American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, July 31, 2014

QD: News Every Day--Middle age alcohol misuse may play a role in later dementia

Middle-aged adults with a history of alcohol use disorders have more than double the risk of developing severe memory impairment later in life, a study found.

Researchers looked at the association between history of alcohol misuse and severe cognitive and memory impairment in more than 6,500 middle-aged adults from the Health and Retirement Study, starting in 1992 and reassessed biannually from 1996 through 2010. Alcohol misuse was assessed with the 3-item modified CAGE questionnaire, which eliminated the question about cutting down on drinking because the behavior is common in those over 50, which reduces the questions discriminatory value, the authors noted. Memory was assessed at the final follow-up evaluation using the 35-item modified Telephone Interview for Cognitive Status, with incident severe cognitive impairment defined as a score ≤8, and incident severe memory impairment defined as a score ≤1 on a 20-item memory subscale.

Results appeared in The American Journal of Geriatric Psychiatry.

During the nearly 2 decades of follow-up, 90 participants experienced severe cognitive impairment and 74 participants experienced severe memory impairment. History of alcohol use was associated with severe memory impairment (odds ratio [OR], 2.21; 95% CI, 1.27 to 3.85; P=0.01), while there was non-statistically significant trend for severe cognitive impairment (OR, 1.80; 95% CI, 0.97 to 3.33; P=0.06).

“Gaining greater insight into the role comorbid conditions, such as (alcohol use disorders) AUDs, play in the natural history of dementia may lead to new opportunities for prevention,” the authors wrote. “The CAGE questionnaire may offer clinicians a practical way to identify individuals at risk of adverse dementia-related outcomes who may benefit from interventions targeting AUDs.”

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Wednesday, July 30, 2014

Update for Lyme disease

Lyme disease is probably the most common tick-borne illness in the U.S., and the best understood. It’s a regional disease, very common in some areas, vanishingly rare in others for reasons that aren’t yet clear. There are about 35,000 cases reported yearly in the U.S., but this likely underestimates the true incidence as many people either don’t seek help or are not properly diagnosed.

Many people present with the classic “bullseye” rash, but many (about 20-30%) do not. During the first month after infection, many people experience fatigue, fevers, and joint aches. At this point testing is rarely necessary and the disease can be treated with a short course of antibiotics based on the symptoms and physical exam alone. During this early stage, some people may get more serious symptoms, such as facial paralysis, meningitis, and heart problems. If the infection goes untreated, many people will get recurring joint inflammation, with large joints such as the knees becoming swollen, red, and warm.

Antibiotics are still effective even at this later stage of the disease, but if left untreated, some people experience lingering symptoms. In general, these ease up over time, and once treated with a standard course of antibiotics, no further antibiotics are of any help. There is a great deal of controversy surrounding this “post-treatment” or “chronic” Lyme disease. The evidence from many well-conducted studies is unequivocal. Whatever it is that ails people with so-called chronic Lyme disease, it cannot be treated with antibiotics. There is a temptation for people with no clear history of the disease and negative blood tests to blame a wide array of symptoms on “chronic Lyme disease” but despite decades of research, this has never been confirmed. There is an entire medical industry devoted to giving patients with so-called chronic Lyme disease long-term IV antibiotics, and using blood tests that haven’t been validated to make the diagnosis.

It very well may be that people who have been cleared of infection with the Lyme bacteria may experience lingering symptoms, but these do not represent infection and cannot be treated with antibiotics. At this point, the best approach is to look for the proper diagnosis and treat symptoms as they arise.

Prevention is the most important treatment. Avoiding areas where you are likely to be bitten by ticks, limiting exposed skin, removing ticks promptly, and using DEET-based repellants will help protect you.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog at Forbes. His blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.

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Colonized patients (but not infected patients) contaminate the hospital environment

There is a continuous debate in infection control about whether to actively screen patients for multidrug resistant organisms (MDRO) colonization and subsequent isolation. Alternatives to active screening include passive surveillance, where only patients found to be infected through clinical cultures are isolated. Frequently, passive surveillance is justified by saying that infected patients will have a higher bio-burden compared to colonized patients, so they would be more likely to contaminate healthcare workers hands and the environment. However, is this in fact true? Are infected patients more likely to contaminate their rooms than colonized patients?

In part to answer this question, Lauren Knelson and colleagues from Duke and the University of North Carolina just published a study in the July Infection Control and Hospital epidemiology that measured the contamination of rooms after patients colonized or infected with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) were discharged. 48 rooms (33 from colonized patients, 15 from infected patients) were sampled using Rodac plates after patient discharge but before terminal room cleaning. Numerous sites were sampled including sinks, toilet seats, bedside tables, bed rails, chairs, floors, TV remotes, carts, and laundry bins.

This is a very small study, but even with the limited sample size they found that median colony forming units (CFU) were higher in colonized vs infected patients’ rooms (25 CFU vs. 0 CFU, P=0.033). As you can see in the figure, the distribution of room contamination was greatly skewed towards higher levels of contamination at discharge from colonized patient rooms.

There are some caveats. More surfaces were sampled from colonized patient rooms than infected patient rooms (6.52 ± 2.47 surfaces vs 4.07 ± 2.12 surfaces; P=0.02), so it’s possible that surface selection could have biased these findings. And, colonized patients stayed twice as long prior to discharge as infected patients (median 16 vs. 7 days, P=0.28). Even though The P value was greater than 0.05, this could be important since occupied rooms aren’t “terminally cleaned” and “time in room” must increase contamination.

If these findings are validated, they have important implications. First, isolating infected patients (passive surveillance) would be expected to have less utility than expected. Second, the significant contamination of colonized patient rooms prior to terminal cleaning should be a reminder that we need to identify and implement environmental cleaning technologies that work continuously during the patient stay and not just focus on terminal cleaning. Finally, since infected patients would have received effective therapeutic antibiotics, these findings support the idea that effective antibiotics are important adjuvants for infection control. If true, this suggests that as the MDRO crisis expands in the absence of novel antibiotic discovery, infection control will become far more difficult (see 2011-2012 NIH KPC outbreak).

Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.

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QD: News Every Day--GME education should shift to places where patients seek care, report says

A report about a fundamental shift in the way graduate medical education is funded has ACP members taking notice.

The U.S. should significantly reform the federal system for financing graduate medical education (GME) programs because the current methods requires little accountability, allocates funds independent of workforce needs or educational outcomes, and offers insufficient opportunities to train physicians in the health care settings used by most Americans, the Institute of Medicine said in a press release.

The report stated that public financing of GME should remain at its current $15 billion annual level, but Congress should move funding from the teaching hospitals that have traditionally received most of the funding into the clinics or community-based settings where most people now seek care.

Among other reasons for the shift is that physician training slots may be more driven by the needs of the individual teaching hospitals rather than of the populace, the report says. Between 2003 and 2013 there was a disproportionate increase of physicians being trained as specialists despite a greater demand for generalists. Training opportunities are highly concentrated in specific geographic regions and urban areas, and the training system is not increasing the number of physicians willing to locate to rural areas or treat other underserved populations, the release stated.

To encourage training at a variety of sites, funds should be distributed directly to the organizations that sponsor physician training programs including hospitals, clinics, and universities, and the payment methodology should be replaced with a single national, per-resident amount. The committee suggested a 10-year transition period to fully implement its recommendations, because of the complexity of GME education.

ACP members were at the announcement in Washington, D.C., or were following it online, and were tweeting from it:

Tyler Cymet, DO, FACP

Humayun J. Chaudhry, MD, MACP

Susan Hingle, MD, FACP

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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