Thursday, July 31, 2008

Alzheimer's, Alzheimer's, and more Alzheimer's

The International Conference on Alzheimer's Disease is happening this week in Chicago, and not surprisingly, there's a lot of news coming out of it about Alzheimer's. A quick run-down of the findings:
  • Several lifestyle factors have been found to relate to the development of dementia. Living alone in middle age increases your risk, but ruminating about things (like your single status, perhaps?) decreases the risk. Metabolic syndrome (which the Alzheimer's Association press office apparently considers a lifestyle factor) also increases risk.
  • Studies at the conference indicated some promising new avenues for early diagnosis of the disease, including tests of blood, spinal fluid, brain enzymes and PET scans.
  • Of course, early diagnosis doesn't help much without a treatment. Researchers reported a variety of successful drug trials, almost all in Phase II.
  • Another study found that insulin and diabetes drugs might treat/prevent Alzheimer's. Although diabetes has been shown to increase risk for the disease, patients who were on both drugs and insulin had fewer brain lesions than nondiabetics.
  • And, in studies almost worthy of Medical News of the Obvious, researchers found that communicating with Alzheimer's patients in babytalk makes them angry and that exercise is good for you.
Wednesday, July 30, 2008

How do you pick a dermatologist?

So dermatology isn't a specialty particularly known for self-sacrifice and lack of interest in income (it is part of the ROAD, after all), but this New York Times article raises concerns that some dermatology practices are heavily prioritizing cosmetic patients over medical ones. An expert in the article suggests that concerned patients choose a dermatologist who focuses on medical, not cosmetic, problems, but presumably many patients rely on their primary care docs for a referral. Is the balance between cosmetic and medical practice something you think about when recommending a dermatologist? For now, this issue seems to be limited to a few specialties, but what happens if more internists turn to profitable self-pay sidelines (a trend we profiled a little while back)?
Tuesday, July 29, 2008

Deflating overblown health scares

Finally, some good news--or at least a good opinion. New York Times science blogger John Tierny came up with 10 Things to Scratch From Your Worry List, including health related items such as killer hot dogs, cancer-causing cell phones and BPA-laden baby bottles.

And it's all backed up by evidence-based studies meant to debunk what you've assumed was true all along. He found more references to non-ionizing radiation and cancer than I knew about (James Thurber's grandmother?!?). If you can think of other overblown health scares, share them here.
Monday, July 28, 2008

Teach a man to fish

It can be frustrating at times to balance all the competing info on what you should and shouldn't eat. Case in point: A new study in the Journal of the American College of Cardiology found that Japanese men realize cardiovascular benefits from eating a lot of fish. So o.k, their arteries aren't as clogged, but how are their mercury levels? What kind of fish did they eat? Does Japan even have the same issue with mercury as the U.S.? And if we all eat fish, what about the whole problem of over-fishing the waters?

Sigh. Maybe someday we will just get our food from nutritionally-balanced pellets.

And the most depressing study award goes to...

As if dieting and exercise to lose 10% of your body weight weren't hard enough, a new study finds that overweight/obese women may need to exercise almost an hour a day, five days a week, simply to sustain that weight loss. AND, they must do that in addition to continuing to limit their calories.

It seems to me this could be a seriously de-motivating piece of news for someone who has just begun a program to lose weight. Doctors, what do you think? Is it best to share this piece of information about weight-loss maintenance with patients right off the bat, or wait until they've lost some or all of the weight before you hit them with the news?

Medical News of the Obvious

Only one lone Obvious candidate this week, but it's a good one:

Someone did a study to come to the stunning realization that people who attend AA are more likely to drink coffee and smoke cigarettes than the general population.
In other words, people who are in treatment for an addictive behavior are actually more likely to have other addictive behaviors.

Ok, to be fair, the study's authors already knew that people in AA tend to like their joe 'n' smokes, but wanted to quantify the difference between AA and non-AA folks. Also, they wanted to delve into the reasons people like these substances. Here's one theory, put forth by the study's corresponding author:

"Is this behavior simply a way to bond or connect in AA meetings, analogous to the peace pipe among North American Indians?"

Ah, yes, the Peace Pipe Hypothesis. Perhaps we'll be treated to a follow-up study....
Thursday, July 24, 2008

Guidelines aim to clarify treatment of pre-diabetes

The American College of Endocrinology last week issued its first guidelines on managing patients with pre-diabetes, suggesting aggressive lifestyle control as the first line of defense in warding off full-blown disease, followed by selective drug treatment and frequent monitoring of symptoms.

The guidelines recommend prescribing metformin or acarbose to high-risk patients, such as those with cardiovascular disease or worsening glycemia; statins to lower LDL cholesterol to 100 mg/dL; and ACE/ARB inhibitors to reach target blood pressure of 130/80 mmHg. Patients should undergo glucose and microalbuminuria testing annually and have fasting plasma glucose, hemoglobin A1C and lipids tests every six months, the guidelines state.

Physicians often have little success getting patients to embrace lifestyle changes, such as following a low-fat diet and exercising daily, as recommended in the guidelines. Will the new recommendations encourage more use of medications to control symptoms in patients at risk for diabetes? What are you doing in your practice?

Tuesday, July 22, 2008

Viva Viagra....for Ladies?

JAMA just issued a press release about a new study showing that sildenafil-- i.e. Viagra-- helps reduce sexual dysfunction in women on antidepressants (for whom such dysfunction is a common side effect.)

My first question, naturally, is: How are they going to modify for women those cheesy "Viva Viagra" commercials that are now geared toward Boomer males with sterotypical tastes in Harleys, saxophone rock and women 10 years younger than them? What will be the female analogue to the cartoon devil's horns that sprout from the men's heads when the Viagra kicks in?

You can bet yourself a round of Cosmos they aren't going to call it Viagra For Women.

Anyone have any ideas on how they might market this to the fairer sex?
Monday, July 21, 2008

Medical News of the Obvious

A diagnosis of heart disease darkens a person's outlook on life, a new government study finds. Adults with cardiovascular trouble scored up to 9% lower on four scales measuring their quality of life, according to a report in the July 15 issue of Circulation, from researchers at the U.S. Centers for Disease Control and Prevention. (Source, Washington Post.)

Women are more likely than men to seek tattoo removal because they are more likely to be subject to societal fallout from the tattoos, the Archives of Dermatology reports. (So women's appearances are scrutinized/criticized more than men's? No way!) People get tattoos to feel unique and independent and remind themselves of life experiences, the study says. The reasons for removing were "just deciding to remove it" (58%), suffering embarrassment (57%), lowering of body image (38%), getting a new job or career (38%), having problems with clothes (37%), experiencing stigma (25%) or marking an occasion like a marriage (21%).
Friday, July 18, 2008

Wine instead of an apple as gifts for doctors

The Wall Street Journal's "Tastings" blog highlighted what it feels is the common practice of grateful patients offering their doctors bottles of wine. Highlighted was William Shay, ACP Member, who enjoyed one patient's vintage given as a wedding gift, and is aging another patient's Opus One 1999.

The column details other physicians' favorite gifts and memories of the patients and family members who gave them. It even outlines some rules for offering wines as gifts (be thoughtful, make the selection as individual as a handwritten note, and avoid MD 20/20 for ophthalmologists).

In case you were wondering, ACP's ethics manual is OK with small thank you gifts that don't result in favored treatment. Clinical research hasn't been definitive about wine's potential harms and benefits, but the many studies published in the Annals of Internal Medicine are worth perusing (with glass in hand, if desired).

What's your favorite bottle, and why did the patient give it?

Pacemakers for centenarians

An article in today's New York Times discusses a now-104-year-old woman who received a biventricular defibrillator when she was 99 (after being rejected by one cardiologist for the operation). We've covered the ethical debate over dialysis for the very elderly, but the general dilemma of interventions for the oldest patients seems likely to become a bigger issue as more people enter that age range. How do you make determinations about their likely quality of life? (The woman in the story's very happy just to be alive, but lots of people wouldn't feel that way about being so incapacitated.) Can you apply a standard of cost-effectiveness to these decisions? (There are certainly many ways that the $35,000 Medicare spent on her operation could have been used to sustain more healthy life-years.) Who should decide this--patients, docs, insurers?
Wednesday, July 16, 2008

Amid Medicare debate comes mandatory e-prescribing

Included in this week's passage of Medicare payment updates was a carrot-and-stick mandate that doctors electronically prescribe drugs. Starting next year, physicians who do e-prescribe will recoup 2% of their entire Medicare billing component, which some back-of-the envelope math shows could average $4,000. By 2012, though, those who don't e-prescribe face penalties starting at 1% in 2012 and rising to 2% by 2014.

Prescription volume is expected to grow to 4.1 billion by 2010, according to a report by the eHealth Initiative. But the vast majority of docotrs don't e-prescribe today, with only about 2% of all prescriptions getting to the pharmacy electronically.

Doctors don't have good options when trying to adopt e-prescribing systems. Free systems are out there, but these have come and gone in the past decade, with the companies often going out of business. ACP recommends against standalone e-prescribing systems, saying the real benefits come from functions available to fully functioning electronic health records. But such systems cost tens of thousands of dollars per physician to implement, and setting up systems set back doctors for months, as article in Annals of Internal Medicine and ACP Internist point out.

One option that may become popular is hospitals that offer Web-based systems to doctors. The federal government has specifically exempted hospitals from Stark II kickback regulations when they offer EHRs. The systems can be Web-based, requiring no extra hardware or software, and hospitals can then extend tech support to users.

Has your hospital contacted you? Would you accept an offer if it came?

Drugs going to the dogs

Drug sales are down. People are opting for generics over more pricey brand names and the FDA approval process has gotten tougher. So what are ailing drug companies to do? According to a cover feature in last weekend's New York Times magazine, pets are the next frontier.

Does Fido stare miserably out the window when you leave for work? Does Spot, like the dog featured in the article, obsessively chase his tail? A dose of Clomicalm, drugmaker Novartis' canine version of Anafranil, a tricyclic antidepressant, may calm his nerves. Eli Lilly's Reconcile, (Prozac for dogs), is also being billed as a remedy for separation anxiety while Pfizer's Anipryl may help absent-minded dogs remember important facts such as the location of their food dish.

Nice to know but I'll pass on the drugs for my excitable, emotional, run-around-like-crazy (but endearing) spaniel.
Tuesday, July 15, 2008

Is there a web cam in your future?

Evisits--they come up in every lecture about the future of medicine (because patients love the idea of not having to leave home or work to get medical care), but no one seems to have come up with a plan that's really feasible for widespread implementation.

A couple of months ago, we profiled a few effective uses of telemedicine, all of which involve trained providers on both ends of the web cam. One interesting application of the technology that didn't make the story (because we couldn't get anyone from there to talk to us) is the Health-e-station, which purports to be a totally self-serve health care walk-in center. But now, Medical Economics reports that a new online marketplace is trying a more expansive effort, offering physicians and patients from across the country the chance to connect online and have web-only consultations and relationships. It's still a little hard to picture how this will work...will your patients soon be contorting themselves over their Macbooks to give you a clear shot of their nasal passages?
Monday, July 14, 2008

Medical News of the Obvious

Parents of twins report more anxiety and sleeping difficulties in the year after birth than parents of single children, according to a study presented at the 24th annual meeting of the European Society of Human Reproduction and Embryology (via Science Daily). I wonder why?

Another news flash for parents: teenage girls are susceptible to peer pressure! A study published online by the Journal of Youth and Adolescence found that peer groups have a major influence on teen girls' body image. While that part's a no-brainer, the authors did have some interesting findings about which peer groups exert particular influences. For example, 'Jocks' (defined by the authors as athletic peers) were the least concerned about controlling weight while 'Alternatives' (non-conformists) were more likely to be actively trying to lose weight and 'Burnouts' (those who skip school and often get into trouble) placed greater value on thinness and dieting. Girls who did not belong to any particular peer group were the most likely to embrace dieting.

This study, courtesy of the Washington Post, finds that auto deaths decline as gas prices rise because-- ta da!-- there are fewer people on the road to kill or be killed. And that is especially the case for those subgroups (like teenagers) who don't have as much money to burn on gassin' up.

And finally, just when you thought you'd made a positive lifestyle change--not to mention doing your part for the environment--along comes a study to take some of the air out of your tires. Turns out two-wheelin' men need to beware of genital numbness, soreness and skin irritations in the groin area, according to the study published online this month in the urology journal BJU International.
The author even helpfully offers a few tips for avoiding these problems (eg: don't skimp on padding).
Friday, July 11, 2008

A new day for mental health parity

Last September, we wrote a story about how the House and Senate were each crafting bills to require that employers and insurers institute mental health parity-- coverage for mental health equal to that of physical health (a flawed definition, I realize, because it implies the two are discrete).

Well, it appears the two sides have reached a compromise on a bill. According to the WSJ, its components include:

  • Employers who offer mental health coverage must make it equal to physical health coverage, meaning they cover the same number of doctors' visits and hospital stays, and require the same co-pays and deductibles. (The 1996 parity law already requires that annual and lifetime dollar limits be equal for mh and physical health) Out-of-network coverage, if offered, must be the same as well.
  • It doesn't require employers to offer mental health coverage, however. Basically, if you offer it, you have to offer it all the way ... or not at all.
  • Employers with 50 or fewer employees are exempt from parity requirements.
  • It doesn't mandate which specific mental illnesses are covered.

The recently-passed Medicare bill (you know the one, right?) included a provision that would gradually reduce the existing 50% copays for Medicare patients' mental health services to 20%-- the current copay for physical services. Experts hope that not having to chase down patients for half the bill will encourage more psychiatrists (which are in short supply) and psychologists to accept Medicare patients.

Thursday, July 10, 2008

The long arm of your chromosomes and the law

A great debate is raging in the wider genetics community that is directly relevant to day-to-day internal medicine. In the last three years, the advent of genome-wide association studies has facilitated the discovery of more than 180 markers for risk of a growing list of common chronic diseases, including cancers, diabetes, coronary heart disease and Alzheimer's. In the last six to nine months, a number of companies have moved to make these markers directly available to consumers in the form of genome-wide scans that can be obtained over the Internet for between $1,000 and $2,500, and several are seeking to lower that price point drastically.

The companies qualify that all test results provided to the consumer are preliminary in nature and that their products represent information, rather than medical advice. However, after looking at these companies' Web sites, one could conclude that the companies--implicitly or explicitly--suggest to consumers that they might use the results to improve their health. There is no direct evidence that providing patients with genetic risk information from genome-wide association studies improves health outcomes, though, importantly, this is very likely to change in the next few years.

Yet, there are reports--many provided by the testing companies themselves--that patients are bringing their results to health care providers with the expectation that some form of action be taken to mitigate their newly discovered disease risk. However, beyond selected anecdotes, we know little about what providers are doing with the information patients bringing them.

Though direct to consumer (DTC) testing for traditional genetic conditions (think hereditary breast cancer and ovarian cancer syndrome) has been around for a number of years, the sophistication, scale and potential reach of this new crop of offerings has raised the interest of both state and federal regulatory bodies. Not unexpectedly, these companies have also been subject to intense criticism from the scientific and medical communities. The central theme of those voicing concerns is that the health care implications of this embryonic realm of genetic testing is unknown at this time and that potential harms could result from either over-, under- or misinterpretation of test results.

In the last few months, the intensity of the debate has ratcheted up. The state of California sent cease-and-desist letters to 13 concerns offering DTC genetic services to California residents. The letter stipulated, among other things, that the companies need to offer their tests through Medicare approved, CLIA certified labs and that a licensed physician needs to be involved in ordering the test. At the federal level, there is ongoing Congressional scrutiny of the topic, evidenced by a June 12, 2008 roundtable held by Senator Gordon Smith of the U.S. Senate Special Committee on Aging. On July 7 and 8 a committee that advises the U.S. Secretary of the Department of Health and Human Services on issues surrounding genetics/genomics examined this issue in some depth. From these proceedings it is clear that there are widely divergent opinions on the topic of DTC availability of genome-wide scans.

Interestingly, this scrutiny has brought an unexpected windfall to those of us in primary care. Individuals from the most technology-driven reaches of medicine are discussing the need for increased research on determinants of health behaviors and a re-evaluation of how our current system values preventive interventions.

The core questions confronting DTC genetic testing are not new to medicine, nor even genetics/genomics: first, when is a new technology ready for clinical use; and second, how much regulation is appropriate to ensure its safe and effective application while fostering innovation and minimizing risk of disparities?

One side of this debate argues strongly that consumers should be empowered with every bit of information about their health possible, and that to deny them direct access to their genetic makeup through overly strict regulation is old-fashioned and paternalistic. The other side argues that this type of genome-wide scanning is still a research tool. Consequently, offering it DTC at this point in time in a loosely regulated manner may substantially mislead the public and health care providers, incurring costs both in terms of morbidity and scarce health care resources.

Both sides have valid points. The American Medical Association and the American College of Medical Genetics have taken note of the new DTC movement and have developed official positions critical of DTC genetic testing. It is unclear what effect these statements will have on the entities offering this type of testing. What is clear is that much hinges on consumer demand and opinion--and to some extent the ability to shape that demand rests in the hands of health care providers like you. The best two pieces of wisdom at this juncture? First, patients should consider involving their health care provider prior to undergoing any DTC genetic test. Second, patients should hold off for now on getting a genome-wide scan for health care purposes. At present we know far too little about how to use this information to promise or imply benefit.

W. Gregory Feero, MD, PhD, a family physician with a doctorate in human genetics, is senior adviser for genomic medicine in the Office of the Director at the NIH's National Human Genome Research Institute. His column runs every issue in ACP Internist
Tuesday, July 8, 2008

Yeah, yeah, I need to lose weight. But how?

Diet and exercise, diet and exercise... study after study concludes that physicians must emphasize to patients how important these two factors are for staying healthy. But what's the best way to get patients to actually cut back on the calories?

Have them write down everything they eat, a new study reports.

Researchers followed about 1,700 overweight and obese patients for about 20 weeks. They went to weekly group meetings where they were prompted to eat 500 fewer calories/day than usual and exercise 30+ minutes a day, plus follow a low-fat diet with lots of fruits and veggies. They were told to record what they ate and how many minutes they exercised.

People who didn't keep food diaries lost about nine pounds, while those who kept at least six records a week lost about 18 pounds. The study's authors think that keeping records kept the dieters accountable, and let them know about things they ate that might have more calories than they expected. Can't hurt to try, right?

Unveiling the secrets of a long life

Do you have patients who come from a line of long livers? If so, and you are based in Boston, New York and Pittsburgh, the NIH wants to hear from you.

The agency is embarking on a study to discover why some people live longer than others.

Researchers in those three fine cities are looking for families with two or more healthy siblings who have lived to old age and can be interviewed in person. Participants will have blood drawn and physical tests done.

Contact information is available here, if you think you know folks who might qualify.
Monday, July 7, 2008

Medical News of the Obvious

Ok, this first study is more funny than obvious, but we couldn't let it slide by unmentioned. Confirming the claims that desperate teenage boys have made to their girlfriends throughout history, it turns out that if you don't use it, you will lose it. "Erectile Dysfunction Lower In Men Who Have Intercourse More Often," as Medical News Today described the research.

In other "See, it's not my fault" research, a couple of political science professors studied identical and fraternal twins and found that whether a person votes or not is largely determined by genetics. "Genes also play a significant role in political participation, including giving money to a campaign, contacting a government official, running for office and attending political rallies," the Washington Post reported.

Also in the Post, a rat study says that your obesity may be a result of your mother's unhealthy eating while pregnant. Best side benefit of being involved in this research: telling people at cocktail parties that your job is feeding "donuts, muffins, cookies, chips and sweets" to pregnant rats.

In an unrelated Rondetia report, scientists figured out giving gerbils gerbils the three compounds needed for healthy brain membranes--choline in eggs; uridine monophosphate in beets; and docosahexaenoic acid in fish oils--made them smarter after just four weeks. They hope to apply the research to humans. As a bonus chuckle to this Medical News of the Obvious, Gerald Weissmann, editor of the journal that published the results, took the time to snark about his favorite causes:

Now that we know how to make gerbils smarter," he said, "it's not too far a stretch to hope that people's intelligence can also be improved. Quite frankly, this can't happen soon enough, as every environmentalist, advocate of evolution and war opponent will attest."
Thursday, July 3, 2008

Watermelon can have Viagra-like effects

Something to chew over while you're celebrating Independence Day at a cookout or picnic--watermelon can have Viagra-like effects. Watermelons contain citrulline. Large amounts of it react with enzymes and become arginine, an amino acid that boosts nitric oxide, similar to Viagra.

  • You need six cups' worth of watermelon to create an effect, which may make you go to the bathroom more. (The AP explains that watermelon was used as a diuretic and for dialysis treatment for kidney patients.) And, that much watermelon could push enough sugar into the blood to cause cramping.

  • The citrulline is more in the rind than the flesh--yuck. Stick with yellow-fleshed watermelons.

  • The scientists who announced this are at the Texas A&M Fruit and Vegetable Improvement Center. Texas is a major watermelon producer.
Wednesday, July 2, 2008

Drug news

And no, we're not talking about the FDA-approval sort of drug news.

A new study in PLoS seems to indicate that the war on recreational drugs is not going so well. Surveys of 17 different countries found that despite some of the tightest drug laws in the world, the U.S. has near the highest rates of cocaine, marijuana and alcohol use. Overall, "countries with stringent user-level illegal drug policies did not have lower levels of use than countries with liberal ones." Specifically, a smaller percentage of people in the Netherlands are using marijuana than in the U.S.

Heck, they're even doing drugs at Johns Hopkins these days, the Denver Post reports. Researchers, published in the Journal of Psychopharmacology, gave magic mushrooms to 36 healthy volunteers and found that they reported having one of the most "personally meaningful and spiritually significant" experiences of their lives. The mushrooms may be useful in treating cancer-related anxiety, drug dependence or depression, the scientists said. The study was funded in part by the National Institute on Drug Abuse, but no word on whether the DEA is thinking about rolling back prohibitions on hallucinogens.

In other drug-related news, the White House announced today that ten states are now reimbursing under Medicaid for substance-abuse screenings and brief interventions. The states are: Iowa, Maryland, Minnesota, Montana, Oklahoma, Oregon, Tennessee, Virginia, Washington and Wisconsin.
Tuesday, July 1, 2008

Health and socioeconomic status

Last week, we saw more evidence that health outcomes are worse for people with low socioeconomic status. Not exactly surprising, especially since the researchers found that the association was much less true for people over 65, indicating that insurance is probably the issue.

But now, a new study in Academic Medicine finds that contact with poor patients at teaching hospitals causes medical students to have lower opinions of the poor in general. A finding that's not good for anyone involved, and makes you wonder if the link between health and socioeconomic status is more complicated than it at first appears. Is attitude affecting the care that these patients receive? If so, what can be done about it? The authors of the study have some interesting suggestions, including broadening the diversity of the medical student population: if you can't change the students' minds, change the students?