Wednesday, November 26, 2008

I found my brain tumor on the internet!

The phenomenon of cyberchondria (putting your symptoms into a search engine and coming with a dramatic diagnosis) is already well-known to most primary care physicians. A new study from Microsoft delves a little deeper into the causes and potential remedies of this problem.

First, the impressive statistics: a quarter of 250,000 studied users engaged in a medical search, and more than half of 500 Microsoft employees had at some point interrupted their day to search for information about a serious illness. (And not being medical reporters, they can't count that as work.) But what's truly shocking is that a large proportion of the study participants assessed the likelihood of their symptom being caused by a serious disease (i.e., is that headache a brain tumor?) based on the ranking of search results. (If brain tumor comes up before caffeine withdrawal, then you've probably got a brain tumor.)

The finding points out a flaw in the theory behind search engines. While search results are meant to be the product of our collective intelligence (best results at the top of the page), they are just as affected by our collective idiocy/hypochondria.

The computer guys do have some ideas about solutions, although the remedies are almost as scary as the problem. Search engines could be tailored based on individual search histories, they suggest, to keep people who tend to escalate their searches (e.g., from chest pain to heart attack) from getting the most dire results up top. Seems unlikely to be a popular idea, though, since 40% of survey participants admitted to having mistakenly thought they had a serious condition, but only 3.5% of them self-identify as hypochondriacs.
Tuesday, November 25, 2008

How to con friends and influence people

Next time you're on a jury, don't be surprised if the defendant's attorney asks you to wash your hands before deliberating on the verdict.

A new study in Psychological Science finds that, if you feel "clean," you will go easy on judging others, a press release said.

Here's the study design, according to the release:

"The research was conducted through two experiments with university students. In the first, they were asked to complete a scrambled sentence task involving 40 sets of four words each. By underlining any three words, a sentence could be formed. For the neutral condition, the task contained 40 sets of neutral words, but for the cleanliness condition, half of the sets contained words such as ‘pure, washed, clean, immaculate, and pristine’. The participants were then asked to rate a series of moral dilemmas including keeping money found inside a wallet, putting false information on a resume and killing a terminally ill plane crash survivor in order to avoid starvation.

The second experiment saw the students watch a 'disgusting' film clip before rating the same moral dilemmas. However, half the group were asked to first wash their hands."

Subjects with "the cognitive feeling of cleanliness" were less harsh in their moral judgements of others, the release said.

Hmm, could our society's moral decline all be traced back to the increased use of travel-size antibacterial gel?!

Health care is not recession-proof

The economists and financial experts always say health care is recession-proof. Traditionally, health care stocks have performed better in a downturn and people still get sick and need care and services.

But we are seeing a big drop in hospital admissions, doctors visits and elective surgery as people lose their jobs, lose their insurance and can't afford even small co-pays for health care. A large consumer survey conducted in February (seems like long ago!) reported only 11% of people felt they could handle upcoming medical bills. Heck, the economy was practically thriving in February compared to now.

With California unemployment over 8% (and rising) and millions of others working part-time or low-wage jobs, the ability to see a doctor or seek medical care is just out of the question for many people. Even people with insurance will postpone medical treatment because they don't want to miss work or be laid up.

"Consumer driven health care" is a code word for "you pay more," so most folks' co-pays are so excessive, when given a choice of the mortgage payment or doctor bill, the house wins.

Paul Keckley, executive director of the Deloitte Center for Health Solutions, told BusinessWeek that he sees three likely impacts from a recession: delays to primary and preventive care, delayed payment from those with high deductables, and increased bankruptcies from medical debt.

This recession is really going to put a strain on hospitals, care givers and patients in equal doses. It is a glaring example of how fragile our health infrastructure is.

Toni Brayer, FACP

How depression breaks the heart

It's been known for quite some time that depressed patients have a higher risk of heart problems than those who are mentally healthy. What's been unclear is why-- till now.

A new JAMA study finds that, in depressed patients with coronary heart disease, most of the higher risk of CV events can be chalked up to a lack of exercise.

The study followed more than 1,000 outpatients with CHD for nearly 5 years. Patients reporting symptoms of depression had a 50% greater risk of CV events. Adjusting for comorbid conditions and cardiac disease severity lowered the risk to 31%, but adjusting for lack of exercise pretty much wiped out the association completely (along with a few other "health behaviors," like diet). Put another way, not exercising was associated with a 44% higher rate of CV events-- almost the same as the depression association.

So now the real question is: how do you get those depressed patients to exercise? (Which, by the way, is likely to improve their mood.) That's a whole other study in and of itself. For now, the Mayo Clinic has these tips on motivating depressed patients.
Monday, November 24, 2008

Nothing to disclose

Since we spend a lot of time covering the ways that physicians are potentially influenced by pharma companies, it seems only fair to tell you about a new article that says health care journalists might have the same problem.

Writing in BMJ, experts from the Center for Medicine and the Media describe how lavish prizes (e.g., 7500 euros + a international trip for writing about obesity), pharma funding for education (a sponsored professorship in a medical journalism school), and assistance from PR reps in finding sources (ever wonder where they get those patient anecdotes?) can compromise journalistic ethics.

The response from ACP Internist staff: What? Why didn't anyone tell us about all this free stuff?

Rest assured, dear readers, that we would be sure to let you know if we ever won any fabulous prizes, we have no specialized training, and we spend lots of time hunting down our own sources. But, just in case any of you were thinking of buying me a trip to Europe, I promise that such a gift would not cause me to be less critical of you. (My parents can vouch for that.)

Are ants the key to the human aging process?

An NYU School of Medicine researcher is hoping to understand human longevity by using ants as his subjects. The hope is that gene regulation in ants will provide a model for human aging.

According to the researcher, ants can assume either reproductive or non-reproductive roles, and queens live up to 10 times longer than workers. The researcher will completely sequence the genomes of three ant species. Then, he'll assess whether changes in the brain and behavior occur from the environment and what changes in gene expression drive the adaptations.

"I truly believe that this project will open the door for my next 20 years of science," the researcher said. How long is that in ant years?

Medical news of the obvious

With icy winds sweeping the Northeast, it's obvious that many of us would rather be relaxing on a warm, sunny beach. That must be why Aussie researchers decided to release a study confirming conventional wisdom about life at the shore. "Adults and adolescents are particularly at risk for intense, episodic sun exposure while on vacation or in 'high-risk' environments such as beaches," the authors wrote.

Despite that unsurprising conclusion, the study does eventually prove its own value, by establishing that people do not learn from even the most painfully obvious evidence. The researchers surveyed beachgoers and found that 70% of them went to the beach with an intention to tan, despite 40% reporting they had obtained a sunburn in the previous 48 hours. Think, people, think!

But, to get to that warm, sunny beach, you'll have to wait in a line at the airport, which a study now shows that people hate. Researchers in queing psychology are finding ways to keep us amused while waiting in line, or at least reduce the sudden violence of "queue rage." In short, amusement parks and comedy shows add interactive features to their lines to build up expectations, airports offer updates on wait times, banks switch to first-come-first-serve fairness, and Black Friday shoppers think the line is part of the group experience.
Friday, November 21, 2008

Drinking and doctoring

In conjunction with a conference on doctors' health, the new issue of BMJ assesses phyisicians' (sometimes problematic) relationships with alcohol.

Two studies assessed the results of physician-specific substance abuse treatment programs in the U.S. and Canada and concluded that they were fairly successful, since 75% and 85% of the participating docs, respectively, were practicing and staying clean at 5 years. Less happily, the U.S. study found that physicians who didn't complete their treatment programs were much more likely to die (with 6 of the 22 in-treatment deaths caused by suicide) or lose their licenses.

Another study in the issue looked at the potential roots of these substance abuse problems, by analyzing the drinking habits of med students. Although they drink less than their nonmedical peers, U.S. students do find time to knock them back--24% of female and 43% of male students reported excessive drinking in the past month (random fact: non-primary-care-track students drank more than future PCPs).

Why does it matter? The students' habits could have effects on public health as well, the study found. Not surprisingly, the drinkers weren't eager to throw stones in their glass houses and were less likely than non-imbibers to counsel patients about alcohol use. Despite the findings, study authors were pretty moderate in their recommended actions: "Medical schools should consider...discouraging excessive drinking," they concluded. Better get that keg out of the lab.

When patients control their own records

Steve Spadt, ACP's Director of Interactive Product Development for projects such as the College's Diabetes Portal and the MKSAP product line, delivers a round-up of the latest in electronic health records, including patients taking control of their own health records and Web communities that let patients connect with other patients with similar symptoms and diseases, and possibly by-pass medical providers.

Learn more about the latest in medical informatics from the American Medical Informatics Association's annual meeting in Washington, DC.

Patient Health Records (PHRs) continue to gain steam, though there is a key differentiator which is whether or not the system is "tethered," meaning connected to or integrated with a full Electronic Health Record (EHR) or other clinician-managed systems. Medical informatics experts almost universally share the belief that untethered PHRs (systems that operate independently and contain data that is managed solely by patients) may actually negatively impact care as they could strain patient/clinician relationships as clinicians struggle to coordinate the data in their own systems with that in the patient's PHR--an effort that would further burden an already critically low level of time and resources available per patient encounter. AMIA'S journal recently addressed this topic.

The Patient-Centered Medical Home (PCMH) model is universally appealing, particular to primary care physicians who see the tremendous mismatch between the potential for the model to dramatically improve the quality of care and the current payment systems that conflict with the model. From the informatics perspective, successful implementation will depend largely on information systems and technology infrastructure that can facilitate and track teams as they deliver patient-centered, well-coordinated, high-quality care.

Clinical Decision Support (CDS) may finally be coming of age. Numerous resources are now available to assist physicians implement sophisticated decision support systems, including a guidebook whose lead author, Jerry Osheroff, FACP, is a leading authority in CDS and a former ACP staff member. A summary of key CDS initiatives and resources is available on AMIA's Web site.

Electronic Health Records (EHR) Adoption continues to lag behind predictions, limiting the impact of many informatics innovations. The long-expected "tipping point" of adoption appears to be gradually approaching, but it is clearly still not yet upon us.

Patient Communities are growing stronger and are increasingly empowered through the use of so-called Web 2.0 technologies that enable patients to connect with other patients with similar symptoms and diseases, share encouragement and treatment strategies, and even, in many cases, their own clinical data—a serious concern among informatics professionals already wary of the spread of PHR systems and other tools that may not be as secure or private as patients believe. One such community that is rising quickly in popularity is Patients Like Me, which was profiled recently in ACP Internist.

A Medical Informatics Update, presented by Daniel Masys, MD in the style of ACP's own Update series at the annual Internal Medicine meetings, focused on four broad areas in clinical informatics:
1) computerized clinical decision support,
2) personal health records,
3) telemedicine, and
4) the practice of informatics;

and also three areas in bioinformatics:
1) human health and disease,
2) model systems for understanding biology, and
3) the practice of bioinformatics.

He finished with a Late Night ... -style Top 10 list of Notable Events. All of the information is available online.

Thursday, November 20, 2008

Race and the clinical exam

In the last several months it has become increasingly clear that I am guilty of racial profiling. Before you get too upset with me, consider the following behavior: if I see a patient considering pregnancy, and they appear to be Caucasian, I am far more likely to discuss screening for cystic fibrosis carrier status than sickle cell disease. Rarely do I ask the question formally: "With what racial group do you identify?" before I make this decision. Rarely do I discuss the decision process with my patients. I suspect that I am not alone.

What should the health care provider do in light of emerging understanding of race and ethnicity?

"Racial profiling" is reinforced by many national care guidelines, and is embedded in the training of health care providers from their first course in physical diagnosis. The conscious and sub-conscious binning of individuals by observed physical characteristics is one way to estimate an individual's personal probability of having certain diseases. Assessment of individuals through the lens of a population sub-group occurs at many junctures in the care delivery process, and rests on epidemiologic data demonstrating that disease prevalence varies among population groups.

The logic supporting such an approach is as follows: Particular sub-populations are at higher risk for certain conditions. Effectively distinguishing the sub-population to which an individual belongs helps to define that individual's probability of developing a given diagnosis. Accurate assignment of risk brings parsimony to the processes of prevention efforts, screening, differential diagnosis formulation, diagnostic workup and, potentially, therapeutic intervention.

The binning of individuals by race and ethnicity is only one of a variety of discriminators health care providers routinely employ. The utility of binning individuals depends heavily on the quality of the determinants used to separate populations, and while age and gender are arguably fairly clear-cut, less controversial biological discriminators of disease risk, race and ethnicity are most certainly not.

The wealth of accumulating DNA sequence data from multiple individuals representing multiple population groups reveals that our understanding of human genetic variation is only rudimentary. Accompanying this realization is a growing acceptance that current definitions of race and ethnicity are poor proxies for estimating the genetic component of individual disease risk.

The bottom line is that the DNA of the U.S. population defines the cliche: We are a melting pot. Genetic variability is, in fact, greater between unrelated individuals than it is between racial and ethnic groups. Currently accepted racial and ethnic categories are a blur genetically, and drawing clinically useful boundaries for the purposes of assigning individuals to a group is quite difficult.

What effect does this have on clinical care? Fundamentally, it causes errors in assignment of risk because using self-defined race and ethnicity may over or under estimate actual risk. This can result in harms in a variety of ways, but most commonly as a consequence of providing too little (or too much) care.

How might the issue of assigning individual genetic risk in the setting of complex genetic ancestry be resolved? Options include eliminating the use of race and ethnicity as a consideration when deciding whether to offer genetic testing for disease risk or diagnostic purposes. The prototypical example of this approach can be found in the example of cystic fibrosis carrier screening, where the most recent guidelines suggest genetic screening should be offered in the prenatal setting to individuals of all races and ethnicities. Though in the case of cystic fibrosis screening this approach offers increased sensitivity, screening a larger population clearly results in increased costs.

Another approach would be to use genetic markers as a pre-test for the ancestry of regions of DNA harboring potential deleterious gene mutations of interest and then to base genetic testing on this ancestral determination. This could be practical when genetic tests are expensive and knowledge of the ancestral derivation of the DNA would determine the most cost-effective testing strategy. An example would be choosing between targeted mutation testing and full sequencing of the BRCA 1 and BRCA 2 genes in hereditary breast and ovarian cancer syndrome in an individual that might or might not be of Ashkenazi Jewish ancestry. However, such a genetic pre-test would amount to the morally tenuous use of genetic tests for racial and ethnic profiling.

Clearly neither of these approaches is fully satisfying. The best solution would be the advent of extremely low-cost full genome sequencing techniques that would reveal the entirety of an individual's genetic variation. This sequence information would allow an individual's care to be based on their own genetic variations rather than crude estimation of genetic risk. Of course this requires not only the availability of low-cost sequencing (which seems possible in the relatively near term) but an understanding of how the individual's genetic variants interact with each other and the environment to cause disease, a topic for more research and another column.

What should the health care provider do in light of emerging understanding of race and ethnicity? First, re-examine your own preconceptions regarding race and ethnicity, and how you use them in your practice. You may find that you are doing your patients a disservice. Second, take an appropriate family history, including the ancestral origins of the patient's grandparents. Third, if you use an individual's self-identified race/ethnicity in medical decision making, particularly with regard to genetic testing, recognize that the information provided you is less reflective of genetic variation than previously thought.

Patients should understand that we have much to learn about genetic variation, and that our current methods for selecting individuals for genetic tests as well as test interpretation are far from perfect. Finally, if you are an educator, examine how you teach your students and trainees to think about approaching the evaluation of patients. Make sure that they understand what genomics is revealing about how genetic variation in individuals and in populations relate to one another. With a firm grounding and the current pace of genomic discoveries, they will likely be the generation that resolves the controversies surrounding the use of race and ethnicity in health care.

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.

Dr. Robot to the rescue

In all the whining about the impending crisis of primary care, everyone has forgotten one obvious solution at our disposal--robots. Two news items released today describe how electronic devices will soon be replacing health care providers:

"In the not-so-distant future, American seniors may turn to helpful, uncomplaining robots to fill the worrisome 'care gap' that many face today," explains the HealthDay News. In addition to buying groceries, fetching dropped keys and checking blood pressure, the rolling, talking robots (think Rosie, the Jetsons' maid) will have internet connections and video monitors so distant relatives can "jump into" them. In its most creepily sad touch, the article explains how a grandmother could hold the robot's hand as she shows her garden to her faraway grandchild.

And if the realization that you've so neglected Grandma that she is reduced to cuddling titanium has depressed you, tell it to your cell phone. A Japanese professor has launched the world's first web-based cognitive therapy program available through your mobile. The enterprising psychotherapist had previously treated the country's crown princess (although presumably she got in-person service).

He explicitly states that the program is intended to compensate for a national shortage of psychotherapy specialists and doctors. Could a robotic, wired general internist be next?
Wednesday, November 19, 2008

Data-mining goes down in court

The pharma industry took a hit on Tuesday, when a federal appeals court upheld a New Hampshire law that bans data-mining, the practice in which physicians' prescribing records are sold to pharma reps. The opinion came down pretty hard on detailing tactics (calling them mind-boggling), and the ruling may inspire other states, especially those in the same New England judicial district, to follow suit, according the NY Times.

It's good news for docs who don't like pharma reps knowing more about their prescribing habits than they do, but bad news for the pharma and data-mining companies. The decision's also a potential blow to the AMA (which made 16% of its 2005 income selling the info).

First, the ban on free food and pens, now this, what next? Soon pharma's only option will be to buy ads on snarky medical blogs.
Tuesday, November 18, 2008

He's not done yet.

Before leaving office, President Bush is trying to push through one last health-related policy change. The proposed rule would prohibit federally funded institutions from discriminating against health care providers who have religious and moral objections to certain procedures/activities (i.e., abortion, emergency contraception). The idea's raised a storm of protest from health experts, including the AMA, AHA and pharmacists' groups, and President-elect Obama has already promised to reverse it when he takes office. Which makes you wonder, especially given the disagreement over this within the administration, why bother?

If you want to put your two cents in, here's an email address for the Office of Information and Regulatory Affairs.

Unhappy docs

A new survey by the Physicians' Foundation finds that half of practicing primary care physicians plan to either leave practice or reduce the number of patients they see over the next three years. Is this wishful thinking on their part about creating better work/life balance, or an indication that primary care is about to disappear? By the time health care reform is enacted, will there be anyone left to take advantage of it?

The other interesting stat from the survey is that 78% of the physicians believe there is a primary care shortage. Our question: what's up with that other 22%?
Monday, November 17, 2008

Congrats, Burlington: America's healthiest city

Congratulations to Burlington, Vt., which a CDC report found to be America's healthiest city because 92% of its residents reported being in good health.

The AP reported Burlington has relatively low poverty, higher average education, a large employer offering generous health benefits and community support for recreational activities and healthy foods.

At the bottom of the list was Huntington, W.Va., which had twice as much poverty and less than half of the number of college-educated people.

Medical News of the Obvious

Focus on driving. When officials in Florida implemented a law in January 2004 requiring all drivers 80 years and older to pass a vision test before renewing their driver's licenses, did they ever in a million years think that it would lead to fewer crashes? Well, yes, of course they did. But, now there's evidence, notes a press release announcing the results of an Archives of Ophthalmology study. It turns out that failing the DMV's vision screening test removed some shaky drivers from the road and encouraged others to get better glasses.

And at the other end of the age spectrum, a new study finds that modern teens are full of themselves. The research, which compared today's adolescents with those of the 1970's, also found that students claim to get more A's despite doing less homework. And if Grandpa could just find his car keys, he would come over and tell you about how hard it was back in the good old days.

For those facing a mid-life crisis, turn to Botox. A psychodermatologist addressing the American Academy of Dermatology's Skin meeting measured the positive effects of botox on self-esteem. The study surveyed 76 middle-aged patients treated with one botox injection about how they felt: 29% were less anxious; 36%, more relaxed; 49%, more optimistic. The study even addressed seasonal affective disorder. "Feeling stressed, depressed or anxious is exhausting," said the presenter, "and patients who report improvements in these negative feelings following a cosmetic procedure can use that redirected energy to pursue new interests that can enhance their lives," such as having to drive their overbearing parents and snotty teenagers everywhere.
Sunday, November 16, 2008

Colbert on Drugs

In case you haven't seen this...Colbert nails it! Enjoy

Friday, November 14, 2008

Celebrating World Diabetes Day with a splash

Color-coding of disease awareness has become pretty standard--we all know about red dresses for heart disease and the ACP building was bathed in pink light last month to recognize breast cancer.

But the International Diabetes Foundation has taken things to a new level. Today is World Diabetes Day, and to recognize that, a famous Belgian statue of a small boy is peeing blue. (You know, because diabetes makes you pee, and well, blue wasn't taken by any high-profile disease yet.) They've also got some interesting fundraisers going on, like Desert Dingo Racing.

All in support of a good cause though--raising awareness of diabetes in children. We all know about the obesity-driven increase in type 2 diabetes among juveniles, but type 1 is also on the rise, according to the IDF, increasing 5% per year in pre-school children. Which seems like a lot, doesn't it?
Thursday, November 13, 2008

Are we reinforcing your obsession with internal medicine?

Perhaps you've already noticed this, but the internet is bringing crazy people together in all new ways, a group of psychologists have found.

We recently covered the growth of patient-run medical web sites, where patients can compare notes on evidence and treatments for conditions like MS and AIDS. For the most part, docs seemed skeptical of the concept. But this NY Times article investigates online groups for patients with even more unusual issues. Specifically, people who believe they are being targeted for mind control have gathered on certain web sites to discuss their experiences.

This trend raises all sorts of interesting questions, like whether it's good that these people have found peer support or it's bad that they are getting reinforcement of their delusions. And at what point is their group large enough that you can't call their ideas delusional anymore? According to the APA, if a belief is held by a person's culture or subculture, it is not a delusion (the exception that prevents religion from being categorized as mental illness).

The experts say this mind-control thing is a contemporary version of belief in alien abductions, which by the way, Newsweek recently had a really interesting article about. Did you know that 90% of Americans believe in the paranormal?
Wednesday, November 12, 2008

Power to the patient! (with your encouragement)

The theme of several late-breaking trials today seems to be, very loosely, patient empowerment. To wit:

One study compared atrial fib/heart valve patients on warfarin who were monitored monthly at a clinic with those who did weekly home INR testing. There was no difference in the primary outcome-- time to death, major bleed or stroke.

This is a case where a negative outcome isn't really bad. It's good to know, the author said, that patients can test at home just as well as in a clinic, especially for those who live in remote areas or have other barriers to getting to a clinic. Plus, patients were happier with the home testing approach, and Medicare covers it for AF, heart valve and VTE patients.

Next comes a sub-study of yesterday's HF-Action study on exercise and heart failure (see earlier post for main study). This one found patients who did exercise training reported significantly better health status (quality of life, symptoms and physical/social limitations) at three months, and the difference lasted for three years.

Quality of life is important in heart failure patients, because HF is a chronic, incurable disease, discussant Anne Taylor, MD said. She noted that in this study, the subjects were receiving optimal medical therapy, and were 59 years old on average-- while in the general population, heart failure patients don't always get OMT, and are older. Study author Ileana Pina, MD, responded that the group did plan to analyze the results in an older cohort, so stay tuned.

Finally, Lori Mosca, MD, reported on her group's creative study in which researchers screened and counseled the relatives of hospitalized patients about their health risk factors. The control group got a handout about reducing risks, while the intervention group got immediate feedback on screening tests, and a year of diet and exercise counseling.

LDL levels declined in both groups after a year-- a testament to how motivating it is to see a loved on get sick, Dr. Mosca said-- but there was no difference between groups. The intervention group had a significantly better diet score and exercised more, and their HDL went up slightly, while the control group's HDL declined. Both groups significantly decreased their saturated and trans fat consumption.

Given that both groups improved their behaviors after some level of intervention, hospitals have a unique opportunity to educate, motivate and help patients' relatives, observers noted. A lot of these relatives were unaware they had CV risks, Dr. Mosca said, and that awareness alone might have spurred them to action.

Scared straight

I've got a suggestion for how to get your patients to exercise and eat well. Send them to a cardiology conference.

After four days of hearing about all the things that can go wrong with one's body, I'm convinced I need to train for a marathon and eat mostly raw produce and grains. Stat.

Can you trust the medical literature?

Just went to a session on this topic led by Joseph Ross, MD, the author of an April 2008 JAMA study on ghostwriting. He said research indicates that editors prefer studies with positive findings, that studies from U.S. and/or "prestigious" institutions are more likely to be accepted, and that industry-sponsored trials are accepted more often by journals.

In cardiovascular research, studies are 37% more likely to favor newer treatments than existing treatments. In general research, published studies are two times more likely to be associated with pro- than anti- drug industry findings, he said. How does this happen? Some of the culprits include:
--Industry designs studies in such a way as to bias them toward favorable findings
--Industry analyzes results in favorable ways, and displays/states results misleadingly
--Industry suppresses unfavorable findings, choosing to submit positive trials for publication
--Industry supports ghostwriting, in which a reputable person is often brought in at the last minute to edit a study rather than participate in it or its analysis, yet is listed as the lead author.

How to fix the problem? Dr. Ross suggests:
--Prospective public registration of all clinical trials
--Public reporting of all safety/efficacy outcomes
--Improve integrity of study authorship. For one, the principal investigator should be listed as the lead author on studies.

Googling the flu

The datameisters at Google say they can track potential flu epidemics two weeks earlier than the CDC by tracking people's searches for flu information online.

Google's non-profit arm,, is trying to apply its heft as the most popular search engine to tackle poverty, renewable energy and small-business growth. And now, they're applying the power of the millions of global users looking for health data to track the flu.

According to Google's blog, millions of users around the world search for online health information weekly. There are more flu-related searches during flu season, more allergy-related searches during allergy season, and more sunburn-related searches during the summer. A pattern emerges when all the flu-related search queries from each state and region are added together, Google says.

To test their hypothesis, Google compared search queries with CDC data to find out which searches occured during flu season, and then extrapolated that frequency provides an estimate how much flu is circulating. They used last year's flu season as a test and now claim to have accurately estimated flu levels one to two weeks faster than published CDC reports across the nine U.S. surveillance regions.

Additional details are available in a draft manuscript and a later version has been accepted in Nature.

Guest blogger: My pet peeve of the day

Guest blogger Toni J. Brayer, FACP, of ACP Internist's Editorial Advisory Board, offers her comments on how the primary care shortage will doom attempts to reform health care. She writes:

Anyone who reads EverythingHealth or many other health blogs (KevinMD, Maggie Maher, Dr. Rob, Dr. Val, and Happy Hospitalist to name a few) knows that primary care physicians are a dying breed. Everyone talks about the money (painfully low reimbursement) as the cause, but equally annoying is the LACK OF RESPECT for the specialty.

Repeatedly I run across doctors who have no training in family medicine or internal medicine who say "Oh, I'll just be a primary care doctor." One doctor is an 86-year-old surgeon who was denied operating privileges so he's going to "be a primary care doctor." He did surgery training in 1948.

Another doctor hasn't ever seen a live patient. He originally trained in pathology and has done only laboratory work. He is moving to Hawaii to be a "primary care doctor."

Another has been a hospital administrator for years but wants to "see patients again" so he is going to do "primary care a half-day a week."

Give me a break! This is not a specialty you can drop in and out of as a hobby.

There is a severe lack of understanding about primary care medicine and the medical specialties of family medicine and general internal medicine. Each of these specialties requires years of residency after internship and continued medical education and exams for board certification status.

A tremendous body of knowledge is needed to be a primary care physician. One must have diagnostic acumen, know all treatment modalities, have skills in psychology, inherent common sense, knowledge of medical economics, a vast knowledge of pharmacology and hundreds of drug interactions. Primary care physicians must keep up with all of the medical literature and current evidence to be at the top of their game.

I've practiced non-stop for over 20 years and I am still challenged by patient care. Even though I could probably deliver a baby or remove an appendix or even amputate a limb if I were stranded on a desert island, I would never be so bold as to think I could drop in and out of those specialties and render good patient care.

Unfortunately the shortage of REAL primary care doctors means the field is wide open to anyone who wants to hang out a shingle and give it a try.
Tuesday, November 11, 2008

File under "Why not?"

I'm off to a session about how listening to "joyful music" might improve endothelial function. This is one of those things-- like doing yoga, or drinking green tea-- that I put into the "might as well" category.

You don't want your patients trading exercise or medication for listening to happy songs and regular tea breaks, but these things can't hurt, so why not try them? As Dr. Mehmet Oz said yesterday, he doesn't prescribe yoga to his patients, but he does tell them he recommends yoga to his family members.

The joyful music study is far from rigorous-- it involved 10 healthy subjects with an average age of 35.6 years. Seven were male. Over a period of 30 minutes, they listened to joyful music, anxiety-producing music, funny video clips and relaxation tapes. The researchers measured a baseline brachial artery flow mediated dilation, and then measured it again during the study.

The results? Flow mediated dilation increased 26% during the joyful music, decreased 6% during the anxious music, increased 19% during the funny bits, and increased 11% during relaxation. So, ideally, I guess you should find a song that is happy and hilarious, yet relaxing.

I must say, I'm curious about how they classified the music. I've noticed one person's joyful music can be another's schlock, and a song that produces anxiety in me might be motivational to someone else. I'll report back after the session on what the experts say you should plug into your MP3 player, and you can judge for yourselves.

Update: Turns out the joyful music was of the subject's own choosing, as was the anxious music. Heavy metal was most often chosen as anxious music, while country was most often chosen as joyful (really? Isn't country known for its "tear in my beer" lyrics?). Oh, and the "laughter clip" included Saturday Night Live skits and sections of the movie "There's Something About Mary." I bet Cameron Diaz has no idea she's contributed to cardiology research.

Heart failure, part two

Now it's time for the bummer news about heart failure (HF).
Historically, there's been no treatment that improves outcomes for those HF patients who have an ejection fraction of greater than or equal to 45%. And, we learned today, there still isn't.

Researchers studied whether treating these patients with irbesartan (an ARB) might lower death and hospitalizations for HF, MI, stroke and arrhythmia. It was the largest study of an ARB for this condition, ever, with 4,128 subjects and a 4.5 year follow-up. The average patient age was 72 years and 60% were women-- appropriate given that that this condition mostly affects women and older folks.

There was a difference in those who took irbesartan vs. placebo, but it wasn't significant. At least, the researchers said, the study showed the drug was safe, which means it could be a good substitute for patients who can't tolerate other hypertension drugs. But, as Philip Poole-Wilson, MD, said in his inimitable English accent about the exercise and heart failure study: "Safety without benefit is a bit dull, really."

Heart failure and exercise

It's heart failure day at AHA Scientific Sessions-- at least in terms of the late-breaking trials.

During a press conference about some of these trials, several physicians bemoaned the fact that the general public knows little about the common problem of heart failure. Milton Packer, MD, of the Univ. of Texas Southwestern Medical Center, quipped "We've been trying to find spokespeople for heart failure, but they are too short of breath to speak!" (Maybe that was funnier in person.)

One study looked at whether structured exercise training for HF patients reduced hospitalization or death rates. The results weren't statistically significant in the main analysis, but an adjusted analysis showed an 11% reduction in deaths/hospitalization, and a 15% reduction for CV mortality or HF hospitalization (a secondary endpoint).

The regimen in the study involved 36 supervised sessions of 30 mins of exercise 3x/week. At the 18th session, patients began to transition into exercising at home for 40 mins 5x/week by giving them a treadmill or exercise bike (wonder if they got to keep them once the study ended?) All patients were receiving optimal medication therapy.

There was some debate about how seriously to take the results, given that they were only significant after adjustment. The author, Dr. Christopher O'Connor of Duke, argued that since the adjustments were pre-specified, the analysis was "fair". He and several others also discussed how much more difficult it is to measure the effects of lifestyle interventions than, say, a drug-- suggesting one should cut this kind of study a little slack.

Dr. O'Connor also noted that the hazard ratios weren't much different in the two primary analyses: HR of 0.93 for main and 0.89 for adjusted. (The variables in the adjusted analysis, by the way, were CPX exercise duration, LVEF, Beck Depression Inventory and history of HF.)

It's also important to note there were no more adverse events-- like heart attack, angina or arrhythmia-- in the HF patients who exercised vs. those who got usual care. Both doctors and patients are often wary of prescribing exercise for HF patients, for fear of bad consequences, O'Connor said, so this provides some reassurance.
Monday, November 10, 2008

Don't forget your history

Twice today I've heard pleas for doctors to do a better job of collecting family histories. One came as an aside from an audience member at Dr. Oz's lecture, and another from Allen Taylor, MD, who spoke at a seminar about when to order various imaging tests. He was tasked with talking about patients with intermediate risk of heart disease.

Dr. Taylor noted that the classic definition of "intermediate risk" for CAD is 10%-20% on the Framingham, yet this misses some patients because the Framingham doesn't take family history into account. As such, his definition of "at risk" is a patient with a Framingham of 6% or greater and a family history of premature coronary artery disease.

When taking family history, you should go deep, he said. Ask about first and second degree relatives. Ask about the age that relatives developed CAD, and how many relatives had CAD. The more relatives, and the younger those relatives were when they developed CAD, the greater the risk. Especially if they are siblings.

Those deemed at risk by family history should undergo coronary artery calcium testing, he said, especially middle-aged and older patients, for whom it's been shown to be a stronger risk predictor than carotid IMT tests. IMT might make more sense for primary care offices, however, for practical/convenience reasons, he said.

It's really important to identify those at intermediate risk, he noted, because they are a big group-- and also the most likely to improve with therapeutic intervention. It's a message I've heard several times at this conference.


Talk about energy conservation. A team of UK electrophysiologists have created a "microgenerator" that is powered by a beating heart, and produces nearly 17% of the electricity needed to operate a pacemaker.

This technology could eventually lead to smaller pacemakers that last longer and do more to monitor the heart, they said. The official name of the generator? "The self-energizing implantable medical microsystem", or SIMM.

Somehow, the gadget helps the heart produce more than enough energy per beat than is needed to pump blood. The extra energy is then "harvested." (Not surprisingly, the faster the heartbeat, the more energy is created.) Implanting and "harvesting" the energy didn't significantly injure the heart lining, by the way. Which is good.

The view from Oz

Dr. Mehmet Oz-- the infamous author, Oprah guest and cardiologist, spoke to a packed audience today about how to get patients to listen to advice about lifestyle changes. Some tidbits he offered:

--Make health fun, or at least engaging. Don't tell patients that smoking is bad. Show them a picture of a diseased lung (and yes, that falls more into the "engaging" than "fun" category).
--Keep it simple, when you can. Rather than explaining BMI, tell your patient his waist size should be half his height in inches.
--Give 'em tips. Tell those who need to lose weight to eat a handful of nuts about 30 minutes before they eat a meal. It takes 30 minutes to lower ghrelin levels-- which should then curb the amount the patient eats at the meal. Emphasize the importance of sleep for all your patients, and advise those who don't sleep well to dim lights, wear loose clothing, get a good mattress, and reduce ambient noise.
--Make sure the educational materials you give patients are engaging. Dr. Oz's office made a video on health for patients to watch before and after their cath labs-- because what else are they going to do during that time?

Medical news of the obvious

Reader Tanna Lim, M.D. from Atlanta found an item for us. Last week we reported that teens who see less violence on TV are less violent. Now we find that if they are more interested in watching sexual content, they're more likely to be involved with a pregnancy.

Media coverage affects how people perceive the threat of infectious disease. As opposed to people just going out and conducting their own field research about all the infectious disease in the world.

Turns out, if you ask patients whether they're ok with their prescriptions being switched to other drugs without their or their doctor's knowledge, they say no. An obvious study, but not one without a purpose: sponsor Pfizer was trying to make a case against substitution of generic statins.
Sunday, November 9, 2008

It's a brave new world

I just went to a session on personalized genomics, and the speakers seemed pretty unified in feeling that this is an exciting but slightly worrisome time in the field. The reason for excitement is obvious-- personalized medicine and such-- while the concern is mostly that things are moving too fast for doctors. (This, as opposed to concerns about some dystopic sci-fi reality. "I don't think we're going to see genetically-enhanced Super Heart Men in the future," quipped Hank Greely, a Stanford law professor).

When Mr. Greely asked the 200+ audience if a patient had ever brought in a personal genetic test, only a few hands were raised. Yet he predicts this will change soon. "We are within 2-5 years of a full sequence genome for under $1,000," Mr Greely said. "And you will be on the hook to explain it to your patients."

The nation's 800,000 doctors aren't ready for the coming onslaught of patients armed with their own DNA code, said Eric Topol, MD. (Anyone can now get genetic tests for as little as $400.) "Most doctors would probably say 'What's a SNP?' if asked by a patient to look at their genetic test results," Dr. Topol said.

The nation's 3,000 genetic counselors can't fill in the gaps for everyone. So what's the solution? Professional societies need to step up and figure out a way to educate physicians about the clinical significance of genetic variants, Mr. Greely said.

Medical news of the not-so-obvious

Need another reason to push flu shots on your patients? Turns out, the shot might lower one's risk of blood clots (in addition to lowering the chances of feeling like a punching bag from the flu.) Overall, the risk of VTE was 26% lower for those who got the shot compared to those who didn't, a study presented at the AHA conference found. For people under age 52, the risk was 48% lower. (researcher: Joseph Emmerich, MD)

And it seems headphones for MP3 players might interfere with pacemakers and ICDs. Researchers tested eight MP3 headphone models by putting them directly over 60 patients' chests, to see whether the magnets in the headphones would interact with the devices. Fourteen of the patients (23%) had interference-- with the ICD patients more likely to have a problem.

The problems were scary: the pacemakers started beating without regard to the patient's own heart rhythm, while the defibrillators were temporarily deactivated. So does this mean no more music for your patients? Not really, the researchers said: Patients just need to keep their headphones at least 1.2 inches from their pacemaker or ICD. (researcher: William H. Maisel, MD)

What to eat...and not to eat

New Orleans is an eatin' town, so it's apt that a slew of research is being presented on nutrition and heart health. Here's the scoop:

--Vegetables, soy, wine, green/black tea and fish. People who ate these things were less likely to have left ventricular dysfunction than those who ate processed meat/cheese and added fats. (researcher: Longjian Liu, MD)

--Non-soy legumes, like pinto beans, chickpeas and navy beans. Eat a bunch of these and there's a good chance your LDL will drop. (researcher: Lydia A.L. Bazzano, MD)

--Hibiscus tea, if you're mildly hypertensive (129+ systolic). You'll have to drink three cups a day, but if you follow the path of those studied, your systolic BP will drop 7.2 points in six weeks. (researcher: Diane McKay, PhD)

--Folic acid. People who took 2 mg/day along with 1 mg of Vitamin B12 had no extra risk of cancer or other adverse events. They weren't protected against CVD, either-- which was kind of a bummer, since the researchers hoped the B12 would lower homocystine levels and thus CVD risk. But at least the fortified bread is safe. (researcher: Dr. Jane Armitage)

--Fruits and veggies. "Well, duh", you say. What's fairly new in this study is the finding that, for each portion of fruit or vegetable, blood flow in hypertensive folks improved about 6%. So if your patients won't do it for the all the other reasons there are to eat healthfully, hit 'em with the vascular argument! (researcher: Damian McCall, PhD)

--Vitamins E and C... at least if you're doing so to avoid heart problems. The 14,641-subject Physician's Health Study found neither supplement protects against cardiovascular disease when taken separately. Sure, antioxidants have been studied to death, but this study was large and long-term, with an average follow-up of 8 years. (researcher: J. Michael Gaziano, MD)

--Animal and industrial trans fats, which seems fairly obvious. Whether the source is animal or man-made, these acids give you a double shot of nastiness, raising your LDL and lowering your HDL in one fell swoop. (researcher: Ingeborg Brouwer, PhD)

No word yet on the healthful properties of jambalaya and gumbo.

News from JUPITER (and New Orleans)

I'm at the AHA Scientific Sessions conference in New Orleans, and I'd be remiss if I didn't write about the big news of the day--the JUPITER trial.

Briefly, the trial randomized 17,802 patients with normal LDL but high hsCRP to either rosuvastatin or placebo. The patients had no history of cardiovascular disease, though some had risk factors like hypertension, obesity and smoking. The authors found that those who took rosuvastatin had:
-54% fewer heart attacks
-48% fewer strokes
-46% lower need for revascularization
-20% fewer deaths.

These findings held up across gender, race, ethnicity and Framingham scores greater than or less than 10%; there were no differences in cancer rates or serious side effects between the groups, either. There was also no difference in patients who had a BMI above or below 25.

The results are a big deal, of course, because half of stroke events and heart attacks are in people whose cholesterol seems fine, so doctors want to figure out a way to identify these people in advance.

Lead study author Paul Ridker, MD, said at a press conference that the results indicate providers could prevent 250,000 deaths over a five-year period. But discussant Andrew Tonkin, MD, said he'd like to see an absolute risk reduction done for various subgroups, as well as a cost analysis, before anyone starts ordering CRP labs willy-nilly.

"I do think we need to review the guidelines of where CRP sits in risk evaluation," Dr. Tonkin said.

The research still doesn't answer the question of whether lowering LDL or lowering CRP is the most important action, Dr. Tonkin added. Either way, said Dr. Ridker, the study provides some serious support for the safety and efficacy of statins.

"We have so many patients who are nervous about taking statins," Dr. Ridker said. "But the overwhelming evidence is that these drugs, as a class, are highly effective at lowering hard end points."
Friday, November 7, 2008

Tell me about your extra drugs!

Earlier this year, the Associated Press did a big investigation of the levels of pharmaceuticals in our drinking and ground water. A lot of the drugs get into the water after passing through people's bodies, but some end up there because patients are following the traditional instructions for disposal of unused medications--flush 'em.

I'm working on a story, as part of our Medicine and the Environment series, about what physicians can do to help fix this problem. Obviously, if you have a drug takeback program in your area, that's great. But if you don't, what should you be telling patients to do with their leftover meds?

I found one article that details the laborious process (involving kitty litter and unmarked containers) recommended by the federal government, but I highly doubt that's getting a lot of play in offices or homes around the country. So, has anyone ever asked you what to do with their unused medications? What do you tell them? If it were a relatively simple process, would you be willing to collect the meds?

Weekly news translated to Japanese

The American College of Physicians has international reach, and one example of that is how ACP InternistWeekly gets translated into Japanese.

In October 2005, the Japanese Chapter's governor, Kiyoshi Kurokawa, MACP, suggested translating ACP InternistWeekly as a way to inform Japanese chapter members in their native language and enrich the chapter's Web site.

Haruko Miyamoto, the chapter's coordinator, explains that the chapter created a Publication Committee of 32 volunteers specifically to translate the news. Each week, three members translate and a fourth person becomes an editor.

ACP InternistWeekly distributes on Tuesday in the U.S., which is Wednesday in Japan. Members translate the blurbs by Thursday, and the editor checks the translation by Monday morning. The final translations distribute to the chapter's 919 members by e-mail on Monday, and they are also posted on the Web site, which saw a steady rise in readership immediately after posting the content. The final product looks like this:

It is up to each week's editor to address quirks. Some elements may get cut, such as U.S. regulatory actions. Some phrases are tough to translate, such as the cartoon caption contest, called "Put words in our mouth." And, ACP InternistWeekly doesn't publish after some American holidays, so there's no news in Japan following Thanksgiving, Memorial Day or Martin Luther King Day, for example.
Thursday, November 6, 2008

Irony in medicine

It's been well established that stress leads to worse health outcomes, thus creating the paradox that reading health news can actually make you less healthy. But these recent studies in that vein seem particularly unfair:

Pregnant women who are stressed about being in debt are more like give birth prematurely. Then they can add the medical expenses of caring for a premature baby to their existing debt.

And in a study of heart attack survivors, patients who developed PTSD symptoms from the stress of having a heart attack are more likely to die within the next five years. That should make them feel lots better.

This last study probably fits better into Alanis Morrisette's definition of irony than Webster's, but what the heck:

A study of the germs on people's hands found that how much you wash your hands had little effect on the diversity of bacteria on them.
Wednesday, November 5, 2008

Will Obama achieve health care reform?

As Barack Obama's historic victory sinks in, ACP's health policy guru Bob Doherty is optimistic about the chances for meaningful health care reform. An excerpt from his post earlier today on ACP's new advocacy blog:

"Some observers speculate that an Obama administration will back away from health care reform, because it costs too much, the deficit is too high, and there are too many competing priorities. I disagree: President Obama and the congressional leadership will not allow their best chance in a generation to achieve lasting health care reform to pass them by."

Read the full post for details. Do you agree with his assessment of what the 2008 election means for health care reform?

Election results

You may have heard already that the candidate who favors universal health care, Barack Obama, won the election. But there were some other, less-publicized votes on health issues decided yesterday.

In Michigan, voters supported medical marijuana by a huge margin (63% to 37%) as well as approving the expansion of stem-cell research (allowing researchers to use embryos that were created but not used for in-vitro fertilization).

Proposed abortion bans in Colorado and South Dakota were shot down, as was a parental notification proposal in California.

Washington state residents legalized physician-assisted suicide for terminally ill patients. Under the referendum, physicians can prescribe, but not administer, lethal medication for patients who are not depressed and expected to live less than six months.

An Arizona proposal that would have made it illegal for the state to require people to have health insurance looks like it was narrowly defeated but the preliminary numbers are extremely close (867,101 no votes vs. 864,964 yeses, according to the Arizona Republic this morning).
Tuesday, November 4, 2008

Will you be talking politics today?

The results of our presidential election poll show that many of you are willing to tell us (at least anonymously) about your political views. But what if a patient asks?

A recent op-ed in the Washington Post discussed whether it's appropriate for physicians and patients to discuss politics. On the positive side, you might be able to provide useful information or convince someone to your point of view. But the discussion could antagonize patients and/or negatively affect the physician/patient relationship. As the op-ed author points out, there's also a lot of political gray area, including stem-cell research and universal coverage, that you can talk about without specifically supporting a candidate. So what do you do when the conversation turns to politics, as is likely to happen today and tomorrow?
Monday, November 3, 2008

Medical news of the obvious

One of our bloggers found this in a fortune cookie: "You could prosper in the field of medical research." This led us to wonder, how much do they pay test subjects nowadays?

Now, on with some medical research that's less prosperous and more obvious ...

Children and young teens with only minimal exposure to violent entertainment in the media are far less likely to engage in aggressive behavior, a new survey suggests.

College students drink beer and it makes them fat, researchers at Tufts and Indiana universities discovered after extensive research. (Couldn't they just have looked around campus on a Saturday night?)