Sunday, January 20, 2013

Day 218 - this n that

Today's major activities were a trip to Target for gym shorts for Ellie, a little weaving and a bit of reading. There is a really nice article in the 1/17 NEJM about drug eluting coronary artery stents. It explains nicely the basics of the stents and the pathophysiology of restenosis. Then it goes on to compare the various coated stents with bare stents and bypass surgery for a bunch of different indications and for different outcomes. When I was in Exeter, the data about very late stent restenosis with coated stents was just starting to come out and because Exeter has a very active cardiology department and I had a lot of patients who had had stents at one point or another (including while I was their doctor), I knew the data really well. Then in Manchester, my patient population changed a bit and coronary artery disease was no longer one of my top three diagnoses. I lost track of the cardiology data and began to follow the compelling diabetes stories that were unfolding (best blood pressure, whether or not driving the a1c to normal levels was benficial, the whole -glitizone story). It was nice to be brought back up to speed. I've said this before, but I really appreciate the articles that take a broader point of view and go from consideration of molecular mechanisms to organism wide outcomes when discussing a single topic. This was one and is highly recommended even if you won't be putting stents in or needing to explain to patients why their cardiologist put in one kind of stent over another or why they really really need to keep taking that expensive new medication. By the way, I learned that it is now fashionable to call them P2Y12 inhibitors instead of anti-platelet therapy. My patients used to think it was funny when I would tell them what was fashionable in the doctor world, but it's really true that there are terms the cool doctors use to let the other doctors know they're up to date in their journal reading.
The other article in the 1/17/12 NEJM that was interesting was a perspective on FUO (fever of unknown origin) which is a classic internal medicine problem--a patient with a fever over 101 several times over three weeks or more with no diagnosis despite 1 week of in patient workup (more recently 1 week of out patient workup has been allowed to substitute for inpatient workup). The point of the guy's article is not what I want to talk about here although it was a fine article. He describes the typical FUO patient in his hospital as (among other qualities) in the ICU still spiking fevers for weeks and sometimes months on end. Then at the end of the article, he talks about how the patients with FUO often end up having family conferences that include plans for palliative care. Plans for palliative care in a patient who has been in the ICU for weeks? These would be prime examples of patients who should have had palliative care consultations weeks ago. If the NEJM can't get it right, why should I think that the docs at my community based hospital can? It's a little discouraging.
This is not discouraging--for me at least. It's fun to take close up pictures of the long-suffering dog.

Tomorrow, I will be headed up to Lebanon for what I hope will be a very anti-climactic visit where John will say, "You're doing great. See you in three months."
For me, for tomorrow, I'm going to hope for utter dullness. For you, maybe utter dullness is a little too far, so I will hope for regular dullness, of the variety that is most congenial to you.

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