Jones & Bartlett Learning Medicine Blog

    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]
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    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]

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    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

    Botswana and Human Resources for Health - Part 2

    Posted by admin on May 14, 2012 10:49:57 AM

    This is the follow-up blog post from Tarascon Publishing Author, Matthew Dasco, MD, MSc.  Click here to read Part 1 of the Botswana and Human Resources for Health post.

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    Topics: Global health, Africa, Fogarty International Center, health workers, Authors, Matthew Dasco MD, Medical Education Partnership Initiative, MEPI, Ministry of Health, National Institute of Health (NIH), University of Botswana School of Medicine, US Health Resources and Services Organization, Botswana, Global Health Blog

    Botswana and Human Resources for Health – an Ongoing Dilemma

    Posted by Amit Chandra on May 7, 2012 3:42:04 PM

    This is the first in a two-part blog series from Tarascon Publishing Author, Matthew Dasco, MD, MSc.

    Part 1:

    The world’s burden of disease and human resources for health are not well aligned.  While sub-Saharan Africa has 24% of the world’s disease burden, it only has 3% of the world’s healthcare workers.  On the other end, the Americas region has 10% of the world’s disease burden but 37% of its health workers.

    The Joint Learning Initiative (JLI) has calculated that the minimum number of health care workers (doctors, nurses, and midwives) in a population to achieve and 80% coverage rate of skilled birth attendance and measles vaccination is 2.5 per 1000 – countries with fewer than this number run a very high risk of not achieving the health-related millennium development goals (JLI, 2004).  57 countries in the world have been designated by the World Health Organization (WHO) as in this state of “crisis” with regards to human resources for health, which translates to a global shortage of roughly 2.4 million health workers (WHO, 2006).

    (Chart from Kerry, 2011)

    My first contact with the disparity between disease burden and human resources for health occurred while I was attending on the internal medicine wards at Princess Marina Hospital (PMH) in Gaborone, BotswanaPMH is the largest of two public sector tertiary care referral hospitals in the country.  In our department, there were six general medicine teams, an oncology service, and a nephrology service – each was assigned an internal medicine specialist.  The department consisted of two Cubans (a pulmonologist and a nephrologist), a Chinese generalist, an Indian generalist, a German oncologist, an Egyptian cardiologist, and a smattering of Americans working through university partnerships.  I found it odd that there were only two Batswana internal medicine specialists working there – they were among a very small number that had received specialty training abroad and returned to their home country to practice.

    Read More

    Topics: HIV, Tarascon Publishing, UNAIDS, Authors, Joint Learning Initiative (JLI), Princess Marina Hospital (PMH), world's disease burden, Botswana, Global Health Blog, health care workers, Matthew Dacso, World Health Organization (WHO)

    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.

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    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

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    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

    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]

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    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

    Emergency Medicine in the Developing World

    Posted by Amit Chandra on Dec 12, 2011 10:54:51 AM

    Global Health Blog - December 2011

    I just got back to Botswana after attending the Emergency Medicine in the Developing World conference in beautiful Cape Town, South Africa!  It was exciting to meet so many emergency physicians, residents, paramedics, and nurses from across Africa.  Emergency Medicine (EM) is one of the newest specialties in the world with a 30-year history in the United States, and a 10-year history in South Africa.  EM training programs have recently launched in Ghana, Tanzania, Ethiopia, and in Botswana.  The conference was a good opportunity to compare notes, share experiences, and discuss future collaboration.  We even have our own medical journal now, the African Journal of Emergency Medicine, and my team from Botswana co-authored a paper describing the history of our work:
    Development of Emergency Medicine in Botswana

    Alongside academic EM training programs, we are all working to build acute care, emergency, and pre-hospital services in our respective countries.  The sustainability of these models will depend on the success of our advocacy in demanding these services from the health systems in which we work.  New international campaigns focusing on road traffic injuries (the decade of action for road safety launched this year) and non-communicable diseases will hopefully overlap with and reinforce our efforts...

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    Topics: Global health, Tarascon, Disease, African Journal of Emergency Medicine, Authors, Amid Chandra, Cape Town, diagnostics, Global Health Blog, emergency medicine, Matthew Dacso

    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... 

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    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...

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

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