Great news– Doody’s Review Service recently awarded 5 stars to the Tarascon Clinical Review Series: Internal Medicine by Joseph S. Esherick, MD, FAAFP.
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.  Prior to this in 1999, Christenson had demonstrated cardioprotective effects of statins during coronary artery bypass grafting surgery. 
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. 
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
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. 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.
According to the National Resident Matching Program (NRMP), also known as the Match, family medicine attracted more graduating medical students in 2012, marking an increase in the field for the third year in a row.
The Match data provided by the American Academy of Family Physicians (AAFP) includes family medicine, family medicine-psychiatry, family medicine-emergency medicine, family medicine-preventive medicine and family medicine-internal medicine programs.
Topics: Affordable Care Act, primary care, Dr. Joseph Esherick, Family Medicine, Glen Stream, Healthcare Reform Bill, Authors, National Resident Matching Program, AAFP, American Academy of Family Physicians, American Medical Association, internal medicine, Match, NRMP
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
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.
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.
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
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. “ 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. 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].”
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?
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
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. 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...
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.
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. 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.
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...