Go Red?

Tomorrow, I'll be wearing a red sweater to support the Go Red for Women campaign, sponsored by the American Heart Association and the National Institutes of Health, but I do so with mixed emotion. While I support the concept of raising awareness of women's heart health, I get nauseated at the grotesque sums of money this campaign earns from corporate interests, especially when significant potential conflicts of interest arise in sponsorship. It's not to say that the movement's "near-term goal is nothing less than a 25% reduction in coronary heart disease and stroke risk by the year 2010" isn't noble. Certainly the new broader definition of myocardial infarction revealed this year will go a long way toward achieving that goal. In fact, given that new expanded definition, they can probably already proclaim victory in achieving their goal since heart attacks will be diagnosed more frequently next year compared to last year.

Also, zillions of nice "events" are planned for this day - each with tons of sponsors' paraphernalia - all sprinkled about the audience to raise awareness of heart disease, tune-ups, floor tile, and cutlery while corporations add to their marketing budgets. The conflicts that this bling brings to the event reminds me of the conflicts inherent to "free lunches" provided at Grand Rounds sponsored by drug companies.

Take for instance, Merck. They're one of the "Proud National Sponsors" of the Go Red for Women campaign.

But they're also interested in the controvertial promotion of Gardasil for women to prevent cervical cancer. Merck also sells Vioxx, Vytorin, and Zetia - several drugs without such great press lately in their quest to prevent heart disease.

Other corporate sponsors' motivations are less clear - like Jiffy Lube, Diet Coke, Campbell's Soup, Cutco, Brighton, Clairol Professional, Hamilton Beach, Flooring America, Starkist, Del Monte, Swanson's and RiteAid pharmacies. I mean, its so touchy feely and the women's purchasing power so important that corporations have jumped on this feel-good campaign like a tick on a bloodhound. Where exactly are their heart health motivations? In assuring sodium loading, cutlery, or toxic chemical exposures to women?

Or is this campaign really about funding research for the prevention of women's heart disease?

If so, can anyone point me to studies funded by this endeavor? Or does it just go to the general operating budget of the American Heart Association or NIMH for their big comfy corporate furniture, officer salaries, or office appointments? It's just not clear where all the money goes.

Maybe it goes for all those nice red dress pins or the Heart Checkup website? Seems like a heck of a lot of dough for that.

Yes, I'm jaded. I admit it. But I remember grocery store Green Stamps - that cute marketing invention of grocery store chains of the 1950's and 1960's that proported to help people save money if they just saved more stamps, yet actually made money for the sponsors because people never redeemed them. So I am skeptical of corporate marketing bonanzas like the Go Red Campaign that have yet to demonstrate tangible benefits to reducing women's heart disease while exacting considerable costs to our society.

So if you see me in red tomorrow, remember that I hope my red sweater raises awareness of the need for women to have a better appreciation of their heart health. I just hope it doesn't also advocate for the red budgets of families unable to afford healthcare and medications in America.


-Wes

Is the Superbowl Hazardous to Your Health?

Once again, the New England Journal of Medicine has sunk to new lows in the interest of increasing its impact factor.

The very notion that an article that used retrospecive ER chart reviews to evaluate the incidence of heart disease and claims to have identified "risk factors" that increase the incidence of heart attacks in people at the time of world cup soccer while conveniently excluding years when the World Cup was not in Germany is ludicrous. And if not enough, the authors go on to conclude that "in view of this excess risk, particularly in men with known coronary heart disease, preventive measures are urgently needed."

Give me a break.

What should we do, turn off the TV? Or maybe we should ban all hot dogs and salted pretzels at the soccer games?

But the media, oh baby, the media takes this well-timed drivel and extrapolates that men with coronary disease are more likely to have a heart attack watching the Superbowl! (See here, here, and here, for instance).

Well OF COURSE they will! It's really a conspiracy to lower the world's population of men with coronary disease! Why else would they have the halftime band be Tom Petty and the Heartbreakers?

Maybe Barry Manilow would be more calming and preserve a few more lives. (Heck, that would kill me, but I digress).

It is a shame that journalistic marketing of medical journals has sunk to this new low - but hey, it's all about the advertising revenues...

... and the egos.

Here's what I say: Watch. Cheer. Socialize. Be Happy.

After all, it's good for your heart.

-Wes

Dilberts or Doctors?

What do we define as quality care or excellence in a physician? Is it someone who is responsive to your needs, compassionate, caring, communicative, patient, scholarly, or some mix of these?

Or is it someone who checks your blood pressure and lipid panels again and again and tells you to stop smoking?

If you see patients these days, corporate America has decided it’s the latter example.

The Bridges to Excellence coalition of businesses and health plans including General Electric, Verizon, and IBM is now rewarding doctors to provide “quality care” by following cookbook measures. Hell, if you do a good job, they’ll even throw in a $125 gift card for you for each patient you check this way - money they want primary care doctors to throw towards an electronic medical record (before they feed their families, I guess.)

Never mind that the doctors who now collect this small token of corporate beneficence already have an electronic medical record.

You see the Bridges to Excellence has a few little “loopholes” to qualify for that $125 gift card and a gold star. In order to qualify, doctors have to submit their paperwork and documentation of who was “carefully followed.” And only patients over 18 qualify for the program (sorry pediatricians, you’re out of luck). Doctors must prove that at least four of five pre-specified measures of the care have to be met, not just one.

Yep, you need a computer to track this stuff because it’s bureaucratic mindlessness gone wild.

What’s funny (and sad at the same time) is that if we examine the cardiovascular measures for instance, a physician needn’t take part in the “quality care” delivered. Skilled nurses or nurse practitioners could fill the bill. I mean, as long as the “provider” can take a blood pressure, draw a little blood and type in the record that they told the patient to stop smoking, well, – voilá – a “quality physician” is born! A $125 dollar gift card will be delivered to your door and a notation made in the Healthgrades physician database that you’re the highest of high quality physicians. What a deal!

But perhaps a better word for this incentive program is not a reward, but a bribe to do more testing and mindless documentation. Worse, maybe this money is really a kickback scheme to reward the large hospital-owned primary care physician groups (with whom they have contracts); the same groups who already have electronic medical records and teams of gnomes who can sift through these electronically-identifiable “quality” measures. Maybe these refunds will offset the salaries of the gnomes who assure the documentation takes place and constantly remind their doctors to spend a few more minutes clicking checkboxes so the gerbil wheel can continue to spin even faster and faster.

Such incentives do nothing to reward a doctor for taking the time with a patient, explaining their care, walking them through treatment options and reconciling their medicines.

Before handing healthcare over to the Dilberts, caveat emptor.

-Wes

A Pacemaker for Weight Loss?

It's always cool to hear about new ways pacemaker-like therapies can be used to improve patients' lives.

And now there might be some hope of using pacing therapy to help with weight loss by stimulating the vagus nerve. The company generating the most excitement right now is EnteroMedics. Using vagal nerve stimulation, they hope to decrease people's weight by 25%. Seems plausible, especially since stimulating the vagus nerve might cause early satiety. But the vagus nerve is also responsible for the SLUD syndrome: Salivation, Lacrimation, Urination and Defacation as well as heart rate slowing and the development of atrial fibrillation.

Their trial of this device could get interesting, eh?

Unfortunately, the device still has to be surgically implanted - often under general anesthesia - and the risks of depressing respirations in morbidly obese individuals can be considerable. But, like bariatric surgery, if found to be effective and with few side effects, they might be on to something here.

-Wes

Yep, Medicare Can Ration Too

Only took a year to get this ECG reimbursement paid.

For unknown reasons, the paperwork proving Medicare became the couple's primary insurer on Feb. 1 was not submitted until Oct. 3. Every claim submitted by the doctor for the ECG was before Oct. 3, so all the claims were denied, McLeod said.

Funny how the payment went through after the government's new fiscal year starts after 1 October.

-Wes

America's 10 Most Wanted

Cardiovascular services are number one.

-Wes

Neat and Tidy

... and dumb.

A surgical gown has been developed to help medical students get a closer understanding of what it is like to go under the knife.

. . .

The idea is that it should be worn by students in the classroom, and supplement traditional teaching aids in helping to explain surgical procedures.

Plastic models can be used to show areas of the body where incisions will roughly be made, say the creators, but give no sense of empathy for the patient.

Potentially, the gown could also help explain procedures to patients.

How about going to see a patient with the scar instead? Must everything in medical education be depersonalized and sterilized?

-Wes

Grand Rounds - Beatles Style - Vol 4, No. 18

...is up over at Emergiblog.

Hey Jude, don't be afraid...

-Wes

What'dya Expect?

Mandates don't work if you can't enforce them:

The Food and Drug Administration can't keep up with requirements to inspect domestic makers of medical devices to assure manufacturing quality, and the agency rarely examines foreign facilities, according to congressional investigators.

In testimony scheduled to be delivered today before a House Energy and Commerce subcommittee, the Government Accountability Office will tell lawmakers that it found "weaknesses" in the agency's oversight of an industry that makes products ranging from contact lenses to defibrillators. According to FDA officials' own estimates, overseas makers of the riskiest products, such as pacemakers, were examined only every six years, and moderate-risk device manufacturers on average went an estimated 27 years between FDA inspections.

Pacemakers have historically been far safer than their more complicated cousins, defibrillators. Yet it is important to remember that nearly every recall or device advisory in recent times has been generated by either doctors evaluating the outcomes of their patients or by the development of concerning trends in device manufacturers' product performance, not FDA intervention. So why do we insist that the FDA inspect manufacturers biannually?

Probably because knee-jerk scare tactics work best at generating revenues for bureaucracy on Capitol Hill.

-Wes

How Insurers Fail to Serve Their Customers

In 2001, a patient at age 22 crashes their car and is found to be in ventricular fibrillation by police who arrive on the scene. Amazingly, patient is successfully defibrillated before being removed from the car. This patient was later found to have Long QT syndrome. A single ICD was placed. The patient did well, but later had recalled ICD battery in 2005, which was also replaced. No problems since.

This patient has been carefully followed every three months in our clinic since. Seen once in 2006 for another appropriate ICD shock.

Lots of visits. Lots of records taken - all recorded on an electronic medical record. Patient is covered by insurance.

Today, a letter arrives from this patient's insurance company:

"Dear Doctor or Provider:

Thank you for your recent claim. We appreciate the opporunity to be of service to you.

Unfortunately, we are unable to process the claim due to the reason(s) listed below:

Date of placement for defibrillator, the MD evaluation of patients cardiac status prior to the date and medical necessity for the device.

Please submit the information requested above. Once we receive the requested information, we will be happy to complete our review.

...

Sincerely,

Customer Advocate - UR0482
Blue Cross Blue Shield
Rockford Service Center"

My response:

"Dear Customer Advocate - UR0482:

You call yourself a "Customer Advocate?" How, exactly, does this advocate for your customer? It seems to me that this is another effort to ration care and deny your "customer," my patient, from payment as you promised this individual. Please shove your little computer-generated form letter up where the sun never shines.

You have access to the electronic medical record, as you know, as the patient has granted you access to their record for reimbursement purposes. Please take a few minutes of your precious time to review the record and all of the previous reimbursements you have paid for the indication for this individual's device. The patient's past medical events are clearly documented, as we are required to do each time we see the patient so we can get paid. Further, your attempts to ration care like this and delay reimbursement have resulted in significant legal actions against insurers in other states who have generated similar delays to physician payment.

Sorry I had to notify the world about your lack of "customer service" to my patient.

I hope you understand.

Sincerely,

Dr. Wes"

In-ies or Out-ies

Are you an in-network doctor or out-of-network doctor? You know, an "In"-ie or "Out"-ie?

Depends on the insurer, doesn't it?

Honestly, I have no idea which insurer I'm "in" with and whom I'm "out" with for an individual patient. My job is to see patients, irrespective of whose insurance they hold.

But insurers, well, it matters hugely to them who patients see. After all, they have pre-negotiated amounts they are willing to pay for services with those physicians. And for the most part, this is OK - consumers sign up for these cheaper plans knowing they might be inconvenienced from time to time.

Until doctors don't agree to insurers' rates and refuse to accept terms negotiated by insurers. Doctors sometimes decide not to be "in-network" with a particular insurer.

Fair enough.

But sometimes, those doctors are emergency physicians or radiologists - all of 'em - for a particular hospital. So patients in a HMO plan sometimes have to go to the closest hospital for emergent care. They then receive bills from these "out-of-network" physicians. They become enraged because the ER doctor and/or radiologists bill them when the insurer has "promised" to pay for their healthcare! "How dare you!" they scream. Doctors become the bad guy.

But who's the "bad guy?" The doctor or the insurer? Doesn't the insurer have a responsibility to their patient members to at least provide adequate physician panels for coverage of their members? Do people really think doctors should work for free?

Inadequate healthcare networks is becoming an increasingly important issue and the efforts of the Texas Medical Association is a must-read as they fight to place the onus of providing adequate physician networks to the insurer and restore the doctor-patient relationship:

HMOs promise their enrollees that they will provide prepaid health care for a premium. However, they often fail to provide an adequate network of primary care physicians in their plans, leaving enrollees with unexpected medical expenses. A number of legislators and their staff have been victims of an unexpected charge and are blaming the one they receive their bill from – the physician.

At the heart of the inadequate networks issue is deciphering who is ultimately responsible for medical expenses incurred out of network. Insurance companies don’t want to be held accountable for creating adequate networks or informing their enrollees about adequacy of their plans. In essence, they want to keep breaking their promise to enrollees and surprise them with unexpected expenses, while continuing to post record profits and pay their senior executives millions in salaries and bonuses.

The Texas Medical Association clearly has their eye on the ball here and other states' medical societies should take note.

-Wes

h/t: M.D.O.D.

Hospital Wars

"With hospital costs already the biggest driver in overall health-care inflation, employers and insurers have serious concerns.

'Research clearly shows that the more hospital beds there are, the more costs are generated,' said Larry Boress, executive director of the Chicago Business Group on Health, a coalition of some of the area's largest employers, including Harris Bank, Abbott Laboratories and Sears, Roebuck and Co."

- Bruce Japsen, January 25, 2004, Chicago Tribune

"Nationwide, hospitals spent $24.5 billion on construction projects last year, U.S. Census figures show, up from $23.7 billion in 2005.

The five-year period from 2000-2005 saw a 47 percent increase in spending from the previous five-year period."
-Janet Kidd Stewart, March 19, 2007, Chicago Tribune

Here's Chicago's recent hospital construction costs:

Children's Memorial Hospital, Chicago, IL - $1 billion

University of Chicago Children's Hospital - $145 million

Loyola University Medical Center - $123 million

Northwestern's Prentice Women's Hospital - $500 million +.

Rush University Medical Center - $810 million

University of Illinois, Chicago - $326 million

Central Dupage Hospital $257 million

Condell Medical Center - $109 million

And yes, there's still many, many more.

These numbers make a travesty of the entire concept of a "Certificate of Need" states, of which Illinois is one. It is telling that the Illinois Department of Public Health has not updated their Hospital Capital Expenditures and Financial Information Report since 1999. Could it be the report would make a mockery of CON process as a means of controlling health care costs?

So what are the real "needs" for such construction?

Primarily, it is the "need" to attract the well-insured, affluent patient clientele from a high socioeconomic status.

Next, it is the "need" to attract the physicians and surgical groups with large well-insured, affluent patients in their practices.

Finally, it is the "need" to out-distance the competition - a sort of brick-and-mortar war between hospitals eager to compete for the almighty health care dollar: whether it be with other community hospitals or with physician-owned specialty hospitals.

Certainly, to their surrounding communities, large hospital projects are a billed as a source of civic pride, a monument to the great and wondrous miracles that occur in medicine every day. The development of incredible technlogies that permit unparallelled views inside the body or minimally-invasive robotic and nuclear techniques are a wonder to behold. But to the average Joe with common, chronic ailments like heart failure, diabetes, hypertension, renal disease or pulmonary disease - these centralized monoliths offer little additional for their exorbitant price tag. Except spas, flatscreen TV's, and an increased emphasis on running hospital foodservice departments as profit centers. And although hospitals offer some amount of uncompensated care to their communities, it usually comes at the expense of up-charging for services, which affects each of us.

Perhaps, too, the construction at non-profit hospitals serves as a convenient tax shelter should they become suddenly profitable.

Chicago is the third-largest city in the US behind New York and Los Angeles. But there are other large cities out there as well: Houston, Dallas, Atlanta, Birmingham (AL), San Francisco, St. Louis, Boston, Denver, Salt Lake City, Indianapolis, Minneapolis come to mind. What have the hospital construction costs been in these cities recently?

Maybe when we can no longer afford our insurance or gasp when we see exorbitant hospital bills we should ask ourselves: how much of these construction costs am I paying for?

I would dare say, plenty.

-Wes

Pulling Back the Curtain on Statins

Business Week does a fine job.

Liao has charted some of these biochemical pathways. His recent work shows that one of the trucks, as it were—a molecule called Rho-kinase—is key. By reducing the amount of this enzyme, statins dial back damaging inflammation in arteries. When Liao knocks down the level of Rho-kinase in rats, they don't get heart disease. "Cholesterol lowering is not the reason for the benefit of statins," he concludes.

The work also offers a possible explanation of why that benefit is mainly seen in people with existing heart disease and not in those who only have elevated cholesterol. Being relatively healthy, their Rho-kinase levels are normal, so there is little inflammation. But when people smoke or get high blood pressure, their Rho-kinase levels rise. Statins would return those levels closer to normal, counteracting the bad stuff.

Add it all together, and "current evidence supports ignoring LDL cholesterol altogether," says the University of Michigan's Hayward. In a country where cholesterol lowering is usually seen as a matter of life and death, these are fighting words. A prominent heart disease physician and statin booster fumed at a recent meeting that "Hayward should be held accountable in a court of law for doing things to kill people," Hayward recounts. NECP's Cleeman adds that, in his view, the evidence against Hayward is overwhelming.

The field of preventitive cardiology and industry-sponsored drug trials is about to change - for the better.

-Wes

Check Your Heparin

Two different recalls of heparin contamination were just released:

One from Baxter Pharmaceuticals:

(WSJ) The Deerfield, Ill., company began recalling the lots on Jan. 17. Baxter said it normally receives 60 to 70 reports during a given year of possible reactions to heparin, but in this instance it received about 150 such reports just so far in January, the company said Friday. The reactions include a range of symptoms, such as nausea, vomiting, dizziness, fainting, throat swelling and low blood pressure.

The company said that so far one death has occurred that "may be associated" with the heparin in question.

The units in question are called "1,000 units/mL 10mL and 30mL multi-dose vials." Baxter said it hasn't seen an increase in adverse reactions to any of its other forms of heparin.

The other recall comes pre-filled syringes from AM2 PAT, Inc., of Angier, N.C.:

(via the FDA) Two lots have been found to be contaminated with Serratia marcescens, a bacterium that can cause serious injury or death.

These syringes are manufactured by AM2 PAT under the brand names Sierra Pre-filled, Inc. and B. Braun. They are sold in fill sizes of 3mL, 5mL and 10mL and syringe sizes of 6mL and 12mL.

Consumers and health care facilities with any of the recalled, pre-filled Heparin Lock or Normal Saline IV Flush syringes should stop using the product immediately. Health care facilities should immediately quarantine the products in their inventory and return them to their distributor. Individual consumers should return them to the location from which they were received, such as a pharmacy or hospital. They should also let their health care providers know that they have been exposed to syringes recalled by FDA.

The recall affects all lots of these products. The FDA received information that Heparin Lock Flush syringes from Lot 070926H and Normal Saline IV syringes from Lot 070917A have been found to be contaminated with Serratia marcescens, and have resulted in patient infections. The U.S. Centers for Disease Control and Prevention has confirmed growth of Serratia marcescens from unopened heparin syringes.

Traditionally, Serratia marcescens, a bacterium found in water and soil has been linked to pneumonia, blood infections, and urinary tract and wound infections. Some patients exposed to the recalled syringes have developed blood infections.

Weird how these came a day apart. But don't worry, the lawyers are already on it.

-Wes

References: Baxter's recall notice.

AM2 PAT's press release.

Automaticity

Elderly patient comes to ER for "feeling my heart pounding."

Patient seen my emergency room doctor, who does "physical" from EKG and recommends admission (it was thought to caused by his heart, after all).

Patient admitted.

Nurse notes slow heart rate. Recognizes intermittent complete heart block on telemetry. Asks electrophysiologist if he has been consulted.

Electrophysiologist has not been consulted. It is Friday.

Electrophysiologist notes patient is to receive the blood-thinner Lovenox and was presribed warfarin (Coumadin). Reviews EKG - Intermittent complete heart block and Mobitz II AV block on EKG from evening prior.

Electrophysiologist wonders "Why would anticoagulation be prescribed for person who might need pacemaker?"

So he signs on the Emergency Medical Record (EMR) system to write order to stop lovenox therapy until decision is made regarding pacemaker implant.

At which time he the orders algorithm of the EMR suggests that "patient's age and risk factors warrant use of DVT prophylaxis."

Electrophysiologist is enlightened.

-Wes

Dr. Wes Does Internet Talk Radio

Thanks to Dr. Anonymous for the opportunity to appear on The Doctor Anonymous Show last evening, a weekly web-based blog talk radio show about medicine and med-bloggers on the web. The intro theme song? Why "Sweet Home Chicago" of course! Last night we touched on my background, how I came to be an electrophysiologist and med-blogger (and how that related to the t-shirt website I co-founded with my wife, MedTees.com). I also discussed the difference between pacemakers and defibrillators, and a bit about the recent defibrillator recalls and the challenges they posed to doctors as well as patients, and finally, a bit about the future of electrophysiology.

If you missed the show, feel free to check out the archived copy.

-Wes

Cardiology Hospitalist: A New Career Path?

Cardiology Hospitalist?

Will provide direct clinical support, evaluating ED patients for admissions, follow-up care, expediting discharges, assisting with cardiac emergencies, completion of CORE measures, coordinating care teams of house staff and nursing staff. Plenty of opportunity to attend cardiology conferences, lectures, grand rounds.

Opportunty, certainly, but I've never seen any hospitalists attend our cath conferences or most medical conferences for that matter... they're just too busy "expediting discharges."

Sneaky marketing, though, but I'd suggest that the potential "cardiology hospitalist-to be" look at this position with some skepticism.

-Wes

Dr. Wes Live on the Doctor Anonymous Show at 8 PM CST Tonight

Tonight, I will be a guest on the Dr. Anonymous Show, a weekly internet talk radio show conceived, developed and hosted by the infamous Doctor Anonymous at 8 PM Central Standard Time, 9PM Eastern Standard time.

A chat room and call-ins are featured. Directions for participating can be found here.

I stand ready with my flak-jacket look forward to hearing from you.

-Wes

2007 Weblog Awards Announced

Congrats to Paul Levy and his blog Running a Hospital, winner of the Best Medical Blog, who also won the category I was nominated for as well: Best Ethics/Health Policy blog.

Other award-winners include Random Acts of Reality (Best Literary Blog), Dr. Val and the Voice of Reason (Best New Blog) , New York Emergency Medicine (Best Clinical Sciences), ChronicBabe (Best Patient Blog), and the Best Technologies Blog is still pending...

For all who voted for me, I am forever grateful, but as I mentioned, I was happy to have just been selected as a finalist.

Thanks to all of the Medgadget guys for their efforts.

-Wes

Cells: The New Antiarrhythmic?

Innovative work was reported in Circulation on-line (before print) that demonstrated that genetically-enginnered rat fibrous cells that expressed an important potassium channel found in heart tissue could alter the electrophysiologic properties of neighboring cardiac cells to beat slower in culture compared to control cells, and prolong the heart tissue's refractory period (the ability for a skipped beat to re-stimulate the heart).

Rat fibroblasts (fibrous cells) were genetically engineered to express the voltage-sensitive potassium channel Kv1.3 and placed within cell cardiocyte cultures. They altered the electrophysiologic properties of neighboring cardiocytes (heart cells) by reducing (68%) the spontaneous beating frequency of the cultures compared with baseline values compared to control fibroblasts. Following this finding, the same fibroblasts were injected into pig right ventricular tissue and showed some lengthening of the myocardial refractory periods in pigs as well. While very preliminary, the authors (many of whom are affiliated with the Iraeli start-up company GeneGrafts, a Technion University incubator company) observed changes in the local ventricular electrophysiological properties that indicated the "ability of the engrafted engineered fibroblasts to survive, to integrate with host tissue, and to modulate local excitability by generation of electrotonic currents with neighboring cardiomyocytes."

While there was good evidence that the authors' proof of concept study was successful, its application to man is a long way from certain. Fibroblasts, after all, create scar and scar is inherently arrhythmogenic in myocardium. Nonetheless, the concept is intriguing as a new avenue to pursue for possible antiarrhythic therapy.

-Wes

EKG Du Jour

Click to enlarge

It's not everyday a diagnosis falls into your lap.

A 53 year-old man was referred for evaluation because his brother suffered a cardiac arrest at the age of 42. His EKG is above.

Diagnosis? Work-up? Recommendations?

-Wes

Will Big Pharma Run SuperBowl Ads?

Some think it might not be such a good strategy:

"There is a heavy price to pay for mistaking components of strategy for strategy itself, or misreading the strategic effect of components. The pharmaceutical industry, for example, is going through a process of profound transformation and intense negative reaction to its marketing activities. Part of the reason for that has been the lack of strategic thinking around the deployment of direct-to-consumer advertising. While claims can be made for the business value of DTC at a tactical level, the strategic effect of spending nearly $5 billion a year on consumer promotion of prescription medicine (editor's note: breakdown of costs here) has been to open the industry to scrutiny and sanction. Nearly every major drug company active in the United States is facing multiple federal and state investigations into its business practices. Tactical success does not necessarily yield successful strategic performance."

At $2.7 million for a 30-second spot, I just can't see how showing a Superbowl would ad be a good strategy for the pharmaceutical industry either.

But then, I don't make their marketing decisions, do I?

-Wes

What's Wrong With Universal Healthcare

Dr. Rich clarifies.

-Wes

Commercialism Before Evidence

It is yet another striking example of commercial interests superseding patients' best interests: the lure of "personalized medicine."

What is "personalized medicine" as defined by the business community? Is it really up-close and personal attention to your health care needs?

Of course not.

No, to the business community, "personalized medicine" is the deceptive claim that genetic testing can decide what tests you'll need or drugs to take to prevent a heart attack - with business interests telling us so.

Unfortunately, with the exception of some very well-defined and rare genetic diseases - not one shred of data exists that obtaining these heart attack-predicting genetic tests can do what they claim: prospectively predict your risk of getting a heart attack.

That's because all of the data they have obtained is based on retrospective correlational analysis rather than prospective outcomes data.

And yet that's how the headlines are construed:

"Gene Variant Is Said to Be Linked To Heart Attack and Prevention" - Wall Street Journal 22 Jan 2008

"Gene Test Can Identify Heart Disease, Spur Cholesterol Drug Use" - Bloomberg.com 22 Jan 2008

So what are these headlines about?

Well it seems another genetics company feels that they've found a gene called KIF6 (short for "kinesin-like protein family member 6") that correlates (thats the important verb here) with people who got a heart attack and lo and behold they could correlate that patients in their group that took statins did better than those who didn't. Funny how another "correlation genetics company" deCode Genetics, failed to identify the same gene! Gosh, how come? I mean, shouldn't these genetics companies be finding the same genes important to the development of heart attacks?

Or could it be that the business community has found a means to create new blockbuster gene-screening companies as varied as the galaxy? I mean, think of the potential - there are so many genes out there that the number of companies devoted to screenings will soon be just like naming a star after yourself!

But there's another troubling issue here.

It is telling when these sensationalist headlines are published before those of us who paid for journal subscriptions are leaked to the press before they are published "on-line before print." (My statements are made here before reading the publications, since they were not available for my review at the time of this writing). Here was this fine-print disclaimer from the Journal of the American College of Cardiology available to me this AM:

FOR THE MEDIA: THESE ARTICLES ARE TO BE CONSIDERED UNDER EMBARGO UNTIL OTHERWISE NOTIFIED BY ACC MEDIA STAFF. EACH ARTICLE BELOW WILL APPEAR IN AN UPCOMING PRINT ISSUE OF JACC AND WILL BE HELD TO THE STANDARD JACC EMBARGO POLICY, WHICH IS ONE WEEK PRIOR TO THE PUBLICATION DATE. IF YOU HAVE QUESTIONS REGARDING A PARTICULAR ARTICLE, PLEASE CONTACT AMY MURPHY IN THE ACC MEDIA RELATIONS OFFICE AT 202-375-6476. THANK YOU.

You see, it's important to all medical journals that they release these studies to the media before the general public or paid physician subscribers. Why? Corporate interests, of course.

I can hear the back halls of the publishing medical journals' halls now: "Hey guys, this arrangement with media we have is great! We can get the media to interpret the studies before the doctors to assure we help out those nice companies that pay for advertising in our journals! And if we leak it early enough, heck, they'll have time to interview those researchers who's work was supported by the company while really boosting our journal's impact factor! And then our advertisers will have to pay us even more! Damn, I love this business!"

It is a sick game but early leaks to the press can make or break a company eager to generate a buzz for investors.

Just look at the Transcatheter Cardiovacular Therapeutic conference held annually in Washington DC. New start-ups can show-case their wares internationally, and if received well, sky-rocket in value. If they are poorly received, die.

International medical conferences are the same way. Journals now commonly have their on-line publications held for release until the precise second a presentation concludes and shows the slide that says "This publication can be found on-line at http://www.theworldsbestjournal.com" - just so the conference advertisers can draw attendees and can get the (very) short-term buzz before the media hacks into it.

So before going out and dropping $200 into one of these companies' unproven tests promoted by the media, why not do the obvious: lose weight, eat right, spend time with your kids and put the money in an interest-bearing health savings account for when you'll really need it.

Like when you get sick.

-Wes

Image credit.

Merck and Schering-Plough's PR Costs Patients

Upset at the negative publicity of their blockbuster Vytorin, Merck and Schering-Plough are piling on additonal costs to patients by purchasing ads in the New York Times, Wall Street Journal and the Star-Ledger of Newark, New Jersey to defend their drug. In some cases these are full-page advertisements.

No doubt they're using their money earned from the delayed reporting of the ENHANCE trial.

How much does a full page ad in the New York Times cost? Well, one report pegs it at mere $65,000. But if a full page ad appears in the Wall Street Journal, it sets 'em back between $96,900 and $210,300.

"We plan to continue this campaign to provide appropriate balance and perspective to patients and, if they believe they have the need, to encourage them to talk to their doctors about their treatment," Davies said in an e-mail.

Hey, it's okay. It's just PR.

And once again, a lot of patients' money is being spent just for marketing.

-Wes

Could Potent Antacids Affect The Effectiveness of Antiplatelet Agents?

Today's Journal of the American College of Cardiology reports that omeprazole (Prilosec®), a potent antacid that works by proton pump inhibition and is commonly presribed to prevent gastrointestinal bleeding in patients administered clopidogrel (Plavix®) following coronary interventions, interacts with clopidogrel to reduce its effectiveness as an antiplatelet agent.

The clinical implications of this remain uncertain but clinicians should be aware of this possible interaction following angioplasty or stenting procedures.

-Wes

St Jude Announces Defibrillator Update Needed

61 microseconds.

That's a tiny, tiny fraction of a second. 0.000061 second to be exact.

Heck, to put it in perspective, light travels a mile in a vacuum in a little over 5 microseconds.

But if an arrythmia occurs in that tiny window, patient's with St. Jude Epic or Atlas implantable cardiac defibrillators (ICDs) might undersense (not see) a life-threatening arrhythmia. So St. Jude began notifying doctors that a software fix is available to assure their devices work properly, even in this tiny vulnerable timing window.

There are estimated to be 143,000 of these defibrillators implanted worldwide and only 8 patients have been affected with this problem so far. Gratefully, no one has died. The risk of a specific patient being harmed by this defect is estimated to be on the order of one in a million (0.000001).

So what does it mean for defibrillator patients and doctors caring for them?

It is not thought at this time that an extra office visit is required due to the rarity of the problem, but during a patient's next regularly-scheduled device clinic visit, they'll receive a "software upgrade" to their Epic or Atlas ICD to correct the problem.

What I found amazing was the engineers' ability to figure out the root cause of this problem in the first place.

-Wes

Reference: St. Jude's "Dear Doctor" letter dated 16 Jan 2008 (pdf) with the models affected.

SurgXperiences #113 is Up

Amazing stories from the OR as assembled by Terry over at Counting Sheep.

-Wes

Another Unfortunate Consequence of the Loss of Primary Care

... the abrogation of responsibility for the patient.

-Wes

The Election Returns

No, it's not the presidential primaries, but tonight a special audio podcast, hosted by Dr. Anonymous, will air at 8 PM CST (9PM Eastern) to discuss the 2007 MedBlog Award returns with the Medgadget guys.

CNN's getting pretty tiresome, so why not try something different?

Remember, you can still vote for your favorite 2007 MedBlog until midnight (PST) tonight.

-Wes

h/t: Dr. Val

Fire at U of Illinois, Chicago

With the cold and chemical compounds, fires at medical school campuses can get tricky:

Orozco said the fire appeared to have started on the fourth floor. Because there are classrooms and laboratories on that floor, crews called in hazmat teams.

Orozco said fire crews worked with the university, which called in some of its chemists to assist firefighters.

No injuries were reported.

UIC reported substantial damage on the fourth floor and water damage on the lower floors.

Glad everyone was OK. Early reports suggest it was an electrical fire.

-Wes

One Hell of a Way to Detect Alzheimer's

Heh. Just blindfold 'em and see how confused they get.

Of course, like one commenter over at Engadget mentioned: that man is probably a "Prestige Level 5 on Call of Duty 4.

-Wes

HeartNet for Heart Failure

Heart failure occurs then the heart pump is unable to meet the body's metabolic needs. It typically occurs from two basic pathologies: (1) dilated cardiomyopathy, where the force of contraction of the pump is diminished and the wall tension stretches the chamber dimensions of the heart or (2) restrictive cardiomopathy, where is heart pump works normally, but the heart is restricted from receiving blood, either because it's muscles don't relax to fill adequately or because the heart is encased in a non-compliant shell that restricts filling.

To me, I just don't see how the HeartNet device, a nitinol wire mesh that encases the heart and will ultimately be surrounded in fibrous tissue, won't just convert the pathophysiology of a dilated cardiomyopathy into that of a restrictive cardiomyopathy...

A 6-month trial seems much too short to test the long-term safety of this device. After all, the wire mesh puts a whole new meaning to "a porcelain heart."

-Wes

Reference: Early, industry-sponsored results.

Pfizer Responds: What to Do With Tikosyn Shortage

For dofetilide users, the shortage of 500 microgram pills (0.5mg) that I mentioned earlier has been temporarily rectified by Pfizer - it seems they're willing to provide four 125-microgram tablets for the price of a single 125 microgram tablet until the shortage is resolved - hence it will set you back the same $143.24, irrespective of the number of tablets used to achieve the 500 microgram dose. The full notice can be found here (pdf).

Remarkably, a fax was received by my office yesterday. I never did reach anyone via phone, but happened to see my local Pfizer rep Wednesday...

-Wes

"Entrepreneurial Guidelines" SHAPE Up Poorly

Namby pamby. That's what Robert Lindeman, MD (aka the infamous former blogger, Flea) called us bloggers.

A bunch of wimps.

And you know what?

Many of us are. Perhaps for self-preservation. Perhaps to avoid having our words used against us in the court of law later.

But we're not the only ones. Our own professional societies including the AHA and ACC have been namby pamby, too, in my book - especially when it comes to refuting the "entrepreneurial" guidelines proposed by the "Association for the Eradication of Heart Attack (AEHA)." This group, with reportedly altrustic intent, has been so riddled with conflicts of interest, it makes one's head spin.

And now this group wants to MANDATE that insurers HAVE to pay for atherosclerosis screening tests, of which their organizer, Dr Morteza Naghavi, has a significant financial interests as founder and shareholder of Volcano Corporation and Endothelix, Inc.:

Later this year, Texas House Representative Rene Oliveira plans to introduce—for the second time—his bill into state legislature that would mandate insurers to cover screening of asymptomatic atherosclerosis using calcium scanning and carotid ultrasound, as set out in the SHAPE initiative.

Everyone was namby pamby except Peter D. Jacobson, JD, MPH, of the Center for Law, Ethics, and Health, University of Michigan School of Public Health.

He had balls. Big ones. In his editorial in JAMA, he called the practice of accepting unvetted self-initiated "entrepreneurial guidelines" into question, and wondered why the AHA, ACC, and National Institute of Health have been so namby pamby about refuting an initiative so ripe with conflicts of interest.

(theHeart.org) As reported by heartwire, the controversial SHAPE task-force report was published as a Pfizer-sponsored supplement in the American Journal of Cardiology and initiated by the Houston-based Association for Eradication of Heart Attack (AEHA), founded by Dr Morteza Naghavi (American Heart Technologies, Houston, TX). While a number of prominent cardiologists were on the writing group and editorial committee for the SHAPE report, which explicitly billed itself as "a new practice guideline for cardiovascular screening in the asymptomatic at-risk population," neither the ACC nor the AHA—both of which have released their own cardiac imaging guidance documents in the past few years—were involved in the SHAPE recommendations.

In interviews with heartwire when the SHAPE publication first came out, representatives from the ACC, AHA, and the National Heart, Lung, and Blood Institute all distanced themselves from the SHAPE document. In an editorial published in August 2006, shortly after the SHAPE report came out, Journal of the American College of Cardiology editor-in-chief Dr Anthony DeMaria called the SHAPE guidelines "a proactive effort . . . for a strategy for which the evidence of efficacy remains unestablished". He also noted that the contribution of "several individuals who hold or have held leadership positions in national/ international medical societies" to the SHAPE report might convey the impression those organizations "approve" of the guidelines. "This is obviously not the case," DeMaria stated.

From opinion to law?

Oliveira first filed his Texas Heart Attack Prevention Bill in February 2007, his first full day back in office after CABG surgery, a procedure he underwent after a CT scan indicated severe coronary blockages. According to his chief of staff JJ Garza, the first time around, the heart-scan bill was rolled into an omnibus bill that was ultimately voted down, although no one actually objected to the heart-scan portion of the proposed legislation. Oliveira intends to introduce his bill again, as standalone legislation, when the legislature meets again in January 2009, although he may opt to "prefile" his bill in November 2008 after compiling the "latest scientific evidence," Garza told heartwire. Garza also emphasized that the bill "is not the SHAPE recommendations," takes other scientific research into account, and may even be redrafted to reflect new evidence before being filed. "The universe covered by the legislation is smaller than the universe SHAPE outlines," he stated.

In the meantime, Jacobson, in his JAMA commentary, points out that there is no proof that adopting the SHAPE guidelines will do more good than harm, particularly since they were neither peer reviewed nor endorsed by the major professional societies in the US or the European Society of Cardiology. The problem here, he argues, is that while clinical practice guidelines form the backbone of evidence-based medicine and are "flexible instruments" that are or should be subject to rigorous scientific analysis, legislative mandates, by contrast, are "inflexible, static, and not as easily changed as science advances" or may prematurely support unproven strategies.

So kudos to Dr. Jacobson for having the gonads to call a spade a spade. But then again, maybe the ACC's ties to Big Pharma had something to do with their namby pamby attitude toward others with similar conflicts of interest.

Let's hope not.

-Wes

Virtual Surgery - is Wii for Me?

It seems there's real push these days for ways to train our future surgeons without having to get their hands wet. By playing a few Nintendo Wii games, surgical residents improved their performance on a laparoscopic simulator compared to their non-practiced counterparts. I'm not sure why practicing with a Wii to improve upon another virtual experience is big news, but hey, I don't make the rules.

But maybe I should try this. After all, it sounds fun. I could stay up all night gaming and come in to the operating room all bleary-eyed, with Wii-tenosinovitis and be unable to pick up my instruments.

And why stop there? Why not simulate all of medicine? I mean we have SimMan and SimBabies. Heck, why not use SimDolls to simulate overcrowded ER's (sorry, I slipped with this one).

But before I go out on a limb and say too many more disparaging comments, there might be some benefits to all of this, if surgical simulators could be developed from a surgeon's perspective. For instance, Johnnie Chung Lee of Carnegie Mellon University's Human-Computer Interaction Institute has demonstrated simple adaptations of the Wii that could be implemented into virtual surgery simulators, like head-tracking, finger tracking, or even manipulating surgical fields with your hands just like manipulating an electronic white-board. Imagine using these ideas with the anatomy of Argosy's Visible Body. Although the tactile look and feel of real surgery will be hard to replicate, the visual experience could be made very dramatic.

-Wes

Addendum @ 08:30AM 18 Jan 2008: Hmmm. On second thought, now that the video game industry earns $18 billion a year, maybe they're on to something...

Don't Forget to Vote

Just click on the graphic above if you haven't already voted. Only two days left.

-Wes

Dad, I'm Heading Out

"Now? This late?"

"Yeah. I need to give someone a ride home."

"Seriously? Now?"

"Daaaadddd. Please!" (Dad, being ever-clueless, succumbs reluctantly).

"Sure, go ahead."

Seems the last day of finals was today. Dad put 2 and 2 together. Friend likely blasted at party. Son has auditions for college tomorrow, hence is sober.

Best decision I ever made.

-Wes

Freezer Wars

When sales are tough, how do you grow? Well sue for patent infringement, of course!

CryoCor, based in San Diego, won U.S. approval last year for the CryoCor Cardiac Cryoablation System, which freezes tissue to correct certain abnormal heart rhythms.

``We believe that our exclusive license to these patents gives us broad coverage over key technologies that are critical in the field,'' said Edward F. Brennan, chief executive officer of CryoCor, in the statement.

CryoCath said in a statement distributed by Canada NewsWire that CryoCor's claims are ``without merit.''

The U.S. suit targets CryoCath products including the CryoConsole and Freezor brands, according to court documents.

CryoCath, based in Kirkland, Quebec, sued CryoCor in October in the same Delaware court alleging seven patents were infringed and seeking unspecified damages.

CryoCor, with $540,000 in 2006 sales and a $15 million net loss, fell 25 cents to $2.33 in Nasdaq Stock Market trading. The shares fell to a 52-week low of $2.01 earlier today.

CryoCath, with C$39.6 million in sales last year and a C$18.9 million net loss, fell 7 cents to C$4.15 in trading in Toronto.

I hope the judge can keep 'em straight. Imagine the conversation:

"CryoCor wants to sue CryoCath-"
"Hey, but CryoCath sued CryoCor first"
"Cry baby!"
"Oh for crying out loud!"
"Cryoablation was created by CryoCor."
"No, CryoCath."
"CryoCor!"
"CryoCath."
"CathCor, er, I mean..."

(Judge reaches for bottle of Valium.)

-Wes

How to Save Costs in Electrophysiology

Just give patients a three-year wait and reimburse hospitals $1600 for an atrial fibrillation ablation:

David Babiuk, interim provincial executive director for Cardiac Services BC, says the Ministry of Health and the Provincial Health Services Authority (PHSA), acknowledge that current wait times for electrophysiology procedures such as cardiac ablation are unacceptable, and that work is being done to address the issue.

“The wait list is unacceptably high and everybody has acknowledged the fact that this has grown to a state that is not acceptable and no one has attempted to explain or justify that wait,” Babiuk told the Observer. “By the end of January, early February, we’re looking to have completed a review of the current wait list and the indications per use, and… what are all the things that we could do to whittle that wait list down. We won’t be able to do it in 15 months, but we’ll make sure we can get as many people off that wait list as quickly as we can.”

So not only do you have to make 'em wait and pay poorly, you also have to just "whittle that wait list down."

It's no surprise, really. What's amazing is they're still being done at all.

-Wes

A Doctor's Wheels

Shot this pic in our doctor's parking area when I saw this baby. I have no idea who's vehicle this is, but man, I want them to be my doctor.

-Wes

New Innovation for Mitral Regurgitation

File this under "What Will They Think of Next?"

For many individuals suffering from severe leakage of the mitral valve (mitral insufficiency) secondary to an enlarged left ventricle (dilated cardiomyopathy), surgical options are limited, especially in the setting of an individual with reduced left ventricular function. Repairing or replacing mitral valves in this setting risks exposing the left ventricle to increased wall stress following the repair with further dilation of the ventricular pumping chamber, leading to the rapid development of refractory heart failure.

So it is with interest that I noticed a new experimental technology introduced to our group yesterday which is about to begin clinical trials at our institution. This device uses a minimally invasive, percutaneous pericardial approach that applies a device that squeezes together the left ventricular walls beneath the mitral leaflets and maintains this force by way of a subvalvular cord passed through the heart walls and held on place by two epicardial pads on the outside surface of the heart. It is hoped that this technology would improve mitral valve closure while limiting the progressive dilation of the left ventricle.

The iCoapsys device is manufactured by Myocor, Inc of Maple Grove, Minnesota. It is percutaneously installed through a small incision beneath the lower portion of the sternum via the pericardial space. As such, prior open heart surgery would be a contraindication to implantation of this device due to scaring inherent to the pericarial area following surgery that would preclude easy installation of the device. iCoapsys it is a later generation version of their Coapsys device that can be installed during open heart surgery.

So for all the techies out there, here's a brief overview of this device:

How Is It Implanted?

First, a small puncture is made just beneath the lower border of the sternum using a special tool to enter the pericardial sac that lies over the heart:



Next, a guidewire is passed through the pericardial puncture device into the pericardial space over the heart:



Then,a larger dilator and sheath are passed over the guidewire into the pericardial space.



Other catheters are placed through the large staging sheath:



The posterior pad is passed over the posterior catheter:



The anterior pad is placed over the alternate catheter:



The two are aligned in the proper location using fluoroscopy and a special fluoroscopic "targeting" tool. A puncture of the left ventricle is performed and a wire enters the left ventricular chamber which is snared by a basket snare entering from the anterior approach:



Once snared, the cord is drawn taught until mitral insufficiency is diminished and left ventricular function can be assessed:



Once deployed, the percutaneous equipment is removed:



Now, the feasibility trial of this minimally invasive approach is about to get underway by Dr. Ted Feldman, who is the principle investigator at Evanston Northwestern Healthcare here in Chicago. Whether this works or not is uncertain, especially since the cord is likely to tether a portion of the right ventricle as well (and might restrict proper right ventricular function), but the approach heralds a whole new array of pericardial innovations for the heart that are soon to appear on the horizon.

-Wes

Images courtesy Myocor and Ted Feldman, MD

Communication 101

For the majority of people, or people not taking dofetilide (Tykosin), this communication won't mean much, but it pertains to a bugaboo I have with (in this case) the pharmaceutical industry's effort to communicate with their presribing physicians. If this is not of interest, move on.

Otherwise, here's a tidbit I was unaware of until about 5 minutes ago from a letter dated 9 January 2008 to "All Tikosyn Registered Healthcare Professionals"

It seems Pfizer has a shortage of Tikosyn 0.5 mg (500 microgram) x 60 bottles have been "momentarily depleted and are currently on back order." They also go on to say that "Tikosyn 0.250 mg and 0.125 mg are also nearly depleted and are soon to be on back order as well. We are working diligently to have the product available as soon as possible."

The reason?

"This product outage is not result of any efficacy or safety concerns with Tikosyn. An unforeseen manufacturing issue coupled with distribution regulations for Tikosyn (this medication is only drop-shipped and there is no inventory held in trade) have resulted in the product outage."

When will the shortage cease? We're unsure:

"On Wednesday, January 16th, we will send you a follow-up communication to update you on the inventory status to help manage your Tikosyn patients appropriately."

Great. I never received this communication in the first place, even though I am registered with these guys. Unfortunately, I received this notice from our local pharmacy when a patient could not receive their medication refill. And this was despite having to endure an exhaustive process and registration to be allowed to prescribe this medication. I've checked e-mails, mail, faxes and have not found this notice. Nor have my colleagues who are also registered.

We went to the website, and no notice appears, nor a link to this important letter (I'll put it up on my server when I get a chance).

Yet the pharmacies got it (I guess they're considered the important "health care providers" here).

So now, how the heck am I to assume I'll get any update? (Maybe this blog will help)

I am left to ponder (without ANY guidance) what to tell these patients. Seeing as they had to be dosed for three days as inpatients just to take this drug, don't you think they can do better?

And we think the medical device recalls/advisories need work...

-Wes

Addendum: 16 Jan 2008 @ 1530 CST - Called Pfizer's "hotline" (1-800-438-1985) mentioned on their form letter and just got the message that the drugs might be available in "late" January on a recording - the recording went on to suggest that patients on Tikosyn "contact their doctor" and that doctors not start patients on Tikosyn and to "contact their patients to discuss treatment options." I was then offered to hold for a Pfizer medical specialist. I hung up after the phone after 20 minutes. Oh, and that follow-up notice we were promised on the 16th? Never showed.
-Wes

What Kind of Drink are You?

Providing informed consent to patients about conscious sedation is always interesting for providers. We typically use several medications to help patients relax during procedures. By far and away the two most commonly used medications for this purpose are a benzodiazepine (typically midazolam, or Versed) and a narcotic (often fentanyl). Patients familiar with conscious sedation often ask, "Oh, you mean I will get some "twighlight anesthesia?" To which we answer, "Yes!"

But describing conscious sedation to someone who has never experienced conscious sedation before is a bit more challenging. Often, we compare it to having a drink or two, without the hangover, to help "take the edge off" the anxiety of the procedure. Patients seem to understand this. But for us, the doctors and nurses, it helps to be able to relate to the patient before committing to this analogy in the procedure room, so we usually ask, "So what's your drink of choice?"

The tea toadlers might respond: "I don't drink, thank you." To them, they get some "Nectar of the Gods."

For typically the young upwardly mobile professionals, we'll hear: "A nice chardonnay" or "a martini."

The older generation often want a "manhattan" or "scotch, on the rocks."

And for the over-80 crowd, I've now heard this one: "Give me a dry, dirty Rob Roy." Now for me, I'd never heard of this, but it seems it's a combination of shot of scotch added to a dry martini. The "dirty" part is the splash of olive juice added in. (Yes, you can learn a lot about a person from their drink choice.)

So I thought it might be fun to take a poll (anonymously, of course) in the sidebar of this blog for a week or so, to see what kind of concious sedation my readers would ask for. So go ahead, register your choice and be sure to let your anethesiologist know the next time you need a little "something" to calm yourself down before surgery.

By the way, feel free to share your favorite drink in the comments if it doesn't exist.

-Wes

Vytorin's Out, Simvastatin's In

Merck got handed its fanny today as Vytorin demonstrated no benefit over generic simvastatin in reducing plague in the carotid arteries. Merck knew the repercussions of this trial - and this likely was the reason its reporting was delayed: profit.

Stupid, really. Drug companies, in dire straights to rectify their relationship with the public, sided with their short-term monetary gains rather than improve their long-term public perception of the industry.

And they got burned.

Appropriately.

So now, we are left to wonder, what was that gain compared to generic simvastatin?

Turning to our handy-dandy CostCo cost analyzer, we find that a 30-day supply of Vytorin 10/20 (one of the lower-dose sizes), cost a whopping $97.17. Compare that to generic simvastatin 20 mg, at $5.82 - nearly 17 times the cost.

But that's not all. Let's not forget the cost for your time to call your doctor and change the prescription.

Or the costs involved at going to the doctor's office in person and getting a new prescription written. Costs that both you and your doctor have to absorb. Costs that cut dearly into your precious 7-minute primary-care visit.

And this cost is not inconsequential, especially when we realize that there were "1 million prescriptions written for it weekly."

-Wes

A Bioengineered Heart: How Close Are We?

Today's post can be found over at MedPage Today.

-Wes

I've Got A Question

I just got back from the pharmacy. Had to pick up a med for my wife. It seems our insurance plan, orchestrated by Aetna, seems to have "changed their policy" thanks to the New Year.

Before 1 Jan 2008, we paid a $30 dollar co-pay for this medication to receive 30 pills that presumably (according to the receipt I have) would have cost $98.66 if I had paid it outright. Okay. I get this. This is why I pay into my "plan."

Today, after the first, my co-pay rocketed to $66.10. You see it's not "generic" and is a "Level 3" drug, not "Level 1." (Helpful nomenclature, huh?) It seems this is the insurance company's way of communicating with patients. "Ask your doctor to consider a cheaper alternative" they say.

Hey insurance company: since you're so frickin' smart, how about YOU communicate with my wife's doctor?

How about YOU take the time (let's see, if we made an appointment: 20 min to drive there, park, 15 min for the appointment, another 20 min or so to return - let's say an hour or so - or if we call: take a few calls to the office, have them phone in a prescription and make the office staff do work that cannot be reimbursed). Why don't YOU take the time? Aren't you guys "healthcare" companies as you suggest? Or could it be you guys are actually just financial businesses, and therefore CAN'T call?

Or could it be you want us to NOT make the appointment or change the prescription right away? Oh, I know, you're doing your part to "hold down the costs of healthcare," right?

So here's my question now that I had to fork over that extra $36.10: Who's gettin' my extra cash? You? The pharmacist? The drug company? My employer?

I wanna know, dammit!

Clever little scheme, you bast... no, let me calm down a second....

Thank you so much for reinforcing your covert rationing scheme once again.

And Happy Frickin' New Year to you, too.

-Wes

CXO: Chief Woo Officer

Questions only a Chief Experience Officer (CXO) could ask:

"Do you like our appointments in the lobby?

How about the Starbucks our new Spa? We offer massage, empowerment and spirituality training to help you through the toughest of times.

Do you like to music?

How about the HDTV in the rooms?

Was the menu in the rooms okay?

Oh, and be sure to ask our medical students how they like their experience here.

Hope you enjoyed your stay at the brand new Hospital of America.

Would you mind completing our satisfaction survey?

It's how we'll soon be getting paid.

Have a healthy day!

OMG. Enough already! But I guess it's more proof that Happy is right regarding the greed mentality of medicine these days.

Too bad we're all paying for it.

-Wes

Maiden Voyage

“Hey, you wanna see an operation?”

“Uh, sure.”

“Look, when we go in, just tell ‘em you’re a ‘fourth year.’ They’ll think you’re a fourth year medical student, rather than a senior in college.”

“Really? You sure that’s okay?”

“Hey, these guys are cool and they’re doing a really amazing case today. Some guy needs a repair of a huge descending aortic aneurism.”

“Cool,” I said, not really knowing what a descending aortic aneurism was at the time.

“Alright, follow me.” We walked through a labyrinthine series of halls and institutional doors. A few buttons were pushed on a door lock, and the heavy door was pushed aside to reveal the inner sanctum of a men’s locker room. It didn’t look too different from the locker room of my high school: lots of vertical lockers with little padlocks securing the handles and the artificial fluorescent lights that gave a pale green glow to your face.

One particular shelf had his interest as he sorted through some pale blue garments.

“Here, these look like they’ll work. Try these.”

“Can I wear my t-shirt?”

“No! You can take that off and hang it over here with your pants,” as he pointed to a series of hanger hooks perched above a large plastic bin marked “Soiled Linens.”

So I took off my clothes and put on the pale blue pants and shirt. The pants where held in place by a flimsy red draw string, the shirt was large, but felt comfortable with a deep v-neck exposing my upper chest.

‘What shoes should I wear?”

“Oh, those’ll do fine. Just put these over them,” He handed me this ridiculously small shriveled ball of paper with an elastic band attached and said: “One size fits all.”

So I sat on the bench in the locker room, put back on my tennis shoes and stretched the ridiculous elfin shoe cover over each shoe.

“You gotta put on these, too.” And I looked at his hands which held another pale blue paper ball with elastic attached and a surgical mask. It seemed the next elastic paper item was to be stretched over your hair, and the surgical mask had all of these strings attached.

“This is perfect!” he whispered. “Here, let me help you tie that mask.” And he proceeded to tie one pair of ties behind my neck and the second pair over the crown of my head. “There! Check it out,” as he pointed to the mirror.

I looked and saw myself looking every much the part of a surgeon. Regal. Mysterious. Or maybe like a bandito about to rob a train. I smiled as the thought came to me, but he couldn’t see.

“You ready?”

“Sure.”

So off we went, out of the locker room through another door that opened into a long hall of the hospital. Like classrooms attached to a main hall, I could see through windows revealing other rooms packed with equipment, but most were empty. It was a Saturday after all. He waved me on in excitement.

“Here.”

And he opened to door.

I was completely unprepared for what I saw. Worse still, what I heard and what I smelled.

It was an electric kind of smell. Pungent, unfamiliar, like someone burning wood blended with steak and torched with an arc welder. It’s hard to describe. Except that it was unpleasant. No, that’s too kind. It reeked.

The light over the blue-draped table was incredibly bright – and cast a white-orange tint to the drape over the object on the work surface. Several surgeons stood on stools to get a better look wearing funny black-rimmed nerd glasses. A trail of smoke rose from the table each time a high-pitched musical tone could be heard. One of the surgeons held a thin garden hose full of (Holy sh--!) foamy blood. The hose was attached to a large container with a second clear tube attached to the wall. I could hear slurping. Again and again. Sschlluuurrrrrpppppp. Sscchhllluuurrrppppp. Then the tone and smoke and scccchhhuurrrrrppp again.

“Why don’t you stand over here?” he said to me, pointing to the area where the anesthesiologist was standing. “You can get a really good view from there.”

So I hesitantly walked over as he introduced me to the anesthesiologist. “Hi, Joe, this is my brother, he’s a ‘fourth year’ from Duke.”

“Nice to meet you. Wanna stand up here to see?” as he pointed to a small black stool barely 4 inches high. Next to him was a daunting array of machinery with some sort of bellows rising and falling with manometers and electronic gadgetry attached to this thing beneath the drapes. I looked down and saw hair for the first time. There was a body beneath the drape, lying on its side, with a white tube in its mouth and eyes taped shut. I peered over the wall-like drape separating the anesthesiologist from the surgeons and noticed what was happening for the first time. There, to my amazement, was the chest cavity, held open by a large rib-spreader, and a balloon like purplish-red organ rising and falling to the soft sounds of the machine: Shhhhhhhh. Gaaaaaaaa. Shhhhhh. Gaaaaaa. With each “Shhhhhh,” the balloon rose. With each “Gaaaaaaaa,” the balloon fell. It was his lung. Cool.

But there was bleeding. Lots of it. Seems the aneurism was leaking.

Shhhhhllluuurrrrrp. Tone. Smoke. Shhhhhlllluuuuurrrrrrrrrrpppppp. Tone. Smoke. Electronic smells pierced my olfactory bulb. I looked around. Everyone so focused.

“Mets.” I heard the surgeon say as he held out his hand and a scrub nurse slapped a pair of scissors in hid hand. “Hold here. Bovie.” He glanced up at me. “So you’re at Duke?”

“Yeah.”

“Know Dr. So-and-So?”

“No, can’t say I’ve met him.”

“Good guy. Head of Cardiothoracic Surgery. We trained together. Hey, don’t hold that like that, hold it this way. Suck!”

Our conversation was over, thank God. He returned to the operation.

Shhhlluuurrrrpppp. Really long tone. Lots of smoke.

I’d been standing of the stepstool for a while and noticed a sudden wave of nausea hit me. I felt cool. Clammy.

Schhhllluuuurrrp. Sccchhhhhhllluuuuuuup. Gurgle, gurgle. More smoke: like the smell of napalm in the morning. Shhhhhhhhhh. Stink. More smoke. Sccchhhlluuurrrrrp. Bleeps. Gaaaaaaa.

By now, I was feeling really nauseous. The thought of blowing chunks all over the operative field entered by mind. Maybe this is why I was wearing the mask over my face – to prevent such a moment. I noticed the medicinal smell of the mask and noted the little fibers tickling my nose as if to coax me into projectile vomiting.

“Uh, is there a bathroom nearby?”

My brother looked at me. My face was as white as a sheet. Maybe green is a better description. He’d seen that color before, I think, on someone dead.

“It’s just out the door to your left,” pointing me the way. I managed to make it back to the bathroom and just felt like hell. I sat on the toilet, unsure of what would happen next. I wanted to puke, but couldn’t. I put my head down, panting. I just wanted to die I felt so bad. So nauseaus. Oh, pleaaaasssse, just puke and get it over with! But it was not to be.

A few minutes later, my brother came back to the bathroom.

“You okay?”

Never wanting to sound like a wimp to my brother, I proclaimed, “No, I’m okay, I just need a few minutes” from the bathroom stall. My nausea finally seemed to be improving a bit. Slowly, gradually, I was coming back from the dead. Finally, I emerged from the stall, smiling.

My brother looked on in horror as he saw his brother emerge from the bathroom still looking like hell warmed over. He was nice enough to not say anything.

“So what ‘d ya think?”

“Awesome.”

-Dr. Wes

Image credit.

With Healthcare: It's the All About the Money

Our presidential candidates on both sides of the aisle better wake up and smell their coffee: healthcare costs, not just the number of uninsured, now place the US at risk economically:

The US is at risk of losing its top-notch triple-A credit rating within a decade unless it takes radical action to curb soaring healthcare and social security spending, Moody’s, the credit rating agency, said on Thursday.

The warning over the future of the triple-A rating – granted to US government debt since it was first assessed in 1917 – reflects growing concerns over the country’s ability to retain its financial and economic supremacy.

So suddenly, our policy of offering "free" subsidies to maintain corporate profits might not be such a good policy after all, heh?

-Wes

Ballot E-Stuffing

Holy Cow! I just found out from KevinMD's blog that the 2007 Medical Blog Awards can be voted (like Chicago's politics) every day!

It's electronic ballot e-stuffing! What a deal!

So head on over to Medgadget once a day, every day, until the 20th of January at midnight and vote for your favorite med blogs!

Yeee haaaa!

-Wes

Update 14Jan2008 @ 2005: Yikes! Thanks for Dr. Val for pointing this out: Looks like I'm wrong on this. Medgadget's rules state that you should vote once and only once. So BEHAVE and disregard my recommendation above. Sorry about the confusion!

-Wes