By osmosis and by repetition over this month we have all learned to communicate better about patients, to listen to their concerns (and think about sitting down in a chair at their bedside). We have developed management plans to improve individuals' health and relieve their pain. We have all worked hard, grown tired at times, learned, and been part of a team giving good care.
...to be continued.
Trying to hear a patient's concerns is not always easy. Remember, the BATHE algorithm can help us elicit the patient's story and let us offer some empathy.
Question arose about liver transplant for liver failure in the setting of hepatitis C alcoholism. Papers suggest that at least over the short term (29 months) outcome does not vary among individuals transplanted for hepatitis C alone, hepatititis C and alcoholism, alcoholic liver disease, or other causes.
A handheld version of the Childs clinical scoring scale for liver failure, used to assess candidates for transplant can be found in MedRules.
A window-washer says he used hydrofluoric acid to clean windows for years. He also has smoked heavily. Now he has severe emphysema.
Certainly the cigarettes contributed. But what about the hydrofluoric acid? Acute exposure can lead to pulmonary edema and lung injury (with a proposed antidote of calcium gluconate.) While sources cite the association of chronic hydrofluoric acid exposure and emphysema, I could find no primary studies confirming the association. (One interesting secondary source is Dr. Steven Markowitz's Senate testimony on the health risks of nuclear industry workers. Hydrofluoric acid is used in the gaseous diffusion process in refining uranium, as at the Piketon plant near Portsmouth Ohio. He says "20% to 25% of former gaseous diffusion plant workers have chronic bronchitis and/or emphysema, to which their exposure to hydrofluoric acid and other powerful lung irritants in the gaseous diffusion process played a significant contributing role.").
We had talked about breakthrough pain and estimating the amount of "rescue" dose. This article reminds us titrating the rescue dose of opioid to match the breakthrough pain might be more effective than using a fixed rescue dose based on total daily opioid use.
(Derek Doyle's Oxford Textbook of Palliative Care, which is available in our library, suggests that initial rescue dose be based on 10-15% of total long-lasting opioid use.)
Here is a series of brief Fast Facts on opiate prescribing. These are published on the University of Wisconsin's palliative care site called EPERC. (You may be asked to sign up for a username and password. I will try to bring paper copies to rounds.) Eric Warm from the University of Cincinnati created the conscept of Fast Facts and David Weissman leads the Univeristy of Wisconsin efforts.
Percutaneous endoscopic gastrostomy (PEG) tubes can help to feed a disabled patient. But broad use without clear indication has been associated with morbidity. A recent JAMA article documented that in District of Columbia nursing homes 64% of patients with moderate cognitive impairment had PEG tubes.
Have learned from Dr. Sediq that our departure for lunch is at 1:30 today. Will likely head for the Cincinnati Art Museum's Terrace Cafe (the terrace is under construction, but the restaurant is open in the new Cincinnati Wing). Museum admission is always free.
For some other time, try the Contempory Art Center and the neighboring downtown Akash Indian restaurant.
For visual art anytime, try artcyclopedia.com.
Dr. Gandola and I were discussing treatment options for severe emphysema reguarding a patient. There are several ongoing studies on Lung Volume Reduction Surgery, and whether or not it is beneficial.
Here are a few sites that are useful.... National Emphysema Treatment Trial and this New England Journal article.
Lots of our time is spent in gathering data from a computer...downloading clinical information from Meditech. We then manually transcribe and store the data in our "system" of handwritten notes. Be aware that there are time-saving products that export data directly from Meditech into your handheld device (Palm or other). Mecury MD's product, mData, and another company's Patient Keeper are two examples. I have used and am impressed with mData. (All data, including x-ray reports, echocardiograms, labs, and medications, are efficiently stored for your whole census.) Hopefully our hospital will run a trial soon.
How do we learn to give oral presentations of patients. What do we leave in? What do we leave out? (content) Why is it different when we talk with another resident or student than when we present to an attending? (context)
We have all, by trial and error, improved our medical presentation skills this month. How we do this, and how we can teach this better? This is a topic of research.
One student's comments from this paper sound universal:
"You know, the hardest thing about this [oral presentation] is that there is this very rigorous form, but the people who are really good at it don't use it--they just converse. So there's this structure that we learn and that I'm using to present my patient, but they want me to pop in and out of it--I guess to have all the details that following the structure implies, but then to play jazz with it, to ease in and out of it. But how do I know when it's okay to pop out?"
Another example:
"Judy's presentation of a comprehensive social history for a patient admitted to the ICU for resuscitation following head trauma and alcohol withdrawal is interrupted by her resident: 'Just give me the social context stuff when it's warranted, when it's related to the presenting illness.' Judy comments later 'Some people just don't have an intereest in people's lives or what job they have. I don't know if it's because they don't have the time or if it's because they're not interested. ..so I think there's just that line between how medical you make things and how much of people's lives you bring into it all.' Judy therefore is surprised and unprespared when the resident asks her about the patient's social situation, support system, and availabliity of programs for abused men prior to discharge. 'God. I wish he'd make up his mind.' she says."
Haber and Lingard (from San Francisco and Toronto) observed a medical team and noted that somehow our skills improve, but with little explicit teaching about "relevance of content" or how content can vary with the setting of the presentation (context). "Rules" tend to vary with the situation.
"Most feedback that students received was implicit and acontextual, with little guidance provided for determining relevant content. This led to dysfunctional generalizations by students, sometimes resulting in worse communication skills (eg. comment 'be brief' resulted in reading faster rather than editing) and unintended value acquistion (eg. request for less social history interpreted as social history never relevant.)"
The lab has identified Lactobacillus in a recent blood culture. An online review article reports that it can be pathogenic. In the particular case online, a psoas abscess was the source; lactobacillus was resistent to vancomycin but sensitive to clindamycin, penicillin and ciprofloxacin. Liver transplant patients with lactobacillus bacteremia have also been reported. A bacteremic case of cholecystitis also has been reported. Lactobacillus is resident flora in the mouth (and yogurt).
...warm evenings = mosquito-time.
One local bird out of eight tested, and one local mosquito out of 15,000 tested, have been positive for West Nile virus. The Hamilton County Department of Health website has pictures and more links for West Nile information.
More broadly, their site also lists lots of local health resource links.
As mentioned by Dr. Sharaha, a Roth spot is non-specific (not just associated with endocarditis). This example describes it as a "hemorrhagic cotton-wool spot...Cursory differential includes leukemia (and other dyscrasias), endocarditis, and anemia."
As for the skin lesions that can be seen in endocartitis, here is a picture of a Janeway lesion. This close-up gives it a different appearance.
Now, here is an Osler node. Seems difficult to distinguish from a Janeway lesion by image.
Speaking of these lesions, this review article points out that "Manifestations that are thought to represent immunologic phenomena (glomerulonephritis, Osler's nodes, Roth spots and positive rheumatoid factor) are more common in patients with a subacute course than in patients with an acute presentation."
This largely is a diagnosis of exclusion, often associated with para-medical personnnel, and carries a poor prognosis. Anthony Fauci, now the director of the National Institutes of Health, in 1979 reported 32 cases of factitious fever. (I have asked our library for a copy of this article.)
Interestingly, the Cleveland Clinic has patient information online about factitious illness.
JAMA this week reported that Francis Delmonico, MD, director of renal transplantation at Massachusetts General Hospital said "that he senses a growing unease over the practice of transplanting organs from living donors."
In 2001 the number of kidney living-donors surpassed the number of deceased-donors. But liver living-donors dropped by 50% from 2001 to 2002 after a publicized death.
If you have access to JAMA online, here is the link. Otherwise the citation is Vastag B. Living-donor transplants re-examined. Experts cite growing concern about safety of donors. 2003;290:181-182.
On rounds we have mentioned two handheld pharmacopoeia's:
Tarascon Pocket Pharmacopoeia
ePocrates.
Here are some other practical tools with links to more:
MedCalc (Cockroft equation, body mass index and many others)
MedRules (pneumonia severity index, Ranson's criteria and many others)
SDS Time (keeps a weekly time sheet)
HanDbase (for advanced users who want to build databases, or others who want to use them)
National Guideline Clearinghouse
For a rich collection of other handheld clinical guidelines (including the ATP 3 guidelines on lipid management) try the National Guideline Clearing House (www.guideline.gov). Browse around.
The ARC of Ohio is an advocacy organization that "works on behalf people with mental retardation as well as their families."
Of 131 institutionalized individuals with Down's Syndrome, this study found that 38 had clinical heart disease (systolic murmur, abnormally split S2, or systolic click). Septal defects, either atrial or ventricular, were confirmed by further testing in 11, aortic regurgitation in 8, and mitral valve prolapse in 18.
Septal defects are the most well-known associations. Still looking for association with aortic stenosis or coronary disease.
In our case the warm, red quality of the second metacarpal phalangeal joints (MCP) rules against hemochromatosis which is more non-inflammatory.
But keeping in mind this association with non-inflammatory painful enlargement of the MCP joints, (especially the 2nd and 3rd MCP's) could someday speed the diagnosis of hemochromatosis in your patient. Diagnosing the joint changes is not always easy.
See Kelley's Textbook of Rheumatology for a summary of hemochromatosis and arthritis (6th edition, page 977, available on MDconsult). Click below to read an excerpt.
From Kelley's Textbook of Rheumatology for a summary of hemochromatosis and arthritis (6th edition, page 977, available on MDconsult):
"The characteristic articular feature of hemochromatosis that is almost diagnostic is firm bony enlargement of the MCP joints, particularly the second and third, with associated cystic degenerative disease and large hooklike osteophytes on radiographs and, not infrequently, chondrocalcinosis. ...Wrists, shoulders, elbows, hips, and knees are involved less often than the MCP joints. Arthritis leads the list of diagnoses provided to patients to explain their symptoms before their diagnosis of hemochromatosis. [McDonnell] In this series, persons with symptoms received a diagnosis of hemochromatosis only after the symptoms had been present, on average, for an extended period (10 years) and after visiting an average of 3.5 physicians."
Reference
McDonnell SM, Preston BL, Jewell SA, et al: A survey of 2851 patients with hemochromatosis : Symptoms and response to treatment. Am J Med 106:621, 1999
Delayed ankle jerk relaxation was found in 11 of 15 hypothyroid patients studied. The reflex changes corrected with treatment, even before the TSH returned to normal.
British examiners have reported another way to elicit ankle jerks--striking the plantar surface of the foot instead of the achilles tendon. Worked well for them. I have not tried this. (Found this reference on the American College of Physician bibliography of bedside diagnosis. Go there, type in "ankle" into their search engine, and citations will be returned to you.)
Is BNP reliable in diagnosising congestive heart failure if renal insufficiency is present? Yes, according to an excellent review article in Mayo Clinic Proceedings from April. (Full text downloadable as pdf, page 481).
They also mention that with flash pulmonary edema, as in our patient, BNP can be normal (takes some time to rise).
This eMedicine review of radiation colitis and ileus speculates that thin, elderly women may be more predisposed. Treatment seems symptomatic. (Alludes to an FDA-approved radioprotective agent, amifostine, whose role in colitis prevention is unclear.) Natural history or outcome could not be described.
Here are some endoscopic images of radiation colitis.
We talked Wednesday about peripheral edema & CHF associated with thiazolidinediones ("glitazones" or "TZD's") like pioglitazone and rosiglitazone (Actos and Avandia). The pathophysiology is not well understood, but recommendations generally suggest not using these drugs in patients with symptomatic CHF (NYHA 2-4). Association seems stronger when a patient also is on insulin.
A Mayo Clinic article from April (full text available online as downloaded pdf) is an excellent review of "insulin sensitizers," their good-side and their adverse effects (at the Mayo site, scroll down to page 471). And in the same April issue an accompanying article discusses the rational use of insulin in treating Type 2 diabetes (page 459 and 411).
15-20% of patients presenting to an emergency room primarily as stroke end up with another diagnosis. We discussed many of the possibilities during our last session. This article from Emergency Medicine Clinics of North America reviews alternative diagnoses (Huff JS. Stroke mimics and chameleons. 2002;20(3):583-95) .
Listed possibilites include: Metabolic problems (Hypoglycemia, Hyperglycemia, Hepatic encephalopathy), CNS problems (Seizure/postictal , Generalized convulsive with postictal confusion or focal neurologic signs, Nonconvulsive status epilepticus, Hemiplegic migraine, Subdural hematoma, Abscess,Intracranial tumors, Primary CNS, Metastatic, Hypertensive encephalopathy, Multiple sclerosis, Psychiatric problems, Factitious disorders.)
The National Institute of Health and the National Center for Complementary and Alternative Medicine give us a solid review of data on black cohosh and menopausal symptoms. The data on efficacy is conflicting, and the NIH has designed a 12-month randomized controlled trial.
It is Saturday mid-day, not too late to head to Findlay Market (open until 6:00 pm). Outdoor public market. Farmers market, fresh cut flowers, Mediterranean and other international foods, and people and people.
The British Thoracic Society's 2003 guideline on pulmonary embolism (PE) is a rich document. It is available online (you may need to fill out a form to permit free access) along with an informative editorial. Regarding our use of d-dimer testing, it concludes:
1. Blood D-dimer assay should only be considered following assessment of clinical probability.
2. D-dimer assay should not be performed in those with high clinical probability of PE.
3. A negative D-dimer test reliably excludes PE in patients with low (SimpliRED, Vidas, MDA) or intermediate (Vidas, MDA) clinical probability; such patients do not require imaging for VTE. [Parentheses are brand names of commercial assays].
4. Each hospital should provide information on sensitivity and specificity of its D-dimer test.
An Annals of Internal Medicine paper reaches similar conclusions about d-dimer use in the emergency department. "Managing patients for suspected pulmonary embolism on the basis of pretest probability and D-dimer result is safe and decreases the need for diagnostic imaging."
For more on how to calculate clinical probability of PE (including MedRules a handheld Palm tool) continue reading this post.
Here is how PE probability was calculated in the Annals of Internal Medicine emergency room study (this, and other helpful calculations, can be guided by your Palm device using MedRules)...
"The physician assigned points for the following: clinical signs and symptoms of deep venous thrombosis (objectively measured leg swelling and pain with palpation in the deep-vein region), 3.0 points; heart rate higher than 100 beats/min, 1.5 points; immobilization (bedrest, except to access the bathroom, for 3 consecutive days) or surgery in the previous 4 weeks, 1.5 points; previous objectively diagnosed deep venous thrombosis or pulmonary embolism, 1.5 points; hemoptysis, 1.0 point; malignancy (patients with cancer who were receiving treatment, those in whom treatment had been stopped within the past 6 months, or those who were receiving palliative care), 1.0 point; and pulmonary embolism as likely as or more likely than an alternative diagnosis, 3.0 points (5) . For the final variable, which was not strictly defined, physicians were told to use the clinical information (obtained by history and physical examination), along with results on chest radiography, electrocardiography, and whatever blood tests were considered necessary to diagnose pulmonary embolism. The pretest probability of pulmonary embolism was considered low in patients whose score was less than 2.0, moderate in patients whose score was at least 2.0 but no higher than 6.0, and high in patients whose score was greater than 6.0."
"Patients' loved ones often make end-of-life treatment decisions, but the accuracy of their substituted judgments and the factors associated with accuracy are poorly understood."
Authors of this Annals of Internal Medicine study interviewed 250 terminally ill patients and 50 patients from a general medical clinic, along with their chosen surrogate decision-makers. "The accuracy of surrogate predictions was measured by using scales based on ten potential treatments in each of three hypothetical scenarios....Surrogates made correct decisions 66% of the Instances....Accuracy was better for the permanent coma scenario than for the scenarios of severe dementia or coma with a small chance of recovery."
Here is the Boston Globe article about the Clinical Skills Exam (CSE) for all medical students.
The National Board of Medical Examiners (NBME) co-sponsors and co-owns the United States Medical Licensing (USMLE) In February they announced plans for the CSE and published a field trial of this clinical skills exam concept. Their FAQ gives more information.
The American Medical Student Association (AMSA) vigorously opposes the the CSE plans. Last year the American Academy of Medical Colleges' statement of concern focused on the cost of the exam.
Enjoyed yesterday's walk-rounds with Dr. Koselka--short notice on a busy day. (Other walk-rounds take place in Sandwich, England or more locally at Glenview).
In April 2002 the Food & Drug Administration (FDA) warned that pioglitazone (Actos) and rosiglitazone (Avandia) have been associated with edema and congestive heart failure.
Does prescribing triptans combined with a selective serotonin reuptake inhibitor (SSRI) predispose to the serotonin syndrome? While the syndrome is rare it is often mentioned as a potential.
I have asked our library to track down a copy of an evidenced-based review that "reassesses" the triptan/SSRI interaction.
(Curiously, one investigator speculates on using triptans in bipolar patients to intentiaonally enhance sensitivity of SSRI's therapeutically. On rounds we had seen just this setting.)
Brain Naturetic Peptide (BNP) levels are now available for rapid results. (The emergency room physician just called me about a patient with chronic lung disease and question of congestive heart failure. CHF is suggested by the marked elevation of BNP.)
This April 2003 Cleveland Clinic Medical Journal has a good review article (downloadable as a pdf file) which suggests that a BNP of less than 100 pg/ml is normal, and more than 700 pg/ml suggests decompensated CHF.
Friday Dr. Hertzfeld has offered to fill us in about Factor VII deficiency. Until then, here are two quick reports:
A British group reports about their Factor VII genetics database..
"...There are 238 individuals described in the world literature with mutations in their F7 genes."
A Danish review from 1998 suggests:
"Bleeding problems are not often reported in patients having a factor VII:C level at 10-15% of normal or more. Bleeding is frequently of mucocutaneous type, but the whole array of haemophilic bleeding may also occur. "
The British group goes on to say:
"Complete absence of FVII activity in plasma is usually incompatible with life, and individuals die shortly after birth due to severe hemorrhage. The majority of individuals with mutations in their F7 gene(s), however, are either asymptomatic or the clinical phenotype is unknown. In general, a severe bleeding phenotype is only observed in individuals homozygous for a mutation in their F7 genes with FVII activities (FVII:C) below 2% of normal..."
"Factor VII (FVII) is a zymogen for a vitamin K-dependent serine protease essential for the initiation of blood coagulation. It is synthesized primarily in the liver and circulates in plasma at a concentration of approximately 0.5 microg/ml (10 nmol/L). The FVII gene (F7) is located on chromosome 13 (13q34), consists of 9 exons, and spans approximately 12kb. It encodes a mature protein of 406 amino acids..."
How do we learn about prognosis? A relatively inexpensive general resource for cancer information is the American Cancer Society's book, Clinical Oncology.
Our understanding of prognosis can help a patient shape their goals. In the end, the patient autonomously sets a path of care. They may choose a trial of active treatment, or a more palliative route to meet life goals. We can offer current knowledge and options. Patients choose. We support and stay with them (managing problems like neutropenia, pain, diarrhea, nausea, etc).
Specifically we had discussed colon cancer. Even in the elderly, chemotherapy can benefit. (30% of people who died of cancer had chemotherapy within 6 months of death.)
Regarding outcome with metastatic colon cancer, here is a quote from
New therapies, new directions: advances in the systemic treatment of metastatic colorectal cancer. Holen KD. Lancet Oncol. 01-May-2001; 2(5): 290-7
"At least two randomised trials have looked at survival and quality of life in metastatic colorectal cancer. [1] [2] One trial, by Scheithauer and colleagues, [1] compared chemotherapy (fluorouracil, leucovorin, and cisplatin) with best supportive care. They found a median 6-month survival advantage in the patients who had received chemotherapy, with no detriment in the quality-of-life scores compared with those receiving best supportive care, despite the inclusion of cisplatin, an agent with considerable toxic effects, which is no longer used to treat colorectal cancer. In a more recent study, Cunningham and colleagues [2] compared irinotecan plus best supportive care with best supportive care alone in the second-line management of patients who had progressed through a fluorouracil-based first-line treatment regimen. In that study, a clear survival benefit was shown, with a median survival of 9.2 months in the irinotecan group versus 6.5 months in the best supportive care group, and 1-year survival rates of 36% and 14% (p = 0.0001), respectively. Similar to the previous study, this survival benefit was not at the expense of quality of life, with the chemotherapy-treated population having quality-of-life scores that were as good as, or better than those of the best-supportive-care group in virtually all categories that were assessed. [2] "
"Thus, the treatment of metastatic colorectal cancer not only offers modest but significant improvements in survival, but also is useful in palliative care. We must emphasise, however, that the data derived from these studies are based on the treatment of patients who had the organ function, performance status, and motivation to meet the entry criteria of a clinical trial. Extrapolation to a more debilitated patient is invalid. Patients with substantial debilitation, which is indicated by poor performance status, have an exceedingly low likelihood of benefit from chemotherapy, and a high likelihood of severe adverse effects. These patients are generally best managed supportively. If supportive measures such as improved nutrition and adequate pain control result in a substantial improvement in performance status, the appropriateness of chemotherapy can be readdressed. "
We picked up a copy of the brochure, Choices, during rounds. It helps with planning a Living Will and Durable Power of Attorney for health care. More copies can be downloaded from the Ohio Hospice and Palliative Care Organization website.
Question came up on rounds about which family member is responsible if there is no advance directive. Ohio's order of authority within families is: guardian, spouse, adult children, parents, adult siblings, next reasonably close relative.
Possible places to store your advance directives include your doctor, lawyer, family, and county registrar. US Living Will Registry is on the web. They will fax your forms to responsible requesting health care facilities.
Another question: Why is a durable power of attorney called "durable?"
I have found little evidence to substantiate answers. Goldman's Cecil Textbook of Medicine 21st edition says "New-onset chylous ascites is most often due to underlying malignancy, especially lymphoma." But Yu (Clin Liver Dis 2001;5(2):541-568) says "...cirrhosis is responsible for more than 90% of all chylous ascites formation, caused by lymphatics ruptured by high flow and pressure...Of the malignant causes of ascites, lymphoma is felt to be the leading cause."
As for pancreatitis and chylous ascites, here is a case report.
Rare as hens' teeth? This eMedicine review suggests that only 28 cases were seen at Mass General over 20 years.
Goldman: Cecil Textbook of Medicine, 21st ed. page 761
Chylous ascites is milky in appearance because of leakage of lymph into the peritoneal cavity; the triglyceride concentration is markedly elevated, always greater than 200 mg/dL and often greater than 1000 mg/dL. New-onset chylous ascites is most often due to underlying malignancy, especially lymphoma. Occasionally, chylous ascites occurs after trauma, intra-abdominal surgery, heart failure, and peritoneal infection such as tuberculosis (TB). Rarely, it occurs as an incidental unexplained finding in cirrhotic patients. Except in cases of known trauma, investigation is focused on identifying an underlying malignant process, even though malignant chylous ascites rarely contains malignant cells (see Table 142-2) . Appropriate tests include abdominal CT or magnetic resonance imaging (MRI) and bone marrow aspiration. Lymphangiography does not identify intra-abdominal lymphadenopathy when CT or MRI has failed to do so. Chylous ascites , whether of malignant or benign origin, responds poorly to salt restriction or diuretics, except in rare idiopathic cases associated with cirrhosis and portal hypertension. Paracentesis offers simple palliative therapy. In the majority of cases, treatment is directed at the underlying lymphoma. Fat in the diet can be replaced with medium-chain triglycerides that are absorbed directly into the portal blood stream and bypass the lymphatics. Occasional patients may be placed on a regimen of total parenteral nutrition to reduce the formation of chylous ascites .
Yu AS. Clin Liver Dis. 2001; 5(2): 541-68
Malignant lymphoma produces chylous ascites by lymph node obstruction or rupture of chyle-containing lymphatics. Chylous ascites can also be iatrogenically produced by surgical transection of lymphatics [20 ]or retroperitoneal lymph node dissection. [69 ]Nevertheless, cirrhosis is responsible for more than 90% of all chylous ascites formation, caused by lymphatics ruptured by high flow and pressure. [89 ][130 ]
More recent reviews suggest that 90% of all chylous ascites is, in fact, due to cirrhosis. Off the malignant causes of ascites, lymphoma is felt to be the leading cause.
This came up in talking with Dr. Sadiq. Data does suggest that in the elderly, rate control (leaving the patient in atrial fibrillation) is as effective as rhythm control (trying to convert to and maintain sinus rhythm). The June issue of the Cleveland Clinic Journal of Medicine reviews the AFFIRM Trial and other evidence.
For the younger patient, rhythm control may improve exercise tolerance (newer electrophysiologic ablation is also a consideration.) The review article also reminds us of the importance of warfarin to reduce stroke and improve survival in atrial fibrillation.
A helpful table from the American College of Cardiology guidelines lists medications for rate control of persistent atrial fibrillation.
Propoxyphene (Darvon) analgesia has been considered equivalent to an NSAID, or acetaminophen. The VA Pharmacy has published its literature review and their own propoxyphene prescribing experience (full text online, but easier to read if you download their pdf file). They conclude that propoxyphene is a third or fourth line analgesic. Of interest they could document few serious adverse effects at therapeutic doses. (Often the argument is made that propoxyphene's metabolite, norpropoxyphene can have neuro-excitatory effects. This is seen with overdose.) The drug has been associated with misuse and abuse.
Curiously here is an online medication sales site with a good history of Darvon.
..."Lilly even conceded...there was 'no substantial evidence to demonstrate that 65mg of Darvon is more effective than 650 mg of aspirin.'"
VA's conclusions
Therapeutic role of DPP based on a critical review of the published literature can be summarized as follows:
1. For treatment of acute post-operative pain of moderate to severe intensity, the NSAIDs (diclofenac, piroxicam, ibuprofen, or high-dose ASA) should be tried first 46[IA] Extra- strength or high-dose (600 to 1000 mg) APAP would be a reasonable alternative for patients in whom NSAIDs are contraindicated or not tolerated. 19, 46 [2 IA]. If APAP is ineffective, then codeine 60 + APAP 1000 mg or oxycodone 10 mg + APAP 650 mg could be used.46[IA] Patients who do not tolerate or have contraindications to codeine or oxycodone may be treated with DPP 130 mg or DPP 65 mg + APAP 650 mg.46[IA] If masking of fever is undesirable, then DPP 65 to 130 mg or codeine 60 mg alone may be used. If DPP ± APAP is ineffective, tramadol 75 to 150 mg may be tried. 20, 46 [2 IA]. It should be noted that these choices are based on single-dose studies.
2. In multiple-dose studies of acute pain, NSAIDs seemed to have similar or greater efficacy in comparison with DPP ± APAP for mild to severe pain, and would be preferred for treatment of primary dysmenorrhea. Codeine ± APAP also seemed to have similar or greater efficacy relative to DPP ± APAP. The literature search found no RCTs comparing the efficacy of multiple-doses of DPP ± APAP with that of extra- or high-dose APAP alone in the treatment of acute pain. If the analgesic efficacy of single-dose analgesics is used as the basis for selecting multiple-dose analgesics, then it must be done with the understanding that the analgesic efficacy of the former may not accurately reflect that of the latter.
3. There is insufficient data to make recommendations about choice of analgesic relative to DPP ± APAP for treatment of chronic pain. In the rare patient with mild to moderate chronic pain who has a documented allergy to codeine derivatives, or in whom masking fever is undesirable, DPP would be a reasonable alternative. In the treatment of patients with cancer pain, DPP may be considered in patients who are not tolerating other opioids. The decision to use DPP for management of chronic pain should be made after considering the expected low rate of successful long-term analgesia in the treatment of moderate to severe pain with a step 2 agent, and the lack of published data documenting long-term safety.
4. In any case, the use of DPP ± APAP should be avoided or discontinued in patients with certain characteristics associated with intentional or unintentional overdose and development of serious DPP toxicity as described previously.
5. Because the role of DPP is relegated to third- or fourth-line therapy, it is not recommended for inclusion on the VANF, and its nonformulary use should be restricted to patients who do not have the relevant characteristics associated with intentional or unintentional overdose, and who have failed or have contraindications to NSAIDs, APAP, or other opioids that have less favorable cost-efficacy.
The ABCD stages emphasize risks of heart failure, and the subsequent development of structural disease and symptoms. So that just having diabetes or hypertension is Stage A heart failure. Later structural disease may appear, such as coronary disease or left ventricular hypertrophy. That then is Stage B (structural disease but no symptoms). When symptoms appear that is Stage C, and when symptoms are at rest that is Stage D. But the table on the American College of Cardiology website says it best. The table comes from the College's guideline on managing heart failure (full text online).
Xian Zhang graduated from University of Cincinnati's Conservatory of Music (CCM). She conducts Verdi's La Traviata on Saturday at Music Hall. The opera can take you wherever you want to go. But there is much to say about death and dying and love ...and some about doctors and patients.
You have successfully made it to this online journal, bedside.org, that we talked about on rounds. Here we can follow-up on ideas, and link to resources.
Things are posted by date. The most recent posting is always on top. Scroll down to earlier notes. Or, use the Search box to find topics within this website. When you see underlined hot-text you can click it to read more.
Click your browser's Refresh button to be sure your browser is displaying the freshest version of the page.
In addition to reading stuff here, you can author your own postings. We can get into authoring next week.
Helpful examples of talking with patients about end of life decisions.
This Lancet link to the Carvedilol or Metoprolol European Trial may ask you to register for a free password. The study results suggest a decrease in death rate in the Carvedilol group. Questions can be raised about the doses. (Were they equivalent in physiologic effect?)
"The number needed to treat to save one life is 59, which is similar to the effect of an ACE inhibitor versus pacebo in compatible patient populations."
According to drugstore.com comparative cost of one-month of carvedilol is $95.00 versus $10.00 for metoprolol. (That difference is roughly $1,000.00 per year.)
"Oldest Public Golf Course West of Allegheny Mountains"
To get to Avon Field Golf Course take Martin Luther King Blvd to Reading Road (near University Hospital). Turn left (North). Go about three miles. The course is on the left-hand side, between Paddock Road and the Norwood Lateral. (Or take I-75 north to the Lateral. Take the Reading Rd exit. Turn south on Reading and go one-half mile.)
Why do corticosteroids precipitate mania?
Precise answer remains unclear to me. But this article reviews the association with mood disorders. Effect seems to be early in the course of steroid use, and dose dependent.
"This Fox/Movietone film footage (circa 1959-1960) features New York photographer, Tony Chapelle, who was living in his home tethered by a cord to an external pacemaker after suffering from complete heart block. In this dramatic short film, Tony shows how he is attached to the machine and how the machine, operated by his wife, saves him when his heart stops."
We had discussed a woman with a dorsal vertebral fracture most likely due to osteoporosis (inactivity, corticosteroids).
If she fails conservative therapy (persistent pain or progression in vertebral collapse on x-ray) then vertebroplasty might help.
1. Are there controlled trials that demonstrate benefit and risks of vertebroplasty?
2. Does fixing one vertebra increase the risk of fracture in other vertebrae?
3. How fast is the pain relief after vertebroplasty?
Controlled trials
Reports are promising but controlled trials are needed to understand vertebroplasty's safest and best application. A recent study of 245 patients published in Radiology, highlights the need for randomized controlled trials to judge efficacy and safety.
Safety
Possible adverse reactions include leakage of cement into the spinal column and neurologic deficits including paraplegia.
Subsequent fractures in other vetebrae?
In patients with weakened architecture (osteoporosis), is the repaired one vertebra associated with a higher risk of neighboring fractures? One study found a 12% risk of vertebral fracture after vertebroplasty. 67% occuring in vertebra adjacent to the repaired vertebra.
How fast is pain relief?
The 4-12 ml of injected polymethylmethacrylate (PMMA) sets within one hour. This review suggests that patients often notice relief of pain within that hour, and resume ambulation. (Unlike vertebroplasty, kyphoplasty implies the use of a balloon to first expand the collapsed vertebra.)
General Medical Care (reducing deep vein thrombosis)
To reduce deep vein thrombosis risk, consider low-dose heparin. With a vertebral fracture hospitalized patients can be inactive. (Suggestion of Dr. Mbah).