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Anchor lead: Which fluids are best to use in critically ill people? Elizabeth Tracey reports

The fluid known as saline is used a lot in medicine, but now a new study shows that fluids that are closer in composition to bodily fluids may be better. David Hager, a critical care medicine expert at Johns Hopkins, frames up the issue.

Hager: We do a lot of fluid resuscitation in the intensive care unit that has historically been done with normal saline, and sometimes with lactated Ringer’s, which has a few more of the typical electrolytes that are in the serum whereas normal saline is just sodium and chloride.  :14

Hager describes the findings.

Hager: They randomized their ICUs on a monthly basis to provide either normal saline versus a balanced fluid. They found that within 15,000 patients studied that the patients who had the normal saline more often had a composite endpoint of either death, prolonged renal dysfunction or need for renal replacement therapy.  :22

Hager welcomes this study as helping inform best clinical practice when it comes to which fluids are best, noting that further study is still needed. At Johns Hopkins, I’m Elizabeth Tracey.

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Anchor lead: Difficulty swallowing after being on a breathing machine can most often be improved, Elizabeth Tracey reports

Many people have difficulty swallowing after being on a breathing machine, but Martin Brodsky, a swallowing expert at Johns Hopkins, says therapy can help the majority recover some function, even after prolonged periods, according to his recent study.

Brodsky: It’s exercise regimens, it’s drills, it’s very similar to what you would imagine to what you would imagine for physical therapy to be for limbs and trunk strength, and function, though this happens in a very small space of the head and the neck. The vast majority, well beyond 80-90% will recover swallowing to a function where they’re able to take at least something in orally and be able to maintain some level of quality of life.  :27

Brodsky says testing is important to pinpoint the nature of the swallowing problem, so that specific interventions can be applied. He says his study shows that even after five years, improvement in swallowing is still possible. At Johns Hopkins, I’m Elizabeth Tracey.

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Anchor lead: Trouble swallowing is common following use of a breathing tube, Elizabeth Tracey reports

Breathing tubes can save lives, and are frequently used in critically ill persons as well as during many surgeries, yet they can leave people with difficulty swallowing, known as dysphagia, when they are removed. Martin Brodsky, a swallowing expert at Johns Hopkins, says his recent study sheds light on the issue.

Brodsky: People will have symptoms of dysphagia, in the ICU people who had breathing tubes down their throat, typically more than 24-48 hours, once that tube is pulled they’ll have at least minor difficulty swallowing and some voice problems. If it’s bad enough it can last years afterward. We just completed a study in fact. Most patients in this five year study resolved their dysphagia within three to six months, but there were certainly those folks who lasted up to five years.    :29

Brodsky says the good news is that even those who had dysphagia for prolonged periods ultimately did recover some function. At Johns Hopkins, I’m Elizabeth Tracey.

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Dean Rothman talks about Joy in Medicine

Program notes:

0:08 Joy in Medicine

1:02 How do you help people rediscover the joy?

2:03 Help with clinical workflows

3:03 Everyone blames the electronic record

4:03 How to reduce the administrative burden

5:05 A lot of that is technology

6:05 Work life balance in general

7:13 End

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Anchor lead: HIV spread is not controlled, Elizabeth Tracey reports

The International AIDS Society has just released their annual letter, with issues in HIV management and transmission front and center, especially concerns over whether funding from worldwide sources will continue. Joseph Cofrancesco, an HIV expert at Johns Hopkins, says another important issue remains disenfranchisement of populations at risk for HIV infection.

Cofrancesco: There are still certain parts of our societies that are still not well integrated and particularly in certain countries where men who have sex with men, sex workers, people who may use drugs, are criminalized and are still not in the system. So if you look at the rates of transmission in certain populations and in certain countries, and if you look at the United States and in young African American males, there’s still an epidemic.    :31

Cofrancesco emphasizes that we are all at risk when HIV isn’t contained. At Johns Hopkins, I’m Elizabeth Tracey.

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Anchor lead: Is allowing the federal government to negotiate drug prices part of the solution to controlling them? Elizabeth Tracey reports

People who need medicines daily, such as those infected with HIV, may simply choose to stop taking their drugs in the wake of high and increasing drug prices. Joseph Cofrancesco, an internal medicine expert and HIV specialist at Johns Hopkins, says this situation has reached the crisis point for many patients.

Cofrancesco: Part of it is we leave in a system that is capitalist. The part D law prohibited negotiations. If we had a formulary like the VA, then people say oh, then you eliminate drugs from the formulary, yes, but you can do so in a rational way, and you can say this is the other drugs, and you would presumably do that based on guidelines. And then you’d go to the manufacturer and say we have these three HIV drugs, the guidelines say these are the three to use, let us know what your costs are, and they’d have to negotiate.  :27

Cofrancesco notes that so far this year, changes in insurance company formularies have been especially troublesome for many of his patients, who don’t learn that their medicine are no longer covered until they attempt to fill needed prescriptions. At Johns Hopkins, I’m Elizabeth Tracey.

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Anchor lead: Pharmacy benefits managers are in the crosshairs as many try to rein in drug prices, Elizabeth Tracey reports

Drug prices, even for many generics, are too high and seem to keep heading upward, with pressure mounting on lawmakers and administration officials to do something, recent federal activity reveals. Joseph Cofrancesco, an internal medicine expert at Johns Hopkins, says the problem is out of control, with pharmacy benefits managers part of the problem.

Cofrancesco: The price of drugs just keeps going up and up and up to the point of absurdity. So to control that there have been these pharmacy benefit managers, who alter these plans to try to cut back costs. They also cut deals with manufacturers and generic manufacturers and everything else and go through their hoops. So every year their formularies change and one drug is out and another is in, and patients don’t get their meds until they figure out they should call us and tell us they’re not getting them, and we learn oh, that one’s off the formulary, and now you have to use something else.  :31

Cofrancesco says he sees middle income patients as experiencing the heaviest impact, with many simply choosing to go without needed medications. At Johns Hopkins, I’m Elizabeth Tracey.

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