Thursday, July 31, 2014

QD: News Every Day--Middle age alcohol misuse may play a role in later dementia

Middle-aged adults with a history of alcohol use disorders have more than double the risk of developing severe memory impairment later in life, a study found.

Researchers looked at the association between history of alcohol misuse and severe cognitive and memory impairment in more than 6,500 middle-aged adults from the Health and Retirement Study, starting in 1992 and reassessed biannually from 1996 through 2010. Alcohol misuse was assessed with the 3-item modified CAGE questionnaire, which eliminated the question about cutting down on drinking because the behavior is common in those over 50, which reduces the questions discriminatory value, the authors noted. Memory was assessed at the final follow-up evaluation using the 35-item modified Telephone Interview for Cognitive Status, with incident severe cognitive impairment defined as a score ≤8, and incident severe memory impairment defined as a score ≤1 on a 20-item memory subscale.

Results appeared in The American Journal of Geriatric Psychiatry.

During the nearly 2 decades of follow-up, 90 participants experienced severe cognitive impairment and 74 participants experienced severe memory impairment. History of alcohol use was associated with severe memory impairment (odds ratio [OR], 2.21; 95% CI, 1.27 to 3.85; P=0.01), while there was non-statistically significant trend for severe cognitive impairment (OR, 1.80; 95% CI, 0.97 to 3.33; P=0.06).

“Gaining greater insight into the role comorbid conditions, such as (alcohol use disorders) AUDs, play in the natural history of dementia may lead to new opportunities for prevention,” the authors wrote. “The CAGE questionnaire may offer clinicians a practical way to identify individuals at risk of adverse dementia-related outcomes who may benefit from interventions targeting AUDs.”
Wednesday, July 30, 2014

Update for Lyme disease

Lyme disease is probably the most common tick-borne illness in the U.S., and the best understood. It’s a regional disease, very common in some areas, vanishingly rare in others for reasons that aren’t yet clear. There are about 35,000 cases reported yearly in the U.S., but this likely underestimates the true incidence as many people either don’t seek help or are not properly diagnosed.

Many people present with the classic “bullseye” rash, but many (about 20-30%) do not. During the first month after infection, many people experience fatigue, fevers, and joint aches. At this point testing is rarely necessary and the disease can be treated with a short course of antibiotics based on the symptoms and physical exam alone. During this early stage, some people may get more serious symptoms, such as facial paralysis, meningitis, and heart problems. If the infection goes untreated, many people will get recurring joint inflammation, with large joints such as the knees becoming swollen, red, and warm.

Antibiotics are still effective even at this later stage of the disease, but if left untreated, some people experience lingering symptoms. In general, these ease up over time, and once treated with a standard course of antibiotics, no further antibiotics are of any help. There is a great deal of controversy surrounding this “post-treatment” or “chronic” Lyme disease. The evidence from many well-conducted studies is unequivocal. Whatever it is that ails people with so-called chronic Lyme disease, it cannot be treated with antibiotics. There is a temptation for people with no clear history of the disease and negative blood tests to blame a wide array of symptoms on “chronic Lyme disease” but despite decades of research, this has never been confirmed. There is an entire medical industry devoted to giving patients with so-called chronic Lyme disease long-term IV antibiotics, and using blood tests that haven’t been validated to make the diagnosis.

It very well may be that people who have been cleared of infection with the Lyme bacteria may experience lingering symptoms, but these do not represent infection and cannot be treated with antibiotics. At this point, the best approach is to look for the proper diagnosis and treat symptoms as they arise.

Prevention is the most important treatment. Avoiding areas where you are likely to be bitten by ticks, limiting exposed skin, removing ticks promptly, and using DEET-based repellants will help protect you.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog at Forbes. His blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.

Colonized patients (but not infected patients) contaminate the hospital environment

There is a continuous debate in infection control about whether to actively screen patients for multidrug resistant organisms (MDRO) colonization and subsequent isolation. Alternatives to active screening include passive surveillance, where only patients found to be infected through clinical cultures are isolated. Frequently, passive surveillance is justified by saying that infected patients will have a higher bio-burden compared to colonized patients, so they would be more likely to contaminate healthcare workers hands and the environment. However, is this in fact true? Are infected patients more likely to contaminate their rooms than colonized patients?

In part to answer this question, Lauren Knelson and colleagues from Duke and the University of North Carolina just published a study in the July Infection Control and Hospital epidemiology that measured the contamination of rooms after patients colonized or infected with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) were discharged. 48 rooms (33 from colonized patients, 15 from infected patients) were sampled using Rodac plates after patient discharge but before terminal room cleaning. Numerous sites were sampled including sinks, toilet seats, bedside tables, bed rails, chairs, floors, TV remotes, carts, and laundry bins.

This is a very small study, but even with the limited sample size they found that median colony forming units (CFU) were higher in colonized vs infected patients’ rooms (25 CFU vs. 0 CFU, P=0.033). As you can see in the figure, the distribution of room contamination was greatly skewed towards higher levels of contamination at discharge from colonized patient rooms.

There are some caveats. More surfaces were sampled from colonized patient rooms than infected patient rooms (6.52 ± 2.47 surfaces vs 4.07 ± 2.12 surfaces; P=0.02), so it’s possible that surface selection could have biased these findings. And, colonized patients stayed twice as long prior to discharge as infected patients (median 16 vs. 7 days, P=0.28). Even though The P value was greater than 0.05, this could be important since occupied rooms aren’t “terminally cleaned” and “time in room” must increase contamination.

If these findings are validated, they have important implications. First, isolating infected patients (passive surveillance) would be expected to have less utility than expected. Second, the significant contamination of colonized patient rooms prior to terminal cleaning should be a reminder that we need to identify and implement environmental cleaning technologies that work continuously during the patient stay and not just focus on terminal cleaning. Finally, since infected patients would have received effective therapeutic antibiotics, these findings support the idea that effective antibiotics are important adjuvants for infection control. If true, this suggests that as the MDRO crisis expands in the absence of novel antibiotic discovery, infection control will become far more difficult (see 2011-2012 NIH KPC outbreak).

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). This post originally appeared at the blog Controversies in Hospital Infection Prevention.

QD: News Every Day--GME education should shift to places where patients seek care, report says

A report about a fundamental shift in the way graduate medical education is funded has ACP members taking notice.

The U.S. should significantly reform the federal system for financing graduate medical education (GME) programs because the current methods requires little accountability, allocates funds independent of workforce needs or educational outcomes, and offers insufficient opportunities to train physicians in the health care settings used by most Americans, the Institute of Medicine said in a press release.

The report stated that public financing of GME should remain at its current $15 billion annual level, but Congress should move funding from the teaching hospitals that have traditionally received most of the funding into the clinics or community-based settings where most people now seek care.

Among other reasons for the shift is that physician training slots may be more driven by the needs of the individual teaching hospitals rather than of the populace, the report says. Between 2003 and 2013 there was a disproportionate increase of physicians being trained as specialists despite a greater demand for generalists. Training opportunities are highly concentrated in specific geographic regions and urban areas, and the training system is not increasing the number of physicians willing to locate to rural areas or treat other underserved populations, the release stated.

To encourage training at a variety of sites, funds should be distributed directly to the organizations that sponsor physician training programs including hospitals, clinics, and universities, and the payment methodology should be replaced with a single national, per-resident amount. The committee suggested a 10-year transition period to fully implement its recommendations, because of the complexity of GME education.

ACP members were at the announcement in Washington, D.C., or were following it online, and were tweeting from it:

Tyler Cymet, DO, FACP

Humayun J. Chaudhry, MD, MACP

Susan Hingle, MD, FACP
Tuesday, July 29, 2014

Practice guidelines and quality care

As I have noted previously, I have a “love-hate” relationship with practice guidelines. Love because it is often helpful to refer to a set of evidence-based recommendations as part of clinical decision-making; hate because of all of the shortcomings of the guidelines themselves, as well as the evidence upon which they are based.

A recent piece in JAMA and the editorial that accompanied it reinforced my ambivalence.

The research report addressed a straightforward question: how often do “Class I” recommendations change in successive editions of guidelines on the same subject from the same organization. Recall that Class I recommendations are things that physicians “should do” for eligible patients. They are particularly important, because these recommendations often form the basis for quality metrics, against which physician performance is measured, increasingly with financial consequences. It is not hard to understand why.

First, the recommendations are, by nature, definitive. If a patient meets certain criteria (e.g., has evidence of ischemic vascular disease, and no allergy to aspirin), then she should get the indicated therapy or intervention (aspirin), making the quality assessment fairly straightforward. It is also generally easy to detect if the intervention was made. Finally, it is also easier to engage clinicians using quality metrics that detect “underuse” (patient did not get something he should have) than “overuse” (patient got a treatment or service he should not have).

The authors limited their study to guidelines published jointly by the American College of Cardiology and the American Heart Association. These are generally well-respected documents, and are often held up as models for how guidelines should be developed and promulgated. (Disclosure: I am a card-carrying fellow of both organizations.) They categorized the status of the original Class I recommendations in the subsequent guideline as either retained, downgraded or reversed, or omitted.

So what did the study find? Overall, about 9% of the recommendations were downgraded or reversed in the follow-up guideline.

I don’t know about you, but that seems like a lot to me, especially since the median time interval between the paired guidelines was 6 years. This is even more disturbing when you think about how many years it takes to develop quality metrics based on these guidelines, making it inevitable that some quality metrics will be based on discredited recommendations. The discordance of the newest cholesterol management guidelines with the widely adopted HEDIS measure for LDL management is just one example where this is already the case.

I think this is just 1 more reason why quality measures built around “process” (did you do this or that in the care of a patient) have to give way to measuring outcomes (how well did the patient do under your care).

What do you think?

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. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.

QD: News Every Day--Does the '5-second rule' apply to handshakes?

Bumping fists may be a more hygienic greeting than shaking hands, Welsh researchers reported. It may seem obvious, but the longer the grasp, the more bacteria spread from hand to hand in a study.

Two researchers wore rubber gloves dipped into a solution of Escherichia coli, and tested handshakes, high-fives, and fist-bumps to uncover the transfer rates of each greeting.

Results will appear in the August issue of the American Journal of Infection Control. The highest transfer occurred during handshakes, and had a dose-respondent relationship (that is, longer handshakes and grip strength mattered. A high-five reduced the transfer by half, and bumping fists had a 90% lower rate.

The study was inspired by an increase in measures to promote cleanliness in the workplace, such as hand-sanitizers and keyboard disinfectants, according to a university press release.

In case you missed it …

Internist William LaCorte, MD, ACP Member, has found a more lucrative business model than even concierge medicine, namely, filing whistleblower lawsuits potentially worth millions of dollars. A profile in the Wall Street Journal outlines how “qui tam” lawsuits have garnered him $38 million in recoveries from allegations of health care fraud.
Monday, July 28, 2014

Schistosomiasis in Tanzania--a prologue

I am in the African Republic of Tanzania. This year I have again accompanied a group of medical students from University of California at Irvine who will be teaching bedside ultrasound to clinical officer students at a medical school in Mwanza, the second largest city in this East African country. We will also be looking at the utility of ultrasound in diagnosing schistosomiasis, a parasitic disease which is endemic here.

Mwanza is on the coast of Lake Victoria, a huge body of water also bordered by Kenya and Uganda. Much of the commerce here has to do with the lake, both relating to tourism and fishing. Schistosomiasis is a water-borne disease caused by a fluke that lives in the lake, harbored by snails. The snails are infected by schistosomiasis miracidia and shed cercaria capable of infecting humans in the beautiful blue water, where they penetrate the skin of mammals that swim in the lake. The flukes move through the lymphatic system, penetrate the blood vessels of the lungs and end up in the left heart and thence the blood vessels. They attach themselves to our blood vessel walls, nourish themselves on our blood, copulate constantly and produce eggs which are intensely irritating to our various internal organs. We eliminate eggs in our urine and bowels which go back into the water system to mature and complete the cycle.

Infection with Schistosoma mansoni and S. haematobium, which are the predominant species here in Tanzania, can cause fibrosis of the portal veins of the liver with chronic liver disease, scarring of the intestines and bladder with resulting kidney failure, malnutrition and anemia and chronic ulcerations of the lower genital tract. Less common and even more nightmare inspiring complications, including spinal cord and brain infection, also occur. Most people in this community are infected, though only a relatively small proportion have noticeable symptoms. The most heavily exposed people are the most severely infected, including fishermen and car washers, but also include school aged children who are weakened and perform more poorly at school. Women with schistosomiasis genital lesions may be at higher risk for contracting HIV. Patients with associated bladder or liver disease are at higher risk of developing cancer of those organs.

Schistosomiasis is one of the ”neglected tropical diseases“ which are neglected because they occur primarily in very poor areas and to very poor people. In the case of schistosomiasis, neglect is enhanced because it is debilitating and chronic but not usually fatal. Nutrition and genetics affect how sick a person gets after being infected. Tourists sometimes return with schistosomiasis, but rarely to any great harm. The treatment is simple, a big dose of an anti-parasitic medication called praziquantel given once. It will clear the fluke from the blood stream and the body can heal any damage that is not advanced enough to be irreversible. In many patients, though, treatment is delayed until long after the point of no return.

The best way to cure schistosomiasis is to completely prevent infection, and since contact with water is life to many people who live on the shores of rivers or lakes, the solution involves getting rid of the fluke. Some countries, most notably Japan, have entirely eradicated the disease using various approaches. Ideas that can work include biological control of snails, introducing predators or competing snails or infecting bacteria. Poisoning them doesn’t work very well because other mollusks and fish also die. The very successful fishing industry in Mwanza, based on introduced Nile Perch which have decimated the omnivorous cichlid species that ate, among other things, snails, has worsened the snail problem. Dams and irrigation projects move snails to previously unaffected areas, increasing the numbers of people exposed to the disease. Reducing certain plant growth along shores of ditches can reduce snails. Infected humans continue the cycle of infection by soiling water sources with urine or feces, so places with active sanitation efforts can significantly reduce their schistosomiasis burden. Large health organizations have proposed blanket treatment of school aged children with praziquantel, potentially yearly in some high risk communities, to both control human disease and reduce the reservoirs that lead to reinfection. This will be hugely expensive, but is probably necessary as part of a larger prevention effort.

I am looking forward to spending some time with the students on a large island in Lake Victoria where, we are told, 100% of the population has schistosomiasis. I expect we will see a vast array of tropical birds and fish and wide expanses of beautiful water, meet new and interesting people and see all kinds of tragic and preventable pathology. I might even go swimming. More later!

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

QD: News Every Day--Interstate physician licensing compact tries to streamline process, boost telemedicine

The Federation of State Medical Boards unveiled an updated draft interstate compact that could streamline requirements for physician licensure and telemedicine.

“The goal of the Compact is to ensure that qualified physicians are able to practice medicine in a safe and accountable manner and that the strongest health care consumer protections are maintained,” said Humayun J. Chaudhry, DO, MACP, president and CEO of FSMB. “The revised compact helps ensure that as the practice of telemedicine continues to expand, patient protection remains a top priority. We look forward to sharing the revised compact with state medical boards across the country and look forward to working with them to achieve implementation.”

The Compact is designed to streamline an alternative pathway for state-based licensure, create a new process for faster licensing for physicians interested in practicing in multiple states, including those who practice telemedicine, and reaffirm the location of a patient as the jurisdiction for oversight and patient protections.

Specifically, the draft compact would:
• require physicians who wish to participate in the compact to submit to fingerprinting or other biometric background checks to be eligible for licensure in additional states;
• alter specialty board certification requirements of the compact to clarify that those with time-unlimited certification are also eligible under the compact; and
• require that physicians who wish to participate in the compact pass each component of the U.S. Medical Licensing Examination (USMLE) or the Comprehensive Osteopathic Medicine Licensing Examination (COMLEX-USA) within 3 attempts.

The Compact doesn’t establish standards for telemedicine practice. Physicians ineligible for the Compact may still use existing pathways to acquire multiple state medical licenses.

Eating breakfast neither helps nor hinders weight loss

It’s nearly impossible for us not to believe that what we eat has a profound effect on our health. But what we know about the link between food and health is much less than what we believe. A study published this week provides a perfect example.

An overweight person trying to lose weight is likely to hear advice about the importance of eating breakfast. We have some reasons to guess that skipping breakfast might hamper weight loss efforts. Skipping breakfast should increase hunger which might cause overeating at lunch. Hunger can also trigger hormonal changes that make weight loss more difficult. There have even been some observational studies showing that people who eat breakfast are thinner than those who don’t. (See here for a quick primer on the difference between an observational study and a randomized study and why observational studies should be largely ignored.)

Of course in the past we had very good reasons to guess that heavier objects fall faster than lighter objects, that light travels faster going west than north, and that estrogen prevents heart attacks. These guesses were all proven false as soon as someone actually tested them.

In the study, investigators enrolled about 300 overweight and obese adults and randomized them to three groups. One group in addition to receiving general weight loss advice was instructed to eat breakfast every day. The second group was instructed to skip breakfast every day. The third group received general nutrition advice that didn’t mention any advice about breakfast.

The groups were quite compliant with following their instructions. The group that was supposed to skip breakfast almost always did so, and the group that was supposed to eat breakfast almost always did so. The 3 groups lost equal amounts of weight. The senior investigator of the study, David Allison, summed it up well. “The field of obesity and weight loss is full of commonly held beliefs that have not been subjected to rigorous testing.”

There’s nothing wrong with educated guesses. They’re the seeds of discovery. But without testing we shouldn’t forget that they are not knowledge. We mistakenly keep guesses around for decades, grow comfortable with them, and forget that they’re untested. It seems that the field of nutrition is especially littered with these long-held assumptions. (The myth of the harms of saturated fats is another recent example.) I’m delighted that Dr. Allison is committed to either confirming or discarding them. I hope he gets some help.

Learn more:

Skipping Breakfast May Not Be Bad For Weight Loss After All (Forbes)

Eating breakfast may not matter for weight loss (CNN Health blog)

Passing on Breakfast OK for Weight Loss (Medpage Today)

The effectiveness of breakfast recommendations on weight loss: a randomized controlled trial (The American Journal of Clinical Nutrition)

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. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.
Friday, July 25, 2014

Are your medical priorities straight?

The world is asunder. As I write this, Iraq is sinking into a sectarian abyss. ISIS, a terrorist group, now controls a larger territory than many actual countries. Russia has swallowed Crimea and has her paw prints all over eastern Ukraine. China is claiming airspace and territories in Southeast Asia increasing tensions with Japan, Vietnam and the Philippines. The Israeli-Palestinian peace process is in another deep freeze. Terrorists in Sudan and Nigeria are kidnapping and murdering innocents with impunity. The Syrian regime has resulted in 160,000 deaths and has displaced over 6 million people. The Taliban continue to destabilize and terrorize in Afghanistan and Pakistan. Disease and hunger claim millions of lives in the developing world while other world regions have a surplus of food and medicine. We have an immigration crisis in this country that gets worse by the day. Several million Americans are still out of work.

Let’s not be distracted by these trifles. A looming apocalypse exists that dwarfs the above issues and demands our overriding attention: Should the Washington Redskins change their name?

Sometimes, folks have difficulty deciding what’s important.

Assigning rational priorities is an important professional and life skill. Collectively, we all waste an incalculable amount of time, energy and resources pursuing ventures that should be left for another day. All of us do this. Sometimes, we do so deliberately when a lower priority activity will deliver some pleasure or entertainment. In these instances, at least we are aware that we are dipping down on our priority list.

An important physician skill is to judge which medical issues and tests should have a priority status. Hmmm, a patient suffering a heart attack also has athlete’s foot. Which issue do I address first? We would recognize that a patient recovering from a severe pneumonia in an intensive care unit should not undergo a mammogram or a screening colonoscopy. Often, it is not so easy to determine the medical priorities and different physician specialists on the case may disagree on what should be the next step.

Here are a few hypothetical scenarios.

A surgeon insists that an operation is urgently required, but the cardiologist counters that stabilizing the patient’s congestive heart failure must be done first.

A gastroenterologist advises stopping a blood thinner as the patient has a bleeding ulcer, while the pulmonologist disagrees as the patient has a new pulmonary embolus and argues that the blood thinner cannot be interrupted.

A patient comes to his internist very anxious over 3 days of rectal bleeding. He wants a colonoscopy as soon as possible as his father had colon cancer. The physician advises instead evaluating the patient’s recent episodes of chest tightness, which the patient dismisses as anxiety.

Knowing how to do something well is not nearly as important as knowing if and when it should be done at all. Who wants to have his gallbladder flawlessly removed if it didn’t need to come out? You can substitute any surgery, medical procedure, diagnostic test or treatment in this example.

Medical knowledge is important. Technical procedural proficiency is necessary. Communication skills are a distinguishing asset. But, medical judgment is paramount.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who 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.

Oh, what to do about that background hospital beeping?!

You enter a patient’s room, begin a conversation, and then hear it. It may be from your patient’s machine, or the next bed; from the intravenous infusion or the telemetry monitor.

“Beep, beep, beep!”

What do you do? Do you:

A. Look into the situation yourself and work out what’s wrong?

B. Try to silence the alarm immediately?

C. Call the nurse to look into it?

D. Just let the machine keep beeping for now and carry on your conversation?

Which one you usually do probably depends on the clinical situation and what type of machine the alert is coming from. Obviously an emergency telemetry monitor alarm will provoke an immediate response. However, all hospital medicine doctors will be familiar with the above everyday scenario. More often than not, it’s a simple issue with the IV machine, such as an occluded line or an alert that the infusion has finished.

Interestingly, on occasions where people have shadowed me at work—from both clinical and non-clinical backgrounds—I’ve often heard them remark about all the background noise we hear from the machines on the floors. They also frequently ask me what certain alerts mean, and I must admit I’m not always sure without looking in detail at the machines! The volumes and types of alarms can make hospitals very noisy and confusing places. You wouldn’t have the same situation say on an airplane, hearing alerts that aren’t immediately understood and addressed by the pilot or cabin crew. Quite simply, there are far too many background alarms in the hospital environment. In fact, this phenomenon of “alarm fatigue” probably affects hospital medicine doctors more than any other specialty, because we spend the most time on the hospital floors.

And even though most of us have just accepted it as the norm of being in a hospital environment, the issue is finally getting the attention it deserves. The data is truly alarming (no pun intended). One national survey from earlier this year showed that 19 of 20 hospitals ranked alarm fatigue as a top patient safety concern. Statistics frequently cite the number of alarms at up to several hundred per day for some patients. There have even been some well-documented cases in the media of harm resulting to patients when alerts are ignored. As a result of this increased awareness, the Joint Commission recently rated the problem as a National Patient Safety Goal and is requiring hospitals to take steps to address the issue.

It’s easy sometimes for physicians to think about the alarm as a “nurses problem,” but it really isn’t. The issue requires high level thought, because who decides what is or isn’t a necessary alert and is it right that the nurse is typically responsible for adjusting the alarm settings?

Aside from the safety issue, there’s also another elephant in the room. How often have you walked in to see a patient and heard them immediately complain about the fact that their machine has been beeping for a long time and it’s been bothering them? The nurse may have understandably been busy with something else and not gotten to it yet. It can be a big barrier to patient satisfaction and allowing our patients to get a decent rest.

In terms of dealing with the alarm fatigue problem, there are a number of potential solutions. Some institutions such as Boston Medical Center have successfully led initiatives by changing the settings of alert systems, such as those related to non-emergent bradycardia. In the future, different machines could even be designed, quieter for non-urgent alerts, or utilizing built-in systems that automatically page the nurse instead with certain issues such as an occluded IV line. The final option is to just keep the status quo, accepting that hospitals are places that must always have background alarms because of the nature of the work.

There’s no easy answer, but do give it some more thought next time you’re with a patient and hear that beeping …

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. This post originally appeared at his blog.
Thursday, July 24, 2014

Guidelines should rarely become rules

The blog FiveThirtyEight has this wonderful provocative article, ”Patients Can Face Grave Risks When Doctors Stick to the Rules Too Much.”

The subsequent comments have debates over the value of guidelines. Guidelines are like a box of chocolate, you never know what you are going to get. Many clinical questions yield “competing guidelines.” We all know the controversies over breast cancer screening and prostate cancer screening. Recently BP targets and lipid management have become controversial. Pharyngitis (a personal research interest) has multiple varied guidelines.

In the movie Pirates of the Caribbean, this classic exchange makes the point:

Elizabeth: Wait! You have to take me to shore. According to the Code of the Order of the Brethren …

Barbossa: First, your return to shore was not part of our negotiations nor our agreement so I must do nothing. And secondly, you must be a pirate for the pirate’s code to apply and you’re not. And thirdly, the code is more what you’d call “guidelines” than actual rules. Welcome aboard the Black Pearl, Miss Turner.

What is the problem? As one of my heroes said many times, everything in medicine requires context. We have differing opinions on the importance of that context.

Given that I have studied the pharyngitis problem for many years, let me use that as my example.

You are a primary care physician seeing an adolescent with pharyngitis. You have 2 concerns, helping the patient feel better and decreasing the probability of complications, either suppurative or non-suppurative.

Now imagine you are an infectious disease expert. You rarely see pharyngitis patients, but you are worried constantly about antibiotic resistance. Your concern centers on the “overuse” of antibiotics.

You can imagine how these two incarnations of you would view the problem differently. The first you is patient focused; the second you takes a public health viewpoint. Who is correct?

Actually, neither is correct and neither is wrong. The two versions of you have differing context.

Since both views have validity if one agrees with the context, developing a context free rule based on one of these guidelines would constitute a potential error.

The danger of rules (I hope you are reading performance measurement here) comes when they discount context. Some rules have resulted in patient harm.

When insurance companies judge, and even reward, physicians for meeting rule targets, some physicians will overlook context.

This Medscape article about hypoglycemia in the elderly raises important issues about HbA1c targets. Hypoglycemia a Greater Threat Than Hyperglycemia in Elderly.

Performance measures are rampant, primarily because the “suits” believe that we can use them to measure quality. I am proud that the ACP performance measurement committee carefully evaluates many measures. Often these proposed measures get a thumbs down. ACP Performance Measure Recommendations

We need a more widespread accountability on performance measures. The ACP committee careful evaluates the context of proposed measures. Why do other organizations not adopt this enlightened approach?

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.

QD: News Every Day--Drugs that raise HDL didn't reduce cardio events, mortality

Niacin, fibrates, and cholesterol ester transfer protein (CTEP) inhibitors may have raised HDL levels, but they showed no effect on all-cause mortality, coronary heart disease mortality, non-fatal myocardial infarction, and stroke, a meta-analysis concluded.

Researchers reviewed 39 randomized trials of more than 117,000 patients receiving drugs that raise HDL levels. The meta-analysis appeared at BMJ.

No significant effects were seen for:
• all-cause mortality: niacin (odds ratio [OR], 1.03; 95% CI, 0.92 to 1.15, P=0.59), fibrates (OR, 0.98; 95% CI, 0.89 to 1.08, P=0.66), or CETP inhibitors (OR, 1.16; 95% CI, 0.93 to 1.44, P=0.19);
• coronary heart disease mortality; niacin (OR, 0.93; 95% CI, 0.76 to 1.12, P=0.44), fibrates (OR, 0.92; 95% CI, 0.81 to 1.04, P=0.19), or CETP inhibitors (OR, 1.00; 95% CI, 0.80 to 1.24, P=0.99);
• stroke: niacin (OR, 0.96; 95% CI, 0.75 to 1.22, P=0.72), fibrates (OR, 1.01; 95% CI, 0.90 to 1.13, P=0.84), or CETP inhibitors (OR, 1.14; 95% CI, 0.90 to 1.45, P=0.29).

Before the statin era, niacin was associated with a significant reduction in non-fatal myocardial infarction (OR, 0.69; 95% CI, 0.56 to 0.85, P=0.0004) compared to having no effect in patients taking statins (OR, 0.96; 95% CI, 0.85 to 1.09, P=0.52) (P=0.007 for difference).

There was a similar trend for fibrates and non-fatal myocardial infarction for patients before the statin era (OR, 0.78; 95% CI, 0.71 to 0.86, P<0.001) and after (OR, 0.83; 95% CI, 0.69 to 1.01, P=0.07) (P=0.58 for difference).

The authors wrote, “Although observational studies might suggest a simplistic hypothesis for high density lipoprotein cholesterol, that increasing the levels pharmacologically would generally reduce cardiovascular events, in the current era of widespread use of statins in dyslipidemia, substantial trials of these 3 agents do not support this concept.”

The study follows another report that niacin did not significantly reduce vascular events and did cause a variety of serious side effects for high-risk patients.

In case you missed it …

The Guardian brings us “Great moments in science (if Twitter had existed).”
Wednesday, July 23, 2014

Don't let summer bites make you sick

The Polar Vortex that kept so many of us indoors for months has finally retreated. This can only mean 1 thing: mosquito season. As humans spend more time outside, they are exposed to illness carried by mosquitoes and ticks and there are some not-so-fun new ones to learn about. First the oldies but goodies.

Lyme disease is the best-known tick-borne disease in the U.S. It is endemic to the Northeast, parts of the Upper Midwest, and some parts of the Pacific Northwest. It causes a characteristic “bulleye” rash called erythema migrans, and if untreated can lead to fever, joint pains, and occasionally more serious symptoms. It is very easily treated with antibiotics. Despite the hype coming from some patients and doctors, once Lyme is treated it is cured. There is no such thing as “chronic Lyme disease”.

Mosquito bites are a lot more common than tick bites and can cause some remarkably horrid diseases. The worst of these is malaria which kills about 627,000 people every year around the world. Thankfully, it’s quite rare in the U.S. (but it wasn’t always). The biggest risk to Americans is with travel to endemic areas. Malaria classically causes very high relapsing fevers, and any fevers after travel to a malarial area should be evaluated by a doctor.

Gaining a larger foothold in North America is Dengue fever, also known as “breakbone fever” for the tremendous pain it causes.

Dengue is uncommon in the continental US, but is very common in the Caribbean, including Puerto Rico. It causes fever and tremendous joint and muscle pain, but usually no lasting damage. It is generally confined to tropical and sub-tropical regions, but global travel and climate change are putting the continental US at greater risk. In 2009 there was an outbreak in Key West, Fla. that was not imported from abroad.

The latest player, and the one with the best name, is chikungunya. This mosquito-borne virus has recently made its way to the western hemisphere and is becoming a significant problem in the Caribbean. So far there haven’t been an cases transmitted within the continental U.S., but this could easily change as travelers have returned with the disease, and there are native mosquitoes that can carry it. “Chick” is very much like dengue, the name coming from a Makonde word meaning “it bends up”, presumably referring to the contortions of pain suffered by its victims.

The good news is that all of these diseases are preventable. Public health measures can eliminate or treat standing water where mosquitoes breed, and individuals can cover up, use DEET-based insect repellent, and limit exposed skin, especially at dawn and dusk when many mosquitoes prefer to feed. (Ticks are a bit trickier, but they can’t bite through clothes, so tuck in those pant-legs).

Your risk of getting a bug-borne illness in the U.S. is still quite low, but if you want to avoid ruining your day, check your local health department’s website for updates on nearby outbreaks and prevention measures.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog at Forbes. His blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.

Fat: ending the war that nobody started

Given the timing, it is more than a little ironic that the current Time magazine cover story is about an alleged war that has been raging for a long time; about questionable motives and dubious intelligence; about the failure to find what we went after in the first place; and about a whole lot of questions and chaos in the aftermath—yet is has nothing to do with Iraq. As noted, truly ironic.

The current Time magazine cover story refers to ending the war on dietary fat. And overall, writer Bryan Walsh does a good job of war reporting, addressing all fronts of this now decades-long conflict in the span of just a few pages.

As you might expect, though—I am left with some concerns. When it comes to diet, we seem more prone to the crude influence of inertia than a block of flotsam floating through space—and all but immune to the subtleties of actual thinking. Since the current momentum is aimed at a condemnation of the so-called ‘war’ against fat, this article may simply feed into it—and encourage people to feed themselves ever more baloney (and related deli meats). This despite the ongoing parade of studies highlighting the hazards of doing just that.

I also worry that the majority of readers won’t get past the title and cover image, since the majority of readers never do. Most, I suspect, will simply decide on the basis of the buttery cover that the article means just what they want it to mean—and pass the pork chops accordingly.

Whether or not a product of good reporting, that’s bad news. We in the media are overdue to embrace the anti-intellectual realities of this sound bite, Tweet-driven world of ours and acknowledge that titles and cover images matter, as they are all many will ever see. For many—the title or headline is the punch line, not the introduction. Calling all editors: Please choose accordingly from now on!

No, folks. You should not start eating more baloney, nor meat in general, nor butter, nor cheese. We’ll get back to that war in a moment, but for now, here are four important considerations for you:

1) We have been eating fewer vegetables. This is an easily overlooked tidbit in Mr. Walsh’s article—it shows up in the third column of the second row of a figure about where our calorie intake went down. The figure tells us that our intake of calories from vegetables has gone down 3% since the 1970s. Since vegetables don’t have many calories—one of their many virtues—that means our intake of vegetables has gone down rather a lot. That advice to eat less meat, butter and cheese could result in reduced vegetable intake is pretty incredible. If we extend the war analogy, it would be right up there with looking around at the aftermath of the bombardment—and then realizing we had landed the troops in the wrong country altogether. Oops. Sorry, everybody!

2) We increased our calorie intake. This may not have been as diametrically opposed to the intended guidance as reducing vegetable intake—but it’s pretty darn close. Mr. Walsh devotes most of his verbiage to the particular, and competing sources of calories, but he does tell us this one line in 1 little paragraph somewhere in the middle of his piece: “The idea here was in part to cut calories, but Americans actually ended up eating more: 2,586 calories a day in 2010 compared with 2,109 a day in 1970.” We were too fat, and too often sick when the ‘war’ against dietary fat began—and that in fact is why it began, partly in an effort to help curtail our intake of excess calories, driving the obesity epidemic—and the attendant epidemics of related chronic diseases that persist to this day. Calorie intake was supposed to go down, not up. We ate more instead of less, and got fatter instead of thinner. And so again: Oops!

3) We are not clueless about the basic care and feeding of Homo sapiens. I won’t belabor that here, but will note that a recent review of relevant literature lead me to no particular epiphanies about fat, or carbohydrate, or protein; but to the conclusion that the basic theme of healthful eating is very clear to anyone willing to see it. Unfortunately, those hungering for scapegoats or silver bullets are not willing to see it—or swallow it.

4) In an entirely unrelated review of the literature on diet and diabetes, Dr. Frank Hu and colleagues reached a virtually identical conclusion to mine in #3.

But let’s get back to the war. There clearly isn’t a war against all dietary fat, and hasn’t been one for a very long time if ever. Anyone not living under a rock on another planet knows that the ‘Mediterranean diet‘ is one of the healthiest options we’ve got, and it’s awash in olive oil. Anyone not lost at sea without radio contact knows that fish oil is good for us.

But while no one ever really declared a war against dietary fat in the first place, somehow, that distorted perspective took hold. The whole thing resembles nothing so much as a game of ‘telephone,’ in which an initially intelligible message is passed through a series of whispered repetitions, until utter gibberish emerges.

An effort by scientists—whether inspired or misguided—to shift our dietary pattern away from certain foods and toward others was co-opted by food industry opportunists, and shifted toward a different, and newly invented set of foods. Then, we the people, happily eating Snackwells, did the rest—with some help from the usual suspects: media, marketers and faddists. The war we are now being encouraged to end was more of a charade than the one in the movie Wag the Dog.

But even if a war against dietary fat had ever really existed as anything more than gibberish, it would still be long over by now. Recent battles have been far more surgical in nature, although perhaps still not quite enough so. We appropriately went after trans fat. But we have tended to refer to all polyunsaturated fats as “good,” while neglecting the rather extreme and well-documented imbalance in the pro-inflammatory omega-6s and the anti-inflammatory omega-3s (an oversimplification, but useful just the same) in modern diets. We have maligned saturated fat as a class, and only late in the game are coming to realize that not all saturated fatty acids are created equal. We are still a bit stuck with the need to make them all good in order to acknowledge that they aren’t all bad. Modern nutrition seems more a product of Newton’s third law of motion than anything resembling evidence-based sense.

We have certainly had, and continue to have, baby and bathwater issues. Or, to continue the military metaphor—we have at times failed to recognize the enemy disguised as a friend, and at times have perpetrated the inadvertent harms of “friendly fire.”

Mr. Walsh is rather harsh in his characterizations of Ancel Keys, the epidemiologist who was among the first to look for explanations in cultural and dietary variations for the high and rising rate of heart disease in the U.S. But wherever you land with regard to Dr. Keys, it’s important to pause and note this: heart disease rates were high and rising when Keys started this work, and that’s why the work was started. Attempts to blame Keys and his disciples for what ails us run afoul of the fairly standard requirement that cause should precede effect.

The original advice about cutting fat—from Keys and others—was advice to eat fewer of the fat-rich foods that predominated in the then typical American diet—namely meat, butter and cheese—and replace them with more of the then-available foods naturally low in fat. Those foods were vegetables, fruits, beans and legumes, and whole grains. Had that swap ever been made, there would have been no war to wage, no war to end, and many fewer casualties along the way of chronic disease, premature death and obesity.

The intended guidance was never applied. Big Food took over the field, and completely recast the terms of engagement. Rather than eating less steak and more spinach, we passed the Snackwells. As noted, when the advice about dietary fat was first issued, Snackwells had not yet been invented.

That invention inevitably became the mother to new nutritional necessities; suddenly, we all needed low-fat snack foods. That would have been bad enough—but things got worse. Foods like Snackwells came along with propaganda: this is what was meant by ‘cut fat’ in the first place. Of course, it was not.

The ‘eat low-fat junk’ phenomenon was never the product of scientific guidance. It was the result of epidemiology drowned out by economics, public health subordinated by propaganda. Madison Avenue just made it up.

And we went along; of that, we are indeed guilty. Tempted though we may be to blame everybody else, to some extent when we meet the enemy here—it is us.

Our principal transgression was gullibility. It was as if we had all been told that it’s wrong to punch one another—with the intent, clearly, that we use our words to resolve our conflicts. But then the mallet salesmen came along to tell us that what had been intended was we use hammers instead of fists. And away we went, knocking one another over the head—wondering all along why the epidemiology of head trauma never improved. It is long past time for all that hammering to knock some sense into us all.

Only 1.5% of Americans meet daily recommendations for both vegetables and fruits to this day—despite decades of trying to change these deplorable statistics. We got advice to eat less meat and ate fewer vegetables. Looking at the trends in American eating from just a bit of altitude invites nothing so much as an incredulous shake of the head, and a roll of the eyes. We seem badly in need of a war against nincompoopery.

The evidence continues to accrue—with almost surprising frequency—that we should, indeed, eat less meat, butter and cheese (before we even factor in the environmental considerations, which frankly we should do). We just shouldn’t replace them with donuts, Snackwells and soda. Well … duh. Really.

So here we are—striving to end the war that no one really declared in the first place. Certainly no one ever recommended that we reduce our intake of fatty foods, but wind up eating fewer vegetables and more calories. Courtesy of no one’s advice, but a whole lot of agendas mostly involving money—that’s what we did. We have been living, and all too often dying, on a diet of unintended consequences ever since, and are still apparently disinclined to eat more vegetables, fruits, beans, lentils, nuts, seeds and whole grains. Alas.

And now we face the prospect of more unintended consequences, as we are told it’s time to end the war. The starchy, sugary, tasty low-fat junk foods we invented to exploit the ‘low fat’ guidance are still with us, and still tasty. So I envision a peace treaty with dietary fat that is silent on the matter of wholesome foods in sensible combinations ushering in a new era of dietary debauchery: this time, we will add back meat, butter, and cheese while failing to cut much starch or sugar. It is possible to eat even fewer vegetables and more total calories, and if history is any indication—that’s just what we’ll do. That will be tragic, because the evidence for what we really should be doing is strong and clear and consistent and compelling. But it’s devoid of conspiracy theory intrigue, lacking in scapegoats, and bereft of silver bullets. It’s a non-starter in other words.

Which leads us back to where this began, the start of a war no one ever really declared, that it is now time to end.

Okay, but do have a look out at the world—Iraq in particular—and consider that how a war is ended can be at least as calamitous as how it is begun. I told you it was ironic.

David L. Katz, MD, FACP, MPH, FACPM, 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. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

QD: News Every Day--Don't use feeding tubes for advanced dementia, geriatrics society says

Feeding tubes are not recommended for older adults with advanced dementia, according to a position statement from the American Geriatrics Society. They don’t prevent complications of hand feeding, led to complications, and take away life’s simples pleasures of eating and interacting with others.

Hand feeding is at least as good as tube feeding for the outcomes of death, aspiration pneumonia, functional status, and comfort, the statement reads, and tube feeding is associated with agitation, greater use of physical and chemical restraints, tube-related complications, and development of new pressure ulcers.

The position statement appeared online July 17 at the Journal of the American Geriatrics Society.

Among the rationales:
• Survival is not better in those who are tube fed rather than hand fed;
• There’s no evidence that tube feeding prevents aspiration, heals pressure ulcers, improves nutritional status, or decreases mortality;
• Tube feeding is associated with aspirations, malfunctions, oral secretions that are difficult to manage, discomfort, use of physical and chemical restraints, and pressure ulcers;
• Nursing home residents frequently need to be transferred to the emergency department to address tube-related complications such as blockage and dislodgement; and
• Greater levels of discomfort have not been observed, despite eating difficulties.

The position statement recommended involving families about the natural progression of dementia, including eating difficulties, and acting proactively to make decisions through advance directives. It also suggested enhance oral feeding by altering the environment and creating individual-centered approaches.

“Oral feeding may be one of few remaining pleasures and a time for socialization for a person with advanced dementia,” the statement reads. “Mealtime must be regarded as an event of importance, instead of a task that needs to be completed as soon as possible.”
Tuesday, July 22, 2014

Stewardship effective in C. difficile prevention: a meta-analysis

As Dan Diekema, MD, FACP, mentioned last week, when 15% of asymptomatic hospitalized adults carry toxigenic strains of Clostridium difficile, it should alert us to focus on antimicrobial stewardship as a way to prevent C. difficile infections. But how effective are stewardship programs and does it matter what type of program you implement in your hospital? If only there was some sort of systematic review or meta-analysis to guide or decision making.

As if on cue, Leah Feazel and Marin Schweizer at University of Iowa published such a review and meta-analysis titled “Effect of antibiotic stewardship programmes on Clostridium difficile incidence” in Journal of Antimicrobial Chemotherapy earlier this spring. Typical of projects completed by Marin and her group, they thoroughly combed the literature for papers. Here they identified 891 articles, reviewed 78 full articles and included 16 studies in their final analysis. Over all, stewardship programs were associated with a 52% reduction in C. difficile infections incidence. Importantly, programs appeared effective when implemented in whole hospital or geriatric settings and when utilizing a persuasive approach or a restrictive approach. I’ve provided the forest plot of studies below. An additional note is that the studies utilized various quasi-experimental study designs and based on the funnel plot, there appeared to be little publication bias.

Key points: (1) Stewardship works for C. difficile infections prevention, but it would have been nice if there was at least 1 funded randomize, controlled trial or cluster-randomized, controlled trial. (2) The meta-analytic approach, that Marin has pushed through her reviews of surgical site infection bundles and hand hygiene interventions, is a fantastic way to guide medical decision making and should be considered for inclusion in future hospital acquired infection guidelines. The reality is that infection prevention studies overwhelmingly utilize quasi-experimental designs. Why not identify the highest-quality QE studies and rigorously meta-analyze them as done here?

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). This post originally appeared at the blog Controversies in Hospital Infection Prevention.

QD: News Every Day--Young women with heart attacks face more mortality, longer hospital stays

Young women with heart attacks have more comorbidity, longer hospital stays, and higher in-hospital mortality than young men, although their mortality rates are decreasing, a study found.

To determine sex differences in clinical characteristics, hospitalization rates, length of stay, and in-hospital mortality by age group and race among young patients with acute myocardial infarctions (AMIs), researchers applied data from the National Inpatient Sample for patients with AMI across ages 30 to 54 years, dividing them into 5-year subgroups from 2001 to 2010.

Results appeared in the Journal of the American College of Cardiology.

There were more than 230,000 hospitalizations with a principal discharge diagnoses of AMI in 30- to 54-year-old patients, or nearly 1.13 million hospitalizations. Women were nearly 26% of young patients hospitalized with AMI. There were no statistically significant declines in AMI hospitalization rates age groups younger than 55 years old, or when stratified by sex.

Hospitalization rates for AMI were higher in men compared with women across all age subgroups. The absolute number of discharges for AMI among women increased from 56 per 100,000 in 2001 to 61 per 100,000 in 2010. But, the absolute number of discharges for AMI among men decreased from 174 per 100,000 to 171 per 100,000. Although absolute declines were noted for most subgroups of men, women showed either no change (30 to 34 and 35 to 39 years of age) or a slight absolute increase (40 to 44 and 45 to 49 years of age) in hospitalization rates.

Women had higher in-hospital mortality than men across all subgroups. From 2001 to 2010, overall observed in-hospital mortality for women with AMIs declined from 3.3% to 2.3%, (a 30.6% decrease; P for trend<0.0001). For men, the decrease for men was from 2% to 1.8%, (an 8.5% decrease; P for trend=0.6).

Authors noted that the results suggest a greater need for intensive primary prevention efforts in the high-risk young population, and that young women may gain more benefit from aggressive control of cardiovascular risk factors such as hypertension, hyperlipidemia, obesity, smoking, and diabetes.

An editorial stated that persistent excess mortality among young women emphasizes the ineffectiveness of current practices and the need for sex-specific research and guideline development. “It remains vital that sex-specific differences in guidelines constitute more than 1 page of our large guideline documents.”
Monday, July 21, 2014

Medical 'reversals'

Twenty-five years ago, the New England Journal of Medicine issued a report on a stunning new medical discovery: Aspirin helps prevent heart attacks.

Yes, good ol’ aspirin. Known since the time of Hippocrates for its magical abilities to quell fever and pain, it took only 2000 years for us to understand the science of it well enough to design a ’sufficiently powered’ double-blind, placebo-controlled randomized trial on aspirin’s efficacy in preventing heart attacks. The Physicians’ Health Study, so named because the study subjects were randomly selected physicians from across the U.S. (whom it was correctly assumed would have higher adherence in swallowing daily pills), addressed the question of whether or not aspirin has true live-saving benefit.

It does. Citing aspirin’s “extreme beneficial effects on non-fatal and fatal myocardial infarction”—doctor speak for heart attacks–the study’s Data Monitoring Board recommended terminating the aspirin portion of the study early (the study also looked at the effects of beta-carotene). In other words, the benefit in preventing heart attacks was so clear at 5 years instead of the planned 12 years of study that it was deemed unethical to continue blinding participants or using placebo.

Confusingly, there is now strong evidence that what’s beneficial for hearts can be harmful in eyes: older people who routinely take aspirin are nearly three times as likely to develop macular degeneration than non-users. Macular degeneration is the leading cause of blindness in Americans 55 and older. It presents a vexing medical problem, in that once it’s discovered, it’s too late to do anything about it. Macular degeneration afflicts more than ten million people in the U.S., which is likely an underestimate of its true prevalence.

What we see in this situation is a classic story arc in modern American medicine: Wonder-drug saves lives. Study stopped. Practice adopted. Then, years later: wonder-drug causes harm. Edicts to stop prescribing it, or be much more selective about recommending it.

Adam Cifu, a doctor (and former colleague) at the University of Chicago, has written about the concept of “reversals” in medicine. In a fascinating paper, Cifu and colleagues catalogued several examples of new knowledge leading to “abandonment” of mainstream medical practices. A major example is hormone replacement therapy for post-menopausal women. For decades estrogen was given to American women as an elixir for many ills. All of the data in support of the practice was observational; outcomes conformed neatly to expectations about the drug. When good science (a randomized, controlled trial called the Women’s Health Initiative) finally challenged the practice, it was almost entirely abandoned.

I asked Cifu for a prediction about the near-blanket recommendation to people of a certain age to take aspirin, which is prescribed so widely, including to many who do not actually have heart disease or elevated cardiovascular risk. In an email, he wrote: The [Physicians’ Health Study] never showed mortality benefits but only benefit to lesser outcomes such as [heart attack]. Even in the earliest studies there was evidence that the benefit was only in limited populations, older ones, and was balanced by significant risk of bleeding (GI [stomach, etc.] and CNS [brain]). I think what has happened is that as the scope of the trials have expanded in terms of both patients and endpoints, we have gotten a more nuanced view. Certainly the idea that [not] everyone over 40 should be on aspirin is a reversal but we will probably always be giving prophylactic [aspirin] to a subset of patients.

Got that?

One thing seems to be sure in medicine: if we just wait long enough for excellent science to guide us ahead, things we trust as ironclad rules often change.

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.
Friday, July 18, 2014

Is my medicine on the prescription drug formulary?

One of the frustrating aspects of medical practice is trying to divine if the medication I am prescribing is covered by the patient’s insurance company. Even with the advent of electronic medical records, which should be able to determine this, we are often left to hope and pray.

Here’s how it works. Individual insurance companies have formularies, lists of approved drugs, that they encourage patients and their physicians to use. Of course, this is all about the money. There’s nothing evil about an insurance company making a deal with a particular drug company that gives them a price break. The drug company will be delighted to offer the insurance company a discount in return for an anticipated high volume of prescriptions. You can easily picture an insurance company negotiating with several different GERD medication representatives watching them each lowering their bid trying to get the contract.

Nexium Guy: We’ll only charge you $0.67 a pill

Prevacid Gal: We’ll only charge you $0.84 a pill and will throw in the Japanese steak knives

Protonix Guy: We’ll lower our already rock bottom price down to $0.65 a pill for an exclusive contract

Prilosec Gal: We’ll only charge $0.57 a pill for a brief term of 10 years with an option to renew

When a patient sees me for heartburn, and I recommend a medication to ease their pain, often neither the patient nor I know which of the 6 proton pump inhibitor medicines (e.g. Nexium, Prilosec, etc.) or the generics will be covered. That’s when the guessing starts. My objective, of course, is that the patient pays the least amount of money without sacrificing medical benefit. When I guess wrong, I am then welcomed by phone calls, faxes and other forms of denial that we then devote time to sort out.

Recently, I called a pharmacist with the patient seated before me to try to be a hero and figure out which medicine was the right stuff. Even the pharmacist couldn’t figure it out. She explained to me that she couldn’t price the medicine for this specific patient unless I prescribed it officially and she then processed it through. I thanked her, hung up and resorted to my default strategy. I guessed.

Keep in mind that these formularies change yearly. In other words, a medicine that’s preferred in December may be tossed aside in January when a new drug underbids them. This adds to the adventure. We have an office pool every December when we offer prizes for guessing the new medication changes. We use this changeover as an opportunity to increase staff morale.

Next time you’re in your doctor’s office, ask what a “prior auth” is.

In my practice, I might see 15 or 20 folks each week who want me to put their GERD fires out. They have different insurance plans with different formularies and different restrictions. The chance that I prescribe the preferred medicine to each of them on the first try is much lower than winning the lottery. If fact, if I were to achieve this pharmaceutical tour de force, I think I am entitled to instant wealth. Perhaps, the pharmaceutical companies would pool their resources an sponsor a contest for gastroenterologists. What a slick marketing campaign!

Prescribe Heartburn Medicines Correctly for a Week and Win a Million Dollars!

They have nothing to fear. While physicians may accept the challenge with enthusiasm, they will never succeed. They would do better buying a lottery ticket.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who 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.

When a well-intentioned, authoritative 'no' is better than an insincere 'yes'

The above title may sound rather controversial at a time when patient satisfaction and improving the health care experience is a hot topic around every hospital administration table. It’s something that I’ve thought and written a lot about and also personally feel very strongly about, because nothing short of total commitment to our patients is required when they are at that low point in their lives. There’s so much room for improvement.

Unfortunately though, as hospitals grapple with the issue of how to make the health care experience a better one, some of the ideas being put forward are rather gimmicky. For instance, I’ve seen name badges saying “Have a nice day” or “What can I do to help you?”, which are probably more appropriate for an auto shop or fast-food restaurant. Physicians and nurses simply shouldn’t be wearing them! An attorney, teacher or even a banker wouldn’t dream of wearing that on their suit, so why should a doctor wear it on their white coat? We must keep our respect as a profession and remember that the main driver of patient satisfaction will be the human interaction between doctor and patient. Everything else is secondary.

There are in fact some very real differences between customer service in hospitals and customer service in other arenas. The mantra in the business world that “the customer is always right” does not hold true for many scenarios in health care, when the patient doesn’t know what’s best for them. This is not meant to sound paternalistic, because patient-centered care is the right way forward, but there are definite limits and boundaries in health care. Making informed choices, yes. Being in charge of their own health care, yes. But the reality is that doctors often do know what’s best based on their professional knowledge. Examples include prescribing the most appropriate medication, recommending a certain type of surgery, and not being over-zealous with pain medications, despite the patient’s wishes. In fact, not doing what they think is right may frequently lead the physician down the path of inferior patient care.

The best, and for that matter most popular, physicians that I’ve observed have actually been far from “customer service” types. Not that they don’t strive to go the extra mile for their patients and provide the best possible care, but they also balance their compassion with a strong personality and strong principles too. They are physicians that know when to say “no” and are not afraid of telling their patients what they need to hear and not what they want to hear. Sometimes what they say to their patients could be construed as bordering on rudeness to an outside listener, but their rapport is good enough to negate any hard feelings. I’ve encountered several dozen physicians like this, most of them the “old-school” types near retirement age, and never fail to hear positive glowing reviews from their patients who truly respect them. These are the role model doctors for me. It’s what we have to remember if we think any patient needs a “yes man” doctor to get good medical care. Patients actually respect a well-intentioned authoritative “no” rather than a smiling insincere “yes” over a long-term relationship. Indeed, in most areas of life, this is the case. It holds true for a family member, friend, or even a politician! A recent article in Forbes magazine discussed this very issue, in a piece titled Dr. House Was Right: Give Patients What They Need, Not What They Want”. The article described how patient satisfaction is tied to higher costs, and more concerning—higher mortality. It posed an interesting question between choosing between a nice doctor or a brilliant doctor. The author chooses the latter. However, the 2 don’t have to be mutually exclusive. They can be perfectly balanced. It would be a big mistake if we train the next generation of doctors to be “yes men/women” types in the fear of being seen as giving poor customer service or worried about poor patient satisfaction scores. In our relatively new internet age, when online ratings are available in a second, it’s understandably a worry for many doctors. This has turned medicine into a completely new ball-game that the older generations didn’t have to concern themselves with. Gone are the days when doctors could be safe in the knowledge that they were good at what they did and had patients flocking to them. Will the patient give me a bad review if I don’t do exactly what they want? Should I try to make my patient happy even though I know it’s not good for them?

Patients should know that it may be a mistake to seek out a doctor who pleases them, or use online recommendations to choose them. If you want to find a good doctor, nothing could be better than a solid word of mouth recommendation from a family member or friend.

New physicians should understand that their best peers aren’t necessarily the ones with the best ratings. They should be guided by their knowledge, principles, and stand firm if they believe something is right. As we endeavor to provide excellent care and a better experience, doctors shouldn’t be striving to make their patients happy at every opportunity. We should be striving to make our patients better. With a dose of compassion, empathy and sincerity—the rest will take care of itself.

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. This post originally appeared at his blog.

QD: News Every Day--Lifestyle interventions could cut Alzheimer's by a third globally

One-third of Alzheimer’s diseases cases worldwide might be attributable to potentially modifiable risk factors such as physical inactivity, smoking, midlife hypertension, midlife obesity, diabetes, and depression, a study found

Researchers used relative risks from existing meta-analyses done from 2004 to this year to estimate the population-attributable risk of Alzheimer’s disease worldwide by accounting for the association between 7 risk factors: diabetes, midlife hypertension, midlife obesity, physical inactivity, depression, smoking, and low educational attainment. They then examined the combined effect of relative reductions of 10% and 20% per decade for each of the 7 risk factors on projections for Alzheimer’s disease cases to 2050 in order to determine the potential of risk factor reduction.

Results appeared in the August issue of The Lancet.

Worldwide, the highest estimated risk factor was low educational attainment (19.1%, 95% CI, 12.3% to 25.6%). Among Western nations, the highest estimated risk factors was physical inactivity, in the U.S. (21.0%, 95% CI, 5.8% to 36.6%), Europe (20.3%, 95% CI, 5.6% to 35.6%), and the UK (21.8%, 95% CI, 6.1% to 37.7%).

The combined worldwide population-attributable risk for the 7 risk factors was 49.4% (95% CI, 25.7% to 68.4%), or 16.8 million attributable cases (95% CI, 8.7 million to 23.2 million) of 33.9 million cases. When researchers adjusted for the association between risk factors, the estimate fell to 28.2% (95% CI, 14.2% to 41.5%), or 9.6 million attributable cases (95% CI, 4.8 million to 14.1 million) of 33.9 million cases.

Combined population-attributable risk estimates were about 30% for the U.S., Europe, and the UK, researchers noted. Reducing the prevalence of each of the 7 risk factors by 10% per decade could reduce Alzheimer’s disease in 2050 by 8.3% worldwide.

Researchers wrote, “Although the analysis herein is necessarily simplistic, and other approaches to reduce disease burden for the tens of millions of people who will develop Alzheimer’s disease or other forms of dementia will be important, public health interventions targeted at vascular risk factors (e.g., physical inactivity, smoking, midlife hypertension, midlife obesity, and diabetes), depression, and low educational attainment will probably achieve the greatest reduction in the prevalence of the modifiable risk factors and will provide other major benefits to society and health-care systems.”
Thursday, July 17, 2014

They do make an ultrasound probe that plugs into a USB port!

“They should make an ultrasound probe that plugs into your laptop. It could just hook into a USB port.”

Ultrasound technology has become progressively more accessible to doctors who aren’t radiologists. During my training, some obstetricians imaged the bellies of their pregnant patients to quickly see how the baby was lying in the womb and assess its progress. Other than that, ultrasound resided in the realm of the radiologists, who lived in dark rooms and interpreted blurry pictures for the rest of us.

Since ultrasound is not expensive and has many potential applications, far beyond just seeing fetuses, other specialties have adopted it and doctors in resource poor countries where there are no radiologists have come to rely on it for all sorts of information. Trauma surgeons and emergency physicians can use it to rule in or out life threatening conditions, and internal medicine physicians like me can improve on the accuracy of our physical exams and sometimes avoid the cost of more complex and dangerous imaging procedures. Ultrasound can be used to guide procedures, making them safer. The machines have become smaller and are even pocket sized. It’s all so very exciting.

So why not an app for the iPhone? Why not Google glasses with which one can see ultrasound images of the patient in front of me? Why not a wireless ultrasound transducer?

The possible avenues of progress in very portable ultrasound technology have been slow for various reasons. First, many people are happy with radiologists imaging the body and cardiologists imaging the heart using large and expensive machines. The system works. It doesn’t require the rest of us to learn ultrasound and the pictures are good and the rather large charges benefit hospitals. Bedside, ultrasonographers are looking for inexpensive machines and it is unclear how much the use of these will increase the revenue stream which drives much of what happens in research and development in medicine.

Having wandered through the health care device industry’s displays at many ultrasound conferences and having surfed the Internet I thought I knew what kind of technology was available for doing bedside ultrasound imaging. I had seen an ultrasound transducer that plugged into an iPhone made by a company called Mobisante, and had seen their iPad/transducer combo. The software was buggy and the pictures were not impressive and the whole package did not end up being handy or attractive. I bought the GE Vscan machine which is about the size of my hand, and like my hand, fits in my pocket. The pictures are good and it does most of what I want it to do. So when people asked about just buying a transducer for a laptop and plugging it in I told them that clearly that was a great idea but it didn’t exist.

Except that I was wrong. The company Interson, out of the Bay Area in California, makes transducers for imaging blood vessels, deeper structures such as abdominal organs, and cavities such as the throat and vagina/uterus. I had the opportunity to try their abdominal probe in the last few weeks. It is definitely a clever and versatile device, despite several drawbacks.

The probe is called SeeMore, which will probably not help sell the product. It is about as heavy as a small hardback book and it is a little big to have comfortably in a pocket. It has an inescapable resemblance to a personal vibrator which will also not help sell it. It is actually the same transducer that Mobisante used in their iPhone device. On the very positive side, though, it gives really good pictures of the abdomen, uterus and bladder. Its resolution is good enough that it could be used to rule in or out a pneumothorax, which my Vscan is not quite up to. Its image acquisition is slow so when looking at the heart it is not possible to see the delicate movement of the heart walls or valves, though it is possible to see grossly abnormal cardiac function or pericardial effusion from an abdominal approach. It does not do color Doppler, so it cannot give any indication of blood flow. It has its own software that loads quickly onto a laptop and it could be used with a tablet so long as it has a windows operating system.

The USB attachment can go into a USB to mini-USB converter so the tablet doesn’t even need to have a full size USB port. Once the software is loaded it has calculations that are user friendly and intuitive calipers for measurements plus all of the usual gain adjustments that a person might want. There is a button on the transducer that freezes and unfreezes the image. After images are stored they can be printed or transmitted easily as JPEGs.

If I worked in a bush hospital somewhere and needed my ultrasound just to evaluate unborn babies or critically ill or traumatized patients, this transducer would be just the ticket. If I used a laptop as I went from room to room, as I did at my last job, I can imagine information from this device being integrated seamlessly into my documentation as I examined the patient. The transducer I tried does not visualize superficial structures, like blood vessels or bones or tendons, abscesses or thyroids, but Interson makes a linear transducer that does. Each transducer costs $4000 new, and the software, support and hefty plastic case with tiny tube of ultrasound gel are included. My Vscan cost over $8000 and the cheapest portable ultrasound machine that hospitals in the US buy costs over $40,000 new. (Veterinary ultrasound machines and ones that are used in developing countries can cost much less than this, even in the sub $1,000 range for a used machine.) From where I stand this USB transducer is an affordable alternative for point of care ultrasound, though I do like a machine that gives better pictures of the heart.

What about the Google glasses thing? I think somebody has a patent for that, though it’s not commercially available. What about the wireless transducer? Yes. It exists. It is not Bluetooth, a proprietary short distance wireless connection that uses ultra-high frequency radio waves. It uses a different proprietary ultra wide band wireless connection which can handle more information. The one that I found is called the Freestyle, by Acuson, which is now owned by Siemens. It looks like a TV remote and I think it’s just for superficial structures.

As there is demand, these machines will get lighter, cheaper, more versatile and attractive. The potential is awesome and I’m looking forward to trying out new toys that will allow me more capably to help my patients.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.