Jones & Bartlett Learning Medicine Blog

    Joseph Esherick

    Recent Posts

    Perioperative Statin Therapy Reduces Perioperative Cardiac Events and Hospital Length of Stay

    Posted by Joseph Esherick on Aug 28, 2012 9:47:52 AM

    Perioperative statin therapy has long been felt to confer cardiac protection during both cardiac surgery and major noncardiac surgery.  Until recently the data have been scarce to definitively make claims in support of this belief.  In 2004, Durazzo et al. conducted the first randomized trial examining the use of Perioperative statins in major noncardiac surgery.  They compared the use of atorvastatin 20 mg daily compared against placebo initiated 2 weeks prior to elective major vascular surgery and continued for 45 days post-operatively.  The investigators found that statins were associated with a 70% relative risk reduction of the combined end-point of death, nonfatal MI, unstable angina, or stroke. [1] Prior to this in 1999, Christenson had demonstrated cardioprotective effects of statins during coronary artery bypass grafting surgery. [2]

    Statins are thought to be beneficial for a myriad reasons:

    • They lower lipids and have additional pleiotropic effects.
    • The cardioprotective effects of statins during the perioperative period is more likely related to their pleiotropic effects than their lipid-lowering effects.
    • Statins inhibit the action of HMG-CoA Reductase which is the rate-limiting step in cholesterol synthesis, but effective lipid lowering takes months.
    • Perioperative studies have demonstrated that statins confer a cardioprotective benefit when started even 1-2 weeks in advance of major surgery.
    • These pleiotropic effects of statins include suppression of endothelial nitric oxide which promotes coronary vasodilation.
    • Statins also reduce lipopolysaccharide-induced tissue factor release, decrease plasminogen activator inhibitor levels, and increase tissue plasminogen activator; the combination of which reduces coronary thrombosis.
    • Statins also have anti-inflammatory properties which may provide more plaque stability. [3]
    Read More

    Topics: Stroke, cardiac surgery, cholesterol, Dr. Joseph Esherick, Authors, MI, atorvastatin, atrial fibrillation, beta-blockers, bypass grafting surgery, Cardiology, cardioprotective, coronary artery, Hospital Medicine Blog, lipids, myonecrosis, statin therapy, unstable angina

    The Dangers of Acid Suppressive Therapy

    Posted by Joseph Esherick on Jul 18, 2012 10:02:33 AM

    Acid suppression has long been associated with an increased risk of developing Clostridium difficile infection (CDI), having recurrent Clostridium difficile infection, and now has been shown to increase the complication rate and mortality from Clostridium difficile infection.  This risk applies to both H2-blockers and proton pump inhibitors (PPI), but the risk appears to be significantly higher for proton pump inhibitors.

    Several prior studies and meta-analyses have demonstrated an increased risk of Clostridium difficile infection with proton pump inhibitor therapy.[1,2,3]    Howell et al. performed a case-cohort study investigating over 101,000 patient discharges at a tertiary medical care center over a five-year period.  They discovered a three-fold increased incidence of nosocomial CDI in patients receiving daily PPI therapy compared with controls not receiving any acid suppression therapy.  The risk of CDI was two-fold in patients receiving daily H2-blocker therapy and 4.5-fold increased risk for patients receiving twice daily PPI therapy.[1]  The meta-analysis performed by Deshpande et al. reviewed 30 observational studies between 1990 and 2010 and concluded that PPI therapy is associated with a two-fold increased the risk for CDI.[3]

    In addition, we know that PPI use increases the risk of recurrent CDI.  A retrospective, cohort study by Linsky et al. analyzed 1166 inpatients at a single center over a five year period and determined that use of PPI within 14 days of CDI diagnosis increased the rate of recurrent CDI after appropriate treatment by 42% compared with those patients not receiving PPI therapy.[4]

    Read More

    Topics: acid suppressive therapy, cephalosporins, clindamycin, fluoroquinolones, H2-blockers, hospital-acquired pneumonia, Authors, peptic ulcer disease, Acid suppression, and intravenous vancomycin, antibiotics, Beta-lactamase inhibitor combination antibiotics, carbapenems, CDI, chronic gastroesophageal reflux disease, Clostridium difficile infection, community-acquired pneumonia, Hospital Medicine Blog, PPI, proton pump inhibitors

    Ultrasound is More Sensitive Than Chest X-ray for Detection of a Pneumothorax

    Posted by Joseph Esherick on Apr 24, 2012 4:26:04 PM


    Pneumothoraces are a common problem in the ER and the ICU.  The traditional screening test for a pneumothorax in the hospital is the chest radiograph; however, chest radiographs are not very sensitive in the setting of trauma and in ventilated patients.  A recent study of 225 trauma patients demonstrated that an AP chest x-ray had only 20.9% sensitivity for detecting a pneumothorax versus a CT scan of the chest.[1] A chest CT scan is the gold standard for the diagnosis of a pneumothorax, but a CT scan is extremely expensive and exposes a patient to about 7 mSv radiation (the equivalent of 70 chest x-rays).  Another modality that is gaining traction as the principal diagnostic modality to evaluate for post-traumatic pneumothoraces is a transthoracic ultrasound.  Thoracic ultrasound look for the presence or absence of lung sliding, comet tail artifacts, A line, a lung point, and a “Seashore sign” or “Bar code sign” on M Mode sonography to determine whether a pneumothorax is present.  A transthoracic ultrasound takes only a few minutes to perform and is performed as a part of the E-FAST exam right in the trauma bay of the ER.  It costs nothing, is associated with no radiation exposure, and requires no transport of the patient.

    Read More

    Topics: CT scan, Dr. Joseph Esherick, Authors, Pneumothorax, x-ray, Hospital Medicine Blog, E-FAST, sonography, thoracic

    Daily Aspirin Decreases the Development of Cancer

    Posted by Joseph Esherick on Mar 22, 2012 9:05:28 AM

    Dr. Joseph Esherick Monthly Blog – March 2012

    Read More

    Topics: oncology, Breast Cancer, colorectal cancer, Dr. Joseph Esherick, gastric cancer, Authors, lung adenocarcinoma, metastasis, pancreatic cancer, aspirin, biliary cancer, brain cancer, Hospital Medicine Blog, Dr. Peter Rothwell, esophageal adenocarcinoma, hospital medicine, Lancet

    Simulation-Based Procedural Training Improves Job & Patient Satisfaction

    Posted by Joseph Esherick on Feb 29, 2012 5:33:55 PM

    Dr. Joseph Esherick Monthly Blog – February 2012

    Are you a hospitalist who would like to incorporate procedures into your practice but don’t feel competent or confident in your skills?  Are you a hospitalist who does procedures so infrequently that you feel more comfortable referring your patients to a specialist for such procedures?  Are you a hospitalist who believes that you can get better reimbursement seeing more inpatients rather than incorporating hospital procedures into your practice?  Are you a hospitalist who believes that doing procedures will decrease your job satisfaction?  These are a few of many scenarios and myths that prevent hospitalists from performing bedside procedures.

    Hospitalists who perform procedures enjoy their jobs more than those who do not.   In one Canadian study of over 19,000 physicians, the degree of job satisfaction was directly linked to the range of procedures performed by the physician.[1]

    Additionally, patients feel better when the bedside procedures are performed by their primary physician with whom they have developed a rapport.  There are a few reasons for this.  Frequently, procedures performed by a specialist, especially an interventional radiologist, require that the patient has long waits, is taken away from their room, their nurse, and their family.  Furthermore, patients have often developed a relationship and trust with their primary inpatient physician and feel more comfort when they are performing the procedure rather than a complete stranger.

    Read More

    Topics: primary care, Physician, American Board of Internal Medicine, Dr. Joseph Esherick, simulation-based training, American College of Physicians, bedside procedures, Hospital Medicine Blog, hospital medicine, hospitalist, patient, point-of-care, Society of Hospital Medicine, surgical skills

    Beta-Blockers: Beneficial For Older Patients with Chronic Obstructive Pulmonary Disease?

    Posted by Joseph Esherick on Jan 26, 2012 10:32:42 AM

    Dr. Joseph Esherick Monthly Blog – January 2012

    When I was in medical school in the early 1990’s, one of the principles that I learned was to never prescribe beta-blockers to patients with chronic obstructive pulmonary disease (COPD).  We knew that stimulation of beta-2 receptors caused bronchodilation and therefore the belief was that beta-blockers would cause bronchospasm and lead to COPD exacerbations.  This practice was analyzed in a Cochrane review by Salpeter et al. in 2005 which concluded that, “cardioselective beta-blockers, given to patients with COPD do not produce a significant short-term reduction in airway function or in the incidence of COPD exacerbations. “[1] Another study focusing on the treatment of systemic hypertension in patients with pulmonary disease also concluded that cardioselective beta-blockers (β1-selective antagonists) were safe to use in patients with stable COPD.[2] One final review of the available evidence came to the same conclusion that, “the use of cardioselective beta-blocker therapy in patients with cardiovascular disease and comorbid COPD [appears safe].”[3]

    These previous reviews attested to the safety of beta-blocker therapy in patients with stable, mild-moderate COPD.  However, a recent study analyzed the question whether beta-blockers in patients with COPD are beneficial if there is an indication for their use?[4]

    Read More

    Topics: cardiovascular disease, Dr. Joseph Esherick, Authors, Tarascon Medical Procedures Pocketbook, Tarascon Primary Care Pocketbook, beta-blocker therapy, beta-blockers, bronchospasm, Cardiology, chronic obstructive pulmonary disease, COPD, Hospital Medicine Blog, Tarascon Hospital Medicine Pocketbook

    Ultrasound-guided Thoracentesis Reduces the Rate of Pneumothorax and Tube Thoracostomy

    Posted by Joseph Esherick on Nov 28, 2011 11:16:57 AM

    Dr. Joseph Esherick Monthly Blog – November 2011

    Numerous studies have shown that ultrasound guidance lowers the rate of complications and increases the success rate for virtually every hospital procedure compared with traditional landmark-based techniques.   This has proved to be the case for ultrasound-guided central lines, ultrasound-guided paracentesis, and ultrasound-guided lumbar punctures in obese patients.  This essay will focus on ultrasound-guided thoracentesis which has a decreased rate of pneumothorax and need for tube thoracostomy compared with the blind approach.

    Pleural effusions affect nearly 1.5 million people each year in the United States.  Many of these people require thoracentesis for pleural fluid analysis to either determine the etiology of their pleural effusions or as a therapeutic procedure to relieve dyspnea and hypoxia.  Examination of the pleural space with sonography is best carried out using a convex array 3.5- to 5 MHz probe.[1]   Ideally, the patient is in the sitting position and sonography should identify the uppermost extent of the pleural effusion and the location of the diaphragm.  The depth of insertion can also be approximated by using the depth markers on the ultrasound screen.  At this point, a mark can be made on the posterior thorax just above the rib at the optimal site for thoracentesis.  The thoracentesis can then be carried out in standard fashion with the patient in the same sitting position.   Alternatively, the convex array probe can be placed in a sterile sheath and the thoracentesis can be performed using real-time ultrasound guidance.  The complication rate is identical with either technique for ultrasound-guided thoracentesis...

    Read More

    Topics: Dr. Joseph Esherick, paracentesis, pleural effusion, thoracentesis, ultrasound-guided, Hospital Medicine Blog, hospital medicine, lumbar puncture, pneumothroax, ultrasound

    The Rise and Fall of Xigris (Drotrecogin-alfa)

    Posted by Joseph Esherick on Oct 31, 2011 3:10:09 PM

    Dr. Joseph Esherick Monthly Blog – October 2011

    Drotrecogin-alfa (DrotAA) has been an integral part of the care bundle for adult patients hospitalized with severe sepsis or septic shock and a high risk of death since 2002.  DrotAA is a synthetic activated Protein C (APC) which has good scientific evidence for why it may be beneficial in patients with severe sepsis and septic shock.  Patients with severe sepsis have abnormal activation of their coagulation pathways and inflammatory system and impaired fibrinolysis, which lead to a procoagulant state.  Normally, APC acts with Protein S to degrade clotting factors Va and VIIa to promote anticoagulation.  However, intrinsic levels of APC are diminished in patients with severe sepsis because of impaired APC synthesis and increased degradation by neutrophil elastases.  Therefore, the theory was that a synthetic APC could benefit patients by decreasing the abnormal clotting which occurs in the micro-circulation.

    Read More

    Topics: Dr. Joseph Esherick, DrotAA, sepsis, septic shock, Activated Protein C, APC, clotting, Hospital Medicine Blog, hospital medicine

    Do Resident Work Hour Restrictions Improve Either Patient Safety or Postgraduate Medical Education?

    Posted by Joseph Esherick on Sep 28, 2011 8:10:01 AM

    Dr. Joseph Esherick Monthly Blog – September 2011

    National resident work hour restrictions were first implemented by the ACGME in 2003.   The debate started initially after the unfortunate death of Libby Zion in 1984 which prompted the state of New York to restrict resident duty hours.   The assumption was that resident fatigue caused the death of Libby Zion.  Among other restrictions, the 2003 regulations restricted resident shifts longer than 30 hours.  The regulations also stipulated that resident physicians must have at least one day in seven off and must have a 10 hour break between work shifts.

    In 2008, the Institute of Medicine (IOM) declared that resident duty hour restrictions must be tighter to reduce medical errors and improve resident education.  The IOM proclaimed that resident shifts should not exceed 16 hours unless they are interrupted by a five-hour uninterrupted nap, no shift should exceed 30 hours, and moonlighting hours are counted as a part of the 80-hour weekly maximum.  Based on these recommendations, the ACGME has imposed new 2010 regulations that prohibit first-year residents from working shifts longer than 16 hours, senior residents must work shifts no longer than 24 hours, and shifts must be separated by a 10 hour break.  The assumption that has been made is that these duty hour restrictions will decrease resident fatigue and therefore lead to improved patient safety and improved resident education, which will eventually lead to better graduating physicians.

    The reality, however, is these residency duty hour restrictions have led to neither improved patient outcomes nor improved resident education.  The data suggest that the IOMs assumptions are wrong... 

    Read More

    Topics: Institute of Medicine, Physician, ACGME, Authors, medical educaction, resident, work hour restrictions, Hospital Medicine Blog, Joesph Esherick, Libby Zion

    Antibiotic Stewardship with the Aid of Procalcitonin Measurements

    Posted by Joseph Esherick on Aug 23, 2011 4:37:43 PM

    Dr. Joseph Esherick Monthly Blog – August 2011

    There has been considerable interest in antibiotic stewardship programs over the past decade given the increase in drug-resistant bacteria.  The best way to combat the problem of drug-resistant bacteria is to develop systems which discourage the inappropriate initiation of antibiotics or the unnecessary prolongation of antibiotics.  The measurement of serum procalcitonin levels can aid sound clinical judgment for decisions regarding proper antibiotic use.

    Procalcitonin, the precursor peptide of calcitonin, is released in response to a body’s exposure to bacterial antigens or toxins.  Furthermore, the procalcitonin levels are suppressed by exposure to cytokines activated during viral infections, namely interferon gamma.  We know that the level of procalcitonin elevation is directly correlated with the severity of the bacterial infection.[1] In addition, procalcitonin levels rise within 6-12 hours after symptom onset of bacterial infections and decrease by about 50% per day once a bacterial infection is under control.[2]

    A number of randomized controlled trials have led to the development of procalcitonin guided clinical algorithms for various infections which have been used throughout Europe.  These protocols have led to a marked reduction in the use of antibiotics in adult patients treated in a variety of clinical settings with no increase in mortality or morbidity...

    Read More

    Topics: Dr. Joseph Esherick, Authors, Prescribing, viral infection, antibiotic, Hospital Medicine Blog, drug-resistant bacteria, hospital medicine

    Subscribe to Blog Email Updates

    Recent Posts

    Posts by Topic

    see all