MedWorm: Internists and Doctors of Medicine

Dr. A Show 129: Saturday Night - Nov 22,2009

Doctor Anonymous Live — Fri, 20 Nov 2009 16:30:00 +0100

Looking for somewhere to relax on a Saturday night, why not come on into The Doctor Anonymous Show as we talk about the serious and not-so-serious news stories of the week including the areas of medicine/health, entertainment, pop culture, and whatever else comes up.Doctor | Anonymous | Medblogger | New Media | Medicine (Source: Doctor Anonymous Live)

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AHA 09: the POPE study

Notes from Dr. RW — Fri, 20 Nov 2009 14:50:00 +0100

Hospitalists involved in the care of CABG patients will find this study of interest. Pericardial irritation occurs post CABG. Pericarditis can cause arrhythmias as well as lead to effusion progressing to tampanade. Frequently NSAIDs are given to reduce these complications. Evidence to support this strategy has been lacking. The POPE study, presented at AHA 09, looked at the use of diclofenac to reduce the volume of pericardial effusion. The findings, from the press release:A non-steroidal anti-inflammatory drug, diclofenac, failed to reduce fluid accumulation around the heart after cardiac surgery.The NSAID after heart surgery also did not reduce the serious problem of cardiac tamponade, compression of the heart by fluid. Only patients with pericardial effusion at baseline were enrolled. T...

Amyloid cardiomyopathy

Notes from Dr. RW — Fri, 20 Nov 2009 13:46:00 +0100

This Clinical Perspective piece in Circulation stresses the little appreciated fact that there are actually three types of cardiac amyloidosis: the AL type that we’re used to thinking of as well as two types of transthyretin related disease, the mutant type (of which there are over 100 mutations) and the wild type seen almost exclusively in older men. The three types differ in clinical features and prognosis. (Source: Notes from Dr. RW)

Dr. A Show 128: Mammogram Guidelines - Nov 20,2009

Doctor Anonymous Live — Fri, 20 Nov 2009 02:00:00 +0100

This week, you may have heard that there are new mammogram guidelines from the US Preventative Services Task Force which is a federal government panel. Debate in the medical community has been fierce. I'll review the guidelines and I'll break down the arguments both for and against the USPSTF guidelines.Doctor | Anonymous | Mammogram | Breast Cancer | Medicine (Source: Doctor Anonymous Live)

EMRs don't improve health care---yet

Notes from Dr. RW — Thu, 19 Nov 2009 18:41:00 +0100

Claims made over the last several years that EMRs lead to better quality of care have been devoid of supporting evidence. Now we have evidence from a large study that EMRs in fact don't improve quality. I apologize for not having a better source for this than a New York Times article, which reports that the findings were to have been reported at a conference in Boston. Unfortunately, the article didn't provide a link to the conference proceedings and didn't name the conference. Maybe I'll find the primary source later. In the mean time the article reports:But a new study comparing 3,000 hospitals at various stages in the adoption of computerized health records has found little difference in the cost and quality of care.“The way electronic medical records are used now has not yet had a re...

Autoimmune polyendocrine syndromes

Notes from Dr. RW — Thu, 19 Nov 2009 12:15:00 +0100

Reviewed here (Expert Review of Endocrinology and Metabolism). (Source: Notes from Dr. RW)

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Colchicine toxicity

Notes from Dr. RW — Thu, 19 Nov 2009 12:00:00 +0100

Brief review and lessons from the courtroom. (Source: Notes from Dr. RW)

AHA 09: the FOCUS study

Notes from Dr. RW — Thu, 19 Nov 2009 11:28:00 +0100

This study addressed an issue that often plagues hospitalists who are involved in co-management of patients undergoing hip fracture repair: when the patient's hemoglobin and hematocrit drop following surgery, what is the appropriate transfusion target in patients with cardiovascular disease or risk factors for CVD? While a H/H target of 8/24 has been validated for patients across the board, conventional wisdom has it that 10/30 is a more appropriate target for patients with cardiovascular disease. FOCUS compared strategies utilizing these two targets and found no advantage of the more aggressive transfusion strategy in terms of death or cardiac event rate. Results concerning the effect on functional outcomes have yet to be announced. (Source: Notes from Dr. RW)

From AHA 09 scientific sessions: CT-STAT

Notes from Dr. RW — Thu, 19 Nov 2009 00:51:00 +0100

It's always fun, after national meetings, to observe how the popular press botches the reporting of important findings that were presented. CT-STAT compared two diagnostic strategies for ER evaluation of chest pain in low and intermediate risk patients: initial cardiac markers and electrocardiograms followed by either traditional stress imaging or CT coronary angiography. Here's an Associated Press report on the findings. Nowhere in the report is there a link to the primary source (other than a link to the AHA website) and nowhere is the name of the study mentioned. Moreover, the article failes to inform readers of which of the several types of CT scans was used (it was CT coronary angiography). The article gets it wrong right out of the gate:A CT scan — a kind of super X-ray — provide...

ARBITER 6–HALTS---what does it really mean?

Notes from Dr. RW — Wed, 18 Nov 2009 22:11:00 +0100

This is somewhat old news by now, but its results have been widely distorted in popular media. With this post I hope to put the issue in perspective.From the NEJM abstract (italicized comments mine):Methods We enrolled patients who had coronary heart disease or a coronary heart disease risk equivalent, who were receiving long-term statin therapy, and in whom an LDL cholesterol level under 100 mg per deciliter (2.6 mmol per liter) and an HDL cholesterol level under 50 mg per deciliter for men or 55 mg per deciliter for women (1.3 or 1.4 mmol per liter, respectively) had been achieved. (Since when is an HDL cholesterol below a certain target an achievement?). The patients were randomly assigned to receive extended-release niacin (target dose, 2000 mg per day) or ezetimibe (10 mg per day). (A...

Dr. A Show 128: Mammogram Guidelines - Nov 20,2009

Doctor Anonymous Live — Wed, 18 Nov 2009 16:45:00 +0100

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As Hospitals Gain Cardiologist Employees, Private Cardiologists Are Shunned

Dr. Wes — Wed, 18 Nov 2009 15:20:00 +0100

An interesting story has developed in Missouri where a private group of cardiologists was asked to no longer see their patients at the local hospital. It seems the hospital hired it's own group of cardiologist-employees. Things grew so contentious according to the video accompanying the report, when the cardiologists asked for an OR lite, they were told to use a flashlight (the hospital disputes the claim).As the cardiologist shift to adjust for the economic realities that confront them, they have much more to lose from their patient relationships as its the patients that are inevitably affected the most when these shifts occur.-WesMusings of a cardiologist and cardiac electrophysiologist. (Source: Dr. Wes)

Sirolimus for Polycystic Kidney Disease

All Kidney News — Wed, 18 Nov 2009 15:07:58 +0100

New treatment options for polycystic kidney disease do not come along very often. The nature of the disease is such that treatment is inherently difficult as the pathophysiology is incompletely understood. Despite that various methods are currently being investigated. One such is the drug sirolimus, which has been mentioned before. More recently however a pilot study performed in adult polycystic kidney disease patients has added further hope that sirolimus may one day be used routinely in this disease. The effect of the drug sirolimus on development and growth of cysts was investigated over 6 consecutive months in 8 patients. Patients also received angiotensin receptor blockers which are considered standard therapy in kidney disease. A control group that consisted of another 8 patients...

How should hospitalists be cultivated?

Notes from Dr. RW — Wed, 18 Nov 2009 12:00:00 +0100

Here are the two competing models: 1) as clinicians at the top of their game and 2) as stage performers. I’ve been in the field since its beginnings and over the years I’ve seen it devolve from model number 1 towards model number 2. If the practice management track at SHM 2009 is any indication, model 2 is winning. Not a good thing, in my opinion. The title of hospitalist leader Mary Jo Gorman’s talk about running a program is a dead giveaway: “Performance Reviews: Dealing with the Problem Performer.” I don’t run a hospitalist program but if I did I’d be more interested in how my hospitalists functioned as clinicians than how they performed. Anyway, the focus of the talk was on behavior and conformity. Clinical skills were mentioned only in passing. There were some good point...

Sebelius: Talking the Talk or Walking the Walk?

Dr. Wes — Tue, 17 Nov 2009 20:38:00 +0100

Here's a bit of the transcript from Kathleen Sebelius, Department of Health and Human Services Secretary, speaking to the Wall Street Journal's CEO Council (approximately 2 min, 45 sec into video) about saving health care costs:... There are lots of features of the House Bill and that are already in the Senate bill that change that (the way doctors are paid). We are beginning to move away, particularly in Medicare, from traditional fee-for-service pay that I would suggest not only causes redundancy but doesn’t encourage innovative, high quality, low cost practices to moving toward a system that exists in pockets, exists in Mayos, Geisinger, (Inter-)Mountain Health Care. We know what it looks like. It isn’t how medicine is practiced it isn’t the the hospitals and providers are paid, s...

Medical Bloggers' Grand Rounds Is Up

Dr. Wes — Tue, 17 Nov 2009 17:49:00 +0100

... this week over at Colorado Health Insurance Insider.-WesMusings of a cardiologist and cardiac electrophysiologist. (Source: Dr. Wes)

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Monitoring patients for HIT

Notes from Dr. RW — Tue, 17 Nov 2009 12:15:00 +0100

Guidelines exist for monitoring hospitalized patients for the development of HIT and for evaluation of patients who develop thrombocytopenia. How well are they followed? Not very well at one academic medical center in the Netherlands: The frequency of compliance with platelet count monitoring recommendations was 26.3% for all patients receiving dalteparin, 35.6% for all patients receiving nadroparin, 23.0% for surgical patients receiving prophylactic dosing of either dalteparin or nadroparin, and 41.5% for patients exposed to UFH within 100 days before the start of either dalteparin or nadroparin treatment. Regular platelet count monitoring was strongly positively associated with medical patients (relative risk [RR] 2.33), surgical patients (RR 2.03), critically ill patients (RR 2.80), a...

Proper diet and exercise may stem cognitive decline

Notes from Dr. RW — Tue, 17 Nov 2009 12:00:00 +0100

Via Internal Medicine News. (Source: Notes from Dr. RW)

Compensating Doctors for After-Hours Call Coverage

Dr. Wes — Tue, 17 Nov 2009 11:13:00 +0100

Should there be a premium added to physician compensation for on-call coverage after hours, or are Medicare rates enough?This appears to be the central question between two competing hospitals in Longview, Texas where a $300,000 stipend was paid to a cardiology group by one hospital and not the other for cardiology on-call coverage.Guess which one the doctors are promoting now?Banos said the Diagnostic Clinic cardiologists recently approached Good Shepherd "demanding hundreds of thousands of dollars in compensation from Good Shepherd for providing call coverage to the patients of Good Shepherd.""This is in addition to whatever money they are able to bill and collect from patients and their insurance companies for the services they actually provide when they are called in to perform a proce...

Preventing Repeat Hospitalization in Dialysis

All Kidney News — Mon, 16 Nov 2009 17:24:08 +0100

Dialysis patients are known to have greater rates of hospitalization as compared to other patients. The cause for this is believed to be multifactorial. The present study by Chan et. al. looks at possible factors which may reduces the rate of hospitalization of dialysis patients after an initial admission. The population studied was quite large with over 126,000 dialysis patients involved. The premise of the study was that the management strategy at the time of first discharge was a significant contributor to the time to readmission of the patient. The Primary outcome of the investigation was therefore readmission of the patient within 30 days. Based on the abstract the study can be summarized as follows: Compared to pre-hospitalization values, the levels of hemoglobin, albumin, phospho...

Another review of autoimmune pancreatitis

Notes from Dr. RW — Mon, 16 Nov 2009 17:21:00 +0100

Via Expert Review of Gastroenterology and Hepatology.Key points:This is a newly appreciated clinical entity.It is a mimic of pancreatic carcinoma.It is very responsive to corticosteroids.Elevated IgG4 is characteristic. (Source: Notes from Dr. RW)

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Mechanical ventilation 101---understanding the modes

Notes from Dr. RW — Mon, 16 Nov 2009 16:16:00 +0100

This review in CCJM can be considered a companion paper to an earlier one I linked here, explaining the terminology of modes of mechanical ventilation. The CCJM review bridges the gap between theory and practice, focusing more on clinical application. It briefly covers basic terminology and focuses on newer (“alternative”) modes:We call these innovations “alternative” modes to differentiate them from the plain volume-control and pressure-control modes. Some clinicians rarely use these new modes, but in some medical centers they have become the most common ones used, or are being used unknowingly (the operator misunderstands the mode name).Say, for example, your hospital uses Dräger ventilators. You order CMV, and dial in a tidal volume. Think your patient's getting simple volume c...

How Not to Consent a Patient for Angioplasty

Dr. Wes — Mon, 16 Nov 2009 15:22:00 +0100

Yikes! "Honey, all you need to worry about is if I am going to listen to opera or Steely Dan during the procedure."-WesP.S. I told you "Honey" was bad.Musings of a cardiologist and cardiac electrophysiologist. (Source: Dr. Wes)

Dr. A Show 128: Thursday Night - Nov 20,2009

Doctor Anonymous Live — Sun, 15 Nov 2009 16:15:00 +0100

Looking for somewhere to relax on a Thursday night, why not come on into The Doctor Anonymous Show as we talk about the serious and not-so-serious news stories of the week including the areas of medicine/health, entertainment, pop culture, and whatever else comes up.Doctor | Anonymous | Medblogger | New Media | Medicine (Source: Doctor Anonymous Live)

US Health Care Reform Photoshop Contest

Dr. Wes — Sun, 15 Nov 2009 06:01:00 +0100

In the spirit of the upcoming holiday season and to make sure something on health care reform gets done before the end of the year, Dr. Wes and his wife, Diane, would like to propose the first (and perhaps only) US Healthcare Reform Photoshop Contest.Bring us your snark, your wit, your creativity about the health care reform efforts encapsulated in a single photograph. Photographs in support or against the current efforts will be equally considered, and you, dear internet devotees, will be the final judge. The winner receives an iPod Touch.Rules: No more than one photo entry per household, please. Create a single photo using Photoshop or other equivalent photo-editing software that encapsulates the essence of health care reform as you see it. Photographs must be G, PG, or PG-13 rated and f...

Methadone and Torsades

Notes from Dr. RW — Sun, 15 Nov 2009 03:00:00 +0100

This review contains a summary of the literature and recommendations for safety monitoring. (Source: Notes from Dr. RW)

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The ECG that screams for bicarb

Notes from Dr. RW — Sun, 15 Nov 2009 02:57:00 +0100

When AVR points toward heaven in the appropriate clinical setting your patient may be headed there before her appointed time without prompt action on your part. In another of his entertaining and fascinating discussions on telltale ECG patterns which guide emergency decision making Dr. James Roberts discusses the electrocardiographic toxidrome of tricyclic antidepressant poisoning. (Source: Notes from Dr. RW)

Dr. A Show 127: Faith Ignited - Nov 15,2009

Doctor Anonymous Live — Sun, 15 Nov 2009 02:00:00 +0100

Thanks so much to Kat from the BTR show Faith Ignited for calling into the show around halfway into the show. Before that, I talked a little bit about World Diabetes Day and also shared a few stories about what's been going on around here with me.....Doctor | Anonymous | Faith Ignited | New Media | Medicine (Source: Doctor Anonymous Live)

Dr. A Show: Saturday Night - Nov 15,2009

Doctor Anonymous Live — Sat, 14 Nov 2009 16:30:00 +0100

What is Intradialytic hypertension?

All Kidney News — Fri, 13 Nov 2009 22:37:11 +0100

This study suggests that use of a body composition monitor to determine percentage fat muscle and water may be able to assist in titrating a patient to the correct dry weight. Such a tool may be very useful in the treatment of patients with intradialytic hypertension. (Source: All Kidney News)

The Road to Servitude

DoctorMental — Fri, 13 Nov 2009 21:16:00 +0100

This was the name F.A. Hayek wanted to use for The Road to Serfdom in 1944, but because de Toqueville had already used it a couple of hundred years ago to describe the same thing, he changed it. The sentiment remains the same after all these years: collectivism enslaves us and diminishes our productivity, creativity, and humanity. It leads to immoral man ruling immoral society.Reading political economics from the first half of the twentieth century has an interesting dialect: "liberal" does not mean "liberal" the way Americans have known the word for a hundred years. Rather, when Hayek uses the work, he means "libertarian", or specifically, one who loves individual liberty and objects to collective planning. What we call "liberal" in the States, he calls socialism. Again, just a translatio...

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I’m not going to be a pregnant man

FtM Doctor — Fri, 13 Nov 2009 19:31:15 +0100

My wife and I have decided for a variety of reasons not to have children. She doesn’t want them and I can’t have them. In the early days of our relationship we thought it would be a short-term thing and I was only 23, so it just wasn’t an immediate issue. Then it got to crunch time. If I wanted to have a family I was going to have to find another girl. And lets face it men just don’t do that do they? Split up with women because they want children? Eventually I realised that I loved her more than I wanted to have children – this discussion ended up with us getting married. I still occasionally have a twinge of pain when I see children and realise they’re not going to be part of my life. But by and large it goes away. Sometimes I think of getting more invo...

ECG changes in STEMI

Notes from Dr. RW — Fri, 13 Nov 2009 16:09:00 +0100

This review in the American Journal of Emergency Medicine describes in detail the sequence of electrocardiographic changes over time in STEMI. (Source: Notes from Dr. RW)

Problems With Low-Energy External Defibrillators?

Dr. Wes — Fri, 13 Nov 2009 15:31:00 +0100

Seems the FDA wants to know more:FDA is investigating energy levels in (automatic) external biphasic defibrillators (AEDs) with shocks ≤ 200 J. FDA has received reports of 14 events since 2006 in which a 200 J biphasic defibrillator was ineffective in providing defibrillation/cardioversion therapy to a patient, whereas a subsequent shock from a different 360 J biphasic defibrillator resulted in immediate defibrillation/cardioversion. The majority of events occurred during attempts at cardioversion of atrial fibrillation, but there was at least one instance with defibrillation of a ventricular arrhythmia as well. FDA is seeking additional information in order to interpret the significance of these events, and to determine whether FDA activities are advised.I haven't seen this, but others ...

Stress testing in low risk chest pain patients---is it always necessary?

Notes from Dr. RW — Fri, 13 Nov 2009 14:02:00 +0100

Stress testing for patients presenting to the hospital with chest pain, particularly in this era of order sets and templates, has become knee-jerk. For low risk patients under 40 it may not be necessary according to this study:In our study, a combination of age younger than 40 years, nondiagnostic ECG result, and 2 sets of negative cardiac biomarker results at least 6 hours apart identified a patient group with a very low rate of true-positive provocative testing. Routine stress testing added little to the diagnostic evaluation of this patient group and was falsely positive in all patients who consented to diagnostic coronary angiography (4 of 6 cases).If nothing else, maybe stress testing could be deferred to out patient testing in some low risk patients who “rule out”, resulting in c...

DDAVP for prevention and treatment of overcorrection of hyponatremia

Notes from Dr. RW — Fri, 13 Nov 2009 12:55:00 +0100

Conclusion: Desmopressin acetate is effective in preventing and reversing inadvertent overcorrection of hyponatremia.The link above is to the entire paper free of access controls, which is worth reading in its entirety. I was struck be several points:The authors are experienced clinicians who are thoroughly familiar with the pathophysiologic rationale for the use of DDAVP. When used by such clinicians DDAVP is safe and effective in preventing and mitigating overcorrection of hyponatremia. The authors present several pearls governing effective use.Impending overcorrection is often signaled early by a return of renal diluting capacity evidenced by urine volume, urine osmolality, or the initial rate of rise in sodium concentration.Hyponatremia in this series was often multifactorial but the f...

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Perioperative care of patients with obstructive sleep apnea

Notes from Dr. RW — Fri, 13 Nov 2009 12:30:00 +0100

One of the speakers at SHM 09 mentioned that there were guidelines out concerning this. I was not aware they existed. They make some fairly strong statements which hospitalists need to be aware of, so I'm posting them here. (Source: Notes from Dr. RW)

Atherosclerotic renal artery stenosis

Notes from Dr. RW — Fri, 13 Nov 2009 12:15:00 +0100

In conclusion, the additional value of renal artery stenting needs to be established in patients who are aggressively medically managed; and a functional test to help us discern patients who would benefit from renal revascularization from patients who would not is needed. Because the issue of benefit from renal artery revascularization is still undecided, patients should be encouraged to enroll in randomized clinical trials. Only when we have solid evidence that patients will benefit significantly from renal artery revascularization in addition to optimal medical therapy should we incorporate RAS revascularization into routine medical practice. (Source: Notes from Dr. RW)

Systolic and diastolic heart failure represent a false dichotomy

Notes from Dr. RW — Fri, 13 Nov 2009 12:00:00 +0100

---one which was forced on us by clinical trial design and perpetuated by administrative documentation requirements.Read about it here. (Source: Notes from Dr. RW)

Waiting, and Hoping, For a Heart

Dr. Wes — Fri, 13 Nov 2009 10:45:00 +0100

A patient, recently listed for cardiac transplantation, tells his story about being rejected, then accepted, to the cardiac transplantation list:Next week, I'll check into Mayo, one of the world's premier hospitals, to undergo additional treatment in preparation for receiving a new heart. Since my brain tumor turned out to be benign and my prostate cancer has responded to treatment, doctors there said those issues no longer should disqualify me as a candidate for a heart transplant.Now that I'm on the list, I am on an around-the-clock standby alert. I have to be ready to be on the operating table within four hours once a compatible heart becomes available. The fact that Chicago is 331 miles from Mayo, in Rochester, Minn., complicates things since I don't have my own charter jet. But the Ma...

How to Find the Arrhythmia Patient's Room

Dr. Wes — Fri, 13 Nov 2009 02:51:00 +0100

When it's 1:00 AM and you're not sure where the patient with incessant ventricular tachycardia is located in the ICU, just turn to the telemetry strips:Click image to enlarge-WesMusings of a cardiologist and cardiac electrophysiologist. (Source: Dr. Wes)

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Need a New Medical School?

Dr. Wes — Fri, 13 Nov 2009 02:18:00 +0100

... just be a holdout on the vote to approve the House health care bill:In a statement, Costa said he succesfully negotiated funding for a UC Merced medical school."I am voting for HR 3962 because the choice of doing nothing was not an option. During my negotiations to help improve the bill for our Valley, I was able to achieve funding for a medical school in the Valley, with studies at UC Merced and residency in Fresno, as well as additional incentives to bring health professionals to our Valley. Increased funding in this bill for programs ranging from nurse training to health career opportunity programs to community health centers and increased reimbursement rates for low-paying Medicaid will go a long way in strengthening our health system in the Valley," Costa said.The bill, HR 3962, p...

Frontloading Surgical Performance

Dr. Wes — Thu, 12 Nov 2009 20:51:00 +0100

I must say, in all the years I have been practicing medicine, I have never seen a "thank you" gift delivered before surgery, but recently, our team got delivered this:Click image to enlargeNeedless to say, I was floored.But then I read the note, which was priceless:Click image to enlargeFortunately, all ended well, and no "oops" were had. But talk about the pressure to perform well!:)-WesMusings of a cardiologist and cardiac electrophysiologist. (Source: Dr. Wes)

Dr. A Show 127: Saturday Night - Nov 15,2009

Doctor Anonymous Live — Thu, 12 Nov 2009 16:45:00 +0100

Steroids for meningitis in adults and adolescents

Notes from Dr. RW — Thu, 12 Nov 2009 15:43:00 +0100

CONCLUSION: Our meta-analysis suggests that the adjunctive administration of corticosteroids is beneficial in the treatment of adolescents and adults with bacterial meningitis in patient populations similar to those seen in high-income countries and in areas with a low prevalence of HIV infection. (Source: Notes from Dr. RW)

Non-acetaminophen induced acute liver failure---is there a role for N-acetylcysteine?

Notes from Dr. RW — Thu, 12 Nov 2009 14:00:00 +0100

I've been hearing some noise about this lately. What does the evidence show? I got six citations doing a PubMed search with the following strategy:("acetylcysteine"[MeSH Terms] OR "acetylcysteine"[All Fields] OR "n acetyl cysteine"[All Fields]) AND non-acetaminophen[All Fields]Here they are:This small study compared treated patients with a historic controls and demonstrated reduced mortality. Oral NAC was used.This recently published RCT used IV NAC and demonstrated improved transplant free survival if used early. (For patients with advanced encephalopathy nothing short of transplant seems to salvage them).This Chest review of ALF makes mention of it as a possible modality in non-acetaminophen ALF.This paper suggests efficacy and safety in the pediatric population.This systematic review wa...

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More evidence that guideline adherence improves outcomes

Notes from Dr. RW — Thu, 12 Nov 2009 12:15:00 +0100

These data are from the Get with the Guidelines program, for heart failure and MI. (Source: Notes from Dr. RW)

Endemic mycoses

Notes from Dr. RW — Thu, 12 Nov 2009 11:54:00 +0100

We're talking, of course, about histo, blasto and cocci.Here are a couple of pearls from a review in Clinics in Chest Medicine:All can present as “CAP.” Coccidioidomycosis accounted for 29% of CAP cases in one Arizona survey!Endemic mycoses, particularly blasto, can present as ARDS.A systematic approach to diagnosis is outlined. (Source: Notes from Dr. RW)

On teenagers

FtM Doctor — Thu, 12 Nov 2009 00:10:04 +0100

Tonight I discovered Lamebook - think Regretsy for facebook. Oh? you haven’t discovered regretsy? Oh dear. It would have been such a productive evening if only you’d not checked my blog post. Lamebook is a website of a screen captures of face book, think Chealsee (14) annoucing she has genital warts, Kasha showing you pictures of her home waterbirth with little Kelsy watching. It’s great. And it’s finally taught me that teenagers are a different species. I can’t spell very well, but compared to some kids today I am a master of the art. Also I seem to have got the hang of using capital letters. One at the begining of the sentances, and also for abreviations and the word ‘I’. I have a vauge grasp of ‘you’re’ and ‘your’. ...

The House Health Care Bill and Bureaucratic Duplication

Dr. Wes — Wed, 11 Nov 2009 17:00:00 +0100

I don't mind health reform. In fact, I believe we need it. But when reform bills fund projects that already exist, or fund special projects for other non-health care professionals, like lawyers, I have to wonder what Congress is doing. The recently passed House bill (H.R. 3962 pdf) contains a multitude of grants and "demonstration projects." I wasn't sure what some of these grants were meant to support, so I looked them up. I was surprised to find that many of the grants duplicate programs or departments already in place. While this list is by no means comprehensive, I thought I would provide a few comments on a few of these grants shown in italics):Grant program for "community-based collaborative care"(Seems this is really a grant to fund telemedicine programs and HL-7 hospital coding sta...

Hyponatremia in hospitalized patients

Notes from Dr. RW — Wed, 11 Nov 2009 13:00:00 +0100

This is one of many reviews on this topic but it's not just any review. It is the most thorough examination of the pathopysiology I've seen in a long time. Read it when you're well rested and well fed. Two or three times.Via Medscape. CME available. (Source: Notes from Dr. RW)

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Heparin treatment of extreme hypertriglyceridemia

Notes from Dr. RW — Wed, 11 Nov 2009 12:45:00 +0100

Extreme hypertriglyceridemia is a significant threat when it occurs in hospitalized patients. It typically presents itself as a call from the lab that the patient's serum is lipemic. The patient is at risk for acute pancreatitis if s/he doesn't already have it. Compounding the management difficulty is the interference by lipemia with certain laboratory procedures, the best example of which is pseudohyponatremia although there are also other laboratory problems, and special analytical methods are needed.The Archives of Internal Medicine presents a case report and literature review of the use of heparin to rapidly clear triglycerides. The patient in question had DKA. Because lipemia is often post prandial NPO status itself may reduce triglycerides to a safe level. Insulin is a cofactor for l...

Statins and COPD outcomes

Notes from Dr. RW — Wed, 11 Nov 2009 12:28:00 +0100

Statin treatment is the first thing to come along since oxygen and smoking cessation to influence the long term outcome in COPD patients. From a new systematic review in BMC Pulmonary Medicine:Outcomes associated with treatment with statins included decreased all-cause mortality in three out of four studies (OR/HR 0.48–0.67 in three studies, OR 0.99 in one study), decreased COPD-related mortality (OR 0.19–0.29), reduction in incidence of respiratory-related urgent care (OR 0.74), fewer COPD exacerbations (OR 0.43), fewer intubations for COPD exacerbations (OR 0.1) and attenuated decline in pulmonary function. The RCT reported improvement in exercise capacity and dyspnea after exercise associated with decreased levels of C-reactive protein and Interleukin-6 in statin users, but no impro...

Should family members be present during CPR?

Notes from Dr. RW — Wed, 11 Nov 2009 12:15:00 +0100

Conclusion: The presence of a family witness may have a significant impact on physicians' ability to perform critical actions during simulated medical resuscitations. Further study is necessary to see if this effect crosses over into real clinical practice and if training ameliorates this effect.H/T to The HospitalistThe obvious limitation here is that the study was of simulated resuscitations. (Source: Notes from Dr. RW)

When patients admitted with COPD exacerbation die in the hospital

Notes from Dr. RW — Wed, 11 Nov 2009 12:00:00 +0100

---it's more often due to co-morbid conditions than from the COPD itself:Forty-three patients with a hospital admission diagnosis of COPD exacerbation underwent autopsy; all had died within 24 h of admission to the hospital. Twenty-three patients (54%) had a long COPD history (greater than 10 years), and 19 patients (44%) had more than one hospitalization in the last year of life. The median age at death was 70 years (interquartile range, 65 to 75 years), and male sex was predominant (n = 31; 72%). The main (primary) causes of death were reported as cardiac failure (n = 16; 37.2%), pneumonia (n = 12; 27.9%), and pulmonary thromboembolism (PTE) (n = 9; 20.9%). Respiratory failure due to a progression of COPD was the primary cause of death in six patients (14%). Most patients had more then o...

Eroding empathy

Notes from Dr. RW — Tue, 10 Nov 2009 13:30:00 +0100

Conclusions: It is concluded that a significant decline in empathy occurs during the third year of medical school. It is ironic that the erosion of empathy occurs during a time when the curriculum is shifting toward patient-care activities; this is when empathy is most essential.Ironic but intuitive. (Source: Notes from Dr. RW)

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When patients present with their first seizure

Notes from Dr. RW — Tue, 10 Nov 2009 13:15:00 +0100

Who needs AEDs and which ones? What work up?Here's a concise discussion of the ins and outs. (Source: Notes from Dr. RW)

Therapeutic hypothermia after cardiac arrest

Notes from Dr. RW — Tue, 10 Nov 2009 13:00:00 +0100

Beneficial in the latest Cochrane review.Medscape Heartwire coverage here. (Source: Notes from Dr. RW)

Quiz of the Day: The Distance Traveler

Dr. Wes — Tue, 10 Nov 2009 12:30:00 +0100

Q: What's a hundred years old and has traveled over 5 million miles?A: Would you believe a basketball?-WesMusings of a cardiologist and cardiac electrophysiologist. (Source: Dr. Wes)

Ischemic colitis for hospitalists

Notes from Dr. RW — Tue, 10 Nov 2009 12:00:00 +0100

Very helpful nuts-and-bolts review from CCJM. (Source: Notes from Dr. RW)

Where Treatment Guidelines Fall Flat

Dr. Wes — Tue, 10 Nov 2009 11:55:00 +0100

... when cases don't follow the rule book:All of the planned means of tackling Stellan's SVT today during his ablation failed initially. Heart block was induced each and every time from each and every angle they tried to ablate. Dr. A and his team were left with little choice but to ablate Stellan's AV node in order to get rid of his accessory pathway. But before they did, one of Dr. A's colleagues threw out a wild idea."Let's try to go through his aorta."Not in the plan. Not even in the possible or hypothetical plans. Not considered safe or feasible or wise on a 10 kilo baby. But with few options left before destroying Stellan's node, they decided to risk it.To be honest, I'm glad I didn't know about it at the time.So from his groin, they threaded the catheter up into his aorta, down into...

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Beneficial Effect of Coffee in Dialysis Patients

All Kidney News — Mon, 09 Nov 2009 22:24:41 +0100

Coffee is arguably the most popular beverage worldwide yet its impact on renal disease is largely unknown and its effect on dialysis patients is even more obscure. There have been many claims of medicinal or health benefits for drinking coffee. Studies have shown apparent reductions in the risks of: From http://en.wikipedia.org/wiki/File:Main_side_effects_of_Caffeine.png Alzheimer’s disease Parkinson’s disease Heart disease Diabetes mellitus type 2 Cirrhosis of the liver Gout. Recently a small study has reported that dialysis patients who drink coffee were more likely to have lower cholesterol. Of the 30 patients studied 26 were on peritoneal dialysis and only 4 were on hemodialysis. The patients were divided into two groups. Group I patients drank 1-3 cups of coffee per day ...

Balloon pumps for the rest of us

Notes from Dr. RW — Mon, 09 Nov 2009 12:15:00 +0100

Here's a primer on intra-aortic balloon counterpulsation. Full text from Medscape. (Source: Notes from Dr. RW)

Hyponatremia, gait disturbance and patient falls

Notes from Dr. RW — Mon, 09 Nov 2009 12:00:00 +0100

This article is a little dated. I just ran across it and found it of interest. Mild, chronic hyponatremia in the elderly is common and often thought best left alone. In this study it was associated with gait disturbance and fall risk. (Source: Notes from Dr. RW)

Bloggers Can Make a Difference on Veteran's Day

Dr. Wes — Mon, 09 Nov 2009 03:56:00 +0100

Meet the Eleven Eleven Campaign -- a nationwide campaign by BeyondTribute.org to change the way America honors its Veterans by hoping to raise $11 from 11 million Americans beginning (when else?) but November 11th.To learn more about the campaign and how you can help make this November 11th a day when bloggers come together to support our Vets, join the conference call Monday, November 9th at 8 pm ET/7 pm/CT/5 pm PT.Please RSVP to the conference call here:http://action.eleven-eleven.org/t/5400/signUp.jsp?key=2817Dial-in Number: 1-213-289-0500Participant Access Code: 4670471-Wesh/t: Glenn Reynolds at Instapundit.Musings of a cardiologist and cardiac electrophysiologist. (Source: Dr. Wes)

More acid base resources

Notes from Dr. RW — Sun, 08 Nov 2009 19:08:00 +0100

I'm linking to this Wikipedia article for the links at the bottom. Some of them are dead, but there are several excellent sites on the list. (Source: Notes from Dr. RW)

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220-215

Dr. Wes — Sun, 08 Nov 2009 11:41:00 +0100

House Bill 3962 passed by the narrowest of margins. I find it interesting that when others parse the implications of the bill's passage, doctors aren't mentioned.Kind of says it all.-WesMusings of a cardiologist and cardiac electrophysiologist. (Source: Dr. Wes)

The Acid Base Book

Notes from Dr. RW — Sat, 07 Nov 2009 23:00:00 +0100

---is an on line, open access textbook on acid base disorders currently under development as a labor of love by Robert Centor, MD, the blogger at DB's Medical Rants. Although it deals with some advanced concepts in acid base disorders it is case based and written in plain language.Comments are enabled; the site exemplifies the beauty of Web 2.0. This is a wonderful resource. More chapters are planned, but if you can't wait check out additional case discussions in DB's Medscape cases. (Source: Notes from Dr. RW)

NHLBI CPR study halted

Notes from Dr. RW — Sat, 07 Nov 2009 21:56:00 +0100

The ROC PRIMED trial, comparing different EMS protocols for cardiac arrest, was halted after data analysis showed no difference in outcomes. The two arms of the trial evaluated 1) an impedance threshold device attached to the airway and 2) two different durations of CPR applied before rhythm assessment and (when indicated) defibrillation. The NIH press release is a good example of the obfuscation that results in many attempts to make scientific findings palatable to the lay public. It reads in part (my emphasis):Enrollment has ended early in a large, multicenter clinical trial comparing two distinct resuscitation strategies delivered by emergency medical service (EMS) providers to increase blood flow during cardiac arrest. The study's independent monitoring board and the National Heart, Lu...

Should beta blockers be held or reduced when patients are hospitalized with acute decompensated heart failure?

Notes from Dr. RW — Sat, 07 Nov 2009 18:03:00 +0100

Conclusion: In conclusion, during ADHF, continuation of beta-blocker therapy is not associated with delayed or lesser improvement, but with a higher rate of chronic prescription of beta-blocker therapy after 3 months, the benefit of which is well established. In the vast majority of subjects the beta blocker dose was not changed. Patients requiring drugs like dobutamine were excluded. According to this Medscape commentary the OPTIMIZE-HF registry also supports beta blocker continuation: B-CONVINCED is consistent with an analysis from the OPTIMIZE-HF registry [3], in which maintenance of beta-blocker therapy in systolic ADHF dramatically cut mortality at two to three months (p=0.044), as did starting the drugs at discharge in such patients who hadn't previously been on them (p=0.006). Also ...

Neutropenic enterocolitis

Notes from Dr. RW — Sat, 07 Nov 2009 17:54:00 +0100

AKA typhilitis. Another review. (Source: Notes from Dr. RW)

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Autoimmune pancreatitis

Notes from Dr. RW — Sat, 07 Nov 2009 17:49:00 +0100

It mimics pancreatic carcinoma but there are differentiating clues. (Source: Notes from Dr. RW)

Criminal Penalties For No Insurance Possible Under Pelosi Bill

Dr. Wes — Sat, 07 Nov 2009 17:11:00 +0100

From a letter from the the non-partisan Joint Committee of Taxation from Rep David Camp to explain penalties for not carrying insurance under the Pelosi Bill (H.R. 3962):Americans who do not maintain “acceptable health insurance coverage” and who choose not to pay the bill’s new individual mandate tax (generally 2.5% of income), are subject to numerous civil and criminal penalties, including criminal fines of up to $250,000 and imprisonment of up to five years.Is this what American's want, criminal penalties including jail time?If not, I'd suggest you call, fax, or e-mail your Congressman today.-WesMusings of a cardiologist and cardiac electrophysiologist. (Source: Dr. Wes)

Cardiology Consolidation Continues

Dr. Wes — Fri, 06 Nov 2009 22:48:00 +0100

This time, in Kansas City:Cuts of the magnitude envisioned by Medicare, Holkins said, would present “a significant problem for the revenue side of our business model.”The 14-physician practice, which has roughly 80 employees, has been independent since its founding in 1975.So, Holkins said, the decision to affiliate was not taken lightly.“I have really liked the idea of being independent,” he said. “But I also like to be able to pay our employees well and have enough left so our physician partners make a comparable salary to their peers in Kansas City, and I saw that as something I would not be able to do going forward.”-WesMusings of a cardiologist and cardiac electrophysiologist. (Source: Dr. Wes)

Cardiac CT

Notes from Dr. RW — Fri, 06 Nov 2009 20:51:00 +0100

Here I will try and put together the essentials of this sometimes confusing and ever changing topic. Most of this information is from a lecture by Stephen Frohwein, M.D., delivered at the 2009 Tutorials in the Tetons Update in Cardiovascular Diseases. The use and indications for cardiac CT are more complex than many people appreciate. Although appropriate use of the various types of cardiac CT is becoming better understood, confusion abounds. Dr. Frohwein did such a good job of reducing it down to the nuts and bolts while maintaining the important distinctions that I thought it useful to summarize a few key points here. I will amplify this post with reference to the ACC Appropriateness Criteria. The notion of “cardiac CT” is meaningless unless distinctions are made. Three types of scan...

Reading the Fine Print of Government-Run Comparative Effectiveness Research

Dr. Wes — Fri, 06 Nov 2009 18:08:00 +0100

This week, the New England Journal of Medicine published the comparative effectiveness research trial "ROOBY" comparing conventional cardiac bypass surgery to off-pump bypass surgery. The study was conducted at VA medical centers and randomly enrolled 2203 patients between conventional bypass and off-pump bypass surgeries. The study concluded "At 1 year of follow-up, patients in the off-pump group had worse composite outcomes and poorer graft patency than did patients in the on-pump group. No significant differences between the techniques were found in neuropsychological outcomes or use of major resources." Excellent reviews of the trial (with associated surgeon commentary) are provided at theHeart.org and at MedPageToday.com.What I found interesting was the fact that over half of the oper...

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New Dialysis Modality Daily OL-HDF

All Kidney News — Fri, 06 Nov 2009 17:17:29 +0100

CONCLUSIONS: Daily OL-HDF promotes catch-up growth in children despite being on chronic dialysis. This catch-up growth if continued, should allow the children to reach their mid-parental target height in the future. It could be speculated that the improved response to rhGH is the result of several combined factors conducting to less malnutrition and to less cachexia. (Source: All Kidney News)

Dr. A Show 127: Thursday Night - Nov 13,2009

Doctor Anonymous Live — Fri, 06 Nov 2009 16:30:00 +0100

CDC Stroke Registry Suggests Ways to Improve Care

APCblogit — Fri, 06 Nov 2009 16:21:18 +0100

In treating stroke, both physicians and the public can improve their roles, according to a 3-year analysis of results published in MMWR.Data on some 60,000 patients with stroke from Georgia, Illinois, Massachusetts, and North Carolina were entered into the federally sponsored Paul Coverdell National Acute Stroke Registry between 2005 and 2007. Stroke types were as follows: hemorrhagic, 14%; ischemic, 56%; transient ischemic attack, 22%; and "ill-defined," 7%.Researchers examined 10 treatment performance measures and their use among eligible patients. Among the results: Over a third of patients used private transportation rather than emergency medical services to get to the hospital. Only about 20% arrived at the hospital within 2 hours of symptom onset. Almost all got antithrombo...

Reader Poll: Should House Health Care Bill Pass?

Dr. Wes — Fri, 06 Nov 2009 14:50:00 +0100

With the US House of Representatives set to vote on the ‘‘Affordable Health Care for America Act’’ (H.R. Bill 3962) this weekend, should the bill pass?Vote in the sidebar and feel free to leave any comments you'd like to make below.-WesP.S. I'm not tracking URL's nor marketing - promise - just interested what others who read this blog think.Musings of a cardiologist and cardiac electrophysiologist. (Source: Dr. Wes)

Six Sigma and Lean

Notes from Dr. RW — Fri, 06 Nov 2009 12:15:00 +0100

---are process improvement methodologies originated by industry (Motorola and Toyota, respectively) increasingly employed by health care systems. They are coming to be viewed as more robust than the traditional quality improvement methods used by hospitals. Joint Commission is getting interested. Expect to hear more about this. Here is a paper describing the experience of four hospital emergency departments using Lean to improve throughput and patient satisfaction. (Source: Notes from Dr. RW)

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Renal injury after sodium phosphate bowel prep

Notes from Dr. RW — Fri, 06 Nov 2009 12:00:00 +0100

Phosphate nephropathy, which can lead to not only AKI but also CKD, is an emerging concern as more and more case reports appear. Here is an in depth review. (Source: Notes from Dr. RW)

Dr. A Show 126 Wrap-up: Crzegrl

Doctor Anonymous — Fri, 06 Nov 2009 05:09:00 +0100

Thanks so much to Emily from Crzegrl.net for being my special guest on Show 126. To be honest, with her very busy schedule these days, I wasn't sure if she would be available to be on the show. That's why I didn't mention it beforehand. The show was orignially titled "Guy Fawkes" and that's what you hear at the beginning of the show (don't be alarmed). Anyway, Emily called in from her car, and we had a great interview.In case you hadn't heard yet, Crzegrl will be hosting next week - not only Grand Rounds, but also Change of Shift - sheesh! With next week being Veteran's Day, she's thinking of that type of theme for GR and CoS next week. We also talked about other things as well: Her mother was recently diagnosed with breast cancer, Emily was promoted to Army Reserves Commander of her Medic...

Cancer's Miracle

Dr. Wes — Fri, 06 Nov 2009 05:04:00 +0100

It's a strange thing, cancer.It renders the greatest intellect impotent.Families coalesce, grapple, then muster their courage to confront the reality, their angst cloaked in platitudes and favors. Certainly there must be something we can do!Slow. Gradual. Relentless. And yet it's moving too fast.I wake at night to my wife's restlessness, the thoughts of her mother circulating. Why her? Why now?A sniffle, a sigh. There is little I can do.The relentless march goes on, the cadence quickening.We realize now what's important; her mother's gifts to us a gem.-WesMusings of a cardiologist and cardiac electrophysiologist. (Source: Dr. Wes)

Influenza update

Notes from Dr. RW — Fri, 06 Nov 2009 04:21:00 +0100

Recent coverage of influenza in the professional media has consisted of a dizzying flurry of disjointed sound bites. I have set out to put together the essentials here. We continue to struggle to find an appropriate name for the pandemic strain. The latest is “2009 H1N1” (formerly novel influenza A H1N1, to be distinguished from any ordinary seasonal H1N1 strains). Who should receive antiviral treatment? This Medscape Medical News piece summarizes the latest revision (October 16) of the CDC recommendations. In short, the treatment is recommended for individuals with suspected influenza considered to be at high risk. This will include 70% of hospitalized patients. From the news piece: High-risk groups include children younger than 2 years, adults 65 years or older, and pregnant women an...

One Special Operation

Dr. Wes — Fri, 06 Nov 2009 03:02:00 +0100

Real life is so much better than Grey's Anatomy.-WesMusings of a cardiologist and cardiac electrophysiologist. (Source: Dr. Wes)

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A Cardiology Fellow Saves a Life on the Subway

Dr. Wes — Fri, 06 Nov 2009 02:02:00 +0100

Dr. Sonia Tolani, 32, a first-year cardiology fellow at NewYork-Presbyterian/Columbia, notches her belt with another save after 20 minutes of CPR on the subway..."Stayin alive, stayin' alive, ah ah ah ah..."Nice work!-WesMusings of a cardiologist and cardiac electrophysiologist. (Source: Dr. Wes)

Dr. A Show 126: Crzegrl - Nov 06,2009

Doctor Anonymous Live — Fri, 06 Nov 2009 02:00:00 +0100

Thanks to much to Emily from Crzegrl.net for stopping by the show tonight to talk about her hosting the medblog carnivals Grand Rounds and Change of Shift - in the same week! We also talked about the tragedy that occurred today at Fort Hood Army base in Texas. We also talked about her mom's battle with breast cancer, Emily's promotion to Army Reserve Commander of the 334th Medical Group in Michigan, and the upcoming Veteran's Day next week. Following the interview, I talked about some recent stories in the news. Thanks to those who listened live and to those who will listen on the archives. I very much appreciate it!Doctor | Anonymous | Crzegrl | Emily McGee | Fort Hood (Source: Doctor Anonymous Live)

Is the American Medical Student Association contributing to the infiltration of non-evidence based woo in academic medicine?

Notes from Dr. RW — Thu, 05 Nov 2009 18:47:00 +0100

Multiple factors have contributed to the rising promotion and teaching of quackery in mainstream academic medical centers, something I've called quackademic medicine. Financial incentives, such as funding from the National Center for Complementary and Alternative Medicine (NCCAM) and the Bravewell Collaborative, are well known. Add to this the fact that more and more consumers demand quackery and are willing to pay for it out of pocket. Yes, it is to a large extent about money. Medical educators and health system administrators have sold out.But it's not all about money. There's a deeper cultural change at work at the medical student level, driven by the American Medical Student Association (AMSA). As the largest and most influential organization of medical students, AMSA is not only groo...

Do the Ends Justify the Means?

Dr. Wes — Thu, 05 Nov 2009 18:32:00 +0100

John Cassidy of the New Yorker thinks so:So what does it all add up to? The U.S. government is making a costly and open-ended commitment to help provide health coverage for the vast majority of its citizens. I support this commitment, and I think the federal government’s spending priorities should be altered to make it happen. But let’s not pretend that it isn’t a big deal, or that it will be self-financing, or that it will work out exactly as planned. It won’t. Many Democratic insiders know all this, or most of it. What is really unfolding, I suspect, is the scenario that many conservatives feared. The Obama Administration, like the Bush Administration before it (and many other Administrations before that) is creating a new entitlement program, which, once established, will be vir...

Will the copyright treaty take us back to Web 1.0?

Notes from Dr. RW — Thu, 05 Nov 2009 14:43:00 +0100

Here's some of what's leaked from secret negotiations to hammer out the treaty, according to Boing Boing:That ISPs have to proactively police copyright on user-contributed material. This means that it will be impossible to run a service like Flickr or YouTube or Blogger, since hiring enough lawyers to ensure that the mountain of material uploaded every second isn't infringing will exceed any hope of profitability. I have no idea what this really means. Read the rest of the post and the large comment thread. (Source: Notes from Dr. RW)

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Tygecycline for refractory C diff?

Notes from Dr. RW — Thu, 05 Nov 2009 12:15:00 +0100

This is not something worthy of a change in practice yet. File it away in the “stay tuned” category. (Source: Notes from Dr. RW)

Natriuretic peptide levels to guide heart failure therapy

Notes from Dr. RW — Thu, 05 Nov 2009 12:00:00 +0100

Although this has been a swinging pendulum the latest meta-analysis suggests that using BNP or proBNP to guide treatment improves mortality. (Source: Notes from Dr. RW)

Dr. A Show 126 Tonight

Doctor Anonymous — Thu, 05 Nov 2009 10:48:00 +0100

Thursday, November 5th, 2009 at 9pm ETI hope that you can join us tonight for the show. There is no scheduled guest, but there may be an "unscheduled" guest. You'll just have to tune in to find out. There's a lot going on in the news and current events to talk about as well on the show this week. I was happy to participate to day in what is called "BlogBlast For Peace" in which a group of bloggers place what is called a "peace globe" on their blog. You can read my post here, and you'll notice I don't have much of a peace globe, but I wanted to write something for today.I also wanted to point out that our good friend Crzegrl has chosen - has volunteered - host not one but two blog carnivals - Grand Rounds and Change of Shift - in the same week. Why? Who knows? I thought that I was crazy for...

Blogblast For Peace 2009

Doctor Anonymous — Thu, 05 Nov 2009 01:01:00 +0100

I know this post is early, but it's already November 5th in some parts of the world. I wanted to thank Mimi for all of your hard work in putting this together. The Peace Globe Movement has been very inspiring to watch over the past couple of years. The video above pretty much sums it up. I invite you to read my posts from 2007 and 2008 for Blogblast For Peace.But, if you would like to learn more from the founder herself - Mimi Lenox. I invite you to check out two interviews I had with her. The first interview was Doctor Anonymous Show number 11 on October 25, 2007. And, the second interview was during Doctor Anonymous Show number 56 on November 6, 2008. I'm sorry that I was unable to bring Mimi back on the show in time for BlogBlast 2009, but I hope to have Mimi back on the show soon. Enjo...

Latest Kidney News: Post ASN Round Up.

All Kidney News — Wed, 04 Nov 2009 20:19:18 +0100

This report is based on a study done 314 dialysis patients in Finland published online in the journal nephrology dialysis and transplantation. The reason for improved survival is believed to be due to improvement in diabetes care over the years studied, which were 1995 to 2005. Elements of improved care which have been cited include better blood pressure control with newer drugs as well as adherence to modern protocols concerning the control of blood glucose in diabetes. Medpage is reporting that the use of EPO has been trending upwards for the last few years, supporting data has been recently published in abstract and presented at the ASN this year. However the data captured did not include years after the outcome of several negative trials for the use of EPO in the treatment of anemia in...

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Health Care Insurance Gift Cards

Dr. Wes — Wed, 04 Nov 2009 19:53:00 +0100

... for Florida residents, they're just in time for the holidays!Starting this month you can find these gift cards at any Winn Dixie and in November you can find them at CVS pharmacy stores.There are two types of gift cards available. One is called "the blue health care card" It acts like a temporary health insurance. For $59.00 it gives you health insurance coverage for one to 2 1/2 months based on your age. Here's how it works. You buy the gift card at the store, and the person receiving the card activates it. Then they enroll in a variety of plans offered. After that, you'll receive a package in the mail with a member id card.You can use the temporary insurance gift card to see a doctor, a dentist, at the pharmacy, or for lab work.The other gift card is called the family blue discount c...

Prescription benefit plans in Canada

Notes from Dr. RW — Wed, 04 Nov 2009 12:15:00 +0100

Conclusion— Among HF patients, residing in a province with a more restrictive prescription plan may be associated with lower use of restricted HF medications over and above the expected regional differences in HF drug use across provinces. (Source: Notes from Dr. RW)

Are Pharmacies Getting Flu Shots Before Doctors?

Dr. Wes — Wed, 04 Nov 2009 12:14:00 +0100

From the Chicago Tribune:"I am a pediatrician in suburban Cook County. We signed up to receive the vaccine, and have yet to get it. I hear it is going to go to local pharmacies before we get it. They only vaccinate children 9 and above. ... Who is going to ensure that infants and asthmatics get vaccinated?"The response from the Illionois Department of Public Health's spokeswoman Kelly Jakubek was telling:"We currently are only placing orders for hospitals and health departments, which we consider the front line of health care," she said.Chicago vaccine providers are under a similar system in which the first shipments go to places that serve the most at risk, said Dr. Julie Morita, medical director of the Chicago Department of Public Health. Her department places the orders and selects the ...

Aortic valve calcification

Notes from Dr. RW — Wed, 04 Nov 2009 12:00:00 +0100

---(calcific aortic sclerosis or stenosis) is an atherosclerotic process and predicts atherosclerosis elsewhere. (Source: Notes from Dr. RW)

A Little Electronic Health Record Satire

Dr. Wes — Wed, 04 Nov 2009 04:48:00 +0100

SEEDIE (The Society of Exhorbitantly Expensive and Difficult to Implement EHR's) (the same organization that certified Extormity) issues it's definition of "meaningful use:""What is meaningful use?" asked executive director Sal Obfuscato at a recent SEEDIE executive retreat in Belize. "We believe the question is the answer, as man has always struggled to find meaning in this world."This insight led SEEDIE to suggest that certified EHR vendors should embed quotes from well known philosophers in their applications. This approach will prompt physicians and other caregivers to actively seek meaning as they document patient encounters. "When I am treating a patient, a thought-provoking quote from Jean Paul Sartre or Voltaire is far more valuable than the ability to e-prescribe or adhere to evid...

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Show 126 Preview

Doctor Anonymous — Wed, 04 Nov 2009 03:01:00 +0100

I'd like to invite you to Doctor Anonymous Show 126 this week which will be Thursday, November 5th, 2009 at 9pm Eastern Time. There is no scheduled guest but there may be an "unscheduled" guest - we'll see. But, there are lots that are going on this week to talk about.On November 5th will be the latest observance of what is called the "BlogBlast For Peace." I first heard about this when I first started blogging about 3 years ago. The founder of this movement calls herself Mimi Lenox, and she's been on the show before. It's basically the idea to get as many bloggers to talk about the same thing on the same day. You'll see my post when I put it up - probably late tomorrow or on Thursday.Election Day in the United States also took place this week. I might mention that on the show. Plus, who k...

EP Woo: Electrohypersensitivity Syndrome

Dr. Wes — Tue, 03 Nov 2009 22:03:00 +0100

Do you have headaches, difficulty concentrating, insomnia, heart irregularities and headaches, fatigue, poor short-term memory, difficulty sleeping, skin problems, tinnitus, nausea, and dizziness? You might have electrohypersensitivity syndrome, a variant of "cell-tower blues!" Yep, conclusive data gleaned from a study of twenty-five whole patients out of 100 to be studied has discovered at least one example of a "DECT" (aka Digital Enhanced Cordless Telecommunications in the 1.9-2.4GHz band) cell phone causing increased heart rate and irregularities! Never mind that actual signals are not included in the data, but only a graph of "R-R intervals." (Um, in case you were wondering, noise will cause variations in surface EKG signals and shortening of RR intervals.)But don't pay attention to d...

What drug is best for initial treatment of rapid atrial fib?

Notes from Dr. RW — Tue, 03 Nov 2009 21:21:00 +0100

According to the results of this study it's good old, tried-and-true diltiazem: Measurements and Main Results: The primary end point was sustained VR control (less than 90 bpm) within 24 hours; the secondary end points included AF symptom improvement and length of hospitalization. At 24 hours, VR control was achieved in 119 of 150 patients (79%). The time to VR control was significantly shorter among patients in the diltiazem group (log-rank test, p less than 0.0001) with the percentage of patients who achieved VR control being higher in the diltiazem group (90%) than the digoxin group (74%) and the amiodarone group (74%). The median time to VR control was significantly shorter in the diltiazem group (3 hours, 1-21 hours) compared with the digoxin (6 hours, 3-15 hours, p less than 0.001) ...

Factors in hospitalist retention

Notes from Dr. RW — Tue, 03 Nov 2009 19:16:00 +0100

Compensation is the obvious one according to this article in ACP Hospitalist, but there are intangibles:Professional development activities can also give hospitalists a chance to bond with their colleagues and build loyalty to a program. “Whether it’s journal clubs or in-service training by specialists, those are all part,” said Dr. Sheff.These activities can also contribute to hospitalists’ sense of identification with their field, which may currently be lacking. “Some physicians are seeing a [hospitalist] career path as being nothing more than a glorified resident,” Dr. Sheff said.Blogging about hospital medicine is one of my remedies for that. It keeps me engaged and interested in the field. (Source: Notes from Dr. RW)

How hospital medicine groups have thrived in troubled economic times

Notes from Dr. RW — Tue, 03 Nov 2009 19:13:00 +0100

Two new themes emerge from this article in The Hospitalist:Hospitalist groups need to align their incentives with hospitals.Hospitals with hospitalists have an easier time recruiting subspecialists. (Source: Notes from Dr. RW)

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Easy rule out test for aortic dissection?

Notes from Dr. RW — Tue, 03 Nov 2009 19:02:00 +0100

Conclusion— D-dimer levels may be useful in risk stratifying patients with suspected aortic dissection to rule out aortic dissection if used within the first 24 hours after symptom onset.As with VTE, although the negative predictive power is good, the positive predictive power is poor. (Source: Notes from Dr. RW)

When Hoop-Jumping Becomes Patient Care

Dr. Wes — Tue, 03 Nov 2009 13:31:00 +0100

"Doc, I've got good news and bad news.""What's that?""Well, I've lost six more pounds!" "Wonderful! What's the bad news?""Well, you know that new-fangled drug you gave me that works so well for my atrial fibrillation?""Yes.""We'll, I'm part of that AARP Medicare Advantage Part D drug plan, and I just got the "partial" approved drug list for 2010 in the mail. My drug's not on the list, so I called and found the drug's been moved from a Tier II drug to a Tier III drug. That means it will cost me twice what I paid for it this year. That's gonna be tough, doc. I can't afford it.But I also read that if you call this '800' number and speak to them, they'll allow me to obtain an exemption to keep the drug on Tier II for next year."I called the number as I typed his note. The patient seemed please...

Election Day 2009

Doctor Anonymous — Tue, 03 Nov 2009 05:18:00 +0100

I think the image above this pretty much sums it up. I know that this is not a presidential election year. But, there are a lot of important issues out there especially on a local and state level. So, do yourself and your fellow citizens a favor and make the time to head on out to the voting place today and make your voice be heard - no matter how you feel about a particular candidate or issue. Happy Election Day! (Source: Doctor Anonymous)

Show 125 Wrap-up

Doctor Anonymous — Tue, 03 Nov 2009 05:10:00 +0100

Thanks again to Gina from CodeBlog for being on Doctor Anonymous Show 125 last week. (I know that this is late getting posted - sorry about that.) I don't know about her, but I had a great time during the interview. And, I know that the people in the chat room had a great time as well. The medbloggers are very fond of CodeBlog, and I can see why.We talked about her origins in nursing and the origins of her in the blog world. Did you know that Code Blog was one of the first medblogs out there? Not only one of the first nursing blogs, but, arguably, one of the first medblogs that was created. We had a great conversation about that and about Grand Rounds and her experience at BlogWorld Expo 2009.As always, you can listen to the show on the player above. Or, if you like, you can download the s...

Darbepoetin alfa is unsafe as well?

All Kidney News — Mon, 02 Nov 2009 23:33:08 +0100

Darbepoetin alfa is a an erythropoesis stimulating agent marketed under the name Aranesp by AMGEN. It is used for the treatment of anemia ( a lower than normal blood count) as a consequence of renal failure or cancer. The use of other similar agents has been questioned over the last 2 to 3 years due to studies in both patients with cancer as well as patients with CKD and on dialysis, which demonstrated an increased risk of mortality, which was due in large part to cardiovascular disease particularly stroke. The debates that occurred due to the outcome of these studies were legendary, due to the counterintuitive findings that suggested treatment to a target normal Hb was dangerous. Yet some learned individuals maintained that the issue was less the target Hb and more the dose of EPO and tim...

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Overuse of CTPAgrams for diagnosis of PE

Notes from Dr. RW — Mon, 02 Nov 2009 16:39:00 +0100

According to a poster presentation at a recent conference of the American Thoracic Society:The total number of CTPAs performed for suspected PE stood at 87 in 2000 but jumped to 1,115 in 2005 and to 1,883 in 2008, reported Dr. Chandra, a second-year fellow in the division of pulmonary and critical care at the medical center. In contrast, the percentage of CTPAs that were positive for PE declined during the same period, from 30% in 2000 to 20% in 2005 to 15% in 2008.According to the survey results docs are not applying pretest probability assessment to guide use of CTs.Even more importantly, why not just order a good old fashioned V/Q scan? Test performance in appropriately selected patients is as good as CT.I bet this is keeping the nephrologists busy.Via Hospitalist News. (Source: Notes f...

Not Seeing the Forest for the Trees

Dr. Wes — Sun, 01 Nov 2009 12:27:00 +0100

Congress, in their efforts to be conciliatory to specialists, is now working to alienate primary care physicians, too:(Medicare payment) Reductions will be made over four years rather than imposed at once in 2010, the U.S. Centers for Medicare and Medicaid Services said yesterday in a statement. In July, the agency said it planned to slice $1.4 billion, or more than 10 percent, in payments for each of the two specialties, triggering what an advocate promised would be a “tooth and nail” battle. The administration argued that the lower reimbursements for specialists would make more dollars available for lower-paid non-specialists who can focus on preventing expensive, chronic illnesses. That would tame the growth in medical costs, one goal of President Barack Obama’s effort to remake t...

New Treatments For FSGS -ASN Conference

All Kidney News — Sun, 01 Nov 2009 01:11:07 +0100

Idiopathic focal and segmental glomerular sclerosis or FSGS is one of the most common causes of non diabetic kidney disease in the world and also one of the least satisfying to treat due to the difficulty with initiating and maintaining a durable remission. For decades the standard of treatment has been steroid therapy in high doses given either daily or every other day. This results in significant toxicity which includes the development of diabetes mellitus, osteoporosis, personality changes, weight gain, easy bruising etc. Yet these negative effects of steroid therapy are outweighed significantly by the result of not treating FSGS as the disease will usually progress to end stage renal disease (with a requirement for dialysis and transplantation). Even after transplantation there is a ri...

Hospitalists at your beck and call

Notes from Dr. RW — Sat, 31 Oct 2009 01:58:00 +0100

(Source: Notes from Dr. RW)

ASN conference day 2

All Kidney News — Fri, 30 Oct 2009 21:14:34 +0100

The conference has been extremely crowded so far with some talks having to close doors due to inability to accommodate any more people after all sitting and standing room has been exhausted. So I have turned to the poster sessions in attempt to connect with some of the breaking research which is yet to be published. When they are eventually published the data presented in posters may be the source of the next oversubscribed big session at ASN next year. Dr. Mita M shah et. al. sought to answer the question as to whether the immune system in older patients becomes less responsive. If this is true then older patients who receive transplants will need less medication. This would be an important finding because immunosuppressive medications have side effects which worsen lipid profile and may ...

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Could Statins Be Protective Against H1N1 Flu?

Dr. Wes — Fri, 30 Oct 2009 19:40:00 +0100

In a retrospective study, it's a definite maybe:Of the patients studied, 801 were taking statins anyway and continued taking them while hospitalized. Seventeen patients who were taking statins died while in the hospital or within a month afterward, compared to 64 who were not taking statins, Vandermeer said.Overall, 2.1 percent of patients taking statins died, compared to 3.2 percent of patients not taking statins. That means patients taking statins were just under 50 percent less likely to die.Turns out this is from a press release regarding reports being presented this weekend at the annual meeting of the Infectious Diseases Society of America (IDSA) in Philadelphia, so while the data are intriguing, they are by no means conclusive.-WesMusings of a cardiologist and cardiac electrophysiol...

Dr. A Show 126: Thursday Night - Nov 06,2009

Doctor Anonymous Live — Fri, 30 Oct 2009 16:30:00 +0100

Significant Digits

Dr. Wes — Fri, 30 Oct 2009 13:45:00 +0100

I find it interesting that the Congressional Budget Office's House health care bill budget estimate was posted to four significant digits ($1.055 Trillion dollars) even though CBO Director Doug Elmendorf, in a Thursday letter to House Democratic Chairmen, cautioned that his estimates are preliminary and "subject to substantial uncertainty."Why is that so?Could it be that the "estimate" looks better as $1.055 trillion when reported in the press than $1.1 trillion? I guess these days, what's a few hundred billion dollars among friends?-WesMusings of a cardiologist and cardiac electrophysiologist. (Source: Dr. Wes)

Hands can do incredible things…

Ivor Kovic, M.D. — Fri, 30 Oct 2009 09:51:00 +0100

…but nothing compares to using them to help save a life American Heart Association is conducting a promotional campaign to motivate and educate people to learn and if necessary perform Hands-Only CPR. They say that…. “When an adult has a sudden cardiac arrest, his or her survival depends greatly on immediately getting CPR from someone nearby. But less than 1/3 of those people get that help. Most bystanders are worried they might do something wrong or make things worse.” Could not agree more. Among other very useful materials, they have created this great interactive web application called Hands Symphony which is so incredibly fun. Try it and share it with other. If you get only one person to learn Hands-Only CPR, that would be a great thing. Tweet This (Source:...

Hospitalists and comanagement---the debate continues

Notes from Dr. RW — Fri, 30 Oct 2009 04:11:00 +0100

But the debate, as illustrated by a point-counterpoint piece in the October issue of The Hospitalist, is not about whether collaboration among hospitalists, surgeons and subspecialists is good for patient care. It's about the importance of dealing with unintended consequences and defining the relationships.There are strong arguments in favor of comanagement as a model which benefits patients. It it's not done carefully, though, the adverse consequences for patient care are many and it is a driver of career dissatisfaction. Eric Siegal, M.D., a co-author of the piece, described a situation all too familiar:In the wee hours of a recent busy call night, the ED called me to admit a patient whose automatic implantable cardioverter cefibrillator (AICD) had fired repeatedly. The patient had no ot...

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Dr. A Show 125: Code Blog - Oct 30,2009

Doctor Anonymous Live — Fri, 30 Oct 2009 01:00:00 +0100

Six time Grand Rounds host Code Blog will be our guest on The Doctor Anonymous Show this week. Blogging since 2002, Code Blog is one of the leading nursing bloggers, if not one of the leading medical bloggers out there. We'll talk about her hosting Grand Rounds this week with a Halloween theme, her experience at the Medblog Track at BlogWorld Expo, and we'll talk about her long running blog. Hope you can join us!Doctor | Anonymous | Grand Rounds | Code Blog | Medicine (Source: Doctor Anonymous Live)

Halloween Edition of 'Change of Shift' Is Up

Dr. Wes — Thu, 29 Oct 2009 21:42:00 +0100

Change of Shift, the best each week of the nursing blog-o-sphere, is up this week over at Reality Rounds.-WesMusings of a cardiologist and cardiac electrophysiologist. (Source: Dr. Wes)

Highlights of the American Society of Nephrology Conference Day 1.

All Kidney News — Thu, 29 Oct 2009 20:12:32 +0100

After a whirlwind 12 hours of connecting flights I have finally arrived in San Diego to attend this years American Society of Nephrology conference. The opening session of the 42nd annual conference was kicked off with an engrossing lecture by Nobel Prize winner Dr. Roger Tsien MD. Dr Tsien gave an overview of his prize winning research on labeling of molecules with photo-labile elements and fluorescent techniques which allow direct visualization of processes which could only previously be imagined. The highlight of his presentation was his novel use of color as a tool and guide for surgeons. By injecting molecules that bind to cancer cells or their products, cancer cells can be made to glow any color that he chooses. This allows the operating surgeon to see the extent of the tumor in real...

Coincidence or Foreshadowing?

Dr. Wes — Thu, 29 Oct 2009 17:31:00 +0100

Funny. Nancy Pelosi introduces the 1,990 page health care bill the same day Walmart announces they're going to sell caskets and urns.-WesMusings of a cardiologist and cardiac electrophysiologist. (Source: Dr. Wes)

When Hospitals Do Halloween

Dr. Wes — Thu, 29 Oct 2009 17:03:00 +0100

... they can get creative with "pump-kin" decorating:Click image to enlargeHeh. Happy halloween!-WesMusings of a cardiologist and cardiac electrophysiologist. (Source: Dr. Wes)

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Dr. A Show 125: Code Blog

Doctor Anonymous — Thu, 29 Oct 2009 03:31:00 +0100

Thursday, October 29th, 2009 at 9pm ETI am so happy to welcome Gina from Code Blog to this week's edition of The Doctor Anonymous Show. Code Blog was the host of Grand Rounds this week and it had a Halloween theme. For the first time, I think this year, I made a contribution to Grand Rounds. I know that's pretty pathetic - especially since I have been a past host to the premiere medblog carnival around.Anyway, we'll be talking Grand Rounds this week along with talking about Code Blog which has been around since 2002. Code Blog is one of the leading nursing blogs out there. In addition to all of this, we'll be talking (again) about BlogWorld. I first met Gina in Las Vegas a couple of weeks ago, and we'll get her perspective of the MedBlog Track. So, I hope that you can join us!If you are ne...

Best. Heart Pillows. Ever.

Dr. Wes — Wed, 28 Oct 2009 18:57:00 +0100

Wish I'd seen this earlier (Picture at the link):The girls of Girl Scout troop 6254 will literally and figuratively give away their hearts next weekend.As part of the troop's "stress for less" badge project, the troop's 10 fifth graders have spent about six weeks cutting, stuffing and sewing heart-shaped pillows. But instead of sitting on living room sofas, the throw pillows will land in the arms of heart surgery patients at Scott and White Hospital in Temple.Rachael Clift, one of three co-leaders of the troop, said the project was born when the troop came up with ways to be less stressed."One of them was to give to others because if you can focus on other people, sometimes that's helpful instead of concentrating on what you're stressed about," she said.Each troop member gave individual at...

Dr. A Show 125: Code Blog - Oct 30,2009

Doctor Anonymous Live — Wed, 28 Oct 2009 16:30:00 +0100

Show 125 Preview

Doctor Anonymous — Wed, 28 Oct 2009 10:51:00 +0100

The Doctor Anonymous Show proudly welcomes six-time Grand Rounds host Gina from Code Blog to the show. For her post this week, she had a Halloween theme which was very well done. I encourage you to check it out if you haven't had a chance yet. Something I really enjoyed this week was that on her twitter account, he took us behind the scenes about what it was like being a GR host. We'll talk about that as well. Even the Grand Rounds founder, got a little nostalgic about that.....We'll also talk about her blog, which according to her archives, goes all the way back to 2002. I could be wrong, but this has to be one of the first medical blogs out there. She and I only met in Las Vegas a couple of weeks ago at the Medblog Track at BlogWorld Expo. And, I admit that I wanted to get to talk with h...

Management of ulcerative colitis in hospitalized patients

Notes from Dr. RW — Wed, 28 Oct 2009 04:40:00 +0100

Steroid therapy is the mainstay in severe cases. How long should you wait for a response before resorting to surgery or rescue medical therapies? What rescue therapies are available? These issues are discussed in a recent review in Expert Review of Gastroenterology and Hepatology. (Source: Notes from Dr. RW)

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Mechanical ventilation strategy in ARDS/ALI

Notes from Dr. RW — Wed, 28 Oct 2009 04:37:00 +0100

Conclusion: Available evidence from a limited number of RCTs shows better outcomes with routine use of low VT but not high PEEP ventilation in unselected patients with ARDS or acute lung injury. High PEEP may help to prevent life-threatening hypoxemia in selected patients. (Source: Notes from Dr. RW)

Might Medicare "Bundled Payment" Incentives Influence Patient Care Decisions?

Dr. Wes — Tue, 27 Oct 2009 22:12:00 +0100

One wonders, might this be construed as a bribe?Under the pilot project, Medicare is saving 4.4% on the base rates for heart and joint surgeries at Hillcrest because the hospital is offering a discount. For Morrow's knee replacement, for example, the government is paying $13,211, about $450 less than it normally would.Meanwhile, Morrow, who is eager to get back to playing basketball, gets a portion of the savings from Medicare — $271 as an incentive for going to a hospital that participates in the program.The three-year experiment, which began in May, is taking place at five hospitals identified by Medicare for high-quality, cost-efficient care. All competed to get into the program by offering discounts to Medicare.Besides Hillcrest, Baptist Health System in San Antonio is taking part, w...

What Congress Missed in the Health Care Reform Debate

Dr. Wes — Tue, 27 Oct 2009 22:06:00 +0100

I mean, how are we going to pay for this?-WesMusings of a cardiologist and cardiac electrophysiologist. (Source: Dr. Wes)

Defibrillators and Video Pill Endoscopies Can Mix

Dr. Wes — Tue, 27 Oct 2009 21:24:00 +0100

A radiofrequency interference myth debunked:A new Mayo Clinic study suggests that video capsule endoscopy (CE), a procedure that uses wireless technology in diagnosing intestinal disease, is safe for patients with heart devices. Wireless electrical gadgets, such as cell phones, have been shown to interfere with implanted heart devices, including pacemakers and defibrillators. This risk has led medical experts to speculate that capsule endoscopy could similarly cause heart devices to fail. As a result, the noninvasive procedure has been contraindicated by the U.S. Food and Drug Administration (FDA) for patients with cardiac devices. Contraindication means an increased risk may be involved.Generally, the topic has remained in the subject of speculation, although several small studies have fo...

When New York Health Care Moves to Tennesee

Dr. Wes — Tue, 27 Oct 2009 16:06:00 +0100

From the mail bag:Market forces today are causing more hospital systems to "affilitate" so they can share (pdf) management expertise to improve staffing efficiencies and purchasing power with lucrative medical device contracts. I find it interesting that hospital systems and their administrators can move across state lines at will, but patients can't get similar leverage across state lines for their health insurance purchases.Always good to see whose driving the bus in health care reform.-WesMusings of a cardiologist and cardiac electrophysiologist. (Source: Dr. Wes)

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For Cardiology Fellows: One Tough Job Market

Dr. Wes — Tue, 27 Oct 2009 03:15:00 +0100

The e-mails from fellows are coming from far and wide. Faced with the uncertainty over health care reform, the slumping economy, and the looming pay cuts to cardiologists, cardiology fellows are seeing one of the most challenging job markets in years. As a result, the number of e-mails we've received from fellows probing for potential job openings has accelerated to unprecedented levels. For those who fear health care reform, fear not.Before any bill has made it to the Congressional floor, certain aspects of health care reform are already here.-WesMusings of a cardiologist and cardiac electrophysiologist. (Source: Dr. Wes)

The Shortage of Primary Care Services: Utilizing Nurse Practitioners and Physician Assistants to Relieve the Crisis

APCblogit — Mon, 26 Oct 2009 14:54:07 +0100

From Bob Blumm, MA, PA-C, DFAAPA:t is evident that the American system of health care is in need of an overhaul. Current figures indicate that there are over 46 million people who are uninsured. This equates to 15% of our nation's citizens who may not be able to access health care. The American College of Clinicians submits that Physician Assistants (PAs) and Nurse Practitioners (NPs) already significantly improve access to primary care services, but are underutilized in our current health care delivery system. While fewer physicians are choosing primary care, a new paradigm exists. But there has been a systemic failure to recognize that the skills and knowledge of PAs and NPs makes them well qualified to fill the role of primary care provider. Even though these individuals demonstrate...

Paved by Good Intentions

Dr. Wes — Mon, 26 Oct 2009 11:13:00 +0100

"After this shift, I will have worked 105 hours this week.""Why is that?" I asked."Because unlike the emergency room, where care is transfered easily to guys arriving at the next shift, hospitalists don't have that luxury. We have to stick with our patients once they're ours. Let's say it's quarter to five. The nocturnist comes on at six. The call comes from the ER and you get a guy that's sick as hell: something like an aortic dissection with crappy renal function that's too sick for surgery. He's never been in our system. No history. No real physical. The family doesn't know his medications. The ER only provides a listing - no doses - I have to call their home and get the list or wait for them to bring in the bottles, review the labs, order a slew more tests. I can't just offload the cas...

My Take on H1N1

Doctor Anonymous — Mon, 26 Oct 2009 04:01:00 +0100

A lot of people have been asking me what I think of the H1N1 virus and the vaccine that will eventually be made available to the public. Here are some facts to start out with - these come right from the CDC website. More than 9000 hospitalizations and nearly 600 deaths have been reported to CDC associated with H1N1 - of these deaths, approximately 95 have been in children (as of this post 10/26/09).Now granted, annually, approximately 36,000 deaths occur with regular seasonal flu. This fact alone should at least make you think about getting your seasonal flu shot, if you haven't already done so.I also agree that the press has been hyping the situation up for the past six months with the H1N1 story - prior to that months and months of stories about the bird flu (remember bird flu?). Plus, w...

Insulin Resistance and Kidney Disease, some thoughts.

All Kidney News — Sun, 25 Oct 2009 01:21:56 +0100

Insulin resistance Insulin resistance is a term many doctors and scientists are already familiar with. However not that many patients have a concept of exactly what is meant by resistance to insulin. Other than its role in the causation of type 2 diabetes, Ginsberg considers insulin resistance a major underlying abnormality driving cardiovascular disease, the major cause of morbidity and mortality in much of the world. Although most of the research produced thus far focused on the role of insulin resistance in diabetics, it is now apparent that insulin resistance is important in its own right. Insulin resistance is a syndrome that has been linked to increased risk for cardiovascular disease. However its effect is believed to act via promoting dyslipidemia, hypertension, hypercoagulability,...

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Type 2 diabetes cures

Notes from Dr. RW — Sat, 24 Oct 2009 17:32:00 +0100

Generally I don’t like to be anecdotal but today I will. The testimonials in this LA Times piece are so compelling I’ll even overlook the Yoga references. These were obese folks with “bad” type 2 diabetes who used lifestyle changes to dispense with insulin and completely reverse their disease processes. It drives home the point that you treat insulin resistance with exercise and caloric reduction. These patients’ doctors were treating overeating with more and more insulin. Predictably, they got worse. Of course these were exceptionally motivated people. For folks who can’t seem to diet and exercise we sometimes have to treat their overeating with insulin just to decrease microvascular disease, but it’s not physiologic. Read the whole article but ignore the parts about Yoga. (...

The Senate Finance Committee’s proposed device tax

Notes from Dr. RW — Sat, 24 Oct 2009 15:42:00 +0100

---is part of the Senate health care bill. After explaining how it works Dick Morris notes: The result will be that virtually every piece of advanced surgical equipment will be subject to a price increase to meet the levy from Washington. No matter that these devices often make the difference between life and death and that, in effect, taxing them raises the cost of vital treatments. The vengeful White House will have its pound of flesh from the medical device industry for daring to be independent and to refuse to knuckle down to administration pressure.This tax, imposed in a spirit of haughty arrogance, falls on totally inappropriate objects. Valves, prosthetic limbs, pacemakers, hearing aids and such are essential therapies that make life longer, better and less painful. To tax them make...

The Pacemaker Tax

Dr. Wes — Sat, 24 Oct 2009 13:33:00 +0100

... or is it really just an "assessment?"The legislation does not work like a sales or excise tax. Rather, it follows the model of the punitive tobacco settlement imposed on cigarette companies in the '90s. It assesses an industry-wide payment that firms must make in proportion to their market share. It bars the them from passing along the cost of the assessment by charging more for certain basic products, but allows them to raise the price of others to raise the funds for the fee.The result will be that virtually every piece of advanced surgical equipment will be subject to a price increase to meet the levy from Washington. No matter that these devices often make the difference between life and death and that, in effect, taxing them raises the cost of vital treatments. The vengeful White ...

Dr. A Show 125: Thursday Night - Oct 30,2009

Doctor Anonymous Live — Fri, 23 Oct 2009 15:45:00 +0100

Think You Know Government Health Care?

Dr. Wes — Fri, 23 Oct 2009 12:01:00 +0100

Now you can prove it.Bring friends and family together to tackle this crossword comprised of only five complete words and twenty common government health care-related acronyms. Only the uniquely tolerant will survive:Click image to enlargeHave fun! -WesGive up? Answers here.Musings of a cardiologist and cardiac electrophysiologist. (Source: Dr. Wes)

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Pulmonary embolism review

Notes from Dr. RW — Fri, 23 Oct 2009 10:55:00 +0100

One glaring flaw in this review: the claim that CTA is the imaging modality of choice without evidence to back it up. Otherwise it's pretty good. (Source: Notes from Dr. RW)

WPW syndrome

Notes from Dr. RW — Fri, 23 Oct 2009 10:48:00 +0100

Review in American Journal of Emergency Medicine. (Source: Notes from Dr. RW)

Pneumothorax for hospitalists

Notes from Dr. RW — Fri, 23 Oct 2009 10:46:00 +0100

Here are the nuts and bolts. (Source: Notes from Dr. RW)

Peritoneal Dialysis and Encapsulating Peritonitis

All Kidney News — Fri, 23 Oct 2009 04:04:23 +0100

Sclerosing Encapsulating Peritonitis affects alters the normal Peritoneum Image Source (http://us.i1.yimg.com/us.yimg.com/i/edu/ref/ga/l/1035.gif) Peritoneal dialysis relies on the peritoneal lining as a surface for the exchange of substances during dialysis. However the peritoneal membrane was never intended to be used for this purpose. The goal of peritoneal dialysis research is to find the least traumatic and disruptive method of ensuring efficient dialysis occurs for as long as possible before the peritoneal lining is “worn out”. The greatest advance in this area would entail some method that allows the membrane to continue to function indefinitely. One of the unsolved problems remains the absence of any clear way to predict the peritoneal membrane will react under the same...