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Wednesday, November 19, 2014
Lions and Tigers and Doctors Unionizing, Oh My! Interesting developments in the field of hospital medicine. (Fresenius buys Cogent and Sound hospitalist companies. Is that good?)
When I first worked here, 2 years ago, they had just transitioned away from a national company that organized and provided hospitalist coverage. The company was expensive for the hospital and refused to work with the doctors to allow them to have reasonable work loads. Not having a reasonable work load as a doctor is not just an irritation, it is dangerous. An overworked physician is not available to respond to, or ideally avert, emergencies. Because doctors are primarily over achievers, being unable to provide good care because of being responsible for too many patients is incredibly demoralizing and often results in burnout, with its associated depression, anxiety and sometimes substance abuse. We hurry through our visits with patients because there are so many to see, missing important clues to diagnoses and ignoring social issues that are vital for providing appropriate treatment.
At this hospital, the doctors met with the administration and came up with a plan that involved getting rid of the hospitalist company, managing the staffing and billing themselves with the help of a hired coordinator. They still have days when there are too many patients to see, but they have hired enough staff that this is rare and they are free to adjust in order to maintain good patient care. This was not possible when they were employed by the national company.
Hospitals, though, often balk at the idea of managing their own hospitalist groups. This is for good reason. Hospitalists are expensive. Even though we take care of many patients, the money we bring in as revenue to the hospital does not cover our salaries. In fact, it doesn't even cover half of our salaries. Partly this is because many of the patients we see are unable to pay anything for their care. The sickest of patients often have poorly paying Medicaid or state funded insurance or have no money or insurance at all, which is partly why they are so sick, or at least strongly associated. Hospitals are willing to subsidize a hospitalist service, though, because having hospitalists attracts many of the physicians that do make a hospital money, such as surgical subspecialists. These folks need to be able to do operations and be available for emergencies requiring procedures without worrying that they will be called away by hospitalized patients who have complex medical problems outside of their area of expertise. Hospitalists are mostly internal medicine physicians who are good at managing all kinds of chronic medical problems and are in the hospital all the time, ready to take care of any patient who needs urgent help.
There is risk associated with managing a hospitalist program. Doctors sometimes get sick (god forbid) and replacements are needed, which can be difficult at the last minute. Occasionally a doctor who is hired for a position as a hospitalist, who sounded really good on paper, turns out to be pretty awful. They have a terrible temper and yell at nurses or they never do their documentation or they have bizarre practice styles. Whoever is in charge of a hospitalist group must find somebody to fill in, super quick, plus try again to find the right permanent member of the group. Running such an organization is not for the faint of heart.
Intrepid, expensive and mostly mercenary companies have arisen to fill the void. "Afraid to run a hospitalist program? We will do it for you and it will only cost millions or dollars a year!"
A California hospital where I have worked answered just such a clarion call. Their hospitalist group
had formed out of community physicians and new hires and had even involved a merger. The doctors kept track of their patients' billing information and billed them directly, and never worked particularly well together. Nobody was boss, so standards of care were a bit haphazard. They made considerably more money if they saw more patients, so even though they hated being overworked, they tended to end up with over-large patient loads. They knew exactly how much hiring doctors to fill in cost, since it came directly from their pockets, and they were loath to do it. They became burned out. The overwork and burned-outness made other physicians not want to work there. So they agreed to have a national hospitalist company take over. This is looking like a disaster, though only time will eventually tell. They will take a pay cut, and the company will expect them to continue to maintain higher than safe patient loads. Many have already quit.
Just yesterday I heard about a hospitalist group in Eugene, Oregon, which has decided to unionize because of overwork (local paper article here, with excellent commentary). Thirty six doctors at PeaceHealth hospital in Eugene and Springfield have decided to form a union, which will be part of the American Federation of Teachers. This large group also is a home to nursing unions, so the connection is not all that weird. Attempts to reduce costs associated with the hospitalists by the hospital administrators lead to unmanageable patient loads. The hospital dealt with the doctors' complaints by proposing having a national company take over the program. The doctors voted to unionize, a strategy that has helped nurses have a voice in the past, when reduction in staffing and salaries made them very unhappy.
I'm not quite sure how this will play out. The hospital can still hire an outside company to provide hospitalist services, though they will have to negotiate with the union if they want to use the local physicians who really know the patients and the system. Well paid scabs might fill the void.
I have worked for two national hospitalist organizations in the last 3 years, and although I appreciated some of their good ideas in areas like communication and education and patient safety, the workloads were mostly just awful. My very first locum tenens position was with Sound Inpatient Physicians, a large hospitalist company. After 1 day of orientation with 16 patients to see, I accelerated to the usual patient load of 19 patients who I didn't know, many of them complex, during an outbreak of Norovirus, so I had to gown up for about a third of them, and got 2 new admissions. I rarely finished my 12 hour shifts in less than 14 hours, and barely had time to go to the bathroom. A well deserved high level of anxiety plagued me most moments of each day, as I rushed from acutely ill patient to acutely ill patient while receiving multiple pages on my beeper. The other company, Cogent, employed me as a locum tenens physician in a PeaceHealth facility in Washington. The doctors were great, though not happy. At all. The administrators were ninjas of awesome skills, but the workload was ridiculous. Just a few days ago the large German healthcare company Fresenius, which had bought a majority share of Sound Inpatient Physicians earlier this year, purchased Cogent as well. I would like to believe that good qualities of German healthcare will now perfuse these two companies, but I seriously doubt it. Fresenius also owns a large amount of American kidney dialysis capabilities, and hopes to combine their dialysis arm with their hospitalist business to better coordinate care. I will not simply assume that this will raise prices and result in overuse of their technology, since some good might come of it. Fresenius did lose my vote of confidence, though, when they threatened to sue a researcher who wrote a scientific article that showed that a product they sell, hydroxyethyl starch, causes more death and kidney failure when used to resuscitate critically ill patients.
All this said, I should really admit to the fact that practicing as a hospitalist is a pretty good job. The patients are always interesting and they pay us well. There is no pay, though, that is adequate to make it OK to take care of too many patients at one time when doing so puts them at risk. Allowing doctors to have weighty input on work load, be it as part of a union or by being part of a well functioning independent hospitalist group, is vital to having good patient care and sustainable job satisfaction.
Posted by Janice Boughton at 10:03 PM 1 comment: Links to this post
Wednesday, October 29, 2014
How does a non-cardiologist learn echocardiography? What's the deal with all of these ads for "123Sonography"?
But why, one might ask, would it be relevant for me to know echocardiography? I'm not a cardiologist after all. Cardiologists are the people who read most of the heart ultrasounds, or echocardiograms, that are performed in the US. The usual routine is that someone like me, a general internist, or a family practitioner, orders an echocardiogram for a patient with a suspected heart problem. An ultrasonographer, a non-physician with expertise in performing ultrasounds of the heart, obtains images of the heart from various views, saves representative images, performs calculations of movements and sizes of structures and sends the whole file to a cardiologist who interprets the data. The cardiologist then produces a document with various abstruse and arcane abbreviations and corresponding values which also, thankfully, contains a summary paragraph which says if the heart looked normal or not. This whole process can take up to a week from start to finish. The patient or the patient's insurance company will be charged one or two thousand dollars and at the return visit the patient's physician will likely say something like, "it looked pretty good" or "one of the valves is a little leaky so I'm going to have you see the cardiologist" or "it wasn't too bad for someone your age."
I have been doing a rather quicker and more focused version of the echocardiogram as a bedside procedure for the last 3 years which frequently serves my purpose much better than the scenario I just described. It is possible to learn the basics of cardiac ultrasound through continuing medical education classes taught by emergency physicians, who have used bedside ultrasound for decades to more capably triage patients. Ultrasound machines have gotten smaller, more ubiquitous in hospitals (often you can find one nearby if you need it) and even affordable to own and carry around. Mine fits in a lab coat pocket and gets pretty good images from which I can make more informed decisions regarding my patients' diseases and appropriate treatment. It doesn't replace the full scale echocardiogram, except in cases where the details are unnecessary. I have done thousands of focused echocardiograms, reviewed them with experts when that was appropriate, compared the results to full scale echocardiograms when those were done, and know much more about the normal and abnormal heart than I did during the first two decades of my internal medicine practice when I relied primarily on my stethoscope. My bedside echocardiograms tell me if the heart is weak, and how weak, if there is fluid around the heart, whether there is evidence of problems with the blood vessels in the lungs and if there is damage from long term high blood pressure. I can identify the moment of death quite accurately when attending the dying and can see if an acute heart attack is causing a patient's chest pain or breathing problems. I can avoid giving medications that the patient's heart will not tolerate.
When it comes down to it, though, a good cardiologist is better at interpreting an echocardiogram than I am. I am not qualified to take the images and arcane numbers produced by an echo technician and produce a succinct but exhaustive summary. I am an internist, which is a fine and noble job, but not a cardiologist. So, since I look at hearts at the bedside all the time with a small ultrasound, I would like to know more about the fine points of echocardiography.
I have looked around for years for a good way to learn echocardiography and found that, for someone already in medical practice, it is pretty tricky to get echocardiography training. There used to be a guy, an echo technician by training, who ran courses for internists and anesthesiologists in performing and reading echocardiograms, but he got old and pretty much stopped doing it. He also really did not approve of bedside ultrasound. His courses were expensive and weeks long. After completing a course, to be credentialed to read echocardiograms required shadowing a cardiologist for a period of time and then reading echocardiograms which were over-read by a cardiologist. It would have been much easier if I had only known I would need this when I was still in training.
So it was very exciting when the offer of a free echocardiography course came to me in my e-mail. I followed the links and found that the 4 module free course was well taught and informative. I was still wary, but plunked down $757 for a full "master class" in echocardiography which was self paced and gave me 30 hours of training. I had 6 months to use the resource material. It was really pretty good. The faculty is all from the University of Vienna, in Austria, which is a real place, not like University of Phoenix or something. The faculty are real cardiologists, clearly interested in their material and their English is just fine, though spoken with Austrian accents. Both image acquisition and interpretation skills are taught and there is an emphasis on understanding not just the echocardiogram but the physiology of the heart and the underlying disease processes. There were 20 modules, with quizzes following each. The quizzes weren't particularly well written, but were detailed enough that it was necessary to really pay attention. There were exotic European spelling and grammar errors which did not distract from the material. I completed the course, got a certificate of completion and I feel pretty certain that I still am not qualified to read a full scale echocardiogram. I do, however, understand quite a few more subtleties than I did, and will continue to do bedside focused echocardiography with renewed appreciation.
I think this course is much more aimed at training physicians in resource poor settings where nearly all doctors are generalists, and having a physician who is able to read an echocardiogram, even without knowing the finer points, is life saving and really all that is available. Doctors in these situations will use a course like this to go from knowing close to nothing to being able to capably diagnose the majority of cardiac conditions, to their patients' great benefit. This was truly an educational niche that needed filling. The teachers also do in-person few-day courses in various locations, which I would love to attend at some point, not least of all to see what the student body is like. If they are fantastically successful (and I kind of think they are) perhaps there will be competition, and possibly even accessible education in the US. It has seemed like the lack of educational opportunities acted to protect a piece of lucrative turf claimed by cardiologists. The US is not primarily made up of urban areas, though, and large portions of our geography, like where I practice, for instance, are not served by cardiology clinics. I am glad a resource like this exists, even though online training in something that is hands-on cannot expect to fully cover the educational needs of practitioners.
Posted by Janice Boughton at 9:31 PM No comments: Links to this post
Tuesday, October 21, 2014
Ebola!!! What about everything else? Influenza for instance.
Ebola virus has grabbed headlines since the epidemic started in West Africa nearly a year ago. The death toll is estimated at 4500 people, and the epidemic continues to spread. One person infected in Liberia returned to Texas with the disease and died, infecting maybe 2 healthcare workers.
Ebola is a nasty virus, surely, with a case fatality rate of 80%. Overall health and nutrition as well as living conditions have an effect on how sick a person gets with it. We have no good treatments, though antibodies and other biologically based treatments are being used and may be rapidly developed to combat the disease.
But have we forgotten influenza? Influenza is a nasty virus, with a few marginally helpful treatments. Its symptoms are fever, headache, cough, sore throat, runny nose, sometimes also heart failure, respiratory failure and brain dysfunction. It will likely kill tens of thousands of Americans this season, mostly the very old and very young, but also perfectly healthy people.
How about other globally relevant diseases? One and a half million people in the world die of AIDS yearly, the same number of tuberculosis, about 700,000 of malaria and more than the total of all three of these of malnutrition.
So we can't do very much about Ebola at this point, other than perhaps support the overseas programs that are trying to help the affected West African countries--Liberia, Sierra Leone, and Guinea. These
will probably have a more significant second wave of misery due to the economic devastation brought about by the epidemic. In the US Ebola is not likely to be an issue of significance. Perhaps learning to don and doff HAZMAT suits will benefit us in some as yet unknown way. I am open to scorn and censure if I am wrong.
What should we do about influenza, since that routinely kills many thousands of us? Should we all get flu shots? I am not entirely convinced. I get them every year and induce my loved ones to do the same. The flu is utterly nasty, even if it doesn't kill you. It comes on like a freight train, with upper respiratory symptoms and intense misery. It hurts to move your eyes. You can barely think and you certainly can't work, at least after the first day when you go in and infect everyone else. The cough lasts weeks. You are infectious for at least a week. Old folks go from flu to pneumonia and sometimes die. Anything that will lessen my chance of getting it is welcome. Still, wholesale vaccination programs of healthy people do not statistically decrease hospitalizations or work loss, and 70 people must be vaccinated to avoid one case of influenza. This is per a large Cochrane Collaboration evaluation of many well designed studies.
As we enter influenza season probably the most important thing to do to avoid the disease is not to spread it. People with classic flu symptoms should not go to work or school, should not fly or travel in any public conveyance, and if they try, they should be sent home. Will we actually heed this advice? No, at least we haven't so far.
What about malaria and AIDS and tuberculosis and hunger? There are lots of great ideas out there, from newer medications to public health campaigns, promoting peace, helping women farmers, digging wells, curbing environmental abuses, that sort of thing. Committed and creative people are working all the time. We just aren't hearing much about them since apparently the most pressing global health issue right now is Ebola.
Ebola is a nasty virus, surely, with a case fatality rate of 80%. Overall health and nutrition as well as living conditions have an effect on how sick a person gets with it. We have no good treatments, though antibodies and other biologically based treatments are being used and may be rapidly developed to combat the disease.
But have we forgotten influenza? Influenza is a nasty virus, with a few marginally helpful treatments. Its symptoms are fever, headache, cough, sore throat, runny nose, sometimes also heart failure, respiratory failure and brain dysfunction. It will likely kill tens of thousands of Americans this season, mostly the very old and very young, but also perfectly healthy people.
How about other globally relevant diseases? One and a half million people in the world die of AIDS yearly, the same number of tuberculosis, about 700,000 of malaria and more than the total of all three of these of malnutrition.
So we can't do very much about Ebola at this point, other than perhaps support the overseas programs that are trying to help the affected West African countries--Liberia, Sierra Leone, and Guinea. These
will probably have a more significant second wave of misery due to the economic devastation brought about by the epidemic. In the US Ebola is not likely to be an issue of significance. Perhaps learning to don and doff HAZMAT suits will benefit us in some as yet unknown way. I am open to scorn and censure if I am wrong.
What should we do about influenza, since that routinely kills many thousands of us? Should we all get flu shots? I am not entirely convinced. I get them every year and induce my loved ones to do the same. The flu is utterly nasty, even if it doesn't kill you. It comes on like a freight train, with upper respiratory symptoms and intense misery. It hurts to move your eyes. You can barely think and you certainly can't work, at least after the first day when you go in and infect everyone else. The cough lasts weeks. You are infectious for at least a week. Old folks go from flu to pneumonia and sometimes die. Anything that will lessen my chance of getting it is welcome. Still, wholesale vaccination programs of healthy people do not statistically decrease hospitalizations or work loss, and 70 people must be vaccinated to avoid one case of influenza. This is per a large Cochrane Collaboration evaluation of many well designed studies.
As we enter influenza season probably the most important thing to do to avoid the disease is not to spread it. People with classic flu symptoms should not go to work or school, should not fly or travel in any public conveyance, and if they try, they should be sent home. Will we actually heed this advice? No, at least we haven't so far.
What about malaria and AIDS and tuberculosis and hunger? There are lots of great ideas out there, from newer medications to public health campaigns, promoting peace, helping women farmers, digging wells, curbing environmental abuses, that sort of thing. Committed and creative people are working all the time. We just aren't hearing much about them since apparently the most pressing global health issue right now is Ebola.
Posted by Janice Boughton at 5:56 PM 2 comments: Links to this post
Thursday, October 16, 2014
Why do drugs cost so much? Confused and fuming about the unfairness of it all...
Sumatriptan is a nearly magical medicine which was FDA approved in 1991 for treatment of acute migraines.* It is similar to the neurotransmitter serotonin and reduces inflammation of arteries in the brain which is associated with migraine headaches. It does other things as well, and may have a much more complex mechanism of action. Although it has some side effects, it works well for most people, can be given as an injection, pill or nasal spray and doesn't cause drowsiness, constipation or nausea like many other pain medications can. When sumatriptan was first released, under the brand name Imitrex, it was astoundingly expensive. I can't remember what it cost, but it was a bundle. People were willing to pay because it often saved them a trip to the emergency room or many hours of misery. Global sales of this drug top 1 billion dollars yearly. It has been approved as a generic since 2008.
Back to the patient. I prescribed thirty 50mg pills of sumatriptan, generic, via a national pharmacy chain, hoping that she would be able to treat her migraine at home, have leftover medications for future migraines and avoid a trip to the emergency department. The pharmacy told her it didn't take her insurance and that the prescription would cost her $550. She didn't have $550. I called the pharmacy, told them that I meant generic, not brand name, and they told me that they understood that and that the cost was $550. I called an independent pharmacist who I know well and asked if this drug was still ridiculously expensive or if there might have been some mistake. She said that her cost for 9 pills (they come in 9 packs for no particular reason) was $6.50. At her pharmacy she would charge an uninsured patient cost plus a dispensing fee. That would be about $30 for 30 pills. I got online to see how Canada charges for this drug, and"Canada Drugs" which sells medications at Canadian-ish prices to people in the US charges about $40 for nine 50 mg pills. A physician blogger, Leslie Ramirez MD, who is particularly interested in pharmaceutical costs reported that Costco, an American wholesale warehouse club had drug prices that were at pharmacy cost plus 14% dispensing fee. Costco's price for nine 50 mg sumatriptan pills was about $14. Although Costco requires a membership for most of their merchandise, anyone with a prescription can buy medications there. (Leslie Ramirez's website on cost comparison of drugs in the Chicago area disappeared around 2011 after this article was written about it in Forbes Magazine.)
So this person, my patient, with a raging headache, left her pharmacy empty handed because she was unable to afford a medication which had been marked up over $500 above cost, a medication which has been available as a generic for over half a decade.
I asked my pharmacist friend what this was all about, and she said that it had to do with "Average Wholesale Price" which is a number created by pharmaceutical people and distributors, originally intended to represent the actual cost of medications, allowing the price paid by insurance companies to be standardized. Since large pharmacies base their prices on AWP, that $550 for 30 sumatriptan tablets was probably pretty well set among retail pharmacies. Hiking up the AWP has various benefits to the many players in the pharmaceutical industry. Pharmacies can benefit because their costs are usually much lower than the published price (on average 14% lower, but clearly much much lower in some cases) meaning they make a handsome profit on some generic medications, wholesalers benefit since pharmacies want to buy drugs that they can sell at a substantial profit and pharmaceutical companies that produce brand name products benefit if generic drugs are kept artificially more expensive, since patients will often spring for the brand name original or be willing to pay high prices for new nearly identical brand name drugs.
It sounds like drugs are more expensive than they should be because there is collusion to overcharge for them. But it is not all based on Average Wholesale Price rigging. The cost of generic drugs to pharmacies has also gone up drastically. This article in the online version of the Wall Street Journal reports on rising costs of generic drugs, sometimes as much as 8000 percent (in the case of the antibiotic doxycycline), at least some of which was associated with rising costs to pharmacies. I wasn't able to find the actual data, but apparently lawmakers are "probing staggering price hikes" and sending letters of inquiry to the drug manufacturers asking why prices were raised, how much money they are making off of the affected drugs, who is responsible for price hikes and how costs for these medications compare overseas. The letter I linked was sent earlier this month and I don't see any information yet about a response.
Price hikes would seem to negatively affect patients, of course, but also insurance companies which pay at least some of these costs. In my review of the Affordable Care Act I haven't come across any provision that controls how much drug companies charge for their products. Old laws against price fixing do seem to apply to this sort of thing, but there is nothing new that says that Mylan, for instance, can't make a drug that cost $11 a bottle one month increase in cost to $400 a bottle a few months later. The insurance industry, though, is powerful enough that I would think they would balk at these price hikes. Medicare itself is not allowed to negotiate prices with drug companies but private insurance companies can. I'm not quite seeing what dynamic is at work here to keep them from refusing to pay for overpriced drugs.
Another thing I don't quite understand is why, when Costco charges cost plus 14% for medications consumers and insurance companies don't avail themselves of this option. I do love my corner drugstore, and realize that they survive partly by selling inexpensive drugs to insured patients for inflated prices, but I wonder why this continues to happen. It is truly valuable to have an independent pharmacist dispense medications and maintain a relationship with physician prescribers and patients, as happens in locally owned pharmacies, but we should find some way of paying for this service that is not arbitrary and subject to whimsical fluctuations.
The explanation that makes the most sense regarding drug prices is that the producers and purveyors of pharmaceuticals will charge as much for their wares as anyone will pay. Doctors cannot help because they are not aware, at the time of a patient encounter, what of their many drug options for a given condition is the best value. Unless lawmakers have the stomach to regulate the profits of big pharmaceutical companies, their most powerful lobbying entity, or enact legislation to allow market forces to reduce drug costs, prices of medications will continue to be subject to staggering increases.
*"Nearly magical " is a bit of an overstatement. It does work pretty well compared to other pain relievers, but only about a third of patients taking it have relief of their headache in an hour, and only 1 in five is headache free 24 hours later.
Posted by Janice Boughton at 10:19 PM 1 comment: Links to this post
Sunday, October 5, 2014
Moxifloxacin for MRSA (methicillin resistant Staph aureus): Why is this not standard of care?
The drug company Bayer applied for a patent on yet another drug in the flouroquinolone category of antibiotics in 1989 and received approval by the FDA (Food and Drug Administration) in 1999 for Avelox, the brand name they gave to moxifloxacin. A Japanese company had discovered in the 1970's that adding a flourine to relatively ineffective antibiotics in the quinolone family, such as nalidixic acid, made them dramatically more active, thus creating flouroquinolones. That discovery led to the development of norfloxacin, then ciprofloxacin and levofloxacin which have become mainstays of antibiotic therapy. Ciprofloxacin is extremely useful for treating urinary infections and a variety of other serious infections including anthrax and traveler's diarrhea. Levofloxacin has become one of our drugs of choice for treating pneumonia and is especially useful because it achieves the same levels when given by mouth as it does by intravenous injection. Moxifloxacin hasn't really caught on to the same extent, even though it also is absorbed extremely well when taken orally and achieves particularly high levels in the lungs. It is also more effective for treating infections caused by gram positive organisms than ciprofloxacin or levofloxacin, including resistant Strep pneumoniae and Staph aureus. It is approved for treating skin, lung and abdominal infections caused by susceptible organisms and in some hospitals (like the VA, I hear) it is the least expensive flouroquinolone option due to deals with the manufacturer, so it is used more often. It just became available in a generic form in the US this year (2014).
Methicillin resistant Staphylococcus aureus has grabbed headlines as it has become more common, both as a bug acquired in the hospital and now in the community, that is to say outside of hospitals. In some places resistant staph infections are now more common than the ones that are sensitive to the antibiotics we use most often. Staph aureus is usually quite a virulent bug, spreading aggressively in infected tissue and often seeding the bloodstream and even establishing itself on heart valves. It can cause particularly severe pneumonia, especially in already ill hospitalized patients and patients from nursing homes. It has become an especially big problem among intravenous drug abusers who are some of our sickest patients anyway, with coexisting issues like HIV infection and lack of adequate medical care. We have struggled to find antibiotics which work for MRSA and have turned to older and sometimes less effective antibiotics as well as newer and absurdly expensive ones.
A few weeks ago, while treating a patient with a MRSA infected wound, a colleague who is a wound care doctor suggested using moxifloxacin to treat her infection. I thought he was maybe just a little stupid, not to know that MRSA is usually resistant to flouroquinolones. I told him as much, except the stupid part and he told me that I was wrong, that he had just heard a talk at a wound care meeting and that moxifloxacin was good for MRSA. I checked the microbiology sensitivity sheet for my patient's MRSA to see what antibiotics it was sensitive to, and it was, indeed, resistant to levofloxacin and ciprofloxacin and our lab did not even test for moxifloxacin. I started poking around in the literature to find out what supported his claim that moxifloxacin was good for MRSA. There wasn't much, but there was an article that showed that, using MRSA from 12 patients who acquired it in the community or the hospital, moxifloxacin was more effective in killing the staph than trimethoprim sulfamethoxazole, linezolid or clindamycin. Another article showed that moxifloxacin was more effective than vancomycin, a standard treatment for MRSA, in treating MRSA in experimental biofilms, like the bacterial mats that characterize infected wounds. A third one looked at the effectiveness of vancomycin, ciprofloxacin and moxifloxacin at curing experimental heart infections (endocarditis) in rats and found that moxifloxacin was more effective than vancomycin and that ciprofloxacin didn't work at all. There were no human studies comparing moxifloxacin, head to head, with other standard antibiotics such as vancomycin for MRSA. So I guess he was right and I was wrong.
Standard of Care
This week's JAMA (Journal of the American Medical Association) featured an article entitled Clinical Management of Staphylococcus aureus Bacteremia, A Review, by Thomas L. Holland MD et al. The article concluded that vancomycin and daptomycin (a moderately toxic and very expensive new antibiotic for MRSA) are the first line antibiotic choices for MRSA bacteremia , that is infection found in the blood. This was based on 81 studies, none of which looked at moxifloxacin. The antibiotics studied were pretty much all the newer, recently released, very expensive and usually intravenous antibiotics. Studies involving humans are very expensive to perform, and funding is usually from pharmaceutical companies attempting to show that their drug works, which will make back the money they spend in research if all goes as planned. To give the article credit, the final conclusion was that well-designed studies to address the management of S. aureus bacteremia are needed.
Sepsis and Pneumonia
The standard of care in the hospitals where I have practiced is to use vancomycin (along with other broad spectrum antibiotic coverage) for patient who are seriously ill, in whom MRSA is suspected. Vancomycin is a difficult antibiotic to use, requiring measurement of levels to assure it is effective but not reaching toxic levels. It can cause kidney failure and hearing loss and if it is given quickly can cause "red man syndrome" which is what it sounds like, and quite disconcerting, though not deadly. Vancomycin must be given slowly which is a bit of an issue when a person is dying of rapidly progressive infection. But that's not actually the whole problem. We tend to use vancomycin when we suspect that there may be resistant staph in the lungs, but vancomycin actually has poor lung penetration and, even at standard doses, falls to what are probably ineffective levels during treatment.
It is often difficult to exclude pneumonia as a cause of serious infection in a patient who presents with sepsis, and the usual approach is to clobber them with broad spectrum antibiotics to cover whatever they might have. We try to get the antibiotics in to the patient as soon as humanly possible, ideally within an hour of arrival. Sometimes, however, it is difficult to get an intravenous line started and so a central venous catheter is placed, which must wait for a physician to do it, usually. Then there is a chest x-ray done to make sure that the line is in the right place and there is no lung collapse complicating the procedure. Then come the antibiotics. It can be agonizingly slow to get that first dose of life-saving antibiotics into a patient. Moxifloxacin can be given orally. "Here, take this." Bloop. Done. Or it can be given intravenously, if gut function is questionable, but quickly. Moxifloxacin covers most gram negative and gram positive organisms as well as atypical lung pathogens that cause serious infection including MRSA. Moxifloxacin dose is 400mg once daily and need not be adjusted for kidney or liver function.
So what is the catch?
What is wrong with moxifloxacin and why are we not using it more commonly? Moxifloxacin does not reach adequate levels in the urinary tract to treat urinary tract infections, which can be the cause of sepsis. But we can evaluate the urine quite quickly, in minutes actually, and adequately rule out urinary tract infection. Moxifloxacin can cause liver failure and serious skin rashes, but liver failure is extremely rare and all antibiotics cause skin reactions in some patients. It can cause tendons to rupture, similar to other fluoroquinolones, though that is also pretty rare. Moxifloxacin isn't cheap, somewhere between 5 and 20 dollars a pill. But that is compared to $8 a day plus high administration and monitoring costs for vancomycin and about $300 for daptomycin, plus administration costs. And moxifloxacin is now generic and produced by over 30 companies worldwide so its cost will likely become negligible. The biggest issue is that it hasn't been adequately studied in the setting of serious infection and isn't likely to be studied because it will make nobody money to do the expensive research. There is some evidence that staph aureus can become resistant to moxifloxacin in cultures, but, although this would certainly limit its usefulness, there has been no studies that I can find showing that this is actually relevant clinically, and some evidence implies that it might not be.
If, by some chance, it were to be studied and found to be superior to our present goofy standard of care, it would make some pretty profound changes in the way we do things. If moxifloxacin could be used to treat Staph aureus bacteremia then patients would not have to remain in the hospital or have outpatient intravenous antibiotics for 2 weeks, or 4-6 weeks in the case of complicated infections. It is incredibly inconvenient and dangerous to have patients on intravenous antibiotics for a prolonged amount of time. Intravenous drug abusers cannot be allowed to go home with an intravenous catheter in place because they will use it to inject drugs and the catheter will become infected. Those patients end up becoming fixtures in our hospital wards, often bored and disruptive, as they finish their prolonged treatments. When they leave against medical advice without completing their course of treatment a significant number will return, gravely ill, with a recurrence of their infection. The intravenous lines themselves, in addition to being very expensive, can cause infections and blood clots. Moxifloxacin achieves nearly identical levels when given orally as it does when given intravenously, so there would be no need for IV lines for 2-6 weeks.
In light of this information, what now?
I am not prepared to go against the standard of care at this point and use oral moxifloxacin for Staph aureus bacteremia, except in patients for whom intravenous therapy is impossible or likely to cause harm. I am, however, likely to use it for sepsis, when the urinary tract is not the source, in place of vancomycin plus other empiric gram negative and atypical organism coverage. I am also likely to choose it for treatment of wounds in which Staph aureus and gram negative organisms are identified or suspected. It is more than about time that adequate research was done to determine how we should use this drug for Staph, especially MRSA bacteremia.
Posted by Janice Boughton at 11:01 PM 1 comment: Links to this post
Thursday, September 18, 2014
Emergency room doctors can safely use bedside ultrasound to diagnose kidney stones, saving billions of dollars and preventing some radiation induced cancers
An article came out just recently in the New England Journal of Medicine, which has a large circulation and should make a bit of a splash. This multi-center study looked at the option of having patients (excluding the very obese, pregnant and critically ill) with abdominal and flank pain suspected of having kidney stones evaluated first by emergency physicians with ultrasound of the kidneys and bladder before considering getting a CT scan. Normally a patient with suspected kidney stones (crampy pain in the back or abdomen, blood in the urine, suggestive history) will be referred for an abdominal and pelvic CT scan, which costs over $3000 and carries a significant amount of radiation exposure. In perfect circumstances performing the test and getting the results takes an hour, but it can end up taking several hours due to the usual delays. Sometimes patients with kidney stone type symptoms are referred by the emergency physician for an ultrasound by the radiology department, which takes about the same amount of time as the CT which takes the same amount of time, but costs a bit less and delivers no ionizing radiation. CT scans have beautiful pictures and can often find the kidney stone, if it's in there, and not finding the stone is strongly suggestive that the diagnosis of what is causing the pain must be sought elsewhere. Ultrasound can show if the kidney is blocked by showing lack of flow into the bladder or buildup of fluid in the kidney (hydronephrosis) but rarely actually visualizes the stone. This information, however, is adequate to make the diagnosis in most cases, when combined with a good clinical history, physical exam and lab tests.
It turns out that the bedside ultrasound exam done by emergency room docs (in this study they were from multiple medical centers including University of California at San Francisco, Cook County and Rush Medical Centers in Chicago, Group Health in Seattle and many more high quality locations) is adequate in cases of abdominal or flank pain as a first evaluation to rule in or out kidney stones. It is much more focused than an ultrasound performed by the radiology department and it only takes about 5 minutes or less to perform. Since it is done by the physician examining the patient it is also a time to take more history and do more general observation, which is always a good thing. About 40% of the patients initially evaluated this way got an official radiology ultrasound or CT scan which were felt to be necessary by the ER physician to clarify what was going on. About a million patients with kidney stones visit emergency rooms each year in the US and more than 10 times that many visit ER's with symptoms that sound a bit like kidney stones and have to be evaluated for them. If all of them got bedside ultrasound as the initial evaluation of their kidneys, my back-of-the-envelope calculations suggest that multiple billions of dollars could be saved on imaging costs and lives could potentially be saved due to reduced radiation exposure. The study showed no significant increase in complications in the patients first receiving bedside ultrasound. Actual cost savings were calculated, but not reported in the study (why?)
We can't just start doing this because not all ER doctors are yet comfortable performing and interpreting bedside ultrasound of the kidneys and bladder. But they could be. It is not hard. Pretty much anybody could learn to do this in maybe an hour and could certainly be competent after doing 50 exams. The implications of this are bigger than the article points out. When ER physicians start doing regular bedside (or "point of care" as it's sometimes termed) ultrasound they are going to get better at it. They will start to use ultrasound more and develop some pattern recognition skills that can't be predicted which will likely lead to more accurate diagnoses of other diseases, and possibly less dependence on ionizing and expensive radiation in the form of CT scans.
Unfortunately CT scans for abdominal pain in the emergency room are an important source of revenue for both radiologists and hospitals which puts a little kink in the clear path toward adopting bedside ultrasound as a diagnostic procedure of choice. It's not clear what to do with this, because we could surely use the expertise of radiologists and radiology technicians in training physicians to be good bedside ultrasonographers and presently that would be a pretty big conflict of interest for them. Still, there is so much good stuff going on in the field of high tech ultrasound that is not in the scope of bedside ultrasound that radiologists and technicians could be kept gainfully occupied by doing things that other physicians can't and shouldn't do. In the journal of the American Institute of Ultrasound in Medicine there were several articles about amazing and technically challenging imaging applications that non-radiologists might be wise not to try. There were articles about ultrasound of the midbrain to evaluate Parkinson's Disease, ultrasound of the liver to look at severity of cirrhosis, ultrasound of children with intestinal intussusception (telescoping of the bowel) to follow the success of noninvasive treatments and detailed prenatal evaluations for conditions I didn't even know existed. Ultrasound to diagnose appendicitis has become nearly standard now, but is really hard to learn and ultrasonographers and radiologists do it well (some ER physicians do it well too, but it's far from an entry level skill.) Looking at the kidneys in 5 minutes in the ER is clearly fine for evaluating possible kidney stones. An abdominal ultrasound in the radiology department with their big powerful machine with the gorgeous images combined with the stunning command of anatomy of radiology professionals is a different and differently beneficial thing. This recent article may help move us as hospitalists, ER physicians and primary care providers toward doing more bedside ultrasound, which could be a very good thing. Perhaps more radiologists will find peace with that and can bring themselves to help teach other medical staff who need to learn how to do it.
Posted by Janice Boughton at 9:28 PM 2 comments: Links to this post
Tuesday, September 16, 2014
American College of Physicians blows this one: Pri-med "free" education on safe opiate prescribing, REMS and drug companies
So that is why I opened the slick tri-fold large format postcard that I got in the mail today rather than recycling it immediately. It said, "Practice safe opioid prescribing with ACP's resources." Over-prescribing opiate painkillers such as morphine, oxycodone and hydrocodone is a huge problem in the US. In 2010 60% of the nearly 40,000 opiate overdose deaths were due to prescription medications, and that number is continuing, I believe, to rise every year. In addition to relieving pain, medications of this class can make people stop breathing, fall asleep at inopportune times, make poor decisions, be unable to have bowel movements and other life ending scenarios. The US uses 80% of the prescription opiates produced in the world. Many of the opiates we as physicians prescribe end up being misused or abused or sold illegally. In the 1990s there was a huge increase in understanding that pain needed treatment and in the 10 years between 1997 and 2007 prescriptions for pain medication increased 600%. I see patients frequently in the hospital whose illnesses become life threatening because they use prescription opiate pain medications. There are nearly a half a million emergency room visits each year related to prescription opiate abuse and the cost in healthcare dollars of this problem is many billions of dollars. There is a problem with our prescribing habits.
The tri-fold postcard from the ACP offered a 6 hour continuing medical education credit online course on appropriate prescribing of opiate pain medications, with a focus on avoiding overdose and addiction. The course was free to me. When I went to the ACP site I was re-directed to Pri-Med's site where the audio and slide program was available. Pri-Med is a medical education company which makes low cost (to us) online programs on all sorts of subjects. The programs are so low in cost that they can't possibly actually cover the expense of creating the content. Hmmm. Vewwy Intewwesting.
I went ahead and took the 6 modules which covered appropriate use of long acting opiate pain medications to treat chronic pain. I learned some interesting things about risk factors for prescription pain medication abuse, some obvious (active ongoing drug abuse) and some less so (age 18-45 with family history of drug abuse). I learned about different opiates' side effects and interactions with other drugs based on the cytochrome P450 system. I also heard stuff I already knew, such as the fact that long acting opiates are not supposed to be taken "as needed" but should be scheduled and that most of them must be left intact, not chewed or crushed, in order to remain long acting. Most of all I was exposed to a bunch of brand name opiates and exactly how they worked and what doses were standard and how they compared to each other. What I didn't learn was how much each of these drugs cost and how those costs and potential advantages compared to generic long acting opiates. There was nothing useful about how to help pain patients get off of opiates or alternatives to starting them in the first place.
After a rather long program I felt as if I had been cornered by a drug rep (representative from a pharmaceutical company). I am not pleased. I have been effectively inoculated with wonder drug propaganda. In return I will have a certificate that says I have been educated in safe opiate prescribing, which many state medical boards now require for licensure.
Why did this happen? Here's the story. The FDA now requires that companies that produce long acting opiates do something to make less people die of their drugs. The Food and Drug Administration Amendments Act of 2007 gave FDA the authority to require a Risk Evaluation and Mitigation Strategy (REMS) from manufacturers to ensure that the benefits of a drug or biological product outweigh its risks. For long acting opiates this consists of providing free education to prescribers and proving that at least 60% of them partake of these educational programs. Pri-Med makes its money from the healthcare industry, I'm guessing primarily from drug companies. This particular program skillfully combines risk mitigation with drug detailing. Clever pharma.
I'm disappointed in the ACP, though. On their website they did mention that this educational activity was supported by industry, but it was in very small print. With $525 of dues money times 140,000+ members, along with other sources of income, the ACP does not need drug company support to create educational material. State boards of medicine require education in safe opiate prescribing, but they do not require that it be provided by drug companies. It sounds like drug companies may have to prove that their educational materials are being disseminated, but that is not the business of the ACP and is not my responsibility. And the shiny tri-fold postcard. Who paid for that?
Posted by Janice Boughton at 10:11 PM 1 comment: Links to this post
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12 yo
Naked girls have hot lesbian sex together
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If you enjoy watching two naked girls making love together you will love our next film. Sexy blonde and brunette have hot lesbian sex together! This sexy blonde girl invited her super hot brunette friend to spend the weekend together at her place. They had a fun night watching movies and eating popcorn, staying up late, so the next morning she gets up and takes a nice, hot shower. Naked girl lathers up her sexy body and her friend arrives just in time to fetch her a dry towel. She was checking her out while she showered and going crazy looking at her flawless body. As her friend helps her get dry, she can't resist sniffing the back of her neck and kissing her gently, her skin smells so nice fresh off the shower. The girls kiss gently and passionately, pressing their naked bodies together. The blonde puts her friend against the wall, grabs her below her thighs and lifts her up, pressing her body against hers as they swap tongue and saliva! Hot girls roll on the bed and the blonde spreads her legs so the brunette can eat her out, sinking her tongue deep between her parted pussy lips. Squeezing her breast with one hand the blonde uses the other one to move her friend's head up and down over her moist pussy slit. The friend sucks on her sensitive clitoris, pushes her tongue deep into her vagina, lapping her wet pussy slit with her tongue like a doggy. I like it! The brunette positions her sideways and spreads her ass cheeks, tossing her salad, fucking her asshole with her tongue, giving her a hot black kiss! Turned on by the intense anilingus, the blonde masturbates and soon it's her turn to eat her friend out. Naked girl sinks her face between her legs, her tongue penetrating her friend's delicious, wet muff. Naked girls kiss and the blonde rubs her lover's snatch and they engage in a steamy 69. Watch these naughty lezzies cum over and over in bed! Satisfied, the two naked girls cuddle together on the bed, so beautiful! Great scene! Loved the pussy eating & ass licking by both girls. Good match between the two girls in the scene. WATCH THE FULL FILM 1080P HD by the link.
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Get ready to enjoy some sensual erotica with these two young girls making love to each other. It's wonderful to see two beautiful naked girls appreciating and exploring every inch of each other's body. Beautiful women with even more beautiful chemistry! In this lesbian film we get a great balance between feelings and the erotic. They are a blonde and a brunette, both dressed in sensual lace lingerie, playing together in bed, enjoying a hot afternoon of Sapphic love making. The blonde is on top, gently kissing and caressing her lover, feeling her soft, warm skin on her lips and finger tips. The blonde cups her lover's breasts in her hands and presses them gently, licking her cleavage and going down on her, kissing her over her lace panties, already soaked in her pussy juices as the brunette spreads her legs and caresses her thighs. She removes the thong and licks that delicious slit, up and down, parting her pussy lips and teasing her clit. The brunette caresses her own breasts as she feels her friend's fingers sinking inside her wet pussy, finger fucking her, masturbating her, jerking her off. The girls kiss some more and the brunette fills her mouth with her friend's tender breasts and hard nipples. She masturbates her and watches her reactions, her expression, the way she moves her body, it's so fucking hot and sexy! The blonde gets on top, getting closer to her lover, feeling her lips all over her body and her tits, her hands fucking her cunt so hard! The brunette finger fucks her harder, faster, with more intensity and raw lust as the blonde gets closer and closer to an incredible orgasm! They are two of the most enchanting and beautiful women. Two young naked girls are enjoying pleasuring each other in bed, what more could you ask for? Get a taste of each yourself? Then don't miss this girl-girl sex in full HD.
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Do you want a submissive woman in bed? Don't miss this X-ART video. Nude girl enjoys a dripping creampie after submissive sex! As her lover waits, this sensual beauty provocatively strip teases for him in the living room. It's been a fabulous first date, he's been very kind and respectful, a perfect gentleman, and it's time for him to get his reward for knowing how to treat a lady! She looks so beautiful as she sheds her thong and leaves her stockings dangling below the knee, crawling down on all fours towards her man with her lovely naked ass and her long sleeved tight black top still on. When she's in front of him, she turns over, still down on all fours, offering her delicious bubble shaped ass and her parted pussy lips for him to admire and take. He stimulates her snatch with his hands as she moans and grunts, dripping lube down the crack of her ass, fingering both her pussy and her asshole. Squatting, naked babe leans against him, he holds her by her neck softly as he masturbates her. They move to the bed, she crawls on all fours over the mattress and gives him head, sucking his cock and licking his balls. She tells him to do whatever he wants. This girl is submissive and gets off to a guy dominating her so he would put her hands above her head, tie her up, bend her over and touch her pussy, have her on all 4s and make her beg for it. She enjoys being so submissive for her man. He pulls the top over her head, covering her eyes and eats her out. Her naked pussy is delicious, her bald pussy mound looks amazing in the sun! She feels his throbbing dick penetrating her, pounding her pussy, it feels so big and hard inside her. She wants him to be in total control. He fucks her hard and she can feel him cumming inside of her! When he pulls out, he leaves a trail of oozing hot cum dripping from her tender snatch!
Naked girl blindfolded, bound, fucked and creampied
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Have you ever thought about having sex with a blindfolded naked girl? In lingerie, topless, blindfolded and bound by cuffs to the ceiling, this sexy lady is making her 50 shades of grey fantasies cum true! Her lover arrives and kisses her softly, she can feel his hands caressing her naked body, it gives her goose bumps, makes her pussy drip with arousal as moans escape from her tender lips. His hands crawl underneath her lingerie and she feels his fingers digging into her wet snatch, masturbating her, finger fucking her. He strips her naked amidst wet kisses and dirty caresses that arouse her even further. Naked girl squirms and writhes, as he runs his hands up and down her bare body. He pays special attention to her sensitive nipples to the sweetness between her legs. Sitting right between her legs he guides his mouth to her shaved pussy and begins to kiss her beautiful crotch. Blindfolded and bound she gasps as her lover teases her clit, sticks his tongue between her pussy lips, sometimes sliding through the length of her wet slit with passion. But this oral pleasure are only the prelude to a hot sex. She feels him parting her legs, she feels his throbbing erection parting her pussy lips as it slips inside her and he begins fucking her. He removes the blindfold so she can see how he's banging her so hard from behind and she uses the bounds to support herself as she wraps her legs around his waist. He fucks her hard and she can feel when he blows his load inside her, leaving a sticky, dripping creampie as his dick exits her pussy. This has been the most arousing sexual experience ever, so much better than that silly book! Enjoy the seductive play between this couple, as his babe enjoys being tied up and blindfolded and he enjoys her naked body.
Naked gymnast masturbating in random public places
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And now it's time for some nude gymnasts. Meet Mary, a hot 21 year old amateur gymnast from Colorado in her total first time experience in adult! She is cheerful and playful and ready to show everything you want! Mary is a beautiful teenage girl, with a very cute, firm and petite figure. She isn't shy about getting fully naked in public. Young girl bottomless in the park – awesome! Nude girl masturbating in random public places, in the park, in the mall, flashing her breasts, raising her skirt up and showing off her cute little pussy – impressive! She's always been open minded about spreading her legs and showing her lil pussy while she fingers and rubs it, masturbating in front of the camera at the mall is a dream cum true for this naughty exhibitionist babe. We go for a burger and a shake and she flashes her tits while sitting in our booth, fingers her pussy under the table and takes her fingers to her mouth, sucking them with a dirty look on her face. Next we hit a sports store, where Mary flashes us her hot bubble shaped ass and finds yet another good spot to finger her pussy some more! The fun continues outdoors, by a nearby park where she gets naked from the waist down! She shows us some of her moves, but her flexible body looks the hottest when she's getting herself off! Nude girl goes running in front of a tennis court while people play and then fully naked she does some acrobatics & back flips. We take her back home so she can get totally naked and spread her long legs in bed, masturbating and showing us her unique control over her vaginal muscles, too fucking hot! Back home, teen girl experiments with a couple of sex toys for the first time in her life. After some intense masturbation with the clitoral vibrator she ends up having her very first orgasm! An amazingly talented girl, gorgeous, energetic and fun. Don't miss more young NUDE GIRLS in their total first time experience in adult in FTVgirls.
Hot girls in a lesbian mini orgy
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Amia Miley and Natasha White are two of the hottest girls you'll ever see. The girls are all over each other, kissing and caressing each other's delectable bodies. Natasha has already pulled down Amia's pink panties so that she can run her hand down to her dripping wet pussy and her sensitive clit. After a bit of kissing and some initial pussy rubbing in the hall the girls get fully naked and start making out on the couch with lots of pussy and ass licking, clit tongue flicking, facesitting and intense pussy fingering. Two naked girls facesitting on each other – amazing! At first Amia was nervous because she'd never done that with another woman but very soon she gets quite relaxed. Amia flips over onto all fours with her naked ass in the air and her friend gives her pussy and her anus a good working over with her tongue. For a brief period Natasha even gets her tongue right up her ass hole. Now it's Amia's turn to explore Natasha's pussy and ass. It's her first time touching another girl's bits so she's a little tentative at first but before long she's really digging in deep and loving it! There's lots of pussy eating in the missionary position, on all fours and passionate 69 with these two hot naked girls. Make sure you don't miss this video if you are a fan of lesbian love because these hot girls are amazing! Amia says: My very first and very arousing lesbian sex experience! My roommate and I went out for lunch and while we sipped on some margaritas, she kept complimenting me on my tight salmon colored dress and my long sexy legs. She never flirted with me before, maybe it was the margaritas talking, and I've never been into girls before, and maybe it was the margaritas talking, but I felt quite turned on and I could notice my panties were getting wet! We went back to our place and we hadn't finished crossing the doorway when my roommate pushed me against the wall, pressed her hot latina body against my aroused body and started feeling me up and kissing me! I was loving it! Our tongues clashed, exchanging saliva in wet kisses as she lifted my dress and I felt her hand under my panties, rubbing my twat! She turned me over, spanked my ass, bent me over and shoved her tongue between my ass cheeks! I felt it crawling into my asshole and almost cummed on the spot! She finger fucked my pussy while eating out my asshole and let me do the same to her, I'm fucking in love with a dyke!
Two naughty teen girls and a guy fucking outdoors
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What could be better than outdoor sex with two young naked girls? Check out Girl On Girl new scene. If you dream about outdoor sex with two naked teens you wont want to miss this one. These teens in schoolgirl uniform are so hot and together the girls create one hell of a sensual movie. It's hard to imagine a more sexy uniform than their school skirts, school tie, white panties and white knee high socks! Two teen girls and a guy fucking outdoors! These two naughty teen schoolgirls just ditched classes because it's a beautiful day and they want to spend it outdoors, making hot lesbian love under the sun's rays and between the green by a nearby grassy knoll. Teens walk hand in hand, lie back on the grass and check out the passing clouds, exchanging wet kisses and arousing stares. Their white panties quickly became wet from touches. They wander into a nearby location and check out this young stud taking a nap by an old trailer, hidden from him, the girls make out and start taking off their clothes. Their hot lesbian make out session awakens the young lad and, curious, he approaches the naughty teens, with a huge tent pitching underneath his slacks. The girls worry he might get hurt and decide to help him relieve his arousal, pulling his slacks down and sucking on his monumental erection! One of the naked teens straddles herself over the trailer's stairs so he can fuck her from behind while her lesbian friend eats her out from underneath! This way she gets to taste her pussy and also lick the guy's dick and balls! Watch two naked teens fuck in a hardcore outdoors threesome that ends with his blowing his load all over their faces and open mouths! Don't miss the most intense hardcore scenes with schoolgirls and young horse riders by the link above.
Beautiful erotica
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A handsome guy, sexy girl with beautiful body, lots of tender kisses, caresses, touches… This erotica is so beautiful and tasteful; even your girlfriend who gives porn a bad rap will end up masturbating to it after watching! Enjoy this delicious kitchen romp between the beautiful naked and her lover. Delicious brunette and her man make love in the kitchen until they both cum! This handsome stud is fixing up a couple of drinks for his beloved and himself. Watch her walk into the room, a stunning brunette goddess in the nude except for a silky white blouse that reveals her luscious breasts. They made love three days in a row and his hot girlfriend still wants more, she in insatiable. They really love each other and you can see it in the video and that makes the sex even better. His hands, his lips and his tongue slide down her firm breasts, her sensitive nipples, her slippery flat belly, down to between her legs to her sweet bald pussy and her little clit. He begins to kiss, lick and suck her delicious pussy. When her pussy is dripping with anticipation her beau slides a couple of fingers in to make her pussy eating experience even better. Naked girl corners her man against the refrigerator and goes down on him, sucking his throbbing rod and licking his tightened up balls. She knows he's got a good load of hot cum in them and she wants to milk them! His girlfriend demonstrates him her love for oral sex with soft moans of happiness. After sucking his cock he puts her against the fridge and fucks her tight snatch from behind, they are both so turned on by each other, the power of love and sex combined! He lies on the floor so she can squat on top of his dick and ride it, it buries deep inside her gash and she feels so wet and turned on! After eating her out and fucking her over the kitchen counter she is ready to take his precious load all over her face and mouth! The season of love is here!
Sensual naked girl masturbating for you
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Are there fans of Dillion Harper? Are there fans of Masturbating Girls? This beautiful video is for you! I could watch a video with naked girls masturbating their pussies all day long! I'll hope you like this video too. Totally naked and looking like a modern day Venus, sensual and naked Dillion shows off her fabulous bubble shaped ass and big tits as she strolls around the patio, looking for her lover. It looks like he's not around, but she is feeling so aroused and in need of his massive cock inside her, the naked girl lies on the ground and spreads her long legs, masturbating while she waits for his arrival. Her flawless skin and body are illuminated by the soft light and nature. Her succulent teen breasts, her perfect ass, long legs and pretty face are almost not believable! Her bikini tan lines are so sexy!!! Watch as this sensual naked girl makes herself "cumfortable" lying on the pillows outdoors. She rubs and fingers her wet slit and passes her hands all over her naked body, lying on top of pillows and wishing his dick would be with her right now! She turns over, down on her knees, her face against the pillows and her back arched up, her sexy ass jutting outwards as she keeps masturbating, moaning and panting for breath with her eyes closed and her hands fondling her snatch and engorged nipples. Next she's back on her knees and spread wide open, eyes closed and facing the skies as her fingers invade her most sacred temple between her legs, finger fucking viciously until her body trembles and convulses, her eyes go blank and she gasps for air, climaxing deliciously for us! You won't want to miss X-Art "Luminescense" video in 1080p and more videos with this babe!
Naughty blonde goddess masturbates her tiny pussy
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Charlotte is a mesmerizing blonde goddess that enjoys time by herself at her home, just getting naked and exploring her sensual body, touching herself and masturbating until she reaches incredible orgasms. This girl like the sun, with beautiful golden hair, gorgeous blue eyes and pretty smile. This sunny blonde is a pretty and charming girl. Her boyfriend is away and won't be back for weeks and he has forbidden her to see any other guys or girls, so what can a dirty girl like Charlotte do? She masturbates all day long, God bless multiple orgasms! I love the way this naked girl runs her hands all over her sensitive titties and then touches her pussy lips and clit. Her favorite technique involves stuffing two or three fingers up her tight pussy while rubbing her clit and it gives her the most incredible orgasms. Her home has many different locations where she enjoys pleasuring herself, one of her favorites being on top of the coffee table with its mirrored countertop, it lets her check out her naked body and her dripping wet pussy as she plays with herself. Look how her naked body shakes, grinds and convulses as waves of pleasure overcome her, she just wishes her boyfriend were there to fuck her pussy and ass, stuff her mouth with dick meat and blow his load all over her sensational body! Well, at least we get to watch her getting off! I really love when girls do a solo masturbation scenes that show off the depths of their passion. This blonde girl is sure to brighten your day!
Young pussies getting destroyed by huge cocks
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Visitors already tipped me off about new videos from TEENS LOVE HUGE COCKS. A new scene with a huge cock pounding a tiny pussy finally is out. I'm always a fan of films with teen girls, especially when the young girls get a huge cock like this one. If you're of the same mind then you will love this movie. Prepare yourself for the sensational 18 year old teen babe getting a giant dick deep in her tight teen pussy. Big cocks young pussies, you are right! His third leg just about poked her in the eye as it popped out from the pants. Nature has not stinted giving him a long hose. Teen girl rubbed her eyes in amazement when she saw his massive cock. After seeing his big cock, her little pussy became wet at the same moment. Young naked girl quickly bent over and asked him to filed her tiny pussy from behind. Please put that thing inside me!? But dont tell my dad… OK?… Pimples on her ass were nearly exploded when he shoved the full length of his big cock deep in her pussy. She has never had sex with well hung guy before. She loved it and moaned the whole time. Teen came a few times with his giant cock at work. At the end she asked him to cum all over her face. Of course this guy fulfilled her desire leaving her with a sperm bubbles on her cute smile and with a cum dripping down on the floor from her teen pussy. He says: They say size doesn't matter, but that's just a lame cliché made up by losers with tiny peckers, man! I have a big cock and believe me, size matters and girls know it! This redhead teen I picked up at the mall wanted to check out my package so I took her back to my pad and made her finger her snatch for me. When she got down on her knees, pulled down my trousers and pulled out my dick, she couldn't fucking believe what her eyes were seeing! She checked it out with a huge smile on her lips and since she couldn't manage to close her mouth form the awe, I rammed my cock down her throat, bent her over in bed and fucked her tight tiny pussy from behind. When you got a girl in this position, you must absolutely shove your thumb up her asshole while fucking her twat, it makes teen sluts like this whore squeal like a pig in heat!
I just can't get enough of watching this big cock pounding her hot little body. You don't want to miss this amazing sex scene in full length, so be sure to download the whole video by the link above. These young girls have never tried huge cocks before. At the ripe age of 19, the girls can no longer resist the urge to see what a huge cock is all about. Teens take an 11 incher for the first time! These girls use their cat-like eyes, soft lips and their tight young pussies to make a giant cock fill all their holes with big hot loads.
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Meet Faith, she's a smoking hot ebony babe and she's taking some naughty pics of herself in the bathroom when her boyfriend walks in on her! She tries to explain to him that these pics are for him, but he believes they are for somebody else! Faith drops to her knees and begs her boyfriend to believe her, but maybe he needs something more than just words… how about some action to back them up, Faith? The sultry black girlfriend got on her knees to beg for forgiveness and ended up taking his big white cock in her mouth and sucking it deep down her throat. She takes his big white cock in her hands and sucks hard on it, she loves giving her man head to prove how much she loves him. He eats out her nipples and spreads her legs wide open so she can lick and suck on her pink twat. When they got to the bedroom, sexy girl stripped down to reveal her luscious ebony body. The lovely babe spend some time just teasing her boyfriend in her black panties and bra. But after a while her panties come down around her thighs. Her titties were so nice, and her black pussy and ass were perfect. When she bared her titties, her boyfriend couldn't help himself from sucking and licking on those delicious black nipples. Now sexy black girl asks her bf to lay down so she can straddle herself on top of his monumental white dick and ride him. Then he bends her over, puts her down on all fours and fucks her from behind, doggie style. Her juicy black butt shakes like mocha pudding while he plows her tight cunt. She grinds that sexy ass in reverse cowgirl and makes him blow his load all over her cute face! Cum in my mouth… i want to taste it! Her man couldn't hold out any longer and pulled out to give her a nice gooey glazing all over her face. Now take a selfies of that and send it to all your friends in Whatsapp, bitch! He fucked that black girl like she was the last one on Earth. I'm sure he will not think he could fuck a white girl again after such hot black girl like Faith.
Do you like amateur videos with black girls? I have a treat for you to kick off the new year! Here is BlackGfs next movie and a new black girl! She was so excited to show off her stunning body and her cock sucking and cock riding skills. Be sure to check out other amateur videos with black girls. You won't want to miss these amazing homemade footage with these black cuties. BlackGFs is #1 porn site for all lovers of black girls!
Fucking my sexy girl in front of the camera
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Enjoy this delicious fucking between a sexy girl and her boyfriend. Watch as her playfulness be-cums naughty very quickly. The way this sexy girl teased the camera with her pussy lips bulging through the hole in her jeans at the start of the video was enough to make you want to pull out your cock and start pounding her pussy straight away, but resist the temptation because it only gets better. She is full of passion, with a girly slim figure that could kill, lovely long legs, tight tiny pussy and a gorgeous ass. Her boyfriend says: My naughty GF loves to make love on camera and she's always coming up with kinky shit, like turning her denims into crotchless jeans so she can show off her naked pussy in front of the camera! I ran my finger up and down her slit, feeling it get wet and slick and popped it inside her. Finger fucking her turns us both on and I made her lean back and spread her legs wide open so I could push my big fat dick inside her sweet pussy. So I started banging her on the kitchen table and we moved on to the living room sofa, over which she bent over and offered me her juicy bubble butt to bang from behind right through a hole in her jeans. After fucking her like this I stripped her jeans off, pulled her legs over her head and ate her out before plowing her snatch some more! I fucked her so hard, let her ride my dick and had her squat on top of it while the camera caught every single second! Finally I couldn't hold out any longer and pulled out to give her a nice gooey glazing all over her face and titties. She turned around and laid her head over the couch, so I could stroke my cock down her throat. She sucked on my throbbing cock for a while and looked up with those pretty green eyes waiting a good portion of my cum in her mouth.
Don't forget to say thanks this couple who busted out their own home porn collection. See more of the most sexy girls having sex on camera, masturbating, getting naked at Watch My Girlfriend. This is an awesome girlfriend's porn website with some of the hottest girls and amateur sex videos made by real girls, couples and lesbians. These girls are submitting their own homemade sex videos to WatchMyGf so they may see some dirty comments from you. These amateur sexy girls do incredible things on camera and then share their own sex tapes. Enjoy!
Amateur sex tape with smoking hot gf
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Fucking my hot blonde girlfriend after the beach! My girlfriend went to the beach and I tagged along with my camera, getting some awesome shots of her coochie as she got rid of the sand under the exterior showers. My girlfriend even let me to make some close up shots of her naked pussy under the towel. Do you like inspect a pussy close up? Then I made this video is for you. The first view up her naked pussy when she pulled down her wet bikini was quite stunning and then the bare pussy views just got better. I venture directly underneath her pussy for some super sexy bottomless views. This got my girlfriend particularly hot and she let me get some close up shots as she ran her fingers up and down her wet slit. She put on her denim skirt with no panties and as we walked back home she teased me with her pink burger all the way, man! By the time we got back, my dick was so fucking hard, she got down on her knees and began sucking it hard. Her sweet lips around my dick, it was just what I needed. My girlfriend knows how to pleasure my cock. Time to bent her over and worked that hot ass from the back. After licking my salty balls my naked girlfriend bent over and showed me her ass, spreading her butt cheeks wide open with two hands so I could fuck her twat from behind. I took over the camera and got all the best angles, as I worked that pussy good on the bathroom counter. Then I fucked her in missionary so she could get a good look at my dick as I slapped it against her cunt, jerked off and blew my cum all over her belly and pussy! Look at my horny babe, she began rubbing my cum all over her belly and tits with her hand and then lewdly licked her hand clean. At that moment I realized that she wanted more! I bent her over and continued to pound her doggy style. The second time she reached an intense orgasm and after I filled her mouth with cum.
This couple is one of my favorite to date! Why, you ask? Well, because of their enthusiasm to have sex and record it! Usually, the boyfriend is the one hounding his GF to let him record a little naughty homemade video, but that wasn't the case with this babe. When the video started out, it was her that was grabbing his cock to get him into the mood to make a sextape. Are you looking amateur sex videos? Don't miss GF Revenge. This site is filled with amateur sex tapes that was submitted by real guys or girls. Amateur naked girls doing incredible things on camera. Join GF Revenge and check out all these smoking hot ex-girlfriends!
Amateur hardcore videos
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This dude busts out his amateur collection that he made with his girlfriend. Impressive! Holy fuck look at this tight teen body! I love amateur hardcore videos like this! His chick has the hottest body, and she knows how to put on a show. I've always wanted to fuck my babe on video, and here is proof that I have! My girlfriend and I filmed our very own homemade sex tape! We decided to make amateur hardcore video last week and we posted it online so everybody can check us out! She really got into it, watch her still clothed and sucking my cock while I'm already naked! I love the way she grabs my balls with one hand and sucks my dick at the same time, and having the camera on us made me harder than ever! I made her get down on all fours with her bubble butt facing the camera and pulled down her leggings to expose her gaping asshole and wet slit, going down on her and eating her out like tossed salad! I pulled her back and rammed my dick up her tight twat, pounding her sweet snatch from behind while watching ourselves in front of the camera. Check out my gf's freshly shaved pussy! She turned over so I could keep fucking her hard in missionary, rubbing her clit and begging me to fuck her asshole hardcore too, I guess my girlfriend always fantasized about anal sex and I have no complaints about that! Watch her bouncing up and down my hard dick! I pushed my dick into her tiny little box from every angle possible. She was cumming over and over again, and soon it was time for my dick to explode with sweet streams in her mouth. After plenty of hard fucking, my sexy girlfriend got on her back to suck every drop from my throbbing dick.
Hardcore video that was sent in to WatchMyGf by this hot couple. If your girlfriend and you enjoy making your very own homemade hardcore videos and fucking in front of the cameras, what are you waiting to share your amateur porn with everybody else right here at Watch My GF? You can also come and jerk off to real girlfriends showing off all their goods and talents, sucking dick, fucking hard, getting covered in cum and exposing all their naughty ways in hot user submitted content! They get new girlfriends and amateur sex videos and pictures added all the time so don't miss out and join us today!
Naked pics with new Met-Art girls
Here are four naked girls for those who just find the female body to be beautiful, gorgeous, and breathtaking. There are four girls all exposed for your viewing pleasure. Another amazing, young, gorgeous models which I hope you will love. Their explicit poses are quite awesome with all their prettiest places out in the open and nothing left to the imagination. These pics are for the naked girls connoisseur who likes to soak in the lovely shapes and contours of the female body. Enjoy!

subset: commoncrawl


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Joan Rivers' Cause of Death Revealed
Six weeks after the news of her death broke, the cause of Joan Rivers' passing has been revealed.
Six weeks after the news of her death broke, the cause of Joan Rivers' passing has been revealed.
Who knew we were all so, so wrong about Taylor Swift's cryptic lyrics this entire time.
Just in time for for our daily Taylor Swift freak out, the 'Shake It Off' singer posted yet another batch of cryptic lyrics to Instagram today (Oct. 16) and we still have no idea what's going on.
What do 'Spaces,' 'Clouds' and the number '18' all have in common? They're all tracks on the upcoming One Direction album 'Four.'
Phillip Phillips talks 'Thicket' and the bravery that comes with putting out a new album.
Alright everyone, remember: we're all in this together. It looks like 'High School Musical' actor Corbin Bleu is officially off the market!
Imagine having not only one superstar in your Algebra class -- but two! Yep, some high schools are lucky enough to be graced with two future celeb students at the same time.
Selena Gomez is sending a message to all of the haters out there -- especially the adult ones.
The feud between Snoop Dogg and Iggy Azalea is over, and it took the help of Iggy's mentor T.I. to help squash the beef.
Actress Elizabeth Pena, whose most recent notable credits include TV's 'Modern Family' and Disney/Pixar's 'The Incredibles,' has died at the age of 55. The Los Angeles Times reports that Pena had been suffering briefly from an undisclosed illness.


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Sons of XXXcalibare - Scene 4
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DVD Title Sons of XXXcalibare
Category Hunks
Added January 17, 2014
Viewed 0 times
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Duration 20m, 29s
Tags Anal Licking, Anal Sex, Blowjobs, Cum on Ass, Cum on Hands
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Sons of XXXcalibare
January 17 2014
More Scenes From DVD
- Scene 4 - Sigmund And Oswald Enjoys Sucking Eachother Cock
- Scene 1 - White Boys Go Inside And Fuck And Suck Cocks
- Scene 2 - Three Men Start Fucking One Another In Bed
- Scene 3 - Orric Godric Wolf Three Gays Are Fucking In The Mini Pool
- Scene 5 - Horny Guys Bede And Edwin Enjoy A Backdoor Pounding On Bed
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Courtesy of the PRCA:
LOUISVILLE, KY. – This was the perfect tune-up for bareback rider Tim O'Connell.
The Zwingle, Iowa cowboy, who will be competing in his first Wrangler National Finals Rodeo next month, had a dominating performance at the RAM Great Lakes Circuit Finals Rodeo (Nov. 13-15) at Freedom Hall.
O'Connell won one round and tied for first in the other two rounds to capture the average title with 245 points on three head.
Thanks to his performance, O'Connell also won the Great Lakes Circuit year-end title.
"I was doing what I have been doing all year and that's having fun, and trying to be aggressive and trying to take care of business," said O'Connell, 23.
This season has been a magical one for O'Connell as he finished fourth in the final regular-season Windham Weaponry High Performance PRCA World Standings with $102,890. The WNFR is Dec. 4-13 at the Thomas & Mack Arena in Las Vegas.
"I feel like I'm riding good and I'm in control with what I want to do," O'Connell said. "Everything is going correctly and the good Lord has blessed me. I'm ready to experience my first NFR. It is something I have dreamed about since I was knee-high and I feel like I'm riding good enough that I can compete at the highest level."
Back in 2012, O'Connell finished first in the Great Lakes Circuit year-end standings and earned $20,242 on his permit, but he never had any luck at the GLCFR until this year.
"I had never even won a round at the Great Lakes Circuit Finals Rodeo," said O'Connell, who was the PRCA Resistol Bareback Riding Rookie of the Year in 2013. "This year things went much better for me."
In the first round, O'Connell had a first-place tying 77-point ride on Barnes PRCA Rodeo's Pull Ups and he then won the second round with an 84-point ride on Three Hills Rodeo's Rocky. O'Connell capped things with another 84-point ride on MJM Rodeo's Hawley Falls in the third round to tie for first again.
With his year-end and average titles, O'Connell qualified for the RAM National Circuit Finals Rodeo March 25-28 at the Silver Spurs Arena in Kissimmee, Fla.
"That's awesome and I think it is great what the PRCA is doing (increasing the money at the RNCFR)," O'Connell said. "It is better for everyone and makes circuit cowboys want to compete at the highest level to make the (RNCFR). They did a great thing and I'm excited to go and compete against those guys for a national title. Next to a world title, the Ram National Circuit Finals Rodeo title is right there."
The other winners at the $125,005 rodeo were all-around cowboy Kyle Whitaker ($2,431, saddle bronc riding, tie-down roping and steer wrestling), steer wrestler Tooter Silver (13.7 seconds on three head), team ropers Jason Arndt and Gabe Gwaltney (21.2 seconds on three head), saddle bronc rider Austin Joseph (237 points on three head), tie-down roper Jared Kempker (26.4 seconds on three head), barrel racer Natalie Foutch, (46.97 seconds on three runs), and bull rider Will Crain (155 points on two head).
For more in-depth coverage on the 2014 Great Lakes Circuit Finals Rodeo, see the Jan. 16 issue of the ProRodeo Sports News.
In an effort to help promote the sport of Pro Rodeo, GreatLakesProRodeo.com provides pertinent information such as standings, rodeo schedule, rodeo results, general information and articles written about the cowboys and barrel racers who choose to compete for the Great Lakes Pro Rodeo Circuit. We also provide information that pertains to cowboy values and the western lifestyle. While working to positively promote the PRCA and the Great Lakes Pro Rodeo Circuit we are not affiliated with, governed or attached to the PRCA or the Great Lakes Pro Rodeo Circuit.
© 2002 – 2014, All Rights Reserved. Text, graphics, and HTML code are protected by US and International Copyright Laws, and may not be copied, reprinted, published, translated, hosted, or otherwise distributed by any means without explicit permission.


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- Champions League
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Arsene Wenger admits he does not have the answer. After 18 years at Arsenal he has scrutinised every detail and sought to move with the changing times(...)
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Arsenal will be without midfielder Aaron Ramsey (hamstring) and captain Mikel Arteta (calf) for tomorrow night's Champions League Group D match aga(...)
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SATURDAY Arsenal (4) v Tottenham (9) Arsenal expect to have midfielder Mathieu Flamini back from a dead leg. Defenders Kieran Gibbs and Per Merte(...)
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Arsenal manager Arsene Wenger has confirmed France defender Mathieu Debuchy will be absent for three months after ankle surgery.Debuchy – signed from(...)
- Soccer
- September 20, 2014, 12:00
Monday night, St James' Park: in the glass foyer opposite the Milburn entrance a handful of Newcastle United fans are gathered. There is a reserve tea(...)
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- September 19, 2014, 16:13
Mesut Özil must not be used as a "scapegoat" for Arsenal's shortcomings, Arsene Wenger has insisted.The German World Cup winner, who is Arsenal's reco(...)
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Arsenal have been here before. Twice in the previous three seasons they have made the trip to this blue-collar German city to take on Borussia Dortm(...)
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Arsenal 2 Manchester City 2Martin Demichelis seized a point for Premier League champions Manchester City with a late headed equaliser at the Emirates (...)
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ArsenalPlayers in: Alexis Sánchez (Barcelona, £30m), Mathieu Debuchy (Newcastle, £12m), David Ospina (Nice, undisclosed), Calum Chambers (Southampton,(...)
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Leicester 1 Arsenal 1It was a day that did nothing for Arsène Wenger's dubious claim that Arsenal are well-stocked in the striker department and under(...)


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November 27, 2014
Stay up-to-date with KAKE News:
TOPEKA, Kan. (AP) — A Kansas House committee has approved a resolution protesting President Barack Obama's plan on climate change after stripping out language suggesting the science behind it is flawed.
The Energy and Environment Committee's voice vote Tuesday sends the measure to the House for debate.
The nonbinding resolution says the plan released by the president last year would harm the economy and asks Congress to block it. President Obama's plan includes tougher pollution standards for power plants and higher vehicle fuel efficiency standards.
The resolution initially contained more than a page of language questioning the scientific consensus that human activity contributes to climate change. Environmentalists labeled it a denial resolution.
Overland Park Republican Craig McPherson pushed to shorten the measure and said the committee wanted to highlight the economic harm of the president's plan.
Click Here to access the online Public Inspection File
Viewers with disabilities can get assistance accessing this station's FCC Public Inspection File by contacting the station with the information listed below. Questions or concerns relating to the accessibility of the FCC's online public file system should be directed to the FCC at 888-225-5322, 888-835-5322 (TTY), or email@example.com.


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Electronic Music + Progressive Soul. From WDET Detroit.
Fresh Air
Intimate conversations on contemporary arts and issues.
Friday, May 16, 2014
Photo courtesy Huffington Post
Knights were once imagined as lumbering tin men, but recent discoveries found in forgotten manuscripts are redefining them as sophisticated martial artists. Jeffrey Forgeng, Curator of Higgins Armory Museum discusses the real life of the knights and modern research on the combat arts of the Middle Ages. He will be holding court at the DIA on Saturday, May 17 at 2 p.m.