Could an FPNP start an operate a "cash only" walk in...

hopbalt · Feb 21, 2004

I would also like to be able to integrate alternative and complementary medicine that had significant science supporting its efficacy. Is this something that NP's are typically able to do within their "scope" of practice? I've had MD's tell me that THEY would like to utilize more A&C approaches, but fear professional ridicule (thus I suspect that it would be even HARDER for NP's to integrate such approaches).

alternative medicine is quackery. If its labeled "alternative" that means it hasnt been proven safe and effective thru double blind, randomized placebo trials.

Roland · Feb 21, 2004

Hopbalt, I would argue that there are many alternative approaches with dozens to hundreds of studies supporting their efficacy. There is of course a continuum between absolute proof and little to no scientific support for a given alternative intervention. Consider for example research that seems to support the use of coenzye Q-10 supplementation in the treatment of those on long term statin therapy (indeed there exists a good deal of evidence that coQ10 might be useful as a primary intervention for those with congestive heart failure and other sequlae of CHD, but I will confine my discussion here to its use in conjunction with statins). Even though a major US pharmaceutical company (Merck) patented the supplement for this very purpose it is very seldom, utilized in "mainstream" American medicine. Another, example of an "alternative" therapy with considerable support is the use of Garlic in fighting MERSA/ and even VERSA strains of infection (albeit there is less research for this usage than the one referenced above). Dismissing ALL alternative and complementary medicine as quackery may be indicative of a certain amount of intellectual laziness, and would seem to be a conclusion at variance with established scientific fact (at the very least such a interpretation requires a very subjective analysis of the available facts).

A SMALL sample of Co-enzyme Q-10 research especially as it relates to CHD/ACS and statin treatment:

1. Ellis CJ, Scott R. Statins and coenzyme Q10. Lancet. 2003 Mar 29;361(9363):1134-5.

2. Singh RB, Neki NS, Kartikey K, et al. Effect of coenzyme Q10 on risk of athero- sclerosis in patients with recent myocardial infarction. Mol Cell Biochem. 2003 Apr;246(1-2):75-82.

3. Ohmoto N, Fujiwara Y, Kibira S, Kobayashi M, Saito T, Miura M. Cardiomyopathy showing progression from diffuse left ventricular hypertrophy to dilated phase associated with mitochondrial DNA point mutation A3243G: A case report. J Cardiol. 2003 Jan;41(1):21-7.

4. Fosslien E. Review: Mitochondrial medicine--cardiomyopathy caused by defective oxidative phosphorylation. Ann Clin Lab Sci. 2003 Fall;33(4):371-95.

5. Engelsen J, Nielsen JD, Hansen KF. Effect of coenzyme Q10 and ginkgo biloba on war- farin dosage in patients on long-term war- farin treatment. A randomized, double- blind, placebo-controlled cross-over trial. Ugeskr Laeger. 2003 Apr 28;165(18):1868-71.

6. Singh RB, Kartik C, Otsuka K, Pella D, Pella J. Brain-heart connection and the risk of heart attack. Biomed Pharmacother. 2002;56 Suppl 2:257s-265s.

7. Sarter B. Coenzyme Q10 and cardiovascu- lar disease: a review. J Cardiovasc Nurs. 2002 Jul;16(4):9-20.

8. Piotrowska D, Dlugosz A, Pajak J. Antioxidative properties of coenzyme Q10 and vitamin E in exposure to xylene and gasoline and their mixture with methanol. Acta Pol Pharm. 2002 Nov-Dec;59(6):427-32.

9. Tran MT, Mitchell TM, Kennedy DT, Giles JT. Role of coenzyme Q10 in chronic heart failure, angina, and hypertension. Pharmacotherapy. 2001 Jul;21(7):797-806.

10. Feher J, Papale A, Mannino G, Gualdi L, Balacco Gabrieli C. Mitotropic compounds for the treatment of age-related macular degeneration. The metabolic approach and a pilot study. Ophthalmologica. 2003 Sep- Oct;217(5):351-7.

11. Blasi MA, Bovina C, Carella G, et al. Does coenzyme Q10 play a role in opposing oxidative stress in patients with age-related macular degeneration? Ophthalmologica. 2001 Jan-Feb;215(1):51-4.

12. Muller T, Buttner T, Gholipour AF, Kuhn W. Coenzyme Q10 supplementation pro- vides mild symptomatic benefit in patients with Parkinson's disease. Neurosci Lett. 2003 May 8;341(3):201-4.

13. Shults CW, Oakes D, Kieburtz K, et al. Effects of coenzyme Q10 in early Parkinson disease: evidence of slowing of the function al decline. Arch Neurol. 2002 Oct;59(10):1541-50.

14. Beal MF. Mitochondria, oxidative damage, and inflammation in Parkinson's disease. N Y Acad Sci. 2003 Jun;991:120-31.15. Beal MF. Bioenergetic approaches for neu- roprotection in Parkinson's disease. Ann Neurol. 2003;53 Suppl 3:S39-47; discussion S47-8.

16. Kishimoto C, Tomioka N, Nakayama Y, Miyamoto M. Anti-oxidant effects of coen- zyme Q10 on experimental viral myocarditis in mice. J Cardiovasc Pharmacol. 2003 Nov;42(5):588-92.

17. Jauslin ML, Meier T, Smith RA, Murphy MP. Mitochondria-targeted antioxidants protect Friedreich Ataxia fibroblasts from endogenous oxidative stress more effective- ly than untargeted antioxidants. FASEB J. 2003 Oct;17(13):1972-4. Epub 2003 Aug 15.

18. Sandhu JK, Pandey S, Ribecco-Lutkiewicz M, et al. Molecular mechanisms of gluta- mate neurotoxicity in mixed cultures of NT2-derived neurons and astrocytes: pro- tective effects of coenzyme Q10. J Neurosci Res. 2003 Jun 15;72(6):691-703.

19. Chuang YC, Chan JY, Chang AY, et al. Neuroprotective effects of coenzyme Q10 at rostral ventrolateral medulla against fatality during experimental endotoxemia in the rat. Shock. 2003 May;19(5):427-32.

20. Shults CW. Coenzyme Q10 in neurodegen- erative diseases. Curr Med Chem. 2003 Oct;10(19):1917-21.

21. Kishimoto C, Tamaki S, Matsumori A, Tomioka N, Kawai C. The protection of coenzyme Q10 against experimental viral myocarditis in mice. Jpn Circ J. 1984 Dec;48(12):1358-61.

22. Mancini A, Milardi D, Conte G,. et al. Coenzyme Q10: another biochemical alter- ation linked to infertility in varicocele patients? Metabolism. 2003 Apr;52(4):402-6.

23. Lamperti C, Naini A, Hirano M, et al. Cerebellar ataxia and coenzyme Q10 defi- ciency. Neurology. 2003 Apr 8;60(7):1206-8.

24. Langsjoen PH, Langsjoen A, Willis R, Folkers K. Treatment of hypertrophic car- diomyopathy with coenzyme Q10. Mol Aspects Med. 1997;18 Suppl:S145-51.

25. Langsjoen P, Langsjoen P, Willis R, Folkers K. Treatment of essential hypertension with coenzyme Q10. Mol Aspects Med. 1994;15 Suppl:S265-72.

26. Langsjoen H, Langsjoen P, Langsjoen P, Willis R, Folkers K. Usefulness of coen- zyme Q10 in clinical cardiology: a long-term study. Mol Aspects Med. 1994;15 Suppl:s165-75.

27. Langsjoen PH, Langsjoen PH, Folkers K. Isolated diastolic dysfunction of the myocardium and its response to CoQ10 treatment. Clin Investig. 1993;71(8 Suppl):S140-4.

28. Folkers K, Langsjoen P, Langsjoen PH. Therapy with coenzyme Q10 of patients in heart failure who are eligible or ineligible for a transplant. Biochem Biophys Res Commun. 1992 Jan 15;182(1):247-53.

29. Folkers K, Hanioka T, Xia LJ, McRee JT Jr, Langsjoen P. Coenzyme Q10 increases T4/T8 ratios of lymphocytes in ordinary subjects and relevance to patients having the AIDS related complex. Biochem Biophys Res Commun. 1991 Apr 30;176(2):786-91.

30. Folkers K, Langsjoen P, Willis R, et al. Lovastatin decreases coenzyme Q levels in humans. Proc Natl Acad Sci U S A. 1990 Nov;87(22):8931-4.

31. Langsjoen PH, Langsjoen PH, Folkers K. A six-year clinical study of therapy of car- diomyopathy with coenzyme Q10. Int J Tissue React. 1990;12(3):169-71

zenman · Feb 21, 2004

alternative medicine is quackery.

Don't know if you're trolling or not but you will be shot down in flames (as many others have) if you want to engage me in a discussion of this subject.

If you want to continue, let's do so. Hopefully, you are a physician or scientist so I'll have a more interesting time. Now let's start by you looking up and comparing the death rates from western medicine and "alternative" medicine. Later.

hopbalt · Feb 21, 2004

CoQ10 is NOT alternative medicine. As you can see, there is clinical trial data to back up its effectiveness. Doctors are now starting to embrace it.

Alternative medicine is stuff like aromatherapy, chiropractic, homeopathy, etc.

Those are all forms of quackery.

Chiropractic is effective for CERTAIN KINDS OF LOW BACK PAIN. Of course, your chiro wont tell you that, he'll tell you that spinal manipulation cures cancer, heart disease, asthma, etc. He'll tell you that all vaccines are evil ploys by doctors for mind control. He'll tell you that his back popping technique can cure your infertility.

Homeopathy is probably safe for the most part, but its 100% placebo effect. The fact that people claim that they feel better is irrelevant, because people feel better taking a sugar pill too, yet thats hardly considered "medicine"

suzanne4, RN · Feb 21, 2004

Not to change the subject, but back to the original post, YES, in some states a NP can open and have their own clinic without a physician there. You probably would want to have a physician that you could call or about a problem, but that does not mean back-up. You are operating with your own license, not under the physician.

Ted · Feb 21, 2004

warning! do not feed the trolls!

Tenesma · Feb 21, 2004

how about we compare the death rates with western medicine and without western medicine:

1) a patient comes in with dense hemiplegia and a history of a-fib... do we treat him with western medicine (thrombolytics?) or do we watch his stroke become permanent.

2) a patient comes in in a coma after a fall - do we provide decompression for a subdural bleed or do we watch him die?

3) a patient comes in with end-stage liver failure - do we provide him a liver transplant - and bridge him with a liver machine?

4) a neonate is born with a diaphragmatic hernia - ???

5) a septic nursing home patient with a UTI - ???

don't give me this crap about western medicine having a higher death rate than alternative medicine.... that is like comparing morbidity/mortality of the treatment modalities of ventricular rupture vs. "achy" elbow...

and zenman - don't get all high and mighty - i think the OP has some good points, that are worth discussing...

Dave ARNP · Feb 22, 2004

I thought this forum was for NURSE PRACTITIONERS.

Dave

Tenesma · Feb 22, 2004

i figured since most posters aren't NPs that i could throw in my 2 cents as well ---- sorry if i intruded.

by the way, MD terminator --- why the handle, if you are planning on becoming a doctor? any insecurities there?

Dave ARNP · Feb 22, 2004

Wasn't directed toward you Tenesema. I read alot of your posts in the CRNA forum and find them rather informational.

I assure you there are absoultely no insecurites coming from my SN. I chose it because of alot of the critisim NP's receive from MD's. I will not disagree that doctors bring important things to the table, but I also think we bring alot to the table that they don't.

With that being said, the reason I am considering medical school is simply to further my ability to care for my patients. I had considered Ob/Gyn, but after alot of soul searching, I do not think it is my calling. I will however, most likely attend medical school so I can persue a residency in either PM&R, Anest, or PSYC, then on to a fellowship in Pain.

Pain is truely where my heart is. Anything I can do to further my ability to treat pain... I'm there.

Dave

Roland · Feb 22, 2004

I would argue that the best of Western medicine should be integrated with those aspects of alternative and complementary medicine that are supported by empirical research. This is of course where the subject become sticky because exactly WHAT constitutes and acceptible threshold of scientific support for something to be considered supported? One standard is FDA approval, and while I'm not saying that is a BAD standard it is one which is fraught with political and economic considerations (many promising agents will not be able to matriculate through the lengthy clinical trial process due to economic considerations). In addition, many so called CAM approaches are not even eligable for the traditional clinical trial process because of synergestic considerations (one example of the importance of synergy might be Dr. Folkman's anti angiogenic inhibitors angiostatin and endostatin which received attention in the 1990's after a famous article in the Journal of Nature. He has expressed frustration that despite low toxicities that these agents have only been tested seperately and never together in clinical trials because of FDA policy on investigational agents. Apart these agents have produced only mediocre results in humans. However, at least in animals TOGETHER they are able to demonstrate action against a wide range of solid tumors).

Another important point is that even when effective teatments receive main stream endorsement such as the four drug therapy approach for care after an MI that I posted in the General Discussion area a few days ago, they STILL are often not widely utilized (I will re-post below for reference).

Do nurses have a role in "educating" physicians in new treatments? Consider the story

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below which details four established drugs, that when used together SEEM to cut the risk of death by up to 90% after a heart attack. For instance if you worked in a Cardiac unit and noticed that NONE of the patients that you cared for were benefiting from this new research would any "mechanism" exist for sending a "memo" to the physicians in such a way that it might actually be considered? The implications are profound if the latest treatments are not adopted by physicians. I have what I call the "Integrated health care team theory" of the nursing process which focuses on nurses as patient advocates, and their role as a "check and balance" upon the health care system. In the same way that a "wide receiver" can suggest to the quarterback of a football team that maybe he should consider calling a different play, nurses should when warranted be able to make similar suggestions to doctors without fear of reprimand.

Source: University Of Michigan Health System

Date:

2004-02-17

Inexpensive Four-drug Combo Saves Heart Patients' Lives

ANN ARBOR, Mich. - An inexpensive cocktail of four tiny pills can make a big difference in heart patients' death risk, a new University of Michigan study finds. And the life-saving effect of the four-drug regimen is bigger than the sum of its parts.

In the new paper, U-M Cardiovascular Center researchers report that heart attack and unstable angina patients who were prescribed all four types of proven medications had a 90 percent lower risk of dying in the six months after they left the hospital than those who received none of the drugs. Even patients who got only two or three of the drugs had a much lower death risk than those who got none.

The research is published in the rapid-access online edition of the journal Circulation, and an accompanying editorial notes the clinical importance of the findings.

The four classes of medications are:

* Anti-platelets: Aspirin and other drugs that keep blood clots from forming

* Statins: Cholesterol-lowering drugs

* ACE inhibitors: Blood pressure-lowering drugs that have other beneficial effects

* Beta blockers: Adrenaline-blocking drugs that ease the burden on the heart

Many studies have already shown that individual drugs in each one of the four classes can help prevent problems in patients with previous heart problems and clogged arteries. All four are recommended in national guidelines for doctors. And all four classes of drugs include many individual medications, with at least some available in inexpensive generic form.

The new study is the first to show the power of the four types of drugs together, and it does so in a "real world" setting of 1,264 adult patients treated between 1999 and 2002. All the patients had been admitted to the U-M hospital with an acute coronary syndrome: either myocardial infarction (heart attack) or unstable angina.

The results surprised the researchers, who analyzed the patients' hospital records to see how many of the drugs they had been prescribed and to determine how many would be appropriate for them. Then, they checked in on the patients six months after they left the hospital to determine if they were still living.

"We knew that each of these kinds of drugs works pretty well alone, but we never expected that together they would be this powerful at improving survival," says lead author and U-M cardiologist Debabrata Mukherjee, M.D. "These results clearly show that the effect of combination therapy is synergistic, not just additive: the drugs work together to create a bigger benefit for the patient."

This amplified effect may stem from a beneficial interaction between the ways in which the four types of drugs fight the plaque that builds up in clogged, hardened arteries -- the atherosclerosis that leads to chest pain and reduced blood flow to the heart.

The bottom line for patients, Mukherjee says, is that people who have a history of heart attack or unstable angina should talk with their doctor about making sure they receive prescriptions for as many of the four types of medications as they are eligible for.

And, he notes, they should ask for generic drugs whenever possible. If all four drugs in the cocktail are generic, the total cost may be under $50 a month. "That's a lot of bang for your buck," he says.

The bottom line for physicians is also clear, says U-M CVC clinical director and senior author Kim Eagle, M.D. "Get in line with the guidelines published by the American College of Cardiology and the American Heart Association, and help as many patients as possible benefit from these four proven therapies. There's no reason not to."

Eagle notes that the study's result confirms a known real-world problem: Despite those national guidelines, not all heart attack and unstable angina patients get prescribed all the drugs they should. No drug was prescribed to 100 percent of eligible patients in the study, and 40 percent of patients who could have received ACE inhibitors didn't. About 5 percent lacked an aspirin prescription, almost 18 percent didn't get beta-blockers, and 16 percent weren't prescribed statins.

Since the study ended in 2002, U-M has created a system that reviews each inpatient's eligibility for these agents, and their lifestyle goals, before the patient is discharged, in order to enhance the long-term outcome for every patient. Says Eagle, "We have now created a system to guarantee the best possible treatment at discharge for these at-risk individuals."

About 70 percent of patients in the study had suffered a heart attack, and 30 percent had unstable angina. Just over 63 percent of the patients in the study were men, and the average age was nearly 64. Two-thirds of the patients included in the study had blood tests positive for biomarkers that indicate damage to the heart muscle, while others were included because of symptoms of acute coronary insufficiency or an electrocardiogram that indicated a blockage in a heart blood vessel.

Patients tended to be obese and many were smokers, with a large percentage having a history of heart attack, angina, high blood pressure and high cholesterol before the acute episode that sent them to the hospital. A sizable minority had a history of stroke, heart failure or diabetes, and many had had angioplasty or bypass surgery in the past.

The researchers reviewed each patient's chart and assigned each a score based on what percentage of the four drug classes they had been prescribed, compared with how many drugs they were eligible to receive based on ACC/AHA guidelines. This score corresponded with an "Appropriateness Level" of 0, I, II, III or IV, with IV being the highest.

Patients who were prescribed none of the four drugs were assigned to Level 0, while those who were prescribed one of the four drugs when they could have been given three or four were grouped into Level I. Patients who received two drugs but could have used three or four, and those who received one when they could have taken two, were classed in Level II. Those who got three medications but could have taken all four were in Level III, and those who were prescribed all four were in Level IV.

In all, Level IV patients had a 90 percent lower risk of dying in the six-month follow-up period than the Level 0 patients. Level III patients and Level II patients also had an advantage over Level 0 patients, of 83 and 82 percent, respectively. And even Level I patients did better with just one drug than those who got none, showing a 64 percent lower risk of dying.

"These very high risk patients received a tremendous benefit from the preventive effects of these drugs, and we need to seize the opportunity to make sure that all patients receive appropriate care," says Mukherjee. "Simple things can make a big difference, if we use them as we know we should."

In addition to Mukherjee and Eagle, the study's authors are Jianming Fang, M.D., Stanley Chetcuti, M.D., Mauro Moscucci, M.D., and Eva Kline-Rogers, RN, all of the U-M Cardiovascular Center.

Editor's Note: The original news release can be found here.

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This story has been adapted from a news release issued by University Of Michigan Health System.

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