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

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Monday, June 30, 2008

Medical news of the obvious

Hospitals that are overcrowded and understaffed have less control of MRSA than hospitals that are well-staffed and not crowded, The Lancet Infectious Diseases reports.

And breaking news from Circulation's July 15 issue, courtesy of the Washington Post: Eating veggies, fruit, whole grains and fish is better for your heart and helps you live longer than eating processed meat, French fries and sweets.

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Wednesday, June 25, 2008

More thoughts on obesity

Today's release of CDC statistics on diabetes (24 million Americans with the disease, another 57 million pre-diabetic) has inspired the usual hand-wringing about how obese and sedentary Americans have become. But a Slate article offers an interesting new twist on the discussion, suggesting that the increase in U.S. obesity correlates with increases in women's wages and decreases in the savings rate (and they have graphs to prove it). In sum, the idea is that over the last 20some years, women have been working more instead of cooking and spending all their money on unhealthy restaurant food. The silver lining, then, is that a recession might shrink American waistlines as well as wallets. Of course, the theory doesn't account for the fact that unhealthy, fattening food is often less expensive than healthy alternatives, so that eaters on a tight budget might actually be pushed further down the road to obesity and diabetes.

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Tuesday, June 24, 2008

Obesity...of course

I'm looking through my notes from the Endo conference for any last tidbits that might be useful for blog readers. Everyone's interested in obesity, so I thought I'd share the observations of Daniel Besessen, MD, of the University of Colorado at Aurora, who led a session on "The Year in Clinical Obesity."

He started off by noting that the CDC data from 2001-2003 suggest the rise in obesity over the last several years in the U.S. is slowing... at least for adults.

"Maybe we have reached a plateau" for adults, Dr. Besessen said. "But obesity in children still grows and there will be health consequences as those kids get older. Even a modest increase in body weight leads to an increase in mortality."

The authors of a 2007 article in the New England Journal of Medicine (NEJM) used 2000 data on adolescent obesity for a computer simulation that found that, by 2020, 37%-40% of 35-year-olds will be obese, he noted.

On the treatment side, bariatric surgery and gastric banding have gotten more popular, he noted. That's good news, in a sense, since a 2007 NEJM study found that bariatric surgery decreased an obese person's risk of death by 30% compared to the use of conventional behavioral therapy.

A 2008 Journal of the American Medical Association study, meanwhile, found that gastric banding in diabetics led to remission for 73% of patients, compared to 13% remission in the conventional therapy group-- all of which came about from the weight lost, Dr. Besessen said.

"Bariatric surgery has been shown to have dramatic benefits, and people are moving toward banding," Dr. Besessen said. "The effectiveness and safety of these treatments really depends on the (skill of the) surgeons, however."

And at a session on Novel Factors Contributing to the Obeisty Epidemic, experts tossed out these interesting tidbits:

  • 7.5 hours of sleep is associated with the lowest BMI. More or less than this and the BMI starts creeping up, especially under 5 hours. In part, that's because inadequate sleep leads to an average increase of 24% in one's hunger level-- with people specifically craving fatty and starchy foods.

  • High fructose corn syrup is similar to fat in the way it is metabolized. Fructose consumption is up 30% since 1970, with the average person drinking 56 gallons a year of sweetened soda. Diets high in fructose may cause dyslipidemia and insulin sensitivity, and increase intra-abdominal fat.

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Monday, June 23, 2008

Medical news of the obvious

This week's edition focuses on attempts by medicine to delve into basic human psychology.

Our first exhibit comes from the Endo '08 meeting. A group of pituitary researchers recruited recreational athletes for a test of human growth hormone. Some were given the hormones, some were given placebos, then they were asked to guess whether or not they were taking the real thing. The results: study participants who (wrongly) believed that they were taking hormones improved their athletic performance over the course of the study. Experts concluded that this finding could explain why athletes continue to take HGH even though there's no scientific evidence that it works. Uh, yeah. Or maybe the common assumption that HGH works leads people to attribute their performance improvement to it?

Then, a study in Archives of IM explored why HIV-positive patients participated in a phase III drug trial and found that "individuals participating in a clinical trial hope to benefit personally from the research but also understand they are contributing to society." So, to sum up, people actually have logical reasons--expected benefit either for themselves or others--that motivate them to take banned hormones or experimental drugs. Who knew?

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Thursday, June 19, 2008

Looking for a profitable sideline?

One of the perks of writing for ACP Internist is being on the receiving end of random, tangentially medical press releases, and a stranger-than-usual one came in today.

Acccording to the release, an orthopedic surgeon from Nevada was performing a trauma surgery when he noticed that the reconstructive plate he was using could be made into "an awesome ring." After he started wearing his home- (or hospital?) made jewelry around, patients and colleagues wanted their own. So now, at the Hard Rock Cafe of all places, Dr. Mike Crovetti is selling jewelry modeled on reconstructive plates. (At least, we're assuming the earrings, bracelets and rings are replicas, rather than leftover surgical supplies. Although, wait, that might be an idea--another option for reducing hospital waste.)

Targeted customers include extreme athletes who want bragging rights about the crazy injuries they've brought on themselves, the release said. No word on whether you get a discount if the hardware comes from your own joint re-replacement.

And if you really must know more, here's a link to the Web site.

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Wednesday, June 18, 2008

Endo '08: Counseling patients about weight loss

Here's how Daniel Bessesen, MD, of the Univ of Colorado in Aurora, recommends dealing with patients who say they want to lose weight.


  • Try to understand what the patient wants, and tailor your approach to that. Some want help with diet and exercise, others just want to take medication. Tell the patient his/her options are to either accept his/her current weight, to diet, to take drugs, or to have surgery. Also share the success rates of these approaches. Weight loss from diet/exercise is usually about 3-5% of current weight, drugs is 5-8%, and surgery is 3%,
  • Consider how heavy the person is in considering whether a modest (like diet) or more serious (like surgery) approach is best. Also consider co-morbidities.
  • If the patient decides to opt for changing his/her diet, send to a nutritionist if possible. Other options are meal replacement programs (like Slim Fast or Lean Cuisine), commercial programs like Weight Watchers, and Internet diet programs. There isn't much data on Internet programs yet, but there is quite a bit of data supporting the effectiveness of meal replacements.
  • Keep circling through the patient's four options if he or she is resistant to your ideas. If, for example, a patient says she hates her weight but doesn't want to diet, then says she doesn't have time to exercise and that medications and surgery are too expensive, say "Well, it sounds like you want to accept your weight, then?" If she says no, then bring up the option of changing her diet again. This tactic works.

...and that concludes our on-site coverage of Endo '08. Hope you enjoyed it half as much as I did!

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Behind the scene: a cartoonist speaks

Today's guest post comes from cartoonist JC Duffy, one of the two artists who comes up with the scenes for which our readers create captions. We asked him for his reactions to our latest contest, which appeared online in February's ACP InternistWeekly e-mail newsletter and then in our print edition.



"Our anesthesiologists are on strike."

JC says:
When I create my own cartoons, I generally think of a gag first, and then illustrate it. Although once in a while I'll do it the other way around. For me, the latter is harder than the former, and usually when I see The New Yorker's caption contest drawing I'm stumped as far as a punchline. And when I see the winning entry later, I think, "Of course. How obvious!"

Being a New Yorker cartoonist myself, I've submitted drawings for their caption contest. What I try to go for is something that's visually incongruous, throwing things together that don't usually go together. And since I'm not the one who has to come up with the caption, I can get as crazy as I want. When a cartoon is driven by a good verbal gag, you can have that gag delivered by one person talking to another person at a bar, or whatever. But you can't get away with that in a caption contest. The image needs to be more striking, surprising or evocative, and make the reader wonder what the heck is going on in the picture.

Other than making a caption as concise as possible, I really know of no formula for creating a funny cartoon. After doing it for many years, it's still largley a mysterious process to me.

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Endo 08: Rats 1, Birds 0

Here are some interesting endocrinology findings from the animal world, courtesy of a session this morning by David Crews, PhD, a professor of zoology and psychology at UT-Austin:

Male starlings that were fed mealworms pumped with endocrine-disrupting compounds had a more elaborate song repertoire once mating season rolled around, which in turn made them more attractive to female starlings. That's all good, right?

Not really, because thes males were also found to be immuno-compromised, which means there's a pretty good chance their offspring would be, as well.

The good news, though, is that rat studies have shown female rats can actually discriminate (I believe by smell, but I'm not sure on this point) between those male rats that are immuno-compromised and those that aren't, and they prefer to mate with the latter.

Er, I mean, I guess that's good news, if you prefer rats to starlings.

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Tuesday, June 17, 2008

Endo 08: What to do about HRT in menopausal women?

Kathryn Horwitz, PhD, of the Univ. of Colorado Health Science Center, gave a fascinating talk today on "The Year in Hormones and Cancer."

As everyone knows, the WHI showed years ago that HRT increased the risk of breast cancer (though the numbers were small), and that the greatest risk seemed to be for women who were within five years of the start of menopause.

This is "disconcerting," Dr. Horwitz noted, since the effect of HRT on CVD is the opposite-- the further away from the start of menopause one is upon taking HRT, the greater the risk of CV problems.

What to do, then?

That's up to you. But if your patients are gonna use HRT, they should stick to transdermal applications and use the lowest possible dose, since research has found the direct delivery of HRT (as through a skin patch instead of an oral med) may decrease the risk of breast cancer.

And, she advised, don't use HRT at all with breast cancer survivors.

Why? Because research indicates that tumor cells stick around in women who had breast cancer and mastectomies up to 22 years after the mastectomy, even if there are no overt symptoms of the disease.

And-- get this-- one study in which researchers did autopsies on women who did NOT die of breast cancer found that about 10% had evidence of dormant cancerous cells. And 82% of those wouldn't have been detected on a mammogram.

Dr. Horwitz's theory from all this is that HRT doesn't actually cause new cancer cells to develop; instead it activates a reservoir of occult, silent disease cells in some women, and reactivates the dormant cells of breast cancer in others.

The good news is that she thinks this activation can be avoided or mitigated by using local delivery methods of HRT.
And she thinks she'll have a paper out in the next few months to help prove it.

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Endo 08: Weight loss fairy dust

In the future, you'll be able to sprinkle a magical powder on your food that will help you lose weight.

Scratch that. The future is now, and this magical formula is already available for the low low price of $210, thanks to Alan Hirsch, MD, neurologic director of the Smell and Taste Treatment and Research Foundation in Chicago. Dr. Hirsch presented the results of a study testing his magical weight-loss powder during a press conference here.

He says his study found that (surprise!) overweight and obese folks who flavored their food with calorie-free seasonings and sweeteners called "tastants" were more successful at losing weight than those who didn't use the tastants.

The 2,436 subjects put salt-free savory flavors on salty food and sugar-free sweet crystals on sweet or neutral foods. The"salty" flavors were cheddar cheese, onion, horseradish, ranch dressing, parmesan or taco, while the "sweet" flavors were cocoa, spearmint, banana, strawberry or malt. A control group of 100 didn't use tastants, and both groups were allowed to diet and exercise if they were already doing so.

After 6 months, the 1,436 subjects who finished the study lost an average of 31 pounds, vs. the average of 2 pounds lost by the control group. The BMI reductions were five vs. 0.3, respectively. Dr. Hirsch said he thinks tastants make people feel full faster and thus eat less and/or that the crystals make bland healthy food, like tofu and certain veggies, taste better-- which makes it easier to stick to healthy eating.

You can buy the powder online-- $210 gives you a six-month supply. The PR staff of the Endocrine Society tested a free sample on an apple mere minutes ago and report that it tastes pretty good. (None of them have lost weight in the last five minutes, however.)

If $210 is a bit rich for your blood, take Dr. Hirsch's alternate advice on how to use your senses for weight loss:

"Sniff your food before you eat. Chew it a lot."

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Endo 08: Forecast? Unprepared.

Success can be found in the most unexpected places. Like Walgreen's.

Allow me to explain. Many conference attendees, including me, were caught off guard by the cold and windy front that swept into SF on Sunday and Monday. (The high temperature Monday was 54 degrees. Without the windchill.) I saw several ENDO-badged brethren wandering the floors of the department stores near the convention center looking for warm clothes as they (and I) shivered in lightweight suits. Personally, after going to six stores, I could find only a gold hooded sweatshirt suitable for a 13-year-old, and a winter coat "on sale" for $300 at Macy's.
Then, on a side trip to Walgreen's for toothpaste, I hit upon a bonanza of toasty, affordable sweatshirts and jackets for tourists.

So if you someday find yourself at a conference in SF having a Mark Twain moment (he's the one who said his coldest winter was a summer in SF), you now know where to go to warm up. As long as you don't mind wearing a Giants jacket in front of your colleagues.

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Endo 08: Hot topics in reproductive biology

I sat in on an informal session with Kelly Mayo, PhD, a reproductive biologist at Northwestern University in Chicago, yesterday. He and the audience came up with a list of the hottest topics in reproductive biology at the moment, as well as the topics that represent the next frontier for research. Here are some of the ones they came up with:

Hot topics currently: PCOS, the ethics of reproductive science (stem cells, cloning, etc), endometriosis, circadian rhythms, diabetes in pregnancy, ovarian cancer, germ line stem cells, early puberty, hypertension in pregnancy, STDs, endocrine disruptors, orphan receptors.

The next frontier: the immune system role in reproduction, fetal/maternal interaction issues, gamete biology (i.e. what is a high-quality sperm or egg?), ovarian follicle formation, epigenetics in development, novel contraceptive options, reproductive cancers, regulation of meiosis, oocyte preservation, reproduction and metabolism.

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Monday, June 16, 2008

Endo 08: The role of exercise in weight loss

Conferences are a hotbed of divergent opinions on the same issue, which is one of the things that make them so exciting.

Today, there was a press conference (which I skipped to attend the session I just blogged about) about how 3 months of aerobic exercise decreased body fat and caloric intake in overweight and obese folks. Researchers think that changes to a CNS factor are the reason; they spotted increased levels of a protein that they think suppresses appetite.

A reasonable hypothesis might be that exercise inhibits appetite, which helps people eat less, and thus diet plus exercise work in tandem to help people lose weight.

Yet just yesterday, Daniel Bessesen, MD, of the Univ of Colorado in Aurora told an audience that if their patients really want to lose weight, the key is diet, not exercise. He said that, to lose weight, a person needs about a 500 kilocalorie deficit each day compared to her current diet, and that's really difficult to achieve through exercise. Exercise, he noted, has great health benefits and is helpful for maintaining weight...but it's not going to get those initial pounds off unless the person also diets.

Further, he said, past research has shown that the amount of weight a person loses from dieting, compared to dieting plus exercise, is pretty much the same. Exercise has the advantage of preserving lean body mass-- which may or may not be important to patients.

What do you think? Any internists out there want to share the weight-loss strategies that worked (or didn't) for their patients?

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Endo '08: Hypoglycemia in diabetes

A session on "Innovative Strategies for Prevention and Treatment of Hypoglycemia in Diabetes," by Stephen Davis, MD, was so packed that there was a horde outside the room watching the lecture on a TV screen, and a staffer blocking the door so no one else went in the room ("The fire marshall will have our heads," she said.)

The upshot was that there are multiple approaches under investigation that aim to amplify counterregulatory responses during hypoglycemia. Various recent studies, which point the way for future research and treatment, have found:

  • Patients who were given troglitazone for 7 days had increased glucagon.
  • Fructose significantly increases epinephrine and endogenous glucose production.
  • After 7-days, caffeine-replete patients had significantly improved hypoglycemia awareness and response.
  • Oral ingestions of amino acids for hypoglycemia can increase glucagon responses during hypoglycemia.
  • SSRIs can progects against the deletrious effects of hypoglycemia. Non-depressed type 1 diabetics who took fluoxetine saw dramatic increases in norepinephrine and epinephrine , and their muscle and nerve activity also significantly increased.

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Overtime linked to anxiety and depression

Employees who work overtime are at increased risk of anxiety and depression, suggests a study conducted by researchers at the University of Bergen, Norway. They used a questionnaire to test for symptoms of anxiety and depression among 1,350 workers who worked 41 to 100 hours per week, compared to about 9,000 workers who worked 40 hours or less.

Men and women suffered equally when it came to longer hours. "Possible" depression increased from about 9% for men with normal work hours to 12.5% for those who worked overtime. For women, possible depression increased from 7% to 11%. Men working more than 48 hours per week are at highest risk, although the authors noted that working even moderate overtime seems to increase the risk of "mental distress."

The relationship between overtime and anxiety/depression was strongest among men who worked the most overtime--from 49 to a whopping 100 hours per week. There was no word on when these workers found the time to respond to a survey, let alone seek treatment.

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Medical news of the obvious

The National Poll on Children's Health reports that parents actually worry about their 11-13 year-old kids when they leave them home alone!

Here's the part that is not obvious: Parents worry more about their kids giving out personal information online or not knowing what to do during a severe weather event than they do about their kids playing with guns or using the oven in their absence. Hmm.

The Washington Post also reports that motorcyclist head injury deaths are up 32%, and head injury hospitalizations are up 42%, in Pennsylvania since that state repealed its law requiring all motorcyclists to wear helmets.

And last, a gold mine from SLEEP 2008, the annual meeting of the Associated Professional Sleep Societies, in Baltimore. (Stories courtesy of the Washington Post):

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Sunday, June 15, 2008

Endo 08: Diabetes gender gap

As soul icon James Brown told us, "This is a man's world."

Ioanna Gouni-Berthold, MD, can attest to that: her new study of almost 45,000 type 2 diabetics shows women with comorbid heart disease get less intensive medical treatment for, and have poorer control of, their diabetes and heart disease than comorbid men. Specifically, the women were 44% more likely than men to have high LDL, yet 15% less likely to get lipid-lowering medication. The women were also 19% more likely to have uncontrolled high BP, and 15% more likely to have poor long-term control of their blood glucose level.

These findings may explain why death from heart disease has decreased among diabetic men in the past 25 years, but it hasn't decreased for diabetic women, said Dr. Gouni-Berthold, a professor of medicine at the University of Cologne in Germany.

...A second study unveiled here found that it's important to stress exercise in type 2 diabetic men, no matter what their body type. That's because maintaining a moderate fitness level can reduce the risk of death by 40-50% for diabetic men, even if they are obese or overweight.

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Endo '08: Father's day edition.

Nothing like kicking off a convention with a press conference called "Sexy Sex Findings."

Aksam Yassin, MD, briefed reporters on a study that suggests internists should look carefully at male patients who show up in their office complaining of ED. These patients often have testosterone deficiency, diabetes, high BP and/or dyslipidemia, his study found, yet many of the patients are unaware of their problems. ED can thus be the gateway to finding and treating these issues, said Dr. Yassin, who is from the Clinic for Urology and Andrology of the Segeberger Clinics in Norderstedt, Germany.

And now a little something for the ladies, as they say. Michael Snabes, MD, VP of clinical development at BioSante Pharmaceuticals, spoke about a planned study to test LibiGel, a testosterone treatment for low sexual desire in menopausal women. (Libido + Gel. Get it?) The study is examining CV and breast effects. If all goes well, the gel is expected to be available in 2011 for women age 50+ years. Mr. Snabes declined my offer to speculate on how much it might cost.

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Endo 08: Ill-advised session titles

I'm at the Endo '08 conference in San Francisco this week, which means it's time for another round of Ill-Advised Conference Session Titles. Without further ado:

Female Reproduction: Follicle follies in the ovary

Male Sexual function: Turning it on, off and keeping it alive

and my favorite:

The Thyroid & the Heart: A Lifelong Intimate Relationship.

...Feel free to vote on your favorite!

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Friday, June 13, 2008

Overcompensating for our mistakes?

In a very strange and hilariously funny article, today's New York Times describes a new program in Japan to measure every citizen's waistline and impose financial consequences on companies and cities that have too many overweight people. It's not clear how or why, but apparently the Japanese have become obsessed with the idea of metabolic syndrome as a driver of health care costs (to the point of writing songs about it), even though the country's population is generally slender. In the article, one critic astutely notes that the program might be better suited to the U.S., where obesity actually is an expensive and pervasive problem. Hard to imagine Americans lining up for waist measurements and singing cheers about dieting, though.

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Skin patch targets common vacation spoiler

You can get one for motion sickness, so why not have one for diarrhea? The Lancet reports that a new vaccine skin patch appears to prevent or reduce the severity of traveler's diarrhea.

Phase II study participants were vaccinated with two patches (given 2-3 weeks apart) before travelling to Mexico or Guatemala. Half got patches with heat-labile enterotoxin from Enterotoxigenic Escherichia coli (ETEC), and half got placebo patches.

The lucky participants then got to track their stool output on cards during their vacation.....and, if they got diarrhea, to collect samples. What fun!

But it appears their sacrifice will benefit the rest of us: 21% of placebo patients had moderate to severe diarrhea, compared to 5% of vaccine patients. For severe diarrhea, it was 11% with placebo vs. 2% with vaccine. And those with the vaccine had diarrhea for just half a day vs. two days for the placebo folks.

The patch still needs to go through a Phase III study, of course, and isn't expected to be available until 2011, the Washington Post reports. Plan your vacation destinations accordingly.

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Wednesday, June 11, 2008

The hardest conversation

The perceptions of patients who are nearing the end of life seem to be a hot research topic right now, at least over at JAMA.

Last issue, a study ran which concluded that "ambulatory patients with heart failure tended to substantially overestimate their life expectancy compared with model-based predictions for survival." Initially, the research seemed to us to verge on the obvious. Why torment these people in their last days by eliciting their overestimates about survival? Isn't another way to describe those "overestimates" actually "hope"?

But a case study of end-of-life chemotherapy, in this week's JAMA, delves a little further into the issue. The authors claim (and they use both research and individual anecdotes to back this up) that physicians frequently fail to adequately explain the likelihood of survival to patients, and even if they do, patients often misunderstand. These misunderstandings (or overestimates), in turn, cause the patients to choose care that is not in their best interest (i.e., more chemo over hospice).

As for our concern about hope, the authors shoot that one down firmly but briefly. "No data are available that show hope can be taken from patients," they say. Good to know, but perhaps a bit more explication on this issue would be helpful.

The article does offer more detail, and what seems like useful advice, about how to talk to patients and how to work in conjunction with palliative care physicians.

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Tuesday, June 10, 2008

Debt causes stress, which causes everything else

Debt causes stress, which is causing the common health complaints that are the bread and butter of a busy internal medicine practice.

There's certainly more people worrying about the economy, but does that really mean internists will see more patients? An AP-AOL Health poll suggests so.

The AP consulted with Paul J. Lavrakas, a research psychologist who created an index to measure how much people are stressed by debt. He analyzed the poll's results and suggested that the estimated 10 million to 16 million people with debt could have health problems.

Look at the symptoms that arise: digestive tract problems or worse pain from ulcers, migraines and headaches, anxeity and depression, muscle tension or low-back pain, and double the rate of heart attacks. They're what internists deal with daily, and are all linked to the fight-or-flight response to stress that, if it lingers, can affect everything about the body.

What's really stressful is that Mr. Lavrakas reported a link between credit card debt and health eight years ago, in what seems now like a serene economy that was pre-9/11, pre-tech bubble and pre-housing crisis.

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Monday, June 9, 2008

Medical News of the Obvious

A new study, published in Nature, finds that humans, instead of foraging over large areas for food as they did in millenia past, now spend most of their time in two primary locations. To determine this, scientists used cell phone towers to track the movements of 100,000 people.

Explained a study author to the Washington Post, "We can't say for certain exactly which location people are going to. But we assume, of course, that the two preferred locations are a person's place of work and their home." A news story from the journal adds the additional groundbreaking information that people "pepper these [commutes] with occasional longer forays such as vacations."

Um, do you really need a PhD in physics and an elaborate (and potentially privacy-invading, according to some commenters) study to figure out that people work, go home and take vacations?

Meanwhile, a study in Clinical Psychology: Science and Practice reveals that obesity and depression may be connected. It seems depressed people have a hard time eating well and exercising because, uh, they are depressed, so that leads to obesity.

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Friday, June 6, 2008

Talk to your patients about alternative medicine

The NIH has launched an educational campaign to encourage providers and patients to talk with one another about the use of complementary and alternative medicine (CAM). The campaign, called Time to Talk, offers the following tips for providers:

-- Include a question about CAM use on medical history forms.
-- Ask patients to bring a list of all therapies they use, including prescriptions, over-the-counter, herbal therapies, and other CAM practices.
-- Have medical staff initiate the conversation about CAM.

Nearly 2/3 of people age 50+ use some form of CAM, yet fewer than 1/3 of them discuss it with their providers, an NIH survey found. The most common reasons were that the doctor didn't ask, that patients didn't know they should discuss CAM, or that there wasn't enough time during the office visit.

Tools and resources about CAM, including wallet cards, posters and tip sheets, are on the NIH Web site.

An article with advice on talking to your patients about CAM ran in the November ACP Observer.

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Wednesday, June 4, 2008

Camera pills get remote control

It's impressive enough that scientists have developed tiny pill-size cameras that allow physicians to view images inside a patient's intestine--now, in the not-to-distant future those cameras may come with remote control, allowing physicians to steer and stop the device as they would a vehicle.

Currently, patients can swallow a camera--the same way they would a hard candy--which transmits images to an external receiver attached to a belt worn by the patient, allowing the physician to identify any hemorrhages or cysts. But until now there has been no way to control the camera's speed as it travels through the esophagus to the stomach. Thus, patients with potential problems in the esophagus or stomach still have to swallow a thick endoscope.

Now, those hard-to-get images are within reach, according to researchers from the Fraunhofer Institute for Biomedical Engineering in Sankt Ingbert who developed the idea and are working to refine it with engineers from the manufacturer Given Imaging, the Israelite Hospital in Hamburg and the Royal Imperial College in London.

“In future, doctors will be able to stop the camera in the esophagus, move it up and down and turn it, and thus adjust the angle of the camera as required,” said research team leader Dr. Frank Volke, in a news release. “We have developed a magnetic device roughly the size of a bar of chocolate. The doctor can hold it in his hand during the examination and move it up and down the patient’s body. The camera inside follows this motion precisely,” Dr. Volke explained.

Researchers have already tried out a prototype on themselves and reported that the camera passed the test of staying in the esophagus for about 10 minutes, even if the patient is sitting upright.

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Tuesday, June 3, 2008

How to win at our cartoon caption contest

Slate has dissected ways to win The New Yorker's cartoon caption contest. I'll tell you how to win ACP Internist's.

ACP Internist didn't really break new ground when it developed the cartoon caption contest and let readers vote online for the winner. Our six original cartoons had captions! We stripped them out when we started to brainstorm funny lines and decided that our readers would have just as much fun. Our cartoonists have also drawn for The New Yorker! Heck, other medical publications have caption contests too, although the readers don't get to vote.

The Slate article details ways to win. In short, appeal to the gatekeeper; follow the "theory of mind"; and use simple words and few, if any, proper nouns. The same advice applies to ACP Internist staff.

To appeal to our gatekeeper, it's tougher. At The New Yorker, a lone staffer picks though all the entries and narrows them down. At ACP Internist, there's five of us and we vote democratically on three finalists. Demographically, we're in our 20s through 40s. Two of us hold master's degrees and a third has one in progress. We're all journalists, although from a wide variety of backgrounds and experiences.

The New Yorker entries overwhelmingly follow the theory of mind, which the Slate article explains very well but can be summarized as making a funny scenario out of the intent of one of the characters. We have that, but we're not above the simple pun when we have to, as you can see here and here.

Finally, The New Yorker winners phrase their entries simply, and that's usually what we pick up on when we screen entries to put forward to a vote. We don't pick obscure diseases. Other ideas are funny but invariably don't make the final cut because it took a paragraph to explain the gag.

Ultimately, though, it's our internist readers who decide the final winner. Let us know what you find funniest.

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Confirming our suspicions

The whole country--ok, those of us who pay a lot of attention to health policy--has been waiting to see the results of Massachusetts' experimentation with mandatory health coverage. Now, the results of a study of the program (explained in this New York Times article) so totally confirm everything that the College has been saying about the uninsured, it sounds like one of our advocacy papers.

First, the good news...the study found that the newly available, affordable coverage reduced the ranks of the uninsured by half, bumped up the use of preventive care, and did not cause employers to drop coverage.

BUT, the article says, "Undercutting the positive trends for Massachusetts are signs that the state's supply of primary care physicians is not sufficient to handle the increased demand created by newly insured residents." The study found that although overall fewer people are going without needed care, inability to find a doctor is becoming a more common reason for not receiving care.

It's uncharitable to say "I told you so," but did we tell them or what?

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Patients as partners

The old paradigm of the patient waiting passively for their doctor's expert instructions is gradually eroding. A recently published analysis of 11 randomized controlled trials lends credence to that assumption, concluding that shared decision making (SDM) often leads to better outcomes.

Would anyone dispute that patients benefit from knowing what's going on? Perhaps not, but hard evidence was lacking, according to the study published in the fourth 2008 issue of Psychotherapy and Psychosomatics.

SDM--when patient and physician act as partners sharing in decisions about treatment preferences and choices--is particularly effective for long-term decisions involving chronic illnesses, according to the study. The authors stopped short of endorsing SDM as the best approach in all treatment situations, saying more research is needed.

The medical evidence may be lacking but common sense says that you can't go wrong by keeping patients in the loop.

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Monday, June 2, 2008

Medical News of the Obvious

Groundbreaking research from the University of New Hampshire:

Parental Involvement Strongly Impacts Student Achievement

But HOW does it impact achievement, you ask? Well:

"Researchers... found that parental involvement has a strong, positive effect on student achievement." (italics mine)

Seriously, though, this part is kind of interesting:

"Parents seemed particularly interested in the academic achievements of their daughters. The researchers found parents spent more time talking to their daughters about their schoolwork during dinnertime discussions"...possibly because girls are more communicative, the researchers said.

...And one from the
Archives of General Psychiatry that isn't grossly obvious, but was strongly suspected:

Long-Term Cannabis Users May Have Structural Brain Abnormalities

The amygdala (fear and aggression) and hippocampus (emotion and memory) tended to be smaller with heavy cannabis users, the study found.

So smoking pot might, say, make a person paranoid? And/or forgetful?

I guess Hollywood gets some things
right, after all.

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Blog keeps track of all those guidelines

A new blog could help internists stay on top of the hundreds of major guidelines, position statements, meta-analyses, systematic reviews and articles offering by agencies, organizations and journals. Evidence Alert compiles them to a single page, and will even push links to your RSS feed reader.

As evidence how much this service is needed, Evidence Alert compiled 110 guidelines and reviews in May alone.

A second blog lists health literacy and patient communication issues.

The LSU Health Sciences Center Medical Library hosts the blogs, which grew out of work by Julie Esparza with hospitalists at Deaconess Health System and continues through her position as clinical medical librarian LSUHSC-S.

To sign up go to http://lsuhsc-sevidencealert.blogspot.com and click on RSS feed orange button.

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Contact ACP Internist

Send comments to ACP Internist staff at acpinternist@acponline.org.

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.

Auscultation
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.

DrDialogue
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.

FutureDocs
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.

KevinMD
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).

Prescriptions
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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