Monday, February 7, 2005

Wired Magazine: Pain Management in Iraq

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.



Tuesday, January 18, 2005

JAMA -- Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac Arrest, January 19, 2005, Wik et al. 293 (3): 299

JAMA -- Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac Arrest, January 19, 2005, Wik et al. 293 (3): 299 (free article)

Bottom line--it's hard to do it right. I have given chest compressions in the operating room with an arterial line in place so I can see what effect my compressions are having in terms of generating a pressure. Depressing the chest 4 to 5 cm is a lot, but that's the guideline, and that's what it takes to keep blood pumping to the brain. If you're going to the OR and know you're going to have a cardiac arrest, ask for me.



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.

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]



Sunday, December 26, 2004

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]



Tuesday, December 21, 2004

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"
"



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

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]



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

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.

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