Tuesday, June 7, 2011

Move Over MRSA - It's VISA and VRSA Time

Is it too late to buy stock in the company that makes linezolid?

This group up in Detroit reviewed 320 patients with MRSA bacteremia and found that 52.5% experienced Vancomycin failure.  Their conclusion states several significant OR for failure, but review of the between-group differences doesn't show a lot of significant differences.  Nursing homes, for example, were the only p < 0.05, and predicted vancomycin success with a p of 0.02.

What is more important than their clinical predictors, however, is their review of the bactericidal activity of vancomycin - and that higher MICs and higher troughs are needed to effectively treat patients.  I've seen our pharmacists recognize this at my hospital as well - the 1g IV Vancomycin standard initial load is transitioning to a weight-based dose.

But, more importantly, what we're probably really observing is the initial stages of the end of vancomycin's utility for MRSA.  And, I hate to see what happens when TMP/SMX stops working, too....

http://www.ncbi.nlm.nih.gov/pubmed/21460309

Monday, June 6, 2011

Overdiagnosis of Pulmonary Embolism

Another over-testing over-diagnosis article effectively illustrating issues endemic to our current medical culture.

They do a retrospective national database review regarding the impact of the introduction of CTPA protocol for rule-out PE, and note that we've diagnosed three times as many PEs in 2006 as we did in 1998.  And, by detecting more PEs, we managed to reduce mortality attributed to PE...along the same gradually decreasing trendline that was present prior to the introduction of CTPA.

Figure 2 is the truly damning graphic - look at all those extra PEs we're finding and treating for effectively no substantial benefit.  Their secondary analysis was in-hospital anticoagulation complications on patients with any diagnosis of PE, which has jumped 71%.  Thank goodness we can put them on dagibatran now instead of coumadin and not be able to reverse their life-threatening bleeding episodes....

Again, we are testing people who shouldn't be testing, finding disease of uncertain clinical significance, and harming them with overtreatment - and let's not even start with the costs.

http://www.ncbi.nlm.nih.gov/pubmed/21555660

Sunday, June 5, 2011

Physician Perception of Ethnicity Preferences at End Of Life

I'm not sure what this paper definitely adds to the body of literature, but it's been awhile since I read anything on this topic, so I thought it was interesting.

I will give the disclaimer that this has been my limited anecdotal experience during my time in MICU, SICU, PICU etc., that certain ethnic groups were less likely to be amenable to withdrawal of care discussions, transitions to comfort care, hospice, etc., much to our absolute frustration that we were expending inordinate resources to torture some poor ventilated husk of person with no chance of functional recovery.  This study, in a small single-center sample, more or less confirms that we all share that same perception - but, in theory, it doesn't change our practice.

This study surveyed physicians regarding their perceptions of black vs. white end-stage cancer patients, and they tended to believe that a black person would be more likely to want continued aggressive treatment at the end of life.  The remainder of their article, which is a little more difficult to interpret, basically said that regardless of the perceptions, they still recommended the same (in statistical aggregate) treatment to the black vs. white hypothetical cohorts.

While this study didn't find any measurable treatment differences, we've seen all throughout the literature that perception tends towards reality, and that there are many cases of measurable outcomes differences for different ethnicities.  This study just leaves me with a sour taste and more questions than answers.

http://www.ncbi.nlm.nih.gov/pubmed/21460710

Friday, June 3, 2011

Testing For Pulmonary Embolism is More Harmful Than Helpful

This is, in my opinion, the most conceptually important article I have read in the few months I've been posting to this blog.

This is where Dr. Newman and Dr. Schriger, outstanding clinicians and analysts of data, present a compelling case regarding the diagnosis and treatment of pulmonary embolism.  In brief, the authors try to estimate, based on the limited evidence, both the benefits and harm of diagnosis and treatment of pulmonary embolism.  In their review, very few patients were found to benefit from treatment of pulmonary embolism - the existing evidence is weakly supportive of anticoagulation.  Additionally, they show a great many patients were harmed by excessive testing and treatment of clinically unimportant pulmonary embolisms.

This is, while a complicated opinion piece, a lovely summation in a nutshell of the concept that finding more "disease" does not equal better outcomes.  And, depending on the risks of testing and treatment - the barbaric contrast, radiation, and rat poison that diagnosis of PE typically entails - more people would be alive today if we all stopped testing for pulmonary embolism.

This is not unique to pulmonary embolism - this is partly the same issue we encounter with overtesting our low-risk chest pain patients, particularly with CTA.  What this means - and, of course, subject to legal challenge in our bizarre society - is that with our current methods of detection and treatment, society would be better off as a whole if we missed a few pulmonary embolisms in order to find and treat the few clinically relevant ones.  The only shame in this article is that not nearly enough people will read it and take it to heart.

http://www.ncbi.nlm.nih.gov/pubmed/21621091

Thursday, June 2, 2011

Liability Protections For Emergency Services

Smart folks at ACEP - tying liability reform to cost savings, which makes liability protection for Emergency Physicians an easier sell.  I have to say, the training environment these days is so skewed, I don't think anyone graduating now knows how to practice without scanning everyone, as it's become generally the standard of care.  The "quality of care" argument is a little new to me - but I certainly could move patients through more quickly, have less sign-out liability, etc., if I weren't tying up beds waiting for scans.

But, the threat of a lawsuit is a big one.  And it's not just us - so many PMDs refer their patients to the ED for a CT scan - whether the test is indicated, how miserable a malpractice hearing would it be to have testimony from the PMD who thought a CT was indicated after you declined to order it.

Next step beyond liability protection - Press-Ganey protection - for all these patients who expect answers, and CTs at the minimum, and aren't going to fill out very favorable patient satisfaction surveys without getting what they want....

http://www.acep.org/Content.aspx?id=79958

Wednesday, June 1, 2011

Hurricane Season

June 1st marks the start of Hurricane season.

Many Emergency Physicians are acutely aware of the need for disaster preparedness, but there are also many areas that have not sustained significant natural calamity and may be complacent.

Most of the expert predictions are expecting above-average Hurricane activity - and the Eastern Pacific wind environment that pushed all of last year's storms out to sea in the Atlantic is not present this year.

We will have a major hurricane event somewhere on U.S. soil this year.  Or, at least, we should be preparing like there will be one.

http://www.nhc.noaa.gov/

And, on a related note, where disasters are like to occur:

http://www.nytimes.com/interactive/2011/05/01/weekinreview/01safe.html

Two Months

So, it's been two months since I started this little professional development experiment.

April: 31 posts, 49 pageviews
May: 30 posts, 221 pageviews

Still working off the "if you build it, they will come" premise that if I create a resource that people think is worthwhile and important, it will gather steam of its own accord and slowly gather an audience and referrals with minimal intervention.

The next thing I am working on to complement the blog is an audio digest podcast for each month.  I'm about halfway through April and it's fun, but a little time consuming.

Update: I finished the April Podcast - and it's really not very good.  It's going to stay on the cutting room floor.  I'm going to rethink the format and content before recording another month.