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

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Monday, June 29, 2009

Medical news of the obvious

We've noticed a slowdown in studies that qualify for our Weekly e-newsletter in the last few weeks, and it seems the sluggish study season now applies to obvious news as well.

Yes, for the first time in the history of Medical News of the Obvious, we didn't find anything last week that wasn't actually sort of reasonable. But, hey, we'd love it if we were wrong about this, so feel free to toss some studies our way if you feel we've missed something eye-rollingly obvious.

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Thursday, June 25, 2009

If they don't give you the flu...

It's good news for people who like to cuddle wild animals. The CDC's Advisory Committee on Immunization Practices has determined that four, rather than five, rabies shots are enough to protect an exposed human, according to an AP report.

Apparently (bet you didn't know this either) there's been a nationwide shortage of rabies vaccine, so the experts are hoping that reducing the number of shots will help to alleviate that problem. On the other hand, Novartis, which charges $100 to $200 per shot, expressed concern about the recommendation and hasn't announced any plans to change their labeling info from 5 shots to 4.

Maybe you can offer that extra shot to your friendly neighborhood bat. They seem to be having a rough year.

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Wednesday, June 24, 2009

One more thing to learn

As part of ACP Internist's standard profile feature, we ask physicians "What's one thing you wish you had learned in medical school?" Their answers are usually something about communicating with patients or accepting people's inability to change.

But an article on Slate.com makes the argument that what's missing from medical education is health policy. The authors report on how some schools are trying change the system, so that students actually know what a "third-party payer" is by the time they graduate.

The article may exaggerate students' ignorance a little. I've certainly seen a lot of med students/policy activists at ACP's Leadership Day. But spreading the knowledge more widely sounds like a good thing. Only one problem: what classes will these health policy lessons replace? Maybe, to be more useful, we should rephrase our profile question. What do you wish you hadn't learned in med school?

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Tuesday, June 23, 2009

The doughnut hole will need a new name

Yesterday, pharmaceutical companies agreed to shrink the Medicare doughnut hole by offering a 50% discount on meds purchased while a patient in the hole. The full price of the medicines will continue to count toward getting back out the other side. Given this development, the gap in coverage is going to need a new name to convey its smaller size--maybe the icing in the eclair or the Oreo filling?

More seriously, the most interesting thing about this change is how it benefits everyone involved. The advantages to patients are obvious. But the seemingly altruistic move by big pharma will probably benefit their bottom line, too, according to an analyst interviewed by the New York Times.

"'Because of the discounts,' he said, 'Medicare beneficiaries are likely to continue filling prescriptions in the doughnut hole, whereas in the past many stopped taking their medications because the drugs were unaffordable to them.'"

It makes you wonder why they didn't do it sooner. Was this strategy reserved until it would have the biggest possible PR impact as a contribution to health reform?

And if the talk of doughnuts and Oreos has made you desperately crave some junk food, my apologies. The NYT also has an interesting article about this psychological torment.

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Monday, June 22, 2009

Medical news of the obvious

It's best not to get holes in one's surgical gloves in the middle of a procedure, as this leads to a higher risk of infection for the patient, the Archives of Surgery reports in a study about the effect of ripped gloves. "Pathogens can still be transmitted through contact with skin or blood," quoth the press release. Which is, perhaps, why the surgeons put on the gloves in the first place?

Teens often stop drinking milk after they leave home. A study (Eating Among Teens, or EAT) in the July/August issue of the Journal of Nutrition Education and Behavior notes that the transition from high school to young adulthood often triggers a dramatic drop in calcium intake--a problem, since bones are still developing until roughly age 30. The authors don't address whether the drop is linked to leaving the family meal table (typically with limited, healthy choices) for the cafeteria smorgasboard or solo apartment (abundant or limited choices, but rarely healthy). They suggest fixing the problem by using peer pressure, so it becomes cooler to swig a carton of milk than a bottle of beer ("c'mon, have another one, it won't hurt you--really!")

People who live close to fast-food restaurants and convenience stores tend to eat fattening food. Researchers at the University of Alberta studied associations between the "retail food environmental index" and levels of obesity, boldly concluding that people are more likely to eat healthy food if they actually have easy access to it (i.e., by living close to supermarkets that sell more than burgers, fries and super-size sodas). Writing in BioMed Central's BMC Public Health, researchers make the astute observation: "Your local food environment can affect your weight."

Contributors: Jessica Berthold, Janet Colwell

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Thursday, June 18, 2009

ADHD drug study swerves way off course

Recently, parents of children with ADHD were subjected to some alarming headlines warning of a possible association between the use of stimulant medications for the disorder and sudden cardiac death.

The study, published in the American Journal of Psychiatry, seemed to carry some weight and even prompted a communication from the FDA (who provided funding, along with the National Institute of Mental Health), but pay close attention to the study's many limitations. Consider the unusual design of the study: researchers compared two groups of healthy children using stimulant medications. Half died suddenly in car accidents while the other half died suddenly from other causes. Because fewer kids in the car accident group died than in the other causes group (10 vs. 2), while taking the drugs, researchers surmised that there may be an association betwen the drugs and sudden death in healthy children. Huh?

And how did the researchers determine whether the deceased children were taking stimulants at time of death? They simply asked the grief-stricken parents, often years after the fact -- that's one of the "limitations" mentioned by the FDA. Another is the very real possibility that a child's death from unexplained causes prompted an autopsy investigating medication use. According tothe FDA, "the low frequency of stimulant use in both groups, as well as possible differences in the type of post-mortem inquiry, could have a profound biasing effect on the results." No kidding.

It's bewildering as to how this study even got funded. With so many problems with the methodology and possibilities for biases, the only effect of publicizing the results appears to be stirring up needless panic in the many parents whose children are being treated for ADHD.

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Wednesday, June 17, 2009

Did you miss it? Rationing already happened.

Maybe you've heard that Obama is planning some kind of health care reform. In fact, reading the health news this week you might think that all scientific research and disease spread (where did you go, swine flu?) had been halted while the country debates health insurance.

Comparisons to Canada and their "rationed" health care system are a popular conservative talking point. But a column in today's New York Times makes the point that health care in the U.S. is already rationed--against other resources, between the insured and uninsured, and perhaps most significantly to our audience, in the allocation of physicians' time. When a patient can't get an appointment, or the doc doesn't have time for one more question--that's rationing.

Might be a useful rebuttal in those cocktail party debates over health care that you're likely to run into this summer. And if that doesn't work, maybe it's time to change the subject. Have you heard about the pandemic?

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Monday, June 15, 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

Rx for health care: good medicine
By See First Blog
Evan Falchuk joins the chorus of comments that have arisen about Atul Gawande, MD's, influential New Yorker article on the U.S. health care system. Unfortunately, most readers are missing the most important point, "that we need to put good medicine back at the center of health care."

For health care reform, keep it simple
By Colorado Health Insurance Insider
Sen. Ted Kennedy's health care reform bill includes good ideas but attempts to do too much.



Opinions
For best care, doctors must keep the whole patient in mind
By Not My Second Opinion
A family medicine doctor provides clarity for a confused patient whose dizziness led her to see several specialists--and get several diagnoses. To prevent such situations and fix our broken healthcare system, doctors need to start treating the whole patient.

Even evidence-based medicine has its exceptions
By The Jobbing Doctor
Of course, doctors should practice evidence-based medicine. But they should know when it's time to break the rules, as well, a 30-year veteran writes.

Predicting the shape of health care reform
By ACP Advocate
Potential consensus legislation could include higher Medicare payments for primary care physicians but might be "too little, too late."

When it comes to diabetes, misinformation abounds
By Six Until Me
Kerri Sparling writes about some of the most common diabetes misconceptions and stereotypes she's encountered in the 22 years since her diagnosis.

Letter to the editor
Duncan Cross responds to a Wall Street Journal editorial that holds patients responsible for health care costs by suggesting the members of its editorial board either have perfect health or a virulent strain of contagious rectocephaly.



Medicine
Insight into asthma
By Allergy Notes
Allergy Notes highlights some intriguing research on how Leukotriene B(4)-BLT1 axis may contribute to airway remodeling in asthma.

Some evidence isn't ready for practice
By Laika's Medliblog
There is a lot of talk in medical circles about bridging the gap between evidence and practice, but even the gold standard randomized controlled trial doesn't always give useful answers.




Finance

Factor patients into the health care cost equation
By Marianas Eye
David Khorram discusses the ways in which patients' behavior can drive up health care costs.

Slow and steady might win the health care reform race
By HealthBlawg
Health care reformers may be biting off more than they can chew. The Massachusetts approach of addressing one thing at a time--access, cost and quality--might be worth considering at the national level.



International
Don't blame Canada
By Canadian Medicine
Some commentators have pointed to Canada's health care problems as an excuse to avoid further federal involvement in the U.S. health care system. But this argument is no more than fearmongering, Canadian Medicine writes.



Health and Lifestyle
If changing a habit is hard, try 1/2 instead
By How to Cope With Pain
Sometimes tackling a habit is too hard. Make incremental changes instead for healthier choices about diet, exercise or smoking cessation.



Women's Health
Gynecology rules, but birth process is more boredom than miracle
By Vagus Surgicalis
A New York Times piece on maternal mortality prompts an Australian medical student to reflect on his recent OB/GYN rotation.

Lessons learned from a bittersweet birth
By Beyond the Short Coat
A medical student recounts his very first delivery--of a baby destined to die from severe holoprosencephaly--and his subsequent interaction with the patient's family.

Addicted to ultrasounds
By Reality Rounds
A NICU nurse wittily recalls her obsession with weekly ultrasounds while pregnant--until a wise medical director puts her in her place.



Sports
Arthroscopy results no better than pretend surgery
By The Fitness Fixer
Knee surgery is done, recommended, repeated and taught, but the evidence base shows it is more often not needed. A study shows that having arthroscopy is no more effective than having fake surgery.

Your mattress, your health, your choice
By The Back Pain Blog
PubMed archives shed light on sleep studies that examine whether quality mattresses help back pain.

Hip replacement technique may benefit 'young actives'
By InsureBlog
Henry Stern talks to orthopedic surgeon Robert Roman about the pros and cons of the Birmingham approach.



Technology
Tricky diagnosis? Consult Dr. Google
By Clinical Cases and Images
Ever wonder how you can use Google Squared to create an automatic differential diagnosis list? Find out on the latest post.

Cloud computing for automated patient reminders
By Medicine and Technology
Systems can gather medical information and alert clinicians and patients if a problem is detected. These types of automated reminders are not difficult to generate with the right algorithms that are driven by evidence-based practice guidelines. Will electronic health records lead to improved patient outcomes?



Weekender
Catch more than a sunburn at these beaches
By Medicine for the Outdoors
California and Illinois beaches have particularly high levels of bacteria and swimmers may want to check online water quality reports before diving in.

Add footwear to the list of essential protection
By Teen Health 411
It's a good idea to keep your shoes on this summer in the locker room or at the pool, where viruses and fungi often lurk.



Family
Not a DIY project: curing depressed teens
By Doc Gurley
Paying for professional help, in the form of cognitive-behavorial therapy, is worth the money for the parents of depressed teens, according to new research.

From caregiver to 'care-taker'
By In Sickness and In Health
When a serious illness strikes, the role of caretaker often falls to the patient's significant other. But what happens when the caregiving partner gets sick?

Curing bad behavior in the hospital family
By Florencedotcom
In an effort to improve patient safety, the Joint Commission is targeting disruptive behavior, yet another area where health care can take a cue from the aviation industry.

Your career
Saying no to new business
By Novel Patient
It takes some hunting to find an internist who wants a new patient with multiple complex chronic illnesses, according to this first-person investigation.

Be honest about your experience (or lack)
By Suture for a Living
When a patient asks how many procedures a physician has performed--or even if they don't ask--telling the truth is the right thing to do.

Entertainment
Nurse Jackie Disappoints
By Digital Doorway
Our "TV critic," Keith Carlson, RN, offers his reaction to the premier of Nurse Jackie, a new Showtime "dramedy" that showcases a drug-diverting, fib-telling, take-no-prisoners nurse who does little to advance the image of nurses in the public eye.

Jenny McCarthy feuds with science
By Dr. Val
Dr. Val suggests a boycott of Oprah and provides evidence-based rebuttals to Jenny McCarthy's anti-vaccination propaganda.



The Funny Pages

Cartoon Caption Contest
Each month, ACP Internist lets readers create their own cartoon captions and vote for the winner. Submit all entries by June 18. 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.

"Bob at the Carnival"
Bob the Male Nurse Action Figure goes to the carnival, a part of the continuing photographic adventures of Bob the Nurse.



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

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More than skin deep: Psoriasis has hidden dangers

As we note in this month's cover story about dermatology for the internist, psoriasis is common, affecting about 2% of the general population. It's been known that patients with the condition are more vulnerable to heart attack, and thus their lipid and BP levels should be monitored. But a new study in the Archives of Dermatology suggests even this level of vigilance may not be enough.

Researchers at the University of Miami analyzed the records of 3,236 patients with psoriasis and 2,500 individuals without it, and found that even after age, sex, smoking status and history of hypertension, diabetes and dyslipidemia were controlled for, patients with psoriasis still were significantly more likely to have atherosclerosis, as well as ischemic heart disease, cerebral vascular disease, or PAD. As such, psoriasis carries an independent risk of higher mortality--19.9% vs. 9.9%.

So what's an internist to do with his or her psoriatic patients? Vigilantly screen them for CV risk factors, and consider prescriptive aspirin, the authors said, until more research can be done.

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Medical news of the obvious

It should be obvious but ... That's what researchers at King's College London predicted when they embarked on a study to find out if the average person's knowledge of anatomy has improved over the past 40 years. But upon being shown pictures of the male or female body with certain areas shaded, fewer than half of the 722 study participants correctly identified the heart and almost 70% were wrong about the location of the lungs -- even if they were currently receiving treatment involving the organ in question. The findings were published in BMC Family Practice. Researchers astutely point out that their findings bode ill for doctor-patient communication. No doubt everyone is more satisfied with the encounter when they're on the same page about which body parts are being discussed.

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Friday, June 12, 2009

Good news (which we still don't believe)

There is still no convincing evidence that mobile phones cause brain cancer, according to a new review published in Emerging Health Threats Journal. But the authors won't absolutely rule out risks from long-term exposure.

The review finds that most studies of mobile phone use show no significant link to brain cancer or other health effects. However the authors point out that less is known about long-term effects, for example, children who would use mobile phones their entire lives.

A feature article about the good news is here. Still convinced cell phones will main or kill you? You're 100% right. Click here and here for proof.

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Cure for sleep apnea in the woodwind section?

There is good and bad news from a recent study of musicians and sleep apnea reported at the annual meeting of the Associated Professional Sleep Societies this week: First the good news: playing a high-resistance woodwind instrument, like the bassoon, may protect against sleep apnea. The down side? You have to practice for three hours a day.

Researchers floated the idea of having people with the sleep disorder take up double-reed instruments as therapy but quickly acknowledged the impracticality of expecting non-musicians to spend three hours a day on the oboe or English horn. According to an article in MedPage Today, researchers also theorized that perhaps just developing an appropriate embouchure would work. I'm trying to imagine the prescription: contort facial muscles and position lips and tongue in a woodwind-playing position for 60 minutes, three times a day. Avoid food and drink during therapy.

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Tuesday, June 9, 2009

Throwing the baby out with the snake oil.

A few weeks ago, I vented my frustration about reports that budget-conscious patients where prioritizing supplements and vitamins over standard medical care. Apparently the news got the Associated Press even more fired up.

A new AP IMPACT report goes after alternative medicine like it's a potential terrorist network. And mainstream medicine is on the conspiracy! "Some medical schools are teaching future doctors about alternative medicine, sometimes with federal grants," the article warns. The author notes that most CAM (complementary and alternative medicine) education is designed to teach doctors about the products their patients may be using. "But some schools have ties to alternative medicine practitioners and advocates." Well, yes, in order to learn about alternative medicine you might actually have to have contact with those who provide it.

Absolutely, alternative medication is controversial and some treatments are total scams. But is demonizing the whole field--and anyone who tries to study it--going to help sort out what's helpful and what's harmful? When one of the top problems with CAM is that patients don't tell their doctors what alternative therapies they're using, maybe we should be calling for more research and more cooperation, not less.

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Monday, June 8, 2009

Medical news of the obvious

Look what the cat dragged in ... or, don't take a dead bat for show-and-tell. A lesson learned the hard way by parents of two students at a Ravalli County elementary school in Montana who, upon being presented with a bat carcass by the family cat, proceeded to store it in a jar overnight and take it to school the next day to be examined by budding young scientists. The parents not only encouraged students and teachers to remove and handle the bat but also took it along to after-school soccer practice, according to an account in the CDC's Morbidity and Mortality Weekly report . Enter the school nurse, who orders tests and--shockingly!--reports back that the bat tested positive for rabies. After further evaluation, one student was referred for postexposure prophylaxis but most opted for it anyway, just to be on the safe side. Fortunately, it all ended well. And in case you're wondering, the cat emerged unscathed.

A picture is worth a thousand words, in this case, not in a good way. The old maxim is proven once again in a recent study published in BMJ that tests the effectiveness of video support tools vs. verbal descriptions for helping patients with dementia with advanced care planning. After watching a video of an elderly woman in the advanced stages of dementia, the age 65-plus participants were more likely to choose "comfort care" over life-prolonging or limited care in a hospital. Draw your own conclusions by watching the video, a disturbing depiction of a woman lying helpless in a wheelchair unable to speak, feed herself or otherwise function independently. The study's conclusions may be obvious, but painfully so.

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Thursday, June 4, 2009

DDW: NOTES worth a mention

Removing a gallbladder through the mouth? That's how natural orifice translumenal endoscopic surgery (NOTES), a new surgical procedure that even its backers call "a bit unorthodox," currently being tested, would work. The doctor would insert a tube down the esophagus, make a small incision in the stomach or digestive tract to access the abdominal cavity and take the organ out.

The idea is that the procedure would be easier on patients because it is less invasive and would thus reduce recovery time, be less uncomfortable, and leave virtually no visible scarring. It could also be used for gastric bypass, fallopian tubal ligation, and ovary removal. Some operations might be done via the rectum or vagina. (See more on this subject in ACP Hospitalist.)

This initiative is from the Natural Orifice Surgery Consortium for Assessment and Research, a joint effort supported by the American Society for Gastrointestinal Endoscopy and the Society of American Gastrointestinal and Endoscopic Surgeons.

--By Paula S. Katz, special to ACP Internist

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DDW: Managing IBS

CHICAGO--Because physicians are unlikely to cure irritable bowel syndrome (IBS), their most important interventions are to listen to the patient, explain a little of the pathophysiology of IBS so the patient knows she's not crazy, set appropriate expectations, and establish an effective patient-physician relationship, said Philip Schoenfeld, MD, during "New and Emerging Approaches to the Management of IBS" at Digestive Disease Week.

Instead of just writing a prescription for Prozac when he feels it's necessary, he shows the patient an image of the body that clarifies a brain-gut connection to validate that there may be a defect in how the gut communicates with the brain. Then he says, "And here's a medicine to modify how the brain receives it." In those circumstances he said the vast majority of his patients are willing to give the medication a try.

After walking attendees through the pros and cons of currently used medications, Dr. Schoenfeld offered his take on other treatments:

Peppermint oil: This "has pretty darn good data" showing 60% of patients' symptoms are likely to improve compared with placebo. His warning: Be sure the patient doesn't bite the tablet. "It tastes horrible and gives incredible heartburn," he said.

Probiotics: Evidence isn't that good for probiotics because it's a "mishmash of information" using different strains, although he emphasized that he's not saying it is ineffective--just that data don't show effectiveness. The only one that showed efficacy, Dr. Schoenfeld said, and that he uses is Align's bifidobacterium infantis 35624.

Isphagula husk: He called this moderately effective, but urged caution because patients can get more bloated.

--By Paula S. Katz, special to ACP Internist

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DDW: Fecal incontinence

CHICAGO--Lack of physician training and enthusiasm are the main hurdles to using biofeedback to help patients suffering from fecal incontinence, said Satish Rao, MD, PhD, during a presentation at Digestive Disease Week yesterday.

Physicians hesitate despite studies that show biofeedback shows improvement relative to pelvic floor exercises and that this is a problem of brain-gut axis that can be addressed through biofeedback, he said during his presentation on "Behavioral Therapies for Fecal Incontinence."

"[They wonder] does it really work? Are we doing some voodoo?" he said.
He said physicians who want to try biofeedback should recognize that it's labor intensive and that they will need six sessions with the patient before seeing improvement. He also recommended using guidelines, establishing clear goals, and supplying supportive therapy (e.g., laxatives, diet, and exercise).

--By Paula S. Katz, special to ACP Internist

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DDW: Point-of-care Web sites

CHICAGO--ACP's online resources got a major shout out at a session on "Evidence-based Answers at the Point-of-Care" held yesterday at Digestive Disease Week.

When discussing what he called physicians' "new generation of tools" to increase quality of care and enhance physician learning, Benjamin Krevsky, MD, listed several point-of-care Web sites including ACP Medicine. In addition, he walked attendees through how to use PIER to answer a question about a patient with upper gastrointestinal bleeding. (The answer was to recognize the need for endoscopic therapy.)

Here are the other sites he recommended:

Access Medicine
Dynamic Medical
Emedicine
Essential Evidence Plus
First Consult/MDConsult
Ovid

PogoFrog
UptoDate


He said pogofrog, one of his favorites, is a Google-run site just for physicians. For example, he said a regular Google search yielded 90,000 hits for a search on a specific medical topic; the same search on pogofrog gave him 10.

--By Paula S. Katz, special to ACP Internist

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Wednesday, June 3, 2009

DDW: Who are your IBS patients?

They are likely problem-solvers, the ones always pitching in for the neighborhood bar-b-que or organizing the carpool to a kids event. They look for control, and when it comes to irritable bowel syndrome (IBS), that's a major stumbling block, said Jeffrey M. Lackner, a clinical psychologist specializing in working with IBS patients and director of the Behavioral Medicine Clinic at the University at Buffalo (NY). He recommended cognitive behavior therapy for patients who:

  • Prefer a non-drug option,
  • Have persistent IBS without significant relief from first-line treatments,
  • Have moderate to severe symptoms,
  • Have an impaired quality of life, or
  • Display illness behaviors such as seeking reassurance or requesting testing.

During today's session with Dr. Tillisch he said IBS patients need to learn coping strategies to manage controllable as opposed to uncontrollable factors. One way, he said, is to ask, "What can I do about this," then accept that answer or at least resign yourself to whatever that is. Cope by commiserating with friends or using relaxation techniques.

"Try to handle the unpleasantness of the problem versus solving or controlling it," he said.

--By Paula S. Katz, special to ACP Internist

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DDW: Signs of the times

Catching my eye at the meeting:

  • The Internet stations are among the busiest areas at the convention center
  • It looks like something you'd see at Best Buy, but not really: The high-definition endoscopy screens.
  • Only at a digestive conference? BeneFiber samples in the Exhibit Hall.

--Paula S. Katz

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DDW: Beyond drugs for IBS

Given all the high-tech and traditional drug therapy sessions available, why did some attendees at Digestive Disease Week attend a session on "Non-pharmacologic Treatments for Functional GI?" Here were some of their answers:

"I see a lot of IBS and I'm finding drugs don't seem to work well."

"I'm looking for pathways other than drugs."

"I'm interested in multidisciplinary approaches."

During the session they found out the pros and cons of acupuncture, hypnotherapy, and herbal therapies such as peppermint oil from presenter Kirsten Tillisch, MD.

She said physicians need to know how to approach their IBS patients who are going to health stores and picking up products saying they address IBS, or try eliminating foods on their own, she said. "It's becoming really hip to eliminate gluten," she said. She said she doesn't use elimination diets without the help of a nutritionist.

She also talked about the benefits of referring patients for psychological therapy--when they're willing--as well as working closely with a few psychologists to best coordinate care.

--By Paula Katz, special to ACP Internist

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DDW: Nonalcoholic steatohepatitis

Although everyone would like a quick fix to treat nonalcoholic steatohepatitis (NASH) and its attendant problems with blood pressure and diabetes, the best bet seems to be the one that can be hardest to sell to patients: weight loss.

The question then becomes, which is the most effective way to make that happen? During today's session on "Approaches to Weight Loss in NASH: When and How Aggressive," presenter Kittichai Promrat, MD, made the case for lifestyle intervention. He said a recent study he was involved with showed a 9.3% weight reduction in patients who received a portion-control diet, a meal plan, a pedometer to measure steps, and other interventions versus 0.2% of those who did not.

The major challenge after that, he said, is finding a self-regulating program that will help patients maintain that weight loss.

Is one diet better than another? According to Dr. Promrat, the answer is no. He cited a recent study that found that while a low-carb diet reduced more fat initially, once patients reached 7% weight loss, the amount of fat reduction was the same. And because compliance is so difficult, he recommended that doctors be flexible.

"A diet that fits the patient's personal preference and can be maintained is best," he said.

Before recommending surgery...
At that same session, Raphael Merriman, MD, urged caution when looking to bariatric surgery to resolve NASH. He said that's a very real concern given that in 2008 there were more than 200,000 bariatric surgeries, what he called "a staggering number."

Although some data show promising results with certain types of bariatric procedures, he said more is needed to make the recommendation. He noted that the surgery's main goal is weight loss--not fixing NASH. In fact, not all patients undergoing the procedure have fatty liver disease.

--By Paula Katz, special to ACP Internist

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Tuesday, June 2, 2009

News from Digestive Disease Week: PPIs and CAT

CHICAGO--Is there a link between acid-reducing meds and hip fractures?
A new study released here today reports that taking even less than one proton pump inhibitor (PPI) or histamine-2 receptor antagonist (H2RA) could increase your patients' risk of hip fractures.

Fracture risk rose 12% for those taking less than one pill a day, 30% for those taking the usual dose of one pill a day, and 41% for those taking more than one pill a day among patients studied at the northern California Kaiser Permanente integrated health-services organization. Patients with hip fractures were 30% more likely than controls to have taken PPIs and 18% were more likely to have taken H2RAs for at least two years.

While risk seemed greatest among patients 50-59 years old, the greatest number of fractures was among the 80- to 89-year-old group, which had a lower PPI-relative risk.

"Patients taking acid suppressors should continue treatment at the lowest effective dose. However, they should discuss treatment options with their doctor if they are at risk of osteoporosis," said Douglas A. Corley, MD, of Kaiser Permanente in San Francisco, and the study's lead investigator. The study looked at up to 10 years of exposure to PPIs and H2RAs for 33,752 cases.

New CAT cautions: The risks of giving complex antithrombotic therapy (CAT) to your patients may be higher than you think.

New data released here today shows that veterans aged 60-99 who were prescribed aspirin-antiplatelet therapy or aspirin-anticoagulant therapy were two to two-and-a-half times more likely to suffer significant upper gastrointestinal events (UGIE) like bleeding or perforation. The least harmful CAT combination was anticoagulant-antiplatelet therapy.

However, younger patients (those between ages 60 and 69) who received CAT were at highest risk of experiencing UGIE, and their risk of bleeding within one year of taking the drugs was four times higher. These patients were likely to be on aspirin-anticoagulant-antiplatelet therapy for a history of ischemic heart disease, hypertension, diabetes, and peripheral artery disease.

"The observed magnitude of UGIE risk suggests an unfavorable risk/benefit profile for CAT in the short term," says Neena S. Abraham, MD, lead investigator of the study, conducted with the Michael E. DeBakey VA Medical Center and Baylor College of Medicine in Houston. The study was conducted from Jan. 1, 2003 to Sept. 30, 2006.

--By Paula Katz, special to ACP Internist

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Monday, June 1, 2009

News from Digestive Disease Week: Crohn's disease

CHICAGO--IBD radiation risk: Are your patients with ulcerative colitis (UC) or Crohn's disease getting too much radiation exposure?

Patients with Crohn's--who often have complications that require radiologic tests sometimes starting at a young age--were exposed to twice as much radiation as patients with UC, according to the results of a study of 500 patients with Crohn's and UC presented here today.

Between 66% and 75% of the radiation came from CT scans, which produce more radiation than X-rays or MRIs, but do a better job diagnosing complications associated with irritable bowel disease, according to the study's lead researcher Karen Kroeker, MD, fellow with the division of gastroenterology at the University of Alberta.

She said the problem could be addressed by finding new diagnostic tools such as intestinal ultrasound that could eventually replace CT scans.

Meanwhile, she suggested doctors keep closer tabs on what their patients are experiencing. "Physicians need to be aware of how many CT scans their patients have been exposed to so that they can determine the risk of additional CT scans," she said.

The environment and Crohn's: Pollution, changes in diet, or smoking habits could be responsible for the 48.5% increase in Crohn's disease in patients under age 19, according to another study released today.

Investigators tracked nearly 6 million patients in northern France between 1988 and 2005. While the incidence of Crohn's increased 20.7% overall, that rate had stabilized after 10 years. Not so for people under age 19; that rate had a linear and dramatic increase.

Future studies should look at why Crohn's disproportionately affects young people, said Guillaume Savoye, MD, EPIMAD registry and department of gastroenterology, University Hospital, Rouen, France.

--By Paula Katz, special to ACP Internist

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News from Digestive Disease Week: Patients often in the dark about NAFLD

CHICAGO--Primary care physicians should take more initiative in talking to their patients about how they can avoid non-alcoholic fatty liver disease (NAFLD), according to the results of a new study released at Digestive Disease Week here today.

In what the lead researcher called a "disturbing and significant" finding, 98% of 5,000 outpatient adults studied said their physicians had never talked to them about NAFLD. The survey also found that 95% did not know that fat in the liver could lead to serious health problems and 80 percent had never heard of cirrhosis.

Prevention is critical since treatment options are limited for "this silent but deadly disease," said Sury Anand, MD, chief of gastroenterology at Brooklyn Hospital Center. He recommended that physicians encourage their patients to maintain healthy weight through diet and exercise to avoid NAFLD just as they limit carbohydrate intake to prevent diabetes.

NAFLD is the most common cause of abnormal liver enzymes, one of the most common causes of cirrhosis of the liver, and the 10th leading cause of death.
--By Paula Katz, special to ACP Internist

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Digestive Disease Week: Colorectal cancer detection

Digestive Disease Week is underway in Chicago this week, and our correspondent Paula Katz will be dispatching news from the meeting over the next few days. Studies on tools to detect colorectal cancer are among today's research highlights:

Fewer perforation risks: Rates of perforation, a serious complication of colonoscopy, are low and decreasing, according to the results of a new study. The study analyzed 17 abstracts that included 274,265 colonoscopies to find an accurate measure of perforation rates, which other research has found ranged from 0.01 percent to 1.1 percent. This study found that the perforation rate in therapeutic colonoscopies was 0.066 percent (one in 1,500) and .017 percent in diagnostic colonoscopies (one in 6,000) with a trend towards decreasing perforation rates for both procedures. Further studies should be done in community and university settings, stratify patients by different risk factors and indications, and follow up at day seven or 30 to capture all complications, said researcher S. M. Abbas Fehmi, MD, clinical faculty at the University of Pennsylvania School of Medicine.

Advantage deep sedation? Endoscopy found 25% more large polyps in patients who had deep sedation during colonoscopy than those who had the procedure performed under moderate conscious sedation, according to a new study. Researchers examined a database of endoscopy reports from 61 practice sites from patients who had average risk screening colonoscopy and controlled for age, gender, and race. Researcher Katherine M. Hoda, MD, senior fellow, department of gastroenterology, Oregon Health & Science University, said it's unclear if those polyps would have been found if the patients were under moderate sedation and that more studies are needed since this study was small and not randomized.

Three-year follow-up: Patients who had advanced pre-malignant polyps removed during colonoscopy had a substantial rate of advanced polyp detection at second colonoscopy, which guidelines recommend after a three-year interval, according to the results of another study. Removal of polyps with villous and high-grade features was particularly predictive of more future advanced polyps and increased susceptibility to cancer. The rate of discovering advanced polyps at the third colonoscopy was less than the second colonoscopy. However, researchers said it was still high enough to suggest that continued exams are an efficient use of resources.

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Medical news of the obvious

People choose high-calorie over healthier drinks, especially when they're on sale. Sad but true, it often costs more to buy healthy or organic products than their high-fructose, saturated-fat-bearing cousins. A New Zealand study, published in Nutrition and Dietetics, corroborates this notion, concluding that of 1,500 supermarket discounts on non-alcoholic drinks, only 15% were considered "healthy." Although, researchers noted, the difference may have something to do with there being signficantly more non-healthy drinks on shelves than the alternatives, no doubt a savvy move by companies that are interested in making a profit as opposed to feeling good about their customers' eating habits. It turns out that water, plain reduced-fat milk and plain reduced-fat soy beverages (the "healthy" drinks) aren't as appealing as sodas and flavored sports drinks--sadly, I suspect that price has very little to do with it.

Driving everywhere is making us less healthy. By how much? A Reuters feature reported that driving cuts the average person's 10,000 steps a day to as few as 1,000. Because it cuts into potential time for exercise, each 30 minutes of driving translates into a 3% greater chance of being obese.

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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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