Did you know that about half of cardiologists’ $400,000+ average income comes from self-referring patients to undergo imaging studies on scanners owned in part or in whole by the physicians themselves? This type of arrangement violates the spirit but not the letter of the Stark Law, created in 1992 to address the inevitable economic and medical inequities that result when physicians are permitted [… read more]
(image: People’s Pharmacy) Sure to re-light controversy around Pfizer’s varenicline (Chantix): a new study concludes the smoking cessation drug likely carries no increased risk for cardiovascular events. Judith Prochaska and Joan Hilton (University of California – San Francisco) report the results in the May 4 BMJ. Sonal Singh (Johns Hopkins) et al’s previous meta-analysis, reported in CMAJ [… read more]
Mechanical Ventilation in ARDS: Overview Mechanical ventilation in ARDS is almost always required, as people with acute respiratory distress syndrome are by definition severely hypoxemic. Yet mechanical ventilation itself can further injure damaged lungs(so-called ventilator induced lung injury); minimizing any additional damage while maintaining adequate gas exchange (“compatible with life”) is the central goal of mechanical [… read more]
(image: flickrCC) Is acetaminophen responsible for the worldwide rise in childhood asthma over the past 30 years? Citing a mounting pile of circumstantial evidence from epidemiologic observational studies, John McBride of Akron’s Children’s Hospital in Ohio believes so, and that it’s time to officially push the worry button. The theory is that the fear of aspirin-induced [… read more]
Reimbursement for Palliative Care in the ICU By Intensivists To an intensivist, providing palliative care often means having multiple time-consuming and emotionally challenging interactions with families struggling to cope with the impending loss of their loved one. The emotional content of these interactions can be strongly positive, negative, or somewhere in between, but frequently it’s [… read more]
(image: flickrCC) Foam in, foam out, gown on, gown off … ah, the tedium of practicing critical care medicine in the age of rampant, lethal, multi-drug resistant bacteria. As a reminder to keep your guard up and your gear on, here’s a yucky study from Daniel Morgan, Elizabeth Rogawski, and Anthony Harris of the University [… read more]
Chronic Obstructive Pulmonary Disease (COPD) Review Epidemiology of COPD Globally, ~10% of people older than 40 have airflow limitation of GOLD stage 2 or worse (FEV1 < 80% predicted); up to 25% may have GOLD stage 1 (FEV1 ≥ 80% predicted but FEV1/FVC < 0.7). Up to 60-85% of people with COPD (mostly mild/moderate severity) [… read more]
(image: flickrCC) Do protocols make trainees’ brains go soft? That’s the assertion of more than a few crusty hard-liners who miss the good old days — when you got 2-liter tidal volumes for your ARDS and liked it, dad-gum-it!! Prasad et al can’t say whether critical care fellows can actually run ventilators in the post-protocol [… read more]
(image: Hospira) Akihito Hagihara et al present suggestive data in the March 21 JAMA that giving epinephrine to people with out of hospital cardiac arrest increases their chances of making it to the hospital with a pulse, but not of making it home with decent brain function or functional status. In a prospective observational analysis [… read more]
(image: flickrCC) Health insurance plans are shifting an increasing portion of costs for prescription medications onto patients. A recent study in JAMA concluded that such cost shifting decreased asthma medication use and increased hospitalization rates in U.S. children. But the effect, if real, was small. What They Did Pinar Karaca-Mandic et al looked back at [… read more]
The content here previously has been removed at the request of the American College of Chest Physicians. For the ACCP’s Guidelines for Diagnosis and Management of DVT/PE/VTE, 9th edition, please visit the ACCP’s web site. PulmCCM is not affiliated with the ACCP.
The CDC announced in its Morbidity and Mortality Weekly Report (MMWR) the sad story of three members of a close-knit Maryland family who all died within days of each other from pneumonia due to seasonal influenza A (H3N2) with methicillin-resistant Staph aureus (MRSA) co-infection. Three additional family members acquired the same influenza A strain (which was [… read more]
(image: flickrCC) Endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA), when performed by skilled physicians, reduces the need for mediastinoscopy and unnecessary thoracotomies with their associated morbidity, and is poised to permanently alter the landscape of lung cancer diagnosis and staging. Prior to 2008, Medicare seemed to recognize the potential value of EBUS by paying hospitals [… read more]
The content previously here was removed at the request of the American College of Chest Physicians. For the ACCP 9th edition clinical practice guidelines for prevention and treatment of venous thromboembolism (VTE), please visit the ACCP website. PulmCCM is not affiliated with ACCP or Chest.
(image: Cardinal Health) Should you routinely check pleural pressures with bedside manometry during thoracentesis? David Feller-Kopman of Johns Hopkins says, of course: it’s zero risk, zero cost, only seconds of extra time, and provides potentially useful clinical information. Specifically, one can identify people with “entrapped lung” and “trapped lung”: Identifying “Entrapped Lung” by Pleural Pressures [… read more]
Mechanisms of Pneumothorax in the Critically Ill Air can accumulate in the pleural space in three ways: Rupture of the visceral pleura allowing air to travel from alveoli to the pleural space (an “internal” pneumothorax, as from barotrauma from mechanical ventilation, or the rupture of a bulla or bleb); Entry of air from the atmosphere [… read more]
Texting while doctoring is a newly hyped threat to patient safety. Multitasking and the constant flow of new distracting information in the form of alarms, interruptions, pages, etc. have always been inherent to the practice of medicine. But some are wondering if the ubiquitous temptations of personal social media-enabled smartphones and tablets in the medical [… read more]
(image: Plioz.com) Ever cared for that patient with metastatic cancer in your ICU, intubated for acute respiratory failure and surrounded by a bewildered and stressed family who cope by emotionally blaming you, the intensivist, because “He just saw his oncologist last week, and he said everything was OK!”? Forcing you to begin painful end-of-life discussions [… read more]
Provent is the trade name for disposable, stick-on nose plugs made by Ventus Medical that are a relatively new (second-line) treatment for obstructive sleep apnea. The bandage-like device has pinholes cut in the nostrils that let air in during inspiration, but create back pressure during exhalation, helping prevent airway collapse. The New York Times just [… read more]
We have our hands full at PulmCCM Central just keeping up with the best published literature in pulmonary and critical care medicine. Somehow, the folks at NYU manage to vet the much larger volume of literature published in internal medicine, and offer it in a user-friendly review in their Clinical Correlations blog. Clinical Correlations is [… read more]
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