But today I received the press release that crossed the line. It began, "The worst case scenario for a Swine Flu epidemic looks grim, according to government sources. Two million dead. Hospitals overwhelmed. Schools closed."
Are you scared yet? Don't worry, this being a press release, everything will work out happily in the end. And yes, it turns out that these terrifying predictions can be avoided simply by the purchase of a new book, "Free Yourself from Sinus and Allergy Problems--Permanently." If that scientific-sounding title hasn't sucked you in already, perhaps a glimpse at the book's advice will: drink tea and eat chicken soup. Apparently these helpful tips are as effective at preventing pandemic flu as they are at eliminating allergies.
Wow. Stop the presses and tell Joe Biden to get back on Amtrak. Problem solved--Permanently.
The popular show has created an online wedding registry for betrothed Drs. McDreamy and Grey which includes the option of donating to the American Academy of Neurology Foundation, the American Skin Association, and the Alzheimer's Association. Loyal fans can give a straight-up cash donation to any of these charities, or for only $5, buy a "virtual brain"--essentially, a little brain icon with one's name and message slapped on it, which will appear on the AAN Web site.
Now, who says television rots the brain?
Anyway, this week we learned that mothers actually serve a purpose. A new study found that the children of women in the military misbehave while their mothers are deployed. Special obvious commendation goes to this somewhat off-topic quote that made it into the HealthDay coverage. "Women find meaning in this work, just as a man finds meaning in this work," she said. "Like dads, moms feel they are contributing to a greater good in the world."
And, in case you parents were thinking of risking the likely consquences and getting away from the kids, you might want to know that hanging out at the beach is less stressful than ekeing out an existence in Appalachia. That's right, according to CDC reports, Hawaiians report less mental distress than the rest of the country, while residents of Kentucky and West Virginia have the most. No word on how those stats compare to the unhappiness of residents of 19th century Russia, though.
Next time the family piles into the station wagon for a vacation (Appalachian get-away, perhaps?), remember that aggressive driving is responsible for 56% of fatal crashes nationwide, said the AAA Foundation for Traffic Safety. AAA defines commonly witnessed behaviors as aggressive: speeding (a factor in a third of crashes) is only 15 miles per hour over the speed limit. Also cited were running red lights and speeding through yellows, blocking others trying to pass, tailgating, forcing others to speed, driving on the shoulder and failure to yield.
Marie de Medici had a goiter, and Rubens painted her with it in 1622. According to Dr. Susan Mandel, who spoke on thryoid nodules at a session today, this painting made goiters all the rage. Other women of the period would actually ask their painters to add goiters to their portraits--even if they didn't have one--in order to be a little bit more like Marie.
Sounds crazy... but is it any worse than injecting yourself with botulinum toxin to get lips as fat as Angelina Jolie?
(Image courtesy of Olga's Gallery at www.abcgallery.com)
So here goes: The president wants to decide which law enforcement agency is the best so he releases a rabbit into the woods and sends the CIA, FBI and NYPD to get it. The CIA interviews all the animals, can't find it. The FBI kills everything in the woods, including the rabbit. After the NYPD goes in, a badly beaten bear comes out saying, "Yes, yes, I swear I'm a rabbit." The point was something about how electrophysiology is like the NYPD--you get an answer but it might not be the right one.
Then, presenter Fred Kusumoto, MD, told us about how premature ventricular contractions are like bear poop. If you're hiking in the woods and you see poop, you'd better watch out for a bear. Cleaning up the poop will not make you any less likely to run into a bear. Similarly, studies have found that using medication to get rid of patients' PVCs does not improve mortality.
He particularly dislikes the one which says there must be tenderness in at least 11 of 18 tender point sites to diagnose the disease. "When insurance companies come asking me about this, I say I don't know, and I don't care," said Dr. Clauw during a session on fibromyalgia this morning. "It's not even objective."
Indeed, one reason fibromyalgia is commonly--and erroneously--known as a women's disease is because women are more likely to report tender points than men, he said. It's true that the disease is 1.5 to 2 times more common in women, but there are plenty of men who have it, too--and they often go undiagnosed because of the "women only" myth.
"When males have fibromyalgia, the doctor keeps looking (for an alternate reason) until he finds a peripheral cause, like a bulging disc in the back. Then the patient gets surgery, and when that doesn't work, it's said that the patient 'failed back surgery,'....not that the surgeon failed by doing the surgery."
Martin A. Samuels, MACP, told the story of a woman whose primary progressive aphasia caused her to become a great painter. As her frontal lobe deteriorated, her talent emerged. The theory is that the inhibitory part of her brain had previously been masking her creativity. Not sure whether it's inspiring or depressing to learn that us overly analytic scientific types might actually have artistic genius buried somewhere in our heads.
Dr. Samuels joked, "I've told my wife, 'If I ever paint anything halfway decent, get some long-term care insurance.'"
Today's "Essential Dermatology for the Practicing Internist" session was packed to the gills, with audience members consuming all available floor and wall space. Speaker Julia Nunley, ACP Member, even encouraged folks to sit down front in the area before the podium, "like little children at church."
Once settled in, we all enjoyed a pre-lunch earful and eyeful of scaly patches, inflamed sores, engorged pustules--and juicy clinical tidbits. Among them:
--Be sure to tell patients you treat for acne that it can take 2-3 months to clear up, and that the acne may not disappear completely. Many will quit treatment after three weeks if they don't see results.
--When female patients come in with acne, always ask about their menstrual cycles. "You don't want to miss PCOS," Dr. Nunley said. "When I'm checking out faces, I tuck my finger under the chin so I can feel to see if she's shaving. Often she won't tell you."
--Ask older patients with acne about flushing and blushing; you don't want to miss a diagnosis of rosacea.
--www.rosacea.org is a good site for patients to learn about things that can cause rosacea flair-ups. "You won't see this in any dermatology textbook, but rosacea flairs with menses," Dr. Nunley said. "For me personally, it flairs when I fly."
--Sun protection is the single most important treatment for rosacea. People are born with rosacea, and it gets worse with age-- but it can be stemmed if one is careful in the sun.
--Treatment for dandruff (Seborrheic Dermatitis) varies with ethnic background. African- Americans typically wash their scalps once per week, so shampoo treatments are of limited benefit. Ointments (fluocinonide) and oils (fluocinolone) should be used instead. For Asians and Caucasians, solutions (clobetasol) and lotions (triamcinolone) work well.
...and finally, the one that caused some gasps and murmurs to ripple through the crowd..
--HPV can actually live in liquid nitrogen. Never, ever double dip when performing back-to-back cryosurgery on warts.
The discussion naturally led to the financial incentives that shape physicians' behavior, from pay for performance to pharma support. And that led to some hot debate on whether meetings like Internal Medicine 2009 should allow any industry funding--an issue that doesn't seem likely to be resolved any time soon.
If you were in the Philly Convention Center Exhibit Hall today around 10:30 am, you may have seen-- or heard-- some Mummery afoot. (And if you've never heard the word "Mummer" in your life, stop now and read this.)
A small but potent parade of Mummers made a circuit 'round the hall, dressed in full regalia and blaring classics like "Baby Face" on their saxes and banjos. With luck, we may catch them again on Friday-- and they may play the penultimate Mummer tune "O Dem Golden Slippers." If so, I'll bet at least one person won't be able to resist doing a bit of the Mummers strut around the booths. You'll know it when you see it.
(The stock photo is courtesy of gophila.com. Today's Exhibit Hall Mummers were too fleet of foot for an action shot.)
Shameless plug alert! ACP is Twittering from Internal Medicine 2009, as is Vineet Arora, FACP.
- Hoodia, the trendy OTC weight loss supplement, is not a good idea. The extract it comes from could have negative cardiac effects. "The good news is that most compounds that are said to have hoodia actually have no hoodia in them," Dr. Arronne said.
- Exercise is important, particularly for weight maintenance. You're not going to lose weight with just exercise, unless you work out like Michael Phelps. But exercise can compensate for the increased muscle efficiency that follows weight loss, the doctor said.
Seriously, though, there is some evidence that riboflavin can be an effective migraine prophylaxis, Dr. Paauw said. It can't hurt to give it a try, but if it doesn't work after a few months, you might as well stop it. Unless your patients are really into having unusually colored urine, that is. A recent study also found that vitamin E helped with severity and disability from menstrual migraine headaches, Dr. Paauw noted.
In case the "natural" options don't work, and you run into a patient with moderate to severe headaches, Dr. Paauw also offered his basic treatment algorithm. First, try an NSAID with a motility drug like metoclopramide, then an oral triptan, and only if that doesn't work, prescribe oral narcotics. But don't let them take too many narcotics, or they'll get rebound headaches.
Today, ACP's Board of Governors voted for more collaboration between human and veterinary medicine, in order to prevent disease transmission across species.
Are they on the ball or what?
(Ok, so the measure was originally inspired by West Nile virus, which was recognized by vets in animals before anyone noticed it in humans. Still.)
Specifically, the Governors' measure supports cross-species disease surveillance, and joint efforts to develop new diagnostic methods, medicines and vaccines to prevent and control the diseases.
I, for one, am comforted by the fact that this may prevent any of us from ever knowing what hippopotamus flu feels like.
- Most common reason that patients' finger-sticks are inaccurate? They don't wash their hands beforehand. If you eat an orange, then test blood from one of your sticky fingers, the glucose from the fruit could make the result inaccurately high.
- But should your type 2 patients who aren't on insulin even be bothering to self-monitor? Given that there's no proof that home testing affects outcomes and test strips are expensive, Dr. Hirsch sees the main use being special occasions, like when a patient is eating something new and wants to see how her blood sugar responds.
- A1cs are good, but not perfect. Anemia, in particular, can make their results inaccurate. Also, did you know that half of an A1c result is determined by glucose levels over the previous 30 days?
- The newest big thing in diabetes monitoring--real-time continuous glucose monitors. They work great (i.e., significantly lower A1cs) if patients wear them all the time and pay attention to them, Dr. Hirsch said. Best used by patients and physicians who are tech-savvy and willing to devote some real time and attention.
- The next big thing, however, could turn out to be a very old thing--urine glucose testing. If a currently underway study proves that it's as effective as home blood testing, payers could push for a move back to the older, cheaper option.
- In the afternoon, David Kendall, MD, made a convincing case for incretin-based therapies. In addition to improving insulin secretion and response, the drugs reduce food intake and cause weight loss. So how to decide if exentide and the other on-their-way-to-market options in the class are right for your patients? That was a little fuzzier--you'll know 'em when you see 'em was the gist of his message.
Er, anyway. This groovy online tool leads physicians through a short series of screening questions for alcohol, smoking and other substances, then spits out a score based on a patient's answers. The score suggests the intensity of the treatment needed.
The site also offers links to resources for carrying out a brief intervention, and for treatment referrals. Plus, one can use it to download waiting-room postcards which encourage patients to tell their docs about drug use.
The degree to which people smile in childhood photos predicts their later likelihood of divorce, said DePauw University researchers who asked adults for school pictures and rated their smiles. Those with the weakest smiles were more than three times as likely to divorce. It's not a genetic link between strong enamel and marital bliss, or that people with toothpast-minty breath kiss their spouses more often. The suspicion is that happier people (those who smile for pictures) might be more likely to work through marital problems, or might be marrying similarly happy people.
Tweets, those brief, annoying communications of 140 characters or less, might make users less moral and indifferent to human suffering. Not really, but researchers pressed on with the theory that the faster pace of news feeds doesn't allow people to fully empathize with the people to whom the news is happening. While we can rapidly process physical pain in others, emotions associated with morality take much longer to develop. We've heard it before here at Medical News of the Obvious (even if we paid attention for just a brief moment before moving on.)
Intrigued, I decided to engage in some heavy-duty journalistic investigation (Googling the press release mentioned in the article). I thought I found it here, but was surprised to find the study author saying, "But we think that the effect of the pressure bands was primarily a placebo effect. It appeared that the bands themselves did little or nothing, just as a placebo pill does nothing by itself." Wasn't that the opposite of the study findings?
Sure enough, it was. Because that press release was from a study released in 2003, by the same researchers, at the same university, published in the same journal, on effectively the same subject (one study covered nausea after chemo, while the other did radiation), with opposite results. The new press release for the 2009 study at least links back to the first study, but it still leaves one at a loss for the real implications of the research. Is the acupressure working, or the placebo?
Maybe it doesn't matter. As a recent ACP Internist article revealed, a lot of docs figure that if a treatment's cheap, not likely to cause harm, and the patient thinks it will work (all likely to be true of an acupressure wristband), why not give it a try?
With Internal Medicine 2009 less than a week away, it's time for another edition of "Ill-advised Session Titles." We are disappointed to report that ACP presenters are unusually matter-of-fact in their session-naming. Still, there are some awards to be distributed.
Best pun: Shocking Developments in Resuscitation
Most likely to be a spam email: How to Live (and Want) to Be 100!
Most likely to be a cable show: The V Words
Best session for the whole family: Adventures in Liver Land
Best follow-up to the above: Adults Beware! Children Are in the Building
And finally, the grand prize goes to the session that makes us nervous about wandering the halls here at headquarters: Anorectal Disorders Encountered in the Office Setting
From personal experience (as one of the epidemic's early "victims"), I know that not all docs are completely familiar with the signs of bed bugs. I was diagnosed with first an allergic reaction to dust mites, then scabies, and tried antibiotics, steroids, antihistamines, scabicide and Lysol before catching one of the little buggers for a positive ID.
So if you've got a patient with inexplicable itchy bumps (example photos available here), you might want to suggest referral to an exterminator. Or moving. And if you want to join the fight against this scourge of humanity, get yourself down to the Crystal City Sheraton (a bed bug-free location, according to the Washington Post).
--Turns out 90% of couples experience a decrease in marital satisfaction after their first child, especially right after birth, an eight-year study of 218 couples found. A baby accelerates the process, which is also seen in childless couples, according to research in the Journal of Personality and Social Psychology. Dirty diapers and constant sleep interruption aren't so romantic, it seems.
--Once a couple has a child, they should work hard to instill a sense of self-control. Young kids with low self-control are more likely to become overweight by their preteen years, because they lack the ability to delay gratification for a larger reward, a new study in the Archives of Pediatrics and Adolescent Medicine finds.
--And once that child gets a driver's license, couples should be on high alert for any suspicious smells leaking out from his or her bedroom door. Turns out marijuana use and reckless driving are related, according to Canadian researchers: "Our study found that men with self-reported DUIC (driving under the influence of cannabis) tend to be associated with an increased risk of being involved in a car accident," said study author Isabelle Richer, according to an article in U.S. News and World Report.
A Toronto research group has found that, by measuring levels of urinary potassium, one can get a good idea of whether a person is hitting the salad bar on her lunch breaks-- or taking a trip to Mickey D's.
Researchers evaluated urine samples from 220 people aged 18 to 50 with kidney stones, over a period of 24 hours. The patients also filled out questionnaires about the kind of food they ate over that same time period. Turns out, those with more potassium in their urine reported eating healthier foods like veggies, fruit, whole grains and low-fat dairy, while the low-potassium crowd more often reported eating fast food, red meat and sugary drinks. The study is in the April issue of the Journal of Nutrition.
The absurdist possibilities of such a test are endless. Will health nuts take to measuring their urine every few hours, to ensure they are getting the proper ratio of flax to wheat germ? Or will insurance companies require urine tests as pre-requisites, trying to spot heart-attacks-in waiting via a Whopper-a-day dinner habit? The mind reels...
Since Slate.com has an entire department devoted to debunking these sorts of trend stories, you'd be well-advised to take this news with a serving of salt (even if the NYC health department would disapprove). But it does raise some interesting questions. Is a slowing of population growth going to be a silver lining to the economic crisis? Is this good or bad for medicine? Sure, there'll be less strain on overcrowded maternity wards, but who's going to grow up to fill the dwindling ranks of primary care physicians?
But apparently the word has not gotten out to the general public. Or so it seems from a recent New York Times article which is likely to send shivers down the spine of any believer in evidence-based medicine. The article describes a recession-linked upturn in vitamin sales (new customers up 20% at the Vitamin Shoppe in the last six months) and quotes several economizing shoppers who are replacing their prescription meds and doctor visits with vitamin and supplement purchases. There's even a physician-assistant student who has cut back on fruits and vegetables to buy fish oil and antioxidant supplements.
Ack! It's one thing to spend a little disposable income on probably useless vitamins, but to buy them instead of healthy food? Of that $400 mill the government's planning to spend on comparative effectiveness research, maybe a little should go toward telling people about the things we already know are ineffective.
The article in the British Journal of Nutrition compared DXA measurements to BMI for white, African American, Hispanic, Asian and Asian-Indian men and women age 17-35 years. Here were some results:
--The DXA estimate of percent fat for African American women was 1.76% lower than in white women with the same BMI. So, assuming you trust the DXA as more valid, the BMI for obesity in African American women should be about 32, not 30 as it is for white women.
--For Hispanic, Asian and Asian-Indian women, the DXA of percent fat is higher by 1.65%, 2.65% and 5.98%, respectively, than for white women of the same BMI. Based on this data, the BMI threshold for obesity in Hispanic women should be 28, not 30.
--For African American men, DXA was 4.59% lower than it was for white men of the same BMI; for Asian-Indian men, it was 4.29% higher.
So the lesson here is, if you use a non-diverse sample to construct a measurement or screening tool, you limit its applicability. Hmm, sounds a little...obvious?
Here at ACP Internist, we're better at critiquing research ideas than coming up with them, so feel free to send your ideas along to us first, and we'll save you the embarrassment of hearing from NASA that they don't need any more research into whether depressed people are unhappy.
The president did make a move likely to gain support among the fake doctors of America. Kal Penn, who had a role on the TV show House but is best known as stoner/would-be med student Kumar (of Harold and Kumar Go to White Castle), is now going to the White House as a liason between the administration and arts groups, news organizations reported today. Makes us wonder--has anyone considered Neil Patrick Harris (aka Doogie Howser, MD) for the open surgeon general slot?
Children prefer bright colors. So concluded a study in the Journal of Clinical Nursing that assessed hospitalized children's perceptions of nurses wearing non-traditional, brightly colored uniforms vs. the traditional drab attire. I bet smiling works, too. But that's another study.
Sugary soft drinks were associated with more weight gain than other beverages, according to researchers. To come to this conclusion, researchers looked at 810 adults and weighed them over an 18-month period, doing unannounced 24-hour dietary recall interviews by phone during the study. Sugar-sweetened beverages were the only ones significantly associated with weight change. What rescues this study from being totally obvious is that it tracked how much weight could be cut by not swigging sodas. Cutting liquid calories was associated with losing 0.25 kg at 6 months and 0.24 kg at 18 months. Cutting just one sugary drink was associated with losing 0.5 kg at 6 months and 0.7 kg at 18 months. Lay off the soda already, especially those of you who start the day with a can or two.
Researchers assessed the severity of H. pylori in participants at enrollment and again at four and eight weeks using standard breath, serum and stool tests, according to an American Association for Cancer Research news release. Reducing H. pylori levels presumably will lead to a lower risk of developing stomach cancer, said researchers, noting the well-established link between the two.
It's food for thought, and many may deem broccoli the lesser of two evils considering the alternative: alfalfa sprouts. The study randomly assigned participants to an equivalent daily amount of the sprouts, which had no effect.
It may be a hassle to get to a paperless system, but at least it's not so much trouble when it's time to get rid of stuff. Between the move to electronic recordkeeping and the demise of American consumerism, it must be a depressing time for self-storage businesses.
It's hard to criticize any program that provides care to the uninsured, but this plan does seem designed to use fear of the recession to lure insured patients away from their doctors' offices. Will this lift some of the burden of unpaid care from internists, or realize the concerns of the anti-minute-clinic crowd? Tough call.
"Particularly in primary care, you address your patients' vulnerability to not just disease, but also to loneliness, fear, and anxiety. True, a disturbing number are noncompliant with the help and advice you offer, but never doubt the effect you've had on people who survive and thrive simply because you bothered to listen."
When asked for an explanation of the trend, Rarepoverty president Fay Kinnitt attributed the field's growth to the popularity of certain blogs dealing with primary care. "What can I say? They've made internal medicine cool again."
There are no side effects to the medication, which will cost 77 cents per pill and should be in stores by Memorial Day-- "just in time for class reunions and the summer beach season," said lead researcher Shirley Ujest, PhD, of Arcadia University.
The study was presented April 1 at the annual meeting of the Society of Human Ambition Medicine (SHAM) in Santa Claus, Indiana .