Could an FPNP start an operate a "cash only" walk in... - page 3

clinic without a doctor onsite? If I couldn't become a CRNA I think that this would be my secondary goal. When I was a Corpman in the Navy I dreamed of going to medical school and gaining a Family... Read More

  1. by   zenman
    so zenman,

    it looks like we agree on a few points

    1) prevention/education is key
    2) we need to merge the good components of both western and eastern medicine
    3) our medical/nursing education should have a larger component dedicated to health education/prevention, nutrition, proven "alternative"/"eastern" medicine - for a more holistic approach
    4) that you would rather have me at your bedside when you are close to death, and that i would rather have you at my bedside for "chronic" unresolving ailments
    Sounds good to me! However, you would like me at your bedside near death or not...cause I do bodywork...just call me Dr. (Hon) Feelgood! :chuckle
  2. by   gwenith
    Quote from Roland
    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).
    Roland I am interested in this I tried searching for this article and could only find one article written by Dr Folkman on endostatins

    Prothrombin kringle-2 domain has a growth inhibitory activity against basic fibroblast growth factor-stimulated capillary endothelial cells.
    AU: Author
    Lee TH; Rhim T; Kim SS
    AF: Affiliation
    Department of Biochemistry, College of Science and Bioproducts Research Center, Yonsei University, Seoul 120-749, Korea.
    SO: Source
    The Journal of biological chemistry, 1998 Oct 30, 273(44):28805-12
    IS: ISSN
    AB: Abstract
    Recently, O'Reilly et al. (O'Reilly, M. S., Holmgren, L., Shing, Y., Chen, C., Rosenthal, R. A., Moses, M., Lane, W. S., Cao, Y., Sage, E. H., and Folkman, J. (1994) Cell 79, 315-328; O'Reilly, M. S., Boehm, T., Shing, Y., Fukai, N., Vasios, G., Lane, W. S., Flynn, E., Birkhead, J. R., Olsen, B. R., and Folkman, J. (1997) Cell 88, 277-285) developed a simple in vitro angiogenesis assay system using bovine capillary endothelial cell proliferation and purified potent angiogenic inhibitors, including angiostatin and endostatin. Using a simple in vitro assay for angiogenesis, we purified a protein molecule that showed anti-endothelial cell proliferative activity from the serum of New Zealand White rabbits, which was stimulated by lipopolysaccharide. The purified protein showed only bovine capillary endothelial cell growth inhibition and not any cytotoxicity. This molecule was identified as a prothrombin kringle-2 domain (fragment-2) using Edman degradation and the amino acid sequence deduced from the cloned cDNA. Both the prothrombin kringle-2 domain released from prothrombin by factor Xa cleavage and the angiogenic inhibitor purified from rabbit sera exhibited anti-endothelial cell proliferative activity. The recombinant rabbit prothrombin kringle-2 domain showed potent inhibitory activity with half-maximal concentrations (ED50) of 2 microg/ml media. As in angiostatin, the recombinant rabbit prothrombin kringle-2 domain also inhibited angiogenesis in the chorioallantoic membrane of chick embryos.
    LA: Language
    PY: Publication Year
    PT: Publication Type
    Journal Article
    CP: Country of Publication
    DE: Descriptors
    Amino Acid Sequence; Animals; Base Sequence; Capillaries: cytology; Cattle; Cell Division: physiology; Cell Line; Chick Embryo; DNA, Complementary; Endothelium, Vascular: cytology; Fibroblast Growth Factor 2: antagonists & inhibitors; Fibroblast Growth Factor 2: physiology; Growth Inhibitors: chemistry; Growth Inhibitors: genetics; Growth Inhibitors: physiology; Lipopolysaccharides: pharmacology; Molecular Sequence Data; Rabbits; Sequence Homology, Amino Acid; Support, Non-U.S. Gov't
    RN: Registry Number
    0 (DNA, Complementary); 0 (Growth Inhibitors); 0 (Lipopolysaccharides); 0 (angiogenic inhibitor protein); 103107-01-3 (Fibroblast Growth Factor 2)

    I note that you said your source was the journal of nature - this is not a medical text though and therefor may not have had the specific peer review that medical research is normally subject to.

    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


    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

    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.


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


    I also searched the University of Michigan's site and I could only find the following article of Dr Mukherjee's original article. Could you provide a link to your source???


    Peripheral vascular disease (PVD) is a manifestation of systemic atherosclerosis and is associated with an increased risk of cardiovascular morbidity and mortality. We examined clinical outcomes in sixty-six consecutive patients undergoing peripheral vascular interventions at our institution between January 2001 and October 2001. At hospital discharge and at six-months, lifestyle modifications and use of evidence based therapy was suboptimal. At six months, a significant proportion continued to smoke (22.7%) and only half of the patients exercised, controlled their weight or modified their diet for lipid control. The use of anti-platelet therapy was 77.2%; angiotensin converting enzyme (ACE) use 35.9 %; beta-blocker use 42.5 % and statin use 50 %. Twelve of the 66 patients (18.2%) had a clinical event of death, MI or stroke. An appropriateness algorithm for use of secondary prevention measures was created using evidence-based therapy guidelines and a composite appropriateness variable created. The use of evidence based therapy was associated with a significant reduction of the composite of death, MI and stroke at 6 months (OR 0.02, 95% CI 0.01 – 0.44, p=0.01). Atherosclerosis risk factors are very prevalent in PVD patients, but these patients receive less than optimal treatment following a predominantly technical vascular intervention. Effective secondary prevention with appropriate lifestyle interventions and evidence based medical therapy needs to be strongly encouraged and implemented in these patients.
  3. by   Roland
    The article for the four drug combo came from . The original press release came from the University of Michigan and can be found here . You may find it helpful when you search sites to use Google advanced rather than the "built in" site search engines. By using Google advanced and restricting the domain to the site you are interested in (in this case the University of Michigan) you will USUALLY get far superior results (I've even found this to be true at which has one of the best site search engines).

    As for the article in Nature it gained NATIONAL attention when it was published. Unfortunately, The Journal of Nature (like it's cousin Science) are considered my most scientists (and many Dr's) to be the TWO most preminent journals published and are extensively peer-reviewed. Unfortunately, they are also quite expensive and are difficult to access online unless your university or employer pays for the access (almost all public libraries carry these journals). Indeed, several clinical trials have been conducted on endostatin, and a few on angiostatin (in fact there is one in Indianapolis right now being led by Dr. Nassar Hanna). However, they have not been utlilized in combination in people. This is because the FDA usually does NOT test two NEW investigational agents at the same time. My point is that this policy intrinsically limits the success of agents which rely upon synergy. There is also a good article in this edition of Harrison's by Dr. Folkman that starts on page 517 and runs through page 530. It has a nice bibliography on page 530, and most of the scouces are available through Medline, or even through one of the other free search engines linked at allnurses.

    You may wish to consider buying the following article available at Medline:

    [The story of angiostatin and how controversy is useful in science]
    [Prica o angiostatinu ili koliko je osporavanje korisno u znanstvenom radu.]
    Acta Med Croatica 2003;57(2):145-8 (ISSN: 1330-0164)
    Kurjak A
    Klinika za ginekologiju i porodnistvo Medicinskog fakulteta Sveucilista u Zagrebu, Opca bolnica Sveti Duh, Sveti Duh 64, 10000 Zagreb, Hrvatska.
    Angiogenesis is the formation of new capillary blood vessels. It has a very important role not only in physiological conditions but also in the process of malignant human growth. Latest data suggesting that drugs inhibiting angiogenesis can stop the growth of malignant tumors have made the research on tumorous angiogenesis a hot topic recently. The pioneers in the field of angiogenesis, Judah Folkman and his team, have been challenged ever since they began the research. Several articles questioned the effectiveness of systemic gene therapy with anglostatin as an anticancer treatment in a mouse model of transduced hematopoletic stem cells.

    In a recent issue of Nature Medicine, Folkman has elegantly answered all the difficult questions of his criticizers showing impressively how criticism and controversies in scientific work represent the main generator of new ideas.
    Major Subject Heading(s) Minor Subject Heading(s) CAS Registry / EC Numbers

    Indexing Check Tags: Human
    Language: Serbo-Croatian (Roman)
    MEDLINE Indexing Date: 200308
    Citation Type: English Abstract
    Publication Type: Owner: NLM
    Publication Type: Journal Article
    PreMedline Identifier: 0012879695
    Journal Code: IM
    Last edit by Roland on Feb 25, '04
  4. by   gwenith
    Thank-you now that I have access to the original article I can assess for myself the rigor, validity and skew of the research - I do note however that this is a press release and NOT an actual research report. As such it is a shaky foundation to base claims upon. As it is a press release you cannot review or critique the research and so it becomes less than useful.
  5. by   Roland
    You may also note that it indicates that the use of these four drugs post MI is ALREADY a reccomendation of the American College of Cardiology AND the American Heart Association! This study was confirmatory rather than revolutionary it's just that the researchers were surprised to see how POWERFUL the four drug combination actually was in reducing mortality. The other "story" was that despite the ACC and AHA advising the use of these medications (based upon previous studies) that FEW patients who are eligable are actually RECEIVING ALL four medications. "Translational" medicine that is to say the translation of the latest scientific findings into clinical practice often lags years behind what it should! Consider, that we have had considerable evidence that elevated C-Reactive protein, and homocystein are AS predicative for CHD as elevated LDL cholesterol. However, many practitioners do not utlilize these relatively inexpensive tests (my FP told me that he had never even heard of c-reative protein).
    Last edit by Roland on Feb 25, '04
  6. by   jenfnp
    Quote from Tenesma

    you are confusing a lot of points in one paragraph

    1) my primary practice is "western" medicine, but as part of my pain practice i rely on "alternative" medicine: acupuncture, behavioral modification, etc..

    2) comparing length of existence is not a valid point: eastern medicine has been around for a long time, and it has a poor track record. Like you said, the biggest changes in global health have been public health issues (sanitation, urban reorganization, hospital hygiene, washing hands, smoking cessation) and those all stem from "western" culture. Just because people have been drinking chicken blood for abdominal cramps for thousands of years, doesn't lend more credibility to eastern medicine - superstition is a dangerous thing

    3) when you say that we are ranked behind CUBA - what statistic are you using??? that is just plain ridiculous - and I have been on a medical mission to CUBA - so i saw it first hand.

    4) western medicine has failed with chronic diseases... you gotta be kidding me!!! the reason why we have chronic diseases is because "western" medicine has allowed for people to live beyond 35 years of life!!!! how many chronic diseases would a 28 year old have??? now that we have extended their life expectancy of course there are going to be more chronic diseases
    a) life expectancy in 1900 in China was 25 while the life expectancy at the same time in the US was 48.
    b) life expectancy in 1950 in China was 35 while in the US it was 73
    c) 2/3 of deaths in China were due to infectious diseases - what did their alternative medicine do to help with that? again: sanitation and antibiotics

    5) jumping into the jungle - what? western medicine relies on medication and medical devices, therefore you could never compare western medicine and eastern medicine in that setting as you would be depriving the western practitioner of their devices. I would argue that if you and I jumped into the jungle and performed a double-blinded, randomized trial we would have the exact same mortality rate for our patients

    6) i am glad that you were able to cure/treat your elbows, your wife and orthopedic surgeons.... how can you use that as evidence that eastern medicine is better - especially since your first post was alluding to the higher death rate with western medicine... which brings me to my next point

    7) "how many people are killed by western practitioners?" - first of all that is an inflammatory statement, since the patients that you are alluding to died of medical errors and complications, and were not intentionally "killed".
    - and yes, there is a high number of patients who have died in hospitals due to negligence/errors/complications/device-malfunctions etc, but you would have to compare the general population mortality rate with AND without access to a hospital/"western" practitioner... and you will find that the deaths are a small price to pay for the number of lives saved by western practice. a good example of this would be vaccination, there are annual deaths due to side-effects of vaccines or reactions to the vectors/stabilizers in the vaccine, but that has to be compared to the number of deaths that would have occured without the vaccine

    So, in totum, I agree that an ideal practice of medicine would be the integration of western medicine with the best that eastern medicine has to offer (something i practice already), however, you can't be making generalizations that are erroneous, misleading and just ill-conceived.
    Well said and very to the point. I think the point of any practitioner's practice should be to incorporate the best evidence based interventions (including no intervention) with the needs of the patient. East/West-- it doesn't matter. In rural health care, I use a wide variety of interventions to help my patients. It is important to keep yourself informed of advances in all areas of healthcare. It is also important to remember that just because we can do something, doesn't mean that we should.
    I also get really frustrated by herbalists who suggest that an herb might be bettter, safer, etc. than a medication. The designation of a treatment as a medication only implies that it comes in a form that has been processed and perhaps tested and approved by the FDA (or not). Don't think for one second that "herbs" "homeopathic remedies" etc. don't possess active chemical metabolites just like "medicine". Foxglove grows in the garden... in pill form we call it digoxin. (I am pounding on the keyboard now!) Many of my patients come in asking if this or that interacts with their prescription meds. I have to answer (even with multiple herbal resources to consult) that I have no idea because they haven't been tested together. At any rate, if a patient would like to incorporate herbal remedies with their prescription meds, I always recommend one new product at a time to assess any side effects and measure improvement.
    Thanks for keeping my day very interesting!