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

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Tuesday, March 31, 2009

ACC '09: A vote of confidence for clopidogrel

For the 40-50% of patients with atrial fibrillation and high stroke risk who can't take warfarin, adding clopidogrel (Plavix) to their aspirin regimens might be a good bet, a new study finds. 7,554 aspirin-taking patients given clopidogrel vs. placebo in an RCT had 11% fewer vascular events, with the bulk of the difference comprising strokes (28% reduction in stroke).

Here's the catch: adding clopidogrel increased the risk of major hemorrhage by 58%, taking it from 1.3% to 2% a year. Put another way, if you had 1,000 patients on clopidogrel + aspirin for three years, you'd prevent 28 strokes and six heart attacks, but at a cost of 20 major bleeds, three of which would be fatal, said Stuart Connolly, MD, of McMaster University, at a press conference at ACC '09.

By comparison, warfarin reduces stroke risk by 38%, but increases major hemorrhage by 70%.

"We will need to work through with patients the risk and benefits," Dr. Connolly said. While warfarin is still the treatment of choice, "I think you will see clopidogrel become an alternative therapy," eventually, he added. The study is now online via NEJM.

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Monday, March 30, 2009

Statins, polypills, and more from JUPITER

Not surprisingly, the American College of Cardiology '09 meeting underway in Orlando is chock-a-block with new studies about statins. Herewith, a summary of statin-related research presented today and yesterday:


  • Is there a polypill in your future? A phase II study of 2,053 healthy Indian subjects suggests the answer could be yes. Researchers tested the "Polycap"--which combines three low-dose blood pressure-lowering drugs, a statin and an aspirin--and compared it to eight other drug therapies (each comprising one or more of the drugs in the polypill). The polypill performed best, reducing risk of heart disease by 60% and stroke by 50% without any more side effects than would occur from one or two of the medications. (Hard endpoints weren't measured in the 12-week study; BP, cholesterol and heart rate were.)

Lead researcher Salim Yusuf, DPhil, FRCPC said the five-in-one pill could reduce cost and increase compliance in those already taking the medications. And, pending future trials, it may even become something that virtually everyone over 50-55 years takes, since most people have some sort of CV risk factor by that age, he said. When questioned about whether the magic pill might lead folks to skimp on diet and exercise, Dr. Yusuf responded: "I sincerely hope this wouldn't become an excuse for McDonald's to market the polypill, and put it in with their purple hamburger."
(Click "More" below to continue reading post ...)


  • More news from Jupiter. New results from the famed JUPITER study suggest 20 mg of rosuvastatin per day can cut the risk of VTE by 43%. The trial of 17,802 healthy folks with LDL of less than 130 mg/dL and CRP of 2 mg/L or higher found reduced risk whether or not a person had certain "triggers" for VTE, like recent hospitalization or trauma. The study is online at NEJM.

  • One more hat in the ring for routine CRP testing. An RCT of 15,548 healthy people who took 20 mg rosuvastatin or placebo found that those who took statins and reached LDL and CRP goals had a 65% lower risk of cardiovascular events. This compared to a 36% lower risk for those who took the statin but didn't achieve one or both goals. The goal was less than 70 mg/L for LDL levels, and less than 2 mg/L for CRP, but those who reached more aggressive goals showed even greater reduction in CV risk. Patients were followed for a median of 1.9 years, and had LDL of less than 130 mg/dL at enrollment, meaning they didn't qualify for statins under current guidelines.

  • Still, statins don't work on everyone. Specifically, they don't work on patients with high CV risk who are undergoing hemodialysis. Researchers assigned 2,776 patients age 50-80 to either 10 mg/day of rosuvastatin or placebo for three months. By the end, there was no difference between groups on the combined endpoint of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke; nor was there a difference in all-cause mortality. This, despite a 40% lowering of LDL levels in the statin group. "I think vascular disease is so different, and involves a lot of calcification that may not be treatable with statins. So for hemodialysis patients who have undergone at least 3 months in treatment, statins don't seem to be beneficial," said lead researcher Bengst Fellstrom, MD, of University Hospital in Uppsala, Sweden. The study is online via NEJM.


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ACC conference: Resistant hypertension

A preliminary study unveiled today at ACC '09 in Orlando shows promise for patients with resistant hypertension. The first-in-man study used renal denervation to lower blood pressure in patients who were on an average of 4.7 medications, but whose blood pressure stubbornly stayed high.

The procedure involved inserting a catheter in the renal artery via the femoral artery, then sending out 5 or 6 radiofrequency signals which denervated the sympathetic nerves. Researchers tested it on 45 patients who had systolic BP of at least 160 mm/Hg, and who were on at least three antihypertensives.

The result? An average reduction of 22 mm/Hg for systolic BP sustained over 12 months, and no safety complications. Such a reduction could have "huge" benefits for mortality, stroke and heart failure, said David Holmes, MD, an interventional cardiologist at Mayo Clinic who moderated a press conference where the study was discussed.

"This procedure turns out to be simple and effective, and results in sustained lowering of blood pressure in a population that clearly needs something in addition to pharmacotherapy," said lead researcher Henry Krum, MBBS, Ph.D, director of the Centre of Cardiovascular Research & Education in Therapeutics at Monash University, Melbourne, Australia, at the press conference.

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When test results go missing, an internist searches for answers

Ethics columnist Paul S. Mueller, FACP, discusses a case study that would bring chills to any primary care provider: what happens when an internist orders test results, and then never sees the results?

From an actual case file, Dr. Mueller discusses a 61-year-old asymptomatic man seeing his internist of 10 years for a check-up. When reviewing the medical record, the internist sees PSA test results of 11.8 ng/mL. Surprised by this finding, the internist digs further. A year ago, the PSA was 8.2 ng/mL and three years ago it was normal. The patient was never told; the internist is certain she never saw it. She wonders what to do next.

Click on "More" below for advice on how to handle the disclosure of previously missed test results.

Clinicians experience negative emotions when they realize they have committed an error, Dr. Mueller writes. Nevertheless, they are ethically obligated to disclose errors to patients.

First, clinicians should act in the best interests of patients. Explain the nature of the error and its implications and continue to provide professional and compassionate care.

Second, respect for patient autonomy requires that clinicians disclose errors to patients to allow for informed decision making.

Finally, justice requires that patients be given what is due to them, such as information about their medical condition and, if injured, appropriate compensation.

In this case, the internist met with her patient and his wife to tell them that the prior PSA test result was mishandled. The patient was upset, angry and felt helpless, which internist acknowledged. However, the patient later stated that he appreciated the internist's honesty. Together, they developed a follow-up plan.

Dr. Mueller suggests these steps when disclosing medical errors
-Speak in private with the patient, his or her loved ones, and essential members of the health care team present. Avoid interruptions (such as pagers) and allow time for questions.
-Discern the patient's perception of the problem before disclosing the error. For example, you might ask, "Do you recall the results of your PSA from a year ago?" Such questions allow for correction of misinformation.
-Speak clearly and check for comprehension (such as, "Is there anything I can clarify?"). The patient should understand what happened and the consequences of the error.
-Avoid attributing blame (such as, "The laboratory must have forgotten to call me about the result"). Patients desire a sincere apology and want to know how the clinician and organization will act to prevent future errors.
-Acknowledge the patient's emotional response to the disclosure by using empathic statements, such as, "I can see that you are upset by this news."
-Formulate a plan for further assessment, treatment, and follow-up and how you will work to prevent future errors.
-Document all discussions related to the error and its disclosure.

Dr. Mueller contributes to Ethical Dilemmas, a regular column appearing in ACP Internist.

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Medical news of the obvious

If you want to survive a suicide attack, try getting as far from the bomb as you can in advance.

That's the upshot of a new study by Florida Institute of Technology researchers. The unfortunate first line of this press release about the study may just win the Obvious of the Year award:

"Florida Institute of Technology researchers have determined that where a person is standing in a room or other location during a suicide terrorist attack can have a great bearing on survival and injuries."

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Thursday, March 26, 2009

Bad TV makes for worse medical education

So many medical students and residents at the University of Alberta Hospital were using the wrong technique to insert breathing tubes that educators surveyed them about it. Many admitted they learned how to intubate from the doctors and nurses on TV, mostly from the program ER.

The educators watched a full season of ER and found, of the 22 intubations seen on screen, the head positioning was always wrong. The article is still in press at the journal Resuscitation, but a brief is available online.

With ER going off the air soon, the students will have to go back to the old way of learning that was cited by the researchers--hear a lecture, practice on a live patient with little or no supervision and then teach others.

Some other lessons med students learn from ER:
-Doctors on TV order up a lot of crike trays (probably from intubating incorrectly so often)
-Before working on any patient, pull your hair back into a ponytail.
-The cure for anything is a dose of epi--STAT!
-Ativan for a seizing patient. Unsure how much.
-It's not that your love life isn't interesting, but a patient is coding on the table.
-Patients often leave AMA. Attendings often leave in a huff.

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Wednesday, March 25, 2009

Some worms are better than others

Using maggots to treat leg ulcers works just as well as standard therapy, according to an article on the BMJ Web site.

In the study, 267 subjects with ulcers were randomized to receive either "larval therapy" or hydrogel, and monitored for up to 12 months. While removal of dead skin tissue was significantly faster with maggots (don't think about that one too much), the ulcers healed in about the same amount of time for both groups. A second BMJ study found that the cost of either treatment is about the same.

The upshot, researchers concluded, is that providers have no real reason to prefer one treatment over the other. Except, perhaps, to avoid becoming known as the doctor who likes to sic worms on his or her patients' gams.

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Tuesday, March 24, 2009

Good news for dentists

One might think the recession could be useful in getting overweight patients to shed pounds. The less you eat, the less you pay for food, right? But an unexpected foe has emerged in the battle of the bulge: the cheap, nostalgic thrill of candy.

The New York Times reports candy sales have spiked in response to the recession, as consumers seek an inexpensive way to treat and comfort themselves amid all the rotten news of late. One woman, who runs Weight Watchers meetings in Manhattan, is quoted in the article as saying that candy comes up as a foil to dieters much more frequently than it used to.

Something to keep in mind when counseling patients about diet and nutrition in these unsteady economic times. Perhaps it'd be worthwhile to help patients think of other, more low-cal ways to soothe themselves when faced with a dwindling 401K balance. A few bags of M&Ms might score you a used yoga DVD, for example...

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Monday, March 23, 2009

Medical news of the obvious

--Depressed folks have trouble remembering the good and happy things in life, and tend to focus more on the negative aspects of a situation, a new study finds. Study co-author Laura Conklin offers this helpful tip for psychologists, in case they slept through several years of their training: "Depressed people may have a tendency to remember the negative experiences in a situation, but not remember the good things that happened. Therapists need to be aware of that."

--Not having many close friends makes you feel yucky. And being lonely makes you feel even worse, according to a new study.

--Moms who eat poorly tend to have sicker children than moms who eat well. Because, you know, kids tend to get most of their food from their parents. And diet is important to health.

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Friday, March 20, 2009

Ovarian screening? Nope, nevermind.

Just earlier this week, we reported that a new study showed promise for ovarian cancer screening. A combo of transvaginal ultrasound and a CA125 blood test found early, treatable cancers, according to the research published in The Lancet Oncology. Study authors admitted that they weren't sure how the findings would translate into mortality or balance against the risks of screening.

Now it looks pretty clear that the results aren't going to be good, according to a second study. The new research, published in Obstetrics & Gynecology, found that the predictive value of the tests was only 1 to 1.3% and that a high percentage of the cancers found were late-stage. Scientists need to keep looking for a more sensitive and specific test, the study author told HealthDay.

Not a good week for screening tests.

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Thursday, March 19, 2009

A disparity you can do something about

Just about every week, a new study comes out reporting on health disparities between men and women, blacks and whites, etc. Here at ACP Internist, we've discovered that this kind of research tends to attract little interest from our readers--maybe because it seems like the same sad, but inexplicable, story over and over again. No one favors disparities in care and health, but what do you do about them?

But the latest disparity study from the NEJM comes with some solutions. Blacks are vastly more likely to develop heart failure at a young age than whites, the researchers found. They also highlighted three frequent causes: hypertension, obesity, and systolic dysfunction. Control those conditions in young blacks and the disparity in heart failure should decline. Of course, that's easier said than done (if Americans could find a way to control obesity, we'd be looking very different as a country), but it at least gives the health care community something to work on, instead of just more bad news to bemoan.

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Tuesday, March 17, 2009

For the record, 'mind your own business'

As a journalist, it's nice to imagine that sources feel at least a little bit concerned about how their quotes will be used in a story. That doesn't always happen when you work for a niche publication like ACP Internist, but I'd be pretty confident of that concern if I worked for a major, national newspaper with considerable influence over public opinion. So, it's mystifying as to why the editor of JAMA, presumably no stranger to the press, lashed out at questions from a Wall Street Journal reporter over criticisms of a published study.

The call was prompted by a critique by Jonathan Leo, a professor at Lincoln Memorial University in Harrogate, Tenn., who claims that a JAMA study involving the anti-depressant Lexapro in stroke patients omitted important information and failed to disclose a financial relationship between the drug maker, Forest Labs, and the lead author.

Contacted by the WSJ, JAMA editor-in-chief Catherine DeAngelis called Dr. Leo a "nobody and a nothing," then went on to inform the reporter that the matter was "none of your business," according to the WSJ blog. Telling a reporter to mind his own business when you know you're on the record? She might as well have held a news conference.

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Monday, March 16, 2009

Grand Rounds at ACP Internist

Welcome to Grand Rounds at ACP Internist, a newspaper serving internal medicine. We're paying tribute to the daily newspaper. Read on for the latest headlines, opinions, features and even the funnies.

Click on "More" to read the full post.



Headline News

Juvenile Diabetes Research Foundation addresses end of ban on stem cell research
By Diabetes Mine
JDRF Executive Vice President of Government Relations Larry Soler was at the White House for the signing ceremony and describes the experience.

Business News

Wal-Mart, eClinicalWorks join forces for electronic health records
By the Health Business Blog
Business reporter David E. Williams is skeptical if this joint venture will address all the problems of EHR implementation.

The Perspectives Pages

Editorial
Survey shows broad support for MDs and reform
By ACP Advocate
Voters, even Republican ones, want health care reform, including comparative effectiveness research. Surveyed patients say they trust doctors to help fix the system.

Op-eds
Error reporting should be painless, not just transparent
By Supporting Safer Healthcare
Although error-reporting is supposed to be encouraged in health care, negative consequences often fall on those who committed and/or reported the errors.

Budget-conscious patients attack doc
By Musings of a Distractible Mind
In three anecdotes, patients blame the physician for the outrageous cost of health care. Will health care reform fix the problem?

Government intervention was bad for mammography
By Kennedy's Tumor
Federal regulation reduced the financial incentives to provide mammography. The process has been standardized but not improved.

Better access should cancel out 'conscience clause'
By Colorado Health Insurance Insider
Instead of forcing doctors to provide abortions despite their moral beliefs, let's focus on making sure all communities have access to reproductive services, writes Louise.

Enough talk: psychiatry's drug addiction
By Behaviorism and Mental Health
The psychiatric and pharmaceutical industries have moved in lockstep over the past half century, matching up an ever-expanding list of mental disorders with a pipeline of new drugs, opines Philip Hickey. Instead of talking to patients, psychiatrists' days now consist of "a succession of fifteen-minute med checks."

Columnist

Old diary entries recall teen's life with diabetes
By Six Until Me
Kerri Morrone Sparling, who blogs about life with type 1 diabetes, shares snippets from her teenage diary and recalls longing for a diabetes community long before one existed.

Sports Section

Myth Debunked: Heat loss doesn't happen from the head
By The Fitness Fixer
Sports correspondent Dr. Jolie Bookspan debunks the idea that the body loses heat from the head.

Exercise reduces cravings for chocolate
By Dr. Shock
Exercise can reduce the craving for cigarettes in smoking cessation. Can it also reduce chocolate cravings?


International News

EU rules on doctors' work hours may cause delays, increase costs
By InsureBlog
Henry Stern reports on new EU work hour rules in Great Britain.

Selective decontamination is effective in the ICU
By Laika's MedLibLog
A recent Dutch study found that selective digestive tract and oropharyngeal decontamination each decreased mortality rates in the ICU.


Technology News

Telemedicine expands beyond radiology
By Hospital Impact
Telemedicine systems are moving from concept to reality in rural hospitals.

Health News

Sticking it to cancer: Acupuncture in the exam room
By Own Your Health
Since 2004, a Harvard Medical School oncologist has been offering acupuncture to patients to alleviate the symptoms and side effects of cancer treatment, transforming the sterile exam room into a more peaceful environment.

How to prevent, and treat, ingrown toenails
By Doc Gurley
In part two of her "Well Worth It" series of practical medical tips, Doc Gurley tackles the prevention and care of ingrown toenails from a patient's perspective.

Best care for a bloody nose
By Medicine for the Outdoors (via Healthline)
Wilderness Medicine expert Paul Auerbach, MD, gives a primer on treating patients with nosebleeds--and includes a bonus photo of a bloodied Brad Pitt.

The Science Section

Splendor in the grass: Researchers find new allergen in dog urine
By Allergy Notes
Everyone knows dog dander can bring misery to those with canine allergies. Now researchers have found that a protein in dog urine, called prostatic kallikrein, may bring on the sniffles as well.

New drug shows promise in treating type 2 diabetes
By Clinical Cases and Images
Liraglutide, a new drug, was better at lowering A1C, weight, hypoglycemia and blood pressure than glimepiride, and is safe and effective as initial therapy for type 2 diabetes, researchers found. (If approved, it will be branded as the less tongue-twisting "Victoza.")

Neurofeedback: The next big thing in ADHD treatment?
By SharpBrains
Treating ADHD with neurofeedback, in which a person is taught to alter his or her own brainwave patterns, has showed promise in previous studies--but they were flawed in design. A new study addresses many of the previous flaws, and suggests the treatment really may work, writes Duke psychologist Dr. David Rabiner.

Lifestyle

6 Steps to Breaking that Habit
By How to Cope with Pain
Whether you have chronic pain or not, following the stages of change can help you to either break or start a new habit.

Marriage: If it doesn't kill you, it makes you stronger
By In Sickness and In Health
Some studies show that marriage improves survival and health, while others find that it increases health problems.

Expectant moms should focus on their babies, not their weight
By The Blog that Ate Manhattan
Women miss out on some of the joy of pregnancy when they worry too much about weight gain.

Entertainment News
Former Monkee battles mouth cancer
By Suture for a Living
Peter Tork's recent diagnosis spurs a discussion of mouth cancer symptoms, risk factors and treatment.

Book Review

Memoir illuminates four facets of addiction
By Neuroanthropology
Using descriptions and insights from Caroline Knapp's book "Drinking: A Love Story," medical anthropologist Daniel Lende outlines four factors that lead a person to substance abuse: vulnerability, training, intentional use and meaning.


Weather

Have a migraine? Blame the weather
By Canadian Medicine
A new Web site offers personalized health alerts based on weather conditions, but is the science behind it sound?

Restaurant review

Illness strikes hundreds, forcing restaurant to close
By The Cockroach Catcher
Four hundred diners fall ill at world-renown Fat Duck. Am Ang Zhang investigates possible causes behind the outbreak.

The Funny Pages

Make them laugh
By Other Things Amanzi
A general surgeon working in the 'notorious' province of Mpumalanga, South Africa, relates "the only time I remember when the profs laughed at my often injudicious comments."


Cartoon Caption Contest
Each month, ACP Internist lets readers create their own cartoon captions and vote for the winner. Submit all entries by March 19. Pen the winning caption and win a $50 gift certificate good toward any American College of Physicians product, program or service. (We have a gift shop and non-clinical books for the lay reader.)

Medical News of the Obvious
Every Monday, ACP Internist skewers studies that shouldn't have needed to be done. Read more every Monday at Medical News of the Obvious.

The Final Page


We hope you enjoyed our newspaper. Now that you're finished, don't forget to recycle.

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Medical news of the obvious

--Powerful people think they can control more than they really do. (Hear that, Mr. Madoff?) Stanford researchers had students write about situations in which they had control over others, write about situations where they felt out of control, or write nothing. The students were then given the choice to roll dice for themselves or have someone else do it. Those randomized to remember situations of being in control usually chose to roll themselves, while those in the other two groups were more likely to have someone else do it.

--Worried about the harmful effects of smog as you walk or bike through city streets? Here's a high-tech solution: Wear a face mask. Reporting in the journal Particle and Fibre Toxicology, researchers helpfully explain that covering your mouth and nose can reduce "exposure to airborne pollution particles." (Cyclists might also want to avoid tailgating buses.)

--Having arthritis makes people disinclined to exercise, according to the MMWR Weekly. The study looked at the intersection of arthritis, heart disease and exercise, and found--surprise!--that people with both conditions were least likely to exercise, followed by people with one condition, followed by people with neither condition. (In all seriousness, the researchers make an important point that the ill folks should be encouraged to exercise, as it will help decrease pain.)

...And on the psychology front, researchers came to the stunning conclusion that people like to bond with one another socially by quoting popular movies, according to CNN. (Hmm, CNN... owned by Ted Turner... owner of Turner Classic Movies....). Furthermore, they like to quote from comedies more than children's films. And here I thought my Jar Jar Binks impersonation was the keystone of my cocktail party repartee.

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Friday, March 13, 2009

Pass the salt...and turn that frown upside down

We noted a while back that choosing between alcohol and abstinence may be akin to choosing between cancer and a heart attack. New research ups the ante a bit with another food-related choice: Would you rather by happy, or have low blood pressure?

Physicians have long labored to get hypertensive patients to cut down on salt, but new research suggests salt is a natural antidepressant. University of Iowa psychologists found that when rats are deficient in sodium chloride, they hang back from their favorite hobbies, "like pressing a metal bar that stimulates a pleasant sensation in their brains." (Hmm, do they make human-sized versions of this bar?)

Further, reports ScienceDaily: "Another strong aspect of addiction is the development of intense cravings when drugs are withheld. Experiments by Johnson and colleagues indicate similar changes in brain activity whether rats are exposed to drugs or salt deficiency."

Could salt-addiction treatment centers be on the horizon?

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Finally, a practical use for Twittering

One of our constant questions at ACP Internist is: What is Twitter really useful for? Everyone has a feed but no one is really saying anything. Just as we'd given up on a practical purpose for it, (surgery aside) we found two bread-and-butter applications for internal medicine: smoking cessation and weight loss.

Qwitter helps users track how many cigarettes they smoke, keep a journal, view progress over time and share info with supporters.

Next, you can Tweet what you Eat, using Twitter to set up a diary, track consumption, enter calories and find our how many are in the food you eat.

Personally, I think Twittering would help reduce smoking or eating just because it's something else to do with your hands. If you try these, or let patients try them, let us know how you fare.

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Thursday, March 12, 2009

Obama should check his facts on EHRs, say Harvard docs

At last week's White House health-care summit, President Obama made electronic health records a cornerstone of his proposal for reform, a move he said could save up to $80 billion a year, among other benefits.

Unfortunately, that's wishful thinking, say Jerome Groopman, FACP, and Pamela Hartzband, FACP, in a commentary in today's Wall Street Journal. (Drs. Groopman and Hartzband, both on the Harvard Medical School faculty, write ACP Internist's Mindful Medicine column). The 2005 RAND study upon which the president based his cost savings predictions was funded by companies that stand to benefit from selling EHRs, they point out, and new information has surface over the past four years that contradicts the study's findings.

"The RAND study and the Obama proposal it spawned appear to be an elegant exercise in wishful thinking," Drs. Groopman and Hartzband write. The two note that they voted for Obama in part because of his "openness to changing his mind when those data contradict his initial approach to a problem." They call for him to apply that kind of scientific thinking to the health care conundrum.

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Wednesday, March 11, 2009

In absence of medical home, routine care migrates to specialists

A study in the March/April Annals of Family Medicine reports that specialists are increasingly providing routine follow-up and preventive care that would be better suited to the primary care setting. With no medical home to anchor them, it seems that patients easily drift away from their PCPs.

Researchers looked at more than 1 billion ambulatory visits to U.S. office-based specialists in 2002-04 and found that 46.3% of visits were for routine follow-up and preventive care of patients already known to the specialist, while referrals accounted for only 30.4% of all visits. "The results of our study suggest now that not all activity performed by specialists when in a specialist role may require specialized care," the authors commented.

The findings strengthen the case for the medical home model of care, the authors continue, where greater efficiencies are achieved by having PCPs handle routine follow-up of chronic diseases and preventive services, such as cervical cancer screening -- leaving specialists to focus on their own areas of expertise.

(Make sure to check out our April ACP Internist cover story featuring some of the first payer-supported patient-centered medical homes in the country, part of a pilot project in southeastern Pennsylvania.)

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Wal-Mart to give EHRs the discount treatment

Most small physician offices cite cost as a big reason for not adopting electronic health records but what if they could buy their EHRs at Wal-Mart? Wonder no more. The mega-chain, known for using its huge purchasing power to offer deep discounts, announced that it will begin offering EHR packages through its Sam's Club division this spring, the New York Times reported--for about half the price currently charged by its competitors.

Wal-Mart's package will include hardware (through Dell), software (from eClinicalWorks), installation, maintenance and training. It has already test driven the technology over the past three years in its own clinics. According to the Times article, the package will cost under $25,000 for the first physician in a practice, about $10,000 for each additional physician and $4,000-$6,000 a year for annual maintenance and support. The chain is betting that its rock-bottom prices, combined with financial incentives offered through President Obama's stimulus package, will be the tipping point for doctors who've so far seen EHRs as out of reach.

It could be good news for small practices, even though Wal-Mart's ability to offer all things to all people can get a little scary. Now you can pop an EHR into your oversize cart, along with food, clothing, electronics, cosmetics, prescriptions, photos, eyeglasses -- and the list goes on. However, conditions were ripe for the retail giant to jump in. As an official quoted in the article notes, "We're a high-volume, low-cost company... And I would argue that mentality is sorely lacking in the health care industry."

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Tuesday, March 10, 2009

No performance for peanuts

This time, we're actually talking about doctors, not elephants. A new RAND study (published in Health Affairs) is the latest to assess the impact of pay-for-performance. Participating practices reported increased physician-level performance feedback and accountability, speeded up information technology adoption, and sharpened organizational focus and support for improvement.

BUT, they didn't see the P4P programs having any impact on quality. As researchers told Reuters, that might be because the performance bonuses were too small--about $1,500 to $2,000 per physician annually. "They suggested the incentives needed to be two to five times higher in order to achieve quality improvements."

Sounds like the payers need to find another zero if they want to get everyone's attention. Or just wait for the economic crisis/deflation to make the existing incentives sound relatively appealing.

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90 CVS minute clinics to close

Talk about locums tenens (the topic of our May cover story, btw). The WSJ blog reports that CVS has closed about 90 of its 550 minute clinics and plans to make them seasonal. Most of those clinics are within 10 minutes of other minute clinics, the post says, suggesting there may be a glut in the market.

So the weeding out process has begun-- or is this just another sign of patients cutting back on health care in lean financial times?

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Monday, March 9, 2009

Depression linked to cardiac death

Healthy women with severe depression have double the risk of sudden cardiac death, as well as higher risk for fatal coronary heart disease.

Depression and heart disease are linked by cardiovascular risk factors such as high blood pressure, diabetes, high cholesterol and smoking, which are more common among severely depressed women. Possible explanations could be autonomic dysfunction, higher resting heart rates and reduced heart rate variability.

Researchers prospectively studied 63,469 women from the Nurses Health Study with no evidence of prior heart disease or stroke between 1992 and 2004. They used self-reported symptoms of depression and antidepressant use, and then examined those with the most severe symptoms on a mental health index or those regularly using antidepressants. They reported their results in the Journal of the American College of Cardiology.

Low mental health index scores were associated with an increased risk of heart disease, with a hazard ratio of 1.5 after controlling for other risk factors. Sudden coronary death risk was 3.3 times greater in subjects who took antidepressants, more so than the mental health index scores, causing an editorial writer to raise the specter of needing further research into this drug class while emphasizing that the benefits outweigh the risk. As usual, one study raises more questions to answer. In the meantime, doctors should closely monitor patients with depression for risk factors for coronary heart disease.

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Medical news of the obvious

When it rains, it pours...and there were hurricane-like conditions in Obvious News Country this week. Pull up a chair and watch the storm with us:

  • People in unhappy marriages are more likely to be depressed, say psychologists at the University of Utah. Wives, in particular, have a higher risk of metabolic syndrome (and heart disease) if their marriages are strained. "Improving aspects of intimate relationships might help your emotional and physical well-being," researchers helpfully advised in a release.
  • Attention, parents! Swimming lessons for young kids do NOT increase their risk of drowning. In fact, the lessons "appear to have a protective effect," the NIH pronounced. (Your tax dollars at work, folks.)
  • When asked to turn down their Ipods, teens are more likely to crank the volume. Also, teens listen at a higher volume than adults!
  • Another thing about teens: If they wear t-shirts and baseball hats with beer and booze labels on them, they are more likely to be binge drinkers. You are warned.
  • On that topic, television commercials about drinking make you want to drink, Healthday reports. Madison Avenue breathed a collective sigh of relief at the news...and poured itself a tall one.

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Friday, March 6, 2009

MRSA shouldn't be funny, but...

We know new information about MRSA is of great interest to our readers, so here's an important news update from the CDC's Morbidity and Mortality Weekly Report. An outbreak of community-acquired MRSA in San Diego has been traced back to...a hospital worker? a football team? No, a baby elephant!

But don't throw out your zoo passes yet. The CDC's brave investigators (you have to respect anyone who takes rectal samples from a herd of elephants) have isolated the behaviors which put one at highest risk of developing EA-MRSA (that's my suggested acronym for elephant-acquired Methicillin-resistant Staphylococcus aureus). Among the highest risk activities: bathing the elephant, doing his laundry, and...I'm not making this up...trunk blowing. A helpful footnote to the CDC report explains trunk blowing as "Caretakers blew air with their unmasked mouths into the calf's trunk to stimulate bottle feeding."

This funny story has a sad ending though. The 13 humans infected with MRSA recovered without surgery or hospitalization, but the little elephant that started it all failed to thrive and had to be put to sleep.

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Dr. Gupta withdraws from Surgeon General consideration

Sanjay Gupta, MD, withdrew from consideration for the Surgeon General post. He hadn't been formally nominated, but the White House had announced he was a serious contender.

He hadn't been a popular choice in an informal poll of ACP members, who wanted to see more government or primary care experience in a candidate.

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Thursday, March 5, 2009

Let them eat drugs: An update

An official tip of the hat today to the CDC.

Back in January, we wrote about how grocery store pharmacies were handing out free generic antibiotics....and how this might not be such a great way to curb the spread of antibiotic resistance.

Today, the New York Times reports that the CDC has sent letters to these places, asking them to dole out their medi-candy carefully. Of particular concern, says the article, is the fact that the stores are linking the drug giveaways to cold and flu season, thus intimating that antibiotics can cure these viral conditions. So the CDC basically said "Hey. Cut it out."

True, the CDC took a couple months to get around to doing this. And cold and flu season is already winding down. But if this had been in the hands of certain other three-lettered government agencies, it might not have happened till next Halloween.

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Smoking without the stigma

A press release that crossed our desks recently plugged an electronic, smokeless cigarette made by a European company called SuperSmoker. It's billed as a revolutionary way to kick the habit without giving up the look and feel of actually smoking.

The device itself looks just like a cigarette, comes in similar packaging and is available in normal, light, zero and menthol. But the "smoke" is really odorless water vapor that dissolves harmlessly into the air, thus not aggravating friends, family and co-workers and allowing smokers to stay inside talking to their non-smoking friends during breaks. The unit is powered by a rechargable battery.

The other part of its appeal is nicotine, contained in replacable cartridges, although the company maintains that it doesn't produce tar and has no cancer-causing substances. The FDA has not approved electronic cigarettes but it has caught on in some places, according to this article in the New York Times.

Will electronic smoking be the answer for the many who've tried and failed to kick the habit? Maybe, but won't smokers still be left with nicotine addiction?

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Wednesday, March 4, 2009

Fight back against feedback

Doctors dissatisfied with their online ratings are seeking to have them removed. One advisor suggests asking patients to sign waivers not to post reviews online.

This issue isn't new. Two years ago Texas doctors took a stand against insurers' rankings by ranking the insurers.

While it's important to protect a practice's good reputation, the best way to get a good review is to offer a good experience. If it's time to brush up on patient management skills, here's some suggested reading:
Make the wait shorter and nicer
Reduce bottlenecks
Consider ACP's Center for Practice Improvement and Innovation
Greet your patients properly
Don't be rude

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Tuesday, March 3, 2009

Best drug info doesn't come over free lunch

It's tempting to embrace newer generation drugs that are either more effective or cause fewer side effects than older drugs, but there's also wisdom in waiting for the dust to settle, if the current controversy over the atypical antipsychotic quetiapine (Seroquel) is any indication.

Quetiapine made the news again recently in connection with a federal court case during which manufacturer AstraZeneca PLC revealed a previously undisclosed analysis of studies showing that the newer drug was less effective than the conventional antipsychotic haloperidol, which it was supposed to improve upon, according to the Wall Street Journal.

Court papers have produced other unsettling revelations, including that AstraZeneca apparently told its sales reps to downplay a possible connection between quetiapine and diabetes, even though its own physician had once stated that a link was probable, the Wall Street Journal also reported. The company now faces more than 9,000 lawsuits from people alleging that they developed diabetes after taking quetiapine.

Those reports come after a study published last month in the New England Journal of Medicine concluded that patients taking atypical antipsychotic drugs (clozapine, quetiapine, olanzapine, and risperidone) faced a higher risk than non-users of sudden cardiac failure.

The reports seem like a good reason not to rely on the sales rep for information about new drugs, and to turn to unbiased sources such as Rxfacts, a project initated by Jerry Avorn, MD, and colleagues at Harvard. (See a related ACP Internist article on the project.)

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Monday, March 2, 2009

Medical news of the obvious

Medicare rewards physicians for providing care even when it is not needed. It may not be generally obvious, but it certainly comes as no surprise to doctors that "huge inefficiencies in the U.S. health care system are hamstringing the nation's ability to expand access to care," according to a new report from the Dartmouth Atlas Project published last week in the the New England Journal of Medicine.

Giving kids more unsupervised time encourages bad behavior, concluded a study of fifth-graders in the April issue of the American Journal of Preventive Medicine. Kids who worked (mostly babysitting or yard work) were more likely to try alcohol or get into fights than their unemployed 10-year-old peers, said researchers, who recommended that parents get to know their kids' "employers."

A British neuroscientist claims Facebook and Twitter are altering teenage minds. Baroness Susan Greenfield, director of England's Royal Institution, addressed her country's House of Lords about social media's impact. (How real-life experiences change the brain is her area of expertise.) She told the Lords, "Social networking sites might tap into the basic brain systems for delivering pleasurable experiences, but ones devoid of narrative or long-term significance. As a consequence, the mid-21st Century mind might be almost infantilised into one characterized by short attention spans, sensationalism, inability to empathise and a shaky sense of identity." That teens are self-centered is old news to us at ACP Internist's blog. And Twitter is now a surgical teaching tool, sort of. As for blogging, well, it's not narcissistic at all. We do it with great humility. Really!

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Urbanites have trouble finding healthy food

The availability of healthy food choices and quality of diet is worse for impoverished urban denizens than suburban residents, according to two studies conducted by researchers at the Johns Hopkins Bloomberg School of Public Health. The studies examined healthy food availability and diet quality in the city of Baltimore and its surrounding county.

They found 46% of lower-income neighborhoods had a low availability of healthy foods, items such as fresh fruits and vegetables, skim milk and whole wheat bread as recommended by the U.S. Department of Agriculture. Geography plays a larger role in dietary health than previously estimated. And, 24% of the black participants lived in neighborhoods with a low availability of healthy food compared with 5% of whites.

The second study examined the availability of healthy foods across 159 neighborhoods and 226 neighborhood stores in Baltimore and the surrounding county. Researchers found that 43% of predominantly black neighborhoods and 46% of lower-income neighborhoods had low availability of healthy foods, compared to 4% and 13%, respectively, in predominantly white and higher-income neighborhoods.

Where you live is a major determinant of your health, and staff at ACP Internist noted that this study could happen in our hometown of Philadelphia and probably get the same result. It could happen in any city, we suspect.

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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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