Archive for April 2013

The Dangers of Curbside Consults… and Why We Need Them

Everybody hates curbside consults – the informal, “Hey, Joe, how would you treat asymptomatic pyuria in my 80-year-old nursing home patient?”-type questions that dominate those Doctor’s Lounge conversations that aren’t about sports, Wall Street, or ObamaCare. Consultants hate being asked clinical questions out of context; they know that they may give incorrect advice if the underlying facts and assumptions aren’t right (the old garbage in, garbage out phenomenon). They also don’t enjoy giving away their time and intellectual capital for free. Risk managers hate curbside consults because they sometimes figure into the pathogenesis of a lawsuit, such as when a hospitalist or ER doctor acts after receiving (non-documented) curbside guidance and things go sideways. There is some evidence to support this antipathy. A recent study published in the Journal of Hospital Medicine examined 47 curbside consultations by hospitalists, in which formal consults by different hospitalists (unaware of the details of…

CABG vs PCI: depends on the patient

This large randomized trial found lower mortality with CABG (vs PCI) in patients with diabetes, heart failure, peripheral arterial disease, or tobacco use; but those with none of these risk factors had lower mortality with PCI (abstract).

Following the pulmonary nodule

New updated guidelines provide guidance for what to do when a solitary pulmonary nodule is discovered on imaging. Among the recommendations: Obtain prior imaging; stability over 2 years does not require any further follow up. If no prior imaging for solid nodules <8mm, follow the Fleischner Society guidelines; if solid >8mm assess risk of cancer based on imaging and clinical history and proceed based on guidelines from the ACCP. Subsolid <5mm do not require follow up, but >5mm does. The full guidelines can be found here (guidelines).

Perioperative beta blockers

This large retrospective analysis of VA medical centers found that patients who received perioperative beta blockers (for noncardiac surgery) had significantly lower 30 day mortality if their revised cardiac risk index was 2 or higher. This study adds more evidence base to the practice of continuing or starting perioperative beta blockers in those with a RCRI of 2 or more (abstract).