Monday, December 18, 2017

More on opioid prescribing and the Joint Commission suit

If Joint Commission didn’t start the push for more narcotics, according to this report they jumped on board around the year 2000 which had the effect of converting a promotion into a standard.

Device and drug company payments to cardiologists

In conclusion, pharmaceutical and device manufacturers or group purchasing organizations continue to make substantial payments to cardiac practitioners with a significant variation in payments made to different cardiology subspecialists. The largest number and total payments are to general cardiologists, whereas the highest median payments are made to cardiac electrophysiologists. The impact of these payments on practice patterns remains to be examined.

Note the last sentence. Even if some studies have measured impacts on practice patterns (and there are soft data to that effect) we know very little about the impact on patient outcomes, good or bad.

Sunday, December 17, 2017

Saturday, December 16, 2017

Joint Commission sued over allegations about the opioid crisis

So who’s to blame for the opioid epidemic? How did we get where we are today? There's been a lot of finger pointing at the pharmaceutical industry and while it deserves a share of the blame there have been other factors. The Joint Commission had some pretty aggressive pain management standards starting back in the late 90s. Unless you’re in mid or late career (and didn’t have your head in the sand about 18 years ago) you wouldn’t remember this but I do. Oh, how well I remember it.

I remember our joint commission surveys with all the preparation we went through and how pain management was the hot topic of conversation. There were lots of documents from those days (old Joint Commission manuals and hospital committee records) that I'm sure folks would like to suppress and I can say the same thing for certain CME materials promulgated by our own professional societies who tried to shove this pseudoscience down our throats.

Fingers have been pointed at Joint Commission for a while now concerning this, so recently they issued a disclaimer. That vigorous attempt to deflect blame was recently called out by Skeptical Scalpel and I linked to the post here. From that post it would appear that Joint Commission cooperated with industry in pushing for expanded indications for narcotics while minimizing risks.

So the latest news is that four cities in West Virginia have sued the Joint Commission, claiming economic losses not only for the health care of victims but for the cost of efforts to stem the epidemic. This came out just last month (H/T EP monthly). Whether or not they prevail, this will shine light on the history of the problem by bringing old documents into public view that up to now would have been difficult to access. Joint Commission, in their denial that they contributed to the problem, correctly points out that they did not coin the phrase “fifth vital sign.” But, as the documentation shows, they did a great deal to propagate the idea.

Here are the introductory paragraphs from the court document:

1. In 2001, Defendant JCAHO, as part of its certification program for health care organizations, teamed with Purdue Pharma L.P. and its affiliates (“Purdue”), as well as other opioid manufacturers, to issue Pain Management Standards (or “Standards”) and other related documents that grossly misrepresented the addictive qualities of opioids and fostered dangerous pain control practices, the result of which was often the inappropriate provision of opioids with disastrous adverse consequences for individuals, families, and communities. These dangerous Standards, with minor modifications, exist to this day.

2. JCAHO zealously enforces these dangerous Standards through its certification program and has persisted in this course of action even after Purdue was found by the Food and Drug Administration to have misrepresented the quality of its opioid OxyContin in 2003, after Purdue pleaded guilty to felony criminal charges for making misrepresentations respecting OxyContin in 2007, and after warnings from health care professionals concerning the horrible impact wrought by the Standards.


It then goes on to quote from past JC standards:

36. For the 2001 Standard RI.1.2.8, The Official Handbook provides “[e]xamples of Implementation of Standard RI.1.2.8,” the first of which is: “Pain is considered the ‘fifth’ vital sign in the hospital’s care of patients...”

46. The 2001 JCAHO Monograph stated: “Some clinicians have inaccurate and exaggerated concerns about addiction, tolerance and risk of death...”

62. The 2003 JCAHO Monograph stated:

a. “Clinicians’ misconceptions about pain treatments could include an exaggerated fear of addiction resulting from use of opioids; confusion about the differences between addiction, physical dependence, and tolerance; or unwarranted concerns about the potential for the side effect of respiratory depression.”…

c. “Many practices are faulty and outdated (e.g., promoting the idea that there is a high risk of addiction when opioids are taken for pain relief).”…

The pharmaceutical industry, our professional organizations and published articles promoted pseudoscientific dogma on pain management. Joint Commission made it a mandate.

Breath acetone as a biomarker in heart failure: something to follow?


Background: Although breath analysis has emerged as a noninvasive tool in several clinical conditions, it is not widely used in cardiovascular disease yet. Exhaled acetone is one of the compounds expected as biomarkers for heart failure. However, it is unknown how exhaled acetone concentration changes in clinical course of heart failure.

Objective: To investigate time course of exhaled acetone concentration in acute decompensated heart failure.

Methods: This study included 19 patients with acute decompensated heart failure (ADHF group), and 14 stable patients (control group). Exhaled acetone was collected from these patients and the concentration was measured with gas chromatography.

Results: The ADHF group had higher heart rates (p = 0.020), higher levels of brain natriuretic peptide (p less than 0.001), and blood total ketone bodies (p = 0.003), compared with the control group. In ADHF group, exhaled acetone concentration was significantly decreased after treatment (median: 2.40 ppm vs. 0.92 ppm, p less than 0.001). On the other hand, in the control group, exhaled acetone concentration did not significantly change (median: 0.69 ppm vs. 0.62 ppm, p = 0.370, Table 1).

Conclusions: Exhaled acetone concentration in patients with acute decompensated heart failure was drastically decreased by treatment, and therefore, could be a novel noninvasive biomarker to evaluate the course of acute decompensated heart failure.

Ketosis reflects the neurohumeral response in heart failure. Breath acetone as a measure of ketosis is ultrasensitive, non invasive, low tech and with immediate results available at the point of care.

Friday, December 15, 2017

Atrial dissociation

Two independent atrial rhythms protected from each other by entrance and exit block. One usually associates this condition with heart transplants, but the case described had no history of such.

Thursday, December 14, 2017

Atrioesophageal fistula following a fib ablation

Methods and Results Electronic searches were conducted in PubMed and Embase for English scientific literature articles. Out of 628 references, 120 cases of AEF were identified using various ablation modalities. Clinical presentation occurred between 0 and 60 days postablation (median 21 days). Fever (73%), neurological (72%), gastrointestinal (41%), and cardiac (40%) symptoms were the commonest presentations. Computed tomography of the chest was the commonest mode of diagnosis (68%), although 7 cases required repeat testing. Overall mortality was 55%, with significantly reduced mortality in patients undergoing surgical repair (33%) compared with endoscopic treatment (65%) and conservative management (97%) (adjusted odds ratio, 24.9; P less than 0.01, compared with surgery). Multivariable predictors of mortality include presentation with neurological symptoms (adjusted odds ratio, 16.0; P less than 0.001) and gastrointestinal bleed (adjusted odds ratio, 4.2; P=0.047).

Wednesday, December 13, 2017

The association between aortic stenosis and ventricular conduction disturbances

The more severe the AS the wider the QRS (roughly) and the more likely the patient is to have RBBB or LBBB. This paper looks at the clinical implications.

Tuesday, December 12, 2017

Influenza activity


Influenza activity in the United States was low during October 2017, but has been increasing since the beginning of November. Influenza A viruses have been most commonly identified, with influenza A(H3N2) viruses predominating. Several influenza activity indicators were higher than is typically seen for this time of year. The majority of influenza viruses characterized during this period were genetically or antigenically similar to the 2017-18 Northern Hemisphere cell-grown vaccine reference viruses. These data indicate that currently circulating viruses have not undergone significant antigenic drift; however, circulating A(H3N2) viruses are antigenically less similar to egg-grown A(H3N2) viruses used for producing the majority of influenza vaccines in the United States. It is difficult to predict which influenza viruses will predominate in the 2017-18 influenza season; however, in recent past seasons in which A(H3N2) viruses predominated, hospitalizations and deaths were more common, and the effectiveness of the vaccine was lower. Annual influenza vaccination is recommended for all persons aged greater than or equal to 6 months who do not have contraindications. Multiple influenza vaccines are approved and recommended for use during the 2017-18 season, and vaccination should continue to be offered as long as influenza viruses are circulating and unexpired vaccine is available. This report summarizes U.S. influenza activity* during October 1-November 25, 2017 (surveillance weeks 40-47).