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

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Friday, February 27, 2009

Wanna lose weight? Eat less!

The big diet study in this week's NEJM seemed like a good target for news of the obvious, but since the mainstream media is giving it tons of positive attention ("The secret to weight loss," screamed cable news), we'll play along.

In short, researchers assigned 800-some patients to three different diets with varying proportions of fat, protein and carbohydrates. They found that a) patients weren't very good at sticking to the instructions so they ended up eating more similarly than intended and b) people lost weight at the start of diets but then started gaining it back within two years.

So, the good news is that successful weight loss is not complicated (any kind of diet works as long as it's lower in calories), but the bad news is that it's really hard. As an accompanying editorial said, "even these highly motivated, intelligent participants who were coached by expert professionals could not achieve the weight losses needed to reverse the obesity epidemic."

Need some humor after that depressing news? Check out the "Clinical Directions" comments that accompany the study on the Journal's website. Readers offered a number of interesting weight-loss techniques, including eating like a caveman, following the advice of Muhammed, and carrying a tape measure everywhere.

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Thursday, February 26, 2009

Best care doesn't always get best ratings, doc finds

Medicare's Hospital Compare Web site attempts to help the public compare hospitals based on quality of care, but it can also make good doctors look bad, WhiteCoat blogs.

Case in point #1: Docs are required by offical quality indicators to give thrombolytics within 30 minutes of a heart attack patient's arrival. But what if that patient also just suffered a significant head injury? Does the doc try to meet the 30-minute window by skipping the CT scan, thus risking the patient's life if there is internal bleeding? Of course not, says WhiteCoat, but according to Hospital Compare, "my decision made me a bad doctor."

Don't trust everything you read on the comparison site, WhiteCoat concludes.
But how do patients separate the wheat from the chafe?

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Salmonella, and the sign of the devil

Though it seems like it's gone on forever, the salmonella-related peanut recall is far from over. New products are still added to the FDA's "recall" list on a daily basis, and the number of products on that list is well over 2,000.

A new poll by the Harvard School of Public Health finds that the public, while generally aware of the recall, is unaware of its scope. Less than half of those surveyed knew it includes snack bars, pre-packaged meals, ice cream, candy and jars of dry-roasted peanuts.

One big problem is that a lot of these products are the type that will sit on shelves or in freezers for months (or years), and by the time they are used, people will have long forgotten the recall. Providers should encourage patients to search their cabinets and freezers for any products that may contain peanuts, and check them against the searchable, online FDA database of recalled items (Too bad the URL is so unwieldy: www.accessdata.fda.gov/scripts/peanutbutterrecall/index.cfm).
Consumers can also call 1-800-CDC-INFO (1-800-232-4636) for product info.

(The latest figures, btw, show the outbreak has sickened 666 people in 45 states. That's right, 666.)

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Wednesday, February 25, 2009

What's your poison?

While there has been evidence galore that alcohol in moderation may be good for your heart (see this, this and this for a few examples), a new study has raised a serious counterpoint. The study from the Feb. 24 online Journal of the National Cancer Institute found that women who drank even small amounts of alcohol were at higher risk of cancer than those who drank nothing.

To wit, for every extra drink per day, the increase in incidence per 1000 women was 11 for breast cancer, 1 for cancers of the oral cavity and pharynx, 1 for cancer of the rectum, and 0.7 each for cancers of the esophagus, larynx and liver. That adds up to 15 cancers per 1000 women, the journal said. Put another way, the authors estimated that about 13% of cancers of the breast, aerodigestive tract, liver, and rectum could be attributed to alcohol, an editorial noted.

The editorial goes on to say: "From a standpoint of cancer risk, the message of this report could not be clearer. There is no level of alcohol consumption that can be considered safe."

Has it come to this: Hesitating at the wine or beer aisle, as you contemplate whether you'd rather have cancer or heart disease? That's being melodramatic, of course, but what should a PCP tell a patient who asks whether she should be drinking a glass of wine a day "for her heart"?

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'Cat-boy' and evolution in action

It's not the most credible source of medical news, but London's The Sun reported on a Chinese child with the ability to read in perfect darkness. The rest of the world has picked up on this report of a strange side effect of leukodermia (vitiligo), although The Sun put its typical spin on the story of "cat-boy."

Normally, you could wrap your fish-and-chips in The Sun and that's it, but this made me think of other, more credible reports of genetic mutations that offer evolutionary advantages in humans, specifically their eyesight. Millions of women may have the ability to see an extended range of color--for example, seeing ten colors in a rainbow instead of the seven the rest of us can see. Tetrachromacy, as it's called, is another example of evolution in action. It's been put forth over the years that seeing more colors helps species find riper foods or avoid poisonous ones.

We're in the 150th anniversary of Charles Darwin publishing On the Origin of Species and we're still learning new elements of evolutionary theory and its potential impact on medicine.

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Tuesday, February 24, 2009

Crying wolf: Bypassing EHR drug warnings

WhiteCoats blogs that a recent Archives of Internal Medicine study about the tendency for most doctors to override electronic health record warnings of potential drug interactions, "shows how forcing clinicians to jump through more and more micromanagement and regulatory hoops in order to practice medicine won't necessarily have the intended effect."

The study, which analyzed 233, 537 medication safety alerts generated by 2,872 clinicians in three states in 2006, found that a majority of clinicians bypassed most high-severity DDI and allergy alerts. Researchers concluded that the current warning system falls short of providing meaningful patient protection.

But WhiteCoats counters that since there hasn't been a flood of adverse outcomes reported, maybe the warnings are overblown. Alerts lose power when too many turn out to be theoretical dangers that don't apply to actual individual patients. What do others think? Are electronic reminders of DDIs helpful or just more annoying pop-ups?

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Smorgasbord at Grand Rounds

The latest issue of Grand Rounds, hosted this week by "The blog that ate Manhattan," is an appetizing menu of medically related posts about food. Check out entries from around the blogosphere, including a critique of the New York City health commissioner's low-salt initiative or the relationship between diet, exercise and chronic pain, among many others. (Look for ACP Internist in the "beverages" section.)

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Monday, February 23, 2009

Temper, temper

The stereotypical image of the angry person suddenly clutching his or her chest might have found some physical evidence. Not just stress but strong emotions may lead to potentially lethal ventricular arrhythmias.

Researchers studied 62 patients with implantable cardioverter-defibrillators who underwent monitoring during a mental stress test that asked them to recall a recent situation in which they were angry.

Researchers measured the patients' T-wave alternans (TWA) and then followed them for a mean of 37 months to determine who had arrhythmias that triggered their pacemakers. Patients with higher levels of anger-induced TWA were more likely to trigger their pacemakers--a predictor of heightened risk of up to ten times that of other patients.

Combining exercise tests with mental stress test may help clinicians better select patients likely to have arrhythmia and benefit from a defibrillator, and it might provide insight for patients who can't exercise, researchers wrote in the Journal of the American College of Cardiology.

Naturally, therapies focused on helping patients deal with anger and other negative emotions may help reduce arrhythmias and, therefore, sudden cardiac death in certain patients. It's not the first time anger's been linked to heart disease, but researchers said we are beginning to understand how anger and other types of mental stress can trigger potentially lethal ventricular arrhythmias.

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Medical news of the obvious

Our focus this week is on smoking. A new study in BMJ finds that smoking is bad for you, even if you're rich! As reported by HealthDay, the authors conclude that "in essence, neither affluence nor being female offers a defense against the toxicity of tobacco." So much for the magical properties of our solid gold cigarette holder.

In other bad-but-perhaps-already-known news for women, a group of public health investigators have determined that tobacco companies are trying to make cigarettes appealing. To quote HealthDay again, cigarette ads "depict cigarette smoking as feminine and fashionable rather than the harmful and deadly addiction it really is."

And while we're on the subject, we've got to mention this study, even though its conclusions are far from obvious. A signficant proportion of surveyed smokers said that while the effects of smoking on their own health are not sufficient motivation to quit, they would stop smoking if they knew their pets were being harmed by the habit. Really, people? Really?

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Friday, February 20, 2009

Brain food

Food studies are a staple (pun intended) of medical conferences, and International Stroke Conference 2009 is no exception. As usual, tea and coffee are front and center in the research, though fast food gives them a run for their money. Without further ado:

--Three cups of green or black tea per day lower one's risk of ischemic stroke by 21%, according to a meta-analysis of tea studies from around the world. Pooled results of the 10 studies that examined tea consumption and ischemic stroke found black tea reduced risk by 24%, and green tea by 21%.

--Lest you think you need to swap your morning cuppa joe for tea, take heart: Coffee is also associated with reduced stroke prevalence, an analysis of national health survey data (NHANES III) found. The more you drink, the lower your risk--despite the fact that many heavy coffee drinkers also smoke. Stroke prevalence went from 5% for those who drank 1-2 cups per day, to 2.9% for those who drank more than six cups a day. Cardiac disease, diabetes and hypertension also declined as cups of coffee went up. Could it be that the fountain of youth spurts coffee instead of water?

--To avoid temptation, you might want to skip buying that coffee (or tea) at a fast food restaurant: People who live in neighborhoods with lots of fast food restaurants have a higher stroke risk. Specifically, for each fast food restaurant in a neighborhood, the relative risk rose by 1%. Authors cautioned that this is a correlation--they don't know if the fast food causes the higher risk, or if fast food restaurants are merely a marker of unhealthy neighborhoods. Admittedly, these results seem sort of obvious, but it's interesting that they held up even after researchers controlled for demographic and socioeconomic factors.

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Stroke 2009: Young and dismissed

It's a small study, but no less disturbing for that. Apparently, if you are unlucky enough to have a stroke at the ripe old age of 34, you have the additional bad luck of possibly being misdiagnosed because you don't fit the typical profile of a middle age-to-older patient.

Researchers reviewed data on 57 stroke patients, age 16-50 years, from the Young Stroke Registry at Wayne State's Comprehensive Stroke Center, and found 14% were misdiagnosed and sent home. They were told they were having vertigo, or migraine, or alcohol intoxication, but were later found to have had a stroke.

The study didn't compare this rate of misdiagnosis to that of a more typical (i.e., older) stroke population, but some of the specific examples are chilling. An 18-year-old guy was told the numbness on his left side was due to being drunk; a 37-year-old who had trouble speaking was told she was having a seizure; and a 48-year-old with blurred vision, an off-balance walk and trouble speaking was told she had an inner ear disorder.

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Thursday, February 19, 2009

Stroke news of the obvious

And in our special conference issue of Stroke News of the Obvious...a study out of UNC that finds it takes longer to care for stroke patients in emergency departments that are overcrowded than those that are not. Specifically, it takes longer to triage the patients to ED rooms, physician assessment and hospital beds. "ED clinicians may need to attend to methods of increasing the efficiency of personnel and care processing during periods of overcrowding," the study authors smartly concluded.

Separately, stroke survivors are more likely to fall if they have impaired mobility, have a history of falling, and are still experiencing pain and injury from a previous fall...versus people who can get around just fine, haven't ever fallen, and are feeling healthy to boot. Also, older stroke survivors are more likely to fall than younger ones.

And finally, stroke patients who have heart failure are more likely to die in the hospital than stroke patients without heart failure. (I'm going to go out on a limb and say that adding a serious condition to anyone's health profile is, most likely, going to put her at a disadvantage vs. someone without that extra condition.) Stroke + heart failure patients also stayed in the hospital longer and required more intensive care than those with stroke alone.

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Post-stroke depression: cultural differences

I went to a session far too early this morning on cross-cultural differences in post-stroke emotional distress. It focused mainly on post-stroke depression in both patients and caregivers, though there was some mention of post-stroke anger as well. The upshot seemed to be that there isn't a great deal of research in this area; most of the info about cultural differences comes from the general depression research, or research on depression related to diseases other than stroke. Some interesting tidbits:

--Research on depression in caregivers of patients with dementia suggests that Asian and Hispanic American caregivers are more prone to depression than whites, while African American caregivers are less prone to it. One study on stroke patient caregivers found African American caregivers had a 3.7 times lower risk for depression than whites.

--There is some evidence that genetic differences in ethnicities may affect both the likelihood of getting depression and response to treatment, but it's complicated. Several genes seem to be involved, such that a mutation in any single gene accounts for only a small portion of the disease risk.

--There is some evidence that while somatic symptoms of depression may be the same between cultures, cognitive symptoms may be different. For example, Westerners are more likely to report psychological symptoms than the Chinese. Treatment response appears to be the same among different cultures, however.

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Gender differences in stroke

Several studies were presented at Stroke 2009 today on gender differences in stroke. Here are summaries of two, with more to come:

--A meta-analysis of 18 studies, presented by Archit Bhatt, MD, found that women with acute stroke have 30% lower odds of getting tPA treatment than men. When the analysis pulled out four studies that specified the patients had arrived at the hospital within the 3-hour tPA window, women were still 19% less likely to get treatment--but the difference was no longer statistically significant.

--Louise McCullough, MD, et al reported her findings that women arrived at the emergency department of a single stroke center later than men, despite having strokes of similar severity. Yet unlike Dr. Bhatt's study, Dr. McCullough found that, once the women got to the ED, they were treated just as quickly and often as men. She suggested a number of reasons why women may arrive at the ED later, including the fact that women may not be recognizing their stroke symptoms, or are more likely to be older/living alone when having stroke (thus an observer may not be around to help them get to the ED).

These results are interesting in tandem. Clearly, if women get to the ED later, they are less likely to be eligible for tPA (due to the three-hour time window), which could partly explain Dr. Bhatt's finding that women are less likely to get tPA than men.

The take-home message for internists, I think, is to really hammer home those stroke signs and symptoms with patients, particularly those who are at high risk.

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Wednesday, February 18, 2009

Stroke '09: Local color


These folks gave a talk to media and bystanders, complete with ambulance and stretcher props, about San Diego's emergency stroke response system. To hear them tell it, a call to 9-1-1 sets into motion a highly choreographed series of events-- a neurologist being paged, a radiologist securing a machine for imaging, a nurse clearing a bed for possible admission, so that everyone is ready to go when the patient arrives. Of course, one would like to think this happens everywhere, but there are many areas of the country which don't have well-oiled stroke plans.

I was a little disappointed that we didn't get a tour of the ambulance-- or better yet, a quick spin through town-- but left feeling that, if I had to have a stroke somewhere, San Diego seems like a good place to do it. (Admittedly, I say this having no real sense of how this city stacks up vs. other places in overall stroke care. And having no real desire to have a stroke, ever.) California in general seems committed to a tidy stroke response, according to Dr. James Dunford, the city's emergency medical director: There's a statewide task force underway to help all of the state's communities develop organized stroke response plans, he said.

(Pictured left to right: Dr. Patrick Lyden, medical director of UCSD Stroke Center; Dr. James Dunford, emergency medical director for the city of San Diego and an emergency department doctor at UCSD; and Vicky Powell, a stroke survivor who benefitted from UCSD's emergency response system.)

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Stroke '09: Reaching the underserved

One of the biggest issues in stroke care is how to help patients in "neurologically underserved" hospitals-- places that either don't have access to a specialist, or where a specialist isn't always available to help in the emergency department. (A situation, btw, which can occur in urban hospitals as well as those in rural areas.) Telemedicine (consultation with stroke experts via audio and video feeds) and "drip and ship" (transferring patients to regional stroke centers after they get tPA) are two increasingly common ways to deal with the issue. And both got a vote of confidence in new studies presented at Stroke '09.

Catalina Ionita, MD, University at Buffalo Neurosurgery, Inc., compared outcomes of thrombolyzed stroke patients at a telemedicine "hub" hospital (Millard Fillmore Gates Hospital in Buffalo, NY), with those of the 10 "spoke" hospitals it served. While there were some differences in terms of length of stay and stroke severity, the clinical outcomes were basically the same for patients treated at both-- suggesting that access to a top-notch stroke team via telemedicine is essentially as good as being seen by one personally.

A second study gave a boost to the growing practice of "drip and ship", whereby patients get tPA treatment at a community hospital, and are then transferred to a regional stroke center for follow-up care. Outcomes were similar for patients given tPA at community hospitals and then transferred, vs. those given tPA at the regional stroke center from the start. That's good news, since the alternative to drip and ship is to immediately transfer a community hospital patient to a regional center for tPA, which can be problematic given the 3-hour window for administering the treatment.

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Stroke 2009: Time is brain

Not surprisingly, the first abstract presented to the media here at Stroke 2009 dealt with the perennial issue of tPA timing.

Dr. Jeffrey Saver, director of UCLA's Stroke Center, reported on his huge registry study which found that patients who arrived at hospitals within an hour of stroke symptom onset were more than twice as likely to get tPA as those who arrived in the second or third hour. About 30% of the 100,000+ patients studied arrived within that first hour.

The bad news, however, was that doctors took 15 minutes longer to actually treat these first-hour patients than those who arrived later, perhaps thinking they had a bit of a time cushion to ensure that treatment was the right decision. Current guidelines recommend a "door to needle" time for tPA of 60 minutes from hospital arrival-- and for these patients, the average time was 90 minutes.

"There's a natural tendency for physicians to say we have some extra time to learn about the nature of stroke and make a more deliberate decision...but we are trying to highlight (that for) patients who get to hospitals early, we need to match that effort, and treat those patients more quickly," Dr. Saver said. "For every ten minutes that tPA is delayed, one less patient benefits from it."

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Twittering in the OR

We're getting used to seeing everything on YouTube these days, and surgery is no exception. Now, technology is letting us eavesdrop as well. As CNN reported yesterday, physicians used Twitter to give a blow-by-blow account of removing a cancerous tumor from a man's kidney at Henry Ford Hospital in Detroit. (CNN notes that you can read the "Tweetstream" and link to the YouTube video here).

The surgeon's musings during the operation were dutifully recorded in real time on Twitter by the chief resident. "Tweeple" (Twitter users) worried along with the surgical team when the surgeon announced that the tumor was larger than expected and may require a radical nephrectomy. Everyone breathed a collective sigh of relief after bleeding was controlled and a successful partial nephrectomy accomplished.

The surgeon said he agreed to Twitter because he wanted to show that a tumor could be removed without taking the entire kidney. Other Twitter enthusiasts say it engages people in medicine and makes complicated procedures more understandable. But is Twittering for everyone or is it an example of social networking run amok?

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Tuesday, February 17, 2009

And how are you finding your stent, sir?

It used to be that only teachers and critics gave grades and reviews. Now Netflix asks you to rate every movie you watch and even Kmart receipts ask for your opinion. Two news items out this week show how far the trend has moved into health care.

First, Zagat announced their expansion from restaurant-rating to doctor-rating. According to the NY Times, patients insured by WellPoint (in certain areas) will be invited to rate and comment on their doctors through a Zagat site (viewable only by other WellPoint insureds). Not surprisingly, the announcement didn't attract a lot of positive feedback from physicians. Who wouldn't rather take their job pass/fail?

More likely to please docs was the news that Obama's stimulus bill includes funding for comparative effectiveness research. Up to 15 employees and $1.1 billion will be allocated to reviewing existing research and conducting new comparison trials of various treatment options. Sounds like some grades that could be pretty useful, although critics worry that it's the first step toward rationing health care by cost. For more on the stimulus bill's impact on medicine, check out the The ACP Advocate blog.

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Monday, February 16, 2009

Database may speed diagnosis of drug-resistant TB

A new publicly available Web database allows quick searches of specific mutations associated with drug-resistant tuberculosis. The tool includes the most common mutations found for the major groups of anti-TB drugs, something researchers hope will speed development of new sequence-based diagnostic tools and avoid treatment delays "during which patients receive suboptimal therapy that may lead to development of additional resistance and further spread of drug-resistant TB," according to researchers who developed the tool.

The database is easy to use, just click on a drug class, such as aminoglycosides or ethambutol, select a gene associated with resistance, and a histogram pops up displaying the mutations and corresponding confidence levels.

The research behind the database is explained in a study by led by Harvard epidemiologists published in the current issue of PLoS Medicine.

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Medical news of the obvious

Changes in brain activity, triggered by physical exercise, may help reduce cigarette cravings, concludes a study in Psychopharmacology. Smoky lungs and running don't mix -- the brain's bound to pick up on that.

Those who blurt out the answers in group setting are seen as more intelligent and competent, even when their answers are wrong. Researchers used this to explain how incompetent bosses survive the workplace. Worse, those who chimed in second or third, even if only to agree with the original wrong answer, were also thought of as more competent (think the office toady who shouts encouragement at a bumbling boss).

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Friday, February 13, 2009

Still doing it the hard way

Medicare is probably not going to pay for virtual colonoscopies, according to a story in today's New York Times. The agency found insufficient evidence to support the alternative technology. Not surprisingly, the endoscopic gastroenterologists cheered, while supporters of the CT scans jeered.

Who's right? Hard to say, since no one knows exactly how many more people would sign up for colonoscopies if they had access to the virtual technology. But based on the preliminary CMS decision, it looks like we won't be finding out anytime soon. The agency is accepting public comment for 30 days before making a final ruling on the subject, which experts expect to be against virtual scans.

An article and video in ACP Internist recently assessed (and offered some solutions to) the challenges of getting patients to submit to colonoscopy.

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Thursday, February 12, 2009

Making medicine politically correct

Here at ACP Internist we've had occasional debates about the PCing of medical writing. For example, patient advocacy groups would have one say "people with diabetes" instead of "diabetics" so as not to make the disease more of a focus than the person. But when you're writing about diabetes, and therefore, only mentioning said anonymous, unnamed person because they have diabetes, is it not socially acceptable, and vastly less cumbersome, to refer to him or her as a diabetic?

As the NY Times reports today, the International Longevity Center has raised the standard of PC medical language even further by publishing a list of forbidden synonyms for "old." Not only should we not refer to those with more chronological life experience than us as "coots" or "hags," but "elderly" and "senior citizen" are also to be axed. The experts suggest instead the problematically nonspecific (from a medical writer's perspective) term "older adult."

As one commenter to the NYT article noted, would not our effort be better spent trying to correct the pejorative connotations associated with being "elderly" or--to continue the parallel, the negative consequences of being "diabetic"--than repeatedly changing the terminology? After all, how long did it take for "special education" to go from polite euphemism to children's insult?

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Wednesday, February 11, 2009

Primary care shortage: IMGs filled in gaps, but that's changing CDC says



As the primary care physician shortage worsens, international medical graduates (IMGs) have been critical to filling in gaps in care, especially in underserved areas, according to a CDC report released today.

In 2005-06, one quarter of all visits to office-based physicians were to IMGs, the report says. IMGs also saw a higher percentage of patients using Medicaid or SCHIP as payment compared with their U.S. counterparts and were more likely to practice in shortage areas outside of big cities. However, the report warns that it's getting harder to recruit IMGs to shortage areas because more are coming to the U.S. on less-restrictive visas. The U.S. may face "challenges" if visa policies affecting physician supply remain unchanged, the authors conclude.

With so many new medical graduates rejecting primary care for higher paying specialties and communities struggling to attract primary care docs, should we go back to forcing IMGs to practice in underserved areas as a condition of their visas? Or will the situation force the government to move faster on reforming the dysfunctional Medicare reimbursement system?

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Tuesday, February 10, 2009

Grand Rounds is up

The latest issue of Grand Rounds is up on The Health Care Blog. Host Matthew Holt provides a round up of the best medical postings on the blogosphere over the past week, including a selection from ACP Internist.

Check it out and sign up for the RSS Feed. ACP Internist is slated to guest host the March 17 edition.

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Athletes want to share the fat


Studies about weight typically focus on how to lose it, but a recent study in Spain reveals that fat is sometimes coveted in the world of professional sports.

Researchers at the University of the Basque Country hypothesized that top-flight soccer players are generally more satisfied with their body images than other young men, according to a news release from Spain's Scientific Information and News Service. Predictably, a control group of university-age men said they'd like more muscular bodies but another group of Spanish League soccer players said that while they always try to build muscle they'd also like to add body fat in order to look more like other young men their age. Goes to show that the grass is always greener...

Turns out fat can also help you look younger, according to a new study of identical twins. After age 40, twins who had substantially higher BMIs than their identical sibling also had much younger looking faces.

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Monday, February 9, 2009

Medical news of the obvious

People are more likely to eat expired food if they already own it, a group of researchers offering rotten smoothies discovered. "Our results help explain why a person might consume expired food that they found in the fridge, but not consume expired food found in a friend's fridge," a study author told the Washington Post. Either that, or because it's generally frowned upon to go over to someone's house and start rooting through their moldy leftovers for a snack.

Further confirming that they are not familiar with actual human behavior, the researchers also attempted to analyze the "five-second rule" of eating food off the ground. Kindergartners everywhere are eagerly awaiting follow-up research to confirm precisely when dropped food becomes too dirty to eat.

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Thursday, February 5, 2009

Helping patients manage high cost of cancer care

More cancer patients are surviving their disease but finding that recovery, too, exacts a high price. According to research presented this week at the American Association for Cancer Research conference, many survivors--even those with health insurance--forgo needed medical care due to cost, Reuters reported. According to National Cancer Institute researchers, the prevalence of neglecting care for financial reasons was 7.8% for general medical care, 9.9% for prescription medication, 11.3% for dental care, and 2.7% for mental health care.

In light of those findings, it's fitting that American Society of Clinical Oncology has come out with practical financial guidance for cancer patients. The group's Cancer.Net Web site now has a section about managing the cost of cancer care, including suggested questions to ask your doctor and other professionals. Beyond the strictly medical treatment and medication-related questions, the site lists issues to consider surrounding transportation, living expenses, long-term care and employment issues, for example, as well as a list of organizations that offer financial support to cancer patients.

It's a nice resource for physicians to recommend to patients burdened by financial worries related to their illness.

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Wednesday, February 4, 2009

Not for the squeamish

We profiled the new field of NOTES (natural orifice transluminal endoscopic surgery) in ACP Hospitalist a while back. Diseased gallbladders, kidneys and the like were being taken out through mouths, vaginas and other pre-existing holes in the body. Now surgeons at Johns Hopkins have made a great leap forward, removing a kidney from a donor through her vagina and implanting it in her niece. How'd it go? "Easier than childbirth," the donor told the Washington Post. Reportedly, the next expected advance in the field will be to remove usable organs through the rectum. We don't want to know what donors will compare that experience to.

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Tuesday, February 3, 2009

Redefining "organic"

Organic: Characteristic of, pertaining to, or derived from living organisms.
--Random House Dictionary, 2006

Every day when I come to work, my email inbox is flooded with more product recalls from the FDA, thanks to those darn salmonella-tainted peanuts. The vast number of products supplied by the Peanut Corp of America plant amazes me: they range from store-brand ice cream to high-end "organic" protein bars.

Huh. I never realized the "organic" label referred to animal feces. Though I suppose that is just about as organic as it gets.

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Monday, February 2, 2009

Medical news of the obvious

--Makeover shows like "The Swan" and "Extreme Makeover" don't help women feel better about themselves or the way they look; the shows make them anxious about their bodies, a study in Configurations finds. Interestingly, college students in Buffalo who watch the shows had more body anxiety than those in L.A., Science Daily reports. The L.A. students were more likely to feel that having an imperfect body was a "moral failing," while the Buffalo students worried that it would keep them from being successful.

--Undergrads who play a lot of video games are isolated and don't have great relationships with their peers or families, a study in the Journal of Youth and Adolescence finds. They are also more likely to smoke pot than those who don't play.

--Songs can evoke memories, researchers trumpeted in the Psychology of Music journal. It doesn't matter whether you hear a snatch of a song, see a picture of the song artist(s) or read the lyrics-- all function equally well at triggering memory.
So let's try this out. Here's the song: "1999" by Prince. Any memories springing up out there?

--High-schoolers who watch too much TV are likely to develop bad eating habits, researchers reported in the International Journal of Behavioral Nutrition and Physical Activity. The study of 2,000 high- and middle-school students also pointed out that TV ads might influence students to make bad food choices. (So that's why they ditched their morning oatmeal for a bowl of triple choco-marshmallow puffs!)

--The expectation of post-operative pain directly correlated with the actual incidence of pain following foot and ankle surgery. Researchers thought that, "Believing there will be pain after surgery leads to just that, pain." They continued that cancer patients who have a more optimistic outlook experienced less severe pain.

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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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