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September 11th, 2019

Podcast 233: Antipsychotics are no solution to delirium during hospitalization

(2 votes, average: 3.50 out of 5)

Using “Vitamin H” (haloperidol) or newer antipsychotics to treat delirium in hospitalized patients should be off the menu, writes Edward Marcantonio in an Annals of Internal Medicine editorial.

Dr. Marcantonio agrees with the authors of a systematic review who conclude that “current evidence does not support routine use of haloperidol or second-generation antipsychotics to treat delirium in adult inpatients.” In his commentary entitled “Old Habits Die Hard,” he writes “the findings presented are sufficient to stop this clinical practice.”

Links:

Annals of Internal Medicine editorial

Marcantonio’s “Clinical Practice” article in NEJM in 2017

September 6th, 2019

Podcast 232: Basic organic chem and drug pricing

(No Ratings Yet)

You surely remember “O-chem” — those late-night undergraduate hours spent grappling with benzene rings and alkanes and all the rest. Well, it turns out that drug makers were paying close attention to things like racemic mixtures and enantiomers. The manufacturers usually release their products as racemic mixtures and then, when patents are about to expire, an enantiomer appears. Voila! New drug, new price!

Dr. Joseph Ross and his crew looked at the implications to Medicare spending of all this. They published an interesting letter in the Annals of Internal Medicine detailing how much money the system could save if we stuck with the racemic mixtures. How much? Well, on the order of $15 billion over 5 to 6 years.

Links:

Annals of Internal Medicine letter

NEJM Journal Watch Pediatrics and Adolescent Medicine coverage of albuterol vs. levalbuterol

 

August 30th, 2019

Podcast 231 — The evidence behind VA’s suicide-prevention guidelines

(No Ratings Yet)

Dr. Eric Caine’s editorial in the Annals of Internal Medicine offers a skeptical, yet respectful, take on the evidence supporting the recent suicide-prevention guidelines from the U.S. Department of Veterans Affairs.

What are other countries doing to address suicide? It has increased in the U.S. from about 10.4 per 100,000 residents in the year 2000 to about 14.5 in 2017. Do firearm restrictions help? Better household safety? And how does the U.S. rate compare internationally?

Links:

Annals of Internal Medicine editorial

VA guidelines as published in the Annals

OECD stats on international suicide rates

August 23rd, 2019

Podcast 230 — Hospital-readmissions gaming?

(2 votes, average: 4.50 out of 5)

The Hospital Readmissions Reduction Program (HRRP for short) seems to be reducing 30-day readmissions — but what about revisits to facilities within those 30 days?

Rishi Wadhera and his co-authors measured readmissions, plus treat-and-discharge ER visits, plus stays in observation units among some 3 million Medicare discharges of a near-4-year span. They found that broadening the definition of readmissions to include not only formal returns to the hospital for a standard stay but also those ER and observation-unit encounters tells a different story. It’s a story that should make HRRP’s administrators rethink what should be measured and how expanding the definition of readmissions could benefit patients by truly promoting better quality-of-care.

Links:

Article in The BMJ on readmissions

Earlier article in JAMA on readmissions for heart failure

August 16th, 2019

Podcast 229: Simplifying perioperative anticoagulation in AF

(1 votes, average: 5.00 out of 5)

Patients with atrial fibrillation who undergo surgical procedures need special attention because their anticoagulant medications, if not adjusted, increase their risk for bleeding. Those on direct-acting oral anticoagulants — or “DOACs” — face special problems because assays for the amount of drug on-board before surgery are not routinely available.

Dr. James Douketis and international colleagues have a simpler approach in their PAUSE study. On the basis of the known pharmacokinetics of DOACs, they dispense with coagulation testing and heparin bridging. Their approach involves assessing the likelihood of the procedure to cause bleeding. For low-risk procedures, DOACs are suspended a day before and resumed a day after; for riskier procedures, like resections, it’s two days before and two after.

The drugs under study were apixaban, dabigatran, and rivaroxaban.

We discuss the PAUSE results with Dr. Douketis.

LINKS:

JAMA Internal Medicine paper on PAUSE study

Physician’s First Watch summary (with links to other resources)

August 8th, 2019

Podcast 228: Hematuria — should the workup include imaging?

(2 votes, average: 4.00 out of 5)

Matthew Nielsen and colleagues found almost 80 diagnostic algorithms for working up a finding of hematuria. From these, they chose five representative approaches, ranging from those based on the patients’ risk factors to more aggressive ones that stress CT imaging for all.

Using a 100,000-patient simulated cohort, Nielsen’s group found that more intensive imaging found more cancers than the other approaches. However, radiation-induced cancers from CT wiped out that advantage.

Join us as Dr. Nielsen walks through his findings and their clinical implications. The work appeared in JAMA Internal Medicine.

Links:

JAMA Internal Medicine article

NEJM Journal Watch General Medicine summary of ACP guidance on evaluating hematuria (from 2016)

American Urological Association guideline (from 2012)

 

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