Friday, January 30, 2015

Thursday, January 29, 2015

Hypertension management in stroke patient post discharge

From a new paper in Stroke:

Background and Purpose—We examined blood pressure 1 year after stroke discharge and its association with treatment intensification...

Results—Among 3153 patients with ischemic stroke, 38% had greater than or equal to 1 elevated outpatient SBP eligible for treatment intensification in the 1 year after stroke. Thirty percent of patients had a discharge SBP less than or equal to 140 mm Hg, and an average 1.93 treatment opportunities and treatment intensification occurred in 58% of eligible visits. Forty-seven percent of patients discharged with SBP 141 to160 mm Hg had an average of 2.1 opportunities for intensification and treatment intensification occurred in 60% of visits. Sixty-three percent of the patients discharged with an SBP greater than 160 mm Hg had an average of 2.4 intensification opportunities, and treatment intensification occurred in 65% of visits.

Conclusions—Patients with discharge SBP greater than 160 mm Hg had numerous opportunities to improve hypertension control. Secondary stroke prevention efforts should focus on initiation and review of antihypertensives before acute stroke discharge; management of antihypertensives and titration; and patient medication adherence counseling.

I do have concerns with the authors' last suggestion that some patients' regimens need to be intensified while they are still in the hospital. It is common practice, and in accordance with the guidelines, to allow “permissive hypertension” in the early stages post ischemic stroke. Sometimes we even withhold patients' pre-admission antihypertensives. It is difficult at times to know just when to resume such medications let alone intensify a patient's regimen.

More from ACP Hospitalist Weekly.

Parkinson's disease in the perioperative period: what the hospitalist needs to know

This review from the green journal contains a lot of pearls applicable not only to the perioperative situation but to hospitalization in general. From the abstract:

Challenges in managing patients with Parkinson's disease in the perioperative hospital setting include disruption of medication schedules, “nothing by mouth” status, reduced mobility, and medication interactions and their side effects. Patients with Parkinson's disease are more prone to immobility and developing dysphagia, respiratory dysfunction, urinary retention, and psychiatric symptoms. These issues lead to higher rates of pneumonia, urinary tract infections, deconditioning, and falls compared with patients without Parkinson's disease, as well as prolonged hospital stays and a greater need for post-hospitalization rehabilitation. Steps can be taken to decrease these complications, including minimizing nothing by mouth status duration, using alternative routes of drugs administration when unable to give medications orally, avoiding drug interactions and medications that can worsen parkinsonism, assessing swallowing ability frequently, encouraging incentive spirometry, performing bladder scans, avoiding Foley catheters, and providing aggressive physical therapy. Knowing and anticipating these potential complications allow hospital physicians to mitigate nosocomial morbidity and shorten recovery times and hospital stays.

Wednesday, January 28, 2015

NEJM perspective piece on maintenance of certification

This is an interesting read and it is available as free full text.

Some of the features of the article:

Recent changes in the maintenance or certification (MOC) process are briefly reviewed.

A web based petition now has over 19000 anti-MOC signatures.

MOC is not supported by outcome based evidence, though some research has been done.

Claims that MOC has solid support from practicing physicians are debunked.

The relevance of MOC to the realities of clinical care is questioned.

The American Board of Internal Medicine is beset with the perception, if not the reality, of financial conflict of interest.

The MOC process has been criticized formally by numerous professional organizations, one of which has a lawsuit pending against the American Board of Medical Specialties.

The article concludes:

Regardless of how the MOC issue is resolved, the recent focus on the ABIM has shed a bright light on how medicine is regulated in the United States. The ABIM is a private, self-appointed certifying organization. Although it has made important contributions to patient care, it has also grown into a $55-million-per-year business, unfettered by competition, selling proprietary, copyrighted products. I believe we would all benefit if other organizations stepped up to compete with the ABIM, offering alternative certification options.

More broadly, many physicians are waking up to the fact that our profession is increasingly controlled by people not directly involved in patient care who have lost contact with the realities of day-to-day clinical practice. Perhaps it's time for practicing physicians to take back the leadership of medicine.

Cannabis and cardiovascular risk

From a recent report in the Journal of the American Heart Association:

Methods and Results In France, serious cases of abuse and dependence in response to the use of psychoactive substances must be reported to the national system of the French Addictovigilance Network. We identified all spontaneous reports of cardiovascular complications related to cannabis use collected by the French Addictovigilance Network from 2006 to 2010. We described the clinical characteristics of these cases and their evolution: 1.8% of all cannabis‐related reports (35/1979) were cardiovascular complications, with patients being mostly men (85.7%) and of an average age of 34.3 years. There were 22 cardiac complications (20 acute coronary syndromes), 10 peripheral complications (lower limb or juvenile arteriopathies and Buerger‐like diseases), and 3 cerebral complications (acute cerebral angiopathy, transient cortical blindness, and spasm of cerebral artery). In 9 cases, the event led to patient death.

Conclusions Increased reporting of cardiovascular complications related to cannabis and their extreme seriousness (with a death rate of 25.6%) indicate cannabis as a possible risk factor for cardiovascular disease in young adults, in line with previous findings. Given that cannabis is perceived to be harmless by the general public and that legalization of its use is debated, data concerning its danger must be widely disseminated. Practitioners should be aware that cannabis may be a potential triggering factor for cardiovascular complications in young people.

Tuesday, January 27, 2015

Dr. Lawrence Weed and the problem oriented medical record

The video below is a medical grand rounds presentation by Dr. Weed at Emory
in 1971.



There are several shots of J. Willis Hurst and Nanette Kass Wenger on the front row starting at 11:39.  Following that presentation Hurst went on to champion the problem oriented medical record.  

At 22:30 Weed points out that we should avoid jumping to a premature diagnosis by stating a problem only at the level of resolution we have at the time pending further data or expertise.

At 33:53 Weed states: “The problem list should not have 'rule outs', question marks or 'probables'; it should be a precise reproducible statement of the problem at the level you can undersstand it and guarantee it no matter how unsophisticated you have to get.”

Even with the problem lists embedded in today's EMR we're not nearly as rigorous in our approach as Weed envisioned 44 years ago.  

Medscape interview on maintenance of certification (MOC)

Check out the transcript and audio here of an interview with one of MOC's main detractors who proposes alternative means for accountability which would be less burdensome, more clinically relevant and less expensive.

Precocious acute coronary syndrome

From a recent study of very young patients presenting with ACS:

A total of 124 patients met inclusion criteria. The mean age was 31 ± 4 years for both sexes. Approximately half (49%) of the patients were obese (body mass index greater than or equal to 30 kg/m2); 90% of patients had at least 1 traditional risk factor, most commonly hyperlipidemia (63%) and smoking (60%); 52% of patients underwent re-vascularization, of which 94% were by percutaneous coronary intervention, and 42.9% of patients had intracoronary thrombus, of whom approximately one third had no detectable underlying coronary disease.

Very young patients with acute coronary syndrome tend to be obese, with a high prevalence of smoking and hyperlipidemia. The presence of thrombus in the absence of underlying coronary disease suggests a thromboembolic event or de novo thrombotic occlusion, which may reflect primary hemostatic dysfunction in a considerable number of these patients.

When I first saw the title of this paper I was expecting to see a lot of novel genetic risk factors, but apparently the investigators did not look for those.

Monday, January 26, 2015

Case presentation: a “non STEMI” that wasn't and the no reflow phenomenon

Among the lessons in this case from Dr. Smith's ECG blog:

Acute proximal coronary occlusion may present with ST depression as the principal ST segment abnormality.

The no reflow phenomenon can be diagnosed by serial ECGs.

Background from an older post here.

The conversation on maintenance of certification (MOC) continues

Recently a medical journalist jumped into the discussion on MOC, criticizing the detractors who have expressed recent outrage about the process. I criticized the piece here, calling out what I thought was a series of straw man arguments. Now the journalist, Larry Husten, has opined again.

He states emphatically in his posts that he is not defending the current MOC process. In fact, in one of his comment threads he says he doesn't even know enough about it to do so. He's not defending the process. Practicing doctors merely want to reform it. It would appear we are in agreement. So why all the fuss? Mr. Husten explains it this way, from the same comment thread:

Remember, I am NOT defending the current MOC system. I don’t know enough about it. I am responding to some of the arguments that have been made against MOC. These ideas strike me as wrong and dangerous and should not go uncorrected simply because everyone else is angry– and perhaps justifiably so– at the current MOC system. In other words, just because the current system may need reform does not justify the use of poor arguments.

The problem is, as I pointed out in my earlier post, Mr. Husten has mischaracterized those arguments. His posts read like attack pieces on the character of practicing doctors. The title of his first post implies that the MOC detractors (who represent the rank-and-file of the profession) are a bunch of crybabies: Three Reasons Why You Don’t Need To Feel Sorry For Doctors. The second title implies that the MOC detractors are wanting immunity from accountability: Why Doctors, Like Airline Pilots, Should Not Be Completely Trusted. Straw man again.

The airline industry analogy, popularized in the early days of the patient safety movement, has since been overstretched. It falls apart on many levels. In using it to build his straw man for the medical profession Mr. Husten does have one valid point in that he seems to be saying that since airline pilots have to be accountable so should doctors:

I would never get on an airplane if I didn’t feel highly confident that the pilot was fully competent. In order to fly a commercial airplane a pilot has to undergo rigorous and continuous training and testing. I’d walk before flying with a pilot whose only credential was his assurance that he’d been diligently “keeping up with his field” and that he was extremely confident in his abilities. I’m glad to know that the FAA and the airlines have extremely demanding programs to ensure the competency of pilots.

Nobody in this discussion disagrees with that.

But a little further down he references my earlier post in this manner:

One of my critics proposed that “it is the individual physicians who should be mainly responsible for their own learning needs, not some group of outsiders.” I wouldn’t get on a plane flown by a pilot who was “mainly responsible” for his or her own learning needs. The same logic is even more true for doctors.

Here the airline pilot comparison falls apart. Airline pilots have a domain of knowledge they have to master. If that's true in medicine it's true in a very different way. Medical knowledge is an ever moving, rapidly expanding target.  Over 2000 citations are added to Medline every day. That's why an essential component of the practice of evidence based medicine (EBM) is looking up answers to focused clinical questions at the point of care. This process is widely recognized as a major part of life long learning. And to my earlier point, it has to be done by the individual clinician rather than some outsider because it is centered around a unique patient.

But to say that individual doctors are responsible for their own learning is not to say they are immune from accountability. None of us are asking to make up the questions to our own certifying exams! Accountability must be objective and it must be external. We would all agree with Mr. Husten on that point.

Finally, the conversation up to now has ignored the fact that doctors have accountability structures in place that go way beyond MOC and licensure. In my work in credentialing I deal with other types of certification as well as clinical process and outcome monitoring of physicians which takes place continuously and on many levels.

Statins reduced periodontal inflammation

In this study.

Sunday, January 25, 2015

Palliative care in the ICU

Palliative care is increasingly being recognized as a part of definitive critical care regardless of prognosis. Review here.

Via Hospital Medicine Virtual Journal Club.

Are corticosteroids beneficial for cardiac sarcoidosis?

From a recent systematic review:

There are no published clinical consensus guidelines or systematic evaluation supporting the use of corticosteroids for the treatment of cardiac sarcoidosis. The purpose of this study was to systematically review the published data...

A total of 1491 references were retrieved and 10 publications met the inclusion criteria. There were no randomized trials and all publications were of poor to fair quality. In the 10 reports, 257 patients received corticosteroids and 42 patients did not. There were 57 patients with AV conduction disease treated with corticosteroids, with 27/57 (47.4%) improving. In contrast, 16 patients were not treated with corticosteroids and 0/16 improved. Four publications reported on left ventricular function recovery, 2 reported on ventricular arrhythmia burden, and 9 reported on mortality. However, the data quality were too limited to draw conclusions for any of these outcomes.

Our systematic review identified 10 publications reporting outcomes after corticosteroid therapy. The best data relates to AV conduction recovery and corticosteroids appeared to be beneficial. It is not possible to draw clear conclusions about the utility of corticosteroids for the other outcomes. There is a clear need for large multicentre prospective registries and trials in this patient population.