Clincal Guidelines: Chest Compression First

The American Heart Association (AHA) recommends compressions first for cardiac arrest in a new guideline for 2010:

•  Chest compressions should be the first step in addressing cardiac arrest.
• A-B-Cs (Airway-Breathing-Compressions) of cardiorespiratory resuscitation (CPR) be changed to C-A-B (Compressions-Airway-Breathing).
• Increase the speed of chest compressions to a rate of at least 100 times a minute
• Compressions should be made more deeply,  at least 2 inches in adults and children and 1.5 inches in infants
• Avoid leaning on the chest so that it can return to its starting position
• Compression should be continue as long as possible without the use of excessive ventilation.
• 9-1-1 centers are directed to deliver instructions assertively so that chest compressions can be started when cardiac arrest is suspected.
•  Dispatchers should instruct untrained lay rescuers to provide Hands-Only CPR (chest compression only) for adults who are unresponsive, with no breathing..

Health Care Reform: Meaningful Use

In the stimulus bill of 2009, Congress included funding to help incentivize physicians to convert to and electronic health record (EHR).  Who is eligible?

• Medicare Program: Physicians who demonstrate meaningful use (MU) of certified EHR technology and submit Medicare claims
• Medicaid Program: Physicians who demonstrate MU of certified EHR technology if their caseload includes at least 30 percent Medicaid patients (or at least 20 percent Medicaid patients for pediatricians).
• Physicians may not receive both Medicaid and Medicare incentives, although they are permitted a single switch from one to the other during the five years that the programs run.

What is the size of the incentive?

• Medicare: 75 percent of Medicare allowed charges for the year, up to the year's maximum incentive amount spread out over 5 years
• Medicaid: 85 percent of Medicaid allowed charges up to a different maximum spread out over 6 years.
• Diminishing amounts available to those who start in later years
• For providers in federally designated health professional shortage areas (HPSA), payments will be 10 percent greater.

What are some of the requirements?

• Must have National Provider Identifier (NPI).
• Must be enrolled in the CMS Provider Enrollment, Chain and Ownership System (PECOS).
• Most will also need to have an active user account in the National Plan and Provider Enumeration System (NPPES).
• Reporting of data on three core quality measures in 2011 and 2012: blood-pressure level, tobacco status and adult weight screening and follow-up
• Alternates include influenza immunizations for patients older than 50, weight assessment and counseling for children and adolescents, and childhood immunizations.
• Reporting of three more clinical quality measures chosen from 44 familiar National Quality Forum and/or Physician Quality Reporting Initiative (PQRI) measures.
• Only certified complete EHRs and EHR modules may be used to qualify.

What are some of the reporting requiremens:

• For 2011, CMS will allow attestations for all MU measures, along with provision of aggregate data for numerators, denominators and exclusions.
•  In 2012, CMS will continue accepting attestation for most of the MU objectives but plans to require electronic submission of the clinical quality measures.
•  States will also support attestation initially and then move to electronic submission of clinical quality measures for Medicaid providers' demonstration of MU

What is meaningful use?

• Meaningful use requires physicians to attest to using the EHR – for data collection, e-prescribing, health information exchange, clinical decision support, patient engagement, security assurance and quality reporting.
• CMS specifies a "core set" of 15 objectives and measures that must be met, along with five objective from a "menu set" of additional objectives.

What are the 15 core objectives?

• Computerized physician order entry (CPOE) for medications
•  More than 30% of patients.
•  Implement drug-drug and drug-allergy interaction checks.
•  Use e-prescribing.
•  More than 40% of all permissible prescriptions.
•  Record patient demographics.
•  More than 50% of patients
•  Maintain an up-to-date problem list.
•  More than 80% of patients
•  Maintain an active medication list.
•  More than 80% of patients
•   Maintain an active medication allergy list.
•  More than 80% of patients
•  Record and chart changes in vital signs
•  More than 50% of patients age 2 or older have height, weight and blood pressure
•  Record smoking status for patients 13 years old or older
•  More than 50%t of patients age 13 or older
•  One clinical decision support rule
•  Report ambulatory clinical quality measures to CMS or the states.
•  For 2011, provide aggregate numerator, denominator and exclusions through attestation.
•  For 2012, submit the clinical quality measures electronically.
•  Give patients an electronic copy of their health information upon request.
•  More than 50% of patients who request an electronic copy of their health information get it within 3 business days.
•  Provide clinical summaries for patients for each office visit.
•  More than 50% of all office visits within three business days.
•  Be able to exchange key clinical information with other providers and patient-authorized entities electronically.
•  Test EHR's ability to exchange key clinical information electronically.
•  Protect electronic health information.
•  Conduct or review a security risk analysis, implement security updates as necessary and correct identified security deficiencies.

Additional Menu Choices (need 5)

• Implement drug-formulary checks.
• Incorporate test results.
• More than 40% of all lab test results
• Generate lists of patients by specific conditions.
• Send reminders to patients for preventive/follow-up care.
• More than 20% of all patients 65 or older or 5 or younger.
• Give patients timely electronic access to their health information.
• More than 10% of all patients seen are provided electronic access to their health information within four business days of its updating in the EHR
• Provide patient-specific education resources.
• Use the EHR to give more than 10 percent of all patients seen patient-specific education resources.
• Perform medication reconciliation whenever appropriate.
• More than 50% of patients arriving from another setting.
• Provide summary of care records.
• More than 50% when referring patients to other providers or settings
• Be able to submit electronic data to immunization registries or immunization information systems.
• Be able to submit electronic syndromic surveillance data to public health agencies.

Clinical Reports: There's a New Blood Thinner in Town

An FDA advisory panel has recommended that dabigatran etexilate, an oral direct thrombin inhibitor, be approved for use in reducing the risk of stroke from atrial fibrillation. The doses studied included a 110 mg does and a 150 mg dose.  The FDA has subsequently approved the medication.

The newly approved drug works as well as warfarin in stroke prevention, and perhaps a 150 mg dose was more effective than warfarin.

There was more GI bleeding with both doses of dabigatran, and also more myocardial infarctions, but there was a reduced risk of hemorrhagic stroke. 

The study was an open label study of 18,113 patients with nonvalvular atrial fibrillation and one other risk factor for stroke.  The study was ongoing for two years, and patients were followed for at least one year.  Therapeutic INR's were obtained in 65% of patients on warfarin.

 Iit will be known as Pradaxa, and is the first new oral anticoagulant approved in 50 years.

Pearls: Can You Hear Me Now?

Liquid docusate is an effective agent to soften ear cerumen when treated impacted cerumen in the office.  Docusate applied to the ear canal 15 minutes before irrigation can ease or reduce the need for irrigation.  This seems to be more effective than Cerumenex or warm olive oil which are the next most effective treatments.

Pearls: Nitroglycerin Ointment for Anal Fissure

Many times patients come in with complaints of hemorroids, but what they really mean is they are having pain with bowel movements.  The most common cause of anal pain without an external lump is an anal fissure.  Anal fissures are tears in the anoderm, and are almost always posterior midline.  Usually these can be seen without a speculum on examination, just by spreading the buttocks.  Sometimes a sentinel pyle will be present at the outermost extension of the fissure, and indicate the fissure is chronic. The other major cause of anal pain, thrombosed external hemorrhoids, can be readily identified by taking a history from the patient and by examination.  If there is no external lump, most likely pain with defectation is secondary to an anal fissure.

The most common cause of anal fissures and the easiest to treat is passage of hard stools.  Some patients may deny they have constipation even if they have hard stools, so ask specifically about hard stools.  Diarrhea can also cause fissures, and this can be harder to treat.

Most fissures are posterior midline fissures, although some women will have anterior fissures.  Fissures in atypical locations can indicate inflammatory bowel disease.  If a patient has an anal fissure, an anoscopic examination will be very painful, and most fissures can be seen without inserting anything into the anal canal.

Most fissures can be healed with conservative treatment.  Treating fissures requires a two prong attack:  Softening the stools and treating anal sphincter spasm.  Anal spasm is triggered by pain, and may cause a relative ischemia to the anoderm in the posterior midline, impairing healing.

While pain is the most common symptom of fissure, bleeding can also occur.   The treating physician should make sure any rectal bleeding is not from a more serious cause, especially in older patients.



To treat the hard stools, increase dietary fiber, use fiber bulking agents (psyllium powder) and increase fluid intake.

To treat the anal spasm, and the pain, have the patient take Sitz baths (warm water, no additives, 10 minute duration) three times a day if possible, and after a bowel movement.

To further treat anal sphasm, an ointment of 0.2% to 0.4% nitroglycerin  ointment can be be applied to the perianal area, not in the anal canal, two to three times a day.   Around 5% of patients will get headaches to the nitroglycerin but will develop tachyphylaxis to this.  Tylenol is used for these headaches.  To minimize headaches, for the first 3-5 days of treatment, apply the nitroglycerin ointment once daily right before going to bed.  Being supine may minimize the nitroglycerin headaches.  Tell the patients to use a glove to apply the ointment or wash their hands immediately after application, as the ointment can be absorbed through the finger.  Only a small amount of ointment is applied.  After this initial period, if everything is going well, increase the application frequency to twice daily.

The nitroglycerin ointment can be compounded with 1% lidocaine ointment by the pharmacist.  There are no commercial products of nitroglycerin available in this strength, so compounding by the pharmacist is necessary.

The pain will resolve before the fissure is entirely healed, so have the patient continue the therapy beyond the period when symptomatic relief first occurs.   Over time, have the patient wean the Sitz baths and nitroglycerin therapy, but continue a stool softening regimen for life.

Conservative therapy should heal approximately 70% or more of anal fissures.  Surgerical referral can be made if symptoms do not resolve with aggressive conservative therapy.

Don't use 2% Nitropaste as a substitute, as this seems to cause localized discomfort when applied, along with increased risk of side effects (headache).

Clinical Reports: Paradoxical Bone Therapy?

The FDA is warning that drugs for osteoporosis may lead to atypical fractures of the femur such as subtrochanteric femoral fractures or femoral diaphyseal fractures in patients who have been on bisphosphonates for long periods of time. 

Atypical subtrochanteric femur fractures are fractures in the bone just below the hip joint. Diaphyseal femur fractures occur in the long part of the thigh bone. These fractures are very uncommon and appear to account for less than 1% of all hip and femur fractures overall.

These are very rare fractures, and have only recently been associated with bisphosphonate usage, as noted in AAFP news:

That review included data from a report recently published in the Journal of Bone and Mineral Research that reviewed more than 300 cases of atypical femoral fractures. More than 90 percent of those patients had taken bisphosphonates for five years or more, and 25 percent of the patients had fractures in both legs.

Most patients who suffered these atypical fractures had groin or thigh pain for several weeks or months before the fracture occurred.  Therefore, if any patients on resorptive therapy present with groin or thigh pain, they should be evaluated for these atypical fractures.

The FDA cautions physicians to reassess the bone density of patients on bisphosphonates to determine if therapy can be terminated, especially if the patients have been taking the medication for more than five years. This warning includes all bisphosphonates used to treat osteoporosis.

Clinical Reports: Walking Your Brain

Older adults who walk more than six miles a week (one mile a day) preserve brain volume and cognitive status better than sedentary adults, according to a study published in Neurology by the University of Pittsburgh, Pennsylvania.  They studied older adults, and their walking patterns.  Nine years after the initial assessment, MRI was used to assess brain volume, and four years after this, the participants cognitive skills were measured.

Participants who walked 6 - 9 miles a week had more gray matter than those who walked less.  These same walkers had a two-fold reduced risk for cognitive impairment.

Health Care Reform: Survivor

The efforts of the Florida Attorney General to challenge the constitutionality of the individual mandate in the health care reform bill has survived another legal round.  A federal judge in Florida allowed two counts of the lawsuit filed by the Florida and other states to go forward.  One count preserved was the challenge to the individual mandate based on limitations on the federal government in it's use of the commerce clause, as well as possibly violations of the 9th and 10th amendment. 

According to Judge Roger Vinson, the legal challenge by the Obama administration failed the "Alice in Wonderland" test, by calling the mandate to buy insurance either a "penalty" or a "tax," depending on which definition suited them at the time.

“Congress should not be permitted to secure and cast politically difficult votes on controversial legislation by deliberately calling something one thing," then turn around "and argue in court that Congress really meant something else entirely," he wrote.

Prior to this ruling, a federal judge in Michigan ruled the individual mandate was constitutional.

Health Care Reform: CLASS Act

No, that is not a compliment to the health care reform legislation passed earlier this year.  Part of the legislation included the creation of a long-term care insurance plan by the government, called the CLASS act (Community Living Assistance Services and Supports program). 

Here is an outline of the CLASS act::

WHO CAN ENROLL IN CLASS? Working adults will be able to make voluntary premium contributions either through payroll deductions through their employer or directly.


WHO CAN ENROLL IN CLASS? Working adults will be able to make voluntary premium contributions either through payroll deductions through their employer or directly.


WHO IS ELIGIBLE FOR BENEFITS? Adults with multiple functional limitations, or cognitive impairments, will be eligible for benefits if they have paid monthly premiums for at least five years and have been employed during three of those five years.


WHO IS ELIGIBLE FOR BENEFITS? Adults with multiple functional limitations, or cognitive impairments, will be eligible for benefits if they have paid monthly premiums for at least five years and have been employed during three of those five years.


WHAT ARE THE BENEFITS? Adults who meet eligibility criteria will receive a cash benefit that can be used to purchase non-medical services and supports necessary to maintain community residence;  payments for institutional care are permitted. The amount of the cash benefit is based on the degree of impairment or disability, averaging no less than $50 per day.


WHAT ARE THE BENEFITS? Adults who meet eligibility criteria will receive a cash benefit that can be used to purchase non-medical services and supports necessary to maintain community residence; payments for institutional care are permitted. The amount of the cash benefit is based on the degree of impairment or disability, averaging no less than $50 per day.


HOW IS THE PROGRAM FINANCED? CLASS is financed by voluntary premium contributions paid byworking adults, either through payroll deductions or direct contributions.


HOW DOES CLASS INTERACT WITH MEDICAID? CLASS will generally be the primary payer for individuals who are also eligible for Medicaid.

None of the benefits will be payed out until 2017, and is intended to provide support to individuals with function or cognitive impairments can remain in the community and not enter long-term care facilities.  The CLASS act can provide payments to individuals in long-term care facilties who are receiving Medicaid support.  Beneficiaries will get to keep 5% of the CLASS act for personal allowanced and the remainder will offset Medicaid support to the faciliity.

A beneficiary needs to pay premiums for five years, and work at least three out of five years before being eligible for disbursements.

The CBO predicts the CLASS act will reduce the national debt by 70 billion over 10 years. However, this estimate includes 5 years of payments before any disbursements are made.

Dermatology: Pruritis in the Elderly

What is the most common cause of chronic pruritis in the elderly?

1) Liver or kidney disease
2) Xerosis
3) Seborrheic dermatitis
4) Drug-induced

Answer: Xerosis or dry skin.  However, all the other answers will also cause pruritis in anyone. 

What is the best treatment for chronic pruritis secondary to xerosis?

1) Emollients or barrier creams
2) Topical steroids
3) Topical cannabinoids
4) Topical salicylic acids

Answer: Emollients, especially those with low pH.  If these are applied right after bathing, they will have the most benefit.  Topical steroids reduce pruritis only by reducing inflammation, so can be used when pruritis is secondary to inflammatory skin conditions, such as psoriasis, but may not provide much benefit to dry skin.  Topical cannabinoids may be useful in atopic dermatitis, lichen simplex, prurigo nodularis, and chronic kidney disease-associated itching.  Topical salicylic acid can be used in lichen simplex chronicus.

A low pH is part of the skin's protective function (also called the acid mantel) and primarily helps protect against bacteria and fungal growth. On different parts of the body, the skin's pH varies between 5 and 7. The upper part of the chest and back, where there is greater production of sebum, is where the pH is lowest; while the intertrigious areas (groin; armpit) have the highest pH.  (OTC brands to consider:  Eucerin Daily Replenishing Lotion pH 6-8, KimCare™ Moisturizing Hand & Body Lotion pH 5-7, Aveeno Daily Moisturizing Lotion pH 4.1 - 6.5, Olay Moisturizing Lotion pH 7 - 7.6 )

By reducing the skin pH the damaging effects of both lipases and proteases can be minimised. An emollient for example with a pH of between 4.5 and 5.5 will help to neutralise the effect of the skin-dissolving enzymes.

Cooling agents are generally safe, over-the-counter preparations which contain menthol, camphor, or phenol. These substances stimulate nerve fibers which transmit the sensation of cold to mask the itch sensation.

Topical anesthetics, such as pramoxine and EMLA cream can reduce mild-to-moderate pruritus, and may be combined with coolants.

Topical antihistamines, which block H1-receptors, are effective as antipruritics for urticaria and insect bites. Doxepin is one of the most effective topical antihistamine.

Capsaicin is useful in relieving localized intractable pruritus, by desensitizing nerve endings responsible for itch and pain. It may cause localized burning and stinging initially which limits its use as an antipruritic, but this effect subsides with repeated use. To overcome this, initially use capsaicin four times per day to overcome the irritation, then reduce the number of daily applications. EMLA cream may be used in conjunction with capsaicin to reduce the initial irritation.

Coding: Influenza Vaccine Coding Hints

It's fall, and along with pumpkin patches, falling leaves, and homecoming parades, the flu clinics are in full swing.  AAFP news has some hints on coding this annual affair.

Highlights include:

• No separate code for the H1N1 vaccine this year because it is included in the 2010-2011 seasonal influenza vaccine.
• Two codes for influenza vaccination: CPT code for flu vaccine given and CPT code for vaccine administration.
• CDC's Advisory Committee on Immunization Practices has recommended that influenza vaccinations be given to all people ages 6 months and older in whom the vaccine is not contraindicated.
• Use CPT code 90662 when billing for Fluzone High-Dose, a new flu vaccine approved in December 2009 for use in people ages 65 and older.
• Medicare beneficiaries could receive a seasonal influenza vaccination twice in one calendar year for two different flu seasons; physicians can bill -- and will be paid -- for both vaccine services.

The components of this years seasonal influenze vaccine should protect against the following viruses:

•  A/California/7/09 (H1N1)-like virus (pandemic H1N1 2009 influenza virus),
• A/Perth /16/2009 (H3N2)-like virus, and
• B/Brisbane/60/2008-like virus.

Below are coding hints for this years influenza vaccination:

• G0008, Administration of influenza virus vaccine
• 90465 Immunization administration, < 8 YO (percutaneous, intradermal, subcutaneous, or intramuscular injections) when the physician counsels the patient/family: first injection (single or combination vaccine/toxoid), per day
• 90466 Each additional injection (single or combination vaccine/toxoid), per day (List separately in addition to code for primary procedure)
• 90467 Immunization administration, < 8 YO (intranasal or oral routes of administration) when the physician counsels the patient/family: first administration (single or combination vaccine/toxoid), per day
• 90468 Each additional administration (single or combination vaccine/toxoid), per day (List separately in addition to code for primary procedure)
• 90471 Immunization administration (percutaneous, intradermal, subcutaneous, or intramuscular injections): 1 vaccine (single or combination vaccine/toxoid)
• 90472 Each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)
• 90473 Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)
• 90474 Each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)

For seasonal vaccine products, report the following codes:

• 90655 Influenza virus vaccine, split virus, preservative free, children 6-35 months of age, for intramuscular use
• 90656 Influenza virus vaccine, split virus, preservative free, 3 years and older, for intramuscular use
• 90657 Influenza virus vaccine, split virus, children 6-35 months of age, for intramuscular use
• 90658 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use
• 90660 Influenza virus vaccine, live, for intranasal use
• 90662 High dose influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use.

Diagnosis codes include the following:

• V04.81 Need for prophylactic vaccination and inoculation against viral diseases; influenza
• V06.6 Need for prophylactic vaccination and inoculation against combinations of diseases; Streptococcus pneumoniae (pneumococcus) and influenza.

State of Medicine: New Bill Would Repeal Medicare SGR Formula

Although Congress temporarily fixed the SGR payment system temporarily, the 23% cut is scheduled to return on November 30, and then an additional 6% in January 2011, resulting in a 29% cut.  Congress is currently out of session for the midterm elections, but will have opportunity to address this after returning in November.

Senator Blanche Lincoln (D-Ark) has introduced a bill to address the SGR and rural health in a new bill.

The highlights of the bill

 

 

• Repeal the Medicare physician SGR payment system and provide physicians with annual updates based on a more accurate measurement of the increased costs of providing care, known as the “Medicare Economic Index,” or “MEI.”
•  Address geographic payment inequities in Medicare which exist because of another component of the physician payment formula known as the Geographic Practice Cost Indices, or GPCI, and result in lower payments to rural states like Arkansas.
• Provide a 15 percent increase in the number of medical residency training positions supported by Medicare to help add new physicians to our nation’s health care workforce.

Dermatology: Blistering Diseases

73 year old woman comes to clinic with intensely pruritic blistering lesions on the legs, and chest.  The lesions are 1.5 cm in diameter with a red base.  She has no previous history of these lesions.

An excisional biopsy of one of the lesions indicates bullous phemphigoid as a possible diagnosis.

What do you do now?

1.  Treat with steroids

2. Treat with antibiotics

3. Biopsy normal skin

4. Order a sedimentation rate

Answer:  Biopsy normal skin.  The diagnosis of bullous phemphigoid is made with direct immunofluorescence studies of normal perilesional skin.  The sample is generally sent in formalin, but you should ask your pathology department how they would prefer the sample.

Bullous phemphigoid is a chronic autoimmune skin disorder, affecting older people generally, with a duration of illness of  1 to 5 years.  Occasionally (15-20%), there is mucosal involvement, and possibly ocular involvment. 

Treatment includes topical and/or systemic steroids and possibly immunosuppressives or other anti-inflammatories.

Referral should be made to dermatology for skin lesions, ENT and a dentist for mucosal lesions and an ophthamologist for eye involvement and those requiring prolonged high-dose steroids.

Healthcare Reform: Report on Impact of PPACA on Rural Health

The Robert Wood Johnson has recently released a report on the impact the new health care reform will have on rural medicine.  The report states that the Patient Protection and Affordable Care Act (ACA) will change Medicare payments for almost every type of health care provider.

For primary care physician, one new aspect of this is a bonus to providers in a primarily non-procedural practice:

Primary care physicians will receive a 10% bonus for ACA-defined "primary care services," but only if those "primary care services" represent at least 60% of the practice. The requirement that at least 60% of a practice’s furnished services must be particular "primary care services" to receive the ACA primary care bonus may preclude eligibility for those rural primary care practices that tend to offer more procedures (thus proportionally fewer primary care services) than urban/suburban practices.  Also, the ACA-defined primary care services currently do not include preventive health services.

AAFP news expands the available information on the primary care bonus:

Section 5501 (a) of the Patient Protection and Affordable Care Act creates an incentive payment program for primary care providers that calls for incentive payments equal to 10 percent of a "primary care practitioner's" allowed charges under Medicare Part B for primary care services provided on or after Jan. 1, 2011, and before Jan. 1, 2016.

For rural physician with a practice consisting of less than 40% procedural services, this will be an additional bonus on top of the HPSA bonus or any other federal bonus programs.

Clinical reports: Cryotherapy most effective for common warts

Cryotherapy may be more effective than salicylic acid or a wait and see approach, based on a RCT reported online September 13 in the Canadian Medical Association Journal.

Highlights of the study from Medscape CME dermatology article (free registration required):

• Randomized controlled trial at 30 primary care practices in the Netherlands between May 1, 2006, and January 26, 2007
• Two hundren and fifty consecutive (250) eligible patients (4 - 79 years) with new cutaneous warts.
• Fourty-nine percent (122) were common warts and 51% (128) were plantar warts.
• Treatment groups
• cryotherapy with liquid nitrogen every 2 weeks
• daily self-application of salicylic acid
• wait-and-see approach.
• Overall cure rate at 13 weeks
• 39% with cryotherapy (95% CI, 29% - 51%)
• 24% with salicylic acid (95% CI, 16% - 35%)
• 16% (95% CI, 9.5% - 25%) with the wait-and-see approach.
• Cure rate for common warts at 13 weeks
• 49% with cryotherapy (95% CI, 34% - 64%)
• 15% with salicylic acid (95% CI, 7% - 30%)
• 8% with the wait-and-see approach.
• For plantar warts, no significant differences in cure rates.
• Children with plantar warts had relatively high cure rates of approximately 50% regardless of treatment. 
• Adolescents and adults had cure rates of only approximately 5%.
• Compared with topical salicylic acid, cryotherapy was associated with more frequent and more severe adverse effects

CMAJ. Published online September 13, 2010

Pearls: Abscess Drainage.

A punch biopsy device can be used to drain an abscess on a part of the body which may have a tendency to close prematurely, instead of using a scalpel blade.  The resulting round hole will most likely stay open until it heals by secondary intention.  This will also allow access to the abscess cavity with a small hemostat to allow break up any loculations.  The scar may be somewhat more prominent after final healing than a stab incision, and so consideration for cosmesis should be used when considering this technique.

Quick Review: Brugada Syndrome

The Brugada syndrome is a genetic disease causing sudden cardiac death, first noticed among young Asian men by two Spanish cardiologists, the Brugada brothers.  It can be initially indicated by abnormal electrocardiogram (ECG) findings and results in an increased risk of sudden cardiac death.  It is inherited in an autosomal dominant fashion, and is found in all races and both genders, but is more prevalant in Asian populations.

The syndrome can result in syncope, cardiac arrest, or sudden cardiac death.  The typical patient is a young male, otherwise healthy.

The ECG pattern consists of persistent ST elevations in V1 to V3 leads with a right bundle branch block (RBBB) with or without terminal S waves in the lateral leads.

There are three types of ECG patterns:

• Type 1 has a coved type ST elevation with at least 2 mm J-point elevation and gradually descending ST segment, and a negative T-wave.
• Type 2 has a saddle back ST elevation with at least 2 mm J-point elevation and at least 1 mm ST elevation, with positive or biphasic T-wave.
• Type 3 has a saddle back ST elevation with less than 2 mm J-point elevation and less than 1 mm ST elevation with a positive T-wave.

The diagnostic pattern may be present all the time, may occur spontaneously in response to as yet unclarified triggers, or may be elicited by the administration of class IC antiarrhythmic drugs that block sodium channels.

If this diagnosis is suspected, the patient should be referred to an electrophysiologist.  Treatment is placement of an implantable cardiac defibrillator.

State of Medicine: Rural Ambulance Services.

Rural ambulance services face increasing financial pressure due to declining tax bases, falling Medicare reimbursement for services. Moody county in southeast South Dakota is currently facing these problems. Other states have experienced similar situations in Oklahoma and  Missouri.

State of Medicine: Slow

Rural medicine is slow (not in the way you think).

Health care reform may not reduce solo practices.

Quizzes by Quibblo.com

Status asthmaticus by Quibblo.com