Tuesday, October 26, 2004
Anesthesia Can Dim Elderly Patients' Minds (?)
'Anesthesia Can Dim Elderly Patients' Minds' or
Longitudinal Asssessment of Neurocognitive Function in Elderly Patient after Major, Noncardiac Surgery (pick your title):
""Conclusion: Elderly patients experience a high prevalence and persistence of cognitive decline after major, noncardiac surgery characterized by early improvement followed by a later decline. Cognitive impairment at hospital discharge predicts long-term cognitive impairment. Future investigations should evaluate the mechanisms responsible for postoperative cognitive decline and interventions to reduce this serious complication.""
The actual scientific abstract is here.
Though intriguing, it's only an abstract. There are so many confounding factors, it's really hard to know what to make of this on first blush. Where's the control group? Wouldn't it be better to have a control group that did NOT have surgery or anesthesia at all and see how they fared after two years?
[Via Yahoo! News: Health]
Monday, October 25, 2004
CDC: What Everyone Should Know About Flu and the Flu Vaccine
CDC: What Everyone Should Know About Flu and the Flu Vaccine
New Interim Guidelines Address Use of Antiviral Medications for Influenza
Influenza Antiviral Medications:
2004-05 Interim Chemoprophylaxis and Treatment Guidelines
""Influenza antiviral medications are an important adjunct to influenza vaccine in the prevention and treatment of influenza. In the setting of the current vaccine shortage, CDC has developed interim recommendations on the use of antiviral medications for the 2004-05 influenza season. These interim recommendations are provided, in conjunction with previously issued recommendations on use of vaccine, to reduce the impact of influenza on persons at high risk for developing severe complications secondary to infection.""
[Via Medscape Headlines]
How To Reduce The Risk Of Catching The Flu
From the JCAHO:
New National Campaign Offers Americans Three Easy Steps To Prevent Infections
The Joint Commission urges Americans to do three easy things to limit the spread of respiratory infections in health care settings and communities.
- Clean your hands – Rub hands vigorously with soap and warm water for at least 15 seconds after using the bathroom, taking out the trash, changing a diaper, or before handling food. Use of alcohol-based hand sanitizers is an acceptable alternative. Americans should also not hesitate to ask their doctors, nurses, dentists or other caregivers whether they have cleaned their hands before rendering care. It is also important that your hands be clean when caring for a sick friend or family member at home.
- Cover your mouth and nose – To stop the spread of infectious diseases through sneezes and coughs, cover your mouth and nose with a tissue, your hands, or the crook of your elbow. Then, remember to wash your hands.
- Avoid close contact – A fever or symptoms of a contagious illness are clear signs to you or your child to stay at home and away from other people, either at work or at school. If you are sick and go to work or school, you place others at risk for getting sick as well.
New site: Legal Reform Now
New site: Legal Reform Now
""
LegalReformNow.com, a new website on legal reform, was launched today. The site is managed by the Institute for Legal Reform (ILR), an arm of the United States Chamber of Commerce committed to tort reform at the state and federal level. LegalReformNow.com is intended as a "clearinghouse for legal reform information on the Web sponsored by a diverse coalition of associations, chambers of commerce, think tanks and state-based legal reform groups."""
[Via PointOfLaw Forum]
Sunday, October 24, 2004
Why Are Oil Prices High When Supply Is Ample?
Clayton Cramer: Why Are Oil Prices So High?
""....And from Adel al-Jubeir, Advisor to the Saudi Crown Prince September 28, 2004 at about 1:40 PM Pacific time, CNBC interview with Maria Bartaromo:
"We believe the price of oil should be between $22 and $28 per barrel. $25 is a good reasonable price. There is no extra demand accompanying today's very high price for oil. We are seeing no extra customers lined up and there is no shortage of supply. The high prices we are seeing are due to speculation in the oil markets."""
George Will On Voter Fraud
George F. Will at TownHall.com: How Voter Fraud Threatens Our Democracy
Medical Care Gets Outsourced, Too
Washington Post: Surgeries, Side Trips for 'Medical Tourists'
Affordable Care at India's Private Hospitals Draws Growing Number of Foreigners:
""Taking his cue from cost-cutting U.S. businesses, Staab last month flew about 7,500 miles to the Indian capital, where doctors at the Escorts Heart Institute & Research Centre -- a sleek aluminum-colored building across the street from a bicycle-rickshaw stand -- replaced his balky heart valve with one harvested from a pig. Total bill: about $10,000, including round-trip airfare and a planned side trip to the Taj Mahal.""
[Via Digital Claudio...]
Review of Pediatric Sedation
Review of Pediatric Sedation:
""Sedating children for diagnostic and therapeutic procedures remains an area of rapid change and considerable controversy. Exploration of this topic is made difficult by the fact that the reports of techniques and outcomes for pediatric sedation appear in a wide range of subspecialty publications and rarely undergo comprehensive examination. In this review article, we will touch on many aspects of the topic of pediatric sedation from the perspective of the anesthesiologist. We begin with a review of the historical role of anesthesiologists in the development of the current standards for pediatric sedation. We also examine the current status of pediatric sedation as reflected in published studies and reports. A specific review of the issues surrounding safety of sedation services is included. Current trends in sedation practice, including the expanding role of potent sedative hypnotic drugs outside the field of anesthesiology, are noted. Finally, we suggest future areas for research and clinical improvement for sedation providers.""
[Via Anesthesia and Analgesia: Current Table of Contents]
Surgical Cause of Vocal Cord Paralysis
Guilt by proximity? On more than one occasion (including one very recently), I've received calls from patients complaining of laryngeal symptoms after my general anesthetic. In every case, their surgeon suggested to them that since their symptoms are in their voice box, it must have been something the anesthesiologist did since they stuffed a tube in there. Here's a great example of why it 'ain't necessarily so:'
Vocal cord palsy as a complication of adult cardiac surgery: surgical
correlations and analysis.
Author(s): Dimarakis I; Protopapas A;
""Vocal cord palsy after adult cardiac surgery is often attributed to non-surgical
mechanisms as tracheal intubation and central venous catheterisation.It
may also be caused by injury of the recurrent laryngeal nerves by surgical
dissection. We hereby present a review of relevant clinical reports. The
cumulative incidence was 1.1% (33 in 2980). Main reported surgical mechanisms
of injury were harvesting of internal thoracic artery and topical coldcardioprotection.
Bilateral nerve palsy has been lethal on at least one occasion. Where
vocal cord injury followed harvesting of the left internal thoracic artery,
it was reported ipsilateral to the conduit."
"
European journal of cardio-thoracic surgery: official journal of the European
Association for Cardio; 2004 Oct 1;26(4) p773 - 775
[Via Journals To Go]
Saturday, October 23, 2004
Heal the Law, Then Health Care
I'm reading more about Expert Medical Courts. Although my initial reaction is to avoid the creation of a new expert medical court beurocracy, I'm beginning to see the necessity of it.
Heal the Law, Then Health Care
Troyen A. Brennan and Philip K. Howard
The Washington Post, January 25, 2004
""What's missing from the current debate is any discussion of how the legal system should work in health care. Law is not some sort of sacred mandate but a tool to serve the common good. Asking how law can best serve health care leads to an unavoidable conclusion: A system of justice must be created that makes deliberate judgments -- reliable for patients and providers alike -- with improved patient care as the primary goal.""
Deficit Decline
Jack Kemp--Deficit declines $100 billion:
""Looking ahead to the next four years, our goal should be economic growth rather than reducing deficits per se. If growth is the goal, then tax increases, trade restrictions and nationalized health care are the wrong choices. If long-term growth is our goal, then we will reject tax-and-spend redistributionist policies masquerading as fiscal discipline; and, if long-term growth is our goal, we will continue to pursue lower tax rates on all Americans, free trade, less regulation, tort reform and entitlement reform. Those are the right choices. ""
(emphasis mine)
[Via Kudlow's Money Politic$]
Friday, October 22, 2004
UT El Paso: Herbal Safety
UT El Paso: Herbal Safety
"
"In the past decade, there has been an increased interest in herbal medicines
and treatments, both from the mainstream medical community and the general
public. One need look no further than the cold drink section of the local
supermarket to see the various herbal supplements that are prominently
displayed on many drink labels. In an effort to provide critical evaluations
of these various herbs and related products, the University of Texas at El
Paso has created this important website in order to disseminate information
about research findings related to herbal use and to provide these findings
in both English and Spanish."
"
[Via The Scout Report]
Medical Economics - Malpractice: Who should judge the experts?
Medical Economics - Malpractice: Who should judge the experts?:
"
"Doctors who serve as expert witnesses for malpractice plaintiffs are finding themselves threatened by their state and specialty societies."
"
and
"
"...last May, the Federation of State Medical Boards adopted a resolution defining "false, fraudulent or deceptive" expert witness testimony by a physician as "unprofessional conduct."
"
Thursday, October 21, 2004
The John Edwards Fan Club
"
"Why, I asked, should we carry a $100,000 medical school debt, stay in school for 8 to 12 years, work long hours during and after residency, and fight the bloated bureaucracy of the health care system, when we can get rich quickly by following John Edwards? So here is what I proposed. We physicians should take turns suing one another..."
"
[Via Point Of Law Forum]
BMJ Review: Risks of general anaesthesia in people with obstructive sleep apnoea
Risks of general anaesthesia in people with obstructive sleep apnoea
""Summary points
Patients with obstructive sleep apnoea are at high risk of developing complications when having surgery or other invasive interventions under general anaesthesia, whether or not the surgery is related to obstructive sleep apnoea
Surgeons of all specialties, and especially anaesthetists, should be aware that undiagnosed obstructive sleep apnoea is common
They should be alert to patients who are at risk of having obstructive sleep apnoea and be aware of the potential preoperative and postoperative complications in such patients
Management options include alternative methods of pain relief, use of nasal continuous airway pressure before and after surgery, and surveillance in an intensive care unit, especially after nasal surgery in which packs are used
An algorithm for management of difficult airways should be established""
Common Good: Expert Medical Courts: An Idea Whose Time has Come
Common Good: Expert Medical Courts: An Idea Whose Time has Come:
""A
recent editorial by Dr. Charles Lockwood, Chair of the Department of Obstetrics and Gynecology at the Yale University School of Medicine, endorses Common Good's proposal to create special health courts and calls on doctors to "rally behind [the proposal] by joining and supporting Common Good."
Lockwood lists six key benefits that a health court would produce, including "consistent judgments on standards of care by court appointed experts; accountability for negligent and reckless providers; and powerful incentives for quality improvement in medical systems."
"
Here's my litmus test for this one. Let's ask John Edwards if he thinks it's a good idea. If no, I'm for it. If yes, I'm against it
Failing the Public Health — Rofecoxib, Merck, and the FDA
Failing the Public Health — Rofecoxib, Merck, and the FDA
"
"I believe that there should be a full Congressional review of this case. The senior executives at Merck and the leadership at the FDA share responsibility for not having taken appropriate action and not recognizing that they are accountable for the public health. Sadly, it is clear to me that Merck's commercial interest in rofecoxib sales exceeded its concern about the drug's potential cardiovascular toxicity. Had the company not valued sales over safety, a suitable trial could have been initiated rapidly at a fraction of the cost of Merck's direct-to-consumer advertising campaign. Despite the best efforts of many investigators to conduct and publish meaningful independent research concerning the cardiovascular toxicity of rofecoxib, only the FDA is given the authority to act. In my view, the FDA's passive position of waiting for data to accrue is not acceptable, given the strong signals that there was a problem and the vast number of patients who were being exposed."
"
Emphasis mine.
NEJM -- Bankrolling Stem-Cell Research with California Dollars
NEJM--Bankrolling Stem-Cell Research with California Dollarscontains a very informative passage about how stem cells are obtained:
""What is at issue here is that the derivation of an embryonic stem-cell line requires the dissection and culturing of about 30 cells from the core of a blastocyst, a microscopic early-stage embryo comprising fewer than 200 cells. The derivation process kills the embryo, even as the stem cells persist and propagate. The embryos themselves are obtained from in vitro fertilization (IVF) clinics, where excess embryos are typically produced in the course of assisted-fertility procedures. An estimated 400,000 IVF embryos are currently in frozen storage and will eventually be discarded, except for those that are donated, with informed consent, for use in research. Some religious conservatives and opponents of abortion have taken a firm stance on what seems to be tenuous, ultimately unsustainable moral, ethical, or logical ground: acquiescence to the discarding of excess IVF embryos, coupled with rigid opposition to the use of embryos for biomedical research.""
The same issue contains another article titled Embryonic Stem-Cell Research — The Case for Federal Funding. Both are available free (kudos to NEJM for this).
CME Watch
CME Watch:
""Now there's a freebie,
CME Watch v0.4, to help you keep tgrack of your CME activities!
 Description:
Introducing CME Watch - Track your CME Hours Easily on your Palm.
No more worrying about whether you've accumulated enough hours.
Use the summary function to add up all the CME hours!
Useful for : Physicians, Nurses, Respiratory Therapists....anyone who needs to attend and keep track of Continuing Medical Education Time!
Featuring:
- Automatically Adds and Summarizes Total CME Hours
- Ability to also track days for CME Allowance.
|
""
[Via The Palmdoc Chronicles]
NEJM: Financing Medicare in the Next Administration
Financing Medicare in the Next Administration (free full text)
"
"Because of its size and political impact, Medicare will rank high on the domestic policy agenda of any incoming administration. When that administration assumes office in January 2005, Medicare will account for more than 13 percent of total federal expenditures; the only larger domestic program will be Social Security, which will account for 21 percent.1 By fiscal year 2007, with the phase-in of the prescription-drug benefit, Medicare's share of federal spending will increase to almost 16 percent. In short, the new administration will find the scope of any new initiatives limited by the needs of the Medicare behemoth."
"
Have You No Shame Senators? - Judson Cox
Have You No Shame Senators? - Judson Cox:
"
"Sen. Kerry also sought to take advantage of Reeve's tragedy. According to Tribune National Correspondent, Jill Zuckman, Kerry claimed Reeve called him on the night of the second debate, and left a message thanking him for supporting stem cell research. The excitement in his voice was really just palpable. He was just thrilled at where the discussion of stem cell research had come to." Reeve had already fallen in to a coma at the time Kerry claims he called. Kerry's willingness to exploit people and situations knows no bounds."
"
Bush and GOP Sites Outage, DDOS Attack Suspected
Bush and GOP Sites Outage, DDOS Attack Suspected:
""Web sites for President Bush's campaign and the Republican National Committee are investigating outages.""
[Via eWEEK Technology News]
Wednesday, October 20, 2004
Pentagon Says No Need for a U.S. Draft of Doctors (Reuters)
Pentagon Says No Need for a U.S. Draft of Doctors (Reuters):
""Reuters - The Pentagon said on Wednesday it
does not need or want a draft of doctors and other medical
workers even as another agency updates contingency plans for
such a draft in the event of a national catastrophe.""
[Via Yahoo! News: Top Stories]
Access to Physicians Figures Prominently In Complaints
Annals of Family Medicine: Patient Reports of Preventable Problems and Harms in Primary Health Care:
"
"Conclusion: The errors reported by interviewed patients suggest that breakdowns in access to and relationships with clinicians may be more prominent medical errors than are technical errors in diagnosis and treatment. Patients were more likely to report being harmed psychologically and emotionally, suggesting that the current preoccupation of the patient safety movement with adverse drug events and surgical mishaps could overlook other patient priorities."
"
[Via Science Blog - Science News Stories]
Why Do Carbs Turn To Fat?
Researchers uncover process for carb-induced fat formation:
""Researchers are one step closer to understanding how high carbohydrate diets lead to obesity and diabetes. They have shown that a single protein called carbohydrate response element binding protein activates several genes that cause cells in the liver to turn sugar into fat.""
[Via Science Blog - Science News Stories]
Medical Economics - How I pick the doctors I'll sue
Medical Economics - How I pick the doctors I'll sue:
"
"Many complaints filed against physicians are based on their miscommunication with patients, nurses, or other doctors. But even well-intentioned efforts to improve doctors' communication skills run into opposition from the medical profession. For instance, the National Board of Medical Examiners has introduced a one-day exam designed to test doctors' ability to communicate with patients, as well as their clinical skills. Unfortunately, the American Medical Association has opposed the test, and vows to block its implementation."
"
Tuesday, October 19, 2004
Must Read: Tommy Frank Sets Kerry Straight
New York Times: War of Words
"
"...But the gravest danger would result from the withdrawal of American troops before we finish our work. Today we are asking our servicemen and women to do more, in more places, than we have in decades. They deserve honest, consistent, no-spin leadership that respects them, their families and their sacrifices. The war against terrorism is the right war at the right time for the right reasons. And Iraq is one of the places that war must be fought and won. George W. Bush has his eye on that ball and Senator John Kerry does not."
"
Tommy Franks Sets Kerry Straight. 'Honest, consistent, no-spin leadership.' I love it. Hey, anybody got Chris Matthew's phone number?
[Via Captain's Quarters]
T-Line Tensymeter Instead of Arterial Lines
I remember seeing this product at an anesthesiology meeting last year and thinking how great it would be for bariatric surgery (gastric bypass operations on the morbidly obese). It's an external device which, when strapped to the wrist and calibrated, can give a very accurate blood pressure reading. Depending on their upper arm morphology, a non-invasive blood pressure cuff may not work reliably in morbidly obese patients if the upper arm is cone-shaped. I used to start arterial lines on these patients, but this device, would be an alternative.
As almost all gastric bypass operations I give anesthesia for are done laparoscopically, this is less and less of an issue for me personally.
[Via EchoJournal]
Monday, October 18, 2004
How Technology Failed In Iraq
MIT Technology Review: How Technology Failed In Iraq
"
“Next to the fall of Baghdad,” says Marcone, “that bridge was the most important piece of terrain in the theater, and no one can tell me what’s defending it. Not how many troops, what units, what tanks, anything. There is zero information getting to me. Someone may have known above me, but the information didn’t get to me on the ground.” Marcone’s men were ambushed repeatedly on the approach to the bridge. But the scale of the intelligence deficit was clear after Marcone took the bridge on April 2."
"
FactCheck.org: Kerry Falsely Claims Bush Plans To Cut Social Security Benefits
Kerry Falsely Claims Bush Plans To Cut Social Security Benefits
"
"It's not Bush's plan, and it wouldn't cut benefits.
Summary
A Kerry ad claims "Bush has a plan to cut Social Security benefits by 30 to 45 percent." That's false. Bush has proposed no such plan, and the proposal Kerry refers to would only slow down the growth of benefits, and only for future retirees. It was one of three possible "reform models" detailed by a bipartisan commission in 2001.
The ad also says nothing about what Kerry would do to address the troubled state of Social Security finances. Unless taxes are increased, the system's trustees say currently scheduled benefits would have to be cut 32%."
"
Sunday, October 17, 2004
Coping Strategy For Lack Of Flu Vaccinations
In discussing the issue of influenza vaccinations with your doctor, you should be aware that there are ways to treat the flu once you get it. One drug is called Tamiflu (oseltamivir phosphate). Relenza (Zanamivir) is another. Tamiflu comes in capsule and oral suspension form whereas Relenza is inhaled via 'diskhaler'. These drugs interfere with the ability of Influenza A and B to aggregate and be released from cells. Both are 'designer drugs' in that their molecular structures were created in the lab specifically for their anti-neuraminidase activity:
""What is Tamiflu used for?
Tamiflu is for treating adults, adolescents, and pediatric patients 1year of age and older with the flu whose flu symptoms started within the last day or two. Tamiflu is also used to reduce the chance of getting the flu in people age 13 and older who have a higher chance of getting the flu because they spend time with someone who has the flu. Tamiflu can also reduce the chance of getting the flu if there is a flu outbreak in the community."
"
Though clearly not a substitute for flu shots, their lack of availability makes having a 'Plan B' necessary. If history is any guide, Tamiflu and Relenza will become commodity drugs just like ciprofloxacin was after the Anthrax scare.
Rush Limbaugh Is Playing The Blame Game
Michelle Malkin has a quick note on the flu vaccine shortage, and points to a Rush Limbaugh piece: Clintons Ruined Vaccine Industry. Rush basically argues that it's all Hillary's fault because of her role in the Government Vaccine Buying Program. This is a classic case of hindsight bias; the tendency of people with outcome knowledge to exaggerate the extent to which they would have predicted the event beforehand. Yes, I'm sticking up for Hillary here. It IS a powerful example of why the approach taken by the vaccine buying program is flawed. What we should be doing is asking ourselves whether we need to make changes vis-a-vis our other vaccine programs.
The October 14, 2004 Wall Street Journal editorial 'Infectious Politics' (reproduced here) has some disturbing statistics:
- Hib1 3
- Influenza 2
- Hepatitis A 2
- Hepatitis B 2
- DTaP2 2
- Measles, mumps, rubella 1
- Tetanus 1
- Tetanus-diphtheria 1
- Polio 1
- Chickenpox 1
- Pneumococcal conjugate (children) 1
- Pneumococcal polysaccharide (adults) 1
- Meningococcal 1
and asks the question:
"
"Whether or not Chiron disclosed enough about its manufacturing woes is an issue of financial regulation. The main question for public health ought to be how did we arrive at a place where closing a single plant can endanger so many people?"
"
Let's stop playing the blame game and figure out how to improve our vaccine production system. To again quote the WSJ piece:
"
"There's no shortage of ideas for how to promote greater vaccine production, with many of the best ideas coming from the few manufacturers that remain. Now would be a good time to hear them out. As deadly as the flu is, consider the dangers of such infectious diseases as measles or whooping cough. Those are the next outbreaks to worry about if Washington keeps blaming everyone but itself for the vaccine crisis."
"
Lancet: Summary of Flu Vaccine Woes
The Lancet: Vaccine preparedness, or not:
The problem
"
"So, what went wrong at Chiron's production plant in Liverpool, UK? On Aug 26, according to Chiron, Serratia marcescens was found in a "small number of lots". The company informed health agencies in the UK and USA, and planned to delay release of the vaccine until early October while it tried to resolve the contamination issue. S marcescens is an important human pathogen because of the growing number of cases of infection by this organism, its virulence, and its increasing resistance to antibiotics. MHRA visited the Liverpool site, and Chiron thought it could address the concerns of the inspectors. The problem, says MHRA, is that the contaminated lots cannot be separated from the whole batch."
"
The lesson:
"
"There is a lesson here, about vaccine supply. It is not sensible to restrict manufacturing licences, in the case of influenza vaccine and especially in the USA, to two suppliers. At a blow, half this year's stocks were impounded. The risk (of faulty batches) should be spread across several manufacturers."
"
