Current Issues: VAC

V.A.C. is also known as vacuum assisted therapy. This treatment involves placing a foam dressing on the wound that is then attached to suction. The wound is then suctioned continuously for the first 48 hours, and then intermittently thereafter. In theory, the procedure hastens cleaning by removing harmful substances including bacteria. The 11 major studies advocating V.A.C. have major flaws however. For example, many of the studies showing a benefit of V.A.C. compared the device to older therapies such as wet dressings. Recently, however, the therapy has come under attack and has been shown to be not as effective as other therapies and in some cases may be more harmful in subjecting the wound to suction. In addition, the device is costly, and therapy requires each patient to be immobile and attached to device for long periods of time.

There are many issues that may be addressed in this case. The primary one is our enthusiasm to jump to newer therapies that may not be fully studied. Is it our obligation to adapt to the newer therapies once the research has begun to show a benefit. Should we remain with the older therapies until definitive research is available. If we remain with older therapies, are we negligent in not using what may possibly be the best treatment?

Case 4

A diabetic patient presents with a foot ulcer and the following Xray. What is the recommended initial treatment?

A:


IV Ciprofloxaxcin for 48 hours,

followed by 12-14 weeks of oral therapy may be adequate therapy for a diabetic foot ulcer that involves the bone. Of course, the therapy may need to be changed to be specific to the culture and sensitivity obtained. Surgical treatment may be required if there is not adequate vascularization or if there is not adequate response in the bone involved.

National Healthcare

National Healthcare

Michael Moore's Sicko is a treatise for a National Health Service Program. It sounds good on the surface, to use tax dollars as a means to improve the health of the country. However, if you are an otherwise healthy individual, why should you participate? Granted, as a physician, you applaud the implementation of a plan that would allow everyone the access to health care. However, maybe you feel, as a new graduate at the age of 27, that you shouldn't be paying for a new defibrillator for Dick Cheney or for Bob Dole's erectile dysfunction. Also, with an eye towards history, maybe you think by paying for a health benefit now, you will be paying for a program that will be phased out by the time you really may benefit. But, in a civilized society, what is the option? Do we move towards a nationalized health care system or not? So often these topics are infused with special interest groups and millions of dollars, but as a purely ethical question, is health care a right?

Case 3

This patient comes to your ER complaining of joint pain. On further questioning, you also find the patient complains of pain on urination and matting in her eyes in the morning. What is the diagnosis?


A geographic tongue is a loss of pappillae in the tongue that often changes with time. In general, the patient is asymptomatic, and the patient has spontaneous resolution. The georgrapic tongue may be due to psoriasis, Reiter syndrome, lichen planus, herpes simplex virus. systemic lupus erythematosus, drug reaction and leukoplakia. In this case, the other symptoms of arthritis, urethritis and conjunctivitis comprise the triad known as Reiter syndrome. In a related note, the medical establishment is moving away from the term Reiter syndrome as it is named after Nazi physician who described it after experimenting on unwilling patients during World War II.

Issue 2

Anticoagluation Medication



Often, treatment with anticoaugluation drugs are recommended in individuals to guard against clots resulting in heart attacks and strokes. Aspirin has been advocated as a useful initial guard against these devestating diseases. Recently, however, many NSAIDS such as VIOXX and Celebrex have been shown to actually have an increase in CVA's and MI's. One theory is that ASA inhibits platelet coagulation. Any other NSAID the person may be taking interferes with the action of ASA. Thus, any NSAID will intefere with the action of ASA and result in more cardiovascular events than ASA alone. However, many of these patients suffer from pain, such as the significant pain asssociated with arthritis. If a patient is taking ASA, would you recommend any pain reliever to further decrease the pain experienced more than the action ASA itself would result in. If so, which pain reiever would you recommend in this hypothetical patient?

Case 2

What are the likely responsible organisms?






Staghorn calculi are often the result of urea producing organisms such as Klebsiella and Proteus.

Case of the Week 1

Which group of people do not get these fractures?
The fracture of the 5th metatarsal is known as a Boxer's fracture. Ironically, boxers do not often get this fracture, as they know how to land a punch.