Blog Break

I'll be restoring the creative juices. I'll be back Sunday or Monday. Have a nice weekend.

-Wes

More Light on the Pacemaker/CT Scanner Interaction

St. Jude Medical came forth with a "Dear Doctor" letter (pdf) today regarding their findings regarding pacemaker and CT scanner interactions which represents the most specific recommendations with CT scanners and their devices to date:

Testing has shown that for devices which incorporate an accelerometor for rate responsive activity-based pacing, if the activity sensor is programmed "on" while continuous diagnostic X-ray exposure (e.g. CT scanning) is performed, if the beam of energy is directly over the implanted device, there may be a temporary increase in pacing rate during the exposure. The pacing rate will return to baseline pacing after the X-ray exposure is terminated. If increased rates occur, the pacing rate will be limited to the programmable Maximum Sensor Rate which is generally determined by the patient's physician as the safe maximum rate to be achieved during exercise. To prevent any potential transient rate increase, the clinician may want to consider programming the rate responsive sensor to Passive or OFF, if appropriate, prior to the X-ray procedure and then reprogram the parameter as desired after the diagnostic imaging is completed.

Read the rest for the details.

Medtronic's statement regarding the same issue is included here (pdf).

I cannot recall ever seeing an interaction like the one they're describing, but the implications are that we'll have to be more cautious as CT scanners become more powerful, especially as patients have chest CT's that might scan the pacemaker implant sight. For the great majority of patients, I just do not see this as a "biggie" for patient care. Anyone else with thoughts?

-Wes

EKG's and ADHD: Common Sense Prevails

I'm so glad 'dem der pediatricians set us here cardiologists straight.

Dang, I had no idear there was so many of 'dem der corrections to the original announcement about the need for EKG's before administering ADHD drugs.

Nice to know some common sense could prevail...

-Wes

A Blood Test for Acute Aortic Dissection?

Maybe.

-Wes

Determining Cause and Effect

I wouldn't want the FDA's job.

Today, the Chicago Tribune reported that of the 93 deaths from "tainted" heparin, that analphylaxis (a sudden allergic reaction with associated drop in blood pressure) was identified in 10 of the 93. Of these 10, 3 patients were conclusively found to have the "oversulfated chondroitin sulfate" contaminant in certain vials:

Of 10 reports of death from severe shock known as anaphylaxis or hypotension, three of those could be traced to lot numbers of Baxter products that tested positive for an animallike substance known as oversulfated chondroitin sulfate. Heparin lot numbers were not known for the other seven deaths from anaphylaxis or hypotension, so the FDA could not determine whether those 7 patients received heparin contaminated with the substance.

But what I found interesting were the number of deaths NOT found related to the contaminant. Of the remaining 83 deaths reported:

• 45 didn't have enough data submitted to be able to determine a cause of death
• 25 were causes unrelated to heparin, like kidney failure, pneumonia, and sepsis
• 13 were related to bleeding, a known side effect of heparin

The FDA should be commended on their efforts to cull through a vast sea of medical information to attempt to determine the cause of death in the individuals affected and working so quickly to determine a cause of the contaminant. To me, finding three deaths in a sea of 90 deaths that were definitively determined to be related to the contaminant is like finding a needle in a haystack. Perhaps more importantly, by issuing their summative findings of the evalutation of the deaths, they shed light on the difficulty of monitoring and investigating drug reactions from community-based reporting.

-Wes

Taking the Leap: Why Medicine?

Edwin Leap, MD hosts Grand Rounds this week:

"... my theme this week is ‘Why do we do it?’ That is, medicine being what it is, many providers (nurses, physicians, PA’s, NP’s, etc) are dissatisfied and frustrated. So why is it that all of these good people keep coming back? Why do docs like me return to the packed, over-burdened, understaffed emergency department, day after day, year after year? Why do surgeons operate at all hours on the injured and dying, aging too quickly and leaving their families at home? Why do family doctors care for so many complicated and ungrateful individuals…at a financial loss? Why do students sacrifice so much of their lives to become physicians? Why do nurses endure the hours and patient ratios, the annoying physicians and the pesky families in order to care for the sick? Why do we do it?"

Why?

Because.

-Wes

EKG Du Jour - #10

Ah, it's been a while since I've pulled an EKG from the EKG Hall of Fame series, so here's the tenth installment for your enjoyment:*

A 28 year old man presents to your office with an implantable cardiac defibrillator (ICD) in place. He shows you his EKG, shown here:

Click image to enlarge

You are asked for a second opinion to see if he really needs his ICD. He has no reports from the other hospital with him.

What is the differential diagnoses offered by this EKG, and of those, given his age and EKG findings, what might be the most likely diagnosis?

-Wes

* Prior "EKGs Du Jour" can be reviewed by typing "Du Jour" in the search box on the right side bar of this blog.

Quote of the Day

Today, San Francisco's city board of supervisors will vote on whether to bar cigarette sales at pharmacies and retail stores with in-store clinics that treat common ailments such as sore throats and sinus infections as of October 1. Opponents of the tobacco ban believe stores will get out of the clinic business if they are forced to choose between providing health care and selling cigarettes:

"We do not understand how forcing retailers to choose between having an in-store clinic and selling tobacco products serves the broader goal of providing consumers with easier access to high-quality, affordable health care"
- Tine Hansen-Turton
Executive Director of the Convenient Care Association

Perhaps, Ms. Hansen-Turton, it's because healthcare is about commitment to real health, not just convenience and profit. Frankly, I can't think of a better way to promote sore throats and sinus infections than to sell cigarettes, too.

-Wes

Image reference.

Thoughts on the Canadian Health Care System

It seems that dogs can get hips before people:

From that beginning, in 1958 the clinic expanded to Bank Street at Alta Vista. In 1986, it built a modern new 10,400-square-foot facility further out Bank Street. In 2001, a 13,000-square-foot wing was added. It now has 22 vets, 40 animal health technicians, and about 85 support staff. Specialists include internal medicine, cardiology, surgery, oncology and dentistry.

It has its own high-tech scanners, and can do hip and joint replacements in a fraction of the waiting time people are forced to endure. It is a major supporter of most animal welfare campaigns.

Ah, the power of cash.

-Wes

Making 'Em Look Good

It’s the beginning of the academic medical school year, and a new flock of energetic medical students has arrived. It is evident as they eagerly call the attending to “notify” them of a sick case that was “coming to the ward” having never seen the patient.

It was no biggie, this time. Things were handled. But it was clear during the late-night phone conversation that the medical student hadn’t seen the patient, wasn’t aware of the entire medical history, and was sent as the “messenger.”

Well, we don’t shoot the messenger.

But there’s also an important principle that should be followed when communicating with different members of the medical team involved in a patient’s care:

Make ‘em look good.

If you are a medical student, make your resident look good on rounds. Know the history, medications, lab results, and the patient’s chief complaint that day. If you do, he’ll make sure you look good.

If you’re a resident, make your fellow look good on rounds. Teach the students. Check the patient yourself if needed. Give the fellow the pertinent items to be addressed that day, and make sure they happen. If you do, your fellow will make you look good.

If you’re a fellow, make your attending look good on rounds. Guide the resident. Come prepared, having communicated with the team, understand the next plan of action, and implement it. If you do, your attending will make you look good.

If you’re an attending, make sure the nurse looks good. Point out the good things he or she did overnight, guide them on the items that need attention, and listen to their concerns. If you do, your nurse will make you look good.

If you’re a nurse, make sure the patient looks good. Respond to their calls, check the medications not once but twice, ask why the dinner tray arrived late, and help brush the patient's hair and teeth. If you do, the patient will make sure the whole hospital looks good.

Simple, effective.

That’s the way it works.

Best of luck to all of you.

-Wes

Like Moths Drawn to a Light

Once again, Pay for Performance measures have been demonstrated to be a miserable bureaucratic failure.

But what's the bureaucrats' response? Why, PAY THEM MORE and MAKE MORE MEASURES to make it work, of course!

Rosenthal cautioned that studies finding little quality impact so far "have nothing to do with overturning the theory of pay-for-performance. It can be explained by the way in which these programs have been implemented, and at the top of the list is that the size of the bonus is too small."

Maximum quality incentives average 9% of plan payments, according to a Nov. 2, 2006, New England Journal of Medicine study by Rosenthal, but most physicians average less than a 5% bonus. By contrast, under a British P4P plan that was rolled out in 2004, physicians can more than double their income by achieving high scores on 149 quality indicators.

Don't they get it? THIS DOESN'T WORK! Worse yet, people can get RICH scheming this system: just build a little algorithm to assure everyone gets a test each time they're seen, (performed, of course, under the guise of a "quality initiative") whether they need it or not, and voila' - you're rich! You can name a TON of ways to game the system because each of these "measures" turns the intent of "quality" into a PROFIT motive for doctors and hospitals.*

When it comes to pay and the inevitable declining revenues in the Medicare National Bank, doctors (and hospitals) are like moths: they're drawn to the brightest light with this month's payment rationing scheme. And here's the thing...

...the brighter the light, the more moths will flock there.

-Wes

* Well, not really. Actually Medicare withholds a portion of payments to doctors and hospitals first, and only after completing 85% or more of the "quality measures" will they ante up the full payment amount. (It's like training a dog: "Sit, Fido, sit. Stay. Staaayyy. Good, dog! Here's your treat!")

Image reference.

Pinching Childhood Brain Cancer

Our infamous Dr. Rob of Musings of a Distractible Mind has been working tirelessly with Zippy, the lovable red lobster, to raise awareness and funds to support childhood brain cancer research over at FunWithZippy.com. He asked if we'd help support the effort and host the official "Fun With Zippy" t-shirt on our medical t-shirt site MedTees.com, for which we were only too happy to help out.

All proceeds from the sales of these shirts, button, aprons, mouse-pads, stickers and the like with Zippy's logo will support childhood brain cancer research.

Why not help some kids out today and get your very own shirt? After all, you never know where Zippy will show up next.

-Wes

The Power of Marketing Drugs for Kids

...it's especially evident in our new, burgeoning pharmaceutical market, our children:

Madeira Therapeutics, based in Leawood, Kan., is formulating a liquid statin for children that will be sold in either grape, cherry or bubblegum flavor, according to the company’s chief executive, Peter R. Joiner.

Madeira became interested in the drug to treat children with a genetic cholesterol condition, familial hypercholesterolemia, which strikes 1 in 500 children regardless of their diet. The recent American Academy of Pediatrics statement adds to the potential market, according to Mr. Joiner.

This need is further supported, of course, by powerful marketing data supplied by the monstrously profitable prescription services themselves: Medco Health Solutions, Express Scripts, and Verispan:

Express Scripts and Medco developed estimates of how many children might be taking such drugs by extrapolating their data — involving a total of more than four million children — across the broader population.

The companies use different assumptions to reach their estimates, but the data suggests that at least several hundred thousand children are on various obesity-related medications.

The greatest increase occurred in drugs for Type 2 diabetes, with Medco’s data showing a 151 percent jump from 2001 to 2007.

Medco’s data, released in May, showed that use of drugs to treat acid reflux problems in children, often aggravated by obesity, increased 137 percent over seven years. Its analysis also showed an 18 percent increase in drugs to treat high blood pressure and a 12 percent increase in cholesterol-lowering medications during the seven-year period.

Express Scripts found a 15 percent increase over three years in drugs to treat cholesterol and other fats in the blood, a category that is primarily statins.

“We were amazed at how quickly the rates of drugs used have climbed,” said Dr. Donna R. Halloran, an assistant professor at St. Louis University who worked on the Express Scripts analysis, presented at a meeting of the American Public Health Association in November.

Verispan data recorded a 13 percent increase in high blood pressure prescriptions in the under 19 age group from 2005 to 2007. Its numbers show, however, a less than 1 percent increase during the period in cholesterol-lowering drugs in children.

And therefore, because the rates have climbed, it must be okay, right?

The suspect nature of these culled data draw into question the message we want to feed (pun intended) our children and families, and pushes public health experts (and even our professional societies) to waddle toward the path of least resistance when it comes to caring for our children.

The issue of childhood obesity is a complicated one, fraught with many challenges. The influence of the fast-food industry, internet gaming industry, drops in funding to support school-based physical education programs, and the complicated socioeconomic challenges of fragmented families, have all coalesced to create the perfect storm of influences to promote weight gain in our children. These problems, it seems, have become insurmountable.

Better to just give 'em a pill.

-Wes

Image reference.

Fat Chance That Trans Fat Ban Will Help

Let me see if I have this right:

"A Low-Carbohydrate, Ketogenic Diet versus a Low-Fat Diet To Treat Obesity and Hyperlipidemia" showed low-carbohydrate, ketogenic (high fat) diets were superior to a low-fat diets for weight loss and lipid management.

"A randomized controlled trial of a moderate-fat, low-energy diet compared with a low fat, low-energy diet for weight loss in overweight adults" demonstrated the moderate fat diet helped dieters lose weight faster than low-fat diets.

In a "Comparison of the Atkins, Zone, Ornish, and LEARN Diets for Change in Weight and Related Risk Factors Among Overweight Premenopausal Women," the Atkins diet, with its high fat, won hands down at weight loss and lipid improvement in women.

And now, in the DIRECT Trial testing "Weight Loss with a Low-Carbohydrate, Mediterranean, or Low-Fat Diet," we find that low carbohydrate (moderate fat) or Mediterranean diets are superior to low-fat diets at weight loss and lipid management.

So given all of this prospective, randomized data, why the heck is California so proud to be banning trans fats? Trans fats exist in many, many foods besides baking oils. Meats, butter, and milk all have trans fats. Given the available data above and the efficancy of LOW CARDBOHYDRATE diets to improve weight and lipid panels, might they be targeting the wrong thing?

No wonder patients are confused.

-Wes

Double Trouble: Nurses Gone Wild

It's bad anough having one nurse stealing drugs, but it's even worse when there's two co-workers colluding together:

Det. Scharschmidt says O'Grady knew Hughs' work schedule and the two coordinated the times when O'Grady would go to an area pharmacy to pass a prescription. When the pharmacist would call the medical office to check on the prescription, Hughs would answer the phone, assuring the pharmacist that the prescription was good.

Investigators say Hughs had as many as 30 different aliases she used on the prescriptions to get drugs like Oxycontin, Percocet, Hydrocodone, and Alprazolam.

Parma Heights Police say many of those drugs were then sold on the street.

"One of the females, O'Grady, had had an Oxycontin addiction so some of this was for personal consumption," Said Det. Scharschmidt, "but for the most part they were being sold on the streets and turned into a financial gain for the two of them."

Police estimate that both women obtained 20,000 pills over the course of three or four years, making as much as $200,000.

Scary scenario, indeed.

-Wes

I Didn't Practice Evidence-Based Medicine Today

He was 70 with critical aortic stenosis and ejection fraction of 10%, coronary artery disease and history of 5-vessel bypass in 2001, a history of Stage D colon cancer with lung mets resected 18 months ago, obesity, diabetes mellitus, chronic renal insufficiency and was recently extubated after a failed aortic valvuloplasty. He later developed a wide complex tachycardia at 150 beats per minute for which I was asked to consult. The SVT looked just like his underlying left bundle branch block and would start and stop – usually with a PAC. He was administered 2.5mg metoprolol intravenously and loaded with Amiodarone. His SVT became a non-issue thereafter.

But I didn’t check his HbA1c.

I didn’t check his LDL lipid level.

I didn’t do a diabetic fundoscopic exam.

I didn’t refer him to a neurologist for his mild peripheral neuropathy.

I didn’t get him an evaluation of his footwear.

I didn’t give him an implantable defibrillator or biventricular pacemaker.

I didn’t do universal weight screening.

Instead, I just practiced medicine.

I wonder what my PQRI measure score sheet will look like? I probably won't get my 1.5% bonus from Medicare, I guess. * Sigh *

Too bad there’s no box on that scoresheet for how much money careful judgment could save our healthcare system.

-Wes

The Ultimate Paradox

I found this note in my e-mail this morning:

"My sister’s 3 sons (my nephews, ages 13, 11 and 8) were all diagnose(d) today with the same heart condition I have: Long QT Syndrome. Please pray for their peace & strength and for the wisdom of all doctors who see and test the boys.

They are facing years of tests, possible tachycardia and cardiac arrests, pacemakers, medications."

Positive congenital screening tests result in the ultimate paradox for the patients and families affected by the results:

The good news: the condition was recognized early.

The bad news: the condition was recognized early.

-Wes

Atrial Fibrillation Podcast

I did an hour-long radio show on atrial fibrillation (afib) yesterday afternoon with my colleague Dr. Jose Nazari, MD. The podcast is now up and you can download it here. If you're brave enough to sit through the hour-long show, you can hear all kinds of tidbits: like what I do for my day job, what afib is, where the name "warfarin" came from, treatment options, and coffee's effects on afib, etc.

If you you don't have time to listen to this, or if you have other questions, I'll also be doing a live on-line chat for an hour on August 6th, 2008 at 7PM central standard time. You can request an e-mail reminder here to log on here. We'll see how fast my fingers can type...

-Wes

Change of Shift is Up With Great Content

Kim over at Emergiblog once again hosts Change of Shift - the best of the nursing blog-o-sphere this week. In it, I found this hilarious depiction of a German doctor's clever way to dance his way in to teaching arrhythmias. Be sure to check out atrial fibrillation and the successful defibrillation:



Enjoy!

-Wes

Digitek and Heparin Suits - Forthcoming?

In-pharma Technologist.com has a good review of the Wyeth v. Levine case before the Supreme Court that, like the Riegel v Medtronic case for the medical device industry, will rule if FDA approval of pharmaceutical manufacturing and labeling processes would preempt state liability claims from the recent digitek (digoxin) and heparin manufacturing problems.

-Wes