevalence of Overweight and Obesity Among Adults with Diagnosed Diabetes --- United States, 1988--1994 and 1999--2002

Prevalence of Overweight and Obesity Among Adults with Diagnosed Diabetes --- United States, 1988--1994 and 1999--2002:

""Obesity in persons with diabetes is associated with poorer control of blood glucose levels, blood pressure, and cholesterol (1), placing persons with diabetes at higher risk for both cardiovascular and microvascular disease (2). Conversely, intentional weight loss is associated with reduced mortality among overweight persons with diabetes (3). CDC analyzed the prevalence of overweight and obesity among U.S. adults aged >20 years with previously diagnosed diabetes by using data from two surveys: the Third National Health and Nutrition Examination Survey (NHANES III), 1988--1994, and NHANES 1999--2002. This report summarizes the results of that analysis, which indicated that most adults with diagnosed diabetes were overweight or obese. During 1999--2002, the prevalence of overweight or obesity was 85.2%, and the prevalence of obesity was 54.8%. Encouraging patients to achieve and maintain a healthy weight should be a priority for all diabetes-care programs.""

[Via MMWR]

Sunday, November 14, 2004

Vioxx Non-Cox2 Effect Demonstrated

It's worth pointing out that discussion of a drugs action typically focus on one known effect. That there may be others and that those can be harmful is amply demonstrated by the Vioxx example. An article just published in the journal 'Atherosclerosis' may explain what the second effect is in the case of Vioxx:

Sulfone COX-2 inhibitors increase susceptibility of human LDL and plasma to oxidative modification: comparison to sulfonamide COX-2 inhibitors and NSAIDs

Bottom line: "Abnormal changes in the structure or shape of lipids caused by Vioxx, especially in LDL, may explain why they are more susceptible to oxidative damage, and therefore, contribute to cardiovascular damage. Similar effects on susceptibility of lipids to oxidative damage have been observed with cigarette smoking, diabetes and in patients who have had a recent heart attack."

[Via Medical News Today]

Wednesday, November 10, 2004

Shortage of 200,000 Doctors Predicted in US by 2020

Annals of Internal Medicine (free): Weighing the Evidence for Expanding Physician Supply

"Summary: "Taken together, this body of information indicates that physician shortages are emerging and that they will probably worsen over the next 2 decades. By 2020 or 2025, the deficit could be as great as 200 000 physicians—20% of the needed workforce..."


"... the data, forecasts, and signals discussed earlier indicate that physician shortages are upon us and are likely to worsen over time. The picture that emerges is uncomplicated and unambiguous. In simple numeric terms, the number of physicians is no longer keeping up with population growth. The ability to fully service the population is further compromised by the increasing complexity of the care that physicians provide and the decreasing time commitment that many physicians are willing to make. These limitations collide with economic trends that predict a growing demand for physician services. Recruiters, medical leaders, and patients are already experiencing these shortages, and colleagues in other English-speaking countries see a situation in the United States that is all too familiar to them.""

Missing from the article is any mention of 'malpractice', 'tort reform', or 'liability reform'. These issues do effect how long someone chooses to practice and where. If one believes that there's a physician shortage coming, states would be wise to become 'friendlier' to physicians by enacting tort reform in order to insure they remain a viable choice for physicians looking for a place to practice. Of course, Pennsylvania won't be among them, at least not while Ed [trial lawyer] Rendell is governor, as he's already been quoted as saying that malpractice reform is "the next governor's problem."

[Via Medscape]

Tuesday, November 9, 2004

Liberal Fluid Administration to Improves Recovery After Lap Chole

Liberal Versus Restrictive Fluid Administration to Improve Recovery:

""Results: Intraoperative administration of 40 mL/kg compared with 15 mL/kg LR led to significant improvements in postoperative pulmonary function and exercise capacity and a reduced stress response (aldosterone, antidiuretic hormone, and angiotensin II). Nausea, general well-being, thirst, dizziness, drowsiness, fatigue, and balance function were also significantly improved, as well as significantly more patients fulfilled discharge criteria and were discharged on the day of surgery with the high-volume fluid substitution.Conclusions: Intraoperative administration of 40 mL/kg compared with 15 mL/kg LR improves postoperative organ functions and recovery and shortens hospital stay after laparoscopic cholecystectomy.""

Yawn. This is a 'me too' study, but does provide yet more support to the idea more fluid is good during anesthesia. It's important to note that this is for a 'closed' procedure, not an open one. Insensible loses are minimal with this technique.

Thursday, October 28, 2004

NEJM: Health Care Coverage and Drug Costs — The Candidates Speak Out

The editors asked President George W. Bush and Senator John F. Kerry to respond to two questions regarding health care in the United States. Free full text.

Mortality Rates Associated with Community-Acquired Bacterial Meningitis over the Past 90 Years.

NEJM: Mortality Rates Associated with Community-Acquired Bacterial Meningitis over the Past 90 Years

""The history of community-acquired bacterial meningitis arguably represents the best example of the salutary effect of the introduction of antimicrobial agents. Before the use of specific antiserums, the outlook for patients with bacterial meningitis was dismal (see Figure). In the 1920s, 77 of 78 children at Boston Children's Hospital who had Haemophilus influenzae meningitis died...""

Lot's of progress. Lots more work to do. Much of it by drug companies...

Sunday, October 24, 2004

Review of Pediatric Sedation

Review of Pediatric Sedation:

""Sedating children for diagnostic and therapeutic procedures remains an area of rapid change and considerable controversy. Exploration of this topic is made difficult by the fact that the reports of techniques and outcomes for pediatric sedation appear in a wide range of subspecialty publications and rarely undergo comprehensive examination. In this review article, we will touch on many aspects of the topic of pediatric sedation from the perspective of the anesthesiologist. We begin with a review of the historical role of anesthesiologists in the development of the current standards for pediatric sedation. We also examine the current status of pediatric sedation as reflected in published studies and reports. A specific review of the issues surrounding safety of sedation services is included. Current trends in sedation practice, including the expanding role of potent sedative hypnotic drugs outside the field of anesthesiology, are noted. Finally, we suggest future areas for research and clinical improvement for sedation providers.""

[Via Anesthesia and Analgesia: Current Table of Contents]

Surgical Cause of Vocal Cord Paralysis

Guilt by proximity? On more than one occasion (including one very recently), I've received calls from patients complaining of laryngeal symptoms after my general anesthetic. In every case, their surgeon suggested to them that since their symptoms are in their voice box, it must have been something the anesthesiologist did since they stuffed a tube in there. Here's a great example of why it 'ain't necessarily so:'

Vocal cord palsy as a complication of adult cardiac surgery: surgical correlations and analysis.

Author(s): Dimarakis I; Protopapas A;

""Vocal cord palsy after adult cardiac surgery is often attributed to non-surgical mechanisms as tracheal intubation and central venous catheterisation.It may also be caused by injury of the recurrent laryngeal nerves by surgical dissection. We hereby present a review of relevant clinical reports. The cumulative incidence was 1.1% (33 in 2980). Main reported surgical mechanisms of injury were harvesting of internal thoracic artery and topical coldcardioprotection. Bilateral nerve palsy has been lethal on at least one occasion. Where vocal cord injury followed harvesting of the left internal thoracic artery, it was reported ipsilateral to the conduit." "

European journal of cardio-thoracic surgery: official journal of the European Association for Cardio; 2004 Oct 1;26(4) p773 - 775

[Via Journals To Go]

Thursday, October 21, 2004

BMJ Review: Risks of general anaesthesia in people with obstructive sleep apnoea

Risks of general anaesthesia in people with obstructive sleep apnoea

""Summary points

Patients with obstructive sleep apnoea are at high risk of developing complications when having surgery or other invasive interventions under general anaesthesia, whether or not the surgery is related to obstructive sleep apnoea

Surgeons of all specialties, and especially anaesthetists, should be aware that undiagnosed obstructive sleep apnoea is common

They should be alert to patients who are at risk of having obstructive sleep apnoea and be aware of the potential preoperative and postoperative complications in such patients

Management options include alternative methods of pain relief, use of nasal continuous airway pressure before and after surgery, and surveillance in an intensive care unit, especially after nasal surgery in which packs are used

An algorithm for management of difficult airways should be established""

Failing the Public Health — Rofecoxib, Merck, and the FDA

Failing the Public Health — Rofecoxib, Merck, and the FDA

" "I believe that there should be a full Congressional review of this case. The senior executives at Merck and the leadership at the FDA share responsibility for not having taken appropriate action and not recognizing that they are accountable for the public health. Sadly, it is clear to me that Merck's commercial interest in rofecoxib sales exceeded its concern about the drug's potential cardiovascular toxicity. Had the company not valued sales over safety, a suitable trial could have been initiated rapidly at a fraction of the cost of Merck's direct-to-consumer advertising campaign. Despite the best efforts of many investigators to conduct and publish meaningful independent research concerning the cardiovascular toxicity of rofecoxib, only the FDA is given the authority to act. In my view, the FDA's passive position of waiting for data to accrue is not acceptable, given the strong signals that there was a problem and the vast number of patients who were being exposed." "

Emphasis mine.

NEJM: Financing Medicare in the Next Administration

Financing Medicare in the Next Administration (free full text)

" "Because of its size and political impact, Medicare will rank high on the domestic policy agenda of any incoming administration. When that administration assumes office in January 2005, Medicare will account for more than 13 percent of total federal expenditures; the only larger domestic program will be Social Security, which will account for 21 percent.1 By fiscal year 2007, with the phase-in of the prescription-drug benefit, Medicare's share of federal spending will increase to almost 16 percent. In short, the new administration will find the scope of any new initiatives limited by the needs of the Medicare behemoth." "

Wednesday, October 20, 2004

Access to Physicians Figures Prominently In Complaints

Annals of Family Medicine: Patient Reports of Preventable Problems and Harms in Primary Health Care:

" "Conclusion: The errors reported by interviewed patients suggest that breakdowns in access to and relationships with clinicians may be more prominent medical errors than are technical errors in diagnosis and treatment. Patients were more likely to report being harmed psychologically and emotionally, suggesting that the current preoccupation of the patient safety movement with adverse drug events and surgical mishaps could overlook other patient priorities." "

[Via Science Blog - Science News Stories]

Monday, October 18, 2004

How Technology Failed In Iraq

MIT Technology Review: How Technology Failed In Iraq

" “Next to the fall of Baghdad,” says Marcone, “that bridge was the most important piece of terrain in the theater, and no one can tell me what’s defending it. Not how many troops, what units, what tanks, anything. There is zero information getting to me. Someone may have known above me, but the information didn’t get to me on the ground.” Marcone’s men were ambushed repeatedly on the approach to the bridge. But the scale of the intelligence deficit was clear after Marcone took the bridge on April 2." "

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