Saturday, August 29, 2015

This is the time that doctors' bag content should be changed! Doctors debate need for stethoscope as health care goes high-tech and that turns 200 years old .

Dr. Andrea Leeds, a Bellmore pediatrician, said she never leaves home without hers.
The doctor runs an old-fashioned practice out of her house, just as her father did in Brooklyn a generation earlier.
"I can tell you with 100 percent certainty that not only do I go everywhere with my stethoscope, I use it for every exam.
"I have picked up pneumonia using my stethoscope when the child has come in with a stomachache," Leeds said.
Using a stethoscope, she said, is one of the most important skills doctors acquire.
Chief Medical Officer Dr. Ronald Gulotta of St. Francis Hospital in Flower Hill thinks younger doctors do not know how to use them the way physicians of his father's generation learned to diagnose with them. And Dr. Stephen Gulotta, now retired after more than 50 years in medicine, is certain his son is right.

All of these doctors have an interest in the use and future of the stethoscope, perhaps the best-recognized symbol of the medical profession and a tool that turns 200 years old next year. The instrument's bicentennial arrives at a crossroads, some experts say.
Hank Campbell, president of the American Council on Science and Health in Manhattan, said that while the stethoscope is the instrument that personalized medicine -- bringing the doctor within 8 inches of the patient -- it's on its way out.
He predicts handheld ultrasound devices will replace them in the not-too-distant future.
And Dr. Jagat Narula, chief of cardiology at St. Luke's and Roosevelt Hospitals, divisions of Mount Sinai in Manhattan, is even more succinct: "The stethoscope is dead," Narula said.
That is not welcome news for Leeds, who says she will never give up her stethoscope.
"It's definitely a learned art. You have to know what you're listening to and it takes a lot of practice. I hope it's a skill that we don't lose. Being a doctor is a calling, not a job, and the stethoscope is one of the most important tools of our trade."

"There's a lot of useful information to be gained from using a stethoscope to examine the heart, lungs and abdomen," said Dr. Bruce Polsky, a specialist in infectious diseases at Winthrop-University Hospital in Mineola.
Information gathered through "auscultation," Polsky said of listening to and discerning the meaning of sounds the body makes, provides the basis for further evaluation.

Gulotta, a cardiologist and medical director of St. Francis, thinks technology has lessened the need for the stethoscope compared with its use in 1958, when his father graduated from medical school.
"I graduated from medical school in 1986 and it's still important," Gulotta said. "As a cardiologist there is still an emphasis on the utility of it. But we have the CT scan and echocardiography. Those technologies really gave us the real structure and anatomy, so when there's a murmur you can actually visualize it."
Gulotta, however, has seen decreasing reliance on stethoscopes among new medical school graduates. And he's saddened, he said, because it means the physical diagnosis of patients is an art in decline.
For his dad, he added, the stethoscope was viewed as gold and central to the physical exam.
"The physical examination of the patient was extremely important and the stethoscope had tremendous utility," Gulotta said. "They spent a lot of time with patients and they were true masters of auscultation."
Abnormal heartbeats; rales in the lungs, which are abnormal rattling or clicking sounds; obstructions in the bowel and in the carotid arteries that run along each side of the neck are some of the sounds the trained ear can hear through a stethoscope, which was invented by René Laennec.
"They would put patients through different maneuvers -- to lie on this side or on that side, stand up, squat, inhale, exhale -- to give them clues about the diagnosis" while listening with a stethoscope, Gulotta said.
"We are starting to lose its importance," he said.

Gulotta's dad, Stephen, who lives in Greenwich, Connecticut, said he spent hours in classes as an intern and resident at Montefiore Hospital in the Bronx mastering the sounds the body makes.
"Most people younger than 50 don't know how to examine the heart," said Gulotta, also a cardiologist who, in 1967, founded the cardiopulmonary department at North Shore University Hospital in Manhasset. He later moved to St. Francis.
During his internship and residency, Gulotta said he used what was called a phonocardiographic machine, which had high-fidelity recordings of various heart sounds, including very subtle ones.
He became so astute at diagnosing heart problems with a stethoscope that even now he can diagnose mild, moderate or severe valvular disease with that instrument alone. He officially retired in December.
"I've seen young cardiologists examining patients in the emergency room and it's a disgrace," Gulotta said. "These are ostensibly good cardiologists. But they'll listen to one spot with a stethoscope for two seconds, then another spot for two seconds and they're finished. I am shocked by it; a lot of old guys are shocked by it."
Campbell, meanwhile, predicts that handheld ultrasound devices are the wave of the future. "Nostalgia and symbolism will give way to increased accuracy," he said. "With anything that's 200 years old there's always a lot of art and a lot less science."

Narula agrees and thinks the $8,000 price tag on handheld ultrasound devices will decline if more doctors adopt the new technology. "The physical examination is becoming less and less popular," he said.
all prefer a device that visualizes patient complaints because it avoids guesswork and ultimately saves money spent on additional tests.
"I believe seeing is believing," Narula said. "Why should I imagine what is there? If I have the ultrasound in my hand, I can look at it."

Fondaparinux the Best Option to Tackle NSTEMI?

APRIL 20, 2015
DEATH and in-hospital bleeding in patients with non-ST-segment elevation myocardial infarction (NSTEMI) appears less likely through the use of fondaparinux, a factor Xa inhibitor, compared with low-molecular-weight heparin (LMWH).

These conclusions were drawn from the results of a Swedish registry, which consisted of 14,791 patients with NSTEMI treated with fondaparinux and 25,825 treated with LMWH. Of those who received fondaparinux, 1.1% had a bleeding event and 2.7% died in-hospital, whereas of those who received LMWH 1.8% had a bleeding event and 4.0% died in-hospital.

Patients in the fondaparinux group also showed a significantly reduced risk of severe bleeding and mortality at 30 and 180 days when compared with those in the LMWH group. 4.2% and 8.3% of patients treated with fondaparinux died at 30 and 180 days, respectively, compared with 5.8% and 11.8% of patients treated with LMWH. The results confirm the conclusions of the earlier OASIS-5 study that treatment with fondaparinux is associated with a significant reduction in mortality at 30 and 180 days. Patients in the Swedish registry had lower rates of hypertension and a more frequent history of myocardial infarction and stroke compared with OASIS-5.
The rate of severe bleeding was 5-fold greater in patients with impaired renal function, although fondaparinux lowered bleeding rates in-hospital and at 30 days compared with LMWH. However, these results were not statistically significant in those with the most severe renal dysfunction. The authors note that the successful prevention of bleeding may result in reduced mortality.
However, even though the odds of bleeding were consistently lower across all renal-function categories, the lower mortality with fondaparinux compared with LMWH was not significant in those with worst renal function.This may indicate that the elevated risk of death in those with the lowest renal-function category is explained by other mechanisms unrelated to bleeding.”
While the European Society of Cardiology recommends fondaparinux as a first-choice anticoagulant for acute coronary syndrome patients treated noninvasively or with percutaneous coronary intervention (PCI), in the USA the American College of Cardiology/American Heart Association recommends an anticoagulant for patients with NSTEMI, either fondaparinux or enoxaparin, but only for those not undergoing PCI.

Visipaque Reduces Risk of Renal and Cardiac Events During Angioplasty

CARDIAC and renal events are significantly less frequent during angioplasty procedures using isosmolar contrast medium (IOCM) agent VisipaqueTM (iodixanol) compared with procedures using low-osmolar contrast media (LOCM), according to research presented at EuroPCR 2015.
The results of this study are highly encouraging and support the use of isosmolar contrast media in high-risk percutaneous coronary intervention.

The study, funded by GE Healthcare, retrospectively analysed data from the Premier hospital database in the USA, which describes 334,001 angioplasty procedures that took place between January 2008 and September 2013. The researchers found that 10.5% fewer major adverse renal and cardiac events (MARCE) occurred when Visipaque was used compared with LOCM (p<0.01). The difference was even greater between those hospitals that solely used either IOCM or LOCM, with 26.7% fewer MARCE taking place in the IOCM group compared with the LOCM group. In addition, 2.7% and 0.6% fewer renal failure and kidney injury events, respectively, were observed with the use of IOCM compared with LOCM.
The results of this study are highly encouraging and support the use of isosmolar contrast media in high-risk percutaneous coronary intervention. These data suggest that prior studies with signal of reduced risk of contrast-induced acute kidney injury with Visipaque do indeed translate into a reduction in clinically meaningful MARCE.
These findings are likely to be of great benefit to patients undergoing angioplasty procedures, especially those who are more vulnerable. Indeed, the data showed that angioplasty procedures that used Visipaque tended to be performed in older (66.8 versus 63.8 years; p<0.01) and sicker patients based on the Charlson Comorbidity Index (4.0 versus 3.4; p<0.01). Compared with LOCM, IOCM was also used in more emergency procedures and in more patients who were classified as ‘major’ or ‘extreme’ according to the 3MTM APR-DRG indices of mortality and severity of illness.

IVUS vs. Angiography

Intravascular ultrasound (IVUS) is a valuable adjunct to angiography, providing new insights in the diagnosis of and therapy for coronary disease. Angiography depicts only a 2D silhouette of the lumen, whereas IVUS allows tomographic assessment of lumen area, plaque size, distribution, and composition. The safety of IVUS is well documented, and the assessment of luminal dimensions represents an important application of this modality.

In general IVUS is recommended for complex lesions: bifurcation lesions, long lesions, diabetics, left main and particularly restenosis lesions. But, there are very few cases where IVUS is not useful. The lesions one should  avoid doing IVUS in are situations where we have calcified tortuous anatomy, maybe hemodynamically unstable patients where it’s an emergency and you just need to get in there and get it fixed. Maybe a situation where we’re dealing with a small, very small artery, and there isn’t much doubt that the only size stent we are  going to be able to use is a 2.5mm drug-eluting stent and going in there and IVUS-ing a baseline is probably not going to change the mind.

Sometimes, we can see a somewhat sharp turn artery as a diseased vessel on angiogram which can be rule out by IVUS-ing. Once should not stenting the anxiety related reactions of chest pain with normal coronaries which only confirmed by a doubtful angiography.
IVUS  really helps us figure out where to land our stent. We’ve known for a long time that we want to land the distal end of our stent in as normal an artery segment as we can. Of course, the problem with angiography is we underestimate mild disease. So sometimes the vessel looks pretty good just beyond the lesion, but when we are  looking at that same region on ultrasound, many times we can see pretty severe disease in there.
In the future there will probably be this type of integrated IVUS-angiographic system called AIM, which stands for Angiographic IVUS Mapping, It is  believed by doctors , so you could look at the angiogram and see where your lesion is, put a cursor on there and the IVUS image would automatically link right to that spot.

In IVUS-guided versus non–IVUS-guided procedures, the incidence of stent thrombosis was reduced by 53% (0.55% vs 1.16%; P = .004), the incidence of MI was reduced by 38% (3.47% vs 5.59%; P < .0001), and the incidence of major adverse cardiovascular events (MACE, a composite of stent thrombosis, cardiac death, and MI) was reduced by 34% (4.9% vs 7.4%; P < .001).
IVUS guidance changed the procedure 74% of the time. IVUS use was associated with longer stent length and larger stent size without increasing periprocedural MI or the number of stents utilized. The majority of stents used in the study were of the latest generation and marketed globally. No additional safety issues were identified in the procedures in the study in which IVUS was used to place stents, noted the company.

References :
1-Michael C.Foster ,MD.FACC

2- Relationship Between Intravascular Ultrasound Guidance and ClinicalOutcomes After Drug-Eluting Stents: The ADAPT-DES StudyRunning title:Witzenbichler et al.; IVUS and DES Outcomes-Circulation , 2013